In early 1960, while she was writing Silent Spring, Rachel Carson discovered two lumps in her left breast. Her surgeon didn't tell her she had cancer, not even after he had given her a radical mastectomy, nor when subsequent swelling told him that the cancer had spread beyond her breast. In response to her direct questions, he told her only that she had "a condition bordering on malignancy." A Darker Ribbon: Breast Cancer, Women and Their Doctors in the Twentieth Century
by Ellen Leopold (Beacon Press, $27.50) Carson's surgeon didn't act unethically, at least according to the ethics of the day. In a 1961 survey, 90 percent of surgeons said they would do the same. "I would be afraid to tell [a patient she had cancer]," said one, "in a room with a window." The blunt facts, it was thought, were too discouraging; better to tell women something more comforting than the truth. But Carson saw it differently. Her surgeon's attitude galled her; as a distinguished scientist who had made a writing career out of facing horrible facts, she found it unacceptable to be treated like a weaker vessel. "I appreciate . . . your having enough respect for my mentality and emotional stability," she wrote to her new doctor, "to discuss all this frankly with me. I have a great deal more peace of mind when I feel I know the facts, even though I might wish they were different." Carson died of the disease in 1964, within a few years of her initial diagnosis, at the age of 53. With A Darker Ribbon, Ellen Leopold provides the first true cultural history about breast cancer and its treatment, and it's a story that revolves around women's relationships with their doctors. Many of the women in Leopold's story turn to their doctors for rescue or for the lesser comfort of simply being told what to do. "What was the program? I wanted to know," wrote a woman named Marion Flexner in a 1947 Ladies Home Journal article (one of the first such stories written for a popular audience). Her husband, who happened to be a doctor, told her what the program was, she underwent it bravely ("I tried not to disappoint him," she wrote), and all went well. But, as Carson learned, the facade of medical authority was hiding something: For much of the 20th century, there was no program at all for many types of breast cancer. The only game in town was the radical mastectomy, an operation developed by Dr. William Steward Halsted in the late 1880s that, for lack of better options, remained the "gold standard" of breast cancer therapy for almost a century. Readers unfamiliar with breast cancer treatment may be startled to learn how disabling this kind of surgery can be. Involving the removal of pectoral muscle tissue and lymph glands along with the entire breast, it can leave a woman permanently disabled in the arm and more vulnerable to infections. Much has been said in public about the symbolic and emotional ramifications of losing a breast; if one aspect of breast cancer is familiar, it's the question of reconstruction vs. prosthesis. A woman's loss of "femininity" gets attention, but her loss of the ability to carry out simple tasks of living has remained relatively obscure. Leopold explains that the breast has been "probably . . . the most overworked organ of a woman's body since time began. . . . [E]veryone seems to have a claim on it." The complex cultural aura surrounding breasts has not, Leopold finds, helped women much when it comes to breast cancer. If anything, breast diseases languished in neglect for decades, as gynecologists refused to deal with them (preferring to treat women only from the waist down) and medicine in general showed little interest. Only surgery had any luck with breast cancer, and so breast cancer became the domain of surgeons. Leopold argues that in the long run this shift worked against women's interests. Even though surgery saved many lives, it was never a cure. Halsted developed the radical mastectomy on a mistaken theory: Believing that breast cancer was essentially a local disease, he reasoned that an early, aggressive surgical response could catch it before it spread. Today, Leopold points out, we have learned to consider breast cancer a systemic disease that, in certain forms, metastasizes before a lump is detectable. Halsted's surgery, extreme as it was, couldn't save the lives of many of the women who underwent it. In Leopold's account, generations of women in awe of their surgeons followed a tragically compliant course, never suspecting how poorly the institutional forces they entrusted with their lives were serving their interests. It was only when women began taking matters into their own hands, educating themselves and advocating for more and better research, that meaningful improvement began. But Leopold's history isn't a heroic march of progress of the medical or political kind. Instead, it's a densely researched, admittedly unresolved, multilayered story in which the past may always repeat itself. As long as breast cancer can kill, Leopold says, denial and other ancient atavistic responses will live on among us as "camp followers . . . cropping up wherever the disease shows itself." The story Leopold has to tell isn't a comforting one, but its rough honesty offers something of the "peace of mind" Rachel Carson found in facing facts, however unwelcome.