Refer to: Bland CS: The Halsted mastectomy: Present illness and, past history. West J Med 134:549-555, Jun 1981 Special Article

The Haisted Mastectomy: Present Illness and Past History CORDELIA SHAW BLAND, Topanga, California

The Halsted mastectomy put American of the late 19th century ahead of competing general practitioners at home and the preeminent German surgeons abroad. It thus served economic and nationalistic drives in the nascent specialty of surgery. Such socioemotional forces-and not scientific principles-may explain why Halsted's expansion of the mastectomy to include the pectoral muscles became lastingly institutionalized.

'I WENT TO THE hospital feeling peifectly healthy serves that loss of a breast is as devastating for and came out grotesquely mutilated-a mental some women as loss of the penis is for a man.2 and physical wreck." Nor has the operation's greater trauma been These are the words of a woman who under- justified by greater cure. Before the National went a radical mastectomy in 1971. Although Cancer Institute's (NCI) initiation of the first such anguish is customarily masked by the smil- controlled study in 1971, no comparative findings ing American version of the stiff upper lip (beau- existed. C. D. Haagensen's substantial tifully modeled by former first and second ladies prospective study dating from 1935 had no con- Betty Ford and Happy Rockefeller), this woman trol group,3 and all retrospective studies have may well voice the innermost-even if transient- been essentially anecdotal, small-scale counts of feelings of millions of women subjected to a radi- apples mixed with oranges." cal mastectomy since it was introduced in 1882 by The NCI study, directed by surgeon Bernard American surgeon William S. Halsted of Johns Fisher, has shown that the Halsted operation Hopkins. achieves no higher cure rate than the simple The Halsted operation cuts out the breast, mastectomy that saves the muscles and unin- axillary lymph nodes and chest muscles. Because volved lymph nodes.') Surgeon Alfred Meyer con- loss of the muscles weakens arm function and firmed this conclusion in the first large-scale rules out plastic surgery for a reconstructed breast, (1,686 cases) restrospective study.'; Oncologists the operation is acknowledged by its proponents 1. Craig Henderson and George P. Canellos, in as well as its opponents to be the most traumatic of their recent major review on , found breast cancer treatments. Surgeon George Crile, Jr, no single local therapy to be superior to others. contends that "it seems to have been designed to All these widely publicized findings have fallen on inflict the maximal possible deformity, disfigura- the fertile soil of women's and patients' rights, tion, and disability."' Surgeon Oliver Cope, who with the result that limited excision (lumpectomy) stopped doing radical mastectomies in 1960, ob- followed by primary high-dosage irradiation is now alternative to radical mastec- The author is an editor at the Uhiversity of California, Los considered the major Angeles, School of Medicine, and a free-lance writer. tomy. Despite this improvement in treatment Reprint requests to: Cordelia Bland, 19864 Grandview Drive, Topanga, CA 90290. options, however, the American Cancer Society

THE WESTERN JOURNAL OF MEDICINE 549 THE HALSTED MASTECTOMY

estimated in 1979 that 25,000 women (a fourth a revered leader of that progress. Medicine, how- of newly diagnosed cases) would undergo radical ever, although classed as a biological science, is mastectomy that year.8 So this 19th century a combination of science, humanism and com- operation continues into the 1980's with rumors merce. It does not evolve simply in a test tube, of its demise greatly exaggerated. a Petri dish or "the rat," but in the matrix of Now that the controversy over the Halsted history, culture and socioeconomics. Jacques mastectomy has been decided in its critics' favor, Barzun recalls the comment by physician-poet it is timely to examine why the operation got so Oliver Wendell Holmes that "the truth is that firmly established that it has prevailed for nearly medicine, professedly founded on observation, is a century without real evidence of merit. (The as sensitive to outside influences . as is the popular explanation that medical knowledge in barometer to changes in atmospheric density."" Halsted's day presumed breast cancer to be local- Barzun goes on to say that medicine's external ized is assailable. At the same meeting in 1898 conditioning is usually ignored both in and out where Halsted reported his operation, leading of the profession. surgeon maintained that breast Viewing the origins of the radical mastectomy cancer was systemic and might spread in the blood in this light, I propose that economics (in the stream and by lymphatic routes other than those 19th century surgeons' competition with general in the axilla-unaffected by Halsted's extirpation practitioners) and nationalism (in the American of muscles and axillary nodes.)9 Writer Rosamond surgeons' r-ivalry with their preeminent German Campion suggests that the procedure has had its counterparts) were more responsible for the suc- long reign of error because surgeons emotionally cess of the radical mastectomy than Halsted was. believed in it "with the same sincerity that Tor- He was merely the ideal medium for the message quemada believed he made people more religious of these socioemotional forces. Nonetheless, an by burning them."'0 In like vein, Crile (who car- analysis of the history of the operation must start ried out the limited excision of a Campion breast with Halsted for, as Cope notes, "his remarkable tumor) notes that some surgeons exorcise disease character and influence were a substantial reason as the clergy of the Middle Ages did the devil, wliy so much attention was paid to his operation,"2 "regardless of the consequences to the person."'" and, as Fisher suggests, surgeons have "perhaps Bernard Fisher confirms that surgeons' emotion- uLnknowingly" been defending the eminence of alism has largely called the shots in breast cancer Halsted all these years rather than the merits of treatment and views this as "almost tragic."4 his operation.' The belief in radical mastectomy is If surgeons' emotional faith correlated with so interwoven with faith in Halsted that desancti- benefit to patients, controlled studies would not fying the high priest of surgery could speed the be needed. Rather, as psychiatrist Leon Eisenberg end of his operation and the trend toward less warns physicians, unfounded faith in treatments traumatic treatments. is a major source of medical error for "when good evidence is lacking, the best and most dedi- History cated of us do wrong in the sincere conviction of embodied the success being right."'"2 motif of his place and time. He was born in 1852 Some doctors, as well as some patients, believe to the families who owned the that sexism is associated with this excessive opera- Halsted, Haines & Company drygoods importing tion done by surgeons who are nearly all men on firm. Halsted had governesses and tutors, was sent patients who are nearly all women, and surgeon to boarding school at the age of 10, and gradu- William Nolen concedes that "male chauvinism ated from Phillips Andover Academy and Yale, has been partly responsible for the blind perpetu- where he was on the class crew and captained the ation of the radical mastectomy."13 It seems sexist varsity football team. He was crushed and embit- also when surgeons whose own adherence to the tered when passed over by the Yale undergraduate radical mastectomy is emotional criticize women society Skull and Bones, and his roommate and for being emotional in resisting breast amputation. lifelong friend Samuel Bushnell has suggested that Emotionalism attended the birth of the radical his brilliant medical career reflected his urge to mastectomy. This has been obscured because the show his classmates the merit Skull and Bones late 19th century was an era of phenomenal lhad slighted.15 progress in medical science and Halsted himself Halsted distinguished himself as a medical stu-

550 JUNE 1981 * 134 * 6 THE HALSTED MASTECTOMY dent at Columbia, completing an accelerated in- States, other outstanding American surgeons, such ternship at in his final year of as "father of vascular surgery" Rudolph Matas, the curriculum and receiving his MD degree in also furthered this therapeutic breakthrough and 1877. His independent means enabled him to developed other surgical advances comparable to pursue postgraduate training in Austria and Ger- Halsted's.21 (Halsted introduced the rubber gloves many under such foremost medical scientists as that are the very symbol of aseptic surgery not surgeon Richard von Volkmann. Halsted called for medical science but for romance. He com- his years abroad the happiest of his life. Accord- missioned the Goodrich Company to make rubber ing to Sir , he was ever after very gloves to protect the hands of the head operating verdeutsched and held that "there were only three room nurse at Hopkins, the future Mrs. Halsted, or four good surgeons in the world and they were Caroline Hampton, from contact with irritating all German."'1 His election in later years to the mercuric chloride solution. Halsted himself never German Surgical Association was the honor that used surgical gloves routinely and always doffed gave him the most gratification, despite such them when things were touch and go.'8) laurels on his native heath as honorary degrees Halsted initiated his operation for breast can- from Yale and Columbia and election to the cer in New York in 1882 and briefly reported his National Academy of Sciences. first 13 cases in Reports After returning to New York, Halsted threw in 1 891."2 This first study, his further report of himself into his work with an intensity that 50 cases in the same publication in 1894,23 and showed his zeal for sharing the new techniques his presentation of 76 cases at the meeting of the of aseptic surgery he had mastered abroad; it American Surgical Association in might also have shown something else acquired in 1898,9 make up the data base for the virtually in Germany-a Herr Professor self-image as a routine prescription of radical mastectomies. Hal- superman of surgery. Halsted's prestige was en- sted's 1907 report of 252 patients in Annals of hanced by the rigid distance he kept from others. Surgery appeared long after his operation had This isolation guarded his deep-seated personal become the prevailing procedure. problem of secret, lifelong drug addiction, entail- Halsted could establish his operation so easily ing lengthy absences for cures.10-'9 He fell victim because the cult of the expert dominated the to in 1885 while testing its effects as nerve medical world of the late 19th century and Hal- block and acquired the morphine habit sted's prestige added great weight to his impact as an antidote to cocaine, as was common in as expert. (Psychologist Abraham Maslow termed those days of legal drug use. an expert someone who avoids all the small errors After Halsted's death in 1922, the secret of his as he sweeps on to the grand fallacy.) In those drug addiction leaked out. The revelations led his days, according to a 1973 article in the New Eng- champions to scale up his achievements to scale land Journal of Medicine, "the Herr Professor of down the character cloud of addiction. Thus, al- the community needed only to indicate that his though his drug problem was still being debated personal observations led him to a particular con- in medical circles as late as the 1952 Halsted clusion to have that conclusion accepted."'4 centenary at Hopkins, the tone of that debate is Halsted's prestige could have been just what sounded by pediatrician Edwards Park in his con- the doctor ordered for the new specialty of sur- tribution to the festschrift: "The question whether gery. It was struggling hard for its share of the or not Halsted recovered is an entirely academic 19th century American dream of unlimited growth one, for his life to the very end was one of unin- and success-in the limiting situation of too many terrupted glory."20 Park even likened Halsted to doctors, almost all of them general practitioners Descartes and Einstein. who also carried out surgical procedures. Founded The dark side of Halsted's life should by no in 1880, the American Surgical Association, the means shadow his place in the sun; but this can nation's first organization of surgeons, was dedi- be accorded him as a major pioneer on the fron- cated to rigorous quality in operating techniques tiers of medical history without transmuting him and in surgeons. It was surely also concerned, into an Einstein of the scalpel. Although Halsted however, with the new specialty's financial pros- was, by virtue of his unprecedented American pects in times that were precarious for physicians. version of the Herr Professor of surgery, typecast An overpopulation of physicians extended from as major importer of aseptic surgery to the United the 1860's, when there was one doctor for every

THE WESTERN JOURNAL OF MEDICINE 551 THE HALSTED MASTECTOMY 572 persons,25 until long after the 1910 landmark able. Besides the higher fee, however, the profes- Report on Medical Education by Abraham Flex- sional status offered by the more technically de- ner set in motion a process of reducing the manding Halsted procedure promised still greater quantity while raising the quality of the nation's long-term reward. Halsted was far from indifferent medical schools. The cited "the to the pecuniary aspects of surgery. Osler wrote enormous overproduction of physicians in the that "he secured a very good income from a very last 25 years" that gave the a doctor few patients as his fees were enormous ... to population ratio four to five times higher than Thanks to his enormous fees, Halsted, as recalled that of other western nations such as Germany.26 by neurosurgeon , long his stu- The profession's conflicts could not have aided dent, "spent his medical life avoiding patients."19 fee collection. The regular or allopathic physicians were regrouping after prolonged assault by the Lifesavinig homeopaths and Thomsonians,* and by the Halsted apparently referred to his operation People's Health Movement organized by Sylvester as lifesaving* to justify its destruction of the Graham, a nutritionist whose name is ingrained muscles. Thus, although he admitted that his pa- in the graham cracker. Medical historian Richard tients complained they could no longer "dress Shryock quotes a writer in a journal of opinion their back hair"' in the elaborate fashion of the who warned that the public itself would act as day, he advised his colleagues that "disability, umpire between the regular and challenging ever so great, is a matter of very little importance schools of medical practice and reach its verdict as compared with the life of the patient,"'' and, after careful perusal of the undertakers' bills.25 "We should, perhaps, sacrifice many lives if we Against this background of hard times Hal- were to consider the disability which might result sted's mastectomy can be seen as filling the bill from removing a little more tissue here and for the nascent specialty-separating the surgeons there.""' He noted, "Furthermore, these patients from the general practitioners by a swath only are old. Their average age is nearly 55 years. skilled surgeons could cut. Surgeon Frederick They are no longer very active members of Gerrish, discussant of Halsted's report of 76 cases society."2'1 (Yet Halsted seemed to contradict his at the 1898 meeting of the American Surgical own lifesaving contention by admitting in the same Association in New Orleans, stated, "We now report that "one might literally flay the patient's have an operation which should be regarded as chest and side only to find a few weeks or months unjustifiable for the general practitioner, since it later one or more cancer nodules in the skin of demands the anatomical knowledge, the trained the neck or back or abdomen.") mind, and the steady nerves of the expert, I had Still invoking lifesaving in defense of the Hal- almost said of the specialist."9 Halsted was less sted operation, a surgeon in a 1978 symposium shy in staking the specialist's claim: "Now that claimed that lesser operations catering to "femi- surgery is specialized to such an extent, surgeons nine whims" may result in "a dead woman with a have plenty of time to drill themselves in opera- somewhat more pleasant-appearing chest wall."' tion. They should not cast about for easy opera- Because it is well known that each sort of treat- tions-for operations that anyone can do . . .. ment for breast cancer has widely varying out- (Halsted's preference for operations of magnitude comes, governed by whether the tumor is fast- still exists. An eminent surgeon was quoted in a growing or slow and a host of other factors, such 1974 magazine article as warning that progress lifesaving claims are more of the "emotionalism" in breast cancer surgery would recede "if you do Bernard Fisher deplores. all this crappy small stuff."10) We would expect Halsted to have-had a com- The simple mastectomy could be done by a pelling medical reason for overturning the teach- general practitioner in an hour. The radical mas- ing of his mentor Volkmann, who had 23 years tectomy, according to Halsted, "including the more clinical experience than he, that the muscles toilet of the wound and the grafting, requires from should be spared in the mastectomy. Volkmann two to four hours....." The greater time required explained that "I was led to adopt this procedure for the radical mastectomy made it more profit- because on microscopic examination I repeatedly found when I had not expected it that the fascia *Homeopaths followed the "like cures like" theory-that is, drugs that in large doses produce certain symptoms cotunteract *That many women have a normal life span after radical mas- them in minute doses. The Thomsonian or botanic system con- tectomy does not alter the fact that there has never been any demned all mineral and metallic remedies. proof that the operation is lifesaving.

552 JUNE 1981 * 134 * 6 THE HALSTED MASTECTOMY was already carcinomatous, whereas the muscle CASE 4. No local or regional recurrence. Re- was certainly not involved"22 (findings confirmed ported dead. by pathologists today). CASE 9. Three years and two months after Halsted's first report ( 1891 ) gives this explana- operation died from internal metastases. tion for excising the muscles: "It is impossible to No local recurrence. determine with the naked eye whether or not the CASE 10. Died with symptoms of internal me- disease has extended to the pectoral muscles."22 tastases in seven months. Neither local Since Volkmann found that cancer did not nor regional recurrence.23 extend to the muscles, a finding in which Halsted concurred, to wit, "his observations were correct, Surgeon Rudolph Matas, Halsted's friend as and they have been confirmed in almost every well as critic, countered that "a far more import- detail,"23 it is hard to understand why Halsted ant question than that of local recurrence is that sacrificed the muscles because he could not see which refers to the actual numbers of cures ob- if they were invaded. Surely the inability to see tained."9 Matas shot down Halsted's lifesaving if cancer existed applied also to other tissues on claim in this eloquent exposition of the tendency the borders of the operation. of breast cancer to spread in the blood stream In his 1894 report, Halsted advanced this quite and by lymphatic routes other than, or in addition different reason for taking the muscles: to, the axillary lymph nodes-a challenge to the to the 1980's as to The pectoralis major muscle . . . should be excised in "get it all" theory as relevant every case of cancer of the breast because the operator the 1890's: is enabled thereby to remove in one piece all of the We operate on the presumption that metastatic migration suspected tissue. has followed the widest and most direct highway (the The suspected tissues should be removed in one piece axillary route), and that the less frequent byways of (1) lest the wound become infected by the division of travel have not yet been utilized by the enemy. Success tissue invaded by the disease, or of lymphatic vessels in avoiding intrathoracic and visceral metastases must, containing cancer cells, and (2) because seeds or pieces therefore, remain, to a large extent, an affair of chance, of cancerous tissue might equally be overlooked in a not of certainty that all the avenues of escape from the piecemeal extirpation.23 primary focus have been cut off ..." The words con- stantly used to qualify the operation of the day as Why Halsted decided to remove with the "sus- "complete" and "radical" are anatomical misnomers pected" tissues the muscles he agreed with Volk- which serve only to indicate evolutionary phases in the mann were not cancerous can only be guessed. surgical technique, and are illusory if used in the sense that they root out the evil with any degree of certainty.9 What Halsted lightly referred to as "removing a little more tissue here and there" has left mil- Matas concluded that Halsted's operation lions of women with weakened arms. Breast sur- "offers no more prospect of cure or chance of geon Jerome Urban states that "women mind los- escape from internal metastases and secondary ing their muscles more than their breast, because recurrence in the neck than that obtained by the they can hide the loss of a breast with a falsie but older and less mutilating operation." they can't hide the hollow in the axilla."'0 Besides Matas's caveat on the spread of breast cancer the muscles' value for a woman's strength and ap- was lost on Halsted. Halsted also apparently failed pearance, they have a role in physical affection. to see the import of a finding by Harvey Cushing Marriage counselor Eleanor Hamilton advises: that following a mastectomy, a patient was found "Hugging allows you to have body contact with to have cancer growing between the costal car- the pectoral (chest) muscles, one of the most tilages next to the sternum. Halsted's failure to receptive areas of the body. Since these muscles pursue the meaning of Cushing's observation set are involved with the sexual muscles, hugging the stage for American surgeons to overlook the can initiate sexual feelings."28 critical role of the internal mammary lymph That Halsted's true goal for his operation was nodes in the spread of breast cancer. In 1932 more modest than its being lifesaving, however, the French anatomist Henri Rouviere elucidated is suggested by his interest in local recurrence. the significance of both the internal mammary He was entirely candid in maintaining that "the lymph nodes and the posterior mediastinal nodes. efficiency of an operation is measured truer in He showed that breast cancer often spreads to terms of local recurrence than of ultimate cure."23 these nodes within the chest-far out of reach Concern with local recurrence underscores his of a surgeon.29 In 1959 the surgeon R. T. Turner- case histories. These are typical: Warwick of the Middlesex Hospital also cited the

THE WESTERN JOURNAL OF MEDICINE 553 THE HALSTED MASTECTOMY importance of the internal mammary chain as a Preserving ethnological purity as an ethical instinct in pathway of lymphatic spread of cancer from both our contact with the lower races, and, therefore, race dominance, we have developed and overspread islands the lateral and medial halves of the breast." Re- and continents, always in the direction of greatest possi- cently, Urban, Haagensen and Cope have re- bilities, albeit, sometimes of greatest resistance . . . . On sponsibly stressed the problem of the internal this continent we did not commingle with, but wiped out, the incorrigible Indian, and extinguished the pretensions mammary nodes. Clearly, it can offer patients of France and .31 scant help to excise diseased axillary lymph nodes when cancer has spread to the internal mammary Holt quotes a Dr. F. S. Dennis that "if what nodes as well, and in some cases it has spread to Americans have accomplished be eliminated from the internal mammary nodes alone. the sum total of the surgical work of the world, Halsted's case results were far from lifesaving, there is little left to other nations." Holt so de- even for his time, when a three-year survival plored the traditioin for young American physi- gauged the success of therapy. Of his 50 cases cians to take postgraduate training in Europe that reported in 1894, none were followed for more he denied it still existed (whereas it continued than 31/2 years; 19 patients were dead, and most until at least World War I): of the 27 counted as alive and well were less than hi times past this yearning for a foreign diploma as next best to a foreign title, betraying a smallness of spirit and 18 months postoperative. Of his 76 cases re- a childish vanity almost despicable and wholly un-Ameri- ported in 1898 and followed up to three years, can, was almost the rule, but is now an exception, for only 31 patients were alive and well. Thirty-five even with the weakest worshipper of the glittering tinsel had died (seven which adorns foreign titles and honors, the center of with local recurrence) within aittraction has been shifted from abroad and localized in three years of the operation. One wonders what our home institutions, not by patriotic sentiment, but by induced this serious clinical scientist to claim the law of natural selection in favor of the fittest, which, favorable results from such a small number of not always, but in this instance, is also the best. dead, dying and doomed women. Sadly, Halsted's Surgeon Theodore Prewitt concluded his presi- legacy of a lifesaving myth around his operation dential address to the meeting with this paean to has probably deterred generations of physicians progress: from developing treatments that are lifesaving-- Railroads, steamboats, telegraph, telephone, photograph, and life-serving. electric light, electric motor, with many other marvellous things, have made this century the most brilliant epoch Nationalism in the world's history. We are proud to say that medicine and surgery have That Halsted's mastectomy surpassed (in not been laggards in this phenomenal procession of won- "thoroughness") the Volkmann operation pre- derful achievements. Within the period named they have leaped from a crude empiricism to a status closely ap- ferred by the top surgeons of Germany must have proaching exact science. Will the 20th century find them been deeply gratifying to American surgeons. keeping abreast of the advances made in the material Medicine in the 19th century United States still world? Will surgery advance with strides commensurate depended on Europe for scientific developments with those of the past 50 years?32 because American physicians had little interest in Although Prewitt's belief that medicine closely research. Shryock notes that professional prestige approached an exact science was unfounded, his here was gained by "a fashionable practice, which hope that 20th century medicine would advance presumably aided the sick and at the same time in step with the material world was realistic. bore the hallmark of financial success."25 Ameri- Progress in medicine and surgery has indeed can medicine's prolonged dependence on the exceeded his fondest dreams in many areas-but mother continent bred a nationalistic rivalry with not in cancer of the breast. It is still the chief medical leaders abroad. killer of American women in the prime of life, The flagrant nationalism of the period could and the Halsted operation, introduced when Presi- not have been more boldly articulated than by dent McKinley led a nation of 30 million souls prominent New Orleans physician Joseph Holt in thrilled by the first electric light, is still done today his welcoming address to the American Surgical when President Reagan heads a country of 240 Association in 1898, the year the United States million citizens blase about trips to the moon. launched the jingoistic Spanish-American War. The expansionism boasted by Holt may be seen Conclusion as a metaphor for Halsted's operation presented Halsted mirrored-as well as served-Ameri- later at the meeting. Said Holt: can surgeons' nationalistic rivalry with German

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15. MacCallum W: William Stewart Halsted: Surgeon. Balti- surgeons and economic competition with general more, Johns Hopkins Press, 1930 practitioners. This strange confluence of condi- 16. Penfield W: Halsted of Johns Hopkins: The man and his problems as described in the secret records of William Osler. tions favored the radical mastectomy and medical JAMA 210:2214-2218, Dec 22, 1969 17. Whipple AO: Halsted's New York period. Surgery 32:443- science played small part in its success. 550, Sep 1952 18. Harvey AM: Early contributions to the surgery of cancer: REFERENCES William S. Halsted, Hugh H. Young and John G. Clark. Hopkins Med J 135:399-417, Dec 1974 1. Crile G Jr: What Women Shotuld Know About the Breast 19. Holman E: Osler & Halsted, a contrast in perscnalitics. In, Cancer Controversy. New York, Macmillan Publishing Co, 1973 McGovern JF, Burns CR (Eds): Humanism in Medicine. Spring- 2. Cope 0: The Breast: Its Problems-Benign and Malignant- field, IL, Charles C Thomas, 1973 and How to Deal with Them. Boston, Houghton Mifflin Co, 1977 20. Park EA: A pediatrician's chance recollections of Dr. 3. Haagensen C: Treatment of curable carcinoma cf the breast. Halsted. Surgery 32:443-550, Sep 1952 Int J Radiation Oncology Biol Phys 2:975-980, 1977 21. Who was Dr. Rudolph Matas? Tulatian, Mar 1968 4. Fisher B: The surgical dilemma in the primary therapy of 22. Halsted WS: Operations for carcinoma of the brcast. Johns invasive breast cancer: A critical appraisal. Curr Probl Surg 3-53, Hopkins Hosp Reports 2:277-280, Oct 1970 1891 23. Halsted WS: The results of radical operations for the cuire 5. Fisher B, Montague E, Redmond C, et al: Comparison of of carcinoma of the breast performed at the Johns Hopkins Hos- radical mastectomy with alternative treatments for primary breast pital from June, 1889, -to January, 1894. Johns Hopkins Hosp Re- cancer. Cancer 39:2827-2839, Jun 1977 ports 4:297-327, 1894 6. Meyer AC, Smith SS, Potter M: Carcinoma of the breast. 24. Weiner M: Raw vs cooked data. N Engl J Med 289:974- Arch Surg 113:364-367, Apr 1978 976, Nov 1, 1973 7. Henderson IC, Canellos GP: Cancer of the breast: The past 25. Shyrock RH: Medicine in America: Historical Essays. decade. N Engl J Med 302:17-30, Jan 3, 1980 and 302:78-79, Jan , Johns Hopkins Press, 1966 10, 1980 26. Flexner A: Medical Education in the United States andi 8. Randal J: News story on the June 5, 1979 NIH Consensus Canada-Report to The Carnegie Foundation for the Advancement Development Conference. New York Daily News, Jun 6, 1979 of Teaching, Bulletin No. 4, 1910. Boston, DB Updike, The 9. Halsted WS: A clinical and histological study of certain Merrymount Press, 1910 adenocarcinomata of the breast-And a brief consideration of the 27. Ariel TM: The treatment of breast cancer by radical and supraclavicular operation and of the results of operations for stuper radical mastectomy. Resident Staff Physician 57-62, Sep 1978 cancer of the breast from 1889 to 1898 at the Johns Hopkins 28. Sandler L: How touching can help strengthen a marriagc. Hospital. Trans Am Surg Assoc 16:144-181, 1898 Nat Enq, Jun 7, 1977 10. Nobile P: King cancer. Esquire 108-111 and 204-225. Jun 29. Rouviere H: Anatomie des lymphatiques de l'homme. Paris, 1974 Masson et Cie, 1932 (Rouvibre H: Anatomy of the Human Lym- 11. Crile G Jr: Surgery: Your Choices, Your Alternatives. New phatic System, translated Jy Tobias MJ. Ann Arbor, Michigan, York, Delacorte Press/Seymour Lawrence, 1978 Edwards Brothers, Inc, 1938) 12. Eisenberg L: The social imperatives of medical rcscarch. 30. Turner-Warwick RT: The lymphatics of the breast. Br J Science 198:1105-1110, Dec 16, 1977 Surg 46:574-582, 1959 13. Nolen WA: How doctors are unfair to women. McCall's 31. Holt J: Address of welcome. Trans Am Surg Assoc 16: 50-52, Aug 1973 c-xii, 1898 14. Barzun J: The medical profession uinder fire. Harper's 32. Prewitt TF: Address of the president. Trans Am Surg Assoc Magazine 257:61-68, Oct 1978 16:1-5, 1898

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