Almost every patient mentions how cold it is in the operating room. We keep the room around 60° F, in part to keep comfortable in our layers of clothes and gowns and in recognition that keeping a chillier room helps keep infection rates lower. Lisa is no exception. As she’s being wheeled in on the gurney, she’s groggily awake and mutters something about the cold.
Before rolling her into the operating room, Dr. Cohen, my anesthesia guide today, performed a nerve block injection on Lisa. He used an ultrasound wand to guide the trajectory of the needle via computer screen as it delicately plunged through the skin and explored the depths of tissues around the neck. Once the shadow of the needle tip approached the brachial plexus (the bundle of nerves that connect brain and limb), he injected a syringe-full of numbing medicine around the nerves. The procedure rendered her arm simultaneously numb and paralyzed. On cue, our little team trekked toward the operative theater.
Underneath her translucent blue surgical bonnet, Lisa’s bright auburn hair is visible, tucked safely away in our clean environment. She’s another East Coast transplant who moved west to Colorado in middle age. In the last several years her left shoulder has become unbearably painful, and after failing injections and physical therapy, she has opted to undergo shoulder replacement surgery. In the preoperative staging area, Lisa nervously asked about how much pain she’d be in tonight, but that’s a faraway concern now. Her sedative medicine has rendered her punch-drunk and unaware. Her sister confided that they watched a shoulder replacement on YouTube last night, only barely enduring the odious presentation.
While in high school, I saw a television special about Dr. Frank Jobe, the longtime team physician for the Los Angeles Dodgers, who pioneered so many shoulder and elbow operations. That day, I decided to be an orthopedic surgeon and never wavered in that pursuit. Following medical school in the Midwest and surgical residency in Pennsylvania, I was accepted at the sports medicine fellowship overseen by Dr. Jobe, the same man who had inspired me almost twenty years before. I have traveled with the Lakers, ran onto the field of the LA Coliseum with the USC Trojans, lived in a bungalow on Jackie Robinson Way during spring training, and listened to the plaintive cries (bad back, bad feet) of a now middle-aged Mike Eruzione in the dressing room of the US Olympic ice hockey team in their only reunion since 1980 Lake Placid gold. Those experiences, teamed with guidance from world-class joint doctors, turned me into the surgeon I am today.
All of us in the operating room wear scrubs, caps, and masks, but only the surgical tech dresses in her sterile gown as she prepares the instrument table. My physician’s assistant Ashley and I help Lisa scoot over onto the narrow surgical table.
Dr. Cohen administers more anesthesia through a combination of intravenous sedatives and inhaled gases. Our main goal is pain-free surgery, but we also want the patient motionless so we don’t have to worry about injuring a nerve or vessel with a sudden jolt. Cohen renders Lisa unconscious. As the gas mask is held firmly over her mouth, milky white Propofol pushes into the IV. In the few seconds it takes to travel to the heart and circulate into the brain, Lisa plunges into the marvel of senselessness.
Now that Lisa is completely anesthetized, we position her body carefully on the table. Great care is required: while her body is completely alive, it is incapable of self-protection and as vulnerable as a newborn.
We position her to minimize bed sores or nerve injury, and then I adjust the height of the table so that the surgical area matches the height of my elbows. This minimizes shoulder strain and allows for up-close visualization. During shoulder replacement surgery, I stand. Once we’re all positioned, the circulating nurse paints the surgical area with skin prep chemicals, including alcohol and other bactericides.
While the nurse paints the patient’s shoulder, and after scrubbing our hands, I perform an intricate dance with the scrub tech, who already has her gown and gloves on. While facing her, she slides my gown over my outstretched arms without touching the unsterile parts of my body or clothes. She snaps latex gloves over my freshly doused hands. From behind me a nurse ties my gown and I twist 360 degrees to cocoon myself in a sterile microenvironment.
After all the busyness of collecting Lisa from the preoperative holding area, dealing with her sister’s anxiety, hustling to finish a basketball player’s physical so he can play this weekend, phoning my office assistant to hear the results of a rugby player’s MRI, and readying the patient for surgery, it’s time to cut. Dr. Cohen and I catch each other’s gaze, connecting in a deep sense of trust over the dominion of life. His somber eyes and a gentle nod of assent confirm that we are ready to journey on.
The scalpel is made of two parts, the handle and the blade. The scalpel handle is flat and made of stainless steel, which allows for repeated washing, sterilizing, and packaging. A scalpel handle can last for years, even decades. The scalpel blade, however, only lasts one case. Instead of stainless steel, the blade is made of carbon steel, which is much sharper. In many operations, a blade loses its requisite sharpness in the middle of surgery and must be discarded.
As a surgeon, you always ask for instruments without turning toward the scrub tech or without taking your eyes away from the surgical field. An experienced tech knows, within a few tools, the instrument the surgeon will ask for next, along with the proper orientation to place the tool into the surgeon’s hand. To the close observer, surgery looks as well choreographed as oceangoing sailors maneuvering their craft with minimal conversation and maximal coordination.
My gaze is now firmly fixed on the purple line I’ve drawn over the front of Lisa’s shoulder. All the acts of positioning, scrubbing, gowning, prepping, and draping have come down to this. It is time to make an incision. It is the moment of truth beyond which there is no turning back.
“Scalpel.”
There are two ways of holding a scalpel. In one position, you hold the stainless steel handle like a pencil; in the other, you hold it like a conductor holds a baton. The former technique makes the majority of incisions, while the latter is employed during larger incisions. When I perform the incision on Lisa, I steady my hand and wrist, and use the muscles around my elbow and shoulder to direct the blade across the skin.
With the scalpel in my right hand, I hold my gloved left thumb and index finger on either side of the incision site, stretching the skin tight. Nothing else in the world exists, no other thoughts, no realities, no controversies. Nothing funny, nothing sad, nothing interesting. I’m in a vacuum where everything further than ten inches away vanishes.
My father was a Marine Corps sniper in Korea before becoming a veterinarian. Curious about his military days, I watched a documentary on sniper training, wherein elite marksmen like him were taught to deeply inhale and exhale before squeezing the trigger. This same technique helps me steady my hand during precise movements; I use it every day in the operative theater.
After my brief breathing exercise, I move the scalpel blade to the uppermost part of my planned incision. The razor-sharp blade is touching the skin and yet no penetration of the metal edge has occurred until I downwardly angle the instrument toward the elbow. New surgeons notoriously misjudge the correct pressure required to properly cut through the skin. Typically, rookie cutters barely scrape the skin, and their supervisors joke about paperclips inflicting greater damage. However, too great a pressure will plunge the knife deeply into the wound, causing potentially catastrophic damage to deep nerves or arteries.
Cutting skin feels like slicing into a fresh peach. As I draw the knife along the skin, yellow fat billows up from the wound. As we age, our skin becomes thinner, so I account for this as my scalpel blade progresses across Lisa’s shoulder. The tiny vessels along her skin’s edge emit droplets of bright red blood where they have been transected; these must be cauterized, or heat-sealed, with an electrothermal device called a “Bovie.”
A perfectly executed cut penetrates only the dermis, leaving further dissection to scissors and electrocautery. Having made the initial surgical incision, I hand over the scalpel and retire the blade. The skin layers contain dangerous bacteria (even after the most fastidious surgical prep), which contaminate the “skin knife.” After mere seconds of use, that scalpel blade is done forever.
Lisa doesn’t move and doesn’t recognize the violation of her body’s boundaries.
The remainder of the shoulder replacement operation involves exploring deeper and deeper layers of tissue. This kind of deep investigation of the corpus was unimaginable at the same time that photography, the telegraph, the steam engine, and perforated toilet paper were being invented. Every great surgeon requires an innate sense of three-dimensional space buttressed by years of anatomic learning. The location of every muscle and minute blood vessel and nerve is surprisingly predictable; a gifted surgeon comprehends these laminations with rapid, precise dissection. An aging joint, like an ancient tree tentacled onto a rocky cliff face, develops thickened stratums of bony spurs, loose cartilage bodies, and overgrown, inelastic ligaments. As I delve deeper toward the diseased shoulder joint, I have to abandon the scalpel for stouter instruments.
Other specialists deal with soft tissues like brains and bowels. Orthopedic surgeons deal with bones, ligaments, muscles, and joints. Our tool kit includes hardware: metal saws, chisels, drills, and hammers. After dissecting deeply through the soft tissue layers around the humeral head, I expose the arthritic joint, cut off the top of the bone with a metal battery-powered saw, and place successively larger metal stems down the hollow humeral canal. Once prepared, I can insert the final total shoulder implants. At some stages, every operation is like a project, and requires the use of brute force to pound, shape, smooth, and extract tissues and body parts.
After implanting the new shoulder replacement components, I reverse course and backtrack my way out of the shoulder joint. The last step is always skin closure. Back in the days before antibiotics, early surgical pioneers used silk or catgut sutures to bring tissue edges together. Those materials were dissolvable, which created an immune reaction that opened the door to infection, and commonly death. We now use “inert” or low-inflammatory suture materials or metal staples that hold skin together.
As my surgical team applies the final dressings, Dr. Cohen also reverses his steps. He stops the short-acting inhalant anesthetics that were vaporized into the breathing tube and discontinues the intravenous drugs that kept Lisa sedated. Gone are the days where drugs, such as ether, took days to wear off: today’s designer molecules wear off in minutes. Lisa begins to move her body and fight against the tube in her mouth. When it is safe, we remove the breathing tube and shuttle her back onto the gurney.
Our little contingent rolls Lisa down the hallway, now progressing toward the recovery room. Patients often fear saying something stupid or embarrassing in the operating room. Most do not. There tends to be only incomprehensible mumbling in the moments surrounding the induction and reversal of anesthesia. However, there is a disarming sentiment most patients have in the first minutes of wakefulness: loss of awareness in the passage of time. With me at Lisa’s side helping to guide the gurney, Dr. Cohen asks her if she’s doing all right.
“Are we almost ready to go?” she asks.
In 1877, in stately Breslau, Germany, Robert Koch first met a young American named William Henry Welch. Just twenty-seven years of age, Welch had graduated from Yale and Physicians & Surgeons (the medical school affiliated with Columbia University in New York City), and like so many new American graduates, went to Continental Europe for his “grand tour.” Stops in Strasbourg, Leipzig, and Breslau had exposed Welch to the world’s most sophisticated microscopists, pathologists, and bacteriologists. The eager Welch, encouraged by his serendipitous timing, realized that this new field of pathology would now be his life. Being tutored by the fathers of the new disciplines, like Koch, Friedrich von Recklinghausen, Ludwig, Wagner, and Cohnheim would position Welch for a preeminent role in American medicine.
While Welch was in Leipzig, he met with Dr. John Shaw Billings, the Army colonel who was responsible for building the Library of the Surgeon General (now the National Library of Medicine) and who had been hired by Daniel Coit Gilman, the new president of Johns Hopkins University, to help design the new hospital at the fledging institution, and was tasked with recruiting promising physicians to Baltimore.
Armed with an enormous endowment from the wealthy industrialist Johns Hopkins (a bachelor Quaker), the university was unlike anything ever built. The hospital (and its associated medical school) would be patterned after the German laboratory-centric model and the clinically-based British model.1 Gilman’s and Billings’s dreams of a scientific hospital staffed by full-time professors was revolutionary, and demanded innovative doctors who would commit their lives to changing the way hospitals operated. Welch and Billings met in 1877 to drink beer at Leipzig’s Auerbachs Keller, a legendary wine bar and restaurant (frequented by Goethe), and the prospect of Welch becoming the linchpin hire at Hopkins was tempting to both visionaries.
In time, William Henry Welch would become the founding physician at Johns Hopkins University. First, however, he would return to New York City, where he oversaw the building of the United States’ first pathology laboratory, at Bellevue Hospital. This new discipline required the latest microscopes and their associated tools, chemicals, and supplies, as well as organized morgues and structured protocols to imitate the very latest in German pathology.
Welch, the luminary in his field in the city, was a celebrated educator among the ambitious medical students looking to supplement their learning. Welch’s intelligence and unsurpassed training greatly accentuated his social standing, but it was his congeniality, borne from a household of generations of Connecticut country physicians, that endeared him to students and patients. Welch’s father was “close to the people not only as their medical adviser but also as their true friend and counselor.”2 The short and pudgy Welch was tapped as a member of Skull and Bones at Yale University (class of 1870), and would forever enjoy the company of colleagues at clubs, dining halls, and home parlors.
In September 1880, William Stewart Halsted, a commanding and vivacious New Yorker returned home from his own European postgraduate tour of duty, ready to claw and climb and outwork every other surgeon in the city. Where Welch had been tutored by the finest pathologists on the Continent, this former Yale football player had been inculcated by the leading surgeons in Vienna and was an enlightened Listerian. Halsted, son of a successful merchant, would lead one of the most remarkable lives in American history, starting with a stint as a surgeon at Roosevelt Hospital and as an anatomy demonstrator at Physicians & Surgeons.
It took little time for Dr. Halsted to make an impact in New York. His enthusiasm, expertise, and panache made an immediate impression; his groundbreaking methods and sheer brilliance fortified his status as one of the medical men of the future, and his zeal led to appointments at multiple hospitals around Manhattan in an era where horse-drawn carriages were the mode of transportation. Halsted’s steel-blue eyes, cosmopolitan manners, and impeccable wardrobe, together with his tony Madison Square address, cemented his reputation as a cultivated physician in a specialty that only recently had risen above the level of derision.
One of Halsted’s first innovations was to organize an informal evening of medical didactics for the P&S students. Held several times a week, the “quiz” was typically held in his home office in his 25th Street residence,3 and the teaching duties were shared among the young stars of the medical community. The two most popular instructors were Halsted and his good friend William Welch, two years the surgeon’s senior. The two trailblazers were both Yale and P&S graduates, gregarious and gifted educators who inspired devotion to this new form of medicine.
After accepting the offer to become the founding physician at Johns Hopkins University, Welch departed for another expedition to Europe in 1884. He had spent seven years as a pioneering physician at Bellevue, but his Gotham contributions would be dwarfed by his future work at Hopkins. Granted an eighteen-month sabbatical to revisit the leading medical centers, Welch was also leaving his close friend, Halsted, who was transforming medicine metropolis-wide as a surgeon, anatomy prosector, quizmaster, and experimental scientist.
By 1884, Halsted was on staff at five hospitals (including Presbyterian, the New York Hospital, and the prestigious Bellevue Hospital), but his dream of a “modern” operating room with comprehensive antiseptic facilities was unmet. Raising money from friends and family, Halsted organized the construction of the most state-of-the-art operating room in the country, an elaborate standalone tent replete with maple floors, skylights, running water, gas for lighting, and sterilization facilities. In 1885, this was likely the most advanced operative theater in the Western Hemisphere.
Halsted’s operating room bivouac at Bellevue Hospital was a utilitarian version of the operative theaters he had seen in Austria and Germany, while hovering over the shoulders of luminaries in Vienna, Leipzig, Halle, and Kiel. His most famous exemplar surgeon was the sensitive and melancholy physician-poet Theodor Billroth, the self-styled “sentimental North Sea herring.”4 For twenty-five years, Billroth was professor of surgery at the University of Vienna following his training under Bernhard von Langenbeck in Berlin (1853–60).
Langenbeck contributed significantly to the development of surgery at a time of great philosophical upheaval. He received postgraduate training in surgery in London in the 1830s (predating anesthesia by more than a decade), serving under Astley Cooper and Benjamin Brodie; thus linking the German school of surgeons to John Hunter (1728–1793).
Langenbeck’s clinical career was interrupted several times by war, including the Schleswig-Holstein Wars (1848–52 and 1864), the Austrian War of 1866, and the Franco-Prussian War of 1870.5 Battlefield medicine has never changed so dramatically in any twenty-year period; in those two decades, anesthesia was discovered and antiseptic surgical treatment was introduced. In the Franco-Prussian War, German acceptance of the antiseptic technique was instrumental in vastly superior surgical outcomes among Prussian forces (cared for by Langenbeck and his associates) compared to the old-fashioned treatment rendered by the French doctors. German and Austrian physicians therefore became among the earliest and most ardent adopters of Listerism.
Bernhard von Langenbeck was heralded as a humanitarian in the treatment of both allies and adversaries, and as a founding member of both the German Red Cross and the Geneva International Convention, concluded, “a wounded enemy is no more an enemy, but a comrade needing help.”6 The seemingly endless wars of Prussia and Germany in the 19th and 20th centuries would demand many contributions from the German surgeons, and in a sick twist of fate, German surgeons were still pioneering surgery during World War II, with injured American soldiers returning home with innovative orthopedic implants net yet imagined in the United States.
Langenbeck’s other major contribution was his apprentices themselves; he is credited with training nearly every prominent surgical operator of his time, including Billroth, Emil Theodor Kocher, and Friedrich Trendelenburg. His idea of organized training following medical school, wherein the young pupil would live at the hospital and gradually assume greater responsibility over the course of years, has earned him the sobriquet as the “father of surgical residency.”
If John Hunter is the father of scientific surgery, then Langenbeck can rightly be described as the progenitor of modern antiseptic battlefield surgery, physician battlefield neutrality, and surgical residency. Langenbeck was at his pinnacle when antisepsis and anesthesia converged, releasing surgery from its “constraining medieval chrysalis.”7 Theodor Billroth’s Berlin tutelage under Langenbeck witnessed two of the most powerful surgeons ever to coexist, with Billroth advancing as his most important protégé.
After a transitory stint in Zurich, Switzerland, Theodor Billroth permanently settled in Vienna, becoming the most influential surgeon in the world for a quarter of a century. From 1867 till the 1890s, Billroth’s surgical amphitheater at the University of Vienna was the center of the surgical universe, where he pioneered surgical techniques, tutored numerus graduates from Europe and America, refined his version of surgical residency, published numerous articles and refined his classic textbook, promulgated the process of surgical audits (predecessor of surgical outcomes), and inspired generations of surgical leaders. All the while, he fostered intimate relationships with musicians and composers, including his close friend Johannes Brahms.
Professor Theodor Billroth was uniquely poised to drive the final stake through the vampire heart of ancient, nonsensical humoral theory and quackery. The amalgamation of chemistry, microscopy, bacteriology, embryology, physiology, and diagnostics heralded a stunning transitional moment in medicine, with Billroth the unquestioned dean of surgeons. “It was a yeasty time for researchers, and the atmosphere of the German hospitals was a ferment of possibilities.”8 Bloodletting, cupping, purging, leeching, and poisoning were being replaced with careful German laboratory studies and scientific interventions based on organ and cell function. It was the German understanding of disease that enlightened investigators about normal structure and function.
Billroth spent long hours dissecting cadavers and planning on surgical interventions. He was able to pioneer abdominal surgery with careful preparation and strict adherence to meticulous antiseptic technique. Animal experimentation and cadaveric-rehearsed surgery emboldened the Viennese professor; perhaps the abdomen could be entered. Nothing short of a “godlike creative spirit,” as Mukherjee calls it, would suffice when it came to intestinal surgery. Vienna has a centuries’ old reputation for virtuoso performances; with Imperial spirit, maestro Billroth would take his place for master class performances in the greatest theater in the City of Music: the Allgemeines Krankenhaus operative theater.
In 1872, Billroth resected a portion of the esophagus and joined the ends together. In 1873, he performed the first complete excision of a larynx. Even more amazing, he became the first surgeon to excise a rectal cancer, and by 1876, he had performed thirty-three such operations.9
What seems commonplace today (abdominal surgery) is nothing short of a stupendous magic act, in reality.
First, surgery on any part of the bowel is fraught with danger, particularly the lowermost portion of the bowels: the colon and rectum. Conceptually, the gastrointestinal tract connects the mouth to the anus in a continuous tube that averages about thirty feet in humans. It is comprised of the esophagus, stomach, small intestine (duodenum, jejunum, and ileum), large intestine, rectum, and anus. The “tube” of the gastrointestinal tract is comprised of many soft-tissue layers that are waterproof and bacteria-proof, so long as the integrity of the layers is maintained. The curvy, writhing, self-contained conduit has attachments to the deep portion of the abdominal cavity that suspend the intestines and connect the blood vessels that nourish the guts, and absorb the nutrients being processed. Importantly, outside the alimentary cylinder, the abdominal (or “peritoneal”) cavity is perfectly sterile and lethally vulnerable to infection. While the stomach and small intestine are relatively “clean,” the large intestine and rectum are teeming with bacteria; while these bacteria often maintain a symbiotic relationship with the host (us), they represent a grave danger if the contents of the tube cross the layers of the large intestine and spill into the peritoneal cavity.
The second half of the scientific sleight of hand is the possibility of any two surgeon-connected tissue ends healing together. We take this proposition for granted, but how is it that we presume that the distinct edges will harmonize, nurture each other, and synthesize a bond that is functional, waterproof, and resilient? This is surgery in a nutshell: connecting, stapling, sewing, screwing, splinting, and gluing entities together, and soliciting the body to microscopically, even at the molecular level, lay down connective tissues to supplement those artificial connections, and in time, supersede the temporary scaffold-works.
Billroth, in heroic quantum surges, was making proper diagnoses (remember, they had no MRI machines, CT scanners, ultrasound devices, or X-rays), achieving anesthesia under the most primitive of conditions, and performing surgery with no electrical lighting. Hence, the positioning of operative theaters on the top floor of hospitals to harness skylights above; the gods of surgery beckoned the sun to shine upon them. Billroth was avoiding infections with early antiseptic techniques and with limited sterilization of instruments, cutting and manipulating flesh with bare hands, and sewing together intestinal tissue with primeval catgut and silk ligatures. Somehow, hubris be damned, Professor Billroth was achieving significant success, and the world was noticing.
It is estimated that 40 to 50 percent of the leading physicians of the United States between 1850 and 1890 studied in Germany and Austria. No fewer than “ten thousand Americans took some kind of formal medical study at Vienna between 1870 and 1914.”10 They were coming for the new emphasis on laboratory medicine, and Billroth exemplified the German experimental physiology and pathology and the ability to translate that into meaningful clinical interventions, for the first time in human history.
Into that world had come William Stewart Halsted, from 1878 to 1880. He had absorbed the mindset, the techniques and protocols, and had observed what tools and machines were required. He would replicate the structures (organizational and physical edifices) that Billroth had erected, down to the building of a tent on Bellevue grounds. His rapacious animal spirit, initially under Teutonic tutelage and now unbridled in New York City, was on the prowl. Halsted demanded tailored suits, Parisian-made Charvet shirts, French laundering (sending his dirty shirts by steamship to Paris, and weeks later receiving back laundered garments), dandy hats, ties, and eyeglasses. The same sartorial impulses and obsessions were unleashed in his medical practice all over the city at all times of the day and night.
Henry Welch left New York in March 1884, stranding Halsted in the New World. Welch’s arrival in Europe coincided with a pharmacological coup; the German pharmaceutical company Merck had isolated and purified an alkaloid from the leaves of the Erythroxylon plant that was indigenous to the eastern slopes of the Andes mountains. There was a primordial Incan tradition of chewing and sucking the leaves to achieve an energizing mood alteration, but the transoceanic voyage had always neutralized and weakened the plant’s powers once back in European capital cities. Scientists at Merck were able to cultivate the Erythroxylon coca plant, and using the newly refined chemistry, were able to isolate the active chemical compound, an alkaloid they labeled “cocaine.”
Alkaloids are a diverse group of simple chemical compounds with a dizzying array of conformations, and to science novices, it is surprising that bacteria, fungi, plants, and animals all make these “lock and key” molecules that dock into certain cell receptors to effect a change. Curiously, our mammalian brains have cellular receptors that anticipate interactions with molecules from the coca plant from Colombia, opium poppy seeds from Afghanistan, coffee beans from Ethiopia, and marijuana from Mexico. These alkaloids have wide-ranging pharmacological activities, including psychotropic, antiarrhythmic, anticancer, antimalarial, antibacterial, and vasodilatory, among others. Scientists believe these interactions (which are often toxic or lethal) occur because of evolutionary selection pressure that favors the development of an alkaloid by one species as it interacts with another.
The question must be asked; why would the coca plant synthesize cocaine? Chemists have discovered that cocaine functions as a pesticide, powerfully inhibiting neurotransmitters (the chemicals that nerves use to interact with other nerves) in the brains of insects that would otherwise threaten the coca plant. In essence, the honeybee is offered a tantalizing “bolus of blow” that tempts them to stay and continue to fertilize the plant. A bee that is high is a useful foot soldier in the game of fertilization. Perhaps we shouldn’t be too surprised to learn that we have thousands of the same molecular receptors in our bodies that function across the spectrum in the plant and animal kingdoms.
Although the chemical structure of cocaine was not accurately described until 1898 (by Richard Willstätter, a future Nobel laureate), the isolation of cocaine had been achieved by German pharmacists in 1859.11 It seems like an obvious first move to place cocaine in the mouths of research subjects (read: medical students), replicating the Incan model. Numbness of the oral surfaces was invariably noted, although many young men also behaved bizarrely. In Würzburg, and later Vienna, pharmacists noted positive effects upon persons with melancholy dispositions and among Bavarian soldiers who were under severe physical duress.
Vienna was alive with speculation about the possibilities with the new drug. The Viennese neurologist Sigmund Freud (1856–1939) heard about the new drug, considering it “magical.” In 1884 he wrote his fiancée, “I take very small doses of it regularly against depression and against indigestion, and with the most brilliant success.”12 At the Vienna Clinic of Ophthalmology (mere steps away from Billroth’s surgical amphitheater), a junior intern, Carl Koller, had been experimenting with drugs to anesthetize the eye, including morphine, sulfate, chloral, and bromide. Koller’s mind was prepared.
Koller had been assisting in experiments on cocaine, and decided to place the substance in his own mouth. Appreciating the effects upon his own oral mucosa, Koller knew the next step was an animal experiment. In 1884, with a colleague holding down a large frog, Koller prepared a solution by mixing cocaine powder into distilled water. He placed a drop of the solution into one of the frog’s protruding eyes. After waiting a few seconds, Koller touched the eye, testing the reflex. Initially there was no drug effect, but after a minute, “came the great historic moment … the frog permitted his cornea to be touched and even injured without a trace of reflex action.”13 After testing rabbits and then a dog, the young interns turned to each other. The solution was trickled into their own eyes, and then with pin in hand, they touched their selfsame eyes with the head of a pin. His assistant later recalled, “Almost simultaneously we could joyously assure ourselves, I can’t feel anything … with that the discovery was completed. I rejoice that I was the first to congratulate Dr. Koller as a benefactor of mankind.”14
Soon the cocaine solution was used in actual eye surgery with great success. The German Ophthalmological Society Conference was held a few days later in Heidelberg, and Koller, seeking the claim of priority, sent a colleague to present their new discovery. Most medical meetings, then, as now, are characterized by presentations that are moderately mundane and rarely scintillating. Occasionally, a paper is given, and reverentially, the room of professionals marvels at the breakthrough. For good measure, eye surgery was performed the next day in front of the conference audience. An American, Henry Noyes (1832–1902), was in the room that September day in 1884, and rushed home to publish a note on the use of cocaine to achieve local anesthesia. In the October issue of the New York Medical Record, Noyes described the use of cocaine, but concluded, “It remains, however, to investigate all the characteristics of this substance, and we may yet find there is a shadow side as well as a brilliant side in the discovery.”15
William Stewart Halsted read the 1884 report in the Medical Record, and immediately pondered how to further harness cocaine. Halsted’s practical savoir faire, honed over the years, led him to believe that he could use the cocaine solution in a novel way. Instead of dripping it into eyes or swishing it in mouths, Halsted perceived the real potential lay with the use of the newly invented hypodermic needle. As a master anatomist, with incredible knowledge of nerves, where they traveled and what they innervated, Halsted at once conceived the notion of regional anesthesia.
This author, as a young medical student in his first anatomy lab, was unsure how large nerves are in the human body. “Are they even visible with the naked eye?” I asked myself. To my great surprise, the peripheral nerves are very large, and as they course down the arm or leg, are as big as a pencil before they branch out into tiny tendrils to where they terminate in muscles or the skin. Within each nerve there are imperceptible nerve fibers that are alternately carrying signals down from the brain or upward toward the brain. Motor nerve fibers carry the electrical signal down the spinal cord, along the peripheral nerve, and connect to the muscles they command. Conversely, sensory nerve fibers within the peripheral nerve carry the electrical signals from the skin, bones, and soft tissues, communicating messages of pain, touch, sensation, vibration back to the “central processing unit,” the brain.
Halsted was sailing in completely uncharted waters. The only way to test his hypothesis of regional anesthesia was to start injecting subjects, and what would be impossible now, he approached the best guinea pigs he could find: his medical students at the quiz sessions. By comparison, Koch seems positively cosmopolitan by experimenting on his daughter’s pet rabbit.
Within two weeks of Noyes’s publication, Halsted had secured a 4 percent cocaine solution from Parke-Davis and Company, and began injecting students in his Madison Square home office. The injecting parties that ensued must have been sensational. Halsted, elaborate metal-and-glass syringe in hand (no modern sensibilities of “single-use” needles), parading around the parlor and plunging the needle into arms and legs. Occasionally thrusting deeply into a nerve, with an electrical blast of pain down a limb, Halsted would have been as frightened as his vassal. However, when the medicine was deposited adjacent to the nerve, numbness ensued down the limb in an anatomic distribution. Within days, it was obvious that regional anesthesia was not just a conceptual dream, it was a reality.
Many of the students experienced a rush of energy, with occasional nausea, flushing, palpitations, and dizziness. By altering the concentration of cocaine, symptoms were mitigated. Soon, operations were being performed on real patients on a regular basis at Roosevelt, and dental procedures were also accomplished by Halsted’s dentist friends.
Today, names like lidocaine, Novocain, and xylocaine are familiar to the reader, but few appreciate their close kinship with cocaine. While the former group of medicines are safely, and innocently, used in clinical settings around the world, cocaine is a different beast altogether. As Noyes had predicted in the first American paper dealing with cocaine, there is a shadow side to the remedy.
In New York, by the fall of 1885, signs of trouble were emerging. The students and surgical apprentices who had started to use cocaine snuff and even inject the concoction in social settings were now mired in tribulation. “The students began to drop from sight. The doctors’ behavior grew increasingly erratic. They slept less, talked endlessly and excitedly, and eventually performed less surgery and ignored their duties.”16 What started as good-intentioned, quasi-scientific experimentation had led to chemical dependency.
They had become cocaine addicts.
Within a year of the first experimental injections, Halsted, his colleagues, and his students had ceded control of their lives to cocaine. Halsted himself was beginning to miss morning sessions at his Roosevelt Hospital clinic, his erratic behavior resembling that of the junkies that were starting to materialize around the city. His coworkers witnessed his spasmodic gesticulations, nervous tics, impatience, and perspiration-filled encounters. A pharmacologically stimulated comrade is a wild, fiendish alternate of himself, frightening and unnerving.
Halsted made a triumphant return trip to Vienna in the fall of 1885, continuing his cocaine binge while abroad. He demonstrated his regional anesthesia technique to surgeons and dentists, and connected with old friends. There is no record of him meeting with Freud in Vienna, but one can imagine what that interaction might have entailed. Gerald Imber, in Genius on the Edge, writes that Halsted had lost command of his life, and those closest to him feared that he would be lost forever.
William Stewart Halsted was back in New York by January 1886, further spiraling out of control, lying, and obfuscating. Welch, his erstwhile friend, now in Baltimore to start the work of establishing Hopkins as an elite institution, was alerted by a mutual colleague about Halsted’s deterioration. “Once modest and self-effacing, he was now abrupt, spoke incessantly, and cared little for the response of those he was speaking with.”17 Welch formulated an intervention with two other physician friends, the four professionals meeting in an office to save the young surgeon from cocaine damnation.
The one physician, probably the sole human being, who could confront Halsted was the collegial and brilliant Welch, the scion of Connecticut physicians and Yale Skull and Bonesman, gifted in camaraderie and reasoning. The bachelor Welch directly confronted Halsted about his drug abuse, but didn’t stop at the chastisement; he proposed a solution: a lengthy, rejuvenating sea voyage, with the combined benefits of fresh sea air and eventual, forced drug weaning and disentanglement of cocaine’s grip. Halsted consented, and by February 1886, Welch had chartered the schooner Bristol, bound for the Windward Islands in the southern Caribbean.
The arrangement between Welch and Halsted was for the elder physician to obtain a very large quantity of cocaine and to serve as the custodian and administrator of the medication. The treatment plan stipulated that Welch would gradually decrease the daily dosage until Halsted had become completely weaned off cocaine, and by the time the four-thousand-mile round trip voyage was complete, Halsted would be cured.
On the outward passage, the Bristol was a vessel of the gods, a veritable Pegasus of the seas. Welch, the Greek literature expert (and once aspiring college professor), must have been recollecting Odysseus and his evasion of the Sirens. The goddess Circe had warned Odysseus that the Sirens were, in reality, murderous monsters disguising themselves as enchanting women with supernaturally enticing voices. Famously, Odysseus stopped his men’s ears with wax to deafen and inoculate them from temptation; but so that he “may have the pleasure of listening,” Odysseus kept his ears unplugged. Lashed to the mast so that he could not escape, Odysseus was tantalized beyond his power to resist, straining so vigorously that the bonds cut deeply into his flesh.
The journey degenerated as they arrived in the Caribbean, with Halsted bedeviled by the dwindling doses. The friendship between Welch and Halsted came under extreme duress, and late one night, Halsted broke into the captain’s medicine chest to procure the remaining cocaine doses. In every sense, Halsted was adrift at sea, and by the time they had reached the Florida coastline on the return trip, he was “plagued by nightmares, exhaustion, irritability, [and] outright suspicion of his fellow travelers …”18 Truly a Greek tragedy, perhaps the only explanation for Halsted’s survival is that the gods wanted Halsted to live, both to see the New York harbor, but also to rule in Baltimore someday.
Having failed deprivation treatment, it was clear to Halsted that more intensive medical intervention was required. Welch still believed in his friend, but insisted that he seek help at a sanitarium, at the time just becoming popular for treatment of drug addictions. Halsted checked himself into the Butler Sanitarium in Providence, Rhode Island, in 1886, and would spend seven months hospitalized for his cocaine addiction. A mainstay of treatment at the time was substitution of one drug for another, and Halsted was placed on a regimen of morphine—leading to a lifelong addiction to that as well. While there was an emphasis on healthy eating and outdoor activities, the introduction of morphine would lead to an awkward balancing act; “one drug heightened sensations and a feeling of omnipotence, the other a peaceful release from the world.”19
Halsted was now in a precarious station in life. Instead of private wealth, his father’s business was coming to ruination. There was nothing to fall back on; now six years removed from completion of his medical training, the previous great name he had made for himself was ruined. His lavish tastes firmly set in stone, Halsted desperately needed to revive his professional standing. In December 1886, just eight months from his disastrous oceanic experiment, Welch once again came to the rescue. Teetering, Halsted arrived by train in Baltimore and moved into the same boarding house in downtown Baltimore with Welch.
Johns Hopkins University was founded in downtown Baltimore in 1876 (later moving to a more suburban location in the early 20th century), and although two hundred years younger than Harvard and Yale, is considered the first research university in America. Following the lead of German educational leaders (particularly Wilhelm von Humboldt, founder of the Humboldt University of Berlin), President Gilman emphasized the role of research in education, both at the undergraduate level and among the graduate schools. This scientific discovery of new knowledge, as opposed to unimaginative recitation of outmoded facts, would greatly alter the American academy.
The metamorphological growth in understanding of human disease had changed stunningly in the preceding one hundred years. Morgagni first connected symptoms with anatomical conditions. Rokitansky and Virchow performed organ-based and cellular-oriented autopsies, thus furthering the understanding of morbidity. But it was the new science of bacteriology that was unlocking the comprehension of disease, and the new preeminence of laboratory science was poised to change healthcare in the new world, and Welch (under the watchful eye of Gilman) would establish on Laudenslager’s Hill in Baltimore the pantheon of American medicine. It cannot be overemphasized that the first building was the Pathology research building. Instead of conceiving a medical campus with medical wards, surgical amphitheaters, and a lying-in clinic, the enterprise’s cornerstone would be a building dedicated to the understanding of disease. Morgagni, Rokitansky, and Virchow would have been proud.
With the hospital not scheduled to open until 1889 (and the first medical school class not convening until 1893), Halsted’s proposed role in life would be to work in the pathology laboratory with Welch. For the next several years Halsted focused on animal experimentation and basic science research, greatly advancing the science of surgery.
In Vienna, Billroth had blazed a trail in abdominal surgery, but his outcomes were still hit-and-miss. Halsted theorized that a better technique might improve the clinical results, but what was demanded was a scientific analysis of the technique and more important, a technique based upon microanatomy. Within a week of his arrival, Halsted and Franklin Mall began animal surgery and microscopic evaluation of the different layers of the intestines, discovering the heretofore unappreciated role of the seemingly mundane “submucosa.”
The intestines have a three-layer configuration: an outer muscular layer, an absorptive interior lining layer, and a thin middle lining of connective tissue—the submucosa. Over the course of a few months, sixty-nine experiments were performed, evaluating the role of the submucosa and testing the strength of the new repair. In April 1887, Halsted presented a paper at the Harvard Medical School, advancing the understanding of how best to achieve robust tissue healing. This groundbreaking research (a cornerstone of general surgery to this day) made intestinal anastomosis (the sewing together of two ends) dependable, immediately impacting the survivability of abdominal surgery. Intestinal surgery would never be the same.
Curiously, Halsted couldn’t be positive he was correct; he was not operating on humans. Welch had brought him to Baltimore to labor under his supervision, but as a surgical pariah, he was not to be trusted with real patients. The laboratory was his clinic, and dogs were his patients. Admirably, Halsted administered fastidious care to the dogs. In fact, he developed “a manner of dealing with animal experiments that soon became the national standard,”20 his second major contribution to surgery in Baltimore in an amazingly brief time.
Welch had petitioned President Gilman’s tolerance of Halsted’s poor reputation; such was Welch’s esteem of his New York companion. The dog surgery, gainful basic science research, positive reception at Harvard—by all appearances William Halsted was finally righting the ship, except he wasn’t. Soon after his Boston presentation, Dr. Halsted checked himself into Butler Sanitarium again, this time for nine months. Over a twenty-two-month-long stint, “William Stewart” (his assumed name at Butler) spent sixteen months at the sanitarium, accomplishing nothing scientifically in the prime of his surgical career. No one taking bets at that time would have predicted he would ever resume surgical practice again, let alone assume the mantle of the most significant surgeon in American history.
Halsted clandestinely returned from his sophomore recuperation at Butler in December 1887, and quietly returned to work at the Pathology Building. The bachelor surgeon faithfully dined and socialized at the Maryland Club near his Baltimore dwelling, fastidiously researching by day with Welch and the young coterie of physicians. The previously energetic and gregarious surgeon had adopted a protective carapace, his old-fashioned pince-nez eyeglasses perched on his nose, shielding a dark secret of combined addiction to cocaine and morphine. Perhaps only Welch ever knew (for sure) that Halsted was an unrelenting, unrepentant, and partially incapacitated user.
In the classic German legend of the scholarly alchemist Faust, the malcontented intellectual makes a pact with the devil, exchanging his soul for unlimited knowledge and worldly pleasures. There is no doubt that Halsted’s cocaine use started innocently, but he rapidly was bewitched by its powers. Prescribed morphine at the sanitarium, the Greek god of dreams, Morpheus, also entranced Halsted. Sadly, a pervasive personality change gripped Dr. Halsted to his grave. Serious, secretive, ashamed, and vulnerable, he retreated into a cocoon that few could break into. By our nature, surgeons are “control freaks,” and the powerlessness must have tortured Halsted.
The routine at the “Pathology” had been comforting to William Stewart Halsted, and by early 1889, he had begun seeing patients and operating at local hospitals. He had arrived in Baltimore just two years before, shattered. Slowly, the former metropolitan bon vivant was reclaiming pride of profession, and a major decision now faced the administration at Johns Hopkins. Who would be hired as surgeon at the new hospital?
The Johns Hopkins Hospital opened in May 1889. Although the Pathology division had been functional under William Welch for several years, a full-time surgeon was only hired in the months before the hospital opened. Today, every hospital in America thrives or dies based upon surgical volume. In the 21st century, surgeons find themselves in very advantaged positions based upon the revenue generated by their work. In 1889, there were fewer than ten physicians in the United States whose practices were limited to surgery,21 such was the nascent nature of the profession. It is not so surprising that President Gilman had already hired the scientist and pathologist Welch, and then in turn employed William Osler to be the founding internist. Osler, a Canadian by birth, moved from the University of Pennsylvania and would become the preeminent physician in the world, eventually settling at Oxford as the Regius Chair of Medicine.
Just months before the opening of the hospital there was still no surgeon on staff. The leaders at Hopkins determined that their fledgling institution would be one of the rare hospitals that would hire a fully engaged surgeon. The successor to John Lister in Glasgow, Sir William Macewen was a pioneering surgeon in his own right. An important innovator in brain and bone surgery, Macewen’s prospects unraveled when his insistence on bringing his entire nursing staff was not acceded to. Now scrambling, the board of trustees at the hospital faced a difficult decision, hire the one surgeon known to them, warts and all, or scurry to find another European candidate.
After some deliberation, and more than a little trepidation, Halsted was invited to be the surgeon-in-chief to the dispensary and acting surgeon to the hospital in February of 1889. Three months later the hospital would open, and more than three years would transpire before the medical school commenced.
High on a hill above Baltimore, the domed redbrick buildings with intricate roof lines were rising in magisterial dominion. The dome of the administrative building, perched on the western edge of the campus, has become synonymous with Hopkins medicine, but Welch and Halsted were making scientific history at the nondescript hindmost of the university grounds.
At Bellevue in 1885, Halsted had overseen the construction of an operating room tent, but at Hopkins (for the first fifteen years), all surgical procedures were performed in the basement of Ward G, in a makeshift area lit by gaslight. All of the early anatomical and surgical theaters throughout Europe and America were at the top floors of academic buildings, harnessing the natural light streaming in from skylights and large building windows. Unglamorously, Halsted operated under improvised conditions in the women’s ward near the Pathology building.
Halsted had an old German operating table from the Franco-Prussian War, equipped with a central trough that drained blood and the deluge of caustic preparatory solutions. On the table was stationed a stretcher that also served as the implement for patient transport. Instead of the classic black wool Prince Albert frock coat favored by surgeons, Halsted selected white duck cotton operating suits, with high collars and short sleeves, topping off the ensemble with a little cotton skull cap. Indeed, the garb was still primarily worn to protect the surgeon’s finery beneath, but it was still a dramatic improvement over the blood-caked and detritus-covered coats.
There in the basement, dressed in white, incorporating what he had learned in Vienna, Berlin, and Würzburg, Halsted cobbled together a surgical practice from scratch. Having pioneered regional anesthesia and scientific animal experimentation, Halsted initiated a series of innovative changes that resonate in every hospital and academic institution to this day. In the opening years of the Johns Hopkins Hospital there were no trees, no medical students, and few surgical colleagues. “Halsted was a complex and isolated man, forbidding and nurturing; rigid, proper, and secretive; compulsive and negligent; stimulating and reclusive; addicted and abstemious; oblivious and solicitous; and always concerned with advancing the science of surgery.”22 If Halsted’s story is familiar, it may be that you have seen The Knick, the television series whose central figure is Dr. John Thackery, a character who is very much based upon William Stewart Halsted. Forever burdened with his drug impulses, he pushed on, his revolution beginning almost immediately at Hopkins, starting with his care of a nurse’s chafed and inflamed hands.
Lister had pioneered antiseptic surgery a quarter of a century prior to the naissance of Johns Hopkins Hospital. It had started with sponge dousing of carbolic acid to a surgical site, and then evolved to the use of an atomizer to spray the acid into the air. Next, the surgeons’ hands were approached with special indignity, with application of strata of acids, oxidizing agents, and amalgams. Scrubbing, dipping, coating, and painting was consigning everyone’s hands to becoming reddened and inflamed, if not purified. In particular, a well-to-do Southerner, nurse Caroline Hampton was troubled with dermatitis of her hands.
Welch had brought rubber work gloves back from Germany, using them for autopsy duty. They were too thick and clumsy for surgical work, so Halsted had another thought: could an American company help him develop a product better suited for the operating room? Halsted later recalled, “As she [Caroline] was an unusually efficient woman, I gave the matter my consideration and one day in New York requested the Goodyear Rubber Company to make as an experiment two pair of thin rubber gloves with gauntlets. On trial these proved to be so satisfactory that additional gloves were ordered.”23 It took a few years for everyone in the operating room to adopt Caroline’s gloves, but the “single greatest advance in the history of sterile technique”24 had occurred because of Halsted’s concerns for his nurse, who, just a few months later, became his wife. Almost forty years old, Halsted broke the bonds of bachelorhood, with Welch (forever single) serving as best man.
Before his arrival in Baltimore, Halsted had performed a series of “firsts” that were simultaneously courageous and bizarre. He was the first surgeon to remove gallstones, performing the operation in the home of a privileged and elderly woman suffering a life-threatening gallstone attack. The patient happened to be his mother. Later, he performed the first blood transfusion, using the new implements of hypodermic needles and tubing. The patient was suffering from postpartum uterine bleeding, but her life was spared after the transfusion. The donor? Dr. Halsted himself. The recipient? Halsted’s own sister. He also performed the first appendectomy, but tamely not on a relative.
The surgeon-in-chief Halsted quickly settled into a routine of bold surgical innovations with assistant surgeon J.M.T. Finney and his first resident Fred Brockway. Gerald Imber, in his book, Genius on the Edge, poignantly captures the first breast cancer operation performed at Johns Hopkins in June 1889, on a thirty-eight-year-old mother of ten who had furtively battled a growing, abscess-filled tumor for six months:
Halsted inscribed an extensive incision from the axilla, near the old abscess site, counterclockwise down and along the sternum, under the breast, encompassing the entire breast, and up the lateral aspect, meeting the original swipe and forming a giant, bloody teardrop.
Hardened by infection, the skin near the axilla was unusually difficult to reflect upward, and the lymph nodes under the arm couldn’t be reached. The recent abscess had matted them down. Common sense dictated returning to the axilla on another day. Dissecting with a scalpel, Halsted mobilized the entire breast and much of the underlying pectoralis major muscle. He applied artery forceps to arteries and veins as they appeared, and secured the vessels with fine silk sutures to minimize blood loss and crushed tissue. He removed the anatomical specimen in its entirety and carefully examined it at the operating table. Having taken great care to avoid cutting into the tumor for fear of spreading the cancer, Halsted now rolled the mass between bare fingers, and cut through its substance, making careful mental notes of its consistency and appearance before sharing his thoughts with his assistant. He placed numerous suture tags on areas of interest before sending the specimen to Welch’s pathology laboratory, where microscopic sections would be prepared for later examination.25
Halsted, like his mentors in Vienna and Halle, was attempting the first forays into the war against cancer. Pioneers like Virchow had identified the bizarre and warped cells that characterized tumors. These brigand cells, pathologic by nature, bunched into colonies and then whole masses, feeding off the host, multiplying, occupying, and eventually achieving a self-defeating coup d’état when the host succumbed. Richard von Volkmann, Billroth, and now Halsted, believed that cutting wider, deeper, and more aggressively was the answer to freeing the patient from the invader.
The ancient Greek word for cancer was karkinos, or crab. In 400 B.C.E., Hippocrates observed a tumor mass as a “clutch of swollen blood vessels around it, [reminding] Hippocrates of a crab dug in the sand with its legs spread in a circle.”26 Later writers would further embellish upon the idea of cancer as an alien invader, the crab outfitted with a tough carapace and bellicose pincers. With this mindset, the Halstedian concept of the surgeon’s role as liberator, the chief function was to separate the patient from her disease. Unlike the Greeks, who had no microscopes and no conception of the cellular basis of disease, Halsted understood that cancers were comprised of abnormal cells. What he and other dauntless surgeons were missing was the pathologic process of vascular metastases, where the cancer cells spread through the bloodstream and not just through contiguous, centrifugal growth.
Only decades since the discovery of what cancer really was—the pathologic transformation and growth of cells—and decades before chemotherapy and radiation would become available, Halsted perceived his heroic task was to lacerate, harrow, and extirpate (and disfigure and dismember, if need be). In the few years between the launch of the hospital and the opening of the medical school in 1893, Halsted would enlarge the zone of excision, eventually removing the entire pectoralis, and occasionally ribs, the collarbone, and all the lymph nodes. He wanted to get at the root of the cancer, naming the operation radical mastectomy, from the Latin word for root, radix. We misconstrue the meaning of radical in this context when we assume it means “severe” or “profound.” Clearly, radical mastectomy, in Halsted’s hands, was severe and uncompromising, but he was conceptually digging deeper.
In the end, the radical mastectomy would lose its favored position among cancer surgeons. A few brave surgeons, like Geoffrey Keynes, George Crile Jr., and Bernard Fisher, bucked tradition, believing that simple, less aggressive surgery was just as effective, and certainly less morbid, than radical mastectomy. (This transformation is elegantly reported by Siddhartha Mukherjee in The Emperor of All Maladies.) While the technique itself is no longer performed, we can certainly understand why Halsted posited that it might work. Wide resection is still a mainstay in solid tissue oncology, where shockingly wide swathes of muscles, skin, and bone are removed. Halsted did dramatically improve cancer mortality, but a cure was (and is) still on the horizon.
If radical mastectomy did not have staying power, other initiatives of Halsted did. Halsted had been inspired by the German way of training surgeons, notably Langenbeck’s and Billroth’s ideas of robust, demanding inculcation. Osler agreed with Halsted, and the first formal residencies in American institutions were at Hopkins. By 1893 Halsted was granted the title “Professor,” and he formalized his total immersion training system, where young men (required to be unmarried) would live at the hospital, and be available twenty-four hours a day, seven days a week. Old-time surgeons laugh at young American trainees who complain about “living at the hospital,” when in fact they “only” work eighty hours per week, as limited by federal law. (My wife reported a sobering story to me while I was a resident, years before the law went into effect and I regularly worked more than one hundred hours per week. Driving by the Penn State Hospital, my young daughter cried out, “Mommy, that’s where Daddy lives!” I actually shed a tear when I heard the story, pangs of guilt and remorse crushing me.)
Halsted’s particular skill of identifying potential, imbuing confidence and crafting surgical skill potentiated his reach across the United States for decades, since so many of his disciples became surgical leaders themselves. Gone were the days of part-time hacks with no scientific training masquerading as surgeons. “Laboratories were integrated into the great hospitals, aseptic surgery was slowly accepted, and postgraduate training became available.”27 “Halsted’s legacy was built on two equally potent, unimpeachably world-altering platforms. The first was the establishment of the school of scientific, safe, and anatomically correct surgery; the second, a working environment that shaped the education of generations of surgeons and propelled American surgery to its preeminent position in the world. The former brought about an undeniable surgical revolution, proven by consistently superior results …”28
As a young surgical resident, learning the delicate technical points of surgery, a professor of mine, displeased with my unrefined approach, said at one point, “Did you just hear that?”
Confused, I said, “No, I didn’t hear anything.”
My professor replied, “I think that was the ghost of Dr. Halsted rolling over in his grave, the way you just crushed that tissue in your forceps.”
Through years of careful badgering, we all learned how to be elegant surgeons. “Aseptic technique, gentle handling of tissue, scrupulous hemostasis, and tension-free, crush-free, and anatomically proper surgery are the rules. And they are Halsted’s rules. Although “Halsted” is not a household name, every individual in America who undergoes successful surgery owes William Stewart Halsted a nod and a deep debt of gratitude.”29
As important as Halsted was in transforming “the shunned black sheep of the medical world into a specialty offering the promise of mightily alleviating the suffering of the human condition,”30 helping reinvent a discipline and a surgical philosophy,31 perhaps one of his greatest innovations was performing elective surgery.
From the beginning of time, prototypical surgeons were busy draining abscesses, applying salves, and engaging in bonesetting. These primordial healers, retaliating against the gods and evil spirits, were always reflexive, responding to bad fortune. The forebears of surgery were the physicians to the gladiators and military doctors. With advancement, surgeons turned from hopeless emergency cases to conditions where their intervention might actually be beneficial. Patients submitted at a point of in extremis prior to Billroth, but cancer patients in Vienna, ill and racked with cancer, allowed him to remove parts of their bowels. Confidence in surgery was growing.
In the same month that Halsted executed his first Hopkins mastectomy, he performed, arguably, the most important elective operation ever attempted.
Children are born with inguinal hernias at a rate of 5 percent, but the incidence rises to almost 15 percent among adults, with men eight times more susceptible. “Turn your head and cough,” is the stuff of legends, but prior to successful surgery, hernias led to millions of deaths around the world. Prior to safe operations, hernia belts (“trusses”) and postural exercises were the only remedies offered, even if ineffective.
A hernia is a loop of bowel spouting into a weakened portion of the abdominal wall. This can occur at the umbilicus or at a surgical incision, but most commonly in the groin. An inguinal hernia occurs when “a 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.”32 Stated simply, a weakness in the lower abdominal wall allows your “guts” to billow through. Every medical student remembers the photo of a man with a hernia so massive it spilled dozens of pounds of intestines into his scrotum, necessitating ambulation with a wheelbarrow in front of him. I shudder just thinking about it.
The loop of bowel that pokes through the abdominal wall can become strangulated, hastening death, but typically, the hernia patient presents with non-life-threatening complaints of pain and unsightly swelling. With no effective treatment, and a tacit “you’re not dying,” physicians were accustomed to brushing away patients. That all changed on June 13, 1889.
Halsted was not the first to attempt hernia repair, just the first to report (in English) a dramatically effective technique. Of course, it was based on scientific analysis of the anatomical structures. He had performed numerous fastidious dissections, comprehending that deep repair of the tough fascia and muscles to the stout inguinal ligament, and reinforcing the internal abdominal ring, were the keys to a successful repair. Making an incision in the groin area, Halsted would discerningly tease the tissue layers apart, protect the spermatic cord, excise the hernia sack, and suture the appropriate layers together. The Halsted repair was born.
Halsted presented his technique in late 1889 at the Johns Hopkins Hospital Medical Society, and published his report in January 1890. In retrospect, Edoardo Bassini, an Italian surgeon in Padua, had independently published a similar procedure (in Italian) a couple months before, leading some academics to give dual credit to Bassini and Halsted. Rapidly, patients came streaming from all over the country to have Halsted repair their hernias.
Further refinement by Halsted, and his star residents, drove the success rate even higher. One of Halsted’s great legacies was Henry Cushing, another Yale graduate, who would refine the hernia repair of Halsted to include the use of cocaine anesthesia. (Cushing would become the father of neurosurgery, and his face can be seen on the logo of the American Association of Neurological Surgeons.) Today’s technique of hernia repair is technologically different than the Halsted/Bassini approach, but the significance of Halsted’s intervention for a serious condition, under elective scheduling, shocked the trajectory of hospital care. Just a few decades before, hospitals were only death houses, and no one (in their right mind) would consult with a surgeon when relatively well.
By the 1890s, the Professor, with dozens of residents in the wings, was overseeing a vast surgical empire. For only a few cognoscenti, Halsted’s travails with cocaine and morphine addiction were known. He would disappear every summer for months, leaving assistant surgeons and surgical residents in charge of the most sophisticated hospital in the world. His absence was ideal training ground for a life of surgery, at times the loneliest profession.
In the 20th century, there were a small number of hospitals in America that had become surgical meccas, including Johns Hopkins and the Mayo Clinic. Medicine and surgery, under the leadership of German thinkers and refined under American devotees, was no longer dependent upon divination and sorcery. Medical education reform, by way of the Flexner report of 1910, had revolutionized the way medical schools operated, and had resulted in the closure of half of American medical schools by 1920. Flimflam no longer tolerated, only schools with true academic missions would be accredited, facilitating the transfer of the mantle of leadership of surgery from Europe to America. This handover was complete with the cataclysms of the world wars.
Halsted passed in 1922 at the Johns Hopkins Hospital. Days shy of his 70th birthday, he died childless, but with numerous professional heirs and innumerable philosophical debtors. Patients had reason to believe in medical sciences by the Roaring Twenties, even before the advent of antibiotics. And a great deal of that confidence is owed to Professor Halsted. “For the few who knew of his ability to navigate uncharted waters [drug use] while the siren song rang in his ears, his journey was nothing short of heroic. If a single person can be considered the father of modern surgery, the only contender is William Stewart Halsted.”33