Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (39 page)

His work in that specific arena revolved around the difficulty of controlling bile loss after opening the common duct for removal of gallstones. Stones often occlude the common duct and impede passage of bile from the gallbladder, where it is stored and concentrated, into the intestine, where it is necessary for digestion. This results in the backup of bile in the gallbladder and biliary tree, painful colic caused by contraction of the duct against the stone, and often inflammation and infection. Hence the common bile duct has to be opened to extricate the stone.

Immediately after opening the common duct, bile does not yet flow freely to the intestine even though the obstruction has been relieved, so some artificial mechanism is necessary to drain the excess to the outside. Bile is rich in digestive enzymes and electrolytes, and its chronic loss is quite debilitating. Leakage of bile into the abdominal cavity is irritating and inflammatory, and long-term external drainage through the skin depletes essential elements. Halsted designed a device that looked like a small rubber hammer, which, when inserted into the common duct, facilitated almost complete closure of the duct around it and easy removal. Bile spilling from the remaining rent in the duct was conducted to the exterior by a series of drains brought out through the skin, and the near complete closure was an improvement. Although he rarely performed gallbladder surgery, it was never far from his mind, and he would continue to work on devices to assist and improve its performance.

In the operating room Halsted was famous for his unshakeable cool and detachment. At moments of surgical crisis he was known to reprimand his assistants and order them to “act like surgeons.”
Even the direst of surgical reversals did not change his tone or wet his brow. With his hands wrist deep in fresh blood pumping from a ruptured aorta, he murmured quite evenly to his resident, “Heuer, I fear we are in trouble.” With that, he gained control of the situation, apologized to the room full of German observers for his difficulties, tied off the aorta, and completed the operation. The patient died 48 hours later. Halsted could have done no more, and he remained unshaken and unapologetic.

Halsted believed that crystal-clear thinking and a decisive and unemotional approach were the duty of the surgeon. He could calmly operate on both his mother and his sister as they lay before him in extremis, he maintained his composure when the ether anesthetic caught fire as he was cauterizing Sam Crowe’s throat, and he showed no emotion when another ether explosion killed an anesthetized dog.

Physically, Halsted’s hands were wide. He had thick, graceless fingers and thumbs foreshortened enough to appear deformed—certainly not the picture one conjures up of the hands of a master surgeon or a pianist spanning octaves. Despite his short stature, odd posture, and physically ungainly hands, Halsted’s surgical ability was confirmed with every difficult dissection he performed. He rarely entered uncharted territory, studying and practicing until the anatomy was indelible in his memory. He never operated without a plan, demanded numerous experienced, attentive assistants who knew their jobs, spoke little, and focused. Nothing else existed but the work at hand.

He was detached, austere, and direct. In the operating room at least, he lived by the rules, and demanded no less of others.

Willis Gatch, a former resident, echoed the sentiments of many when he said, “Dr. Halsted had a long line of devoted assistants because of his austerity and not in spite of it.”

1 The sternal notch, or jugular notch, is in the midline at the top of the sternum (breast bone) bordered by the heads of the right and left clavicles.

CHAPTER TWENTY-NINE
Addiction

HALSTED WAS A SURGICAL
phenomenon during his New York period, when his technique, daring, and imagination set him apart from others. Cocaine crippled him, and that heroic stage of his career ended abruptly. Intimations that the subsequent morphine use altered his surgical personality seem far-fetched, but nothing about his behavior remained as it had been. Certainly the drug inhibited his ability to live anything close to a transparent existence and was responsible for changes intrinsic to his persona. His social reticence and his lifestyle in general can be attributed in large measure to serving his addiction, while chronic absenteeism and some level of disorganization and detachment resulted from it.

In a number of instances cited previously, Halsted claimed illness and was unable to operate. But if drug-related disability drove him from the operating room, there is no evidence of his being at all impaired at surgery. With the sole exception of Cushing, none of the assistants or residents so closely associated with him over the years expressed an inkling of the influence of drugs on The Professor’s life.

Willis Gatch, wrote, “I have been often asked whether I think Dr. Halsted conquered his cocaine habit. I never saw him do anything that would make me think otherwise. I knew nothing of this habit
until I read MacCallum’s
Life
, nor had anyone I knew at Hopkins ever heard of it.”

Clearly, they knew nothing of the continuing morphine use, which had largely supplanted cocaine. The facts came as a shock when Osler’s
The Inner History of the Johns Hopkins Hospital
revealed the secret in 1969.

Alfred Blalock, the next great professor of surgery at Hopkins, graduated from the medical school in 1922. It had been his intention to follow his hero, William Stewart Halsted, into surgery, and train under him at the hospital. In letters exchanged during his senior year he requested an internship on the surgical service. He was denied by Halsted, who died that same year. Wishing to stay at Hopkins, Blalock did an internship under Young, in urology. Then he contracted tuberculosis and left Baltimore to recover in the sanatorium at Saranac, New York. With his health regained, he returned as assistant resident in surgery but was not appointed resident. Disappointed, he left Hopkins and was briefly at the Peter Bent Brigham Hospital, in Boston. Once saying he wasn’t there long enough to unpack, he left Boston precipitously to become the first chief resident at Vanderbilt, in Nashville. Blalock stayed at Vanderbilt and distinguished himself with his work on shock, pioneering the use of blood volume expanders to prevent circulatory collapse. He returned to Hopkins in 1941, as professor and chief of surgery. Three years later he performed the lifesaving “blue baby” operation, which effectively began the era of cardiac surgery.

Blalock held Halsted in great esteem. He knew Halsted as his teacher, followed him as chief, and was a student of his life and accomplishments. In a letter to the surgeon Allen O. Whipple, Blalock wrote, “I think it is all to Dr. Halsted’s credit that he was able to overcome this habit, and I think it is probably very fortunate for American surgery that he acquired it.”

This thought, echoed by Halsted scholars, can be very confusing. It is generally agreed that the cocaine episode in 1885 effectively
ended Halsted’s period as a hardworking, successful New York surgeon. But it was the prelude to his scientific awakening in the laboratories at Johns Hopkins, and the school of safe surgery, which then developed. It is incorrect to interpret this as validation of Halsted’s lifelong morphine use as a source of inspiration, moderation, and personality change. It is not clear what details of the drug saga were available to Blalock, beyond the New York cocaine history, as Osler’s notes became public years after Blalock’s death. Welch’s 1930 revelation of Halsted’s continued episodic use of cocaine may or may not have been available to him.

Halsted was uncompromised in the operating room, analytical and productive in the laboratory, and able to spend long hours at intellectual pursuits. And yet he was undoubtedly addicted to morphine throughout his career at Johns Hopkins. A minority of Halsted scholars believe he may have abandoned morphine in his final years, but there is no hard evidence for that position. We must consider that he lived with a 35-year morphine habit and that he was never fully free of cocaine, in which he indulged only far from home and far from acquaintances with whom he would have to interact. After absenting himself and indulging his addiction for weeks at a time, he very likely tapered off by substituting morphine for cocaine, as he had learned at Butler. Then he returned home and routinely purged himself by confessing to Welch. Welch was initially unaware of what had been going on, and in fact had not even been suspicious. But since Halsted believed he knew the nature of his solitary holidays, Welch listened and did not betray his ignorance. The pattern was established: Halsted isolated and far from home, indulging his habit, confessing to Welch, and then dosing himself with morphine and resuming life as usual in Baltimore.

Halsted’s summer travel puzzled everyone else. He did pay brief visits to surgeon friends, usually in Germany and Austria, visited their clinics, and kept up a lifetime of relationships. He collected honorary
degrees and delivered papers, but for the most part he was alone. Osler wrote from England in 1911, “I have not seen the Professor, when over here he keeps in seclusion in a very funny way.”

Halsted rarely spent time in London, or visiting Oxford. Instead, he passed through on his way to Brighton or Folkestone, seeing no one. On one such trip he wrote one of his secretaries, Miss Stokes:

This is an ideal spot. En route for Bonn, I have been here for a week, unable to tear myself away. Go to bed at ten punctually, and sleep usually until six. My corner room on the fifth floor has an unobstructed view of the oceanfront, and of the downs on the side. At night, I can vividly see the flashlights on the coast of France, 27 miles away. On a clear day one can see the French coast, and steamers and fishing boats are constantly in sight. I have a soft coal fire constantly, much to the amusement, I fancy, of the servants, who do not quite approve of the combination of open windows and a fire, when the thermometer registers perhaps 60 degrees, and they are complaining that it is ’ot.

In Paris, Halsted favored the Hotel Continental. Most of his time was spent in his room, and when he exited the hotel he did so by the side door to avoid acquaintances in the lobby and hotel staff. He did, in fact, make most of the scientific pilgrimages planned for each trip, but the majority of his time was solitary, answering to no one.

WHAT, THEN, IT MUST
be asked, was the effect of a lifelong drug addiction on this most unusual man? One cannot claim Halsted’s potential was never realized. He maintained his mental and physical strength and was, throughout his life, an enormously productive individual. What really can be ascribed to the chronic morphine addiction and episodic cocaine use? Did it change his personality? Very likely so. The initial cocaine episode documents evidence of
his response. Hyperactivity, rambling speech, inattention, and suspended decision-making ability were hallmarks of this period, and drove him to seek help. The later cocaine use was episodic, restricted to private time, hidden from view, and relieved by reversion to morphine as he reentered society, and it is doubtful that he shared this secret with Caroline.

The use of morphine as a cocaine substitute was learned early, but never fully laid the craving to rest. The euphoria and sedation of morphine were easier to live with on a full-time basis, and he juggled the demands of daily existence and the drug quite well. But with the development of systemic tolerance, these effects become blunted. The need for “reward” offered by the drug does not diminish, and tolerance requires ever-larger dosage to sustain the same sense of well-being. The morphine sedative effect became less pronounced and increasingly integrated as a personality trait. Reticence gradually supplanted a more social alter ego, but only those familiar with the extrovert Halsted were aware of the dramatic change. Secrecy was a variable best managed by withdrawal, and the combination transformed a socially outgoing young man into the isolated and insulated individual that Halsted had become.

Managing drug dosage is an unpredictable art. Numerous factors including purity, route of administration, and metabolism vary, but usually within an acceptable range. Occasionally, the balance is disturbed and early signs of withdrawal or overdosage are manifested. Halsted on rare occasions suffered one or the other of these debilitating syndromes. At those times he was “ill,” or “had a terrible Headache,” and was forced to retire from surgery, or was taken with tremors and perspiration, as when Osler came upon him. The episodes, while unusual enough to gain notice, were insignificant within the span of a brilliant, 35-year career. Did the morphine make him more thoughtful, careful, and insightful? Unlikely. Halsted’s evolution as surgeon and scientist was just that, an evolution. He was able to work with
the morphine, not because of it. His insights into the direction that surgery should take were formed early, and the path through which they were achieved followed a logical progression.

The idea that the father of modern surgery could be addicted to morphine and cocaine throughout his long career is plainly counterintuitive. More unsettling still is the level of performance he was able to maintain during those years. Surely the course of his life would have been far less convoluted without it, and perhaps his relationships a bit more traditional. But in all, he was unbent, healthy, able to function in civil society, accomplish more than most men could ever dream of, and set off no alarm bells. While hardly typical, the story belies the conventional wisdom concerning long-term drug use. What destruction the morphine wrought was served solely to William Stewart Halsted. There was little or no collateral damage.