History of Cancer Care

First Steps in a New Century, 1901-1927
by Henry K. Sharp, Ph.D.
*edited for online viewing, see book for full text

In the late summer of 1907, a farmer from Rockingham County, Virginia, took a lengthy trip over the Blue Ridge Mountains to Charlottesville.  Nearing the end of his journey, perhaps he stepped off a day-coach vestibule onto the platform at Union Station or instead observed the country road widening into a street as he approached the town by highway.  However he came to Charlottesville, the pain in his jaw must have troubled him and he sought relief.

A mile from the center of town stood the University of Virginia, where a modern, new hospital had opened its doors six years earlier in 1901. According to the hospital’s admission records, which begin in 1907, cancer was among the first diseases treated at the UVa Hospital.¹ Moreover, the first of those patients recorded was the farmer who had traveled from Rockingham.  He presented with a sarcoma of the lower jaw.² Stephen H. Watts performed the surgery and the patient “left shortly after [the] operation,” evidently without explanation, only to return nine days later for what was to be a more drastic treatment: “removal of 1/2 lower jaw.”³ Watts discharged his patient after thirteen days’ stay, condition “improved.”

The case of the Rockingham farmer is significant to the larger history of cancer treatment at the University of Virginia in several ways and not merely because he was the earliest identified cancer patient.  Consideration of this early case also extends to what the farmer’s diagnosis, behavior, and therapy communicate about cancer as a disease and a cultural phenomenon at the beginning of the twentieth century.⁴ While medical practitioners have recognized a disease called ‘cancer’ since antiquity, little progress in effectively treating the malady had been made through the centuries.  Many cancers had to be manifest in plain view to be identified for treatment and those that originated inside the body had also to become palpable or painful before recognition.  This limitation severely restricted a twentieth-century physician’s ability to treat cancer just as it had a practitioner of antiquity.

Patients often did not enter into the care of a physician until the disease was quite advanced, as in the case of the Rockingham farmer. Pain drove patients to seek medical care.  By the time our farmer arrived he would have been in considerable distress.  Unfortunately, with the treatments available at the turn of the century, this meant that patients often came far too late to treat the disease successfully.  Of the forty cancer cases which presented at the hospital in that first recorded year, 1907-1908, sixteen had to return home with conditions too advanced for therapy of any kind and seven died in the hospital. The delay in seeking medical care limited the possibility of remedy and necessitated more invasive methods when cancer was found.  The escalation of the Rockingham farmer’s treatment to a drastic surgery also demonstrates that even if one left the hospital, prospects were not good.  Cancer was indeed a “dire malady.”⁵

No one whom the disease struck would have been able to consider his or her chances of survival good.⁶ Most patients understood cancer to be a death sentence with or without medical intervention.  Although those forty cancer patients would have arrived at UVa at different stages in the course of their respective diseases, it is unlikely any expected a cure (no matter how one defines it) but only temporary relief from the disease.  To a degree then, hospitals functioned only to diagnose cancer and to alleviate pain.  The long-standing conception of cancer as incurable must have weighed heavily on the attitudes of patients, like the Rockingham farmer, and physicians alike. The change in mentality regarding the hospital as an institution capable of promoting improvement or cure, instead of being a place to die, would be slow in coming and require a shift in understandings of and treatments for cancer.

In contrast to other maladies, cancer struck not just the young and old of society, but primarily those in middle-age who formed the back-bone of economic and social life in America.  Indeed the majority of those first forty cancer patients at UVa were middle-aged; twenty-six were between the ages of forty and sixty.  The disease represented a grave menace to society due to its prevalence in the adult population.

Yet, despite discouraging cancer statistics and continuing despondence over the success of available cancer treatments, there were also developments of promising medical research and more sophisticated surgical procedures at the dawn of the twentieth century.  Additionally, the role of education in changing behaviors and views about cancer emerged as a critical element in the narrative of cancer worldwide. A number of hospitals, research institutes, and associations devoted to cancer studies were organized and professional journals uniquely concerned with cancer topics were published.

The May 1911 issue of the Virginia Health Bulletin was the first statewide publication devoted to cancer education.  It was also during this period when physicians and public health officials recognized that early intervention improved an individual’s response to treatment, and thus practitioners and patients could influence the outcome of cancer diagnosis. Public education efforts were a key factor in changing concepts of cancer treatments and their outcomes.  Importantly then, the Virginia Health Bulletin pursued many of the critical public education objectives that the American Society for the Control of Cancer began to publicize two years later.  Public education has evolved over the century, and with greater understanding of the risks and benefits of various therapeutic regimes, patient involvement in decisions concerning medical care has come to be regarded as a critical component in the process of treatment.

In the spring of 1913, a spate of articles addressing the diagnosis and treatment of cancer appeared in publications intended for lay readers.  The articles in magazines, such as Collier’s, Harper’s Weekly, McClure’s, and Ladies’ Home Journal, effectively launched a public discussion of cancer for the first time in the United States.⁷ Many local and regional publications subsequently entered this national dialogue.⁸ These articles encouraged patients to seek diagnosis and treatment for suspected cases of cancer, and galvanized physicians and nurses treating those patients.  There was a uniform emphasis on the importance of competent, professional medical advice and treatment.  Sponsoring organizations and cancer-related journal articles were at pains not only to communicate the importance of public knowledge about cancer in general, but also to reinforce public confidence in professional scientific institutions and methods.  Individuals were to feel confident that physicians could diagnose cancer and prescribe helpful remedies if only individuals would take the necessary step of seeking out medical care from a professional physician. All the authors agreed that early medical treatment was crucial to increased chances of survival.

Professionalization and improvement of medical care is a central theme in the historical development of cancer treatment, complementing the campaign for public education.  In the 1890s, the University’s Board of Visitors approved changes to the medical curriculum.  These improvements included lengthening the period of time for scientific study and instilling a greater emphasis on clinical training.  Paul Brandon Barringer, appointed professor of physiology and surgery at age thirty-two in 1889, led this movement to reformulate the curriculum of the medical school.  The length of study was extended from one year—as it had been since the first medical class entered in 1825—to two years starting in the academic year of 1893.  Microscopic studies were integrated into the medical curriculum for the first time and the period of study was again lengthened — first to a three-year program in the 1897 session and finally to four years in 1900.  The School of Medicine at UVa was modernizing to keep in line with the new standard of conduct for professional doctors—to reinforce the knowledge and skills they saw as setting physicians apart from uneducated competitors and bringing greater success in treating diseases.

The medical faculty continued to press for a full-service hospital, recognizing its utility both to public health in general and the education mission of the University.  The idea of a full-service hospital, in actuality, was at the core of the evolution of the medical school’s curriculum and of the commitment of the new faculty.  In 1893, the medical faculty recommended building a hospital on university grounds not merely to better serve the needs of the student body and local community, but also to provide essential clinical training for medical and nursing students and to become a venue for medical research.⁹ The hospital would allow for the fusion of education and community needs.  By the spring of 1899, the Board of Visitors had approved initial disbursement of funds for the project.  The new UVa Hospital opened in April 1901.

While negotiating for funds to run the hospital, Barringer also enacted a plan to expand the hospital staff in order to better meet the goals of fusing modern treatment for patients with professional clinical education at the new hospital.  He hired Charlotte Martin to be Superintendent of Nurses for the hospital, under whose attention the initial organization of the University’s School of Nursing took shape.¹⁰ As a result, student nurses began to receive a full two years of professional training while providing necessary patient care.  The hospital likewise continued to offer more sophisticated clinical experiences for medical students who in turn cared for patients.  The medical faculty established a more structured system for the clinical education and service of medical students at various levels of experience.

Richard Henry Whitehead, appointed Dean of the Medical School in 1905, quickly moved to make changes that would have a direct impact on patient care. He raised the entrance requirements for medical students and elevated the academic basis of the new clinical departments to that of the established sciences, such as biology, anatomy, and physiology.  With the improvements in clinical facilities and a greater emphasis on academic research by clinical faculty, in essence, the entire hospital became a clinical laboratory.  In 1910, when Abraham Flexner published his famous review of every medical school program in the country, the University of Virginia obtained a superior ranking within the state and region precisely because of its modern clinical facilities and its association with an academic research institution.  The UVa program had a clear advantage over the more common, but poorly funded and less professionally staffed proprietary schools.¹¹ Significantly, Abraham Flexner’s 1910 report on national medical education assessed school quality in reference to the Hopkins standard.¹² The influence of both the Hopkins curriculum and the Flexner Report in the reformulation of medical education, and hence the profession, cannot be overestimated.  And the early adoption of principles upheld by both at UVa greatly advanced the University’s reputation.

Subsequent to the Flexner Report, a number of state leaders made a series of attempts to combine the University of Virginia program with that of the Medical College of Virginia in Richmond.  They reasoned that the larger population of the state capital would provide a greater and more diverse patient pool, and that state funding might be more efficiently applied to a unified institution.  The persistence of these initiatives into the 1920s proved distracting to a certain degree, but ultimately could not withstand the strength of the investment in physical and human resources already well-established and growing in Charlottesville.¹³

It was in 1896 that an article titled “On a New Kind of Rays” appeared in the journal Nature, introducing Wilhelm Conrad Rontgen’s recently discovered X-rays to an English-speaking audience.  Scientists quickly grasped the diagnostic and therapeutic potential of X-rays, and equipment was manufactured and installed in many hospitals across Europe and America.¹⁴ At the University of Virginia, diagnostic machines were in operation no later than autumn 1908. By 1917 the Alumni Bulletin made it clear that,

far more important, both in the treatment of patients and in teaching equipment, is the provision of special rooms in which to carry on the diagnostic and therapeutic procedures which constitute the work of a modern hospital.¹⁵

Advances in scientific research in the fields of surgery and X-rays took place in late-nineteenth- and early-twentieth-century Paris. Antoine-Henri Becquerel, a physics professor, isolated uranium as the source of these images and immediately published his findings in 1896.  Becquerel’s physicist colleagues Marie Curie and her husband Pierre, a professor at the renowned Sorbonne (University of Paris), undertook further experiments and isolated the radioactive elements radium and polonium in 1898.  Together the three scientists shared the 1903 Nobel Prize in Physics.¹⁶ Scientists had quickly realized the therapeutic potential of X-rays for superficial lesions and recognized the similar potential of radium soon after its discovery.   Beginning in 1901, medical experiments with radium were conducted at the Saint-Louis Hospital in Paris and at other sites throughout Europe.  Becquerel’s 1903 Nobel Prize lecture addressed some of these initial efforts to develop radium treatment regimens for cancer.¹⁷ Paris remained the center of research into radioactivity, in large part as a result of Marie Curie’s leadership.

It was the intervention of the Great War though, which appears to have propelled the University of Virginia into the radium age.  A number of University Hospital physicians and nurses staffed the military Base Hospital 41, established during the war at Saint Denis, France, a suburb of Paris.  During their service, they gained exposure to the work of the Parisian scientific community, and intensive wartime experiences with ‘roentgenology’—the field that became radiology and radiotherapy—provided them the skills to pursue these advances at home.  On February 12, 1920, Watts, as senior surgeon, performed the first application of radium at the University Hospital, to a cervical case.¹⁸ Soon afterwards, Joseph L. Wright applied radium surgically in a case of carcinoma of the uterus so advanced as to be considered inoperable.¹⁹

The progress in cancer therapy brought to UVa after World War I was not, however, limited to radium.  Surgical pathology, as well, came into its own in 1920.  In this year the University hired a technician to perform tumor and tissue analysis exclusively, both for the house staff and consulting medical personnel.²⁰ It is important to note that although the treatment and diagnostic tools in cancer therapy were expanding, surgery remained the dominant force and center of cancer care.

In the 1920s, the medical faculty began to voice the need for a new facility to house the medical school, in order to unify medical education in a single complex and more closely link it to the hospital.  A new generation of faculty leaders would guide the medical program in this direction, and with it came the first specialized program to coordinate cancer treatment and study at the University: the McIntire Tumor Clinic.  These important developments kept the institution in the regional vanguard as cancer care came to be integrated into a greater number of medical specialties.

1. There are many names for the University of Virginia Hospital from its inception as a small institution to a large complex of medical facilities. Throughout the narrative we will refer to the hospital as contemporaries did. Some of the various names are the following: University Hospital, UVa Hospital, University of Virginia Medical Center, University of Virginia Health Sciences Center, and University of Virginia Health System. [↩]
2. Admissions Book no. 1, case no. 4, University of Virginia Hospital Record Books, 1907-1995, Claude Moore Health Sciences Library (CMHSL), University of Virginia Libraries. [↩]
3. Admissions Book no. 1, case no. 41, University of Virginia Hospital Record Books, 1907-1995, CMHSL. [↩]
4. Scholars, including historians, sociologists, and anthropologists, have all explored how individuals and societies conceptualize disease. Although multiple layers exist, there is both the physical (or we would say biological) existence of disease and the network of social, political, and religious ideas about disease generally and certain diseases in particular. The ‘construction’ of disease and its treatments through social and cultural means is essential. See, for example, Charles E. Rosenberg and Janet Golden, eds., Framing Disease: Studies in Cultural History (New Brunswick, N.J.: Rutgers University Press, 1992), xiii and xiv. [↩]
5. “Cancer: What Our People Should Know about It,” Virginia Health Bulletin 3, no.5 (May 1911): 67. [↩]
6. The following compilation of Hospital Admissions Book no. 1 cases was done by the author and lists the evaluation of the patient upon departure from the hospital. Medical Service, 3 total cases: 1 no treatment, 1 unimproved, 1 deceased. Gynecological Service, 1 case: no treatment. Surgical Service, 33 total cases: 13 no treatment, 6 deceased, 6 well, 5 improved, 1 unimproved, and 2 condition not noted. Service not noted, 3 cases: 1 no treatment, 1 improved, 1 well. The three “service not noted” cases occurred within the first six weeks of recorded admissions, so I suspect the lack of assignment in the ledger was an oversight. They were most likely surgical cases, as Watts was listed as attending physician. Additionally, after this initial six-week period of recorded admissions, all gynecological cancer cases were assigned automatically to the surgical service rather than the gynecological service. The one gynecological service assignment recorded had Watts as attending and likely would have been switched to surgical service if treatment had been pursued. Of the three medical service cases, a Dr. Magruder took charge of one and a Dr. Davis of the other two. It is not clear if those patients listed as deceased had been operated on before their death or if they died before beginning a plan of treatment. [↩]
7. Barron H. Lerner, The Breast Cancer Wars: Hope, Fear, and the Pursuit of a Cure in Twentieth-Century America (New York: Oxford University Press, 2001), 30. [↩]
8. See, for example, articles in Harper’s Weekly, Collier’s Weekly, McClure’s Magazine, Ladies’ Home Journal, and Journal of the Medical Society of New Jersey during 1913-1914. [↩]
9. UVa Catalogues, and John Staige Davis, History of the Medical Department of the University of Virginia 1825-1914, ([n.p., 1914]), 13. [↩]
10. Barbara M. Brodie, Mr. Jefferson’s Nurses: The University of Virginia School of Nursing, 1901-2001 (Charlottesville, Va: University of Virginia, 2000), 3-5; UVa Alumni Bulletin, n.s., 2, no. 1 (January 1902):127-128. [↩]
11. Abraham Flexner, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (New York: Carnegie Foundation for the Advancement of Teaching, 1910), 315-316. Also, UVa Catalogue and UVa Record lists of students, 1905 to 1915. [↩]
12. Lerner, 23-24. [↩]
13. Staige Davis, History of the Medical Department of the University of Virginia 1825-1914, ([n.p., 1914]), 16-17; Theodore Hough, “The Proper Location of the State-Supported Medical School in Virginia,” UVa Alumni Bulletin, 3d ser., 14, no. 1 (January 1921): 5-7. [↩]
14. Richard F. Mould, A Century of X-rays and Radioactivity in Medicine, with Emphasis on Photographic Records of the Early Years (Bristol and Philadelphia: Institute of Physics Publishing, 1993), 1, 20 and 108. [↩]
15. Theodore Hough, “Medical Education at the University,” UVa Alumni Bulletin, 3d ser., 10, no. 1 (January 1917): 58. [↩]
16. Mould, 10-12; Jean-Jacques Mazeron and Alain Gerbaulet, “The Centenary of the Discovery of Radium,” Radiotherapy and Oncology 49, no. 1 (December 1998), 209. [↩]
17. Jean Dutreix, Maurice Tubiana, Bernard Pierquin, “The Hazy Dawn of Brachytherapy,” Radiotherapy and Oncology 49, no. 3 (December 1998): 223, 228; Nobel Foundation, Nobel Lectures, Physics, vol. 1, 1901-1921 (Amsterdam: Elsevier Publishing Company, 1967), 66. [↩]
18. Two days later, he performed the operation on a different patient, this time without anesthesia which indicates there was no incision. Surgical Record Book no. 5, 12 and 14 February 1920, University of Virginia Hospital Record Books, 1907-1995, CMHSL. [↩]
19. Surgical Record Book no. 5, 5 March 1920, University of Virginia Hospital Record Books, 1907-1995, CMHSL. [↩]
20. UVa Alumni Bulletin, 3d ser., 13, no. 4-5 (Aug- Oct 1920): 338. [↩]