The Emperor of All Maladies

Halsted entered surgery at a transitional moment in its history. Bloodletting, cupping, leaching, and purging were common procedures. One woman with convulsions and fever from a postsurgical infection was treated with even more barbaric attempts at surgery: “I opened a large orifice

(#litres_trial_promo) in each arm,” her surgeon wrote with self-congratulatory enthusiasm in the 1850s, “and cut both temporal arteries and had her blood flowing freely from all at the same time, determined to bleed her until the convulsions ceased.” Another doctor, prescribing a remedy for lung cancer, wrote, “Small bleedings give temporary relief,

(#litres_trial_promo) although, of course, they cannot often be repeated.” At Bellevue, the “internes” ran about in corridors with “pus-pails,”

(#litres_trial_promo) the bodily drippings of patients spilling out of them. Surgical sutures were made of catgut, sharpened with spit, and left to hang from incisions into the open air. Surgeons walked around with their scalpels dangling from their pockets. If a tool fell on the blood-soiled floor, it was dusted off and inserted back into the pocket—or into the body of the patient on the operating table.

In October 1877, leaving behind

(#litres_trial_promo) this gruesome medical world of purgers, bleeders, pus-pails, and quacks, Halsted traveled to Europe to visit the clinics of London, Paris, Berlin, Vienna, or Leipzig, where young American surgeons were typically sent to learn refined European surgical techniques. The timing was fortuitous: Halsted arrived in Europe when cancer surgery was just emerging from its chrysalis. In the high-baroque surgical amphitheaters of the Allgemeines Krankenhaus in Vienna, Theodor Billroth was teaching his students novel techniques to dissect the stomach (the complete surgical removal of cancer, Billroth told his students, was merely an “audacious step” away

(#litres_trial_promo)). At Halle, a few hundred miles from Vienna, the German surgeon Richard von Volkmann was working on a technique to operate on breast cancer. Halsted met the giants of European surgery: Hans Chiari, who had meticulously deconstructed the anatomy of the liver; Anton Wolfler, who had studied with Billroth and was learning to dissect the thyroid gland.

For Halsted, this whirlwind tour through Berlin, Halle, Zurich, London, and Vienna was an intellectual baptism. When he returned to practice in New York in the early 1880s, his mind was spinning with the ideas he had encountered in his journey: Lister’s carbolic sprays, Volkmann’s early attempts at cancer surgery, and Billroth’s miraculous abdominal operations. Energized and inspired, Halsted threw himself to work, operating on patients at Roosevelt Hospital, at the College of Physicians and Surgeons at Columbia, at Bellevue, and at Chambers Hospital. Bold, inventive, and daring, his confidence in his handiwork boomed. In 1882, he removed an infected gallbladder

(#litres_trial_promo) from his mother on a kitchen table, successfully performing one of the first such operations in America. Called urgently to see his sister, who was bleeding heavily after childbirth, he withdrew his own blood and transfused her with it. (He had no knowledge of blood types; but fortunately Halsted and his sister were a perfect match.)

In 1884, at the prime of his career in New York, Halsted read a paper describing the use of a new surgical anesthetic called cocaine. At Halle, in Volkmann’s clinic, he had watched German surgeons perform operations using this drug; it was cheap, accessible, foolproof, and easy to dose—the fast food of surgical anesthesia. His experimental curiosity aroused, Halsted began to inject himself with the drug, testing it before using it to numb patients for his ambitious surgeries. He found that it produced much more than a transitory numbness: it amplified his instinct for tirelessness; it synergized with his already manic energy. His mind became, as one observer put it, “clearer and clearer, with no sense of fatigue

(#litres_trial_promo) and no desire or ability to sleep.” He had, it would seem, conquered all his mortal imperfections: the need to sleep, exhaustion, and nihilism. His restive personality had met its perfect pharmacological match.

For the next five years, Halsted sustained an incredible career as a young surgeon in New York despite a fierce and growing addiction to cocaine. He wrested some control over his addiction by heroic self-denial and discipline. (At night, he reportedly left a sealed vial of cocaine by his bedside, thus testing himself by constantly having the drug within arm’s reach.) But he relapsed often and fiercely, unable to ever fully overcome his habit. He voluntarily entered the Butler sanatorium in Providence, where he was treated with morphine to treat his cocaine habit—in essence, exchanging one addiction for another. In 1889, still oscillating between the two highly addictive drugs (yet still astonishingly productive in his surgical clinic in New York), he was recruited to the newly built Johns Hopkins Hospital by the renowned physician William Welch—in part to start a new surgical department and in equal part to wrest him out of his New York world of isolation, overwork, and drug addiction.

Hopkins was meant to change Halsted, and it did. Gregarious and outgoing in his former life, he withdrew sharply into a cocooned and private empire where things were controlled, clean, and perfect. He launched an awe-inspiring training program for young surgical residents that would build them in his own image—a superhuman initiation into a superhuman profession that emphasized heroism, self-denial, diligence, and tirelessness. (“It will be objected that this apprenticeship is too long, that the young surgeon will be stale,” he wrote in 1904, but “these positions are not for those who so soon weary of the study of their profession.”) He married Caroline Hampton, formerly his chief nurse, and lived in a sprawling three-story mansion on the top of a hill (“cold as stone and most unlivable,”

(#litres_trial_promo) as one of his students described it), each residing on a separate floor. Childless, socially awkward, formal, and notoriously reclusive, the Halsteds raised thoroughbred horses and purebred dachshunds. Halsted was still deeply addicted to morphine, but he took the drug in such controlled doses and on such a strict schedule that not even his closest students suspected it. The couple diligently avoided Baltimore society. When visitors came unannounced to their mansion on the hill, the maid was told to inform them that the Halsteds were not home.

With the world around him erased and silenced by this routine and rhythm, Halsted now attacked breast cancer with relentless energy. At Volkmann’s clinic in Halle, Halsted had witnessed the German surgeon performing increasingly meticulous and aggressive surgeries to remove tumors from the breast. But Volkmann, Halsted knew, had run into a wall. Even though the surgeries had grown extensive and exhaustive, breast cancer had still relapsed, eventually recurring months or even years after the operation.

What caused this relapse? At St. Luke’s Hospital in London in the 1860s, the English surgeon Charles Moore had also noted these vexing local recurrences. Frustrated by repeated failures, Moore had begun to record the anatomy of each relapse, denoting the area of the original tumor, the precise margin of the surgery, and the site of cancer recurrence by drawing tiny black dots on a diagram of a breast—creating a sort of historical dartboard of cancer recurrence. And to Moore’s surprise, dot by dot, a pattern had emerged. The recurrences had accumulated precisely around the margins of the original surgery, as if minute remnants of cancer had been left behind by incomplete surgery and grown back. “Mammary cancer requires

(#litres_trial_promo) the careful extirpation of the entire organ,” Moore concluded. “Local recurrence of cancer after operations is due to the continuous growth of fragments of the principal tumor.”

Moore’s hypothesis had an obvious corollary. If breast cancer relapsed due to the inadequacy of the original surgical excisions, then even more breast tissue should be removed during the initial operation. Since the margins of extirpation were the problem, then why not extend the margins? Moore argued that surgeons, attempting to spare women the disfiguring (and often life-threatening) surgery were exercising “mistaken kindness”

(#litres_trial_promo)—letting cancer get the better of their knives. In Germany, Halsted had seen Volkmann remove not just the breast, but a thin, fanlike muscle spread out immediately under the breast called the pectoralis minor, in the hopes of cleaning out the minor fragments of leftover cancer.

Halsted took this line of reasoning to its next inevitable step. Volkmann may have run into a wall; Halsted would excavate his way past it. Instead of stripping away the thin pectoralis minor, which had little function, Halsted decided to dig even deeper into the breast cavity, cutting through the pectoralis major, the large, prominent muscle responsible for moving the shoulder and the hand. Halsted was not alone in this innovation: Willy Meyer, a surgeon operating in New York, independently arrived at the same operation in the 1890s. Halsted called this procedure the “radical mastectomy,” using the word radical in the original Latin sense to mean “root”; he was uprooting cancer from its very source.

But Halsted, evidently scornful of “mistaken kindness,” did not stop his surgery at the pectoralis major. When cancer still recurred despite his radical mastectomy, he began to cut even farther into the chest. By 1898, Halsted’s mastectomy had taken what he called “an even more radical” turn. Now he began to slice through the collarbone, reaching for a small cluster of lymph nodes that lay just underneath it. “We clean out or strip

(#litres_trial_promo) the supraclavicular fossa with very few exceptions,” he announced at a surgical conference, reinforcing the notion that conservative, nonradical surgery left the breast somehow “unclean.”

At Hopkins, Halsted’s diligent students

(#litres_trial_promo) now raced to outpace their master with their own scalpels. Joseph Bloodgood, one of Halsted’s first surgical residents, had started to cut farther into the neck to evacuate a chain of glands that lay above the collarbone. Harvey Cushing, another star apprentice, even “cleaned out the anterior mediastinum,” the deep lymph nodes buried inside the chest. “It is likely,”

(#litres_trial_promo) Halsted noted, “that we shall, in the near future, remove the mediastinal contents at some of our primary operations.” A macabre marathon was in progress. Halsted and his disciples would rather evacuate the entire contents of the body than be faced with cancer recurrences. In Europe, one surgeon evacuated three ribs

(#litres_trial_promo) and other parts of the rib cage and amputated a shoulder and a collarbone from a woman with breast cancer.

Halsted acknowledged the “physical penalty” of his operation; the mammoth mastectomies permanently disfigured the bodies of his patients. With the pectoralis major cut off, the shoulders caved inward as if in a perpetual shrug, making it impossible to move the arm forward or sideways. Removing the lymph nodes under the armpit often disrupted the flow of lymph, causing the arm to swell up with accumulated fluid like an elephant’s leg, a condition he vividly called “surgical elephantiasis.” Recuperation from surgery often took patients months, even years. Yet Halsted accepted all these consequences as if they were the inevitable war wounds in an all-out battle. “The patient was a young lady whom I was loath to disfigure,” he wrote with genuine concern, describing an operation extending all the way into the neck that he had performed in the 1890s. Something tender, almost paternal, appears in his surgical notes, with outcomes scribbled alongside personal reminiscences. “Good use of arm.

(#litres_trial_promo) Chops wood with it . . . no swelling,” he wrote at the end of one case. “Married, Four Children,” he scribbled in the margins of another.

But did the Halsted mastectomy save lives? Did radical surgery cure breast cancer? Did the young woman that he was so “loath to disfigure” benefit from the surgery that had disfigured her?

Before answering those questions, it’s worthwhile understanding the milieu in which the radical mastectomy flourished. In the 1870s, when Halsted had left for Europe to learn from the great masters of the art, surgery was a discipline emerging from its adolescence. By 1898, it had transformed into a profession booming with self-confidence, a discipline so swooningly self-impressed with its technical abilities that great surgeons unabashedly imagined themselves as showmen. The operating room was called an operating theater, and surgery was an elaborate performance often watched by a tense, hushed audience of observers from an oculus above the theater. To watch Halsted operate, one observer wrote in 1898, was to watch the “performance of an artist

(#litres_trial_promo) close akin to the patient and minute labor of a Venetian or Florentine intaglio cutter or a master worker in mosaic.” Halsted welcomed the technical challenges of his operation, often conflating the most difficult cases with the most curable: “I find myself inclined

(#litres_trial_promo) to welcome largeness [of a tumor],” he wrote—challenging cancer to duel with his knife.

But the immediate technical success of surgery was not a predictor of its long-term success, its ability to decrease the relapse of cancer. Halsted’s mastectomy may have been a Florentine mosaic worker’s operation, but if cancer was a chronic relapsing disease, then perhaps cutting it away, even with Halsted’s intaglio precision, was not enough. To determine whether Halsted had truly cured breast cancer, one needed to track not immediate survival, or even survival over five or ten months, but survival over five or ten years.

The procedure had to be put to a test by following patients longitudinally in time. So, in the mid-1890s, at the peak of his surgical career, Halsted began to collect long-term statistics to show that his operation was the superior choice. By then, the radical mastectomy was more than a decade old. Halsted had operated on enough women and extracted enough tumors to create what he called an entire “cancer storehouse”

(#litres_trial_promo) at Hopkins.

Halsted would almost certainly have been right in his theory of radical surgery: that attacking even small cancers with aggressive local surgery was the best way to achieve a cure. But there was a deep conceptual error. Imagine a population in which breast cancer occurs at a fixed incidence, say 1 percent per year. The tumors, however, demonstrate a spectrum of behavior right from their inception. In some women, by the time the disease has been diagnosed the tumor has already spread beyond the breast: there is metastatic cancer in the bones, lungs, and liver. In other women, the cancer is confined to the breast, or to the breast and a few nodes; it is truly a local disease.

Position Halsted now, with his scalpel and sutures, in the middle of this population, ready to perform his radical mastectomy on any woman with breast cancer. Halsted’s ability to cure patients with breast cancer obviously depends on the sort of cancer—the stage of breast cancer—that he confronts. The woman with the metastatic cancer is not going to be cured by a radical mastectomy, no matter how aggressively and meticulously Halsted extirpates the tumor in her breast: her cancer is no longer a local problem. In contrast, the woman with the small, confined cancer does benefit from the operation—but for her, a far less aggressive procedure, a local mastectomy, would have done just as well. Halsted’s mastectomy is thus a peculiar misfit in both cases; it underestimates its target in the first case and overestimates it in the second. In both cases, women are forced to undergo indiscriminate, disfiguring, and morbid operations—too much, too early for the woman with local breast cancer, and too little, too late, for the woman with metastatic cancer.

On April 19, 1898

(#litres_trial_promo), Halsted attended the annual conference of the American Surgical Association in New Orleans. On the second day, before a hushed and eager audience of surgeons, he rose to the podium armed with figures and tables showcasing his highly anticipated data. At first glance, his observations were astounding: his mastectomy had outperformed every other surgeon’s operation in terms of local recurrence. At Baltimore, Halsted had slashed the rate of local recurrence to a bare few percent, a drastic improvement on Volkmann’s or Billroth’s numbers. Just as Halsted had promised, he had seemingly exterminated cancer at its root.

But if one looked closely, the roots had persisted. The evidence for a true cure of breast cancer was much more disappointing. Of the seventy-six patients with breast cancer treated with the “radical method,” only forty had survived for more than three years. Thirty-six, or nearly half the original number, had died within three years of the surgery—consumed by a disease supposedly “uprooted” from the body.

But Halsted and his students remained unfazed. Rather than address the real question raised by the data—did radical mastectomy truly extend lives?—they clutched to their theories even more adamantly. A surgeon should “operate on the neck

(#litres_trial_promo) in every case,” Halsted emphasized in New Orleans. Where others might have seen reason for caution, Halsted only saw opportunity: “I fail to see why the neck involvement in itself is more serious than the axillary [area]. The neck can be cleaned out as thoroughly as the axilla.”

In the summer of 1907, Halsted presented more data to the American Surgical Association

(#litres_trial_promo) in Washington, D.C. He divided his patients into three groups based on whether the cancer had spread before surgery to lymph nodes in the axilla or the neck. When he put up his survival tables, a pattern became apparent. Of the sixty patients with no cancer-afflicted nodes in the axilla or the neck, the substantial number of forty-five had been cured of breast cancer at five years. Of the forty patients with such nodes, only three had survived.

The ultimate survival from breast cancer, in short, had little to do with how extensively a surgeon operated on the breast; it depended on how extensively the cancer had spread before surgery. As George Crile, one of the most fervent critics of radical surgery, later put it, “If the disease was so advanced

(#litres_trial_promo) that one had to get rid of the muscles in order to get rid of the tumor, then it had already spread through the system”—making the whole operation moot.

But if Halsted came to the brink of this realization in 1907, he just as emphatically shied away from it. He relapsed to stale aphorisms. “But even without the proof

(#litres_trial_promo) which we offer, it is, I think, incumbent upon the surgeon to perform in many cases the supraclavicular operation,” he advised in one paper. By now the perpetually changing landscape of breast cancer was beginning to tire him out. Trials, tables, and charts had never been his forte; he was a surgeon, not a bookkeeper. “It is especially true of mammary cancer,”

(#litres_trial_promo) he wrote, “that the surgeon interested in furnishing the best statistics may in perfectly honorable ways provide them.” That statement—almost vulgar by Halsted’s standards—exemplified his growing skepticism about putting his own operation to a test. He instinctively knew that he had come to the far edge of his understanding of this amorphous illness that was constantly slipping out of his reach.

The 1907 paper was to be Halsted’s last and most comprehensive discussion on breast cancer. He wanted new and open anatomical vistas where he could practice his technically brilliant procedures in peace, not debates about the measurement and remeasurement of end points of surgery. Never having commanded a particularly good bedside manner, he retreated fully into his cloistered operating room and into the vast, cold library of his mansion. He had already moved on to other organs—the thorax, the thyroid, the great arteries—where he continued to make brilliant surgical innovations. But he never wrote another scholarly analysis of the majestic and flawed operation that bore his name.