William Stewart Halsted

William Stewart Halsted was the son of William Mills Halsted, Jr., and Mary Louisa Haines. His grandfather and father were successful merchants in New York City, and the family occupied a prominent position financially and philanthropically. His early education included a private school in Monson, and Phillips Academy, Andover, both in Massachusetts, prior to his entering Yale College in 1870. Halsted was a mediocre student but an exceptional athlete who first became interested in medicine in his senior year.

Halsted graduated A.B. from Yale in 1874 and that year entered the College of Physicians and Surgeons of New York. Halsted was strongly influenced by the physiologist John Call Dalton (1824-1889), America's first professor of neurophysiology, with whom he worked as a student assistant. He graduated M.D. among the top ten members of his class from the Columbia University College of Physicians and Surgeons, in 1877. In 1878 completed an eighteen-month period of training in the fourth surgical division of Bellevue Hospital, under the guidance of Frank Hastings Hamilton (1813-1886). He then served briefly as house physician at New York Hospital.

In the fall of 1878 Halsted went to Europe for two years of further study in Austria and Germany. In Vienna he worked under Christian Albert Theodor Billroth (1829-1894). He also worked in the basic sciences and particularly in anatomy under Emil Zuckerkandl (1849-1910) and Moriz Holl (1852-1920). He attended many clinical lectures and first became acquainted with the German method of graduate surgical education which was to have profound effect on his future. In 1880 he returned to New York City, quickly building a successful practice that demanded his services at six hospitals.
At Roosevelt Hospital he initiated the outpatient department, and held visiting or attending positions at four other hospitals. He also established a private practice limited to surgery and a quiz session which was academically sound. Besides all this, he joined the faculty of the College of Physicians and surgeons as a demonstrator in anatomy.

The surgeon addict
By self-experimentation Halsted investigated the properties of cocaine hydro chlorate as a surgical anaesthetic. In 1885 he was the first to describe injection of cocaine into the trunk of a sensory nerve to block pain transmission and the use of localized ischemia to prolong cocaine's anaesthetics action. This description was based on self-experimentation in 1884. However, both Halsted and several of his colleagues and students became addicted to cocaine.

In an attempt to overcome the addiction, he was hospitalized in Butler Hospital, Providence, Rhode Island, for six months in 1886 and for nine months in 1887. This illness ended his professional career in New York City, and he moved to Maryland, to work in the laboratory of William Henry Welch (1850-1934), professor of pathology at the Johns Hopkins University, in December 1886. Halsted and Franklin P. Mall spent the three years before the opening of the Johns Hopkins Hospital perfecting techniques for intestinal suture and wound healing in dogs.

It was during this concentrated period of research that the concept for the Halsted School of Surgery evolved. Halsted's methods consisted of strict aseptic technique, gentle handling of tissue, use of the finest silk suture material, small stitches and low tension on the tissue, and complete closure of wounds whenever possible. These basic procedures had a far-reaching effect on the practice of surgery, making it safer and more effective than it had been previously.

When Halsted had apparently regained his health and the authorities of the Johns Hopkins Hospital (and later the Johns Hopkins Medical School) were convinced of his capabilities and reliability, he was appointed surgeon in chief to the hospital in 1890 and professor of surgery in 1892. The question of Halsted’s drug addiction and his apparent cure has been discussed for years. William Osler’s «The Inner History of the Johns Hopkins Hospital» confirms that Halsted was treated for morphine addiction as late as 1898.

Wearing gloves
In 1890 Halsted introduced the use of thin rubber gloves that do not impede the delicate touch demanded by surgery. By ensuring totally sterile conditions in the operating room, Halsted’s gloves allowed surgical access to all part of the body. Halsted originally developed rubber gloves to protect the hands of his operating room nurse, who was allergic to antisepsis chemicals. That nurse late became Mrs. Halsted.

His emphasis on the maintenance of complete homeostasis, or balanced body metabolism, during surgical operation, gentleness in handling living tissue, accurate realignment of severed tissues, and his creation of hospital residencies in training surgeons did much to advance surgery in the United States.

The great teacher
Halsted was an excellent teacher of the exceptional student and resident but devoted little time to others. Those selected few residents who trained under him for seven years or more were given complete patient responsibility, a significant alteration of the German system enthusiastically adopted by Halsted. This system for residency training is a major contribution of the Johns Hopkins Hospital to American medicine. Halsted felt that the leading surgeons in Germany, Austria, and Switzerland were the world’s finest, and he made frequent trips to their clinics. Besides his work as a professor, Halsted had a modest but lucrative private practice prior to the institution of full-time clinical chairs at Johns Hopkins in 1914.

In his later years, Halsted was almost bald, and wore a moustache which hung down and a little tuft of grey hair on his lower lip. It was quite obvious that he was very short-sighted, and his ears projected to such a degree that he had finally become insensitive on the subject, and was known to have joked about it. He was not very tall, and his powerful shoulders were a little stooped. To the majority of his colleagues he was cold and reserved, avoiding social intercourse whenever possible. To a few intimate friends he was warm and exceedingly hospitable, and displayed a rich sense of humour. He rebelled against his strict Presbyterian upbringing and was an agnostic in his adult life. In 1890 he married Caroline Hampton, a niece of Wade Hampton III of South Carolina. She was formerly the chief nurse in his operating room. They had no children. Following his marriage he retired to his estate, High Hampton, in Cashier’s Valley, North Carolina, for a portion of each summer. In 1919 he underwent cholecystectomy, but in 1922 he had another attack of jaundice and pain that required an operation. He died the day after he had undergone surgery.

«The interne suffers not only from inexperience, but also from over-experience. He has in his short term of service responsibilities which are too great for him; he becomes accustomed to act without preparation and he acquires a confidence in himself and a self-complacency which may be useful in times of emergency, but which tends to blind him to his inadequacy and to warp his career. » Bulletin of the Johns Hopkins Hospital, 1904, 15: 267.

«We can hardly understand in these days that surgeons who were at the same time anatomists and physiologists could have accepted for so many centuries, almost without remonstrance, Galen’s views. Our inability to comprehend their state of mind with reference to this problem illustrates particularly well the difficulty experienced when we attempt to transport ourselves to other times, to obtain the point of view which subjugated our forefathers of centuries ago. It is now, as it was then and as it may ever be; conceptions from the past blind us to facts which almost slap us in the face. »
Surgical papers. Volume II. «The Training of the Surgeon»

«Not so very long ago a surgeon requested me to assist him to perform a circular suture of the intestine (end to end anastomosis) upon one of his patients. He readily consented to practice the operation upon dogs. At first his dogs died. He finally succeeded in saving more than 50 per cent of the dogs operated upon. The operation upon his patient required five hours, but was successful. It is not difficult to predict what the result would have been if the practice on dogs had been omitted.
I believe that the license to practice general surgery should be withheld from those who have not practiced on animals the operations for circular suture of the intestine and intestinal anastomosis. » Surgical papers. Volume I,
«Inflated Rubber Cylinders for Circular Suture of the Intestine.»

«The only weapon with which the unconscious patient can immediately retaliate upon the incompetent surgeon is hemorrhage.»
Bulletin of the Johns Hopkins Hospital, 1912; 23: 191

«In a wound that is perfectly dry, and in tissues never permitted to become even stained by blood, the operator, unperturbed, may work for hours without fatigue. The confidence gradually acquired from masterfulness in controlling hemorrhage gives to the surgeon the calm which is so essential for clear thinking and orderly procedure at the operating table.»
The Johns Hopkins Hospital Reports, 1920; 19: 71.

«In ligating the first portion of the left subclavian within the chest the operator may not, as formerly, be more greatly impressed by the magnitude and cleverness of his performance than by the miraculous effect of ligation of the artery upon the great, pulsating tumor which with each beat of the heart jarred the whole frame of the sufferer. The moment of tying the ligatures is indeed a dramatic one. The monstrous, booming tumor is stilled by a tiny thread, the tempest silenced by the magic wand.» Surgical Papers.
Volume I, Ligations of the Left-Subclavian Artery in Its First portion»

«When oppressed by the seeming magnitude of one of my little anthills of work I have recalled the advice of Dr. [John Shaw] Billings: «Devote a small amount of time each day to it and the mountain will go away with astonishing rapidity.»
Bulletin of the Johns Hopkins Hospital, 1914; 25: 244.

The main biographical source for this entry is:
• Peter D. Olch:
  William Stewart Halsted. In: Charles Coulston Gillispie, editor in chief: Dictionary of Scientific Biographies. Charles Scribner’s Sons. New York, 1970. Volume 6: 77-78.

• Practical comments on the use and abuse of cocaine; suggested by its invariably successful employment in more than a thousand minor surgical operations.
  The New York Medical Journal, 1885, 42: 294-195.
• Circular suture of the intestines; an experimental study.
  The American Journal of the Medical Sciences, 1887, 94: 436-461.
• The radical cure of hernia.
  The Johns Hopkins Hospital Bulletin, 1889, 1: 12-13, 112.
  Simultaneous with with he Italian surgeon Edoardo Bassini (1844-1924), Halsted devised the modern operation for the radical cure of inguinal hernia.
• The treatment of wounds with especial reference to the value of the blood clot in the management of dead spaces.
  The Johns Hopkins Hospital Reports, 1890-1891, 2: 255-314.
  Halsted showed that optimum wound healing was most easily obtained by avoiding haematoma formation. Contains descriptions of Halsted's method of radical mastectomy. This paper also contains the first mention of the use of rubber gloves(a Halsted invention) in an operating room.
• Ligation of the first portion of the left subclavian artery and excision of a subclavio-axillary aneurism.
  The Johns Hopkins Hospital Bulletin, 1892, 3: 93-94.
  First successful ligation of the left subclavian artery.
• The results of operations for the cure of cancer of the breast performed at the Johns Hopkins Hospital from June, 1899, to January, 1894.
  Johns Hopkins Hospital Reports, 1894-1895, 4: 297.
• Contribution to the surgery of the bile passages, especially of the common bile-duct.
  The Boston Medical and Surgical Journal, 1899, 141: 645-654.
• Auto- and isotransplantation, in dogs, of the parathyroid glandules.
  The Journal of Biological Chemistry, Baltimore, 1925, 63: 395-438.
• Partial progressive and complete occlusion of the aorta and other large arteries in the dog by means of the metal band.
  The Journal of Experimental Medicine, New York, 1909, 11: 373-391.
• A diagnostic sign of gelatinous carcinoma of the breast.
  Journal of the American Medical Association, Chicago, 1915, 64: 1653.
• Surgical Papers by William Stewart Halsted.
  Edited by W. C. Burjet. 2 volumes. Baltimore, Johns Hopkins Press, 1924.