In Vienna in 1848, for example, Ignaz Semmelweis discovered that women who died following childbirth of puerperal fever were infected as a result of physicians failing to wash their hands between deliveries. Yet because of the complete entrenchment of practice, doctors not only offered up great resistance to his ideas, but fiercely ridiculed him for suggesting that respectable physicians needed to wash their hands. Even though the death rate in Semmelweis's clinic dropped immediately, it was not until Louis Pasteur presented his theory of germs 3 decades later that routine cleanliness was integrated into practice.

Thirty years after encouraging the continuation of the war in Vietnam, former Secretary of Defense Robert McNamara⁸ said in retrospect that we should have left sooner. What is categorical and undisputed in one epoch may be reversed in another. One hundred years after William Stewart Halsted popularized what came to be known as the Halsted mastectomy, the large majority of women diagnosed with breast cancer still undergo a modified version of his procedure even though no good data indicate that mastectomies have ever effectively resolved the wracking actuality of cancer.

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.