TERRY GROSS, host:
This is FRESH AIR. Im Terry Gross. Chances are youve never heard of William Stewart Halsted. But if youve ever had a surgical procedure of any kind, you could say he's affected your life. Halsted was born in the 1850s, when Americans were in appallingly poor health. Only half the children born lived to age five. More New Yorkers were dying from disease every year than were being born.
The practice of medicine was crude, and operations, when conducted, were barbaric. Surgeons worked with dirty hands, and nearly every patient developed serious infections.
Our guest Gerald Imber says no one did more to modernize medical surgery than William Halsted. He brought rubber gloves and sterile instruments to the operating room. He developed several innovative surgical techniques and revolutionized medical training. But he also suffered for decades from cocaine and morphine addictions, which he acquired while experimenting with anesthetics for surgery.
Gerald Imber is a plastic surgeon who's written several books. His latest is "Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted." He spoke with FRESH AIR contributor Dave Davies.
DAVE DAVIES, host:
Gerald Imber, welcome to FRESH AIR. William Halsted, he became known for conducting operations in ways that prevented infection and other advances. But even in his early years, he was an innovator. You tell the story that he did the first emergency blood transfusion, which was kind of a remarkable tale. Tell us what happened.
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Dr. GERALD IMBER (Plastic Surgeon, Author): Yeah. He was a young surgeon practicing in New York, and he was fairly successful. And his sister was in Albany and was giving birth to a child, and he was called up there to see her and to visit with her, and she began to hemorrhage. And her husband - who happened to be one of Halsted's friends and a physician, as well - and the obstetrician couldnt stop the bleeding. And Halsted was called in with them, and they packed her uterus with ice and gauze, and she became very, very weak and pale and was going into shock. And he drew blood from his own veins and injected into her. And it was claimed that she perked up, and this saved her life.
In retrospect, there are a couple of amusing things about the story. A: a few syringes full of blood will not make the difference. It won't -and that's not the difference between life and death. The second thing is: taking unmatched blood and donating it, as it were, to someone else is a recipe for disaster. And he luckily got away with it perhaps, because of the genetic closeness from sister and brother. But it's an interest anecdote. It was the first time anyone recorded a blood transfusion in an emergency situation, but he might very well have made the situation worse under different circumstances.
DAVIES: He certainly wasnt afraid, in an emergency, situation to take direct action, and you begin the book with a remarkable tale involving his mother.
Dr. IMBER: Yes. It's an interesting story. In 1882, Halsted had been in practice for a couple of years, and his mother was visiting this very same sister up in Albany. She - his mother had lived in New York. And she had, for a long time, had abdominal pain that radiated to her back and a sour taste in her mouth and just constant discomfort. And all the great doctors in New York couldnt make the diagnosis. But while she was visiting in Albany, she became extremely sick. She became moribund, and Halsted was called up to see her.
He arrived in the middle of the night with all his surgical instruments. He had his mother placed on the kitchen table and examined her. And he noticed under her - the right rib cage, she had a red-hot mass. And when he touched it she flinched and pulled away. And he immediately made the diagnosis of an acutely inflamed gallbladder with puss in the gallbladder and gallstones.
And on the kitchen table in Albany, he put his mother to sleep with some ether that he brought with him. Then he took his instruments and put them in carbolic acid, then dipped his hands in carbolic acid and took a scalpel, opened his mother's abdomen on the kitchen table, then opened her inflamed gallbladder, allowed a copious amounts of puss to be removed from the gallbladder - to run out of gallbladder, removed seven gallstones and saved his mother's life. And that was the first recorded incidence of anybody ever having removed gallstones surgically.
DAVIES: Wow. Did...
(Soundbite of laughter)
Dr. IMBER: With his mother on the kitchen table in Albany.
DAVIES: And did he repeat the surgery, and did it then become more widely practiced?
Dr. IMBER: It became very widely practiced. And over the course of the next number of years, as sterile technique became available every place and people realized that that's what was necessary for survival, one had two things that weren't available before: one had anesthesia and sterile technique. So people became more adventurous in general, and gallbladder surgery became fairly routinely done. Appendectomies became routinely done.
Halsted actually realized that one of the surgeries that had been done throughout history and never, never successfully, was the correction of hernias - anglinal hernias. He devised a method to correct hernias surgery, which was successful in 90 some-odd percent of the cases.
DAVIES: Right. And remind us - I mean a hernia is - it's when a piece of the intestine sort of penetrates the containing wall? You describe it.
Dr. IMBER: Yeah, that's exactly right. I have nothing to add. I rest your case.
(Soundbite of laughter)
DAVIES: William Halsted was an innovator in specific types of surgery. But you make the case here that what he really did that benefited all surgeons forever more was to develop techniques which avoided infections which had been so deadly before. Tell us how he did that.
Dr. IMBER: There was - first of all, there were three things he actually did that were critical in that sphere. Now - and those things were A: realizing that using sterile technique alone as Lister had done wasnt quite good enough, that you had to use truly aseptic technique.
DAVIES: That's Joseph Lister...
Dr. IMBER: Yeah.
Dr. IMBER: ...who, before him, had developed the technique of what, soaking things in carbolic acid, right?
Dr. IMBER: Yes.
Dr. IMBER: Which was the greatest step forward, but Halsted said that kills the infection that's there. Why dont we prevent the infection from getting there? And that's by the development of aseptic technique. And he actually had the audacity as a surgeon in practice three years in New York City to get on the staff of Bellevue Hospital and ask them to build a sterile operating room just for his use. And when they laughed him out of the room, he raised the money and built a tent on the grounds of Bellevue Hospital that had a floor laid in maple like a bowling alley, had gaslights and sterilization and was an operating room that cost $10,000 in the 1880s for his exclusive use. And it was the first sterile operating theater in New York, and probably in the world.
But taking it a step further, he recognized the fact that the surgeon's hands were the main culprit in spreading the infection. So he insisted on all sorts of sterilization techniques for the surgeon's hands, ultimately resulting in - serendipitously perhaps - but resulting in the use and development of rubber gloves for surgery. So...
DAVIES: Yeah, how did that happen? Because, you know, he was cleansing the hands. How did he move to rubber gloves?
Dr. IMBER: Well, his scrub nurse when he was at Johns Hopkins became allergic to the caustic solutions with which the hands were cleaned, and she had this terrible dermatitis. And, you know, one day, he was visiting at the Goodyear Rubber Company in New York for something else and he said, well, why dont you develop a pair of rubber gloves for us that we could use to protect the nurses hands from the caustic solutions and that we could sterilize? And they did so. And it was very useful for nurses, and the nurses adopted it regularly. And the surgeons didnt adopt it regularly for another six years. But when they did, that was the greatest step forward in preventing the transmission of infection to patients.
DAVIES: How did his ideas spread?
Dr. IMBER: Well, his ideas spread because he was the first great teacher of surgery. And at one point, the overwhelming majority of the professors of surgeries around the United States were all his disciples. So the Halsted method of surgery, the Halsted method of teaching surgery was what became the American method of surgery, which became the most important in the world.
From his seed came almost all the great surgeons in America, and every one of us, every practicing surgeon in any specialty in - maybe in the world, but definitely in America - can trace his lineage back to Halsted. And every patient who has ever had successful surgery for any problem in America owes a debt of gratitude to Halsted because his technique of teaching surgeons and teaching surgeons what to do is what turned the corner for us.
DAVIES: We're speaking with Gerald Imber. His biography of Dr. William Stewart Halsted is called "Genius on the Edge." We'll talk more after a break.
This is FRESH AIR.
(Soundbite of music)
DAVIES: If youre just joining us, our guest is Dr. Gerald Imber. He has a new biography of Dr. William Stewart Halsted, who perfected many modern techniques of surgery. The name of the book is "Genius on the Edge."
I want to talk about one more particular kind of surgery that he innovated, and that was the treatment of breast cancer. First of all, I mean, this was not an uncommon cancer to women in his time. What was typically done before?
Dr. IMBER: Well, there were a number of things that affected what was done with breast cancer prior to the turn of the 20th century. And basically, in that Victorian era, there was no self-examination, and women didnt go to doctors to have their breasts examined. People didnt go to doctors, period, until there was some emergency, and there was no such thing as a checkup. So women would know something was wrong when a baseball-sized tumor was felt or there was a separating mass - an effective mass in their breast.
And, of course, as we know now, that's way too late for a successful treatment, in most cases. So what was done in those days was basically watch people die. And then some people had the idea of removing the tumor and the local tissue and removing the breast. And you have to remember that the patients, for the most part, were patients with very advanced disease. And the way a successful treatment of that disease was measured was not by ultimate five-year or 10-year survival rates, but by the absence of local recurrence of the disease. So you do the mastectomy, and if there wasnt cancer visible in the area of the chest later, then it was considered something of a success.
Halsted developed a method by which the breast and the central tumor and the whole breast around it and the underlying musculature removed in one piece - which is called on block - in one large piece, and he never cut through the tumor because he knew that would spread it, and he took the lymph nodes out in the surrounding areas. And he had more than a 50 percent incidence of absence of local recurrence or cure of cancer by the yardstick of the day, whereas everybody else had a virtual zero percent success rate in curing the cancer.
And he called his operation the radical operation for cure of cancer of the breast, which it was. And that became what we know as the radical mastectomy, which was the gold standard operation for the next 50 or 60 years, and which - because of innovative doctors and pressure from women's groups - ultimately became - evolved into the modified radical mastectomy, and then evolved into the lumpectomy with radiation.
DAVIES: Halsted spent his early years in New York, but eventually settled in Baltimore because he was on the faculty of Johns Hopkins University. And a good part of your book describes what an innovative place it was. Just give us a little sense of what was unique about Johns Hopkins and its, you know, its place in the history of American medical education.
Dr. IMBER: Well, the Johns Hopkins Hospital was opened in 1889, and it was really the first hospital that had the idea of being integrated into a medical school with professors who would work at the hospital and in the medical school rather than people who would drop by to teach a little bit. And it was the first place that actually revered science and began with the idea of promoting scientific medicine.
And Hopkins - Mr. Hopkins, in his will, when he left some $7 million for the creation of the hospital and the university, made it clear that the best men available in the world were the first priority. And the people who were on his board of trustees took that to heart, and they found the best people in the world in the period of 1880, '85 or '86, when they were being recruited. And these included William Osler, who was perhaps the most important physician ever, William Welch, who was the great pathologist and the ambassador of scientific medicine to the world, William Halsted, and the great gynecologist Howard Kelly. But it was the first place where a scientific academic faculty was gathered for the teaching and advancement of medicine. And they had research laboratories, which never happened before.
DAVIES: Well, Gerald Imber, there's another side to Halsted's life, and that is his narcotics addictions, which began with cocaine. How did he first get introduced to it?
Mr. IMBER: Well, the story starts with, of all people, Sigmund Freud. In 1885, Freud was a neurologist in Vienna, and he had read about this new drug, this new alkaloid cocaine, which allegedly German troops were taking and were able to stay up for days on end and fight and not eat. And Freud got some cocaine. He tried it himself. He felt it had great potential, and he enjoyed the sensation of using it, as well. And he also noticed that there was a numbness of his tongue in any place that the drug touched.
And he and a friend started using it for topical anesthesia for people with an eye disease called trachoma, which is very painful. And they found that the eye became numb and the pain from the disease was abolished. So he had the idea that perhaps it might be useful other places. But meantime, some young man who was working with him began to use the cocaine for - to numb the eye and to do surgery on the eye under cocaine aesthesia. He published that.
Halsted read about it in New York in the New York Medical Journal, and a week later, he got a supply of cocaine and he started injecting cocaine into all of his medical students and all of his associates to determine how he could best block nerve impulses. And his idea was that if it makes things numb, that it could block the impulse from a nerve, stop pain and you could do surgery under local anesthesia.
And he began to use it successfully and used it on about a thousand patients at Roosevelt Hospital where he was working in the outpatient department. And he also introduced it to dentists to be used for local anesthesia for dentistry, and it changed the face of dentistry. But while he was learning how to use cocaine, there were a number of side effects that people had. But the worst of it was that the majority of the medical students involved became addicted, all of his associates became addicted, a number of them died, and a number of them just dropped out.
DAVIES: And he began using it himself, too, and he became addicted? Yeah.
Mr. IMBER: Well, he began using it on himself because he experimented on himself first, and he not only liked the feeling that it gave him socially, but he soon became addicted to it and developed a tolerance to it. And to get - he needed to have the cocaine, and to get that same level of euphoria, being the dosage that he needed increased, and he was injecting enormous quantities of cocaine. And at times, the things he wrote were total gibberish. And people would visit with him and say he stayed up all night talking nonsense in an animated fashion.
And finally, his family members did what we would call an intervention, and they took him off to Butler Hospital in Providence, Rhode Island where, obviously, cocaine addiction was not very well-known. It was not heard of. So they did the only sensible thing to break the cocaine addiction: They treated him with morphine. So he became addicted to morphine, also.
DAVIES: And did there come a point in which the dangers of the drug were realized and people stopped using it as an aesthetic? Or what happened?
Mr. IMBER: Well, not very soon. Once Halsted got his life almost under control - he never quite did. That, of course, was the precipice on which his genius was balanced. But once he got his life in order, he would never voluntarily use cocaine as a local anesthetic because he shied away from it. He kept on using it as his addictive drug of choice, but he just didnt want other people to use it and he was against it because he knew what it did.
But cocaine was a great local anesthetic. And until the advent of a drug that we all know as Novocain, cocaine was what every dentist used, what every minor surgery was done under, what most hernia repairs were done under. As long as the dose was very small and it was limited, and other medications were given afterwards, it didnt result in the patients becoming addicted. But cocaine was what you were injected with when you went to have a cavity filled.
DAVIES: We're speaking with Gerald Imber. His biography of Dr. William Stewart Halsted is called "Genius on the Edge."
We'll talk more after a break.
This is FRESH AIR.
(Soundbite of music)
DAVIES: If youre just joining us, our guest is Dr. Gerald Imber. He has a new biography of Dr. William Stewart Halsted, who pioneered many techniques of modern surgery. The name of his book is "Genius on the Edge."
Its interesting that Halsted wasnt even a drinker. I mean, but these addictions stayed with him after he was - he went from New York to Baltimore to work at Johns Hopkins and became this admired, you know, figure of enormous stature in medicine. Right?
Mr. IMBER: Well, he was, you know, abstemious, as you mentioned. And, you know, he was judgmental and he was difficult and he was the sort of person that was forbidding and - but the same token, he was a human being and he was as weak as anyone else. And breaking the hold of cocaine without having anyone supporting you wasnt an easy thing, so he became very addicted to morphine on a daily basis because the treatment of cocaine addiction with morphine created two drugs to which he was addicted: one which made him excitable and high, and the other made him pacific and relaxed.
And so the morphine he took every day - every work day, and sometimes he took a little too much and that didnt work out. And occasionally, he had withdrawal symptoms, and certainly that didnt work out. But for the most part, for 30-something years, he managed this, and no one was aware of it.
DAVIES: Halsted also seems to have been obsessive about certain aspects of life.
(Soundbite of laughter)
DAVIES: Like his dress and his food. What was - give us some examples of that.
Mr. IMBER: Obsessive hardly describes it. You know, it's interesting that the neurosis that makes you great is also the neurosis that makes you crazy. And Halsted was fastidious about - so fastidious about his dress that he had his shirts made at Charvet in Paris in large, large quantities, and then he sent his shirts back to Paris to be laundered because he felt no one in America could wash and iron his shirt. When he made coffee, he would pick coffee beans for size and color, and they had to all match precisely before he ground them and used them. And it goes on forever. That's the way he lived his life.
He was obsessive and ridged and a perfectionist in certain portions of his life, whereas in other portions of his life he was totally negligent, totally forgetful and not at all the same person. For example, he could leave a patient in a hospital bed for weeks on end and forget to operate on them. It's just who he was, and no one would ever remind him because you didnt want to incur his wrath. And he was really, a very complex individual.
DAVIES: Yeah, leaving them in the hospital bed, not on the operating table, right?
Mr. IMBER: Precisely. They never made it to the operating table.
DAVIES: Do you think that these obsessive traits came with the drug addiction or preceded them?
Mr. IMBER: I think they preceded it. And, you know, and as one becomes older, one becomes a caricature of his own self. And I think the same thing happened to Halsted, and there were a number of factors acting on that. One, that no one ever corrected him because he was William Stewart Halsted. Two, he did have the lack of inhibitions that come with drug use, and he was odd to begin with.
So that with no checks and balances, he did, in fact, become a caricature of the person he was in the old days in New York, although his surgical personality had changed dramatically, because in New York he was a fast, dexterous surgeon. And once the locale changed to Johns Hopkins, he became a slow, plodding, thoughtful surgeon. His results may have been excellent in both places, but the surgeons who came to visit him at Hopkins that knew him in New York didnt recognize him.
DAVIES: You know, I wonder if - since, you know, a lot of people are reluctant to deal with addiction and believe they can manage it in their lives, is it unsettling to find a story of someone who accomplished so much while being addicted for 35 years?
Mr. IMBER: Boy, I wrestled with this one, because to me, it's terribly counterintuitive, what he did. And I like to say that if he - look what he did while compromised by drugs. Think of what he could've done without being compromised by drugs. Other people say perhaps he needed that to loosen him up in some way. I absolutely reject that. I think that that's a fallacy. You know, there are numerous examples of people who think they're so creative when they're stoned, and they come back and look at what it was that they created and its laughable. I think one has to look at it as this man had the ability to succeed despite the disability, not because of the disability.
DAVIES: Gerald Imber, thanks so much for speaking with us.
Mr. IMBER: Thank you.
GROSS: Gerald Imber is the author of "Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted." He spoke with FRESH AIR contributor Dave Davies.
You can find an excerpt from Imber's book on our Web site, freshair.npr.org, where you can also download podcasts of our show. And you can follow us on Twitter and friend us on Facebook @nprfreshair.
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