Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (21 page)

Surgery for incarcerated hernia was, and still is, performed on an emergency basis when the trapped loop of intestine cannot be freed by ordinary means. Complicating the situation were the extreme reactions these fragile patients often exhibited to ether and the difficulty in managing them safely. Cushing reasoned that eliminating the general anesthetic in favor of local would serve the patient well.

There was still only one local anesthetic available, and that was cocaine.
¹
Knowing nothing of Halsted’s history, but recognizing the value of cocaine as a local anesthetic, Cushing took the leap forward that Halsted may have been psychologically unable to consider.

WHEN LARGE AMOUNTS
of cocaine solution were injected into the operative site, patients felt a euphoric rush, which soon disappeared, and in its place came shaking, sweating, and palpitations. The solutions were diluted in an attempt to reduce these side effects, and a successful balance between efficacy and toxicity was achieved. Cushing’s theory proved correct. Hernia repair was perfectly suited for the use of local anesthesia. Cushing published his experience with the use of cocaine locally in hernia surgery in 1898, and the procedure became standard at Hopkins. On one occasion, Halsted was making ward rounds with the resident and encountered a patient suffering extreme cocaine agitation. Looking at the man, he instructed the resident, Jim Mitchell, “Give him morphia. If you knew how terrible the suffering is with that restlessness after cocaine you would not stint his morphia.”

HALSTED’S WELL-ARTICULATED
technique was painstakingly followed with 21 days of hospital-enforced, strict bed rest, which he believed crucial for a successful outcome. To this end, the surgical dressing was covered widely with gauze and plaster of Paris, and reinforced with wooden battens from armpits to knees.

His second hernia patient, George Holdorf, a 20-year-old blacksmith, was banished from the hospital on the seventh postoperative day for “insubordination.” Holdorf had left his bed several times and took a cathartic pill without permission. The hernia promptly recurred, and Halsted repeatedly made the point that wound strength is negligible after seven days, and still so compromised at 21 days that he considered enforcing a still longer period of bed rest.

Today’s approach to hernia surgery would be unrecognizable to Halsted. Endoscopic techniques, and often the addition of synthetic mesh tissue support, have largely replaced the open, Bassini/Halsted approach. Local anesthetic is routinely employed instead of general, and patients are discharged to home and activity only hours after
surgery. The progression of knowledge and technique have made operation and aftercare considerably less daunting for the patient, but the current cure rate for indirect inguinal hernia cannot be much more impressive than the 94.4 percent reported by Halsted more than a century ago.

Halsted often acknowledged the value of Cushing’s contribution, but it is very telling that he, the prime mover in both hernia surgery and cocaine anesthesia, did not himself initiate the use of local. Halsted either refused to be openly associated with his nemesis or was psychologically unable to consider it, and perhaps one cannot avoid ascribing the oversight to denial. But cocaine was never far from his thoughts.

IN ANOTHER INCIDENT
, Mitchell was helping Halsted with a thyroid operation. The procedure was still unusual in 1899, and several distinguished surgeons were present to observe Halsted’s technique. It was decided to do the operation under local anesthetic, with a dilute solution of cocaine and morphine called Schleich’s solution. Halsted injected it sparingly. He opened a large wound in the patient’s neck and began applying tiny Halsted clamps to control hemorrhage in what was a notoriously bloody operation. With a flurry of activity around him and numerous clamps hanging from his neck, the patient became agitated and began to struggle. Halsted looked across the table at his assistant.

“Mitchell, I have an awful headache.”

With that he withdrew, went into the next room, drank a cup of coffee, and returned to the now quiet patient. He changed his gloves, began to reapply the clamps that had been removed, and calmly set about splitting the neck muscles over the thyroid gland. Again the patient became restless. Again Halsted withdrew.

“My headache is worse. I am going out and rest a while.”

After a third attempt to sedate the patient he said, “Now this time you go ahead with the operation. Good-bye.”

Only seven thyroid operations had ever been done at The Johns Hopkins Hospital. Halsted had done six, Cushing one, and Mitchell none. Now he faced a complicated operation before an audience of surgical luminaries on the largest thyroid that his chief had ever seen. Somehow, the surgery went well, and the elated Mitchell was entertaining the guests at dinner when a messenger arrived with a package from Halsted. The attached note read, “Dear Mitchell. I telephoned and found you finished the operation and that your patient was all right. Some day you will know what it means to have an assistant in whom you have confidence. I hope you will enjoy this bottle of old Madeira.”

Mitchell, who went on to become the leading surgeon in Washington, D.C., very likely had no knowledge of The Professor’s enduring drug use.

1 As safer local anesthetics were developed, they supplanted cocaine. The first was procaine, universally known by the trade name Novocaine. Lidocaine was developed in the 1940s and remains the most popular local anesthetic.

CHAPTER EIGHTEEN
Establishing the Routine

IN 1890, THERE WERE 100,000
physicians in America, roughly one for every 150 people. Steeped in archaic ideas, they behaved like guild members and aggressively protected their fiefdom and their incomes, but they were rarely able to alter the course of disease or prolong life. Standard practices for medical training were absent, ignorance was rampant, and science didn’t have a chance. Bright spots of progress appeared sporadically, but largely, the state of the art was abysmal. All the while, great progress in the laboratory and clinical sciences was being made in Europe. Men like Pasteur, Cohnheim, and Koch had challenged the preconceived notions of the past, and the germ theory was alive and well. Antiseptic surgery, though increasingly practiced in Germany, was still not generally accepted in America, more than two decades after being introduced by Joseph Lister.

The country was ready for change, and the four young men of Hopkins were poised to turn the ignorance on its ear. There was little serendipity involved in these men standing together and finding themselves on the threshold of seismic change. All four, Welch, Osler, Halsted, and Kelly, knew where they had been and where they wished to go. Gilman, Billings, and Welch had been given the general direction and blessed with the wherewithall by Johns Hopkins. The
scientific vision was pure and strong and shared. Each of the four came of age when it was necessary to augment an inadequate medical education by studying with the European masters. Each wished to change the situation, and was able to see how that model could be expanded and improved.

In the structure of the new hospital, each would be absolute master of his domain. Similarly, each would head his respective department when the medical school opened. One of the great attractions was the novel idea of departments in the hospital and medical school directed by the same chief. The first six months of operation had been something of a learning experience for all concerned. But they were adaptable, worked as a team, and supported one another, and the hospital was an enormous success.

Halsted was made associate professor in 1890. His operation for cancer of the breast had awakened hopes for a surgical cure, and patients sought help from Hopkins and Halsted. His operation for the cure of inguinal hernia found wide acceptance as well, and despite the unresolved issue of bragging rights between Halsted and Bassini, Johns Hopkins quickly became a center for hernia surgery. From the start, all surgery was performed under what were then the strictest aseptic conditions, and infections became increasingly rare.

WILLIAM OSLER
, the new physician in chief, was not particularly enamored of Baltimore, but it was of little importance since he spent most of his time working. With his resident, Henri LaFleur, and assistant resident, William S. Thayer, he established a routine of hands-on ward rounds and laboratory analysis. Osler saw the value of both German laboratory medicine and British clinical medicine, and his interest in malaria and dysentery kept the house staff at the microscope. All clinical laboratory work, urinalysis, blood examination, and stool examination was performed by the house staff, and this added
considerably to their workload. Not only did this work result in established routines and discipline, it was academically rewarding, and the rigorous studies led to expertise and renown for the young physicians.

Initially, Osler was an omnipresent figure on the medical wards, but as routine set in he was no longer fully occupied. Still unmarried, he initially had furnished rooms in the administrative building of the hospital complex, and then kept house off the hospital grounds. With his cousin Georgina serving as his hostess, Osler began an open-door policy that endeared him to the residents and became a hallmark of his presence at Hopkins. He was funny, intelligent, welcoming, and enjoyed a happy evening of drinking and storytelling every bit as much as his young followers. After Georgina married one of the residents, Osler resumed his bachelor life. He was not a clubman in the style of Welch, and did not have the range of outside interests of Kelly. He related well to the residents, and immediately became their older brother. There was none of the standoffishness typical of Halsted, the preaching of Kelly, or the detachment of Welch. Osler was truly the residents’ friend, and without doubt, their role model.

Osler was an instinctively great teacher, able to tell the story of disease and the human consequences in a cogent and logical manner. He wrote frequently, but not exclusively, on medicine, and was a prolific producer of prose, poetry, and humor, the latter usually penned by his alter ego, Egerton Y. Davis. Over the years he became increasingly philosophical, and his writing more figurative and dense. But at Johns Hopkins in 1890, he was focused and direct. Among Osler’s recurring themes was the diminishing effect of age. During that first winter and spring, he toyed with the idea of writing a comprehensive textbook of medicine. By the following fall he claimed he had sold his “brain to the devil,” and signed a contract with the New York publisher D. Appleton and Company for
The Principles and Practice of Medicine
. The $1,500 initial advance proved to be a stimulating omen of things to come. Osler would ultimately achieve a comfortable level of financial
independence from decades of sales of his book as revised and updated editions became an annuity.