divulgatum está dedicado a la difusión de conocimiento científico en español e inglés, mediante artículos que tratan en detalle toda clase de temas fascinantes pero poco conocidos.
divulgatum is devoted to the dissemination of scientific knowledge in Spanish and English, through articles that go into the details of all sorts of fascinating, if not
widely known, subjects.

Friday, July 22, 2016

A history of malignancy

Mankind’s relationship with cancer and attempts to cure it stretch throughout history, from ancient Egypt to present.

The Agnew Clinic, by Thomas Eakins, 1889. (Public domain.)

CANCER IS perhaps the most feared and infamous disease of our time. A cancer diagnosis implies, even in the best case scenario, a period of severe emotional burden for the patient and their loved ones, with the prospect of an uncertain future, uncomfortable and prolonged treatments, and the absolute disruption of the patient’s life, whilst beating the disease becomes the main goal.

Despite this, we are incredibly fortunate to live in an era in which we have a profound knowledge of cancer’s nature and causes, as well as effective ways to treat many of its hundreds of types and subtypes. For us, the horror that this disease must have conveyed in past ages, when society did not even have the certainty of knowing what cancer was, is almost unimaginable. Numerous historical descriptions of cancer cases illustrate the utter despair that used to accompany the malady, and the extreme measures which patients, medics and surgeons were all willing to take in attempts to resolve it.

The first records of cancer trace back to the ancient Egyptian and Greek civilisations. However, such evidence is ambiguous and scarce, which may be due to two factors. On the one hand, it is likely that the short life expectancy at the time — some twenty-five or thirty years for the less privileged classes — together with differences in nutrition and other environmental factors, prevented a high incidence of cancer in these early populations. Today, it is well known that the main risk factors in the development of cancer are age and exposure to the carcinogenic effects of external agents, such as ultraviolet light and cigarette smoke. On the other hand, medical diagnosis thousands of years ago was more an art than a science, often being notably imprecise; many descriptions of ‘cancer’ in antiquity might well refer to other maladies, from ulcers or inflammation to leprosy. Add to this the fact that only those tumours located on or near the body’s surface could possibly be detected.

As Alanna Skuse’s book Constructions of Cancer in Early Modern England emphasises, in order to comprehend the ways of diagnosing and treating cancer in times gone by, it is first necessary to know the prevailing medical model back then, which differs extraordinarily from the present one. Until the early nineteenth century, Galenism or humoralism, born in classical Greece by the hand of Hippocrates and Galen of Pergamon, dominated medical thought. This theory is founded on the notion that there are four different humours flowing within the body: phlegm, blood, cholera and melancholy. These four fluids mix together to form the so-called ‘nutritive blood’, which circulates inside the blood vessels. Human health thus relied on a delicate balance between the four humours, every disease being considered as the consequence of an unhealthy imbalance, which arose from a combination of innate predispositions and environmental factors. Not only did the humours affect physical health, but also personality itself, with the predominance of one of the four fluids resulting in persons of phlegmatic, sanguine, choleric or melancholic character, respectively. Cancer, in particular, was strongly linked to the build-up and subsequent corruption of melancholy in certain areas of the body.

Cancer has always been distinguished from many other fatal diseases. Its perception as a condition derived from the body itself, but at the same time capable of slowly consuming it, embodied the malady as a conscious creature that surreptitiously ‘devoured’ the body from within. This is the origin of the term ‘malignancy’, which has survived the advent of modern medicine. The word ‘cancer’, for its part, has considerably ancient roots: the term is derived from the Greek karkinos, ‘crab’. The association between animal and disease apparently had its inception in the crab-like shape of certain tumours, as well as in the fierce resistance imposed against any attempt of cure, which calls to mind the crab’s strong grip. Images of cancer as a cruel, flesh-eating disease also led to a metaphorical identification with other animals, like the wolf or the worm; similes that, over time, sometimes degenerated into literal parallels, with some texts relating the actual presence of wolves and worms inside a tumour.

The female breast was without a doubt, and until some two centuries ago, the disease’s quintessential site, to the extent that the term ‘cancer’ was understood, unless otherwise indicated, as breast cancer. In fact, medical writings from the long period spanning the Middle Ages to the eighteenth century — in which medicine was an invariably masculine field — repeatedly describe the female body as something mysterious, capable of engendering life while also imperfect and vulnerable. There existed a widespread belief that women normally had difficulty in regulating their body’s humoral composition, which resulted in strange phenomena such as menstruation, whereby the body got rid of a harmful excess of humours. Curiously, whilst cancers in men, including tumours in the genital area, were never considered to be a consequence of masculine physiology, but the effect of a humoral imbalance caused by lifestyle, it was common practice to attribute the apparently elevated breast cancer incidence to different ‘defects’ in feminine anatomy, which were unavoidably linked to the enigmatic features that distinguished women from men. Of particular prevalence was the notion that the accumulation of milk in the breasts, perhaps due to a reticence of the woman to breastfeed, led to degradation of the fluid, having a noxious effect on the bosom. On the other hand, blows and bruises, which were not rare in times when domestic violence was perfectly acceptable, if not defendable, were also associated with the appearance of tumours. So well established was such relationship that, in eighteenth-century England, a man was brought to court accused of causing a woman’s cancer after punching one of her breasts in the street.

In those times, cancer therapy involved the application of progressively more aggressive treatments, as the tumour proved resistant to the ‘softer’ options. The first stage was usually based around considering the disease as the consequence of a humoral imbalance: prescriptions of diet, exercise and complex concoctions with anti-inflammatory, sedative or even toxic properties were aimed at averting the harmful build-up of melancholy in the patient’s body. Some remedies, due to the proposed association with various creatures, attempted a ‘like versus like’ approach, featuring ingredients such as crab shell powder, mashed worms or wolf tongue. This illustrates how the medical discourse gradually shifted from a symbolic identification of cancer with these animals to a belief in their literal implication in the disease. However, once these proved to be ineffective, the next step could be the application of extremely aggressive substances, such as mercury and arsenic — which could be considered as a primitive form of chemotherapy. These chemicals, with their tremendous corrosive power, were sometimes considered the only thing capable of thwarting the flesh-eating impetus of a rebellious cancer. Although the side effects of such treatments were so serious that many doctors strongly opposed their use, most patients would choose them in order to escape the most terrible weapon of the medical arsenal — surgery.

The illustrations in Johannes Scultetus's book Het vermeerderde wapenhuis der heel-musters (1748) exemplify the dehumanisation of the patient as a way to ignore their tremendous suffering. (Image courtesy of Wellcome Library, under a CC-BY 4.0 licence.)

If even the most extreme chemical remedies had no effect, some patients were persuaded that the only hope of cure lay in trying to excise the tumour. Whereas many of today’s medical interventions have minimal impact on the patient’s life, only two centuries ago the situation was radically different. Before the advent of anaesthesia, antiseptics and antibiotics, even the least invasive operations not only caused terrible pain, but also put the patient at risk of death due to haemorrhage, infection and other complications. All of the above made surgery the most dangerous and feared of medical procedures. Lacking modern anaesthesia, surgeons administered opiates and alcohol before the operation, in order to make it more bearable; however, the patient was to be kept awake, since unconsciousness could signal excessive blood loss or other problems.

Cancer surgeries were particularly risky, invasive, lengthy and painful, to an extreme that probably eludes the imagination of modern man. Breast cancer being the most frequent form of the disease, most surgeries were radical mastectomies — complete amputations of the breast — although there are also descriptions of interventions in areas as diverse as the eyes, legs and scrotum. The most complex surgeries took several days, during each one of which the patient’s body was opened with blades or similar instruments in order to excise as large a part of the tumour as possible; the wound was later cauterised with sizzling irons or pledgets. The patient stayed at the surgery overnight, in excruciating pain; and, if necessary, the process was repeated the following day.

It is evident that the reason for cancer patients agreeing to undergo such brutal interventions was the belief that this was the only way to avoid death. On the other hand, the majority of such operations resulted in the patient's demise; it is likely, therefore, that surgeons were not eager to complete them, since deaths could land a lasting blow to their reputation, and therefore to their income. It is to be supposed that surgeons agreed to carry out such risky surgeries due to a moral desire to alleviate the suffering of advanced cancer patients. The paradox of the surgeon, who damages the patient in order to heal them, has been highlighted by medical historians throughout the centuries.

Nevertheless, even if both surgeon and patient agreed that surgery was the best option, this was no easy undertaking for either. Such was the suffering of patients during operations that multiple assistants were needed to hold them in place during the whole procedure — as well as to prepare the instruments. The patients’ traumatic screams of agony made the longest operations emotionally strenuous. As a consequence, surgeons mentally prepared themselves to ignore any signs of suffering, suppressing the patient’s presence to focus on the extirpation of the tumour; this attitude earned surgeons a reputation for heartlessness, being sometimes compared to butchers or torturers. Medical texts from past times clearly reflect their obliviousness to the patient during surgery as a way to ignore their tremendous agony: no one description of an operation mentions the state of the patient as a person, but just as a body wherein the battle against the tumour progresses. In the same vein, the illustrations in these texts show women with invariably peaceful expressions, even during the perforation or amputation of their breasts. Those records that have survived suggest that, as opposed to the ‘softer’ treatments, once the operation was agreed upon, the patient moved off the scene, leaving surgeon and cancer alone.

Doubtless, both practitioners and patients must have contended with the decision of how far it was worth going to try to cure a disease that, after all, could well be incurable. The fact that a large proportion of cancer treatments transpired to be just as painful as the disease itself — and that surgeries often resulted in death — made some patients incline towards palliative treatments, aimed simply at delaying death and alleviating suffering as far as possible. The main components were plants with analgesic and opiate properties, such as laudanum. There can be no doubt that, in the most advanced cases, patients would also resort to these kind of medicines to achieve a painless death.

Although before the twentieth century there was no shortage of devastating or highly contagious diseases against which medicine could do little, cancer has always stood out amongst them due to its particularly ‘evil’ nature. The characterisation of cancer as an entity belonging to the body and, at the same time, utterly alien to it, with a cruel and treacherous disposition, has survived until our time and can even be recognised in many media campaigns related to the disease. The frequent use of cancer as a symbol of internal corruption and moral degradation is not new either; in fact, few aspects of the relationship between humanity and cancer are. What has changed in this last century, however, is the astounding power of science and medicine to diagnose and treat this malady, delve into its causes and, with colossal efforts, slowly advance on the trail to put an end to it. As terrible as the impact of cancer may be, we must not forget that the horizon has never been brighter than today.

Special thanks are due to Isobelle Bolton for her invaluable help with translation.

Skuse, A. Constructions of Cancer in Early Modern England (Palgrave Macmillan, 2015).
David, A.R., Zimmerman, M.R. Cancer: an old disease, a new disease or something in between? Nature Reviews Cancer (2010).