Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (29 page)

Since elective surgery was still in its infancy, these operative trips were mostly in response to emergency situations. It was not uncommon for express trains to make special stops to afford the surgeon better proximity to the patient’s home. On one occasion, Halsted, who had been complaining about the attitude of the new, young nurses, engaged an older nurse to accompany the team. The nurse interrupted
several times during a difficult operation and in an entirely uncharacteristic rebuke, Halsted raised his voice and ordered, “You shut up and get out of here.”

It was a rarely seen display of temper, and nothing more was said following her exit. The remainder of the operation was spent in silence. The next day he approached Finney.

“I’m not as much stuck on that old woman as I was. She talks too much.”

In the operating room, on the wards, or traveling to operate in patients’ homes, Mitchell became accustomed to Halsted’s intense concentration, his unbending demands for excellence, and the attention he lavished on even the most trivial detail of his surroundings. When Mitchell produced a photograph of Halsted, Kelly, and Osler, which had been dubbed “The Fates,” Halsted, already known to be pathologically camera shy, looked at the photograph and recoiled. Mitchell wondered what faux pas he had committed, and was surprised when his annoyed boss remarked, “Mercy! My hat never looked like that.”

Mitchell explained that the picture of the three men had been cropped from a larger group photo, and the cropping accounted for the irregular appearance of the silk top hat he so carefully tended. The explanation satisfied Halsted and relieved Mitchell, who wanted to avoid the wrath of his employer at all costs. Increasingly he seemed to be courting it. One morning after returning from holiday, Halsted was called away during a surgery, leaving Bloodgood to close the abdomen. Bloodgood, too, was called out, and the junior resident, a notoriously lazy individual, turned to Mitchell and said, “Here, you damn nurse, sew up this belly,” and left.

No sooner had Mitchell begun to work than Halsted returned. He watched for a few minutes and quietly asked, “Mitchell, do you close all the abdomens now?”

“No, sir, not all of them.”

Halsted left again, and Mitchell thought his job was lost. Instead, from then on Halsted would not allow anyone else to make his dressings. The operating room joke was that Mitchell could anticipate what his boss wanted by the wrinkles on the back of his neck.

The relationship between employer and employee was quietly satisfactory. Mitchell was fully aware that he’d been thrown into the DNA of surgical evolution, and expected to return to medical school at the University of Maryland far the better for it. It was the fall of 1893, and The Johns Hopkins Medical School was about to welcome its first class. With no preamble, Halsted said, “Mr. Mitchell, I have taken the liberty of entering you in our first year class and have arranged with Dr. Mall, Dr. Howell, and Dr. Abel that you may attend classes when you wish, so you can go on with your work in the operating room.”

Apparently his efforts had been appreciated. Mitchell was overwhelmed, and gratefully accepted the appointment. Nothing more was said, and Mitchell did double duty for the next two years. Finally, physically exhausted and having lost a great deal of weight, he was ordered by Osler to give up the nursing work. He did service again as an undergraduate intern; then, after graduation in 1897, Mitchell became first assistant to Harvey Cushing, who had come from Massachusetts General Hospital to begin his tenure as resident. Cushing would virtually invent neurosurgery and become the brightest star in the pantheon of Halsted trainees. Three years later Cushing was about to begin an extended European tour, and Halsted announced with no time to spare, “Mitchell, Cushing is leaving tomorrow and I have taken the liberty of naming you as his successor. What do you say?”

Mitchell tried to express his gratitude, and was waved away.

“Don’t say anything. Just get to work.”

The pattern was becoming clear to those close to The Professor. If one was insecure enough to require reassurance and compliments, one was certain to be sorely disappointed. By the same token, abject disapproval would be reserved for those in mortal disfavor and would
be delivered unemotionally, in a quiet and withering tone, with an expressionless face and unyielding ice blue eyes. In one case Halsted told a resident, in all seriousness, that he should specialize in operating on piles (hemorrhoids), as it would not be too taxing for his abilities. Offended and dismissed, the young surgeon fed on the insult and built an admirable surgical career, at least in part stimulated by his determination to show The Professor that he had been wrongly judged.

Halsted was often aloof, but it would be erroneous to assume that he did not register everything significant to him. In the pursuit of excellence, he drew no boundaries between the precise manner in which a suture should be placed and the precise place on a skin from which shoes should be crafted. His intense concern with subjects in which he was interested left little time for consideration of issues that didn’t interest him. Assistants marveled that a man who would spend an intense hour palpating the skin and lymph nodes about a cancerous breast prior to surgery could be the same man who was often unaware of the identity of his junior staff. Asking Mitchell, a senior student, to join his staff after graduation, he was surprised to be told that Mitchell was already on the staff. Another member of the first class, Tom Brown, was apparently from a prominent family. Halsted asked Mitchell to point him out.

“He comes of good stock and I want to know him.”

Later he asked Mitchell if he thought Brown would like to join the staff, only to be told he had been on the staff for months. At other times he would simply forget to schedule surgery on patients who spent long days and more awaiting their turn. He could be reminded of his forgetfulness only at the risk of his wrath.

At surgery Halsted demanded help but did not welcome suggestions. Multiple assistants attended every operation and were expected to anticipate his every move without a word being said. Cushing and Mitchell were proud of their ability to identify and cross-clamp every tiny vessel in the potentially bloody mastectomy surgery before it
could be cut. Dozens of clamps hung from the specimen waiting to be tied or released, and everyone worked quietly. Everything was done with precise technique, and no task was too unimportant for personal attention. Halsted personally assumed the tedious task of winding silk suture material around glass bobbins before sterilization. Everything was to be just so. Tissue was brought together in a tension-free manner with small sutures of fine silk that had been threaded on sterile straight needles and stuck through sterile towels in precise formation. Skin sutures were carefully buried beneath the surface to minimize the possibility of seeding infection from the skin. Later, buried silver wire was used for the task. Bacteriological studies had shown that gold and silver had properties that inhibited bacterial growth, and after abandoning gold for its expense, silver wire closure became the method of choice until the advent of truly aseptic technique with the adoption of sterile gloves, caps, and masks.

Halsted came to believe the only true barrier against infection was sterile gloves. Infection was often the difference between success and failure, and for the first time it became clear that the manner in which surgery was performed was important. Gentle tissue handling diminished devitalized tissue, and hence did not produce a good medium for bacterial growth. Dead space—a gap between the sides of a wound—was to be avoided for similar reasons, though Halsted did believe allowing a clean blood clot to form in the wound would promote healing. The anesthetists, who were initially residents, interns, or the ubiquitous Finney, were told to give less ether, not more. The order shocked Bloodgood, who had been taught precisely the opposite in Philadelphia. Halsted devised an ether cone, which would allow a greater admixture of air for the patient to breathe. Blood loss was sharply reduced, aseptic technique ruled, anesthetic dose was reduced, and in abdominal operations sterile gauze soaked in sterile saline solution was used to protect the intestines from trauma and drying. Patients were kept warm after surgery, the foot
of the bed was raised slightly, and replacement fluids were given by rectum to prevent postoperative shock. Day after day, and year after year, it became abundantly clear that thinking and technique counted. Safe surgery was good surgery.

1 The complete blood count reflects changes in the response to infection by an increased number of white cells, or leukocytes. Changes in the red cell count and hemoglobin would reflect blood loss but would be unlikely to change on a half-hourly basis. These tests are now performed by automated equipment. Drawing and transporting the blood takes far longer than the test. In 1893, it was a tedious and time-consuming process. Blood was drawn by the doctor, dilutions done, slides prepared, and the slides read under the microscope.

CHAPTER TWENTY-THREE
Changes

ADECADE AT JOHNS HOPKINS
had passed fruitfully for Halsted. Dealing daily with unyielding personal demons, as well as the growing pains of a revolutionary organization, he had reinvented himself as the leader of the scientific surgery movement and conceived a surgical philosophy that would be adopted worldwide. He had devised and popularized two gold-standard operations, put surgeons’ hands in sterile gloves, and begun a training system that would prove itself by providing three generations of the most influential surgeons in America

But by 1896, The Professor had changed appreciably. Pushing his starting time back to 10
A.M.
may have been the first signal of a waning ardor for the daily grind of surgery. He was doing fewer operations, rarely completing them, and quite regularly handing them off to his assistants. “You know what I want done,” he would say, leaving the room. He frequently carried the specimens to the lab, where he dissected and pondered them himself. In later years, as Bloodgood established the surgical pathology service, he would oversee the tagging and sectioning of areas of interest to him. Experimental work in the dog lab consumed more of his time as he became increasingly involved in the newly evolving issues related to the thyroid gland, and the techniques of what would become vascular surgery.

For the first year Halsted operated every day, followed every hospital patient, and was regularly present in the dispensary. Gradually, according to plan, the resident assumed responsibility for more of the surgery and aftercare. As Halsted’s comfort level with the resident rose, his oversight diminished. Soon the resident assumed primary teaching responsibilities for his juniors, and a functioning system was in place. Gradually, The Professor became a visitor to his wards and a less frequent operator. By the end of the first decade, he had established a routine in which he would visit the ward and politely ask the resident whether he would mind if “I examined this patient.” Similarly, he would choose a patient whose problem interested him and ask permission to do the surgery. This, of course, was nothing more than a polite sham, but it became the manner in which he laid claim to his interests and allowed the rest to pass to the resident.

He frequently arrived late for surgery, casually offering excuses varying from lame to the bizarre. These were duly noted but never challenged. Some were too comical to imagine, including the morning he claimed to have lost track of time while he and Mrs. Halsted were killing rats in their cellar. Often, he said he had been working late into the night preparing a paper or studying the literature on a surgical problem and was too tired to operate, deliver a scheduled lecture, or conduct a clinic. In these events he issued a last-minute note or telephone call to the resident, asking him to serve in his stead. Standing instructions were issued to start surgery without him, should he be late. Few outside the administration were bothered by his absences. The resident was pleased with the opportunity to perform more surgery, and the medical students learned early in their tenure that Professor Halsted was not the answer to their prayers.

After pioneering abdominal surgery techniques, he rarely performed them, preferring to study the problem and pass the actual surgery to Finney and the residents. Breast and hernia surgery held fast as the “routine” procedures in which Halsted maintained a
working interest, but they had become the magnet attracting patients to Hopkins, and the volume was shared. For his entire tenure, he was the only senior surgeon at The Johns Hopkins Hospital and the only professor of surgery. Not even the long-serving Finney had the privilege of caring for his private patients at the hospital. All patients on the surgical service, private or not, were Halsted patients, to whom he would dispense care as he wished. Customarily this took the form of assigning operations to the resident surgeon or Finney, while reserving those of interest for himself. This, too, would change.