Assessing Autoimmune Disease Symptoms in Silicone Breast Implant Recipients

My nurse, Joanne, took me aside before I began my next consult. “Room No. 5, breast implant patient. Her lawyer organized the records.” She handed me a hefty three-ring notebook organized by color-coded tabs. “Her attorney called just now,” Joanne raised an eyebrow, “and told me to tell you that, to save time, he highlighted in yellow marker the most critical aspects of the case for you to review. The breast implant settlement agreement is on the last page.”

This would take some time. On my way to my office, I grabbed a fresh cup of coffee and caught a glimpse of my next patient through the half-open exam door. Middle-aged, razor-cut layered blond hair, ivory cheeks, white sweater, eye-catching silhouette, she was speaking to someone seated, hidden beyond the exam table. Just before I ducked into my office I heard her ask Joanne where the bathroom was located. I looked back and watched her scurry down the hallway. I had a few minutes.

I cracked open the notebook.

Breast Implants & Automimmune Disease

It is 1994, and each month I consult on two or three women with silicone breast implants who may or may not have autoimmune disease. Without exception, they are in diffuse, excruciating pain and wonder if—no, they’re convinced that—the implants are the reason. It is a dramatically different consult from what I am accustomed to. As a rule, I see patients in consultation to answer two basic questions: What is the diagnosis? And second, how can the disease best be treated?

This paradigm is completely turned around by my silicone breast implant evaluations.

The Case

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Whitman, Connolly, and Favio, a New Orleans law firm representing thousands of breast implant sufferers, has kindly organized Mrs.—I flipped the page—Mrs. Hayden Morse’s medical file in minute detail and wants me to qualify her for the Dow Corning Breast Implant Settlement.

In the introductory letter, I am informed that I am worthy as a board-certified rheumatologist to verify that the claimant has scleroderma, systemic lupus erythematosus (SLE), mixed connective tissue disease, polymyositis, dermatomyositis, primary Sjögren’s syndrome or an atypical rheumatic syndrome. My job is to review the documents, particularly those aspects of her case highlighted in yellow marker, examine the patient and check off the appropriate box on the settlement page. Browsing through the trail of yellow highlights, it’s pretty clear that the law firm is convinced its client has SLE. Do I agree?

I turned to the last page of Mrs. Morse’s records, Exhibit F, the Disease Compensation Schedule. This is, ultimately, the bottom line. How much money is she owed from Dow Corning? I have to merely check a box, and the settlement award for a 35-year-old woman with silicone breast implants and severe SLE is—$1.9 million.

My finger lingered over the number, $1.9 million. How did we get here? And why are so many women so sick after silicone breast implant surgery?

History of Breast Implants

Plastic surgeons Thomas Cronin and Frank Gerow are generally credited with performing the first silicone breast augmentation in 1962 on Texas housewife Timmie Jean Lindsey.

By wrapping the silicone-filled product in an impermeable silicone envelope developed by Dow Corning, the surgeons hoped to achieve the look and feel of breast tissue without the risk of inflammatory reactions previous surgeons had experienced with direct silicone injections into the breast. The procedure was a success (Ms. Lindsey is also reported to have had her prominent ears pinned back as part of the bargain), and thus began the modern era of breast augmentation and post-mastectomy reconstruction.

For several decades, women quietly underwent the procedure with little fanfare. The implants could shift or leak, breasts could pucker or contract, infection could occur post-operatively, but these poor outcomes were uncommon enough that the procedure remained popular. Dow Corning, the manufacturer of most of the silicone breast implants in the U.S., quietly prospered.

Of course, no one actually knew how often complications occurred. Oversight of breast implants by the Food and Drug Administration (FDA) was minimal due to a grandfathering clause in regulations. It was not until the early 1980s, when Ralph Nader’s Public Citizen Health Research Group alleged that breast implants increased the risk of breast cancer, that the FDA began to give silicone breast implants a closer look. New rules were developed that required silicone breast manufacturers to conduct studies to prove their products were safe if they were to remain on the market.

But this potential link between silicone breast implants and breast cancer was not borne out by further research. Numerous studies addressed the issue, all with the same conclusion: Silicone breast implants do not raise the risk of breast cancer or other forms of malignancy. But if malignancy risk was not an issue, other concerns soon arose.

Litigation Ensues

The landscape for litigation dramatically changed when Maria Stern brought suit against Dow Corning in 1984, claiming that her autoimmune disease was triggered by her silicone breast implants. Ms. Stern’s case was successful, aided in part by the discovery of incriminating, secret Dow Corning documents.¹ The jury awarded her $211,000 in compensatory damages and $1.5 million in punitive damages.

In that same year, an article by Kumagai in the journal Arthritis & Rheumatism described 18 patients with connective tissue disease following silicone cosmetic surgery.² All of the diseases reported were rare. Diffuse scleroderma, for example, has an incidence of only one to two cases per 100,000 individuals. The report recommended further study, pointing out that because there were no exact figures on how many women each year were undergoing silicone breast surgery, there was no way of knowing whether these rare diseases were happening more frequently than in the general population.

In 1990, millions of television viewers tuned in to watch Connie Chung on a segment of Face to Face interview five women who believed their silicone breast implants had triggered muscle and joint pain, rashes, mouth ulcers and debilitating fatigue. Chung’s show kindled a wave of uncritical media scrutiny. That same year, congressional hearings by New York Democrat Ted Weiss also spotlighted the apparent plight of breast implant sufferers. Subsequent lawsuits against Dow Corning and other silicone breast implant manufacturers flooded the courts.

A jury in San Francisco awarded Mariann Hopkins $7.3 million in 1991, convinced that her ruptured silicone implants were linked to her mixed connective tissue disease.³ The following year, FDA Commissioner David Kessler, MD, after reviewing the recommendations of the General and Plastic Surgery Devices Panel, ruled that silicone implants be available only to women who required breast reconstruction after mastectomy. The wording of the decision was vague. It did not say that the implants were unsafe, but rather, the manufacturers had not provided sufficient evidence for the FDA to declare them safe.

The number of individual lawsuits against Dow Corning ballooned to 12,359.

Dow Corning contested the claims that its implants triggered autoimmune disease. Individual jury trials slogged through the courts, and in fact, some juries did not find Dow liable. When they did, however, the awards were huge. A Houston jury awarded three women a total of $27.3 million in 1994 for silicone-induced autoimmune problems. The cumulative impact of litigation brought Dow Corning to its knees. A $4 billion agreement, the largest class action settlement in U.S. history, resolved the lengthy battles over causation.⁴ Dow Corning (and other smaller manufacturers) agreed to pay claimants a set amount of compensation for a menu of diseases.

All a patient needed to do was be diagnosed by a board-certified rheumatologist with an autoimmune disease listed in the settlement. That’s where I came in.

Back to the Present Case

I scan through Mrs. Morse’s records. It was a quicker read than expected. Her lawyers had spread a wide net, and much of the info was irrelevant to the case: office visits with her family doctor for colds and sore throats, flu shots, Pap smears, bunion surgery.

I jot down her medical and social history on a separate yellow sheet: Depression treated with amitriptyline in 1984, mild asthma, chronic insomnia, divorce in 1985, two children ages 8 and 11, non-smoker, rare alcohol use. Let’s see: silicone breast augmentation in 1988, remarried in 1989, currently not working out of the home.

I flip to the tab titled Lab. Over the years, the majority of her lab tests were routine—the type of blood work one might draw for a yearly physical. Blood counts, thyroid studies, chemistry profiles, liver and kidney function: normal. Testing for Epstein-Barr virus, chronic hepatitis and HIV. Hmm, that’s a little out of the ordinary. Extensive viral testing is usually reserved for patients who feel unwell. They were drawn in 1986, two years before breast augmentation and then again in 1990. Normal and normal.

I scan down the tests evaluating Mrs. Morse’s markers for systemic inflammation—an erythrocyte sedimentation rate (ESR), normal at 17, and several C-reactive proteins (CRPs), one of which was borderline abnormal at 1.3 mg/dL (this was highlighted with a “!!!!” by the law firm in yellow marker).

The immunologic studies follow: A series of anti-nuclear antibody (ANA) tests were listed, several going back to the mid-1980s. I look these over more carefully. The presence of ANA may be associated with various autoimmune diseases, but they are not diagnostic of autoimmune disease. Numerous studies have documented that an ANA can be detected in the blood of patients with infection, with certain medications and, at times, in healthy adults. There were five ANA blood tests reported, two before Mrs. Morse’s breast implants in 1988, both negative, and three subsequently, only the last of which was positive at a low level. This was also boldly underlined in yellow with a comment: “SLE test positive.”

I take a closer look at the identifying lab information at the top of the sheet. The most recent positive ANA was performed at a specialty lab I was unfamiliar with in faraway Louisiana. That’s strange. There are plenty of good reference labs in Maine. If you want to be picky, the Mass General Hospital has an excellent lab for immunology. But to send a lab specimen all the way to Louisiana? Below the ANA were several additional tests assessing for the presence of antibodies against silicone. These were markedly positive, with an asterisk over the values. In fine print at the bottom of the page, a corresponding asterisk divulged “silicone antibodies are performed in house and have not been validated by an outside independent lab.” Next to the silicone antibody values was another breathless, yellow exclamation mark.

I flip back to the title page in the notebook—Whitman, Connolly, and Favio, New Orleans. A fleeting image of a lawyer objecting to his opponent’s tactic flashes to mind: “You’re leading the witness!!” I’ve read enough. Time to see the patient.

In the Exam Room

Mrs. Morse says she is tired. So tired, she has all she can do to get out of bed most mornings. “My mother’s a godsend for those days I have trouble just putting one foot in front of the other. Plus, she’s another set of ears. Honestly, I can’t count the times I’ve completely forgotten everything the doctor told me. Brain fog, that’s what it feels like I’m in, a complete brain fog.”

I look up from my notes. “Other than the fatigue, how are you feeling?”

She pulls her shoulders back and sighs. “Weak. I’m weak. The pain is everywhere.”

“That must be difficult,” I say. “Does the pain keep you up at night?”

“I never sleep. I don’t know the last time I slept.”

Mrs. Morse’s mother shakes her head in disbelief. “On her bad days—I live next door—I come over and help with the children, get them dressed, fix their lunches, get them off to school. Tom, Hayden’s husband, is away frequently on business trips, so he doesn’t know just how much she struggles. I don’t think he realizes …”

“And all of these problems? They go back how long?” I ask.

“About two years after the breast implants,” Mrs. Morse whispers, almost inaudibly. “The rashes, the fatigue, the pain, it slowly crept over me, until now—look at me? Is it the lupus? Is that what I’m struggling with?”

Momentarily, I say nothing. I am sorting things out, sifting the evidence and trying to maintain my objectivity. In truth, I would have to say my patient looks remarkably healthy, no, beyond healthy, absolutely stunning. I take off my glasses and clean them with a tissue paper.

Lupus is not a disease diagnosed by a checklist of symptoms and a borderline ANA. The diagnosis requires objective physical findings and significant, widespread lab abnormalities. I ask her to sit on the exam table. Her mother reflexively moves to her side and takes an arm. Mrs. Morse waves her off, but the effort seems to exhaust her.

“I’ll be okay. Give me a moment. I’ll be okay.” A series of deep cleansing breaths follow.

Numerous studies addressed the issue, all with the same conclusion: Silicone breast implants do not raise the risk of breast cancer or other forms of malignancy. But if malignancy risk was not an issue, other concerns soon arose.

Physical Exam

I flash back to the image of Mrs. Morse hurrying down the hall to the bathroom. Focus. I am here to render an opinion. When all else fails, a former professor once reminded me, examine the patient.

I begin by examining Hayden Morse’s scalp. Lupus patients often have patches of alopecia—discrete areas of hair loss. Mrs. Morse’s scalp is luxuriously normal. There is no butterfly rash across the cheeks. The oral cavity does not demonstrate ulcerations. There is no pericardial rub—a sign of inflammation in the sac surrounding the heart—and the lungs are clear. Her joints are benign: there is no swelling, warmth or limited motion.

She is tender in the soft tissues of the neck and shoulders. She flinches when I palpate her forearms, low back and thighs. I ask Mrs. Morse to lift up her arms and tell her that I need to palpate the armpit for signs of lymph node enlargement. In some cases, silicone breast implants have been known to rupture, setting off an inflammatory reaction in the adjacent lymph nodes. Although the area is exquisitely tender there are no palpable lymph nodes and no tissue thickening. With the exception of scattered muscular tenderness, my examination is unremarkable.

Next, I test various muscle groups for weakness. With some encouragement, Mrs. Morse gives a good effort and convinces me there is no true weakness.

Behind me, her mother clears her throat. She wants me to know just how weak her daughter truly is. “Today, she looks pretty good. She doesn’t want you to see how weak she really is. She’s giving you her best effort, but I know tomorrow, she’ll be in bed all day.”

“Mother. I will not. That’s not true.”

Lupus is not a disease diagnosed by a checklist of symptoms & a borderline ANA. The diagnosis requires objective physical findings & significant, widespread lab abnormalities. … There’s treatment for lupus. With the proper medications, nearly all of my lupus patients are living well with their disease.

“It is so. Dr. Radis, I need to tell you something. Like I said, when Hayden has taken to bed, she calls me, and I come over and get the children fed, dressed and off to school. What I didn’t say, is that those are the mornings I have to feed her!”

“Well, she’s lucky to have you,” I say, half-listening, as I finished up with my neurologic exam. “It must be a great help to have you to pitch in with the cooking.”

“No, Dr. Radis,” she says sharply. My head spins round. “I’m saying I have to come over some mornings and feed her!” With that, the mother dips an imaginary spoon into a bowl, pushes it toward Mrs. Morse’s mouth, squeezes her cheeks and gives her daughter a spoonful of pretend cereal. Then, she takes out her handkerchief and dabs her daughter’s mouth. My reflex hammer falls to the floor. I sit down and record my findings, hoping to avoid any eye contact. Normal. Normal. Normal.

“Some mornings, she’s so weak,” the mother continues, “I have to help her chew. That’s a fact. That’s what that, that boob job did to her.”

“Okay. I think I understand,” I suck on the inside of my cheeks. There is not enough air in the room for the three of us. My mind is on the verge of exploding, not to make sense of what I have just witnessed—no, that’s the easy part. There is no medical disease that can fluctuate in severity so dramatically from stone cold normal to floppy premature infant from one day to the next. No, I am thinking about an exit strategy. I am absolutely certain that Hayden Morse and her mother will not be relieved that she doesn’t have lupus. Mrs. Morse’s lawyer will not be pleased that his client does not have lupus. And frankly, although there is absolutely no evidence that Mrs. Morse has lupus, I wish she did have lupus.

There’s treatment for lupus. With the proper medications, nearly all of my lupus patients are living well with their disease. Plus, I am a little scared of Mrs. Morse’s mother.

Alternatives

The diagnosis of Munchausen syndrome floats to mind. Patients with Munchausen syndrome consciously exaggerate or invent symptoms of a disease to gain attention from medical providers. But that doesn’t ring true. Mrs. Morse seems to honestly believe that her symptoms of fatigue and muscle pain and weakness could be related to her breast implants. Her past history of anxiety and depression could easily reemerge at a time of stress and uncertainty. There is nothing calculating about her.

On the other hand … I turn my attention to Mrs. Morse’s mother and consider Munchausen by proxy, the elaborate scheme by another (usually a mother of a child) to suggest or transfer symptoms of a disease onto the child. This possibility, that Mrs. Morse’s mother may be fueling Hayden’s decline in order to share in a huge settlement, is both unsettling and unprovable. As a non-psychiatrist, I am in uncharted territory.

So I prevaricate. I pick up Mrs. Morse’s chart and tell them, “This is a very complicated case. I need time to review the notes from the other consultants as well as the extensive labs your lawyer forwarded,” I pause. Okay, so far so good. “Early next week, I’ll get a letter out to your lawyer. I’ll be calling your primary care doctor and reviewing my thoughts on how you can begin to feel better. For now, I want you to continue on the same medications you’ve been on.”

“Doctor,” Mrs. Morse’s mother points a bony finger at my nose. “Hayden does have lupus. She has that ANA and everything else. We know all about the symptoms, and what’s more, she has those reactions in her blood to the silicone. I’ve seen the tests. Now exactly what is the problem? I’m sick and tired of doctors putting her down. Now, are you going to sign off on the settlement or not?”

I am not a psychiatrist, but I know when I am in the presence of significant mental illness, and I am not about to be bullied. I focus on Mrs. Morse, who remains seated on the exam table. “Mrs. Morse, I’ll go over your chart to see if I’m missing anything, and if I am, I’ll be in touch with you, but from the information I have, you don’t have lupus or another immune system disorder. So I can’t sign the settlement form saying you have lupus. I’m sorry, but I can’t.”

Mrs. Morse stiffens, then begins to sob uncontrollably. “I knew it. I knew it. You think I’m making all of this up. Well, it’s real, and I hope someday you realize how wrong you are. I am sick from the silicone. Sick. And it’s already too late. The silicone, it’s poisoning me,” she brushes her hair back and dabs her eyes with the Kleenex I hand her. “It’s everywhere. Everywhere.”

I never saw Hayden Morse again, but her mother wrote me a letter threatening to report me to the Maine Board of Medicine. She never did. I don’t know if the Louisiana law firm that sent Hayden Morse to my office sought a second or third opinion, but it was common knowledge at the time that certain rheumatologists believed silicone breast implants caused autoimmune disease and interpreted the evidence more favorably. Perhaps, she was eventually reimbursed for her suffering.

Continuing Saga

The question in the early years of the silicone breast implant controversy was not whether some women with breast implants had autoimmune diseases, such as lupus or scleroderma, but whether this was happening more commonly than one would expect by chance alone. And the answer to this key question took time to definitively answer. By one estimate, by the mid-1990s, more than a million women had undergone the procedure in the U.S., but the actual number remains unknown because no central registry existed to provide firm numbers.

But if there were no national data bank, the people of Olmstead County, Minn. (where the Mayo Clinic is located), provided the first tentative answer to this question. For decades, Mayo Clinic researchers have detailed the health and habits of residents of Olmstead County. Public Health reports detailing how much the population smokes and drinks, what they eat and their risk of developing disease have helped shape public health policy for the entire county. What’s more, patients with rare diseases, such as connective tissue disorders, in Olmsted County are almost always followed at the Mayo, ensuring accuracy of diagnosis. Scouring this databank for women who had undergone silicone breast surgery, researchers were able to provide an estimate of how likely a woman who had undergone silicone breast implants was to develop a connective tissue disorder.

The paper, published in the New England Journal of Medicine in 1994, found no increased risk of developing connective tissue disease.⁵ But it was largely ignored, at least by the courts. Under the weight of more than 400,000 potential claims, Dow Corning filed for bankruptcy, and the multi-billion dollar settlement collapsed.

The next year, the Nurses’ Health Study, reporting on the long-term health of 87,501 women, failed to demonstrate an increased risk for developing connective tissue disease in women with silicone breast implants.⁶ A Swedish study found similar results.⁷ In all, 20 subsequent studies failed to demonstrate risk, while only one, published in the Journal of the American Medical Association in 1996, reported a possible, small increased risk.⁸ This last study was widely criticized, because it did not require confirmation of the diagnosis by an independent physician.

Impact on My Practice

Eventually, I stopped seeing breast implant consultations; the office visits were uniformly adversarial. The women in the class action suit were not patients; they were plaintiffs. And although I sympathized with their pain and uncertainty, none of the 30 or so women I saw had evidence of an autoimmune disorder. Without exception, they were angry—angry at their surgeons who failed to warn them of potential complications, angry at Dow Corning and the FDA, who they blamed for marketing an unsafe product, and angry at me because I wouldn’t certify them for million-dollar payouts.

Juries and courts began to catch up with the science, and Dow Corning’s luck began to change. By 1995, the silicone implant makers were winning the majority of cases that went to trial. Judges became more selective in the evidence they would accept by “experts” who claimed a connection between silicone breast implants and connective tissue disease. The concept of junk science entered the popular lexicon.

In 1998, under yet another reorganization plan by Dow Corning to emerge from bankruptcy, women who wanted to cash out immediately and not file a disease claim were promised $2,000. For those who had previously filed a disease claim, between $10,000 and $250,000 was to be awarded, a far cry from the millions promised in the original settlement.

From time to time, I would see women who had signed up for the settlement but needed a local rheumatologist to manage their symptoms. And I gradually began to better understand the powerful psychodynamics that prevented them from recovering.

Over time, they became patients as opposed to litigants. Several improved—to some degree—by having the silicone breast implants removed; others did not. I neither encouraged them to take, nor discouraged them from taking, this step; I just couldn’t predict if it would help.

Medication trials were largely ineffective; muscle relaxants helped to some degree with insomnia and muscle tension, and many patients were prescribed combinations of anti-anxiety and anti-depression meds by their primary care providers, again, with mixed results.

For the most part, my subset of silicone breast implant sufferers remained unwell. Diffuse pain and stiffness and depression were their constant companions.

My Understanding

One woman in particular, who I followed for the better part of four years, helped me understand the mystery of why silicone breast implant sufferers were more functionally impaired than my worst rheumatoid patients. The answer, I believe, goes to the heart and mind of who the breast implant patients were before they underwent breast augmentation.

Milly T. just wanted to feel better. She’d been evaluated by two previous rheumatologists, and both agreed that she didn’t have a connective tissue disorder. Instead, they diagnosed her with fibromyalgia syndrome, a diffuse pain syndrome associated with non-restorative, fragmented sleep, often accompanied by depression and anxiety. And for the most part she accepted the diagnosis. But near the conclusion of our initial visit, I noticed in her patient questionnaire that her mother had died at age 34 and asked her what happened.

“Murdered,” she said simply.

“And you were how old? 12?”

“Yes.”

“And your sisters?”

“7, 10, l4.”

“Well, I’m sorry. Do you want to tell me what happened?”

“No. … Well, she was killed at home. It was a robbery, and he … he …well, he shot her in front of us.”

I closed my eyes, the image of that awful blistering moment filling my mind.

“Well, I got over it. I mean, I don’t think anyone really gets over something like that. The guy was caught. He’s in jail for life, like he’s off the street. But I wish they’d electrocuted him. It was tough. One sister died of an overdose five years later. The other two drink. I mean, they’re definitely alcoholics. Me … I saw a therapist for a while and was admitted when I took an overdose of Valium. I finished high school, married too young, got divorced.” She stopped for a moment. “I sound really whacked, don’t I?”

“No, it sounds like things were awful.”

“Well, they were. But the next guy, Stanley, that’s who I’m married to now, he’s a peach. Good guy. Getting the implants helped. He liked them. He still likes them, and then—like out of the blue—I’m screwed again. The silicone implants are killing me.”

Mass somatization, I believe, was at the root of the silicone breast implant epidemic. A perfect storm of circumstances existed: A susceptible population of women, initial reports linking silicone implants to autoimmune disease, media hype & litigation lit the fuse of disabling fear & suffering.

Milly’s story was extreme, but researchers have documented a number of differences between women who are seeking breast augmentation and the general population. In nearly every measure of psychological health, from low self-esteem, to depression, to frequency of psychiatric admissions, divorce and increased alcohol and cigarette use, in general, breast augmentation women differ from women who forego the procedure. Although some women report improved self-esteem and other measures of improved psychological health after augmentation, imagine the emotional trauma to a woman who is told her breast implants have triggered an incurable connective tissue disease?

The vivid imagery of silicone particles traveling throughout the body means you can’t undo the damage. The poison is everywhere. Sleep is impaired. Stress goes through the roof. Free-floating anxiety settles in. Headaches, fatigue, diffuse pain ensue. This process of somatization—the development of myriad unexplained bodily symptoms without a clear underlying disease—may morph into mass somatization when the suspected trigger is subject to mass media coverage and potential litigation.

Mass somatization, I believe, was at the root of the silicone breast implant epidemic. A perfect storm of circumstances existed: A susceptible population of women, initial reports linking silicone implants to autoimmune disease, media hype and litigation lit the fuse of disabling fear and suffering. Hundreds, then thousands, then hundreds of thousands of women developed life-altering symptoms they believed were due to their breast implants.

Sadly, in our consultations with silicone breast augmentation patients, rheumatologists became gatekeepers instead of allies. We did not heal, because we didn’t understand. And even if we did, our training didn’t prepare us for the emotional deluge, the unremitting pain our patients experienced.

Milly, I think, got it. She began to see a therapist again and was diagnosed with recurrent post-traumatic stress disorder. Once she understood how anger, stress and uncertainty could feed into musculoskeletal pain, she was able to keep the symptoms from overwhelming her. She decided to keep the breast implants and joined a support group for depression. I suggested that she try to swim at the local YWCA, and six months later, she proudly announced she routinely swam 30 laps every Monday, Wednesday and Friday.

I wish I could say that her symptoms melted away. They didn’t. Even with exercise, counseling and medications, she was in that gray world of neither altogether well, nor entirely symptom free. But she was better.

The last time I saw her, she told me that her husband, Stanley, was still a “good guy.” She had withdrawn from the silicone breast implant suit. And as she was leaving, she wanted me to know that she was working on forgiving the man who shot her mother. It was hard work, she said, but every day she felt a little better.

Charles Radis, DO, is clinical professor of medicine at the University of New England, College of Osteopathic Medicine and employed part time at Maine Coast Memorial Hospital in Ellsworth, Maine.

References

1. Schleiter KE. Silicone breast implant litigation. Virtual Mentor. 2010 May 1;12(5):389–394.
2. Kumagai Y, Shiokawa Y, Medsger TA Jr., et al. Clinical spectrum of connective tissue disease after cosmetic surgery: Observations on eighteen patients and a review of the Japanese literature. Arthritis Rheum. 1984 Jan;27(1):1–12.
3. Carlsen W. Jury awards $7.3 million in implant case: Verdict in 1976 surgery favors Sebastopol. San Francisco Chronicle. 1991 Dec 14:A13.
4. Angell M. Shattuck Lecture—evaluating the health risks of breast implants: The interplay of medical science, the law, and public opinion. N Engl J Med. 1996 Jun 6;334(23):1513–1518.
5. Gabriel SE, O’Fallon WM, Kurland LT, et al. Risk of connective-tissue diseases and other disorders after breast implantation. N Engl J Med. 1994 Jun 16;330(24):1697–1702.
6. Sanchez-Guerrero J, Colditz GA, Karlson, EW, et al. Silicone breast implants and the risk of connective-tissue diseases and symptoms. N Engl J Med. 1995 Jun 22;332(25):1666–1670.
7. Nyrén O, Yin L, Josefsson S, et al. Risk of connective tissue disease and related disorders among women with breast implants: A nation-wide retrospective cohort study in Sweden. BMJ. 1998 Feb 7;316(7129):417–422.
8. Hennekens CH, Lee IM, Cook NR, et al. Self-reported breast implants and connective-tissue diseases in female health professionals. A retrospective cohort study. JAMA. 1996 Feb 28;275(8):616–621.