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Cancer: medical history and the framing of a disease. (JAMA 100 Years Ago ... in Perspective)
Martensen, Robert L.
JAMA, The Journal of the American Medical Association , Volume: 271 , Number: 24 , Page: 1901(1) , June 22 1994

To say that the heterogeneous diseases known today as cancer have loomed large in 20th-century medicine is an understatement. Incidence is believed to be rising, and vast resources are devoted to elucidating cancer's nature and devising better treatments. Moreover, the word "cancer" has taken on broad cultural meaning as a metaphor for a number of uncontrolled and self-destructive processes. If tuberculosis was the cardinal disease of the 19th century, cancer has occupied that place for most of our own century. Cancer, in this sense, has been one of our major diseases, a profile it began assuming in the medical literature in the closing decades of the 19th century.[1]

Most of us would locate the proper setting for cancer investigation in the laboratory or cancer institute. Other than providing useful epidemiologic data, the social disciplines of medicine, including history, have relatively little to offer, or so many think. I would suggest, however, that an appreciation of the intellectual history of cancer, as well as medical specialization in the late 19th century, is helpful in achieving an understanding of the ways in which cancer has been investigated and treated during most of the 20th century.

Since the second half of the 19th century, cancer has been thought of primarily as a surgical disease. This belief was not so much because only surgeons talked about it - Osler, after all, spoke and wrote at length on cancer[2] - but because it was believed to be a local process in the body and, hence, amenable to surgical extirpation. In emphasizing cancer's locality, late 19th-century physicians and surgeons believed they were making a significant advance over previous "constitutional" explanations from Hermann Boerhaave (1668-1738), John Hunter (1728-1793), and others who characterized cancer as a local inflammation resulting from systemic humoral stasis or injury.

Given their interpretive framework of cancer as a primarily local disturbance, the late 19th-century surgeons' plea to their generalist colleagues was not to "temporize" with medical treatments in the case of suspicious symptoms and lesions, but instead to refer early for tumor extirpation. Reflective of this belief was the 1893 declaration of the St Louis surgeon, W. L. Rodman, MD: "Let it be remembered as an axiom that every growth, benign or malignant, should be condemned to the knife at the earliest practicable moment."[3] Surgeons of Dr Wheaton's generation embraced the single-organ and cellular analyses of sick and well bodies promoted by influential mid-century investigators such as Rudolf Virchow, MD (1821-1902), and were eager to extend new technical improvements in surgical anesthesia, antisepsis, and instrumentation to permit aggressive surgical maneuvers on behalf of cancer patients.[4] Although cancer was becoming appreciated primarily as a disease of tumors, nonetheless the lymphatics were believed by most to be involved early in the spread of most cancers.[5] As a consequence, influential operators - most notably William Stewart Halsted, MD (1852-1922), at Johns Hopkins - encouraged what they termed "radical" resections of the presenting organ and its surrounding muscles amid lymph nodes for cancers in several locations.[6]

Although late 19th-century investigators could not agree on a unified theory of causation, they tended to agree on what today would be termed risk factors for malignancy. In 1894 cancer was considered to be primarily a female disease; the commonly cited sex ratios for overall incidence of malignancy averaged two to one.[7] Age was a major risk factor, and cancer was considered rare in those people younger than 40 years. Also, cancer was thought to be prevalent among those people existing in the "highest state of culture and civilization" in temperate climes, absent in Native Americans, and infrequent in US blacks.[3(p410)] Borrowing heavily from Virchows doctrine of cellular irritability, physicians linked tobacco use to the prevalence of lip carcinomas in men and alcoholism to tumors of the stomach, duodenum, and pancreas. Heredity was considered important, but late 19th-century commentators emphasized that it was not as important as earlier generations had believed. The "constitutional origin" of cancer and its corollary of transmissibility from parent to offspring were, after all, in eclipse since "It has been clearly shown to be primarily a strictly local affection."[3(p413)]

Regarding the past 100 years of cancer, have we come full circle? Conceptualized primarily as a local disease beginning in the second half of the 19th century, cancers are now most often thought to be - as they were in constitutional times - systemic diseases with local manifestations. Radical procedures of the type promoted by Halsted and others are now out of favor; current surgical journals publish articles promoting conservative surgery.[8-10] However, it was only in the 1960s that preoccupation with locality and lymphogenous spread began giving way to theories of genesis and metastasis that included diverse cell types, viruses, and oncogenes.

This decline in localism during the past 30 years has been paralleled by a reconception of cancer as primarily a systemic disease amenable to medical, as opposed to surgical, treatments. As the editor of the European Journal of Surgical Oncology noted in 1993: "In the 1970s operative surgery for cancer entered a phase of near confusion which had persisted to the present.[10(p508)] Our professional ancestors of 100 years ago would be amazed at the current situation, but the constitutionalists who preceded them might smile at the irony. Both would be saddened, however, to learn that, despite the expositive confidence expressed today by cancer researchers in several subdisciplines, many of our patients still experience a diagnosis of malignancy, at least initially, as most did in 18k - notice of imminent doom. [1.] Sontag S. Illness as Metaphor and AIDS and Its Metaphors. New York, NY: Doubleday & Co Inc; 1990. [2.] Osler W. Lectures on the diagnosis of abdominal tumors. N Y State Med J. February 3, 1894:130-134; February 10, 1894:161-165; February 17,1894:193-198; March 3,1894:260-265. [3.] Rodman WL. Cancer, its etiology and treatment. Am Pract News. 1893;16:409-417. [4.] McGraw TA. Our present knowledge of tumors and cancers. JAMA 1895;25:387-394. [5.] Reineking H.A. plea for the early and systematic removal of the inguinal lymphatic glands. JAMA. 1894;23:98-99. [6.] Curtis BF. The cure of cancer by operation. Med Rec. 1894;45:225-230. [7.] Pilcher LS. A study of one hundred and seventy cases of cancer. Ann Surg. 1894; 20:1-77. [8.] Oldhoff J. Conservative surgery achievements, risks and limitations. Eur J Surg Oncol. 1992;18:205-208. [9.] Rush BF. Wither, whether, or whither surgical oncology. Arch Surg. 1991;126: 302-303. [10.] Burn I. Surgical oncology. Eur J Surg Oncol. 1993;19:507-509.

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