Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (12 page)

Halsted was good company. He was outgoing, always attentive, full of good humor, ready with an amusing remark, and every bit
Welch’s match. His disposition in the evenings stood in sharp contrast to the quiet, reserved, often acidic demeanor for which he was known at work. The comfort of being with friends substantially contributed to his ease and confidence. In the late afternoon, Halsted sequestered himself behind locked doors and emerged after 90 minutes refreshed and in high spirits. Productive mornings, midday letdown, occasional sweats and shaking chills, followed by afternoon seclusion and strong evenings lead to obvious conclusions.

Halsted traveled a great deal during his tenure at Johns Hopkins, just as he had before. Medical meetings and clinic visits in Germany and Austria, small hotels on the English coast, and quiet places in France all called to him. His long itineraries were mostly unannounced, and he invariably traveled alone.

Welch also traveled alone. But unlike his friend, who favored isolation, Welch was enamored of the seashore, rest cures, and garish resorts such as Atlantic City. Little of what occupied him on these holidays was known, but he wrote frequently, socialized freely, and was happy to see a friendly face. There were no women in his life. Harvey Cushing, in his Pulitzer Prize–winning biography of William Osler, suggests that Welch was homosexual, though no evidence was offered beyond personal suspicion. The private Welch was something of a mystery to everyone at Hopkins. Lovingly referred to as Popsie, a limerick popular among the students tells the story:

Nobody knows where Popsie eats,

Nobody knows where Popsie sleeps,

Nobody knows whom Popsie keeps,

But Popsie.

William Welch was the least physical of men. Never known to indulge in any form of sport, he suffered from gout, and was always overweight and under-exercised. As a celebrated elder statesman,
H. L. Mencken described him as a “two hundred pound eighty year old” who had been up late into the previous night at a banquet. At lunch the following day, Mencken reported that he ate a large portion of ham and greens washed down with several mugs of beer, and followed by “an arc of at least 75 degrees of lemon meringue pie, after which Welch smoked a six inch panatela, made a speech in English and finishing in German, and ambled off to attend a medical meeting and to prepare for dinner.” Mencken wisely concluded “that pathology is still far from an exact science.”

1 Here things get a bit fuzzy. The information about Butler comes from a 1952 recollection of Halsted by a Hopkins pediatrician named Edwards A. Park. Park, who had lost the notes of his interviews with Shattuck, states that Sawyer died in December of 1885, which, if true, would make the episode temporally impossible.

CHAPTER NINE
Baltimore

IN 1886, SOUTHBOUND TRAINS
from New York were boarded at the Baltimore and Ohio terminal in Jersey City, less than two miles across the harbor from the tip of lower Manhattan. Wind-driven snow and frigid air had plagued the Northeast for days, and the crossing was rough early that December morning. The rail trip to Baltimore took nine hours along the well-traveled line between New York City and Washington. The old steam locomotive pulled slowly up the grades, and the cars rattled and screeched around every turn, but it was far more comfortable than the ferry crossing. The food was good, there were gas lamps for reading, and all the proper amenities were provided for first-class passengers.

Halsted had pleasant memories of Baltimore and had remained in contact with his Yale chum Henry James, the son of a prominent Baltimore banker. But he was no longer a college student and his circumstances had changed. At 34 years of age, he was both fragile and hopeful, and was attempting to outrun the cocaine addiction that had left his professional life in ruins. This was a chance for redemption and a new start, and he was determined to make the best of it.

Welch welcomed Halsted with the warmth and good fellowship that only a truly close friend could provide, and arranged accommodations
for him in the Cathedral Street rooming house where he himself resided. There, Welch could watch over him, and he would be well cared for by Mrs. Simmons. Halsted appeared healthy and self-confident, and exhibited none of the excitability and nervous energy that had characterized his plummet. Still wearing a neatly trimmed mustache and beard, his immaculate figure and shambling gait soon became familiar sights at the laboratories on the second floor of the Pathological. Halsted cut quite a figure in the winter streets, his silk top hat sitting jauntily on his head above his jutting ears. Men in Baltimore typically wore homburg or derby hats, and the topper was a New York affectation to which he continued to cling.

Halsted was immediately comfortable in the laboratory. He and the men around him were intellectually connected by their devotion to the scientific method that had germinated in Europe. Projects quickly materialized, and the atmosphere was electric with ideas. From the earliest days, it was clear that this might well be the best group of young medical scientists ever assembled in America. Welch, ever the sounding board, thoughtfully considered the ideas presented to him, advised when asked, and never interfered. His new teaching method was finding its sea legs. Learn by doing was the rule from the start, and most of the early group were self-motivated and able to thrive under the lax but nourishing conditions.

A bit removed from the hubbub around him, Halsted often walked past colleagues in the corridor without greeting them, as if he were elsewhere. For the most part, his detachment was attributed to immersion in his work, but severely compromised vision and his unwillingness to update his glasses added a physical aspect to the isolation.

From the beginning, even during his New York years as a harried, old-school surgeon, Halsted was able to step back and question why things were done the way they were and wonder how they could be done better. Now distanced from the pressure of patient care and teaching, he was able to concentrate on the whys and wherefores
of surgery and confront the issues standing in the way of progress. At the Pathological, he developed a manner of dealing with animal experiments that soon became the national standard. Physiological experiments were usually performed on small animals, which were abundant and inexpensive, but surgical procedures demanded larger subjects, usually dogs. With the growth of experimental science, the use of the dog laboratory increased. Animal experimentation, whether humane or callous, whether performed on frogs or dogs, drew the wrath of the increasingly powerful antivivisectionists.

Halsted, not in the least bending to pressure, and perhaps not even mindful of it, demanded that all surgical procedures performed on the experimental animals were to be conducted with the same care and humanity afforded hospital patients. He set these standards for himself, lived by them, and demanded nothing less from others. Dogs were properly cared for. They were fully anesthetized for surgery, which was carried out under stringent aseptic conditions using sterilized surgical instruments and proper technique. The dogs were the patients. They were treated carefully and humanely, their pain promptly relieved by opiates, their diets nutritious, their environment sanitary, and their surgical findings recorded as thoroughly as in any hospital chart. Halsted took great pride in entrusting the responsibility of overseeing the dog lab to his favored assistant. This scrupulous attention to detail yielded rich dividends.

At the Pathological, Halsted worked alongside Franklin Mall, Welch’s 23-year-old wunderkind and fellow in pathology, who was continuing his own studies of intestinal anatomy and physiology while working on projects with Welch. Mall and his new laboratory mate got on well from the start. Halsted focused on anatomy as it related to surgery, while Mall concentrated on the uncharted fine points of anatomy. His prior work had identified the repetitive arch pattern of intestinal blood supply as discrete segments integrated into a functioning organ. He was interested as well in the role of the microscopic finger-like villi in the absorption of intestinal contents. Recently, Mall had become
aware of the tough submucosal coat between the outer muscular layer and the inner mucosal layer of the intestine, and he was puzzled by its seeming lack of function. Halsted’s interest was piqued. Surgeons had been wrestling unsuccessfully with the problem of reconnecting two ends of surgically separated intestine, or intestinal anastomosis, for years, unaware of any possible role for the submucosal coat.

The intestine is a long, squirmy tube filled with food and rapidly multiplying bacteria digesting that food. The contents are more liquid in the small intestine near the entry of food and water from the stomach, and are propelled through the intestine by muscle contractions called peristalsis, where nutrients and liquids are absorbed. Farther along the 25 feet of intestine as water is absorbed in the large intestine, or colon, the contents become increasingly fecal through bacterial proliferation until they ultimately become stool.

Typically, the excision of a cancer or the correction of an intestinal obstruction requires the removal of a section of intestine. The surgeon was then faced with both the need to avoid spilling bowel contents into the abdomen and to find a method of joining the two ends of intestine together in a manner that could withstand the movement and pressure of peristalsis. Careful handling could minimize the initial problem of spillage, but the frequent late breakdown of the anastomosis was catastrophic, spilling feces throughout the peritoneal cavity. Half a century before the advent of antibiotics, this often resulted in death. Abdominal surgery was in its infancy, and surgeons used thick sutures to sew the two ends of the tubes together, intestinal muscle layer to intestinal muscle layer. They tied the heavy sutures tightly and hoped for the best. More often than not, the muscle was devitalized, and when the catgut sutures dissolved, or tore through, the muscle-to-muscle anastomosis broke down, spilling intestinal contents into an abdomen compromised by devitalized tissue.

Mall’s curiosity about the submucosal layer seemed worth exploring for its surgical implications. Halsted set about suturing cut
intestines together, incorporating various suturing levels and techniques, and ultimately coming to believe the key to a strong anastomosis was, in fact, in the mysterious submucosa.

Halsted wasted no time. The first experiments were completed one week after his arrival in Baltimore. Ensconced in a small room on the southeast corner of the second floor of the Pathological, close by Mall and Welch, he worked feverishly. Total immersion had always been the way he approached new projects, and in that regard intestinal anastomosis was no different from the cocaine experiments, but now the stakes were higher. He had to fit in, justify Welch’s faith in him, and keep control of his private life.

The work went well and it soon became clear that the hypothesis was correct. Intestinal anastomosis using fine silk sutures incorporating the submucosal layer withstood the pressures of normal function. To reinforce the point, Halsted devised a demonstration measuring the force needed to pull apart intestines sutured by the various methods. Invariably, an anastomosis including the submucosa was stronger and more difficult to separate. According to Councilman, Welch’s assistant pathologist, he was also “fond of demonstrating that when a loop of small intestine was clamped in the handle of a scissors and pulled through, both the muscularis and mucosa were stripped, but a stitch caught in the submucosa still held.” The graphic evidence was undeniable.

Sixty-nine experiments were carried out through the winter. They were completed on April 1, 1887. On April 5, only four months after arriving at Johns Hopkins, Halsted delivered an important paper on his findings at the Harvard Medical School.

Among his remarks were the following:

The current ideas among surgeons are not only incomplete, but absolutely incorrect as regards some important details in the structure of the intestinal coats. My experiments have led me to attach great weight to an accurate knowledge of the thickness and physical characters of the submucosal coat of the intestine. I am not aware that the importance of this coat in connection with this operation has hitherto been emphasized.

Typical Halsted. Direct, severe, and gentlemanly.

OTHER SURGEONS SOON
corroborated the importance of the submucosal layer in intestinal anastomoses. In short order, the maneuver was generally adopted. Combined with the growing application of aseptic precautions and gentle handling, it provided the link necessary to make intestinal surgery safe and predictable.

Halsted’s surgical work was performed only on laboratory dogs and not tested on humans. The dog lab was his life, and he often referred to these years as his happiest. Perhaps more important than discovering the use of the submucosa was the methodology: rigorous animal testing in a controlled surgical environment prior to human trials.