Genius on the Edge
Author: Gerald Imber
This biography explores the life of an enigmatic physician who the author referred to as ‘indeed among the greatest surgeons of his day’, and whose work transformed surgical practice in fundamental ways. Asserting that William Stewart Halsted is the only contender for the title of ‘the father of modern surgery‘, the book documents how he ‘invented an entire surgical philosophy‘, and how he ‘instituted a system to inculcate in surgeons this philosophy, which spawned several generations of the finest teachers of surgery in the world’. And just as the biography captured the essence of his revolutionary career, it also delved into the tortured mind that lied behind the personality. In depicting how Halsted precariously balanced the two conflicting sides of his persona, the book succeeds in portraying the full range of his qualities, from his drive for excellence and his impulsion to innovate, to his career-disrupting addiction and his reclusive lifestyle. And to contextualise his life, the book also discusses the edifice in which he worked, the people with whom he collaborated, and the surgical giants who he trained (page 348-349).
The chronological account of Halsted’s life goes back to his three-year medical school experience which the author referred to as ‘haphazard‘ and ‘almost purely didactic‘, a view he justified by asserting that ‘lectures were poorly prepared and poorly attended’, and often ‘students did not see patients at all’. The book however noted that ‘Halsted managed to ferret out the best teachers and role models‘, and that despite the ‘dismal system’, Halsted ‘had the ability to associate himself with the important figures in his world’. It was pertinent that whilst still a student, Halsted became ‘an expert in the use of the experimental model‘ by spending a lot of time with the physiologist John C. Dalton. His keen interest in surgery also revealed itself at that time, the author describing how Halsted ‘bought extra cadavers‘ and ‘seized every opportunity for dissection‘. The book also charted his experience after qualifying as a doctor with a detailed description of his internship at Bellevue Hospital, ‘a very busy place’ where ‘interns worked a grueling seven-day week‘, and his work as a house physician at New York Hospital where the author said he ‘redesigned the patient’s bedside chart‘ – an early indicator of his innovative bent (pages 21-31).
Halsted’s surgical training was expectedly a prominent theme of the book, and the narration emphasised his experience in Germany where he studied with Anton Wolfler and Johannes von Mikulicz – assistants to the foremost surgeon Theodor Billroth. This exposure, the author maintained, was key to Halsted’s future success mainly because Billroth was ‘an early subscriber to Lester’s antiseptic technique‘, and he advocated such critical surgical principles as ‘careful preparation‘ for abdominal operations, and ‘attention to hemostasis‘. On his return to America, the author remarked that Halsted was ‘charged with energy and ideas’ and ‘couldn’t wait to get to work’ at five New York hospitals. The author described his working days then as ‘staggering‘, consisting of clinics, operating, instructing, dissecting, and ‘frequent trips to charity hospitals‘. During this time, Halsted also showed a keenness for teaching, and this was evident in the medical student quiz he developed with William Welch – his close friend and future colleague at the Johns Hopkins Hospital. Such was the influence of his teaching that the author said Halsted was ‘idolized by the students’; it was therefore unfortunate when the book pointed out that after he moved to Baltimore, he became a poor teacher who ‘had no relationship with the medical students and made no effort to develop one’ (pages 31-44 and 191).
A remarkable feature of Halsted’s life is the professional decline he suffered in New York where the author said he ‘wrecked his career‘ and become ‘a surgical pariah‘ due to a life-long and destructive cocaine addiction. Illustrating the impact of this habit which he acquired whilst researching the use of cocaine in surgical anaesthesia, the book described how the drug began ‘taking command‘ of his life and made him lie to cover up for his erratic behaviour, and for such physical symptoms as hand tremors. The severity of the addiction was such that Halsted ‘withdrew from all of his professional responsibilities when he could no longer disguise the extent of his disability’, and on moving to Baltimore, was initially restricted to laboratory work ‘on trial and under scrutiny‘. Relying on ‘a balancing act’ of morphine and cocaine that the author said became central to the rest of his life, Halsted was able to excel in the laboratory where he ‘developed a manner of dealing with animal experiments‘ that were humane, careful, aseptic, and meticulous, – a method which the author said ‘soon became the national standard‘. Halsted’s laboratory work with Franklin Mall particularly led to insights into resolving recalcitrant surgical problems, and the author illustrated this with the challenge of surgical anastomosis. Halsted also carried out thyroid gland pathological studies at this time, a project the author said led to the ‘publication of the definitive tome on the subject’ 30 years later (pages 47-57 and 79-92).
Halsted’s clinical surgical work at the Johns Hopkins Hospital lies at the root of his fame, and the book traced this to his appointment as acting surgeon with the support of William Welch and William Osler. In exploring Halsted’s operating methods, the author characterised his surgical technique as ‘anatomically correct dissection and compulsive attention to detail’, with a commitment to the concept of aseptic surgery. The book’s depiction of Halsted in the operating room was of a surgeon who ‘spoke little during surgery, and expected the same of others’, and as an operator who ‘sacrificed speed and style for scrupulous care and anatomical integrity‘. Halsted also made several far-reaching surgical innovations such as the introduction of rubber gloves – what the author said ‘inadvertently set into motion the single greatest advance in the history of sterile technique‘. The book also described several of Halsted’s operative procedures; these included his famous radical mastectomy for breast cancer, a technique which the author said ‘became the gold standard for care until the mid-20th century’, and his revolutionary approach to the repair of inguinal hernias, a problem he resolved by ‘a departure in the technique’ which had ‘nearly 100 percent‘ failure rate. Halsted’s other innovations which the book documented included ‘the first known operation to remove gallstones‘, which he performed on his own mother, and carrying out the first ever emergency blood transfusion (pages x, 42, 96-99, 111-124 and 145-149).
The author painted a multifaceted portrait of Halstead’s personality as an ‘isolated man, forbidding and nurturing; rigid, proper, secretive; compulsive and negligent; stimulating and reclusive; addicted and abstemious; oblivious and solicitous; and always concerned with advancing the science of surgery‘. In the early phase of his career, the author portrayed Halsted as ‘vivacious and amusing‘, and as ‘unfailingly thoughtful and extremely well-mannered‘. This was in stark contrast to the older Halsted who the book characterised as ‘dismissive’, ‘increasingly aloof, and perhaps out of touch with simple human situations‘. Halsted’s sterling qualities as a surgeon however symbolised the epitome of professionalism, the author for example referring to ‘his unbending demands for excellence, and the attention he lavished on even the most trivial detail of his surroundings’. In describing his technical skills, the author said Halsted ‘rarely entered uncharted territory…until the anatomy is indelible in his memory’, and he ‘never operated without a plan‘. And when faced with operating room crises, the author said Halsted reacted decisively with ‘cool and detachment‘ and with ‘crystal-clear thinking‘ (pages 40, 140, 161, 200, 274-275 and 349).
This biography narrates the life of one of medicine’s most intriguing personalities. The book depicts him as a haunted genius whose lasting contributions to the profession however far outstrip his ill-fated addiction to cocaine. With a generally lucid, undramatised, and detailed prose, the biography not only captures the essence of its subject, it also provides a detailed historical context to his life and career. The author used Halsted’s story to illustrate the horizons that imaginative and dedicated work open up, and to portray the human side of doctors, and their vulnerability to the hazards of their trade. The book was marred by its poorly structured themes and disjointed storytelling, and this may explain its tendency to be repetitious. There were also relatively few anecdotes, the author tending to describe his subject with superlative generalisations. These apart, the biography adequately justifies its captivating title.
The book has wider lessons for healthcare in its depiction of the value of the acquisition of knowledge and skills from inspiring teachers, and the responsibility to plough this back into raising the standards of clinical practice. In its exploration of Halsted’s work, the author critically appraised his famous operative techniques, and set them in the context of subsequent developments in the field. The book’s review of the history of different surgical operations was also a masterclass replete with insights and helpful contrasts with contemporary practice. Beyond Halsted’s life, the book is also a comprehensive repository of the history of surgery, and of the Johns Hopkins Hospital, and I recommend it to all doctors.
Publisher, Place, Year: Kaplan Publishing, New York, 2011
Number of chapters: 37
Number of pages: 389
Star rating: 4