William Halsted's Radical Mastectomy Patients: A Historical Analysis Through Patient Narratives.

INTRODUCTION
“Mrs. Healy arrived home safely and seems to be gradually gaining her strength. I hope that before long she will be restored to her normal condition, both physical and moral, after the terrible cataclysm she has passed through.”1 These were the words in 1914 of a Virginia woman’s husband to William Stewart Halsted—a surgeon at The Johns Hopkins Hospital in Baltimore, Maryland. Josephine Healy had just undergone a radical mastectomy for the treatment of carcinoma of the breast. Her husband hoped that the favorable results of the surgery would compensate for all the “moral and physical agony” she had gone through.1
After Halsted reported in an 1889 meeting of the American Surgical Association in New Orleans that the outcomes of women who underwent his radical mastectomy surpassed those of other techniques, this surgery was hailed as a cure for breast cancer.2(p. 22) But what did Halsted’s carcinoma of the breast patients think of the radical mastectomy? Although the radical mastectomy was seen as a “miraculous operation” by surgeons like Halsted during the early 20th century, Josephine’s husband’s reference of the surgery as a “terrible cataclysm” suggests that perhaps patients saw it differently.
As surgeons today consider the impact of surgery on their patients, it is important to remain aware of the patients of the past. Despite advancements in breast surgery, many concerns faced by Halsted’s patients remain today. Current medical literature alludes to chronic pain, lymphedema, and patients’ poor quality of life after breast cancer surgical treatment.3–5 Moreover, Patient-Reported Outcome Measures have been identified as relevant in various surgical subspecialties, including breast surgery, plastic surgery, and orthopedic surgery.6 Breast surgeons, for instance, have alluded to their utility in understanding differences between patients’ and surgeons’ perceptions.6 Narratives from the past help surgeons think critically of the procedures they perform, always keeping patients’ opinions in mind.
This article provides relevant insight into breast cancer patients’ perspectives and takes a less-explored approach to Halsted and the history of surgery, which has mostly focused on Halsted’s innovations in surgery or his long-lasting struggle with addiction. By examining correspondence between Halsted, his patients who underwent radical mastectomies in the early 20th century, and their families, it argues that there was a disconnect between what Halsted and his patients considered a cure after a radical mastectomy. While Halsted focused on measurable outcomes like prevention of local recurrence, patients went beyond this notion of success and thought about their quality of life. They were concerned about limitations in arm motion, arm swelling, and pain. They also worried about recurrence and doubted the surgery’s success. Letters from both patients and their family members provide us with an intimate perspective of what patients were going through, even during times when patients were too ill to write to Halsted themselves. The lens through which I chose to interpret the historical sources was refracted through the question, what do these letters tell us about the patient’s life after surgery? This approach was inspired by other patient-centered histories, such as Dr. Christopher Feudtner’s Bittersweet: Diabetes, Insulin, and the Transformation of Illness and Dr. Sheila Rothman’s Living in the Shadow of Death: Tuberculosis and the Social Experience of Illness in American History. These histories provide a patient-centered model of analysis for infectious diseases and chronic medical conditions, which this article then applies to surgery in the case of the radical mastectomy. Hence, I shift from surgeons’ narratives on radical mastectomies to patients’ perspectives and their experiences, ultimately using historical sources to argue for patient-centered care today.

Restrictions in Arm Motion
Halsted first presented an article on the results of his operation for carcinoma of the breast to the Clinical Society of Maryland in 1894. He commented on the importance of removing the pectoralis major muscle by saying, “why should we shave the under surface of the cancer so narrowly if the pectoralis muscle or part of it can be removed without danger, and without causing subsequent disability?.”7(p. 507) Then, when discussing the outcome of the surgery, he mentioned some patients complained they could not “dress their back hair,” but that this had been relieved twice through skin grafting.7(p. 512) Moreover, he added that “disability, ever so great, is a matter of very little importance as compared with the life of the patient.”7(p. 513) Halsted justified the mutilating and debilitating outcome of the surgery by claiming he had saved the life of the patient. It did not matter whether patients could perform daily tasks or not; what mattered the most was that they were alive.8(p. 552)
Yet, patients’ correspondences with Halsted give us another perspective, different from what Halsted presented to medical societies. For patients, moving their arms after surgery and performing certain tasks did not always translate into performing these tasks with ease. Patients who alluded to feeling “splendidly” often accompanied their descriptions with a “but”–then stating what they could not do or the sequelae they were still experiencing.9 For instance, Sophia Bruce’s son pointed out that his mother had “almost complete use of her arm, although she cannot comb her own hair.”9
Georgia Anderson had a similar experience. Anderson, from Tennessee, underwent surgery in 1912.10 Unlike Sophia, Georgia could arrange her hair. However, being able to do so still came with a set of challenges. In a letter 2 years after her surgery, Georgia stated that “in arranging my hair, my left arm tires easily, and perhaps to be rested, although I can accomplish the result.”10 She had to take pauses and put a lot of effort into doing something that would have come with ease before. In another letter, she sent a photograph and mentioned that she could not “reach up with it [her arm] as before the operation or exert the same muscular strength.”10 To provide more context, she wrote that “one movement that may be difficult to reproduce but you will understand when I say that a noticeable restriction in the use of the arm occurs when someone tries to help me from a lower to a higher level by taking my left hand—as in stepping up from a boat.”10 Sophia and Georgia’s arm restrictions after the surgery meant patients could not perform tasks they could perform with ease before. What they could or could not do was dictated by the aftermath of the surgery.

Arm Swelling and Its Impact on Patients’ Daily Lives
Aside from arm restriction, patients experienced arm swelling—now known as lymphedema. Halsted acknowledged in the medical literature that “edema following operative blocking of the lymphatics” was frequently observed after the “radical operation for cancer of the breast.”11(p. 309) The cause of lymphedema, Halsted believed, was related to infection.12(p. 108) Still, he claimed that “swollen arms of dimensions sufficient to distress or annoy the patient were no longer observed” after he started using a new method for operation around 1910.11(p. 310) Patient correspondence, however, shows that lymphedema still occurred after this date and affected patients’ daily choices and work.
Elsy Bauer, who was an unmarried private secretary from New York, recorded details about her experience with arm swelling.13 Elsy’s dressmaker discovered her tumor 6–7 weeks before her admission to the hospital. According to her medical history, she came to the hospital when she was 50 years old. She was operated on in 1917 and had an “uneventful convalescence.”13 Elsy was in frequent contact with Halsted. One and a half years after the surgery, she explicitly mentioned her concern at a “very decided swelling” in her “left forearm.”13
Two and a half years after the surgery, Halsted wrote to Elsy inquiring about the history of her arm swelling. He was interested in the swellings because he believed “many of them” were “determined by a very mild grade of infection.”13 He asked Elsy to recall a detailed history of her condition and whether she had had a cold before the appearance of the swelling. Elsy gave a detailed response. When it came to the state of her arm, she specifically said she did not think her arm “had diminished in size” since she last saw Halsted.13 The only time she noticed a disturbance was when she wore “a sleeve or glove which contracts the arm or hand,” causing “perceptible swelling and discomfort.”13 She tried to prevent “this as far as possible by wearing” a “sleeve or glove” that allowed “expansion.”13 Even a simple choice like deciding what to wear was impacted by the aftermath of the surgery.
While Elsy told Halsted about her experiences in terms of daily living, never mentioning her work as a secretary, Caroline Schmidt emphasized the impact of her own radical mastectomy on her work. Caroline went to Halsted’s clinic twice after her surgery.14 Although there is no correspondence from her, there are notes of her words in the clinic records, suggesting how the surgery affected her daily life. The first time she attended the clinic she mentioned her “arm swells when she uses it too much” and that it “bothered her in this way ever since [the] operation,” although it was “never bad enough to interfere with the use of the arm.”14 One year later, after her initial follow-up visit, her arm was still swollen. She complained her arm felt “more heavy and tired following a day’s work.”14
Overall, arm swelling was a visible aftermath of the surgery. Even if patients did not seem to be alarmed, their words—verbal and in writing—show that the swelling impacted their daily choices and their ability to work. Breast cancer-related lymphedema remains a concern for surgeons and patients today.15 As surgeons attempt to address this issue with procedures like immediate lymphatic reconstruction, it is essential to consider the impact this condition has on patients’ daily lives.15

Long-Term Pain and Seeking Ways to Manage it
Some patient concerns, however, were marked by a sense of urgency. Three patients—Dorothy, Lily, and Emma—experienced excruciating pain to which they could not find relief despite receiving medications. Dorothy Neff was a woman from Alabama who underwent surgery in 1912.16 A couple of months after the surgery, her physician back home updated Halsted about Dorothy’s health. He said that she was in good health and that her “hand and arm” were not “giving her any trouble.”16 But the physician’s opinion did not necessarily match what Dorothy felt. In the same letter, Dorothy’s physician wrote that, although Dorothy had “improved in color and in general health,” she seemed to “not to think so.”16
According to correspondence between her home physician and Halsted, Dorothy first started experiencing a “rather constant” pain “in the posterior part of the shoulder but more particularly in the arm” 1 year after the surgery.16 In this letter, her home physician also noted lymphedema, writing that 1 arm had been “larger…since the operation…than the other.”16 Simultaneously, Dorothy’s daughter wrote to Halsted about her mother’s arm pain and asked him if there was anything she could give her to find relief. Two years after her surgery, Dorothy’s arm pain increased and became more unbearable. Her daughter described this pain as “violent,” saying it had “not left her in fourteen months” and only “increased in violence each week.”16 At the time of the letter, Dorothy was already taking codeine “when the agony was unbearable” for almost 6 months, but this drug had “very little effect on her pain.”15 Dorothy’s daughter desperately sought for help as she told Halsted that “someone somewhere must know something to do.”16
Halsted’s proposed solution was unsatisfactory from the perspective of Dorothy and her daughter. He said that there was only “one relief for the pains,” which was to “divide the nerve in the neck.”16 According to Halsted, this was not “a serious operation,” but had “to be done by someone who thoroughly understands it.”16 He urged Dorothy to come to The Johns Hopkins Hospital to get this procedure and, in the meantime, suggested “large hypodermics of morphia” for her pain.16 Upon reading Halsted’s suggestions, Dorothy’s daughter said it was “impossible” to bring her mother to Baltimore and said that she would “try to control her pain for the present with opium.”16 Since traveling to Baltimore was not an option, the daughter’s response suggests that she may have expected some other solution from Halsted that did not require another operation.
But Dorothy was not the only patient to use medicines for her pain after the surgery. Another patient, Lily Fellin, tried various therapeutics and did everything she could to find relief.17 Her response to Halsted’s inquiry about her condition conveys a similar feeling of frustration: “I am feeling worse every day. I have received pills and medicines but nothing did me any good and I was told not to come to the hospital any more…Hoping you will find & try something that will relieve me of the pain.”17 Why was Lily told not to come to the hospital anymore? The actual reason is unknown. However, an analysis of her short letter tells us that those she consulted for help at the hospital thought that therapeutics were more than enough to treat her pain. It also reinforces the idea that hospital medicine was associated with reduced autonomy for the patient.18(p. 310) Being told not to come to the hospital anymore suggests that patients’ pain after the radical mastectomy was not taken seriously, forcing patients to search for alternatives and seek help from other physicians.
Finally, Emma Norton—a woman from Georgia—faced similar issues.19 She discovered her lump by accident 4 years before her surgery. Since then, she started experiencing pain as the lump grew gradually to the size of a “flat goose egg.” Seeking relief, she began taking codeine, increasing the dose gradually to “4 grams a day.”19 She later underwent surgery in 1908. After the surgery, her husband wrote to Halsted saying that although she could sew, knit, write, and arrange her hair, when she used her arm “very much” it ached and caused pain “in the region around the shoulder.”19 What was done to address the pain after this letter is not documented in correspondence. Still, Emma’s experience was similar to those of other patients who wrote to Halsted.
These women’s experiences with pain speak to the desperation and frustration they felt after surgery. Even if there were no complications, patients did not consider the surgery successful unless they could live a life free of pain. The urgency in their letters emphasizes the extent to which they wanted to find relief. Overall, their written interactions with Halsted—as well as Lily’s encounter at the hospital—highlight the importance of taking patients’ postoperative concerns seriously. Likewise, they show the profound impact pain can have on patients—a concern that remains today as physicians try to understand the impact of pain on patients’ quality of life.3

Anxiety About Cancer Recurrence
While radical mastectomies removed gross disease, psychological challenges persisted, with patient and family narratives speaking to the significant worries patients had about their cancer returning. But Halsted’s writings downplay these worries. He reported the success of the radical mastectomy in surgical journals. In Halsted’s first report of the surgery’s success to the Clinical Society of Maryland in 1894, he compared the outcomes of the surgery to that of German surgeons.7 Of the 50 patients operated at The Johns Hopkins Hospital, he reported only 3 exhibited local recurrence.7(p. 497) In contrast, according to Halsted, other surgeons such as Ernst von Bergmann and Vicenz Czerny reported recurrence in more than 50% of their cases.7(p. 503) Although Halsted focused on statistics of recurrence and the measurable outcomes of the surgery, he did not consider that, for patients, going back to their previous lifestyle and living a life free of worry was important to feeling that they were cured after the surgery. Even if Halsted sought to reduce the probability of recurrence through his surgical technique, removing tissue did not fully soothe patients’ anxieties.
Josephine Healy was a mother from Virginia who was operated on in 1914.1 Right after the surgery, her husband—a military general—wrote a letter to Halsted asking about the surgery’s outcome and his wife’s chances of survival. His “anxiety” was “very great” and his “mental state” was in a “most disordered” state of “uncertainty.”1 He confessed that he expected such a “dreadful operation” to result in a feeling of certainty of her cure.1 However, upon hearing that Halsted removed not only her “entire right breast but the entire lymphatic area,” he knew that her cancer was more serious than he initially thought.1
The first time Josephine wrote to Halsted regarding her worries was 1 year after the surgery. She told him she had been “made slightly apprehensive by the appearance (on the scar) of a dark-looking spot” and asked whether this could be “only a stitch that is making its appearance at this late day.”1 At first glance, Josephine’s words suggest that she was not overly worried about the spot but still wanted to make sure it was not something that required medical attention. The composure she seemed to have at the beginning of her letter was then replaced by an explicit fear over what could happen in the future as she mentioned the “slightest change” in her condition filled her with “alarm.”1 Her words now implied extreme worry that went beyond slight apprehension. In the late 19th century and early 20th century, premalignant changes in the breast were thought to precede the appearance of cancer.20(p. 248) Thus, Josephine carefully monitored her body because she saw every change as a potential site of cancer recurrence. Furthermore, Josephine’s own hypotheses about what the spot could be were perhaps a coping mechanism to quiet her worries while she waited for Halsted’s medical opinion.
Josephine wanted reassurance about this spot from Halsted himself, suggesting a high level of trust in his opinion. She suggested a time to come to see him in Baltimore, but Halsted was set to attend a meeting of the American Surgical Association. As alternatives, Halsted told Josephine she could visit a local physician in Virginia or see him at another time. The next day, Josephine wired Halsted and told him to “please give appointment at once,” as she “would like” to see him.1 There was a clear sense of urgency on her part and Josephine immediately underwent a procedure where part of the granulated tissue in her surgery wound was sent for diagnosis.
According to the surgical notes, no stitch was found to account for the wound and the analyzed tissue was not found to be cancerous. After the procedure, Halsted sent a letter to Josephine telling her about the surgery’s findings. He told her he “asked Dr. McClure to reassure you, fearing that you were not sufficiently recovered from the gas when I left to recall what I said.”1 Then, he explained that the “little tumor” was “not of a bad nature” and that it was an “infectious granuloma” instead.1 Josephine responded by saying that she did not “recall anything that was said” when she was “recovering from the gas” and, hence, that Halsted’s letter had given her “great relief.”1
Almost 4 years after the surgery, Josephine wrote to Halsted again saying that she had a “slight and constant pain, like neuralgia” in her ear and right side of her head.1 She cautioned that she was “always apprehensive of the old trouble in new form” and described that there was no “sign of swelling or anything unusual” in her throat, as she had “examined carefully.”1 Now Josephine started to worry not only about what she could see in her breasts but also in her body. Despite not being initially told by Halsted about the possibility of recurrence, Josephine was aware that cancer could spread to other parts of her body in the form of metastases. She also distinguished between what was normal and pathological and seemed to be relieved by the fact that she could not find a visible lump. Thus, her relationship with her body changed as every symptom prompted a careful examination for possible signs of cancer. She could not live a life without worry anymore because her disease could manifest itself in many ways.
Josephine was examined by Halsted 2 months later. In his examination notes, he wrote about the presence of a “slightly suspicious gland about the size of a small pea” close to her neck.1 But Josephine did not know about this gland at the time and, instead, noticed it 1 year after being examined by Halsted. One year later, she told him that she had “just discovered a small growth in the gland” of her “throat” which “alarmed” her greatly.1 This time, however, she emphasized this lump was “not invisible” and, again, mentioned she was “always anticipating trouble.”1 This letter reveals differences between what Halsted and Josephine knew. In other words, Halsted knew about the gland before it became noticeable to Josephine, providing evidence for medical paternalism in this time. Further examinations by other physicians revealed the presence of more glands in her neck, which were “undoubtedly cancerous.”1 She also developed a cough, which was presumed to be indicative of lung metastases. Although no correspondence is available from Josephine herself at the time, her biggest worries became reality in the end. She passed away in 1923, almost 6 years after she underwent the radical mastectomy.
Meredith Fowler’s experience also shows anxiety about recurrence. She was a woman born in Maryland who in 1901 got married to Mr. Fowler, a fire insurance agent who was also from Maryland and attended her church.21 Together they visited New York frequently and, by the time of the surgery in 1917, were living in that state. More than any other patient found in the archives, Meredith talked about her hobbies and wrote to Halsted like a friend. For instance, she told Halsted about important moments in her life. She told him how she spent her 18th wedding anniversary “quietly.”21 The weather was sultry, and it looked like it was going to rain. Meredith and her husband went out for dinner and later sat on their “lovely bench” at their house.21 Furthermore, in a very excited tone, she mentioned she went up to register to vote since she now had “a vote up here in New York State. Ha! Ha!.”21 She did not know whether she would take “advantage of it or not,” as she had her “hands full enough with household duties without attempting more.”21 Meredith also wrote to Halsted during his own times of sickness. In 1919, Halsted became a patient himself upon recurrent attacks of cholecystitis. His gallbladder was removed in August of that year.22(p. 328) Upon finding out about Halsted’s illness, Meredith wrote to him from New York: “Now if I were only nearer, maybe you’d like me to run in and tell you a good joke or teach you the Chinese prayer or maybe you’d rather not be pestered by visitors…However, I am far enough for you to be safe, whichever you decide.”21 The fact Meredith told Halsted about moments with her husband and wrote to him when he was sick shows a certain level of trust.
Around two and a half years after her surgery, Meredith’s husband wrote to Halsted. The purpose of the letter was so that Halsted could “keep more closely in touch” with her symptoms since Meredith had recently fallen ill.21 A local physician pronounced she had a “catarrh”—or blockage—of the gall duct and “whatever the nature of the trouble,” was “far from being well.”21 He also described that, since her second operation in 1919, her wound still had a “pronounced red, or angry appearance.”21 The tissues around the wound were hardened and about the “size of a large pea.”21 Meredith had also discovered a “similar spot under the arm pit where the flesh appears to have been rightly drawn in the grafting,” giving the appearance of the skin being “puckered.”21 Things seemed to not be going well and Meredith’s body was not showing signs of improvement. He said that, thus far, her spirits had been good, although she occasionally got the “blues due to the ever-present dread of recurrence of the trouble with a consequent operation.”21 Upon finding more spots and signs of the disease in her body, Meredith felt as if she lost control: “Her spirits broke with the discovery of this additional spot under the arm and unless she can have some very positive reassurance, I am inclined to believe she will break under the mental strain and have a complete nervous breakdown.”21
Thus, both Josephine and Meredith worried about their progression of their cancer. The surgery and removal of tissues did not quiet their worries as every change in their bodies could be a sign of cancer recurrence. It is important to highlight that this concern—in contrast to the ones previously explored—does not focus on physical ailments. Rather, it touches on the psychological strain breast cancer had on patients, even after a procedure that was deemed curative at the time. Today, fear of cancer recurrence after their initial surgery continues to impact patients. As the number of breast cancer survivors increases due to advancements in surgery and other treatments, survivorship care and surveillance of recurrence have become increasingly important to patients’ quality of life.23 Fear of recurrence has also been documented to shape patients’ perspective of and desire to undergo subsequent procedures, including breast reconstruction.24

Doubt About the Surgery’s Success
Finally, patients did not only worry about recurrence, they also questioned the surgery’s overall success. Even if physicians’ perceived effectiveness of the radical mastectomy was tied to observations of lower rates of recurrence and higher rates of patient survival,12(pp. 91–92) patients doubted whether the surgery had provided them with a cure even without signs of recurrence. For instance, in one of her update letters 2 years after the surgery, Georgia told Halsted she had had “often wished to know” Halsted’s position “in regard to the use of radium for carcinoma.”10 Although she clarified that “personally” she “would choose the operation, if you [Halsted] would perform it,” the contradictions in her letter are clear.10 The fact she asked about other treatment options suggests she probably doubted the success of the surgery.
From the tone of his response, one can infer that Halsted was not pleased to hear that Georgia thought about other options. He told her that he was “positive” that in her case it would be “useless to employ radium.”10 In explaining why, he said that he was “sure” nothing remained “to be cured” and, even if there were “traces of the disease anywhere in the body, neither radium nor the X-ray could find them.”10 Halsted believed that the surgery was superior to any other form of treatment because it removed tissues in such a way that it did not leave any cancerous cells behind. Nothing—not even radium or X-rays—would be better than the radical mastectomy.
Georgia apologized, telling Halsted she was sorry he “misunderstood” her “reference to radium.”10 To reassure Halsted that she did not doubt the surgery, she wrote that she felt “assured” of her “own cure” and was “absolutely at ease.”10 Nonetheless, what she says later in her letter shows that she perhaps did not feel like the surgery was the best option. She told Halsted she thought about the “possibility” of not knowing of the “existence of anything wrong.”10 In other words, she questioned whether cancer was still spreading in her body without her knowledge. After all, she had discovered her lump accidentally and, hence, she “ought not to feel so sure” that the surgery had completely cured her.10 Overall, Georgia’s exchange with Halsted shows patients questioned the success of the surgery.
Amelia Hoffmann—a widow from Mississippi—was another patient who communicated her doubts to Halsted.25 She first noticed her lump when she “felt sharp pain radiating from such spot.”25 She recalled having struck her breasts twice before noticing it. Amelia was referred to Halsted by her home physician, who will be called by the pseudonym of Dr. Wilson. In his referral letter, Dr. Wilson emphasized Amelia was from “ordinary means” and asked Halsted how much he would charge to operate on Amelia.25 Alluding to Halsted’s reputation as a surgeon, he also told him Amelia wished “the most experienced surgeon to do the work.”25 In response, Halsted agreed to perform the surgery for no charge. Accompanied by her brother-in-law, Amelia immediately left Mississippi, and her left breast was operated on in 1913.
After the surgery, Halsted sent a telegram to Amelia’s son—the youngest of her 4 children—saying that the “operation” was “successful and satisfactory” and that the “patient” was in “excellent condition.”25 She returned to Mississippi and was examined periodically by Dr. Wilson, who said she only had a “slight enlargement at the right-hand side of the operation.”25 No other issues were brought up at this point.
Six months after the surgery, however, Amelia received a note from Halsted that would make her question the outcome of her surgery. Every year or two, Halsted would request patients to come to The Johns Hopkins Hospital to observe the result of the surgery and the patients’ arm function.26(p. 416) In the note he sent to Amelia, Halsted wrote that he was “greatly interested in perfecting the operation which was performed” on Amelia and asked her to come to the hospital.25 Although “nothing would give” her “more pleasure than to grant” Halsted’s request, the surprise in Amelia’s response hints at her doubt about whether she received the best treatment for her condition.25 She wrote: “I don’t know that I quite understand your first paragraph—that you are “greatly interested in perfecting the operation which was performed for you on…1913. It must still be improved in certain particulars. Do you think further treatment is advisable or not? I am improving in many respects but still find the spot just where the cancer was very tender and somewhat annoying. Hoping to hear again from you on the subject, I remain.”25 Halsted’s note made her think that there were still things to be improved in the surgery and, hence, that she probably thought she did not receive the best treatment available.
Georgia and Amelia’s worries illustrate patients’ doubts regarding the unrivaled efficacy of the radical mastectomy. Georgia wondered about other treatment options while Amelia thought the surgery likely was not enough to cure her cancer. One cannot help but wonder if they would have chosen other treatments if there had been another option, highlighting the importance of patient decision-making in surgery.

CONCLUSION
Although Halsted’s patients did not voice their opinions in public regarding the radical mastectomy, the hundreds of letters they and their families wrote to Halsted are a rich source to understand what they thought of the surgery. Even if Halsted saw the surgery as successful from a medical perspective, patients were concerned about their ability to live their life as they did before—because of limited mobility, pain, anxiety, or doubt. This suggests that the surgery was not seen as completely successful by patients.
Patients’ power of expression has changed breast cancer treatment since Halsted’s time. Most notably, in 1974, Rose Kushner—a journalist born in Baltimore, the same city where Halsted first performed the procedure—was diagnosed with breast cancer.2(p. 175) She opposed the radical mastectomy and critiqued standard breast cancer treatments at the time through her book “Why Me? What Every Woman Should Know About Breast Cancer Treatment to Save Her Life.”27 She would later become the only nonphysician to vote in the National Institute of Health’s “Consensus Development Conference on the Treatment of Primary Breast Cancer” that established the radical mastectomy would no longer be the standard treatment for breast cancer.2,27,28 In talking about Kushner’s efforts, Dr. Bernard Fisher—a surgeon at the University of Pittsburgh in the seventies—said she made “women and men stop and think about the issues.”27 Her story is a more recent example of patients’ power in generating change in surgery.
Additionally, even though none of the patients in this article alluded to a loss of sexual identity, current procedures such as breast reconstruction underscore the cultural links between breasts, femininity, sexuality, and identity.29(p. 154) Indeed, Halsted’s belief that skin transfer could conceal the “underlying recurrence…for an indefinite period of time” and aid in the “dissemination of the disease” meant that the patients discussed here did not have access to breast reconstruction in the same way patients do today.26(p. 418) Acknowledgement of these cultural links was crucial to the development of present breast reconstruction techniques.30 As such, future innovation in breast cancer treatment should continue to recognize breast surgery’s impact on all aspects of a patient’s life.
Overall, the concerns explored in this article provide a lens through which to understand patients’ experiences with breast cancer, especially as current patients continue to experience chronic pain, lymphedema, and issues related to quality of life and survivorship. Therefore, as patient-reported outcomes continue to gain more relevance in surgery, an analysis of the radical mastectomy through patient narratives reminds us that patients’ opinions regarding surgery do not always align with those held by surgeons and that we should always strive to understand those differences and why they exist.

ACKNOWLEDGMENTS
The author would like to thank Dr Mary Fissell for her mentorship, Dr Barron Lerner and Dr Christine Slobogin for their assistance reviewing the manuscript, Allison Seyler for her support through the Hopkins Retrospective initiative, and Andy Harrison, Phoebe Evans Letocha, and Kate Ugarte from the Alan Mason Chesney Medical Archives for their support while conducting the primary source research.
J.M.M.: conducted the primary and secondary source research, analyzed the archival materials, and drafted and revised the manuscript.