Surgery has changed, and not changed, a lot through the years. But it’s hard to watch a riveting and harrowing show like The Knick and not think about how surgeons, despite how refined their art has seemingly become, are basically glorified butchers. The Knick makes this visually evident at every turn. They feel like they are the right hand of god – I think “innovative butcher”, looking for creative but ultimately untested ways to fix things. Not that there are not randomized controlled trials and other forms of evaluation to test the efficacy of procedures and their outcomes. But every procedure had to have a first time, right?

Yes, surgery, the O.R. – things have changed, but things are not that different. Look at the antiseptic issue – it evolved, even if we still have debates about single-use versus reusable textiles and microorganisms that can live on in multi-use drapes or gowns.

Or I think of the idea of cutting people open. It seems like a good idea – cut whatever ails someone out entirely. But when we look historically, some of the most radical cutting, which was until recently seen as the only course of action, has been unnecessary or at least did not lead to better outcomes. (Don’t miss the PBS documentary, Cancer: Emperor of All Maladies to get more insight on the changing face and understanding of cancer.) How much of medical science is not even understood?

When I think of, for example, the Star Trek film, Star Trek IV, much maligned for its “fluffy” environmental storyline and time travel premise, I am struck by the scene when the team goes to a hospital to rescue Chekhov. Dr McCoy goes nuts, railing against the idea that you could cut people open and think it would produce a good outcome. It could alternately be interpreted as new-agey mumbo jumbo, or a different look at “standard” medical practice.

This also makes me think of a recent article series (“Medicine without Blood”)  on bloodless medicine. It argues that, while Americans embraced the almighty, “life-giving” blood transfusion in WWII, followed by a wholesale, post-war adoption of transfusions as an accepted, mainstream tenet of modern medicine. But had the blood transfusion ever been subjected to the same level of scrutiny and testing that other procedures and treatments are?

“Yet, in the thrall of wartime transfusion, blood had never been treated like an experimental drug and subjected to rigorous, randomized clinical trials assessing risk and benefit. Its power was intuitive. Doctors observed that patients with anemia seemed to feel better following transfusion. “The patients looked rosy and felt full of energy,” one older doctor told me. No one was thinking yet about adverse effects.”

Or…

“Some bloodless medicine experts have also helped lead a national movement calling for more sparing use of transfusion. Donor blood comes with risks for all patients, including the potential for immune reactions and infections. And clinical trials have shown that, for a broad range of conditions, restrictive transfusion practices do not lead to worse outcomes than liberal ones. In recent years, the American Medical Association has listed transfusion as among the most overused therapies in medicine.”

The point of these diversions is only to highlight that what was accepted as life-saving, mainstream practice at one point becomes passe, restricted or even recognized as dangerous later. And some procedures come back into favor as more and more evidence is collected, as different diseases and bacteria are understood better, and so on. It’s not an exact science and always evolves.

And The Knick, set at the dawn of the 20th century and in the frenzied, competitive dawn of surgical practice, shines a light on these questions and contradictions. Clive Owen is outstanding (he usually is when he plays an arrogant, brilliant but self-destructive asshole). The supporting cast is also superb. I was particularly surprised by Eve Hewson (daughter of U2’s Bono) and her role as young but increasingly independent and fierce nurse, Lucy, a West Virginia native who cares for but enables Owen’s Dr Thackeray during his drug abuse.

As the show explores the expanding world of surgery, it also expands the worldview, in some ways defying the norms of the time. In the most obvious way – the hospital employs a new assistant chief surgeon – who happens to be black. In less obvious ways, The Knick gives us characters who and stories that defy their time. Women characters come to mind here, particularly in the form of the aforementioned nurse and also in the character of Cornelia Robertson, who is the head of the hospital’s social welfare office. She serves as a part of the hospital board of directors, and as such, is a working woman and an executive-level participant in decisionmaking. Of course this is all because of her family, not because of her qualifications. But she is expected to step away from these roles when she marries. And while I enjoyed the storylines involving this character, in particular her interracial relationship with the previously mentioned assistant chief and the abortion she has when she becomes pregnant with their child, I think maybe this story strains credibility.

The Knick isn’t perfect, and not everything comes together beautifully, but I don’t expect perfection from good TV. I expect ambition and striving for something. And this show isn’t lazy.

It proves that in medicine, and in gender roles, as in the rest of life, the more things change, the more they stay the same.