The Left Atrium · De l'Oreille Gauche

CMAJ 2000;162:1021-4

• A social history of breast cancer
• Pain and pathos in Mexican art
• Damocles

A darker ribbon: breast cancer, women and their doctors in the twentieth century
Ellen Leopold
Beacon Press, Boston; 1999
334 pp. US$27.50 (cloth) ISBN 0-8070-6512-9

Mueller could not thank Halsted enough for his attention. "I want to thank you for your deep interest in my welfare as it is indeed flattering to know that I am still in your mind," she wrote to him in 1920. "However I want to assure you that I shall always feel the deepest gratitude to you for the wonderful success you achieved in my operation." Eighteen months later, after more than a year of intense suffering, Mueller was dead. Halsted's "wonderful success" notwithstanding, the cancer had metastasized into her bones and brain.

Despite the evidence of numerous cases like Mueller's, radical mastectomy continued to be the only treatment for breast cancer throughout most of the 20th century. As surgeons became more discriminating about which patients might benefit from mastectomies, survival rates improved. Yet these operations never offered better than 50–50 odds for recovery. Clinicians did not understand why the operation sometimes worked and sometimes didn't. Nevertheless, mastectomies were the closest thing that medicine had to a "cure" for a disease shrouded in taboos. Thanks to the power of inertia, and the disease's low status in the hierarchy of medical concerns, the one-size-fits-all surgical approach to breast cancer continued to hold sway well into the 1960s. This meant that breast cancer continued to be regarded as a local rather than systemic disease.

Ellen Leopold is a member of the Women's Community Cancer Project in Cambridge, Mass., and has written about medical issues for The Nation, the Chicago Tribune and Self magazine. A Darker Ribbon, her first book, is a social history of breast cancer. It is a highly readable, original contribution to an overcrowded field. Books about breast cancer fall into three categories: medical texts that deal with the disease, not the woman; personal narratives written by breast cancer survivors; and self-help manuals. Almost all of these books display a complete disregard for the issues Leopold covers: the determining influences of society and culture.

"How is it," asks Leopold, "that a subject so utterly taboo, for so long, has become so commonplace so quickly, taking up residence in every cultural medium, from soap operas to sculpture?" The author traces the evolution of attitudes toward and treatments of breast cancer within the context of broader changes in society, particularly the rise of feminism and the women's health movement. She argues that early 20th-century campaigns to promote breast self-examination and today's obsession with diet and lifestyle share a disturbing goal: to condition women to believe they alone are responsible for their cancers.

Leopold writes as a feminist and a breast cancer survivor. But her book is no polemic: she is far too intelligent a researcher to wrench context. At the core of her book are two fascinating, unpublished correspondences that illustrate the gradual pace of change in the breast cancer field. The first comprises the letters of Barbara Mueller and Professor Halsted. The second features the correspondence between Rachel Carson, the acclaimed ecologist who wrote Silent Spring whilst in the final stages of breast cancer, and her physician and friend Dr. George Crile, Jr.

Few women diagnosed with breast cancer in 1960 were more aware than Rachel Carson of the controversies surrounding both the causes of cancer and its treatments. While researching Silent Spring she had looked at evidence of cell damage caused by industrial and agricultural chemicals. She was a scientist herself, and would not be intimidated by doctors. "As you know," she wrote to Crile in March 1961, "I'm not an especially tractable patient, and don't just go along with such things without doing some inquiring and thinking on my own."

In Carson, the disease followed a painful trajectory. She resisted a mastectomy. The cancer metastasized into her bones; a bombardment of radiation and treatment with hormones and the unproven anticancer drug Krebiozen could neither slow Carson's decline nor alleviate her pain. Yet, until a few weeks before her death in 1964, she insisted on being a fully-informed partner in her health care, in a way unthinkable 50 years earlier for Mueller. Nevertheless, like Mueller, Carson regarded her experience of breast cancer as a private affair. She shared her history with only a few intimate friends. A conspiracy of silence continued to envelop breast cancer, although the percentage of sufferers was rising steadily.

As the 21st century dawns, medical science has still not triumphed over breast cancer as it has over smallpox and polio. However, in the years since Carson's death, we have come to understand that it is not simply one invariant fatal malignancy, but a complex taxonomy of diseases. Women (and men) with breast cancer are now seen as medical consumers rather than the helpless victims of a killer. The disease has finally been liberated from taboos and inhibitions (until the 1990s, it was never mentioned in obituaries.) Yet breast cancer is still seen as an issue of corporate accountability through the control of toxic substances.

A Darker Ribbon not only gives readers an uncompromising and unsentimental view of breast cancer. It also explores why it took so long for both physicians and patients to come to grips with the disease. It is a book that anyone with a personal or professional interest in breast cancer will find not only illuminating but also enjoyable as social history and cultural analysis.

Charlotte Gray

A CMAJ Contributing Editor, Ms. Gray is writing the biography of E. Pauline Johnson, the Mohawk poet who died of breast cancer in 1913.

[Contents]

What insight, what emotional understanding, can medicine gain from the artistic expression of physical or mental suffering? Several works in Mexican Modern Art 1900–1950, a groundbreaking exhibition now on view at the National Gallery of Canada, pose this question. Most notably, the intensely personal paintings of Frida Kahlo (1907–1954), Mexico's ambassador of art, shout out not only the agony she endured as a result of polio and, later, of a bizarre accident, but also the emotional turmoil of her life. The intricately wrought and disturbing canvases of her lesser-known contemporary, Manuel González Serrano (1917–1960), express the precarious mental state that resulted from bouts of depression and the guilt of religious doubt.

Frida Kahlo, Self-portrait with Thorn Necklace and Hummingbird (1940). Oil on canvas, 62 × 47 cm. Harry Ransom Humanities Research Center, University of Texas at Austin

Kahlo placed her pain front and centre in her art. Exposed bones and organs, and medical aids such as the corsets she wore to support her spine, are recurring motifs.¹ Polio at age six caused permanent disability to her right leg, which later became gangrenous and had to be amputated. And, in a horrific bus accident at age 18, she was impaled on a metal rod from her left hip through to her genitals, suffering, in addition to extensive soft-tissue injuries, fractures of the third and fourth lumbar vertebrae, pelvis, and right foot, and dislocation of the left elbow. Years of her life were spent in bed in unspeakable pain as she tried to recover from a succession of spine fusions and other procedures. A mirror attached to the canopy of her bed and a special easel enabled her to paint in the prone position. In the self-portraits that resulted, her intense and apparently calm countenance belies her inner anguish.

The Ottawa exhibit features what Luis-Martín Lozano, guest curator from Mexico City, considers Kahlo's four best self-portraits, in addition to a depiction of a friend's suicide and two still lifes. For Lozano, Self-portrait with Thorn Necklace and Hummingbird shows Kahlo at her most artistically mature. She uses Christian (thorn necklace) and native (hummingbird) imagery to express the pain of divorcing her husband, the renowed muralist Diego Rivera (whom she remarried later that year). The seemingly placid image is about to erupt into violence. The hummingbird, a Mexican love charm, is in the throes of death after pecking at Kahlo's chest, causing the thorns to pierce her skin. The cat, perched on her left shoulder, is about to leap on the bird. When that happens, the pet monkey, for Kahlo a symbol of domesticity, will no doubt leap into the fray.

González Serrano's work speaks to a different pain — that of debilitating depressive illness. He died while undergoing a lobotomy that was intended to relieve his mental suffering. The painting entitled Equilibrium expresses the delicate balance of his life. The board that supports the broken pot and cannibalistic-looking flowers is held by two unravelling threads. In what is perhaps a representation of modern life, everything — including the marbles — will soon be lost in an abyss of geometric patterns. A related painting, Self-portrait at Three Ages, shows the same precariousness, but this time a board supports a three-sided death mask, eyes empty but crying, mouth open in horror, while butterflies and the tendrils of plants emerge from the top: pain and life at the same moment.

Manuel González Serrano, Equilibrium (c.1944). Oil on cardboard, 56 × 30 cm. Andrés Blaisten Collection.

With 270 works by 50 artists, this exhibition is remarkable in its expanded chronology of contemporary Mexican art and is enriched by the inclusion of prints, photographs and mural sketches. An ideal antidote to rainy spring days, it delivers sunshine and colour, plot and pathos, drama and dissertation. Mexican Modern Art is on view Wednesdays through Sundays until May 17 at the National Gallery in Ottawa.

Reference

1. Zamora M. Frida Kahlo: the brush of anguish. San Francisco: Chronicle Books; 1990.

Barbara Sibbald
Associate Editor, News and Features

[Contents]

Dionysius the Elder invited Damocles to a sumptuous banquet to dramatically demonstrate the insecure nature of grandeur and happiness. Damocles was thoroughly enjoying the banquet until he was asked to look upward. There above his head, hanging motionless by a single horsehair, was a razor-sharp sword.

Hesitantly, he closed the car door and walked up the driveway. I noticed that his beard and moustache were grizzled, but otherwise Jack Weber looked just as he had 30 years ago.

Bev and I had met Jack and Cathy Weber as far west as you can go in this country and 40 miles farther. We were drawn to the Queen Charlotte Islands to cut our teeth in our brand-new careers and marriages. We worked with Cathy at the hospital, and it wasn't long before I got to know Jack, who was grading logs for one of the lumber companies. We were isolated, far from home, and the Webers became like family to us. We shared the newness, the adventure: fishing, beachcombing, getting lost in the great Sitka forest. One overcast day toward the end of spring, Jack and I hiked through the rainforest to explore the elk barrens, the home long ago of early settlers. At the edge of the barrens we found an old log cabin. Most of the shingles had blown from the roof, the chimney was precariously askew, the verandah had collapsed at one end, and the once robust cedar logs had begun to come apart. Suddenly we heard a strange trumpeting, and from the fringe of the forest a great white bird magestically emerged and then slowly disappeared into the mist. We watched in awe.

It was to be our last outing on the Charlottes. That summer Bev and I returned to the east. The Webers remained for a time and then moved to the mainland. We kept in touch with fitful Christmas cards that chronicled the happy and sometimes sad milestones of our lives.

Jack had always wanted to visit the east coast and when he had a chance to attend a conference in a neighbouring province he took it. We welcomed Jack and introduced him to our youngest daughter, who gave him a hug and made him feel right at home with her friendly chatter. Soon we were recounting fish stories over a cup of tea, but I couldn't help noticing how restless Jack was on the couch. He seemed uncomfortable.

"It was a long drive," I remarked. "Is your back bothering you?"

"No, my back is fine."

Later, in the kitchen, Jack was talking about grading cedars before transporting them to the mainland. Suddenly he was on the floor. He had slipped. The transition in his sock feet had been so smooth that not a drop spilled from his teacup. He sat there for a moment with just a hint of embarrassment, declined my help, and slowly, awkwardly, stood up.

"Where was I? Oh yes, red cedar."

The next morning was a bright end-of-summer day. We opted to head down the coast. Along the way I talked about the fishing villages and how the glaciers had affected the terrain.

Jack was looking out the car window at stunted, wind-sculptured spruce trees when he said, "Cathy left me two years ago. We had some counselling but it seemed she had made up her mind. There was nothing I could do."

I was still putting a sentence together in my mind, some kind of appropriate response, when he continued.

"It's been really difficult the last few years. My older brother had a successful business, then all of a sudden he started making very bad decisions. He lost everything. His behaviour became progressively more disturbed, and he had to be committed, just like our mother years ago. That's when they did the genetic testing on him. Then the other six children in the family got tested. Only my sister and I asked for the results. She was negative, I am positive."

The Huntington's disease (HD) gene, IT15, is on the short arm of chromosome 4. The RNA transcribed from the HD gene can be found in all organs of an affected person, and codes for a protein called "huntingtin."

The road to the ocean led down through a cranberry bog to a fishing village. Brightly coloured houses were strewn over the barren landscape, some nestled in the lee of huge granite boulders, others jauntily perched on the rocky ground, exposed to all the beauty and fury of the north Atlantic. We drove in silence to the end of the road and parked the car. In the distance the seagulls were wheeling and diving near some fishermen who were transferring mackerel to an offshore cage. The salt air was invigorating. Jack slowly got out of the car, marvelling at the enormous smooth granite headland. Nuggets of mica danced in the rock, the tidal pools shimmered, and the ocean swells surged up beneath brown ribbons of slippery kelp, sending spray over the bald rock. Jack moved tentatively out over the granite toward the water and I followed.

The neural damage in HD proceeds from the caudate to the putamen, resulting in damage to frontocaudal and frontolimbic circuits. HD is classified as a neurologic condition characterized by chorea, dystonia, athetosis, bradykinesia, dysarthria, dysphagia and urinary incontinence. Psychiatric manifestations include mood changes, anxiety, psychosis, personality changes and aggressive behaviour.

The rock surface was uneven with crevices and sheer faces. Moving across it amounted to horizontal rock climbing. We moved obliquely toward the ocean and the sign bolted securely to the rock: danger! do not go beyond this point. The warning was not to be taken lightly. In the past year a young couple strayed beyond the sign when the seas were running high. A moment's inattention, a rogue wave, and they were gone.

Jack was out in front of me, heading toward the receding waves.

"Jack! It's dangerous down there!"

He disappeared behind a ridge of granite.

Death in HD is caused by cardiac and pulmonary complications, suicide and self-destructive behaviours.

I scrambled around the far side of the ridge. There was Jack — waiting for me, camera in hand, ready to immortalize my consternation and the majestic white lighthouse looming behind me.

That day we dined on fish chowder and lobster rolls, explored the cove, the fish sheds and the wharves, whose pilings were festooned with barnacles and mussels and rhythmical seaweed. Jack talked to the fishermen and found a shop that sold old glass floats reminiscent of our beachcombing days. Toward the end of the afternoon a piper began playing near the lighthouse. Jack was mesmerized, and at the end of her set he talked to the piper about Celtic music and where in the province he could go to hear the best.

The next morning Jack headed out after breakfast, travelling farther east. He returned in three days, full of stories about ceilidhs, amazing fiddlers and virtuoso spoon players. He had not attended the conference on Huntington's disease. "There will be another one," he said.

That spring our youngest daughter graduated from high school. She received a card from Jack. The handwriting was resolute. He thanked her for her smiles, her joy, her acceptance of a stranger. He wrote: "May the Lord bless you as you begin your new life."

Ian A. Cameron, MD
Department of Family Medicine
Dalhousie University, Halifax

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