Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (45 page)

The eureka moment occurred when Dandy was looking at the chest X-ray of a patient undergoing an abdominal catastrophe. He could see at the top of the film that the liver was separated from the diaphragm by a layer of gas due to the intestinal perforation. The free air had clearly outlined the surrounding organs. Dandy began injecting air into the spinal column and the ventricles of the brain, and taking X-rays of the result. The injected air was less dense than cerebrospinal fluid and would show a blockage of the flow or a change in the position of the ventricles. This helped localize the space-occupying mass in the silent areas of the brain. If brain tumors could be localized, they could be removed earlier, and the patient offered a chance for cure rather than only palliation.

Dandy’s development of pneumo-ventriculography was probably the greatest single advance ever made in neurosurgery. Halsted was happy to note that Dandy had done it again. In 1920, he wrote, “I know of no contribution to surgery since the opening of the Johns Hopkins Hospital which might rank with Dandy’s … already it has made possible the precise location of cerebral tumors, the situation of which was not even suspected by competent men.” Not a statement that would please Cushing.

Publication of the technique brought surgeons flocking, once again, to Johns Hopkins, this time to Dandy’s operating room. Many of the visitors informed the Baltimore press of their presence in the hope of having the item picked up by their hometown papers. The publicity stunt was not lost on Halsted, who popped his head into Dandy’s operating room, and was told what the neurosurgeon proposed to do. Halsted nodded and said, “Dandy, that’s fine. If you hurry you can get it in the afternoon papers.”

The animosity between Cushing and Dandy accelerated with Dandy’s increased prominence. Cushing, the diminutive aesthete,
had little time for anything but his work. Dandy was a larger man, round-faced and thick-waisted, with an intense personality. He was as devoted to his family as he was to his work, deriving great joy from both. He rarely attended medical meetings, believing they were social gatherings, and wasted time. A well-prepared, master technician, Dandy was fearless in expanding the boundaries of neurosurgery, often distressing or angering others along the way. In describing complicated and dangerous techniques, Dandy often wrote, “In safe hands this is a very safe procedure,” which did little to win friends.

The feud was memorialized in irate letters from Cushing, and considerable grumbling on both sides, but a mutual admiration persisted amidst the rivalry. Cushing accused Dandy of being ill mannered, and of slighting him. Dandy intended from the beginning to be the best, not second best after Cushing. Though he felt no need for his approval, he was deeply hurt by Cushing’s vitriol.

Dandy went on to make many memorable scientific and clinical contributions. In 1911, he addressed a more common ailment when he discovered the cause of what we now call a slipped disc, and devised the first treatment for it. Prior to Dandy, there had been no knowledge of the true nature of the spinal cord “tumor” that caused the symptoms bundled into the term
sciatica
.

Dandy’s diagnostic skills were such that after yet another intuitive success, a neurologist who had been observing the phenomenon was driven to say, “Doctor, I think God must whisper in that man’s ear.”

Halsted was devoted to Dandy and had the highest regard for his abilities, but was continually frustrated by his inability to write a comprehensible paper. Halsted, who was anything but a gifted writer himself, made the issue a personal project. Books, poems, and a private English teacher could do nothing to turn the tide. Eventually, Halsted gave up and edited many of Dandy’s early papers himself.

When Cushing made plans to leave for Harvard, Halsted wished him well. When Dandy was offered the professorship at the University
of Cincinnati, Halsted did not want him to leave and suggested Heuer, Reid, or Carter in his stead.

Dandy was brilliant, loyal, hardworking, and arguably the most important neurosurgeon in the world. He spent his entire career at Johns Hopkins, but during Halsted’s lifetime he never rose above the rank of associate professor of surgery. At Johns Hopkins there was only one professor of surgery.

GEORGE HEUER WAS RESIDENT
from 1911 to 1914. He stayed on as Halsted’s assistant and was in charge of neurosurgery until 1922, when he left to become professor of surgery at Cincinnati. During these formative years of his career he may have became closer to The Professor than any previous resident. For most of that decade, Heuer, Mont Reid, and Richard Follis were the surgery team. William Stevenson Baer led orthopedic surgery, Hugh Young urology, and Sam Crowe otolaryngology. Joe Bloodgood ran surgical pathology, and J. M. T. Finney was the reliable backbone of the department, as he had been since the hospital opened.

Heuer, like Dandy and Crowe, was seduced by Cushing and became his special assistant, thereby relinquishing his position as assistant resident on the surgery service. In 1909, when he hoped to return as assistant resident, there were no openings. Henry Hurd was still director of the hospital. In his usual grumpy fashion, he always saw to the welfare of the residents, and allowed Heuer to live at the hospital until an opening materialized on Halsted’s staff. Working with Cushing never turned out the way one had envisioned.

CHAPTER THIRTY-FOUR
The World Changes

FRANKLIN P. MALL WAS
a small man. Short, fine boned, and ascetic looking, he had light brown hair that he wore parted on the left and a faraway gaze. Neither his hair nor his bushy mustache appeared tamed, and he always looked younger than his years. He was a physician who didn’t practice medicine, an anatomy teacher who refused to demonstrate anatomy to his students, perhaps the foremost proponent of medical science at the expense of clinical medicine, and the leading embryologist of his day. Mall’s inquiring mind and soaring intellect made him one of the most celebrated of medical researchers, and his impatient and dismissive nature made him the most universally disliked professor on the faculty of The Johns Hopkins University School of Medicine.

Mall required junior lecturers to teach his courses, and survived generations of complaints about his acid tongue, simply because he was too valuable an asset to shed. The scope of his work was vast, and despite being thought of otherwise, he nurtured intellectual discourse and helped fellow researchers wherever he could. In addition to holding the chair of anatomy at Hopkins, he was the director of the embryological department of the Carnegie Institution in Washington. But Mall was not widely known beyond the most exalted scientific circles. His
work was the bedrock of basic science, and far too arcane to make him a hero of the average physician. He was unknown to the lay public.

Mall, the prodigy, had studied embryology and pathology in Germany and was 23 years old when he arrived at the old pathological laboratory as Welch’s first fellow. Halsted had already done a great deal, and certainly had been through a lot, when he arrived in December 1886. They were thrown together in the large south room at the Pathological, where it was impossible to be unaware of what was being done at the next bench. Halsted quickly found that Mall’s work on the intestinal submucosa could have great implication in his work on intestinal anastomosis. They joined forces, lunched together in the gritty back room of the old beer saloon across from the Pathological, and enjoyed each other’s company.

They were an intense pair. Both were fond of joking at the expense of others, and neither was particularly gracious on the receiving end. Once, in the saloon, after Halsted passed some amusing remark, the barman passed his dirty hand over the seated Halsted’s bald head and said,
“Du hast deine Haare nicht umsonst verloren.”
(You are bald for good reason.) In what his residents would soon recognize as the first sign of his anger, Halsted’s neck and ears got red. Then his face flushed, and everyone but he had a good laugh.

These days Halsted lunched on milk, bread and butter, and cold meat, taken alone in his office on the top floor of the surgical building. When he found himself in the hospital staff dining room, he joined the table kept for the department heads and senior staff. But despite the fact that he chose to sit with his colleagues, he was uncomfortable in large groups and was always just on the outside of the friendly laughter—not at all like the quick wit Mall knew him to be.

Their early work on the submucosa was well received, and their friendship blossomed. Both were regular diners with the initial, little group at the Maryland Club, and spent a great deal of their time together during the early years. When both men married, their
relationship continued in the laboratory, at lunch and the occasional dinner, and in regular Sunday visits to Halsted’s home. Neither Mrs. Mall nor Mrs. Halsted was included in the socializing.

Mall had suffered with indigestion for years, but complaints of bloating and heartburn were far too common to be taken seriously. In late October 1917, he developed severe abdominal pain. His skin and eyes became yellow with jaundice, there was bile in his urine, and he was vomiting and hiccoughing uncontrollably. A low-grade fever developed, and his white count jumped to 24,000. The diagnosis of acute cholecystitis, with gallstones blocking the common bile duct, was obvious.

Halsted had just returned from his long summer holiday, and Finney, who was the ideal surgeon for the case, was away on his. No one dared tell Halsted he was second choice, nor call Finney back from vacation. On October 28, Halsted operated, assisted by Richard Follis. He found what he had expected: a gallbladder full of pus, stones, and gravel, much like the findings at his mother’s operation. It was a recurring theme in his life.

Bile and pus drained from the tube in Mall’s common duct, but the symptoms didn’t abate. Mall continued to do so poorly that Halsted operated again on November 7. More stones were found in the duct, and another lodged in the entrance to the duodenum, which required the intestine to be opened, and resulted in peritonitis.

In April of that year, America had joined the war that had been raging in Western Europe for nearly three years. The celebrated surgeon Alexis Carrel, of the Rockefeller Institute, had recently returned from the front. Carrel had been treating war wounds with an irrigating technique. Utilizing an infusion apparatus he pumped Dakin’s solution into the wound. Carrel claimed great success in sterilizing wounds thoroughly enough to allow the growth of new blood vessels in the form of granulation tissue to invade the area and begin the process of healing. Surgeons in the hospitals of the British Expeditionary Force conducted a six-month field experiment and confirmed
Carrel’s results. The technique was hailed as a great advance. Coverage in both medical journals and the lay press, including the
New York Times
, hailed the achievement.

Halsted, at a loss for something to help Mall combat the infection, dispatched his assistant resident, Adrian Taylor, to the Rockefeller Institute, in New York. Halsted had a good relationship with Carrel, and instructed Taylor to question him about the use of the Carrel-Dakin treatment in an open abdominal infection. It is unclear why Halsted did not telephone Carrel himself and get the information firsthand, although the trip very likely also involved procuring the solution and observing the apparatus at work. Carrel advised Taylor that it would be safe to use in the abdomen and taught him the elaborate technique.

The rubber tubes were installed in Mall’s abdomen, and a flushing routine was begun using Dakin’s solution, which is a neutral 0.5 percent hypochlorite of soda—essentially, Clorox. The irrigations continued over the following week, closely overseen by Halsted. In the particularly bitter November week, he arrived by taxicab several times each day, formally dressed as always, and visited with Mall. He sat by Mall’s bedside for hours and thought through the problem as his friend weakened. The Carrel-Dakin’s flush eroded Mall’s duodenum, and it perforated in several places. Mall lost a great deal of fluid and electrolytes as gastric juices and bile poured out of his intestine. The infection worsened when fecal contents from the perforations poured into his abdomen.