A social history of breast cancer ================================= * Charlotte Gray **A social history of breast cancer; A darker ribbon: breast cancer, women and their doctors in the twentieth century**; Ellen Leopold; Beacon Press, Boston; 1999; 334 pp. US$27.50 (cloth) ISBN 0-8070-6512-9 In 1917, a 50-year-old single woman named Barbara Mueller was admitted to a private ward at Johns Hopkins Hospital, Baltimore. She had a tumour in one breast, evidence of chronic cystic mastitis, and both her nipples were retracted. Thanks to family connections, she had managed to get an appointment with the renowned William Halsted (1852-1922), the founding father of modern surgery. By the time Mueller's case notes fell into his hands, Halsted had already established the first surgical residency program in North America, revolutionized surgical practice with such innovations as sterile rubber gloves, and developed the procedure that became the "gold standard" for the treatment of breast cancer for three-quarters of a century: the radical mastectomy. (He had also become a cocaine addict - a foible to which colleagues such as William Osler turned a blind eye.) Halsted performed a radical mastectomy on Mueller and continued to monitor her case sporadically. Mueller could not thank Halsted enough for his attention. "I want to thank you for your deep interest in my welfare as it is indeed flattering to know that I am still in your mind," she wrote to him in 1920. "However I want to assure you that I shall always feel the deepest gratitude to you for the wonderful success you achieved in my operation." Eighteen months later, after more than a year of intense suffering, Mueller was dead. Halsted's "wonderful success" notwithstanding, the cancer had metastasized into her bones and brain. Despite the evidence of numerous cases like Mueller's, radical mastectomy continued to be the only treatment for breast cancer throughout most of the 20th century. As surgeons became more discriminating about which patients might benefit from mastectomies, survival rates improved. Yet these operations never offered better than 50-50 odds for recovery. Clinicians did not understand *why* the operation sometimes worked and sometimes didn't. Nevertheless, mastectomies were the closest thing that medicine had to a "cure" for a disease shrouded in taboos. Thanks to the power of inertia, and the disease's low status in the hierarchy of medical concerns, the one-size-fits-all surgical approach to breast cancer continued to hold sway well into the 1960s. This meant that breast cancer continued to be regarded as a local rather than systemic disease. FIGURE ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/162/7/1021/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/162/7/1021/F1) Figure. Ellen Leopold is a member of the Women's Community Cancer Project in Cambridge, Mass., and has written about medical issues for *The Nation,* the *Chicago Tribune* and *Self* magazine. *A Darker Ribbon,* her first book, is a social history of breast cancer. It is a highly readable, original contribution to an overcrowded field. Books about breast cancer fall into three categories: medical texts that deal with the disease, not the woman; personal narratives written by breast cancer survivors; and self-help manuals. Almost all of these books display a complete disregard for the issues Leopold covers: the determining influences of society and culture. "How is it," asks Leopold, "that a subject so utterly taboo, for so long, has become so commonplace so quickly, taking up residence in every cultural medium, from soap operas to sculpture?" The author traces the evolution of attitudes toward and treatments of breast cancer within the context of broader changes in society, particularly the rise of feminism and the women's health movement. She argues that early 20th-century campaigns to promote breast self-examination and today's obsession with diet and lifestyle share a disturbing goal: to condition women to believe they alone are responsible for their cancers. Leopold writes as a feminist and a breast cancer survivor. But her book is no polemic: she is far too intelligent a researcher to wrench context. At the core of her book are two fascinating, unpublished correspondences that illustrate the gradual pace of change in the breast cancer field. The first comprises the letters of Barbara Mueller and Professor Halsted. The second features the correspondence between Rachel Carson, the acclaimed ecologist who wrote *Silent Spring* whilst in the final stages of breast cancer, and her physician and friend Dr. George Crile, Jr. Few women diagnosed with breast cancer in 1960 were more aware than Rachel Carson of the controversies surrounding both the causes of cancer and its treatments. While researching *Silent Spring* she had looked at evidence of cell damage caused by industrial and agricultural chemicals. She was a scientist herself, and would not be intimidated by doctors. "As you know," she wrote to Crile in March 1961, "I'm not an especially tractable patient, and don't just go along with such things without doing some inquiring and thinking on my own." In Carson, the disease followed a painful trajectory. She resisted a mastectomy. The cancer metastasized into her bones; a bombardment of radiation and treatment with hormones and the unproven anticancer drug Krebiozen could neither slow Carson's decline nor alleviate her pain. Yet, until a few weeks before her death in 1964, she insisted on being a fully-informed partner in her health care, in a way unthinkable 50 years earlier for Mueller. Nevertheless, like Mueller, Carson regarded her experience of breast cancer as a private affair. She shared her history with only a few intimate friends. A conspiracy of silence continued to envelop breast cancer, although the percentage of sufferers was rising steadily. As the 21st century dawns, medical science has still not triumphed over breast cancer as it has over smallpox and polio. However, in the years since Carson's death, we have come to understand that it is not simply one invariant fatal malignancy, but a complex taxonomy of diseases. Women (and men) with breast cancer are now seen as medical consumers rather than the helpless victims of a killer. The disease has finally been liberated from taboos and inhibitions (until the 1990s, it was never mentioned in obituaries.) Yet breast cancer is still seen as an issue of corporate accountability through the control of toxic substances. *A Durker Ribbon* not only gives readers an uncompromising and unsentimental view of breast cancer. It also explores why it took so long for both physicians and patients to come to grips with the disease. It is a book that anyone with a personal or professional interest in breast cancer will find not only illuminating but also enjoyable as social history and cultural analysis.