Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (17 page)

The cancer can spread its tentacles in every direction—most frequently through the lymphatic channels, as suggested by the presence of cancer-free tissue between the original mass and the lymph nodes into which the lymphatics drained. It burrowed deeply as well, sometimes onto the fascia covering the pectoralis major, the large muscle that makes up most of the substance of the chest; sometimes into the muscle itself; and often into the fat between the pectoralis major and the smaller, underlying muscle, the pectoralis minor.

Halsted studied all this. He examined every patient in painstaking detail, asking, touching, moving, and smelling. He examined every surgical specimen with Welch or Councilman, correlated his impression of gross appearance with microscopic findings, and ultimately followed those who succumbed into the dead house.

The conclusion was obvious: the only way this awful disease could be contained was to be more aggressive than the disease itself. Halsted postulated that removing the breast, including all the skin above it; the pectoralis muscles, major and minor, beneath it; the lymph node–rich axillary fat; the lymph nodes beneath the clavicle; and even removing a section of the bone itself to reach the lymph nodes above would encompass the most frequently involved sites. This he did “en bloc,” or in one mass, never detaching pieces, cutting through possibly involved tissue, or excising separate segments. The large teardrop incision made through the skin and fat surrounds the breast. The insertions of the pectoralis muscle near the sternum are cut, and the entire specimen pulled upward until the axillary contents are dissected free and removed, hanging like a tail from the large bloody specimen.

Throughout the procedure, assistants applied dozens of fine artery forceps to every artery and vein in the field, taking care to cross-clamp, divide, and tie them with fine silk thread before they could
be accidentally cut and bleed. Each vessel was cleanly identified, and care taken to grasp only the blood vessel, and not surrounding tissue, in the jaws of the fine instruments Halsted had designed after those brought back from Germany. Some 250 clamps hung from the wound and the specimen, this at a time when most hospitals owned a half dozen clamps, if any at all. Halsted demanded the silk tied around the vessels be applied with just enough force to stem the hemorrhage, and not enough to crush the tissue.

Anatomically correct dissection and compulsive attention to detail were required. It was not the province of the slash-and-dash surgeon. In fact, it was not then the province of any other surgeon in the world, and it fell to Halsted and his diaspora of residents to preach this gospel and make the surgical world believe.

If Halsted’s examination of patients was lengthy, his operations seemed interminable. Some years after the first operation, Will Mayo, one of the famed Mayo brothers of Rochester, Minnesota, came to watch Halsted perform his by then famous breast operation. After watching for two hours, Mayo left the operating room and said, “I have never seen a wound operated at the top while the bottom was already healed.”

Visiting colleagues who had known Halsted as one of the fastest, slickest surgeons in New York City were amazed by the transformation. In Baltimore, he had become a thinking surgeon who sacrificed speed and style for scrupulous care and anatomical integrity.

His blue-gray eyes were fixed on the surgical field, and he stared down transgressors over his pince-nez glasses when his attention was diverted. He spoke little during surgery, and expected the same of others. Once during a procedure he turned to an assistant and said, “May I ask you to move a little? You’ve been standing on my foot for half an hour.”

Nothing took place in Halsted’s operating room without study and planning, yet the hospital staff had nicknamed him “Jack the Ripper.”
Much of the joking must have stemmed from how busy the surgical service was from the day the hospital opened its doors, and some may have arisen as a result of the magnitude of his new procedure. The apocryphal dark joke in the hospital was of the orderly asking Halsted which part of the patient was to be returned to the ward.

In the seven months from the hospital’s opening in early May to the end of 1889, 316 patients were admitted to the surgical wards. Not all of these admissions culminated in surgery, but the sheer volume kept Halsted, Finney, Brockway, and the assistant resident, George Clarke, very busy. Five of these early patients had carcinoma of the breast. As word spread of Halsted’s new operation, and its apparent success, women in need were drawn to Johns Hopkins for treatment.

To the uninitiated, the sheer magnitude of the procedure must have been seen as terribly brutal, despite its being devised to save, or at least extend, lives. Other surgeons were experimenting with similarly extensive procedures. One English surgeon summed up the new philosophy by saying that doing anything less was “a mistaken kindness to the patient.” Osler and the other clinicians were impressed with the new surgical service, as well as the new attitude toward surgery, and began suggesting surgery for patients where previously they would have shunned the idea. Halsted quickly became a star.

In time, the “Jack the Ripper” sobriquet disappeared, and “The Professor” took its place. The new nickname originated with the father of a young patient who kept referring to Halsted in conversation as “professor” this, and “professor” that. Halsted turned to the man and said, “Oh, don’t call me professor. I’m no dancing master.”

That was enough for the residents and students, and “The Professor” it was. Welch was “Popsie,” and Osler “The Chief.” Halsted was “The Professor” for the remainder of his life. He endured the name in silence, and it was never uttered to his face.

In April 1894, Halsted presented a paper before the Clinical Society of Maryland, in which he reported that of “50 cases operated upon by
what we call the complete method, we have been able to trace only three local recurrences.”

Three local recurrences of 50; 6 percent local recurrence with the Halsted method, against more than 50 percent for surgeons employing older, less “complete” methods. Once the paper was published, surgery for cancer of the breast changed. Surely, the astounding difference in local recurrence was worth the extra effort. The Halsted mastectomy became the gold standard for care until the mid-20th century.

Halsted was seen as a formidable and eccentric figure. He was now using a great deal of morphine, and had become enigmatic and detached. He became increasingly fragile as the day progressed and his morphine level ebbed, yet he maintained a bruising schedule, rushing from operating room to dispensary, afternoon lectures to graduate students, and finishing the day in the experimental laboratory. By evening he was once again the Halsted of old.

HISTORICAL NOTE
: By the 1960s, proponents of both more radical surgery and less radical surgery were challenging the Halsted mastectomy. Confusing and counterintuitive as this seems, it was the state of affairs. The ability to detect breast cancer using X-rays was demonstrated in 1913 by a German surgeon who studied 3,000 mastectomy specimens and was able to show a distinctive X-ray pattern associated with the cancers, making them identifiable within normal tissue. By the mid-1950s mammography was being used as a diagnostic tool, and by the mid-1960s it was generally available, and far more sophisticated and accurate. Breast cancers were being detected much earlier, and the huge tumors presaging florid disease became less common. Cure rates improved—not simply local recurrence rate, as in the Halsted years, but actual and complete cure as measured by five- and ten-year disease-free survival. As mortality figures plummeted with the mastectomy, some surgeons felt more aggressive surgery would save more lives. They encouraged wider dissection of lymph nodes, including
chains within the chest. In effect, they were proposing super-radical mastectomies. These procedures were encumbered by longer hospitalizations and greater postoperative morbidity. They may, or may not, have increased cure rates in more advanced cases. With no clear statistical evidence of superior results, the super-radical mastectomy was not generally adopted.

From the other flank, a few well-regarded surgeons dared to suggest that with the disease being discovered so much earlier, perhaps smaller, less mutilating surgery would suffice to treat the much smaller tumors being incurred. By the 1970s, the surgical community had rallied behind the muscle-sparing modified radical mastectomy, which replaced the Halsted operation. Meanwhile, others were studying the possibility of doing even less extensive procedures. Leading the charge were Oliver Cope of Boston and George Crile Jr. of Cleveland, the latter the son of an esteemed contemporary of Halsted’s. The medical community was fairly unanimous in their damnation of less radical surgery, calling the concept a step backward. But survival rates for “lumpectomy” and radiation for smaller tumors were the same as for the similar tumors treated with mastectomy. Growing pressure from women encouraged larger-scale trials resulting in similar outcomes within the early-diagnosis groups. With early diagnosis and the advent of effective adjunct therapy, lumpectomy with radiation and/or chemotherapy has replaced the radical mastectomy in the majority of breast cancers.

One hundred years ago the breast cancer patient was virtually doomed. Halsted changed all that. His actual cure rate was very likely depressing, given the advanced stage in which his patients were seen. However, he dramatically reduced the incidence of local recurrence, ensured an apparently disease-free period, and very likely cured a large number of previously incurable cases. He established a protocol for removing cancers and developed a more effective operation against which all others had to be compared. As diagnostic tools improved
over the years, and smaller tumors were being detected and treated, the overall cure rates rose to nearly 90 percent. In smaller, early-stage cases the cure rate now approaches 100 percent.

CHAPTER FIFTEEN
Life in Baltimore

DURING THAT FIRST HECTIC
year, Halsted took his leave of Welch and the Simmons house on Cathedral Street. Johns Hopkins had made provisions for in-hospital living accommodations for interns, residents, and senior nursing personnel. For the young doctors under the new teaching regime, there would be little time for life beyond work. The in-hospital quarters not only implied total commitment, but facilitated it. Staff nurses were not lucky enough to have hospital housing. As a group, they felt themselves underpaid and overworked. In addition to learning nursing skills, the Training School taught them to cook and clean. Part of their uniform included brown oxford shoes. These, the nurses called their “duty bootie,” and felt signified their underclass treatment and “second class citizen plight.”

Both Halsted and Osler wished to be as close as possible to their still-evolving responsibilities. They chose to live in rooms not far from each other, on the third floor of the hospital. Halsted, far more particular about his surroundings than Osler, found time to furnish his small, two-room apartment with fine antique furniture and good carpets. Continually dissatisfied with the overall look, Halsted had the walls repainted a number of times until he found the proper shade.

One day in the spring of 1890, he entertained three young women in his suite. His guests were his surgical nurse, Caroline Hampton; her sister, Lucy Haskell; and their old friend, Sally Carter. The rooms had a Victorian air, with stuffed furniture, antique tables, and a large photograph of the Sistine Madonna over the mantel. There, in front of the open fire in the sitting room, Halsted and his guests chatted and drank black Turkish coffee, which he had carefully prepared.

The nature of Halsted’s relationship with Caroline Hampton was immediately apparent to the two other women, and upon leaving the hospital they drew the obvious conclusion. Despite what she witnessed, Lucy Haskell knew her sister, and their upbringing, and could not imagine her marrying anyone but a southern planter. Certainly not a doctor.

WITHIN THE HIERARCHY
of the antebellum South, few families had earned the distinction and power of the South Carolina Hamptons. Caroline Hampton was the daughter of Frank and Sally Hampton, granddaughter of Wade Hampton II, and great-granddaughter of the first Wade Hampton. By 1860, the Hamptons were among the wealthiest families in the South, holding vast cotton estates in South Carolina and Mississippi, and more than 3,000 slaves.

Caroline’s mother, Sally Baxter Hampton, died of tuberculosis in 1862, and her father, Frank Hampton, was killed on June 9, 1863, at the Battle of Brandy Station, leaving the children in the care of his three unmarried sisters. The family fortune did not survive the war either. With the loss of slave labor and destruction everywhere, economic recovery for an agricultural dynasty was soon found to be all but impossible. Millwood, the ancestral family home, was directly in the path of Sherman’s march to the sea and had been burned to the ground.

Land rich and cash poor, the remainder of the family struggled along as impoverished aristocracy. Apparently enough money was available for the children to be sent off to school. Caroline and her
sister Lucy were educated at Edgehill, near Monticello, run by Miss Randolph, a great-granddaughter of Thomas Jefferson. Caroline returned home as young woman of 18, and for a number of years spent her time with her dogs and horses until the need to strike out on her own brought her to New York, where her maternal grandmother and aunt lived. Initially, Caroline enrolled in nursing school at Mount Sinai Hospital, but quickly transferred to New York Hospital, where she earned her degree and some nursing experience before relocating to Baltimore and her new job at The Johns Hopkins Hospital.