Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (41 page)

The medical school had set absurdly high standards for admission and drew the best students in the country. A decade later, they, too, took their place at the forefront of medicine and science. Mall, Halsted, MacCallum, Cushing, and the others kept the experimental laboratories operating at full throttle, and the combined institutions were cranking out great works at a breathtaking pace. Things were moving ahead marvelously, but change was in the air.

By the time Osler was preparing to leave for England in 1905, a schism had developed in the previously unified approach to the new medicine, and the departing Osler had already taken a side. The heated power struggle between the basic scientists and the clinicians was coming to a boil. What had long been a philosophical argument now had practical implications. Welch and Mall were the primary proponents of a research-based faculty. Welch, forever the politician, continued to straddle the fence. He truly believed academic medicine belonged in the laboratory, but he wouldn’t defend the position with all the power he could wield. Mall was probably the most significant and sought-after scientist on the faculty. He was strident in his advocacy of research as the highest academic calling, even at the expense of teaching, of which he had given evidence time and time again. Mall was the great prize won by Welch, when he lured the anatomist back from his professorship at the University of Chicago. He was a brilliant researcher, his lab was opening the world of embryology, and he was always available to help his colleagues think through their projects. Detested by students in the basic anatomy course he taught, he was beloved by those whose intellectual curiosity led them down the path of independent investigation. Those few young people Mall gently
taught, in a manner Fleming described as not with a guiding hand but by “jogging the elbow,” and looking in and offering words of advice from time to time. He intended to build a tradition of scientists, and he had no interest in teaching clinicians.

Osler did not shy away from the laboratory, but he was first and foremost a clinician and teacher. When asked what he would choose for his epitaph he had responded, “He taught medical students.” So the lines were clearly drawn: Osler the clinician versus Mall the pure scientist. Welch valued both and took care not to openly take sides. The differences, while deeply held, did not suffuse the environment with animosity. The faculty members were in constant contact with one another, and despite the tension over the direction in which Hopkins should go, the overriding sense remained one of community. But at the last faculty meeting that he attended before leaving, Osler said to Mall, “Now I go, and you have your way,” exposing his fear that the balance of power over Welch would now shift in Mall’s favor.

William Stewart Halsted, a pivotal figure in the philosophical shift to pure science over clinical medicine, sat out the arguments and voted with his actions, which had been steadily drifting away from clinical practice and into research. Cushing summarized Halsted’s attitude as “ … caring little for gregarious gatherings of medical men, unassuming, having little interest in private practice, spending his medical life avoiding patients, even students, when possible, and when health permitted, working in his clinic and laboratory at the solution of a succession of problems which aroused his interest.”

By 1905, Halsted was operating infrequently and had all but lost interest in private practice. But his stellar reputation and vast experience in surgery of the breast, hernia, and thyroid continued to attract well-heeled patients from around the country. Increasingly, the resident performed the routine procedures on Halsted’s private patients. His fees could sometimes be outrageous, but most often they were not very different from those generally held in the community. One of the
functions of the local medical societies was to fix fees at a comfortable level for the practitioner, and the guidelines were generally adhered to. The money was good, and he certainly knew how to spend it, but increasingly, his heart was in problem solving.

For Halsted, experimental surgery did not end at the Hunterian Laboratory. Private and charity patients alike were there for learning and teaching. Halsted’s huge reputation and frosty manner projected supreme confidence, and he was able to convince patients to submit to procedures of little value to them, in the name of science.

At a thyroid surgery conference in Atlantic City, Professor Albert Kocher of Berne, son of the great surgeon Theodore Kocher, read a paper on his recent finding of increased numbers of circulating lymphocytes in patients with Graves’ disease. Halsted had earlier shown the presence of masses of lymphoid tissue in the thyroid specimens removed from patients with the disease. It was too much of a coincidence to be ignored, and he set out to attempt to correlate the two findings. In his protocol, blood samples from his patients would be studied before and after surgery. But the patients were scattered throughout the country. Not trusting local facilities to study the samples, Halsted wrote his patients and asked them to return to Johns Hopkins to participate in the study. Though the text of the request has been lost, it must have been persuasive. The response astounded George Heuer, who helped coordinate the project.

“They came from long distances for a procedure which required but a few moments. One woman came from a remote place in Texas and spent four days on the train coming to Baltimore. Dr. Halsted saw her, thanked her for coming, remained while a drop of blood was removed from a prick in her finger, wished her a pleasant journey home and left her. Eight days on the train and the expense of coming and going for a five minutes’ visit!”

Heuer remarked about it to Halsted, who replied, “How better could she spend her time than contributing to the problem of this disease.”

Another example involved the work of Alexis Carrel,
¹
a French surgeon working at the Rockefeller Institute for Medical Research, in New York City. Carrel had found that if a fixed amount of skin was removed from a dog, and the wound remained clean, the time to complete healing could be plotted, and the resulting curve could be converted to a formula that predicted the time required for healing.

Halsted set out to reproduce the results in humans, reasoning that it would be easier to keep the wounds clean in human subjects, and the result would have a more direct application. If humans were the most reliable subjects, then, he reasoned, private patients should be the most reliable humans to study. He assumed, of course, that the patients would cooperate. Heuer was witness to Halsted explaining to one woman the scientific journey on which they were about to embark. He told her that during her operation he would remove “precisely one square inch of skin” from her abdomen. “And then together we will study the healing of the wound.”

Precise measurements of wound size were recorded, wounds were carefully dressed and kept scrupulously clean, and bacteriological samples of the healing wound were taken daily. As with virtually all the other subjects, the patient was as excited as Halsted about the ongoing experiment, and his daily visit was eagerly awaited. The wound from the surgery, for which she had entered the hospital, had long
since healed, and the woman happily continued to pay private patient hospital charges as she remained the subject of his little experiment. Halsted saw nothing unusual about the arrangement.

WITH OSLER LEAVING,
the strongest clinical influence on Welch disappeared, and Mall assumed undisputed control of his ear. Mall believed the departmental chairs should abandon practice and devote themselves to science, leaving patient care, and the attendant compensation, to others. It was Carl Ludwig who planted the full-time seed in Mall when he studied with him in Leipzig, in 1886. Ludwig believed the ideal system would have the clinical as well as preclinical professors devoting full time to research and abandoning private practice.

Mall had no interest in clinical medicine and wished to see Osler replaced by someone who could move the department “to a higher level.” By this he meant a full-time research scientist. This was an audacious proposition, for Osler embodied everything that was good in medicine. With support from Mall and Halsted, Welch chose Lewellys Barker as professor of medicine. Barker was a Canadian trained by Osler at Hopkins. He had never been in clinical practice and was professor of anatomy at the University of Chicago. Primarily a researcher, he had spoken out in a 1902 address in favor of the fulltime system. Osler had favored his longtime assistant William Thayer for the job, but Thayer was purely a clinician, and Mall, Welch, and Halsted had other ideas.

While the debate over full time smoldered, Halsted and the department of surgery marched forward. He no longer cared much for private practice but continued to charge the occasional outrageous fee, as did Kelly, and their actions added fuel to the trustees’ dissatisfaction with the system. With Welch and Mall whispering in their ears, the trustees wondered out loud whether the hospital would not be better served by billing for these services and putting the chiefs
on salary. But they didn’t push too hard. Kelly already had a private hospital and could easily do without admitting patients to Hopkins at all. The heads of the newly formed surgical sub-departments had similar outside arrangements, and Halsted did as he pleased. The last thing the trustees wanted was to lose Halsted and Kelly, particularly while still licking their wounds over the departure of Osler.

HALSTED WAS NOW
52 years old. His face had become a bit fuller and flushed with color, and he was quite bald. The drooping mustache and patch of beard he wore beneath his lower lip were not yet fully gray, he continued to wear rimless glasses pinched on his prominent nose, and his protruding ears were accentuated by his short, sparse hair. His neck had thickened, and he appeared slightly stooped and shorter, but his muscular arms and upper body appeared unchanged. He worked at his own pace, slowly compiled his papers, and maintained active correspondence with surgeons around the world. He traveled to medical meetings with some regularity, usually favoring the East Coast, particularly New York, where he sometimes visited with his sisters. He spent considerable time at clinics in Europe but never bothered to do so in America, fearing there would be nothing to learn and he would waste precious time. His extended absences continued without excuse and with less resistance from the trustees. He was a valuable property, and they had learned to accommodate his idiosyncrasies. Laboratory experiments were terminated in the spring so that The Professor could leave, and during his absence experimental surgery ground to a halt. For Halsted, the Johns Hopkins season was a seven-month affair.

THE HOSPITAL HAD
been in operation for 15 years, the medical school for 11 years. Welch, Osler, Kelly, and Halsted had established well-deserved, worldwide reputations, and Hopkins had become the most forward thinking medical institution in the world.

Welch had all but abandoned research, wrote almost no scientific papers, and continued to shirk teaching responsibilities. But he had become the country’s most potent force in the advancement of medical science. He was consulting, supporting, counseling, and helping great minds and institutions make the decisions, which would move medical science, and public health, forward.

Halsted, alone among them, had reinvented a discipline. At every crossroad he had made decisions that changed the way surgery was performed, taught, and expanded. He had transformed the shunned black sheep of the medical world into a specialty offering the promise of mightily alleviating the suffering of the human condition.

Kelly was the greatest technical surgeon of his day, and a prolific writer and innovator. Osler, master of bedside medicine and teaching, brought clinical and laboratory disciplines together. But Halsted had quietly shown the way through the dark as he invented modern surgery. In time, he would be measured by the work of his disciples, and Cushing, Bloodgood, Finney, and Young were growing in stature.

Everything was going better than imagined at Johns Hopkins, but Osler’s departure signaled the end of an era.