Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (22 page)

The book took over his life. The Johns Hopkins Hospital seemed to be taking care of itself, and
Principles and Practice
was a monumental undertaking. Although his huge fund of knowledge provided the skeleton of the work, Osler supplemented what he knew with copious research. Surrounded by handwritten notes and piles of books, he dictated the text to his stenographer. He spent early mornings on the book, a morning hour or two on ward rounds or seeing patients, the afternoon again on the book, and an hour in consultations outside the hospital; then he dined at the Maryland Club and enjoyed a few hours at leisure before his 10
P.M.
bedtime.

After his initial flurry of activity, he expended less energy on hospital business. The new hospital was well staffed and not overly busy. LaFleur, Thayer, and the intern cared for the inpatients and the clinic patients, performed all the laboratory work, and ran the day-to-day operation of the service. This was the dawn of academic medicine, and roles were not yet fully defined. There were few hospital beds for private patients, no medical school in sight, and only the house staff was burdened with work.

With an annual salary of $5,000, and some additional income from outside patients, Osler and his fellow chiefs were meant to be free of the business of medicine. Handsomely compensated, they could carry on as they wished. Though Halsted was paid less, he was happy with the new organization of his life, and his operating schedule was soon as demanding as it had been in New York.

Halsted arrived early, changed clothes in his office, and was in the operating room by 8
A.M.
The surgical dispensary opened at 10:00, and as surgeon to the dispensary, he tried to attend as soon as his operating schedule allowed. The Roosevelt Hospital Dispensary had become a model of its kind, and making use of his experience there the board of trustees put Halsted in charge of all outpatient services.
The dispensary was the primary source of surgical cases, and the two responsibilities were closely related. As the surgical load increased, Finney assumed increasing responsibility for the dispensary and Halsted spent more of his time in the operating room. Soon he was doing several operations each morning, with Finney administering ether until he was needed in the dispensary. At noon, Halsted retired to lunch with the others.

The nuclear members of the Hopkins staff lunched together regularly. In that fraternal atmosphere someone was always the butt of Osler’s pranks. Halsted participated in the freewheeling discussions and parried well with Osler, but he was not the witty raconteur of evenings at the Club. Welch, Osler, Councilman, Kelly, and LaFleur were lunch regulars, joined by a steady stream of visiting dignitaries from around the world who had made the trip to Baltimore to see what the medical revolution at Johns Hopkins was all about. None of the visitors were immune to the infectious goodwill that was palpable everywhere. The Hopkins people were pleased to be where they were, pleased to be in one another’s company, and certain they were on the leading edge of medical history.

During that first year, all levels of professional staff lived in close proximity in the hospital administrative wing. Accommodations for the house staff included a well-furnished bedroom and the ultimate luxury of a separate sitting room or study. Senior staff had similar, if larger, apartments. Living together and sharing meals, with waiters, maids, and bootblacks attending to their personal needs, they enjoyed a pleasant environment that fostered a vertically integrated sense of community, to which even Halsted was not immune. Busy as they were at the outset, there was always time for pranks and exercise, and sometimes, women. Baseball and tennis were popular with the staff, and Halsted excelled at both. Those who knew him in later years might find it incongruous to think of the distracted Professor racing the bases or gracefully covering ground on the
tennis court. Finney was witness to both the early and late conditions, and as his doubles partner in the early years, benefited from his chief’s athletic ability.

After lunch Halsted made ward rounds with Brockway, Finney, the intern, graduate students, and whoever else could be rounded up. It was the resident’s duty to make it known that The Professor was en route and see to it that a respectable turnout materialized. Often this included physicians from the Baltimore medical community who were invited to lectures and clinical demonstrations at Hopkins as part of the initiative intended to soften local resentment toward the academic interlopers. Halsted’s rounds were long and formal affairs, and not necessarily enjoyed by those in attendance. He spent inordinate amounts of time at the bedside of each patient. Often, an hour of questioning and probing passed without any explanation of his thinking to the assembled staff or the patient. The population of the hospital was overwhelmingly composed of charity patients, with only the occasional private, or paying, patient, and few private rooms to accommodate them. In 1889, surgery for private patients was still performed predominately in their homes, although Halsted was beginning to treat some in the hospital.

During ward rounds, or in the dispensary, he was unfailingly professional and courteous to patients from every stratum of society. His quiet, cold demeanor, and the slavish need to please him exhibited by the house staff, made the chain of command clear. It was rare for a patient to so much as pose a question.

Part of the responsibility of the resident staff was to prepare for Halsted’s pointed questions. What are the symptoms? Has the patient’s blood count changed? Are there signs of suppuration beneath the bandage? Concise and accurate answers were expected. In the event that the resident was unable to provide the information, he was met with an icy stare and a withering comment. A humiliating “Perhaps you should find a different line of work” drove at least
one young doctor away, and surely encouraged others to either fully prepare or absent themselves. Halsted would then turn away and continue his line of thought as if the embarrassing incident had not occurred, and never mention it again. The single transgression that would end a man’s career was lying about patient care. When an assistant resident reported a wound to be healing cleanly, having not actually changed the dressing and observed it, Halsted peeled away the bulky gauze bandages to reveal an open and pus-filled wound. In front of the gathered staff, he dismissed the man from his position. If the patients were not intimidated by his presence, and they usually were, the staff certainly was.

Occasionally Halsted’s sarcasm or caustic comments provoked an unexpected reaction. On formal surgical rounds, one of the duties of the ward nurse was to prepare bandages for Halsted to apply to the wound. Holding the bandage and attempting to apply it, Halsted became entangled in the untrimmed threads. He was becoming visibly distressed. Raising the now tangled dressing, he said, “In New York, where I was brought up surgically, a nurse would blush to hand a doctor a bandage such as this.”

“Ah, but we are more brazen than they,” replied the unintimidated nurse.

Halsted said nothing. He reddened from the top of his bald head to his ears and down his neck, removed the loose threads, applied the bandage, and left the ward without another comment.

If he often turned away from confrontation, examples of pure dismissive behavior abound in Halsted legend. So prevalent are they that they must be considered indicative of character. But Halsted had become increasingly aloof, and perhaps out of touch with simple human situations. The same man capable of cutting one off at the knees could be enormously thoughtful and generous. The same man of legendary attention to detail could continually pass the bed of a patient awaiting surgery and repeatedly neglect to schedule the operation.

Often comments that he meant to be amusing either missed the mark or struck accurately, at the expense of others. Among equals or the uninitiated, a joke or prank might be directed at him. At these times he was unable to respond in kind, or accept the remarks in the manner in which they were intended. Osler visiting the operating room and parking his hat, gloves, and walking stick in the sterilizers, provoked an irritated, “Osler, won’t you ever grow up?”

The Osler behavior that so endeared him to others caused Halsted to consider him something of a buffoon. William Halsted’s humor was predicated on his sense of the absurd, which he happily shared with a very few intimate friends. But all too often it was unpleasantly to the detriment of others, who were not in a position to respond in kind. Not even his peers considered him jolly, but in social circumstances Halsted was amusing and happy to be amused. His blue eyes revealed a smile before his lips turned up, although no one remembers him actually laughing.

At 3:00 in the afternoon, Halsted either conducted a formal clinic in which patients were presented and discussed or he lectured graduate students. Then, at 4:00 or 5:00, he was off to the Pathological and his experimental surgery. From the opening of the hospital on May 7 through the end of the first year, 316 patients were admitted to the surgery ward. Many of these admissions were tuberculosis related, in the form of abscesses, suppurating lymph nodes, and pus-filled joints. Nine patients were admitted for surgery of inguinal hernia and five for carcinoma of the breast. One patient was admitted for appendicitis, though preemptive appendectomy was not performed.

BEGINNING WITH ONLY
Brockway, Clark, and Finney, the size of the surgical staff grew to include the resident surgeon, assistant residents, and interns. There were no bad habits to unlearn at Johns Hopkins. The routines established for the house staff were worthy of Voltaire’s “best of all possible worlds.” The institution was well
endowed and could afford the best equipment. The house staff was culled from an admirable pool of applicants, willing to work long hours and remain on call the rest of the time. The position was 24 hours, seven days a week. The chiefs of service were all under the age of 40 when the hospital opened, and they were bright, energetic, and consumed by their profession.

In 1890, Robert Koch, the high priest of the germ theory, made a startling announcement to the world. The man who identified the tubercule bacillus was once again at work trying to conquer the ubiquitous scourge. He believed a substance obtained from tubercle bacillus cultures, which he called tuberculin, would favorably alter the course of the disease, and perhaps cure it. At least it seemed to have cured tuberculosis in guinea pigs in his lab. The world waited expectantly for the result of clinical trials. Through the John Shaw Billings connection, Hopkins acquired tuberculin, and immediately, and with great fanfare, began injecting it into patients with advanced tuberculosis. A momentous day was dawning.

As it turned out, tuberculin did not cure tuberculosis, nor did it positively affect the course of the disease. Much later it was found to be a reliable indicator of exposure to tuberculosis, but as a therapeutic modality it was worthless. The experiment was an abject failure, but Johns Hopkins was in the forefront of medicine. There were no recriminations. The feeling of all concerned was “at Hopkins we try things.”

On Monday evenings the weekly Medical Society meetings were held for the general discussion of medical topics, with the first and third Mondays reserved for the presentation of interesting cases and the reading of papers on the work of the staff.

Medical papers were being published everywhere and on every subject, and it was virtually impossible for individuals to keep up with the literature. In Philadelphia, as in Montreal, Osler had organized small groups for the discussion of foreign papers. As a natural extension of the past success, the chiefs organized a Journal Club for
themselves and the house staff, which institutionalized the practice of organized discussions of interesting medical papers. Meetings were held on Thursday afternoons in the small medical library of the hospital. This was very likely the first “official” journal club in the nation, with its stated purpose “to enable all members of the staff to keep fully informed as to what is being accomplished by workers in every branch of medical science with the least expenditure of time.” It was a good idea, and it spread to every service of every teaching hospital in the country. Specialty specific, journal clubs are as important and popular now as on October 29, 1889, when they began.

In December of 1889,
The Johns Hopkins Hospital Bulletin
was initiated to chronicle medical events at the new institution and scientific papers. So convinced were the participants of the importance of their mission that the
Bulletin
was offered outside the hospital by subscription. The first issue included an introduction to the hospital and its educational philosophy, Johns Hopkins’s letter to the trustees and president of the Board of Trustees, Francis King’s address on the opening of the nursing school, Hospital Director Henry Hurd on the relationship of the nursing school to the hospital, Halsted on the radical cure of inguinal hernia, Osler on malaria, and Welch on hog cholera. The
Bulletin
also included the proceedings of the Journal Club and The Johns Hopkins Hospital Medical Society.
The Johns Hopkins Hospital Reports
became a vehicle for in-depth exploration of particular medical subjects.

The
Bulletin
was where Halsted reported his first five hernia operations in 1890, and then a total of 82 cases three years later. The
Bulletin
, from the outset, was the propaganda organ of the hospital, albeit with a scientific bent. A great deal of innovative work was being done, and they made it their business to get the word out. The breadth of ambitious medical talent made it possible to fill the pages of the
Bulletin
with stimulating material, and the interest engendered by the papers served the institution well. The Hopkins experiment, as
chronicled in the
Bulletin
, made it required reading throughout the world of academic medicine, and its practical value to the practitioner was soon recognized as well.