The whole procedure took seventeen and a half minutes, though it must have seemed a lifetime to poor Fanny Burney. Remarkably, it worked. Burney lived another twenty-nine years.
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Although the development of anesthetics in the mid-nineteenth century did much to remove the immediate pain and horror of surgery, treatment for breast cancer became, if anything, even more brutal as we moved into the modern age. And the person almost single-handedly responsible for that was one of the most extraordinary figures in the history of modern surgery, William Stewart Halsted (1852–1922).
The son of a wealthy businessman in New York, Halsted studied medicine at Columbia University and upon graduating quickly distinguished himself as a deft and innovative surgeon. You will recall him from chapter 8, where we noted that he was one of the first people daring enough to perform gallbladder surgery, on his mother on a kitchen table in the family home in upstate New York. He also attempted the first appendectomy in New York (the patient died) and, more happily, one of the first successful transfusions in America—on his sister Minnie after she suffered a severe hemorrhage in childbirth. As she lay near death, Halsted transferred two pints of blood from his arm into hers and saved her life. This was before anyone understood the need for blood type compatibility, but luckily they were a match.
Halsted became the first professor of surgery at the new Johns Hopkins Medical School in Baltimore after its founding in 1893. There he trained a generation of leading surgeons and made many worthwhile advances in surgical techniques. Among much else, he invented the surgical glove. He became famous for instilling in his students the need for the most exacting standards of surgical care and hygiene—an approach so influential that it soon became universally known as “Halstedian technique.” People commonly referred to him as the father of American surgery.
What makes Halsted’s achievements all the more remarkable is that for much of his career he was a drug addict. While investigating methods for providing pain relief, he experimented with cocaine and soon found himself helplessly attached to it. As his addiction took over his life, he became conspicuously more reserved in manner—most of his colleagues thought he was simply being more thoughtful and reflective—but in print he became positively manic. Here is the opening of a paper he wrote in 1885, just four years after he operated on his mother: “Neither indifferent as to which of how many possibilities may best explain, nor yet at a loss to comprehend, why surgeons have, and that so many, quite without discredit, could have exhibited scarcely any interest in what, as a local anaesthetic, had been supposed, if not declared, by most so very sure to prove, especially to them, attractive, still I do not think that this circumstance, or some sense of obligation…”—and so it goes on for several lines more without straying at any point to within sight of coherence.
In an effort to remove him from temptation and break the habit, Halsted was sent on a Caribbean cruise but was there caught searching for drugs in the ship medicine locker. Then he was committed to an institution in Rhode Island where unfortunately doctors tried to wean him off cocaine by giving him morphine. He ended up addicted to both. He lived out his life with almost everyone except one or two immediate superiors unaware that he was completely dependent on drugs to get through the day. There is some evidence that his wife became an addict, too.
In 1894 at a conference in Maryland, and at the height of his addiction, Halsted introduced his most revolutionary innovation—the concept of the radical mastectomy. Halsted believed, wrongly, that breast cancer spread by radiating outward, like wine spilled on a tablecloth, and that the only effective treatment was to cut out not just the tumor but as much surrounding tissue as one dared. The radical mastectomy wasn’t so much surgery as excavation. It involved removing the whole breast and surrounding chest muscles, lymph nodes, and sometimes ribs—whatever could be taken away without causing immediate death. The excision was so extensive that the only way to close the wound was to take a large skin graft from the thigh, giving yet more pain and an additional site of disfigurement to the poor, battered patient.
But it got good results. About a third of Halsted’s patients survived for at least three years, a proportion that astounded other cancer specialists. Many more patients gained at least a few months of reasonably comfortable life without the embarrassing stench and seepage that made so many previous sufferers into recluses.
Not everyone was convinced that Halsted’s approach was the right one. In Britain, a surgeon named Stephen Paget (1855–1926) looked at 735 cases of breast cancer and found that cancers didn’t spread like a stain at all, but rather cropped up in distant locations. More often than not, breast cancers migrated to the liver—and, moreover, to specific sites within the liver. Though Paget’s findings were correct and incontestable, no one paid any attention to them for about a hundred years, during which time tens of thousands of women were disfigured to a far greater degree than was necessary.
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Meanwhile, elsewhere in the world of medicine researchers were developing other cancer treatments, which generally proved just as taxing to the patients and sometimes to those who treated them. One of the great excitements of the early twentieth century was radium, discovered by Marie and Pierre Curie in France in 1898. Quite early on, it was realized that radium accumulated in the bones of people exposed to it, but this was thought to be a good thing because it was believed that radiation was wholly beneficial. Radioactive products were liberally added to many medications, with sometimes devastating consequences. A popular over-the-counter painkiller called Radithor was made with diluted radium. An industrialist in Pittsburgh named Eben M. Byers treated it as a tonic and drank a bottle every day for three years until he discovered that the bones in his head were slowly softening and dissolving, like a stick of blackboard chalk left in the rain. He lost most of his jaw and parts of his skull en route to dying a slow and hideous death.
For many others, radium was an occupational hazard. In 1920, four million radium watches were sold in America, and the watchmaking industry employed two thousand women to paint the dials. It was delicate work, and the simplest way to keep a fine point on the brush was to roll it gently between one’s lips. As Timothy J. Jorgensen notes in his superb history, Strange Glow: The Story of Radiation, it was subsequently calculated that the average dial painter swallowed about a teaspoon of radioactive material a week in this way. There was so much radium dust in the air that some of the factory girls noticed that they glowed in the dark themselves. Not surprisingly, some of the women soon began to sicken and die. Others developed strange fragilities; one young woman’s leg broke spontaneously while she was on the dance floor.
One of the very first people to take an interest in radiation therapy was a medical student at the Hahnemann Medical College in Chicago named Emil H. Grubbe (1875–1960). In 1896, just a month after Wilhelm Röntgen announced his discovery of X-rays, Grubbe decided to try X-rays out on cancer patients, even though he was not actually qualified to do so. All Grubbe’s early patients died quickly—all were near death anyway so probably beyond saving even with today’s treatments, and Grubbe was only guessing dosages—but the young medical student persevered and had more success as he gained experience. Unfortunately, he did not understand the need to limit his own exposures. By the 1920s, he had begun to develop tumors all over, most notably on his face. Surgery to remove these growths left him disfigured. His medical practice failed as his patients abandoned him. “By 1951,” writes Jorgensen, “he was so badly disfigured by his multiple surgeries that his landlord asked him to vacate his apartment because his grotesque appearance was scaring away tenants.”