The Fight Against Cancer

France 1890-1940

Patrice Pinell, David Madell

• Publisher: Taylor & Francis
• Year: 2003
• eBook ISBN: 9781134467563
• Edition: 1
• Topic: History
• Subtopic: World History
• Index: History

Between the two World Wars an illness that mainly affects adults over fifty years old became so prominent that it superseded both tuberculosis and syphilis in importance.
As Patrice Pinell shows, the effect of cancer in France before World War Two reached far beyond the question of its mortality rates. Pinell's socio-historical approach to the early developments in the fight against cancer describes how scientific, therapeutic, philanthropic, ethical, social, economics and political interest combined to transform medicine.

1 A fatal and incurable disease

Rheims owes the distinction of being the first town in the world with a ‘cancer hospital’ to the compassion of a Jansenist Canon. But, little realising the future historical interest of the project, the majority of the inhabitants tried to oppose it. They even went so far as to send a petition to the king for the institution to be set up elsewhere. The intendant of Champagne responsible for sorting out the matter dismissed the complainants and the hospital was able to open its doors in 1742: it was to operate in this way for a century, and then lose its specific nature and become a hospice annex for incurable patients of all types.

Having fallen completely into oblivion, the Rheims experience was resurrected at the beginning of the twentieth century when a thesis was written. The candidate, Ledoux-Lebard, dealt with a previously unpublicised theme (as the subject of his thesis), that of the ‘Fight against cancer’. The approach was critical and emphasised the shortcomings of French medicine regarding cancer organisation.¹ In this subtle but still dangerous exercise, which consisted of emphasising the superiority of work done abroad – principally in Germany, the United Kingdom and the United States – the hospital founded by Canon Godinot allowed Ledoux-Lebard to preserve national pride. Even in this area, where delay nonetheless occurred, the French were forerunners. This ‘completely new initiative’, presented as the first tangible sign of a will to fight cancer, became a compulsory reference in the cancerology promoters’ argument. In 1926, Doctor Pol Gosset, delving into the Rheims hospital archives, wrote its history, and called this ‘cancer hospital’ the forerunner of the cancer centres.² In addition, when retracing the controversy which took place over its creation, he opposed the open-mindedness of the instigators to the false beliefs of the inhabitants, who, persuaded that cancer was a contagious disease, were hostile to it being established in the town. But this flattering vision, inspired by the wish to establish a bridge between the past and the present does not hold up to the analysis of the documents which he himself mentioned in his text.

Charitable spirit and sense of opportunity

In 1738, Jean Godinot, Canon, doctor of theology, Vicar General of the Sainte-Chapelle in Paris and Vicar General of the Abbaye Saint-Nicaise in Rheims, made a donation of 14,000 livres to the administrators of the Saint-Marcoul hospital to ensure its support in perpetuity of two poor cancer sufferers, on condition that they were Christians and natives of Rheims. The man was moved because ‘the poor of this town who have been affected by the disease that is vulgarly known as cancer are not sufficiently cared for’.³ The Rheims General Hospital, although charged by two royal decrees (the first by François II, the second by Charles IX) with the care of cancer sufferers, did not rest until it had succeeded in abandoning this duty, going so far as to give small amounts of money to patients to get them to go home.

Its administrators explained: ‘After several visits to all the sites of this General Hospital, [they] recognised that it was overcrowded everywhere and that cancer patients could not be sheltered in it without harming other patients and even the public, as the General Hospital is in the heart of the town.’⁴ The cause of its potential harmfulness was the stench which their badly bandaged wounds produced. The ‘stench’ was not just bad odours in the sense in which we understand them. According to the medical opinion of those days, marked by the renewal of ‘Hippocratic airism’, stench, pestilence or anything which contributes to the production of polluted air is a source of infection and a menace to those exposed to it. A cancer patient whose bandages are suppurating is a nuisance and a danger if he is enclosed in a limited space with others, since there is overcrowding. Hence the argument which puts forward the topography – of the hospital firstly (it was crowded everywhere) – and of the place it occupied in the city area (in the town centre).

Mindful of these arguments, the Canon considered another hospital, Saint-Marcoul, because it was situated in a large green area in the ‘fresh air’. But there he met with a rejection. Saint-Marcoul was a special hospital reserved for patients with ‘scrofula’. The medical arguments advanced by its administrators returned to the risk of infection:

Scrofula is a scirrhous tumour which you recover from, but cancer is a hard tumour, full of melancholic and silted blood, which is so incurable that, according to doctors, it is the worst disease that affects man. These two types of disease are infectious, therefore they infect each other. The individual affected by scrofula, in this weak state is very susceptible to poor air, and far from getting better, runs the inevitable risk of being at any moment infected by an incurable disease.⁵

Once more, the arguments seemed irrefutable to the Canon, who did not persist and decided to look for other solutions. His obstinacy was finally rewarded.

The administrators of the General Hospital, who should not have been completely unaware of the amount of the donation (which in the meantime had risen to 25,000 livres), decided to turn a house that belonged to them in the Bourg Denis into a hospital exclusively reserved for cancer patients. They argued that the house was surrounded by gardens and built on a plot with only a very narrow strip opening on to the road, thus ensuring favourable conditions for isolation. The donation was made, the site was ready to be arranged, when the inhabitants of the Bourg Denis using the same arguments protested and presented a petition to the king for the hospital to be built elsewhere.

The intendant of Champagne, after hearing the different parties, took the side of those responsible for the General Hospital who, even if they acknowledged the ‘bad odour of cancer suppurations’, denied ‘formally, with all the doctors and pharmacists and from the most extensive experience, that the air was infectious and contagious’⁶; the proof of this was that the servants of a rich middle-class person did not get cancer, nor did the charitable ladies who took care of cancer victims. The ease with which these same persons were capable of developing opposing arguments, according to whether they wanted to refuse to accommodate the cancer patients in the General Hospital or to explain that grouping them together in a special hospital did not pose any risk to neighbouring citizens, at least showed the vagueness which existed regarding the possibility of transmitting cancer. The weight of the argument concerning the ‘most famous experiment’ did not overcome the doubts, since a site guaranteeing isolation was chosen. In this type of uncertain situation where, at the end of the day, all arguments were valid, decisions were taken according to pure social influence. If the hospital was finally built in spite of the protests of the neighbouring population, it was because they were confronted with a more powerful coalition of interests centred around the donation. The General Hospital became more prosperous (under acceptable conditions for its efficient operation, cancer patients would be kept apart) and the intendant of Champagne was certainly mindful that a large part of the money would fill the kingdom’s coffers. In other words, it could be said that it was a long way from a victory of medical enlightenment over working-class obscurantism.

It is very difficult to see an outline of future cancer treatment centres in the cancer hospital. The staff who looked after the few patients (the number of beds was to increase progressively from two to twelve) would decrease to one nurse carrying out the job of manager and to one, then two maids. Even if the establishment received a weekly visit from two nuns, the doctor himself visited it only occasionally, whenever the need to treat an acute case was felt to be necessary. This same doctor (practising in the General Hospital) confined himself to the annual examination (in March) of the patients ‘well enough to be sent home to their families’.⁷ Under no cicumstances was there a question of his undertaking the slightest cancer treatment, an abstentionist line which was perfectly in tune with the institution’s mission. Canon Godinot had wanted to remedy the unjust situation of certain cancer patients only. The criteria for admission specified that patients to be received were the poor with ulcerated cancers. If doctors sometimes tried to treat cancers by various methods, including cauterisation or surgical removal, while having few illusions on the effectiveness of their method, they did not risk attacking ulcerated cancers. A person seen at this stage was considered an incurable patient, someone whose disease would never improve because it thwarted the vis medicatrix naturae, the ‘healing force of nature’. Medical orthodoxy adopted a relatively fixed position of non-treatment on this point, as remedies, whatever they were, were only complementary to the action of nature and could only, since the latter was impotent, be harmful.

The cancer hospital was from the beginning an ‘asylum for incurables’. It was established in the eighteenth century, when the king gave his approval to the Cardinal of La Rochefoucauld to establish an institution ‘conceived for the well-being and the relief of our poor subjects afflicted with incurable diseases and to remove a hideous and pitiable spectacle from the eyes of the people’.⁸ It was, as with all asylums, a question of offering a refuge to unfortunates ‘whose condition renders them incapable of earning their living by working or begging’,⁹ and to alleviate in some way a social disability which became evident when the tumour opened to the exterior and ulcerated. The need felt to open a special establishment for incurable cancer sufferers did not come from any concern for treatment. It arose from the refusal of other hospitals to accept the patients, a refusal which, we have seen, originated from the uncertainty of medical knowledge on the question of the ‘contagiousness’ of cancer. Is this refusal peculiar to Rheims? Historical information is not sufficient to provide us with an answer. One thing at least seems certain, the hospital, after a century of operation, was transformed into a hospice annex for incurables and was to disappear without there being any emulators, even in Paris, which was, after all, the city where institutional specialisation appeared the most advanced.

Cancer was, therefore, one of those diseases where it was thought that treatment and care were not matters for any particular institutional measure, even though, as we shall see later, the admission of patients into general hospitals could be problematic. In order not to stop at this simple declaration and to understand the reasons for a situation which would last for the whole of the nineteenth century and until the First World War, it is necessary to make a detour and replace the question within the context of the changes in the medical field brought about by the French Revolution and their conceptual, institutional and political incidence.

The modern hospital and clinical medicine: origin of new knowledge about cancer

On the eve of the Revolution, there was no real institution devoted exclusively to the ‘art of healing’. General hospitals fulfilled the functions of care, asylum and police at the same time. They received poor patients, but were also used to confine vagrants of all types, and many had a custodial section.

The opening of special establishments sometimes originated from a decision to isolate patients affected by an epidemic (thus the Saint-Louis hospital was built in Paris in 1607 in order to be used as an isolation hospital for the ‘pestiferous’). More often, it was in response to initiatives from Church officials (Canon Godinot for cancer patients, the Cardinal of La Rochefoucauld for incurables, Abbot de l’Epée for the deaf-and-dumb). Their purpose was not to respond to a specific medical problem, but to supply a refuge for those categories of people unable to make a living.

The revolutionary crisis and its developments were to profoundly affect this situation by changing, chiefly, the nature of the hospital in order to transform it into a more ‘specialist’ institution in the study and treatment of diseases. After having advocated closing hospitals for a time, the Republic began to favour reforming the institution by removing its police role. The hospital’s provision of health care created a new structure able to generate new attitudes in doctors. The charitable aspect became secondary, or, more specifically, was viewed in a different light, a tacit agreement between the rich and the poor whereby, in return for the care taken of him, a poor man offered his body for medical research, so contributing to the gathering of knowledge about the disease. This is the origin of the clinic examined by Michel Foucault,¹⁰ a new step emphasising observation at the expense of theory. From this there progressively emerges a rearrangement of the classification of diseases based on a concept of disease inspired by sensualist philosophy, which broke with centuries of ‘humoralism’. The classification of symptoms (fevers, coughs, pains, etc.) into pathological entities was based on the idea of lesion – the disease is in a local area, indicated by the seat of the lesion which is revealed by pathological anatomical examination. Using the post mortem to cast light on the in vivo, the ‘clinic’ invents a whole arsenal of observation techniques (percussion, palpation, auscultation) using the senses, as well as instruments in order to amplify acuity (the stethoscope), or facilitate examination (the speculum), which revolutionised diagnosis.¹¹

Cancer occupied an important place within the intense output of which the Ecole de Paris was the epicentre. With the decline of the humoral theory and the growth of localist ideas, it changed ‘nature’ to become, according to Bichat, a disease of the tissues, affecting the intimate structure of the organs.¹² At the same time, as descriptions were refined and typologies were elaborated, distinguishing between different forms of cancer according to the nature of the tissues affected, more and more internal organs were discovered which were likely to provide a seat for cancer, and the differentiation between malignant and benign tumours became established pathological anatomical foundations. Until then, because of a lack of pertinent criteria, differential diagnosis of benign tumours and malignant tumours was carried out according to the progress of the disease; Laënnec differentiated from cancers serous cysts of the kidneys and ovaries as well as uterine fibromas. Bayle identified benign breast tumours. The concept of cancer as a local disease also led to a different thinking about the way it developed and its dissemination. C.A. Récamier established the first meticulous descriptions of the metastatic phenomenon. In fifty years, the vision of cancer profoundly changed, even if, at one time, new knowledge considered today as ‘an important advance’ was waiting in the wings of a medical scene occupied by the theories of Broussais (who saw the origin of all diseases, including cancer, as a local inflammation of the intestine). It had to wait until his doctrine was discredited in order to come into its own.¹³ However, this major turnaround in knowledge had no direct impact on the treatment field. This contradiction was not peculiar to cancer. The Ecole de Paris had made few innovations in the area of treatment and professed a scepticism bordering on abstention. If we set aside the fashionable treatment of ‘fasting and leeches’ (the famous antiphlogistic method invented by Broussais, which he advised for cancer), healing methods had hardly changed and pessimism was in order. The gloomy reflections in Geoffroy’s Manuel de médecine pratique published in 1800 were topical until the last years of the century.

Internal cancer is always incurable and fatal, the doctor can only try to alleviate and calm the acute pains which the patients suffer. When external cancer is confirmed, there is no recourse but removal. This is often impracticable if the cancer is adherent, useless if other glands are already engorged and if the mass of blood is infected with the cancerous evil; and however beneficial such an operation might seem, when circumstances become more favourable, very often the cancer affects another gland and at the end of a certain time, the same illness appears in another part of the body.¹⁴

Certainly, Claude Anthelme Récamier may well have dared and succeeded in carrying out, in 1829, the first total hysterectomy on a cancer of the womb, but this feat was too closely associated with the amazing skill of the surgeon to be repeated. Of the twenty-one patients who had a hysterectomy in 1832, none survived the operation: so it was quickly decided not to repeat the experience.¹⁵ Similarly, if Lisfranc removed certain cancers of the rectum (the first in 1826) and could boast about an ‘acceptable’ postoperative result (five patients out of nine), his relative success remained ‘technical’, as the patients still died of recurrences.¹⁶ At best, some progress was made in accomplishing palliative operations, such as the diversion of the intestine to the surface with the insertion of an artificial anus, conceived by Amussat and attempted for the first time in 1839.

The invention of anaesthetics (chloroform and ether) made these various attempts possible. It also, and above all, encouraged surgeons to operate more on breast cancers, long considered as the most favourable site for removal. The poor rate of success obtained, however, hindered this trend and certain surgeons openly questioned the relevance of their intervention. An enquiry by Leroy d’Etiolles, dating from 1844, showed that survival at thirty months was less frequent in women who were operated on than those treated by drugs or who remained untreated. Having said this, in each case, survival was an exception (18 out of 1,192 for those not operated on, and 4 out of 804 for those operated on).¹⁷ We understand that in this context where any method could be attempted, eclecticism reigned supreme. Broussais’s leeches, the grey lizard treatment once advocated by Bayle,¹⁸ treatments with zinc or cod liver oil favoured by Velpeau¹⁹ were not, from experience, more or less effective than surgical removal. If the latter seemed more legitimate, it owed this particularly to the prestige attached to the profession. In other words, in practice, the contribution of ‘clinical knowledge’ to cancer did not fundamentally change the status of the patients who all remained incurable. The twofold task of a place of study and care in a hospital was hardly exercised, as the condition of the cancerous patient was recognised as being beyond the reach of treatment. Hence there was a confirmed tendency to discharge him, so that he did not take up the bed of another patient for whom hospital care might be beneficial. Moreover, he was not the only one in this position. By becoming a medical institution, the modern hospital tends to be differentiated from a h...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Acknowledgements
• Introduction
• 1 A fatal and incurable disease
• 2 The first successes in treatment
• 3 Academicism and marginality
• 4 War and the birth of the Anti-Cancer League
• 5 The beginnings of a policy for the fight against cancer
• 6 The policy for the fight against cancer
• 7 The rise of ‘big medicine’
• 8 Between science and charity
• 9 Publicity, education, supervision
• 10 A modern illness
• Appendices
• Notes
• Bibliography