Views & Reviews Past Caring

Extreme measures: the history of breast cancer surgery

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e834 (Published 08 February 2012) Cite this as: BMJ 2012;344:e834
  1. Wendy Moore, freelance writer and author, London
  1. wendymoore{at}ntlworld.com

The rage for breast surgery attained manic proportions in the late 19th century in the United States and Europe. But the trend was driven by surgeons, not women, and the results were far from aesthetic.

Surgeons in ancient Egypt described breast cancer, but wisely refrained from wielding the knife. The first recorded attempt at mastectomy is attributed to the surgeon Leonides of Alexandria in about the second century AD, but caution remained the watchword. By the 1600s prints in northern Europe show women stoically undergoing breast amputations by surgeons using forceps, knives, and cauterising irons long before the arrival of anaesthesia or antisepsis.

In 1748 the German surgeon Lorenz Heister described using a fork, or ropes attached to lances, to lift the breast before amputation, but warned against operating if the axillary lymph nodes were affected, because “the Virus of the Cancer, which lies concealed in the other Parts, will make the same Disorder break out in a short Time.” The Parisian Henri Le Dran advised, “provided the operation is not delayed, we may hope for a perfect cure,” and the London based John Hunter cautioned that “leaving the least part of the cancer is equal to leaving the whole.”

Eagerness to advance understanding of breast cancer led to the taking of extreme measures. The French surgeon Jean Astruc discounted black bile as the cause after baking and eating a tumour with a slice of beef as his experimental control in 1740. Not to be outdone, in 1777 the English surgeon James Nooth injected breast cancer tissue into his arms to prove it was not infectious.

Surgeons grew bolder in the 19th century even if their patients remained largely silent. The novelist Fanny Burney wrote a rare, detailed, and harrowing description of how she endured a mastectomy at the hands of Napoleon’s surgeon Dominique Larrey in 1811. With only a “wine cordial” against the pain and a cambric handkerchief over her eyes she felt “the dreadful steel” as it “was plunged into the breast” and “began a scream that lasted unintermittingly during the whole time of the incision.” She survived to live another 29 years. Abigail Adams, daughter of American founding father John Adams, was not so lucky. She too endured a mastectomy in 1811 but lived just two years before the cancer returned.

Emboldened further by the advent of anaesthesia and antisepsis, surgeons advocated more and more aggressive methods. In London Charles Hewitt Moore advised complete removal of breast, lymph nodes, chest muscles, and skin in one piece from the 1860s. But it was William Stewart Halsted in Boston who made radical mastectomy routine for every case of suspected breast cancer. His disciples went even further, removing ribs, collarbone, and even shoulder joints for the smallest of tumours. Doubtless they saved many lives, but they also performed surgery on unknown numbers of benign lumps, mutilated countless women, and killed thousands.

Conservative voices were shouted down throughout the 20th century even when figures began to show that simple mastectomy coupled with radiotherapy was equally effective as more extreme methods. It was the mid 1980s before caution and science prevailed in breast surgery—for cancer at least.

Notes

Cite this as: BMJ 2012;344:e834

Footnotes

  • Sources: Heister L. A general system of surgery. London, 1748; Leopold E. A darker ribbon: breast cancer, women, and their doctors in the twentieth century. Boston, 1999; Olson JS. Bathsheba’s breast: women, cancer and history. Baltimore, 2002; Austoker J. The “treatment of choice”: breast cancer surgery 1860-1985. Soc Soc Hist Med Bull (Lond) 1985;37:100-7.