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Jim Olson's Essay on Abigail Adams

One of the essays in James Olson's book, "Bathsheba's Breast: Women, Cancer & History," is about Abigail "Nabby" Adams

Perhaps the disease had started out as a tiny dimple. On a man's chin it would have looked rugged and distinguished. On a woman's cheek it might have been called a "beauty mark." It was on her left breast and Abigail "Nabby" Adams wondered what it was. She had never noticed it before. Perhaps it was just another sign of age, an indicator that she was not a young woman anymore. Actually the dimple was not really the problem. Beneath the dimple, buried an inch below the skin, a small malignant tumor attached itself to surface tissues and drew them in, like a sinking ship pulling water down its own whirlpool. Nabby was forty-two years old.

At first she did not give it much thought, noticing it now and then when she bathed or dressed. Nor did she talk about it. She was a shy, somewhat withdrawn woman, quiet and cautious in her expressions, most comfortable with people who guarded their feelings. She blushed easily and rarely laughed out loud, allowing only a demure, half-smile to crease her face when she was amused. She had a pleasant disposition and a mellow temperament, both endearing to family and friends. Nabby was a striking woman, with long, red hair, a round face, deep-blue eyes, and a creamy, porcelain complexion. She commanded respect, not because of an aggressive personality but simply because of the quality of her mind and her unfailing dignity.

She was born in Quincy, Massachusetts, in 1766. Her parents named her Abigail Adams, but they began calling her "Nabby" when she was still an infant. Nabby had an extraordinary childhood. Her father was John Adams, the future president of the United States, and her mother Abigail Adams, the most prominent woman in early American society. Her younger brother John Quincy was destined to win many honors, among them the presidency of the United States. From the time of her birth, Nabby's parents busied themselves with colonial politics, eventually playing leading roles in the American Revolution. They raised her on a steady diet of political talk about freedom, liberty, rights, despotism, and foreign policy. Nabby absorbed it all.

An only daughter, she enjoyed the special attentions of her father, who felt the need to protect and pamper her. Abigail doted on her, dressing her up in the latest fashions when she was little and counseling her when she was an adolescent. Their relationship evolved into a deep friendship. Nabby took it all in stride, never becoming spoiled or self-indulgent. She was even-handed, thick-skinned, and unafraid of responsibility.

In 1783, when Congress appointed her father as minister to England, Nabby was seventeen-years-old. The family took up residence in a house on Grosvener Square in London. Caught up in a whirlwind of social and political activity, they met King George III at court and other prominent politicians at parties and banquets common to the life of an ambassador. After a few months, Nabby became acquainted with William Smith, a thirty-year-old veteran of the Continental Army and secretary to the American legation in London. A dashing, handsome figure, Smith raced around London in a two-seated carriage, the eighteenth-century equivalent to a modern sports car. He dressed well and kept company with people in London's expatriate community, especially Latin American liberals and radicals interested in securing independence from Spain. He was bold and impetuous, inspired by courage and limited by poor judgment. Because of his work with the U.S. legation, and his role as secretary to Minister John Adams, he saw a great deal of the Adams family, and Nabby fell secretly in love with him. Drawn to Nabby's beauty, grace, and intelligence, he soon felt the same way about her. They married in June 1786, after a courtship which John and Abigail Adams felt was too short. They accepted it, however, because "a soldier is always more expeditious in his courtships than other men."

But Colonel William Smith was a soldier without a war, a has-been at the age of thirty, and Nabby, an innocent victim of what her brother John Quincy called "fortune's treacherous game," faced a difficult life. Colonel Smith was not cruel. In fact, he always loved and cared for Nabby and their three children. With a stoicism that would have made the most devout Puritan proud, she accepted her fate and made a life for her family wherever Smith settled. The problem was that Smith never really settled down. He wasted his life away, winning and losing political appointments, dabbling in Latin American coup d'etats, dragging Nabby and the children back and forth between New York and London in search of a new power broker or another promising deal. He spent more money than he ever earned, and Nabby worried constantly about bills and the family reputation. Early in the new century, Smith tried his hand at real estate speculation, but he lost everything. In 1809, when Nabby first noticed the lump in her breast, they were living on the edge of the frontier, on a small farm along the Chenango River in western New York, where Smith spent his days behind a walking plow and a mule.

Nabby was a well-informed woman, and breast cancer was as much a dread disease in the early 1800s as it is today. No records exist describing her initial reaction to the lump, but it is safe to say that concern about the dimple flared into gut-twisting fear. Like so many women, then and today, she tried to ignore the lump, hoping that in the busy routines of running a small farm and household she would not have time to think about it. But cancer has a way of asserting itself, finally obliterating even the most elaborate denials. Nabby was no exception. The lump grew ominously, in spite of the efforts of local healers and their potions. She wrote home to John and Abigail Adams in February 1811 that her doctor had discovered "a cancer in my breast." As soon as they received the letter, the Adams wrote back urging her to come to Boston for medical advice.

In June 1811, with the lump visible to the naked eye, a desperate Nabby returned to Massachusetts, accompanied by her husband and daughter Caroline. As soon as she arrived in Quincy, she wrote to Benjamin Rush, describing her condition and seeking his advice. When Abigail Adams first looked at her daughter's breast, she found the condition "allarming." The large tumor distended the breast into a misshapen mass. John and Abigail took Nabby to see several physicians in Boston, and they were cautiously reassuring, telling her that the situation and her general health were "so good as not to threaten any present danger." They prescribed hemlock pills to "poison the disease."

Soon after those reassuring examinations, however, the family received an unsettling reply from Benjamin Rush. In her initial letter, Nabby told Rush that the tumor was large and growing, but that it was "movable"--not attached to the chest wall. Rush found the news encouraging, as would most cancer specialists today. Malignant tumors which are "movable" are better candidates for surgery, since it is more likely that the surgeon can get what is termed a "clean margin"--a border of non-cancerous tissue surrounding the tumor--reducing the odds that the cancer will recur or spread. Knowing that Nabby had already traveled from western New York to Boston to seek medical advice, Rush wrote to John and Abigail, telling them to break his news gently to Nabby:

I shall begin my letter by replying to your daughter's. I prefer giving my opinion and advice in her case in this way. You and Mrs. Adams may communicate it gradually and in such a manner as will be least apt to distress and alarm her.

After the experience of more than 50 years in cases similar to hers, I must protest against all local applications and internal medicines for relief. They now and then cure, but in 19 cases out of 20 in tumors in the breast they do harm or suspend the disease until it passes beyond that time in which the only radical remedy is ineffectual. This remedy is the knife. From her account of the moving state of the tumor, it is now in a proper situation for the operation. Should she wait till it suppurates or even inflames much, it may be too late... I repeat again, let there be no delay in flying to the knife. Her time of life calls for expedition in this business... I sincerely sympathize with her and with you and your dear Mrs. Adams in this family affliction, but it will be but for a few minutes if she submits to have it extirpated, and if not, it will probably be a source of distress and pain to you all for years to come. It shocks me to think of the consequences of procrastination.

Mastectomy was Nabby's only chance, but first the family had to convince William Smith, who was in an advanced state of denial. When he learned of Rush's recommendation, he reacted indignantly, heading for libraries to learn whatever he could about the disease and hoping to spare her the operation. He convinced himself for a while that perhaps the tumor would just go away, that it was not so bad. Nabby's mother had more faith in Rush and wrote to Smith: "If the operation is necessary as the Dr. states it to be, and as I fear it is, the sooner it is done the better provided Mrs. Smith can bring herself along, as I hope she will consent to it." She even asked her son-in-law to be with "Nabby through the painful tryal." Smith finally agreed. They scheduled the operation for October 8, 1811.

The day before the surgery, John Warren, Boston's most skilled surgeon, met with the family in Quincy. He gave Nabby a brief physical examination and told her what to expect. His description was nightmarishly terrifying, enough to make everybody reconsider the decision. But Rush's warning--"It shocks me to think of the consequences of procrastination in her case"--stuck in their minds. Nabby had no choice if she ever hoped to live to see her grandchildren.

The surgery took place in an upstairs bedroom of the Adams home in Quincy, Massachusetts. It was as bad as they had all feared. John Warren was assisted by his son Joseph, who was destined to become a leading physician in his own right, and several other physicians. Exact details of the operation are not available, but it was certainly typical of early nineteenth surgery. Warren's surgical instruments, lying in a wooden box on a table, were quite simple--a large fork with two, six-inch prongs sharpened to a needle point, a wooden-handled razor, and a pile of compress bandages. In the corner of the room a small oven, full of red-hot coals, heated a flat, thick, heavy iron spatula.

Nabby entered into the room as if dressed for a Sunday service. She was a proper woman and acted the part. The doctors were professionally attired in frock coats, with shirts and ties. Modesty demanded that Nabby unbutton only the top of her dress and slip it off her left shoulder, exposing the diseased breast but little else. She remained fully clothed. Since they knew nothing of bacteria in the early 1800s, there were no gloves or surgical masks, no need for Warren to scrub his hands or disinfect Nabby's chest before the operation or cover his own hair. Warren had her sit down and lean back in a reclining chair. He belted her waist, legs, feet, and right arm to the chair and had her raise her left arm above her head so that the pectoralis major muscle would push the breast up. A physician took Nabby's raised arm by the elbow and held it, while another stood behind her, pressing her shoulders and neck to the chair.

Warren 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, Warren lifted it away from Nabby's chest with the fork. But the tumor was larger and more widespread then he had anticipated. Hard knots of tumor could be felt in the lymph nodes under her left arm. He razored in there as well and pulled out nodes and tumor. Nabby grimaced and groaned, flinching and twisting in the chair, with blood staining her dress and Warren's shirt and pants. Her hair matted in sweat. Abigail, William, and Caroline turned away from the gruesome struggle. To stop the bleeding, Warren 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. Warren then sutured the wounds, bandaged them, stepped back from Nabby, and mercifully told her that it was over. The whole procedure had taken less than twenty-five minutes, but it took more than an hour to dress the wounds. Abigail and Caroline then went to the surgical chair and helped Nabby pull her dress back over her left shoulder as modesty demanded. The four surgeons remained astonished that she had endured pain so stoically.

Nabby endured a long recovery. She did not suffer from post-surgical infections, but for months after the operation she was weak and feeble, barely able to get around. She kept her limp left arm resting in a sling. Going back to the wilds of western New York was out of the question, so she stayed in Quincy with her mother, hoping to regain strength. What sustained all of them during the ordeal was the faith that the operation had cured the cancer. Within two weeks of the surgery, Dr. Rush wrote John Adams congratulating him "in the happy issue of the operation performed upon Mrs. Smith's breast...her cure will be radical and durable. I consider her as rescued from a premature grave." Abigail wrote to a friend that although the operation had been a "furnace of affliction...what a blessing it was to have extirpated so terrible an enemy." In May 1812, seven months after the surgery, Nabby Smith felt well again. She returned home to the small farm along the Chenango River.

But she was not cured. Breast cancer patients whose tumors have already spread to the lymph nodes do not have good survival rates, even with modern surgery, radiation treatments, and chemotherapy. In Nabby's case, long before Warren performed the mastectomy, the cancer had already spread. Nabby suspected something was wrong within a few weeks of arriving home in New York. She began to complain of headaches and pain in her spine and abdomen. A local physician attributed the discomfort to rheumatism. The diagnosis relieved some of her anxiety, since she was already worried that the pain had something to do with cancer.

But it was not "the rhemuatism." That became quite clear in 1813 when she suffered a local recurrence of the tumors. When Warren amputated her breast and excised tissues from her axilla, he thought he had "gotten it all." But cancer is a cellular disease, and millions of invisible, microscopically-tiny malignant cancers were left behind. By the spring of 1813 some of them had grown into tumors of their own--visible in the scar where Nabby's breast had once been and on the skin as well. Her doctor in New York changed the diagnosis: the headaches and now excruciating body pains were not rheumatism. The cancer was back--everywhere.

She declined steadily in the late spring, finally telling her husband that she "wanted to die in her father's house." William Smith wrote John and Abigail in May that the cancer had returned and that Nabby wanted "to spend her state of convalescence within the vortex of your kindness and assiduities than elsewhere." The colonel was back in denial. Since the country was in the midst of the War of 1812, he told his in-laws he had to go to Washington, D.C. for a military appointment, and that he would return to Quincy as soon as Congress adjourned. John and Abigail prepared Nabby's room and waited for her arrival. The trip was unimaginably painful--more than three hundred miles in a carriage, over bumpy roads where each jolt stabbed into her. Nabby's son John drove the carriage. When they finally reached Quincy on July 26, she was suffering from grinding, constant pain. Her appearance shocked John and Abigail. She was gaunt and thin, wracked by a deep cough, and her eyes had a moist, rheumy look. She groaned and sometimes screamed with every movement. Huge, dark circles shadowed her cheeks, and a few minutes after she settled into bed, the smell of death fouled the air.

Nabby's pain was so unbearable, and misery so unmitigated, that Abigail slipped into a depression so deep she could not stand even to visit her room. It was John Adams who ministered to their dying daughter, feeding her, cleaning her and seeing to her personal needs, combing her hair and holding her hand. He tried to administer pain killers, but nothing seemed to help. Smith returned from Washington, and the deathwatch commenced. On August 9, Nabby's breathing became shallow and the passage of time between breaths lengthened. The family gathered around her bedside. She drew her last breath early in the afternoon.

A few days later, in a letter to Thomas Jefferson, John Adams wrote: "Your Friend, my only Daughter, expired, Yesterday Morning in the Arms of Her Husband her Son, her Daughter, her Father and Mother, her Husbands two Sisters and two of her Nieces, in the 49th. Year of Age, 46 of which She was the healthiest and firmest of Us all: Since which, She has been a monument to Suffering and to Patience." Jefferson understood his friend's pain: "I know the depth of the affliction it has caused, and can sympathize with it the more sensibly, inasmuch as there is no degree of affliction produced by the loss of those dear to us, while experience has not taught me to estimate...time and silence are the only medicine, and these but assuage, they never can suppress, the deep drawn sigh which recollection for ever brings up, until recollection and life are extinguished together."

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Sept. 30, 2002
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