Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (8 page)

Their success at inducing local anesthesia exceeded all expectations, but there were side effects. Several minutes after a trial injection, Hall reported feeling giddy. He soon became disoriented and nauseated, his skin dripped with perspiration, and his pupils dilated widely. The symptoms persisted for 20 minutes and abated at about the same time the anesthesia wore off. The predictable combination of unpleasant symptoms was observed repeatedly during the first few weeks of experiments, and strategies were considered to make the process less forbidding.

In succeeding trials, Halsted decreased the concentration of the cocaine solution and was able to achieve equally potent, and predictable, local numbness of the tissue without the profound side effects. Carrying this to the ultimate dilution, he began injecting water into the skin. When the skin was fully distended with water, it became briefly numb. Halsted attributed this to the effect of volume blocking sensation in a small area of skin. He also found he could increase the duration of anesthesia by using a tourniquet to prevent the cocaine being flushed away by the circulating blood. The technique also lessened generalized symptoms by keeping the drug localized.
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Halsted postulated that blocking the inferior dental nerve, which was easily located as it exited the jaw, would provide a pain-free field for dental work on the lower jaw. Blocking the infraorbital nerve branches, which exited from the cheekbone beneath the eye, could provide anesthesia to the upper teeth. Armed with this extrapolation
from earlier tests on other nerves, he planned to test his hypothesis and present his findings.

Dentistry in 1884 was in an unhappy state. Extractions and serious dental surgery could be performed under general anesthesia, but the state of the art was crude. Inducing anesthesia, breathing, and access to the teeth all needed control of the same small space, the open mouth. These operations were dangerous. Dental work such as simple extractions and fillings was done without anesthesia of any sort, making the procedures agony. If Halsted could anesthetize the specific nerves carrying sensation from the teeth and jaws, he would revolutionize the profession. He didn’t have to wait long to put it to the test.

On November 26, Hall developed an excruciating toothache. Visiting Dr. Nash, his dentist, he brought along a syringe of cocaine solution. Hall convinced the dentist to inject the nerves exiting the infraorbital foramen, under the eye, to try to deaden the pain. Nash inserted the needle from inside the upper lip at the gum line and aimed toward the cheekbone. Hall felt no pain on the introduction of the needle or from the injection of the cocaine solution. “In two minutes there was complete anesthesia of the upper jaw.” Hall went on to detail the dental work done on the previously exquisitely painful tooth, all without pain.

Halsted was elated by the news. He spent the next two weeks injecting cocaine in and about the dental nerves of the medical students until he could reliably reproduce the desired area of anesthesia. The cocaine tests began to consume a great deal of the evening quizzes, and animated talk carried on late into the night. Reduced concentrations of cocaine had resulted in significant numbness, with fewer frightening symptoms, and an increasing sense of strength and pleasure.

While these experiments were going on at Madison Square, Halsted brought his new discovery to the Out Door Department at the Roosevelt Hospital. There, Halsted and his assistants successfully performed more than 1,000 minor surgeries under cocaine local anesthesia.

Thomas McBride, though not an active part of the team, was aware of the new discovery, and referred a wealthy and prominent woman suffering from facial pain to Halsted’s care. Localizing the neuralgia to the trigeminal nerve, Halsted set up for the surgery in his home office. Assisted by Hartley and Hall, he injected the nerve with cocaine, totally anesthetizing the area in the otherwise alert patient. Using a finger to guide a large clamp into an incision made in the mouth, he found the nerve trunk, clamped and cut it, and was met by “a great gush of arterial blood.” Unable to reach the large, bleeding artery, and fearing the patient would drown in her own blood, the unflappable Halsted firmly packed the open cavity with gauze. McBride, not wishing to be present for the demise of his patient, left the room when the hemorrhage seemed uncontrollable. Halsted’s quick action stopped the bleeding, but the pressure of the tight packing created the additional risk of crushing and devitalizing the surrounding tissue. Two nurses were hired from the Presbyterian Hospital to attend the patient, and after two stable days she was transferred to Presbyterian and recovered. Eight days after surgery, the packing was removed and the patient discharged. Though the whole episode was more dramatic than expected, it proved to Halsted once again the value of cocaine local anesthesia.

By December 1884, Halsted was barraged by surgeons and dentists interested in his new local anesthesia. On January 20, 1885, the regular meeting of the New York Odontological Society was held at the East 43rd Street home of Dr. W. E. Hoag. The subject was cocaine local anesthesia. Halsted was called in to inject the inferior dental nerve of Dr. John Woodbury, who was about to have a “very sensitive cavity” evacuated and filled. The introduction of local anesthesia was accomplished without difficulty. The lower jaw became numb, the tooth senseless, and the entire procedure painless. Glowing reports followed, and the technique was widely adopted to the delight of both patients and dentists.

Meanwhile, the medical students and their teachers came to enjoy the sense of exhilaration they experienced in the experiments, and began to use cocaine snuff and injections in social circumstances. It enhanced their appreciation of theater and music, helped ward off drowsiness, and generally made their days more enjoyable. They began using it more regularly and in increasing amounts. Gradually, doctor by doctor and student by student, they became addicted. The students began to drop from sight. The doctors’ behavior grew increasingly erratic. They slept less, talked endlessly and excitedly, and eventually performed less surgery and ignored their duties.

By September, when Halsted finally set about writing a paper on his findings, he was himself lost in the netherworld of drug addiction and unable to communicate in anything approaching a clear and concise manner. His paper, published in the September 12, 1885, issue of the
New York Medical Journal
, began:

Neither indifferent as to which of how many possibilities may best explain, nor yet at a loss to comprehend, why surgeons have, and that so many, quite without discredit, could have exhibited scarcely any interest in what, as a local anesthetic, had been supposed, if not declared, by most so very sure to prove, especially to them, attractive, still I do not think that this circumstance, or some sense of obligation to rescue fragmentary reputation for surgeons rather than belief that an opportunity existed for assisting others to an appreciable extent, induced me, several months ago, to write on the subject in hand the greater part of a somewhat comprehensible paper, which poor health disinclined me to complete.

The long-winded, rambling article was impossible to follow and made it obvious to all who knew him that something was terribly wrong. Some, including McBride and Welch, understood the nature
of the problem. Although the use of cocaine was a relatively recent phenomenon, scientific papers and newspaper articles had begun to appear warning of its “debasing and enslaving of the will.”

The drug was taking command of Halsted’s life. He began to miss morning sessions at the outdoor clinic and was erratic in meeting surgical responsibilities, to say nothing of the embarrassment and whispering caused by his unreadable paper. But his addiction had just begun, and he was unable to fully comprehend the chokehold it had on him. He made excuses to himself and others, lied when he had to, and tried to carry on with both his increasing cocaine habit and his busy life. It proved impossible. He had passed the point of exhilaration, heightened sensibility, and “super human strength.” His hands shook, he often became suddenly drenched in perspiration, and he lost focus. His need for the drug grew. Claiming failing health due to overwork, Halsted said his “breakdown necessitated a trip abroad” to recover his strength.

The most comfortable destination for him would be Vienna. He was fluent in German, had influential friends in the surgical community, and was anxious to spread the word of his new discovery. The drug was readily available in Europe, through Merck, and there was no stigma associated with its purchase.

Much of Halsted’s time in Vienna was spent with Anton Wölfler, Billroth’s former assistant, with whom he had developed a warm friendship during his visit five years before. Both men had achieved a great deal during the hiatus, and they had exchanged letters and maintained their relationship over the years. Halsted and Wölfler expressed great joy to see each other, dined together, and caught up. Halsted’s personal grooming, dress, and manners remained elegant, and Wölfler had only laudatory comments about the visit. Halsted, for his part, was excited to show Wölfler his new technique for injecting the cutaneous nerves. He had last been to Vienna to observe and learn, and now he was proud to be teaching the teachers. Wölfler
did not believe that cocaine anesthetic would work and had previously told Halsted as much. But Halsted successfully demonstrated its use in a number of surgical procedures, and Wölfler was suitably impressed. The following day he published a laudatory paragraph about cocaine anesthesia in the Vienna morning newspaper, neglecting to credit Halsted’s role.

In a formal demonstration, Halsted taught the technique of injecting the inferior alveolar (dental) nerve to a Dr. Thomas, a well-known American dentist practicing in Vienna. He spoke of the new technique to anyone who would listen and demonstrated it to whomever would watch. Before cocaine, Halsted had never sought credit for his achievements, never promoted his contributions, and never talked about himself. He was now clearly under the influence of the drug, and off balance.

Although he was in Vienna, where the whole cocaine story had begun, Halsted did not meet with Freud. One wonders whether Freud, who was already familiar with the characteristics of cocaine abuse, would have recognized Halsted’s aberrant behavior.

Returning home in January 1886, Halsted resumed his heavy workload. George Brewer, who worked with him in the outdoor clinic, described a conversation in which Halsted spoke constantly, excitedly, and endlessly, “about everything under the sun.” Halsted was losing control.

WILLIAM WELCH HAD
left his position at Bellevue in March 1884 to become professor of pathology at the new Johns Hopkins University in Baltimore, and part of the team chosen to build the institution from the ground up. He had spent a year in Europe immersed in the latest experimental techniques before settling in Baltimore in 1885. Alerted by McBride to the rapid deterioration of his friend, Welch immediately returned to New York to help. He hired a sailing vessel with captain
and crew, and planned to take Halsted on a long sailing trip to the Windward Islands off the coast of South America. The trip was to last through February and March—long enough, he hoped, to gradually wean Halsted from his drug, watch over him, counsel him, and help him break the habit.

It did not end well. Halsted had brought a two-week supply of cocaine aboard. Either Welch had miscalculated how much to allot or Halsted had not shared with him the increasing dosage necessary to satisfy his need, but in mid-passage Halsted ran short of cocaine. In desperation, he broke into the captain’s medicine locker. In the most dramatic retelling of the story, he was caught in the act of stealing cocaine and restrained by the crew. However, it is unlikely that a sailing ship would have any reason to carry cocaine, unless the locker was the repository for Halsted’s personal supply and some had been withheld as part of the process. It is far more plausible that the drug stolen from the captain’s locker was morphine, which would have been carried on board for emergency medical situations. In either event, Halsted’s desperation had transformed him overnight from a model of patrician rectitude to a thief.

UPON RETURNING TO
New York, Halsted continued using the drug. Welch returned to Baltimore, where he was immersed in his laboratory work and building the team for the Johns Hopkins Hospital.