• Conquering Our Demons: From Cocaine Addiction to Surgical Greatness

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    We senior ophthalmologists have been privileged to witness many remarkable advances in our profession during our careers. We saw cataract surgery go from 180º incisions, with seven-day hospitalizations and Coke-bottle glasses, to microscopic surgery with minute incisions amazingly sophisticated intraocular lenses and stay times in hours, rather than days. We have also seen significant changes in the way we anesthetize the eye, from retro bulbar and lid blocks to topical anesthesia.

    Of course, topical anesthesia is not new to ophthalmology. It has been more than 125 years since Sigmund Freud shared his interest in cocaine with his friend, Carl Koller, MD, whose work on anesthesia of the cornea was read to the German Ophthalmological Society in 1884. That was a seminal moment in medical history, not only for ophthalmology, but for all of medicine. In our profession, it paved the way for modern tonometry, among other things.

    However, as with numerous contributions in medicine, it came at a heavy cost to many who pioneered the discovery. For some, the cost was too great and led to the tragic derailment of promising careers. But for others, it was only a temporary roadblock on their way to immortality in the annals of medical history.

    One person who took a special interest in Dr. Koller’s work was a young physician christened William Stewart Halsted, who was born into a wealthy New York family in 1852. As a youth, Halsted did not demonstrate much promise, other than in his passion for athletics and having a good time. As an undergraduate at Yale, he excelled in sports (he was captain of Yale’s first 11-man football team, two years before the inaugural Harvard-Yale game), but was mediocre at best in academics.

    During his senior year, however, he began reading some medical books and attended a few clinics at Yale Medical School, which was near where he lived. This experience convinced him to enroll in the College of Physicians and Surgeons in New York, where his influential father was on the board of trustees. That proved a transforming moment in the young man’s life.

    He earned his M.D. degree with honors, interned at Bellevue Hospital, served as house physician in New York Hospital and then went overseas for a two-year period of study in Europe, primarily in Austria and Germany. Such study was customary in those days for students who could afford it.

    During those formative years, Dr. Halsted began to show great promise as a surgeon. Upon his return to New York, he joined a surgical practice and received several prestigious appointments at local hospitals. But the roadblock in his career came in 1884, when he read Dr. Koller’s paper on cocaine anesthesia and embarked on his own experiments with a small group of colleagues.

    They were interested in blocking major nerve trunks with local infiltration techniques and used each other as experimental subjects. They soon discovered the exhilarating effect of the drug and some took to sniffing cocaine powder to enhance social experiences. Unaware of its addictive properties, several became addicted, including Stewart.

    Of those who became addicted, all were eventually destroyed by it, with the exception of Dr. Halsted. However, he spent the rest of his life fighting his drug dependency, first with cocaine and later morphine. Those who knew him well saw the drastic change it had on his personality.

    As the Yale surgeon Sherwin Nuland, MD, put it, Dr. Halsted metamorphosed from “an intrepid, even audacious, young surgeon ... into a remote, ploddingly cautious, compulsive researcher whose earlier exhilarating instruction of students had turned lackluster...”On more than one occasion he admitted himself to a private psychiatric facility, but was never able to break his morphine addiction.

    His life took a remarkable turn in 1888, however, when a fellow Yale alumnus, the pathologist William Welch, MD, brought Dr. Halsted to Johns Hopkins Hospital in Baltimore to get his life together. Dr. Halsted initially worked in Dr. Welch’s laboratory, but soon started a private practice where his skill as a surgeon quickly became evident.

    Johns Hopkins University and Hospital were established in the late 19th century with a bequest from the Baltimore merchant and banker Johns Hopkins, who left instructions to the trustees of the hospital that they should address contemporary deficiencies in American medical education. This included making the institution part of the university's medical school.

    It was an American experiment in a model of medical education to rival that of Europe, and its success was the beginning of the preeminence of American medicine. Dr. Welch was named professor of pathology in 1884, followed by William Osler, MD, in medicine and Howard Kelly, MD, in gynecology. When the first choice for professor of surgery, William Macewen, MD, of Glasgow, declined the offer, Dr. Halsted was appointed surgeon pro tempore in 1889 and made associate professor the following year.

    Despite the challenge of his addiction, which was known by only a few of his closest associates, Dr. Halsted excelled beyond expectations. At the urging of Dr. Osler, he became professor of surgery in 1892.

    During his 30 years at Johns Hopkins, Dr. Halsted made landmark contributions to the advancement of medical education and surgery in America. He instituted a new method of training surgeons that led to the residency training program of today. He introduced a more cautious, gentler approach to surgical procedures, with emphasis on accurate anatomical dissection and an attempt to restore the physiologic condition of the tissues. And he developed a group of new operations, including the first reliable repair of hernias, radical mastectomy for breast cancer and a technique of thyroidectomy.

    And so it was that William Stewart Halsted, MD, became one of the founders of Johns Hopkins School of Medicine and, with indomitable courage, he conquered his inner demon and went on to have an illustrious career, for which he is rightfully remembered as the father of American surgery.