Sunday, 12 August 2018

GENIUS ON THE EDGE

The John Hopkins Hospital



John Hopkins
Johns Hopkins born in 1795, an entrepreneur and philanthropist was one of the richest Americans of his time. In 1889 Johns Hopkins donated this huge hospital and the university to Baltimore and it was to be called The Johns Hopkins Hospital “the greatest gift to mankind”. Dr. Welch was a trustee. Welch had already established himself as a great pathologist. He was a friend of Dr. John. S. Billings who had been librarian of the Surgeon General’s Office and was now chairman of the board of trustees of the Johns Hopkins Hospital.

Welch had suggested to Billings that William Halsted was the right man for the chair of surgery in spite of his recent addiction to Cocaine which he had got over. He was appointed to this prestigious position. Besides Welch there were on the team William Osler now called the father of modern medicine and Kelly a man who had blazed a trail in gynecology. So it was Osler, Welch, Kelly and Halsted who formed the nucleus of this great team, an institution that would break all barriers in medical science. No more did people talk only of Berlin and Vienna but they spoke in the same breath of The Johns Hopkins and the Mayo clinic. American medicine had come into its own.
            
William Halsted
What was William Halsted’s background before he joined the Johns Hopkins in 1889. He ardently believed in the work of Pasteur, Koch and Semmelweis, and Lister’s application of the antiseptic theory and applied it to his work in New York where he had already established himself as a surgeon of repute. In 1882 he was the first surgeon to do a cholecystectomy and that too on his mother. Halsted was also the first to give his own blood to his sister who was dying of postpartum hemorrhage, and this was before Landsteiner had discovered the blood groups. His sister lived, they must have been of the same group or Halsted must have been group ‘O’. He was also the first to device an ingenious method of treating carbon monoxide poisoning. He drew blood from the patient in a citrate solution in an open container and then shook the flask to oxygenate it and injected it back into the patient. His patients lived.

Then tragedy struck Halsted. He had heard of Karl Koller an ophthalmologist’s work on Cocaine- he was removing cataracts painlessly under a local drop of Cocaine in the eye. This was actually suggested to Koller by a paper published by his friend Sigmund Freud, Halsted always the scientist and experimenter began to experiment on himself and some of his pupils. He performed major surgery by using Cocaine as nerve blocks. He also found that he under Cocaine had developed tremendous energy and capacity for work without any fatigue. Then one tragic day as he picked up his knife to operate he found that his hand was shacking. He was shocked, looked around amazed, handed the knife to his assistant and had to be helped out of the theater. That night was the darkest night in William Halsted’s life this great surgeon with a remarkable future had become a physical and mental wreck. Welch who was following Halsted’s career closely and believed that the man had a great future came to his rescue. He institutionalized him, opium was used in small doses to get him off cocaine. But unfortunately he got hooked on to opium so it was from the frying pan into the fire. It took a long time to get this man back to work.

Portrait of 'the big four' at Hopkins - Drs. Welsh, Osler,
Halsted and Kelly from the medical archives of the John
Hopkins Medical Institute.
It was then that he took on the chair of surgery at The Johns Hopkins and accepted Billing’s offer prompted by Welch. This he did with great hesitation for he was not sure of himself. Prior to this he had spent a lot of time while recuperating in Welch’s laboratory where he had ample opportunity to study both anatomy and pathology in the cadaver.  Cocaine had changed his personality and this fast, bold and rather traumatic surgeon became slow and meticulous. He devised new and systematic operations- one of the examples was his work on Cancer of the Breast. Kelly said of him, half in joke, that William Halsted is the only surgeon whose upper incision healed before he has come to the lower part. From Halsted’s cocaine addiction came the three principles of good surgery, reverence for tissue, elimination of dead space, and complete hemostasis.

Halsted fell in love with his theater sister Caroline Hampton and married her. Caroline was a remarkable woman and supported Halsted in his work, she developed an allergy to carbolic and Halsted had the Leyland rubber company make surgical gloves for her, which later became part of the ritual for the exercise of aseptic surgery and every surgeon began to wear sterile rubber gloves. At about this time Johns Hopkins decided to appoint an Urologist under Halsted. By now The Johns Hopkins had become a famed center and hoary professors of surgery applied for the post from all over Europe and America. Osler, Welch, Kelly and Halsted were on the selection committee. During the interview Halsted kept falling asleep and the others would wake him up saying “William this is going to be your decision. Wake up and listen” and Halsted would say “I am listening, I am listening”. At the end of the three days they asked him, “William who is your choice?” Back came the answer like a bolt from the blue. “why who else but young Hugh” the pun was on the word young. The others almost jumped out of their seats and they asked “what does Hugh Young know about uro surgery?” Nothing replied Halsted but what do those old fogies that we have heard know about the subject? “This man has a clean incisive virgin mind you appoint him and you take my word he will blaze a trail and one day Johns Hopkins will be proud of him”... They appointed him, Halsted was right, you open any chapter on genito urinary surgery and Hugh Young has made a contribution. Today he is remembered for his radical perineal prostatectomy for cancer of the prostate.

Halsted was not only a great surgeon but he was a great teacher of surgery. He collected in his unit at one time men like Harvey Cushing who pioneered neuro surgery, Bloodgood, who made monumental contribution to breast pathology, Foley of Foleys catheter fame, Finney, who did the first pyloroplasty and revolutionized gastric surgery, Mitchell who devised his clips and Hugh Young who pioneered uro surgery and above them all was Osler the father of modern medicine, Welch a great pathologist and Kelly who was a master of gynecological surgery.

In 1918 Halstead recognized that he had like his mother gall stones and that he would require a surgery of which he was a pioneer. One of his assistant Dr. Foley operated on him. The recovery was slow and he was never the same man again. He said to Caroline one day “I can still think, I can read & write and talk. When I can’t do any of these things, it will be time to quit.” Papers on the thyroid, on arteries, aneurysms and cancer poured from his pen. He spoke occasionally at meetings.

On an August morning he quietly told Caroline to phone up the hospital in Baltimore and have a surgeon ready to operate “It is my old enemy again Caroline. Dr. Reid was to operate. “Be sure that the drainage is done through the cystic duct, this might be my last experiment”. There was a faint smile on his face as he went under. A large stone was removed from the common bile duct. In early September Halsted developed Pneumonia. His old friend and mentor Sir William Osler had called Pneumonia “the old man’s friend”. On September the 7th William Halstead died. A postmortem was conducted according to his request. The cause of death was pneumonia, pleurisy and advanced atherosclerosis. There was no peritonitis, the drainage through the cystic duct had been perfect. William Halstead’s “last experiment” as he called it was a success.

The next day the Baltimore Sun carried an editorial the rest of the page was left blank and this is what it said:-“Because Dr. William S.  Halsted lived, the world is a better, a safer, a happier place in which to be. In his death, not only Baltimore, but civilization everywhere has sustained a heavy loss. He was one of the few men who really did count. Quiet, simple, un-ostentatious except in the medical world, where he towered, a great and dominating figure, the full scope of his genius and the tremendous extent and value of his service to mankind were neither generally known nor generally appreciated. To the Johns Hopkins hospital, the institution to whose reputation and up building he had so enormously contributed, his death is a staggering blow. Along with Osler and Welch he laid the foundation upon which Hopkins so solidly rests today.
                       

I am posting some pictures of these great men all from the Johns Hopkins and all at the same time. I have always been fascinated by this story and would like to share it with you.