William Stewart Halsted

William Stewart Halsted (September 23, 1852 – September 7, 1922) was one of the most influential surgeons of the 20th century. He, by virtue of both his innovations in surgical practice, and, most importantly, his spawning of an entirely new method of training surgeons, was instrumental in launching surgical practice into modern medicine. He developed basic operative techniques and methods of postoperative care, that hybridized the then newly emerging fields of bacteriology and histologic pathology, along with a detailed knowledge of anatomy and understanding of investigative methods.

Halsted oversaw the training of "house staff" who rarely left the hospital, but dedicated themselves to the care of patients along with study and research in a program largely of his own design. Although Halsted was strongly influenced by German and Austrian practices, he changed the focus of academic surgical education from the "professor" to the house staff officer. In his program, the detailed care of the patient, and much of the actual surgery, was in the hands of the house officers - they were always supervised, but were given graduated responsibilities, so that the resident surgeon would be experienced and adept at the finish of the program. Rather than merely observing in the operating room, the surgical house staff at Hopkins learned to operate independently.

Halsted personally trained over a hundred men at Hopkins who then went on to themselves establish key training programs in general surgery, orthopedics, neurosurgery and urology, among other subspecialties, in other programs around the country. These men taught Halstead's precepts to new generations of sugical house officers, in programs modelled closely on the one that they had trained in themselves. In this way, Halsted, who never had any biological children, became father and grandfather to an elite corps of physicians who claimed him in their "surgical pedigree". Even today, in the United States and throughout the world, Halstead's name is heard in the operating rooms where attending surgeons and resident surgeons operate together, as the younger surgeons are taught techniques and ideas that the older surgeons had themselves been schooled in. Although many of the actual operations and underlying concepts have changed, their development and evolution are recounted as the new procedures are performed, and in this way, Halstead's descendents still acknowledge him.

Early life to early adulthood

Born in New York City to William Mills Halsted, Jr. and Mary Louise Hanes, an affluent couple, William was the eldest of four children. He was followed by two sisters, Bertha and Mary Louisa, and a brother, Richard. The Halstead family had counted physicians in previous generations, but were merchants at the time of William's upbringing. The family fortune was due to his paternal grandfather's land investments in Chicago, to his father's frugality, and to operation of an import company called Halsted, Haines, and Company. Halsted was raised on 5th Avenue in privileged circumstances, summering in the family house on the Hudson River at Irvington-on-Hudson in Westchester.

He was privately educated as a boy, and then attended Yale University. He is said to have been undistinguished as a scholar but notable on the playing fields, being one of the first captains of the Yale football team ("William Stewart Halsted." Dictionary of American Biography Base Set. American Council of Learned Societies, 1928-1936. Reproduced in Biography Resource Center. Farmington Hills, Mich.: Thomson Gale. 2007). "Friendships and close associations during this part of Halsted's life apparently were common. He was outgoing, popular, and socially very active and at ease."

The youngest child in the family, Richard, never went to college but became a stockbroker.

Medical School

After college, William returned to Manhattan, where he studied medicine, graduating from the College of Physicians and Surgeons in 1877 after completing the 3-year course. Although this was certainly one of the better medical schools in the United States at that time, it was not the scholarly institution it would later become when fully integrated into Columbia University. However, William Halsted, in both personal background and education, was a far cry from many of the physicians then in the United States. Medical schools in more rural areas, and in the west and south, often accepted students with no college education; some schools required only literacy and others did not even require that.

Early postgraduate training

Unlike most physicians of his day, Halsted took further clinical training and became a house surgeon at Bellevue for a period of 18 months, and then, briefly, was a house physician at New York Hospital. Still, he felt that more training and education was required in order to master his field, and he spent the next two years in Austria and Germany studying the basic sciences, including bacteriology and chemistry, and focusing on human anatomy. At the time, education and training in laboratory science was considered to be at the highest level in the world in those particular countries.

Return to New York, a young professor

Halsted became an instructor of anatomy at the College of Physicians and Surgeons, while attending patients at Roosevelt Hospital and establishing a surgical practice.

He and several colleagues experimented with cocaine hydochloride and developed an effective method of regional anesthesia using the drug. Halsted also developed an addiction to cocaine that persisted despite voluntary hospitalizations lasting months at a time. Leaving his professiomal career behind in NYC, he moved on to Baltimore to start afresh. Although he apparently was also able to leave behind his habitual dependence on cocaine, it was only by replacing self-administration of that stimulant with self-administration of a narcotic, the drug morphine sulfate.

Shattered career, family financial straits

Halsted was not unusual in those times in terms of his willingness to sample new pharmaceutical compounds. This was an accepted way for physicans to learn about the effects of drugs. The addictive and debilitating effects of repeated use of cocaine were then unknown.

John Hopkins

Halsted married Caroline Hampton, the head nurse of the operating suites at Hopkins; she was an unusual woman who had left her aristocratic Southern upbringing to obtain professional training as a nurse "graduating from the New York Hospital in 1888". "When Dr. Halsted married Caroline Hampton, it was a merging of the wealthy merchant class of the north, with the planter aristocracy of the south." (reference for both quotes: Rankin JS. William Stewart Halsted: a lecture by Dr. Peter D. Olch. Annals of Surgery. 243(3):418-25, 2006 UI: 16495709). William Welch, the great pathologist who along with Halsted, Kelly, and Osler was one of the Hopkins professors known as "The Big Four", was best man.

Halsted was chairman from 1890 to 1922.

Sterile technique

It was at Hopkins that Halsted began the practice of wearing sterile gloves. Previously, he used disinfectants on his hands, as was the practice of Louis Pasteur and is still followed in some laboratories in France. However, Caroline had severe skin reactions to the disinfectants (mercuric chloride), so rubber gloves were initially obtained for her use. Apparently another surgeon, Dr. Joseph Bloodgood, adopted the gloves for asepsis within a few years, and so established this new method.

Training of surgeons

"Up until the opening of The Johns Hopkins Hospital in 1889, there was no formal system to train surgeons in the United States. All surgeons were self-trained or learned by way of an apprenticeship, and few spent more than one or two years in a hospital setting. Halsted introduced a system in which medical school graduates entered a university-sponsored, hospital-based surgical training program that, over a several-year period of increasing responsibility slowly led to the training of young surgeons who were well versed in anatomy, pathology, bacteriology, and physiology. The training program culminated in a final period of near-total independence and autonomous activity." (reference for quote: Cameron JL. William Stewart Halsted. Our surgical heritage. Annals of Surgery. 225(5):445-58, 1997 May. UI: 9193173) Original research was required of all surgical residents during training.

Death

His tombstoned grave lies in Greenwood Cemetery, Brooklyn, NY.

Addiction

There is no doubt that Halsted's drug addictions affected his life. His brother Richard was an alcoholic who developed esophogeal varices and there may have been some genetic predisposition to substance abuse. On the other hand, at the time that Halsted began using cocaine, the drug was new and its potential for addiction was unknown. Further, both it and narcotic drugs were common ingredients of over-the-counter remedies in his lifetime.

Much of his personality during his most productive years at Hopkins may have been colored by his addiction. He has been described, during those years, as “an elusive personality, so hidden in his habitual reserve and so hedged round with the formality of his manner that few knew him well". One of his most outstanding students, and a great admirer, Dr. George W. Heuer, described Halsted as follows: “he was intimate with few and his habits at work precluded frequent contacts with his colleagues... his own shyness made it difficult for him to participate easily in the friendly, laughing intercourse of a large group... he avoided people, very often deliberately... in relation with his colleagues he seemed a lonely figure." (reference for quotes: (Cameron JL. Gordon TA. Kehoe MW. McCall N. William Stewart Halsted: letters to a young female admirer. Annals of Surgery. 234(5):702-7, 2001 Nov.)

Contributions to surgery

There is little doubting the fact that his efforts introduced a "new" American surgery, based as much on pathology and physiology as on anatomy. Halsted's list of accomplishments seems nearly endless, including: pioneering the use of cocaine for local anesthesia and setting the foundations for neuroregional anesthesia; introducing a host of surgical techniques and procedures for dealing with cancers, goiters, hernias, and aneurysms; and emphasizing the necessity for careful exacting procedures in the operating room, especially the need for aseptic surgery and tedious dissection. " (Reference for quote: Rutkow IM. Moments in surgical history: William Stewart Halsted. Archives of Surgery. 135(12):1478, 2000 Dec. UI: 11115357)

He developed the surgical training program at John Hopkins University that became a model for post-graduate residency training for both medical and surgical specialists in the United States. His contributions to surgical techniques lay in advocation of preservation of anatomy and gentle handling of tissues. He invented the operation called radical mastectomy, which provided the only cures for breast cancer in his era. He introduced regional anesthesia.

References

Rankin JS. William Stewart Halsted: a lecture by Dr. Peter D. Olch. [Biography. Historical Article. Lectures] Annals of Surgery. 243(3):418-25, 2006 Mar. UI: 16495709