Re-Examining The Father Of Modern Surgery.

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Connecting The Dots Between PhRMA And Congress

TERRY GROSS, host:

This is FRESH AIR. I'm Terry Gross. When Barack Obama was running for
president, he promised to change Washington's culture of lobbyists.
Here's one of his campaign ads.

(Soundbite of political advertisement)

President BARACK OBAMA: The pharmaceutical industry wrote into the
prescription drug plan that Medicare could not negotiate with drug
companies. And you know what? The chairman of the committee who pushed
the law through went to work for the pharmaceutical industry making $2
million a year.

(Soundbite of crowd moaning)

Unidentified Woman: Imagine that.

Pres. OBAMA: Imagine that. That's an example of the same old game-
playing in Washington. You know, I don't want to learn how to play the
game better. I want to put an end to the game-playing.

(Soundbite of applause)

GROSS: Okay, the person referred to in that ad, the chairman of the
committee who pushed through the law and then went to work for the
pharmaceutical industry, is Billy Tauzin. Within a few months after
Obama became president, his administration was secretly negotiating with
Tauzin, who was then the head of PhRMA, the pharmaceutical industry's
lobby group.

The deal he made with the pharmaceutical industry and what he gave up to
bring them on board for his health care plan is detailed in an
investigative article by my guest, Paul Blumenthal. Blumenthal is a
senior writer with the Sunlight Foundation, a nonprofit organization
dedicated to making government more open and transparent.

Paul Blumenthal, welcome to FRESH AIR. So why do you think the Obama
administration wanted to meet with the pharmaceutical industry? What did
he want from them?

Mr. PAUL BLUMENTHAL (Senior Writer, Sunlight Foundation): I think that
what he was looking to do - which was definitely something that he
promised to do in the campaign - was to bring everyone to the table, and
that included special interest groups and industry groups and try to get
them to back a piece of legislation by any means necessary.

He was looking at a way to get this done and to diffuse the actors and
lobbyists in Washington so that they wouldn't run advertising against
legislation, and they wouldn't lobby against legislation. And that
involved making some serious concessions to industry.

GROSS: So let's look - before we get into the actual meetings, like who
met and what kind of dealings they had, let's just talk about the
agreement that the Obama administration reached with the pharmaceutical
industry. What did the Obama administration get out of it? And then
we'll talk about what the pharmaceutical industry got out of it.

Mr. BLUMENTHAL: Well, what the Obama administration got out of it was
taking the biggest lobby in Washington and putting them onto the side of
health care reform, as opposed to having them oppose the legislation.
They received around $100 million in advertising to support the
legislation, spent by PhRMA, the industry trade group. That certainly is
a big deal if you're trying to push a kind of bill like this.

GROSS: And what did the pharmaceutical industry get out of this deal
with the Obama administration?

Mr. BLUMENTHAL: Basically, what they got was that Congress would not
legislate any kind of cost-cutting that would make a serious dent in
industry profits, and that includes taking things off the table like re-
importation of drugs from first-world countries or...

GROSS: In other words, buying drugs at cheaper prices from other
countries, like Canada.

Mr. BLUMENTHAL: Yes. Yes.

GROSS: Yeah. What else?

Mr. BLUMENTHAL: Allowing Medicare to negotiate for cheaper drugs, just
as the Veterans Administration does in their health care program. These
were pretty big Democratic policies that had been supported by the
Democrats since 2003 and by then-candidate Obama in the 2008 elections,
and the administration allowed these kind of policies to be pushed off
to the side so that they could support of the pharmaceutical industry.

GROSS: The pharmaceutical industry promised the Obama administration
savings up to $80 billion. Through what?

Mr. BLUMENTHAL: Most of that was through partially closing what's called
the doughnut hole in Medicare Part D, where at a certain point of
spending on prescription drugs, you enter this hole where you don't have
any coverage for that amount of money. And once you get over a certain
amount, you have more coverage. So it was $30 billion to partially cover
those drugs being spent for people spending over a certain amount of
money within Part D on prescription drugs. That was the majority of it.

GROSS: So let's look at who was at these secret meetings between the
Obama administration and the pharmaceutical industry. First of all, how
many meetings were there? Was this, like, a series of meetings that
ranged over a period of time?

Mr. BLUMENTHAL: This was definitely a series of meetings with the White
House that totaled around four or five that show up on the White House
visitor logs, which the White House has made publicly available for the
first time. And the people involved are Billy Tauzin, who is the
pharmaceutical industry's chief lobbyist for their trade group, PhRMA.
And the other main actors include the CEO of Pfizer, which is the
largest pharmaceutical industry company, CEO of AstraZeneca, the CEO of
Abbott Laboratories. These are pretty much the main people who you see
show up in most of these meetings with the White House and with the
Senate Finance Committee Chairman Max Baucus.

GROSS: And who are the main representatives from the Obama
administration meeting with these members of the pharmaceutical
industry?

Mr. BLUMENTHAL: The chief people include the chief of staff at the White
House, Rahm Emanuel, and the deputy chief of staff who is involved in
more of the meetings, Jim Messina, who happens to be the former chief of
staff to Max Baucus in the Senate.

GROSS: So Max Baucus, who is the head of the Senate Finance Committee
that drew up the Senate health care bill, he already had contacts with
the health care industry. How did he make those contacts?

Mr. BLUMENTHAL: Well, those contacts were made over a series of years.
He was previously the ranking member of the Senate Finance Committee
when the Republicans were in charge, when they were passing prescription
drug expansion for Medicare. And he was deeply involved in those
negotiations for that legislation.

He also has a large number of former staffers who have gone on to lobby,
and a number of those have become lobbyists for pharmaceutical industry
groups and for other health care organizations. One of the chief former
staffers of his is his former chief of staff, David Castagnetti, who is
a major lobbyists in Washington, who lobbies for PhRMA and America's
Health Insurance Plan, among another maybe 10 or so health care
companies. Baucus is also a major fundraiser in - from 2003 to 2008,
raised well over a million dollars from the health care industry for his
election.

GROSS: If you're just joining us, my guest is Paul Blumenthal. He's a
senior writer with the Sunlight Foundation, which is a nonpartisan,
nonprofit group that advocates for more openness and transparency in
government.

Now, Billy Tauzin is an interesting character, and he is the chief
lobbyist for PhRMA, the main pharmaceutical industry lobby. He has an
interesting history in terms of how he crossed over from Congress to the
pharmaceutical industry. Tell us a little bit about his history as a
congressman.

Mr. BLUMENTHAL: Well, Billy Tauzin was a longtime Democrat in the House
who, in 1994, after the Democrats lost their majority, switched over to
being a Republican. As a Republican, he held the same seniority that he
had as a Democrat and began to quickly move up to become the chairman of
the House Committee on Energy and Commerce, which is one of the most
powerful committees in the House of Representatives.

And in 2002 and 2003, he took up this issue of expanding Medicare to
cover prescription drugs, and at this time, it was a pretty
controversial issue for Republicans, as many of them opposed this new
expansion of safety net program, and Tauzin seriously pushed for this
bill, helped craft the bill and, in a lot of instances, met behind
closed doors with pharmaceutical industry leaders to help craft the
bill, which did not include any of these cost-cutting measures that
we've already talked about that he later on got to keep out of the 2009
health care reform bill: re-importation of drugs, negotiations like the
VA has.

So the bill was seen by a lot of people as really just a handout to this
industry, and pretty soon afterwards, he announced he was retiring from
Congress and that he was in negotiations with the pharmaceutical
industry lobby to become their president at a $2-million-a-year salary.

GROSS: So how much of a role do you think that the pharmaceutical
industry leaders and lobbyists who met with Max Baucus, how much of a
role did they have on shaping the bill that emerged from his committee?

Mr. BLUMENTHAL: I don't know if I can totally answer that question, but
I think considering Baucus' history, I'm sure that there was a decent
amount of industry influence.

I think that the key in what happened in Baucus' committee is that the
White House made this deal with the pharmaceutical companies and told
them to only go through Baucus, that they were only supposed to work
with him, and no other committee in Congress really knew about these
deals going on behind the scenes, except for Baucus.

And so the entire health care reform effort really relied on whatever
process Max Baucus was going to go about using to create a bill, which
wound up being a fairly drawn-out process after bills had passed every
other relevant committee in the House and the Senate.

GROSS: So what about the House of Representatives? Like, there was no
similar committee from that House that was represented in this deal-
making?

Mr. BLUMENTHAL: No. The major committee in the House of Representatives
is the House Committee on Energy and Commerce, which is headed by Henry
Waxman, who's a noted foe of the pharmaceutical industry. And he
included a number of these provisions in the House bill that were just
verboten for the pharmaceutical industry and the Obama administration,
that they'd already made this deal on that whatever Waxman was putting
in, it just wasn't going to happen.

But what did happen in the House was Waxman's bill really scared the
pharmaceutical industry and forced their hand to make the Obama
administration admit that a deal was made.

GROSS: What do you mean by that?

Mr. BLUMENTHAL: So Waxman's bill passed around July 31st, and then we
went into the August recess. And at that time, the board of PhRMA got a
little skittish by seeing this bill with everything that they had
thought that they would have eliminated: re-importation of drugs and
negotiations for Medicare Part D and a number of other cost-cutting
measures that well above the $80 billion that they had agreed to and
thought that maybe the Obama administration was trying to fool them.

And so Billy Tauzin came out in an article to the L.A. Times and
explained that a deal had been made with the White House and sort of
forced the hand of the White House, who, a couple days later, were
quoted as saying that this deal did exist.

GROSS: So the head lobbyist for the pharmaceutical industry leaked the
deal that the industry had made with the Obama administration because
they were afraid Obama would renege on it after the House passed a bill
that had all the things that the industry had wanted taken out?

Mr. BLUMENTHAL: That's correct.

GROSS: My guest is Paul Blumenthal, senior writer for the Sunlight
Foundation. We'll talk more about the secret negotiations between the
pharmaceutical industry and the Obama administration after a break. This
is FRESH AIR.

(Soundbite of music)

GROSS: If you're just joining us, my guest is Paul Blumenthal. He's a
senior writer with the Sunlight Foundation, which is a nonpartisan,
nonprofit group that advocates for more openness and transparency in
government.

When Senator Max Baucus was meeting with pharmaceutical lobbyists,
working on this compromise that the lobbyists had agreed to at the Obama
administration, was he getting money from those lobbyists, too?

Mr. BLUMENTHAL: Well, I think that Baucus did a very smart thing as a
politician handling this kind of issue and actually refused money from
health care PACs and lobbyists during the course of 2009. So he actually
wasn't getting any money in 2009.

However, his previous election campaign, from 2003 to 2008, he received
well over a million dollars from health care industry players.

GROSS: Can you give us a sense of how much money and how many lobbyists
the pharmaceutical industry has?

Mr. BLUMENTHAL: Well, the pharmaceutical industry in total certainly
spends over $100 million, probably, on lobbying. I know that the trade
group PhRMA, who is deeply involved in this, spent $28 million in 2009,
which was a record for them, and had hired $165 lobbyists. And that
includes their in-house lobby shop and outside lobbying firms.

And from going over these names of these lobbyists, I was able to
determine that 137 of them had previous experience in government,
whether in Congress or in the executive branch.

GROSS: How do they do it? How do they push, and what is the money used
for? What did that $28 million go to?

Mr. BLUMENTHAL: I don't know exactly what the $28 million goes to.
Lobbying disclosures are very opaque. I know that they're supposed to be
transparent disclosures, but they aren't, really, and we only really
know how much they spend and not what they spend it on. We don't even
know the salaries of lobbyists or who lobbyists are meeting with, and
it's a serious problem in trying to cover these kinds of issues.

GROSS: One of the things that the pharmaceutical industry promised to do
in its deal with Obama was to spend up to $150 million on advertising.
Why was that important to the Obama administration?

Mr. BLUMENTHAL: Well, they really didn't want to have a replay of 1993
and 1994, with the Harry and Louise ads run against the health care
reform proposal put out by Bill and Hillary Clinton. And they really
wanted to diffuse that situation by getting these industry players to
back health care reform and to have them spend this large sum of money
on advertising in key states in key congressional districts for pushing
members of Congress or pushing their constituents to call their members
of Congress in support of the legislation.

GROSS: Now, you write that the company that was hired to produce the ads
and to place the ads was a company that David Axelrod, one of Obama's
chief advisors and one of his chief campaign managers, the company that
he used to be a partner in.

Mr. BLUMENTHAL: Yes. His company, which still employs his son and still
owes David Axelrod $2 million, was the initial company to be hired to
place the beginning $24 million in advertising that was spent through to
advocacy organizations that were created in a secret meeting between Jim
Messina, John Selib, the chief of staff to Max Baucus, and the
pharmaceutical industry and a number of other groups.

GROSS: So anything about that that, to you, does not pass the sniff
test? I mean, I could see why the Obama administration would want that
company to do the ads. They obviously felt that company did a great job
with the Obama campaign. So is there anything that seems not right to
you about that?

Mr. BLUMENTHAL: It definitely appears questionable, and I don't think
we've heard enough answers about why that company was chosen. The
pharmaceutical industry says that they chose that company because it was
one of the better advertising companies out there. And why wouldn't they
go with the company that had run ads for President Obama?

GROSS: What were some of those ads? Refresh our memories. Which were
these ads?

Mr. BLUMENTHAL: Some of the first ads that they played actually brought
back the characters of Harry and Louise from the 1993 advertisements
against health care reform. And in these advertisements, Harry and
Louise are now talking about the rising costs of health care and why
they actually do need health care now. And this was in support of the
legislation.

GROSS: And when those ads were shown, was it clear that it was the
pharmaceutical industry who was funding the ads?

Mr. BLUMENTHAL: Absolutely not. Actually, these were run through an
advocacy organization called Healthy Economy Now, which included a
number of other groups, including labor unions like SEIU and the Robert
Wood Johnson Foundation, and they don't have to disclose in their
advertising who is paying for these ads. But most of the money came from
the pharmaceutical industry and from PhRMA.

GROSS: The health care bill appears to be stalled. Scott Brown was
elected to replace Ted Kennedy's seat in the Senate. He's a Republican.
So the Democrats no longer have that 60-seat super-majority that's
needed to block a filibuster. So with health care stalled for now, where
do you think that compromise between the Obama administration and the
pharmaceutical industry stands?

Mr. BLUMENTHAL: Pharmaceutical industry CEOs are still mostly backing
the deal and would still love to see a health care reform bill passed
with only the $80 billion in cost-cutting. The passage of the bill would
certainly be a windfall for the industry. They'd have so many more
people with health insurance coverage who would be able to purchase
pharmaceuticals, and with the small amount that they agreed to on cost-
cutting, their profits would shoot up exponentially. There's no doubt
that they're happy about what they got out of this, for the most part,
but they're definitely not thrilled with the fact that they spent 100 to
$150 million in advertising, and it really seems like this legislation
is not going to pass.

GROSS: Shortly after Scott Brown was elected to the Senate, Billy Tauzin
resigned. He resigned around the second week of February. What do you
know about why he resigned?

Mr. BLUMENTHAL: There are some people, some of the board members are
saying that they didn't like his style, and there are other reports that
there are a number of board members who weren't involved in this deal
who never really liked the deal to begin with.

And I think that probably one of the better explanations is that Billy
Tauzin and a number of these board members made this deal, and part of
the deal was to spend 100 to $150 million in advertising for a bill that
wound up going nowhere. And that's kind of a bad way to run a business,
even for a lobbying firm, is to spend that much money and get nothing
out of it.

GROSS: Well, Paul Blumenthal, thank you very much for talking with us.

Mr. BLUMENTHAL: Thanks for having me.

GROSS: Paul Blumenthal is a senior writer at the Sunlight Foundation,
which is dedicated to making government more open and transparent. You
can find links to his investigative articles on our Web site:
freshair.npr.org.

Today, president Obama released a new blueprint for health care reform.
It does not include part of the deal he made with the pharmaceutical
industry. On Thursday, he plans to hold a health care summit with
Democrats and Republicans.

I'm Terry Gross, and this is FRESH AIR.
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Re-Examining The Father Of Modern Surgery

TERRY GROSS, host:

This is FRESH AIR. I’m Terry Gross. Chances are you’ve never heard of
William Stewart Halsted. But if you’ve ever had a surgical procedure of
any kind, you could say he's affected your life. Halsted was born in the
1850s, when Americans were in appallingly poor health. Only half the
children born lived to age five. More New Yorkers were dying from
disease every year than were being born.

The practice of medicine was crude, and operations, when conducted, were
barbaric. Surgeons worked with dirty hands, and nearly every patient
developed serious infections.

Our guest Gerald Imber says no one did more to modernize medical surgery
than William Halsted. He brought rubber gloves and sterile instruments
to the operating room. He developed several innovative surgical
techniques and revolutionized medical training. But he also suffered for
decades from cocaine and morphine addictions, which he acquired while
experimenting with anesthetics for surgery.

Gerald Imber is a plastic surgeon who's written several books. His
latest is "Genius on the Edge: The Bizarre Double Life of Dr. William
Stewart Halsted." He spoke with FRESH AIR contributor Dave Davies.

DAVE DAVIES, host:

Gerald Imber, welcome to FRESH AIR. William Halsted, he became known for
conducting operations in ways that prevented infection and other
advances. But even in his early years, he was an innovator. You tell the
story that he did the first emergency blood transfusion, which was kind
of a remarkable tale. Tell us what happened.

(Soundbite of laughter)

Dr. GERALD IMBER (Plastic Surgeon, Author): Yeah. He was a young surgeon
practicing in New York, and he was fairly successful. And his sister was
in Albany and was giving birth to a child, and he was called up there to
see her and to visit with her, and she began to hemorrhage. And her
husband - who happened to be one of Halsted's friends and a physician,
as well - and the obstetrician couldn’t stop the bleeding. And Halsted
was called in with them, and they packed her uterus with ice and gauze,
and she became very, very weak and pale and was going into shock. And he
drew blood from his own veins and injected into her. And it was claimed
that she perked up, and this saved her life.

In retrospect, there are a couple of amusing things about the story. A:
a few syringes full of blood will not make the difference. It won't -
and that's not the difference between life and death. The second thing
is: taking unmatched blood and donating it, as it were, to someone else
is a recipe for disaster. And he luckily got away with it perhaps,
because of the genetic closeness from sister and brother. But it's an
interest anecdote. It was the first time anyone recorded a blood
transfusion in an emergency situation, but he might very well have made
the situation worse under different circumstances.

DAVIES: He certainly wasn’t afraid, in an emergency, situation to take
direct action, and you begin the book with a remarkable tale involving
his mother.

Dr. IMBER: Yes. It's an interesting story. In 1882, Halsted had been in
practice for a couple of years, and his mother was visiting this very
same sister up in Albany. She - his mother had lived in New York. And
she had, for a long time, had abdominal pain that radiated to her back
and a sour taste in her mouth and just constant discomfort. And all the
great doctors in New York couldn’t make the diagnosis. But while she was
visiting in Albany, she became extremely sick. She became moribund, and
Halsted was called up to see her.

He arrived in the middle of the night with all his surgical instruments.
He had his mother placed on the kitchen table and examined her. And he
noticed under her - the right rib cage, she had a red-hot mass. And when
he touched it she flinched and pulled away. And he immediately made the
diagnosis of an acutely inflamed gallbladder with puss in the
gallbladder and gallstones.

And on the kitchen table in Albany, he put his mother to sleep with some
ether that he brought with him. Then he took his instruments and put
them in carbolic acid, then dipped his hands in carbolic acid and took a
scalpel, opened his mother's abdomen on the kitchen table, then opened
her inflamed gallbladder, allowed a copious amounts of puss to be
removed from the gallbladder - to run out of gallbladder, removed seven
gallstones and saved his mother's life. And that was the first recorded
incidence of anybody ever having removed gallstones surgically.

DAVIES: Wow. Did...

(Soundbite of laughter)

Dr. IMBER: With his mother on the kitchen table in Albany.

DAVIES: And did he repeat the surgery, and did it then become more
widely practiced?

Dr. IMBER: It became very widely practiced. And over the course of the
next number of years, as sterile technique became available every place
and people realized that that's what was necessary for survival, one had
two things that weren't available before: one had anesthesia and sterile
technique. So people became more adventurous in general, and gallbladder
surgery became fairly routinely done. Appendectomies became routinely
done.

Halsted actually realized that one of the surgeries that had been done
throughout history and never, never successfully, was the correction of
hernias - anglinal hernias. He devised a method to correct hernias
surgery, which was successful in 90 some-odd percent of the cases.

DAVIES: Right. And remind us - I mean a hernia is - it's when a piece of
the intestine sort of penetrates the containing wall? You describe it.

Dr. IMBER: Yeah, that's exactly right. I have nothing to add. I rest
your case.

(Soundbite of laughter)

DAVIES: William Halsted was an innovator in specific types of surgery.
But you make the case here that what he really did that benefited all
surgeons forever more was to develop techniques which avoided infections
which had been so deadly before. Tell us how he did that.

Dr. IMBER: There was - first of all, there were three things he actually
did that were critical in that sphere. Now - and those things were A:
realizing that using sterile technique alone as Lister had done wasn’t
quite good enough, that you had to use truly aseptic technique.

DAVIES: That's Joseph Lister...

Dr. IMBER: Yeah.

Dr. IMBER: ...who, before him, had developed the technique of what,
soaking things in carbolic acid, right?

Dr. IMBER: Yes.

DAVIES: Okay.

Dr. IMBER: Which was the greatest step forward, but Halsted said that
kills the infection that's there. Why don’t we prevent the infection
from getting there? And that's by the development of aseptic technique.
And he actually had the audacity as a surgeon in practice three years in
New York City to get on the staff of Bellevue Hospital and ask them to
build a sterile operating room just for his use. And when they laughed
him out of the room, he raised the money and built a tent on the grounds
of Bellevue Hospital that had a floor laid in maple like a bowling
alley, had gaslights and sterilization and was an operating room that
cost $10,000 in the 1880s for his exclusive use. And it was the first
sterile operating theater in New York, and probably in the world.

But taking it a step further, he recognized the fact that the surgeon's
hands were the main culprit in spreading the infection. So he insisted
on all sorts of sterilization techniques for the surgeon's hands,
ultimately resulting in - serendipitously, perhaps - but resulting in the
use and development of rubber gloves for surgery. So...

DAVIES: Yeah, how did that happen? Because, you know, he was cleansing
the hands. How did he move to rubber gloves?

Dr. IMBER: Well, his scrub nurse when he was at Johns Hopkins became
allergic to the caustic solutions with which the hands were cleaned, and
she had this terrible dermatitis. And, you know, one day, he was
visiting at the Goodyear Rubber Company in New York for something else
and he said, well, why don’t you develop a pair of rubber gloves for us
that we could use to protect the nurses hands from the caustic solutions
and that we could sterilize? And they did so. And it was very useful for
nurses, and the nurses adopted it regularly. And the surgeons didn’t
adopt it regularly for another six years. But when they did, that was
the greatest step forward in preventing the transmission of infection to
patients.

DAVIES: How did his ideas spread?

Dr. IMBER: Well, his ideas spread because he was the first great teacher
of surgery. And at one point, the overwhelming majority of the
professors of surgeries around the United States were all his disciples.
So the Halsted method of surgery, the Halsted method of teaching surgery
was what became the American method of surgery, which became the most
important in the world.

From his seed came almost all the great surgeons in America, and every
one of us, every practicing surgeon in any specialty in - maybe in the
world, but definitely in America - can trace his lineage back to
Halsted. And every patient who has ever had successful surgery for any
problem in America owes a debt of gratitude to Halsted because his
technique of teaching surgeons and teaching surgeons what to do is what
turned the corner for us.

DAVIES: We're speaking with Gerald Imber. His biography of Dr. William
Stewart Halsted is called "Genius on the Edge." We'll talk more after a
break.

This is FRESH AIR.

(Soundbite of music)

DAVIES: If you’re just joining us, our guest is Dr. Gerald Imber. He has
a new biography of Dr. William Stewart Halsted, who perfected many
modern techniques of surgery. The name of the book is "Genius on the
Edge."

I want to talk about one more particular kind of surgery that he
innovated, and that was the treatment of breast cancer. First of all, I
mean, this was not an uncommon cancer to women in his time. What was
typically done before?

Dr. IMBER: Well, there were a number of things that affected what was
done with breast cancer prior to the turn of the 20th century. And
basically, in that Victorian era, there was no self-examination, and
women didn’t go to doctors to have their breasts examined. People didn’t
go to doctors, period, until there was some emergency, and there was no
such thing as a checkup. So women would know something was wrong when a
baseball-sized tumor was felt or there was a separating mass - an
effective mass in their breast.

And, of course, as we know now, that's way too late for a successful
treatment, in most cases. So what was done in those days was basically
watch people die. And then some people had the idea of removing the
tumor and the local tissue and removing the breast. And you have to
remember that the patients, for the most part, were patients with very
advanced disease. And the way a successful treatment of that disease was
measured was not by ultimate five-year or 10-year survival rates, but by
the absence of local recurrence of the disease. So you do the
mastectomy, and if there wasn’t cancer visible in the area of the chest
later, then it was considered something of a success.

Halsted developed a method by which the breast and the central tumor and
the whole breast around it and the underlying musculature removed in one
piece - which is called on block - in one large piece, and he never cut
through the tumor because he knew that would spread it, and he took the
lymph nodes out in the surrounding areas. And he had more than a 50
percent incidence of absence of local recurrence or cure of cancer by
the yardstick of the day, whereas everybody else had a virtual zero
percent success rate in curing the cancer.

And he called his operation the radical operation for cure of cancer of
the breast, which it was. And that became what we know as the radical
mastectomy, which was the gold standard operation for the next 50 or 60
years, and which - because of innovative doctors and pressure from
women's groups - ultimately became - evolved into the modified radical
mastectomy, and then evolved into the lumpectomy with radiation.

DAVIES: Halsted spent his early years in New York, but eventually
settled in Baltimore because he was on the faculty of Johns Hopkins
University. And a good part of your book describes what an innovative
place it was. Just give us a little sense of what was unique about Johns
Hopkins and its, you know, its place in the history of American medical
education.

Dr. IMBER: Well, the Johns Hopkins Hospital was opened in 1889, and it
was really the first hospital that had the idea of being integrated into
a medical school with professors who would work at the hospital and in
the medical school rather than people who would drop by to teach a
little bit. And it was the first place that actually revered science and
began with the idea of promoting scientific medicine.

And Hopkins - Mr. Hopkins, in his will, when he left some $7 million for
the creation of the hospital and the university, made it clear that the
best men available in the world were the first priority. And the people
who were on his board of trustees took that to heart, and they found the
best people in the world in the period of 1880, '85 or '86, when they
were being recruited. And these included William Osler, who was perhaps
the most important physician ever, William Welch, who was the great
pathologist and the ambassador of scientific medicine to the world,
William Halsted, and the great gynecologist Howard Kelly. But it was the
first place where a scientific academic faculty was gathered for the
teaching and advancement of medicine. And they had research
laboratories, which never happened before.

DAVIES: Well, Gerald Imber, there's another side to Halsted's life, and
that is his narcotics addictions, which began with cocaine. How did he
first get introduced to it?

Dr. IMBER: Well, the story starts with, of all people, Sigmund Freud. In
1885, Freud was a neurologist in Vienna, and he had read about this new
drug, this new alkaloid cocaine, which allegedly German troops were
taking and were able to stay up for days on end and fight and not eat.
And Freud got some cocaine. He tried it himself. He felt it had great
potential, and he enjoyed the sensation of using it, as well. And he
also noticed that there was a numbness of his tongue in any place that
the drug touched.

And he and a friend started using it for topical anesthesia for people
with an eye disease called trachoma, which is very painful. And they
found that the eye became numb and the pain from the disease was
abolished. So he had the idea that perhaps it might be useful other
places. But meantime, some young man who was working with him began to
use the cocaine for - to numb the eye and to do surgery on the eye under
cocaine aesthesia. He published that.

Halsted read about it in New York in the New York Medical Journal, and a
week later, he got a supply of cocaine and he started injecting cocaine
into all of his medical students and all of his associates to determine
how he could best block nerve impulses. And his idea was that if it
makes things numb, that it could block the impulse from a nerve, stop
pain and you could do surgery under local anesthesia.

And he began to use it successfully and used it on about a thousand
patients at Roosevelt Hospital where he was working in the outpatient
department. And he also introduced it to dentists to be used for local
anesthesia for dentistry, and it changed the face of dentistry. But
while he was learning how to use cocaine, there were a number of side
effects that people had. But the worst of it was that the majority of
the medical students involved became addicted, all of his associates
became addicted, a number of them died, and a number of them just
dropped out.

DAVIES: And he began using it himself, too, and he became addicted?
Yeah.

Dr. IMBER: Well, he began using it on himself because he experimented on
himself first, and he not only liked the feeling that it gave him
socially, but he soon became addicted to it and developed a tolerance to
it. And to get - he needed to have the cocaine, and to get that same
level of euphoria, being the dosage that he needed increased, and he was
injecting enormous quantities of cocaine. And at times, the things he
wrote were total gibberish. And people would visit with him and say he
stayed up all night talking nonsense in an animated fashion.

And finally, his family members did what we would call an intervention,
and they took him off to Butler Hospital in Providence, Rhode Island
where, obviously, cocaine addiction was not very well-known. It was not
heard of. So they did the only sensible thing to break the cocaine
addiction: They treated him with morphine. So he became addicted to
morphine, also.

DAVIES: And did there come a point in which the dangers of the drug were
realized and people stopped using it as an aesthetic? Or what happened?

Dr. IMBER: Well, not very soon. Once Halsted got his life almost under
control - he never quite did. That, of course, was the precipice on
which his genius was balanced. But once he got his life in order, he
would never voluntarily use cocaine as a local anesthetic because he
shied away from it. He kept on using it as his addictive drug of choice,
but he just didn’t want other people to use it and he was against it
because he knew what it did.

But cocaine was a great local anesthetic. And until the advent of a drug
that we all know as Novocain, cocaine was what every dentist used, what
every minor surgery was done under, what most hernia repairs were done
under. As long as the dose was very small and it was limited, and other
medications were given afterwards, it didn’t result in the patients
becoming addicted. But cocaine was what you were injected with when you
went to have a cavity filled.

DAVIES: We're speaking with Gerald Imber. His biography of Dr. William
Stewart Halsted is called "Genius on the Edge."

We'll talk more after a break.

This is FRESH AIR.

(Soundbite of music)

DAVIES: If you’re just joining us, our guest is Dr. Gerald Imber. He has
a new biography of Dr. William Stewart Halsted, who pioneered many
techniques of modern surgery. The name of his book is "Genius on the
Edge."

It’s interesting that Halsted wasn’t even a drinker. I mean, but these
addictions stayed with him after he was - he went from New York to
Baltimore to work at Johns Hopkins and became this admired, you know,
figure of enormous stature in medicine. Right?

Dr. IMBER: Well, he was, you know, abstemious, as you mentioned. And,
you know, he was judgmental and he was difficult and he was the sort of
person that was forbidding and - but the same token, he was a human
being and he was as weak as anyone else. And breaking the hold of
cocaine without having anyone supporting you wasn’t an easy thing, so he
became very addicted to morphine on a daily basis because the treatment
of cocaine addiction with morphine created two drugs to which he was
addicted: one which made him excitable and high, and the other made him
pacific and relaxed.

And so the morphine he took every day - every work day, and sometimes he
took a little too much and that didn’t work out. And occasionally, he
had withdrawal symptoms, and certainly that didn’t work out. But for the
most part, for 30-something years, he managed this, and no one was aware
of it.

DAVIES: Halsted also seems to have been obsessive about certain aspects
of life.

(Soundbite of laughter)

DAVIES: Like his dress and his food. What was - give us some examples of
that.

Dr. IMBER: Obsessive hardly describes it. You know, it's interesting
that the neurosis that makes you great is also the neurosis that makes
you crazy. And Halsted was fastidious about - so fastidious about his
dress that he had his shirts made at Charvet in Paris in large, large
quantities, and then he sent his shirts back to Paris to be laundered
because he felt no one in America could wash and iron his shirt. When he
made coffee, he would pick coffee beans for size and color, and they had
to all match precisely before he ground them and used them. And it goes
on forever. That's the way he lived his life.

He was obsessive and ridged and a perfectionist in certain portions of
his life, whereas in other portions of his life he was totally
negligent, totally forgetful and not at all the same person. For
example, he could leave a patient in a hospital bed for weeks on end and
forget to operate on them. It's just who he was, and no one would ever
remind him because you didn’t want to incur his wrath. And he was
really, a very complex individual.

DAVIES: Yeah, leaving them in the hospital bed, not on the operating
table, right?

Dr. IMBER: Precisely. They never made it to the operating table.

DAVIES: Do you think that these obsessive traits came with the drug
addiction or preceded them?

Dr. IMBER: I think they preceded it. And, you know, and as one becomes
older, one becomes a caricature of his own self. And I think the same
thing happened to Halsted, and there were a number of factors acting on
that. One, that no one ever corrected him because he was William Stewart
Halsted. Two, he did have the lack of inhibitions that come with drug
use, and he was odd to begin with.

So that with no checks and balances, he did, in fact, become a
caricature of the person he was in the old days in New York, although
his surgical personality had changed dramatically, because in New York
he was a fast, dexterous surgeon. And once the locale changed to Johns
Hopkins, he became a slow, plodding, thoughtful surgeon. His results may
have been excellent in both places, but the surgeons who came to visit
him at Hopkins that knew him in New York didn’t recognize him.

DAVIES: You know, I wonder if - since, you know, a lot of people are
reluctant to deal with addiction and believe they can manage it in their
lives, is it unsettling to find a story of someone who accomplished so
much while being addicted for 35 years?

Dr. IMBER: Boy, I wrestled with this one, because to me, it's terribly
counterintuitive, what he did. And I like to say that if he - look what
he did while compromised by drugs. Think of what he could've done
without being compromised by drugs. Other people say perhaps he needed
that to loosen him up in some way. I absolutely reject that. I think
that that's a fallacy. You know, there are numerous examples of people
who think they're so creative when they're stoned, and they come back
and look at what it was that they created and it’s laughable. I think
one has to look at it as this man had the ability to succeed despite the
disability, not because of the disability.

DAVIES: Gerald Imber, thanks so much for speaking with us.

Dr. IMBER: Thank you.

GROSS: Gerald Imber is the author of "Genius on the Edge: The Bizarre
Double Life of Dr. William Stewart Halsted." He spoke with FRESH AIR
contributor Dave Davies.

You can find an excerpt from Imber's book on our Web site,
freshair.npr.org, where you can also download podcasts of our show. And
you can follow us on Twitter and friend us on Facebook @nprfreshair.
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