Chirurgery

The application of medical technology and practice is often an afterthought in a world where magical healing exists, but in a campaign with steampunk elements or a horror theme it’s entirely keeping that both legitimate physicians and mad scientists alike may study anatomy, physiology, surgery, anesthesia, and more. Characters can learn such chirurgical procedures from discovered or purchased tomes containing the instructions for the operation or may be taught by fleshworkers (see the fleshworker archetype) who already knows it, though you do not absorb the knowledge until you have practiced on a living humanoid or a humanoid corpse that has died within the past 24 hours (including a corpse affected by gentle repose, as long as it was cast within 24 hours of the creature’s death). Once you have practiced a chirurgical procedure at least once, you can perform it at any time. The time required for each procedure is listed, during which time the patient must be incapacitated, restrained, or unconscious. A restrained or willing patient can remain awake during the procedure, though they automatically gain a level of exhaustion and are poisoned for the duration of the procedure and 1 hour afterward.

When performing chirurgery, you make one Wisdom (Medicine) check and one Intelligence (surgical tools) check against the listed DC, the latter representing your skill at manipulating the body’s intricate and delicate organic mechanisms. Two successful checks are required for a complete success and a single successful check produces a partial success. If all checks fail, the procedure goes horribly awry, resulting in malpractice and dire complications. If the result of any skill check is a natural 1, the target must succeed at a Constitution saving throw (DC equal to the procedure’s DC) or else the entire procedure results in malpractice regardless of the result of the other skill check. If two checks produce natural 1s, malpractice automatically occurs and the patient dies if they fail their Constitution saving throw.

Each procedure has a DC, requires the listed amount of time to complete, and the listed number of uses of a healer’s kit. When chirurgery begins, if a proper supply of healing kit is not available or the target is below 1 hit point all ability checks to perform the operation are made with disadvantage.

Chirurgical procedures are strenuous for the body. The patient gains 1 level of exhaustion that lasts for 1 week. When you exceed the procedure’s DC by 5 or more, a patient’s exhaustion only lasts for 1 day. In addition, after receiving a chirurgical procedure any checks to perform another procedure are made with disadvantage. Any saving throw DCs or spell attacks for effects that duplicate spells use your Intelligence as your spellcasting attribute.

Unless otherwise noted, all effects of a chirurgical procedure are permanent, and many are damaging to the patient’s psyche or the natural balance of their biological processes. This imbalance extends into the spiritual plane, and creatures who recently underwent mind-altering chirurgical procedures might have a greater than normal chance of arising as unquiet dead, perhaps haunts that spread madness and torment, or as actual undead creatures such as ghouls or, more rarely, ghosts or specters. For ever chirurgical procedure a creature receives, its Sanctity score decreases by 1 and its Sin score increases by 1.

Adjust Appearance (DC 13, 1d4 days, 5 uses per day)

Your surgery alters the outward appearance of a patient, changing their features or proportions as you deem fit (as disguise self).

You cannot change the patient’s creature type (although the patient could be made to appear as another subtype, granting advantage on any ability checks made to impersonate a creature of that type). Otherwise, the extent of the apparent change is up to you. You could add or obscure a minor feature or change the patient to look like an entirely different person or gender.

Complete Success: the intended adjustment in appearance Deception any other checks made to impersonate a creature of the is achieved. If your appearance is changed to resemble another subtype or gender, your likeness is uncanny, granting the patient advantage on checks and ability chosen type.

By spending 1d4 hours and 2 uses of a healer’s kit, you can change the appearance of the patient to that of a different member of the same race that this procedure has altered them to appear like.

Partial Success: the intended adjustment in appearance is achieved but not with entirely desirable effects. The patient gains advantage on ability checks made to impersonate a creature of the chosen type but their sense of self is affected, reducing their Charisma by 1. By spending 1 day and 5 uses of a healer’s kit, you can change the appearance of the patient to that of a different member of the same race that this procedure has altered them to appear like.

Malpractice: the patient becomes horribly disfigured as grafts and adjustments become infected and necrotized while the disfigurement is also psychologically damaging. The patient reduces their Charisma score by 2 and contracts a vile disease.

Reversal: regeneration Graft Flesh (DC 16, 2d4 hours, 1 use per hour): You surgically remove (if necessary) and replace some portion of the target creature’s body with something else. The tissue you wish to engraft onto the patient must be fresh, ideally taken from a still living creature. For every hour the tissue has been removed or the donor creature has been dead, all skill checks take a -1 cumulative penalty. If the affected tissue or creature is under a gentle repose spell, only time that elapsed before the spell was cast counts toward this penalty. Skeletal or corporeal undead creatures can have flesh grafted from other undead of the same type or from dead flesh (or bone, for skeletal undead) without facing this penalty.

Having alien flesh grafted is hard for the mind to accept.

If the new limb is not essentially identical to the original limb (from the same creature type) the target makes a DC 15 Wisdom saving throw or reduces its Wisdom by 1 after a graft is installed regardless of the chirurgery’s success or failure.

Complete Success: You can replace a creature’s natural weapon with a different one suited for the same limb (bite or gore for head; claw, slam, or wing buffet for arm; claw or hoof for leg; sting or tail slap for tail). You can instead add a prehensile hand in place of a claw on an arm. These do not grant any features the original creature might have had. The natural weapon deals damage appropriate to the patient’s size and you are able to transplant a natural weapon from a creature one size category larger or smaller. Whenever you add a natural weapon the creature did not previously possess, the patient is considered proficient with that natural weapon after 1 week.

If you graft wings onto a creature that previously lacked them, the patient can use them as natural weapons. Wings grafted this way are not functional for flight and instead reduce the damage the patient takes from falling by 3 per point of proficiency bonus it has.

A fleshworker may use this procedure to grant a creature a grafting feat as long as the patient possesses any prerequisite feats the grafting feat requires (none of the grafting feat’s other prerequisites are needed).

By increasing the DC, you can add one of the following specialized grafts:

• DC 17: vestigial fins (the patient gains a swim speed equal to half their speed)
• DC 18: functional fins (the patient gains a swim speed equal to their speed)
• DC 19: bestial leverage (the patient gains a climb speed equal to their speed)
• DC 20: functional gills (the patient can breathe both air and water)
• DC 22: functional wings (requires two wings; the patient gains a fly speed equal to their speed)

Partial Success: the graft succeeds but a natural weapon takes a permanent -2 penalty to attack rolls and deals damage as one size smaller than normal.

Failure: the graft functions as a partial success but ultimately necrotizes and fails, rotting away after 2d4 days. The patient makes a DC 12 Constitution saving throw each day for 1 week, gaining the poison condition on a failure.

Malpractice: the patient’s Intelligence is reduced by 2 and it gains amnesia.

Reversal: regeneration

Implant Psychic Trigger (DC 18, 1d4 days, 2 uses per day)

You implant a psycho-neurological back-door designed to produce a certain behavioral reaction in the patient through the use of a triggering word, phrase, whistle, image, or song.

Activating this trigger is a bonus action for you and can cause in the patient any form of insanity you choose, the compulsion to follow a suggestion (as the spell), or an urge to complete a geas/quest. If you use this procedure on a patient upon whom you have previously used the instill identity or lobotomize procedure, you gain advantage on checks to perform the operation and it requires only one day.

Complete Success: the key functions as desired, with the effects lasting for up to 1d4 hours. Completing a suggestion or geas/quest before this time ends the effect.

Partial Success: As a complete success, but the effect lasts only 4d10 minutes.

Failure: The reaction of the patient when the key is activated is random, as the confusion spell.

Malpractice: When the key is activated, the patient reduces its Intelligence, Wisdom, and Charisma scores by 2.

Reversal: Heal or any effect that remedies insanity

Induce Amnesia (DC 17, 2d4 days, 3 uses per day)

You can manipulate the patient’s mind to selectively erase specific memories or to wipe its mind clean.

Complete Success: You may choose to erase or alter a memory (as modify memory) or to give the patient amnesia. Alternatively, you may erase the memory of a number of feats, spells, or class features equal to half your proficiency bonus, causing the patient to permanently lose access to them. Each feat, spell, or class feature to be erased receives a Wisdom saving throw (as modify memory).

Partial Success: As a complete success, but you may choose only to modify memory or induce amnesia.

Failure: Your mental manipulations have the desired effect but last for only 1d100 hours. In addition, the patient remembers your role in the corruption of its mind and permanently gains advantage on Wisdom saving throws made against you.

Malpractice: the patient reduces its Intelligence by 2 and gains amnesia.

Reversal: Heal

Insert Limbic Reservoir (DC 18, 2d4 hours, 5 uses)

You implant a volatile cocktail of psychoactive compounds that you can unleash at a later time to drive the patient into a drug-fueled frenzy. You can refill the compounds in the limbic reservoir by using this procedure again, reducing the DC by 5 and requiring only 1 hour and 1 use of a healing kit.

Refilling a limbic reservoir does not cause exhaustion or the poisoned condition as other procedures do.

Complete Success: You can insert up to 5 doses of any drug (most often nigrum polinus or proelio) which then can be infused directly into the patient’s subdural spaces for faster absorption and intensified effect. The beneficial numeric effects of the drug are increased by 50%, but the saving throw against addiction to the drug is increased by 2. The reservoir can be activated with a manual switch as a bonus action that does not provoke attacks of opportunity. If the patient also has an implanted psychic trigger, that trigger can be used to activate their limbic reservoir in addition to (or, if you wish, instead of ) its normal effect.

Partial Success: the limbic reservoir functions as above, but each activation consumes 1d3 doses of the drug. The addiction save DC of any drug used in the limbic reservoir is increased by 4 (instead of 2).

Failure: the implantation process damages the target’s brain, reducing its Intelligence and Wisdom scores by 1. The limbic reservoir also begins to leak, delivering a dose of the drug every 1d6 hours even when not triggered. When triggered, there is a 50% chance that all remaining contents of the reservoir are released at once (reducing the patient’s Intelligence and Wisdom scores by 1 again).

Nigrum Pollinis (15 gp) When smoked (or infused if made into liquid form) the imbiber feels a sense of euphoria, gains 10 temporary hit points, and gains advantage on Constitution saving throws for one hour.

After its effects cease, the imbiber makes a Constitution saving throw (DC 10 + 1 per dose of black smoke in the last month) or gains a level of exhaustion. This exhaustion remains until the imbiber takes more nigrum pollinis or makes another saving throw 24 hours later.

Proelio (50 gp) This cocktail of stimulants and painkillers makes those who use it a dangerous companion to travel beside— proelio addicts are often violent and will do absolutely anything in order to acquire more of the drug.

As an action a creature can expel this drug into their lungs (if an aerosol) or inject it into their bloodstream (if in liquid form), granting advantage on attack rolls, resistance to all types of damage, and a 20-foot increase to speed for a number of rounds equal to the creature’s proficiency bonus.

After its effects cease, the imbiber makes a Constitution saving throw (DC 15 + 1 per dose of proelio in the last week) or gains a level of exhaustion for each dose of proelio taken in the last day. This exhaustion remains until the imbiber takes more proelio or makes another saving throw 24 hours later.

Malpractice: the limbic switch fails to function and the compounds within cause the target to reduce its Intelligence and Wisdom by 2.

Reversal: Ill effects from inserting a limbic reservoir can be remedied by the heal spell. The limbic reservoir itself, however, can only be removed with the surgery procedure.

Install Kill-Switch (DC 21, Disable Device, 2d4 hours, 8 uses)

You implant in the patient a permanent physical kill-switch of some kind, such as a removable heart plug or a razorchain loop around the spine.

Complete Success: Activating the kill-switch can be done remotely as a bonus action if the patient is adjacent, and as an action and bonus action if the patient is within 10 feet. The creature makes a DC 18 Constitution saving throw or takes an amount of damage equal to its Constitution ability score.

Even if the target survives, it gains the grappled condition for 1d4 rounds and takes an amount of damage at the end of each of its turns equal to its Constitution ability score.

Partial Success: Activating the kill-switch is an action if the patient is adjacent and cannot be performed if the target is not adjacent. It otherwise functions as a complete success, but a patient that makes its saving throw is grappled for only 1 round and takes an amount of damage equal to its Constitution modifier (instead of Constitution score).

Failure: Activating the kill-switch is an action and bonus action if the patient is adjacent and cannot be performed if the target is not adjacent. It deals damage equal to the patient’s Constitution modifier.

Malpractice: the patient lowers its Constitution score by 1 immediately upon completing the surgery. The kill-switch itself has no effect.

Reversal: Ill effects from an installed kill-switch can be remedied by effects that cure hit points (as normal). The killswitch itself, however, can only be removed with the surgery procedure.

Instill Identity (DC 21, 1 week, 10 uses)

You create an entire false identity in the patient’s mind, including a new name and new memories; unlike implanting a psychic trigger, however, this effect is permanent. The procedure allows you to create an entire false personality, which may be of a radically different alignment if desired, though the DC is increased by 1 for each step of difference between the patient’s original alignment and the alignment of the alternate personality.

Complete Success: the new personality becomes the dominant personality and the patient gains advantage on saving throws to avoid changing personality.

Partial Success: the new personality does not replace the old one and whenever the patient completes a long rest, they roll randomly to determine which is dominant.

Failure: the new identity fails to form and the patient reduces its Wisdom and Charisma by 1 due to mental uncertainty, disruption, and warped sense of self.

Malpractice: the patient develops a new personality of the GM’s choice (with a randomly determined alignment).

Reversal: none

Lobotomize (DC 19, 1d4 hours, 6 uses)

You remove the frontal lobe of a creature’s brain.

Complete Success: the patient’s emotional centers are completely severed and isolated. The patient changes its Intelligence and Charisma scores to 1 but gains immunity the charmed and frightened conditions. The patient’s diverted synapses cause it to make initiative checks and Intelligence checks with disadvantage.

Partial Success: the patient’s emotional centers are deadened but not completely severed. The patient reduces its Intelligence and Charisma scores by 5 but gains advantage on saving throws made to resist the charmed and frightened conditions. If the patient becomes charmed or frightened, there is a 50% chance they become confused (as the confusion spell) instead of the normal effect.

Malpractice: the patient is affected as the feeblemind spell and automatically contracts amnesia.

Reversal: Heal or regeneration

Stimulate Adrenal Cortex (DC 15, 1 minute, 5 uses)

This procedure taps into the body’s natural reserves of energy to fight off tiredness and to temporarily recover from extreme weariness, though this treatment may sap the target’s energy and health once the rush wears off.

Complete Success: the patient heals 2 hit points per character level, removes a level of exhaustion, and recovers from the poisoned condition. A patient who is sleeping is immediately awakened (even if magically asleep) and an unconscious creature is stunned for a number of rounds equal to its Hit Dice plus its Constitution modifier (minimum 1 round) before lapsing back into unconsciousness.

Partial Success: the patient only heals 1 hit point per character level. In addition, after a number of hours equal to the patient’s Constitution modifier (minimum 1 hour), the patient gains a level of exhaustion.

Failure: the patient only heals a number of hit points equal to its proficiency bonus. In addition, after a number of minutes equal to the patient’s Constitution modifier (minimum 1 minute) the patient gains 2 levels of exhaustion.

Malpractice: the patient gains the benefits of the haste spell for a number of rounds equal to their Constitution modifier (minimum 1 round). However, once the effects end the patient gains 3 levels of exhaustion and takes 1d6 points of damage for each round spent hasted. The haste effect is not magical, cannot be dispelled, and cannot be ended voluntarily (though it can be suppressed by slow).

Reversal: Ill effects of stimulating the adrenal cortex can be removed by any effect that cures exhaustion or hit point damage (as appropriate).

Special: This procedure does not cause lasting exhaustion or the poisoned condition as other procedures do.

Surgery (DC 16, 1d4 hours, 5 uses)

You can conduct surgery to repair major damage to the target’s body and mind. After surgery, the patient gains 1 level of exhaustion for 1 day.

Complete Success: the patient heals 1d8 points of damage per character level (up to the patient’s full normal hit point total).

Partial Success: the patient heals 1d4 points of damage per character level (up to the patient’s full normal hit point total).

Failure: the patient heals 1 point of damage per character level (up to the patient’s full normal hit point total).

Malpractice: the patient takes 1d6 points of damage and gains the poisoned condition for 1 day.

Reversal: Ill effects of surgery can be removed by any effect that cures hit points or the poisoned condition.

Special: You can also use surgery to amputate a limb, excise a tumor, or remove an implanted device. Other surgeries require the normal amount of time.

Amputation requires only 1d4 rounds. Each round during the surgery the creature must make a DC 15 Constitution saving throw or go unconscious for 1d4 minutes. Removal of a limb eliminates any natural weapon that is a part of that limb. Removal of an arm also precludes the use of two-handed weapons or any other action requiring two hands, spell attacks with somatic components are made with disadvantage, and saving throws to resist the spells with somatic components that an amputee casts are made with advantage. Removal of a leg reduces the patient’s speed by half if they still have 2 or more ambulatory limbs remaining.

If only one ambulatory limb remains, the patient can move only 5 feet per round.

Surgery can also be used to peel off natural armor, reducing a creature’s AC by 2 each time the procedure is performed (to a minimum of 10 + Dexterity modifier).

Removing a tumor or lesion assists in curing a diseased character, granting the patient advantage to its next saving throw against a disease.

Surgery can also remove a tumor familiar, magical tattoo, or similar effect, as well as implanted mechanical devices such as a kill-switch or limbic reservoir. Such surgical removal requires the normal amount of time for a surgery and a complete success to be correctly removed.

Talentia Enhancer (DC 20, 3d4 hours, 10 uses)

You install a device designed to specifically enhance particularities of your subject’s body, bolstering their natural talents to ultimately make the patient more effective at whatever they already have a penchant for doing. Unlike other chirurgical procedures, a complete success or partial success is enough to install a talentia enhancer and there is no malpractice.

However, a creature may only undergo this chirurgical procedure only once whether successfully or not; any further attempts automatically fail and without a successful DC 20 Constitution saving throw, the patient dies.

• Barbarian: Iecur Liver. The barbarian’s Constitution increases by 1 and they gain immunity to the poisoned condition as well as non-vile diseases.
• Bard: Synthetic Vocal Cords. The bard can mimic animal sounds and humanoid voices. A creature that hears the sounds can tell they are imitations with a successful Wisdom (Insight) check (DC 8 + the bard’s proficiency bonus + the bard’s Charisma modifier).
• Cleric: Vocivus Actuators. The cleric can use channel divinity to conjure a wave of dark power that roils forth and drains the life of creatures. As an action, the cleric twists their hands in an unnatural fashion before clenching them into fists that explode with stuff of the void, dealing 1d8 necrotic damage per point of proficiency bonus they possess. The cleric can choose to direct this energy at one creature within 60 feet or a number of creatures equal to their Wisdom modifier that are within 30 feet. A Wisdom saving throw against the cleric’s spell save DC reduces this damage by half. A single creature targeted by this effect makes its saving throw with disadvantage and takes double damage if it fails its saving throw. This feature has no effect on undead or constructs.
• Diabolist: Superno Proficiscentur. Thin leather scripts covered in Vilespeech are embedded throughout the diabolist’s flesh, allowing them to channel unholy energies directly from the Abyss and Hell. The diabolist is able to summon 1 more diabolus at a time than normal.
• Druid: Abeo Biologis. While the druid uses wild shape, they can spend a bonus action to activate or deactivate a viral infection tied to their soul. When active the druid’s wild shape form is covered by an aura of dark red and purple energies, granting them 1d4 additional damage with natural attacks and increasing their AC by 2.
• Fighter: Offensionibus Spine. The fighter’s Strength and Constitution increase by 1. In addition, they gain resistance to falling damage.
• Mad Scientist: Adapertio Ocular Nerve. The mad scientist is able to cast the detect magic spell without components or concentration. By spending a bonus action, they can alter their ocular nerve to instead emulate the effects of detect evil and good or detect poison and disease.
• Monk: Tenibrus Talons. The monk’s ki pool increases by 1 and by spending a bonus action, they can deploy or retract talons that change their unarmed strike damage to slashing.
• Occultist: Inanis Lancino. The occultist’s dark strikes increase in potency, driven by miniature servos and pistons that deal an extra 2 (1d4) damage.
• Paladin: Osseus Skeleton. The paladin’s bones are seared with the ancient language of Vilespeech, the runes making it impossible to detect their true alignment. When a creature or effect would detect the paladin’s alignment, they see an alignment of the paladin’s choice.
• Ranger: Argentum Eyes. The ranger’s eyes become featureless silver orbs. They can see normally in darkness, both magical and nonmagical, to a distance of 60 feet (if they already have darkvision, its range increases by 60 feet).
• Rogue: Currax Nerves. The rogue’s Dexterity increases by 1 and their speed increases by 10.
• Sorcerer: Devoco Glands. The sorcerer gains 1 sorcery point (if they do not yet have sorcery points, they gain an additional sorcery point when they acquire the class feature) and learns a cantrip. In addition, by spending a bonus action the sorcerer can convert 2 Sin points into 1 sorcery point.
• Warlock: Festino Charge. The warlock’s soul is imparted with dark energy that allows them to gain a second pact boon. Once chosen, this second pact boon cannot be changed.
• Wizard: Prolixo Ganglia. The wizard’s Intelligence increases by 1, they learn a cantrip, and they gain advantage on saving throws when resisting the charmed and stunned conditions.