By Ashley Shirazi
The transformation in the human understanding of cancer reached a pivotal point during the late eighteenth century and on through various developments emerging in medical education, hospital expansions, print accessibility, and – most notably – in the routine reports by physicians and medical professionals on the common illnesses and trends they observed in their immediate area. In 18th and 19th century London, these reports were especially relevant to the advancement in medical practice and treatment through the work of the Medical Officer of Health (MOH) reports. Through these reports, statistical data about births, deaths, and diseases were featured. Although the reports stated solid numbers and statistics in their area, the officers were able to express the diversity of their local communities with specific concerns and trends in their area. This enabled physicians to identify growing health issues in their specific district of London, assisting the entirety of the city and the country through these reports. Within the vast array of health concerns written at the time, cancer was arguably one of the most devastating to afflict individuals due to the lack of proper treatments and understanding at the time. Of the diverse amount of cancers known, breast cancer has and continues to receive perhaps the most fascination not due entirely to its repute as a medical marvel, but to its theorized nature and social implications.
The female breast has been a symbol of beauty, fertility, and femininity for centuries. However, in medicine, it has challenged physicians and their treatments if not equally as long. Breast cancer has been mentioned in almost every period of recorded history, often in detail and in marvel (1). Due to the visible symptoms, especially at later stages, breast cancer is not easily overlooked or ignorable, specifically for the individual afflicted. Unlike other internal cancers, breast lumps tend to manifest themselves as visible tumors. Although historical writings mention lumps of the breast and the “disfigurement of beauty”, herbal remedies and calls for the divine would not be able to effectively cure the cancer (2). Despite the earliest known mastectomy being performed at least as early as 548 AD, it was not until the surgical revolution in the 16th to 18th centuries did they become the most popular. Interestingly, mastectomies became one of the most widely operated surgeries for cancer in proportion to the amount of actual diagnoses (4).
In the 16th and 17th centuries, French physicians published extensive data on breast cancer operations. Claude-Nicolas Le Cat, a prominent French physician, argued that surgical therapy was the only method to treat this cancer. Henri Le Dran, another leading French physician, suggested that the removal of the tumor – which could only be done through surgery – could help treat breast cancer, as long as infected lymph nodes of the armpits were removed with the actual breast, often entirely (4). This led to the creation of the radical mastectomy. It is especially critical to note that, during the earliest surgeries of the time, anesthesia was not used, and the fatality rates after surgery were extremely high. Likewise, the disfigurement of the breast was inevitable, and most that underwent such surgeries were left with permanent scars. Even with the chance of survival after a diagnosis from these advancements in surgery, cancer continued to be regarded as incurable.
Likewise to their European neighbors, the medical profession in Britain broadly agreed on cancer’s ultimate incurability, although they were less uniform in their understanding of its origin. The disease was thought to develop from a range of harmful tendencies and events acting together (3). For breast cancer specifically, the essential biology of being female was mentioned in some of the earliest reports from the medical officers of health in London as one of the causes (Stoke & Newington in 1922, Acton in 1924), although later reports disproved this theory through the increase in male diagnosis (Coulsdon & Purley in 1952, Greenwich in 1971). Nevertheless, breast cancer continued to be regarded as the “female cancer”, and conclusions on the origin were attributed to faults of the female afflicted. These conclusions may have influenced the recorded number of diagnoses for breast cancer due to the social implications involved.
For example, in the 1925 report by the London City Council, it is mentioned that the comparison of that year’s records confirm the observation that breast cancer was “more frequent among the unmarried, and further shows that among married women the incidence is greater among those who have not suckled their children or are childless.” This hypothesis of the unmarried was not supported in data later on from other reports, such as Coulsdon & Purley’s report in 1935, as it is documented to be highest in women, older and married. There is no mention of whether the women are childless or how they fed their young in any other MOH reports available, while it is explicitly mentioned in Coulsdon & Purley‘s other reports that cancer in the breast can afflict any woman, regardless of age and lifestyle. The number of reported diagnoses in the London writings from 1924 through 1935 was sparse compared to those between 1936 and 1952. This change could be attributed to a variety of factors, but an increased comfort in visiting a physician may be a factor, as the social stigma from a diagnosis could have fluctuated.
Even with a possible shift in the social causes of breast cancer, reported afflictions may have increased during the mid-nineteenth century due to the improvements in surgery practices. The development of anesthesia and blood transfusions during this time made survival after surgery more possible. Diagnoses increased alongside the improved survival rates from the surgeries, suggesting that surgery was not understandably sought prior due to the possibility of pain and even death (4). In London, while the statistics noted in Lewisham‘s 1967 report show that there were men who were diagnosed with it, most men did not seek treatment until it began to affect their way of life (4). When analyzing the numbers in the numbers of diagnoses and actual surgeries mentioned from the reports, it appears both men and women felt perhaps ashamed of their cancer, but for different social reasons. Breast cancer was seen as an effeminate form of cancer due to the high prevalence in women. On the other hand, lung cancer was reported higher in males than in females, often seeing an increase in one and a decrease in the other during the same years. Lung cancer was not regarded as a masculine form of cancer, and incidence reports do show that it affected men and women almost equally, suggesting that when without the possibility of stigma, cancer reports could be unaffected.
Today, less than 10% of women undergo a mastectomy (2). This can be attributed to modern scientific developments in the therapies for breast cancer, such as hormone treatments, surgeries, and biological therapies. Although some MOH reports, such as those from Lambeth in 1969 and Wandsworth in 1972, encouraged the importance of routine at-home breast examinations, it was in the advent of mammographies that breast cancer detection has considerably increased (4). Although breast cancer typically affects women more than men, the number of male diagnoses appears to have increased over the years (4). Likened to the early 1900’s shift in breast cancer reports of women affected in London, men may feel more comfortable in seeking medical opinions involving such conditions as breast cancer. The social implications and stereotypes of breast cancer appear to have affected documented historical reports and may continue to today. While some forms and stages of cancer are extremely difficult to treat, negative social implications should not add any further to the hardships of cancer.