Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (5 page)

At the completion of his premature internship in May 1877, Halsted returned to finish his final year of medical school and prepare for examinations. He finished in the top ten students of the class,
was graduated with honors, and qualified for the honors essay contest. Halsted spent the entire three hours on a single question: the description of the arteries of the neck. It was as if the young anatomist had written his own question. In a final coup for the student who had shown no academic aptitude before finding medicine, he won the contest and the $100 prize.

CHAPTER FOUR
Becoming a Surgeon

TO GAIN FURTHER EXPERIENCE
, Halsted took a newly created position as house physician at New York Hospital. It was not a surgical post, but at least he would be able to learn more of the ins and outs of a doctor’s work in a hospital setting.

New York Hospital, chartered by King George III in 1771, was the second oldest hospital in the nation. From inception it was an important local institution, and its governors were the leaders of the New York business and social worlds. Halsted’s father and grandfather were members of the board of governors and significant financial supporters of the hospital. An uncle, Thaddeus Halsted, had been an attending surgeon at the hospital as well, so the Halsted name was anything but unknown when the young physician sought employment. Halsted always claimed to have taken a competitive exam to win the position, but New York Hospital records make no mention of an examination ever being offered. The medical wards of the new hospital building were about to open, and based on a glowing recommendation from Dr. Henry Sands, the board of governors ordered “Dr. William S. Halsted, late house physician at Bellevue hospital,” appointed without delay.

In March 1877, the new hospital opened. A six-story, neo-Gothic brick building, it occupied the entire block between 15th and 16th
streets and Fifth and Sixth avenues. It was said to be at the cutting edge of hospital design. A decade earlier, the tragic conditions of the Civil War underlined the need for a sanitary environment, good ventilation, and adequate heating in hospitals. A report in
Harper’s Weekly
said of the new building:

Various appliances said to be available in no other public hospital in the world have been introduced, which add to the comfort of the patients and reduce at the same time the labor of attendants. Bell wires and speaking tubes are placed throughout the building, and two elevators run from the basement to the top story …. Bars will be placed over beds offering patients able to take advantage of them the means of shifting their positions without assistance.

Many of the faculty members of the College of Physicians and Surgeons used New York Hospital for their patients, and Halsted was happy to find himself among familiar faces. Though he was house “physician,” he utilized the opportunity to attend conferences, observe surgeries that interested him, and continue his relationship with the professors he admired from his student days. Fascinated by the clinical and surgical challenges around him, he studied every aspect of hospital life and questioned everything he saw.

Clinical progress notes were made in longhand in the physician’s recording book. All entries were made by the same man, and since hospitalizations were usually long, the notes read like an epic novel. There were no laboratory tests to scan daily, so the only recognizable signs of change were the patient’s appearance and the chart of vital signs: pulse, temperature, and number of breaths per minute. Blood pressure monitoring would not be invented until the turn of the 20th century. This graphic record of vital signs was then made available on the bedside chart. While still a junior staff member, Halsted
redesigned the patient’s bedside chart to include color-coded graphs of temperature and pulse, marked by joined dots. This made changes in the pattern of vital signs quickly apparent. Halsted had these charts lithographed and provided them for use at the hospital.
¹

While he spent as much time as possible observing surgery, it became clear that little more could be learned under a stagnant system with no organized postgraduate training. He made it his business to read the flood of new surgical papers coming from the European capitals where the leading professors and practitioners held forth. Great strides were being taken in Germany, Austria, Switzerland, and Great Britain; barely the smallest steps were being made at home. Observing these great men at work was the most desirable training available. With the indulgence of his proud father, Halsted set off to spend two years traveling through Europe, availing himself of the best that surgery had to offer.

GIVEN THE RIGOROUS
track of modern surgical training, it is difficult to imagine the haphazard state of higher education in Halsted’s time. Formal surgical training simply did not exist in America. Young surgeons, at least those with the means, would seek out this or that great European surgeon, brush up on the language, study the written works of the master surgeon, present himself, and proceed to shadow the master through clinics and surgeries. Experiences varied. Sometimes the visitor could ask questions, sometimes he was permitted to assist at surgery, and sometimes he was lost in the gallery, unable to see much more than the surgeon’s back and an occasional glimpse of the procedure.

Halsted had performed well and was fairly well connected in the New York medical establishment, and he was easily able to secure the proper letters of introduction for access to European surgical circles. Financed by his father, he sailed for France. Arriving in Paris in the fall of 1778, Halsted was met by several New York friends, including his P&S chum Samuel Van der Poel, who had been studying in Germany. The two young doctors planned to travel and study together for the next several months.

The trip got off to a bad start, and they aborted their stay in Paris after only a few days. The New York friends hosting them were anything but serious, intent only on squiring them to local hot spots. After a night in Montmartre, and too many bars and cafés, the new arrivals were already worn down. They had little interest in nightlife, and promptly packed up and left for Vienna.

Arriving by train on November 4, the two young men threw themselves into their studies. The first task was to become fluent in German. Halsted was capable enough in the scientific German needed for medical reading, but the living language was another matter. He engaged two tutors, took German lessons early and late in the day, and in between studied pathology; diseases of the eye, ear, and skin; and gynecology. His German was soon passable, and he took every opportunity to speak it instead of English whenever he could.

Still interested in anatomy, he studied with the notoriously standoffish Professor Emil Zuckerkandl. In a stroke of good fortune for Halsted, Zuckerkandl developed a painful inflammation of the epididymis, and asked the young surgeon to care for him. Halsted applied a poultice of iodoform ointment to the professor’s scrotum, which brought relief. Thereafter, said Zuckerkandl, Halsted “was invited to do all my dissection in his private room to which no one else was admitted.” Access to fresh bodies for dissection in the pre-refrigeration era was still a difficult hurdle, and he now had bodies available straight from the morgue, as well as the professor’s full
attention whenever he needed it. It was an anatomist’s dream, and Halsted made the best of it.

Knowing little neuroanatomy, Halsted persuaded Professor Theodor Meynert to tutor him on the dissection of the brain. The sessions took place at 6
A.M.,
before Halsted’s pre-breakfast German lesson. It was not a pleasant experience.

“He was always in bed on my arrival and the lesson was given in his unsavory bedroom,” Halsted wrote. It was not long before Professor Meynert was “released from the contract.”

Giving up on neuroanatomy, Halsted began work in the new science of embryology, which was attempting to explain the origin and relationship of body parts by studying the differentiation of fetal cells from fertilization through birth. The new science captured his imagination, but it did not supplant surgery.

He also made the acquaintance of two men with whom he felt instantly close: Anton Wölfler, whose work on surgery of the thyroid gland particularly interested Halsted, and Johannes von Mikulicz, a Polish-born contemporary of Halsted’s who would gain great fame as a pioneer of abdominal surgery. Both were serving long assistantships under the acknowledged master, Professor Theodor Billroth, the most famous surgeon in Europe. Billroth was known as an accomplished musician as well and was the closest friend of Johannes Brahms, who dedicated two string quartets to him.

Among his surgical contributions were the first excision of a rectal cancer, the first laryngectomy, and the first successful gastrectomy to treat stomach cancer. Billroth was an early subscriber to Lister’s antiseptic techniques, and pioneered abdominal surgery adventurously but with careful preparation. As a believer in long and intensive surgical training, his graduate doctors served two or three years as apprentices doing hospital care and anatomical dissections, followed by numerous assistant years during which they performed surgery and studied the surgical literature. Everything about the
experience was stimulating, and Halsted found a regular place in the amphitheater observing the master at work.

The new discipline of abdominal surgery with attention to hemostasis (control of bleeding) and antiseptic technique, use of the animal lab, and Billroth’s concept of surgical training left their mark on young Halsted. They would all resurface at Johns Hopkins a decade later.

IN THE SPRING
of 1879 Halsted left Vienna to study embryology in Wurzburg, and then went on to Liverpool, where he would join his parents and siblings and travel with them for the summer. Halsted looked forward to the reunion and the respite from constant study. With his father’s permission, he invited Samuel Van der Poel to join the family traveling party. The trip was a great success, and by summer’s end Van der Poel had become engaged to marry the youngest Halsted daughter, Minnie.

Returning to Vienna in the fall, Halsted continued his studies with Richard von Volkmann, another proponent of aseptic surgery and a pioneer of joint and extremity surgery; Johannes Friedrich von Esmarch, a German military surgeon who instituted training in first aid for civilian and military personnel, and introduced the use of the first-aid bandage on the battlefield and a surgical tourniquet that allowed a bloodless field for extremity surgery; and Karl Thiersch, who is credited with having invented skin grafting. All three surgeons are still known for work they did more than 100 years ago. On his two-year learning tour, Halsted had yet again managed to find himself in very accomplished company.

He took up residence with two other men in a boardinghouse, where they took their meals. The arrangement forced them to speak German all day. Although he never mentions women in his journals and letters home, he referred to his Vienna housemate, George Dixon, as a very attractive man who became involved with numerous women and whose charm opened many doors for the trio.

Another American friend who had joined him in Leipzig soon fell ill with typhoid. One day Halsted was called to see him by the attending nurse, who anxiously reported the patient’s pulse had risen to 200. Halsted was stymied. His friend looked well enough, and his pulse was quite normal. Apparently, the nurse, who didn’t have a watch, held his wrist to count pulse beats while the patient was instructed to count out loud to 60, to determine the number of pulse beats in a minute. His German was halting and he counted very slowly. Halsted later commented, “This was beyond his powers and I have never understood why the nurse stopped counting at two hundred.”

The final stop on the tour was to study with Karl Thiersch, who introduced the split-thickness skin graft in 1874. Halsted found most of Thiersch’s operations “minor,” and knowing that his friend Frank Hamilton of Bellevue had been performing skin grafts for years, he was unimpressed.