The Bizarre Double Life of Dr. Halsted

from left to right: Kergin Lecturer Gerald Imber with historian Michael Bliss

Dr. Gerald Imber began his Kergin Lecture with a riveting clinical case –an operation for gall stones in April of 1882 on a 70 year old febrile jaundiced patient in extremis. The description concluded with a sentence characteristic of Imber’s writing style. “The patient recovered uneventfully and was symptom free for the remaining two years of her life. William Stewart Halsted had successfully performed the first known operation to remove gall stones and in the process had brought his mother back from the brink of death.”

Imber described Halsted as an innovator in surgery and surgical education. He invented local anesthesia for surgical treatment, successful repair of inguinal hernia, radical mastectomy, and surgical training as we currently know it. He was a pioneer of sterile technique. All of these contributions were made during 33 years of addiction to cocaine and morphine.

The story Imber told(1) at University Rounds began with a picture of New York City in 1852, the year of Halsted’s birth. “The city was not pretty. Manure and sewage in the streets. Tuberculosis rampant. 50% of children died before the age of 5. The Halsted family moved uptown to 14th Street, where they lived next to Thomas Edison, who lit his house 24 hours a day to advertise his invention of the incandescent bulb. Halsted was initially home – schooled, then entered boarding school at Andover, Massachusetts from which he escaped and was recaptured twice. At Yale, where he walked with a George W. Bush swagger, he played shortstop on the baseball team and was captain of the football team. He graduated near the bottom of his class, having never borrowed a book from Yale Library. In his 4th year, he discovered Gray’s Anatomy and Dalton’s Physiology text, which he memorized, and then decided on a career in medicine. He entered the Physicians and Surgeons Medical School at Columbia, a few blocks from his home. There were no laboratories, poor lectures and jeering students. The best educational pathway was via the ‘quizzes’, given by individual practitioners on a private tuition bases.

“Halsted bought extra cadavers, and became expert enough in anatomy to teach his fellow students. He served as an assistant to Dalton who was his laboratory mentor, and then interned at Bellevue hospital, the first choice of the best students in the city. During those years 50 operations were performed per year, mostly for treatment of fractures and drainage of abscesses. Surgeons wore dirty operating coats and there were no efforts at aseptic technique. Frank Hamilton, the surgeon-hero of the Battle of Bull Run, rode to New York Hospital on his white horse and went directly to the operating room to perform surgery.

“Halsted finished in the top 10% of his class, then took a job at the New York Hospital on 16th Street. There he developed many innovations including charting the pulse, temperature and respiratory rate of patients. He completed a 2-year tour in Europe, where he worked with Billroth, Esmark, and other surgical leaders. In 1880, he returned to New York, where he joined the staff of six hospitals including Roosevelt, New York Hospital, Bellevue and others. He became an extremely busy surgeon, invented aeration of the blood as a treatment for carbon-monoxide poisoning, a common problem in those days, related to the engine exhaust of ferry boats in the New York area. He may have transfused his own blood into his sister for treatment of puerperal hemorrhage.

“In 1884, the distinguished Viennese neurologist Sigmund Freud described the use of cocaine as a local anesthetic. Freud used it in the eye for trachoma. Halsted tried cocaine, injecting at many sites to see the blocking effect on various nerves, using his own body for the experiments, and administered it to his quiz groups, many of whom became addicted and some of whom died. He performed 1,000 operations under local cocaine. When he became addicted, his friend and colleague William Welch, later Dean at Johns Hopkins, took him on a sailing trip to the Windward Islands, titrating his cocaine use in an attempt to wean him from the drug. Halsted broke into the locker, stole the cocaine, returned to New York and was subsequently sent to the Butler Hospital in Providence for treatment. He spent 7 months at that institution where his cocaine addiction was ‘cured’ by the substitution of morphine addiction.

“Welch eventually invited Halsted to Hopkins where he studied anatomy with Franklin Mall. They described the arcades of the mesentery and Halsted invented a technique to make intestinal anastomosis safe, by emphasizing the strength of the submucosa. He lectured at various medical schools. On the way to Harvard, he stopped at the Butler Hospital in Providence, to once again be cured of cocaine addiction. Halsted and Welch were subsequently joined at Hopkins by William Osler and Howard Kelly, a gifted gynecologic surgeon. These four leaders were portrayed by John Singer Sargent.

“The surgeons began to follow the precepts of Joseph Lister. Halsted emphasized clean nails, clean clothes, and well laundered white duck uniforms. Eventually, he ordered rubber gloves from the Goodyear Tire and Rubber company for his scrub nurse and future wife, Carolyn Hampton, who had developed dermatitis from the antiseptic use of carbolic acid. In 1889, Halsted developed an anatomical operation for inguinal hernia, which until that time had been uniformly resistant to repair. He published 12 cases with no recurrence. Bassini, unknown to Halsted, had developed a similar operation and Halsted always gave credit to Bassini for his contribution. Halsted next worked on breast tumours, which had a 50% local recurrence rate. Halsted devised the radical mastectomy, lowering the local recurrence rate to 6%. He was a meticulous surgeon, slow by the standards of the day, which expected ‘slash and dash’ operations derived from the military surgeons of the civil war like Frank Hamilton. During the war, surgeons kept the sutures in their mouths, so that they were immediately available for mass ligation. Halsted devised the Halsted hemostat, gentle handling of tissues and changed surgery for ever.

The Four Doctors by John Singer Sargent, 1906. From left, Welch, Halsted (standing), Osler, and Kelly

“Halsted decided to train resident surgeons and hire surgical professors as full- time employees of the medical school. He progressively drifted from his extremely busy surgical schedule, tending to drop out during cases only to return reinvigorated later in the day. He once admitted to Osler that he was taking 195 mg of morphine per day. He was able to titrate himself with the 4 PM break, so that he came back refreshed.

“Halsted developed surgical specialties through his trainees. Hugh Young was designated to develop urology and Harvey Cushing, who brought an X-ray machine with him from Massachusetts General Hospital when he was hired in 1896, was encouraged to develop neurosurgery. Cushing remained with Halsted for 14 years as resident and assistant.

“Johns Hopkins developed its medical school to a 4 year program, with a dog surgery laboratory rotation in the 3rd year. Halsted rarely showed up for these exercises. Cushing taught them meticulously, requiring that dogs be treated the same as human patients, with charts, sterile technique and vigilant follow-up care. Cushing introduced the repair of inguinal hernia under local cocaine anesthesia. Halsted was not allowed to use cocaine in patients because of his prior addiction. He drifted in and out of the clinics, asked about scheduling patients already two weeks post-op. Cushing fathered neurosurgery, eventually leaving Hopkins for the Peter Bent Brigham Hospital. Hoyer, one of Halsted’s trainees, developed chest surgery for the Hopkins Hospital. He became a noted chest surgeon after leaving Hopkins for Cincinnati, and then Cornell, where he was chief of surgery for twenty years.” Halsted spent 2 months each year, living with his wife in Hampton, then travelling for 4 months in Europe, visiting various surgeons. It is suspected that he used cocaine during these sojourns and then came back to work on morphine. At 70, Halsted developed acute cholecystitis and common duct stones, followed by gastrointestinal hemorrhage. He died following surgery by his residents.”

Imber’s excellent biography “Genius on the Edge: The Bizarre Double Life of Dr. William Steward Halsted” was distributed by our Department to the overflow audience attending Imber’s Kergin lecture. It is a fascinating story, brilliantly told.

M.M.

1. I have reported the lecture here from my notes. Quotation marks are used to convey a sense of participation to the reader. They should not be taken as evidence of an accurate record of what was said.