Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (19 page)

Returning to Johns Hopkins after that first summer, Halsted resumed work at a breakneck pace, operating almost every day. Surgery began at 8 A.M., and Halsted performed two or three operations each day, assigning the rest to the resident staff or his assistant, Finney, who was already doing double duty as anesthetist on
Halsted’s cases. After lunch he conducted formal ward rounds, during which he was trailed by a retinue of residents, interns, and several surgical nurses. He was in the habit of changing dressings on surgical wounds himself, using starched cotton that the nurse first wet and rolled, then trimmed of all loose threads before passing to him for application. It was a rigid routine, followed exactly. Everything adhered to rigid routine. This aspect of Halsted’s world was stifling to some, and impossible for others. For those able to find its rhythm, it provided predictable guidelines, and allowed for inordinate freedom of action within the grid of those issues important to the professor. But rigidity did not preclude an open mind, and Halsted was ready to consider better options and change direction whenever clear thinking suggested a better course.

Afternoons, following rounds, were spent primarily in the surgical laboratory. In the four years prior to opening of the medical school, the laboratory work was performed with the assistance of residents and graduate students. Some worked on The Professor’s projects, others on problems of their own choosing or “suggested” by him. Few declined, and once involved they were afforded latitude bordering on absolute freedom to work as they pleased. Occasionally they were looked in upon, queried, and helped over hurdles.

CHAPTER SIXTEEN
The Big Four

IN 1888, AUSTIN FLINT
, the well-known Bellevue physician, wrote, “What has been accomplished in the last ten years as regards knowledge of the causes, prevention, and treatment of disease far transcends what would have been regarded a quarter of a century ago as the wildest and most impossible speculation.”

For the first time, a quantifiable relationship between science and well-being had become obvious. Physicians were able to prevent disease and, in some cases, actually effect cure. In surgery the ability to cure had begun as well, and anesthesia and antisepsis had made it possible to enter any closed space, body cavity, and joint with relative impunity.

Halsted had performed what was very likely the first surgical removal of gallstones on his mother in 1882; the first appendectomy was performed in 1885. Treating all manner of internal catastrophes was no longer beyond the imagination. The greatest strides forward were yet to come, and they would come very soon in an overwhelming cascade of progress. Much of this progress would take place at the new hospital and medical school on a hilltop in the sleepy Chesapeake backwater of Baltimore, Maryland.

By 1890, Halsted had narrowed his focus to a number of issues that would become synonymous with his name. Among them, aseptic
surgery and wound healing, the cure of breast cancer, the surgical repair of inguinal hernia, and graduated responsibility residency training would rank among the most important surgical advances in the next half century. These, along with the techniques of intestinal anastomosis, the surgery of the thyroid gland, and the surgical treatment of vascular aneurysm, were topics that would interest him throughout his life.

Halsted exhibited meticulous attention to detail in every aspect of surgery. He insisted on the gentle handling of tissue, and consistently made the point that rough handling of or crushing tissue in an attempt to control bleeding was counterproductive. Devitalized tissue was the perfect medium for infection. He often illustrated the point by opening the abdominal cavity of an animal under sterile conditions, introducing a virulent bacterial culture into the peritoneal cavity, and gently closing the abdomen. With no devitalized tissue to harbor infection, the body’s natural defenses would render the bacteria harmless by engulfing and destroying them, and the animal would heal without infection. Conversely, if an animal was inoculated with the same culture and even a small portion of tissue was intentionally devitalized, an overwhelming infection would result, clearly demonstrating the natural defenses of the body and the importance of gentle surgery.

Halsted recognized the need to organize and institutionalize the learning process in order to transform a journeyman surgeon into a scholar. He intended to change the very nature of surgery, and to do that he would train surgeons to train other surgeons. The road would be long and arduous, but the men who endured would be ready to take up positions at the head of other hospitals and universities throughout the country, teaching the gospel and training generation after generation of scientifically grounded surgical educators. The process of becoming a surgical leader would require independent laboratory studies, a complete knowledge of surgical pathology, gradual assumption of surgical responsibility, and teaching one’s juniors. All this would take up to eight years, and result in the development of
surgeons who would leave their residencies qualified to become surgical leaders at major institutions. Over the years Halsted would train 17 residents, most of whom went on to illustrious careers. He was more interested in training surgical educators and investigators than merely competent surgeons, and it did not take long until he was able to determine which young men met his criteria. His mission was to produce men who were both teachers of the Halsted school of careful, thoughtful, scientific surgery and future contributors to the body of knowledge in surgery.

IN THE FALL OF 1890
, shortly after Halsted returned to Baltimore from his extended wedding trip, Osler saw him in a hospital corridor suffering shaking chills. “This was the first intimation I had that he was still taking morphia,” he wrote. As Halsted’s physician, colleague, and as one in large measure responsible for his having been given the opportunity to lead the department of surgery, Osler was concerned by what he saw. He confronted Halsted, who confessed that he was, in fact, still taking morphine and could not manage to reduce the dosage below three grains daily, or about 195 milligrams, an enormous amount. The typical dose for severe pain rarely exceeds 40 milligrams daily, usually administered in divided doses of less than 10 milligrams. Halsted was using more than four times the normal therapeutic dose and was apparently undergoing symptoms of narcotic withdrawal. Osler wrote, “On this he could do his work comfortably and maintain his excellent physical vigor (for he was a very muscular fellow). I do not think that anyone suspected him, not even Welch.”
¹

Halsted continued his routine: surgery, ward rounds, laboratory experiments, study of the surgical literature, lunch at the hospital, dinner at home with Caroline, and large daily doses of morphine. In the first years, with the exception of the episode witnessed by Osler, there was no evidence of drug-related disability, but with succeeding years he would sometimes become “ill” and retire from surgery. His summer holidays stretched to five months, and his excuses to the indignant trustees ranged from recurring malarial fever to none at all. It was to become an annual pattern: great productivity, followed by unexplained absences. The length of time during which he was out of contact with Caroline and his colleagues suggest his repeated dalliance with cocaine. Since he confided in no one but Welch, and took great care not to leave written records of his behavior, one cannot reasonably think otherwise. Like Osler, Welch held his tongue.

BILLINGS AND WELCH
had not foreseen the need for a professor of gynecology at Johns Hopkins. The oversight became apparent soon after the hospital opened, and Osler threw his support behind a young phenomenon he had come to know in Philadelphia. Affectionately calling his man the “Kensington Colt,” Osler convinced the trustees to offer the position to 31-year-old Howard Kelly. Kelly jumped at the opportunity, gave up his thriving practice and the private hospital he had built outside Philadelphia, and decamped to Baltimore.

Howard Atwood Kelly was the son of a wealthy sugar broker. He was brought up in Philadelphia, attended the University of Pennsylvania, and intended to become a naturalist. After a stint as a cowboy, he
returned to Penn for medical school and an internship at the Episcopal Hospital in Kensington. Following the best practices of the day, he traveled to Europe to study gynecology and surgery. Kelly was unusually dexterous and astounded everyone at Hopkins with his surgical skill. Swift and sure, his focus was on clinical gynecology rather than science, and in that role he established new parameters for the specialty.

Halsted and Kelly were polar opposites in every aspect of their personal and professional lives. While Halsted had become a plodding, thoughtful, and rigidly routinized surgeon, Kelly was inspired, balletic, and lightning fast. Halsted observed everything and kept his own counsel; Kelly was garrulous, opinionated, and forgiving. Halsted was a very lapsed Presbyterian, while Kelly was an Evangelical Christian. He prayed before surgery, and he prayed for his patients and colleagues. Paramount among his many spare-time activities was public proselytizing, and he soon became a familiar figure among the fallen women of Baltimore and on street corners where lost souls gathered. He was an abstemious and vocal “anti-saloonist;” an avid outdoor-sman; a voracious collector of rare books, portraits, and specimens from nature; a knowledgeable collector of snakes, alive and dead; and perhaps the highest-earning physician in America.

Money was always an important aspect of Kelly’s life. Earning it, spending it, and giving it away seemed to bring him equal measures of joy. While still at Kensington, Kelly had founded a private gynecology hospital. He followed the same path in Baltimore, and operated a private clinic concomitantly with the finest teaching service and charity ward yet seen in his field. By 1892, Kelly was ensconced in a huge mansion on Eutaw Place, not far from where Halsted would ultimately live. There he housed his eclectic collections, worked in his library, and with his quiet, German wife raised nine children.

Kelly was a complicated and talented man who could shift from interest to interest and do justice to them all. It was said that watching him operate made other surgeons despair for their own ability.
Exceedingly fast and precise, he demonstrated an innate ability to recognize the proper surgical path and follow it unerringly. He was continually devising and implementing new modalities for the treatment of gynecological disease, ultimately championing the use of radium for the treatment of uterine cancer. Though his colleagues often worried about his increasingly vociferous fundamentalist preaching, their opinions were always softened by his thoughtful gifts, interesting writings, love for his family, and superb work. Over the course of his career, Kelly wrote more than 500 scientific papers. Among 18 books he authored are
Operative Gynecology
, a superbly illustrated surgical manual;
Medical Gynecology
, a comprehensive gynecology text; a number of biographies; books on botany; and
A Scientific Man and the Bible
, a tome justifying the relationship between science and religion.