George Rousseau
Oxford University

Women presenting with lumps in their breasts (their “mammas”) in Jane Austen’s England would have found their doctors responsive to many of the concerns of British women today: whether or not to operate, how soon, and whether to elect (what we now call) lumpectomy or full mastectomy; how to decide among competing therapies; whether to manage the condition oneself as primary agent or entrust its management to someone else; the cost of treatment and its likelihood of success; finally, firsthand observation of, and often dismay at, the feverish quarrels of their doctors. The difference then, in addition to the obvious anesthetics and surgical gadgetry, was causation: most Georgian doctors believed the origin of breast cancer to be an accident or injury, including the friction and pressure of stays. As Scottish surgeon James Hill put it in 1772, “by far the greatest part of cancers are local, occasioned by some accidental hurt.”[1] Others dissented, such as the socially notorious but intellectually polymathic figure John Hill, who considered cancers in 1770—including breast cancer—to be “diseases in the blood, which will appear in one place after another.”[2] Hill meant metastasis throughout the body.

A generation earlier, when the first readers of Samuel Richardson’s Pamela (1740) and Clarissa (1748) were turning the pages of these remarkable fictions, responses would have differed: not merely the causes and diagnoses but the remedies, most British “doctors” (a catchall term for apothecaries, surgeons, as well as qualified physicians who had been licensed by the College of Physicians) having been educated to think that cancer had a low profile. Flash back a further two decades from the 1740s to the 1720s and to the first readers of Daniel Defoe’s Robinson Crusoe (1719) and Jonathan Swift’s Gulliver’s Travels (1724) and to the medical practitioners to whom these female readers presented, and you find the medical profession adopting a wide variety of approaches to cancer—empirical, mechanical, rational, irrational, magical, superstitious, etc.—an array that had disappeared by century’s end. What spurred this monumental change?

The transformation in the understanding of cancer occurred in the final quarter of the eighteenth century as various trends converged—in medical education, the growth of hospitals, the technology of print, routine publication by physicians of their notes as “case histories,” and, most noteworthy, widespread interest in the diseases of women—to crystallize this developing condition. Indeed, late Georgian doctors illuminated breast cancer more clearly than ever before. A rigorous statistical analysis of medical publications in English (and probably in other European languages too) that were limited to cancer would confirm to what degree medical practitioners augmented their knowledge after approximately 1770. So dramatically that, a generation later, in 1811, when Austen published Sense and Sensibility, which contains no cancer but is permeated with the spectrum of passions then judged to give rise to cancer, a new understanding had been forged; one where mind and body played a more nuanced role in its etiology than had been considered possible a century earlier. A cancer diagnosis whose therapies were lengthening life more robustly than had been imagined in the world of Henry Fielding and Richardson, let alone Joseph Addison and Defoe.

Yet cancer, even chimney-sweeper’s cancer, in Austen’s milieu was statistically far less common or more rarely diagnosed than consumption, that broad disease cluster embracing all wasting-away conditions, not merely (what we label) tuberculosis, phthisis, asthma, and related respiratory ailments, but most ailments of bodily organs (heart, liver, kidneys, gut) resulting in deterioration and death. Consumption—again for context and comparison—then often included a wide range of cancers, and was perceived in the popular imagination as the great leveler of mankind. The pox was disfiguring, malaria and typhoid deadly, dysentery uncomfortable, epidemic ailments and communal malady life-threatening, as were other diseases caused by poor hygiene. William Buchan’s popular Domestic Medicine (1769, often reprinted) lists dozens of medical conditions among which cancer was seen as both excruciating and shaming—this was its difference—yet no reliable information exists about its per capita rates. Less than a decade after Austen published Sense and Sensibility, cholera would be introduced to England (in 1817), potentially a greater threat to the population than consumption. Context and comparison do not explain everything, of course, but provide a sturdy cultural frame in which to situate what was seen as a terrifying female malady.

If breast cancer was gender based, it was also class specific and age related (numbers of young women under the age of forty were reported to have contracted it). Surgery was the main therapy, and as the century progressed, the knife increasingly became the pathway of choice, which significantly elevated its psychological profile—so great was fear of excavation in an epoch before modern anesthetics. Breast cancer’s ethical realm also altered in that final quarter of the eighteenth century, as surgeons were expected to perform the operation in record time with professional sanctions if they did not, often within a few days of diagnosis, an admirable time frame compared to ours. This imperative included the patient’s pre-surgical decision-making activity, women being free agents to submit or not to surgery. Some financial arrangements are known: the patient paid the surgeon (most apothecaries and physicians did not operate);  rates were steep relative to comparative costs of accommodation, food, transport, and clothing;  and no national, civil, or other type of medical insurance existed. Masters often paid for their servants’ surgery and postoperative care as well.

This skeletal profile is already documented in recent histories of medicine and scholarship by Michael Stolberg, Barbara Duden, James Olson, Julia Epstein, Siddhartha Mukherjee and others.[3] Marjo Kaartinen’s significant addition to Pickering & Chatto’s Studies for the International Society for Cultural History series, Breast Cancer in the Eighteenth Century (2013), compiles more than one hundred cases selected from the century’s end and focuses on the fears attached to diagnosis and the pain associated with remedy. Hers is a short book comprised of four essays, the last and most substantial devoting itself to breast cancer’s psychological facets; and it would have been an even better book than it already is if Kaartinen, a cultural historian at Turku University in Finland, had condensed the first three chapters into one and extended this all-important fourth realm, the psychological. Kaartinen is wise to identify breast cancer’s real and imagined pain, but its presurgical and postsurgical terrors may have been more nuanced than she indicates. The female imagination, then and now, was attuned to the breast’s symbolic, sexual, religious, and physical aspects, even if the vocabulary in which these anxieties were expressed hugely differed from ours.

Kaartinen’s immersion in primary case records also pays off, especially through the examination of extant surgical notes, and it is not her fault that few of these accounts record the patient’s own voice. The picture presented enlists decisions (especially whether or not to submit to the knife), but omits much else about patient’s views and anxieties: domestic, reproductive, sexual, and psychological. All is recorded through the medical practitioner’s eyes—not the century’s great surgeons (the Hunter brothers, William Cheselden, Percival Potts, Charles White), but obscure medical men such as Benjamin Gooch and James Nooth. Henry Fearon, who sat at the feet of John Hunter’s classes in London, took notes at his lectures, and spent his subsequent surgical life in the Surrey Dispensary, claimed to have developed a new method of successfully operating on both breasts and testicles. Fearon was sensitive to cancer’s gender base and distinguished the doctor’s words in contrast to the patient’s. But most surgeons recorded only a limited amount of compassion for their patients and even less sensitivity to their linguistic usage and narrative outpourings.

Frances Burney was the exception in all these generalities. Her mastectomy performed in 1811, the same year Austen published Sense and Sensibility, is already well studied yet would appear to be a glaring gap in any book about eighteenth-century breast cancer if omitted. Kaartinen includes it in a section entitled “Fanny Burney’s Scream” (echoing the celebrated 1893 symbolic painting of a similar name by Norwegian painter Edvard Munch), further emphasizing cancer’s terror. Yet Kaartinen treads lightly, cognizant of how thoroughly Burney’s case has been covered in the secondary literature, and she does not alter the received interpretation of Burney’s courageous pathography written for her sister Esther. Kaartinen succinctly comments on Burney’s embodiment of pain, and deciphers the roles experience and memory played in shaping it as a work of literature. Burney’s fear of the knife and subsequent pain, as well as the heroic courage and stoic fortitude she records having displayed during the operation itself—conflicting drives within a fastidious but almost insouciant concern to annotate every step of Dr. Dominique-Jean Larrey’s procedure—stand out for Kaartinen. Cultural historians continue to record their gratitude to Burney, but it is less clear whether breast cancer patients today would profit by reading it.

Yet even Burney’s reflection on her own response makes plain how breast cancer’s supreme threat was to the mind: “My dearest Esther . . . even now, 9 months after it is over, I have a head ache from going on with the account! & this miserable account, which I began 3 Months ago, at least, I dare not revise, nor read, the recollection is still so painful” (quoted in Kaartinen, 106). Predictably Kaartinen expends most of her energy in an excellent concluding chapter concentrating on her patients’ emotions (and, occasionally, their doctors’ too). Her discussions of fear and imagination focus on the decision making surrounding the knife and subsequent concerns that postsurgical pain would be as great as preoperative (as they had been for Burney), in addition to attendant fears that the organic breast area might never heal.

Eighteenth-century patients expected pain to be their constant companion. Yet the late eighteenth century was also heavily invested in the primacy of fear among the various passions, in its moral philosophy and developing psychology as well as popular ethic. As early as 1753, one of its best-read authors, Tobias Smollett, pronounced that fear was the most interesting of all the passions, a position also confirmed by prominent Enlightenment philosophers. A collective imagination about cancer (then and now) needs to be configured from additional sources than medical. Susan Sontag is mentioned once as having contended in Illness as Metaphor (1978) that even in the twentieth century cancer was still perceived as “embarrassing and shameful.” Sontag’s more striking aperçu was that cancer is incapable of being romanticized in ways other disease clusters (consumption, tuberculosis, leukemia) can; and Kaartinen’s trawl through these cases makes the point writ large. Breast cancer, perhaps analogously to testicle cancer among young men, enlarged the female’s compass of shame, shame symbolized in an ulcerated and suppurating breast during a less secular epoch than ours was destined to elicit varieties of religious guilt.

In our time, breast cancer’s emotional facets are fields for international research, handsomely funded and widely assessed, but in the eighteenth century doctors relied on their intuitions to deal with fear and pain. The two emotions differed: the former anticipatory, the latter consequential. The passions were constantly under scrutiny—not merely the empathy and pity doctors and lay persons should have conferred on the ailing. If Kaartinen’s case studies are representative, breast cancer was not yet established as the “fashionable disease” par excellence claimed by Dr. James Makittrick Adair in his 1787 treatise, although it was probably well on its way to becoming so.[4]

Kaartinen’s book would have profited from further editing. For example, the distinguished surgeon William Cheselden is routinely referred to as “Chiselden” (60, 178). William Rowley, an important surgeon and commentator on breast cancer late in the century, is said to have published Case Histories numbering seventy-four and, alternatively, twenty-four (94). These are representative minor qualms in a book contributing so much to the study of a major disease cluster in the era, and I am happy to have it on my shelf.

NOTES

[1]. James Hill, Cases in surgery, particularly, of cancers, and disorders of the head from external violence (Edinburgh, 1772).

[2]. John Hill, Cautions against the immoderate use of snuff. Founded on the known qualities of the tobacco plant . . . and enforced by instances of persons who have perished miserably of diseases, occasioned . . . by its use (London, 1761), 23.

[3]. See Michael Stolberg, Experiencing Illness and the Sick Body in Early Modern Europe (Basingstoke, 2011); Barbara Duden, The Woman Beneath the Skin: A Doctor’s Patients in Eighteenth-Century Germany (Cambridge, Mass., 1991); James S. Olson, Bathsheba’s Breast: Women, Cancer & History (Baltimore, 2002); Julia Epstein, The Iron Pen: Frances Burney and the Politics of Women’s Writing (Bristol, 1989); and Siddhartha Mukherjee, The Emperor of All Maladies: A Biography of Cancer (London, 2011).

[4]. See James Makittrick Adair, Medical cautions, for the consideration of invalids; those especially who resort to Bath: containing essays on fashionable diseases (Bath, 1786).