Galen performed dissections forcancer of the breast as long ago as thesecond century, and Fabricius abAquapendente, in the 16th century, advocated radical breast resection. JeanLouis Petit, in the 17th century, practiced wide surgical excision of the primary breast tumor and dissection in continuity with the axillary lymph nodes,but removed as little skin as possible.Attempts to develop a suitable operativeprocedure for breast cancer were madein the 19th century by Volkmann, whorecommended removal of the fasciafrom the pectoralis major muscle and byHeidenhain, who proposed cutting awaythe muscle's superficial fibers, but thefirst true advance in the treatment ofbreast cancer was not made until William S. Halsted developed his completeradical mastectomy in 1891. Halstedand Dr. Willy Meyer independentlyconceived the radical mastectomyremoval of the primary tumor, intervening lymphatics and regional lymphnodes en masse—which has remainedessentially unchanged. Halsted's paperof November 2, 1894 is generally believed to be the first description of thisclassical operation, but his first accountwas actually given in a discourse on“¿�TbeWound,― in a section titled,“¿�Operationsfor Carcinoma of theBreast,― which is reprinted here.Halsted's comments reveal the inadequacy of breast surgery before the acceptance of his operation: “¿�Everyoneknows how dreadful the results were before cleaning out the axilla became recognized as an essential operation. Mostof us have heard our teachers in surgeryadmit that they never cured a case ofcancer of the breast.― In contrast to the58—85percent local recurrence ratenoted by others, Halsted reported by1894 that radical mastectomy hadreduced local recurrence to only sixpercent.

William Stewart Halsted was born inNew York City on September 27, 1852.Educated at Phillips Andover Academy

The photograph of Dr. Halsted is reproduced bypermission from the National Library of Medicine.Washington. DC.

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William Stewart Halsted(1852-1922)

and Yale University, he received hisdoctorate in medicine from the Collegeof Physicians and Surgeons, ColumbiaUniversity, in 1877, and then interned atBellevue Hospital in New York. Traveling to Europe for postgraduatestudy, the young physician concentratedon anatomy and embryology in theclinics and laboratories of Billroth,Volkmann, Thiersch, Bergmann andMikulicz. On his return to New York in1880, Halsted was appointed assistantdemonstrator and later demonstrator ofanatomy at the College of Physiciansand Surgeons, attending surgeon anddirector of the out-patient department atCharity Hospital, associate surgeon atRoosevelt Hospital and surgeon in chiefat Emigrant Hospital on Ward's Island.From 1885—1887, Halsted was attendingsurgeon at Bellevue and PresbyterianHospitals.

In the course of his career, Dr.Halsted introduced many radical improvements and innovations concerningthe technique and principles of surgery,exercising probably a greater influenceon the development of American surgery than any other man.

While surgeons debated Lister's concepts, Halsted was one of the first American physicians to understand the principle of aseptic surgery. He introducedsilver sutures instead of catgut becauseof its bactericidal qualities, showed howsilk could be safely buried in tissue andintroduced the use of rubber gloves inthe operating room. Rigorous asepsisand prevention of wound infectionswere practicing rules for Halsted and hisco-workers.

At a time when methods of hemostasis were primitive and elementary,Halsted concluded that “¿�oneof the chieffunctions of surgery is the managementof wounded vessels, the avoidance ofhemorrhage.― He put special emphasison the blood clot in the management ofdead spaces in the treatment of wounds,introduced delicate pointed forceps forhemostasis and used fine silk for liga

tures. He also evolved a method ofslowly constricting major vessels inpatients with aneurysm and was the firstsurgeon to successfully ligate the leftsubclavian artery in its first portion forthis condition. To avoid excessiveblood loss, Halsted developed the principle of reinfusion, whereby the patient'sextravasated blood was collected without contamination and transfused to thesame patient.

Halsted' s innovations also includeneuroregional anesthesia. In 1885,when anesthesia was limited to ether orchloroform, he studied the anesthetizingeffect of the then little-known drug, cocaine, demonstrating the value of thenerve block for tooth extraction and formore extensive operations on the jaws.He also introduced cocaine into the lumbar meninges as a spinal anesthetic.During these investigations, Halstedused himself as a subject, injecting hisown peripheral nerves to chart the zonesof anesthesia and, unaware of the risk,became addicted to cocaine. For morethan a year, ill health prevented Halstedfrom continuing his professional work.In 1887, his friend, Dr. William Welch,extended an invitation to join the pathology laboratory of the future Johns Hopkins Hospital and there, in the companyof Walter Reed, Simon Flexner andothers, Halsted's health was restoredand his surgical research begun again. In1889, he was elected surgeon in chief ofthe newly formed hospital and, on theopening of the medical school, wasmade professor of surgery, a position heheld for 33 years.

While at Johns Hopkins Hospital,Halsted originated his operations forbreast cancer, inguinal hernia and thecommon bile duct and introduced amethod of anastomosis of the bowelwhich was far superior to that of any ofhis predecessors.

He died on September 22, 1922, following an operation for a common ductstone, a condition which few Americansurgeons knew more about.

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