Halsted’s basement operating room in the Johns Hopkins Hospital’s Ward G was relatively small in terms of length and width; nevertheless, it was a place of discovery, miraculous healing, and choreographed action that attracted the most promising surgeons in the country. In 1891, an intern recorded one of the most lyrical accounts of the room’s activities:
Halsted in the operating room (Halsted is the middle figure with his head downward), late 1890s to early 1900s. (photo credit 10.1)
In Halsted’s little operating room, with the old wooden table, the antiseptic technique was so perfect that there was never a moment of anxiety. I could not believe my eyes. It was like stepping into a new world. At the time Halsted’s technique was unique and the sureness and perfection of his results seemed to me then [to be] the nearest thing to a miracle that had been given to me to witness.
Unlike in his bold, hurried days while operating at Bellevue, Halsted was now the slowest and most painstaking of surgeons. In the decades before he first took to the operating table, the years marked by an absence of anesthesia let alone antiseptic surgery, doctors were forced to operate as quickly as possible, lest they invite complications of excruciating pain, shock, and infection. As a young man, Halsted had learned how to operate from those who valued speed above every other surgical technique. At Johns Hopkins, however, he elaborated an extremely gentle but time-consuming means of operating known as the “School of Safety.” His meticulous methods minimized damage to blood vessels and nearby tissues and all but eliminated unnecessary traumatic or immunologic injury to the operative field. Halsted also created a series of elegant suturing techniques, always using silk or thin silver wires rather than the traditional catgut, to better conjoin what the surgeon cut apart. Virtually all of his now universally practiced techniques facilitate far better and faster recuperation rates, even after the most aggressive surgical assaults.
Halsted (center, holding the instrument) in the operating room at the Johns Hopkins Hospital, c. 1905. (photo credit 10.2)
Dr. William Mayo, cofounder of the Mayo Clinic, is said to have quipped that the procedures at the Johns Hopkins operating room took so long that the patients typically healed before Dr. Halsted had a chance to close the incision. Perhaps more generously, the surgeon and historian Sherwin Nuland described the critical nature of such gentle techniques in a recent eulogy of another great operator, Dr. Michael DeBakey. Nuland’s assessment is equally apt in describing the miracles that transpired in Halsted’s operating room: “[His] fingers are engaged in a kind of complicated and tightly coordinated dance with those of [his] colleagues … the gentle touch is crucial. Sensitive tissues do not respond well when handled roughly, and may not heal. Living biological structures tolerate very little abuse, and are quick to express their displeasure when treated with less than the consideration that Mother Nature has made them accustomed to. The man or woman who cannot be an artist will never be more than a pedestrian surgeon.” Those of us who are not surgeons have little appreciation for this skill; yet all who have successfully sailed through any item on a wide menu of surgical procedures have the artistic Dr. Halsted to thank.
Some have suggested that the marked shift in Halsted’s surgical technique was due either to his active cocaine use or to his recovery from it; the most convincing arguments tend to side with the latter explanation. Dating back to the days when Sigmund Freud wrote his monograph Über Coca, physicians often believed that cocaine enhanced one’s powers of intellectual concentration and physical strength. Like many other stimulants, it might do so in small doses but only for short periods of time. Long-term cocaine use and surgical craftsmanship, on the other hand, are contradictory activities. Given Halsted’s history of cocaine consumption, it is impossible to imagine him operating so delicately and perfectly while actively under the influence. Cocaine would make his hands (and his brain) jitter and tremor too much to so expertly apply his scalpel.
IN FEBRUARY 1889, Halsted was offered a one-year appointment as chief of the surgical dispensary and acting surgeon of the hospital. Yet even with this promotion, William’s future was far more tenuous than Welch had led him to believe. The trustees had other ideas about whom to appoint as the permanent surgeon-in-chief. In this quest, they approached Sir William Macewen, the accomplished professor of surgery at the University of Glasgow. The arrangement fell apart over control of the surgical nurses, a prerogative the hospital was not prepared to relinquish. The vacuum created by Macewen’s rejection led to an eloquent plea by Welch, who vouched for his protégé’s sobriety. After a series of lengthy conferences, the trustees finally acceded. In October 1889, Halsted was named associate professor of surgery and, in March 1890, surgeon-in-chief at the Johns Hopkins Hospital and chief of the surgical dispensary. Two years later, on April 4, 1892, the mollified trustees rewarded Halsted’s exemplary work with the lifetime appointment of professor of surgery at the medical school. In a little more than two decades, he had gone from Yale undergraduate and College of Physicians and Surgeons medical student to becoming, seriatim, the surgical wunderkind of New York City, a raging cocaine addict, an asylum inmate, a brittle recovering and relapsing addict, a distinguished surgical scientist, and, finally, holder of the most prestigious professorship of its kind in North America and, soon, the world.
Beginning in 1889 and continuing through the 1890s, Dr. Halsted worked to create a remarkably aggressive means of battling breast cancer. His bold operation called for removing the breast and lymph nodes in the affected region as well as the major and minor pectoral muscles lying underneath. This drastic, disfiguring procedure became one of Halsted’s most famous contributions to surgery, even though it is, thankfully, no longer performed. In an era before early detection, radiation, and chemotherapy, a diagnosis of breast cancer was essentially a death sentence, and those stricken had few options available. At the opening of the twentieth century, Halsted performed his radical mastectomy at the Hopkins with the full expectation that his procedure worked to tame the cancer, if not cure it; that it should be offered to all women with breast cancer; and that it needed to be performed in a timely, precise, and uniform manner.
But this was hardly Halsted’s only surgical interest. During these years, he perfected new treatments for thyroid gland goiters, huge, unsightly growths on the neck once common in the United States before the development of iodized salt. He also created several virtuoso techniques for correcting inguinal hernias and aneurysms of large arteries, and the safe removal of gallstones. All of these problems counted among the most common (and once most vexing) of surgical maladies known to humankind.
After the last suture was stitched on each of these thousands of procedures, Halsted immediately dictated their precise details to a secretary, who just as quickly typed them up for the professor’s review, analysis, and eventual conversion into widely read and authoritative journal articles. His surgical word was law; every practitioner of the craft followed what Halsted of Baltimore decreed. As a result of his renown, he maintained a voluminous correspondence with a legion of surgeons and patients around the the globe seeking his help.
Halsted’s inguinal hernia repair, 1893. (photo credit 10.3)
LONG A DEVOTEE OF PERFORMING SURGERY under the most germ-free, or aseptic, conditions possible, Halsted, as one might expect, was among the first surgeons in the world to insist that he, his assistants, and all his nurses completely remove their street clothes before entering the operating room. The uniform Halsted chose for himself consisted of a freshly steam-laundered and sterilized short-sleeved white duck suit with white tennis shoes and a white skullcap. Over this garb he wore a sterile white gown tied from behind by his chief nurse. Such a uniform would hardly raise an eyebrow in today’s operating rooms, with the exception of its bright white color, which was later discarded for scrubs dyed greenish-blue, to cut down on the glare generated by the operating room’s intense lights. But in the late 1890s, when many could still recall surgeons who operated in frock coats spattered
with the blood and sinew of operations past, Halsted’s sartorial choices represented a true advance. If scrupulously adhered to, it did and does reduce unnecessary infections introduced into the open bodies of unsuspecting patients.
Halsted insisted on a ritual of painting the incision site with alcohol, iodine, and other disinfectants, followed by an elaborate draping with sterile cloth, leaving only the operating field in view. Soon after these preparations were completed, the master surgeon nodded to the residents to securely strap the patient to the operating table. He then asked the anesthetist, typically one of his junior residents, to begin the onerous task of placing an “ether cone,” a funnel covered with oiled silk and a towel, over the patient’s nose and mouth. Because a nearly strangling dose of ether was employed, a period of intense struggle often followed this action, forcing the residents, nurses, and orderlies to throw their bodies across the patient in order to keep him still. Eventually, the ether did its work, and within minutes the patient was “under,” insensate, and the operation began.
Caroline Hampton as a nurse, 1889. (photo credit 10.4)
For procedures requiring local anesthesia, weak solutions of cocaine were “not infrequently used” by residents in the Hopkins operating room, even if William rarely prescribed it. One morning during the late 1890s, while examining an agitated patient who’d undergone hernia repair with cocaine anesthesia, Halsted told a resident surgeon to administer some morphine as an antidote. “If you knew how terrible the suffering is with that restlessness after cocaine,” Halsted remarked, “you would not stint his morphia.” Yet even with the power to medically counteract cocaine, keeping his addictive archenemy so close at hand was akin to lighting a cigarette in a gas station. Such daily proximity to cocaine may well have constituted one of the greatest risk factors in Halsted’s episodic relapses in the years to come.
Medical historians have fiercely debated whether it was true love or William’s fetish for cleanliness that led him to create the iconic symbol of modern surgery: the rubber glove. Like all Listerians, William insisted that everyone entering his operating room vigorously scrub their hands in abrasive toxic chemicals that killed microbes. At Johns Hopkins, Halsted’s assistants immersed their hands in a basin filled with permanganate, followed by a dip in a basin of oxalic acid, and then a five-minute soak in a corrosive bichloride of mercury solution. They used stiff brushes, along with plenty of soap and water, to scrape and clean every millimeter of their hands, from the nail beds and crevices between their fingers all the way up to the elbows. The fastidious Dr. Halsted preferred to wash his hands with a sterilized cloth in a special basin filled with rubbing alcohol.
In 1889, one of the Hopkins surgical nurses caught William’s eye. Her name was Caroline Hampton. A tall woman with piercing eyes, she hailed from a distinguished family of planters that included her uncle Wade Hampton III, a decorated Confederate general. A photographic portrait of Caroline in her nurse’s uniform exhibits a bright air of confidence and a prematurely pear-shaped figure. Robust and horsey, Caroline was especially good at maintaining the various mechanical gadgets then in use at the hospital. By some accounts, she was difficult, spirited, prone to haughtiness, and high-strung. But Dr. Halsted saw her worth and appointed her to be the head nurse in his operating room.
The abrasive chemicals Caroline doused her hands in every day rendered her skin rough, cracked, and marred by red, angry rashes. None of these traits appealed to either the southern belle or the surgeon who pursued her. As the dermatitis traveled up her fingers and hands and extended to her forearms, a besotted William grew determined to do something therapeutically definitive and sweetly chivalrous. In the winter of 1889–90 (in later years he could never recall precisely when), the surgeon took a train up to New York and met with an executive at the Goodyear Rubber Company. Armed with drawings of prototypes, he asked the rubber man if he would kindly manufacture “two pairs of thin rubber gloves with gauntlets.” Soon after, all the surgeons and nurses in his operating room donned them. William’s invention may have begun as a means to win Caroline’s heart, but it ultimately changed the way doctors operate, much to the benefit and safety of their patients.
In March 1890, William proposed marriage to Caroline. Whether this reveals his caustic sense of humor or signs of a conflicted inner life, a few weeks later he wrote to his Johns Hopkins colleague, the acerbic anatomist Franklin P. Mall: “I know that you will be astounded to hear that I am engaged to be married. A good joke for you I know. I wish that I could see you chuckle. Miss Hampton reminds Booker and me very much of you. I suppose that is the reason that I proposed to her.”
The couple wed in Columbia, South Carolina, at the Hampton family–endowed Trinity Episcopal Church on June 4, 1890, with William Henry Welch standing up as the best man. Before the nuptials, Caroline resigned from her post at the hospital.
In later years, colleagues would comment on Dr. and Mrs. Halsted’s distant marriage. Theirs was a type of relationship that was rather common in the late nineteenth and early twentieth centuries: spouses lived together and shared emotional connections but pursued activities that did not include the other. Some criticized her mannish dressing style and his general avoidance of any close contact with her. It was well known in Baltimore that the Halsteds occupied separate floors of their enormous town house at 1201 Eutaw Place. He lived on the second floor, with his books, papers, and a secretary desk stocked with boxes of freshly filled fountain pens, Pall Mall cigarettes, cigarette holders, and eyeglasses. She resided on the third floor, with their beloved black dachshunds, Sisly, Fritz, Nip, and Tuck. The union produced no children. They supped as a couple, followed by a brief conversation of the day’s events and withdrawal to their separate quarters. According to those familiar with the couple’s domestic routine, they never had breakfast together.
Eutaw Place, Baltimore, c. 1900; the street where the Halsteds lived. (photo credit 10.5)
As exacting about his home environment as he was about his operating room, William made the sort of incessant demands that proved particularly grating for Caroline. The surgeon’s Turkish coffee had to be ground and brewed just so; the table linens were always to be freshly laundered and flatironed. He typically interfered with the management of dinner parties by insisting on ordering groceries from nearby Lexington Market, planning the menu, arranging the flowers and china, and, even though he rarely drank, selecting the wines. William’s ceaseless search for perfection often exhausted the migraine-prone Mrs. Halsted.
In 1898, Harvey Cushing, then a surgical resident of Halsted’s and soon to be a founder of modern neurosurgery, wrote his mother that William’s “stone-cold” lair reminded him of Charles Dickens’s Bleak House. The house overflowed with antiques, Oriental rugs, blooming dahlias, leatherbound books, telescopes, knickknacks, and an intricate telephone system linking each room in the house and connected to an outside line, the latter strictly guarded by servants ordered to tell any callers that the Halsteds were unavailable. It was an unwritten law among his residents at the hospital that the chief was not to be disturbed at home, no matter how dire the situation. Once his castle’s heavy door was slammed shut for the evening, William intended it to stay that way.
Mrs. Halsted, out for a carriage ride, c. 1910s. (photo credit 10.6)
Even at his healthiest, Dr. Halsted did not operate often: three mornings a week at the most and rarely more than one patient in a single morning. In the latter years of his career, he operated far less frequently. The cases he chose were selected from among the many patients seeking care at the Hopkins’s surgical clinic, but Halsted limited his practice to the conditions he was studying at the time.
Those days he did operate, he left the surgical theater promptly at the stroke of noon. From there he beat a hasty retreat to his rooms on the second floor of the hospital for a light and solitary luncheon. This suite was where he’d lived in 1889 and 1890, until he’d married Caroline. William was so finicky about the decor of his pied-à-terre t
hat he ordered the painting of its walls to be done over and over again until the color suited his aesthetic sensibilities. Equally central to the setting was a marble-manteled fireplace that was kept well stoked by an orderly assigned to fulfilling his every wish. The small suite of rooms, with its overstuffed Victorian furniture and a large photograph of Michaelangelo’s Madonna of Bruges, was his refuge from the tumult and stress of his surgical world.
Halsted organized his hospital service into a hierarchy of men and offered them an unparalleled training experience. Composing the base were several interns and junior residents. As the pyramid rose to its apex, the surgical wheat was separated from the chaff. Those still standing assumed increasing responsibilities in and out of the operating room. At the end of a term of eight or more years, the most able trainee was handpicked to become Halsted’s chief resident. This lofty position, one that held the keys to the fabled Hopkins operating room, invariably led to a professorship and chief of surgery post at a premier hospital. Rigorous, entirely exhausting, and challenging to even the hardiest of men, this system was quickly adopted by virtually every surgical residency program in the United States and, for decades, produced many thousands of qualified surgeons.
Halsted (center, in black) on ward rounds at Johns Hopkins Hospital, c. 1914. (photo credit 10.7)
Once patients left the operating room, Halsted relegated their care to his residents. These young doctors stayed up night and day, paying scrupulous attention to the operative wounds with frequent dressings and bandage changes. They were also on the lookout for signs of the surgeon’s greatest nemesis: postoperative fevers, the sometimes subtle, sometimes raging indication of infection brewing below the surface of the skin.
An Anatomy of Addiction Page 20
