Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (40 page)

CHAPTER THIRTY
Vascular Surgery

THIRTY YEARS AND 20
surgical papers passed between the startling surgery performed on Levin Waters and Halsted’s final work on the subject of arterial aneurysms. Untold hundreds of dogs, dozens of patients, and numerous residents contributed to the journey, which was applauded for its fine scientific underpinnings by the National Academy of Science, whose membership had been disdainful of the idea of pure science associated with the craft of surgery. Halsted’s work had forced the rethinking of that outdated position, and he took great pride in being accepted into the family of scientists. He had approached the great vascular unknown with the mind-set of a scientific explorer. While the wide range of his work was ultimately inconclusive, it cleared the way for some of the most dazzling medical achievements in history.

THE AORTA IS THE
largest artery in the human body. The heart pumps the entire blood volume, some six liters, through it every minute. Rupture of the aorta is a cataclysmic event. The abdomen or chest fills with blood escaping from the rent in the great vessel, veins returning blood to the heart collapse as the circulating volume suddenly depletes, and shock and death result in minutes. The aorta
is subject to the shearing force of trauma. It can be torn by penetrating injury, rupture at the site of an aneurysm or weakness in its wall, or in the hands of a surgeon attempting to repair it or prevent rupture. More frequently a weakness, distortion, or an internal tear manifests itself painfully, dangerously, and potentially lethally. There is no room for error.

Halsted was not the first to work in the area. It had always tempted surgeons as the most obviously dramatic time bomb presented to them. Wartime surgery brought opportunities for intervention. Larger arteries, wildly spraying blood, were crushed in clamps and tied off, usually resulting in amputation but sometimes in a warm, functional salvaged limb. Injuries to the aorta were a death notice, and reports of the occasional positive outcome stimulated thought. The great success in Waters’s case raised the question of how one could interrupt flow through the major artery to a limb without resulting in gangrene of the limb. Halsted studied previous reports of ligation of the common iliac artery, the main blood supply to the leg, and came to the conclusion that the larger the artery, and the closer to the heart, the less the impairment that resulted from its occlusion. The salvation of the limb beyond the roadblock was due to collateral circulation, or arterial detours around the roadblock, which expanded and provided circulation.

The pathophysiology is a bit more complicated than the above description implies, but it did become clear that aneurysms of the larger vessels in the limbs could be safely tied off if one respected the collateral vessels arising before the aneurismal sac. Progressive occlusion of the vessel proximal to the aneurysm promoted collateral circulation. To encourage this, Halsted applied an aluminum band around the artery, which could be manually tightened to increase occlusion.

In March 1905, he summarized 90 experiments on the great vessels of dogs. The objective was to find a way to compress the aorta, which had never been successfully performed in man or beast. The aorta in
humans was subject to marked degeneration over the years. Brittle cholesterol deposits in the wall of the aorta rendered it weakened and fragile, and syphilitic granulomas, which were not infrequent, ate away at the wall. Experimental studies showed that after complete occlusion, the vessel wall became atrophic and paper thin. Mont Reid, who worked with Halsted on the experiments, showed that though thrombosis and thinning of the wall occurred when the aluminum band was applied tightly enough for complete occlusion, loosely applied bands did not cause visible injury to the arteries. This was heartening news, since Halsted had been discouraged by an early case in which the pulsations of the dog’s aorta against the aluminum band had caused it to cut through the wall, causing a hemorrhagic death for the dog. In other cases the aortic wall had become dangerously thin after three months of pressure. From 1904 to 1906, he applied the band to the large arteries of 100 dogs, with excellent results, and only one instance of the band cutting through the wall. It seemed safe enough to consider partial occlusion of the aorta in a human.

In 1909, Halsted reported, “The aluminum band has now been successfully applied in man to the common carotid artery twelve times, and once each to the thoracic aorta, the abdominal aorta, the common iliac, the femoral, and the innominate arteries.”

Later that year he attempted three cases of banding the aorta. One was the first successful partial occlusion of the thoracic aorta to treat an enormous aneurysm of the upper abdominal aorta. In the second case, a band was first placed around the thoracic aspect of the aorta. Three weeks later the aorta was banded below the aneurysm in the abdomen. Ten days later the aorta ruptured. The third patient was operated on for a large abdominal aneurysm. The mass caused technical difficulties in reaching the band, and Halsted removed his gloves in order to more easily grasp the band and tighten it. The patient developed an overwhelming postoperative infection and died. Halsted was devastated. He had coolly dealt with losing patients before, and
not infrequently while attempting to alter the explosive course of an expanding aneurysm. But this patient died from an infection as the result of a deviation from aseptic technique, which, as Halsted guiltily noted, was “the first in the annals of the Johns Hopkins Hospital in a clean abdominal case.” To the ultimate detriment of his patient, even William Stewart Halsted suffered costly lapses.

Work on aortic aneurysm continued. Halsted’s residents took up the mantle and helped establish additional benchmarks in surgery of the great vessels. It took half a century before the work finally bore fruit. Halsted spent thousands of hours in the Hunterian Laboratory facing off with the basic mysteries of the vascular system. So complex and consuming are the dynamics of blood flow and vascular integrity, and so deadly were surgical missteps, that Halsted may have devoted more time and energy to this subject than to any of his other interests. Among his collected surgical papers, 274 pages are devoted to a topic he was unable to master.
¹

1 In 1952, Michael DeBakey, then a young Texas surgeon, excised an aortic aneurysm and replaced it with a section of cadaver aorta. The following year he nudged the revolution a step further by replacing an aortic aneurysm with a tubular Dacron graft he fashioned on his wife’s sewing machine.

CHAPTER THIRTY-ONE
Scientist

1
904 h
AD BEEN A YEAR
of significant change at Johns Hopkins, and not all of it good. At 10:48 on the windy Sunday morning of February 7, the Great Baltimore Fire ignited in the city’s commercial district. Baltimore’s 51 horse-drawn, steam-powered pumpers taxed the ancient system of hydrants and proved inadequate to fight the blaze. Emergency equipment was rushed up from Washington, but that city’s hose couplings did not match the Baltimore hydrants. Makeshift patching resulted in the loss of valuable water pressure, leaving the city to burn unchecked for 34 hours. Miraculously, no lives were lost to the fire, but among the material casualties of 1,343 buildings in 80 city blocks was considerable income-producing real estate provided by Johns Hopkins’s bequest. The loss inflicted a great strain on the operating budget of the hospital.

William Osler, now the most famous physician in the world, was feeling wanderlust. It was no secret that the Canadian-born Osler was an unabashed Anglophile, and as early as 1894 he had told Kelly it was his dream to be knighted. In 1904, he was offered the Regius professorship of medicine at Oxford. It was a great honor, and the Hopkins community was not surprised when Osler accepted. By his own estimate he had been working too hard. That summer, at age 55, William
Osler prepared to leave for Oxford. Dinners and tributes were being planned everywhere in the months before his departure. Osler became increasingly emotional as his time at Hopkins drew to a close. In his farewell address he shook things up by reiterating his refrain on age: a man’s great accomplishments occur before the age of 40; and at 60 he is useless to his profession, and should be put out to pasture. The new position would offer a quieter life, time to read and write, and the opportunity to educate his children in English schools. Much as he would miss the Hopkins social life that orbited about him, he believed an academic life required change to ward off going stale.

ON THE POSITIVE SIDE
of the ledger, the new surgical building opened in the fall. For the first time since its inception, the Department of Surgery would be housed in comfortable, modern facilities. Halsted had toiled for 15 years in the afterthought of an operating suite in the basement under Ward G. As early as 1899, he had charged Cushing with drawing up preliminary plans for the new operating suite.

The construction of the surgery building was the first in a series of events after the fire that would have far-reaching effects on the institution. After the fire, the hospital trustees requested financial help from the Rockefellers, and John D. Rockefeller responded with a much-needed gift of $500,000. Over the ensuing years the relationship would grow, culminating in Rockefeller financial support for the establishment of the full-time system. Welch was already the president of the Board of Scientific Directors of the new Rockefeller Institute for Medical Research, in New York. Frederick Gates, Rockefeller’s trusted adviser on philanthropic matters, was a great admirer of Osler. He had already read
The Principles and Practice of Medicine
and had become well acquainted with Welch.

The new building housed Baetjer’s X-ray department on the second floor, Bloodgood’s surgical pathology laboratory on the third floor, and on the top floor a large surgical amphitheater flanked by two sizeable
operating rooms. Halsted and the resident staff used the west-facing operating room, and Cushing, Young, and the other subspecialists used the east room. The surgical amphitheater was used by Halsted for his “dry” clinics, and by Finney for his Friday-morning operative clinics. The Professor’s office suite was on the operating floor as well. It consisted of an office, where he kept a substantial surgical reference library; an examining room; and a dressing room. But he rarely saw patients there. The office was occasionally used for meetings with visiting surgeons or for conferences, but he preferred to work at home, away from the interruptions and hospital chatter.

The opening of the new facility was celebrated with an “All Star” operation on October 5. Halsted chose a patient with osteomyelitis (bone infection) of the femur and was assisted by Cushing, Finney, Bloodgood, and Young, with Mitchell administering anesthesia. By all accounts, Halsted was in fine form that morning and enjoyed the tribute paid by his former residents in gathering around him. The surgeons, fully dressed in white, and gowned, had not yet begun wearing surgical masks, and the intense concentration on Halsted’s face was plainly visible as he hammered away at the bone cavity with his favorite wooden mallet. There was no audience in the amphitheater, which wasn’t a surprise, since little could be seen beyond Halsted’s broad back. Sunlight streaming through the enormous window facing the benches blinded observers and silhouetted the action at the operating table. The only way to see anything was to stand with one’s back to the window and face Halsted. Few dared that without an invitation.

BY THE START OF
the 20th century, Johns Hopkins was unchallenged as the premier medical school in the country. “The very happy band” had pulled together and truly redefined the state of the art of medical education. The hospital had achieved international renown on the strength of the incomparable clinical work of Osler, Halsted, Kelly, and their stellar residents. Important visitors were commonplace at
clinics, laboratories, lectures, and in the operating room, and a barrage of papers and bulletins chronicled their deeds and saw to it that the word got out. Texts by Osler and Kelly became required reading, and Halsted’s monographs reinforced the position of the Halsted school of surgery.