Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (44 page)

IF HALSTED CHANGED
appreciably with the new system it was seen in the vigor with which he approached his experimental work. Lifting the restraints allegedly hampering the flowering of the academic lives of the professors had little more than symbolic effect on him. Halsted, more than anyone else at Hopkins, had done pretty much as he pleased. He had already cut back on surgery, but the constant talk about laboratory science touched everyone. Even Kelly, whose department was not included in the initial move to full time, announced
his intention to spend more time in the laboratory. The topics that interested Halsted remained largely unchanged, but his residents and assistants became more deeply involved in laboratory problems than ever before. His relationship with the residents became somewhat more relaxed, and several of them were welcomed to the fringes of his private world.

Perhaps the first of the young people to see The Professor in a purely social setting had been Sam Crowe, then a medical student, in the summer of 1904. Over the years, Crowe got a lot of mileage out of the story of his ill-fated summer camping trip to the Black Mountains of North Carolina. The week he spent at High Hampton, the kind hospitality, the personal, time-consuming attention to the sick horse, the beauty of the surroundings, the elegance of The Professor strolling among his dahlias in white flannels and silk shirt, and the contrasting simplicity of Mrs. Halsted’s homespun dress all made an indelible impression on the young man.

Crowe had the good fortune to have gained Halsted’s attention as a medical student. Later, his work in the Hunterian Laboratory exploring pituitary function under Cushing led to an interest in neurosurgery. He hoped to accompany Cushing to Boston, but The Professor thwarted his plans by assigning him to head the department of otolaryngology. In the years from the opening of the hospital in 1889 until 1912, when Crowe was enlisted, diseases of the eye, ear, nose, and throat were treated in the dispensary. Distinguished specialists from the Baltimore medical community volunteered their time at no salary. If patients required surgery they were admitted to the hospital and assigned to Finney, Bloodgood, or the resident. The otolaryngologists serving in the dispensary had varying levels of training, and had never been granted operating privileges at Hopkins.

Halsted felt the time had come to organize the specialty of otolar-yngology under a director within the hospital. The task fell to Crowe, who, like Young in urology, professed ignorance of the subject. Halsted
would have none of it, and brought the topic to the medical board. Under questioning, he acknowledged that Crowe had no training in the specialty but was an able man, and would have time to travel to Germany to study. He went on describing his plan, including the proposal of a small salary for Crowe, when he was interrupted by Howard Kelly. The righteous Kelly demanded to know whether the proposed reorganization had been discussed with the men who had been serving so loyally in the outpatient department.

Halsted responded that he was embarrassed, but no, they had not been consulted. Kelly banged his fist on the table, outraged.

“Halsted, I am opposed to this. Everything we do here must be open and above board.”

Halsted flushed.

“Kelly, you are absolutely right. How could I have perpetuated such an offense? It was an awful thing for me to do. I am ashamed, and I apologize for bringing such a recommendation before this dignified Board …” Halsted continued to castigate himself and beg forgiveness, but he never withdrew his suggestion. Finally, Kelly had had enough.

“Halsted, stop it. I’ll vote for it.”

And another subspecialty of surgery had been created.

Crowe and his wife took up residence around the corner from the Halsteds, and despite the 30-year disparity in their ages, a friendship grew between the two couples. Mrs. Crowe found Mrs. Halsted interesting, and Caroline seemed to relish the company of the young woman. Halsted, while he liked and respected Crowe, continued to occupy his time with his work, his reading, and occasionally the old group from the Maryland Club.

GEORGE HEUER WAS
Halsted’s 13th resident surgeon and had come to think of him as his second father, hardly the description most would associate with the unreachable Professor. Medical school, assistant
residency, and three years as resident had taught Heuer what he needed to know about how to approach an issue, when to make suggestions, when to make his own decisions, and how to become invisible when The Professor’s neck turned red. Pleasing The Professor was a role he mastered, as had the residents before him. And Halsted, through the last decade of his career, came to appreciate, enjoy, and depend on the talented Heuer, who had mastered the disciplines of neurosurgery, general surgery, and thoracic surgery.

In the fall of 1914, Heuer returned from a surgical tour of Europe. Halsted invited him to stay at his home until he got settled. Caroline was still away, and Heuer was installed in her apartment on the third floor. Halsted’s hospitality and generosity rained on the young surgeon. He personally carried logs for Heuer’s fire up three flights of stairs and saw to it that fresh water and flowers were always at his bedside. After breakfasting in his suite, Halsted spent a few minutes in the dining room with Heuer as he was served. Scrutinizing every detail, he would not allow the famished Heuer to eat the boiled eggs in front of him, sending them back to the kitchen several times until they were properly coddled. Halsted even traveled across town to the Lexington Market to choose the grapefruit for the breakfast table.

The kindness and attention embarrassed the retiring Heuer, who tried to be as unobtrusive as possible. “I had been writing in my room on the third floor and my pen ‘went dry’; and not finding any ink I went down to his room to fill it.”

The fountain pen–obsessed Halsted asked to see Heuer’s pen, examined it carefully, then opened a drawer in his secretary and produced three boxes of fountain pens. Each box contained a dozen pens, and each of the 36 pens was filled with ink and ready to use.

“You might like to try another,” Halsted said, handing a box of a dozen to Heuer. “A perfect fountain pen is not easy to find.”

The simple excess carried over to cigarettes and the inexpensive cigarette holders Halsted was rarely seen without. Heuer wrote that
there were great quantities of cigarettes everywhere in the house, and Dr. Halsted “heaped upon me, many more than I could possibly smoke. There were boxes of cigarette holders, one of which containing 100 he gave me on my arrival with the statement that I should call on him for more when I had used them.”

The atmosphere of disorganized pampered profusion was not lost on the household servants, who took advantage of the situation. Heuer overheard a conversation on the house phone in which large quantities of ham, pork chops, and other meats were being ordered, none of which ever appeared on the table. Halsted responded that he was probably “feeding the entire colored population of the neighborhood,” but in the absence of Caroline, he didn’t know what he could do about it.

After dinner the two men took coffee in the library. The ritual was an event in itself. After sorting the beans for size and color, Halsted ground them slowly and carefully, and then prepared the thick, black coffee. Conversation over coffee was heavily weighted toward surgery, and Halsted offered that Heuer’s career should take him to New York. It was a prescient moment, for long after his mentor’s death, and following a decade as professor at Cincinnati, Heuer became professor and surgeon in chief at New York Hospital–Cornell Medical College, where he established the institution’s first residency program on the Halsted model.

WALTER EDWARD DANDY,
the son of recent English immigrants, showed up at Johns Hopkins as a second-year medical student in 1907. He had forgone a Rhodes scholarship to begin his medical studies with advanced standing. Dandy and Mall found each other, and the medical student was assigned the daunting task of describing a two-millimeter human embryo, at that time the smallest specimen studied. The work became a benchmark in embryology and the specimen became known as The Dandy Embryo.

After graduation, Dandy worked in Cushing’s lab for a year, trying to determine the vascular and nerve supply of the pituitary gland. His work proved important, and Cushing made Dandy his clinical assistant. Dandy was a driven, self-confident, and difficult individual. He and Cushing clashed loudly and often, yet Cushing invited the young man to go with him to Harvard. Thinking Dandy was leaving, Halsted filled his position in the program. Cushing then changed his mind and refused to take him along, and Dandy was without a job.

As usual, Halsted was gone for the summer. Dandy threw himself on the mercy of Winford Smith, Hurd’s replacement as hospital director. Smith took pity on Dandy, and provided room and board for him, saying, “Sometime during the next year you will probably find out from Doctor Halsted what your status really is.” It hadn’t taken Smith very long to figure out how Halsted operated.

Dandy set to work in the lab and in short order produced a monumental piece of work. He was interested in the nature of cerebrospinal fluid, the liquid that bathes the brain and spinal cord. Hydrocephalus, originally meaning “water on the brain,” actually refers to the production or accumulation of excessive amounts of cerebrospinal fluid. Within the skull the cerebrospinal fluid, or CSF, circulates around the brain in the subarachnoid space, where it floats the brain and acts as a shock absorber. The fluid circulates through the ventricles within the brain, and equalizes pressure between the brain and spinal cord. Hydrocephalus in children can cause, among other symptoms, enlargement of the not-yet-fused skull. In adults, all manner of symptoms from vomiting and dizziness to mental retardation and convulsions are associated with the condition.

Of particular interest to Dandy was the cause of hydrocephalus, and with Kenneth Blackfan, a resident in pediatrics, he was the first to produce hydrocephalus in experimental animals. Dandy developed a method to block free communication between the third and fourth ventricles by occluding the aqueduct of Sylvius, an anatomical canal
between the ventricles, and hence circulation of CSF to the subarachnoid space. The resulting hydrocephalus suggested that little or no CSF was absorbed through the ventricles. If it could be absorbed, hydrocephalus would not result from blocking the aqueduct. Dandy then tested the theory by injecting the dye phenolsulfonphthalein into the ventricles of nonhydrocephalic patients. Within minutes the dye appeared in the CSF and urine. Using the same test in patients with hydrocephalus secondary to a blocked Aqueduct of Sylvius, the appearance of the dye was delayed for hours. Dandy had devised a test for blockage of the aqueduct and explained many of the mysteries of CSF absorption. Subsequently, Dandy and others performed studies confirming his findings.

Halsted said, “Dandy will never do anything equal to this again. Few men make more than one great contribution to medicine.”

He was wrong.

If one needs to be reminded how very much an infant neurosurgery was at the time, consider that when Harvey Cushing left for Boston in 1912, Halsted replaced him as neurosurgeon with the resident George Heuer, who had risen to the position only the previous year. Heuer’s experience was limited to a year as Cushing’s assistant. Dandy worked with Heuer in the clinical practice of neurosurgery and continued his laboratory investigations on his own. From 1916 to 1918, Dandy was Halsted’s resident. During that time he continued working in neurosurgery and became increasingly critical of the policy of decompressing the brain for palliation alone. Cushing had popularized the procedure and with his extraordinary care, made it easy to perform. Dandy thought there had to be a better way. Brain tumors, he felt, should be identified and removed like any other cancer. Anything less was doing the patient a disservice. But localizing the site of brain tumors was virtually impossible unless specific symptoms spelled out their site, or they were encountered upon opening the skull. In most cases the symptoms were only those of increased intracranial
pressure. Headache, seizure, and loss of consciousness did nothing to locate the site of the tumor.