Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (20 page)

Along with Welch, Osler, and Halsted, Kelly completed the luminous “big four” that would lead Johns Hopkins to greatness. The interaction among the four, and the time and place in which they found themselves, made the whole of their work greater than the sum of its parts.

1 This information was first made public in William Osler, MD, FRCP, FRS, “The Inner History of the Johns Hopkins Hospital,”
The Johns Hopkins Medical Journal
, October 1969, vol. 125, no. 4, pp. 184–94. The article included information originally in Osler’s hand, with entries impossible for experts to date. The book—locked, sealed with wax, and tied with ribbon—was intended to remain sealed until the centenary of The Johns Hopkins Hospital, in 1989. Through a series of convoluted decisions the family decided to release the contents in 1969. In addition to the text there are dated notes of questionable significance. Osler goes on to write, probably at some later date, “subsequently he got the amount down to 1 ½ grains, and of late years (1912) has possibly got on without it.” This remains unsubstantiated.

CHAPTER SEVENTEEN
Hernia

OF THE AFFLICTIONS AMENABLE
to surgical cure, none is as prevalent as inguinal hernia. None has extracted so great a social price, or has dropped so precipitously from the public conscience as inguinal hernia. It has become a curable, nonlethal annoyance, and more the stuff of humorous tales than tragic endings. A cold invading finger, and the eternal “turn your head and cough.”

Five percent of children are born with inguinal hernias. Somewhere between 10 and 15 percent of adults develop them, and 500,000 hernia repair operations are performed annually in the United States. Prior to 1889, there was no successful surgical procedure to correct the defect. Findings varied from a small lump in the groin to a huge bulge of intestine expanding the scrotum or vaginal labia. Worse than the incapacity caused by these painful masses was the ever-present specter of a piece of intestine becoming trapped in this abnormal position, having its blood supply compromised by the pressure and the development of a full-blown, gangrenous abdominal catastrophe.

With no cure in sight, something was needed to keep the hernia contained and allow the victim to work. Trusses were just the thing, and an enormous industry evolved. Any gadget, strap, or spring
that put pressure on the defect was a welcome thumb in the dike. “Miraculous” and often confounding contraptions came and went, but they offered no cure. Nor did surgery: in 1889 the surgical failure rate was nearly 100 percent.

Clearly, the problem represented a significant economic and physical burden to the individual and to society. Hernias were nothing to be trifled with. Not only are they painful, but they carry the potential to become incarcerated, a situation in which the loop of bowel has insinuated itself into the abdominal wall defect to become trapped. In these desperate circumstances, everything short of surgery was attempted. In 1890, surgery for incarcerated bowel often resulted in fatalities. The first course of non-surgical treatment was called taxis, in which the patient was placed flat, with head flexed and knees drawn up to relax the abdominal muscles, or head down on an inclined bench. Pressure was then applied to the trapped loop of intestine to force it through the constriction and back into the abdomen. But the intestinal loop had often become swollen and compromised, and gentle pressure often proved too forceful, resulting in perforation, peritonitis, and death.

Hernia, by definition, is any circumstance in which part of an internal organ protrudes through a weakness in the containing wall. Usually this refers to intestines protruding through a weakness in the abdominal wall. There are many sites of potential weakness where this may occur. These include the umbilicus, the site of major blood vessels perforating the abdominal wall; any man-made weakness, such as a surgical incision; and far and away the most common of all, the inguinal hernia, in which the ring in the lower abdomen through which the spermatic cord exits is unnaturally expanded to allow the insinuation of bowel, which follows the path of the spermatic cord through the external inguinal ring and into the scrotum. The anatomical variations of inguinal hernia—indirect, direct, and femoral—are different entities sharing common anatomical ingredients within the
confined space of the groin. The most prevalent, complicated, and potentially dangerous of these is the indirect hernia, which occurs far more frequently in males.

AS EARLY AS THE
Middle Ages, the debilitating symptoms of hernia were of such magnitude that men were willing to endure the brutality and risk of surgery for the chance of relief. Such relief, when it came, was fleeting. More often infection, recurrence, and sometimes death were the result of surgery. Sometimes the testicle and spermatic cord were removed, and a caustic solution or hot iron was applied to the open tissues in the hope that the resulting scar would prevent recurrence. Later, various attempts were made to cure the hernia and save the testicle. Most of these met with failure as well. Then came the idea of opening the groin area, reducing the hernia, and amputating the peritoneal hernia sac into which the bowel had inserted. Soon sutures to tighten the enlarged ring were added to the procedure, with the same dismal result. By the late 19th century surgeons came up with the idea of rolling the redundant hernia sac into a tampon and suturing it into the internal inguinal ring. The success reported for these procedures was never reproducible in the hands of anyone other than the reporting surgeon, making the subjective optimism look more like dishonesty. This led Halsted’s New York friend William T. Bull to cite his personal statistic of a 100 percent recurrence rate by the fourth postsurgical year. Bull announced that he would henceforth abandon the term “cure” and resume performing the simplest possible procedure, as its results could be not worse than all the new, more complicated techniques.

Events took a turn for the better on June 13, 1889, when Halsted operated on an eight-year-old boy with a large, congenital right inguinal hernia. This was the first time Halsted would try a radical new technique to reconstruct the hernia defect in the groin. The departure in the technique was the use of the muscle and tough fascial sheath of
the oblique muscles of the lower abdomen to reconstruct the inguinal canal floor. Halsted sutured the muscle and fascia to Poupart’s ligament, an anatomical inguinal ligament that traverses the iliac bone of the pubis. Strong silk sutures were used to tighten the internal abdominal ring as well. Halsted had gained an intimate knowledge of groin anatomy through innumerable, fastidious dissections. In each case he amputated the hernia sac, created a new internal abdominal ring at the most lateral portion of the wound, and transplanted the spermatic cord superficially. Together the steps comprised what became known as the Halsted hernia repair.

Halsted also inserted several gauze drains beneath the skin and closed it with fine silk sutures inserted into the deep layer, or dermis, of the skin. He had previously shown that the skin was impossible to sterilize. Since these buried sutures did not puncture the surface, they would remain sterile and not introduce infection. Later, sterile silver wire was employed in a continuous buried suture. Silver was believed to possess inherent antiseptic properties, and drains were abandoned. The subcutaneous closure, whether of silk or silver wire, greatly reduced the incidence of dangerous wound infection and wound breakdown in that pre-antibiotic era, and it became part of the Hopkins routine.

Halsted’s first cases were reported at a meeting of The Johns Hopkins Hospital Medical Society on November 4, 1889, and subsequently published in
The Johns Hopkins Bulletin
of January 1890. In his historic report delivered to The Johns Hopkins Hospital Medical Society, on October 20, 1890, Halsted referred to his operation as The Radical Cure of Hernia. Among the first 12 patients, there were, as yet, no recurrences.

Edoardo Bassini, a surgeon in Padua, Italy, had been doing a similar operation for some time. He first presented his technique in Genoa, in 1887, in a talk called “A Radical Cure of Inguinal Hernia.” This was followed by a 106-page report, published in the Italian, in 1889. The month of publication was not noted, but Bassini had obviously been
doing a similar procedure for some time. But he who publishes first owns the operation.

In answer to questions about priority, Halsted wrote to Welch, “Bassini’s brochure anticipated my first report by at least a month or two. Whether my first operation was performed before the appearance of Bassini’s pamphlet in Italian I cannot say, for the precise date of the pamphlet is not given. In any event I had not heard of Bassini’s operation until his German article appeared—possibly about one year after my first operation, neither was I or any American or German, so far as I know, aware of Bassini’s first report until the appearance of the second. Bassini unquestionably has the priority. Our operations differed in several respects, but in the essential features were the same.”

As early as 1893, Halsted wrote in the
Bulletin
, “Bassini’s operation and mine are so nearly identical that I might quote his results in support of my operation.”

Halsted wanted nothing to do with jockeying for position in the who-came-first hernia stakes. In the few comments he made on this aspect of the operation, he always acknowledged Bassini.

Over the years, Halsted refined and revised his hernia operation, and carefully correlated each change with results. What became known as the Halsted II operation resembles the original in only the most basic aspects. His residents were so intimately involved with the operation that they became completely comfortable in this anatomically complex region. Patients from all over the country flocked to Hopkins for his care. In the Hopkins system there was only one senior surgeon, William S. Halsted, and very few private patients. Most patients were seen first in the surgical dispensary, where the decision for hospitalization and surgery was made. It was Halsted’s service. He performed the operations that interested him and assigned the remainder to an assistant, or the resident. After the initial years spent developing his technique, most of the hernia surgery was passed on to the resident. The system allowed the resident
autonomy, and over the years, some residents came to favor other techniques. Rather than insist on strict adherence to the Halsted operation, the department kept careful statistics, which indicated far fewer recurrences when the strict rules of the Halsted operation were employed. Halsted’s own cases had a less than 8 percent recurrence rate, and cases done by the residents employing his method were successful as well.

Harvey Cushing, Halsted’s fifth resident, a supremely talented surgeon and the man destined to become the father of neurosurgery, achieved distinction in two aspects of the history of hernia surgery. Cushing was independent minded and perhaps resentful of his chief. After a 14-year association, he was one of the great gifts of the Halsted system to the world of surgery. But the trajectory to greatness was painful for Cushing, and his relationship with his chief was complex. Cushing had his own strong ideas and biases, and took issue with Halsted whenever he could substantiate his point of view. Rather than being impressed by the success of Halsted’s hernia operation, Cushing made light of the minute details of which it was fashioned and believed that any operation properly performed could cure hernias. Using other techniques, Cushing’s recurrence rate of 28 percent proved far higher than the recurrence rate for residents who adhered to the Halsted method, a fact not lost on his mentor.

Others had their own hernia surgery innovations as well. Among them was Howard Kelly, whose superior surgical skill and intelligence made careful consideration of his techniques imperative. Nothing Kelly did in the operating room could be dismissed. Halsted observed Kelly perform his new hernia repair, in which he implanted a marble in the inguinal canal to hold back the hernia sac. Halsted watched closely, and typically, said nothing. Finally, he could no longer avoid comment when Kelly asked him what he thought of the procedure. “Just one question, Kelly, does the marble have to be green or would a pink one do just as well?”

CUSHING DID MAKE
a significant and oddly interesting contribution to the treatment of hernia, though it was not, strictly speaking, surgical. Before the development of trained anesthesiologists and sophisticated anesthetic agents, Cushing had become distressed with what he considered “inept anesthetizers.” Although Cushing sometimes used chloroform, ether was the anesthetic of choice, and it was difficult to manage. To deliver the vapor, a paper cone containing an ether-soaked sea sponge was held over the patient’s nose and mouth by the intern. The first few breaths caused extreme agitation, and attendants were required to hold the patient to the table until the sleep phase was reached. Observation of respirations and pupil size and testing of the eyelid reflexes were the sole indicators of whether the anesthetic level was safe and appropriate. What monitoring equipment existed was, at best, rudimentary. Patients went from agitation to deep anesthesia, and often to too-deep anesthesia. Blood pressure monitoring devices had not yet been invented, and the onset of circulatory collapse could not be anticipated.