Breast Cancer and The Language of Risk

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2002 The Society for the Social History of Medicine
Breast Cancer and the Language of Risk, 17501950

By PATRICIA
JASEN *
S U M M A R Y . The language of risk, in relation to disease, is usually viewed as having developed

in the post-war era, but in fact it has a much longer history. Focusing on the period from
the mid-eighteenth century to the mid-twentieth century, this article examines evolving
beliefs about what makes women vulnerable to breast cancer and traces the history of certain
risk factors, such as the presence of benign breast disease, the experience of injury to the
breast, the influence of unhappy emotions, the onset of menopause, and a family history of
cancer. It situates beliefs about breast cancer within their social and cultural contexts,
examining ideas concerning the relationship between mind and body, the impact of new
medical knowledge, the social meanings of cancer, definitions of femininity and images of
the female body, and womens own views on what places them at risk. It concludes that an
historical perspective adds an important dimension to our contemporary understanding of
the concept of medical risk.
K E Y W O R D S : women, breast disease, breast cancer, risk, cancer aetiology, menopause,
surgeons, mastectomy, psychosomatic medicine.
It goes without saying that the language of risk is central to our understanding of
health and illness. We are urged to avoid behaviours which place us at risk, and to
be aware of factors beyond our control which may increase our level of risk. In the
case of breast cancer, an assessment of risk is vital to the process of clinical decisionmaking when ominous symptoms appear. Thus a woman consulting a physician or
surgeon about a lump in her breast may find herself answering a whole series of
questions: When did you begin menstruating? When did you have your first child?
Did you breast-feed, and for how long? How much alcohol do you drink each
week? Do you exercise regularly? Has anyone in your family had breast cancer?
Data collected in this manner are used to assess the patients risk factors, all of which
are commonly related to the history of her bodyher possible genetic inheritance,
her reproductive history, as well as the habits of health or neglect which she has
cultivated over the course of her life. Depending upon the physician, habits of
mind may also be considered relevant. If the patient is considered high risk, the
likelihood that she will undergo a biopsy increases. If she is diagnosed with cancer,
she and others may look to these risk factors for some causal explanationsome
way of making sense of her misfortune. Even if the lump is benign, the very fact
that she has had a biopsy will place her within a new category of risk.
The language of risk is a familiar aspect of medical discourse in our time, but is
commonly believed to have developed only recently. In her aptly-titled article,
The Meaning of Lumps, Sandra Gifford traces the rise of the concept of risk
back to the 1950s, when the notion of probability came into use in the epidemiology of chronic disease.1 Robert Aronowitz, in Making Sense of Illness, locates the
* Department of History, Lakehead University, 955 Oliver Road, Thunder Bay, Ontario, Canada
P7B 5E1. E-mail pat.jasen@lakeheadu.ca
1
S. Gifford, The Meaning of Lumps: A Case Study of the Ambiguities of Risk, in C. R. James, J. R.
Stall, and S. Gifford (eds.), Anthropology and Epidemiology: Interdisciplinary Approaches to the Study of Health
and Illness (Dordrecht, 1986), 21346, p. 217.
0951-631X Social History of Medicine Vol. 15 No. 1 pp. 1743
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Patricia Jasen
beginnings of the risk factor approach in the same period, when the question of
why some individuals get sick and others not became the main focus of research.2
The purpose of this article is to contribute to an emerging understanding of the
much longer history of medical risk through a study of a particular illness, as it was
portrayed in the medical literature of Britain and North America.3 A time frame
extending from the eighteenth to the twentieth centuries allows the subject of
breast cancer risk to be situated within the context of changing social attitudes and
medical beliefs.
I
One of the reasons why an historical awareness of medical risk goes unrecognized
is that it has so often been defined as something that must be calculated, in Deborah
Luptons words, through systematic statistical correlations and probabilities based
on populations rather than the close observation of individuals.4 But, as Becker
and Nightingale point out, the dominant model of risk in biomedicine has been
an epidemiological one, and S. E. Hansson suggests that perhaps a kind of scientific
linguistic imperialism has been at work in this treatment of the word risk as a
unidimensional, technical concept when in everyday popular usage the term has
many other layers of meaning.5 The problem is not just that lay constructions of
risk have been regarded as unimportant. As Gifford argues, epidemiologists,
clinicians, and patients all speak different languages of risk. Epidemiologists are
concerned with groups and with the identification of risk factors and their relative
importance. Clinicians, by contrast, must apply that knowledge to the treatment of
individuals, and for them risk becomes the property of the particular patient. They
also have to deal with their own experience of the risk of being wrong, and this
can affect decisions regarding surgery. The patient, meanwhile, experiences risk on
a very personal level, as a state of being, as Gifford says, which may even change
from day to day. Lived risk is much more ambiguous and subjective than scientific
risk, but it is no less real.6 An historical perspective can tell us a great deal about
how clinicians and even patients dealt with the question of risk in the past, and it
can also provide insights into the long evolution of the epidemiological model.
Another limitation imposed by a narrow vision of risk is the assumption that,
prior to the mid-twentieth century, medical practitioners and researchers concerned
themselves solely with the causes of disease. It is certainly true that cause and risk
are not interchangeable terms; while the former explains why something occurred,
the latter merely assesses the likelihood that something may happen. Therefore,
2
R. Aronowitz, Making Sense of Illness: Science, Society and Disease (Cambridge, 1998), p. 112.
Some general studies of risk do contain an historical component, although conclusions are often
contradictory. For example, see M. Douglas and A. Wildavasky, Risk and Culture (Berkeley, 1982) and
D. Lupton, Risk (London, 1999).
4
Lupton, Risk, p. 92.
5
G. Becker and R. D. Nachtgall, Born to be a Mother: The Cultural Construction of Risk in
Infertility Treatment in the U.S., Social Science and Medicine, 39 (1994), 50718, p. 507; S. E. Hansson,
Dimensions of Risk, Risk Analysis, 8 (1988), 10712, cited in M. V. Hayes, On the Epistemology of
Risk: Language, Logic, and Social Science, Social Science and Medicine, 35 (1992), 4017, p. 403.
6
Gifford, The Meaning of Lumps, pp. 21730.
3
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from a modern epidemiological standpoint, risk refers to the estimated excess

frequency of an event within a population; it does not demonstrate causality, nor
does it predict outcome.7 But various studies have shown that, for clinicians and
patients, not only is the focus on the individual rather than on the group, but the distinction between cause and risk is often blurrednot merely as a result of imprecise
thinking, but because these concepts overlap.8 The same is true in the historical
literature. Even though the word risk was only occasionally used, eighteenth- and
nineteenth-century case histories of breast cancer patients commonly discussed all
of the factors that might have played a role in the genesis of the disease, and all of
the characteristics of the patients then known to be associated with a cancerous
tendency or liabilitythe latter word being used with great frequency to explain
why some people got sick while others did not. Very commonly, the term
predisposing cause (in contrast to exciting cause) was used to identify factors
which were believed to have increased a patients level of risk, even if they did not
explain the onset of illness. A surgeons goal in analysing case histories was not just
to ponder the fate of individual patients but to find a means of predicting which
women were vulnerable. As is the case today, their efforts represented an attempt
to tame uncertainty9 in the face of a frightening and mysterious disease.
The historian might also consider distinctions within the current language of
risk which may illuminate past experience. For example, in her study of Risk
Discourse and Diagnostic Testing in The Imperative of Health, Lupton distinguishes
between external and internal risk factors in a modern context. She defines
external factors as being beyond ones control, whereas internal risk factors are a
function of the individuals ability to manage the selfa language not entirely
foreign to the late eighteenth-century understanding of personal responsibility for
health of body and mind which Rosenberg has described.10 Similarly, Hayes
distinction between modifiable and non-modifiable risks (such as the difference
between family history and dietary habits in the case of heart disease) has historical
relevance in the case of breast cancer. For example, surgeons have long believed
that risk may be modified through medical intervention aimed at removing the
possible dangers associated with benign breast disease. The practice of prophylactic
mastectomy is one means by which both nineteenth- and twentieth-century
surgeons attempted to discipline the future.11
An historical approach can also bring into sharper focus the ways in which the
discussion of medical risk was culturally constructed. As Therese Taylor points out,
the study of breast cancer has not been so suited to the social constructionist model
as have conditions such as hysteria, for, in the case of cancer, the organic reality of
the disease . . . takes control, overcoming the social determinants which are left
17
Becker and Nachtgall, Born to be a Mother, p. 507.

Gifford, The Meaning of Lumps, pp. 2145; E. Parsons and P. Atkinson, Lay Constructions of
Genetic Risk, Sociology of Health and Illness, 14 (1992), 43755.
19
D. Lupton, The Imperative of Health: Public Health and the Regulated Body (London, 1995), p. 79.
10
Lupton, The Imperative of Health, p. 77; C. E. Rosenberg, Body and Mind in Nineteenth-century
Medicine: Some Clinical Origins of the Neurosis Construct, in Rosenberg, Explaining Epidemics and
Other Studies in the History of Medicine (Cambridge, 1992), 7489, p. 78.
11
M. Hayes, On the Epistemology of Risk, pp. 4045; Lupton, The Imperative of Health, pp. 779.
18
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Patricia Jasen
trailing in its wake.12 The concept of cancer risk, however, was historically seldom
separated from ideas about womens essential nature, and this article attempts to
discern the ways in which constructions of gender and breast cancer interacted and
changed over time. For example, as the nineteenth century progressed, womens
biological destiny, from child-bearing to breastfeeding to menopause, was increasingly linked with their cancerous tendency. The discussion of whether unhappy
emotions were a precursor to cancer was a constant in the medical literature, but
was subject to changing ideas about the relationship between body and mind and
diverse theories regarding womens emotional fragility. Patients, meanwhile, had
their own views concerning the circumstances and conditions which placed them
at risk, and their unease at living with those fears parallels, to some degree, our
modern experience. The evidence suggests, for example, that the loss of a mother
to breast cancer aroused fears for oneself even in periods when little professional
attention was paid to the importance of heredity.
The continuing failure to solve the mystery of cancer is one reason, argues Ellen
Leopold, for its marked neglect by historians. The subject makes for poor narrative
history, for there has been no march to victory to unify the story of breast cancer,
unlike that of tuberculosis, diabetes, or polio.13 And yet this does not explain why its
impact on womens lives has been left largely unrecorded, apart from the rare but
invaluable records we have of the individual suffering of famous victims. Even
histories of womens encounters with illness and doctors during the much-studied
nineteenth century, when gynaecology was developing as a profession, do little
to narrow the gap. This may be partly due to cancers relative unimportance
compared with the toll exacted by other diseases, but must also reflect the growing
silence surrounding breast cancer in this perioda silence related to fear, shame,
and a sense of hopelessness in the face of the unexplainable. Unfortunately for the
historian, the medical literature reflects that silence; for example, most nineteenthcentury womens health manuals and texts dealing specifically with the diseases
of women have little or nothing to say about breast cancer. A reliance on the
one major body of literature which does not shirk the subjectthe writings of the
surgeons who were largely responsible for diagnosing and treating the disease
necessarily affects the kind of history that can be written.14 By the very nature of
their profession, surgeons viewed the aetiology and treatment of cancer from
particular perspectives, very often hoping to advance their reputations through their
published works. In what follows, I emphasize the diversity of opinion among
surgeons (especially prior to the twentieth century) and also, of necessity, remain
tentative in my analysis of a debate which is still in process.
12
T. Taylor, Purgatory on Earth: An Account of Breast Cancer from Nineteenth Century
France, Social History of Medicine, 11 (1998), 381402, p. 384.
13
E. Leopold, A Darker Ribbon: Breast Cancer, Women, and their Doctors in the Twentieth Century
(Boston, 1999), pp. 34. Important works on the history of women and medicine, such as R. Apple (ed.),
Women, Health, and Medicine in America: A Historical Handbook (New York, 1990); A. Dally, Women under
the Knife: A History of Surgery (New York, 1992); W. Mitchinson, The Nature of Their Bodies: Women and
Their Doctors in Victorian Canada (Toronto, 1991) contain little or no mention of breast cancer.
14
Many physicians were also licensed as surgeons and performed breast cancer surgery on occasion,
but were less likely to publish on the subject. For example, see J. Duffin, Langstaff: A NineteenthCentury Medical Life (Toronto, 1993), pp. 1714.
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The remainder of this article deals with the discussion of breast cancer and risk
during three time periods. The section which follows focuses on the period from the
1750s to the early nineteenth century and examines beliefs about what made women
vulnerable to cancer in the light of contemporary medical theories, surgeons own
professional concerns, and the concerns of the women they treated. The next section
considers the evolving language of risk in the context of Victorian social values, new
medical knowledge, and the growing hegemony of surgeons in the realm of breast
disease. The final section looks at the first half of the twentieth century, when rising
cancer rates brought a new sense of urgency to the search for answers concerning
causation and risk. This period saw growing agreement concerning the factors considered most relevant, but, at the same time, the discussion of breast cancer became
more narrowly focused upon womens inherent vulnerability to the disease.
II
In 1753, William Norford, a country surgeon and man-midwife practising in
Halesworth, East Suffolk, published a treatise on the treatment of cancerous
tumours, in which 12 of his 18 case histories involved patients with breast cancer.
In describing the case of one such woman who had been under his care before her
death, he began by recording a series of events which he considered relevant to her
trouble. Many years earlier, in 1733, when she was 37 and pregnant, she observed
that the Nipple of her right Breast was drawn inward, and when she gave birth
the Child could not catch hold of it to suck it. When the child was a year old, the
Mother was suddenly frighted when her Menses were upon her; which put them
away, and she never after had any Return of them. In March of 1739, she had a
dangerous fever and was then exposed to cold; not long after, she was violently in
Wrath, Fear, and Grief, receiving at the same Time a Bruise on her right Breast.
She was confined to bed for three months, then found a small, painful red Tumor
in the inferior exterior Part of the right Breast, which she ignored. It grew, but she
refused surgery until it was too late.15
The Enlightenment physician, as David Harley writes, depended upon an interpretation of signs and story when assessing a patients illness,16 and case histories
such as this illustrate the importance that surgeons also placed upon their patients
testimonies. The woman described above had given Norford, either voluntarily or
in response to questions asked, a series of possible reasons for her illness derived
from her life history or bio-logy, as Barbara Duden expressed it. This was in
keeping with the contemporary belief that the entire life as lived had a bearing
upon individual health.17 In this case, both the patients reporting and Norfords
recording were guided by the fact that each of these events corresponded to an
ancient and still-popular notion of why cancer might develop, such as a problem
15
W. Norford, An Essay on the General Method of Treating Cancerous Tumors (London, 1753), p. 30.
D. Harley, Rhetoric and the Social Construction of Sickness and Healing, Social History of
Medicine, 12 (1999), 40736, p. 420.
17
B. Duden, The Woman Beneath the Skin: A Doctors Patients in Eighteenth-Century Germany
(Cambridge, MA, 1991, trans. T. Dunlap), p. 43; Rosenberg, Body and Mind in Nineteenth-century
Medicine, p. 89.
16
22
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with lactation, a stoppage of menstruation and the onset of menopause, an exposure

to cold, the experience of unhappy emotions, and the damage done to the breast
by a blow. None pointed with certainty to the origin of the disease, but all were
circumstances long associated with women who developed breast cancer.
Norfords contribution to the literature should be seen in context. In the late
eighteenth century, many surgeons served as general practitioners in their communities, and some also took the title of man-midwife, signalling their growing
involvement in womens reproductive lives. Seeking to improve their professional
status, some surgeons produced works on cancer which promoted their own theories
on its nature and appropriate treatment, and sought to undercut the influence of
quacks who peddled solutions less painful than surgery.18 As Daniel De Moulin
points out, despite the proliferation of literature on cancer during the Enlightenment, little progress had yet been made in understanding the disease,19 and surgeons
writings both supported and challenged ancient ideas. For example, was the old
distinction between scirrhus and cancer still validwas an indolent tumour to
be regarded as harmless, as a sign of possible trouble in the future (that is, risk), or
as an early stage in the disease itself requiring immediate action? There was
also disagreement over whether cancer was a local or a constitutional disease. This
mattered in a very practical sense, for the decision to operate often rested on
whether the surgeon believed that removal of the tumour or the breast would be
sufficient to halt the disease, and whether the patient herself accepted that assessment of her situation and the risk which surgery would entail.
Womens responses to the threat and reality of disease can often be gleaned
from surgeons case histories, which provide glimpses into the social history of breast
cancer during this era. Medical authority was not as monolithic as it would later
become, and there is evidence to suggest that women often resisted surgery, sometimes going from one practitioner to another until a favourable prognosis was offered
or an alternative treatment was proposed.20 Even though breast cancer claimed far
fewer victims in proportion to the population than it does today, its spectre still
loomed in womens lives.21 Fanny Burneys familiar but chilling description of the
pre-anaesthesia mastectomy leaves no doubt as to why the procedure inspired such
fear, and womens terror speaks loudly from the pages of medical treatises.22 In an
era when privacy was unusual and when women shared the travails of childbirth
18
On the surgeons profession c. 1790, see W. F. Bynum, Science and the Practice of Medicine in the
Nineteenth Century (Cambridge, 1994), pp. 211. On the ambitions of surgeons and men-midwives in
the late-eighteenth century, see O. Moscucci, The Science of Woman: Gynaecology and Gender in
England, 18001929 (Cambridge, 1990), pp. 507. On the history of womens surgery, see Dally,
Women under the Knife.
19
D. De Moulin, A Short History of Breast Cancer (The Hague, 1983), p. 33.
20
Duden, The Woman Beneath the Skin, p. 98.
21
For some early statistics on cancer rates, see W. H. Walshe, The Nature and Treatment of Cancer
(London, 1846), p. 152; E. Shorter, Womens Bodies: A Social History of Womens Encounters with Health,
Ill-health, and Medicine (New Brunswick, NJ, 1991), pp. 2424.
22
Burneys letter describing her ordeal is reprinted in D. J. Rothman, S. Marcus, and S. A. Kiceluk
(eds.), Medicine and Western Civilization (New Brunswick, NJ, 1995), 3839. On Burneys case, see J.
L. Epstein, Writing the Unspeakable: Fanny Burneys Mastectomy and the Fictive Body,
Representations, 16 (1986), 13166; J. Wiltshire, Early Nineteenth-century Pathography: The Case of
Fanny Burney, Literature and History, 3rd ser., 2 (1992), 923.
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and illness with one another, the fate of those afflicted with cancer was often
known in the community.23 Henry Fearon, surgeon to the Surrey Dispensary,
described the case of Elizabeth Ellis of Cumberwell, whose fear of breast surgery
had been riveted more firmly in her mind from the sufferings of a neighbour who
had given her a dreadful account of the pain of the operation, while John
Rodman, surgeon and medical superintendent of the Dispensary and House of
Recovery of Paisley, made the not-surprising observation that womens alarm
tended to increase about the time of a cancerous breast being cut off in their
neighbourhood.24 Surgeons inability to interpret lumps accurately, their common
assumption that pain meant cancer, and their frequent reports of very young
women undergoing cancer treatment, also suggest that many women had
mastectomiesoften resulting in sepsis and deathwhen they did not have cancer
at all. John Ewart, a physician at the Bath City Infirmary, observed that in its early
stages cancer was hard to distinguish, and that many tumours of a very different
character have been mistaken for it and extirpated improperly.25 Even women
who accepted that they had cancer had to weigh the possibility of dying immediately as a result of surgery against the possible benefits of treatment. Everard Home,
surgeon at St Georges Hospital, wrote in 1805 that one of his patients sought
surgery to preserve her life on account of her children, but also asked for
reassurance that it could be done without risk of her life.26 And Fearon reported
that a patient of his, named Mary Smith, chose surgery because her pain was so
acute that she was willing to run any risk.27
Were women at much greater risk of cancer than men? Edward Shorter may
overstate his case in assuming that, until the late nineteenth century, cancer was
thought to be primarily a womens disease because malignancies of the breast,
cervix, and other external organs were the only ones that could be diagnosed.28
Surgeons also wrote of cancers affecting men, especially those of the genital and
facial region, though it is true that the rate of known or suspected cancers was far
greater among women in the period under study.29 After surveying available
figures for cancer deaths in European cities during the early nineteenth century,
W. H. Walshe concluded that There is no fact in the history of cancer more
absolutely demonstrated than the influence exercised by sex on its development . . ..
Hence it follows that the female population of this country is destroyed to about
23
Some surgeons even identified their patients by name and place of residence. For example, see
Minutes of Cases of Cancer and Cancerous Tendency successfully treated by Mr. Samuel Young (London,
1816).
24
H. Fearon, A Treatise on Cancers, with an account of a new and successful method of operating, particularly
in Cancers of the Breast and Uterus (London, 1790), p. 161; J. Rodman, A Practical Explanation of Cancer in
the Female Breast, with the Method of Cure and Cases of Illustration (Paisley, 1815), p. 58.
25
J. Ewart, The History of Two Cases of Ulcerated Cancer of the Mammae (Bath, 1794), p. 31. For doubts
concerning professional honesty regarding breast cancer diagnoses, see J. Adams, Observations on the
Cancerous Breast (London, 1801), p. 32 and passim.
26
E. Home, Observations on Cancer, Connected with Histories of the Disease (London, 1805), pp. 523.
See pp. 99101 for further discussion of the risk associated with surgery.
27
Fearon, A Treatise on Cancers, p. 146.
28
Shorter, Womens Bodies, p. 242.
29
For example, see the range of cancers discussed in B. S. Shoenberg, A Program for the Conquest
of Cancer: 1802, Journal of the History of Medicine and Allied Sciences, 30 (1975), 322.
24
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Patricia Jasen
two and three quarters times as great an extent by cancer as the male.30 What
Walshe meant was that women were more predisposed to cancer because of their
genital functions and were especially at risk during their declinea conclusion
which most surgeons already took for granted.
The association between menopause and cancer would be a lasting feature of the
language of risk, but, in this time period, it was supported by the lingering influence of humoral theory, which held that the excess of any humour could produce
dangerous masses in the body.31 Hippocrates had believed that when menstruation
ceased, the body remained uncleansed; therefore the breasts became engorged and
developed lumps which could degenerate into cancer.32 Galen, of course, attached a
special importance to the accumulation of black bile as a precursor of cancer, providing the material explanation for the familiar association between cancer sufferers
and melancholy temperament. As Luke Demaitre writes, this idea fits the case of
breast cancer particularly well, for the disease was thought to arise from insufficient cleansing by menstruation of the blood from the dregs of spoiled black bile.33
Henry Fearon, for example, proceeded on the belief that the excess of blood brought
about by the cessation of menstruation was a strong predisposing cause. In order to
demonstrate the benefit of his interventions, he offered the case history of a patient he
successfully treated in 1784, who, after her menses had apparently ceased, had discovered a lump in her breast which he viewed as potentially cancerous. She finally had a
heavy flow and her painful lump subsided. He agreed thereafter to bleed her regularly
to keep her body open, and took credit for her continued freedom from disease.34
Such beliefs were compatible with what Rosenberg has referred to as a holistic
pathology. During the late eighteenth and early nineteenth centuries, he writes,
disease entities played a relatively small role in a scheme that emphasized the
bodys unending transactions with its environment. Disease shaded graduallyand
dangerouslyfrom minor to serious forms.35 Surgeons writings show that,
although they were concerned with defining and identifying cancer, they did not
necessarily see its development as an irreversible process. As Rosenberg says, disease
theory was also interactive, in that health was constantly being negotiated by each
individuals body and mind as that body moved through time.36 The proper
regimen might restore health even to cancer patients, and the individual bore some
responsibility for the outcome. Most at risk of disease were those of strong
sensibility, especially women, for they were more responsive to outside stimuli.
As Elizabeth Bronfen writes, Women, made of frail fibers, were seen to have easily
impressionable souls and unquiet hearts readily carried away by lively imagination.37
30
Walshe, The Nature and Treatment of Cancer, p. 152.

On humoral theory and cancer, see L. J. Rather, The Genesis of Cancer (Baltimore, 1978), pp. 845.
32
M. Yalom, A History of the Breast (New York, 1997), pp. 1067; De Moulin, A Short History, p. 37.
33
L. Demaitre, Medieval Notions of Cancer: Malignancy and Metaphor, Bulletin of the History of
Medicine (1998), 60937, p. 618.
34
Fearon, A Treatise on Cancers, pp. 42, 645.
35
Rosenberg, Body and Mind in Nineteenth-century Medicine, p. 77.
36
Ibid., p. 78.
37
E. Bronfen, The Knotted Subject: Hysteria and its Discontents (Princeton, 1998), p. 114;
L. Jordanova, Sexual Visions: Images of Gender in Science and Medicine between the Eighteenth and Twentieth
Centuries (Madison, 1989), pp. 258.
31
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But they still had some control over whether they exposed themselves to the
circumstances that might cause illness to develop, including feelings of anxiety,
depression, and fear. The causal connection between emotions and disease was
taken for granted; as Rosenberg says, until about the middle of the nineteenth
century all medicine was necessarily and ubiquitously psychosomatic .38
A connection between unhappy emotions and breast cancer was discussed by some
surgeons during this period, although the explanations they devised were based on
more than one medical philosophy. Richard Guy, writing in 1759, made the
familiar observation that women of a certain type of constitution were most vulnerable to the disease, namely those of a sedentary, melancholic Disposition of Mind,
although he also observed cases where previously healthy women succumbed to
cancer in the wake of grief caused by the death of loved ones.39 John Rodmans A
Practical Explanation of Cancer in the Female Breast (1815) emphasized instead that the
excessive sensibility of women in general put them at risk of cancer, and that those
who failed to regulate their passions and imaginations were courting that very outcome. The woman who allowed her mind to be kept in a state of constant ferment
produced a diseased turgidity in her breasts which might progress to cancer, especially if she indulged her fears of the disease. There is a peculiar sympathy which
reigns amongst females respecting cancer of the mammae, mused Rodman, for,
when they hear of another woman suffering from the disease, they start brooding
over ideal miseries until the frame is disturbed and disorder commences in their own
breast. He recommended that such a patient should never discuss her fears with
friends, and should be advised to examine her own breasts but seldom herself, and
allow no other person to examine them. In his view, it was because of this latent
agency, the mind, that breast diseases were more common in some parts of the
country than in others. But he also held that the greatest danger arose when an unsafe
sensibility was combined with poor physical habits, such as the wearing of clothing
which exposed the breasts to cold and injurious pressure, and a poor diet which caused
indigestion and the contamination of weakly constitutions. He cited a number of
cases in which he believed that his own interventions had reversed a dangerous process,
especially when he was able to gain ascendancy over a perturbed imagination.40
Case histories very often illustrate an inter-connectedness among factors associated
with breast cancer and a rather complicated relationship between notions of cause
and risk. The importance attached to the experience of physical trauma by many
surgeons during this period is a case in point.41 The conviction that blows could
serve as an exciting cause in breast cancer went back to classical times and was
ubiquitous in Western medicine, possibly reflecting how often women suffered
38

R. Guy, An Essay on Scirrhus Tumours and Cancers (London, 1759), quoted in S. J. Kowal,
Emotions as a Cause of Cancer: 18th and 19th Century Contributions, The Psychoanalytic Review, 42
(1955), 21727, p. 219.
40
Rodman, A Practical Explanation of Cancer, pp. 6, 19, 910, 569, 6670, and passim.
41
Ewart, The History of Two Cases, pp. 11, 40; Fearon, A Treatise on Cancers, p. 30 and passim.;
T. Gataker, Essays on Medical Subjects (London, 1764), p. 61. For womens references to blows
reported in case histories, see R. Guy, Practical Observations on Cancers and Disorders of the Breast
(London, 1762), pp. 65, 67, 79, 80, 83, 85, 95, 100, 102, 105, 112.
39
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Patricia Jasen
violence through accident or malevolence. Although such revelations were

unusual in surgeons writings, Norford remarked on how one of his patients, a
woman of 48, had received blows on both face and breast from her husbands fist.
But, in his view, whenever cancer was blamed on a blow, there was almost
certainly some internal pre-disposing latent Cause in the Blood and Juices which
conspired with the external one to occasion it. He explained that there are some
Constitutions which, if you were to bruise, or otherwise hurt every Part of their
Bodies, . . . you could never make the thus injured Parts terminate in a Cancer. On
the contrary, there are others so prone to this Disease, that almost the slightest
Blow or Pressure shall immediately give Rise to it. But violence could also
contribute to cancer in a reverse fashion. A blow received early in life might
produce a lump, or scirrhus, which posed little risk until the woman reached a
more vulnerable stage in her life, namely menopause. At that time, melancholy of
the blood might cause the scirrhus to degenerate into a Cancer, according to the
Degree of Acrimony the Humours have acquired before their Stagnation.42 The
association between trauma and risk would persist throughout the period, even as
the language of humoral medicine was left behind. Joseph Adams, for example,
explained in 1801 that the cancerous period might be anticipated when any part
of the breast became useless either through injury to any of the tubuli lactiferi or the
onset of menopause.43 Not all surgeons agreed on the importance of this factor,
however, and William Nisbet of Edinburgh believed that patients so often linked
their cancer with injury in an attempt to avoid the disgrace associated with an
hereditary or constitutional taint.44
Surgeons used the term constitution in more than one context in their
discussions of breast cancer. They disagreed, for example, over whether the disease
was constitutional or local in origin, with the latter view gaining ground by the
late eighteenth century.45 In his treatise on cancers of the breast and testes published
in 1790, Fearon asserted that the disorder is not originally connected with the
system, but [is] merely a local complaint . . . the cancerous virus is absorbed into
the constitution from the local affection. If the surgeon were allowed to intervene
in time, he argued, it need not result in the whole breast being swept off.46
Surgeons also used the term to differentiate among types of individuals and their
vulnerability to cancer. Were women sufferers more numerous because they had
weaker constitutions? Were certain types of constitution, in the old humoral sense
or otherwise, more associated with cancer? And was this tendency hereditary?47
Everard Home viewed cancer as entirely a local disease more common in persons
42
Norford, An Essay on the General Method of Treating Cancerous Tumors, pp. 1568.
Adams, Observations on the Cancerous Breast, p. 78.
44
W. Nisbet, An Inquiry into the History, Nature, Causes, and Difference Modes of Treatment Hitherto
Pursued, in the Cure of Scrophula and Cancer (Edinburgh, 1795), p. 155.
45
Ewart, The History of Two Cases, p. 42; Fearon, A Treatise on Cancers, p. 41; D. Hussack,
Observations on the Advantages of Exposing Wounds to the Air after Capital Operations, with some remarks
upon the Removal of Scirrhus Tumors from the Breast (New York, 1813), pp. 1011; C. Aldis, Observations
on the Nature and Cure of Glandular Diseases, Especially those Denominated Cancer (London, 1820), p. 4.
46
Fearon, A Treatise on Cancers, pp. x-xi.
47
For conflicting views on the question of heredity and cancer, see Shoenberg, A Program for the
Conquest of Cancer, pp. 11, 15, 18, 21.
43
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27
whose constitutions are of one kind, which explained why the breasts of females
of one family may be more liable to have their natural actions disturbed by slight
causes, than those of the females of other families, especially at the time of life
when the gland is becoming less perfect in its functions.48 Fearon, by contrast,
believed that the general notion of the hereditary disposition had been carried a
great deal too far, and John Rodman was of the view that cancer was wrongly
assumed to run in families because mothers passed on faulty dispositions to their
daughters which encouraged fretfulness of temper and superfluous anxiety. He
also believed that, when mothers died of breast cancer, daughters typically sank
into despair anticipating their own fate, thus leaving themselves open to the very
disease they feared most.49
The possibility that child-bearing and breastfeeding might predispose a woman
to cancer was another ancient idea still widely discussed. Norford held the fairly
common view that unreasonable Stoppage of the Milk from whatever cause
could create trouble, for the milk might stagnate in the dilated lactiferous Vessels,
then thicken, grow dry, and form a scirrhus.50 For most practitioners, this was just
one of a constellation of factors, and not one they might be inclined to emphasize
at a time when breastfeeding was gaining in cultural and political significance.51
London surgeon and man-midwife, William Rowley, however, openly held that
the foundation of cancer was almost always laid during child-bearing, and while it
may have been unusual to share such concerns with female patients, Rowley
addressed the Ladies of Great Britain directly in his 1772 tract. He appealed to
their fears and made a case for the special knowledge of his rising profession, whose
business it was both to attend women in childbirth and treat cancer when it arose.
Only men like himself, he pointed out, were in a position to trace the disease to its
original source, and with that knowledge they would be able to play a role in
reducing or eliminating the risk of cancer. Reflecting the growing condemnation
of the use of wet-nurses, Rowley was careful to emphasize that refusing to suckle
posed a risk to health in itself, the order and designs of nature being perverted,
and this was a view some other surgeons shared. Instead, women should commence
breastfeeding as soon as the milk appeared, and any abscesses or hardnesses that
developed should be treated with bleeding, laxatives, diuretics, and a strict regimen.
Rowley promised that his methods would rescue women from the cruelty of the
knife and virtually wipe out cancer with all its miserable symptoms.52
48
Home, Observations on Cancer, p. 151.

Fearon, A Treatise on Cancers, p. 32; Rodman, A Practical Explanation of Cancer, p. 133.
Norford, An Essay on the General Method of Treating Cancerous Tumors, pp. 13, 94; De Moulin, A
Short History, pp. 18, 35; Shorter, Womens Bodies, p. 244.
51
L. Schiebinger, The Mind Has No Sex: Women in the Origins of Modern Science (Cambridge, MA,
1989), pp. 21920; idem., Natures Body: Gender in the Making of Modern Science (Boston, 1993),
pp. 6974; A. Vickery, The Gentlemans Daughter: Womens Lives in Georgian England (New Haven,
1998), pp. 1078.
52
W. Rowley, A Practical Treatise on Diseases of the Breast in Women . . . with the Method of Preventing
the Cancer (London, 1772), pp. iii, 434, 24, 27, vii; Nisbet, An Inquiry, pp. 1312; J. Burrows, A New
and Practical Essay on Cancers (London, 1767), p. 29; T. J. Graham, A Treatise on Cancer (London, 1826),
pp. 512.
49
50
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Patricia Jasen
III
None of the factors considered above was dismissed by surgeons during the
Victorian era, even though their knowledge of cancer and the body was changing.
De Moulin has outlined some of the most significant developments to occur in the
nineteenth century, such as the shift towards a solidistic concept of cancer and the
understanding that cells were the basis of both life and disease.53 What remained a
mystery was what caused cancer cells to form and multiply: Whence does the
mandate of disobedience arise? asked Thomas William Nunn, a consulting surgeon
to the Middlesex Hospital, in 1882.54 Increasingly, the search for the causes of
cancer took place in the laboratory, but surgeons on both sides of the Atlantic
whose status rose markedly during this eraadvanced their own theories based
upon clinical experience and death rates. The introduction of anaesthetics and
asepsis made breast surgery more commonplace, while the growing collection and
use of cancer statistics brought a scientific aura to the discussion of causation and
risk. Even though techniques were crude and conclusions often faulty, assessments
of risk could now be made among specific populationsthe nullipara and the
multipara, the young and the middle-aged, the European and the African, the
robust and the frail. Possible risk factors were proposed for other kinds of malignancies as well, such as the connection between child-bearing and uterine cancer,
but cancer of the breast continued to evoke the most detailed discussion.
The study of cancer also reflected the powerful influence of Victorian social
values upon science and medicine. For example, even as the surgical literature on
breast cancer proliferated, public silence surrounding the disease deepened. This
was partly due to the separation between public and private life cultivated by the
Victorian middle class. Only gradually did private functions retreat to a hidden
core, as the authors of Family Fortunes have observed,55 but few duties became
more private than caring for a family member with cancer. Pat Jalland describes
how, in a culture preoccupied with death and its meanings, death from cancer
represented the antithesis of the good death.56 Cancer was considered such a
disgrace in middle- and upper-class society, argues Leopold, that it descended into
the black hole of social taboos, and families strove to conceal its presence, even to
the point of falsely reporting a cause of death.57 When Sara Coleridge was dying of
breast cancer, she made a constant effort to cover up her ailment or call it something
else, explaining in her diary in the summer of 1851 that People so dread this
malady of mine. I remember thro life I have regarded it with peculiar horror.58 In
all likelihood, the breasts association with sexuality (and cancers violation of the
mothers nourishing breast) further contributed to this process of silencing, even
53
De Moulin, A Short History, pp. 5771.

T. W. Nunn, On Cancer of the Breast (London, 1882), p. 141.
55
L. Davidoff and C. Hall, Family Fortunes: Men and Women of the English Middle Class, 17801850
(Chicago, 1987), p. 319.
56
P. Jalland, Death in the Victorian Family (Oxford, 1996), pp. 37, 53, 612.
57
Leopold, A Darker Ribbon, p. 32; D. K. McGregor, From Midwives to Medicine: The Birth of
American Gynecology (New Brunswick, NJ, 1998), p. 175.
58
K. T. Meiners, Imagining Cancer: Sara Coleridge and the Environment of Illness, Literature and
Medicine, 15 (1996), 4863, pp. 501.
54
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29
among doctors themselves. Although surgeons continued to comment upon the

fear cancer inspired in women,59 what is most striking is the extent to which a
substantial segment of the medical profession sought to isolate the disease and deny
its reality. The growing field of gynaecology had supposedly claimed the whole
woman as its sphere of study and practice60, and yet it largely ignored breast disease.
Many texts on the diseases of women make little or no mention of the subject, and
the same was true of medical advice literature aimed at a female audience.61 The
rise of gynaecology, nevertheless, was part of a process whereby womens physiology was increasingly defined as pathological, and a whole range of vaguely defined
afflictions, from hysteria to lumpy breasts, fell under a more intrusive programme
of medical management. Historians have explored the impact of gynaecological
surgery on womens lives during the Victorian era, but, so far, we know little
about their experience of intrusive surgical treatments for a variety of breast
conditions.
The surgeons growing hegemony in the realm of breast disease both supported
and was supported by the fact that cancer was increasingly understood as a disease
of local origin, a process which coincided with the final abandonment of humoral
theory and rising doubts concerning the role of heredity in cancer risk.62 In the
early Victorian period, surgeons still spoke with conviction of the association
between certain types of constitution and the risk of cancer. In 1846, Walshe
reported findings from a continental hospital to the effect that of 44 cancerous
persons, whose original constitutional bias was sufficiently marked for purposes
of observation, 20 were of lymphatic, 12 of sanguineous, 8 of bilious, and 2 of
nervous temperament.63 Once the cellular basis of pathology became more widely
understood after mid-century, the belief in a constitutional predisposition lost
ground. In 1889, Charles Egerton Jennings expressed a common view that cancer
begins locally and then invades the body, but that it grows plant-like in a congenial soil, some soils being more congenial than others for reasons not yet
understood.64
Even though an emphasis on cancers local origins did not necessarily undermine
the role of heredity as a predisposing cause, opinion drifted in that direction,
although the matter remained controversial.65 While St Bartholomews surgeon
and pathologist, Sir James Paget, maintained that a hereditary link could be found
in one of every three cases and was therefore highly significant, Herbert Snow,
surgeon to Londons Cancer Hospital, believed that because breast cancer most often
occurred where not the slightest evidence of inherited taint can be discovered,
59
For example, see A. Cooper, The Anatomy and Diseases of the Breast (Philadelphia, 1845), p. 10.
Moscucci, The Science of Woman, p. 103.
61
For example, J. C. Websters Diseases of Women: A Text-book for Students and Practitioners (London,
1898) contains no information on breast disease, and E. J.Tilts voluminous work, The Change of Life in
Health and Disease (Philadelphia, 1871) contains a single sentence on breast cancer, citing Galen and
Paget on the frequent occurrence of the disease between the ages of 40 and 50.
62
J. Austoker, The Treatment of Choice: Breast Surgery, 18601985, Bulletin of the Society for the
Social History of Medicine, 37 (1985), 1007, p. 101.
63
64
C. E. Jennings, Cancer and Its Complications (London, 1889), p. 54.
65
W. L. Rodman, Diseases of the Breast with Special Reference to Cancer (Philadelphia, 1908), p. 180.
60
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Patricia Jasen
there was no reason to accept the authority of exceptional outbreaks in mother

and daughter or in sisters.66 At the turn of the century, both William Rodman and
Roger Williams agreed that the tendency to dismiss heredity had gone much too
far, and Williams blamed the problem on misunderstandings about how heredity
worked. Both men asserted that what was passed from parent to child was not the
disease itself, but a predispositiona view not very different from what Everard
Home, for example, had believed a century earlier, even though the language of
the debate had changed. The disease, of course, is not inherited, wrote Rodman,
but the soil is prepared and made ready should the seed be sown at a time when
the epithelial tissues are prone to run wild.67
The emphasis upon the local genesis of cancer and the belief that it spread
outward in an orderly fashion favoured both heroic breast cancer surgery and the
attempt to reduce the risk of malignancy through the surgical treatment of benign
breast disease. Although the most famous exponent of the radical mastectomy was
William Stewart Halsted, this procedure, which included the removal of the
pectoral muscles and other adjacent tissues, was coming into use on both sides of
the Atlantic for some years before it became linked with his name.68 At the same
time, surgeons became more willing to deal aggressively with what they called
chronic mastitis, though they gradually recognized by the end of the century that
this term was apt to mislead by implying that there was only one kind of chronic
inflammation of the breast.69 Case histories provide abundant evidence of breasts
removed for multiple cysts, and many surgical texts instructed students in this
procedure. That a patients state of mind should influence surgical practice was
suggested by surgeons affiliated with Kings College Hospital, who advised that if
many cysts can be detected, and especially if the patient is anxious and worried
about herself, it is wise to remove the affected portion, or even better to excise the
whole breast, especially when there is a family history of breast cancer.70 The
American, Homer Ostrom, agreed that mental anxiety associated with the presence
of cysts could lead to serious nervous consequences, and cheerily reported that in
such cases the whole breast might be conveniently removed with Mr
Richardsons serrated scissors.71 Given surgeons growing enthusiasm for both
radical and prophylactic surgery, it is not surprising that many women turned to
alternative practitioners when faced with breast disease. Although their approaches
varied according to their particular philosophies, many of them still held firm to
66
H. Ostrom, A Treatise on the Breast and Its Surgical Diseases (Philadelphia, 1877), p. 119; H. Snow,
A Treatise, Practical and Theoretic on Cancers and the Cancer Process (London, 1893), p. 15.
67
R. Williams, A Monograph on Diseases of the Breast, Their Pathology and Treatment, with Special
Reference to Cancer, (London, 1894), pp. 2602; Rodman, Diseases of the Breast, pp. 1801.
68
Jennings, Cancer and Its Complications, p. 41.
69
C. B. Barrett Lockwood, Chronic Mastitis and Its Relation to Carcinoma, Lancet (29 January
1910), 2857, p. 285.
70
W. Rose and A. Careless, A Manual of Surgery for Students and Practitioners (Toronto, 1900), p. 829;
T. G. Roddick, Fifteen Cases of Tumour of Breast, Montreal General Hospital Reports, 1 (1880), 116,
p. 8; F. J. Shepherd, Some Rare Forms of Tumors of the Breast, Montreal Medical Journal (August,
1890); McGill Surgery: Embracing the Full Surgical Course of Lectures (Montreal, 1898), p. 233; R. W.
Garrett, Text Book of Medical and Surgical Gynaecology (Kingston, 1897), p. 387.
71
Ostrom, A Treatise on the Breast, p. 148.
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31
the view that cancer was a constitutional ailment which could often or always be
treated without surgery.72
The localist view of cancer also kept the emphasis on trauma in the foreground.
As in earlier decades, a blow to the breast was seen in some instances as predisposing a woman to cancer (that is, increasing her risk of disease in the future by
altering breast tissues), and, in other cases, as providing the exciting cause of a cancer
in an already vulnerable breast. There is ample evidence that patients continued to
rely on such explanations to make sense of their situation. Usher Parsons, professor
of anatomy and surgery at Brown University, observed that a woman typically may
suspect some mechanical injury, such as a blow against a chair or door, or the
pressure of her dress.73 This observation was repeated many times throughout the
century. Most medical men have been told the story from a mother of a child
kicking her in the breast, wrote Horace Manders in 1898. Another story has often
been told me when in Wiltshire, that the sufferer remembered leaning heavily with
her breast on the handle of a hay-rake, and that ever since then the breast had felt
more or less tender, until the time when a distinct swelling was noticed . . ..
Whether the subjacent tissues are weakened by irritation or blows, and therefore
cannot resist the invasion of the epithelial columns, we are not as yet in a position
to say.74 In light of the number of women who reported encounters with chairs,
doors, bedposts, and other household objects, the historian might wonderthough
never knowabout the role of family violence in producing such injuries. Roger
Williams, also writing in the 1890s, was unusual in declaring patients explanations
to be largely imaginary, but still allowed that blows might play a part in a long
train of antecedent preparation. He wrote I regard the relation of trauma to
cancerto borrow a Darwinian simileas resembling that of a spark in contact
with combustible matter, the result depending upon the nature of the latter, rather
than upon the spark itself.75
Chronic irritation was another factor which some surgeons repeatedly mentioned,
using language which often blurred distinctions between causation and risk. As
Sander Gilman notes, during the latter part of the century, the search for the specific
irritants linked to various cancers (such as pipes and oral cancer) was intensifying,76
and the long-term effects of wearing stays or corsets was often cited in surgical texts
in connection with breast disease. One striking example of the gulf between the
medical discourse on cancer and what was acceptable in polite Victorian society
was that the literature of dress reform remained silent on the subject of cancer
while blaming almost every other malady imaginable on the evils of tight lacing.77
72
See Dr Elliston, Cure of a True Cancer of the Female Breast with Mesmerism (London, 1848); J. Pattison,
Cancer: Its Nature and Successful and Comparatively Painless Treatment without the Usual Operation with the
Knife (London, 1866); D. Turnbull, The New Cancer Treatment (Cheltenham, 1876); P. S. Brown, Medically Qualified Naturopaths and the General Medical Council, Medical History, 35 (1991), 5077, pp. 645.
73
U. Parsons, Cancer of the Breast, in Boylston Prize Dissertations (Boston, 1839), 156.
74
H. Manders, The Ferment Treatment of Cancer and Tuberculosis (London, 1898), p. 235.
75
Williams, A Monograph on Diseases of the Breast, pp. 2967.
76
S. L. Gilman, Freud, Race and Gender (Princeton, 1993), p. 175.
77
For example, neither A. G. Woolson (ed.), Dress-Reform: A Series of Lectures delivered in Boston on
Dress and How it Affects the Health of Women (Boston, 1876), nor Dress and Health (Montreal, 1876),
contain any reference to breast cancer.
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In the 1880s, Willard Parker examined the case histories of 397 women who had
come under his care during his fifty-year career, and concluded that although the
damage done by the wearing of stays and tight dresses could not be precisely
known, it was likely an influence whenever no other record of trauma existed.78
When looking for the one factor that which might explain womens proclivity to
cancer in civilized society, Snow pointed to the fact that from girlhood they
enveloped their upper bodies in a rigid circular splint, thus emphasizing the
singular risk posed to women by their habit of dress.79 Surgeons had long suspected
that one risk factor could produce another, and Garretts Text Book of Medical and
Surgical Gynaecology (1897) proposed that chronic mastitisin his view often a
precursor to cancerwas sometimes set up by continued irritation of the
clothing.80
Opinion continued to be divided, meanwhile, about whether women who bore
children and nursed them were more susceptible to cancer than those who did not,
with no firm position on these questions being reached by the end of the century.
In 1839, Astley Cooper maintained that women who bore children were less liable
to cancer, and Walshe agreed in 1846 that it was probable that women who suckle
their offspring are less exposed to the risk of cancer of the breast than those who
consign the duty to others.81 But other surgeons reported cases where they believed
the link was irrefutable. Oliver Pemberton, a surgeon at the General Hospital in
Birmingham, described the history of A. S., age 36: In August 1856, one month
after her confinement, she suffered from milk abscess. This left a hardness in the
breast, above the nipple. In December 1857 after the birth of a second child and
whilst suckling, the hardness referred to grew into a tumour which ulcerated and
eventually caused her death.82 Willard Parker confirmed that in any individual, or
number of individuals, pregnancy and child-bearing increase the risk, and argued
that when barren women did contract cancer in disproportionate numbers, it was
only because some of the same disorders that prevented conception also promoted
breast cancer.83 Williams, meanwhile, reported that his data gave no proof that
suckling predisposes the cancer, but Rodman managed to claim that while there
was a direct, causative relationship . . . between the functional activity of the
[breast] and the occurrence of carcinoma, childlessness was risky for its own
reasons. Every surgeon, he wrote, had seen breast cancer in maiden ladies whose
sexual life had beyond doubt been absolutely negative. In such cases it would not
be illogical to infer that the organ assumes morbid activity to compensate for the
deprivation of normal function which it has sustained.84 Such an explanation was
compatible with a common Victorian belief that womens reproductive role was
78
W. Parker, Cancer: A Study of Three Hundred and Ninety-seven Cases of Cancer of the Female Breast
(New York, 1885), p. 11.
79
H. Snow, The Proclivity of Women to Cancerous Diseases (London, 1891), pp. 23, 37.
80
Garrett, Text Book of Medical and Surgical Gynaecology, p. 387; Rose and Careless, A Manual of
Surgery, p. 838.
81
82
O. Pemberton, Clinical Illustrations of Various Forms of Cancer (London, 1867), pp.1314.
83
Parker, Cancer, p. 22.
84
Williams, A Monograph on Diseases of the Breast, pp. 2878; Rodman, Diseases of the Breast, pp. 1812.
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33
inherently dangerous and that illness was womens natural statethat both obeying
and refusing natures dictates would bring women to grief.85
But most surgeons agreed that, where cancer was concerned, the most dangerous
period in a womans life cycle was the passage through menopause. Statistics
confirmed that breast cancer was far more common in women in their forties and
fifties than in younger women, and the fact that only a minority of women lived
to old age supported the belief that cancer took most of its victims around the time
of menopause.86 Parsons referred to these years as the cancerous period, when,
due to the sympathy between uterus and breast, the irregularity of menstruation
produces a most decided influence on the mammae.87 There was nothing new
about this observation, but a growing emphasis on womens proclivity to cancer at
this stage of life may have reflected a broader social agenda. During the latter half of
the nineteenth century, arguments aimed at limiting the sphere of women drew
increasingly upon ideas concerning their biological limitations, and the claim that
menopause was debilitating was heard more and more often.88 In this context,
breast cancer, as Leopold suggests, could be viewed as just one more symptom of
female decline.89 Conversely, the emphasis upon age as a risk factor could mean that
younger womens cancers would be missed; shortly after the turn of the century,
Rodman felt compelled to point out that mammary carcinoma is much more
common in young women than it is supposed to be.90
Breast disease was also viewed as one more manifestation of womens susceptibility to nerves. The association between emotions and the risk of cancer was
debated throughout the Victorian period, with more uncertainty expressed on the
issue at mid-century than was typical some years later. Walshe observed in 1846
that the connection in some cases was clear and decisive, but that the extent to
which this influence works practically has doubtless been over-estimated.91
Birkett similarly did not dismiss the danger posed by trouble and grief, but pointed
out, rather poignantly, that many women who have not a want, a care, a thought
but of enjoyment, are attacked with this fearful disorder; and it is only within the
last few months that I saw one of the worst forms of cancer in a lady who knew
no grief but in her disease, and wanted no enjoyment but that of which she was
deprived by the existence of the malady.92
By the 1860s, however, the question was being viewed in a new light. With the
rise of neurology, nervous disorders came to be regarded as diseases which had
their own somatic origins; similarly, many physical diseases were seen as resulting
85
On beliefs concerning the frailty of woman, see Mitchinson, The Nature of Their Bodies, pp. 4876;
Moscucci, The Science of Woman, pp. 10233; C. Russett, Sexual Science: The Victorian Construction of
Womanhood (Harvard, 1989), pp. 11625.
86
Walshe, The Nature and Treatment of Cancer, pp. 1501; Parker, Cancer, pp. 1011; T. W. Cooke,
Cancer: Its Allies and Counterfeits (London, 1865), pp. 223.
87
Parsons, Cancer of the Breast, p. 164.
88
See M. Lock, The Making of Menopause, in M. Lock (ed.), Encounters with Ageing: Mythologies
of Menopause in Japan and North America (Los Angeles, 1993), 30329.
89
Mitchinson, The Nature of Their Bodies, pp. 947; Leopold, A Darker Ribbon, p. 33.
90
Rodman, Diseases of the Breast, p. 177.
91
92
J. Birkett, Diseases of the Breast and Their Treatment (London, 1850), p. 219.
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Patricia Jasen
from a failure of nerve force. If the nervous system was now seen as governing all
of the chemical processes in the body, then, as the American neurologist, C. H.
Hughes, suggested, it was possible to propose a purely materialist theory of the
identity and interchangeability of the cancerous and neuropathic diatheses.93 In
other words, both neuroses and cancer could have their origins in the same
biological deficiency. Herbert Snow explained womens greater risk of cancer as
a function of their nervous debility. He wrote that women possess certain special
organs, rich in cells, which are always changing, and that process evinces a very
delicate adjustment and control, by a regulating nerve-machinery. When that
machinery malfunctions (as it so often does, women being by far the more
neurotic and emotional of the two sexes) cancer frequently develops, especially
during the period of involution.94 The association between breast disease, hysteria
and neurosis was commonplace in late nineteenth-century medical literature.
George Napheys, author of one of the few womens health manuals to mention
cancer, cited a celebrated teacher of obstetrics who insisted upon placing it among
the nervous diseases to which women are especially prone.95 Benign tumours in
young women were referred to by Garrett as neuroses of the breast, while other
authorities regarded such conditions, as well as periodic breast pain, as symptomatic of the hysterical or neurotic disposition.96 Clearly, the definition of hysteria
could comprise, as Bronfen says, whatever medical authorities chose to include.97
European and North American women were at risk of cancer because they were
nervous, but they were nervous, some surgeons argued, because they were living
in a highly civilized society. Walshe was among the first writers to make statistical
comparisons of cancer rates around the world. He concluded that cancer, like
insanity, follows in the wake of civilization, and others would join him in this
point of view during the latter part of the century.98 Rosenberg shows that,
although a highly civilized condition had become associated with the risk of nervous
disorders much earlier, only in the later Victorian period did this concern become
an obsession, as Social Darwinism focused attention on the perils of human
progress and the search for signs of racial degeneration. Modern life was artificial;
artifice implied deviation from design, and thus risk, says Rosenberg, and the
measure of the unnatural was the measure of that risk.99 As Susan Sontag observed,
93
C. H. Hughes, The Relationship of Nervous Depression to the Development of Cancer, St.
Louis Medical and Surgical Journal (1887), 2679, p. 267. And see E. Stainbrook, Psychosomatic
Medicine in the Nineteenth Century, Psychosomatic Medicine, 14 (1952), 21127.
94
Snow, The Proclivity of Women, p. 28; idem., A Treatise, p. 14.
95
G. Napheys, The Physical Life of Woman: Advice to the Maiden, Wife, and Mother (Toronto, 1871),
p. 43.
96
Garrett, Text Book of Medical and Surgical Gynaecology, p. 383; McGill Surgery, p. 233; Williams, A
Monograph on Diseases of the Breast, p. 565; Parker, Cancer, p. 43. Williams advocated treatment on the
Weir Mitchell principle, including complete change of surroundings for purely hysterical cases of
breast pain and fear of cancer. See also E. P. Fowler, Neurotic Tumors of the Breast, Medical Record,
37 (New York, 1890), 17982.
97
Bronfen, The Knotted Subject, p. 102.
98
Walshe, The Nature and Treatment of Cancer, p. 159. And see Williams, A Monograph on Diseases of
the Breast, pp. 24751; Snow, The Proclivity of Women, pp. 305; Parker, Cancer, pp. 515.
99
C. Rosenberg, Pathologies of Progress: The Idea of Civilization at Risk, Bulletin of the History of
Medicine, 72 (1998), 71430, p. 719.
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35
Victorians were thought to get cancer as the result of hyperactivity and hyperintensity, and, in Snows view, the alarming growth in cancer deaths was hardly
explicable upon any other grounds than those of the increasing severity of the
struggle for existence.100
Many surgeons commented on the rise in cancer rates and, as James Patterson
observes, blame was increasingly placed not just on stress but on luxurious habits
of life.101 Williams calculated in 1894 that, for women aged 35 and over, the rate
of cancer deaths had grown from one in ninety-one for the decennial period,
185160, to one in twelve for the period 18879. He cited eating too much and
exercising too little as factors which not only distinguished the cancer-prone
European from other races but the vulnerable middle and upper classes from those
below. The people most at risk of cancer are large, robust, well-nourished, florid
persons, he wrote Mr and Mrs John Bull . . . are the physical types of the majority
of cancer patients.102 Willard Parker took note of whether his breast cancer
patients were of full habit of body or otherwise, and related the frequency of the
disease among married women to their more luxurious lives.103 Mal-assimilation
or constipation was one of his concerns, and this was a factor also mentioned by
Snow. He went so far as to propose that the common statementLa femme est
une maladecould only be said of woman when she is placed amid the artificial
surroundings of civilization. Because so-called primitive women lived naturally,
he claimed, they did not experience constipation, over-pressure at school, or the
effects of neurotic substances such as tea; therefore, they gave birth with ease and
did not suffer from cancer.104 Such arguments had little merit, but serve as a
reminder that, during the Victorian era, breast cancer was still understood by some
surgeons as a disease with an environmental context.
IV
In 1939, a Canadian professor of surgery encapsulated his sense of the breasts proclivity to disease in the opening to a chapter in a text on the diagnosis of swellings.
Of all organs, he wrote, the breast most aptly merits the sobriquet of the living
museum specimen jar.105 During the first half of the twentieth century, the
discussion of cancer risk would move towards a closer emphasis on the natural
pathology of the breast and a de-emphasis on factors originating outside the body,
such as the dangers of civilization (still the focus of alternative practitioners)106 or
the impact of trauma. During this period, surgeons still authored a majority of the
works on breast cancer, but pathologists, endocrinologists, and radiologists also
100
S. Sontag, Illness as Metaphor (New York, 1978), p. 52; Snow, A Treatise, p. 37.
J. T. Patterson, The Dread Disease: Cancer and Modern American Life (Harvard, 1987), pp. 434.
102
Williams, A Monograph on Diseases of the Breast, pp. 279, 284.
103
Parker, Cancer, p. 25.
104
Snow, The Proclivity of Women, pp. 347.
105
C. E. Corrigan, The Clinical Diagnosis of Swellings (Baltimore, 1939), p. 221.
106
See J. Cope, Cancer: Civilization: Degeneration (London, 1932); A. E. Blackburn, Cancer:
Causation, Prevention, and Treatment (London, 1939); J. H. Hett, Cancer: Its Causes and Prevention and
New Treatment (Toronto, 1943); J. H. Young and R. E. McFadyen, The Koch Cancer Treatment,
Journal of the History of Medicine and Allied Sciences, 53 (1998), 25484.
101
36
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Patricia Jasen
published their findings. These usually contained a statistical component, although

the use of control groups in assessing the importance of various risk factors was
only gradually established. Collections of individual case histories, so common in
earlier centuries, were replaced by literature reviews and experimental results, and the
published record reflects a growing separation between the experience of clinicians
and the priorities of researchers. On the subject of trauma and cancer, for example,
Dr Laura Charleton Knox of New York City noted in 1935 that, although the
pathologist might easily dismiss any such correlation on statistical grounds, the
clinician on the other hand sees the dramatic aspect of the situation and might
easily reach a very different conclusion in the case of an individual patient.107
By the interwar period, the steady increase in cancer rates had inspired governments and those in the medical profession to declare a new war on cancer.108
Authorities undertook campaigns to educate the population through the use of
advertising and the efforts of public health nurses. As in any battle, victory had to
be anticipated, and the message they conveyed was that cancer could be defeated
through early detection. [O]nly neglected cancer is incurable, announced the
American Journal of Nursing in 1927, even if the general public insists in considering
cancer a hopeless condition.109 The dread disease was now out of the closet, and
by the 1930s mass circulation magazines were pointing to shame and silence as
womens greatest foes in the fight against breast cancer. But, as Leopold points out,
a sanitized image of cancer shifted responsibility to the victims and tended to blur
the distinction between detection and prevention.110 Women who die of breast
cancer die tragically and for nothing, scolded Ora Marshino in Hygeia, an organ of
the American Medical Association, in 1945. If a woman fails to watch for early
signs and act upon them, she has no one to blame for the consequences but
herself.111 The writings of surgeons and pathologists, meanwhile, seldom suggested
such facile optimism, but their now firm conviction that breast cancer began
locally and progressed outwardly according to an orderly pattern not only justified
their belief in radical mastectomy, but supported the notion that womens greatest
risk lay in the failure to be vigilant in detecting and reporting suspicious lumps.112
During the first half of the twentieth century, the belief that certain women
were at greater risk due to an hereditary predisposition became more firmly
established. There could be little doubt that women in some families were afflicted
to an extraordinary degree, and many studies included reports of mothers and
numerous daughters all suffering from the disease. The reason why this happened
was still unknown, but the language of the debate now included references to the
107
L. C. Knox, Trauma and Malignant Tumors, American Journal of Surgery, 26 (1935), 6678, p. 66.
On rising cancer rates, see Patterson, The Dread Disease, p. 102; B. Clow, The Problem of
Cancer: Negotiating Disease in Ontario, 192545 (unpublished Ph.D. thesis, University of Toronto,
1994), pp. 45; Leopold, A Darker Ribbon, p. 157.
109
I. Levin, The Cancer Problem and the Nurse, American Journal of Nursing, 27 (1927), 839,
pp. 867.
110
Leopold, A Darker Ribbon, pp. 15574; M. E. Black, What did Popular Womens Magazines
from 1929 to 1949 Say about Breast Cancer?, Cancer Nursing, 18 (1995), 2707, p. 275.
111
O. Marshino, Breast Cancer, Hygeia, 23 (1945), 1767, 2012, p. 177.
112
S. Hellman, Dogma and Inquisition in Medicine: Breast Cancer as a Case Study, Cancer, 71
(1993), 24303.
108
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37
developing field of genetics. Surgeon John Deaver and pathologist Joseph McFarland
dismissed older studies of heredity because they had been based upon the line of
direct inheritance and without regard to the laws discovered by Mendel, and Duncan
Fitzwilliams cautioned that, until the implications of Mendels doctrines were better
understood, it was difficult to say anything with certainty about heredity.113
Experiments conducted by Maude Skye on the breeding of cancer-free and cancerprone mice were widely cited and, by the 1930s, authorities G. L. Cheatle and Max
Cutler felt able to propose that the hereditary tendency was probably of a recessive
mendelian type.114 Growing confidence in the significance of heredity had some
implications for the management of risk in particular patients; for example, Deaver
and McFarland remarked that when there is a familial predisposition we are
justified in adding one link to our chain of suspicion that the individual in question
is suffering with cancer, and F. D. Saner confirmed that any woman with a relative
diagnosed with breast cancer should probably be on special guard.115
In the Victorian era, the growing understanding of the local origins of cancer
had supported the belief that trauma was one of its principle causes, but by the early
twentieth century this assumption was being questioned. Trauma was still included
in most discussions of risk, and certainly women continued to blame injury for
their breast cancersnearly 30 per cent did so in a study of 500 patients conducted
in London in the mid-1920s.116 But, as surgeons and others were increasingly
asking, what did this signify? One widely-used text on breast diseases pointed out
in 1917 that The literature is full of examples of tumors occurring after injury; the
life of every individual is full of injuries that are not followed by tumors.117 In
an effort to find clarity, many writers searched for ways of defining exactly how
an injury could give rise to a tumour and how it might predispose a patient by
producing abnormal conditions.118 Cheatle and Cutler argued in 1931 that, while
it was doubtful that normal cells could be changed, breasts may contain a primary
epithelial neoplasia of potential carcinoma within normal boundaries which the
traumatism may rupture and thus open the surrounding tissues to direct invasion.119
R. J. Behan of the Pittsburg Skin and Cancer Foundation wrote that it was so
common for women to injure their breasts going about their daily work that no
particular significance should be attached in many instances to the history of a
preceding trauma as given by the patient unless there was bruising, swelling, or
haematoma, and his view was increasingly shared by others.120
113
J. B. Deaver and J. McFarland, The Breast: Its Anomalies, Its Diseases, and their Treatment
(Philadelphia, 1917), p. 335; D. Fitzwilliams, On the Breast (London, 1924), pp. 3001.
114
Sir G. L. Cheatle and M. Cutler, Tumours of the Breast: Their Pathology, Symptoms, Diagnosis and
Treatment (New York, 1931), p. 28.
115
Deaver and McFarland, The Breast, p. 519; F. D. Saner (ed.), The Breast: Structure: Function:
Disease (Bristol, 1950), p. 173.
116
De Moulin, A Short History, p. 89.
117
Deaver and McFarland, The Breast, p. 337.
118
J. Ewing, Neoplastic Diseases: A Text-book on Tumors (Philadelphia, 1919), pp. 11012;
Fitzwilliams, On the Breast, pp. 3012; Cheatle and Cutler, Tumours of the Breast, p. 254; W. Boyd,
The Relation of Trauma to Cancer, The Canadian Nurse, 44 (1948), 6247, p. 624.
119
Cheatle and Cutler, Tumours of the Breast, p. 254.
120
R. J. Behan, Cancer: with Special Reference to Cancer of the Breast (St. Louis, 1938), p. 76.
38
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Patricia Jasen
It might be logical to assume that the theory of trauma lost favour simply because
clinical evidence did not support it, and yet other factors may have come into play.
For one thing, some surgeons appear to have gendered their understanding of
injury and breast cancer in concluding that the female breast could endure a good
deal more battering than the male breast without increasing the risk of cancer.
Behan reported that, in contrast to women, when men suffered from breast cancer
trauma is regarded by nearly all observers as a definite etiologic factor, and that
the injury need not even be severe for the causal connection to be drawn.121 More
influential, perhaps, in eventually limiting the importance of trauma as a risk factor
was the attempt to control its use in lawsuits. Samson Handleys account of the first
case in which the doctrine of traumatic carcinoma has been accepted in the
English High Courts illustrated the laypersons willingness to accept the role of
injury. The plaintiff was Mrs W., who had fallen over a beam on a building site
in November 1911, and developed cancer shortly thereafter. During the trial, the
defence pointed to other risk factorsher age, childlessness, and the state of her
breasts soon after the accidentin order to rule out any responsibility on the
builders part. The jury, nonetheless, found in favour of Mrs W., concluding that
the blow caused the disease, in the sense that it made a fair possibility a
certainty.122 The number of such cases would steadily increase. As Behan wrote in
1938, there is a great tendency at the present time for claims to be made and suits
to be entered on the flimsiest pretexts. Medical insurance writers, in particular,
recognized the importance of emphasizing certain factors over others, and in so
doing exercised some influence on the developing discourse of risk.123
A different kind of controversy attended the discussion of chronic irritation as a
risk factor during this era. Although some authorities still accepted that tight corsets
or ill-fitting brassieres could give rise to cancer,124 the term irritation increasingly
referred to problems originating within the breast itself, such as the effects of
abnormal lactation. There was still controversy over the benefits and dangers of
breastfeeding, but in 1931 Cheatle and Cutler could assert with confidence that
the old notion that carcinoma of the breast is decidedly more common in married
women has been demonstrated to be a statistical fallacy.125 A number of researchers
agreed that child-bearing and breastfeeding served as a direct protection against
breast cancer, but emphasized the dangers of faulty lactation, which included
serious infection, nursing for too long and the growing habit of early weaning.126
121
Ibid., pp. 779.

W. S. Handley, Cancer of the Breast and Its Treatment (London, 1922), pp. 3747.
123
Behan, Cancer, pp. 767; Deaver and McFarland, The Breast, p. 522; Ewing, Neoplastic Diseases,
pp. 1123; W. G. Barnard and A. H. T. Robb-Smith, Kettles Pathology of Tumours (London, 1945), p. 38.
124
J. Ewing, The Prevention of Cancer, in G. Pack and E. M. Livingston (eds.), Treatment of
Cancer and Allied Diseases (New York, 1940), 313, p. 7; B. J. Lee, Cancer of the Breast: The Sphere
of the Trained Nurse in Detecting it, American Journal of Nursing, 30 (1930), 9756; W. Bauer,
Cancer, MacLeans Magazine (1 May 1945), 1920, 234, p. 20; P. Morrell, Early Cancer Can Often
be Cured, Ladies Home Journal, 57 (1940), 12, 118, p. 118.
125
126
Ibid., pp. 2523; I. T. Nathanson, The Relationship of Hormones to Diseases of the Breast, in
Endocrinology of Neoplastic Diseases: A Symposium by Eighteen Authors (New York, 1947), 13978,
p. 161; Ewing, Neoplastic Diseases, p. 489; Behan, Cancer, p. 85.
122
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39
Far more attention was devoted to the dangers associated with inflammation
caused by chronic cystic mastitis. In 1919, surgeon James Ewing declared that this
condition was by far the most important element in tissue predisposition, and
many researchers agreed.127 The discussion over the level of risk implied was similar
to the debate over fibrocystic breast disease in our own time. Behan regarded it
as potentially, very dangerouseven a precancerous lesion, while Duncan
Fitzwilliams viewed that popular notion as an exaggeration.128 While sometimes
recognizing that the criteria used to define the condition affected their results,
researchers attempted to calculate more precisely the danger posed by chronic cystic
mastitis, with estimates in the 1940s ranging as high as a twelve-fold increase in
risk.129 By that time, however, some studies were proposing that perhaps most
types of the condition were not precancerous, while others stressed the importance
of individual risk profilesperhaps some people cannot handle the hyperplasias
which to others seem controllable and innocuous, suggested one endocrinologist.130
In contrast to earlier periods, almost nothing was said about how chronic mastitis
might be prevented or relieved, although, in an article on the prevention of cancer
published in 1940, Ewing warned that a systematic scheme for the hygiene of the
breast is urgently called for. In a manner unusual for his time and profession, he
also pointed out the risks posed to women by closer surveillance, cautioning his
colleagues to be conservative. He observed that, due to the publicity cancer had
received, more women were coming forward with breast lumps, and more were
undergoing diagnostic surgery. The time is past, he wrote pointedly, if somewhat
hyperbolically, when every suspicious precancerous lesion should lead to radical
mastectomy.131
The assumption that oestrogen played a part in producing both chronic mastitis
and breast cancer also became part of the discussion of risk in the first half of
the twentieth century. Experiments in the 1920s showed that tumours could be
produced in male mice implanted with ovaries, and during the same decade, Janet
Elizabeth Lane Claypon, who conducted the first study of breast cancer to include
both a large group of patients and a control group of healthy women, showed that
lifetime exposure to oestrogen was a significant factor. Her conclusions confirmed
the growing consensus that those who had fewer children, who breastfed less, and
who had a longer menstrual life were at greater risk, and her research was cited
repeatedly during the 1930s and 1940s.132 The dangers of menopause loomed large
in all studies, but Cheatle and Cutlerechoing Rodmans earlier concern about
missed cancers in younger womenreminded fellow practitioners that statistical
evidence is of little value in the interpretation of any given case.133 To some writers,
127
Ewing, Neoplastic Diseases, p. 490.

Behan, Cancer, p. 69; Fitzwilliams, On the Breast, p. 302.
129
C. F. Geschickter, Diseases of the Breast: Diagnosis, Pathology, Treatment (Philadelphia, 1943), p. 401;
L. V. Ackerman and J. del Regato, Cancer: Diagnosis, Treatment, and Prognosis (St. Louis, 1947), pp. 9289.
130
Nathanson, The Relationship of Hormones to Diseases of the Breast, p. 162.
131
Ewing, The Prevention of Cancer, pp. 67.
132
Austoker, A History of the Imperial Cancer Research Fund, pp. 99100; De Moulin, A Short History,
pp. 8990.
133
128
40
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Patricia Jasen
late menopause was so hazardous that it should be prevented for women at risk,
and Behan cited one study which recommended that women with cystic mastitis
(or who were otherwise predisposed to cancer) undergo artificial prophylactic
menopause at the age of forty-eight or fifty years by means of x-ray.134 At the same
time, however, women were urged to undergo hormone therapy to deal with the
symptoms of menopause which could threaten youthful femininity and endanger
their marriages. The Canadian Home Journal advised women that, when you feel
your whole life getting out of focus, you probably need a shot or a pill. Ask your
doctor and follow his advice.135 In the 1940s, research into whether the clinical
use of oestrogen might contribute to breast cancer was still in its infancy.136
One factor which virtually disappeared from mainstream medical literature during
this period was the relationship between emotions and the risk of cancer. When
the link re-emerged at mid-century, it was cast in crudely Freudian terms which
further emphasized womens inherent vulnerability to disease. As outlined above,
the reductionism of late nineteenth-century neurology had regarded nervous
complaints as somatic and originating in the same biological processes as cancer and
other diseases. With the growth of psychoanalysis, however, neuroses were once
again seen as originating in the mind and were attributed to the individuals life
experiences and thwarted sexual drives. Regular physicians and surgeons regarded
this area of medicine as beyond their purview and were typically dismissive of the
powers of the mind as they affected health; as Rosenberg says, it is not surprising
that the term psychosomatic and the interests it stood for could seem . . . novel and
reformist in the late 1930s and 1940s.137 Pioneers in the new field of psychosomatic medicine included Felix Deutsch and Georg Groddeck in Germany, and
Franz Alexander and Helen Flanders Dunbar in the United States. Alexander, in
particular, became associated with a new reductionism which held that specific
emotional conflicts could be related to specific organ systems.138
Psychosomatic medicine paid little attention to cancer during these decades, but
on the fringes of the movement there were exceptions. Elida Evans was a Jungian
therapist whose work with nervous patients and cancer over a period of 15
years was published, in 1926, in A Psychological Study of Cancer. In this book, she
developed her theory of how emotional loss contributed to cancer risk. She was
convinced that those who succumb to the disease are absolutely in the power of
the collective unconscious; they have lost their individuality yet have a strong,
unyielding personality. In her experience, they were always extroverts, by which
she meant that they were entirely dependent upon others to meet their vital needs
and typically had suffered the loss of an emotional relationship which left them
with no outlet for their psychic energy or libido. How helpless is a person with an
unattached libido, and what a menace to himself, she wrote. Of course, Evans did
134
Behan, Cancer, p. 44.

F. Brento, Womans Dangerous Years, Canadian Home Journal (August 1943), pp. 1011, 50.
136
Ackerman and del Regato, Cancer, p. 928.
137
138
F. G. Alexander and S. T. Selesnick, The History of Psychiatry: An Evaluation of Psychiatric Thought
from Prehistoric Times to the Present (London, 1967), pp. 3925.
135
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41
not use the term libido in a primarily sexual sense; rather, she defined it as a
current of interest, pleasure, or affection. Its frustration in women was often related
to disappointments in marriage and motherhood, and cancer so often occurred in
the breast, she believed, because it was the seat of longings for maternity which
went unsatisfied.139 In the decades that followed, Wilhelm Reich gained far more
notoriety with his work on The Cancer Biopathy, which attributed cancer directly
to sexual dysfunction and especially chronic orgastic impotence in women.
Dissatisfied with the notion of a cancer disposition, he held that the degenerative
diseases are biopathiesthat is, pathological developments in the biological
process.140 Anxiety produced a crawling back into the self and a chronic tension
around certain glands which produced organic disease. In his view, the sexual
inhibition so often found in women is responsible for the prevalence of breast and
genital cancer.141
The American psychosomatic movement ignored Evans for 25 years and
distanced itself from Reich, and its journal, Psychosomatic Medicine, did not publish
any research on women and cancer until the middle of the century. At that time, a
series of articles began to appear which signalled a renewed interest in the link
between emotions and cancer risk, and which demonstrated the influence of the
conservatism and anti-feminism evident in post-war culture generally and in the
literature of psychoanalysis.142 For example, both Helene Deutschs work on
feminine masochism and Therese Benedeks theories on what constituted normal,
hormonally-determined feminine behaviour were often cited in early studies of
personality and breast cancer. In contrast to late nineteenth-century writings, this
research portrayed the cancer patient not as the over-taxed victim of civilized life
nor as the hysteric in need of a rest cure, but as the repressed and helpless victim of
an unhappy past whose deviation from normal female behaviour signalled her
vulnerability to the disease. The first study of this kind used Rorschach test responses
to determine personality differences between eleven breast cancer patients and
eleven women with cervical cancer. It reported that all of the subjects tended to
have dominant mothers and negative feelings towards sex, but found that, of the
two groups, those with breast cancer were much less willing to accept their inner
drives.143
This approach began to attract some interest within the medical mainstream,
and a study of forty breast cancer patients conducted by surgeon Max Cutler and
others at the Chicago Tumor Institute (clearly influenced by Alexander) demonstrated just how seductive it could be. Although these researchers claimed to have
avoided creating a cancer character, they concluded that the outstanding traits of
139
E. Evans, The Psychology of Cancer (New York, 1926), pp. 4052, 71, 1935.
W. E. Mann, Orgone, Reich and Eros: Wilhelm Reichs Theory of Life Energy (New York, 1973),
pp. 1935.
141
W. Reich, The Cancer Biopathy (New York, 1973), pp. 1568.
142
On anti-feminism and psychoanalysis during this period, see M. J. Buhle, Feminism and Its
Discontents: A Century of Struggle with Psychoanalysis (Cambridge, MA, 1998), pp. 165205.
143
M. Tarlau and I. Smalheiser, Personality Patterns in Patients with Malignant Tumors of the
Breast and Cervix, Psychosomatic Medicine, 13 (1951), 11721. A similar study was conducted in 1955
using a control group. See J. I. Wheeler, Jr. and B. M. Caldwell, Psychological Evaluation of Women
with Cancer of the Breast and of the Cervix, Psychosomatic Medicine, 17 (1955), 25668.
140
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Patricia Jasen
the woman with breast cancer were the masochistic character structure, inhibited
sexuality, excessive pleasantness and the inability to express anger, unresolved
conflict with the mother, and delay in getting treatment. We believe we have
developed a feeling for a malignant history, they wrote, and in their clinical
work they applied this new strategy to the assessment of individual risk. They
reported having detected a number of benign tumors in this manner, and to have
become more cautiously observant with several of our cystic patients possessed of a
borderline malignant psychiatric history.144 Subsequent studies were equally insistent that womens sexual and maternal experiences were an important influence in
the development of breast cancer. In the 1950s, the association between emotions
and cancer was a flourishing new area of cancer research, one which mirrored
conventional expectations concerning womens natural functions and desires.
V
This article has shown that the language of risk has been influencing the
understanding and treatment of breast cancer over a longer period of time than is
usually considered. By modern epidemiological standards, the discussion of risk in
the eighteenth, nineteenth, and early twentieth centuries was imprecise and inadequately distinguished from the language of causation. But as modern researchers
begin to recognize that present-day clinical and lay interpretations of risk are
characterized by some of the same ambiguities, and as they work towards widening
our understanding of risk and the contexts in which it is constructed, parallels with
past experience become more evident. An historical approach to risk can highlight
the way that certain problems are discovered and rediscovered over time; for
example, it was recognized at least a century ago that the risk factor approach may
jeopardize the lives of women defined as low risk, such as young women, if their
symptoms are not taken seriouslyan issue which is still current today. In addition,
the history of risk illustrates how an apparently objective concept is influenced by
cultural factors, not least, in the case of breast cancer, by definitions of femininity
and images of the female body. The recurring interest in the association between
mental states and breast cancer risk also provides a clear illustration of how the same
medical questions may be construed in vastly different ways in the light of contemporary beliefs about gender, the mind, the body, and personal responsibility for
illness.145 Finally, the historical record, scant as it is, shows that women throughout
this period had their own understandings of risk, not only in relation to the hazards
of medical treatment but with respect to their vulnerability to the disease. Those
who had suffered injury, who had difficulty nursing, or who had lost a mother to
breast cancer were sometimes haunted by the fear that their chances of developing
144
C. L. Bacon, R. Renneker, and M. Cutler, A Psychosomatic Survey of Cancer of the Breast,
Psychosomatic Medicine, 14 (1952), 45360. M. Reznikoff, an American Cancer Society Research
Fellow at Yale, narrowed his focus to maternal experiences and heterosexual relations, the two areas
in which the breast would have primary psychological meaning. See Psychological Factors in Breast
Cancer, Psychosomatic Medicine, 17 (1955), 96108.
145
See J. Stacey, Teratologies: A Cultural Study of Cancer (London, 1997), pp. 448, 11723, and
passim.
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43
the disease were now greater. For them, as for many women today, the idea of
being at risk became incorporated into their understandings of their bodies and
their lives.
Acknowledgements
For their assistance during the preparation of this article, I would like to thank Vera
Fast, Kimberley Hagarty, Frederick Holmes, Eileen OConnor, Scott Sellick,
Gillian Siddall, Helen Smith, and Pamela Wakewich; the librarians and archivists at
the University of Minnesotas Owen H. Wangensteen Historical Library of
Biology and Medicine, the Osler Library of the History of Medicine at McGill
University, and the Inter-library Loan Department at Lakehead University; and
the editors and anonymous reviewers of Social History of Medicine. Research
funding was provided by the Social Sciences and Humanities Research Council of
Canada.
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Breast Cancer and the Language of Risk, 17501950

S U M M A R Y . The language of risk, in relation to disease, is usually viewed as having developed

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from a modern epidemiological standpoint, risk refers to the estimated excess

Becker and Nachtgall, Born to be a Mother, p. 507.

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with lactation, a stoppage of menstruation and the onset of menopause, an exposure

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Walshe, The Nature and Treatment of Cancer, p. 152.

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Breast Cancer and the Language of Risk, 17501950

Rosenberg, Body and Mind in Nineteenth-century Medicine, p. 77.

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violence through accident or malevolence. Although such revelations were

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Breast Cancer and the Language of Risk, 17501950

Home, Observations on Cancer, p. 151.

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De Moulin, A Short History, pp. 5771.

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Breast Cancer and the Language of Risk, 17501950

among doctors themselves. Although surgeons continued to comment upon the

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there was no reason to accept the authority of exceptional outbreaks in mother

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Breast Cancer and the Language of Risk, 17501950

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Breast Cancer and the Language of Risk, 17501950

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Breast Cancer and the Language of Risk, 17501950

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published their findings. These usually contained a statistical component, although

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Breast Cancer and the Language of Risk, 17501950

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Ibid., pp. 779.

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Breast Cancer and the Language of Risk, 17501950

Ewing, Neoplastic Diseases, p. 490.

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Behan, Cancer, p. 44.

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Breast Cancer and the Language of Risk, 17501950

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Breast Cancer and the Language of Risk, 17501950

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