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Physician, Heal Thyself: Part I

1.

Among American surgeons, William Stewart Halsted (1852–1922) was never the most dexterous or brilliant. Indeed, he wasn’t even minimally reliable during the second half of his forty-two-year surgical career. Offering spurious excuses, he absented himself for long periods from his duties at the Johns Hopkins University Hospital. When on hand, he delegated most operations to a resident, sometimes walking away in the middle of a risky procedure. And he was worse than useless as a classroom teacher, lecturing over the heads of interns and students and treating them with icy disdain. Yet a case can be made that medical posterity owes more to Halsted than to any of his compatriots from colonial times until now.

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Freud Museum, London
Sigmund Freud and Martha Bernays during their engagement, Wandsbeck, near Hamburg, 1885

When Halsted first picked up his scalpel in 1880, general anesthesia with ether had already rendered most surgery painless. A patient, however, was still as likely as not to die from an infection introduced during the procedure. The germ theory of disease was still in dispute, and doctors used tainted hands and knives to excise tissue. But transatlantic advances made by Louis Pasteur, Robert Koch, and Joseph Lister—the last a demigod in Halsted’s eyes—had rendered antiseptic (and later aseptic) surgery feasible; and it was the methodical, uncompromising Halsted, first briefly in New York and then in Baltimore, who established our national model of the sterile operating environment.

Halsted’s “safe surgery,” perfected at Johns Hopkins, included more elements than clean gowns, rubber gloves, sterilized instruments, and disinfected wounds. One priority was the avoidance of trauma to adjacent flesh that could tip the balance unfavorably between ambient bacteria and natural defenses. Adapting the best European practice, which he had witnessed at first hand in 1878–1880, Halsted employed minuscule artery forceps to control bleeding. Through trial and error he improved both the material chosen for sutures and their placement when rejoining opened organs. And his meticulousness extended to lengthy and vigilant postoperative care. As his unprecedented success rate—notably with his innovative procedures for treating breast cancer, hernia, and thyroid disease—became widely known, initial resistance to the instituting of his reforms melted away.

Meanwhile, however, Halsted’s most original gift to surgery was one that cost him dearly, leading to the seeming contradiction of meticulous attentiveness and undependability. On September 15, 1884, at a Heidelberg conference, the medical world received the electrifying news that a young Viennese ophthalmologist, Carl Koller, had shown how a solution of cocaine, the most active alkaloid of the coca leaf, could numb an eye for surgery without producing unconsciousness or nausea. Halsted wasn’t there, but he read about the event, and six weeks later he was already at work in New York experimenting with cocaine injections in every nerve he could find throughout the body.

Halsted’s trials, executed on himself and twenty-five to thirty of his medical students, produced results that were both encouraging and disturbing. Cocaine proved capable of deadening not only an individual nerve but all of its descending branches. Only when the solution and dosage were finely calibrated, however, could the drug cancel sensation without causing disruptive side effects. Continual experimentation was called for. By the time, in November 1884, that a dental colleague performed a triumphant tooth extraction using nerve-blocking cocaine, Halsted and his fellow subjects had undergone far too many injections, closely spaced in time. The entire crew was in the grip of cocaine euphoria, and Halsted, formerly known for his calm and decisive manner, was turning manically restless.

It must have been in such a state that Halsted, in 1885, composed a short but rambling and belligerent paper defending the “Invariably Successful Employment [of cocaine] in More than a Thousand Minor Surgical Operations.” Its opening sentence would become notorious as an exhibit of cognitive impairment under cocaine:

Neither indifferent as to which of how many possibilities may best explain, nor yet at a loss to comprehend, why surgeons have, and that so many, quite without discredit, could have exhibited scarcely any interest in what, as a local anaesthetic, had been supposed, if not declared, by most so very sure to prove, especially to them, attractive, still I do not think that this circumstance, or some sense of obligation to rescue fragmentary reputation for surgeons rather than the belief that an opportunity existed for assisting others to an appreciable extent, induced me, several months ago, to write on the subject in hand the greater part of a somewhat comprehensive paper, which poor health disinclined me to complete.1

When “poor health” rendered Halsted incapable of functioning any longer in his profession, he was induced by two friends to undertake a lengthy sailing voyage in February 1886, heading for the Windward Islands in the southern Caribbean. He would be allowed to bring some cocaine, but just enough for daily tapering off until he could refrain altogether. The trip proved disastrous when the desperate Halsted, having exhausted his stash, was caught trying to steal drugs from the captain’s medicine locker.

Halsted’s two friends refused to give him up for lost. Aided by one of his brothers, they induced him to commit himself for a seven-month course of rehabilitation at Butler Hospital in Providence. Unfortunately, the treatment featured shots of morphine that were meant to take the place of cocaine. Halsted emerged as a morphine addict, but one whose brain still craved the other drug. And not long after, a cocaine relapse landed him back in Butler for further morphine therapy.

Between the hospital retreats, however, Halsted received the luckiest break of his life. One of those concerned friends, William H. Welch, had been appointed professor of pathology at Johns Hopkins in 1884. Eventually Welch became the dean and guiding spirit of the Hopkins medical school, whose other luminaries would be William Osler, Howard Kelly, and Halsted himself. Believing in Halsted’s capacity for self-mastery, Welch brought him to the university’s new Pathological Laboratory on a provisional basis, permitting him to operate only on dogs for the first two years.

In spite of such setbacks as the second hospitalization, the plan succeeded magnificently. Some of Halsted’s best insights into effective surgical technique were gained in that period, when canine subjects gave him the freedom to execute and refine every hypothesis that occurred to him. From 1890 onward he would be Hopkins’s distinguished surgeon-in-chief and the hands-on mentor to residents who would propagate his methods across the country.

The Hopkins trustees and a few members of the faculty and administration were aware that Halsted had once fallen victim to cocaine. Except for Welch, though, none of them knew that his frequent and prolonged absences were the result of cocaine binges; and not even Welch, it appears, guessed that his late afternoons at home were reserved for injecting the morphine he needed to combat symptoms of morphine withdrawal. The full truth of Halsted’s dependency emerged only piecemeal, in memoirs and investigations after his death in 1922. Only his wife, herself possibly a morphine addict, would understand that his remoteness, severity, and mordant sarcasm were products of a daily struggle with addiction. Steadied by morphine, Halsted could still be charming in soirées with friends. But at work he had no charity to spare, especially toward those interns and nurses who struck him as observing a lower standard of care than his own.

The story of Halsted’s astonishing ride—from child of privilege and Yale’s diminutive football captain to quick and intrepid young surgeon to helpless addict, and thence to a double life while earning worldwide renown—is crisply told in Gerald Imber’s Genius on the Edge. A surgeon himself in Halsted’s line of succession, Imber excels in characterizing Halsted’s techniques and discoveries and the general state of Victorian medicine. But he is equally adept at the more delicate task of portraying Halsted evenhandedly. Halsted’s tenacity, perfectionism, and scientific acumen aren’t easily reconciled with his furtive and precarious private life. Avoiding both censoriousness and idolatry, Imber gives us the fully human Halsted, who disgraced himself more than once, puzzled and alienated many associates, but successfully worked around a handicap he had incurred through an honorable zeal for discovery.

Although it appeared eighteen months ago, Genius on the Edge goes unmentioned in Howard Markel’s An Anatomy of Addiction, which, in alternating sets of chapters, pairs Halsted and his contemporary Sigmund Freud as major figures who were almost destroyed by cocaine. Where Halsted is concerned, Markel covers roughly the same narrative ground as Imber. He does so, however, with a forced jauntiness that soon becomes annoying. And in nearly every other respect, from accuracy of detail and clarity of prose to consistency of attitude toward his subject, Markel’s book falls short of Imber’s standard.

An Anatomy of Addiction shows signs of having been hastily assembled. To Halsted’s baroque sentence about cocaine, quoted above, Markel adds no fewer than seven errors of transcription, one of which turns an already tangled statement into outright nonsense. The pharmaceutical company G.D. Searle is rendered as “John Searle.” And the book’s endnotes, some of which are of dubious pertinence, contain numerous errors of citation.

Markel’s diction repeatedly misses its mark: “pandered for new patients,” “a harem of student nurses,” not eyes but “steely-blue orbits.” Clichés abound,2 and dead metaphors mischievously come to life: “these pharmacological morality plays end with the drug relegated to the medical equivalent of the proverbial doghouse”; “as the pyramid rose to its apex, the surgical wheat was separated from the chaff.”

In spite of such awkwardness, Markel does go beyond Imber in his detailed explanation of the neurophysiological action of both cocaine and morphine. As he writes, when cocaine lies within reach of its daily users, no drug produces more reckless craving or more irrational behavior. Occasional recreational users, however, can get by without it when it is unavailable. Moreover, its withdrawal symptoms are much less severe than those of morphine. Thus we see why the partially reformed Halsted, while capable of postponing his cocaine holidays until he was away from Baltimore, needed to inject morphine every single day. In the long run, his management of his cocaine habit was less preoccupying than his continuous enslavement to morphine.

That fact, however, is precisely what Markel tends to forget from time to time, thanks to his predetermined focus on cocaine. An Anatomy of Addiction begins on a note of cocaine sensationalism and never quite succeeds in establishing a more balanced point of view. Of the two authors, it is Imber who does full justice to the complex outcome of Halsted’s battle with both morphine and cocaine: a shrinkage and embittering of his once outgoing personality but a renewed adherence to scientific principles that could easily have been undermined by the drugs.

Oddly, however, both Imber and Markel grant only slight attention to an intriguing and possibly important topic: Halsted’s sexuality. On the evidence they supply in isolated passages, there can be little doubt that the great surgeon was homosexual. His childless marriage at age thirty-eight to a “mannish” woman who coveted his fortune, lived on a separate floor of his house, and spent half of each year alone in North Carolina hardly counts against that inference.3 Announcing his plans to a colleague, Franklin P. Mall, Halsted wrote the following sardonic lines:

  1. 1

    William S. Halsted, “Practical Comments on the Use and Abuse of Cocaine; Suggested by Its Invariably Successful Employment in More Than a Thousand Minor Surgical Operations,” New York Medical Journal, Vol. 42 (1885), p. 294. 

  2. 2

    On one page alone, for example, we read that someone “could not get a word in edgewise” and “beat a hasty retreat,” that Welch “laid all his cards on the table,” and that Halsted took drugs to escape “a hundred and one other slings and arrows of life” (p. 108). 

  3. 3

    Caroline Halsted railed against her husband’s preference for laboratory research over lucrative private surgery. (He once charged the present-day equivalent of $260,000 for removing a dowager’s bile duct stones.) When Johns Hopkins raised its professors’ salaries but discouraged outside income, Caroline complained that William’s newly fixed pay, roughly $300,000 in our money, constituted a financial sacrifice. Needless to say, she disapproved when he returned much of his salary to the medical school for the benefit of its underpaid employees. 

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