Number of words: 786<\/p>\n\n\n\n
It took a Philadelphia surgeon named Bernard Fisher to cut through that knot of surgical tradition. Fisher was brackish, ambitious, dogged, and feisty\u2014a man built after Halsted\u2019s image. He had trained at the University of Pittsburgh, a place just as steeped in the glorious Halstedian tradition of radical surgery as the hospitals of New York and Baltimore. But he came from a younger generation of surgeons\u2014a generation with enough critical distance from Halsted to be able to challenge the discipline without undermining its own sense of credibility. Like Crile and Keynes, he, too, had lost faith in the centrifugal theory of cancer. The more he revisited Keynes\u2019s and Crile\u2019s data, the more Fisher was convinced that radical mastectomy had no basis in biological reality. The truth, he suspected, was quite the opposite. \u201cIt has become apparent that the tangled web of threads on the wrong side of the tapestry really represented a beautiful design when examined properly, a<\/p>\n\n\n\n
meaningful pattern, a hypothesis . . . diametrically opposite to those considered to be \u2018halstedian,\u2019\u201d Fisher wrote.<\/p>\n\n\n\n
The only way to turn the upside-down tapestry of Halstedian theory around was to run a controlled clinical trial to test the radical mastectomy against the simple mastectomy and lumpectomy+radiation. But Fisher also knew that resistance would be fierce to any such trial. Holed away in their operating rooms, their slip-covered feet dug into the very roots of radical surgery, most academic surgeons were least likely to cooperate.<\/p>\n\n\n\n
But another person in that operating room was stirring awake: the long-silent, etherized body lying at the far end of the scalpel\u2014the cancer patient. By the late 1960s, the relationship between doctors and patients had begun to shift dramatically. Medicine, once considered virtually infallible in its judgment, was turning out to have deep fallibilities\u2014flaws that appeared to cluster pointedly around issues of women\u2019s health. Thalidomide, prescribed widely to control pregnancy-associated \u201chysteria\u201d and \u201canxiety,\u201d was hastily withdrawn from the market in 1961 because of its propensity to cause severe fetal malformations. In Texas, Jane Roe (a pseudonym) sued the state for blocking her ability to abort her fetus at a medical clinic\u2014launching the Roe v. Wade case on abortion and highlighting the complex nexus between the state, medical authority, and women\u2019s bodies. Political feminism, in short, was birthing medical feminism\u2014and the fact that one of the most common and most disfiguring operations performed on women\u2019s bodies had never been formally tested in a trial stood out as even more starkly disturbing to a new generation of women. \u201cRefuse to submit to a radical mastectomy,\u201d Crile exhorted his patients in 1973.<\/p>\n\n\n\n
And refuse they did. Rachel Carson, the author of Silent Spring and a close friend of Crile\u2019s, refused a radical mastectomy (in retrospect, she was right: her cancer had already spread to her bones and radical surgery would have been pointless). Betty Rollin and Rose Kushner also refused and soon joined Carson in challenging radical surgeons. Rollin and Kushner\u2014both marvelous writers: provocative, down-to-earth, no-nonsense, witty\u2014were particularly adept at challenging the bloated orthodoxy of surgery. They flooded newspapers and magazines with editorials and letters and appeared (often uninvited) at medical and surgical conferences, where they fearlessly heckled surgeons about their data and the fact that the radical mastectomy had never been put to a test. \u201cHappily for women,\u201d Kushner wrote, \u201c. . . surgical custom is changing.\u201d It was as if the young woman in Halsted\u2019s famous etching\u2014the patient that he had been so \u201cloathe to disfigure\u201d\u2014had woken up from her gurney and begun to ask why, despite his \u201cloathing,\u201d the cancer surgeon was so keen to disfigure her.<\/p>\n\n\n\n
In 1967, bolstered by the activism of patients and the public attention swirling around breast cancer, Fisher became the new chair of the National Surgical Adjuvant Breast and Bowel Project (NSABP), a consortium of academic hospitals modeled self-consciously after Zubrod\u2019s leukemia group that would run large-scale trials in breast cancer. Four years later, the NSABP proposed to test the operation using a systematic, randomized trial. It was, coincidentally, the eightieth \u201canniversary\u201d of Halsted\u2019s original description of the radical mastectomy. The implicit, nearly devotional faith in a theory of cancer was finally to be put to a test. \u201cThe clinician, no matter how venerable, must accept the fact that experience, voluminous as it might be, cannot be employed as a sensitive indicator of scientific validity,\u201d Fisher wrote in an article. He was willing to have faith in divine wisdom, but not in Halsted as divine wisdom. \u201cIn God we trust,\u201d he brusquely told a journalist. \u201cAll others [must] have data.<\/p>\n\n\n\n