Michael Neff
Dallas, Texas
Mariam Banoub
Julius Bonello
Peoria, Illinois

Late at night, nearly as exhausted with worry as the patient suffering severe abdominal pain before him, William Halsted made an executive decision. “Mother,” he pleaded, “you have an infected gallbladder and you need an operation.” After more reassurance, Mrs. Halsted, clutching her side, lay on the table and was quickly put to sleep by the ether drop method. After cleaning the skin, William picked up the scalpel and made a six-inch incision. He found the infected gallbladder, quickly aspirated the contained pus, and removed eight gallstones. The year was 1882. The time was 2:00 am. The location was Mrs. Halsted’s kitchen. This harrowing occurrence would be one of the many events that established William Halsted’s legendary and timeless legacy.

William Stewart Halsted was born in 1852 to a well-to-do family in New York City. His family had a strong reputation; Halsted Avenue in Chicago was named for his grandfather and great-uncle who had successful business investments in Chicago, although they only visited the city once. After being homeschooled, William attended Phillips Academy in Massachusetts, then began studies at Yale University in 1869. He pursued his interest in medicine at Columbia, which eventually led to an early internship at Bellevue Hospital working under the renowned Dr. Frank Hamilton, a distinguished Civil War surgeon and author of a leading surgical textbook. Graduating with honors, Halsted continued his pursuit of a career in medicine, first as a non-surgical physician at New York Hospital. He then took this experience and pursued a two-year exploration of Europe, where he found himself under the mentorship of the world’s surgical giants. With new-found knowledge and expertise, he came back to work at New York’s Bellevue Hospital where he developed a relationship with William Welch, a luminary in medical education.

In 1874, the U.S. medical environment was one of miasmatic science, clinical disarray, educational profiteering, and abject barbarism. Halsted’s introduction to surgery came shortly after the discoveries of general anesthesia and the germ theory, but well before the universal adoption of either one in the operating theater. Pioneering surgeons of the time proudly exchanged their finer attire for blood and pus-stained “working coats,” operating with uncleaned, ungloved hands. They worked rapidly to spare prolonged agony and limit largely uncontrolled blood loss. Halsted saw this chaos and was determined to implement some order. Through his expertise and grit, he developed innovative techniques to address many of these problems, including the early adoption of aseptic technique, the first documented blood transfusions, and standardized techniques for hernia repair, gallbladder drainage, and radical breast cancer surgeries. However, not all his contributions were of merit. His implementation of cocaine as a local anesthetic had become an overnight success, but it also led to his own lifelong addiction, which required frequent treatment attempts and hospitalizations. Despite this pitfall, Halsted never lost his curiosity or decreased his productivity. In time, he shifted his focus to medical education and implemented a new residency paradigm with the help of his colleagues William Welch, William Osler, and Howard Kelly at the newly founded Johns Hopkins Hospital and School of Medicine.

Halsted quickly rose through the ranks at Johns Hopkins and was promoted to surgeon-in-chief. With this promotion, he hired residents not only for their potential to become skilled surgeons, but also excellent investigators, educators, and leaders in the field. Among the seventeen residents he took on were future pioneers in neurosurgery, otolaryngology, and urology. Many produced cutting-edge research and went on to become department directors elsewhere. His paradigm had forever changed surgical training, and his legacy lives on today.

Halsted’s teaching methodology, however, was not characterized by the same meticulous attention to detail and careful thought that permeated his operating room and laboratory. He would often disappear for months at a time, returning to a staff whose names he had either forgotten or may never have known in the first place. In the early years of the Johns Hopkins School of Medicine, Halsted shirked many of his teaching responsibilities, appeared for fewer surgeries, and became almost entirely absent in all but the most interesting cases that entered the hospital. What resulted, deliberately planned or otherwise, was the assumption of gradually increasing responsibility by Halsted’s residency staff, with the more senior members taking on the roles of attending surgeon and teacher. At the time, this practice often resulted in animosity, but it also established the structure for modern surgical residency programs. Halsted’s students held residency posts for uncertain and often outrageous time periods, had no guarantee of being kept under his leadership, and were promoted anachronistically. They worked long hours, were sometimes forced out of residency and into specialized careers at Halsted’s bidding, and often relied on the benevolent personality of William Osler for face-to-face mentorship. Their eventual successes, however, cannot be discounted, and it is hard to imagine that such success would have existed without Halsted’s expertise and ardent commitment to the field.

Halsted’s incidental residency paradigm laid a foundation on which medical education would evolve. In the early 1900s, the vast majority of the 155 medical schools in the U.S. were proprietary and taught by volunteer doctors. There were no strict requirements for admission, the second year was a repeat of the first, and the students examined no patients. Some of the schools accepted students directly after high school. This all changed when the United States government commissioned the Flexner Report (1910), which exposed these practices and prompted radical changes within medical schools. Fortunately, at John Hopkins, a group of female benefactors used their financial leverage to require an almost unheard-of admissions prerequisite of four years of undergraduate education, including a working knowledge of two foreign languages and courses in biology, chemistry, and physics. They would also enforce equal acceptance, training, and treatment of women within the hospital and school. Amidst this rapid evolution and the residency model of Halsted, Osler, and Welch, John Hopkins School of Medicine became an exemplary model of medical education.

Reference

Barker C. “Genius on the edge: The bizarre double life of Dr. William Stewart Halsted.” J Clin Invest. 2010 Jul 1;120(7):2253. doi: 10.1172/JCI43427. Epub 2010 Jul 1. PMCID: PMC2898614.