Surgery

Surgery is the branch of medicine that treats disease and injury by manual operation on the body. For most of its history it was the lowest-status division of the healing arts, performed by barber-surgeons, military practitioners, and craftsmen rather than university-educated physicians. The reasons were practical: before anesthesia, speed was the surgeon’s primary skill; before antisepsis, infection killed more patients than the disease the surgeon was treating. The transformation of surgery from a manual trade into the most prestigious branch of modern medicine required two revolutions — the conquest of pain (anesthesia, 1840s) and the conquest of infection (antisepsis, 1860s) — and a political one: the unification of medicine and surgery into a single profession, achieved in France during the Revolution and in Britain through the nineteenth century.

Ancient Surgery

Celsus records that the division of medicine into three parts — curing by diet, by medicaments, and by hand (surgery) — came early in the Greek tradition, and that even among practitioners of dietary cure there was a further division between those who prescribed from reasoning and those who relied on practical results. (Stapley, 2024) The oldest surgical evidence is prehistoric: trepanned skulls from Neolithic sites show that humans were cutting into living bone thousands of years before they could write. The Edwin Smith papyrus (c. 1600 BCE) gives a head-to-foot inventory of forty-eight case reports with surgical treatment of wounds, fractures, and abscesses. (Porter, 1997) The Code of Hammurabi included surgical instructions with a sliding scale of fees by patient rank and draconian fines for failure — the surgeon who caused a lord’s death would have his hand chopped off. (Porter, 1997)

The Indian surgical tradition produced a parallel achievement of comparable depth. The Sushruta Samhita, attributed to Sushruta and dated traditionally to the mid-first millennium BCE, is a text on surgery that contains procedural descriptions including rhinoplasty; some modern rhinoplasty techniques were taken directly from Ayurvedic physicians practicing according to its methods.(Willard, 2021)

Herophilus of Chalcedon, practicing in Alexandria under the first Ptolemies, dissected human cadavers in public, discovered and named the prostate and duodenum, and established that nerves originate in the brain rather than the heart. (Porter, 1997)

The ancient Greek notion of surgery was broader than its modern sense. The term cheirourgía referred literally to “the part of medicine that cures with the hand” — Celsus’s Latin translation — and covered all manipulations with hands and instruments on a patient, not merely cutting.(Pormann (ed.), 2018) The surviving Hippocratic surgical texts form a thematically specialised sub-corpus within the Corpus, comparable in character to the gynaecological writings.(Pormann (ed.), 2018) Erotian, the first-century CE Hippocratic glossographer, identifies eight treatises in his index of “definitely authentic works by Hippocrates” under the category of therapeutic writings pertaining to surgery; all are preserved except the lost Wounds and Missiles.(Pormann (ed.), 2018) The corpus leaves a clear gap in non-trauma surgery: this branch of the discipline appears only in the minor treatises Haemorrhoids and Fistulas, both dealing with anal surgery.(Pormann (ed.), 2018)

Although narcotic drugs such as mandrake and opium were known since Homeric times, all Hippocratic surgical operations were performed without anaesthesia. Evidence from Physician, Haemorrhoids, and Joints shows that narcotics were not administered before operations, largely because achieving safe dosage in ancient drug preparations was too dangerous; the risk of killing the patient made it preferable to operate on conscious subjects rather than attempt chemical sedation.(Pormann (ed.), 2018)

The Hippocratic surgical texts insist on a comprehensive sensory examination as the physician’s primary instrument. Surgery 1.1 states the programme directly: “It’s the business of the physician to know … [things] which are to be seen, touched, and heard; which are to be perceived in the sight, and the touch, and the hearing, and the nose, and the tongue, and the understanding.” Epidemics 6.8.17 gives a complementary formulation: “it is a laborious task to employ the whole body in the inquiry: vision, hearing, nose, touch, tongue, reasoning arrive at knowledge.” When sensory examination proved insufficient, the author of the Art (chapter 11) held that the physician must resort to the “eye of the mind” to understand what lies beneath the surface of the skin and the explorable parts of the body.(Pormann (ed.), 2018)

The author of Fractures and Joints is a recognisable literary presence throughout the treatises: he speaks in his own voice, criticises colleagues for sensationalism using both polemics and irony, and has been characterised as displaying an “aristocratic attitude” hostile to laymen. He is equally candid about his own failures, writing that “my attempt was not a success … I relate this on purpose; for those things also give good instruction which after trial show themselves failures, and show why they failed.”(Pormann (ed.), 2018) His critique of charlatanism is explicit: he condemns physicians who use shaking on a ladder to treat humpback as performing for “the vulgar herd,” claiming that “such methods appertain rather to charlatans,” and attacks those who apply “fine bandaging without judgement” to fractured noses as practitioners who “devote themselves to a foolish parade of manual skill.”(Pormann (ed.), 2018) Elsewhere the text performs a kind of fictitious anatomical experiment: since human dissection was taboo in ancient Greece, the author of Joints imagines a fictitious operation in which a patient would have to be cut open to demonstrate the impossibility of reducing a certain vertebral dislocation — a thought experiment that is unusual even for ancient medical writing.(Pormann (ed.), 2018) The same author insists on the importance of studying incurable disorders: “one must study incurable cases so as to avoid doing harm by useless efforts.”(Pormann (ed.), 2018)

The Hippocratic Oath’s prohibition of lithotomy — “I will leave [stonecutting] to those who are craftsmen in this kind of work” — has long puzzled interpreters. Witt reads the phrase as carrying an explicitly pejorative charge: Hippocratic physicians spoke always of their “art” (téchnē), never of their “work” or “job” (prêxis), and they were not “craftsmen” (ergáteis) but prestigious practitioners with an aristocratic family tradition. The Oath’s wording thus signals that risky procedures were left to ordinary doctors outside the Hippocratic circle who practised medicine as a craft rather than a noble art.(Pormann (ed.), 2018) More broadly, the refusal of lithotomy reflects an aristocratic code of ethics in which treatment is declined when the physician’s image and repute may suffer — a logic that determined the limits of Hippocratic operative ambition.(Pormann (ed.), 2018)

Specific technical achievements preserved in the surgical treatises include the use of finger traps for repositioning finger dislocations (Joints 80), a technique still in clinical use today.(Pormann (ed.), 2018) Wounds in the Head distinguishes five types of head injury, describes both conservative and operative treatment, and presents trepanation — performed with rasps and apparently bow-driven crown trephines — as the primary operative approach. The treatise recommends trepanation with notable frequency, including for minor injuries; Witt interprets this as a generalisation from the observation that the procedure prevented neurological damage and allowed patients with severe head injuries causing intracranial pressure to survive, leading practitioners to apply it even in cases where modern standards would consider it unnecessary.(Pormann (ed.), 2018) The lost treatise Deadly Wounds can be partially reconstructed from fragments: it described suturing of penetrating abdominal wounds (gastrorrhaphíe) and detailed methods for extracting weapons including arrows and spears, with techniques varying according to whether barbs were present — some barbs were covered with pieces of reed before extraction.(Pormann (ed.), 2018)

Mochlicon occupies a distinct position in the surgical corpus: in contrast to the elaborate Fractures and Joints, it is a succinct, stylistically sober summary of bone surgery focused primarily on the reduction of dislocated joints, arranged systematically from head to toe. It was compiled either from Joints and Fractures directly or from an earlier work that served as a common source for all three treatises.(Pormann (ed.), 2018) The treatise Sores extends the corpus beyond trauma surgery into soft-tissue surgery, treating both traumatic lesions and chronic ulcers under the shared Greek term hélkos; a distinctive therapeutic feature is the administration of evacuating measures and laxatives to promote wound healing, reflecting the humoral logic that internal evacuation aids external healing.(Pormann (ed.), 2018) Joints 53 is unusual even by ancient medical standards: the author quotes Homer and refers to the myth of the Amazons in a medical context, an intertextual gesture without parallel in most ancient medical texts.(Pormann (ed.), 2018)

The relationship between the surviving Hippocratic surgical treatises is more complex than their independence suggests. Mathias Witt has argued that Surgery, Fractures, Joints, Wounds in the Head, Sores, Wounds, and the lost Wounds and Missiles may all descend from one large work or, more precisely, an archive on emergency surgery that was never published as originally intended but was instead divided into several treatises by a later hand and subsequently re-elaborated by different authors.(Pormann (ed.), 2018) Galen himself speculated that the original compound treatise was split into two parts shortly after it was written, and noted that earlier commentators before him already recognised that Fractures and Joints had originally formed a single work.(Pormann (ed.), 2018) Of all the Hippocratic texts, Fractures and Joints present the strongest case for genuine Hippocratic authorship, based on shared style, method, and surgical expertise; Craik holds they are the texts most likely to be by the historical Hippocrates of Cos.(Pormann (ed.), 2018) Hippocratic gynaecological surgical techniques were, by comparison, modest in scope: simple and not particularly audacious, ensuring no particular danger to the patient in the manner that lithotomy would have posed.(Pormann (ed.), 2018)

Women’s participation in ancient medicine extended beyond midwifery. Inscriptions and literary evidence show female healers were not confined to obstetric roles; women like Antiochis of Tlos, Metilia Donata of Lyons, and others practiced general medicine and possibly surgery, attesting to a wider range of female medical activity than later periods would permit. (Nutton, 2023)

Roman Surgical Achievement

Roman surgical practice reached a level of sophistication not matched again in Europe for over a millennium. By 14 CE the Roman army had developed permanent legionary hospitals (valetudinaria) with standardized plans including cubicles, operating rooms, store rooms, and kitchens. (Nutton, 2023) The Vindolanda duty roster from around 100 CE shows 31 of 752 men unfit for duty — 15 ill, 6 wounded, 10 with eye problems — indicating that non-combat illness and injury dominated military medical needs. (Nutton, 2023)

A surgeon at Rimini around 257-258 CE possessed over 150 instruments with subtle differences implying a high degree of specialization and expertise. (Nutton, 2023) The majority of Roman surgical tools were made of bronze following Hippocratic tradition, though the best steel for instruments came from Noricum. (Scarborough, 1969) The Roman military had no official medical corps; the medicus ordinarius, medicus cohortis, and medicus legionis were soldiers first who learned medicine from senior medici in the ranks. (Scarborough, 1969) The legionary hospitals themselves, built on the frontier as a response to isolation, became integral parts of the castra, carefully planned with attention to drainage and sanitary conditions. (Scarborough, 1969)

Celsus described ophthalmological treatment in De Medicina using saffron, myrrh, and poppy tears most frequently, with ointments incorporating long pepper, white pepper, and acacia gum alongside mineral preparations; when cataract had become established, he recommended surgical treatment. (Stapley, 2024) Archagathus of Laconia, recorded as arriving in Rome in 219 BCE, was given citizenship and a publicly funded workshop but was soon nicknamed “the executioner” for his violent surgical methods — a story that, whether or not strictly historical, captures the Roman public’s ambivalence toward surgical intervention. (Nutton, 2023)

Galen of Pergamon used surgical skill as a competitive weapon in the crowded medical marketplace of second-century Rome. Mattern identifies a structural pattern in his case histories she calls the “cattle call”: a wealthy patron summoned multiple physicians to consult on a difficult case, and only Galen proved willing and capable of acting.(Mattern, 2008) The most dramatic example involved a slave of the actor Maryllus who had sustained a wrestling injury. While other physicians gathered at the bedside refused to operate, Galen removed the abscessed rib and was forced to excise part of the pericardium as well, briefly exposing the beating heart — a feat, Mattern notes, that Galen explicitly credits to his extensive dissection experience, since only a physician who had studied cardiovascular anatomy in animals would risk the operation.(Mattern, 2008) The episode illustrates how anatomical knowledge functioned in Galen’s practice not only as theoretical preparation but as an active source of surgical confidence that set him apart from rivals who lacked equivalent training.

Galen’s literary use of surgical texts was, however, not always intellectually honest. Pormann’s Cambridge Companion notes that Galen’s citations of the Hippocratic surgical treatise Surgery are given the seal of approval on the basis of notional but objectively non-existent teleological content — a pattern consistent with his approach to Nature of Man, where an excessively favourable view resulted from the text’s clear expression of humoral theory meshing with his own.(Pormann (ed.), 2018)

The Medieval Separation

The conventional view that the Church banned dissection and arrested surgical progress is wrong. Pope Sixtus IV in 1482 told Tubingen that human anatomy was permitted provided the body came from an executed criminal and received Christian burial. (Porter, 1997) The more consequential division was social: university-trained physicians increasingly distinguished themselves from surgeons, who worked with their hands and were classed with barbers and craftsmen.

Constantine the African’s translations at Montecassino in the late eleventh century introduced the first surgical treatise in medieval Europe: his Latin rendering of the Kitab al-maliki (Royal Book of Haly Abbas), known as the Bamberg Surgery, was also the first text to mention an inhaled anaesthetic. (Stapley, 2024) A generation later, the Salernitan surgeon Theodoric preserved in his Chirurgia a recipe for the soporific sponge: narcotic herbs including henbane, opium, and mandrake were boiled until absorbed into the sponge, which could then be soaked in hot water and applied to the patient’s nostrils before an operation. (Stapley, 2024)

Islamic Surgery

The Islamic surgical tradition resisted that separation. Abu al-Qasim al-Zahrawi (Albucasis, d. c. 1013), whose Kitab al-Tasrif devoted a final treatise to surgical practice, “elevated surgery from a craft practiced by barbers and cuppers into a component of scientific medicine, making exceptional anatomical demands on surgeons” — Ullmann reads him as insisting that the operator must “be trained in anatomy as Galen has described it” before he can practice.(Ullmann, 1978) By the early fourteenth century the field had been formally subdivided: Ibn Qayyim al-Jawziyya describes the classification of physicians into eight specialties — oculist, surgeon, circumciser, phlebotomist, cupper, bone-setter, cauteriser, and enema-administrator — as a recent development in Islamic medical practice.(Pormann, 2007)

Specific procedural achievements survive in the record. Medieval Islamic physicians developed a technique for excising pannus (vascular invasion of the cornea from trachoma) using fine hooks and a thin scalpel; the procedure was independently “reinvented” in Europe in 1862 and continued in use until after the First World War.(Pormann, 2007) Cataract couching — depressing the opaque lens to one side with a needle — was used by medieval Islamic oculists with no reliable evidence for it in medieval Latin Europe before the thirteenth century.(Pormann, 2007) On amputation, al-Zahrawi warned against attempting it when gangrene had spread above the elbow or knee; his colleague al-Kaskari, observing tenth-century Baghdad hospital patients whose hands and feet had been amputated as judicial punishment, recorded that not one of them survived — a sober report on surgical mortality from inside the era’s most sophisticated medical infrastructure.(Pormann, 2007)

The Unification of Medicine and Surgery

The French Revolution’s reorganization of medical education was decisive for surgery’s status. The 1794 law establishing three Ecoles de Sante integrated physicians and surgeons into a single educational system — “medicine and surgery are two branches of the same science,” Fourcroy proclaimed. (Bynum, 1994) This had consequences beyond administration: it taught generations of students to conceptualize disease as surgeons would, in terms of anatomic structures, solid parts, and local lesions.

The Age of Agony

Before anesthesia, operating theaters were crowded, theatrical spaces where spectators jostled for views of surgery as public entertainment. (Fitzharris, 2017) In 1840 only about 120 operations per year were performed at Glasgow’s Royal Infirmary, reflecting how rarely surgery was attempted. (Fitzharris, 2017) Surgery was always a last resort, undertaken only in matters of life and death, because the pain was unspeakable and the infection that followed was often fatal.

Hospital mortality rates in the mid-nineteenth century were three to five times higher than home-based care. Florence Nightingale declared in 1863 that actual mortality in hospitals was much higher than any calculation founded on the same diseases treated outside them would lead one to expect. (Fitzharris, 2017) James Y. Simpson estimated that a soldier had a better chance of surviving Waterloo than a man entering a hospital. (Fitzharris, 2017) His comparison of amputation mortality in country versus hospital settings revealed that urban hospital patients were far more likely to die of infection than shock, while rural patients showed the reverse. (Fitzharris, 2017)

The Conquest of Pain

Ether’s stupefying properties were synthesized by Valerius Cordus in 1540, but it was not used as a general anesthetic on humans until Crawford Long’s operation in 1842 in Georgia. (Fitzharris, 2017) Robert Liston performed the first use of ether anesthesia in Britain on 21 December 1846 at University College Hospital, completing a mid-thigh amputation in twenty-eight seconds. (Fitzharris, 2017)

The two decades following the popularization of anesthesia saw surgical outcomes worsen. With their newfound confidence about operating without inflicting pain, surgeons became ever more willing to take up the knife, driving up incidences of postoperative infection. Operating theaters became filthier than ever as the number of surgeries increased. (Fitzharris, 2017)

Hospitalism

The four major hospital infections plaguing Victorian surgery were erysipelas, hospital gangrene, septicemia, and pyemia — collectively called “the big four” of hospitalism, which surgeons attributed to miasmatic air in overcrowded wards. (Fitzharris, 2017) Victorian surgeons operated in blood-encrusted aprons without washing hands or instruments, carrying the unmistakable smell of rotting flesh — “good old hospital stink.” (Fitzharris, 2017) Between 1843 and 1859, forty-one young men died of fatal infections contracted at St. Bartholomew’s Hospital before even qualifying as doctors. (Fitzharris, 2017)

Wound management before antisepsis reflected competing theories with no consensus. Surgeons managed wounds using the “occlusion method” (airtight dressings to exclude miasmatic air), “water dressings” (wet bandages to reduce inflammation), and Syme’s preferred approach of loose closure with lint — reflecting widespread disagreement about whether wound exposure or occlusion better prevented infection. (Fitzharris, 2017)

Burke and Hare murdered sixteen people to sell their corpses to anatomists, exposing the crisis of body supply that led to the 1832 Anatomy Act granting the profession rights to unclaimed pauper bodies. (Porter, 1997)

The Antiseptic Revolution

Pasteur’s experiments with swan-neck flasks proved that microbes do not arise spontaneously, establishing that only life begets life. (Fitzharris, 2017) Carbolic acid had first been used at the Carlisle sewage works to deodorize waste; an unexpected benefit was that it also killed protozoan parasites causing cattle plague — a practical application that caught Joseph Lister’s attention. (Fitzharris, 2017)

In August 1865, eleven-year-old James Greenlees became Lister’s first successful compound fracture patient treated with carbolic acid; after six weeks he walked out of Glasgow Royal Infirmary with his leg intact. (Fitzharris, 2017) Of ten compound fractures treated with carbolic acid at Glasgow in 1865, eight recovered — a failure rate of 9-18 percent compared to the near-certain infection rate previously. (Fitzharris, 2017) On 16 March 1867, The Lancet published the first of a five-part article by Lister titled “On a New Method of Treating Compound Fracture,” publicly announcing his antiseptic principle and explicitly grounding it in Pasteur’s germ theory of putrefaction. (Fitzharris, 2017)

Most fundamental bacteriological discoveries were made in a roughly nine-year span between 1878 and 1887, during which the causative agents of gonorrhea, typhoid, tuberculosis, cholera, diphtheria, tetanus, pneumonia, and plague were all identified. (Ackerknecht, 1955) The antiseptic principle transformed surgery from a desperate last resort into a systematic discipline capable of entering body cavities — the abdomen, the chest, eventually the skull — that had previously been inviolable.

Acceptance was neither rapid nor universal. Ackerknecht notes that Lister’s results, “which he started publishing in 1867, were astonishing,” but their adoption depended on German uptake: only after von Volkmann, Thiersch, Mikulicz, and others took up the techniques in the early 1870s did medical practice in the United States, France, and eventually England follow. The carbolic-spray antiseptic method was, in turn, “later replaced by the aseptic technique of steam sterilization” — a transition from killing microbes in the wound field to excluding them from it altogether.(Ackerknecht, 1955)

Ambroise Paré (1510-1590) rose from apprentice to the most celebrated surgeon of the sixteenth century. Born near Laval in Maine, he began as a barber’s apprentice, trained for years at the Hôtel-Dieu in Paris, and then joined the French army as a regimental surgeon. (Henry E. Sigerist, 1933) He transformed military surgery through an accidental empirical discovery. During the 1536 campaign in Italy, the standard treatment for gunshot wounds — based on Giovanni de Vigo’s teaching that gunpowder poisoned wounds and required cauterization with boiling elder oil — ran into a supply problem: Paré’s oil ran out. Forced to improvise, he dressed wounds with a salve of egg yolk, attar of roses, and turpentine. The next morning, the improvised patients were comfortable and free of inflammation, while the cauterized ones were feverish and in agony. (Henry E. Sigerist, 1933) The dominant theory, from the Pope’s own surgeon, held that this cauterization was essential to neutralize poison from the gunpowder. (Henry E. Sigerist, 1933) Paré published his findings in 1545, the first of a long series of surgical monographs that established empirical observation over inherited dogma. (Henry E. Sigerist, 1933) John Hunter (1728-1793) brought experimental method to surgery. A Scottish surgeon who arrived in London as his brother William’s anatomical assistant, Hunter devoted himself to comparative anatomy, arguing that only by dissecting many animal species could one understand the general functions of life, normal and pathological alike. (Henry E. Sigerist, 1933) His museum — thousands of preparations spanning human and comparative anatomy — became the core collection of the Royal College of Surgeons. (Henry E. Sigerist, 1933) During the Seven Years War, Hunter treated military injuries as scientific problems of general pathology rather than purely surgical challenges, laying the groundwork for his later treatise on blood, inflammation, and gunshot wounds. (Henry E. Sigerist, 1933) The anaesthesia story is more complex than the triumph narrative suggests. Ether’s stupefying properties were synthesized by Valerius Cordus in 1540, but three centuries elapsed before Crawford Long used it as a general anaesthetic in 1842 in Georgia. (Fitzharris, 2017) The two decades following the popularization of anaesthesia saw surgical outcomes worsen, not improve: freed from the constraint of the patient’s pain, surgeons operated more frequently and more ambitiously, driving up incidences of postoperative infection. (Fitzharris, 2017)

Surgical Oncology and the Limits of the Knife

The antiseptic revolution made it possible to enter body cavities that had previously been inviolable, and cancer surgery was among the most consequential beneficiaries. William Halsted at Johns Hopkins developed the radical mastectomy in the 1890s as a systematic response to breast cancer, premised on what Mukherjee’s The Emperor of All Maladies (2010) calls a “centrifugal theory”: cancer spread outward from a local origin through the lymphatics in a predictable, wave-like pattern, so the surgical solution was to excise the tumor, surrounding tissue, pectoral muscles, and axillary lymph nodes in a single en-bloc resection.(Mukherjee, 2010) The operation dominated breast cancer surgery for nearly a century. Its theoretical elegance — identify a spreading pattern, then outrun it — made it authoritative.

That authority was not unchallenged. Geoffrey Keynes at St. Bartholomew’s Hospital in London was performing lumpectomies combined with radium-needle implants as early as 1924; his results, published in 1932, showed his patients survived as well as Halsted’s. The surgical mainstream largely ignored him.(Mukherjee, 2010) By the 1950s, the logic of the centrifugal model had pushed surgery further still: some surgeons removed not just the breast and pectoral muscles but ribs and internal mammary nodes in “superradical” procedures.(Mukherjee, 2010) George Crile Jr. at the Cleveland Clinic challenged this in print, arguing that the Halsted mastectomy was “surgically unnecessary and ethically unjustifiable” — that surgeons were “mutilating women … without a shred of evidence that the mutilation is doing them any good.”(Mukherjee, 2010)

The resolution came not from clinical argument but from randomized evidence. Bernard Fisher at the National Surgical Adjuvant Breast and Bowel Project (NSABP) applied Neyman–Pearson statistical theory to the question, insisting that only a properly randomized trial could settle whether radical surgery improved survival. The NSABP-04 trial published in 1981 found identical survival rates across radical mastectomy, simple mastectomy, and lumpectomy — definitively refuting the centrifugal theory. Breast cancer was systemic from inception; operating wider did not catch what had already disseminated.(Mukherjee, 2010)

The moral Mukherjee draws is methodological: “The lesson was not that surgery was bad, but that surgery without evidence was bad. Fisher had shown that the randomized trial was the supreme arbiter of medical truth.”(Mukherjee, 2010) The same lesson applies in reverse to patient rights. Rose Kushner, diagnosed with breast cancer in the 1970s, refused to consent to the combined one-stage biopsy-mastectomy procedure then standard, insisting on a two-stage process so she could participate in the treatment decision. This demand — for informed consent in cancer surgery — was, Mukherjee argues, the first patient demand to make a medical decision jointly with a physician, and it catalyzed a broader shift toward patient autonomy in oncology.(Mukherjee, 2010)

] page for Fisher’s contribution to trial methodology.]

Women’s Entry into Surgery in the United States, 1849–1950

When Elizabeth Blackwell became the first formally credentialed woman physician in the United States in 1849, access to surgical training was controlled by institutions that had no intention of sharing it. The story of how women obtained that access over the following century is also a story about surgery itself: about which institutions controlled the awarding of surgical competence, and what happened when those institutions systematically refused entry.

The timing of women’s push into medicine was not accidental. The discovery of ether anesthesia in 1846 had begun to erode one of the profession’s standing arguments: that surgery demanded a constitutionally masculine capacity to inflict necessary suffering. As Morantz-Sanchez observes, the adoption of ether and chloroform “would quickly undermine a major objection to women practitioners while ‘feminizing’ medicine by calling into question the ‘heroic’ image of the physician.”(Morantz-Sanchez, Regina Markell, 1985) If the surgeon no longer needed to function as a species of controlled executioner, the case for excluding women on grounds of temperament grew correspondingly thinner. The rise of gynecological and abdominal surgery in the 1880s, itself made possible by the linked advances of anesthesia (1846) and antisepsis, gave women physicians a further foothold: they could argue that female patients had specific need of female operators, and that the body of clinical work being generated in obstetrics and gynecology was precisely the surgical domain in which women could build legitimate expertise.(Morantz-Sanchez, Regina Markell, 1985)

The formal problem was that regular medical schools controlled access to that expertise and were not admitting women. By 1893 only 37 of 105 regular medical colleges accepted women students at all.(Morantz-Sanchez, Regina Markell, 1985) The response was institution-building from within the movement. Between 1850 and 1900, women founded five orthodox women’s medical colleges and a number of sectarian schools. This was not the arrangement women’s leaders wanted: Mary Putnam Jacobi, probably the most respected woman physician of her generation, stated plainly that “coeducation in medicine is essential to the real and permanent success of women in medicine,” since “isolated groups of women cannot maintain the same intellectual standards as are established and maintained by men.”(Morantz-Sanchez, Regina Markell, 1985) Separate education was an expedient forced on women by exclusion. As Morantz-Sanchez frames the structural logic: “each of the five most successful female medical colleges was established in response to the exclusionary policies of men’s schools in the area.”(Morantz-Sanchez, Regina Markell, 1985) Jacobi herself described this as women “merely endeavoring to reenter the stream” of a profession from which they had been driven only when universities and licensure systematized it.(Morantz-Sanchez, Regina Markell, 1985)

The significance of this institutional detour for surgical training became visible in the career pathways of women who did manage to become surgeons. Elizabeth Blackwell, writing in 1863, conceded that the existing women’s schools gave students only the “legal right” to practice, without yet providing much “theoretical instruction.”(Morantz-Sanchez, Regina Markell, 1985) In 1869 Dean Ann Preston of the Woman’s Medical College of Pennsylvania won permission for thirty-five students to attend the Saturday surgical clinic at Pennsylvania Hospital in Philadelphia — one of the first formal opportunities for women to observe clinical surgery in that city. The male students responded by throwing stones, missiles of paper, and tobacco quids at the women, defiling the dresses of those nearest them.(Morantz-Sanchez, Regina Markell, 1985) The incident drew public sympathy to the women rather than their attackers, but it illustrated the depth of resistance to women’s presence in surgical teaching spaces.

The Jefferson Medical College case is the starkest instance of institutional intransigence. When the surgeon Bethenia Owens-Adair sought admission there, the well-known surgeon Samuel D. Gross told her personally that he would “gladly open the doors of Jefferson” to her, but that the board of regents held the power “and they are a whole age behind the times.” Jefferson did not open its doors to women until 1961.(Morantz-Sanchez, Regina Markell, 1985)

By the late nineteenth century, a small number of women had made their way into surgical practice. Morantz-Sanchez notes that by the 1890s “a handful of women surgeons had demonstrated their proficiency in a specialty that was visibly gaining status within the profession as a whole.”(Morantz-Sanchez, Regina Markell, 1985) The opening of Johns Hopkins Medical School to women in 1892, and the subsequent spread of coeducation to most major universities, appeared to promise a different future. But the post-Flexner contraction of medical education between 1904 and 1915 killed that promise for a generation. Ninety-two schools merged or closed in response to rising state board requirements, financial difficulties, and Flexner’s public criticism; by 1920 only 85 of the 155 schools Flexner had visited still operated.(Morantz-Sanchez, Regina Markell, 1985) Women’s medical colleges, chronically underfunded, were among the first to close or merge. The number of women medical students actually fell from 1,280 in 1902 to 992 in 1926, a decline that made medicine the only profession in which women lost ground in absolute numbers during this period.(Morantz-Sanchez, Regina Markell, 1985)

The structural consequences for surgical training were direct. AMA-approved hospitals refused to open their internships and residencies to women, and the surgical tracking systems within those hospitals ensured that the women who did pass through coeducational schools had limited routes into operative experience.(Morantz-Sanchez, Regina Markell, 1985) The result was a durable dependency on women’s institutions. Bertha Van Hoosen, in findings from 1926 that Morantz-Sanchez presents as the sharpest statistical summary of the entire pattern, surveyed the women surgeons then active: 75 percent of them had either graduated from a women’s medical school or served their internship and residency at hospitals staffed entirely by women.(Morantz-Sanchez, Regina Markell, 1985) The number is not merely a historical curiosity. It is a measure of the degree to which women’s institutions functioned, for most of a century, as the only reliable pipeline into surgical careers.

Alma Dea Morani, who became the first woman certified as a plastic surgeon in the United States, made the point from personal experience. A 1931 graduate of the Woman’s Medical College of Pennsylvania, she had planned from the start to become a surgeon. Even at WMCP the route was narrow: the head of the Department of Surgery had not yet trained a woman, and the faculty did not encourage women toward general surgery, though gynecologists on staff performed operative work. Morani concluded that she “would not have had the slightest chance of becoming a surgeon if she hadn’t attended a woman’s school.”(Morantz-Sanchez, Regina Markell, 1985)

The internship and residency data confirm the scale of the problem. A 1946 survey published in the Journal of the American Medical Women’s Association found that 41.7 percent of available internships and 34.2 percent of available residencies were still formally closed to women medical graduates.(Morantz-Sanchez, Regina Markell, 1985) The New England Hospital for Women and Children, which had served as one of the primary surgical training sites for women from the mid-nineteenth century onward, came under sustained pressure by 1952 to abandon its women-only character. By that point it had only four residents and one intern; community funders argued that the hospital’s founding mission had become obsolete. The women’s hospital as a surgical training institution was being dismantled from the outside at precisely the moment when the exclusions that had made it necessary had not yet been formally abolished.

The arc of this history runs from 1849 through the slow attrition of women’s institutions in mid-twentieth century. Women obtained surgical training in the United States not through the main pathways the profession offered, but through a parallel institutional network built to absorb the exclusion from those pathways. The Van Hoosen figure (75 percent of women surgeons trained in women’s institutions as late as 1926) stands as the quantitative record of that detour.

See Also

• Anatomy
• Antisepsis
• Anesthesia
• Hospital Medicine
• Pathological Anatomy
• Joseph Lister
• Bacteriology
• Military Medicine
• evidence-based-medicine
• randomized-controlled-trial

Sources

Auto-generated from evidence card IDs listed in frontmatter.

Editorial Notes

• [Resolved: women’s entry into surgical training covered by Morantz-Sanchez (1985), drawn from ch01, ch02, ch04, ch09, ch11 — see “Women’s Entry into Surgery” section.]