Doctor's Review: Medicine on the Move

December 17, 2017

© Traité complete de l'anatomie de l'homme, by J.M. Bourgery

Early attempts at breast cancer surgery were extraordinarily painful and often fatal to the patient

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A terrible disease, a worse treatment

For millennia, breast cancer treatments were equal parts grisly and ineffective, until William Halsted came along

Breast cancer holds the dubious distinction of being the first form of cancer recorded in the literature. It was mentioned as a distinct pathological entity in both the Edwin Smith and Georg Ebers papyri, dating to around 1500 BCE.

But what the Ancient Egyptians did not know was how to treat it. Their successors over the next 3000 years or so did not fare much better. The treatment of breast cancer remained one of the most horrific and least successful forms of treatment right up until almost the 20th century.

A BAD SENSE OF HUMOUR

A millennia or so after it was first recorded, Hippocrates (460-370 BCE) declared breast cancer – and all cancers – to be the result of too much black bile, in accordance with his humoural theory of disease, in which an excess or lack of the four humours (black bile, yellow bile, phlegm and blood) could account for all illness. Hippocrates actually coined the word cancer, from the Greek word karkinos for crab, which he found looked similar to the tumours he observed in his patients. He also noted that most patients who underwent the early surgical attempts at tumour excision did not live as long as patients in whom the disease was allowed to run its course.

Roman wonderdoc Galen (129-200/216 AD) expanded upon and disseminated Hippocrates’s humourism. For Galen, the increased risk of breast cancer post-menopause was proof that a lack of menstruation was the reason black bile built up in the body. With surgery having been proven such a risky endeavour, Galen instead practice aggressive and invasive bloodletting techniques directly at the tumour sites in order to allow the black bile to be purged more effectively.

For many centuries, the medical community was content to follow Galen’s methods, with a few primitive surgical attempts thrown in for good measure. As legions of patients could attest, humoural theory was anything but funny. Standard treatments of breast tumours were limited to various incarnations of quackery: poultices, enemas and increasingly creative forms of phlebotomy.

Not surprisingly, breast cancer rivalled childbirth in the fear and pain it inspired. To do nothing was likely a death sentence, but women could be just as terrified of the prospect of treatment, especially as surgical experimentation became more common. The combination of non-sterile surgical practices and the virtual absence of anesthesia left countless women wishing they had simply let the disease run its course. The example of Anne of Austria (1601-1666) is telling. As the wife of Louis the XIII, she the Queen of France and had the brightest medical minds of the time at her disposal. Fearing what she knew would be an agonizing ordeal, she kept the tumour she discovered in her breast to herself for a couple of years.

When she could no longer hide her worsening condition, Anne endured two years of purgation, bleeding and arsenic poultices. Over the course of five months, she suffered daily surgery to scrape away the rapidly necrotizing tissue in her breast and underarm, before dying at the age of 65.

REMOVAL ON THE RISE

The 2000-year long influence of humoural theory finally began to be questioned in the late 18th century, with the hope that the burgeoning field of surgery might promise some relief from dark-age cures. With the now-outdated humoural theory set aside, countless new causes for breast cancer were proposed, from too much sex to not enough sex; from depression and childlessness to not enough exercise and poor diet. The one thing most physicians could actually agree on was that despite breast cancer’s origins, the disease was localized in the breast, and therefore surgery was the answer. As if the draining, cupping and leaching of centuries past weren’t enough, women would soon be subjected to brutal and frequently fatal mastectomies en masse.

These surgical interventions were practiced with the best intentions and cutting-edge science in mind, and often led to the worst of results. French surgeon Henri François Le Dran (1685 - 1770) performed breast amputations combined with axilla-node dissection in 1757. He was the first to claim that cancer was a disease of stages, and that preventing the spread to the lymphatic system was crucial to a cure. Another Frenchman, Claude-Nicolas Le Cat (1700-1768), performed an even more aggressive surgery in which he also removed the underlying pectoral muscles. Neither doctor’s patients fared particularly well, simply due to surgical complications.

FIRST-HAND HORRORS

First-hand accounts of these sorts of mastectomies read like Victorian forerunners to horror movies. The novelist Fanny Burney underwent a mastectomy without anesthesia in 1811:


When the dreadful steel was plunged into the breast — cutting through veins, arteries, flesh, nerves — I began a scream that lasted unintermittingly during the whole time of the incision... so excruciating was the agony. The air that suddenly rushed into those delicate parts felt like a mass of minute but sharp & forked poniards, that were tearing the edges of the wound, cutting against the grain, if I may so say, while the flesh resisted in a manner so forcible as to oppose & tire the hand of the operator, who was forced to change from the right to the left – then, indeed, I thought I must have expired.

U.S. President John Adams’s daughter Abigail underwent a similar experience in 1809. One Dr. John Warren of Boston performed the procedure while straddling poor “Nabby” – whose arms were tied above her head and held down by another doctor – using straight razors and a red-hot spatula for cauterization. She died anyway a few years later at the age of 48.

Finally, over the course of the 19th century, medicine had progressed to the point where a less crude form of mastectomy could be performed. The combination of aseptic technique, blood transfusion, biological and cellular understanding and of course controlled anesthesia meant that a patient could be put under safely and for a long enough period that a surgeon might perform the operation with the skill and finesse crucial to its success.

HALSTED TO THE RESCUE

The first physician to do so was New York-born William Halsted (1852-1922), one of the four founding medical professors of Johns Hopkins University. A brilliant medical mind with the skilled hands to match, he pioneered Joseph Lister’s aseptic technique and disseminated its importance to his many students. He is considered largely responsible for the implementation of medical sanitation in North America, following the success of his first-ever sterile surgical suite, which he erected in a tent on the grounds of Bellevue Hospital, paid for with his own money.

Halsted was brilliant, eccentric and obsessed with cleanliness (for example, he didn’t trust American laundromats so he sent his clothing all the way to Europe to be cleaned). But of course, this fastidiousness was part and parcel of his success as a surgeon, and was the reason he pioneered the practice of wearing rubber gloves. He performed many other important medical firsts too, from the first emergency blood transfusion (on his sister, after a post-partum hemorrhage ) and the first recorded surgical gall bladder stone removal (on his mother, performed on the kitchen table). And, despite a lifelong addiction to cocaine and morphine – the latter of which he began taking to cure his addiction to the former – he also performed the first so-called radical mastectomy in 1882.

TURNING POINT

Halsted’s procedure was extreme. Since he believed that the surgeon could spread and drop cancer cells into the open wound below if the breast and/or underlying muscles were removed in stages or smaller pieces, his technique involved removing the major and minor pectoral muscles, axillary nodes and all breast tissue in one large swath.

It was a truly debilitating and permanently disfiguring procedure, but it worked. The five-year survival rate for patients who’d had the so-called Halsted mastectomy climbed to 40 percent from virtually nil. As his students moved around the world to begin practices of their own, they brought his operating procedures with them, and Halsted’s radical mastectomy became the gold standard of breast-cancer care until the 1960s, when it was recognized that less invasive techniques were equally effective. Still, Halsted’s mastectomy had been a far cry – and a welcome relief – from the bloodletting, filthy surgeries and nearly certain death that accompanied a diagnosis of breast cancer in centuries past.

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