Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (16 page)

For the surgeons, preparing their hands for surgery was an unpleasant but necessary evil. Orange sticks were used to clear debris from under their fingernails, after which they scrubbed their hands for five minutes with green soap and scalding water. Then they dipped their hands and arms up to the elbows in permanganate solution, an oxidizing agent, which turned the skin a dark brown color. This was followed by an oxalic acid soak, which neutralized the permanganate and decolorized the skin. The process was completed with a final five-minute dip, fingers to elbows, in corrosive sublimate, now known more commonly as mercuric chloride, the most toxic substance of the lot. Mercuric chloride has a health rating of “4-poison.” It is potentially fatal if ingested, causes redness and pain when applied to the skin, may cause allergy, is readily absorbed through the skin, and can cause neurological damage and kidney failure. Otherwise, it was a safe and useful tool.

For a time open wounds were irrigated with corrosive sublimate as well, but observation of the toxic effects led to the discontinuation of its use. Sterile instruments were stored before use in a dish of carbolic acid beside the operating table. The combination of mercuric chloride and the carbolic acid in which the sterile instruments were stored caused frequent painful rashes and red pimples, which were often debilitating. Weaker solutions of corrosive sublimate were tried, and soon it was replaced entirely with less irritating substances and reduced rituals, but until the advent of sterile rubber gloves the process of preparing for aseptic surgery remained decidedly unpleasant.

Traditional black, fitted Prince Albert coats had been in favor as operating garb since the 1876 visit to America by Albert, consort to Queen Victoria. Knee length, and with a full skirt, instead of being “cut away” the coats had notched velvet collars in single- or double-breasted styles. Before surgery they were pulled from pegs in the operating room where they hung, caked with old blood, tissue detritus, and pus from previous surgery. Using these filthy coats saved the surgeon’s street clothes from becoming soiled, and the cumulative signs of battle on the coats became something of a badge of honor. In Halsted’s operating room they were shed in favor of white duck operating suits, consisting of short-sleeved shirts, trousers, and a little round skull cap. In the final touch, the traditional short, rubber boots worn over street shoes were replaced by white tennis shoes.

While steadfast in his belief in aseptic technique, Halsted was willing to experiment with any modality to improve operating conditions and patient safety. Nurse Caroline Hampton fell victim to severe dermatitis of her hands, assumed to be caused by constant contact with mercuric chloride. Halsted sought a solution for the painful rash, which threatened to drive her from his operating room. On a trip to New York he met with representatives of the Goodyear Rubber Company, and arranged for them to produce two pairs of fine rubber gloves with wrist gauntlets. These were not unlike the rubber gloves

Welch had brought from Germany, and that he wore at autopsy, but Welch’s gloves were very thick and dulled sensation far too much for use in surgery. The Goodyear gloves were thin enough to cause only modest loss of sensation, and after a bit of experience caused no appreciable tactile deficit. The gloves protecting Caroline’s hands were sterilized by boiling and dipped in carbolic solution. They were sturdy and reusable, and allowed Caroline to continue to function as Halsted’s surgical nurse.

By the end of 1889, rubber gloves were regularly worn by the nurses who squeezed out the gauze sponges soaked in bichloride of mercury, as well as the intern who passed instruments and was constantly fishing them from the carbolic basin and threading carbolic-soaked needles.

The introduction of rubber gloves to surgery began as simply and unremarkably as protecting a nurse’s skin from irritation. No one, it seems, saw this innovation as anything more than that. Halsted had inadvertently set into motion the single greatest advance in the history of sterile technique.

Several months later, when Caroline Hampton left the operating room, rubber gloves were abandoned other than for optional use by the intern. Over the next six years, sterile rubber gloves were worn only when surgeons opened clean joints, which required the utmost sterility. Once a joint was seeded with bacteria, the infection was almost impossible to uproot. Why the enormous potential of sterile rubber gloves was missed for so long after being introduced remains a mystery. Halsted’s seminal bacteriology work had proven the impossibility of sterilizing hands by scrubbing and immersion in bichloride of mercury, or other antiseptic solutions. The use of gloves by the nurse was ultimately ordered because Halsted felt that handling, dipping, and squeezing out sponges carried an additional risk of infection when done bare-handed. And yet he did not expand the use of gloves to include the surgeon. One would have expected a bell to go off long before 1896, when his resident, Joe Bloodgood, in a conversation about
the gloves quipped, “What’s sauce for the gander is sauce for the goose,” and began wearing rubber gloves for every operation. Soon afterward, the entire team followed suit, and the days of bare-handed surgery came to a close as a sterile rubber barrier was placed between the surgeon’s hands and the wound.

Soon the rubber gloves were heat sterilized, too, and the circle of sterility was complete. With routine use of sterile operating gloves the story of aseptic surgery was changed forever. Prior to this, Halsted had established an admirable record of clean, infection-free wounds, which was justifiably attributed to his technique. He insisted on scrupulous asepsis, gentle handling of tissue, careful control of bleeding, the use of fine silk sutures to minimize tissue damage, and subcutaneous silver wire closure to eliminate contact with the unsterile skin by tunneling under, rather than piercing, it.

Halsted’s rate of infection after hernia repair was a very respectable 9 percent. After introducing the use of sterile surgical gloves, it dropped to less than ½ of 1 percent.

CHAPTER FOURTEEN
The Radical Cure of Breast Cancer

FINNEY SAT AT THE
patient’s head with the ether apparatus set in a box on the floor at his feet. The task was new to him, but he managed the inhaler well, keeping the patient unconscious without asphyxiating her. He had been enlisted for his free hours before the 10 A.M. opening of the dispensary, and though it wasn’t what he chose to do, at least it brought him into the operating room. When the woman was fully asleep, her skin was washed with green soap, painted with mercuric chloride, and draped with sterile white sheets, exposing her lumpy, battle-scarred left chest. Thirty-eight years old and the mother of ten, she was fully occupied at home, and had waited until the pain in her breast and arm became severe enough to drive her to the hospital. The mass had been present and growing for at least six months, and the pain and infection under her arm could no longer be ignored. The tumor now occupied virtually her entire left breast. The nipple was retracted, and the infected, cancerous lymph nodes in her axilla had developed an abscess, which Halsted and his team had drained 17 days earlier. On the surgical table, her axilla was no longer inflamed, but it remained rock hard.

It was mid-June of 1889, and this was the first surgery for cancer of the breast to be performed at Johns Hopkins. Caroline Hampton, the scrub nurse; Fred Brockway, the newly minted surgical resident; and his assistant resident scrubbed their hands as directed with green soap and a stiff brush, rinsed in scalding water, and disinfected their hands and arms with the same caustic solution of mercuric chloride used on the patient. Dressed in the new operating uniforms of short-sleeved, white cotton operating suits and sterile gowns, they took their positions. Halsted inscribed an extensive incision from the axilla, near the old abscess site, counterclockwise down and along the sternum, under the breast, encompassing the entire breast, and up the lateral aspect, meeting the original swipe and forming a giant, bloody teardrop.

Hardened by infection, the skin near the axilla was unusually difficult to reflect upward, and the lymph nodes under the arm couldn’t be reached. The recent abscess had matted them down. Common sense dictated returning to the axilla on another day. Dissecting with a scalpel, Halsted mobilized the entire breast and much of the underlying pectoralis major muscle. He applied artery forceps to arteries and veins as they appeared, and secured the vessels with fine silk sutures to minimize blood loss and crushed tissue. He removed the anatomical specimen in its entirety and carefully examined it at the operating table. Having taken great care to avoid cutting into the tumor for fear of spreading the cancer, Halsted now rolled the mass between bare fingers, and cut through its substance, making careful mental notes of its consistency and appearance before sharing his thoughts with his assistant. He placed numerous suture tags on areas of interest before sending the specimen to Welch’s pathology laboratory, where microscopic sections would be prepared for later examination.

Halsted had performed the 12th operation at the new hospital, and the first for breast cancer. He had previously performed this new, extensive technique in New York more than five years earlier, and he
had been determined to expand on it. Over the last decade, surgeons had searched in vain for a procedure to halt the ineluctable mortality from cancer of the breast.

European surgeons like Volkmann and Billroth were advocating radical removal of the breast for every cancer. For tumors that seemed particularly deeply invasive, the pectoralis muscle beneath the breast was removed as well. The concept of cancer of the breast spreading through microscopic lymphatic channels draining tissue fluid and lodging in lymph nodes was generally accepted, but the idea of the removal of all the regional lymphatic channels and the lymph nodes was not. Volkmann postulated that the fibers of the pectoralis muscle propelled the cancer cells along by muscle action, so he stripped off the fibrous facial coating of the muscle, sometimes including muscle fibers as well. Little thought was given to the possibility of distant spread of the cancer through the bloodstream. The success of surgery was determined by the presence or absence of local recurrence of the cancer. In the best hands, the rate of local recurrence—the reappearance of the cancer in the previously operated area—exceeded 50 percent. Distant metastases were universally lethal, and preventing their spread was not even considered.

Excluding death by distant metastases from the measure of success was not surprising. One changes what is changeable; impossible tasks come later. The idea of preventing distant metastases was simply impractical. Knowing what we know now, this seems insanely pessimistic, and the idea of a 50 percent local recurrence rate, unthinkable.

This abysmally poor performance was a direct consequence of how advanced the disease was at the time of detection. Though the first rudimentary mammography was performed in Germany in the late 19th century, it did not come into general usage until the 1960s. Public health information was negligible, and usually restricted to epidemic problems such as containing the spread of cholera and influenza. Self-examination of the breasts was unthinkable in the
shadows of Victorian morality, and certainly not a topic of conversation. Breast cancers grew unimpeded and undetected, noticed only when they couldn’t be ignored and treated when they couldn’t be tolerated. Routine checkups didn’t exist, and doctor visits were restricted to serious illness or injury. Most breast cancers grew larger than a lemon, ulcerated through the skin, retracted the nipple, or massively involved the axillary lymph nodes before they were treated. In all likelihood the advanced disease had already spread unseen to other parts of the body. Small wonder success was judged by reduction in the incidence of local recurrence. Radiation and chemotherapy were decades away, public awareness was negligible, and regular medical care was out of the reach of most women. Understandably, surgeons measured success in small increments.

ON THIS DAY
, Halsted was frustrated by his inability to complete the operation. He had come to believe that the best chance at containing cancer of the breast was full removal of the tumor, the surrounding tissue, overlying skin, underlying muscle and fat, and all the regional lymphatic tissue into which the area drained. Giving the tumor a wide berth was essential. When he explained the extent of his radical surgery, he made it clear that he had weighed the efficacy of extensive excision of involved tissue against the added morbidity and discomfort to the patient. He always underscored the fact that “getting around” the tumor was crucial; one had to avoid cutting through tumor-infiltrated tissue. Halsted was certain that violating this premise would spread the cancer. The very knife used to remove the cancer would “infect” clean tissues with cancer cells if one cut through any involved area.

In the late stages of breast cancer commonly seen in clinics at the time, the tumor frequently grew into the undersurface of the skin, and sometimes through it, presenting as a fungating mass on the chest. The lymph nodes in the axilla, around the clavicle (collarbone), and
even along the sternum (breastbone) were frequently enlarged, and were found to contain tumor at postmortem examination.