Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (7 page)

The identification of the ABO blood groups by Karl Landsteiner would not occur until 1900, but Halsted hinted at some early insight into the risk of blood group incompatibility, saying, “This was taking a great risk but she was so nearly moribund that I ventured it and with prompt result.” He left no clue about the volume of transfusion. A small volume of transfused blood would have been unlikely to turn the tide, and a significant transfusion would have required more than simply drawing and transferring a syringe or two of blood. Minnie Halsted Van der Poel was a lucky woman, as mismatched blood might have killed her.

Halsted’s interest in transfusion led him to focus his efforts on a common condition of the day, illuminating gas poisoning. The first residential electric lights became available in New York City in 1882, but consumers had to be within a one-mile radius of Thomas Edison’s direct-current generating plant on Pearl Street in order to receive service. It would be another decade before alternating current, which could transmit current farther, became generally available. Meanwhile, homes, businesses, and streets continued to be illuminated with gas, and a by-product of burning gas was carbon monoxide. Workers exposed to illuminating gas were often acutely poisoned by it, particularly in confined spaces like the gaslit night boats plying the rivers. In the emergency ward at the Chambers Street Hospital, Halsted devised a procedure called centripetal transfusion, in which the patient’s blood was removed, aerated, and returned to the donor. Aeration removed carbon monoxide from its combination with hemoglobin and allowed the hemoglobin to combine with oxygen from the air. Halsted believed it was preferable to retransfuse the blood into
an artery rather than a vein, so that it would go “against the stream and not mix with other blood and cause gangrene of the extremity.” Whether arterial retransfusion was of any particular value is debatable, but the blood’s renewed ability to carry oxygen cleared the acute toxicity and patients recovered rapidly.

A year after transfusing his sister, Halsted received the telegram summoning him to Albany to see his moribund mother, whose condition had so mystified her doctors, including Halsted’s housemate Thomas McBride, under whose care she had been. Dramatic as operating on his own mother on the kitchen table would seem, the finest surgical suites of the day were not much better equipped, and it was common for visiting surgeons to operate in patients’ homes. Tools were rudimentary, sterility was in its infancy, and anesthesia was administered by untrained assistants or bystanders.

By 1882, things were beginning to change. Henry Sands was named sole attending surgeon to Roosevelt Hospital, and Halsted, assistant to the attending surgeon. For the first time, a single surgeon was given the responsibility of overseeing a department of surgery. Roosevelt Hospital had been founded with a bequest from James Roosevelt, an uncle of Theodore Roosevelt. It was privately funded and open to all patients regardless of their ability to pay. At the time it may well have been the finest hospital in New York City.

Halsted was soon named to the staff of both the Presbyterian Hospital, the New York Hospital, and the Chambers Street Hospital, and was now actively working at five hospitals, consulting, operating, and teaching. In 1883, he became visiting physician to Bellevue, the very busy city hospital where teaching was held in high regard. It was here that Welch had established the first surgical pathology lab. The availability of teaching material at Bellevue was perhaps the greatest in the city. For a young surgeon eager to innovate, operate, and teach, this was a significant career opportunity. Halsted had had Bellevue in his sights ever since the joyful, sleepless night he was accepted for internship.

Happy to return, but finding the operating conditions unacceptable, Halsted requested a modern operating room be built for his sole use. This was an outrageous request from a young man in practice barely three years. His proposal was promptly denied for lack of funds and conflict with the hospital charter.

Unwilling to abandon the idea, Halsted raised $10,000 from family and friends, secured a site on the Bellevue grounds, and had an elaborate tent constructed. Designed by an architect, the tent was large, fully enclosed, and heated. The floor was constructed with tightly laid maple, much like a bowling alley, and sloped gently toward gutters for drainage and cleaning. Skylights were built into the roof, hot and cold running water were provided, as was gas for light, heating, and sterilizing instruments. In 1885, this tent at Bellevue Hospital was perhaps the most modern operating room in the country.

However, Halsted would work in his new operating room for only a few months, as his life was about to take a drastic turn.

CHAPTER SIX
Cocaine

IN APRIL 1884
, an impoverished young physician in Vienna named Sigmund Freud wrote the Merck Company of Darmstadt, Germany, to inquire about purchasing a gram of their newly available cocaine alkaloid. Shocked at the cost of three gulden, 33 kreuzer—ten times what he had expected to pay (about $1.27 U.S. at the time)—Freud was so excited about the experimental possibilities that he made the purchase anyway. He would worry about finding money to pay for it later. He had been reading a great deal about the unique stimulant properties of the drug, which was said to enable German soldiers to fight like supermen without sleep. Abstinence from food was possible for days without feeling hunger, and users reported a mild euphoria and general sense of well-being. The substance, long used by South American Indians in religious rituals, had recently been extracted from the coca leaf by Merck chemists and made available for sale.

Having only recently entered practice, Freud was constantly searching for a way to make his mark. He was engaged to marry his beloved Martha Bernays, and frustrated by his inability to earn enough money to support them. His fledgling neurology practice was not yet busy, and his experimental work, though significant, had not yet been noticed. As a laboratory scientist, he had already developed
a method for staining nerve fibers with gold, which would later prove to be an important contribution to neuropathology. Meanwhile, Freud was suffering from depression, both psychological and situational.

As an alkaloid that lent itself readily to solution in alcohol, the new drug was fairly easy to deal with. Freud carefully calibrated dosages and reactions in animals and human volunteers, primarily himself. Astounded by the elation he felt shortly after using the drug, he praised it in letters to Martha and referred to it as a “magical drug” in conversation with colleagues. When feeling depressed he found that a small dose left him euphoric and exhilarated yet in every other way normal, and without a craving for more.

Among the friends he introduced to the new drug was Dr. Ernst von Fleischl-Marxow, who had developed a morphine addiction from the treatment of neurological pain. Freud’s idea was to substitute cocaine for morphine and break the addiction. Fleischl began using enormous amounts of cocaine, often as much as a gram a day. These were massive doses by Freud’s standards; he himself had been using occasional injections of 50 milligrams, one-twentieth of a gram. Fleischl became severely addicted and, to Freud’s dismay, developed a full-blown cocaine psychosis: “white snakes creeping over his skin,” paranoia, disorientation, and a full separation from reality.

But this was the only bad reaction Freud observed in the early days. Others, using smaller amounts, found the drug cured colds or at least dried up the sniffles, boosted energy levels, cured nervous exhaustion, and allegedly sharpened the senses. It became a pleasant recreational tool.

Freud, meanwhile, had noted that when taken orally the drug caused a numbness of the lips and tongue. He injected himself in an attempt to cause localized anesthesia, but because of his imprecise knowledge of the anatomy the experiments proved unsuccessful. He abandoned the idea of injection but remained steadfast in his belief that anesthetic possibilities existed. Freud mentioned his suspicions to
an ophthalmologist friend, Leopold Königstein, and encouraged him to experiment with cocaine to relieve the pain of trachoma, a common agonizing infection caused by poor sanitation and hygiene that often led to blindness. Königstein found treatment with cocaine controlled the pain of trachoma as well as several other eye ailments, and the experiment was considered a great success.

Freud performed experiments with an ophthalmology intern to determine whether the sense of increased physical strength associated with cocaine was objective or subjective. The intern, Carl Koller, noticed, as had the others, that the drug caused numbness of the mucous membranes. While Freud and Königstein were dealing with the drug’s various therapeutic properties, Koller began experimenting with cocaine as a topical anesthetic for eye surgery. He was not alone in understanding what might be possible, but he was alone in testing it, using it, and writing about it.

In July 1884, Freud published his quickly written but comprehensive paper on the history and properties of cocaine. In the last paragraph he mentions that “cocaine and its salts have a marked anesthetizing effect when brought in contact with the skin and mucous membrane in concentrated solution; this property suggests its occasional use as a local anesthetic.”

By September, Koller was testing the anesthetic properties for surgery on the eyes of animals, and then humans. It worked. On September 15, Koller sent a communication to the Ophthalmological Congress meeting in Heidelberg, and on October 17 read a paper on his findings in Vienna. Freud and Königstein soon began similar testing of topical cocaine for eye surgery, but it was too little too late. Koller gracefully credited his interest in working with cocaine to Freud, but the great discovery and international fame went to Koller. Freud was surprisingly sanguine about the whole issue, blaming himself for missing the forest for the trees, and for laziness in not pursuing every avenue.
ON OCTOBER 11
, Dr. Henry Noyes, who attended the congress in Heidelberg, published a report of Koller’s work in the
New York Medical Record
. Reading this, Halsted saw the possibilities for the use of cocaine as a local anesthetic in surgery.

As was his routine, each morning Halsted attended the “outdoor clinic” at Roosevelt Hospital, the equivalent of today’s ambulatory or outpatient clinic. Chatting with his first assistant, Frank Hartley; second assistant, Richard J. Hall, with whom he had studied in Vienna; and third assistant, George Brewer, he suggested they conduct some experiments. Coca extract was already in everything from tonics to Coca-Cola. In America, the Parke, Davis and Company had begun extraction and distribution, and was selling coca-leaf cigarettes, elixirs, nasal sprays, and injections. Cocaine powder was being used as snuff and in dilute solutions as a tonic. The talk of superhuman strength crossed the Atlantic. An apocryphal story circulated about a confrontation between a group of southern blacks and police in which the rioters were so supercharged on cocaine that they could not be brought down by the .32-caliber bullets routinely used by police. Police forces around the country switched to .38-caliber pistols for their greater stopping power based on an incident that never occurred.

There were some anecdotal reports of addiction, but Halsted’s decision on that morning in late October 1884 to begin experimenting with cocaine was neither rash nor without a reasonable possibility of success.

The human nervous system is made up of two portions. The central nervous system which is comprised of the brain and spinal cord, and the peripheral nervous system comprised of sensory and motor nerves. Motor nerves receive impulses from the central nervous system and relay them to the muscles, initiating movement. Sensory nerves bring sensations such as pain, heat, and cold from body parts such as skin, teeth, or joints to the brain for interpretation. Scratch
your cheek, and the sensation is read by a sensory nerve ending that carries the sensation along its branch to its trunk, through the cheekbone and ultimately to the brain for interpretation. It’s just a scratch, and so it feels benign, like a scratch. But if a surgeon cuts through the same skin of your cheek with a scalpel, the sensory nerve carries the sensation to the brain, where it is interpreted as pain.

Halsted, like Freud before him, postulated that if one could inject a numbing substance into a sensory nerve it would block sensation in all the skin served by the branches of that nerve. Cocaine numbed the conjunctiva and cornea of the eye; Koller had just proven that. Why then would it not numb the branches of peripheral nerves?

Halsted knew the anatomy. He had memorized
Gray’s Anatomy
and dissected out all the little nerve branches on all those bodies in the morgue. He knew where to find the accessible sensory nerves. He would inject cocaine into the sensory nerve and block the transmission of the pain sensation to the brain. No sensory transmission, no pain.

Koller’s paper had been delivered on October 17. Within two weeks, Halsted acquired a supply of 4 percent cocaine solution from Parke, Davis and Company, and began testing his hypothesis with a group of 25 or 30 medical students from P&S. The students were easily enlisted, since Halsted was their preceptor. The experiments began in the early evenings, during the quiz at the Madison Square house. Halsted systematically injected every nerve he could locate. He quickly discovered that cocaine injected into a large nerve trunk on the leg would induce anesthesia everywhere below the injection, along the distribution of the nerve, but caused no change in sensation above the point of injection. When the needle was inserted accurately and struck the nerve, the subject felt a sharp shooting pain from the point of entry down the extremity encompassing the area from which the nerve delivered sensation. An injection made through the skin into the subcutaneous tissue near the nerve but not into the nerve itself would not cause the shooting pain, but did
result in anesthesia for several inches below the site of injection. The results were predictable in the arm, leg, face, and wherever the path of a sensory nerve was known.