Allie stepped up on a seat, and laid herself on the table ... arranged herself, gave a rapid look at James [her husband]' shut her eyes ... and took my hand The operation was at once begun; it was necessarily slow; and chloroform--one of God's best gifts to his suffering children--was then unknown. The surgeon did his work. The pale face showed its pain, but was still and silent.... It is over: she is dressed, steps gently and decently down from the table, looks for James, then, turning to the surgeon and the students, she curtsies--and in a low, clear voice, begs their pardon as if she has behaved ill. The students--all of us--wept like children; the surgeon wrapped her up carefully, and resting on James and me, Allie went to her room.4
Four days later, Allie Noble developed an infection that she did not survive. Surgery was excruciating and death from it a likely possibility before anesthesia and asepsis. Interestingly, Symes also noted in 1842: "The result of operations for carcinoma when the glands are affected is almost always unsatisfactory, however perfectly they may seem to have [been] taken away. The reason for this is probably that the glands do not participate in the disease unless the system is strongly disposed to it."4(p650) British breast physician Michael Baum4(p650) comments that "[t]his statement is of great historical significance for two reasons. Firstly, it illustrates that surgeons long before the Halsted era were attempting perfect clearance of the axilla. In addition, it also illustrates that they recognized that such efforts were futile in the presence of extensive involvement, a sentiment that was ignored for a further 120 years."
Accidents in which women's breasts were caught in the wringers of old-fashioned washing machines were commonplace. After such a mishap, women would visit their doctors because of tenderness, swelling, and pain. Probably because an existing lump was noticed following such an accident, it was supposed that breast cancer was caused by trauma. This is one early example of the coincidental being mistaken for the causative. But for the most part, before routine palpation or mammography, breast cancer was not recognized by subtle signs. Instead, women suffered from glaring complaints, such as oozing ulcerations and the malodorous weeping of distended, deformed, throbbing, eroded flesh. Such agonizing symptoms, even more than implacable death, caused the worst despair. In the context of the times, it was highly desirable to seek a cure for these symptoms--to remove the field upon which the game was played, annihilate the messenger (if not the message), and abort the short-term pain (if not the final demise). Today, though there is a pervasive amorphous panic, a spiny dread of death, in this country there are never open, rank, leaking wounds.
In the 19th century, women with breast cancer were in a social sense considered to be lepers--it was a disgrace as well as a medical problem. As late as the 1960s breast cancer was not publicly discussed and women did not openly volunteer that they had the disease. (It was not until 1974 that by announcing her breast cancer diagnosis, First Lady Betty Ford pierced the public veil on the subject. President Ford did not hesitate to decide that she would have a mastectomy.)
Perhaps what Halsted meant when he promised to "cure" carcinoma of the breast was to remove the immediate and recurring misery, not the disease itself or its eventual outcome. In Halsted's paper, published in 1894, he acknowledges: "The efficiency of an operation is measured truer in terms of local recurrence than of ultimate cure."3(p302) But Halsted's zealous victory over local recurrence assumed a life of its own and later followers confused elimination of symptoms with a remedy for the disease. In the urgency to effect an absolute cure, progressively more and more tissue was expunged in an attempt to avert "recurrence." The concept that removing the breast would erase the disease was irresistibly seductive. It is useful to trace the intellectual origins of this theory.
A Short History of Ideas: Virchow's Influence
Tuberculosis, the sovereign disease of the 19th century, was the leading cause of death, as feared as it was widespread. In Europe, the work of the German physician Rudolph Virchow (1821-1902), the father of "cellular pathology," advanced medical knowledge. His contributions were substantial; for example, he identified leukemia in 1845 and in 1846 articulated the process by which blood clots become obstructive. At a time when medical focus was narrowed to the courses of particular diseases, Virchow both broadened and magnified the lens by gazing into the nature of specific pathophysiological processes. He mapped the tissue reactions of atrophy, hypertrophy, inflammation, embolism, necrosis, tuberculosis, cancer, fibrosis, and calcification. Many of Virchow's concepts have withstood the test of decades, but a few of his ideas were off course. Because of his immense stature, however, his faulty conclusions were also fully embraced and perhaps disproportionately influential.
Virchow proclaimed the tissue changes characteristic of tuberculosis as emblematic for the disease process in general, and cancer in particular. His revolutionary biological model of breast cancer professed that tumors arose within the skin, rather than as a systemic disorder, invading locally and centrifugally in all directions, spreading along the planes of muscles and through Iymphatic channels. Furthermore, Virchow thought that the lymph nodes under the arms acted like filters, blocking the spread of the disease to the organs and skeleton. If the tumor burden penetrated the Iymphatic defenses, then the disease progressed in an orderly manner from the center outward to the chest, trunk, upper arms, and thighs.
Virchow was not a clinician. He did not engage in the care of patients, instead focusing solely on tissue reactions in the lab. His positive disdain for clinical evidence became an intellectual trend. A tacit reverence for and acceptance of Virchow's theory that the lymph is the highway of the cancerous process persist today, though we know that metastases require blood supply (angiogenesis) and also travel through the circulatory system to distant (metastatic) sites.
The Legacy of William Stewart
Virchow and Halsted were characterized by monumental achievements. Just as Virchow was credited as the most influential early figure in German medicine, so Halsted occupies that position in American surgery. More than any other physician, Halsted was personally instrumental in the genesis and rise of the specialty of surgery. First, he performed operations that only highly trained specialists could duplicate; second, he transformed surgical education by establishing a residency program in surgery, overturning a hierarchy in medicine that had endured for centuries in both Europe and America. Halsted singularly hoisted surgeons to the pinnacle of the social caste of medicine.
In 1852, when Halsted was born, his family owned the textile import firm of Halsted, Haines and Company (note 4). Halsted attended boarding school at age 10, graduated from Phillips Andover, and joined the Yale Class of 1874. He then entered the College of Physicians and Surgeons in New York (which was to become the Columbia School of Medicine) for the customary 3 years, interned at Bellevue in 1876 during medical school, then in 1878 studied for 2 years in the illustrious medical centers of Vienna and Germany. After returning from abroad, Halsted put Virchow's theories into practice, performing operations that removed the entire Iymphatic and muscular field surrounding carcinoma. The golden rule for the management of breast cancer hence became the Halsted radical mastectomy.
Halsted introduced techniques and set standards that are now customary, but which at that time were startling surgical innovations--namely, radical en bloc removal of the breast; hernia repair; refined thyroidectomy and intestinal anastomosis operations; a completely bloodless operating field and uncompromising sterility; careful, meticulous, anatomically precise surgical dissection that minimized undue trauma to surrounding tissue; direct blood transfusion; and fastidious closure of the j wound, layer by layer, with silk sutures.11(pp386-421) When Halsted's operating room nurse and soon-to-be wife, Caroline Hampton, developed a rash from handling irritating solutions of mercuric chloride, Halsted wrote to Goodyear Rubber and requested that they produce an experimental pair of thin rubber gloves. On trial, they were so successful that more were ordered, and now no surgery can be imagined without them. (Although Halsted was neither the first surgeon to perform a mastectomy nor the first to use rubber gloves, because he popularized them in America it is he who is given credit for them [note 51.)
Halsted was surgeon-in-chief and professor of surgery at Johns Hopkins at the time the medical school opened in 1893. Having personally observed the European medical nobility (Virchow, Billroth, Kocher, von Volkmann), he emulated them, hitching the pathology laboratory to the surgical theater, splicing science with clinical practice. Reproducing the best of w hat he had witnessed a dozen years before, Halsted created the first and foremost surgical residency program in America, directing it for 3 decades. The seeds of his philosophy were sown deep, far, and wide--his residents initiated top-notch residency programs across the country, graduating 166 chief residents who bred successive generations of surgeons. Halsted also trained more than 50 teachers--among them men who became professors of surgery at Harvard, Stanford, Yale, Johns Hopkins, Cornell, Pittsburgh, Cincinnati, Virginia, and other exceptional schools of medicine. This group produced a second generation of 139 teachers of various ranks, influencing a prestigious and vast swath across the geographical landscape of medical education.15 They proceeded to teach others, insuring that Halsted's views were so broadly disseminated that they became the official guideposts and doctrine of the surgical world.
The early 1880s, a decade before Johns Hopkins Medical School commenced, were productive and prolific for Halsted. He published 20 scientific papers, lectured in anatomy at his alma mater, became an associate in a surgical practice at Roosevelt Hospital, and set up the outpatient clinic there. But by 1885 this had changed and Halsted's ability to deliver lectures as well as his attendance at professional meetings dramatically waned. Although a well-kept secret at the time (which wasn't confirmed conclusively until 1969, when the diary of William Osler was unlocked and disclosed), Halsted's study in Europe had launched him into a cocaine and morphine addiction that was to last the
rest of his life. Halsted's dependence began in Vienna in 1884 I when ophthalmology resident Karl Roller discovered that a few drops of cocaine numbed the surface of the eye. This discovery led to the use of local anesthesia and, curiously enough in the light of history, was proposed by none other than Koller's friend, Sigmund Freud, then a 28-year-old neurologist (note 6).
Both Freud and Halsted, inspired by Koller, undertook their own investigations. In 1884, Halsted began injecting this remarkable substance into himself and his colleagues to determine its effect in blocking nerve conduction (note 7). From this time forward, Halsted struggled with a successfully clandestine yet sometimes debilitating addiction that profoundly altered his personality, yet never eclipsed his medical life. Welch, the renown Johns Hopkins pathologist and Halsted's dutiful friend, took him sailing on a 2-month voyage through the Caribbean in the winter of 1886, hoping to correct his habit. But Halsted was admitted to Butler Hospital in Providence for 7 months later that same year, and for 9 months in 1889. Halsted's addiction effectively terminated his career in New York. Again Welch rescued him by inviting him to Baltimore and securing him an appointment at Johns Hopkins.
William Osler, Welch's partner in shaping the medical school as well as its first professor of medicine, regarded as the most eminent clinician of his time, entered in his diary that 6 months after Halsted had been awarded his full position at Johns Hopkins, he saw him in a severe chill, realizing that he was still taking morphia. Having gained one another's confidence, they discussed that Halsted had never been able to reduce the amount to less than three grains daily (one grain equals about 60 mg). Osler also recorded that he did not think anyone suspected Halsted's habit--not even Welch, who assumed the addiction had been conquered. Later Osler added that in 1898 Halsted reduced his dose to 1'/: grains--nine times the standard 10 mg of morphine prescribed for severe pain today. Halsted permitted the popular deception to persist that he had been "cured" after his second hospitalization; in the public eye, he was clean. His close friends, however, noted that the socially exuberant extrovert u ho had studied in Europe had returned strangely altered.