(I was asked to make three short videos on the history of cancer, for the excellent liberal arts college, Gustavus Adolphus, where I spent a year. The theme of their annual Nobel Conference for 2020 was Cancer in the Age of Biotechnology. The videos are available here but if you prefer to read things, here is the script for the third one.)
This time I’m going to focus on changing theories and therapies, and also touch on the metaphors for cancer.
There’s obviously a close relationship between what you think cancer is, what causes it, and how you treat it. In Western medicine, for many centuries, ideas about disease were dominated by a model that came from ancient Greece and Rome: the ‘humoral model’. This was based on the belief that what mattered in your body weren’t the organs so much as the various fluids moving around it. That model makes a lot of sense in terms of what you could see, in this time before any sort of imaging: fluids come out of the body and so they are really obvious! These fluids were believed to be made by the process of digestion: in the most famous version of the model, the ‘4 humours’, they were blood, phlegm, yellow bile and black bile, and the amount of each one in your body depended on your age and the time of year. So, for example, in spring, it was blood which was most plentiful, and when you were young – in the springtime of your life! – you would have more blood in your body. The 4 humours were linked to the 4 elements and the 4 qualities, so blood for example was hot and wet.
The humour associated with cancer was the strangest of the four: black bile. All the others correspond to things we still believe in – blood and phlegm, obviously, but even yellow bile could be, say, stomach acid. But black bile?? If our bodies produce anything black now, that’s seen as a very bad sign, indicating occult bleeding.
It was in around 170 CE that the great doctor of the Greek and Roman worlds, Galen, wrote in his book On Black Bile that karkinos is caused by black bile. In the first of this series of videos I mentioned that word, the origin of our ‘carcinoma’, and made the point that we can’t tell if people then meant the same sorts of disease we mean now. Leaving that problem aside, black bile is cold and dry and associated with the Fall season. Black bile is also linked to scabies, leprosy, elephantiasis and depression: the Greek words for black bile are the origin of our ‘melancholy’, melan black, choly bile. But Galen seems to distinguish between ‘natural’ black bile which is ‘normal’, and an ‘altered’ version which causes disease. Black bile can be harsh, destructive, sour, sharp, eating through the skin. So you can see the possible connection to visible cancer lesions there. Treatment would have been dietary – certain foods cause more black bile so if you leave them out, you get better – but also juice of nightshade to clean any visible lesions.
A humoral reading of cancer makes it much like any other disease, to be treated by the diet and lifestyle changes which were the methods of choice in ancient medicine. Drugs were potentially more risky because people in the ancient world were very much aware that a drug had different effects depending on dose. Surgery was even more risky – no anaesthesia, no antiseptics, not much in the way of pain relief.
Turning now to the more recent language of cancer, although we now know there are many different kinds of cancer, the metaphors used seem to present it as one ‘thing’ – rather than lots of different conditions arising from cell changes. They also present it not so much as a change in the body but as an invader, an enemy, a coloniser moving from one organ to another. I suppose that’s most obvious in the battlefield imagery. The War on Cancer: the slogan of President Nixon in the early 1970s when he signed the National Cancer Act. War implies the possibility of victory, if the weapons are good enough and if there are enough soldiers. Same time as Vietnam War. The history of that language of war is interesting in itself. Battlefield imagery applies in other diseases too, once bacteria were identified as the cause of disease in the late nineteenth century. But it’s particularly popular for cancer. Back in the 1950s, the period of the Cold War, movies, the popular imagination, were about the fear of death from an alien invasion, from the armies of communism, or from The Bomb. The threat was coming from outside us. While there had been cancer movies before, it’s interesting that Love Story was released in 1970, the year that the US National Program for the Conquest of Cancer – that word, conquest – was set up.
Susan Sontag, Illness as Metaphor (1978) challenged the view of cancer as an invading predator, as not helpful to those with cancer. She explored the combination of the ‘fight’ or ‘crusade’ against cancer, and noted that these images existed alongside the idea that the patient was somehow to blame – that there was a ‘cancer personality’. So what’s the source? An outside enemy? The environment? Or something inside you – your genes?
Theories of cause changed a lot over the twentieth century. It was from the 1940s onwards that suspicion grew of an outside cause, smoking, as carcinogenic, but that was immediately disputed, not least because of the implications for the powerful tobacco industry; and once lifestyle decisions like this are seen as important, then individual behaviour also comes to the fore and cancer becomes a choice. But from the 1960s there was also emphasis on people’s jobs and the environment as factors. Asbestos was suspected to cause cancer from the 18thcentury onwards but it has a long latency period – such cancers can take many decades to develop, after exposure to it. Apparently when Hans-Wilfrid Wedler noted the link between working with asbestos, and developing cancer, back in 1943, his work wasn’t taken seriously because it came out of Nazi Germany. Politics can get in the way of medicine. Wider social factors, like the demand for asbestos and people’s working conditions, then affect individual behaviour. What looked like a choice may be no choice at all.
As for treatment, when it was believed that cancer started in one place and would spread, surgery – often very radical indeed – was the first line of attack. The problem with that was that it was possible that the cancer had already spread, before the surgery, so even very disabling and disfiguring surgery wasn’t going to make any difference to the patient’s chance of surviving. The development of anaesthesia and blood transfusion from the nineteenth century onwards meant that more and more radical surgery was possible – but it didn’t necessarily make a difference to the patient, and it led to more fear in the wider population. Think back to the graphic descriptions of surgery I looked at in the second of these videos. The earliest cancer drug therapies included nitrogen mustards, found to be effective when the American army was looking into the effects of these gases, and hormones – which could mean removing glands in order to change the level of hormones in the body. The problem with drug therapies is first that cancer cells can adapt and second that the side effects can be serious, as normal cells are affected as well as cancer cells. It seems that the huge amounts of money spent on cancer research in the 1970s as part of the War on Cancer had little effect on mortality or on the rates of survival after treatment. And then there’s radiotherapy: it emerged as a treatment after the First World War, but it was very expensive indeed, and worldwide radium was in short supply.
It seems clear now that there is never going to be one treatment, one drug, that cures all cancer. Which is why the Gustavus Adolphus conference on biotechnology was so important!
To find out more:
Calloway Scott’s account of reading the Hippocratic treatises and Galen to make sense of his own cancer: https://medicalhealthhumanities.com/2019/01/29/de-atra-bile-an-autobiography-of-cancer/
For Galen on bile: Mark Grant, Galen on Food and Diet (2000)
Keith Stewart, Galen’s Theory of Black Bile: Hippocratic tradition, manipulation, innovation (2018)
Nixon and the ‘War on Cancer’, https://www.cancer.gov/about-nci/overview/history/national-cancer-act-1971
David Cantor (ed.), Cancer in the Twentieth Century (2008)
Robert Proctor, The Nazi War on Cancer (1999)
Mistaking histories 