Halsted's distinguished resident, Harvey Cushing--the progenitor of neurosurgery, the chief of surgery at Harvard, and the man for whom Cushing's Disease was named--knew Halsted only after his temperamental shift. Upon Halsted's death in 1922, Cushing eulogized his mentor (Yale Alumni Weekly. February 23, 1923), regarded by many as the most eminent surgeon of his time:
[Halsted] was a man of unique personality, shy, something of a recluse, fastidious in his tastes and in his friendships, ... the victim of indifferent health, he nevertheless ... may be considered to have established a school of surgery comparable, in a sense, to the school of Billroth in Vienna.... [A]n aristocrat in his breeding, scholarly in his habits ... having little interest in private practice, he spent his medical life avoiding patients.... A bed-to-bed ward visit was almost an impossibility for him. If he were interested he would spend an interminable time over a single patient, ... carrying the problem to the laboratory and perhaps working on it for weeks.
Halsted's lack of interest in his patients as people was reminiscent of the heroic Virchow. He was scrupulous and painstaking in the surgery itself, yet harbored an aversion for interaction as a form of caring for his patients. At the same time, he fashioned himself as their savior. Most significantly, the complicated radical mastectomy launched surgeons on a trajectory of prestigious professional accomplishment. Because of the anatomical and technical prowess required, in 1898 surgeon Frederick Gerrish'6 said of Halsted's radical mastectomy: "We now have an operation which should be regarded as unjustifiable for the general practitioner."
Virchow and Halsted were uncommonly devoted medical scholars and sleuths. Hooked on deciphering pathological mysteries, the interest of science was their priority. Surgery afforded the chance for live dissection, an occasion immensely more instructive than the scrutiny of cadavers. Throughout surgical history, peeking within the pulsing inner sanctum yielded scholarly returns, even when there appeared to be no profit for the patient.
Advances in knowledge sometimes occur in the absence of therapeutic gain--the interests of clinicians and researchers are interdependent, but not necessarily identical. Lithographs of Halsted's early mastectomies illustrate exceptional textbook learning opportunities, showing the skin vividly peeled back from the chest wall, exposing the vast web of glands and vessels. On the other hand, women were left with a large, open chest wound thick with clots that sometimes took months to heal. Halsted defined success by the tissue samples gleaned and the perfection of the technique employed. Ultimately, however, contrary to concurrent insights, he believed in Virchow's notion that cancer spread to muscles via lymph.
As late as 1907, in a follow-up paper titled "The Results of Radical Operations for the Cure of Cancer of the Breast," Halsted17 echoed Virchow's flawed theory, writing:
I recall ... cases ... in which general metastasis was believed, erroneously, I think, to have occurred by way of the bloodvessels [sic].... We believe, with Handley, that cancer of the breast, in spreading centrifugally ... before involving the viscera may become widely diffused along surface planes.... It permeates to the bone rather than metastasizes to it, and, by way of the Iymphatics, along facial planes ... the liver may be invaded by way of the deep fascia ... the brain by the Iymphatics accompanying the middle meningeal artery.... Though the area of disease extends from cranium to knee, breast cancer in the broad sense is a local affection ... invariably by process of Iymphatic permeation, and not embolic by way of the blood. If extension, the most rapid, takes place beneath the skin along the fascial planes, we must remove not only a very large amount of skin and a much larger area of subcutaneous fat and fascia, but also strip the sheaths from the upper part of the rectus, the serratus magnus, the subscapularis, and, at times, from parts of the latissimus dorsi and the teres major. Both pectoral muscles are, of course, removed. A part of the chest wall should, I believe, be excised in certain cases, the surgeon bearing in mind always that he is dealing with Lymphatic, and not blood, metastases.... It must be our endeavor to trace more definitely the routes traveled in the metastases to bone, particularly to the humerus, for it is even possible in case of involvement of this bone that amputation of the shoulderjoint, plus a proper removal of the soft parts, might eradicate this disease.... So, too ... amputation at the hipjoint may seem indicated.
Halsted proposed the notion that more is better, suggesting the removal of the sheath covering all muscles surrounding the breast, the upper part of the abdominal muscle that extends from the rib cage to the pubis, those that control the motion of the shoulder blade and rotate the arm, and, in some cases, removal of the arm and hip as well. Halsted's hypothesis is captured above: to contain the disease it may be necessary to excise all contiguous areas. Of particular note is that this flawed logic persists today. Cancer continues to be treated more like dry rot in the rafters of a house than microbes in a river.
In 1886 Rudolph Matas (1860-1957), founder of the Tulane School of Medicine and the father of vascular surgery, visited Paris and observed breast operations there. Later, in 1898, Matas'8 followed Halsted's protocol, but remarked,
But if we were to follow this principle of prophylactic extirpation to its legitimate and logical conclusions we would be compelled to control part of the vascular (venous) channels which drain the region, as these are just as likely to serve as avenues of dissemination as the lymph tracts. The impracticability of such a proposition is so grossly apparent that it would be absurd even to refer to it were it not that it demonstrates how imperfect and limited are our surgical resources to cope with this illusive [sic] and far-reaching evil. The new operation will unquestionably greatly diminish the probability of local recurrence, but the patients will die, as a rule, just as quickly by regional and internal metastases as if a superficial operation had been performed.
It was common sense to Matas that cancer was as likely to spread via the blood vessels as via the Iymphatic channels, and that if it had disseminated, no amount of local management would be sufficient. He comments that within the abiding logic, all the blood vessels must be removed, along with the Iymphatic channels--a patently infeasible process. Although the observed lions expressed by Matas cast Halsted's model into doubt, the two were close personal friends. Because Halsted was his senior, Matas never crossed him.
Medical Veracity: Authority vs. Standard of Proof
Early in the 1900s it was popular to employ gold salts in the treatment of tuberculosis and arthritis. Not until 1924 was a critical experiment undertaken in which, out of 24 people with similar disease, 12 received gold salts and 12 received distilled water. Those receiving the gold fared worse than did the untreated (control) group. Commenting on the experiment in retrospect, Harry Dowling said it was noteworthy because it introduced the notion of controlled therapeutic trials to eliminate false claims of efficacy. In addition, Dowling19 contended the following: "The I lesson was long overdue. If every therapeutic agent advocated for I an infectious disease since 1900 could have been studied as rigorously, the medical profession would have fewer remedies, but ~ the patients would have been exposed to less discomfort and I danger, the community would have had less expense, and fewer | patients would have died."
An experiment similar to the test for the efficacy of gold salts has yet to be undertaken for women being treated for breast cancer. Physicians sometimes issue proclamations that appear more like sacred doctrine than secular investigations. Reflecting on the shift of belief from religion to science in the 19th century, philosopher Seren Kierkegaard noted that visits with priests were being replaced by appointments with doctors. It was they who were deciding who was crazy or sane, sick or well, who should serve in the army and who should not. By determining how people are born and die; by naming disease; by interpreting feelings, behaviors, signs, and symptoms; and by issuing prognoses, doctors assume immense authority.
Authority by nature commands obedience. Medicine acquires cultural authority by dictating definitions of reality and forwarding judgments about which schema of meaning will triumph as valid. It is ironic that in an attempt to implement scientific advances, verification is sometimes ignored and the principles of science are set aside. At times the mere newness of a technology is taken as evidence of its superiority. An intrinsic contradiction in medicine also exists: because solutions are often fragmentary and incomplete--sometimes merely analytical and speculative--doctors try to avoid saying "we know," yet they must act as though they do! There is a grand expectation on the part of patients for I deliberate, confident action to relieve suffering.
It is superbly American to, as the Nike advertisements exhort, "Just Do It." The preference for intervention over reflection is codified by tradition and practice; doctors charge higher fees for performing procedures than for cognitive services. Within this environment, in which deeds are valued more than deliberation, certainty more esteemed than doubt, an inexorable faith in future progress also exists.20 It is paradoxical that a blind faith in reason sometimes supersedes the doctrine of proof.
Medical sociologist Paul Starr10(p55) comments that, in the beginning of the 19th century, "[the early empirical investigations showed that accepted techniques [like bloodletting] had no therapeutic value, yet there were no effective alternatives available to replace them. This bears surprising resemblance to the use of mastectomy--there is little evidence to validate its use when compared with lumpectomy, yet in a vacuum of viable alternatives it persists, because at least it is something that we can do. Surgeons are loyal to the Nike mentality, even if they wear Guccin on their feet. They are an athletic, action-oriented guild. When Halsted championed mastectomy as "the operation for the cure of cancer of the breast," he did not attempt anything less than complete conquest--a total solution. As captain of both the Yale boxing and football teams, he was nothing if not a man of action, preferring definitive solutions over thorny dilemmas.
A Chronicle of Breast Conservation vs. Removal
The breast-conserving approach to the management of breast cancer is understood as the excision of the tumor itself, the lump, and a small margin of surrounding tissue, but not the entire breast. This is now called lumpectomy. The challenge to Halsted's teachings met with a legacy of disregard and disrespect within devout surgical gatherings.
Just as Semmelweis had been ridiculed for suggesting hygiene in childbirth decades earlier, so Sir Geoffrey Keynes of Britain was scorned when he introduced the breast-conserving tumorectomy with a radium needle insertion in the 1930s. Five-year survival rates were similar to those of Halsted's mastectomy, but Keynes was greeted with profound contempt during his lecture tour in the United States. Twenty years later, failing to adhere to surgical dogma, he was again punished when Scotsman Robert McWhirter spoke at a meeting of the American College of Surgeons. McWhirter suggested replacing radical mastectomy (removal of the breast, pectoral muscles, and Iymph nodes) with what is now called a simple or total mastectomy (removal of the breast, leaving muscles and nodes) accompanied by radiation, and thousands of physicians thunderously booed him off the stage. McWhirter was not even challenging the conceptual model--merely simplifying the surgical procedure. Today the modified radical mastectomy (introduced by Patey and Dyson in England in the 1940s) consists of removal of the breast and nodes, leaving the pectoral muscles intact.