Filler A memorable patient

The Swan Lady

BMJ 2006; 333 doi: (Published 07 December 2006) Cite this as: BMJ 2006;333:1210
  1. Dick Ashford, consultant clinical oncologist, Mount Vernon Hospital, Chipperfield (dickashford{at}

    It is 1946. A young woman is dying of breast cancer in a side street in Streatham. This is before the days of chemotherapy, and her radiotherapy has badly burnt and scarred her. The family doctor tells her distraught husband that there is no more he can do for her. “If they had not cut into the cancer, she might have survived.” A small girl overhears these words and never forgets them. The doctor leaves, and shortly the young woman dies, with little dignity as, in those days, morphine is used sparingly for fear of addiction.

    Sixty years later, an elderly woman consults her oncologist. For seven years she has lived with breast cancer but has refused treatment. Her disease is now very advanced. She is beginning to lose her concentration, and, realising that her memory is becoming faulty, she decides she had better seek orthodox medical advice for the last time. I examine her and find a huge, fixed, offensive cancer of her left breast. Her liver is grossly enlarged. She is cachectic, and there are skin deposits on her back and abdomen. She dresses.

    Back in the consulting room, I am surprised to find her a sophisticated and attractive lady, quite invisible as a patient behind her clothes. She has a gentle, cultured voice. I ask her what she used to do for a living. After being widowed early and childless, she had given educational lectures all around the country.

    “What were they on?” I ask her.

    “Many things, but mainly on swans.”

    “What sort of swan?” I go on, fancying myself as a bit of an ornithologist.

    “Mute swans,” she answers.

    “And why swans?”

    “Because swans are such elegant and beautiful creatures. They are greatly harmed by fisherman, and much maligned. They mate for life, take care of their young, and will fight and die for each other.”

    There is nothing I can say. This perceptive, cultured, and sensitive woman has allowed her breast cancer to progress untreated for the past seven years, refusing all conventional treatment, because of what she overheard as a small child 60 years ago. Those words, spoken in ignorance but never doubted by her, were her death sentence, as lethal as any bullet.

    What can we learn from the Swan Lady? To take care what we tell our patients and to remember the power our words can have. Sometimes our greatest strength, like the swan, is in silence.

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