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The operating theatre is at the heart of the modern hospital. But for a long time, surgery was on the fringes of medicine and surgeons plied their trade in some unexpected places.

A medieval illustration of trephining Wellcome Collection, CC-BY

 

Surgical procedures are among the oldest of medical practices, but as a field of medicine surgery is a relatively recent addition. Surgeons have come a long way: from the battlefield to the operating theatre.

Image: A 13th-century surgeon performing a surgical procedure, possibly trephination, on a man's head. 

 

What happens in an operating theatre?

Surgical operations that require cutting and working inside a patient’s body happen in the operating theatre. They can range from minimally invasive procedures such as keyhole surgery to complicated operations that last many hours.

The operating theatre contains lots of specialist equipment for anaesthesia, breathing and monitoring the patient. All operating theatres are completely sterile to avoid surgical infections.

Almost all hospitals have operating theatres, and some larger hospitals have operating suites containing several theatres, changing rooms and scrub areas for staff, and preparation and recovery rooms for patients.

Who does the surgery?

An 18th century barber standing infront of his shop with his razor and lancet Wellcome Collection, CC-BY
A barber standing in front of his village shop with his razor and lancet. Coloured etching after H.W. Bunbury, 1772.

The modern surgical team varies in size depending on the type of operation, but present in the operating theatre will be the surgeon, the scrub nurse, the anaesthetist and other nurses and surgical assistants.

Today's surgeon has years of training in general medicine before specialising in surgery. But in medieval Europe, surgery was rarely done by doctors.

Religious laws forbade physicians, who trained in religious universities, from shedding blood, so surgeons often worked outside the medical establishment.

Your surgeon might be the local barber, putting his cut throat blades to extra use by offering small surgical procedures in addition to haircuts.  Or a surgeon might travel around the country, extracting teeth and lancing boils in each town or village.

Wealthier patients would see a master surgeon whose status would be closer to that of the physician. And the surgeon would perform the surgery in the patient's home.

The barber's shop

Barbers had their own craft guild and received higher payment than most surgeons. Wealthier barbers worked from shops, where, in addition to hair cutting, hairdressing and shaving, they offered a range of surgical procedures. The red and white barber’s pole, still seen outside some traditional barber shops, is a reminder of the two services offered by the barber.

In England, surgeons with little expertise in hair-cutting began to join guilds such as the Company of Barbers in order to earn more for their services until, in 1368, they formed their own Fellowship of Surgeons.

Surgical skills were learnt from a practising surgeon, and both women and men became surgeons through apprenticeship. Women were forbidden from entering universities, so they couldn’t be physicians, and as surgical training became more formal, from the 17th century, women were gradually excluded from becoming surgeons.

King Henry VIII presenting document of union to the associations of barbers and surgeons, 1540. Wellcome Collection, CC-BY
King Henry VIII presenting a document of union to the associations of barbers and surgeons, 1540.

The Company of Barbers and Surgeons was formed in 1540 to regulate surgeons practising in the City of London. The Act of 1540 also allowed for the dissection of executed criminals four times a year at public anatomy demonstrations. And teaching anatomy became an important function of the Company.

In the larger barber surgeon's shop, a patient might have a surgical procedure alongside customers having shaves and haircuts. In the village, or poorer establishment, the surgeon treated patients from a room in their house, 

Surgeons were cautious in their treatments, mindful of the pain they caused and their limited knowledge of the inner workings of the body. The focused on physical manipulation, repair and maintenance procedures such as: tooth extraction, cuppingbloodletting and leeching, draining or lancing of boils and cysts, and enemas. They might tackle amputations and operations when there was no other option.

The battlefield

Pare on the battlefield Wellcome Collection, CC-BY
Ambroise Paré operating on the battlefield


Surgeons have a long association with war. Armies went to battle accompanied by a barber-surgeon to patch up injured soldiers.

By the 16th century, military surgeons were establishing a reputation for developing innovative surgical techniques, as they dealt with the results of weapons such as gunpowder.

Probably the most celebrated military surgeon of the period was Amroise Paré, who served as royal surgeon to a number of French kings.

Paré's innovation on the battlefield and his elite practice in Paris helped raise the status of surgeons. He said that:

There are five duties of surgery: to remove what is superfluous, to restore what has been dislocated, to separate what has grown together, to reunite what has been divided, and to redress the defects of nature. 

Surgical schools and a Royal College

The 16th and 17th century saw a surge in interest in anatomy. Hospitals offered new opportunities to dissect cadavers and access to surgical cases. And surgeons began to assert their credentials as men of science. 

A class in the anatomy theatre at William Hunter's anatomy school, London Wellcome Collection, CC-BY
A lecture at the anatomy theatre in the Hunterian anatomy school, 1839.

John Hunter was one of a new generation of surgeons. He learned anatomy by assisting his brother William, a physician, at William's anatomy school in London. John then spent several years as an army surgeon before earning his apprenticeship worked with the dentist James Spence. In 1764 he set up his own practice and anatomy school to train surgeons.

The demand for anatomy-based surgical courses grew among physicians as well as surgical students, accelerating the decline of the surgical apprenticeship system.

In 1800 the Royal College of Surgeons, England was established. The College set the qualifications required to become a surgeon and soon the universities began to offer these qualifications alongside physicians exams in their medical schools.

Women surgeons and male spaces

Nowadays all surgeons must have a basic medical degree as well as undergoing several years of training in surgery.

Medical students observing a surgical operation on a screen Wellcome Collection, CC-BY
All male medical students observing an operation on a screen. After H.W. Koekkoek, 1909.

New qualifications for surgeons, introduced in the 19th century raised standards in surgery, but they excluded women, who were not allowed to attend universities until the very end of the century. Surgery effectively became a male profession, 

Portrait of James Barry, 1812 Wikimedia Commons, public domain


One person who didn't let this stop her was Margaret Ann Bulkley. Helped by her relatives, including her uncle (the celebrated artist James Barry), she adopted a male persona and attended medical school in Edinburgh as James Barry, graduating in 1812. 

Barry had a colourful military career, surviving intrigues, a court martial where he was demoted, and illness. But it was only when he died of dysentery in 1865 that the secret was discovered and people realised that Bulkley had spent 46 years as a man in the British Army.

Image: James Barry, shortly after qualifying as a physician. 1813-1816.

The same year that James Barry died, Elizabeth Garret Anderson became the first acknowledged woman in Britain to qualify as a physician and surgeon. Her medical qualification came from a loophole that allowed qualified apothecaries to practice medicine. The Society of Apothecaries promptly banned any more women from sitting exams thereafter.  

It wasn’t until the Enabling Act of 1875 that British universities were able to grant medical licences to women, although most British universities continued to deny access until the 20th century. The Royal College of Surgeons, London, allowed women to sit the College exams in 1906. Dossibai Patel from Bombay became the first female member in 1910 and Eleanor Davies-Colley was the first female Fellow.

The sterile space

By the end of the 19th century, surgeons had found a home to practice their profession: the hospital operating theatre. The design of these spaces was based on the anatomical theatres used to demonstrate and teach anatomy in universities and hospitals.

Drawing of the anatomy theatre at Leiden, Netherlands, 17th century Wellcome Collection, CC-BY
The anatomy theatre at Leiden University, early 17th century.

But thanks to Lister's antisepsis system, it was a growing awareness that a sterile environment was essential for infection control that really defined the modern surgical space.

 In 1884, the German surgeon Gustav Neuber designed and built the first aseptic operating theatre where the walls, floors, shelves and other surfaces were all washable, and all instruments had flat surfaces and were sterilised. 

Staff underwent a pre-surgical ritual of washing their hands, arms and faces with antiseptic mercuric chloride. By the end of the century sterile gloves, masks and gowns were added to the ritual of preparing to perform surgery in the operating theatre.

Black and white photograph of staff in surgical gowns masks and gloves in an operating theatre Wellcome Collection, CC-BY
Operating theatre staff in gowns, masks and rubber gloves, Gloucester 1909.

Surgery in contemporary society

The first half of the 20th century was a ‘golden age’ for surgery, when surgeons made their reputations by attempting increasingly daring procedures. The tradition of pioneering surgery continued into the 1960s and 1970s with surgeons such as Christiaan Barnard, who carried out the first heart transplant.  

Towards the end of the 20th century, the surgeon’s heroic status was challenged by incidents such as the Alder Hey organ scandal and a call for greater accountability. The Human Tissue Act was passed in 2004 as a result of the scandal and established the Human Tissue Authority as a regulatory body.

Surgery in the 21st century is about more than pushing the boundaries of surgical skill and and scientific innovation in order to save lives. Procedures such as facial transplants, gender confirmation surgery and surgical enhancements have an impact on the heart of society by  challenging notions of identity.

Suggestions for further research