BOOK REVIEW

Genius on the Edge: The Bizarre DoubleLife of Dr. William Stewart HalstedImber G. New York: Kaplan, 2010, 400 pages, $15.99.

Gerald Imber’s biography of William Halsted(1852e1922) is a fascinating portrait of the father ofmodern scientific surgery. Halsted both synthesizedall that came before him and laid the blueprint for allthat followed, up to the present time and beyond, inthe development of surgery as a discipline that reli-ably and predictably comforted and cured patients. Incontrast to his surgical contemporaries and pre-decessors, in the era of nonanesthetic, dirty surgerywith all the subtlety of a Cossack swordsman, at fullgallop, beheading an enemy (a 30-s leg amputation asa source of professional pride for an 1870s surgeon),1

Halsted used all anesthetic, microbiological, andanatomical resources available to safely and meticu-lously treat former scourges such as cholecystitis,breast cancer, goiter, and inguinal hernia. Like itssubject, the Imber’s biography has its flaws, but it, inthe end, makes for fascinating reading on its own andis also a great starting point in the study of theinscrutable Halsted.

William Halsted was the son of a prosperous,prominent New York City merchant family. As anundergraduate at Yale, this Knickerbocker aristocratexcelled at sports while somnambulating academi-cally, apparently making zero withdrawals from theuniversity library. In a case of academic spontaneousignition, he started reading a physiology text as a Yaleupperclassman, and then proceeded to a stellar per-formance as a Columbia medical student. Halsted alsoexcelled as a surgery resident and was a sought-afterpractitioner and teacher in the early 1880s.Working allover town, his OR list stayed full, while his “quiz”—tutoring medical students outside of class—was thebest in all of New York, powered by Halsted’s extro-verted energy and curiosity along with his determi-nation to bring the best of European, especiallyGerman, methods of care to the United States.

Insatiable in his appetite for new knowledge,Halsted came upon a report in 1884 that led to aninnovation with far-reaching consequences for bothHalsted and health care in general. The report thatfired Halsted’s imagination came from Austria. CarlKoller, an ophthalmologist, reported on a new topicalanesthetic that could be dripped into the eye,rendering it numb. The new drug was cocaine. Using

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injected cocaine, Halsted invented regional anes-thesia, doing peripheral nerve blocks on basicallyevery trunk and branch that he could reach, workingwith a cohort of fellow practitioners and medicalstudents. Before long, Halsted and most of his co-horts were unwittingly addicted. Ultimately, Halstedceased practicing for a time and went to a RhodeIsland sanitarium for 2 lengthy stays. Halsted’s doc-tors ultimately managed him by a switch to morphine.Halsted apparently maintained himself on around 120to 190 mg (2e3 grains) of morphine per day there-after, as revealed by William Welch and WilliamOsler long after the fact.2,3 Interestingly (or tellingly),Halsted did not accept credit for his cocaine nerve

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block innovations until April 1922, when a literaturesearch by the National Dental Association determinedthat Halsted should receive credit for developingregional anesthesia.4

Although a closely held secret for decades,Halsted’sdrug addiction (morphine on a steady basis, possibleintermittent cocaine relapses) continued until the timeof his death, but he put up a hard fight with his afflic-tion, which likely killed most of his nerve block co-investigators.5,6 In a case of beneficial enabling,secondary to the extraordinary quality of his work,Welch and Osler benefitted countless patients bysticking by Halsted, who was Johns Hopkins’ firstProfessor of Surgery. Their support for their addictedcolleague throughhis 1885 to 1886nadir andonward intime allowed for multiple breakthroughs, including thefirst effective treatments for breast cancer, goiter, her-nia, cholecystitis, and overall concepts of atraumatic,aseptic surgery. Additional Halstedian breakthroughsincluded the use of rubber gloves in the operatingtheater; early blood transfusions; a formal structure forresidency training of new surgeons; and assisting withthe creation of the surgical and allied subspecialties ofneurosurgery (Harvey Cushing), urology (HughYoung), otolaryngology (Samuel Crow), surgical pa-thology (Joseph Bloodgood), and radiology (FrederickBaetjer), among many sterling achievements.

Dr. Imber’s book is difficult to put down, but aserious lack of clear footnoting is a flaw. In a subjectas controversial as Halsted’s narcotic addiction, thisis a problem. With information on Halsted’s drugproblem dribbling out only slowly, likely incom-pletely, after the Chief’s 1922 death (ironically, fromgallbladder disease), it is hard to know in this bookwhere eyewitness reports and recollections start andwhere we are venturing into speculation, regardlessof how well intended and researched. In surveyingthe autobiographical recollections of Halsted’s majoracolytes such as Finney (1940), McCallum (1930),and Crowe (1957), the cocaine episode was describedas past tense. In 1952, George Heuer gave a mostthorough catalog of oddities of the Professor’s pro-fessional performance, cataloging late arrivals, non-appearances, and early departures from operations inprogress or the hospital at large, attributing the quirksto gallbladder disease. In 1969, Oslers’s secret historyof Johns Hopkins Hospital came into print, detailing

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the fact that Halsted never stopped using morphine.Sherwin Nuland, in 1988, connected more dots,conjecturing that Halsted’s absences, daily disap-pearances at 4:30 PM, and lengthy solo vacations toout of the way hotels in England and Europe werelikely solo pharmaceutical binges, corroboratingCushing’s posthumously released reminiscence, asquoted by Howard Markel.5,7e11 In surveying theseHalsted resources, Imber’s conclusions are likelyhighly accurate, but lack of detailed attribution forvarious assertions is a serious weak point.In summary, this life history of a true colossus of

medicine and surgery is fascinating. Dr. Imber’s bi-ography of William Halsted tells of Olympian heightsrefining and perfecting scientific surgery and gutter-level struggles of addiction. Although weak on pre-cise sourcing, the book tells a fascinating tale and isa great springboard to further study of a larger thanlife genius who was also very much an ordinaryhuman being.

David E. Tate, Jr, MDLouisville Arm and Hand

Louisville, KY

http://dx.doi.org/10.1016/j.jhsa.2014.05.016

REFERENCES

1. Nuland S. Doctors: The Biography of Medicine. New York: Knopf;1988:413.

2. Holman E. Sir William Osler and William Stewart Halsted—twocontrasting personalities. Pharos. 1971 Oct:134e139. 144.

3. Osler W. The inner history of the Johns Hopkins Hospital. Bates D,Bensley E, eds. Johns Hopkins Med J. 1969;125:184e194.

4. Markel H. An Anatomy of Addiction: Sigmund Freud, WilliamHalsted and the Miracle Drug Cocaine. New York: Pantheon; 2011:234e235.

5. Markel H. An Anatomy of Addiction: Sigmund Freud, WilliamHalsted and the Miracle Drug Cocaine. New York: Pantheon; 2011:238e239.

6. Nuland S. Doctors: The Biography of Medicine. New York: Knopf;1988:396.

7. Finney JMT. A Surgeon’s Life. New York: GP Putnam; 1940:84e105.

8. McCallum WG. William Stewart Halsted, Surgeon. Baltimore: JohnsHopkins; 1930:51e57, 104e109, 194e208.

9. Crowe SJ. Halsted of Johns Hopkins: The Man and His Men.Springfield, IL: Charles C. Thomas; 1957:29e30.

10. Heuer G. Dr. Halsted. Johns Hopkins Med Bull 1952;(Suppl 90):1e105.

11. Nuland S. Doctors: The Biography of Medicine. New York: Knopf;1988:397.

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