The Four Doctors by John Singer Sargent (1906). From left to right: Welch, Halsted, Osler, and Kelly. (photo credit 12.1)
Legend has it that Halsted was difficult and argumentative during the sittings, and that the artist threatened to use shoddy paints so that in the years to come the surgeon’s face would gradually fade from the picture. Fortunately, Sargent never made good on his threat. More than a century later, Dr. Halsted’s visage is still powerfully visible. And while gazing intently at his stunning portrait, a viewer can easily imagine that he is peering into the soul of a troubled man.
Mary Elizabeth Garrett; 1904 portrait by John Singer Sargent. (photo credit 12.2)
As gifted an artist as Sargent was, however, he was not qualified to diagnose Halsted’s addiction during his visual inspections of the surgeon’s face and body. Instead, that onerous task—one that required more than the eyes alone—fell to William’s former chief resident, a talented surgeon named George J. Heuer.
AFTER GRADUATING FROM the Johns Hopkins Medical School in 1907, Dr. Heuer spent the next seven years toiling away on Halsted’s elite surgical service. In 1915, he sailed for Germany, but his studies there were abbreviated because of the events we now call World War I. A captain in the American Expeditionary Force, Heuer distinguished himself as a combat surgeon specializing in penetrating chest wounds and thoracic surgery. After the war, Heuer returned to the Hopkins as an associate professor and thence to appointments as surgeon-in-chief and professor, first at the Cincinnati General Hospital and University of Cincinnati (1922–32) and then at the New York Hospital and Cornell Medical College (1932–47).
Devoted to his mentor until his dying day, Heuer knew deep in his doctor’s gut that something was not right about Halsted. And true to his professional calling, Heuer was determined to uncover just what was at the root of Dr. Halsted’s countless bad days. He wanted to explain what was behind the anguish and pain Sargent had portrayed. Why the stinging gibes in which the surgeon directed his inner hatred, a sharp knife indeed, out toward others? What about all the episodes of too shaky hands or too rapid a heartbeat that prevented him from operating? Why was William so often absent at critical times in the lives of his patients and students? What did he do when he disappeared every summer? And most peculiarly, why was William routinely incommunicado from approximately four-thirty each afternoon until nine or ten the next morning, while his vaunted residents ran the Johns Hopkins Hospital’s world-famous surgery service?
By the time Heuer walked the wards at the Hopkins, Halsted’s earlier battles with cocaine were the stuff of heroic legend. Interns and medical students had long murmured and bruited about Halsted’s “New York episode.” Many assumed that this part of William’s life had ended precisely when Welch finagled his appointment to the faculty at Johns Hopkins. As the story went, William abandoned his old habits and, while a bit more the cantankerous for it, proceeded on to greater things. Osler’s “Inner History,” of course, had not yet seen the light of day. Consequently, when looking objectively at William’s remarkable record of accomplishment, his development of so many surgical procedures, his creation of the surgical residency program, and his publication of so many lucidly written and pathbreaking papers, many subscribed to this version of abstinence. Or as lawyers like to quip, res ipsa loquitur—the thing speaks for itself.
This was precisely the tale told in the authorized biography William Stewart Halsted, Surgeon by the eminent Johns Hopkins pathologist W. G. MacCallum. Published in 1930 and widely distributed to medical libraries across the nation, the book was read by countless aspiring surgeons for the next several decades. The biography’s introduction, written by William Henry Welch, acknowledges Halsted’s cocaine episode of the late 1880s but does so in a somewhat heroic style:
Dr. Halsted with his early associate and resident surgeons at the twenty-fifth anniversary of the opening of the Johns Hopkins Hospital, October 7, 1914. Standing, left to right: Roy D. McClure, Hugh H. Young, Harvey Cushing, James F. Mitchell, Richard H. Follis, Robert T. Miller Jr., John W. Churchman, George J. Heuer; seated, left to right: John M. T. Finney, William S. Halsted, Joseph C. Bloodgood. (photo credit 12.3)
In the pages of this narrative will be found the story of the break-down in Halsted’s health and of the circumstances which brought him to me in Baltimore. I had guarded unviolated for so many years the confidence which Halsted had placed in me that I confess I was surprised to learn that the secret was more widely known than I had suspected, and its publication after his death shocked me. I now realize that not only should the facts be made known, but that instead of reflecting injuriously upon Halsted’s character, they bring out a triumphant issue of hard struggle rarely exemplified in similar circumstances.
Yet despite Welch’s provocative introduction, the book devotes only a few pages to exploring Halsted’s addiction. Even when MacCallum describes Halsted’s cocaine bottom, he effectively closes the discussion with a theme of permanent triumph:
William G. MacCallum, professor of pathology at Johns Hopkins and Halsted’s first biographer, c. 1903–04. (photo credit 12.4)
Dr. Halsted did not escape. Those who knew of it kept it for many years a secret, and perhaps some of them may still feel that it would be better forgotten, but it is with no thought of uncovering a disgrace or belittling him that we speak of it freely. For, first of all, those early victims were quite innocent of any knowledge of its habit-forming character, and secondly, he almost alone of the many who fell under its influence, conquered it through superhuman strength and determination and came back to a splendid life of achievement.… After this interval he came back to a far more thoughtful, leisurely life, with time for reflection and contemplation of his surgical problems, a life in the end far more fruitful than could ever have been the strenuous rush of his existence in New York if he had kept on at that pace. After all, in his case it was probably no misfortune but rather the reverse.
This “official history” as articulated by MacCallum, however, failed to tally with George Heuer’s firsthand observations. As such, Heuer decided to research and write his own biography, a book that garnered interest from a New York publisher during the 1940s but only appeared in print after Heuer’s death as a special supplement of the Johns Hopkins Hospital Bulletin in 1952. For more than two decades, Dr. Heuer dissected his boss’s disease with the same care and attention William devoted to the women suffering from breast cancer in his famous operating room.
The surgeon began his literary postmortem by reviewing Dr. Halsted’s enormous collection of papers and manuscripts carefully cataloged and filed in the archives of the Johns Hopkins Medical Institutions. Piquing his curiosity were a series of letters to Halsted’s friend Rudolph Matas, a distinguished professor of surgery at Tulane University. In early 1920, Dr. Matas petitioned the National Dental Association to recognize “the Professor” for revolutionizing dentistry by introducing nerve blockade, or local anesthesia. For months, Matas pestered Halsted to write down his thoughts and recollections of the cocaine episode of 1884–85 in order to gather the evidence needed for the judging committee, which ultimately ruled in Halsted’s favor.
William freely described the surgical details to Matas but remained less than forthcoming about his personal experiences with cocaine. For example, in May 1921 he vaguely, if not dishonestly, jotted to Matas:
You are indeed a sturdy friend. I wrote very little on the subject of my cocaine experiments, which for a year were carried on vigorously. Then my health gave way, due primarily to an infected finger and the horrible pains from the neuritis that resulted. For more than a year, I was incapacitated, and thereafter for two years worked in the Pathological Laboratory of Dr. Welch at the Johns Hopkins. Thus my misfortune has its bright as well as its gloomy side.
Less than a year later, after a grand dinner celebrating his contributions held at the Maryland State Dental Association on April 1, 1922, Halsted wistfully wrote his friend Matas:
How can I ever expres
s my gratitude to you for this act of unparalleled kindness—an act which has covered two years.… Not a wink of sleep did I get during the night of Saturday, I was too exhilarated for repose. Once before in my life was I kept awake by great happiness; this was the night that I passed successfully the examination for Bellevue Hospital in 1876. Then, it was in contemplation of the future, now in reflection upon the good fortune that led to our friendship. The reaction from this great joy seems to be setting in tonight and my happiness is tinged with regret for the lost opportunities—for the time wasted from loss of health.
Unsatisfied by these scant archival remnants, Dr. Heuer dashed off dozens of letters to the doctors, nurses, secretaries, librarians, medical students, and former residents who’d spent significant time with Halsted. The scandalous nature of addiction during this era combined with a desire to protect Halsted’s reputation generated a resounding silence—most of the recipients simply refused to answer. Nonetheless, a few responses did make their way back to Heuer.
One reply was from W. G. MacCallum, Halsted’s authorized defender and biographer. Only days earlier, Heuer had written asking MacCallum about the evidence he had with respect to William’s abstinence from cocaine and respectfully inquired if the aging pathologist might have glossed over evidence to the contrary. In a frosty reply handwritten on December 18, 1940, Dr. MacCallum insisted that he had thoroughly investigated the matter and discussed it with several of Halsted’s former residents:
All [MacCallum’s underline] said there was no direct evidence of his having still taken any cocaine and all agreed that he could not have maintained such activity and keenness of intellect if he had continued all those years as an addict. There was not in the least disagreement about it and I feel and did feel at that time, that they were correct about it and never believed that he continued to take any cocaine. I did not hesitate in writing as I did about his recovery. I would like to know on what basis of reliable evidence all these surgeons are still discussing it.
Similarly, two of Mrs. Halsted’s nieces and several secretaries who worked in his home all swore on a proverbial stack of Bibles that “never in their association with him was there the slightest evidence of drug addiction.”
Elliott Carr Cutler, M.D., age thirty-six, in 1924. (photo credit 12.5)
The most damning testimony came in the form of some handwritten notes of a conversation with the world-renowned neurosurgeon Harvey Cushing on March 1, 1931, several months after the publication of MacCallum’s biography. The notes actually represent a roundabout piece of historical documentation in that they were recorded by Dr. Elliott Carr Cutler, a cardiovascular surgeon and one of Cushing’s favorite colleagues at Harvard’s Peter Bent Brigham Hospital, where Cushing was long surgeon-in-chief.
Dr. Cutler scribbled down Cushing’s confidential musings and secreted them away in his files for almost nine years. On November 10, 1939, just over a month after Cushing died of a heart attack, Cutler allowed Heuer to copy the notes. So powerful and controversial were the claims that when Heuer’s biography finally appeared in print they were slightly amended as being the remarks of a “well-known surgeon” rather than directly attributed to Harvey Cushing. While this is not a perfect line of evidence, none of these individuals was prone to exaggeration or lying, nor was there any secondary gain to be had, some seventeen years after Halsted’s death, by vilifying or embarrassing their teacher, a man they had deeply respected if not always understood.
Cushing was particularly qualified to bear witness because of the many years he’d spent as Halsted’s resident, surgical disciple, and key associate at the Johns Hopkins Hospital, from 1896 to 1912. During that time, Cushing often stood directly next to Halsted at his famous wooden operating table. Moreover, Cushing labored at the Hopkins for several years after Osler wrote his hidden memoir of Halsted’s morphine use. Finally, the multitalented neurosurgeon was also an obsessively detail-oriented historian. In addition to many hundreds of surgical papers, books, research reports, and medical monographs, Cushing wrote the critically acclaimed biography Life of Sir William Osler, which won the Pulitzer Prize in 1926. In all his pursuits, Cushing was regarded as a skilled physician and an astute observer determined to get it right—whether deftly removing a rapidly expanding brain tumor, correctly ascertaining a particularly elusive diagnosis, or accurately recounting the history of medicine and surgery.
Harvey Cushing as a young surgical resident at Johns Hopkins Hospital, c. 1900. (photo credit 12.6)
Long after leaving Baltimore for Boston, Dr. Cushing kept in close contact with Halsted and frequently wrote his chief solicitous letters. Earlier in his career, however, Cushing had often been frustrated by Dr. Halsted’s mysterious airs, his inability to quickly make up his mind, his frequent absenteeism accompanied by odd excuses, and his too easy relegation of surgical cases to his assistants. As a junior surgical resident at the Hopkins, Cushing went as far as to misjudge Halsted as lazy. In March 1898, the young surgeon complained to his then sweetheart and soon-to-be-wife, Kate Crowell: “Here I am, a youth, doing surgical work that not one of my school confreres will hope to do for years. It frightens me sometimes. The Chief rarely operates. Today I did all of his cases.”
In the years that followed, however, Cushing revised his diagnosis of Dr. Halsted from slothful to something far more serious. In fact, Cushing’s comments to Elliott Cutler comprise some of the most intriguing clues to be found on William’s heavily shrouded addiction and, while a bit hyperbolic, merit quoting in their entirety:
In a discussion of MacCallum’s book, the Chief [Cushing] pointed out the very abrupt change in Halsted’s nature when he moved from New York to Baltimore; that he had been a rigorous, rather showy, didactic, bustling individual. He became a very refined and most punctilious and fastidious individual. In the interim between New York and Baltimore, he acquired the cocaine habit. The real truth of the matter is that he never conquered it. There are several proofs of this and perhaps MacCallum should have faced this, for he must have known it and should have published it in his book, for it would have been a wonderful story of a person who, like De Quincey, acquired a precarious habit to death and old age unbeknownst to the rest of the world.
There are many instances in support of this. Shortly after accepting the Hopkins post he took a big trip to South America and took with him not quite enough cocaine to make the trip, hoping that he could cut his daily dose down. But he could not do this and found himself about the Equator sailing home with no cocaine. He rifled the captain’s store and stole what was there—a fact which has not got out.
Moreover, his change in philosophy is entirely in keeping with the cocaine habit. The story of his going home at 4:30 every day and locking himself in his room an hour and a half before dinner, the stories of his many trips to Europe each summer when he never saw anyone but locked himself in a hotel room and took his drug, and the fact that Reid Hunt [a professor of pharmacology at Harvard and formerly a Johns Hopkins faculty member] knew all along that he was taking cocaine, leaving to those who know this the feeling that MacCallum failed to write one of the greatest romances of modern life.
There is another very interesting side to this Jekyll and Hyde character. That is that it might even seem that the whole Halsted school of surgery which I have called a School for Safety in surgery may have been due to this drug addiction. Note that Halsted before this addiction with cocaine was a brilliant, rapid, spectacular operator, that just as he changed his character and his dress to that of a fastidious person, paying great attention to details—a matter which characterizes cocaine addicts—so his outlook on surgery itself was changed and he in turn devoted himself to the infinite precision of little details of surgery. There was no longer the picture of the brilliant operator but the cautious individual with tremendous and profound devotion to the little things. His fastidiousness in disposition was carried to fastidiousness in technical surgery and this change in character, which has given rise to the greatest school
in surgery this country has ever seen, may have been due to cocaine addiction. What a romance! And what a wonderful example of how destinies of men are influenced by extremely little things!
ONE OF THE GREAT IRONIES to be found in the lives of many physicians is that their final illnesses often mirror the pathological conditions they pursued during their careers. Dr. Halsted is no exception. Three years before his death, on September 7, 1919, he underwent a protracted operation to remove his gallbladder and clean out his common bile duct, which was filled with “an abundance of putty-like material.” His convalescence was tumultuous, and within a few months, his body rebelled with bouts of severe abdominal pain. By early August 1922, while he was relaxing at High Hampton, North Carolina, the episodes had progressed to daily ordeals. The riot of excruciating gallstones lodged in his liver, causing nausea, chills, fever, vomiting, and jaundice, was unrelenting. On August 21, he had little choice but to make a perilous and jostling journey by horse-drawn carriage, automobile, and train from his remote country home in North Carolina to Baltimore.
Dr. Karl Schlaepfer, the surgeon who admitted William to the Johns Hopkins Hospital on August 23, 1922, described him as “in a condition which terrified every doctor who saw him: deeply jaundiced, dehydrated, under the effect of the constant use of morphia for weeks due to the fact that no day passed without a severe attack.” Initially, Halsted feared the risks of submitting to an operation he had perfected, if not invented. The worsening jaundice accompanied by spiking fevers—all signs of obstruction, infection, and impending death—eventually persuaded him to proceed.
An Anatomy of Addiction Page 24