Unnatural History: Breast Cancer and American Society (review)

For decades, physicians have tried their hand at the history of medicine in medical journals, as if an M.D. degree were adequate qualification. Similarly, more than a few historians have ventured into medical history with little founding in the sciences. The physician-historians usually ignore the questions of most interest to professional historians, whereas most historians possess insufficient medical background to place their points of view in the proper context. Rarely comes a scholar with both the formal training and experience of a physician and the formal training of a historian, Aronowitz being one of the exceptions. Further grounding in linguistics only adds to Aronowitz’s capacity. Unnatural History, a superb book, reflects his interdisciplinary background.

Aronowitz appropriately avoids the “triumphal” history trap common to the work of physician-historians, who tend to see the history of medicine as a story of uninterrupted progress in the conquest of “myth” and the revelation of “truth.” He understands that medicine, no less than other systems of knowledge, is in many ways a social construct embedded in the culture of its own time. Until recent decades, for example, most physicians treating breast cancer operated under the illusion that the disease remained stationary, until at a certain point in its natural history, cancer cells severed their moorings with the tumor site and traveled to distant organs and killed their host. From that paradigm came the logic that shaped breast-cancer treatment for two centuries: Early detection, followed by radical surgery, was the key to a cure. Inherent in that logic was a tendency to blame the patient, not the surgeon, when metastasis occurred on the grounds that she had presented too late for science to rescue her.

Late in the twentieth century, the paradigm shifted. Physicians decided that breast cancer was a systemic disease from the outset and that, as Aronowitz demonstrates, the issue of “time”—of getting to a surgeon immediately and cutting out malignant tissues before they had time to spread—had relatively little to do with long-term survival. The biology of a woman’s tumor, not necessarily the speed with which the patient sought radical treatment, was far more relevant. Chemotherapy and radiotherapy gained ground as alternatives to radical surgery. Aronowitz’s cross-training shows up in his explanation of that shift. He employs articles in medical journals as primary sources, but because he also analyzes the private, personal papers of the physicians writing them, his perspective becomes especially well informed.

In delving into the manuscript collections of surgeons like William Stewart Halsted and George Crile, Aronowitz ventures between the lines of articles in medical journals, describing the evolving thought of the physicians, the physical and emotional condition of patients, and the interplay between both groups. For Aronowitz, the prominence of gender—the issues surrounding female patients being treated by male physicians in a breast-obsessed culture—is no closer to resolution than ever. “Americans live in an era,” he writes, “that celebrates the historical progression to honesty in the naming and diagnosis of cancer, informed patient consent, and shared decision-making. But closely examining the felt experience of breast-cancer patients and their doctors, especially how they have actually made decisions, suggests an alternative history. In this less positivist history, there has been more continuity than progress in the ways in which doctors and patients have actively worked together, often colluded with one another, to balance hope, despair, and the existential demands and consequences of clinical decisions” (283).