How can the very old come to define the very new? The ailments that make up a collection of diseases labelled âcancerâ are described in ancient manuscripts, depicted in millennia of human artifice and exposed within prehistoric human remains. As a species we have always lived with malignant tumours and wasting death. Nevertheless, there is something undeniably modern about cancer. 1 For over a century, the control of cancer has perhaps been the ultimate test of our medical prowess, a yardstick measuring our incremental control over nature and a testament to our unwavering expectation of longer, healthier lives, unhampered by disease and disability. The capricious and intractable nature of cancer has not, by and large, done much to sink our buoyant confidence in scientific progress but it has introduced a paradox, widely felt if not always acknowledged, that all is not well in our scientific age. The history of cancer in the twentieth century is at one and the same time a story of extraordinary optimism for a future mediated and enhanced through technology and a story of human fear and frailty in the confrontation of nature and technology. Charles Rosenberg described his view of this paradox of modern medicine in his book, Our Present Complaint, saying that we have,
Understanding and articulating this âdisconnectâ as Rosenberg describes it is at the heart of this book. How did cancer come to represent our greatest hopes and our most cynical fears for and about the biomedical enterprise?a characteristic disconnect: on the one hand, uncritical faith in the power of the laboratory and the market, on the other a failure to anticipate and respond to the human implications of technical and institutional innovation. And one of those dilemmas grows directly out of our expansive faith in technological solutions to clinical problems; as we are well aware, sickness, pain, disability, and death are not always amenable to clinical intervention. In the late twentieth century, such conflicts are both public policy issues andâinevitablyâelements in individual physicianâpatient relationships. 2
In writing this book I have chosen to focus on just one cancerâprostate cancerâfor a number of reasons, but primarily because it is a very common cancer with little said of it by historians and social scientists and one that perfectly exemplifies the paradox described above. The overwhelming focus of the existing historical literature on cancer has been on breast cancer and while this has been in many ways extremely worthwhile in exposing issues of gender inequality, medical and political paternalism, and issues of activism and so on, it does rather beg the question of why prostate cancer is so under-researched. The two cancers are after all in many ways strongly analogous if we consider what they have to say about social, cultural, and medical interpretations of gender, sexuality, and aging. It is my hope that other researchers with interests in these topics might subject prostate cancer to the same kind of detailed, rigorous analysis that has provided breast cancer and breast cancer patients with such a rich social and cultural history. It is not my intention in this book, however, to write a male version of the existing breast cancer literature. The history of prostate cancer has much to offer on its own accountâfrom a sexualized and pathologized account of masculinity appearing in the new scientific age, through to the creation of new spaces in academic medicine after WWII with integration of the (overwhelmingly male) patients of the Veterans Administration (VA), and the rise of activism that interpreted prostate cancer as part of a systematic exclusion of the interests of men and the male patient from mainstream medical attentionâthis book covers ground only patchily dealt with by existing literature, and, as such, I hope this book with serve as a meaningful contribution to the literature on the history of cancer. To take just one example, the recent controversy over the use of prostate-specific antigen (PSA) testing as a screening tool reveals so much of what is at the heart of Rosenbergâs âcomplaintââparticularly as it concerns overdiagnosis and overtreatmentâand yet that phenomenon too has received little attention from historians and social scientists.
My focus on academic elites in this book leaves it open to (not unreasonable) accusations that it is a kind of âgreat manâ history of medicine. The many remarkable studies I discovered while working on this project have caused me to single out the brilliant work of several individual researchers. In all the ways that matter though, this is not, I think, a hagiography or any kind of history of that narrow type. As I try to make clear throughout the book, the researchers did not make their famous discoveries as feats of virtuosity so much as they were the end results of collaboration between many men and, of course, women, whose work in the wards, clinics, and laboratories made transformational work practicable. That is simply the way science operates, especially as it became more complex in the long twentieth century. As I also try to make clear, the institutional frameworks in which these researchers operatedâwhether in the availability of careers, funds, space, equipment, or patientsâare crucial context. The final part of this brief mea culpa such as it is concerns the patient and his lack of voice in this book. This is a regrettable absence, and one I hope that this account by providing a resource for future historical studies on prostate cancer might help to ameliorate. To this end I have, when appropriate, delved into the political, economic, and cultural life of the disease, but there is much to be done if we are to have a history of male cancer as rich and instructive as that for breast cancer in women.
It might seem sensible to have started this study in the nineteenth century when prostate cancer was for the first time becoming widely discussed and debated in the newly forming era of scientific medicine. I decided to go further back than that in an attempt to do some justice to a story as old as humanityâthe terrible sufferings of men unable to pass their urine and the efforts of healers who tried to help them. As I describe in Chap. 2, sympathetic and compassionate accounts of these miseries date back thousands of years. That men experienced this painful, life threatening, âstranguryâ as a consequence as of their aging was well known to the ancient healers with education enough to record their practices (and more than likely to the many who hadnât and didnât). Doubtless, much of what they described we would now consider to be benign prostatic hypertrophy (another condition ripe for historical analysis), but such was not understood until much later. I have written inclusively in these early chapters of about âprostatic enlargementâ, understanding that causes other than cancer were at the root of the symptoms recorded in the annals of medicine.
We can see in the palaeoarchaeological record that cancer has been with us throughout our history but what we mean by the term âcancerâ has shifted and changed in often confounding ways. The word itself is a Latinized form of the Greek word karkinos found in the writings of the Hippocratics, but we might also reasonably claim that the idea of cancer is a much newer phenomenon than that arising from the cellular vision of the body and disease worked out by Rudolf Virchow and his colleagues during the mid-to-late nineteenth century. 3 If I included in this book everything âcancerâ signified in the Hippocratic sense, I would have to write a history of inflammation, a treatise on the soft and hard tumours, and an account of venereal disease, to name but a few things. 4 It is worth the effort, though, I think, to feel back in time and to not just pick up the story on the more familiar ground of ground of nineteenth century laboratory sciences.
Chap. 2 is also a story about anatomy and the changing nature of learned medicine. As the new spirit of autopsy (from the Greek autopsia, to see for oneself) permeated the dissecting halls of the great medical schools of the European Scientific Revolution so we get, thanks to Andreas Vesalius in the sixteenth century, the first detailed description of the prostate as an organ involved in reproduction. In the eighteenth century the anatomist Giovanni Battista Morgagni turned anatomy to the study of diseases, looking to locate and analyse lesions in the postmortem body that corresponded with symptoms in life. 5 Morgagni also recognized the prostate and regarded it as an important seat of disease, something likewise taken up by the famous eighteenth century surgeon John Hunter. 6 Old boundaries between physicians and surgeons were breaking down by Hunterâs time, and I use his work on the prostate to examine just why and how that was happening. Chap. 2 concludes with a review of âcancerâ as the concept was understood by the mid-to-late nineteenth century, both by laboratory scientists like Rudolf Virchow and by clinicians observing cancer, particularly prostate cancer, in their practice.
Chap. 3 is a study of how issues of cancer and diseases of the prostate were linked to the growth of urology as a surgical specialty. Ancient techniques to relieve urinary problems in men survived relatively intact well into the eighteenth and nineteenth centuries. What had changed a great deal more than the old instruments and practices of surgery by this time though was how diseases treated surgically were coming to be understood and investigated. Once again John Hunter appears in this account because it was he who did so much to place urology on a learned, academic footing particularly with his work on comparative anatomy. Although he himself stopped short of recommending it, Hunterâs observations on the role of the testicles in the function of the prostate encouraged some surgeons to try to use castration as a means of controlling prostatic disease. These operations were highly controversial and it is instructive to look back on the terms and tone of the debates especially as they coincided with moves to craft urology as a recognized surgical specialty at the turn of the nineteenth century.
Although not by any means uniquely American, the push to specialization in the US was particularly rapid as large organizations, including hospitals and universities, looked favourably on the philosophies of scientific management coming out of industry and brought them to their own institutions looking to increase efficiency and increase productivity. 7 One of this group of new specialists was the surgeon Hugh Young whose hugely influential work at Johns Hopkins in the early part of the twentieth century did a great deal to raise the profile of urology even as other surgeons despaired of ever emulating his successes. Young aside, there was an air of gloom within urology during the 1910s and 1920s. By then specialists had become adept at diagnosing prostate cancer even as they were quite fatalistic about what they could then do about it. Some perceived this issue to be one of timing: if general practitioners could be taught to not delay referring patients then they might have more of a chance to intervene. Others still believed that they were doing good by intervening surgically even in advanced cancers and once again we see how debates about restraint and heroic intervention can reveal much about specialties in the making.
Chap. 4 opens with a discussion of the new scientific experimentalism of the mid-to-late nineteenth century, exemplified by the research and writings of Claude Bernard. Along with bacteriology, immunology, and pharmacology, experimental physiology was one of the laboratory sciences underpinning a new style of âbiomedicineâ that helped forge a new identity for academic medicine and by extension to professional medicine as a whole. Abraham Flexnerâs famous report on the state of North American medical education published in 1910 is usually regarded as the turning point in the professionalization of US medical education, but reformers were certainly very active well before then. 8 Decades before Flexner took his tour of the nationâs medical schools to collect material for his report, elite physicians had seen reform of medical education as a means to regulate the profession as a whole by tightening and restricting the route into licensed practice. Indeed, Flexner himself made good use of these reform-minded elites when he held up Johns Hopkins School of Medicineâa school itself modelled on the German academic medical systemâas an ideal and a model to be emulated elsewhere. The Flexner report does, though, act as my turning point in this book. The US-focus that began in Chap. 3 continues for the remainder of Chap. 4 and is the exclusive emphasis in the chapters that follow. There is much to be said about prostate cancer beyond the US, of course, and I hope that others will say it. Because the historical literature on this common cancer is so small, though, the US demands the attention I give it in this book because of the sheer volume of important work that was done there. The elucidation of the biological nature of prostate cancer and the development of the means to treat and detect it is an overwhelmingly American story.
History is seldom about the new replacing the old, 9 and this is beautifully shown by what happened when the brilliant prodigy of Bernard, Charles-Ădouard Brown-SĂ©quard, revealed his glandular theories (and glandular extracts) to the world. 10 Embedded within and emerging from the experimental physiology that academic elites celebrated for the intellectual and cultural capital that it brought to them, Brown-SĂ©quardâs work nonetheless found a comfortable place in the âold-styleâ medical marketplace in the US. The obvious titillations of testicular extracts and the âmasculine rejuvenationâ they promised brought out some of the best (or at least notorious) of that old style, such as the great showman, John R. Brinkley (known across the country as the âgoat-gland doctorâ). While organizations like the American Medical Association (AMA) despised and despaired of such charlatanism, testicular extracts show that the old and the new styles of medicine existed cheek-by-jowl well into the 1930s. This was not simply a case of orthodoxy versus quackery, however. The quasi-respectable provenance of glandular theories (Brown-SĂ©quard had an impeccable scientific pedigree but he certainly attracted criticism) caused lines of respectability to become blurred. This uneasiness continued as several âre...