Despite its prominent position in today's medical research, popular culture and everyday life, cancer's history is relatively unwritten. Compared to the other great ‘plagues’ – cholera, tuberculosis or tropical fevers, to name but a scant handful – cancer has few dedicated pages in the general surveys, and its specialists have largely failed to convince the broader community of medical historians – or indeed historians of anything at all – that histories of the disease can tell us fundamental things about the science and practice of medicine, both past and present. Moreover, cancer has a remarkably stable profile over time, at least in terms of its definition, language and terminology – a detail that only makes the disease's absence from historical literature more surprising.

Certain site-specific cancers have received more scholarly attention than others. This is particularly true of breast cancer, which has, since the women's health movements of the 1970s, held a more prominent place than other cancers in both academia and activism.Footnote ¹ Moreover, cancer has generated a few longue durée accessible and popular studies, but by and large histories of the disease focus on the twentieth century, or at least the fin de siècle onwards.Footnote ² Two recent books on the history of cancer are thus very welcome: Emm Barnes Johnstone and Joanna Baines's The Changing Faces of Childhood Cancer: Clinical and Cultural Visions since 1940 (2015) and Alanna Skuse's Constructions of Cancer in Early Modern England: Ravenous Natures (2015) are reviewed here in turn. Each book, in its own way, prompts us to think about cancer's scarcity in histories of medicine that look before 1900.

One explanation for this absence could be that cancer is conceived of as a twentieth-century disease. Running through popular perceptions of cancer, as well as academic histories, is an association between the disease and modern life. There is a widely held and persistent belief that cancer only emerges onto the stage in the mid-twentieth century. This emergence is understood as political and social – that is, when cancer was supposedly first subjected to public programmes of research, provided with large-scale fundraising plans and debated in Parliament. It is also understood as epidemiological: cancer is, for many, an unintended consequence of modern styles of living and post-industrial life. Both books contend with this relationship between cancer and modernity, albeit obliquely and in very different ways. In The Changing Faces of Childhood Cancer, the paediatric disease moves from unknown in the 1930s to known in the present day: it follows a rapid, and very modern, trajectory. Barnes Johnstone and Baines thus adhere to, and confirm, this chronology of cancer as a peculiarly twentieth-century phenomenon. This is partly a product of their chosen focus. Childhood cancer appears only rarely in the medical literature of the nineteenth century and before, and much of the discussion about age and the disease prior to 1900 constructs cancer as a disease of bodily degeneration in later life. Thus Barnes Johnstone and Baines's dates make sense for their particular speciality. However, they do make several unhelpful generalizations about the state of cancer research and the prevalence of cancer discourse before their chosen time period. This gives the impression that certain key features of the medical history of cancer that they cover in their book – specialization, hospitalization, clinical trials, innovation in treatment, press appearances and registries – are more novel than studies of previous centuries suggest. In what follows, I gesture to various other ways in which both books deal with this chronological restriction of the history of cancer, before concluding with some of my own speculations about the historiographical ‘location’ of the disease.

While Barnes Johnstone and Baines do reify this problem of cancer's absence from pre-twentieth-century histories, they do so in service of enlarging the discussion in other ways. The chief ambition of their book is to establish childhood cancer care as separate from its adult iteration. The first chapter is dedicated to the development of childhood cancer as a set of diseases with different aetiology, pathologies and prognoses to those of adult cancer, and the parallel development of paediatric oncology as a distinct discipline from adult oncology. The book as a whole argues that since the 1940s, a new professional and medical value was recognized in seeing childhood cancer as a ‘disease apart’ (p. 24). In this way they explicitly require the reader to rethink what cancer was and is. It challenges us to consider cancer's plurality: it is simultaneously one disease and many, and the degree to which medical and lay communities consider it as one or the other is historically and culturally contingent. Barnes Johnstone and Baines argue that in the 1930s the category was subdivided. Childhood cancer was made substantively different from adult afflictions, but still recognizably the same disease with the same name. Barnes Johnstone and Baines expand the visibility of cancer in terms of ‘who’ rather than ‘when’. They also ask us to think about the impact of institutional and professional structures on the making of cancer knowledge. The aforementioned subdivision was dependent on factors beyond just the clinical details of the disease. This provides us with a useful corrective to existing longue durée histories of the disease which uncritically take cancer knowledge – if not experience – as stable across time and space.

This question of disease construction is followed through in the second chapter, on the rise of childhood leukaemia. Barnes Johnstone and Baines claim that in the early years of the twentieth century, leukaemia would not have been described as a cancer by researchers or clinicians. While it is beyond the scope of their book, in the nineteenth century the disease was defined by its materiality and could only be treated by surgical methods. Indeed, its identification as a tumour was in part dependent on its categorization as a surgical malady – the preserve of fledgling and then mature surgical expertise. As an aside, a theme that runs throughout Barnes Johnstone and Baines's book is the development of chemotherapy as a viable – and subsequently more effective – alternative to surgery. This reverses the trend of the nineteenth century, when surgeons reconfigured cancer as a malady that could not be effectively treated by internal medicaments. Leukaemia's cancerous nature was eventually demonstrated in the 1930s. In The Changing Faces of Childhood Cancer, the category of cancer is expanded to include paediatric maladies, and the definition of the disease is made more plural. In restricting their breadth, they can layer in greater depth the history of cancer.

Nonetheless, Barnes Johnstone and Baines do offer a chronological corrective of sorts. The inclusion of leukaemia into the cancer category by early twentieth-century doctors allows the authors to contend with one of the key recurring themes in the history of the disease. The last two centuries have been marked by repeated crises over perceived increases in cancer incidence, and debates have raged over whether these increases have been ‘real’ or ‘apparent’. In other words, is cancer's burden on society increasing, or are ‘cancer epidemics’ the product of improved diagnosis, increased hospitalization, longer life expectancies and the reduction of infant mortality?Footnote ³ Barnes Johnstone and Baines interrogate one such sudden increase in the incidence of childhood leukaemia in the 1950s. In post-war Britain the number of cases of acute leukaemia in children rose substantially; this was in part explained by new and more efficient cancer registers. However, the number of children diagnosed with cancer in all its forms was also going up after 1945, and there was a particular surge in leukaemia that could not be explained by better diagnosis and registration alone. Barnes Johnstone and Baines's spike in leukaemia was effected by all of the above. Not only were more children being accurately diagnosed after the Second World War, but also the introduction of antibiotics likely affected the incidence of leukaemia, as children who might have otherwise been killed by infection were now surviving infancy. There was, also, a ‘real’ increase, caused by pregnant women receiving X-rays. This discussion thus places cancer within a matrix of causative factors, and gestures towards the complexity of the disease. It also probes the question of cancer's relationship with modern life, and forces us to think through what ‘modern life’ means in this instance. Is it accurate diagnosis, is it effective public and preventive health, is it pharmacological advance, is it improved life expectancy, or is it increased environmental toxicity?

Barnes Johnstone and Baines contend with various features of modern medical life: specialization, ‘big pharma’, clinical trials and press coverage. However, it is only in the last two chapters on the final decades of the twentieth century that the authors contend explicitly with the lived experience of cancer. While historians of adult cancer in the twentieth century can make use of a plethora of oral histories and personal accounts, historians of paediatric disease are rarely given insight to the interior lives of patients. The authors make certain efforts to overcome this dearth of patient narrative, but the book only really confronts the misery and hope that are the two sides of the childhood cancer coin at the very end when the authors follow the trajectories of three individual children and look at survivorship in the 1980s and 1990s. While Barnes Johnstone and Baines offer traces of pain, suffering and desperation in earlier chapters, there is little space devoted to how these diseases might have impacted young people. For example, there is only brief speculation as to what the emotional and physical cost of invasive, life-changing surgery might have been. Childhood cancer patients were subjected to excision of the eye, limb amputation, X-ray therapy and high doses of radiation over broad areas of their infant bodies – procedures that would have entirely restructured their participation in everyday life and in their communities. However, that Barnes Johnstone and Baines have chosen such a harrowing field of study perhaps explains their reluctance to confront fully the tragedy and tactility of childhood cancer. Moreover, that their chosen time frame is so recent only exacerbates the emotional ‘rawness’ of the subject matter. Their book, and the history of cancer more generally, would thus be well served by an increased focus on the history of emotions, both to contend with the emotional burden and labour that accompany living and dying with cancer, and to think through the emotional cost of studying such a disease.Footnote ⁴

While cancer in the early modern period was predicated on an entirely different way of interpreting the human body and its afflictions, Skuse argues that it nonetheless had much in common with our twenty-first-century malady: cancer then is recognizable to us now. She claims that ‘cancerous disease “existed” in the early modern period, in the sense of there being a distinctive malady known as “cancer” which was broadly contiguous with the illness sharing that name today’ (p. 25). Here she compresses historical time, drawing together understandings from periods separated by centuries. She usefully argues for a long-term continuity in cancer definition, and in doing so makes cancer a more accessible subject for scholars of a greater diversity of time periods. She explicitly challenges the belief that the disease springs anew and fundamentally different in the twentieth century.

If Barnes Johnstone and Baines faced a challenge in the age of their subjects, Skuse has had to contend with a scarcity of source material on the lived experience of cancer sufferers due to her chosen time period. Skuse makes use of a wide variety of source material, from medical tracts and treatises to plays and poetry. The words of patients are refracted and mediated through the words of the doctor. Descriptions of disease are thus a product of both perspectives, melded together. Nonetheless, she is still fundamentally interested in what cancer meant to both the medical community and the laity. The literary bent to this book is made clear in Skuse's attendance to metaphor and analogy. These are not just descriptive devices, but also shaped how people understood and experienced the disease, and many are familiar to us today. She argues that cancer was made into a knowable ‘object’ through its discursive connection to the crab – that in this one creature writers collected together the disease's diverse manifestations and characteristics (p. 30). Similarly, cancer's relation to the early modern gendered body was made, in part, through its metaphorical links to generation and reproduction. Not only did the disease appear to manifest most frequently in female sex-specific organs – breasts and uteruses – cancer tumours’ semi-sentient status also shared much with the nascent life of conception and pregnancy. Cancer was correlated to pregnancy, but also frequently metaphorically connected to a ravenous wolf or infiltrating worm. Skuse devotes the third chapter of her book to zoomorphic images of cancer and argues that this perception of cancer as ‘creatural’ has persisted into the twenty-first century (p. 72). These various ways of imagining the disease constitute metaphors in cancer – analogies used to describe and make sense of the malady's causes and characteristics. However, Skuse also discusses metaphors of cancer – and it is here that she deploys her literary background to its greatest effect. In her fourth chapter, on cancerous growth and malignancy, she suggests that early modern medical practitioners were keenly aware of cancer's malignancy in a clinical sense; that is, the ability of cancerous tumours to grow and metastasize. She does not, though, confine herself to the clinical, but examines the ‘interchange between medical and politic or polemic texts’ (p. 75). In this way she contributes to the heretofore limited scholarship on the meanings of malignancy in the early modern period, and recognizes the interconnectedness between medical and non-medical rhetoric. This is partly made possible by the idea that medicine in the early modern period is in some way more metaphorical than medicine in the twentieth century.

Histories of twentieth-century cancer have drawn on the oral histories and personal narratives produced in the last fifty or so years that craft and adhere to new conventions of illness narratives and the therapeutic benefits of writing through trauma. It is thus comparatively easy for historians of modern disease to incorporate the patient perspective. Nonetheless, Skuse is keen to foreground the words and experiences of early modern cancer sufferers, and takes seriously the ‘felt reality of pain and physical degeneration’ (p. 12). This commitment is evident throughout the book, and makes for an emotionally engaging and oftentimes distressing read. This is, of course, appropriate, as cancer was, and continues to be, both emotionally engaging and often distressing. In a particularly compelling passage on pain as a diagnostic tool, she quotes descriptions of cancer as a ‘corrosive, cruel and terrible pain’ (p. 29). Historians of cancer are repeatedly confronted with such suffering, which is often told through phrases and references that are familiar to us in the twenty-first century (even if we might understand them differently). That cancer is still very much a part of our contemporary lives perhaps makes these histories particularly emotive.

However, the focus on text and language in Constructions of Cancer could have been supplemented by an engagement with sensory history. This kind of methodology has been largely underused in the history of cancer, and thus has managed to escape the baggage that attends many of the different ways of thinking through the disease, past and present. How cancer is embodied is one way of looking at the changing lived experience of the disease over time. Such an engagement with the somatic would also add texture to our understanding of the relationship between cancer sufferers and their bodies. While Skuse does gesture towards the sensory signs and experience of cancer, her book is still predominantly about the written word and the visual features of the disease. She reproduces many and various richly descriptive quotes about tactility, pain, smell and taste without fully engaging with the cultural history of each and all together. Moreover, any attempt to get in touch with the interior lives of patients that does not include an appreciation of the senses and emotions can only offer a single dimension of the disease. This critique also has ramifications for the history of science more generally, a discipline that has tended to privilege intellectual and visual culture over the multifaceted sensory make-up of scientific practice, both past and present.Footnote ⁵ A study of cancer surgery, for example, can only be so compelling if it does not interrogate surgical practice, which must, by nature, include an investigation of the tactility – for both surgeon and subject – of excisions and amputations. This critique could, too, be levied at Barnes Johnstone and Baines. However, it is easier to imagine where the senses might fit into Skuse's book than in The Changing Faces of Childhood Cancer. This is likely another product of cancer's association with modernity. In a world where the gross and grotesque only rarely feature in portrayals of the twentieth- or twenty-first-century patients’ clinical experience, the senses seem stripped from the contemporary cancer experience.

Constructions of Cancer makes for a useful parallel to Barnes Johnstone and Baines's book. Skuse covers the period between 1580 and 1720, and argues that cancer was prominent in life and medical discourse in early modern England. She usefully challenges the association between cancer and modern life – and in particular extracts the disease from the twentieth century. This is an invaluable contribution to the field, and will hopefully prompt further work on the premodern history of the disease. However, her end point is unsatisfying. There seems to be no obvious justification for the book finishing with the early eighteenth century, when the theories and practices of cancer she describes persisted well into the nineteenth century and, in the case of cultural significance, arguably later. There are, of course, many crucial differences between cancer in the eighteenth century and cancer in the nineteenth, but a more appropriate cut-off point might have been institutional or professional changes in medicine rather than shifting disease theory. Finally, there is little sense of change over time in Skuse's narrative. This ahistorical tint is deepened by the scarcity of dates attached to the various quotations and pieces of evidence she deploys. This is an obvious critique of a literary scholar for a historian to make – that her literary methodology renders her text decontextualized – however, it is important to emphasize that this methodology actually brings much to discussion of past cancer. For one, her approach makes moving through historical time far easier. While Barnes Johnstone and Baines are fettered by their framing of cancer as modern, Skuse's alternative disciplinary background is liberating. It allows her to think about the pre-twentieth-century history of the disease, and to fully deconstruct any sequestering of medical language from broader cultural discourse.

These are two very different books: style, substance and centuries set them apart from one another. Comprehensive enough to be read independently of one another, and likely they will each find their place in the historiography of early modern and modern medicine respectively, read together they provide depth, breadth and texture to the historiography of cancer, and orbit around many of the same questions and problems posed by the disease. They provide the chronological scope to fully appreciate the continuities and change present in the history of cancer. The early modern disease is simultaneously recognizable and alien to us as twenty-first-century observers. However, what is left out of both books is as intriguing as what is included. It would be interesting to see the mirror image of each book for each time period: a cultural history of cancer in the twentieth century that applies Skuse's lens to more modern discourse and disease construction, and an early modern medical history of the disease that reconstructs cancer's social and proto-professional landscape in that period. For example, does cancer appear as a cause of death in bills of mortality, and, if so, with what frequency? There is, in other words, still much to be written in the history of cancer.

Research into the field would be advanced by producing some syntheses of the two books’ approaches. For cancer is, in some ways, the archetypical disease that blends social, cultural and political concerns. This means it is particularly ripe for analyses that integrate multiple lenses. It is object, experience and symbol, and has achieved a particular status in society. It is the diagnosis you do not want to be given, and for many people it has become synonymous with death. It is now a near-universal experience – with almost everyone living with cancer, dying from cancer, or caring for someone with cancer, and even in early modern England it had become a recognizable trope that meant something to a broad spectrum of readers, writers, speakers and listeners. And, after all, questions about the nature of life itself do not belong exclusively – or even mostly – to medicine. Rather, cancer forces the historian to come face to face with the inevitable facts of death, disease and decline, and to situate those facts historically.

In addition, the intervening 210 years are still relatively absent from recent histories of cancer. The nineteenth century is particularly prominent in the historiography of British society, politics, economics, industry and medicine. It is the century that is supposed to have made Britain modern. Why, then, is cancer so absent, and is its conceptualization as a modern disease sufficient to explain its scarcity? Perhaps cancer's history does not align with pervasive understandings of the nineteenth century as a period of progress. The disease did not succumb to the professional, institutional, scientific or therapeutic innovations that took place prior to the 1900s. Both the medical and non-medical literature on cancer from that period records a self-conscious narrative of failure. Moreover, while we can imagine ourselves to have departed from the other major themes of nineteenth-century medicine – infectious disease, maternal mortality, insane asylums – we cannot convince ourselves that cancer is a problem solved. Cancer, therefore, disrupts any still-nascent belief that, in the history of science and medicine, things – as well as people – just get better.