This rather drastic surgical routine has flourished during the same century that ushered in the domain of science with its stringent standards of efficacy. How did a speculative hypothesis become converted into an unquestionable dogma, slipping through the net of scientific rigor and leading even the most conscientious to forsake corroboration? Somehow the correlative has been twisted and tangled into a confused web of causality, and fingers have been pointed in mistaken directions.
Scientific facts are not merely discovered--they are produced. Laboratories are not sterile environments from which subjectivity is hygienically excised, but a place where physicians immersed in their own value systems rely on conceptual models and draw on their personal experience. Medicine is as much a cultural product as a scientific endeavor. Acceptance of medical ideas hinges not solely upon evaluations of impartial evidence, but also upon social networking, political savvy, patronage, and an adherence to protocols in vogue. Medical knowledge, like any other, is contingent on the context within which it is constructed. Subject to voluminous acts of interpretation, it is a perpetual challenge to keep a keen eye on clinical efficacy.9
Recent History: Labor Pains and the Birth of a Profession
Today medical institutions have such massive weight and are so embedded within our social landscape that they appear as creations of nature, like the Rocky Mountains. It was not so long ago, however, that the medicine familiar to us today was born. To fathom how Halsted's promulgation of the mastectomy has advanced virtually uncontested since the close of the 19th century, the ground from which it emerged must be sifted, including medical thinking in Europe toward the close of the 19th century, the cultural climate in America, the social history of American medicine, and the burgeoning professionalization of surgery. The singular influence of William Stewart Halsted himself must also be pondered.
There was tremendous activity in medicine toward the end of the 19th century. The profession of nursing originated in London after the Crimean War, when Florence Nightingale founded a school for nurses in 1860. In America Clara Barton founded the Bellevue Hospital School for Nurses in 1873. By 1900 there were 432 nursing schools, and by 1910 there were 1129 more. The trajectory of surgery as a profession mimicked nursing: whereas Midwesterners William and Charles Mayo recorded only 54 operations in the 3 years before 1893, in 1900 they chronicled 612; by 1904 the number exceeded 1000. Wilhelm Roentgen's discovery of x-ray technology in 1895 improved diagnosis, and by 1916, with the aid of Marie Curie, new treatments were being generated as well. Furthermore, the flowering of surgery can be attributed to the discovery of ether as anesthesia, permitting operations to be performed without undue pain; the disinfectant carbolic acid, averting sepsis; and the honing of specialized skills, distinguishing expert surgical craftsmen from the less competent general practitioners.
In Vermont in 1843 there was a 50-cent fee for a doctor's visit at less than half a mile, a $1 fee between a half and 2 miles, $1.50 for 2 to 4 miles, and $2.50 for more than 4 miles. In a 1910 survey, 96 physicians using horses reported costs that worked out to 13 cents per mile, whereas for 116 doctors using cars for which they paid less than $1000, the cost per mile was 5.6 cents. The advent of the automobile considerably widened the market.10
Although ether anesthesia was first demonstrated at the Massachusetts General Hospital in 1846, postsurgical infections caused such high mortality that major surgery was nicknamed a "capital operation." Neither carbolic acid, needed to eliminate microorganisms during surgery, nor sterile procedures were accepted practice until much later. Joseph Lister published papers on antisepsis in 1867 and lectured for 3 hours on the subject at a medical congress in Philadelphia in 1876.11 But at the first meeting of the American Surgical Association in 1883, more speakers opposed his principles than supported them, steadfastly disregarding reports that in European hospitals that implemented his methods, postsurgical problems such as gangrene were no longer rampant. As late as 1900 most surgeries were conducted in the home because hospitals were feared as filthy, foul houses of death.
In 1847, the American Medical Association (AMA) was founded in an effort to upgrade the profession. They vowed that raising educational standards was their ticket, but it took another 60 years for their train to pull into the station. The AMA tracked the career choices of 12,400 men graduating from elite colleges between 1800 and 1850, finding that only 8% became physicians, while more than three times that many entered the clergy and legal professions. The AMA interpreted this as signifying a disdain for medicine among "educated talent."10 Confirming their suspicions, in 1880 fewer students at medical schools had bachelor's degrees than at either law or divinity schools.
In those days, medicine offered more status than wealth--doctors were a cut above manual laborers. Unable to earn a living solely by practicing medicine, doctors cultivated livestock, pulled teeth, mixed herbal preparations, nursed patients through long and difficult nights, and embalmed the dead. Throughout medical history surgeons were regarded as the least sophisticated and learned craftsmen in the guild, trained principally in the use of their hands through apprenticeship, many with barber-surgeons. A carryover of this remains in England today--internists are referred to as doctor, and surgeons as mister, denoting their lesser rank.
As for the specialty of surgery, in 1876 Samuel Gross of Philadelphia wrote his observations about the American surgical scene: "Although this paper is designed to record the achievements of American surgeons, there are, strange to say, as a separate and distinct class, no such persons among us. It is safe to affirm that there is not a medical man on this continent who devotes himself exclusively to the practice of surgery."12 It was Gross who founded the American Surgical Association in 1880, but it would take at least another 2 decades for surgery to become established as a legitimate profession.
Although doctors were aspiring to an image of erudition, few actually completed much higher education. Both of my grandfathers graduated from Long Island College Hospital in 1914 with high school diplomas, never having attended college. Henry Beinfield went on to perform tonsillectomies, earning S900 a week while his nurse and chauffeur earned $8, whereas Harry Roster set up his own research hospital, frequently publishing in JAMA and Archives of Surgery.
Princeton sociologist Paul Starr,10(PP7980) says, "Acknowledged skills and cultural authority are to the professional classes what land and capital are to the propertied. They are the means of securing income and power. For any group, the accumulation of authority requires the resolution of at least two distinct problems. One is the internal problem of consensus; the other is the external problem of legitimacy."
In terms of consensus, physicians were struggling mightily to come to agreement about their common rules and standards. Internal divisions beset the profession from the mid-19th century until the early part of the 20th century. Concerning legitimacy, in Europe medical degrees granted deference and respect, but in America the meager educational requirements left physicians with a perilously slender margin between themselves and their patients--and sometimes no margin at all. Therefore their powers of persuasion, along with their ability to kindle feelings of confidence and trust, were critical to their success. In America a physician's standing was tied to his own family background, as well as the social rank of his patients. At the top were men who, like William Stewart Halsted, had graduated from elite colleges, attended medical school, and received further instruction in Europe.
Although the AMA was in its infancy in the mid-19th century, it wasn't until 50 years later--the early 1900s--that medical societies began replacing the internal dissension and competitive relationships among doctors with a brotherhood of shared interests (note 2). But in 1900 the AMA still sought to address the issue that had motivated its formation: control of medical education. This was the chosen methodology to consolidate the profession: standardized schooling would ensure both conforming ideas and uniform practice.
Reform of medical education had its beginnings in the ~ 1870s when the Quaker merchant Johns Hopkins died in 1874, j willing half of his $7 million estate to found a university, and the l other half to build a hospital. At the time, this was the most substantial endowment in American history, setting the precedent for linking laboratory research with clinical patient care. The prototype came from Europe, where laboratories in physiology, chemistry, pathology, and histology were transforming hospitals. Johns Hopkins University opened in 1876, the hospital in 1889, and the medical school in 1893. Johns Hopkins School of Medicine had the hitherto unheard of admission requirement of a Bachelor of Arts degree, and the curriculum was lengthened from 3 to 4 years. The crucial half million dollars needed to complete the school was donated by wealthy Baltimore women who made their offer contingent upon the admission of women on the same basis as men.
Johns Hopkins was the paragon of virtue in the eyes of the AMA. This single institution had--and continues to have--enormous leverage on the course of medicine. The policies ensconced there determined which institutions survived to govern the field, how they were structured and administered, and what ideology would triumph (note 3).
Finally standards were being set for medical education as graduate study, with strength in both science and clinical medicine. The next advance was creating residencies in specialized fields. Two towering giants in medicine, William Welch, a pathologist, and William Osler, an internist, were dedicated to building Johns Hopkins as the archetype for training not only physicians, but medical scientists as well. Welch, however, vied for the interests of research, whereas Osler championed the interests of clinical medicine. Osler admonished: "Care more for the individual patient than for the special features of the disease.... Put yourself in his place ... enter into his feelings, scan gently his faults. The kindly word, the cheerful greeting, the sympathetic look--these the patient understands."13 Osler further expressed concern that patient care might suffer if it became completely subservient to research, but Welch differed, determined to elevate the role of science in medicine.
Then and Now: History of Cancer of the Breast
The earliest known chronicle of breast tumors was recorded on Egyptian papyrus more than 3000 years ago, but no treatment was described. During the Middle Ages, mastectomy was wielded as tortuous punishment against women accused of religious or political deviation, such as Saint Agatha, patron saint of the breast. In France in the 1820s it was hypothesized that certain personality dispositions were considered to be more prone to breast cancer than were others. Women with a "bilious constitution and a dejected, melancholy character," for example, were especially predisposed.14 In Italy in 1842 Domenico Rigoni-Stern analyzed statistical data from death registries and noted that breast cancer incidence increases with age, and that unmarried women are at greater risk than married women.') Judgments that blamed sad or angry women for bringing breast cancer on themselves as well as the prescient insight that childbearing affects the incidence of this disease both occurred more than a century ago, repeating echoes across a historical canyon.
One of the earliest recorded nonpunitive mastectomies was performed by the accomplished surgeon James Syme (whose daughter married Joseph Lister) in a surgical amphitheater in Edinburgh in 1830. Dr John Brown, recollecting the event in 1863, tells us,