She thought the surgery was over, but Dubois found that the breast was still attached by the tumor, so cutting recommenced. “Oh heaven! I then felt the knife rackling against the breast bone—scraping it!” For some minutes, the surgeon cut away at muscle and diseased tissue until he was confident that he had got as much as he could. Burney endured this final part in silence—“in utterly speechless torture.”

  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.

  * * *

  —

  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.

  * * *

  —

  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.”

  Sometimes, happily, better outcomes were achieved. In 1937, Gunda Lawrence, a teacher and homemaker from South Dakota, lay close to death from abdominal cancer. Doctors at the Mayo Clinic in Minnesota had given her three months to live. Luckily, Mrs. Lawrence had two exceptional and devoted sons—John, a gifted physician, and Ernest, one of the most brilliant physicists of the twentieth century. Ernest was head of the new Radiation Laboratory at the University of California at Berkeley and had just invented the cyclotron, a particle accelerator that generated massive amounts of radioactivity as a side effect of energizing protons. They had in effect the most powerful X-ray machine in the country at their disposal, capable of generating a million volts of energy. Without any certainty what the consequences would be—no one had ever tried anything remotely like this on humans before—the brothers aimed a deuteron beam directly into their mother’s belly. It was an agonizing experience, so painful and distressing to poor Mrs. Lawrence that she begged her sons to let her die. “At times I felt very cruel in not giving in,” John recorded later. Happily, after a few treatments, Mrs. Lawrence’s cancer went into remission and she lived another twenty-two years. More important, a new field of cancer treatment had been born.

  It was also at the Radiation Lab at Berkeley that researchers finally and belatedly began to grow concerned about the dangers of radiation after the body of a mouse was found beside the machine after one set of experiments. It occurred to Ernest Lawrence that the huge amounts of radioactivity generated by the machine might be dangerous to human tissue. So protective barriers were installed and operators retreated to another room when the machine was running. It was subsequently discovered that the mouse had died of asphyxiation, not irradiation, but it was decided to proceed with safety measures anyway, and thank goodness.

  Chemotherapy, the third main prong in cancer treatment after surgery and radiation, came about by similarly unlikely means. Although chemical weapons had been outlawed by international treaty after World War I, several nations still produced them, if only as a precaution in the event that others did likewise. The United States was among the transgressors. For obvious reasons, this was kept secret, but in 1943 a U.S. Navy supply ship, the SS John Harvey, carrying mustard gas bombs as part of its cargo, was caught in a German bombing raid on the Italian port of Bari. The Harvey was blown up, releasing a cloud of mustard gas over a wide area, killing an unknown number of people. Realizing that this was an excellent, if accidental, test of the mustard gas’s efficacy as a killing agent, the navy dispatched a chemical expert, Lieutenant Colonel Stewart Francis Alexander, to study the effects of the mustard gas on the ship’s crew and others nearby. Luckily for posterity, Alexander was an astute and diligent investigator, for he noticed something that might have been overlooked: mustard gas dramatically slowed the creation of white blood cells in those exposed to it. From this, it was realized that some derivative of mustard gas might be useful in treating some cancers. Thus was born chemotherapy.

  “What is quite remarkable,” one cancer specialist told me, “is that we are basically still using mustard gases. They are refined, of course, but they are really not that much different from what armies were using on each other in the First World War.”

  III

  IF YOU WISHED to see how far cancer therapies have come in recent years, you could do much worse than visit the new Princess Máxima Center in Utrecht. The largest children’s cancer center in Europe, it was created through the merging of the children’s oncology units of seven university hospitals in the Netherlands, to bring all treatments and research in the country under one roof. It is a bright, generously resourced, and surprisingly lively place. As Josef Vormoor showed me around, we had to step aside from time to time as small children on pedal go-karts—each child bald and with a breathing tube in his or her nostrils—shot around or through us at breakneck speeds. “We sort of let them have the run of the place,” Josef apologized happily.

  Cancer is actually rare among children. Of the fourteen million cases of cancer diagnosed in the world each year, only about 2 percent are in people aged nineteen or younger. The principal cause of childhood cancers, accounting for about 80 percent of cases, is acute lymphoblastic leukemia. Fifty years ago it was a death sentence. Drugs could put it into remission for a while, but it soon came back. The five-year survival rate was less than 0.1 percent. Today the survival rate is about 90 percent.

  The breakthrough moment was in 1968 when Donald Pinkel of St. Jude Children’s Research Hospital in Memphis, Tennessee, tried a new approach. Pinkel was convinced that giving drugs in moderate dosages, which was then the standard practice, allowed some leukemic cells to escape and to bounce back after treatment stopped. That’s why remissions were always temporary. Pinkel blasted the leukemic cells with the full range of available drugs, frequently in combinations, always at the highest possible dosages, accompanied by bouts of radiation. It was a punishing regime, lasting up to two years, but it worked. Survival rates improved dramatically.

  “We’re still essentially following the approach of the early pioneers of leukemia therapy,” Josef says. “All we have done in the years since is fine-tune things. We have better ways of dealing with the side effects of chemotherapy and of fighting infections, but basically we are still doing what Pinkel did.”

  And that is hard on any human body, not least young ones that are still forming. A significant fraction of childhood cancer deaths come not from the cancer itself but from the treatments for it. “There’s a lot of collateral damage,” Josef tells me. “Treatments don’t affect just cancer cells, but many healthy cells as well.” The most visible manifestation of this is damage to hair cells, which causes patients’ hair to fall out. More critically, there is also often long-term damage to the heart and other organs. Girls who have had chemotherapy have a greater chance of experiencing menopause earlier and run an enhanced risk of suffering ovarian failures later in life. For both sexes, fertility may be compromised. Much depends on the type of cancer and form of treatment.

  Still, the story is mostly positive, and not just for childhood cancers but for cancers at all ages. In the developed world, death rates from lung, colon, prostate, Hodgkin’s disease, testicular cancer, and breast cancer have all fallen sharply—by between 25 and 90 percent—in twenty-five years or so. In the United States alone, 2.4 million fewer people have died of cancer in the last thirty years than would have if the rates had stayed unchanged.

  The dream of many researchers is to find some way of detecting tiny changes in the chemistry of blood or urine or perhaps saliva that would betray the early onset of a cancer when it could be more easily treated.

  “The problem,” Josef says, “is that even when we can detect cancer early now, we cannot tell whether it is aggressive or benign. Overwhelmingly, we focus on trying to cure cancers when they happen rather than prevent them from happening in the first place.” Globally, by one reckoning, no more than 2 to 3 percent of cancer research money is spent on prevention.

  “You can’t imagine how much things have improved in a generation,” Josef reflected as we came to the end of our tour. “It’s the most satisfying thing in the world to know that most of these children will be cured and can go home and resume their lives. But wouldn’t it be even more wonderful if they didn’t have to come here in the first place? That’s the dream.”

  *1 Originally “cancer” described any non-healing sore, from which it is related to “canker.” In its more specific modern sense, it dates from the sixteenth century. The word comes from the Latin for “crab” (which is why the celestial constellation and its associated zodiac sign are called Cancer). It is said that Hippocrates, the Greek physician, used the term for tumors because their shape reminded him of crabs.

  *2 The alert reader will note that all these percentages taken together add up to more than 100 percent. That’s partly because they are estimates—in some cases little more than guesses—and come from different sources, and partly because of double or triple counting. A retired coal miner’s fatal lung cancer could, for instance, be attributed to his working environment or the fact that he had smoked for forty years, or both. More often than not, the cause of a cancer is anyone’s guess.

  22 MEDICINE GOOD AND BAD

  Doctor: What did you operate on Jones for?

  Surgeon: A hundred pounds.

  Doctor: No, I mean what had he got?

  Surgeon: A hundred pounds.

  —PUNCH CARTOON, 1925

  I SHOULD LIKE to say a word about Albert Schatz, for if ever there was a man who deserved a moment’s grateful attention, it is he. Schatz, who lived from 1920 to 2005, was from a poor farming family in Connecticut. He studied soil biology at Rutgers University in New Jersey not because he had a passion for soil but because, as a Jew, he was subject to university admission quotas and he couldn’t get into a better institution. He reasoned that whatever he learned about soil fertility would at least be useful back on the family farm.