Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (43 page)

True, he had already shifted his focus to the laboratory and restricted the number of private patients under his care. Ten years previously he had been billing private patients thousands of dollars for his services. But the evidence supports his lack of commitment to private practice. He never established a private consulting room, and he kept the ample work space allotted to him as a place to hang his hat, study, and write. When he did see private patients it was either at their home, in a hotel room, or in the hospital. His colleagues were far more consumed with the effort and dedicated comfortable surroundings to their private enterprise.

In the beginning, pursuing private practice was not only the norm but was the implied preference of the hospital trustees. Private income
would allow the doctors to live well without adding the burden of large salaries to the budget. The coming of full time, and the Rockefeller money to support it, eliminated the need for this pragmatic solution and obviously played into the hands of the Mall faction.

In the years following the institution of full time, Caroline Halsted often complained of the financial constraints the system imposed upon them. A $10,000 salary in 1913, the year the federal income tax law was ratified, would be about the equivalent of $300,000 in 2009. Not poverty level by any means, but less than Halsted was earning at the time. Their actual financial circumstances are unknown. It is unclear what, if anything, remained of his inheritance, but Halsted had never made an issue of lack of money, just as he never made an issue of having money. Suddenly he could no longer avoid the topic. In the end, he realized that at the heart of the “full time” debate was the money, and “that there were men who needed the stimulus of money making to compel them to work, but that these are not the desirable men.”

“But,” he added, earnestly, “wish men who have learned to work for work’s sake, who find in it and in the search for truth, their greatest reward.”

Halsted warmly endorsed the idea, but he had not romanticized it. He wrote to the trustees: “We should utterly fail as surgeons were our staff composed chiefly of laboratory workers who could not be given patients for treatment.”

He felt that the surgical service was too small for the growing resident staff, and the “majority of patients occupying surgical beds cease to be of particular interest after operation, for their convalescence is uneventful.” This very significant sentence stands as evidence of the sea change in surgery in the two decades with Halsted at its helm, as the struggle against postoperative infection had largely been won by his demand for strict asepsis, hemostasis, and gentle technique.

“In a word, for the success of the surgical department on its new basis it is necessary that the clinical facilities be greatly increased, for,
if not, we shall fail to attract to this service men of the type not only ardently desired but essential to the carrying out of the plan to which we have pledged ourselves to adhere.”

In 1913, it was an experiment meant to apply only to the leaders of the major departments: surgery, medicine, pediatrics, gynecology, and psychiatry. As things stood initially, only the professor would be affected. Proponents at Hopkins were strident in their views, but even supporters, such as Halsted, could paraphrase Osler’s old refrain, that without clinical medicine there would be no medicine at all. Mall’s position not withstanding, patient care did count. To be an effective leader, the professor had to be expert in the clinical practice of his specialty.

In the quarter century after it was instituted, the full-time system was expanded to include junior faculty members. The primacy of laboratory scientists rose and fell in a parabolic course over those 25 years. Sometime before World War II, the medical establishment came to its senses and recognized the importance of clinicians. If the goal was to help humanity, the physicians on the front line needed more appropriate role models and teachers than the laboratory men could offer.

Within the wide range of university full-time systems, some professors would be on straight salary, and others in complex financial arrangements with the university, which allowed them to recapture a percentage of their earnings. Some adopted an arrangement sometimes referred to as geographical full time, where professors were required to practice at the university hospital, but financial arrangements varied widely. Some doctors headed departments and taught medical students and residents for the honor of doing so, and supported themselves solely on patient fees, often quite handsomely.

Increasing financial pressure on hospitals and universities soon found the full-time physicians, from professor to young practitioner, had become profit centers for the institution. The paradigm had
shifted from scientists freed from the constraints of practice, to clinician-teachers working as practitioners and subsidizing medical schools. All manner of arrangements exist today. Medical schools and hospitals pay multimillion-dollar salaries to star clinicians who fill beds and attract wealthy potential donors. They subsidize new, “fulltime” practitioners with comfortable salaries and a promise of patient referral, and generally operate in the manner of large corporations, far removed from the ideals of Mall, Welch, and Halsted.

CHAPTER THIRTY-THREE
A New Era

AT AGE 61, HALSTED’S
nicotine-stained mustache had gone white, his ice blue eyes appeared more forbidding than ever, and the skin of his jaw and neck had loosened. He was not sickly, but he wasn’t quite well. Abdominal and chest discomfort had become a regular part of his life, and like most physicians, Halsted diagnosed and treated himself. Convinced his ailment was angina, he often took to his bed, but for the bulk of the time he was energetic and once again reinvented.

The older Halsted was generally more at ease and able to maintain a genuine interest in his juniors. With the coming of full time he was morally free of what he had come to increasingly dislike: the operating room. Always intense, and increasingly tired at surgery, his great joy had become the experimental laboratory. Halsted felt his duties were now clearly delineated as scientist and teacher. He still spent hours studying particular patients, and was no more communicative than he had been in the past. Patients whose problems interested him were, by unspoken rule, his patients, but they were considerably fewer in number. The resident took great care to follow and prepare these patients, but would never dare take them to surgery. This presented a problem, as Halsted often became otherwise engaged and neglected the patient
for weeks. The resident dared not do the surgery, and feared reminding The Professor that his patient was languishing on the ward. When the patient finally came to his attention, Halsted would say he had been studying the proper treatment, and the issue would drop.

Formality remained the rule. Halsted never referred to colleagues by their given names. It was Kelly, Cushing, and Finney, never Howard, Harvey, or John. Initially, it was Dr. Kelly, Dr. Cushing, and Dr. Finney. Omitting the title was a sign of collegiality. Medical students were mister, or miss, and never called by their first names. No one at Johns Hopkins ever dared call Dr. Halsted “William.”

The formality was rigidly applied to patients, though all were treated with respect. There was no personal banter or small talk with patients, particularly with ward patients, as Halsted felt the intellectual gap between them made such talk inappropriate. A patient’s elevated social status carried no weight, for in his view it was a privilege to be treated by him, and he expected the relationship to carry on thusly.

One patient, a very well known woman, had a chronic condition that required repeated surgery over a period of years.

Halsted announced her arrival over the telephone to the resident.

“Heuer, is that you? I just wanted to say that we are in for a bad winter. Good night.”

Ensconced in a private room made up with her own bed linen, and a telephone line to conduct long-distance business, she routinely ordered the staff about. On his first visit he was told, “Dr. Halsted, I have no time to waste, I am a very busy woman, I expect you to operate on me tomorrow.”

“Yes, Miss A.” And then to the waiting Heuer, “Gracious, Heuer, we are late for that very important operation. Good-bye, Miss A.”

He returned to the irritated woman two days later, and again she demanded immediate surgery. This time he stayed away for five days. Miss A finally got the point, and she humbly requested that Dr. Halsted take care of her as soon as he could find the time.

“Now, Miss A, you are in a proper frame of mind to discuss your problem.”

Halsted was far more strident in his expectations of private patients than the ward population. This attitude obtained in everything from intelligence to personal hygiene. When another socially prominent woman was examined in the hospital prior to surgery, he left the room visibly unhappy with her.

“Why, Heuer, she has a dirty umbilicus.”

HALSTED NOW OPERATED
only a day or two each week, and rarely did more than a single case each day. On operating days he would arrive at the hospital at 9:00 for 10:00 surgery. He took a taxicab from Eutaw Place to the surgical building, and the elevator to the fourth floor. In his dressing room he shed his black derby, his cane and gloves, and changed from his impeccable, dark three-piece suit, white shirt, and dazzling black leather shoes to the white duck operating costume, which now included a cloth face mask and white tennis shoes. He had abandoned the scrubbing and dipping routine in favor of washing with alcohol and a sterilized cloth, and did so before donning the sterile rubber gloves. The gloves were finely made and stood up well to multiple sterilizations. Sterile gloves were now in use everywhere. Other hospitals had already adopted the more convenient dry method, in which gloves were covered with a sterile, dry powder, which made for easier insertion of the hands and less irritation. Halsted stood by the wet method, dipping the sterile gloves in permanganate solution after sterilization. Halsted’s belief in the impossibility of fully sterilizing the hands was unshaken. Sterile gloves were the only safe barrier between wound and surgeon, and he insisted on a change of gloves and instruments if the gloves were pierced, a technique rigidly followed today.

On the days he did not operate, Halsted worked at home until noon, lunched with Caroline, saw a few patients with the resident,
and spent the afternoon at the lab. Some days he didn’t appear at the hospital at all, and when he was feeling poorly he didn’t appear for weeks at a time. During the school year he made formal ward rounds with the students, and conducted a “dry clinic” at which patients were examined and discussed. These sessions took place in the amphitheater on the fourth floor of the surgical building. The rest of the time he was free to dream up projects and concentrate his time at the Hunterian Laboratory across the street from the surgical building.

Cushing had moved on to Boston, leaving the surgery course without its inspired instructor. Rather than assign another assistant, Halsted resumed teaching the course himself. Or, more accurately, began teaching the surgery course. The first time around he had barely met his responsibilities. This time he enjoyed the experience, and threw himself into it. Over the next decade he would establish far closer relationships with the medical students and junior residents, and would be remembered quite differently by later graduates than he had been by their predecessors.

His thyroid, parathyroid, vascular, and intestinal surgery projects were in full swing for seven months of the year. Once May arrived, all work stopped just as abruptly as it always had, and vacation beckoned, but from October to May, Halsted was working full time at being “full time.”