Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (28 page)

MacCallum believed Halsted taught by example. Others were less kind. But medical students could learn little of the master’s methods if they didn’t first learn the basics. A method that was good for the residents was not necessarily good for students. Halsted had been the ultimate quizmaster in New York, plying students with facts, teaching them to think, and drilling, drilling, drilling, and proud that his students routinely finished at the top of the class. Was this an entirely different approach, or simply neglect? If this change in methodology was intentional—and there were those, like MacCallum, who believed it so—then it was congruent with the style evolving in the hands of Mall, Abel, and Welch. Whatever the case, the students may not have been taught in the traditional sense, but they did learn. And disgruntled or not, they became the envy of their peers.

CHAPTER TWENTY-TWO
Residents

AS SURELY AS THE PROFESSOR
ignored the medical students, the interns and junior residents often felt excluded as well. They were at the bedside and in the laboratory to do a job. Instruction was provided by their seniors, technique was learned by doing, and the rest was learned by observing The Professor’s every move.

On hospital rounds Joe Bloodgood ordered his junior, Jim Mitchell, to make a complete blood count on a sick patient every half hour. Mitchell protested that it was impossible for a man to do that and clean his instruments between counts.

Halsted asked Bloodgood, “Have you ever made a blood count?”

Bloodgood acknowledged that he had not.

“Neither have I,” said the Professor, followed by a long silence that the recipient felt more stingingly than a reprimand.
¹

It was the rare junior that caught his eye, and those who did found their future assured. For those who ascended to the residency, the course could be difficult as well. Some, like Bloodgood and Mitchell, saw the best in The Professor and refused to respond to the rest. Other early residents, like Hardy Phippen, were not constitutionally able to do so. Phippen was already trained as a surgeon when he followed Brockway into the residency. Finney had liked him when they worked together at the Massachusetts General Hospital. But Phippen left the Hopkins service abruptly, claiming he could not get along with Halsted. Superintendent Henry Hurd was distressed by both the resignation without adequate notice and the resident’s complaint that his self-respect would not allow him to continue in his position. Halsted did not discuss the matter.

For all his posturing and complaining, Hurd was the ultimate advocate for the house staff. He was known to become apoplectic over less serious infractions than losing a resident and marched, red-faced, to the trustees to complain of the disruption caused by loss of a resident, and Halsted’s behavior.

Positions on the surgical house staff were challenging. Not only were the hours painfully long and the work hard, but it was not a democracy, and there was no room for argument. Halsted was soft-spoken and courteous, but he was also cold, demanding, and painfully honest, at least with regard to other people. Most were able to see the forest for the trees and found him the perfect role model; others found him insufferable. But nearly to a man they persevered, and were better for it.

JOSEPH COLT BLOODGOOD
arrived at The Johns Hopkins Hospital as a surgery intern. He had graduated in medicine from the University of Pennsylvania the previous year and had very little surgical experience. The first thing Halsted told him was to read everything that Joseph Lister had published. Lister’s antiseptic techniques were about
to morph into Halsted’s aseptic techniques, and it was important for the young man to be thoroughly versed. Bloodgood recalled:

When I went to the little library in the Johns Hopkins Hospital I had no difficulty in finding the correct places in all of Lister’s articles published in the
Lancet
and in the
British Medical Journal
. Each article was indicated by a torn piece of blue paper which Dr. Halsted always employed in his correspondence. Thirty years later, when we sat in Halsted’s library during his funeral services and I looked about on the books on the shelves around the four walls, I could see protruding from the top of almost every volume little pieces of blue paper. I advise any young surgeon who reads this article to do as I was advised by Halsted: read everything Lister wrote. To this I would add: Learn by heart everything that Halsted has written in his surgical papers.

Halsted must have seen something special in Bloodgood, for after only six months he sent him off for a year of study in Europe. Upon his return he was made resident surgeon. Bloodgood would distinguish himself in many ways, but he is best remembered as the chronicler of Halsted’s surgery, and the first true surgical pathologist. In the former role he compiled the statistics for Halsted’s signature operations for hernia and breast cancer. In the latter, he took up what The Professor believed to be a critical step in surgical care. Halsted was known to study pathological anatomy on the surgery table during surgery. He would find the mass, touch it, roll it between his fingers, squeeze it to see if the core was solid, and in the early glove-wearing days, he would remove his gloves for a better sense of feel, move the mass between his fingers again, feel the lymph nodes, and contemplate. All the while, progress of the operation had stopped. He would remove the breast, pectoral muscles, and lymph nodes, and carry the specimen off to a room in Welch’s laboratory to study it every bit as carefully as he operated.

Bloodgood returned from Europe with a new microtome for cutting frozen sections, and new staining techniques that allowed nearly instant analysis of a specimen. Halsted saw the frozen sections as a way to corroborate his diagnosis after surgery, not during surgery.

Bloodgood observed, “He made few mistakes in his gross pathological diagnosis at the operation. During the first seven years of my close association with Halsted, we never used the frozen section to help us in the operating room. The frozen section, however, allowed us to see the sections more quickly after the operation to satisfy our curiosity.”

Welch’s lab in the Pathological was a brisk five-minute walk away, and there was not yet blind faith in microscopic diagnosis. Many of those reading the sections were far less experienced than the surgeon making the gross diagnosis. Welch himself said that in these cases “the experienced surgeons were always right.”

The true advantage afforded by frozen sections is to guide the surgeon’s decisions during the procedure. Is it cancer? Is it benign? What is the nature of the tissue in the mass? Should we go on? Halsted was so confident of his preoperative and intraoperative judgment that he considered this an unnecessary crutch, and it would be years until surgeons at The Johns Hopkins Hospital relied on frozen sections for guidance in the operating room. Frozen sections remain imperfect, but for a century they have provided useful information upon which to base surgical decisions. Given the circumstances—the relatively recent development of the frozen section, the imperfect staining technique, and the physical distance between operating room and pathology lab—it was neither hubris nor shortsightedness that kept Halsted from realizing the full potential of the new technique.

JIM MITCHELL SHOWED
up in 1893, a small, solidly built, cleanshaven, fresh-faced young man, looking for work. He was a native of Baltimore, and not exactly a stranger to Johns Hopkins. The Mitchells lived near President Gilman on Cathedral Street, and the families were
friendly. Mitchell graduated from Johns Hopkins, and in the absence of a medical school at Hopkins had just completed his second year at the University of Maryland Medical School. That spring, he corralled Finney, whom he had known for years as well, and got a summer job helping out in the dispensary. Soon after beginning work, Finney made the following proposal: “Jim, I have a good job for you which may be a great thing. Dr. Halsted is away and before leaving told me that, if his operating room head nurse should leave during his absence, he wanted a man in charge … If you make good when Dr. Halsted returns, you will be all right. If not, you can go back to the University of Maryland in the fall.”

Halsted had been at war with the administration over O.R. nurses since the departure of his wife, Caroline Hampton Halsted. Isabel Hampton, the superintendent of nurses, appointed replacements without consulting him, and in the spring of 1893 the situation had come to a head. The most recent appointment had been unacceptable to Halsted, and he rejected her. Isabel Hampton said something to the effect of “this person or no one.” Rather than fight the administration again, Halsted ducked it and left for the country with the issue unresolved. The escalating problem landed in Finney’s lap. He had already learned not to make suggestions to his boss, and the best tactic seemed to be to make decisions and allow Halsted to think they were his own. The idea of installing Mitchell was Finney’s, and he received no support from the superintendent of nurses, who objected to a man taking the position, and particularly without her permission.

Superintendent Hurd thought that no good would come from the confrontation and wanted to hide from the issue as well, saying, “We had better let things drift for the present until a satisfactory solution of the impasse is presented.”

There was a sort of loving give-and-take between Hurd and the house staff, and when Mitchell was ultimately given his job in the operating room Hurd protested, claiming the residents wanted him
to take up the slack so they could go off and play baseball in the afternoon, leaving Mitchell in charge of the hospital. Finney responded that would not happen because “we want Jim for the team.” Of course, that set Hurd off, just as Finney knew it would, and everyone enjoyed the show.

LATER, THE RELENTING
Hurd installed Mitchell in housing on the top floor of the administration building along with Mall, Barker from Medicine, and Flexner from pathology. Obstinately, Hurd refused to provide furniture for the rooms. The residents playfully festooned the apartment with party decorations and spit balls, and Mitchell made do with a bed from the ward and some crates for tables.

Finney and Bloodgood tutored Mitchell in making dressings and passing instruments. He became familiar with the routine, learned to sew, and was functioning as operating nurse by the time Halsted returned. Mitchell did everything he could to make a good impression. He would meet Halsted at the front door in the morning, “Take his hat, coat and gloves, follow him on his rounds, and assist him as nurse in all his operations in the hospital and in private operations outside.”

Though the effort may have been appreciated, Halsted said nothing. Mitchell had been well briefed by Finney and took the silence as a good sign. Shortly after Halsted’s return to Baltimore from his summer hiatus, he and Mall inspected Mitchell’s almost bare rooms on the residence floor of the administration building. Halsted made no comment, but immediately arranged for a complete set of mahogany furniture to be delivered to the apartment. Mitchell considered this a good sign as well.

Halsted was in the habit of spending the time between operations in his dressing room, reading and chain-smoking cigarettes. It was still several years prior to the introduction of the prerolled and packaged Pall Mall cigarettes that Halsted would come to favor. He used Cosmopolite papers and Bob White tobacco, and would smoke one
cigarette while rolling the next, then light one from the other. One morning, having forgotten his tobacco, Halsted searched through Mitchell’s pockets and found his. Dissatisfied with the young man’s choices, he proceeded to lecture him on the virtues of the preferred brands. Thereafter, Mitchell saw to it that Halsted’s table was stocked with Cosmopolite papers and Bob White tobacco.

From the outset, Mitchell, as a second-year medical student at another university, spent more time with the chief of surgery than anyone on the Johns Hopkins staff. The nature of surgery in the early 1890s was such that more affluent individuals still insisted on being treated in their homes. That meant that the operating room would have to come to them. With the adoption of aseptic technique, the traveling staff had to transport increasing amounts of equipment. Often three or four assistants would leave their hospital responsibilities behind and join Halsted on the journey. They packed large glass dishes for soaking the hands and arms in mercuric chloride, and others for the carbolic acid instrument soaks, in two large steamer trunks along with sterile linens, instruments, and bandages. On one such trip, a particularly long affair, while the group waited to change trains after an overnight ride, Halsted led them to a nearby field where he somehow produced sandwiches and a coffeemaker and served breakfast. On these occasions, Halsted, Mitchell, and the residents would spend entire days in one another’s company, something that The Professor rarely allowed in Baltimore, the consequence of which was that they came to see a fuller range of his behavior, and sometimes caught a glimpse of his thinking, as his reserve slipped away.