The Haisted Mastectomy:Present
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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 surgeons 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. Surgeon 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 breast cancer, 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 Rudolph Matas 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 William Stewart Halsted 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 New York City 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 Bellevue Hospital 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 William Osler, 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