Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (38 page)

1 Actinography was the term used for the measurement of X-ray exposure. An actinographer is one who creates the images of X-radiation, and is known as a radiologist today.

CHAPTER TWENTY-EIGHT
New Horizons

THE THYROID GLAND SITS
like a butterfly on the neck, just below the larynx. The two lobes straddle the trachea and are joined together by an isthmus called the body. The gland is fairly superficial, readily visible when enlarged, and covered by layers of flat, vertically oriented muscles. With a normal weight of barely 30 grams, the thyroid is a powerful regulator of human activity.

Through the last quarter of the 19th century very little was known of the gland’s function. It was a surgically accessible, ductless endocrine gland and was associated with Graves’ disease, a dangerous condition characterized by a goiter (enlarged thyroid), bulging eyes, weakness, swelling of the shins, and rapid pulse. Removing the gland reversed the symptoms of the disease but rarely saved the patient, so the surgery was infrequently performed.

Prior to coming to Baltimore, Halsted had assisted his mentor, Henry Sands, on a single thyroidectomy at Roosevelt Hospital in New York. The gland, particularly when swollen, is invested with a very rich blood supply, and in the hurried surgery of the day, hemorrhage was a constant problem, so the patient was seated in a chair with a rubber bag tied around his neck to catch the blood flow. The surgery was ugly
and dangerous, but Graves’ disease, or Basedow’s disease, as it is called in Europe, was not uncommon and could be deadly.

Other forms of goiter were not associated with the symptoms of Graves’ disease but could cause asphyxiation by the pressure of the expanding neck mass on the trachea. Surgical intervention came as a result of attempts to cure Graves’ disease. Simple goiter, it turned out, was related to iodine deficiency and was cured by dietary supplements.

Halsted had been exposed to research on the thyroid in Europe. Although he had little or no experience with thyroid surgery, he was curious about a number of its elements. If the thyroid gland was necessary for life, how much had to be removed to cure the disease, and how much must be left for the patient to survive? How did it function, what did the thyroid produce, and why did patients with the entire gland removed suffer both the weakness and fatigue of hypothyroidism, along with spasms, twitching, and seizures?

Years earlier, in 1887, with the questions clear in his mind, Halsted had gone looking for answers. He started at his laboratory at the Pathological and worked his way to the operating room. Setting up his research model in anesthetized dogs, Halsted began the arduous process of removing sequentially larger portions of the gland, ultimately sacrificing the animals and studying the remaining gland. The results of these first experiments were baffling. The remaining portion of the thyroid gland rapidly increased in size. When the new growth was studied under the microscope it had no similarity to the cellular appearance of the thyroid gland. The cells had become taller and fuller. And colloid, believed to be the thyroid secretion, first accumulated along with the growth of the cells, then abated.

The microscopic changes looked exactly like Graves’ disease, and yet the dogs had no symptoms. Confusing.

The confusion continued for the next 20 years. Meanwhile, Halsted developed a surgical technique for dealing with the formidable enlarged gland of Graves’ disease. He treated the tissue gently, tied off
the small arteries and engorged veins with fine silk, and divided them without blood loss. The large superior and inferior thyroid arteries were then identified and dealt with, maintaining the bloodless field.

In most cases, removing all of one lobe and most of the other cured the symptoms of Graves’ disease. The remaining gland enlarged enough to sustain life without causing hypothyroidism—sluggishness, weight gain, thinning hair, and mental degradation known as myxedema. Still, the balance between how much needed to be removed and how much had to be left remained unclear. And there was more. Often when the superior and inferior thyroid arteries were tied off, both patients and experimental animals developed severe twitching and seizures called tetany, which often resulted in death. Halsted recognized that these were the symptoms of compromised calcium metabolism brought about by removal of the parathyroid glands, four tiny structures associated with the thyroid. But even when he tried to spare the parathyroids, the symptoms often arose.

Since the patient faced death without treatment, Halsted tried everything. Fresh bovine parathyroid was recovered from slaughterhouses and fed to patients. It temporarily relieved the symptoms, but the patients found the volume and presentation of the organs quite disgusting. Halsted tried parathyroid transplants with questionable results. Later an injectable parathyroid extract became available, which seemed effective, and finally the use of calcium salts managed to prevent tetany. The patients improved, but the underlying issue persisted. How does one cure hyperthyroidism and not cause tetany?

In 1907, Halsted asked MacCallum to study the parathyroid glands at autopsy. After 67 consecutive dissections, MacCallum reported the two pairs of tiny glands were most often found in the posterior lateral surface of each thyroid lobe. Significantly, the lower parathyroid gland was always closely associated with the inferior thyroid artery. It was not quite the revelation Halsted had hoped for, so he had a medical student, Herbert M. Evans, study the specific blood supply to each
parathyroid. The goal was to find the place where the large arteries to the thyroid could be divided while still sparing the blood supply to the parathyroids. Evans found that each parathyroid had a small, dedicated artery emanating from the inferior and superior thyroid arteries respectively. That was what Halsted needed to know. Now he could formulate a plan.

The safest strategy would be transecting the large arteries after the dedicated tributaries had been given off. This required delicate dissection within the substance of the thyroid gland itself, a very trying technique, but one for which Halsted was perfectly prepared. Dealing with the distended web of veins and fine arteries was tedious work. Innumerable fine, pointed Halsted clamps were applied, the veins were tied and transected, the arteries to the parathyroids identified and preserved within a surrounding nubbin of thyroid tissue, and then the larger arteries were taken. Special care had to be taken to protect the recurrent laryngeal nerve, which was dangerously close to the inferior thyroid artery. Surgeons had learned by bitter experience that injury to the nerve could paralyze the vocal cords and desperately affect breathing and voice.

Six hundred and fifty cases later, Halsted reported on the overwhelming success of his technique. He taught other surgeons how to approach the gland surgically, but he could not fully unravel its mysteries. In 1920, he published
The Operative Story of Goitre
, which, from the surgeon’s point of view, was all there was to know about the subject. But the essence of thyroid physiology remained elusive. The veil of frustration would not be lifted until the nature of the feedback mechanism between the hypothalamus in the brain, which produced hormones to stimulate the pituitary, and the pituitary, which produced thyroid-stimulating hormone, was fully understood. And this would not come to pass within Halsted’s lifetime. Meanwhile, The Professor had other things on his mind.

LEVIN WATERS WAS
a fair-skinned Negro laborer. At age 52, he was strongly built and had white, closely cropped hair and a full beard. Waters had been in robust good health prior to his April 1892 admission to The Johns Hopkins Hospital. At first, he had noticed a small, nut-sized mass under his left clavicle. The mass grew rapidly, and soon he could “feel it beat like his heart.” There was also a slight numbness in his left arm and hand. On examining Waters, Halsted noted an enormous tumor that now enveloped the clavicle and reached to the left shoulder. It was a pulsating arterial aneurysm, measuring some 42 centimeters in circumference.

The aneurism was located in the left subclavian artery, which is the first branch off the aorta. The left subclavian gives branches to supply blood to the head and neck, before continuing on as the main artery of the arm, where it is called the axillary artery. An aneurysm is a weakening and bulging of an arterial wall. The danger it presents is that the constant pounding of pulse pressure will rupture the thin arterial balloon, risking death by hemorrhage. This was the situation in which Halsted found Waters.

Twice previously in recorded surgical history attempts had been made at excising an aneurysm in this location. Both resulted in death for the patient. With some trepidation, Halsted made a long incision from the sternal notch over the aneurism,
¹
and down the arm. Skin flaps were laid open and the aneurysm was carefully isolated. Heavy silk ties were placed on the vessel before and after the dilation. The aneurysm was excised and the wound closed. Where skin had been excised as well, a dressing of natural latex, gutta-percha, was applied.
Shortly after surgery Waters felt a slight tingling in his fingers, and then full sensation returned. The wound healed without incident, and Waters left the hospital and returned to work.

The first successful excision of an aneurysm of a major vessel had proven two things: that good surgical technique is increasingly the key to success as more intricate surgeries are attempted; and of specific importance to vascular surgery, that smaller communicating vessels in the area, called collateral vessels, can fill the gap, bypass the interruption in flow, and supply the dependent tissues.

The audience at the meeting of the Johns Hopkins Medical Society was spellbound as Halsted presented the dramatic and groundbreaking case, especially when Waters appeared. He was barely a month postsurgery, completely cured, and rehabilitated. Halsted went on to describe the surgical tour de force. But then, in his usual modest fashion, he left the room before Welch could begin the discussion. Welch praised the surgeon in the highest terms and spoke volubly of his immense value to The Johns Hopkins Hospital. The audience concurred, and the field of vascular surgery was off and running.

Halsted had described the operation as “a tedious one” since it took more than three hours to perform. Any surgeon reading this statement realizes that it belies the conventional wisdom that Halsted was a slow, plodding surgeon. In the world of modern surgery, a complicated vascular procedure can easily take the most adept surgeons more than an unremarkable three hours. But following so closely behind the era of five-minute amputations, it must have seemed a lifetime. Halsted routinely spent more than an hour and a half repairing an inguinal hernia. Other surgeons did their hernia procedures significantly faster, often in 15 minutes. But Halsted’s operation succeeded, while all the others failed. In all but the most extreme examples, surgical time is a relative measure.

Once the commitment was made to absolute asepsis and gentle tissue handling, to tying off every blood vessel with silk so fine it
would snap if knotted tightly enough to crush tissue, and to close a wound carefully, layer by layer in anatomically correct position, then surgery took more time to perform. Not too much time, simply more time than was taken in the sloppy, careless, and usually disastrous techniques of old.

Halsted had not been miraculously transformed to a new identity after having been among the best of the slash-and-dash surgeons. He had evolved into a surgeon who understood that aseptic technique, absolute knowledge of the anatomy, and gentle respect for that anatomy would change the world of surgery forever.

Categorizing William S. Halsted as an operating surgeon remains difficult. Few are qualified to pass judgment, and those schooled enough to do so must, by definition, be surgeons themselves. Unless one attempts to perform the feat oneself, the ability to separate flash from excellence becomes confusingly subjective. Looking back on their long professional association, Joseph Bloodgood wrote, “During the operation Halsted was a surgeon, a pathologist, and a thinker. He always had in mind improvements in the operative procedure and carefully studied every bit of tissue exposed by the knife.”

In the end, judgment lies in how well the patient is served. Using this yardstick, Halsted was indeed among the greatest surgeons of his day. Impressions of his surgical ability were blurred by the intensity of purpose with which he performed and the new vocabulary of surgery that he devised. Although not as naturally gifted as Kelly, he was an unquestionably facile and adept operator. And, as was so often said, he was a surgeon of the head, not the hand, meaning a thoughtful surgeon rather than a dazzling technician. Being a surgeon of the hand was what he least aspired to, finding routine performance boring and thoroughly unsatisfying. Over the years Halsted established a pattern of mastering a surgical problem, then moving on. He was fascinated by the many technical issues of intestinal surgery but performed few such operations, and only five
operations on the stomach, over his entire career at Hopkins. Many of the emotional moments of his professional life were associated with gallbladder surgery, but his interest in performing the procedure dwindled to devising gadgets to deal with sticky problems associated with exploring the common bile duct.