Competent, workmanlike biography of an important--and at times disturbing--figure in American healthcare, during a period of tremendous progress and innovation in medicine. During the late 19th/early 20th century, Dr. William Halsted became the father of modern surgery in the United States: perfecting sterile/antiseptic surgery practices, innovating with anesthesia methods, inventing various revolutionary procedures (ranging from a highly creative fix for inguinal hernias to advanced vascular surgeries), and then leading a "coaching tree" of surgical student descendants who went on to innovate still further.
All this, and Halsted was also a gigantic cocaine and morphine addict.
Along with Halsted's career arc, the reader also learns about the 1889 founding of Johns Hopkins Hospital, an institution that did more than any other to revolutionize medicine. In those days medicine was in dire need of a revolution, as medical schools had no consistent requirements for entry and medical school graduates had no standardized qualifications at all. Worst of all, patient outcomes, bluntly, sucked.
Hopkins Hospital was built to be a completely different animal. It would for example impose the previously unheard-of requirement that all med school entrants have undergraduate degrees with heavy science training. And it would innovate a post-medical school "resident" program, where med school graduates would literally live at the hospital (yet another unheard-of idea) while working directly under the supervision of experienced doctors who also lived at the hospital.
Predictably, the Hopkins model was mocked and resisted by established interests in the industry,[1] but ultimately it became the standard for modern medical education.
The reader cannot help but compare medicine in Halsted's day, an era of obvious improvement and innovation, to this era's healthcare industry with its obvious Fourth-Turning characteristics of decline, sclerosis and economic extractiveness. As much as it gives one hope to think about what changes for the good can occur during a society's growth/upcycle phase, it horrifies one to see how entire institutions like American healthcare writ large can degrade during the decline/downcycle phase.
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The author, himself a doctor, has a direct and simple writing style. It's refreshing, you can really inhale the book. And he's full of memorable tidbits and trivia: in one chapter he holds forth for two paragraphs on how to plant and cultivate dahlias (William Halsted's favorite flower); in another chapter he teaches readers the etymology of the phrases "cold turkey" and "kicking the habit" which derive from the chills, goosebumps and involuntary leg movements resulting from morphine withdrawal. Who knew?
Genius on the Edge could have used one or two more editing passes to clean up a couple of minor issues. The author makes a few too many jumps back and forth in time, which makes parts of the book more difficult to follow than should be necessary. Likewise, the author occasionally tells the reader the same thing multiple times in the book, but then elsewhere leaves out telling something that the reader needs to know (you can find various examples if you have the patience to skim my notes below). These are minor errors that are easy to commit (and more difficult to find and fix than you'd think), but they do interfere in the reader's experience.
A few more quick thoughts: The author doesn't say this directly, but a reader able to read between the lines can infer that Halsted was quite likely gay[2], something in those days that had to be kept on the down-low. This brings us to a more sobering thought: in order to be gay (in that era) and a massive coke addict (in any era) and still have a career like this, you have to have friends in high places who will protect you. Halsted had that too. That's how he got his job at Hopkins in the first place (after he had wrecked his career in New York due to his drug use), and it's how he kept it (despite long, unexplained absences from work and occasionally suspect job performance).
This takes us to yet another disturbing thought, as the reader can see here how a doctor can leave one city a pariah with a ruined reputation, but then magically reappear in a far-enough-distant city and just... carry on practicing medicine. This still happens! Note that even today there's no shortage of examples of doctors fleeing their reputations to start elsewhere with a cleaner slate.
Finally, it's worth thinking about how burning the candle at both ends can take you out at a relatively young age. Halsted used a lot of coke, and even more morphine, and he didn't sleep all that much. It all adds up, as Halsted aged rapidly, and died at a relatively young 69 years.
Footnotes:
[1] For the all-time worst example of medicine's inherent conservatism and its tendency to fight--even destroy--anyone or anything threatening the established order, I recommend looking into what the Vienna medical establishment did to Ignaz Semmelweis after he discovered of the enormous merits of handwashing in the mid 1800s. Sadly, the COVID era gave us many, many vile examples of the same: see the destruction of Meryl Nass' pristine career (which included a shadowy peremptory suspension of her medical license under false charges, followed by a wide media campaign to smear her reputation) because she had the courage to criticize the flawed COVID medical doctrines that were being nationally enforced at the time. Nass's appalling story is described in Chapter 3 of Robert Malone's book Lies My Government Told Me. Dr. Nass turned out to be right--about everything--and she was ultimately fully vindicated. But her vindication came years too late, and of course there was little to no media coverage of it.
[2] The reader can deduce also that Halsted and his wife Caroline were also likely "beards" for each other.
John Singer Sargent: The Four Doctors
(l to r: William Welch, William Halsted, William Osler and Howard Kelly)
[See page 353 for an amusing anecdote about Sargent's irascibility over this painting]
[Readers, feel free to skip (or or maybe skim) the notes below. Their purpose is to help me order my thinking and better remember what I read.]
Notes:
Prologue:
ixff The narrative begins with an in medias res scene where Dr. Halsted operates on his 70-year-old mother, near death, with gallstones and severely infected gallbladder. This was the first known operation to remove gallstones; she recovered fully and lived two more years.
Chapter 1: Tumultuous Times
1ff Comments here on Halsted's birth in 1852 in New York City; intriguing comments also on the incredible civil unrest and mass immigration into New York City at the time: sometimes as many as 250,000 new immigrants came to the city in a single year, driving down wages, overrunning the city, increasing the death and disease rate, making the city "almost unlivable." [Off-topic here, but this appears to be the first of three major mass immigration eras in the United States: the pre-Civil War phase which unfortunately produced cannon fodder for the North in the Civil War; the pre-World War I phase which produced cannon fodder for both world wars; and the post-1965 phase which will likely produce... I guess we will learn soon enough what it will produce...] Note the comment here on how the wealthy, including Halsted's family, left lower Manhattan and moved uptown [This also is lamentably common anywhere that the immigration gets too out of control: the wealthiest can easily remove themselves to separate regions, gated communities, safer places--they always have options. Less wealthy people do not.]
3ff Background on the family tree here: The Halsted family arrived in 1657, as Timothy Halsted arrived to Hempstead, Long Island; then the family moved to Elizabethtown, New Jersey; William's great-grandfather and great-great uncle were doctors, the first physicians in the family; Halsted's grandfather William Mills Halsted started a trading import and dry goods company that was immediately successful, his son William Mills Halsted, Jr. succeeded his father at the firm (while his uncle/his father's brother Thaddeus also became a physician); Halsted's father married his cousin Mary Louisa Haines, and William Stewart Halsted was the eldest of William Mills Halsted, Jr.'s four children; he was homeschooled by a governess until age 10, a common practice among the affluent in those days.
5ff Comments here on how the family remained "seemingly untouched" by the Civil War in the 1860s. Halsted was enrolled at Phillips Academy in Andover, he then goes to Yale and is an uneven student there; he was disappointed to be rejected by the Skull and Bones Society, even though his father was a member; late in his senior year he takes interest in medicine and tells his father he wants to become a doctor rather than join the family business.
Chapter 2: Setting the Stage
9ff On the rarity of elective surgery prior to 1846 due to the pain of surgery and generally horrible outcomes due to postoperative infection; nobody had any regard for surgeons, in the medical profession or elsewhere.
11ff On the use of nitrous oxide gas for dental extraction in 1845, and then in 1846 the use of ether, successfully this time, to painlessly remove a tumor from the neck of a sleeping patient. Soon "ether assumed its place in operating rooms around the world." On various variations: chloroform for example became popular as it was less flammable [!] than either, but later was found to be more toxic and soon fell out of popularity; then by the first half of the 20th century ether went away and was replaced by other anesthetics; note that the first operation using ether was later to be found to be done not in 1846 as originally thought, but four and a half years earlier, in 1841, in Jefferson, Georgia by Dr. Crawford W. Long.
14ff On the US Civil War and the inability to control infection: soldiers who were "gutshot" would die within two to three days from infection; on Pasteur's discovery in 1861 of heat sterilization and then his 1878 paper recommending heat sterilization of instruments, bandages and water used in surgery; on Koch's postulates, essentially commandments of medical bacteriology on the relationship between an organism and the disease it causes:
1) the organism can be discovered in every instance of the disease.
2) when recovered from the body, the bacteria can be repeatedly produced in pure culture.
3) the initially isolated pure culture, or its successive generations, when introduced into experimental animals, can reproduce the disease.
4) the organism can be recovered from the animal and re-cultured.
16 Koch goes on to identify the pathogen behind tuberculosis; he also discovers contaminated drinking water is the vehicle for cholera.
16ff On Joseph Lister, working in Scotland on ways to destroy germs in surgical wounds; settling on carbolic acid in dilute solutions, testing it with compound fracture patients; his first two attempts resulted in failure but the third, an 11-year-old boy with a compound fracture, was a success and he recovered, and thereafter Lister had successful results. Lister published his work in The Lancet in 1867, but the theory of antiseptic surgery was not widely adopted by the profession, in fact it was rather met with open hostility. "A few young surgeons, Halsted included, subscribe to the germ theory and Lister's efforts to combat infection, and did what they could to promote its acceptance."
18 A disturbing comment from the author in a footnote on page 18: "Today, the simple expedient of hand washing or disinfecting is often ignored. Medical personnel still go from patient to patient without washing their hands or using antibacterial compounds; hospital personnel wear operating room scrub suits in corridors, hospital rooms, and coffee shops, potentially spreading infection."
Chapter 3: Physicians and Surgeons
21ff On a kind of "butts in seats" financial model of medical schools back in the day: on how medical schools in those days were attempting to integrate science and education into medicine but there was no real model to emulate; Halsted ferrets out some of the best minds in his program at Physicians and Surgeons at Columbia College. [Note here, after describing how Halsted finds the best doctors to mentor him, the author rather darkly foreshadows here with a disturbing quote: "Later in life, when rules were reversed, professor Halsted's radar would be finely tuned against young surgeons seeking his good graces, unfailingly cutting them off at the knees." Yikes.]
24ff Halsted shows up to Bellevue hospital for an intern position right after they changed the requirements to require an MD degree (which he didn't yet have). He takes the entrance exam, places fifth, and is offered the position anyway.
25 Comments here on the ideological struggle in medicine these days between people who embraced Lister and his antiseptic surgery protocols and those who did not; also there's discussion here of famed Civil War surgeon Dr. Frank Hamilton who did not subscribe to antiseptic techniques but was "open-minded enough to allow interns to adopt the new method. Those interns who did so noted a significant reduction in postoperative infection, but their findings had no effect on hospital policy."
26 Amusing comment here on smoking: all the doctors smoked, in particular they smoked during anatomical dissections to protect against noxious odors; the only place they didn't smoke was in the operating theater but this was only because gaseous ether was flammable! Note that surgery also was very uncommon in these days because it was such butchery: only 95 patients were admitted during Halsted's seven-month surgical internship, and 50 of them were simple fractures and dislocations. In those days any kind of abdominal surgery was too risky and was never performed.
Chapter 4: Becoming a Surgeon
29ff Jumping back in time to the 1771 opening of New York Hospital, on the 1877 opening of the new hospital building on 15th and 16th Streets between 5th and 6th Avenues; Halsted's family had contributed financially to the hospital and his uncle Thaddeus Halsted had been a physician at the hospital as well; William Halsted accepts a position there shortly after the new building opened, he also redesigned the patients' charts as a junior staff member--these are now called Halsted charts: they're assumed to be the result of his innovation although there may be some questions about this; note also that all of the innovation in medicine and surgery during this era was happening in Germany, Austria, Switzerland and Great Britain, and so Halsted decides to spend two years traveling in Europe to learn more. "Formal surgical training simply did not exist in America."
32ff Halsted goes to Vienna and studies with the "notoriously standoffish" Emil Zuckerkandl; interestingly the professor developed a painful inflammation of the epididymis [yikes!] and asked Halsted to treat him, and thereafter Halsted was invited to all of his academic activities including dissections of fresh bodies; he had the professor's full attention whenever he wanted it. He meets up with other important pioneers and surgery, including professor Theodor Billroth, the most famous surgeon in Europe who did the first excision of a rectal cancer, the first laryngectomy, the first successful gastrectomy to treat stomach cancer; Billroth pioneered abdominal surgery and also had his graduate doctors serve long apprenticeships.
34ff Other important innovators in medicine that Halsted met: in Vienna, Johannes Friederich von Esmarch, who developed a surgical tourniquet that allowed a bloodless field for extremity surgery; also Karl Thiersch, who is credited with inventing skin grafting; note here that Halsted considered most of his work minor knowing that his friend Frank Hamilton at Bellevue "had been performing skin grafts for years, he was unimpressed."
Chapter 5: New York
37ff Comments here on how Halsted brought artery forceps and various techniques for clamping and tying blood vessels (to prevent hemorrhage) back from Europe; these didn't catch on among other surgeons in New York; also Halsted developed an irrigation therapy for gonorrhea using a disinfecting solution long before the advent of antibiotics; there's a discussion here of Ignaz Semmelweis, who wanted to impose hand washing on hospitals in Vienna, obviously his work was ignored [the author leaves out the awful fact that the medical profession around Semmelweis essentially destroyed his career, and eventually his sanity]. Discussion of both Vienna and the United States and their "grudging acceptance of antiseptic techniques"
41 On Halsted's "staggering" workload.
42ff In 1881 Halsted made medical history by performing the first emergency blood transfusion, as his youngest sister Minnie hemorrhaged after giving birth; Halsted drew blood from his own veins with a syringe and injected it directly into his sister's vein. This was also long before blood typing which did not exist until 1900.
Chapter 6: Cocaine
47ff On the discovery of cocaine by The Merck Company in Germany, said to enable German soldiers to fight like supermen without sleep, abstinence from food was possible for days without feeling hunger, it gave them a mild euphoria and general sense of well-being, etc. Merck chemists had extracted the chemical from the coca leaf and refined it. On Freud experimenting with it on animals, he considered it a magical drug. In 1884 Freud wrote a comprehensive paper on the history and properties of cocaine. Various uses ranging from anesthetic, for mood changes, also for ophthalmology applications.
50ff In the US there was cocaine in Coca-Cola, it was in cigarettes, nasal sprays it was being used as snuff or in dilute solutions as a tonic, etc. Halsted starts experimenting with it in October 1884, thinking he could use it to block sensory nerves on human surgery patients; on various experiments he ran here with different concentrations, also using tourniquets to limit the circulation of the cocaine to increase the duration and limit generalized symptoms; also on various dental applications for use on the inferior dental nerve or the infraorbital nerve; Halsted practices by injecting his students so they can practice identifying where the nerves are, thus reliably reproducing the desired area anesthesia; this turned out to be a massive revolution in dentistry.
55 The various medical students and doctors start to really enjoy the exhilaration from these experiments and they started using cocaine socially, many becoming addicted. [I can also see why Sherlock Holmes used it!] Halsted writes a long rambling article in the New York Medical Journal (the author excerpts a paragraph here and it reads like German run-on sentence) and everybody who knew Halsted knew that something was wrong. Halsted started making excuses, lying when he had to, his hands were shaking, he claimed failing health due to overwork, and took a trip abroad to try to recover his strength.
57ff Disturbing anecdote here of William Welch (who left his position at Bellevue to become professor of pathology at Johns Hopkins), as Welch takes Halsted on a sailing trip to try to help him break his addiction, but Halsted ran short of cocaine at sea and broke into the captain's medical locker and got caught stealing, probably morphine; "Halsted's desperation had transformed him overnight from a model of patrician rectitude to a thief."
Chapter 7: The Visionary
59ff This chapter starts off describing the philanthropist Johns Hopkins and his upbringing; his abolitionist Quaker father freed their slaves and had his own children work the tobacco fields in Maryland; he moved to Baltimore to work with his uncle's wholesale grocery store, fell in love with his uncle's daughter, his cousin, a match that was forbidden by the family; he began making a lot of money in various business ventures and became one of the wealthiest men in the country, director of the Baltimore & Ohio Railroad, etc.
61 Interesting blurb here about the 1872 Great Epizootic, the equine viral epidemic that infected 90% of the horses in the USA and killed 4 million horses "leaving the country at a virtual standstill." [I never heard of this, ever.]
62ff On Hopkins' fortune, which was some $8 million when he died in 1873; he left it to start a great university and hospital which did not actually open until 1889 (and the medical school didn't open until 1893, some 20 years after his death). After the grand plan was unveiled the author comments on the nature of the buildings, how the hospital would incorporate what was learned during the Civil War and the Crimean War about sanitation; also on the hospital's efforts to bring in some of the experts from Halsted's circle, including William Welch who decided to leave Bellevue to come to Hopkins.
72 Another striking comment here about doctors categorically refusing to "believe" in bacteriology: the author quotes the famous physician Alfred L. Loomis in 1882: "People say there are bacteria in the air, but I cannot see them." William Welch replied when he learned this comment, "That's too bad. Loomis is such a nice man." [As always, physics--as well as medicine--moves forward one funeral at a time.]
Chapter 8: The Very Best Men
75ff On William Welch joining Baltimore Society but having no interest in meeting women or socializing; he lived in modest circumstances for the rest of his life while he ran this new hospital; pages here on the various medical leaders that he brought in, including Halsted.
78ff Striking blurb here out of left field about Halsted's father and the collapse of his trading firm, and how the strictly moral Presbyterian father was accused of self-dealing and unethical behavior in dealing with creditors during the bankruptcy of his company Halsted, Haynes & Company.
79ff Halsted was being considered for chair of surgery at Physicians and Surgeons Hospital, but he withdrew, blaming failing health, and then withdrew from all of his other professional responsibilities as "he could no longer disguise the extent of his disability." Welch and some others convinced Halsted to seek hospitalization: he went to Providence under an assumed name and remained there for several months, although the treatment was unsuccessful, he also bribed staffers at the hospital to procure cocaine for him; he received morphine there and ended up likely addicted to both.
81 William Welch goes out on a limb and invites his friend Halsted down to Baltimore, sets him up in his own rooming house, and sets him up in a pathology lab, working on animal surgery.
Chapter 9: Baltimore
85ff Halsted moves in with William Welch in Baltimore, he goes to work in the dog laboratory, he's credited for creating human-caliber sanitary conditions in this lab for surgeries and studies of anatomy and pathology; working with Franklin Mall they discovered the function and role of the submucosal coat in the intestine and its role in surgical separation and reattachment of the intestine (intestinal anastomosis); they develop a technique of stitching the submucosa as well as the outer layer of the intestine and this made bowel surgery far safer and able to withstand peristalsis. "In short order, this [surgical] maneuver was generally adopted. Combined with a growing application of aseptic precautions and gentle handling, it provided the link necessary to make intestinal surgery safe and predictable."
91ff On Halsted being a pariah who had wrecked his career in New York and was at Hopkins on probation and under scrutiny; everybody in New York knew about it; Note that there were many other doctors who also were addicted; Halsted declared himself cured of his addiction but this was untrue; it's likely that Welch was deeply concerned about Halsted's addiction and he had shared it with trustees and other at the Hopkins institution; Halsted more or less controlled his addiction for some six months at first, until giving the intestine paper at Harvard, but then right afterward he checked himself into another hospital, emerging nine months later and declaring himself completely cured; this also turned out to be a lie but at this point he did manage to manage his drug addiction.
93 Interesting comment here about both Welch and Halsted. "Neither man was involved in a relationship with a woman, nor did they profess any interest."
94 The author foreshadows here what Halsted's role would be at Johns Hopkins: "...as yet no one had been chosen as surgeon. In fact, there was only one surgeon associated with Johns Hopkins, and it was barely a year and a half since he had been hospitalized for drug abuse."
Chapter 10: The Hospital on the Hill
95ff On J.M.T. Finney, brought in from Massachusetts General Hospital to work at Johns Hopkins: after a cursory interview, Halsted asks him peremptorily, "When can you begin work?" "Pleased, and confused, Finney had just been hired in some capacity, to do he knew not what. No questions were asked in the three-minute interview, and Dr. J.M.T. Finney had begun a 33-year association with Dr. William Stewart Halsted in which he never received a single word of orders or instruction, and only once in 33 years, a compliment."
97ff The Hopkins leadership actually has to choose Halsted in spite of his addiction, in spite of his dark past, in spite of the fact that they were about to open a hospital and didn't have a surgeon. They had already attempted to hire a surgeon from Glasgow but the deal fell through when he insisted on bringing his entire nursing staff. "Whatever the case, the Johns Hopkins Hospital was about to open without a surgeon. As impossibly short-sighted as that situation seems, the surgical world of 1889 was unrecognizable from today's perspective and did not command the highest priority. So little surgery was being performed that there were fewer than ten physicians in the United States whose practices were restricted to surgery." Comments here on how surgery was about to embark on a new chapter, a new era, as anesthetic and innovation were changing everything, and had Hopkins hired the guy from Glasgow probably everything would have been different because he was an old-school surgeon, whereas Halsted was massively innovating, riding a new wave of aseptic surgery.
99ff On the new teaching model here, somewhat approximating the German system, where young doctors would live in the hospital for extended periods, but without formal training. William Osler and Halsted wanted the men to be unmarried, to live in the hospital, be on call 24 hours a day 7 days a week; there would be a floor for residents' living quarters and they would do this until they were "deemed sufficiently trained." This would be the first genuinely structured environment in order to learn surgery.
Chapter 11: Finding the Way
101ff This chapter backs up in time a little bit to before the hospital opens in 1889, when University president Daniel Coit Gilman and William Osler meet in New York to see how the Fifth Avenue Hotel was run: Gilman says "Between an hotel and Hospital there is no difference... I thought I would first find out how the Fifth Avenue Hotel was managed." On Rachel Bonner, who was going to be matron/head of housekeeping; on key nursing staff and nurse trainers that were to be hired; Isabel Hampton, Luisa Parsons, Annie McDowell and Caroline Hampton (no relation to Isabel), each taking various jobs, one running the private ward, another the surgical ward director, etc.
Chapter 12: William Osler
105ff Osler arrives at Hopkins in 1889 at 39 years old; on his "immortal" farewell address, "Aequanimitas" "a primer for young physicians on the necessity of maintaining an even keel in the face of adversity" [See pages 1-11 for the address]. Osler comes off as a friendly, likeable, accessible guy.
107 It's a little depressing reading the optimism with which the author writes about Johns Hopkins being a new and different kind of school of medicine [especially in light of what medicine increasingly seems to be about in the modern era]: that it would be not-for-profit, the teachers wouldn't share in tuition fees, the teaching faculty would all be full-time and wouldn't be independent operators, this was to be a new model of medical education that would not be a business.
107ff On the creation of a graduated responsibility residency system that Osler and Halsted would innovate, which would "forever change the way doctors were trained." Only qualified students who have already earned undergrad degrees were accepted, this was the beginning of the end for proprietary medical schools where students could pay their way to a medical degree. Also on Osler's suspicion of most medications prescribed in those days: he would joke that he prescribed a few medicines, all of which were poisons; he also wrote "One of the first duties of the physician is to educate the masses not to take medicine." [My, how things have changed.]
108ff Interesting comments here about how Osler philosophically believed in "following the patient to the dead house," meaning learning about the patient's disease did not end at the bedside or the lab, it also involved postmortem examinations of the patient; this guy did 948 autopsies over the course of his life; the whole philosophy here is following health problems to their "ultimate clarification" as the author puts it. [This is quite a bit different from the modern highly-siloed, hyper-specialized medicine we tend to see today where patients are referred out to a specialist, where handoffs occur shift to shift in a hospital, etc., such that nobody really "owns" the patient. This is a scale problem that seems endemic to modern/postmodern corporatized medicine.]
109ff There is conflict right away with the Baltimore medical community: the University of Maryland Medical School and all the regional doctors were threatened by the incursion of this new teaching hospital, so Johns Hopkins created a local board, brought in certain doctors, and then recruited members of the existing medical community to head outpatient clinics, basically they co-opted the opposition.
Chapter 13: The Operating Room
111ff By 1889 most leading surgeons were using antiseptic techniques, and some were implementing aseptic surgery techniques; on problems with carbolic acid (which Lister aerated with sprays, Halsted would use it to sterilize instruments after they'd been boiled), but carbolic acid is toxic even in dilute solutions; discussion of hand washing techniques like dipping the hands up to the arms in permanganate followed by oxalic acid followed by mercuric chloride; also open wounds were irrigated with mercuric chloride but it was discontinued because it was toxic to tissue. Also comments here on the introduction of rubber gloves that were thin enough to work with, this began because one of the nurses fell victim to severe hand dermatitis, probably due to too much contact with mercuric chloride; so this was an indirect reason to set in motion a great advance in sterile technique; but then oddly enough rubber gloves were abandoned by these guys, but then reintroduced by one of the residents in 1896, Joe Bloodgood, who began wearing rubber gloves for every operation and eventually the entire team followed suit for good.
Chapter 14: The Radical Cure of Breast Cancer
117ff 1899: the first surgery for cancer of the breast to be performed at Johns Hopkins, on a 38-year-old patient, a mother of 10 with an advanced cancer progression. This procedure had been around for a while, European surgeons were advocating radical removal of the breast for every cancer, along with the pectoralis muscle if the tumors were deeply invasive; the idea of removing lymph nodes was not accepted yet, no one had thought about spread by the bloodstream either no one was thinking of distant metastases at this point either; about 50% of these patients would have a recurrence of their cancer on a local level, a distant cancer wasn't seen as "the same cancer." Also mammography didn't come into general usage until the 1960s, breast cancers were usually undetected until they couldn't be ignored and then treated when they couldn't be tolerated, radiation and chemotherapy were decades away.
120ff Discussion here of surgical technique, getting around the tumor, removing surrounding tissue, muscle and fat and even lymphatic tissue in the region of the tumor. [PS: do not Google fungating tumor.] Further discussion on the surgical procedure: tremendous numbers of arteries and veins needed to be cross-clamped and tied off; this type of surgery was very slow and very carefully done, it was the exact opposite of the prior generation's pre-anesthetic surgery that had to be [literally] quick and dirty. Halsted's "operations seemed interminable."
122-3 Some dark doctor jokes here: see how the hospital staff nicknamed him Jack the Ripper; also on a [hopefully apocryphal] dark joke where an orderly asked Halsted which part of the patient was to be returned to the ward.
123ff This radical procedure also was seen as brutal by uninitiated but it was designed to save lives or at least extend them. "One English surgeon summed up the new philosophy by saying that doing anything less was 'a mistaken kindness to the patient.'" The other clinicians at the hospital began referring more and more patients as they saw the results. "Halsted quickly became a star." Also on Halsted's paper on radical breast surgery, alleging a 6% recurrence rate which was a tremendously good result, and this radically changed surgery for cancer of the breast. "The Halsted mastectomy became the gold standard for care until the mid-20th century." Note also the disturbing comments here about Halsted at this point "now using a great deal of morphine... yet he maintained a bruising schedule."
124 The author offers a historical note here, talking about the evolution of breast cancer surgery, detection using x-rays demonstrated in 1913 by a German surgeon, by the 50s mammography was being used and by the 1960s it was generally available and accurate; there were very few cases of huge tumors/florid disease, and cure rates improved: not just local recurrence rates but complete cure as defined by 5-10 year survival rates; thus as mortality figures plummeted even more aggressive surgery was encouraged by many doctors, including the so-called super-radical mastectomies, although these were not generally adopted; and then eventually there were suggestions from surgeons that if the cancers were detected much earlier maybe less mutilating surgery could be used, thus muscle-sparing modified radical mastectomies developed in the 1970s to replace the Halsted operation; and then others were studying the possibility of doing even less radical surgeries: see for example the lumpectomy followed by radiation and/or chemotherapy which today has replaced the radical mastectomy; note however that 100 years ago the typical breast cancer patient was basically doomed, and Halsted's procedure changed all that--even though his actual cure rate was probably still depressing, since the patients would typically come to him in very advanced stages.
Chapter 15: Life in Baltimore
127ff Halsted then moves into the hospital residents' floor, no longer living with Welch in his house, there's some odd and suggestive comments here about Halsted's particularity with his furnishings and the carpets in his rooms. Note also this quote: "Continually dissatisfied with the overall look, Halsted had the walls repainted a number of times until he found the proper shade." [As the famous quote from the old cable TV show Queer Eye for the Straight Guy goes, "you have to commit to a color."] Although note in the next paragraph the author talks about the author's clearly apparent relationship with Caroline Hampton, his surgical nurse. Interesting here too that the author makes some veiled comments about Welch being homosexual, then some of similarly odd comments about the fact that Halsted and Welch were close and lived together, etc. [A whole mix here of on the one hand/on the other hand commentary!]
128f Discussion here of Caroline Hampton's family: well-known planters from South Carolina and Mississippi; Caroline's mother died of tuberculosis in 1862 while her father was killed in 1863 at the Battle of Brandy Station [I'm not familiar with this battle, but it occurred as Lee was on his way to Gettysburg]; the family's fortune was destroyed by the war as well as the family's home in Millwood [I guess this is South Carolina?] which was in the path of Sherman's March to the Sea. Caroline moved to New York where her aunt and maternal grandmother lived and studied nursing at New York Hospital; she got her degree and then relocated to the Johns Hopkins Hospital, then resigned from the hospital as she and Halsted announced their engagement; cute comment here from the hospital matron, explaining how well matched they were by calling them both "a little odd."
130ff More questions on Halsted's sexuality as he writes to his friend Franklin Mall, then in Chicago, joking about getting married and saying how Ms. Hampton reminds me "very much of you. I suppose that is the reason that I proposed to her." The author expresses his confusion at this letter and is unsure what to make of it. [If I had to venture a guess I would say that both Halsted and Caroline could have been beards for each other.] Note also Caroline, commenting in a letter that "Dr. H. is the most fussy of men"..."Halsted was a fussy and obsessive youth, and became more so with age. A man intolerant of a speck of dust on his hat and dressed by the finest English tailors and Parisian shirtmakers was about to marry a woman who paid little attention to her appearance; cared not at all for fashion; favored plain, dark dresses and sensible, sturdy flat shoes; and wore her hair tied back simply in a bun. [Yep, they're beards for each other!!]
133ff Comments on how Halsted adapted to the family summer home in South Carolina and the Hampton family farm that "never quite became self-sustaining." Also comments here on how he would be absent from the hospital for sometimes up to five months, and at a minimum for two months of rest and restoration every year, in the country, totally out of touch from his colleagues; these absences would become a recurring problem, more than once bringing him "to the brink of dismissal."
135 The author oddly explains Halsted's persnickety preferences about his fires in his fireplace; referring to his new home in the fashionable district of Baltimore, his fireplace "always ablaze with logs of white oak or hickory, 10 to 18 inches in diameter and aged under cover for two to three years before being shipped to Baltimore from North Carolina." [This is starting to feel like the kind of detail that we read while learning about the Pringle family--likewise from South Carolina--Halsted has become a southerner now and he's becoming particular about everything, also it is sort of interesting, even odd, that the author chooses to share this level of detail.] Some other hilarious details: "Each took breakfast alone. Halsted prepared coddled eggs and toast on the small gas stove in his private bathroom and ate before the fire in his study."
136 A somewhat depressing example of the difference between First Turning-era medicine during a period of progress and post-modern Forth Turning-era medicine during a period of decline: the author comments on Halsted "at his work table, reading surgical literature or working on papers. The late 19th century saw the inception of the greatest period of sustained progress in surgical history. Papers were written and published at a furious pace, and it required time and dedication to keep up. For Halsted, this was a necessity and a joy..." [Today the medical practice model is run in such a way that the average GP has just a few minutes to see you, much less any time to spend reading "the literature": any time and dedication spent on keeping up would be thanks to the pharmaceutical reps slipping into his office at lunch time to "teach" totally, absolutely, completely unbiased information about whatever latest new patented pharma med.]
Chapter 16: The Big Four
139 On this era's innovations in healthcare, particularly in surgery with anesthesia and antisepsis, which now made it possible to enter all parts of the body with--as the author phrases it--"relative impunity." Halsted probably performed the first surgical removal of gallstones on his mother in 1882, also the first appendectomy was performed in 1885 [the author doesn't say it but it was not done by Halsted, but rather by Dr. William West Grant in Davenport, IA]. "Treating all manner of internal catastrophes was no longer beyond the imagination. The greatest strides forward were yet to come, and they would come very soon in an overwhelming cascade of progress. Much of this progress would take place at the new hospital and medical school on a hilltop in the sleepy Chesapeake backwater of Baltimore, Maryland."
140 On the various issues that later became synonymous with Halsted's name: surgery and wound healing, the cure for breast cancer, surgical repair of inguinal hernia, graduated responsibility residency training, intestinal anastomosis, surgery on the thyroid gland, surgical treatment of vascular aneurysms.
140 Fascinating comment here on Halsted insisting on the gentle handling of tissue, crushing or rough handling of tissue in an attempt to control bleeding actually devitalized that tissue, making it a perfect medium for infection, whereas healthy tissue would be able to handle even introduced virulent bacteria. Halsted demonstrated this with the abdominal cavity of an animal, even after introducing virulent bacteria, if the tissue throughout the animal is healthy, there'd be no infection: the animal would use its own natural defenses; but if there is tissue intentionally devitalized the animal would have an overwhelming infection. [This is very, very interesting thinking about how common nosocomial infections are in hospitals today.]
140ff Comments here on training surgeons to train other surgeons: Halsted worked on a program that would take up to eight years to produce surgeons who could leave a residency qualified to become a surgical leader at major institutions. Halsted trained 17 residents, "most of whom went on to illustrious careers."
141 Fascinating and disturbing section here: 1890: Osler catches Halsted having shaking and chills and figures that Halsted is still taking morphine; he's deeply concerned by what he sees and confronts Halsted who confesses that he couldn't reduce the dosage below three grains daily, or 195 mg, "an enormous amount" and "more than four times the normal therapeutic dose." Note also the highly unsettling footnote here by the author explaining that Osler's comments about this in his papers were sealed and meant to stay out of the public eye until the centenary of the Johns Hopkins Hospital in 1989, they were ultimately released in 1969, nearly 80 years after Osler first wrote them. [Talk about protecting your own! This reminds me of the FDA wanting to take 55 years to fully release the underlying data and documentation on the mRNA experimental injections. Both good examples of the "thin white line." Also, amazing that this guy could be so high-functioning under these tremendous morphine doses.] Note also in succeeding years the author say Halsted would become ill and would stop doing surgeries for up to five months at a time using various excuses. In other words he'd show great productivity followed by long unexplained absences.
142ff Comments here on Howard Kelly who became a rockstar in gynecology; he left a practice he had built in Philadelphia to come to Johns Hopkins; he wrote well-regarded gynecological textbooks; this guy rounded out the big four along with Welch, Osler and Halsted who "would lead Johns Hopkins to greatness."
Chapter 17: Hernia
145ff On the inguinal hernia, something that has gone from a problem to a curable, non-lethal annoyance; 5% of children are born with them and somewhere between 10 and 15% of adults develop them; prior to 1889 there was no surgical procedure to correct the defect; instead trusses were used--basically gadgets that were attached to the area to put pressure on the defect; on the risk of a hernia becoming incarcerated, trapping a loop of bowel in the abdominal wall defect; see also the surgical procedure called taxis, where an attempt was made to manually press the trapped loop of intestine back into the abdomen; on the variations of this hernia: indirect, direct and femoral inguinal hernia; the indirect is the most dangerous type, found frequently in males.
147ff Halsted operates in 1889 on an 8-year-old boy with a large congenital right inguinal hernia using a radical new technique: using the muscle and tough fascia of the oblique muscles of the lower abdomen to reconstruct the inguinal canal floor, this became known as the Halsted hernia repair; he was 12 for 12 among his first 12 patients with no recurrences, note also that a surgeon in Padua Italy, Edoardo Bassini, had been doing a similar operation for some time, as the author even quotes Halsted saying that "Bassini unquestionably has the priority." [Thus we have yet another instance of Stigler's Law of Eponymy.]
149ff On Halsted continuing to refine and revise his operation; what became known as the Halsted II operation.
150 Interesting offhand comment on Harvey Cushing, Halsted's fifth resident, who became the father of neurosurgery and had a 14-year association with Halsted. The author describes him as "one of the great gifts of the Halsted system to the world of surgery." The two of them had a complicated and difficult relationship; comments here also on Cushing being frustrated with the blunt tool of general anesthetic in those days; he was upset with what he considered "inept anesthetizers" and thus developed a local anesthetic technique using, ironically, cocaine--while knowing nothing of Halsted's addiction history; thus diluted cocaine local anesthesia was used in hernia surgery beginning in 1898 and then becoming standard. And then a very telling quote here: "On one occasion, Halsted was making ward rounds with the resident and encountered a patient suffering extreme cocaine agitation. Looking at the man, he instructed the resident, Jim Mitchell, 'give him morphia. If you knew how terrible the suffering is with that restlessness after cocaine you would not stint his morphia.'"
152ff Comments on today's endoscopic hernia surgery techniques and synthetic mesh tissue support that would be unrecognizable to Halsted; note however the author makes an interesting comment here about the current cure rate, saying that it "cannot be much more impressive than the 94.4 percent reported by Halsted more than a century ago."
153ff This chapter closes with a somewhat disturbing anecdote here about a thyroid operation that Halsted was performing with "Mitchell" helping. [This is the first mention of this person by last name: it is is James Mitchell, another one of Halsted's famous residents, thus this is a slight editing/continuity mistake here as the reader does not learn about him until chapter 22.] Halsted excuses himself from the operation, saying he had an awful headache, then later in the operation he does the same thing again, and then the third time Halsted says, "Now this time you go ahead with the operation" and just hands over the operation and left. Later Halsted sends a package to Mitchell with a bottle of old Madeira, writing. "Someday you will know what it means to have an assistant in whom you have confidence." The author concludes the chapter writing Mitchell "very likely had no knowledge of the Professor's enduring drug use."
Chapter 18: Establishing the Routine
155ff Comments here on the primitive state of medical care in the United States in the late 1800s, all the more notable because of the tremendous progress being made in Europe, but the US appear to be ready to take some major steps forward as well at this time.
157ff Comments on William Osler: intelligent, welcoming, funny, loved to spend time with his young followers at the hospital, a great teacher, he also wrote quite a bit of prose, poetry and humor under the pen name Egerton Y. Davis; also the author of a major textbook: The Principles and Practice of Medicine, a monumental undertaking. [The link here takes you to a public domain copy.]
158 Interesting and sort of sobering quote here, as Osler was spending less of his energy on hospital business. "The new hospital was well staffed and not overly busy." [You can build it but it doesn't mean they will come...]
159ff [The whole vibe here of this hospital, with its full-time living quarters, pranks, weekend baseball and tennis with the staff, evening bull sessions, etc., it sounds like a working country club, without too much work! These guys are lucky, and that era really illustrates how much of a grind the practice of medicine has become in the post-modern era.]
160 "The population of the hospital was overwhelmingly composed of charity patients, with only the occasional private, or paying, patient, and few private rooms to accommodate them. In 1889, surgery for private patients was still performed predominantly in their homes, although Halsted was beginning to treat some in the hospital."
160ff On rounds: Halsted would expect concise and accurate answers, the residents were intimidated by him and occasionally he would make an icy sterile withering comment if they didn't know the answer, like "Perhaps you should find a different line of work." This drove at least one doctor away; also on another resident who lied about a wound, saying it was healing cleanly without having actually checked it: Halsted looked at the wound, saw the infection and fired the man right there. Comments here also on how Halsted could be amusing among intimate friends, but "no one remembers him actually laughing."
162ff More examples here of a true First Turning-type institution, and the literal geniuses leading it: the house staff was called from a good pool of applicants, and all were willing to work long hours, people were on call 24 hours/7 days a week, all the chiefs of service were under 40 and full of energy "and consumed by their profession." The doctors formed a journal club and other small groups to discuss foreign medical papers.
165 Disturbing foreshadowing here where Halsted remains productive with energy and focus, although his personality was changing. "His dependence on morphine had not yet sapped his strength. Gradually, all but the drug use would change."
Chapter 19: Country Squire
167ff Discussion here of Halsted's acquisition of some 2000 acres in the Blue Ridge mountains, starting with buying land from his wife Caroline's aunts, but also other surrounding farms; upgrading the buildings, adding a guest house, etc. Interesting also that he kept a dahlia garden, and odd that the author notes it--and discusses how dahlias are grown and kept! On the family running the not-particularly-profitable farm with overseers and farm managers.
170 Interesting blurb here on the history of the dahlia: that the flower became something of a fad for gardeners in both the US and Europe towards the end of the 19th century, the plant was indigenous to Mexico where it grows wild and can be processed for food, they're known as the "Dahlia Juarezii" there; a single root survived in an 1872 shipment to the Netherlands where it was cultivated and cross-bred, resulting in tall strong stems and beautiful flowers. The author then explains (in a lot more detail than the reader might expect) how they're handled, how the bulbs are dug up and stored, etc.
171ff More blurbs here on Halsted's life in his country estate; more or less they were gentlemen farmers; he would offer medical care and even veterinary care for mountaineer-type poor people in the district, accepting in-kind payments like labor or produce in return; his amateur astronomy; his wife's plain appearance and vibe; on the fact that they kept four dogs, never had children, etc.
175ff Multiple paragraphs here explaining the Halsteds and their behavior about race: on the use of the word "darkie," where the author spends an entire paragraph saying that that word isn't as offensive as it sounds since both whites and blacks used it widely well into the 1900s, "hence we must not read too much into Halsted's use of the term more than 100 years ago."
177ff Comments on Halsted's travel: how his wife didn't like to go with him, she didn't like going to Europe or traveling at all; also nobody seemed to know consistently where he went when he traveled: these would be trips for weeks and sometimes months every year; he would send letters and postcards from different capital cities and villages "but he was always unaccompanied in his travels" and mostly his whereabouts and routine were "unknown." [The author leaves the reader here to presume that there was a lot of coke, morphine, and perhaps who knows what else on these European trips...]
178ff Allegations here that people in the community thought that both Dr. and Mrs. Halsted were addicted to drugs; note that in those days morphine was readily available without a prescription until the law changed in 1914.
180ff Here the author teaches readers the etymology of the phrase "cold turkey" and "kicking the habit": they spring from the chills and goosebumps as well as involuntary leg movements that come from the "florid withdrawal complex"; comments here on how morphine was given to women for depression, for dysmenorrhea, for morning sickness, etc., and the majority of new addicts were women by the early 20th century; on the "southern addiction" as it was called, basically among middle- and upper-class women of a certain age with nonspecific complaints [some healthcare things never change...]; also medical personnel who had easy access to the drug also became addicts in large numbers, perhaps 10% of physicians were addicted by the turn of the century. "Though a morphine injection could cure little, it could relieve anything."
181ff Comments here on Halsted having easy access to morphine: it was legal, he titred his dosage to his routine or vice versa; on Osler's concern that Halsted wasn't managing his dosages properly; in those days morphine was considered significantly less destructive than alcohol; also comments on Caroline, Halsted's wife, who was socially withdrawn, her marriage probably was unfulfilling, she spent lots of time alone and thus was also a perfect candidate for morphine use.
Chapter 20: The First Great Medical School
183ff Now in 1892, Halsted is made full professor of surgery; but there's only a hospital with no medical school yet, the medical school endowment was dependent on the Baltimore & Ohio Railroad stock which was in deep trouble at the time; the whole project fell into doubt; on the four women who formed a women's fund committee to save the medical school: Elizabeth King (daughter of hospital board president Francis T. King) Mary Elizabeth Garrett, Carey Thomas and Mary Gwinn; details here on Elizabeth Blackwell, who became the first American-trained female physician in 1849, by the 1890s, certain medical schools began to admit women, although most elite medical schools still excluded women. The committee raised $100,000 and made the funds available if they agreed to co-education [savvy!]. There were possible rumors of the leadership defecting; also Harvard tried to hire away Welch and Osler, also McGill University in Montreal tried to get William Osler as well, dangling huge amounts of money; Mary Elizabeth Garrett contributed more than $300,000 to bring the grand total raised to half a million.
186: On debate about the terms for admission of students: Mary Garrett wanted medical students to have a four year bachelor's with pre-med requirements in biology chemistry and physics as well as working knowledge of French and German; all of this in aggregate was viewed as unrealistic: there wouldn't be enough students to fill a class. [This chapter also is indirectly highly instructive on the idea of giving money to an institution but then maintaining leverage over it so that it doesn't violate the agreements that the money was contingent on. Garrett named a committee of six women who would operate in perpetuity to ensure that if the terms of her gift were violated the funds would be returned to her estate. I've lost count of the various instances of Ivy League universities blatantly violating the terms under which money was originally donated--it just goes to show that you never want to give money to any institution no strings attached. As the author puts it, Garrett "had reason to retain the lever of financial power."]
188 The fall semester of 1893, 18 students registered for the first year class at the Johns Hopkins School of Medicine: fiften men and three women, The "faculty greatly outnumbered the student body"; also
"Osler, on considering the high standards for admission to the new medical school, commented, "Welch, we are lucky to get in as professors, for I am sure that neither you nor I could get in as students.'"
Chapter 21: Teaching without Teaching
189ff The second year class had 40 students, including eight women, both of the first two classes were dissatisfied with the instruction they were (actually not) receiving; see for example Franklin Mall, the dissection teacher, who was rarely present and didn't even procure cadavers for dissection; although Halsted was present always in the dissecting room and provided excellent examples of proper dissections to study. The students detested Mall; there was a debate here about philosophy among the faculty and the students, the faculty, at least Mall and Welch, believed that medical students should learn on their own and they were "taught too much"; but even Osler as well as other colleagues believed that Mall and Welch were being derelict in their duties to the medical students; other teachers were duds as well at this new medical school. And the biggest problem was Halsted: he was supposed to lecture on wound healing but he left for North Carolina and "began the extended absences that became the hallmark of his erratic behavior." Also: "Halsted had no relationship with the medical students and made no effort to develop one." He skipped weekly lectures, the things he did lecture on were too far over the heads of the students, his clinic and ward rounds were miserable, etc.
Chapter 22: Residents
193ff More mixed reaction to Halsted, this time from medical residents: some couldn't stand him, some loved him and found him the perfect role model.
194ff On Joseph Colt Bloodgood, a surgery intern under Halsted: Halsted first told him to read everything that Joseph Lister had published, then also to read and learn everything by heart that he [Halsted] wrote in his surgical papers; Halsted saw something special in Bloodgood, also Bloodgood ultimately was remembered as the chronicler of Halsted's surgeries and as the first true surgical pathologist.
196ff On Jim Mitchell, another disciple of Halsted, who arrived as a second year medical school student to work under Halsted, first as a nurse and surgery assistant; he received mostly silence from Halsted which he took is a good sign; also Halsted arranged to have furniture delivered to his rooms in the hospital after the residents and leadership, playing a prank on him, didn't give him any furniture; also Halsted lectured him on the importance of high-quality tobacco; also Mitchell, along with other hospital workers, would go and do in-house surgery with Halsted on wealthy patients, and thus got to see more sides of him on these sometimes long journeys in the region.
200ff More comments on Jim Mitchell here: [He really sounds like the kind of employee, assistant, team member that you really dream of--the kind of guy who can climb into the brain of his boss and easily anticipate his needs.] "The operating room joke was that Mitchell could anticipate what his boss wanted by the wrinkles on the back of his neck." Halsted actually asks Mitchell to join the next medical school class, with the liberty of attending classes whenever he wishes, while continuing all of his work in the operating room; this is a huge compliment from Halsted who was normally much more taciturn. "Mitchell was overwhelmed and gratefully accepted the appointment." Mitchell then went on to work as first assistant to Harvey Cushing who made tremendous innovations in neurosurgery and became the brightest star of the Halsted tree.
202ff More comments here on Halsted's surgical method: he was forgetful, he'd overfocus on certain subjects, he'd even forget to schedule a surgery, but also he would be incredibly precise with the surgeries themselves even personally taking on tedious tasks to assure quality sterilization. "Everything was to be just so."
Chapter 23: Changes
205ff By 1896 Halsted was beginning to age, doing fewer operations, rarely completing them, handing them off; also he would have unexplained absences or arrive late to surgery; but the residents were always happy as this gave them the chance to perform more surgeries; and the students would learn early in their career that Halsted wasn't going to save them from situations; Halsted would also offer excuses for his lateness that were sometimes comical and implausible; the author makes the case here that it was obvious these absences were due to morphine and his addiction to large doses.
207 Comments here on the so-called "malaria letter" where Halsted wrote to the trustees requesting an extended summer leave for a full six months "to cope with what he presumed to be malaria." The author calls this "one of the few concrete instances in which he plainly lied."
208 Unintentionally funny sentence here: "Osler and Welch publicly executed a campaign to correct these public health offenses."
209 More comments here on the relationship between Halsted and his wife Caroline and their marriage of convenience; there was occasionally some anger between them but in general they seem to be devoted to each other and "there is little evidence of over friction between them." [You wouldn't keep your beard around unless they were worth keeping around; also this book pointed me to Wikipedia where I learned the phrase "lavender marriage"--which is precisely what Caroline and Halsted had.]
211ff More comments on the various practical jokes that Welch and Osler would play on the other leaders at Hopkins; on the "genuine fondness" among the group of doctors in the hospital leadership; also comments here on Halsted perhaps playing up his absent-mindedness as a sort of "functional cover from which he could choose the situation in which he wished to interact and ignore the others... He was, if anything at all, a most acute observer." Further comments here on how he was distant and unapproachable to many of the people with whom he worked, but then struck up very close friendships with others.
218 Long footnote here describing the so-called McBurney incision (this was used to treat Caroline Halsted when she had a bout of acute appendicitis), which allowed the lower right oblique muscles to be spread apart but not cut, allowing access to the appendix. This procedure was done for a century until the advent of the laparoscopic appendectomy.
Chapter 24: Into the 20th Century
221ff [Fascinating (indirect) discussion here of appropriate tools for true experts, vs appropriate tools for second-class surgeons: this metadiscussion takes place inside a discussion of Halsted's view on surgical silk sutures and silver wire wound closures versus the common/general use of catgut sutures. In Halsted's surgical ward he essentially banned the use of catgut sutures, but also recognized that surgical silk would provide excellent outcomes only if the surgeon was skillful and could use it without crushing tissue beneath the ties. Less skillful surgeons were better off using gut sutures. This is an interesting commentary on not just the habits of the surgical world at large at that time but also Halsted's awareness that the world would be likely filled with second-class surgeons. A reader would just hope that the first-class surgeons use the best tools available, and that the second-class surgeons actually know who they are. This is likely a tall order.]
222 Comments here on women in the medical school classes: one of the three in the first class married Franklin Mall and then dropped out; the resistance to female students had dissipated, but in general they weren't respected by the institution. See this comment here: "...even Osler was said to have commented on the three classes of humanity: men, women, and women physicians."
223 Comments on Halsted who "still didn't get it" that this was supposed to be a teaching hospital, as his interests were more in unsolved surgical problems, difficult cases and other issues beyond the scope of medical school surgery training; thus the residents had to take care of the teaching. In spite of this the school became more and more popular; note that Gertrude Stein entered with the class of 1901 but she was unpopular with fellow students, thought to be generally unpleasant. She survived her first two preclinical years, but crashed out during the clinical last two years and was denied a degree. She then moved to Paris and gained fame as a writer. Also note this amusingly faint praise from the author: "Stein's influence on the literature of the day was significant, if debated. Much of her writing was obtuse, and though few believed her work to be as great as did she, much of it has survived."
225 Interesting comments here on the real-world incompetence of these top four leaders: Welch was hardly lecturing anymore, wearing foppish hats all the time and eating out; Halsted was being taciturn, mostly just offloading the surgical burdens on to Finney, Bloodgood, and Mitchell; by contrast, William Osler was well-loved by all the students and actually was involved day to day much more.
227 Comments here on how initially the hospital was integrated but then later after protests from patients and staff it was resegregated.
227-8 Comments here on how many aspects of the Hopkins teaching hospital experiment were imitated by other institutions, including having a laboratory integrated into the hospital, using aseptic surgery, including postgraduate training, having much more stringent admission requirements, and a four-year curriculum. Hopkins "stood alone far ahead of the pack, and it would take the organized outrage of the Carnegie Commission to fully turn the page. By the time that would come to pass in 1910, there was Johns Hopkins, and there was everyplace else." [The reference here to the Carnegie Commission is dangling here without context: but the author discusses it further in Chapter 32.]
228 Finally foreshadowing a big shakeup at the department of surgery by way of Harvey Cushing in a poorly worded sentence: "But a big shake-up was headed for the Department of Surgery. It came in the form of an assistant resident, the son of a wealthy Cleveland doctor, by way of Harvard and the Massachusetts General Hospital, and in the person of Harvey Cushing." [It sounds like there are two people here: some unnamed person who was the son of a wealthy Cleveland doctor, and (separately) the "person" of Harvey Cushing!]
Chapter 25: Harvey Cushing
229ff [This chapter opens with some excellent writing, a contrast from the unfortunate sentence quoted above!] On the famous Major General Leonard Wood who in 1910 was developing a huge half-pound tumor in his brain, but was famous for commanding Theodore Roosevelt's Rough Riders; he was military governor of Cuba, military governor of the Philippines and also a physician who was very interested in public health; in these days no one specialized in neurosurgery and the results were almost always bad. "Prior to Cushing taking up the task, postoperative infection killed the patients that the operation hadn't." Cushing opened up the general's head, saw the large superficial mass, and then closed him up again; then several days later opened him up a second time and started to work on the tumor, probably a benign meningioma that had not actually invaded the brain surrounding it. The General would recover fully, making Cushing a national hero.
231ff Backing up now to 1896: Cushing arrives to Johns Hopkins bringing his own x-ray machine, the first one ever seen at Hopkins Hospital. Wilhelm Roentgen had more or less created the apparatus and realized that it could show the bones or the wedding band of his own wife's hand; Cushing provided the initial money to buy the device at Mass General and then brought it with him to Baltimore. He arrives to Hopkins using the Mass General method: no rubber gloves, no pathology, no follow-up, a complete contrast to the Hopkins method of careful study before and after every surgery; he found he had no experience with lab tests, bacteriology or surgical pathology, thus he was in for a huge learning curve.
233ff "Cushing was the most impressive and possibly the most able and ambitious of the 17 Halsted residents. He was the first to utilize local anesthesia in hernia repair, the first to operate on the pituitary gland, the first to routinely open the skull to decompress the brain, the innovator of numerous neurological techniques, and the developer of prototypes for exactly how neurological operations should be performed. Simply put, he invented neurosurgery. All this transpired while Cushing worked as Halsted's assistant in the department of surgery." Eventually Cushing became far better known than Halsted himself.
234ff Cushing has acute appendicitis; Halsted, Finney and Bloodgood all worked on his operation, which was an uneventful surgery, but later a wound infection occurred; Cushing did recover fully, but would complain about the silver wires buried in his abdominal wall [Yeesh]. Also comments here on Cushing gradually becoming disenchanted with Halsted: he was never around, Cushing had to do all of his private cases, he found him odd, later he started to see some of the logic in Halsted's method of letting the residents "learn by doing." Comments also on how Cushing was ambidextrous and could write with both hands on the chalkboard simultaneously. [!] His drawings also were quite advanced for his operations. Also comments on his self-flagellation in his early days (in the late 1800s) of brain surgery, as his failures far exceeded his success.
238ff On Cushing's close relationship with William Osler; Osler helped protect Cushing from Halsted and vice versa; he also would call out Cushing for humiliating remarks he would make about colleagues, telling him "Keep your mouth." Cushing also went on to write a Pulitzer Prize-winning biography of William Osler in 1926.
240 It seems as if Halsted had no idea that Cushing had so much animosity towards him; Halsted comes off here as oblivious; also Cushing may have been the only resident that Halsted treated like an equal.
242ff On Cushing's work on the pituitary gland; also his work diagnosing brain tumors by examining the retina; on some of the innovations/discoveries regarding the various ductless glands, like the thyroid, parathyroid, pituitary, thymus, pancreas--what would later be called the endocrine glands. Also on Cushing's innovations in various pituitary surgeries, accessing the region through the upper lip or nose to remove cysts and tumors of the pituitary gland "although with inconsistent outcomes."
245 A weird blurb here on the acromegalic giant John Turner who was under Cushing's care: when he died the family refused an autopsy and Cushing ran one of his associates into the undertaking parlor to snatch his pituitary gland to bring it back to Cushing. Finally, fast-forwarding to some years afterward where suddenly Cushing moves on. Osler had already left Baltimore five years before Cushing, who at at age 42 decided in 1912 to leave Hopkins to be professor of surgery at Harvard and chief of surgery at the new Peter Bent Brigham Hospital. [I guess this just shows how you can create a great institution but it may be impossible to keep your best people no matter how great that institution is. This team of rockstars actually didn't really last all that long here!]
Chapter 26: All Quiet on the Home Front
247ff Halsted has basically gone full kook now: on his idiosyncratic behavior, he is enigmatic, he's become sort of a legend who everybody just took it in stride; Osler was asked if he had any idea what Halsted was thinking, and he said "No, nor has anyone else."
250ff Multiple paragraphs here on how Halsted dressed: special French shirts, special suits, he even would send his laundry back and forth to France [!] to be washed and ironed because he couldn't find a good enough laundry in Baltimore; also comments on William Osler's dress, which was even flashier. These guys were a bunch of fops!!
255ff Discussion of the relationship between Caroline and William Halsted: their decision to not have children made early in the marriage; they also congratulated each other for making the right choice after hosting young nieces and nephews at their home [!]; discussion of their sexual relationship and possible homosexuality, although nobody really knew; Cushing thought both Halsted and Welch to be homosexual and even hinted that they had had a relationship at some point, but there's no evidence of this, Halsted never had any other relationship with women, only Caroline. Obviously in those days nobody was "out" as homosexuality "would not have been tolerated at Johns Hopkins during the Halsted era."
Chapter 27: After Cushing
257ff Discussion of some of the other important residents who worked under Halsted: see for example Hugh Hampton Young, the father of urology, who randomly got put in charge of the urinary surgery department when he didn't know anything about it. Young ultimately pioneered perineal prostatectomies. See also the quip: "The prostate makes most men old, but it made Hugh Young."
265ff On Frederick Henry Baetjer, the first actinographer, producing X-ray images (what today we would call a radiologist); note that nobody understood the dangers of the radiation and this guy ended up losing most of his fingers and an eye [!] and he developed lymphatic cancer. [Harms are ALWAYS discovered with a lag. Always.]
Chapter 28: New Horizons
267ff On Halsted's largely failed work on the thyroid; different problems his patients would have after surgery, ranging from seizures to tetany.
271ff Halsted does the first major artery aneurism excision, this case was in the patient's left subclavian artery, the patient recovered fully. "The field of vascular surgery was off and running."
274-5 A couple of other anecdotes about Halsted's unshakable cool and detachment at moments of surgical crisis: he would reprimand assistants and order them to "act like surgeons" [This reminds me of the great book The Right Stuff by Tom Wolfe describing a pilot jabbering over the radio about having a MiG on his zero, when an irritated voice cut in and said "Shut up and die like an aviator."] There's another case here where a patient had a ruptured aorta and he said to his resident "Heuer, I fear we are in trouble," and then gained control of the situation and completed the operation.
Chapter 29: Addiction
277ff This chapter speculates on what Halsted was doing on his various European trips, on who among the people he worked with actually (and how much they knew) about his addiction. Note this interesting comment from another great surgery professor at Hopkins, Alfred Blalock, who said, "I think it is all to Dr. Halsted's credit that he was able to overcome this [cocaine] habit, and I think it is probably very fortunate for American surgery that he acquired it." The point here was that his cocaine habit--which wrecked his reputation in New York--caused him to go to Hopkins and begin all these different areas of research; note however that Blalock had no idea about Halsted's morphine addiction as well.
280 "What, then, it must be asked, was the effect of a lifelong drug addiction on this most unusual man?" He likely had used cocaine episodically during his travels, but morphine consistently as a cocaine substitute, "and he juggled the demands of daily existence and the drug quite well." [Uh, until he didn't.]
282 "The idea that the father of modern surgery could be addicted to morphine and cocaine throughout his long career is plainly counter-intuitive. More unsettling still is the level of performance he was able to maintain during those years. ...the story belies the conventional wisdom concerning long-term drug use."
Chapter 30: Vascular Surgery
284ff Discussion here of progressive occlusion experiments to gradually block the throughput of an arterial aneurysm to encourage collateral vascular growth; basically Halsted experimented with an aluminum band used to partially compress an artery; note that Halsted was "unable to master" these various vascular surgery problems and it was another half century before this work started to bear fruit. Note also the footnote on page 286 talking about work in 1952 by Michael DeBakey who excised an aortic aneurysm and replaced it with cadaver aorta; and then in 1953 he took yet another step "by replacing an aortic aneurysm with a tubular Dacron graft that he fashioned on his wife's sewing machine."
Chapter 31: Scientist
287ff Comments here on the 1904 Great Baltimore Fire, where miraculously no lives were lost but some 1,343 buildings were destroyed. Also William Osler leaves Hopkins in 1904 to take a position as professor of medicine at Oxford. Also on the construction of a new surgical building that was funded in part by John D. Rockefeller, with greater and greater support from Rockefeller in the years to come.
290ff Here at the peak of Hopkins' reputation there begins a bit of a schism between the clinicians and the pure science people at the school: Osler, who was leaving, was "foremost a clinician and teacher" and Welch straddled the fence on the issue, whereas Mall and Halsted were more interested in the pure research and pure science and less interested in clinical practice and teaching.
Chapter 32: A New Paradigm
297ff A controversy in medicine in this era on whether medical professors should be full-time salaried employees of a university (and thus restricted from outside earnings), or should they have their own ability to earn income in addition to their salaries by having their own private practice? And likewise, were the doctors to be clinicians or researchers?
299ff On Abraham Flexner, hired by the Carnegie Foundation to prepare a report on the state of medical education in America: the report found all medical colleges in the USA deficient with the single exception of Johns Hopkins. "The death knell had been sounded for proprietary medical schools." The study actually scandalized the country and it gave the American Medical Association, "then a largely impotent organization," quite a lot of power as it had the responsibility to certify schools. [Then the AMA was in a First Turning era; today it's in a Fourth Turning as it showed during the COVID era.]
300 [Interesting comment here about John D. Rockefeller and his growing influence on medicine: it's reminiscent of Bill Gates today. Gates of course has never been more radioactive than he is now, with all the details now widely available on his exploitative and high-mortality medical experimentation in African villages and of course all the Epstein Island stuff coming out.]
300ff The model here was going to be that the medical school professors and faculty would be put on salary, while fees from their practices would go to the university. This would kill off any other side income these doctors could earn. [The reader wishes the author would go into a little more of the nuances here of what was at stake: what's wrong, exactly, with doctors earning income through practicing medicine? If there was such a vicious debate on this question among the former "happy band" at Johns Hopkins, what was the debate really about?] Note that this new full-time system was considered risky because it would separate doctors from their patients, also patients were uneasy about fees earned by the doctors going directly to the university, also there was concerns about Rockefeller/Standard Oil influence.
305 Comment here about "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." [Again the author does not do a very good job of articulating exactly what the problem is here: is it about having full-time salaried doctors and owning all of their income, or is it over the relative importance of research versus clinical medicine? Or what?] This ultimately gave rise to a university full-time system, however, some professors would be on straight salary while others would have very complex financial arrangements where they could have outside income; some also would work and teach medical students, but earn all their money outside on patient fees. "All manner of arrangements exist today. Medical schools and hospitals pay multi-million dollar salaries to star clinicians who fill beds and attract wealthy potential donors. They subsidize new, full-time 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 33: A New Era
307ff Halsted is now 61, he isn't quite well; he is doing hardly any surgery now, just a day or two each week, and rarely more than a single case in a day because of his fatigue and age; treating fewer patients. Interesting blurb here on the level of formality both between the doctors and also the tremendous gulf of formality between doctors and patients. "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."
309 Also a funny comment here about Halsted's expectations of hygiene among his private patients: there was a socially prominent woman who came to the hospital for an exam prior to surgery and Halsted "left the room visibly unhappy with her. 'Why, Heuer, she has a dirty umbilicus.'" [I guess the moral here is always clean the lint out of your belly button before you go to the doctor...]
310 At this point Cushing had left Hopkins and gone back to Boston; Halsted resumed teaching the surgery course himself once again, but this time actually enjoying the experience and throwing himself into it, and finally establishing closer relationships over the next decade with students and junior residents. He "would be remembered quite differently by later graduates than he had been by their predecessors." [Like a lot of dudes, he must have softened with age.] Discussion here of medical student Sam Crowe, who gained Halsted's attention as a medical student and spent a full week at Caroline and William Halsted's country estate. Also on George Heuer who looked at Halsted as his second father, something shocking to people who worked with Halsted earlier in his career. Halsted invited Heuer to stay with him when he returned from a surgical tour of Europe in 1914, even personally carrying logs for Heuer's fire up three flights of stairs; cute blurb here on the fountain pens he gave him, the cigarettes he "heaped" upon him, etc. Heuer went on to become professor and Surgeon-in-Chief at New York Cornell Medical College "where he established Cornell's first residency program on the Halsted model."
314ff On resident Walter Edward Dandy, and the work he did on embryology; on the so-called Dandy Embryo, a two-millimeter human embryo specimen, at that time the smallest specimen studied. Also on his work on cerebral spinal fluid, "a monumental piece of work" that he did on hydrocephalus. Interesting note here on Halsted's comment on Dandy's work which turned out to be wrong: "Dandy will never do anything equal to this again. Few men make more than one great contribution to medicine." [This probably sounds like an insult, but the more I'm getting to know Halsted over the course of this book, this is probably a huge compliment, like an unutterably huge compliment.]
317ff On Dandy becoming critical of the idea of decompressing the brain for palliation alone, something Cushing had popularized; Dandy felt that brain tumors, if they can be identified and found, should be removed like any other cancer; but the problem here was localizing the tumor site; he developed a revolutionary procedure called pneumo-ventriculography, which used injected air into the spinal column followed by X-rays to see if there was any blockage or flow issues, which helped identify the location of tumors.
318ff On the growing feud between Dandy and Cushing: note this condescending remark that Dandy often wrote: "In safe hands this is a very safe procedure." On other contributions Dandy went on to make, like discovering the cause of what we now call a "slipped disc" which caused symptoms that we call sciatica. Note that Dandy could hardly write a comprehensible paper and so Halsted, although he thought Dandy's clinical abilities and research abilities were amazing, ended up editing many of Dandy's papers himself: "Halsted, who was anything but a gifted writer himself," as the author puts it.
Chapter 34: The World Changes
321ff [The book sure has begun to bounce around: the last chapter was bouncing between Dandy and others, and then featured a weirdly-placed appendix/coda re-discussing George Heuer; in this chapter the book goes back in time to some of the work done by Franklin Mall and William Halsted years earlier in the early days of the Hopkins project. The temporal and subject jumps are throwing the reader from the book here.] On Franklin Mall, "one of the most celebrated of medical researchers" of his day but also "the most universally disliked professor" at Johns Hopkins; he survived generations of complaints because "he was too valuable an asset to shed." [An organization will tolerate a lot of bad behavior from its rockstars, whatever the industry.] On his work on the intestinal submucosa and the implications for Halsted's own work on intestinal anastomosis.
323ff on a severe cholecystitis infection Mall had in 1917; also comments here about Alexis Carrel from the Rockefeller Institute who had returned from the front in World War I discovering an effective wound irrigation technique using Dakin's solution [the author doesn't explain what this is until a page later, but it turns out it is a diluted antiseptic solution of sodium hypochlorite, basically a diluted bleach solution buffered with sodium bicarbonate and sodium hydroxide]. This technique came from the collaboration of British chemist Henry Dakin and French surgeon Alexis Carrel; Halsted had a good relationship with Carrel and instructed one of his assistants to question him about the solution, how to use it, etc., and they began using it to flush Mall's abdomen to try to deal with the various infections he had developed; unfortunately the solution eroded his duodenum which perforated in several places and then he died, it is likely his death was hastened by the treatment, although pretty much he almost certainly wasn't going to make it anyway. The "casual approval of the intraperitoneal use of the caustic agent had been wrong." Discussion here about how much Halsted mourned the loss of Mall and also how he never openly disparaged Carrel after this event but did write a warning "against the use of Dakin's solution in so fresh a sinus lined with intestine."
325ff As Halsted became more prolific in his letter writing as he grew older, he started to increasingly employ uncommon words: he "kept a notebook of unusual words and phrases and their derivations."
326 Halsted was convinced that he would die at age 70 of gallbladder disease.
327 Somewhat cryptic foreshadowing here as the author talks about how Halsted developed a method for draining the common bile duct through the stump of the cystic duct in 1915, which allowed closure of the common bile duct, thus preventing debilitating weakness caused by constant loss of bile. The first surgical use of this procedure was in 1917. Then, the author writes this cryptic sentence: "Halsted was impressed, and advised, but did not insist upon, its adoption by his staff, which would come to have personal implications." [I think here is an instance where the author needs to give a little bit more to the reader so we know a bit more about what's going on, this is a bit too cryptic.]
327 The author backs up now to April 1917, where the US is now involved in World War I, deploying a
million soldiers by July of 1917, and by November 2 million. On how hospitals all over the country sent medical and surgical staff to support the soldiers. "Doctors and nurses around the country put their careers on hold to accept military commissions." At this point Halsted was 65 and too old and infirm to serve overseas but he did take on more of the work that was left by Hopkins staff who volunteered. [The author doesn't discuss this but I suppose one of the anti-tragedies of major wars is that medicine tends to advance enormously during them, thanks to all the catastrophic injuries, traumas, infections and diseases that happen to soldiers at scale. Medical knowledge surely seems to grow by leaps and bounds during these periods. For just one example, see here how Heuer returns from the World War I theater as "a leading expert in treating penetrating chest wounds and trauma".]
million soldiers by July of 1917, and by November 2 million. On how hospitals all over the country sent medical and surgical staff to support the soldiers. "Doctors and nurses around the country put their careers on hold to accept military commissions." At this point Halsted was 65 and too old and infirm to serve overseas but he did take on more of the work that was left by Hopkins staff who volunteered. [The author doesn't discuss this but I suppose one of the anti-tragedies of major wars is that medicine tends to advance enormously during them, thanks to all the catastrophic injuries, traumas, infections and diseases that happen to soldiers at scale. Medical knowledge surely seems to grow by leaps and bounds during these periods. For just one example, see here how Heuer returns from the World War I theater as "a leading expert in treating penetrating chest wounds and trauma".]
329 Note also the reference here to John McRae, a battlefield doctor who died of pneumonia late in World War I. The author quotes his poem "In Flanders Fields" which is quite beautiful:
Chapter 35: "My Dear Miss Bessie"
331ff November 1918, the war is winding down, Halsted is now 66 and very tired after two difficult years working harder than he probably should have at this stage of his life; also on Halsted's many friends in the German scientific community with whom contact was difficult during this period; comments here that "the enigmatic Halsted was beginning a relationship with Elizabeth Randall, a woman 40 years his junior." Nobody knows exactly what happened because he didn't keep a diary or tell any of his friends anything, but according to the author it "had all the earmarks of a youthful romance" based on "flirtatious" letters Halsted wrote to her, although her letters to him have not been found. [God bless him! This is Bill Belichick caliber stuff right here.]
334ff Halsted is experiencing pain in his chest and abdomen, he believes it was due to angina, this was years before the electrocardiogram was invented; he continued to basically chain smoke cigarettes; but then he had a particularly severe attack of chest/abdominal pain followed by jaundice, and then it became obvious that it wasn't angina, it was gallbladder disease just like his mother had as well as other relatives before him. "He very likely had a stone blocking his common duct and would need surgery." Because Finney was on vacation, Richard Follis, a resident on staff at Hopkins, performed the surgery; he couldn't use Halsted's "newly devised method of draining bile via the stump of the cystic duct" because Halsted's cystic duct was "in an anomalous and inaccessible position." Halsted eventually recovered, but the illness had aged him; the following year, 1921, his health declined further; more attacks of biliary colic, etc.
337ff Finally, on a 1922 dinner thrown in Halsted's honor by the National Dental Association for his work on local and regional anesthesia; the author notes the various effusive praise spoken on his behalf at this event.
Chapter 36: The Final Illness
341ff Halsted has a recurrence of cholecystitis and becomes very ill in August 1922; he was operated on again, this time by George Heuer; the operation was successful and he began recovering, but then by September 3rd he began vomiting blood and bleeding into his digestive tract; his condition worsened and he died on September 7th.
Chapter 37: Afterward
345ff Halsted's body was autopsied: there was fluid found in the chest cavity, pleurisy, as well as pneumonia, also severe arterial sclerosis and blood throughout the mucosa of the entire small intestine. Note also that Halsted had brought with him on his final admission to the hospital a record of the morphine that he'd been taking the prior two months, but the dosages were very small--no more than 10mg per 24 hours--this would be highly unlikely for somebody who had been using 10 times that dose for more than 35 years. Comments here from Welch, who on his own deathbed commented that Halsted did not ever conquer his cocaine addiction; Halsted would occasionally relapse, always going out of town to do so, but he would later return and apologize to Welch.
346ff Also notable here that Caroline did not accompany the body to its burial place in Greenwood Cemetery in Brooklyn; she wasn't close to the Halsted siblings and did not want to spend this time with them. Caroline seemed to be in a state of panic and was overwhelmed by the death of her husband; she died two months later of pneumonia.
348ff Final memorializing comments about Halsted from the author: his name was not known nearly as much as say Osler, Welch or Cushing; "He didn't make speeches or befriend the powerful, and the fruit of his seminal work would not fully ripen for at least a generation... Over his 33 years at the helm of surgery at Johns Hopkins, Halsted not only invented an entire surgical philosophy, he instituted a system to inculcate in surgeons this philosophy, which spawned several generations of the finest teachers of surgery in the world." Lengthy discussion here of all of his direct and indirect disciples and the high positions they reached throughout the USA's medical establishment.
349 "Although 'Halsted' is not a household name, every individual in America who undergoes successful surgery owes William Stewart Halsted a nod and a deep debt of gratitude."
350ff Comments here on William Henry Welch and various encomiums on his 80th birthday in 1930, including a speech given by president Herbert Hoover; his face was also on the cover of Time magazine that week. On Welch's humility: the author drops a little anecdote here about how after Welch discovered the pathogen that caused gas gangrene he never used his own name to name it, although the rest of the scientific world called it Clostridium Welchii per the custom of discoverers like this; Welch was active until his 84th year when he died of prostate cancer in 1934.
351 Brief comment here on Walter Reed, a US army doctor who identified mosquitoes as the vector for yellow fever and instituted mosquito control, which made the building of the Panama Canal possible.
Epilogue
353ff A discussion of the famous "Four Doctors" painting by John Singer Sargent, commissioned by Mary Elizabeth Garrett and hanging in the Welch Medical Library at Johns Hopkins. "Sargent struggled with the painting for nearly a year" and upon evaluating Osler for the first time, the artist shook his huge head and muttered that he had never before been asked to paint a man with green skin." Sargent also complained, disparaged his subjects, etc. Also apparently Sergeant disliked Halsted and Halsted made withering comments during the process that were not appreciated by the artist. "Legend has it that Sargant took his revenge by painting Halsted poorly, and in colors that would soon fade. Much was made of the depiction of Halsted's thumb as short and graceless and the blue shadow painted under his eyes, but both were accurate." [When you look at this painting it seems very staid and calm: you'd never guess all the childish drama that went on behind the scenes in its creation. Stuff like this is hilarious to me. Things are never, ever as they seem. Even great men fall victim to a rancorous painter.]
Acknowledgments
357 Interesting to learn here that one of the author's teachers, Roscoe Wilcox, was taught by George Heuer, who was taught by Halsted. Also interesting comments here from the author on knowing so many of Harvey Cushing's descendants but knowing so little about the man until reading Michael Bliss's biography of him.
To Read:
Donald Fleming: William Welch and the Rise of Modern Medicine
Harvey Cushing: The Life of Sir William Osler [2 vols]
***William Osler: Aequanimitas: With other Addresses to Medical Students, Nurses and Practitioners of Medicine
William Osler: The Principles and Practice of Medicine
Michael Bliss: William Osler: A Life in Medicine
Michael Bliss: Harvey Cushing: A Life in Surgery
Hugh Young: A Surgeon's Autobiography