Breast cancer has been around for at least 5,000 years, based on observations and/or treatments as recorded in papyri and other written records. It is a disease found in some, but not most, mammals—most notably humans, primates, dogs, cats, ferrets, mice, and rats. Because it affects the mammary glands, it is a type of cancer unique to mammals. It was probably the Egyptians who left the earliest record of breast cancer.
“The Edwin Smith Surgical Papyrus, dating back to 3,000–2,500 B.C., and possibly attributable to Imhotep (the Egyptian physician-architect), provides authentic accounts of breast cancer. A case was deemed incurable if the disease was “cool to touch, bulging and spread all over the breast”.
Early physicians who examined lumps of the breast in ancient Egypt reported
“swelling with pus spread over the breast, redness, penetration to the bone, inflammation, bulging tumor, and abscess in the breast. They also describe diverse tactile characteristics – hot tumors, cold tumors, oily tumors, solid tumors, patient with fever, lack of fever, and patient that shudders when the tumor is touched.”
Leonides of Alexandria (circa first century AD) was perhaps the first surgeon who tackled breast cancer with any precision. He was careful to warn surgons who followed him to be sure they removed a healthy margin of normal tissue that surrounded a tumor, lest any cancer remain.
The terminal ductal lobular units (TDLU) or lobules are the site of origin of most breast diseases, whether benign or malignant.
Breast masses often are detected during breast self-examinations where they are found to be painless, hard or irregular. A dimpling of the breast tissue is also a warning sign, as is a discharge from the nipple. A breast lump in and of itself is not necessarily cancer however, though it should be reported to a woman’s family doctor promptly for further testing.
Women who qualify for annual testing whether by age or family or personal history of cancer should be fastidious about getting screened as schedule and not put it off. Early detection is definitely worth a pound of cure assuming a cure is possible is a particulat woman’s case.
Abigail “Nabby” Adams Smith
Last week was the anniversary of the death of Abigail “Nabby” Adams Smith.“Nabby” was the oldest child of John and Abigail Adams. She was born in Braintree, Massachusetts, on July 14, 1765. Only days before her second birthday, her younger brother, John Quincy Adams, was born. Her father was one of the leaders of the American Revolution and would later become our nation’s second president. Her mother was a close acquaintance of Thomas Jefferson. Nabby’s younger brother would grow up to become the sixth president of the United States.
As a young woman, her father was sent to serve as the U.S. minister to Great Britain. It was there that she met and married Colonel William Smith, who was born on Long Island, New York, and was ten years her senior. He was her father’s secretary in London and something of a dashing figure. However, he went from scheme to scheme in life, always losing more money than he made, and they eventually wound up in a small house on the frontier in New York—a far cry from the privileged life she had grown up in. It was there, in 1809, that Nabby first noticed the small dimple in her right breast.
She didn’t mention it in her correspondence until February 1811 when she wrote to her parents about “a cancer in my breast.” The letter itself was apparently lost to history. The report of her surgery is footnoted here.1
I scoured eighteenth- and nineteenth-century newspapers to see what their obituary columns noted. I learned that, back then, breast cancer was considered shameful to many women, and it was not often acceptable to reference the topic in conversation or in print outside of a physician’s office. Instead, references were made to a “long and painful illness” or “mysterious malady” that took the lives of women at almost any age; even then, this need not refer to breast cancer. Most references dealt with miracle cures, such as Parson’s Pills or Smith’s Sarsaparilla. They were said to cure breast cancer just as readily as they restored hair loss or relieved rheumatism.
Historical sources attribute the term “cancer” to either Hippocrates (460 BC – 370 BC) or Galen (1249 AD – 216 AD). The first case of breast cancer Hippocrates observed was so advanced that the veins approaching the margin of the mass suggested the claws of a moving crab to this famous surgeon. From there after it was called Καρκίνος (karkinos) or Greek for ‘crab’. Hippocrates “regarded breast cancer and cervical cancer with bloody discharge as life-threatening tumors and applied only palliative care.” Recalling his first case of breast cancer in his own words, Hippocrates wrote: “A woman in Abdera developed cancer (karkinoma) on her chest, and bloody plasma leaked out through her nipple. Once the flowing stopped, she died.”Another Greek physician Celsus (175 – 177 AD) “knew that advanced breast cancers have a tendency to recur in the armpit, with or without swelling of the arm, and may cause death by spreading to distant organs”.
How early physicians evaluated a patient
Today, when a patient visits their doctor, the doctor checks the patient’s vital signs, which include temperature, pulse rate, number of respirations per minute, blood pressure, and pulse oximetry or oxygen saturation percent. In the days of Hippocrates, the unit of analysis was an evaluation of the state of the patient’s four humors. The prevailing notion during that time, which continued until about the seventeenth century, was that four substances corresponded with emotional states: phlegm, blood, black bile, and yellow bile.
Phlegm, or what we now refer to as mucus, was logically linked to the patient’s respiratory function. If you have too much mucus (phlegm), it becomes difficult to breathe. Individuals with a phlegmatic temperament were described as calm, thoughtful, and possessing a sense of peace—serene to the point of being reserved. They were also thought to be loyal and dependable. If you were diagnosed as phlegmatic, you embodied these traits more or less in equal measure. However, if you were excessively reserved or impetuous instead of thoughtful, you were believed to have an imbalance of phlegm. At that point, the physician might draw some blood or ask you for a urine or stool specimen to seek some subjective confirmation of their hypothesis.
Women with breast cancer were thought to be under the influence of black bile according to Galen. Such individuals would tend to appear lean or gaunt, perhaps sad, and might reflect on their lives as if the end was near. Occasionally, they could be irritable. They might also have discovered a lump or dimple in their breast, which an artist might faithfully reproduce in a painting that would survive for centuries for all to view. This you can see in the feature photo.
Alchemists and astrologers quickly expanded upon these basic four humors. They noted that there were four seasons and associated each season with a different humor. They recognized that winters were cold while summers were hot, associating these qualities with the humors. Additionally, wet and dry were assigned to complement hot and cold. Thus, a patient’s skin might be hot (feverish) or cold, or if the fever was breaking, the skin might be wet from perspiration, and so forth. Together, this is how the baseline of each patient was determined and how a diagnosis was confirmed or rejected.
Finally anesthesia!
If you read the account of Nappy Adam’s mastectomy, you know that the “knife and fork” approach to removing a breast was positively barbaric. I cannot imagine the pain that this poor woman experienced while strapped to a chair. The introduction of ether made a decisive difference for both the cancer patient who needed an operation and the surgeon, himself who likely felt rushed to complete the procedure. Now, more complicated or intricate surgeries could take place. The patient’s vital signs could remain much closer to normal and while anesthetized, the muscles in the patient were much more relaxed facilitating ease of access thanks to ether. Strangely enough, ether was known in Nappy’s day, but it was a recreational drug used mostly by university students at Bowdoin College, Harvard and elsewhere. Pathway MD describes it:
The structure of ether parties was relatively simple. Students would gather in dormitory rooms or other private spaces, inhale ether vapor from soaked cloths or open containers, and engage in socializing, storytelling, and other recreational activities. The atmosphere was often described as convivial and lighthearted, with participants experiencing laughter, dizziness, and temporary loss of inhibition.
Or loss of consciousness. The description reminds me of how youngsters several decades ago would gather to sniff (huff) glue. Students who participated in these eighteenth century ether affairs and who were caught were sanctioned. But at the time—and when Nappy Adams needed it herself—there was no medical application for ether because it was seen as more alchemical than a product of true chemistry which had not yet been established.
Sixty-five years or so later after Abigail’s death, Alice James, sister to William and Henry James received only palliative care for her breast cancer, with her treatment focused on alleviating pain rather than attempts to cure or surgically intervene. Upon diagnosis of her breast tumor, doctors informed her that “nothing can be done for me but to alleviate pain,” reflecting the late-stage nature of her illness and the medical limitations of the time. She died ten months later.
Innocentia
Around 410 AD, there was a person in St. Augustine’s church named Innocentia, “a very devout woman of the highest rank in the state. She had cancer in one of her breasts, a disease which, as physicians say, is incurable.”
Innocentia went to see her personal physician. He examined her and stated that in cases like hers, doctors “either amputate, thus separating from the body the member on which the disease has seized, or, in order to prolong the patient’s life a little—even if death is inevitable, though somewhat delayed—they abandon all remedies, following, as they say, the advice of Hippocrates.”
Not happy with her choices, Innocentia focused on prayer. Easter was approaching, when new members of the church would line up in the front to be baptized. Shortly before the Holy Day, Innocentia had a dream. The dream instructed
her to stand at the front of the line, and when the first woman among the converts approached the baptistry, Innocentia was to ask the woman to make the sign of the cross on Innocentia’s festering wound. She did as instructed, and the cancer went away.
With some urging, Innocentia was prompted to visit her doctor with the good news.
The doctor examined her and was absolutely stunned to find no indication of cancer. He practically begged her to tell him what she had done to effect a cure. Had she eaten some unusual root or applied some medicinal poultice to her breast? She replied that “No,” she had just turned it over to God and prayed. The physician was very bitter to hear that. He said, “I thought you would make some great discovery to share with me.” Perhaps he thought he could make money
Breast cancer as depicted in the arts
or find fame with a cure for breast cancer.
Book 22, Chapter 8 of Confessions describes many other miracles that occurred while Augustine served there. Augustine lived from 354 to 430 AD and had a church in what is now Algeria in North Africa.
In the early part of his ministry, Augustine had kept any notion of divine healing in his day and age at arms length. But it was just a matter of time before he became an eye wittness to what the Spirit of God was doing in his church. Today, God still heals people, and while there are miracles, He often chooses to work through physicians. I can personally bear witness to this.
It is doubtful that Renaissance painters deliberately sought out women with curious or deformed breasts to include in their paintings. There was a general taboo against portraying women unfavorably that has survived the test of time, largely due to their exalted role as bearers and nurturers of children. Artists such as Michelangelo, da Vinci, and Dürer were skilled observers of detail; however, their anatomical drawings have sometimes been used to illustrate anatomy. While some examples slipped through, as we can see in this post, it is not certain that the artists fully understood what they were painting, although they were aware of variations among women’s breasts. Moreover, their paintings reinforce the belief that women of past times suffered from breast cancer and likely knew some who were stricken or died from this disease.
If you ask Artificial Intelligence (AI) to find you examples of paintings displaying women with breast cancer, you may be told that there are none, when in fact there are. So, if you wish to research further, you will discover more instances in professional medical journals, some of which as footnoted or otherwise cited here.
We will look at a few examples starting with “The Deluge” painted by Michelangelo (immediately below).
Careful observation indicated that her left breast shows age or breastfeeding-associated ptosis with a prominent nipple and smooth contours. The contrast with the right breast is evident. Although slightly elevated by her right arm, there is a significantly retracted and deformed nipple. The areolar/periareolar skin is retracted, the medial part of the areola seems eroded, the skin cranial to the nipple is deeply indented and scar-like retracted. No overt ulcer is depicted. The upper medial quadrant shows a slight bulge consistent with a lump. Similarly, towards the left axilla, another slight bulge is seen, which could represent enlarged nodes. The medial side of the breast appears slightly discolored representing an artistic effect rather than a typical peau d′orang2
The Night (1553-55) pictured left by Michele di Rodolfo del Ghirlandaio is pictured left. Reseachers point out “. . . a malignant neoplasia in the central region of the left breast with progressive nipple retraction.” Investigator Vittoria Traverso points out that this may be the first case of breast cancer depicted and is based on a sculpture by Michelangelo. In the image, a nude woman is reclining and sleeping in a dream world which includes a cherub, an owl, flowers and various masks. Her left breast is smaller than the right and her nipple is retracted, all signs of cancer.”
Another example is The Allegory of Fortitude by Maso da San Friano. In this case, “the feminine figure shows an ulcerated, necrotizing breast cancer and associated lymphoedema (ibid).
Francesco Salviati (aka Francesco de’ Rossi) was a Florentine artist who lived from 1510 to 1563. One of his many works is called *Charity*. The title refers not to a person but to the love and sacrifice that is demanded of Christians. It may have been based on an Italian tale of a man who was sentenced to death by starvation. Fortunately, his postpartum daughter had visitation rights to see him, and she secretly kept her father alive by nursing him, much as Rose of Sharon did for the starving migrant in the last chapter of Steinbeck’s *Grapes of Wrath*. Could this be an extreme, non-erotic application of the Bible verse in Romans 12:1, where Paul writes, “Present yourselves as a living sacrifice…”?
There are two lumps noted in the central figure’s right breast, which I’ve identified with arrows. A doctor today who might see this woman in the picture would think of cancer, but there would be other conditions he would need to rule out first, such as mastitis or inflammation of the breast. This inflammation would be particularly warm to the touch and also inflamed, but Salviati did not use any red to suggest inflammation.
There are two things to note here. First, there is a defect that intrudes into the lower portion of the areola (which could be of some benign origin) and, below that, a lump. Near the top of the insert, there is also a lump in or near the armpit of the woman. Except for the apparent young age of the woman, it would be a slam dunk to conclude that she has breast cancer. In fact, women under the age of 40 account for less than ten percent of breast cancer patients. However, it is possible for a much younger woman to contract breast cancer. Some researchers conclude that this woman in the painting had cancer, while others take a more equivocal stance.
See more in this journal on the topic of Renaissance paintings of women who may have incidentally had breast cancer when they were painted.
IJAE : Italian Journal of Anatomy and Embryology: 128, 2, 2024 in “IJAE : Italian Journal of Anatomy and Embryology. – Four-monthly, Firenze : Firenze University Press, 2024 https://digital.casalini.it/.
Future treatment options
The future of breast cancer treatment is promising. Approaches such as the development of various viral oncolytics are already being featured in clinical trials. In the past, the philosophy behind removing breast tissue was “more was better,” which led to radical mastectomies. However, three decades ago, there was a shift toward lumpectomies when possible, along with MammoSite Brachytherapy treatment, in which an indwelling catheter is positioned within the breast to introduce radioactive seeds. This treatment was reserved for early-stage cancer, followed by a brief course of radiation.
Despite its benefits, the MammoSite regimen carries certain complications, such as seromas, telangiectasia (red or purple spider-like patterns on the skin of the breast), fat necrosis, and hard lumps at the site. As a result, its use seems to be in decline among surgical oncologists. Today, even more precise surgical approaches are practiced; however, the option of reducing tissue removal (cancerous or otherwise) depends on early detection.
Footnotes
1The surgeon was John Warren, the top surgeon in Boston at the time.
“He then straddled Nabby’s knees, leaned over her semi-reclined body, and went to work. He took the two-pronged fork and thrust it deep into the breast. With his left hand, he held onto the fork and raised up on it, lifting the breast from the chest wall. He reached over for the large razor and started slicing into the base of the breast, moving from the middle of her chest toward her left side. When the breast was completely severed, [he] lifted it away from Nabby’s chest with the fork…Nabby grimaced and groaned, flinching, and twisting in the chair, with blood staining her dress and [his] shirt and pants. [He] pulled a red-hot spatula from the oven and applied it several times to the wound, cauterizing the worst bleeding points. With each touch, steamy wisps of smoke hissed into the air and filled the room with the distinct smell of burning flesh. [He] then sutured the wounds, bandaged them, stepped back from Nabby, and mercifully told her that it was over.”
