Surgery
Why This Matters
A deep laceration that won’t stop bleeding. An abscess swelling into the neck, pressing on the airway. A bone broken so badly the pieces are displaced. These are emergencies that no amount of tea or bed rest will fix. Surgery — the physical intervention into the body to repair damage — is what separates watching someone die from saving their life. This article teaches the procedures that were practiced for thousands of years before modern operating rooms existed, using tools you can make and sterilize yourself.
The Mindset: Surgery as Last Resort
Surgery is the most dangerous medical intervention you can perform. Every cut creates an infection risk. Every mistake is amplified. The guiding principles:
- Do nothing that makes it worse. If you are unsure, stop. An untreated wound may heal on its own. A botched surgery will not.
- Asepsis above all. The number one killer in pre-modern surgery was infection, not the wound itself. If you cannot keep things clean, do not operate.
- Plan before you cut. Know exactly what you will do, what tools you need, and what you will do if something goes wrong — BEFORE the first incision.
- Pain management is not optional. A patient in agony moves unpredictably, goes into shock, and may die from the stress response alone. Manage pain first.
- Know your limits. Abdominal surgery, chest surgery, and brain surgery require modern facilities. Do not attempt them. Focus on limb and surface procedures.
What You Need
Surgical instruments (make or scavenge):
- Sharp knife or scalpel (the sharpest, thinnest blade available — a razor blade, obsidian flake, or forged steel blade)
- Curved needle (bend a sewing needle with pliers — heat it cherry-red first for easier bending)
- Needle holder or small pliers (for gripping the needle during suturing)
- Forceps or tweezers (for gripping tissue)
- Scissors (for cutting thread and trimming tissue)
- Hemostats or locking pliers (for clamping blood vessels)
- Retractors (bent spoons or wire hooks to hold wounds open)
- Probe (thin, smooth metal rod for exploring wounds)
Suture materials (in order of preference):
- Silk thread (strong, easy to handle, holds knots well)
- Fishing line / nylon monofilament (strong, resists infection, harder to knot)
- Linen or cotton thread (weakest option, absorbs fluid, but functional)
- Catgut (made from sheep or goat intestine — see preparation below)
- Human hair (emergency only — braid 3-4 strands together)
Sterilization supplies:
- A pot large enough to boil instruments
- Alcohol (at least 60% / 120 proof for surface sterilization)
- Clean water (boiled and cooled)
- Clean cloths (boiled and dried)
- A fire source
Pain management:
- Willow bark tea (see Herbal Medicine) — brew strong: 3 teaspoons bark in 240 ml water
- Alcohol (given to the patient — 30-60 ml of spirits for sedation; more increases bleeding risk)
- Ice or cold water (local numbing — apply 15-20 minutes before procedure)
- Pressure (firm compression upstream of the procedure site reduces sensation)
- Valerian root tea (sedative — give 30-60 minutes before procedure)
- Clove oil (excellent topical numbing for oral procedures)
Sterilization: The Most Important Step
More patients have been killed by post-surgical infection than by the surgery itself. Ignatz Semmelweis proved in 1847 that hand washing alone reduced surgical death rates from 18% to 2%. Joseph Lister’s carbolic acid sterilization in 1867 reduced them further. You must understand and practice aseptic technique.
Sterilizing Instruments
Method 1 — Boiling (most reliable):
Step 1 — Place all metal instruments in a pot of water. Ensure they are fully submerged.
Step 2 — Bring to a rolling boil. Maintain the boil for a minimum of 20 minutes. At higher altitudes (above 2000 m / 6500 ft), boil for 30 minutes — water boils at a lower temperature at altitude.
Step 3 — Remove instruments with boiled tongs or a boiled fork. Place them on a boiled cloth. Do not touch the working ends with your hands.
Step 4 — Allow to air dry on the sterile cloth. Do not towel-dry — you will recontaminate them.
Method 2 — Flame sterilization (for quick use):
Step 1 — Hold the instrument in a flame until it glows red (for steel) or for at least 30 seconds (for instruments that would be damaged by red heat).
Step 2 — Allow to cool in air. Do not quench in water (unless the water is also sterile).
Step 3 — Note: flame sterilization is fast but less thorough than boiling for complex instruments with joints or crevices.
Method 3 — Alcohol sterilization (supplementary):
Step 1 — Submerge instruments in alcohol (at least 60%) for a minimum of 10 minutes.
Step 2 — Remove and allow to air dry. Alcohol is effective against most bacteria but NOT against bacterial spores. Use as a supplement to boiling, not a replacement.
Sterilizing Your Hands
Step 1 — Scrub hands and forearms with soap and clean water for a minimum of 2 minutes. Get under fingernails — use a clean stick or brush. This is the most neglected step.
Step 2 — Rinse with clean water.
Step 3 — Pour alcohol over your hands and rub until dry. Alternatively, rinse in a dilute bleach solution (1 tablespoon household bleach per 1 liter of water — contact time 1 minute, then rinse).
Step 4 — Do not touch anything non-sterile after washing. If you touch your face, hair, or any unclean surface, rewash.
Preparing the Surgical Site
Step 1 — Shave or trim hair around the wound/incision site (hair harbors bacteria).
Step 2 — Wash the area with soap and clean water.
Step 3 — Apply alcohol or dilute povidone-iodine to the area. Wipe outward from the incision site in expanding circles.
Step 4 — Drape the area with clean, boiled cloths, leaving only the surgical site exposed.
Making Catgut Suture
Catgut is an absorbable suture — the body breaks it down over 1-3 weeks, so it does not need to be removed. It is made from the submucosal layer of sheep, goat, or cattle intestine.
Step 1 — Obtain a section of small intestine from a freshly slaughtered sheep or goat (at least 1 meter).
Step 2 — Slit the intestine open lengthwise and wash thoroughly in clean water, scraping away all contents and inner mucus.
Step 3 — Soak in a solution of water and wood ash lye (1 part lye to 10 parts water) for 2-3 days. This loosens the outer layers.
Step 4 — Scrape away the outer muscular layer and inner mucosal layer. What remains is the thin, strong submucosal layer — a translucent membrane.
Step 5 — Cut this membrane into narrow strips (1-2 mm wide) and twist each strip tightly while wet.
Step 6 — Stretch the twisted strips between two points and allow to dry under tension. They will dry into thin, strong cords.
Step 7 — Store dry catgut in a sealed container with alcohol. Before use, soak in sterile water for 15 minutes to soften.
Method 1: Suturing a Wound
Suturing (stitching) closes wound edges together, promoting faster healing and reducing infection. Only suture wounds that are:
- Clean (thoroughly irrigated)
- Less than 6-8 hours old (older wounds have too much bacterial growth — leave them open)
- Not animal bites (high infection risk — leave open and irrigate daily)
- Through skin and subcutaneous tissue only (not exposing bone, tendon, or organs)
When NOT to Suture
- Wounds older than 8 hours (except face/scalp, which have excellent blood supply — up to 24 hours)
- Puncture wounds (impossible to clean the deep track)
- Animal bites (extremely high infection rate)
- Wounds with dead or crushed tissue
- Heavily contaminated wounds that cannot be cleaned adequately
- If you lack sterile instruments — a clean open wound is safer than a contaminated closed one
The Simple Interrupted Suture (most versatile)
Step 1 — Irrigate the wound thoroughly with clean water under pressure. Remove all visible debris with sterile tweezers.
Step 2 — Thread your needle with 30-45 cm of suture material. Tie a knot at one end if using non-absorbable material (silk, fishing line).
Step 3 — Hold the needle with your needle holder (or pliers) about two-thirds from the tip.
Step 4 — Enter the skin 3-5 mm from the wound edge. Push the needle through the skin at a slight curve, going deep enough to catch the full thickness of the skin (dermis). The needle should exit inside the wound.
Step 5 — Cross the wound and enter the opposite side from inside the wound. Push the needle out through the skin 3-5 mm from the wound edge on the other side. Both entry and exit points should be at the same depth and distance from the wound edge.
Step 6 — Pull the thread through, leaving about 3 cm of tail.
Step 7 — Tie a square knot: right over left, then left over right. Tighten just enough to bring wound edges together — the skin should touch but not bunch up or turn white (white means too tight, cutting off blood supply).
Step 8 — Tie two additional throws (additional half-knots) for security. Cut the thread leaving 1 cm tails.
Step 9 — Place the next suture 5-8 mm from the first. Repeat until the wound is closed.
Step 10 — Apply a thin layer of honey or antiseptic to the suture line. Cover with a clean, dry dressing.
Aftercare
- Change dressings daily
- Watch for infection: increasing redness, warmth, swelling, pus, red streaks, fever
- Remove non-absorbable sutures after: face 5-7 days, scalp 7-10 days, trunk 7-10 days, limbs 10-14 days, over joints 14 days
- To remove: snip one thread close to the skin on one side, pull gently from the other side. If a suture is stuck, soak with warm water first
- Catgut sutures dissolve on their own and do not need removal
Method 2: Setting a Fracture with Splint
This goes beyond the basic splinting in First Aid. Here, we address displaced fractures where bone ends must be realigned before splinting.
Warning
Only attempt fracture reduction (realignment) if the bone is clearly displaced AND one of these conditions exists: (1) there is no pulse below the fracture (circulation is cut off), (2) the skin is tenting over a bone end and about to break through, or (3) the deformity is so severe that splinting in position is impossible. Otherwise, splint in the position found.
Closed Reduction (Realigning a Displaced Fracture)
Step 1 — Give the patient maximum pain management 30-60 minutes before the procedure: strong willow bark tea, valerian root tea, and alcohol (30 ml spirits). The patient needs to be as relaxed and pain-free as possible — muscle tension fights the reduction.
Step 2 — Have one assistant firmly hold the limb above the fracture (proximal segment). This anchor keeps the body from moving.
Step 3 — You grip the limb below the fracture (distal segment). Apply steady, firm traction — pull along the axis of the limb. Do not jerk. Slow, sustained pulling for 30-60 seconds. You will feel and sometimes hear the bones grinding — this is expected.
Step 4 — While maintaining traction, gently manipulate the distal segment to align it with the proximal segment. The limb should return to roughly its normal shape and length.
Step 5 — Check: Can you feel a pulse below the fracture? Are the fingers/toes warm and pink? Can the patient wiggle them? These confirm circulation is restored.
Step 6 — While an assistant maintains gentle traction, apply a padded splint. The splint must immobilize the joint above AND below the fracture:
| Fracture Location | Immobilize From | Immobilize To |
|---|---|---|
| Forearm (radius/ulna) | Above elbow | Wrist and hand |
| Upper arm (humerus) | Shoulder | Elbow |
| Lower leg (tibia/fibula) | Above knee | Ankle and foot |
| Upper leg (femur) | Hip | Ankle (long splint) |
| Wrist | Forearm | Fingers |
| Ankle | Below knee | Foot |
Step 7 — Pad all bony prominences (ankle bones, wrists, elbows) with cloth to prevent pressure sores.
Step 8 — Secure the splint with cloth strips or bandages. Firm enough to immobilize but not tight enough to cut off circulation. You must be able to slip a finger under the wrappings.
Step 9 — Check circulation every 2 hours for the first 24 hours, then twice daily. If the limb below the splint becomes cold, blue, numb, or pulseless, loosen the splint immediately.
Step 10 — Keep the fracture immobilized for:
- Fingers: 3-4 weeks
- Wrist/forearm: 6-8 weeks
- Upper arm: 8-12 weeks
- Lower leg: 8-12 weeks
- Femur: 12-16 weeks
Open (Compound) Fractures
If bone is visible through the skin, or the skin was broken by the fracture:
- This is an emergency — high risk of bone infection (osteomyelitis)
- Irrigate the wound copiously with clean water — at least 1 liter flushed through
- Do NOT push bone back through the skin
- Cover the exposed bone with a moist, clean dressing
- Splint without attempting reduction
- Monitor obsessively for infection (fever, increasing redness, pus)
- Administer any available antibiotics — herbal or otherwise (see Antibiotics)
Method 3: Draining an Abscess
An abscess is a pocket of pus caused by a localized infection. Left undrained, it can spread into the bloodstream (sepsis) or deep tissues (fasciitis). Both can be fatal.
When to Drain
- The abscess is “pointing” — a visible white or yellow head, skin is thinning
- The area is hot, red, swollen, and painful
- There is fluctuance — when you press one side, the other side bulges (fluid beneath the surface)
- The abscess is larger than 2 cm or causing significant pain
- The patient has fever (infection is systemic)
When NOT to Drain
- The abscess is near major blood vessels (groin, neck, armpit) — seek the most experienced person available
- It is a deep abscess without a clear pocket (you may be feeling a tumor, hernia, or aneurysm)
- The area has not yet formed a pocket (still in the cellulitis stage — hot compress and wait)
Procedure
Step 1 — Sterilize all instruments and wash your hands (see Sterilization section above).
Step 2 — Clean the skin over and around the abscess with alcohol or antiseptic solution.
Step 3 — Pain management: apply ice for 15-20 minutes. If available, inject or drip alcohol around the incision site. Give the patient willow bark tea and valerian 30 minutes prior.
Step 4 — Make a single, straight incision along the length of the abscess, over the most prominent point. Cut through skin into the pus pocket. The incision should be the full length of the abscess — a small incision that is too short will close prematurely and the abscess will refill.
Step 5 — Pus will drain immediately — it may be under pressure. Let it drain freely. The color and smell of the pus can indicate the type of infection but the treatment is the same: drain it completely.
Step 6 — Gently press around the edges of the abscess to express remaining pus. Be thorough but not brutal — do not squeeze so hard that you push infection into surrounding tissues.
Step 7 — Irrigate the cavity with clean water or dilute antiseptic solution. Flush until the drainage runs clear.
Step 8 — Pack the cavity loosely with a strip of clean cloth. This keeps the wound open from the inside out — the cavity must heal from the bottom up. If it closes at the surface first, a new abscess will form underneath.
Step 9 — Cover with a clean dressing.
Step 10 — Aftercare:
- Change the packing strip daily
- Irrigate the cavity with each dressing change
- Use progressively shorter packing strips as the cavity shrinks
- The wound typically takes 1-4 weeks to heal depending on size
- Watch for recurrence — if the abscess refills, redrain it
Amputation: The Absolute Last Resort
Warning
Amputation is a life-altering procedure that should ONLY be considered when the limb is already dead (gangrene), when a limb injury is so severe that death from infection is certain, or when the patient will die without the procedure. In a post-collapse scenario without blood transfusion capability, the patient has approximately a 30-50% chance of surviving an amputation even under good conditions.
This section is included for completeness, but the details are deliberately limited. Amputation should only be performed by the most experienced medical practitioner available. The key principles:
- Tourniquet first — apply a tourniquet well above the amputation site
- Cut through healthy tissue — at least 5 cm above the diseased/damaged area
- Create a flap — cut the skin and muscle longer on one side to create a flap that can fold over the bone stump
- Saw through the bone — use the smoothest saw available, cutting cleanly
- Ligate (tie off) every blood vessel — individually, with thread
- File the bone edge smooth — sharp bone edges cause pain and skin breakdown
- Close the flap over the bone stump with sutures
- The greatest risks are: blood loss, shock, and post-operative infection
Foreign Body Removal
Splinters, glass fragments, thorns, and other objects embedded in tissue require removal if they are:
- Visible and accessible
- Causing pain or limiting function
- Showing signs of infection around them
Step 1 — Sterilize tweezers and a needle/probe by boiling or flame.
Step 2 — Clean the area with soap and water, then alcohol.
Step 3 — If the object has an exposed end, grip it with tweezers and pull along its angle of entry (not perpendicular to the skin).
Step 4 — If the object is fully embedded, use a sterile needle to carefully open the skin along the object’s long axis. Expose enough of the object to grip with tweezers.
Step 5 — After removal, irrigate the wound, apply antiseptic, and cover with a clean dressing.
Step 6 — If the object is deeply embedded, near blood vessels, or in the eye — do NOT attempt removal. Stabilize it in place and treat the surrounding infection.
Common Mistakes
| Mistake | Why It’s Dangerous | What to Do Instead |
|---|---|---|
| Suturing a dirty wound | Seals bacteria inside, guaranteeing infection and possibly sepsis | Irrigate thoroughly first; leave dirty wounds open to heal by secondary intention |
| Suturing wounds older than 8 hours | Bacteria have already colonized — closing traps them inside | Leave open, irrigate twice daily, let it heal from the bottom up |
| Insufficient sterilization | Introducing bacteria into a clean wound is worse than the original injury | Boil instruments 20 minutes, scrub hands 2 minutes, prep the surgical site |
| Sutures too tight | Cuts off blood supply to wound edges — tissue dies, wound falls apart | Tighten just until edges touch; skin should not turn white |
| Trying to reduce a fracture without adequate pain management | Patient’s muscles spasm, fighting the reduction; risk of shock and further injury | Full pain management 30-60 minutes before any attempt |
| Draining an abscess too early (before it has localized) | Spreads infection into surrounding tissue; the abscess will recur | Wait for fluctuance and pointing; use hot compresses to encourage localization |
| Making a too-small incision in an abscess | Wound closes prematurely, abscess refills, and the patient suffers through the procedure again | Incision should span the full length of the abscess |
| Not packing an abscess after drainage | Skin closes over an unhealed cavity, trapping infection | Pack loosely with clean cloth, change daily, let it heal from inside out |
| Attempting abdominal or chest surgery | Without modern anesthesia, blood products, and sterile environments, this is nearly always fatal | Limit surgery to limbs and body surface; manage internal issues conservatively |
What’s Next
Surgery is a critical skill, but infection control is what determines whether your patients survive:
- Antibiotics — antiseptic solutions, natural antibiotics, and growing penicillin mold
- Herbal Medicine — pain management and wound-healing preparations
- Dentistry — oral surgery and dental extraction techniques
- Metalworking — forging better surgical instruments
Quick Reference Card
Surgery — At a Glance
Before ANY procedure: Boil instruments (20 min) → Scrub hands (2 min) → Clean surgical site → Pain management (30 min before)
Suturing: Clean wound only, under 8 hours old → Enter 3-5 mm from edge → Square knot → Space sutures 5-8 mm apart → Remove: face 5-7 days, limbs 10-14 days
Fractures: Only reduce if circulation is lost or skin is tenting → Steady traction along axis → Splint joints above and below → Check circulation every 2 hours → Immobilize 6-16 weeks depending on bone
Abscess: Wait for fluctuance → Full-length incision → Drain completely → Irrigate → Pack loosely → Change daily → Heals 1-4 weeks
Do NOT attempt: Abdominal surgery, chest surgery, brain surgery, amputation (unless limb is already dead and patient will die without it)
The three killers in surgery: Infection (#1), blood loss (#2), shock (#3). Prevent all three.
Golden rule: A clean wound left open heals better than a contaminated wound sutured closed.