The Emperor of All Maladies. Siddhartha Mukherjee

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      Between 1891 and 1907—in the sixteen hectic years that stretched from the tenuous debut of the radical mastectomy in Baltimore to its center-stage appearances at vast surgical conferences around the nation—the quest for a cure for cancer took a great leap forward and an equally great step back. Halsted proved beyond any doubt that massive, meticulous surgeries were technically possible in breast cancer. These operations could drastically reduce the risk for the local recurrence of a deadly disease. But what Halsted could not prove, despite his most strenuous efforts, was far more revealing. After nearly two decades of data gathering, having been levitated, praised, analyzed, and reanalyzed in conference after conference, the superiority of radical surgery in “curing” cancer still stood on shaky ground. More surgery had just not translated into more effective therapy.

      Yet all this uncertainty did little to stop other surgeons from operating just as aggressively. “Radicalism” became a psychological obsession, burrowing its way deeply into cancer surgery. Even the word radical was a seductive conceptual trap. Halsted had used it in the Latin sense of “root” because his operation was meant to dig out the buried, subterranean roots of cancer. But radical also meant “aggressive,” “innovative,” and “brazen,” and it was this meaning that left its mark on the imaginations of patients. What man or woman, confronting cancer, would willingly choose nonradical, or “conservative,” surgery?

      Indeed, radicalism became central not only to how surgeons saw cancer, but also in how they imagined themselves. “With no protest from any other quarter¹⁷⁵ and nothing to stand in its way, the practice of radical surgery,” one historian wrote, “soon fossilized into dogma.” When heroic surgery failed to match its expectations, some surgeons began to shrug off the responsibility of a cure altogether. “Undoubtedly, if operated upon properly¹⁷⁶ the condition may be cured locally, and that is the only point for which the surgeon must hold himself responsible,” one of Halsted’s disciples announced at a conference in Baltimore in 1931. The best a surgeon could do, in other words, was to deliver the most technically perfect operation. Curing cancer was someone else’s problem.

      This trajectory toward more and more brazenly aggressive operations—“the more radical the better”¹⁷⁷—mirrored the overall path of surgical thinking of the early 1930s. In Chicago, the surgeon Alexander Brunschwig devised an operation¹⁷⁸ for cervical cancer, called a “complete pelvic exenteration,” so strenuous and exhaustive that even the most Halstedian surgeon needed to break midprocedure to rest and change positions. The New York surgeon George Pack was nicknamed Pack the Knife¹⁷⁹ (after the popular song “Mack the Knife”), as if the surgeon and his favorite instrument had, like some sort of ghoulish centaur, somehow fused into the same creature.

      Cure was a possibility now flung far into the future. “Even in its widest sense,”¹⁸⁰ an English surgeon wrote in 1929, “the measure of operability depend[s] on the question: ‘Is the lesion removable?’ and not on the question: ‘Is the removal of the lesion going to cure the patient?’ ” Surgeons often counted themselves lucky if their patients merely survived these operations. “There is an old Arabian proverb,”¹⁸¹ a group of surgeons wrote at the end of a particularly chilling discussion of stomach cancer in 1933, “that he is no physician who has not slain many patients, and the surgeon who operates for carcinoma of the stomach must remember that often.”

      To arrive at that sort of logic—the Hippocratic oath turned upside down—demands either a terminal desperation or a terminal optimism. In the 1930s, the pendulum of cancer surgery swung desperately between those two points. Halsted, Brunschwig, and Pack persisted with their mammoth operations because they genuinely believed that they could relieve the dreaded symptoms of cancer. But they lacked formal proof, and as they went further up the isolated promontories of their own beliefs, proof became irrelevant and trials impossible to run. The more fervently surgeons believed in the inherent good of their operations, the more untenable it became to put these to a formal scientific trial. Radical surgery thus drew the blinds of circular logic around itself for nearly a century.