"Primum Non Nocere"

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A Moment in History

William S. Halsted, MD
(1852 – 1922)

American anatomist, teacher, and surgeon, William Stewart Halsted was born in New York City, USA to a wealthy family of English origin. His father was involved in charitable work and Governor and trustee to a city hospital. Not a brilliant student initially, Halsted took an undergraduate in Liberal Arts in Yale, CT., after which he entered the Medical College of Physicians at the Columbia College, where he excelled.

As a second-year medical student Halsted applied and obtained a position in surgery at a local hospital. In here he learned about Lister’s antiseptic technique and became an adamant proponent of it to reduce infection. In 1877 Halsted obtained his MD. After a short time as House Physician at the New York Hospital, Halsted traveled to Europe to further his education studying for two years at the Universities of Vienna, Leipzig, and W?rzburg.

Besides being at the forefront of surgical and antiseptic techniques (introducing the use of rubber gloves in surgery), Halsted was extremely concerned with the way medical students were taught in the US. He pioneered bedside clinical round discussions with the medical students after two years of basic sciences studies. Halsted developed the idea of a patient chart; he also developed the residency program for medical students in use today.

Halsted is probably the most influential researcher and surgeon at the turn of the century. He dedicated time to the study of intestinal anastomoses and the use of silk as a suture material. His experimental work in 1887 proved that the inclusion of the submucosa layer in an anastomosis was mandatory, as well that a single layered anastomosis was enough to attain closure. Perhaps Halsted’s most important contribution was the application and use of the scientific method to surgical questions. Halsted’s principles, also known as "Halsted's Rules of Surgery", set the standards used today in surgical suturing and surgical stapling.

He also pioneered the development and surgical techniques for radical mastectomy as a treatment for breast cancer.

As a side effect of this studied in anesthesia and the use of cocaine for anesthesia, Halsted became addicted to this substance, a problem that followed him through the years. Without impairing his capacity as a researcher and a surgeon, Halsted eventually recovered. He died in Baltimore in 1922 as a complication to surgery.

Sources:
1. Dubay, A. D., & Franz, G. M. (2003). Acute Wound Healing: The Biology of Acute Wound Failure. Surg Clin NA, 83, 463-481.
2. Halsted, W. S. (1887). Circular Suture of the Intestine - An Experimental Study. Am J Med Sci, 436-461.
3. “William Stewart Halsted: his life and contributions to surgery” Osborne, P. Lancet Oncol 2007; 8: 256–65
4. “William Stewart Halsted: Surgical pioneer” Burress, P Endoc Today (2010), 8: (2) 22
5. “William Stewart Halsted (1852–1922) Neurological stamp” Haas, LF J Neurol Neurosurg Psych 2000;69:641
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Details: Published: February 27, 2015

Atrial fibrillation surgery
Image courtesy of Dr. Randall Wolf

UPDATED: This Latin aphorism is at the core of Medicine and Surgery. It means "Above all, do no harm". Another translation would be "First, do no harm". The works of Hippocrates mentions the concept in his book Epidemics , and it has been presented in one way or another trough the ages. Thomas Sydenham (1624 - 1689), an English physician, is probably the first one to use it in an English publication, although his Latin phrase was "Primum est ut, non nocere". The first use of the modern phrasing "Primum Non Nocere" was by Lewis Atterbury Stimson (1844 - 1917), an American surgeon in 1879.

It seems almost counterintuitive that surgery would attempt to do no harm, but this is what moves innovation. From sharper needles that require less force to penetrate, and sharper scalpels that cause less trauma to tissues, to surgical staplers and minimally invasive techniques that attempt to reduce the size of the incision and the overall damage to the tissues.

The design of new surgical devices and new surgical techniques should always attempt to answer to this most important rule of surgery: "Primum Non Nocere".

As a point of interest, the Latin term [nocere] is the basis for the medical term [noxa] means "injury", "harm", or damage", this being the root for the term [noxious]

Sources
1. "Origin and Uses of Primum Non Nocere — Above All, Do No Harm!" Smith, CM J Clin Pharmacol 2005 45 (4): 371–377
2. "On abdominal drainage of adherent portions of ovarian cysts as a substitute for completed ovariotomy" Stimson LA Am J Med Sci 1879;78:88-100.

"Primum Non Nocere"

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