Tuesday, March 31, 2015

Wiliam Halsted For President

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

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