Where does that come from? A regular column that examines the history and origins of a particular medical topic.

As it happens, a famous and chilling insight into such a procedure was written by the highly regarded novelist and diarist Fanny Burney following her successful breast surgery in 1811 ‚more than 35 years before anaesthetics arrived on the scene. Her remarkable diary recorded the day-to-day domestic life in late 18th and early 19th century England and, incredibly, was a chore she kept up daily for 68 years until her death in 1840 at the age of 87.

Her observations greatly influenced Jane Austen and rank alongside the diary written by the great Samuel Pepys in 17th century England.

Frances Burney was born in Kings Lynn, eastern England, in 1752 and by the age of 10 she had begun scribbling stories, plays and poems. By the end of her life she had written four novels, eight plays ‚of which only one was staged and 20 volumes of journals and letters which made up her diary.

On top of that, in 1786 she was introduced into the court of King George III and became Second Keeper of the Robes to Queen Charlotte, a post she only accepted because she considered that at the age of 34 and single she was on the shelf and unlikely to ever marry.

In fact Fanny did eventually get married at 42 to a French military man, General Alexandre Darblay. They lived in Paris, and she had a son in 1793 and was widowed in 1814, three years after the breast surgery she went through at the age of 59.

Tranquil

Fanny had been experiencing a small pain in her right breast for about a year. It gradually worsened and her husband insisted she consult Dr Dubois, a leading Parisian obstetrician. He advised her to be tranquil and suffer no uneasiness. Easier said than done, of course, and by spring 1811 the pain was so severe she was unable to use her right arm and, as she wrote the hardness of the spot affected encreased [sic].

Darblay arranged for a second opinion with Napoleon‚ a famous personal surgeon Baron Jean Dominique Larrey. He recommended surgery as the only possible treatment, which astonished Fanny as the poor breast was nowhere discoloured and not much larger than its healthy neighbour. The insensitive Dr Dubois was recalled and confirmed Larrey's opinion. She later noted in her diary that her doctors were close to tears, pale and looked aghast‚as well they might be.

A surgical ordeal

So, at three o'clock on the afternoon of 30 September 1811, seven men alighted from four black cabriolets, entered the house of the now tremulous Fanny and ordered her bedstead to be carried into the middle of the room and two mattresses to be laid on top of it. Bandages, sponges and lint were unpacked and the servants ordered to leave. She removed her long robe, put a cambric handkerchief over her face and an assistant, Dr Ribes, told the patient to not hesitate to cry out during the operation when she felt the pain of the scalpel, the glint of which, she later recorded, she could see through the cambric.

There was then silence for several minutes and the patient assumed the doctors were using sign language. The posse of men surrounded the patient to hold her down, whereupon Larrey asked who was going to hold the breast. Fanny cried out, it is mine, sir and promptly sat up. She later wrote that she held the breast in her hand and pointed to the affected area, hoping against hope that only that part would be taken away. She knew the plea was useless and sank back.

I will not go into her recorded details of what happened while fully awake, but merely quote her as she described how the dreadful knife cut through the flesh and how she began a scream which lasted during the whole time of the incision. When the blade was withdrawn the pain seemed undiminished and the operation seemed to tire the hand of the surgeon as he had to change from right to left. Ambidexterity in a surgeon was a handy and well practised skill in the 19th century. Fanny Burney's purposeful column description goes on for several pages as she recalls with unbelievable clarity all the manoeuvres used in her ordeal nearly 200 years ago. Thank goodness it is nothing like surgery today.

Recovery

Though known to be distinctly risky, the procedure was not uncommon in that era. Abigail Adams, daughter of John Adams, second president of the United States, also suffered from breast cancer and underwent a mastectomy in her own bedroom. That was also in 1811; she died two years later. In 1841, Queen Kapiolani of Hawaii reluctantly underwent the same procedure, but died within two weeks from septicaemia.

Fanny's immediate recovery from the operation was cheeringly rapid. She later told her brother the operation lasted 17 and a half minutes and also observed that at the end‚ Larrey was pale nearly as myself, and his expression depicted grief, apprehension and almost horror. She was fortunate to have such an adept and sensitive surgeon looking after her. The year after at the Battle of Borodino the same surgeon carried out over 200 limb amputations in 24 hours. Not much time for grief and apprehension then. By the following evening Fanny was drinking chicken broth and made a good, though not untroubled, recovery. Later she found it difficult to write for long periods with her dominant right hand, the side of the operation, but never complained and continued her journal, which was published posthumously by her niece in 1841.

Fanny Burney died 29 years after that fateful operation, in January 1840 aged 87. Such a survival time after a cancer of the breast operation in the early 19th century is so remarkable one wonders if it was cancer in the first place and not some other pathology such as a non-malignant but hard fibroadenoma or fat breakdown (necrosis), or a persistent tuberculous abscess‚all difficult to distinguish from cancer without today's sophisticated investigations. Surviving for five or so years after a mastectomy for cancer would have been regarded then as a cure; after that you were just as likely to die of something else as you were from the cancer.

Whatever the diagnosis, there is no doubting the fortitude and incredibly strong constitution of Madame Darblay, Fanny Burney.

ACSM #43