Physician, Heal Thyself: Part I

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 …

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Letters

Freud & Cocaine: An Exchange November 10, 2011