The evolution of oncology.

Abstract

THE EVOLUTION OF ONCOLOGY BARRIE R. CASSILETH* Cancer is a long-recognized disease, but oncology is among the most recent of medical specialties. Throughout the 4,500 years between the earliest known reference to cancer and its treatment (Edwin Smith Papyrus) [1] and the 1981 appropriation of over $1 billion to the U.S. National Cancer Institute, the symbolic power ofthis disease has helped define and organize attempts to combat it. The development ofoncology as a medical specialty reflects the ebb and flow not only of technical advance and scientific ideas but also and equally of cultural values and beliefs. The quantity and thrust of federal appropriations for cancerrelated work are illustrative. These appropriations are less indicative of the rational and relative "need" for such funds than of the symbolic meaning of the disease itself. Disorders of the circulatory system kill more people, eight other illnesses impose greater limitations on activity, and cancer ranks only sixth among reasons for hospitalization [2]. But federal legislators appropriate more than twice as much money to cancer than to any other illness [3] Cancer is imbued with special meaning, and it evokes a unique dread. It represents, perhaps, the "wisdom of the body" [4] gone awry, and financial outlays tb combat it symbolize our efforts to cope with the fear and inexplicability of an invisible and seemingly random process. Social conceptions and misconceptions about cancer have determined public support of activity related to this disease, played a role in the kinds of facilities erected to house the cancer patient, and helped guide the development of oncology as a specialty science. The history of the emergence of cancer medicine reflects the interdependent nature of scientific and popular ideas, therapeutic advance and research technolSupported in part by research grant CA 16520 from the National Cancer Institute. This article is a revised and expanded version of"The Evolution ofOncology as a Soçiomedical Phenomenon," in The Cancer Patient: Social and Medical Aspects of Care, edited by B. R Cassileth (Philadelphia: Lea & Febiger, 1979). It appears here with permission of die publisher. ?Director, Division of Human Resources Research, University of Pennsylvania Cancer Center, 7 Silverstein Pavilion, 3400 Spruce Street, Philadelphia, Pennsylvania 19104.© 1983 by The University of Chicago. AU rights reserved. 0031-5982/83/2603-0324$01 .00 362 J Barrie R. Cassileth · The Evolution ofOncology ogy, and an enduring cultural framework ofreaction to the homeostatic derangement which cancer seems to represent. This discussion is an attempt to integrate the various symbolic, social, and scientific elements which, in a mutually influencing fashion, led gradually but only recently to formal recognition ofthe specialty ofoncology, to development ofthe specialized cancer treatment setting, and to the reigning belief system that cancer should be attacked with research, money, and aggressive treatment. Twenty-four centuries ago Hippocrates delineated many forms of cancer, named it karkinos ("carcinoma") because the swollen veins sometimes associated with tumors suggested the claws ofa crab, and identified the illness as natural rather than magical or divine in origin [5]. Treatment of the disease is also ancient. Arsenic pastes were applied to spreading growths around 500 b.c., and in Galen's time the surgical technique of mastectomy was improved. By the sixteenth century, cancer's metastatic potential had been recognized and benign and malignant tumors differentiated. There was enough to say about the illness by 1721 for a surgical encyclopedia published that year to devote 210 pages to "cancer" and "tumors" [6]. The eighteenth century also saw the foundation of the first cancer hospital, created by Canon Godinot in 1740 in Reims, France [7], and development ofthe first cancer service in a general hospital, Middlesex, in London [8]. In what was the earliest recognition of an occupational or environmentally induced carcinoma, scrotal cancer ofchimney sweeps was described in 1775 by Percivall Pott, who developed a surgical cure and propounded social legislation which eliminated the disease within two generations. A landmark in the social history of cancer occurred with two important changes during the seventeenth and eighteenth centuries. Each of these shifts in perspective had important social and scientific impact, the ramifications of which are felt even today. First, the conclusion of Zacutus Lusitanus (1575-1642) and Daniel Sennert (1572...