British surgeon James Young Simpson summed up a 19th-century patient’s chances of survival in one pithy and pitiful statement: “A man laid on the operating table in one of our surgical hospitals is exposed to more chance of death than was the English soldier on the field of Waterloo.” And he was right. Until the 20th century, surgery was a gory, gruesome and grisly ordeal that often didn’t end well for patients.

It wasn’t easy on the surgeons either. With no computers, X-ray capabilities, electrical lighting, sterile instruments or anesthesia, medieval and Victorian surgeons sliced through human flesh and bone by feel. They had to do this in the shortest amount of time possible to keep the most acute part of patients’ suffering to a minimum, through the cacophony of patients’ agonized screams. And yet, despite all these challenges, surgeons weren’t even considered “real” doctors until the 14th century. They were viewed as inferior to physicians, and their work wasn’t part of practicing medicine, says professor emeritus Michael McVaugh, who studies medical and surgical history of the Middle Ages at the University of North Carolina at Chapel Hill. Within the medical hierarchy, surgeons occupied a strange liminal space, fitting somewhere between barbers and butchers.

Nonetheless, the earliest known surgeries were performed centuries before surgery became an established discipline. Archaeologists have found human skulls with holes drilled in them dating back to the Neolithic times, indicative of the primordial doctors performing trepanations, possibly to release pressure from an internal swelling caused by an injury. “There was a whole bunch of injuries that the ancient people had for which this would’ve been an appropriate treatment,” says David S. Jones, professor of the culture of medicine at Harvard T.H. Chan School of Public Health. He adds that even today, when people fall and fracture their skulls or suffer intracranial bleedings, doctors sometimes drill a hole in their skull to relieve the pressure—just like the ancients did centuries ago. “Presumably this was a practice discovered independently by many human societies,” Jones says. “And some people survived, because you can find the evidence that the bone has healed.”

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In similar vein, ancient and medieval doctors attempted to fix other physical ills. They sowed up wounds, mended broken bones and fixed dislocated joints. Some even tried to correct hernias and remove kidney stones or cataracts, medical feats that were rare and few. But there are historical accounts of C-sections. “The cesarean section is an ancient technique,” Jones says. “When labor would go terribly wrong, the surgeon would cut through the abdomen to save the child.”

While these surgeries were certainly not refined procedures, individuals who performed them had enough knowledge and dexterity to get them done. People who hunted or farmed animals for food were fairly familiar with animal and human anatomy and reasonably skilled with a knife. In medieval times, such people were either butchers, who carved meat, or barbers, who cut hair and shaved beards. With no safety razors, being a barber required sliding a sharp knife along a man’s soap-lathered throat at a precise angle, often with meager lighting—and thus demanded a steady hand, a good eye and fine motor skills.

When people needed to fix their broken bones, amputate infected limbs or cut out tumors, such individuals were called to the scene. “There was a concept of barber surgeon,” explains Jones. “It was someone in the community who was skilled with a knife. You’d go to them for shaving and haircutting, and you’d go to them to get abscesses drained, and lumps and bumps removed.” Some even removed bladder stones, either by threading catheters up the urethra or by incisions through the abdominal wall, Jones says.

Whether they anesthetized patients was another story. Although some accounts mention alcohol and opium, analgesics may not have been always available. “The hope was that the patient would faint either from emotional shock or blood loss and it would give the surgeon a quiet time to finish the procedure,” Jones says.

The emphasis on steady hands and knife skills was one reason why surgeons were originally excluded from the official medical doctrine. Physicians treated illnesses with medications, while surgeons worked with their hands. Therefore, they were perceived as manual laborers who worked empirically, by feel, rather than by formal schooling. That made them seem inferior to the university-educated physicians.

“Surgery was a low-class subject to some physicians,” McVaugh says, explaining why surgery was not considered a scholarly discipline. “The highest form of knowledge was intellectual knowledge, and people who were craftsmen—like bakers, carpenters and surgeons—worked with their hands, restoring physical things. That wasn’t considered learning and didn’t belong to universities.”

That perception finally changed in the 14th century, when surgery joined the ranks of official scholarly disciplines. In 1363, famous French physician Guy de Chauliac wrote Chirurgia Magna (“The Great Surgery”), which became the most influential surgical text for over 200 years. Then, in 1540, the Company of Barber Surgeons was founded in London, followed by the Royal College of Surgeons in 1800. Officially endorsed as a scholarly discipline, surgery was now taught in medical schools.

In the 19th century, surgeons acquired more analgesic options. Besides alcohol and opium, they had more chemicals—such as ether, chloroform and nitrous oxide, more commonly known as the laughing gas—to experiment with. But the results weren’t always predictable. When given too little, some patients awoke in the middle of the procedure or suddenly felt excruciating pain. When given too much, some died from an overdose. So many surgeries were still painful for patients and difficult for surgeons. Therefore, performing an operation as quickly as possible was key. Typically, a surgeon’s proficiency was reversely proportional to the amount of seconds they took to carve out a bulging tumor or sow off an infected limb. “One of the measures of the quality of a surgeon was how quickly you could do a mid-thigh amputation—and the goal was to do it under a minute,” Jones says.

Despite its grisly sight, Victorian surgery was somewhat of a public spectacle, medical historian Lindsey Fitzharris writes in her book The Butchering Art, describing the crowd’s excitement over one such a mid-thigh amputation procedure. Not only medical students but also random citizens would flock to surgical theaters to watch famous surgeons wield their terrifying instruments, sending bloody squirts into the air. Not everyone found it amusing, however—for some aspiring medics, that was a major turn-off. Charles Darwin was one of such impressionable young men. “He was supposed to be a physician, as was his father,” Jones says, but “he had to observe a surgery on a child and was so horrified that he dropped out of medical school.” Another problem was a very high infection rate. Surgeons rarely washed hands or changed their instruments or aprons, Fitzharris writes, therefore many of their patients died.  

That, too, began to change in the mid-19th century. As medics accepted the germ theory of disease, they began to introduce various disinfecting protocols. When British surgeon Joseph Lister, who wrote On the Antiseptic Principle in the Practice of Surgery, started treating surgical wounds with germ-killing carbolic acid to prevent infections from taking hold during and after operations, mortality dropped. Later, other surgeons learned to sterilize surgical instruments prior to operating on patients, which reduced infections further. These developments of disinfecting techniques coupled with improvements in anesthesia allowed surgeons to perform more complex procedures, such as removing appendicitis or repairing heart muscles.

From antibiotics to computers and X-rays, the 20th-century technological advances drastically decreased mortality, making some surgeries routine. How good are patients’ survival chances in the 21st? They are pretty high, but not 100%. A 2012 study by surgeon and author Atul Gawande and colleagues found that in 2006, only 1.32% of patients died within a month of their surgery. While seemingly low, that still amounted to 189,690 deaths out of 14,333,993 surgical procedures done. Clearly, modern patients fare much better than those in James Young Simpson’s time, but perhaps one day those 189,690 people won’t have to die either.