William Halsted For President
I have a confession to make.
I was always a history junkie, but I wanted to be a doctor when I was
growing up.
Some of this passion for medicine was no doubt induced in me
by the rather steady stream of pro-doctor propaganda that passed for career
counseling in my household. My extended
family respected hard work and success in business, but doctor/scientist was
simply a higher order of being (out of delicacy, we need not discuss the status
of lawyers here.)
I wasn’t totally unaware of the motives of all this
well-meaning pressure, and I probably wouldn’t have gone along without some
external force. I found it in a
soft-covered version of “The Great
Doctors” which was about—great doctors. Chapter
after chapter contained heroic portraits of great doctors doing great
things. Hippocrates, of course, and Galen,
the Greek-born Roman physician who dominated thought for nearly a millennium. Vesalius,
who snuck into graveyards to dig up corpses for dissection, and, with his drawings,
blasted apart Galen’s anatomical theories.
Also, the 16th
Century French physician, Ambroise Paré, who rediscovered ligature for
treatment of battlefield and surgical wounds. William Harvey, the
English physician who first accurately described blood flow and the workings of
the heart. Albert Jenner, who discovered
vaccination for smallpox. Walter Reed,
who linked tropical diseases to mosquitos and drained marshes to combat them,
and people like Lister for antisepsis, and Salk for polio. But two men interested me intensely. Harvey Cushing, who pioneered new methods in
brain surgery, and William Halsted, the great, innovative surgeon at Johns
Hopkins under whom Cushing had trained a resident.
Even at ten, I knew myself.
I wasn’t going to be blundering about in cemeteries (my mother wouldn’t
let me even if I wanted to) and Hippocrates was way out of sight (my skinny
legs would never have worked with those togas.)
I didn’t see myself in a lab, playing with beakers and burners. Swamps
were out of the question. Cushing’s extraordinary skill seemed beyond my
capacities. But in Halstead, as remote
and forbidding a figure as he could be, I thought I found someone I could
relate to.
Halstead revolutionized the way surgeons thought about what
they did. Up until the discovery of
anesthetics in the mid-19th Century, speed was everything—think of
all those Westerns where the injured man takes a big swig of liquor, bites down
on something, and, then is held down by his mates while the doctor applies the
instruments of torture. You either did
it fast, or the patient could expire from sheer shock alone.
Speed wasn’t pretty. A shattered bone often resulted in
amputation—there was neither the time nor the tools to do better. Few made the
connection that Lister and Pasteur did in the 1850s and 60’s, between dirt,
contaminated hands and instruments, and infection. Those few that suggested it (including Oliver
Wendell Holmes, father of the future Supreme Court Justice) were often
considered impolite and sometimes shunned.
So, the surgeons not only operated quickly, they did so with bare and
unwashed hands, and unsterilized equipment.
Not surprisingly, mortality rates were exceptionally high—shock from
loss of blood or trauma, and infection carried away close to fifty percent. You cut only when you had no other choice.
Halstead helped change that.
Not only was he creative—he did the first gallstone removal, the first
radical mastectomy, and developed advanced techniques for hernia and aneurism
repairs, but he also insisted on absolute sterility, washing his hands and
instruments in a solution of carbolic acid.
And, he taught his students to both slow down and speed up. You move faster because the freedom that
anesthesia brought allowed you to push your instruments deeper. But you moved slower, because precision was
important. You could kill tissue, and sometimes the patient, by being too rough
in making the incision, too crude in using the surgical tools, and too
inattentive in suturing the wound. Better
technique led to better outcomes, Halstead preached, and his students carried
the message to their own practices.
All pretty terrific, but the clincher for me was the rubber
gloves. Halstead’s wife, Caroline, was
also his operating room nurse. She had complained
about the effects that the harsh carbolic acid had on her skin, so they made
plaster casts of her hands and sent them to Goodyear. The gloves produced were perfect for
sterilization, but they were stiff and too clumsy for a surgeon. So Halstead had a second pair of casts made,
of his own hands, but this time he made them in bronze. Ask what a late middle-aged man remembers of
a book he read nearly fifty years ago, and one phrase sticks with me “the era
of the barehanded surgeon was over.”
It really was a thunderbolt.
Something so obvious, something even a boy could figure out, yet so
overlooked. As was true with much of the
rest of Halsted’s clinical approach was.
Care, deliberation, preparation and attention to every detail.
Halsted, I was later to learn, had his demons. Like many men of the late 19th and
early 20th Centuries (including Freud and Sherlock Holmes) he
injected himself with cocaine (legal in those days.) When his addiction became
problematic, his colleagues sent him to a sanitarium to dry out. There he was
weaned by replacing cocaine with something more benign—morphine. By all accounts, Halsted would remain an
addict the rest of his life. But he
continued to achieve.
I guess I really didn’t want to grow up to be Halsted, but
there is something about his story that remains relevant today, and even
relevant politically (you knew I had to get there.)
Ask yourself, regardless of what your party identification
is, or your ideological preferences are, what you expect out of elected
officials. It’s patient outcomes, isn’t it?
You may not love government, but you want it to work.
Not to state the obvious, but it's not. Instead, we have a bunch of quacks crowding
around the hospital bed, each with their own agenda, not looking at the chart
(another Halsted innovation!) and most of the time, not bothering to look at
the patient. The guy with the leeches
looks particularly spooky.
We need a William Halsted—in fact, we need a lot of them. We have to find people willing to think
differently, to challenge existing orthodoxy, to try new approaches, and
finally, to focus on “patient outcomes” instead of just attaining power,
grabbing a knife, and hacking away.
I don't have much confidence in the Republicans. They have a core orthodoxy that seems to trap
new ideas with the intense gravity of a black hole. The debate in this election
cycle is whether to double down on those ideas, and the electorate it attracts
with ever-greater fervor, or to look to appeal to a handful of others to get to
50%+1. They don’t seem to have an
interest in treating the whole patient, except, perhaps, for sexual diseases.
For the Democrats, my group practice, I don't know if they have ideas at all, but I would start by challenging Hillary
Clinton, from both the left and the right.
Make her work—make her work hard.
Don't make it personal—instead ask her to defend her policy
proposals—will they actually help the patient?
If not, then what else does she have in her little black bag? More
importantly, what do we Democrats have in our bags? If it’s as little as I suspect, we can either
adapt, or we can slide into irrelevance.
Unfortunately, the era of the barehanded surgeon may be
over, but the era of the empty-headed politician is not.
Maybe we should all call our lawyers?
March 31, 2015
Michael Liss
Please join us on Twitter, or contact the Moderator.
