Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (4 page)

In addition to the carbolizer, surgeons dipped their hands into a phenol or carbolic solution before surgery. Lister did not encourage scrubbing one’s hands beyond social cleanliness, believing the process of scrubbing forced germs into the folds, lines, and crevices of the skin. Decades would pass before this position was challenged.

For generations, surgeons had entered the operating theater, unbuttoned and rolled their cuffs to keep their sleeves clean, and begun surgery. Some removed their dress coats in favor of “working coats,” already blood-stained and foul from prior operations, which were stored outside the operating room. The coats were donned, the sleeves rolled, and they set to work. Today, “surgeon’s sleeves” remain an arcane fashion statement, and bespoke tailors still incorporate four working buttons on suit coats.

Antiseptic surgery was far better received in Germany than at home in England and Scotland. A lecture and demonstration trip to the United States in 1886 was met with interest, but the leading surgeons of the day were unconvinced, and resistance persisted. A few young surgeons, Halsted included, subscribed to the germ theory and Lister’s efforts to combat infection, and did what they could to promote its acceptance.

The carbolizer, carbolic acid dressings, and hand dip were important steps. Killing the infective bacteria, which were assumed to be everywhere, was the goal of antiseptic technique. For the truly forward-thinking surgeon the goal would become asepsis, the absence of virulent bacteria in the surgical wound and environment.
²

By the time William Stewart Halsted entered medical school, these two leaps forward, anesthesia and antisepsis, opened the door to the future of surgery—a future Halsted envisioned to include true aseptic surgery.

1 In many teaching hospitals the induction of anesthesia with ether was taught into the late 20th century, both for its historical value and to demonstrate the phases of anesthesia through which the patient passes during “induction.” One of these, the excitement phase, was obvious to observers of Morton’s early demonstrations. Modern anesthetics are much faster-acting, and patients are premedicated with intravenous agents to smooth the way to sleep without noticeable stimulation.

2 Eventually, steam sterilization of tools and dressings (as predicted by Pasteur), scrupulous hand scrubbing, sterile gloves, clean if not sterile operating clothing, sterile gowns, and the concept of not bringing bacteria onto the scene became the rule. But proper standards were not strictly enforced until well into the 20th century. Today, the simple expedient of hand washing or disinfecting is often ignored. Medical personnel still go from patient to patient without washing their hands or using antibacterial compounds; hospital personnel wear operating room scrub suits in corridors, hospital rooms, and coffee shops, potentially spreading infection.

CHAPTER THREE
Physicians and Surgeons

HALSTED RETURNED HOME TO
New York City in the fall of 1874 and became one of 550 young men to enroll at the College of Physicians and Surgeons at 23rd Street and Fourth Avenue. Although it was affiliated with the prestigious Columbia College, Physicians and Surgeons, like all medical schools in the country, was a business. They were in reality little more than trade schools, and the instructors benefited from the large enrollment by sharing in the revenue. Applicants did not need undergraduate degrees for entry. Lectures were poorly prepared and poorly attended. Students had little reason to take either lectures or lecturers seriously, and both jeering and snoring were common. The three-year course was almost purely didactic, and no laboratory or clinical work was required. Students did not examine patients and often did not see patients at all. Most of the faculty members were competent and high-minded, but the ultimate goal was to fill the seats and graduate doctors.

To fill the gaps in their education, most students enrolled in private tutoring sessions called quizzes. Participation in the quizzes was expensive, costing as much as $100 a year, the equivalent of more than $2,000 in current value. The annual medical school tuition of $140,
or $2,800 in current value, was not much higher. Various experts, including some of the school’s own lecturers, drummed facts into the heads of the medical students until they could regurgitate enough to pass their final examinations at the completion of the third year. Clinics, where students could observe doctors treating patients, were available but not required and so were infrequently attended.

Inadequate as this education was, Physicians and Surgeons was a cut above most medical schools across the country. Increasingly, schools like Physicians and Surgeons in New York and the Harvard Medical School in Boston were attempting to take science and education more seriously, but there was no consensus, no model to emulate, and they were struggling to find their way. The bacterial basis for disease was becoming clear, but most physicians were unwilling to abandon the faith of Hippocrates in the mystical balance of humors. Scientists were in the minority, and medicine was being taught largely as it had been for centuries.

Despite the dismal system that he entered, Halsted managed to ferret out the best teachers and role models. Each student at Physicians and Surgeons was assigned to a preceptor from among the faculty who would serve as his mentor. The mentoring was spread thinly, as mentors would oversee several students in each of three classes. It was up to the student to make the best of the opportunity. Halsted registered with Henry B. Sands, a surgeon and professor of anatomy, the subject that had sparked his initial interest in medicine.

From the beginning Halsted spent a great deal of time in the dissecting lab, both learning from Sands and doing his own work. Dexterous and diligent, he quickly became expert in the eyes of his fellow students and stood well above the others in the eyes of his preceptor. Sands took the opportunity to shift some of the demonstration and preparation work to his student.

John C. Dalton, whose textbook had inspired Halsted in his extracurricular reading at Yale, was also on the faculty at P&S. Dalton’s
interests were wide-ranging, and he studied everything from localization of brain functions to the physiology of digestion. The work itself was important, but Dalton’s maverick scientific approach was a groundbreaking example of the experimental model. His students were taught to perform animal and human experiments and observe the physiological responses to stimuli. Traditionally, instructors would simply tell students what the expected response would be. Dalton taught the students to stimulate a muscle, measure the response, and learn cause and effect. This method would become the model for medical teaching in the future, and it made a lasting impression on young Halsted. He began spending increasing portions of his day in the physiology laboratory, ultimately becoming Dalton’s primary assistant and an expert in the use of the experimental model.

It was a perfect beginning. In the nurturing hands of Dalton and Sands, Halsted was excited by his work. Attending lectures, reading, and doing dissections with Sands and experiments with Dalton was a full load, but he was energized by the demands. Intentionally or not, Halsted had the ability to associate himself with the important figures in his world. Later in life, when roles were reversed, Professor Halsted’s radar would be finely tuned against young surgeons seeking his good graces, unfailingly cutting them off at the knees.

In his second year at Physicians and Surgeons, he began conducting chemical tests in the office of Dr. Alonzo Clark. Clark was president of the medical school, a professor of pathology and of the practice of medicine, and the leading medical consultant in the city.

In the summer of 1875, Halsted befriended Thomas McBride. McBride, several years his senior, was already physician-in-chief at the Centre Street Dispensary, where Halsted spent the summer working in the pharmacy learning about the potions, plasters, pills, and tonics popularly used at the time. McBride was a fun-loving, handsome man-about-town, and very successful in his practice. He earned a great deal of money and spent it lavishly, and in some ways served as a role
model for the younger man. They spent a great deal of time together, and their lives became closely intertwined.

With his interest focusing on anatomy and surgery, Halsted seized every opportunity for dissection, spending many hours at the table. Having access to adequate finances, he bought extra cadavers, which he dissected and studied well beyond the level required of students.

At the completion of his second year, the hard work and extracurricular activities were finally getting the better of him. Exhausted, he retired to Block Island, one of the rugged and isolated dots of terminal moraine off the coast of Rhode Island. There he spent the summer of 1876 recuperating.

Reinvigorated by sailing and fresh air, Halsted soon returned to his studies in the evenings and decided to prepare for the examination for an intern position at Bellevue Hospital in New York. The possibility excited him, but the rules for internship at Bellevue had just changed, and interns were now required to have already earned an MD degree. Despite this new requirement, Halsted decided to pursue the opportunity, and though he had some difficulty convincing his professors to allow him to sit for the examination, his dogged persistence won out.

“I had little expectation of being admitted to Bellevue for I was ineligible, not having a medical degree, nor had I taken the cram quiz,” Halsted wrote. Tanned and fit from his summer in the sun, “I recall contrasting my physical condition with that of the other fellows who presented themselves for this examination. Most of them were pale and nervous having remained in town all summer for the cram Quizzes.” He took the exam “as something of a lark,” knowing that if he failed he could take it again in the spring. To everyone’s surprise, he placed fifth, and though technically unqualified, he was offered the position, which he happily accepted. Halsted later said that the good news had resulted in one of the few sleepless nights of his life, which he spent contemplating the boundless opportunities of his future.

The internship at Bellevue began on October 1, 1876. Halsted was assigned to the fourth surgical division, although he “would have preferred the second surgical, on which Thomas A. Sabine was visiting surgeon.” Sabine and Stephen Smith were among the few surgeons in New York who enthusiastically embraced Lister’s antiseptic surgery. Halsted was convinced of the importance of the concept, if not of Lister’s specific techniques, and working with believers was where he wanted to be. But the coveted position with Sabine went to Halsted’s friend Samuel Van der Poel. One year ahead of Halsted at P&S, Van der Poel had done poorly in his first attempt at the Bellevue exam the previous year, but after intensive coaching by Halsted, he performed better than his tutor and won the prized position. The two young men were off to Bellevue.

The senior surgeons at Bellevue were a mixed lot. Halsted studied with many of the great ones, but he also encountered many who “left everything to the interns.” His immediate superiors, led by famed Civil War surgeon Dr. Frank Hamilton, did not subscribe to Lister’s antiseptic techniques, but they were open-minded enough to allow interns to adopt the new method. Those interns who did so noted a significant reduction in postoperative infection, but their findings had no effect on hospital policy.

Hamilton was one of the stars of Halsted’s Bellevue experience. An army surgeon who had commanded the field hospital at the first battle of Bull Run, Hamilton cut a dashing figure in riding boots and spurs, arriving dramatically each day on a large, iron-gray charger. An expert in skin grafting, his primary interest was treating fractures, about which he had written a textbook. Surgical intervention to treat disease was not yet a reality and was limited to attempting to stem the damage of traumatic injury, and trauma meant fractures. Not quite convinced of the usefulness of Lister’s new ideas, Hamilton examined patients and operated bare-handed, without washing or decontaminating his hands after his horseback ride to work.

Bellevue was a very busy place, and interns worked a grueling seven-day week. They were a small, close-knit group, helping one another, spelling one another to attend surgery, and spending what little free time they had talking surgery. Looking old beyond their years, they were generally men from affluent families and arrived at work dressed no differently than bankers. Halsted favored wing collars, waistcoats, and wide cravats. Most smoked, and those who did smoked freely at work. This was particularly true during anatomical dissections in the dead house, or morgue, where, before refrigeration, smoking provided a defense against the noxious odors of decomposing flesh. The only area off-limits for smoking was the operating theater, but this was only because of the explosive nature of gaseous ether.

During Halsted’s seven-month internship, there were only 95 patients admitted to the fourth surgical division. Of these, 50 had simple fractures and dislocations. Few elective operations were attempted, for even clean surgical incisions were likely to become infected and result in death. Already contaminated wounds such as compound fractures were doomed to infection and amputation. The fear of infection loomed everywhere, and abdominal surgery remained so risky that even appendectomies had not yet been performed. The diagnosis of perityphlitis, as appendicitis was then called, was made clinically, but nothing could be done other than confirming it at autopsy. Under the best of circumstances an abscess developed around the infected appendix, which could be successfully drained. In some cases the natural body defenses and the large fatty apron in the abdomen called the omentum helped wall off the infection. These defenses, combined with prompt drainage, managed to control the infection and might allow the patient to survive. Often, when the appendix burst and overwhelming peritonitis developed, the less lucky patient died, as expected.