A Darker Ribbon: Breast Cancer, Women, and Their Doctors in the Twentieth Century (review)

Ellen Leopold. A Darker Ribbon: Breast Cancer, Women, and Their Doctors in the Twentieth Century. Boston: Beacon Press, 1999. xi + 334 pp. Ill. $27.50.

The extent to which cultural history now pervades the history of medicine is well demonstrated by A Darker Ribbon. Dutifully citing Charles Rosenberg on the framing of disease, Ellen Leopold, a journalist, argues that cultural beliefs about medicine, women, and the breast have greatly influenced the treatment of breast cancer in the United States since 1900. This approach serves her well. In her opening chapter, she discusses how societal beliefs about women and reproduction in the late nineteenth century led physicians to minimize the significance of breast cancer. The subsequent triumph of William Halsted's radical mastectomy as the treatment of choice for the disease, Leopold convincingly argues, spoke more to the growing authority of the male surgical profession than to the value of the operation. Although she shows how issues of gender have continually influenced breast cancer treatment, she rejects earlier claims that the radical mastectomy was a "conspiracy against women" (p. 7).

Leopold is careful to note that she has not attempted to write a comprehensive social history of breast cancer treatment. Rather, she has selected aspects of the history that have contributed most to "the patient's understanding of and response to [breast cancer]" (p. 7, italics in original). One way she accomplishes this goal is to reprint two collections of letters between patients with breast cancer and their physicians. The first correspondence, between Halsted and the pseudonymous Barbara Mueller, from 1917 to 1922, provides great insight into how one patient confronted both the diagnosis of breast cancer and the disfiguring operation used to treat it. The second set of letters was exchanged from 1960 to 1964 between the famed environmentalist Rachel Carson and her progressive physician, George Crile, Jr. Leopold emphasizes how Carson, who so vocally challenged the chemical industry, kept her diagnosis of breast cancer a secret from both her friends and the public.

This theme of silence and breast cancer runs throughout A Darker Ribbon, including an interesting postscript on obituaries. Ashamed of having breast cancer and having to lose a breast as part of their treatment, American women suffered silently throughout much of the twentieth century. Only with the rise of feminism and the women's health movement in the 1970s, Leopold argues, did the disease begin to lose its stigma. By challenging the authority of the medical profession, feminists helped to popularize treatment options that were less drastic than radical mastectomy. Yet, as the author notes, women's responses to breast cancer have not been uniform. The recent spate of breast cancer narratives, for example, focus not on the social and political context of the disease but rather on how individual women try to incorporate breast cancer into the daily events of their lives.

Despite the growing public attention to breast cancer, Leopold remains frustrated with the pace of progress in fighting the disease. Here her arguments become passionate. Leopold is both a grassroots feminist and a breast cancer survivor. In criticizing the past emphasis on early and aggressive treatment, she states that America has paid insufficient attention to the primary prevention of breast cancer. By ignoring the role of drug companies and other industries in setting the breast cancer agenda, she writes, modern women are being as silent about the disease as were their predecessors.

A Darker Ribbon has a number of problems. Leopold has a tendency to use modern terms, like "sexual politics," to describe events in the nineteenth century. She probably overemphasizes the degree of silence that characterized breast cancer in the early part of the century: the fact that it was not discussed in public does not mean that it was not discussed. By focusing on patients, Leopold paints a rather monolithic picture of the...