An Anatomy of Addiction

by Howard Markel

  Halsted’s visits to the hospital wards were erratic and rarely comprehensive in terms of walking from bed to bed. On some days, he inquired after only a few cases. On other occasions, he discussed unusual conditions and diseases. One morning a week during the school year, Dr. Halsted was required to conduct rounds on one or several wards for the sake of his attention-hungry students. His visits might last fifteen to thirty minutes or as long as an hour or two. Some weeks, he skipped them entirely.

  With the “public” patients, drawn from the neighborhoods surrounding the hospital, Halsted was unfailingly polite but aloof and distant. He rarely discussed precise diagnoses or treatments with these patients. In accordance with the manner of the patrician white American male of the time, he may have assumed that the immigrants, African Americans, and working stiffs he saw on the public wards were intellectually incapable of understanding such complex matters. When attending private patients, armed with both social standing and the resources to meet his outsized fee schedule, he was a bit more solicitous. But even among the very rich, William was quick to assert that he was in command and it was a privilege to be placed on his operating table. Years later, in 1940, Harvey Cushing eulogized William’s bedside manner with the observation that “he spent his medical life avoiding patients.”

  William H. Welch at the pinnacle of his career, c. 1905. (photo credit 10.8)

  AT THE DAWN OF THE GAY NINETIES, Baltimore boasted many amenities, including a burgeoning port, thriving theatrical companies, booming businesses, and a determined zest for consuming meals captured from the “immense protein factory” better known as Chesapeake Bay. In terms of propelling the ancient craft of medicine into modernity, however, it was considered by many toiling in the hospitals of Vienna, Paris, London, and even New York to be little more than a provincial outpost.

  Such derisive assessments began to ebb after the Johns Hopkins Hospital officially opened its doors in 1889 and, even more definitively, in 1893, when the medical school was inaugurated. Before the century turned, crowds of young men with stars in their eyes and ambition in their loins flocked to 601 North Broadway to participate in what historians universally regard as one of the most important developments in American medical education. In fact, Halsted was just one of many distinguished doctors practicing there.

  As the story is told to each intern the night before he takes his first call on the wards of the Johns Hopkins Hospital, in the beginning there were four physicians—each of them under the age of forty—who set out to transform the stodgy and deleterious American medical profession. By every imaginable metric, they succeeded wildly. Almost immediately, the Hopkins assumed its place at the vanguard of a fin de siècle revolution where doctors abandoned a blind allegiance to centuries-old, not infrequently toxic medications and deadly surgical measures in favor of the scientific and evidence-based enterprise that characterizes modern medical practice.

  First among equals, of course, was the majordomo and initial hire of the hospital, the rotund William Henry Welch, whose Vandyke beard grew pointier and whiter with each passing year. At the laboratory bench, Dr. Welch failed to make a lasting mark, although one species of bacteria he described, Clostridium welchii, carried his name for decades. He was an indifferent administrator who often forgot to return phone calls or telegrams and was notorious for misplacing memoranda and manuscripts for weeks on end. Where Welch shined, however, was as the nation’s preeminent medical statesman, with the ability to identify and nurture scientific talent in others long before they knew they had it in themselves. He enjoyed impeccable connections. An executive officer or board member of virtually every major American medical society and research institute, Welch knew everyone who was worth knowing; and virtually every doctor alive wanted to know him.

  In the years before and long after the medical school’s opening, Welch attended countless scientific meetings, trolled the best hospitals and medical schools in the nation, and enticed the brightest doctors to abandon the workaday world of medical practice for exciting careers in the laboratory. It has often been said that William Henry Welch had enough charm to sell a furnace in the middle of a Baltimore summer. It served him well when recruiting the ambitious men who populated Johns Hopkins. In dulcet tones, he described the rich purse his institution was dedicating to medical research. Long before he finished his pitch, Welch convinced most of these listeners to pack their bags and board the next train for Baltimore. Every year until his retirement at the onset of the Great Depression, Welch’s laboratory and pathology residency program attracted a stellar cadre of eager young trainees, the vast majority of whom came to dominate the next generation of academic medical leaders in the United States and around the world.

  Drs. Halsted, Osler, and Kelly, c. 1889. (photo credit 10.9)

  Then there was Howard Atwood Kelly, the ebullient and talented gynecologist from the University of Pennsylvania. In surgical circles, Dr. Kelly is best recalled for inventing several operating tools, including a clamp that still bears his name and is requested every day in operating rooms all over the world. His superb descriptions of diseases ranging from appendicitis to cervical cancer continue to inform physicians who take the time to go to the library stacks and pull down his richly illustrated textbooks. Kelly also wrote authoritative tomes on medical history, biography, mushrooms, snakes, reptiles, and canoeing.

  The love of Kelly’s life was his savior, Jesus Christ. So tightly intertwined was the connection between Kelly’s medical work and his religious beliefs that he often knelt down in prayer before examining a patient or beginning an operation—until, that is, many of his uncomfortable colleagues and patients asked him to stop. A crusader for a number of civic reform movements, Kelly had an odd nocturnal habit of visiting Baltimore’s most notorious street corners. Once there, he approached many a prostitute, not in search of a business transaction but, instead, to facilitate a direct path to the Lord.

  In 1926, Kelly wrote a widely selling book “proving” the compatibility of Christian faith with the tenets of science and evolution, a thesis the famed Baltimore journalist H. L. Mencken publicly dismissed as “completely insane.” Perhaps an even sharper slice at Kelly’s mental status came in the form of a private query the Pulitzer Prize–winning novelist Sinclair Lewis posed to the Harvard neurosurgeon Harvey Cushing. In discussing Kelly’s dual devotion to scientific inquiry and religious faith, Lewis asked, “My dear Harvey, what does an obstetrician know about the Virgin Birth?”

  Dr. Kelly was a neighbor of the Halsteds’ and maintained a profitable practice at his home on Eutaw Place, where he employed radium as a treatment for cervical cancer. In 1898 one of his resident physicians described him as “effulgent as an X-ray tube, he is distinctly phosphorescent.” Such a description may have turned out to be more than metaphor. As Baltimore legend has it, long after Kelly died, when the time came to raze his abandoned house, the amount of radioactive waste left behind in the ground was so great that a team of hazardous materials experts had to come in and abate it.

  The undisputed star of the faculty, however, was William Osler, a Canadian by birth who was formerly professor of the Institutes of Medicine at McGill University, in Montreal (1874–84) and of clinical medicine at the University of Pennsylvania, in Philadelphia (1884–89). The author of the best-selling medical textbook The Principles and Practice of Medicine, Osler was widely known as one of the greatest diagnosticians ever to wield a stethoscope. So remarkable was his personality and presence that it has been said Osler changed the atmosphere of every room he entered. Learned, compassionate, accomplished, and fun, William Osler inspired a cult of hero worship that has never ended.

  At nine o’clock each morning, the great physician heaved open the great wood-and-glass doors of the Johns Hopkins Hospital’s main entrance. He was always impeccably dressed in a silk hat and black frock coat, accessorized by a splendidly striped cravat, a freshly cut flower in his lapel, and an imperious gold chain hanging from his expansive waistcoat. Handi
ng his gloves, hat, and umbrella to a waiting nurse, Osler warmly greeted the weary resident physician on duty, who reported on the patients he had admitted the night before.

  Having gathered this critical intelligence, Osler raced around an imposing marble statue, Christus Consolator (the Divine Healer), and up a quarter-sawn oak staircase centered in a domed octagonal atrium that, quite possibly, constitutes the grandest hospital lobby in the history of medicine. Upon entering the house officers’ quarters, he joyfully spent several minutes offering salutations to an admiring group of junior doctors. Eventually, he descended the stairs and made his way to the wards to visit his patients and enlighten the students assigned to their care. By insisting that his pupils observe, perform, and then teach clinical lessons to others more junior down the line, Osler trained them to think and act like doctors before John Dewey became famous for the educational method he called “learning by doing.”

  One Saturday evening a month, Dr. Osler invited the most promising students to his home for beer and sandwiches. After greeting them warmly in the vestibule of his expansive town house on West Franklin Street, he ushered his acolytes into a richly paneled library that contained a five-thousand-volume collection of the greatest medical and scientific works ever published. “To study the phenomena of disease without books is to sail an uncharted sea,” Osler told them between bites of Virginia ham, sips of pilsner, and the regaling of great medical tales. But he always concluded this point with the warning that “to study books without patients is not to go to sea at all.” Their destiny, the physician insisted was “a calling not a profession.”

  HALSTED’S PUPILS’ educational experience was poles apart from Osler’s. All week long, the students labored on the surgical wards, dressing wounds, examining patients, conducting laboratory tests, and reading up on their cases in the hope of impressing their elusive teacher. The copious notes they took on each patient’s progress became “part of the permanent hospital record and the need for careful work was stressed and the work itself checked by the interns and residents.” The stakes were high, and no student wanted to be caught committing an error or omission. This practical experience was supplemented by attending ward rounds, an operative clinic conducted by one of Halsted’s associates, work in the surgical dispensary (or outpatient clinic), an operative surgery course performed on animals (typically stray dogs caught near the hospital), and, most important, a “dry clinic” conducted each Friday at noon by the eminent professor of surgery.

  Dr. Osler teaching students at Johns Hopkins, c. 1900. The blackboard behind him lists all the typhoid fever patients admitted to the Johns Hopkins Hospital that year. (photo credit 10.10)

  At these formal affairs, Halsted eschewed the traditional discourse on pathology, clinical symptoms, diagnosis, and treatment, assuming that the interested student could easily read about these topics. Instead, he presented an array of surgical problems and experimental questions he was examining in his laboratory. To some, “it was an impressive demonstration of wide reaching, profound knowledge and fertility of suggestion—a keen scientific mind at work.” But for most of his students, it was a boring and intimidating ordeal. There may have been a few inspiring axioms, but there were no moments of kindness in Halsted’s classroom. Crusty and mordant, he was referred to by his students behind his back as “the Professor” because of his scolding and intimidating ways. William detested the nickname, which recalled the title appropriated by many a late-nineteenth-century dancing instructor and vaudeville orchestra conductor. Other medical students took to calling his ward rounds “Shifting Dullness,” a play on the term used to describe a maneuver whereby the physician examines a supine patient for evidence of ascites, or excess fluid, in the abdomen.

  Halsted often came to class late and unprepared. As medical students are all but genetically programmed to do, they complained about this habit to their dean, William Welch. From time to time, Welch angrily pledged to “come down on Halsted who ought to see that they have systematic instruction in surgical pathology as was advertised.” Rarely, if ever, did Welch act upon those threats.

  During many of the Friday afternoon dry clinics, Halsted spoke for the entire hour with his back to the audience, so immersed was he in the undecipherable drawings he chalked up on the blackboard. Cruelly, he took pleasure in speaking in a rapid-fire, prolix manner as he watched his students scribble furiously in their notebooks about surgical procedures they had never performed and did not yet quite understand. Unlike the generous instructor he’d once been in New York, Professor Halsted was frequently condescending and insulting at the Hopkins. Those few brave or completely uninformed students who dared ask him a question soon discovered whether or not their queries were up to Halsted’s intellectual standards. If they received a lengthy and not entirely clear answer, they knew they were on the right track; if they were shot down with a stern rebuke or a sarcastic quip, they knew otherwise. Down the hallway, Osler’s lecture room was filled with the sounds of laughter, learning, and discovery; in Dr. Halsted’s amphitheater, the only voice that mattered was his own, and the only mirth that emerged was the nervous, inappropriate laughter of students forced to watch the humiliation of one of their peers.

  OUTSIDE THE OPERATING ROOM and lecture hall, Halsted’s behavior was even more strange. When walking through the corridors of the hospital, he cast his head and gaze downward. Upon spying someone approaching in the distance, he would duck into a stairwell or an empty patient room to avoid any form of contact. If pressed to explain his misanthropy, Halsted gruffly stated that he avoided those he did not care for or who he felt wanted something; those who would delay or bore him; and the multitudes he judged as simply not up to his intellectual rigor.

  The medical staff, students, and resident physicians at Johns Hopkins tolerated William’s rude and quirky behavior because of his surgical wizardry. His endless capacity for generating new, life-saving operative procedures was truly amazing. Indeed, many seasoned Johns Hopkins doctors advised the offended to thicken their epidermis with the tacit understanding that they were encountering the best surgeon in the world.

  Beyond the sharp remarks, reclusive behavior, and rambling lectures, however, were far more troubling behaviors suggesting that Halsted was never quite as clean a recovering addict as the trustees had hoped when they’d appointed him surgeon-in-chief in 1892. To begin, there was Halsted’s erratic attendance at work, due to a slew of vague illnesses and his extended vacations in North Carolina and Europe. Such absences without leave wreaked havoc on the daily routines of the hospital and prompted numerous meetings of and reports to the hospital board. In fact, Halsted’s absenteeism would surely have resulted in immediate dismissal were he a lesser surgeon.

  One odd morning, for example, an entire team of scrubbed nurses and surgeons, along with a nervous and not yet anesthetized patient, waited ninety minutes for his arrival. The flimsy excuse Halsted offered was that he and his wife had been otherwise preoccupied killing rats in their cellar.

  On other mornings in the operating room, “with the scalpel in his hand ready to begin the operation, [Dr. Halsted] paused, stood perfectly still, his face gray with anxiety and suffering. Without referring to his condition, he handed the knife to his assistant with an apology and with the request that he continue the operation.” Sometimes, Halsted simply sat on a nearby stool for a few minutes, watching the procedure he’d been slated to perform; other times, he exited the operating room, scurried to his office, changed into his street clothes, and left the hospital entirely.

  Joseph Colt Bloodgood, M.D., late 1910s to 1920s. (photo credit 10.11)

  The aptly named Dr. Joseph C. Bloodgood, one of William’s former chief surgical residents, recalled that Halsted often complained of severe tachycardia, an excessively rapid heartbeat, or, as Bloodgood described it, a “thumping of his heart” that Halsted ascribed to smoking too many cigarettes. His staff universally accepted such excuses. Gossiping in early 1931 to H. L. Mencken, Bloodgood descr
ibed William’s many departures of duty in a positive vein:

  This gave me an extraordinary amount of experience, and did me a lot of good. So long as Halsted smoked, whoever was surgical resident at the Johns Hopkins had his hands full. When he stopped smoking he began to do all of his own work. The residents then got less experience, and hence amounted to less when they left.

  Halsted was an incurable chain-smoker, and, as noted in the case of Freud’s legendary cigar habit, consuming large amounts of nicotine can yield a rapid beating of the heart and even chest pain. Still, it is not surprising that he preferred to blame the cigarettes that stained his snowy-white mustache a sickly yellow for his debilitating symptoms.

  With clinical retrospection, however, it seems likely that Halsted’s absences and abrupt exits from the operating room had a great deal to do with the other substances he was actively abusing. Taking cocaine, for example, can easily yield trembling hands and annoying heart palpitations, which would prevent a surgeon from operating well. Explaining the effects of morphine is a bit more complicated. If William took too small a dose for his daily morphine requirement or if he tried to abstain completely, he may have experienced withdrawal symptoms, including shaky hands, sweating, and rapid heartbeat, resulting in his professed inability to operate. On the other hand, if he still felt inebriated from the dose of morphine he’d injected the evening before, Halsted might be slow to rise from bed or not show up at the hospital at all.

  Professional or pedagogic rationales aside, one compelling reason William may have been so motivated to organize his famously competitive residency training program was an unending taste for morphine and cocaine. Sitting atop a pyramid of eager young doctors willing to stay up to all hours tending to his patients was the perfect vehicle for a surgeon with severe addiction problems. Halsted needed the nightly comfort of his narcotics or the occasional cocaine binge without having to worry that those he operated upon while sober in the morning might suffer from his indisposition that evening. In essence, his drug-induced absences were covered and enabled by the residents. Given the effects of morphine and cocaine on the size and appearance of one’s pupils, the days he made the least eye contact with his colleagues, or avoided them outright, may have correlated with his recent drug use and fear of discovery. Those periods in which William “began to do all of his own work,” and was all the grumpier for it, likely corresponded with the days, weeks, or months when he was able to abstain from cocaine and could tightly control, if not completely eliminate, his daily dose of morphine.