Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (15 page)

The indictment was met with a great deal of squirming, nodding, and looking at one’s boots. The entire medical establishment was guilty, and the system had to be changed. Culpability aside, his statement could not have done much to defuse the festering town-gown schism. Osler was committed to improving medical education. He had just spent years at one of the most highly acclaimed institutions, which in reality was not much more than another proprietary school, and he was chomping at the bit for change. On this front, Johns Hopkins Hospital and Johns Hopkins School of Medicine were to make several momentous breaks with the past. The medical school would not be a “for profit” institution. The owners of the medical school would not be the teachers. The teachers would not share in tuition fees, and for the first time the preclinical sciences would be taught by full-time faculty. Hitherto this task had fallen to local practicing physicians. For the first time, the chief of service would be a medical school professor and not an independent operator. Medical education would no longer be a business, and the measure of success would no longer be the number of tuition-paying students enticed to enroll.

Postgraduate medical training was poised to take a major turn for the better as well. In a few short months, Osler and Halsted would institute the graduated responsibility residency system and forever change the way doctors were trained. Four years later, when the doors of the medical school finally opened, they would accept only qualified students who had already earned undergraduate degrees. It spelled the beginning of the end for proprietary schools, where unqualified students could enroll, were poorly instructed, and could pay their way to a medical degree.

Medicine was still largely in its diagnose-and-wait phase, and Osler was among the great diagnosticians. Patients followed him, even
to this new southern outpost of Baltimore. Osler had little belief in most of the medications being freely prescribed, and it was often joked that he prescribed few medicines, all of which were poisons. Aware of the public’s abuse of useless and often dangerous medicines, he wrote, “One of the first duties of the physician is to educate the masses not to take medicine.” His blanket opposition was, in fact, flexible and guided by his desire to alleviate suffering.

Osler had attended the Toronto School of Medicine, a proprietary school, for two years and ultimately graduated from the McGill University School of Medicine in Montreal. He studied in England and on the Continent, and married the English and German systems into his teaching. With immense confidence in the value of laboratory work, he believed above all else that learning and teaching must take place at the bedside.

“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” This became the basis for education in internal medicine at Johns Hopkins, and in tandem with laboratory science made it unlike anyplace else in the world.

Osler was a fixture on the medical wards. He could be seen quietly listening to patients and pointedly asking questions about the individual, not just the disease. But learning about disease did not end at the bedside or the laboratory. Osler had been one of the few physicians who understood the value of following patients to the dead house. The truth would be found on the autopsy table. In Philadelphia, as at Montreal General Hospital, he not only did the postmortem examination of his own patients, but working as a pathologist he had performed a total of 948 autopsies. This was both a source of income and a means of satisfying his immense curiosity about the nature of disease. At Johns Hopkins he remained a firm believer in the value of postmortem examination but was now strictly an observer, as Welch and Councilman were the pathologists. Setting the example for his residents, he not
only attended the postmortem examinations of patients who expired on his service, but insisted on following any interesting and perplexing problems he became aware of to their ultimate clarification.

Unmarried, Osler lived in hospital quarters and spent long hours at work. His rooms, near Halsted’s, were in a section shared by residents and interns. Osler’s immediate neighbor was a resident, who noted that he could pretty much set his watch “at 10
P.M.
each night when I heard him place his boots on the floor outside his bedroom door.”

As an early devotee of surgical intervention, Osler was fascinated by the changes Halsted was bringing to surgery. As a man experienced in bacteriology, he was duly impressed by his new colleague’s meticulous adherence to aseptic technique. This was a welcome change after the Philadelphia years, where little stock was held in its importance.

WITH THE FANFARE
and ceremony behind them, the small, select staff of The Johns Hopkins Hospital set out to fulfill the mandate of the gift. Henry Hurd had replaced President Gilman at the helm; the nursing staff, made up of experienced leaders and enthusiastic newcomers, was quickly integrated into the daily routine, and a spirit of camaraderie was palpable throughout the institution. Much had been made of the quest for excellence at the new hospital, and the public, long-suffering and wary, was heartened by the promise to bring the best of European medicine to America. Despite the awful history authored by generations of surgeons, patients were willing to believe the new discipline would be different, and Halsted’s service was busier than expected. Osler’s reputation as the finest physician in the country immediately drew the rich and famous to Baltimore, and he did not disappoint. Howard Kelly was enlisted to head gynecological surgery, and his practice followed him, and Welch’s reputation as pathologist and spokesman drew doctors and dignitaries alike to see the new phenomenon for themselves. The four young men, Welch,
Osler, Halsted, and Kelly; their assistants; and their residents arrived on the scene at a run.

The only dissenting voices were from within the Baltimore medical community. Not only were their patients being poached, but they were being relegated to an inferior position in the eyes of their community. The University of Maryland Medical School was the backbone of the local medical community, and the incursion of an elite institution, made up almost entirely of outsiders, was perceived as a threat. The possibility of elevating the profession and benefiting mankind did not enter into the equation. In the end it turned out to be a simple question of saving face.

Welch, Gilman, and the trustees were increasingly aware of the resentment building in the medical community, and made an effort to integrate some of the local medical leaders into their organization. The earlier appointment of Councilman, a Baltimore native, as Welch’s assistant had had a salutary effect in the preclinical days, but now patients were added to the mix, and another gesture was necessary. This was found in the creation of a board of consultants. The eleven-man group, made up of prominent local physicians, went far toward defusing the situation, but how much their consultation was sought remains unclear. Additionally, seven influential members of the medical community were asked to head the Johns Hopkins outpatient clinics, which were based on the successful outpatient dispensary Halsted had devised at Roosevelt Hospital. The clinics were instantly popular with the indigent population, and becoming co-workers did much to smooth relations.

1 Scarpa’s space, also known as Scarpa’s triangle, is an anatomical area of the upper thigh, below the inguinal ligament. It is bordered by the sartorius and adductor lon-gus muscles, its floor composed of the iliopsoas and pectineus muscles. Branches of the femoral artery, vein, and nerve pass through it.

CHAPTER THIRTEEN
The Operating Room

BY 1889, MOST LEADING
surgeons were committed to antiseptic technique, and many sought to implement some level of aseptic surgery. Halsted’s surgical service at The Johns Hopkins Hospital was dedicated to the concept of aseptic surgery from the very beginning, even while the goal remained out of reach. It had been easy, in fact a relief, to abandon the antiseptic precautions of Lister. Carbolic acid spray and dressings were unwieldy, irritating, and less than satisfactory for infection control. Halsted had rejected the Listerian idea of dangerous germs circulating in the air. The real threat were the bacteria harbored on instruments and on surgeons’ hands, and all sorts of antiseptic solutions were employed in the effort to control the contamination.

Not long after it opened, The Johns Hopkins Hospital began sterilizing instruments by boiling them. But the withdrawal from carbolic was not complete. Following boiling, the sterile instruments were submerged in tubs of carbolic acid, awaiting use at the operating table. Bichloride of mercury and carbolic acid were still in favor for preparing the patient’s skin for surgery. It was a thoroughly unpleasant experience for the patient. Preparation began the evening prior to surgery with shaving of the skin in the area of the incision
and the application of antiseptic soaks, so that by the time of surgery the next morning the skin was uncomfortably, and sometimes painfully, irritated.

Carbolic acid, commonly known as phenol, was the primary antiseptic for maintaining the sterility of the surgical instruments. Its effectiveness as an antiseptic had been well known since its introduction by John Lister. One of its advantages was that it did not corrode the surgical instruments, but it did not make for a safe, worker-friendly environment. Patients were only occasionally exposed to these agents, but the operating staff was in constant contact with potentially troublesome substances. Carbolic acid, even in dilute solution, is a very toxic agent. In addition to direct local toxicity in the form of irritation, burning, and ultimately coagulation and destruction of skin, it is toxic to the liver and can cause severe cardiac arrhythmias, and possibly death.

For the first 15 years all surgical procedures were performed in a makeshift area best described as functional. The single, small operating room was located in the basement under Ward G. Getting patients into the operating room was a considerable task. Patients were first placed on the removable operating tabletop at their bedside, then the long board and its heavy human cargo were wrestled down the outside stairwell and into the basement and the operating room. Adjoining the operating room was a still smaller room used for the induction of ether anesthesia. Billings’s initial plans for The Johns Hopkins Hospital were a reflection of the low regard in which surgery was held in the aftermath of the Civil War. Halsted made few demands, making do with what was easily available, knowing his needs would evolve over the first few years, as would his concepts of the proper surgical environment. The very basic suite had an open plan and was reasonably well lit. It had running water, which was not available on the wards; waxed hardwood floors; and adequate equipment storage in large wood cabinets in both the operating and anesthesia rooms—every-thing required for modern, aseptic surgery in the year 1889.

Halsted felt no need for so elaborate an exercise as the isolated tent he built at Bellevue to comply with the Listerian concepts of a decade earlier. The need for cleanliness at surgery was not debated at the new, forward-looking Johns Hopkins. The debate, if there was one, was within Halsted alone, for he had begun striving toward true aseptic technique. It was the moment for an open mind, trial and error, and change.

In the center of the room was an old German operating table first used during the Franco-Prussian War. The design of the table accommodated the copious amounts of caustic solutions used in wound preparation. It consisted of a strong wood frame into which was set a shallow trough, two and a half feet wide and six feet long. On the wooden table sat a stretcher, two feet wide and eight feet long, which served as the actual operating surface. A drain within the basin could be opened to collect the antiseptic fluid in a bucket beneath the table. It was a messy operation, and the surgeons often wore rubber aprons over their white operating suits to keep from getting soaked by the splashing antiseptic.