‘A Very Wide and Deep Dissection’

None of the physicians in attendance at the April 20, 1894, meeting of the Clinical Society of Maryland doubted that the medical paper about to be presented would be the highlight of the day. In fact, some in the auditorium had traveled long distances to Baltimore just to hear it, and they paid attention to little else until the name of the speaker, William Stewart Halsted, was announced. Although the hospital he worked in had been established only six years earlier, it was already recognized as having excellent possibilities for reforming the American system of medical education. Johns Hopkins Medical School, with which the hospital was associated, was even newer, having opened less than a year before that day. The school had already showed the promise of accomplishing its announced mission, which was to revolutionize the teaching of young physicians by introducing them to a scientific approach to healing that was virtually absent anywhere else in the US. Of all the talented and enthusiastic young faculty members who had been recruited to the Johns Hopkins Medical School and its hospital, none was more the object of professional and personal curiosity than Halsted. The forty-two-year-old surgeon seemed to many an odd, withdrawn figure.

As he stood there, obviously ill at ease and yet at the same time detached, his dour expression suggested that he would much prefer the company of his microscope or operating table to that of the assembled doctors. For this patrician man resented any distraction from his single-minded crusade to apply the principles of laboratory science to the undisciplined and still immature American specialty of surgery. To Halsted, it was important to understand not only the complex processes of disease but also the body’s methods of healing itself when aided by the efforts of a scientifically based surgery.

The word had gone out that the paper to be read by the Hopkins professor that morning would present the results of a new operation he was proposing, one that held the promise of providing successful treatment for breast cancer, a disease against whose ravages physicians had been impotent throughout the course of medical history. This cancer killed, and in a particularly devastating way, almost every woman who fell victim to it. In most cases, an untreated malignant lump in the breast would slowly continue to enlarge until it burst open onto the skin surface and proceeded to eat away at the surrounding tissue. Most patients died only after years of enduring the presence of an expanding ulcer where the breast had been, painfully eroding its way through the underlying muscle of the chest wall and in time even the ribs beneath, all the while exuding the stench of foul fluid that oozed constantly from its ever-widening circumference. Most experienced physicians had never seen a woman live as long as five years after the initial discovery of a cancerous mass. Usually, the interval between diagnosis and death was less than half that period.

To operate—even when the patient first presented herself to the doctor—was almost always an exercise in predictable failure. The breast would be removed and all might be well for a time. But within months or perhaps a year or two, bits of tumor growth were sure to reappear on the skin of the chest wall, and these recurrent cancers characteristically followed a course just as inexorable as though the breast had never been amputated. Many women became recluses in their own homes. They shunned contact with all but family members, often for years, before finally dying, wracked with pain when the cancer metastasized to bones all over the body and formed tumors in the liver and other organs.

Many women, on recognizing the nature of a newly discovered breast lump and knowing the futility of treatment, adamantly refused to seek medical help. It was common to hide the cancer even from closest kin, until its relentless growth or the evidence of fetid ulceration made further secrecy impossible. And even those who did share their grim discovery with the family doctor would almost invariably delay disclosure for long periods of time, while the mass grew so large that it became visible to even the most superficial medical inspection. Occasionally and against all odds, a woman whose breast had been excised lived a long and healthy life for decades afterward; these instances were so unusual that physicians who knew of them shared the case histories of such patients with one another, as if to offer themselves some hope against the reality of everyday experience.

Halsted began his talk by summarizing the problems of recurrence, and then went on to describe the poor results of some of the leading European surgeons of the time. He pointed out that his own study of excised specimens had convinced him that breast cancer spreads centrifugally in so direct a manner that it progressively infiltrates the tissues leading from its site of origin. Accordingly, cure could only be achieved by a very wide and deep dissection that went far beyond the furthest likely point of the tumor’s invasion. Since the lymph from the breast drains toward lymph nodes in the axilla, the area in and around the armpit, and also through channels that penetrate the muscles of the chest wall, he said, these two areas must be removed as well. In order not to spread cancer cells by cutting across any possible site that was invisible to the naked eye, it was necessary to remove in a single block all of the tissue that might be involved. This demanded an extremely wide excision of skin around the breast and what was called an “en bloc” dissection to include the axillary lymph nodes and the major chest muscle, the pectoralis major.

The operation Halsted had carried out was a more formidable one than anyone had previously attempted, and it required great surgical skill and a highly trained team of assistants. The specimen was so large that it had to be sent to the laboratory in a pail. But Halsted made it clear that there was no other choice. Only by being this radical was there any hope of curing breast cancer. So much tissue had to be excised that the resulting defect could only be closed by the use of a skin graft taken from the thigh. When healed, the resultant wound was extremely ugly to behold.

Calling his operation “the complete method,” the speaker went on to describe his results in fifty cases. To the doctors who heard him, and to the thousands more who would read his paper when it was published in the Annals of Surgery a few months later, his results were nothing less than astonishing. Only three of his patients had developed local recurrences, while eight others were found to have reappearance of tumor in the general region of the chest; this contrasted with rates of approximately 60 to 80 percent after more limited operations by the most highly regarded of the European surgeons. Of the forty-eight patients who responded to the call for follow-up evaluation, only nineteen had died. That the period since operation was still short did not much deter the excitement produced by such figures, because they were already a vast improvement on what had been before.

Halsted would go on to publish a series of papers on the results of his operation, which soon became known as the Halsted radical mastectomy, though other surgeons were starting to use similar procedures at about the same time. In 1907 he reported on 210 patients whom he had followed for a period of three years or longer since surgery. Seventy-five of them were still alive. This result, representing 36 percent of the total, was taken to have substantiated the original impression that a great step forward had been made. Of at least as much importance, the number of patients who died with a foul-smelling mass of tumor eroding through their chest walls was very small, since local recurrence remained much lower than it had been with lesser operations. Many women, no longer immobilized by dread of such a postoperative outcome, and fortified by the new possibility of cure, were coming to doctors for treatment. They were appearing in medical offices and clinics at an earlier stage of disease.

A great change had occurred in the outlook of both surgeons and patients. For the first time since records had been kept, more than a few cases of breast cancer were being cured, a remarkable fact considering that virtually all of Halsted’s patients had come to him with tumors that were already large. At the very least, it was now unusual for treated women to die with the disgusting shame of their sickness evident to everyone who came at all close to them.

A few years after his original Baltimore presentation, Halsted added the removal of the second of the chest wall muscles, the pectoralis minor, to his recommendations; and from that point on the procedure was standardized in the form that would be maintained for more than half a century. Even in the 1960s, when many surgeons had begun to accept a modification in which far less skin was excised and the muscles were left intact—the so-called modified radical mastectomy—the principles on which the revised procedure had been based were still believed by the vast majority of physicians to be valid. Until very late stages, cancer of the breast was seen as a local disease that kills by creeping millimeter by millimeter from the site of its beginning. In addition, it moves out along lymphatic channels to the lymph nodes in the armpit. At any given time, a cure is possible if the surgeon cuts out so much tissue that he has gone beyond the furthest extent of the tumor’s infiltration.

Halsted, once a bold and quick-fingered surgeon in New York, had joined the Johns Hopkins faculty while recovering from a cocaine addiction. He acquired the habit while carrying out America’s first experiments using the drug as a local anesthetic at a time when its dangerous qualities were not yet appreciated. In the therapeutic style of the time, he had been weaned from cocaine by substituting morphine, which was then thought easier to give up. Although no one would know it until decades later, Halsted remained a morphine addict. The drugs seem to have transformed not only his personality but his entire approach to surgery and research. He became obsessed with detail. His personal behavior and his doctoring were methodical, orderly, deliberate, precise—he insisted on rigorous, finicky attention to minute points of procedure. These qualities imposed a heavy burden on Halsted himself and on those around him. But they were appropriate for a surgeon who would introduce the technical rigor required in order to carry out the kinds of experimental and clinical procedures that made medical progress possible and allowed ever more complex therapeutic challenges to be overcome.

For the surgeons who took up the radical mastectomy with such enthusiasm, the operation was more than only a therapeutic triumph—it was a weapon in the campaign to professionalize their specialty. In order to carry out such an operation successfully, one had to be highly skilled in surgical craftsmanship which could not be acquired without years of formal training. Not only that, but the postoperative care of these patients required a thorough understanding of the physiology of wound healing and of the body’s response to the radical assault on its integrity caused by such a traumatic operation. It could not be done in a setting that lacked the appropriate nursing, instruments, and aseptic resources.

Radical mastectomy therefore came to be an enterprise that separated the surgical specialists from the general practitioners who performed most of the operations then being done in American hospitals and medical offices, not to mention the kitchens of rural and even some urban American homes. To be able to perform a radical mastectomy was seen as a sign of professional authority. When the emerging discipline’s leaders founded the American College of Surgeons in 1913, the radical mastectomy was one of a few operations that distinguished those eligible for membership in the elite organization from the large number of untrained operators. Among this small number of demanding procedures, two others had also been developed by Halsted: the thyroidectomy and a new method of hernia repair.

By that time, Halsted had made so many contributions—including the introduction of a new method of training his disciples—that he would later be called the father of American surgery. His surgical students imitated him, and in turn taught their students to do the same. His meticulous, painstaking method of operating, called Halstedian technique and the Surgery of Safety, replaced the crude methods that had preceded it, and became the standard against which all operating was measured. Of the seventeen men personally trained by Halsted at the Johns Hopkins Hospital, eleven went on to establish throughout the US university residencies modeled on Halsted’s. From these, 166 residents eventually graduated to spread the Halsted message into every training program in the country. Thousands of today’s surgeons trace their lineage directly to his teachings. In an essay written twenty years ago, I wrote, “I was trained by Gustaf Lindskog, who was trained by Samuel Harvey, who was trained by Halsted’s first resident, Harvey Cushing.”

All of this forms the background against which American surgery’s otherwise inexplicable stubbornness in refusing to abandon the radical mastectomy, or at least its slightly less drastic modifications, must be evaluated. Beginning in the early 1930s, several surgeons found that less extensive and deforming methods of treatment were often just as efficacious as Halsted’s. But for many years after this, the surgical profession continued to cling to its certainty that extremely wide excision was the only path to therapeutic success. The authority of the Halsted school, the quasi-military sense of tradition ingrained into young people in surgical training programs, the seemingly obvious tendency of breast cancer to spread outward—all of these factors prevented an objective assessment of the gradually accumulating evidence against radical mastectomy. In fact, in the 1940s and 1950s, certain prominent surgeons advocated widening the dissections; as a result, even more radical procedures were introduced in several major clinical centers.

The great strength of Barron Lerner’s scrupulously documented new book lies in its account of the ways by which it finally came to be accepted that breast cancer, from the first phases of its development, is no longer the local disease that Halsted believed it to be. An experienced physician himself, Lerner explains clearly that breast cancer is a systemic, or total-body, process, in which cancer cells are shed from the tumor site into the bloodstream at a very early stage. Having thus entered the circulation, they are distributed throughout the body’s tissues and organs, making radical en-bloc dissections not only unnecessary but often futile. Since it is a systemic disease, breast cancer must be combated with systemic methods. Not only that, but the biological nature of breast cancer differs in each woman it attacks; the behavior of the cancer can range from a sort of indolence to extreme aggressiveness, so that decisions about therapy must be adapted to each person’s case.

Long-term outcomes, in fact, may depend far more on the inherent degree of activity of the tumor than on the method of treatment. For some women local excision may suffice, whereas others require not only removal of the source of shedding cells but also radiotherapy for the remaining breast and its surroundings as well as chemotherapy to kill the distant colonies of malignant implantation. Once physicians appreciated the realities, as a result of the efforts of radiotherapists, oncologists, statisticians, and a handful of outspoken surgeons, a gradual shift took place. By the late 1970s, it had come to be generally accepted that various combinations of chemotherapy, supervoltage X-ray, and minimal surgery, adjusted to meet the therapeutic requirements of particular cancers and the personal needs of individual women, were the proper standard of care.

But the driving force behind the transformation was not the scientific and clinical evidence provided by the medical researchers. Not surprisingly, it was women themselves who were the most effective in demanding change. Although it is sometimes a bit tedious to follow Lerner’s necessarily detailed description of the accumulation of evidence against radical mastectomy, his accounts of the remarkable personalities and accomplishments of such forceful women activists as Rose Kushner, Babette Rosmond, and Audre Lorde are fascinating. They all had taken part in the women’s movement of the 1960s and 1970s, with its demands for “autonomy” and “self-determination.”

Rose Kushner was a forty-five-year-old freelance writer when her breast cancer was diagnosed in 1974. After undergoing modified radical mastectomy, she undertook to learn all she could about the disease. The following year, she published a book entitled Breast Cancer: A Personal History and Investigative Report, and her crusade was underway. In subsequent articles and public appearances, she challenged the treatment methods used by the leading members of the medical profession as well as their refusal to grant any measure of autonomy or even choice to the women whose malignancies they were treating in such routine and standardized fashion. She deliberately used an outspoken style of confrontation, attempting to break through the complacency of the surgeons who insisted that radical mastectomy was the only safe treatment for breast cancer and also to provoke those who were themselves trying to develop less radical procedures. Her main concern was to allow women to have a variety of options so that decisions about treatment would be made on an individual basis.

Within a few years she was having an effect on the highest echelons of medical and governmental power, and she was recognized as the herald of the new order. “I’m a full-fledged member of the Establishment,” she said ironically in 1980, when President Carter appointed her to the National Cancer Advisory Board. Even the American Cancer Society, whose policies she had often criticized, came to recognize the value of her contributions. In 1987, she was given the Society’s highest award, the Gold Medal of Honor, and her citation praised the very qualities that the organization had long castigated: “You presented data, cajoled, wheedled, needled, smiled, brought information to the forefront, developed programs, spearheaded, wrote and wrote and wrote and never lost sight of your goals.”

Kushner’s is the fullest portrait in Lerner’s excellent book and certainly the most colorful, but equally interesting characters are to be found in his pages. Among them are George Crile and Oliver Cope, respectively a leading Cleveland surgeon and a surgical innovator at the Harvard Medical School. Both advocated and performed the more moderate procedure known as lumpectomy and were derided by their colleagues for doing so. So were others. John Christian Bailar III, a biometrician whose statistical studies convinced him that the fight against cancer is a “qualified failure,” was accused by the infuriated director of the National Cancer Institute of having written “the most irresponsible article [he had] ever read.” Lerner also describes the powerful doctors who remained intransigent. Jerome Urban of Memorial Sloan-Kettering Hospital was “the most radical of the radical surgeons.” In the 1950s he outdid even Halsted by extending his operation to include the excision of lymph nodes inside the chest, which meant removing ribs and splitting the breastbone. Even more recalcitrant was Cushman Haagenson, the world’s best-known breast surgeon, who in 1986 published the third edition of his 1,050-page Diseases of the Breast at the age of eighty-six; he was still stubbornly writing that any woman who refused radical mastectomy “is risking her life blindly.”

The Breast Cancer Wars, like Lerner’s Contagion and Confinement, his excellent 1998 account of the conflicts between patients’ rights and the scientific treatment of tuberculosis, is essentially a work of social history, in which he describes the inner world of professional prestige and group conformity. But he also gives a very clear account of the clinical and theoretical aspects of breast cancer. Unlike most other social historians, he is an experienced bedside physician and clinical teacher of medical students, and his perceptiveness shows in his understanding of even the most pig-headed of the characters in his book, who after all believed they were doing the best for their patients. Moreover, he resists the temptation to look back in self-righteous scorn on an earlier time when the concept of the patient’s autonomy would not have occurred to the most enlightened of physicians. They would have scoffed at the words with which Lerner ends his book: “Women should choose what is right for themselves.”

That is the ideal to which treatment must now aspire, but it is far from being universally observed. Many women—among them poor patients on Medicaid, for example, and women who get less than attentive treatment in some HMOs and elsewhere—do not have sufficient opportunities to make informed choices and obtain the treatment best suited to their needs. What is clear, however, is that the Halsted tradition has faded and that less radical methods are generally used.

As a surgeon who realized a little later than he should have that removal of only the cancer, followed by radiation, is as effective for small tumors as a modified radical mastectomy, I found that Lerner’s book helped me to understand my own experience. Not until 1978 did I feel sufficiently convinced of the value of smaller-scale operations that I was able to write, as the editor of a symposium on the contemporary treatment of breast cancer, “Out of the plausibilities and the indications, each patient, with her doctor’s help, should be encouraged to choose her way.” Like most of my colleagues, I had at first thought George Crile and Oliver Cope were aging fools, and that Rose Kushner was an uninformed loudmouth. The powerful reverberations of that long-ago day in Baltimore had too long affected our collective surgical judgment.