by Atul Gawande, M.D., M.P.H.
Surgery is a profession defined by its authority to cure by means of bodily invasion. The brutality and risks of opening a living person's body have long been apparent, the benefits only slowly and haltingly worked out. Nonetheless, over the past two centuries, surgery has become radically more effective, and its violence substantially reduced — changes that have proved central to the development of mankind's abilities to heal the sick.
SURGERY BEFORE THE ADVENT OF ANESTHESIA
The first volume of the New England Journal of Medicine and Surgery, and the Collateral Branches of Science, published in 1812, gives a sense of the constraints faced by surgeons, and the mettle required of patients, in the era before anesthesia and antisepsis. In the April issue for that year, John Collins Warren, surgeon at the Massachusetts General Hospital and son of one of the founders of Harvard Medical School, published a case report describing a new approach to the treatment of cataracts.1 Until that time, the prevalent method of cataract treatment was “couching,” a procedure that involved inserting a curved needle into the orbit and using it to push the clouded lens back and out of the line of sight.2 Warren's patient had undergone six such attempts without lasting success and was now blind. Warren undertook a more radical and invasive procedure — actual removal of the left cataract. He described the operation, performed before the students of Harvard Medical School, as follows:
The eye-lids were separated by the thumb and finger of the left hand, and then, a broad cornea knife was pushed through the cornea at the outer angle of the eye, till its point approached the opposite side of the cornea. The knife was then withdrawn, and the aqueous humour being discharged, was immediately followed by a protrusion of the iris.
Into the collapsed orbit of this unanesthetized man, Warren inserted forceps he had made especially for the event. However, he encountered difficulties that necessitated improvisation:
The opaque body eluding the grasp of the forceps, a fine hook was passed through the pupil, and fixed in the thickened capsule, which was immediately drawn out entire. This substance was quite firm, about half a line in thickness, a line in diameter, and had a pearly whiteness.
A bandage was applied, instructions on cleansing the eye were given, and the gentleman was sent home. Two months later, Warren noted, inflammation required “two or three bleedings,” but “the patient is now well, and sees to distinguish every object with the left eye.”
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