Ton Van Helvoort Maastricht University Cancer Treatment Generally Comes

SCALPEL OR RAYS?

RADIOTHERAPY AND THE STRUGGLE FOR THE CANCER PATIENT * IN PRE-WORLD WAR II GERMANY

Ton van Helvoort Maastricht University**

1. INTRODUCTION

Cancer treatment generally comes in four modalities.1 Traditionally, surgery of tumours was the most important form of treatment, while radiotherapy, chemotherapy and immunotherapy were introduced as new forms of cancer treatment in the course of the twentieth century. While chemotherapy and immunotherapy did not become standard forms of treatment until after World War II, X-rays and radium were used as alternatives to the surgical knife in eliminating cancer cells soon after their discovery at the end of the nineteenth century.2 This essay concerns the way in which radiotherapy for the treatment of cancer took shape, especially in Germany, in the first decades of the twentieth century. The analysis concentrates on two aspects.

The first aspect is that of the struggle between the representatives of orthodox medicine, those using the scalpel in the fight against cancer, that is to say, general surgeons, internists, gynaecologists, dermatologists and oto-laryngologists, and those who perceived in rays a new, separate form of treatment of the cancer patient, i.e. the radiotherapists-to-be. When X-rays and radium were found to be effective in the combat against cancer, radiotherapists sought to create a niche of their own within the existing ecology of medical professions. In his System of Professions, Andrew Abbott argues that the establishment of a profession is best analysed in terms of tasks, jurisdiction and competition.3 The present essay illustrates that this ‘infighting’ over radiotherapy took the form of a struggle for the cancer patient and for jurisdiction over the use of the new techniques such as X-rays and radium.

The second aspect on which this essay focusses is the role of costly instruments and resources

* Will be published in Medical History, vol. 45 (1), 2001. © 1999 Copyright The Trustee, The Wellcome Trust. ** Dr Ton van Helvoort, Maastricht University, Faculty of Arts and Culture, Department of History, P.O. Box 616, 6200 MD Maastricht, The Netherlands. E-mail: [email protected]. Ton van Helvoort and their impact on the organisation of therapy. X-rays as well as radium could be deployed as small-scale or large-scale techniques. Their first therapeutic applications were small-scale, viz., X-ray tubes which had already been used for diagnostics were now applied therapeutically by merely extending the duration of the application; radium was used in milligramme quantities for superficial tumours. In the 1920s, however, a breakthrough had taken place. The X-ray instruments were now operated at several hundreds of kilovolts, and so-called radium bombs or canons, containing several grammes of radium, were designed for cancer therapy. In addition, more knowledge was available on the risks accompanying these techniques, e.g. those of skin burns or tumours. These specific conditions stimulated the establishment of large centralised institutes for cancer treatment and cancer research. At the 1926 congress on Cancer Control, held at Lake Mohonk, N.Y., Claude Regaud, director of the ‘Therapeutic Service’ of the Paris- based Curie Foundation claimed that the developments outlined above indicated the necessity of: “... calling in for the examination and treatment of patients, men of various specialties whose work must be exactly co-ordinated; of placing at the service of diagnosis and treatment different kinds of laboratories, all well equiped; of bringing together special X-ray apparatus which is numerous, heavy, and costly to purchase and maintain; of employing large quantities of radium—all this explains adequately the recent organization of anti-cancer therapy with a view to a work that is to be accom- plished by a collective staff, in special, well-endowed establishments.”4

In France, England, Sweden and the United States such centralised cancer institutes were indeed established in the first decades of the twentieth century, mainly supported by huge philanthropic donations. Although even in these specialised institutes a certain degree of rivalry would have existed between radiotherapists and medical specialists such as surgeons, internists and gynaecologists, these institutes were instrumental in the establishment of radiotherapy as an independent profession and in the development of a multi-disciplinary approach to cancer treatment. In Germany, however, radiotherapy lacked a centralised organisation until well after World War II, and fell under the jurisdiction of various specialties such as surgery and gynaecology.

This delay in the centralisation of German radiotherapy has been generally acknowledged.5 In 1959, the Swiss radiologist Hans R. Schinz stated that in the organisation of radiotherapy “Ger- many, Röntgen’s homeland, has curiously dropped behind ...”.6 And in a discussion of the development of German medical disciplines, Hans-Heinz Eulner concluded in regard to radiotherapy that the Anglo-Saxon countries, the Scandinavian countries and Switzerland were rather advanced in the centralisation of radiotherapy while in Germany “... the clinicians had opted for the principle of decentralisation”.7 Thus, German radiotherapy and specialised cancer institutes became institutionalised relatively late in comparison to countries such as France, England, Sweden and the United States.8

2 Scalpel or Rays?

The conflicts over the introduction of radiotherapy in Germany are well documented by archival and published sources, because around the 1930s a struggle developed over the ‘Institut für Krebsforschung’ (Institute for Cancer Research; ‘IfK’) of the Berlin Charité hospital. At that time, this institute was led by the Jew Ferdinand Blumenthal (1870-1941), who had also been head of the institute when it was established in 1903 by Ernst von Leyden. Von Leyden, who had been a professor of Internal Medicine in Straßburg before he was appointed head of the First Medical Clinic of the Charité in 1885, was Germany’s leading internist and became first director of the ‘IfK’. After a period in which the institute was led by others, Blumenthal had become director of the ‘IfK’ in the mid-1910s, and in the late 1920s he worked towards centralisation and regulation of German cancer control in general and of radiotherapy in particular. In this he was supported by the ‘Reichsausschuß für Krebsbekämpfung’ (State Committee for Cancer Control) which was inaugurated in 1931, signalling the first definite involvement of the German state in this aspect of public health. Blumenthal’s desire for centralisation, supported by the ‘Reichsausschuß’, met with powerful resistance from other Charité clinics, the medical faculty of the Berlin University and the German societies for surgery and gynaecology. In the early 1930s, the latter specialists successfully penetrated the ‘Reichsausschuß für Krebsbe- kämpfung’ and National-Socialist measures against Jews helped to ensure the neutralisation of attempts to centralise radiotherapy in Germany and to establish one or two national cancer institutes.

Thus, the actual development of radiotherapy in Germany differed from that in other countries such as France, England, Sweden and the U. S. A. It will be argued below that this was related to the strength of the German orthodox specialists, the costly nature of radium and the lack of German resources for radioactive substances, as well as to the absence of a philanthropic tradition with regard to cancer control and research and the reticence of the German state to support the latter.9 It must be admitted that the tension between surgeons and medical specialists on the one hand and radiotherapists on the other about the jurisdiction over the new cancer treatment modalities occurred in all countries, but the specifics of the German situation made them more visible and of enduring consequences.

2. INTRODUCING RADIOTHERAPY INTO CANCER TREATMENT

In the late nineteenth century, surgery was the standard treatment of cancer and had achieved a high level of perfectionism. The possibility of general anaesthesia had lessened the fear of operations and also allowed them to last longer. Furthermore, under the influence of the work of Joseph Lister, Louis Pasteur and Robert Koch, the use of antiseptics and a strictly aseptic pro- tocol had ameliorated mortality and morbidity.10 Surgical intervention in cancer was based on

3 Ton van Helvoort the consideration that early cancer was a local disease and only in a later phase did the tumour cells spread via the lymph nodes, after which the disease could establish itself in other organs (metastasis).11

In the first decades of the twentieth century, cancer patients constituted a quarter of the surgeon’s patients.12 For gynaecologists too, the treatment of cancer patients made up a substantial part of their daily activities. Exterior forms of gynaecological cancer, e.g. breast cancer, were relatively simple to deal with surgically. In many cases of cervical cancer, however, the tumour was difficult to access via the vagina. This mode of operation resulted in a high percentage of relapses, i.e. patients in whom the tumour returned or metastasis was not prevented. Difficult cases of cervical cancer were often approached via the abdominal wall (laparotomy) which amounted to a major operation in which the chance of recovery was heavily influenced by the woman’s constitution.13 In addition to these difficulties, there were many inoperable cases of cancer patients whose tumours were too large to be removed surgically or had fused with surrounding organs and tissues. Clearly there was need of an alternative to the scalpel.

In early 1896, Wilhelm C. Röntgen reported that, while working with a cathode tube, he had observed a new kind of rays.14 These he denoted as X-rays, to indicate that their nature was still unknown. Röntgen observed that these rays could pass through the fleshy part of a hand but were attenuated by bones. The visualisation of the inside of the body would prove to have an enormous impact on medicine, and even on the image man had of himself.15

Within diagnostics, X-rays was used in three ways, viz. in trauma medicine, bone diseases and fractures, and the search for corpora alienum such as bullets (‘Fremdkörpersuche’). Therefore, X-ray diagnostics was applied mostly within surgery, orthopaedics and internal medicine. Each specialism claimed the application of the X-ray technique to its own field of competence.16

In the early years of the twentieth century, the Surgical Clinic as well as the First and Second Medical Clinics of the Charité obtained their own X-ray departments. In 1901, the Second Me- dical Clinic, headed by Friedrich Kraus, got such facilities and three years later the First Medi- cal Clinic, headed by Ernst von Leyden, obtained them too. Furthermore, the Nerve Clinic, the Dermatological Clinic and the Medical Out-Patient Clinic had their own X-ray equipment installed.17

Soon after the discovery of X-rays and their amazing ability to pass through flesh, a second application was found for them. It was claimed that X-rays had a specific destructive effect on rapidly dividing tissue cells, especially tumours, compared to their effect on normal tissue.18 Because of the problems discussed above in relation to the surgical treatment of cervical cancer, X-rays were used by the gynaecologist Bernhard Krönig from Freiburg im Breisgau to treat this

4 Scalpel or Rays? disease, with highly promising results. In 1913 Krönig presented his results at the German Con- gress of Gynaecologists in Halle. This congress was a landmark in the application of radiotherapy to gynaecological cancer.19 According to Charité’s gynaecologist Walter Stoeckel, who will be quoted more extensively below, this congress at Halle was to become a historical event because of the jubilant atmosphere which spread “… right up to the most senior ‘Geheimräte’.” Prominent gynaecologists such as Albert Döderlein, Ernst Bumm and Carl Menge argued that if the results reported from Freiburg were to be corroborated, they would refuse to use the scalpel any longer.20

For those gynaecologists who tried out the new radiotherapy, it was beyond doubt that the new cancer intervention technique had a valid role to play. Carl J. Gauß from Freiburg, one of Krö- nig’s co-workers, and the radiotherapists Hans Meyer from Kiel and Richard Werner from Hei- delberg felt that the time was right for an independent periodical and in 1912 they established the journal Strahlentherapie (Radiotherapy).21 Werner was the radiotherapist at the ‘Samari- terhaus’ in Heidelberg, which had been established by surgeon Vincenz Czerny in the beginning of the twentieth century.22 Although Czerny was a surgeon, he clearly saw radiotherapy as having an important role to play in cancer treatment. In a short introductory note to the new journal, Czerny wrote that under favourable conditions radiotherapy “... can even replace the surgeon’s knife. Surgeons, who are constantly overburdened by the many different appeals made on their skills, will welcome being relieved of many thankless tasks. In fact, surgeons have recently learned to adapt to the needs of the radiologists, and will prepare patients for them by treating open wounds and by dissecting out or exposing tumours, etc.”23 Apparently, Czerny was willing to make surgery secondary to radiotherapy in the treatment of cancer, a position that was not shared by many surgeons. Although many cancer patients were in poor condition already, surgeons often did not hesitate to burden them with an exhausting operation. Much was at stake in the competition between surgery and radiotherapy: the status and authority of surgery with regard to cancer treatment as well as certain financial interests.

As was argued above, most medical specialists were familiar with the technique of X-ray diagnostics. The move from X-ray diagnostics to X-ray therapy seemed to be only a quantitative change. In the early years, for instance, X-ray therapy of cervical cancer was performed by the simultaneous application of two X-ray tubes placed on the abdomen and directed at the cervix, and a third one irradiating the cervix through the vagina.24

Two inventions, made during World War I, would make X-ray therapy much more efficient. The first invention was the ‘hot-cathode tube’ (‘Glühkathodenröhre’) which was developed by William D. Coolidge from Schenectady, N.Y., and the second was the ‘cascade transformer’. This more powerful apparatus necessitated a more efficient dosimetry in order to prevent se-

5 Ton van Helvoort rious injuries to the patient.25 Experts tried to solve the problems of quantification by giving a precise description of the instruments used, i.e., the construction of the tube, the electrical power and current applied, and the time period of exposure. Radiation was also empirically quan- tified in terms of the dose the skin could withstand, later followed by more precise methods of dosimetry such as colorimetry and the measurement of ionisation caused by the radiation over a specified period of time.26 In addition to X-ray therapy, however, there was a second type of radiation used in the treatment of tumours, viz. radium therapy.

3. RADIUM THERAPY IN GERMANY

In the context of the discovery of X-rays and their presumed relation to phosphorescence, An- toine-Henri Becquerel made a study of uranium salts. During one of these experiments, in early 1896, he discovered a new form of radiation.27 This discovery was elaborated upon by Marie (Sklodowska-)Curie who used a piezo-electrometer developed by her husband Pierre Curie to study whether this kind of radiation was also emanated by other elements. She found that thorium compounds gave evidence of the same property, and this new form of energy from uranium and thorium she named radioactivity. Subsequently she found that pitchblende (uranite; ‘Uranpecherz’) produced more radioactivity than could be explained on the basis of its uranium content. Apparently, a further radioactive substance had to be present, and her research resulted in the isolation of the element polonium, the discovery of which was announced in July 1898. Subsequently, a second element was isolated, which was named radium (announced December 1898) and possessed 2 million times more radioactivity than uranium. The fact that one part of radium had to be isolated from 4 million parts of pitchblende meant that enormous investments had to be made to isolate enough radium. At that time, the only uranium mine was to be found in Joachimstal, Bohemia, which was then under the authority of Austria (it is now part of the Czech Republic).28

The therapeutic effect of X-rays on dermatological disorders (for instance, lupus) stimulated the application of radium to this kind of disease as well.29 The application of radium to dermato- logy and benign tumours promptly resulted in striking improvements. Radium therapy was even used to heal skin lesions that had resulted from X-ray burns. Success was reported with malignant tumours too. Deeply situated tumours could be caused to regress by placing tubes containing radium deep into the tumour (interstitial radium implantation).30

As was mentioned above, the supplies of uranium were rather limited and as a consequence of the therapeutic application of radium, its price skyrocketed. In 1911, radium was found in car- notite (vanadium oxide) in Colorado (U. S.), which meant that an important additional source

6 Scalpel or Rays? of radium had become available. In Germany, however, the shortage of radium was dire.

In 1904, the German Emperor commissioned Paul Ehrlich to devote himself to cancer research. A few years later, Ehrlich was asked by the Minister of Science Von Trott zu Solz to report on the availability of radium in Germany for the treatment of cancer.31 Ehrlich argued that one metric ton of ‘Uranpecherz’ of the best quality only yielded 0.2 grammes of radium. The ore from Joachimstal had this quality and the French also had a radium production facility at No- gent sur Marne. The only German producer was Buchler & Co. at Braunschweig, and the only German uranium ore was delved in mines at Kreuznach, Bad Dürkheim and Baden-Baden. This ore, however, was of much lower grade. German scientists did manage to find an alternative for radium, however. From the residues of the production of thorium for gas mantles, the radioactive substance mesothorium could be extracted, which was also useful for radiotherapy.32

In a 1909 letter by Von Trott zu Solz to the German Emperor, the Minister presented an outline of the distressing situation regarding the availability of radium for cancer treatment in Germa- ny.33 In this report the world supply of radium (in the form of radium bromide) was assessed at 9 grammes, of which one third was under Austrian authority. Two grammes were held in the Institute of Physics at Vienna, while three-quarters of a gramme were on loan to England. In Paris, Marie Curie had one to one and a half grammes, while the rest was distributed over numerous institutes all over the world. The worrisome situation for Germany is clear from the following summary: in Berlin the ‘Akademie der Wissenschaften’ (Academy of Sciences) held 27 mg semi-pure and 8 mg pure radium bromide, while even less was available at the Charité and at the Technical University. Von Trott zu Solz argued that one quarter of a gramme was urgently needed to keep up with ongoing research. As the price of 1 mg radium bromide had risen from M 12 to M 150 over the previous decade, the Emperor was asked to make available M 37,500 for the purchase of that quarter of a gramme, which was to be supplied by the ‘Chininfabrik Buchler & Co.’ at Braunschweig.

In the previous section of the present essay it was argued that the first results of cancer treatment by radiation, presented at the Congress of Gynaecologists at Halle in 1913, were felt to be a medical breakthrough. In response to this excitement, August von Wassermann, who had devised the serological test for syphilis which was named after him, was asked in 1913 to evaluate cancer treatment by radium and mesothorium.34 Wassermann stated that the results obtained by treating tumours with rays emitted by radium or mesothorium were most promising and that clinicians were already becoming bold enough to speak of curing cancer. However, the action of these rays had to be a direct one, meaning that radioactive rays were ineffective where the tumour had already metastasised and the tumour cells had spread through the body. Wasser- mann reported that the gynaecologist Krönig made use of 400-500 mg of radioactive substance.

7 Ton van Helvoort

He also reported the production of mesothorium, the alternative for radium, to be difficult and costly. The German ‘Glühlicht Gesellschaft’ (Gas Mantle Company) had an annual production of 2 g, and in 1913 each mg cost M 200-300.35

Because of the price and scarcity of mesothorium, it was suggested in the press that its production should perhaps be brought under public ownership. Von Trott zu Solz advised the Emperor regarding the medical use of radioactive substances.36 He stated that medical treatment required at least a sample of 200 mg of radium or mesothorium (which could of course be used repeatedly) and that “... the areas of gynaecological disorders, surgery, skin and venereal diseases, internal medicine and ear, nose and throat diseases” were proper fields of use. In cases where radiotherapy did not cure, it was at least effective in killing pain, which was a valuable application of these substances in itself. Therefore, the Minister of Science had acquired 1250 mg of radium and 250 mg of mesothorium for a total budget of M 500,000. As regards the ‘Verstaat- lichung’ (nationalisation), Von Trott zu Solz had himself been advised by German’s most renowned chemists/physicists Otto Hahn, Emil Fischer and Walther Nernst. The latter arrived at the following conclusions.

Mesothorium was produced from monazite, which was mined in Brazil only. From 1 metric ton of monazite, 2-2.5 mg mesothorium was produced. If mesothorium was to be produced by the state, it would cost M 320-400 per mg, which was about twice the price current at that moment. Furthermore, numerous production installations would have to be bought, as well as various pa- tents which had to be compensated for.37 Worldwide, about 7 grammes of mesothorium were produced each year of which about 5 grammes were extracted in Germany. Furthermore, there was the real possibility of Brazil working up mesothorium by itself, just as was done in Austria in relation to the production of radium. In a report to ‘Ministerialdirektor’ (secretary general) Naumann, Walther Nernst therefore urged to keep the usefulness of mesothorium out of the public eye: “Let us hope the German press will not make too much of the importance of mesothorium, as this might lead to increases in the price that German industry has to pay for the raw material, i.e., monazite.”38

But there were other arguments for not bringing the production of mesothorium under public ownership. First, there was the real possibility that radioactive substances would shortly be produced artificially. Furthermore, in a report to Von Trott zu Solz, organic chemist Emil Fischer argued that in the near future tumours could perhaps be destroyed by making use of X-rays or chemotherapy, which implied that radium and mesothorium would no longer be indispensible. Fischer, a 1902 Nobel laureate, concluded: “I am therefore of the opinion that X-rays should be utilised, and that small, suitable machines should be constructed for this purpose.”39

8 Scalpel or Rays?

4. A RAY OF HOPE: THE ‘INSTITUT FÜR KREBSFORSCHUNG’, 1903-1928

The successes of medical science and bacteriology in particular, during the last decades of the nineteenth century stimulated a renewed attack on cancer. Despite the progress of pathology, the cause of cancer still was a mystery. In 1900 the decision was taken in Germany to organise a census or ‘Sammelforschung’ regarding cancer, in order to investigate whether proof could be obtained for the infectious nature of the disease. Chaired by Ernst von Leyden, head of the First Medical Clinic of the Charité, the ‘Komitee für Krebsforschung’ (Cancer Research Com- mittee) was founded. At the inauguration of this committee Von Leyden declared himself a proponent of the parasitical hypothesis in the question of cancer etiology: “The theory which is now gaining prominence, and to which I myself fully subscribe, is that of the parasitical nature of cancerous diseases. It is the only theory which is in sufficient agreement with the observations and with current biological views.”40

In order to confirm or refute this hypothesis, von Leyden established the ‘Institut für Krebsfor- schung’ (Institute for Cancer Research) in 1903, with Ferdinand Blumenthal as physician in charge. The institute was small, consisting of two barracks for ten patients each (one for men, one for women) and one laboratory barrack.41

In 1911, August von Wassermann reported on a presumed medical breakthrough in that he had found that transplantation tumours (i.e., tumours cultured by transplantation and thus not arisen spontaneously) in mice could be made to regress when the mouse was treated with a selenium compound. Although this was only an animal cancer model, it was received as a possible breakthrough for human cancer.42 Because of this apparent progress in cancer chemotherapy, and after the sudden death of Von Leyden in 1910 by a car accident, the institute was placed under the directorship of the chemist Emil Fischer, with Georg Klemperer as chief physician. Fischer and Klemperer pursued the application of chemotherapy, especially of selenium compounds, in cancer patients, but in 1914 it had to be concluded that this type of compound was without benefit in human cancer. Subsequently, Johannes Orth — who was Rudolf Virchow’s successor as head of the famous Pathological Institute of the Charité — was placed in charge of the ‘In- stitut für Krebsforschung’, although the de facto day-to-day management was in the hands of Ferdinand Blumenthal.

Blumenthal initiated a variety of experimental research projects, many of them experimental models which were unconventional for the clinician: transplantation tumours, chemical carcinogenesis by ‘Teerpinseln’ (tar painting) of mice and rats, Rous sarcoma in chicken, and crown galls of plants. To many clinicians, the relevance of such experimental models for the human cancer problem was by no means evident. One argument for this scepticism was the above-

9 Ton van Helvoort mentioned difference between the results of chemotherapy in animals and man as discussed above.43 Orth had also succeeded Von Leyden as chairman of the ‘Deutsche Zentralkomitee für Krebsforschung’ (‘DZK’; the former ‘Komitee für Krebsforschung’) and after the withdra- wal of the first secretary of the ‘DZK’ in 1919, Blumenthal took over this function.44

Even under Georg Klemperer, the ‘IfK’ had been in need of an outpatient clinic in order to contact patients as soon as possible, and to intervene in the disease process in its earliest stages. This would allow the latest diagnostic methods and therapies to be tried and evaluated. In 1911 Klemperer therefore asked ‘Ministerialdirektor’ Naumann for permission to open an outpatient clinic, arguing that there was special need of patients who had not yet been clearly diagnosed with cancer. Sometimes it took several weeks before the decision was made to operate on a patient and meanwhile the ambulant patient could be diagnosed in more detail. Subsequently, surgery could be performed at the surgical clinic. Klemperer emphasised that until then the ‘IfK’ had mostly received patients who were in a desparate condition. The reason was that the intake of patients was indirect, through referral from the other Charité institutes. This resulted in a situation “… in which our patients come from clinics which only allow them to come here after they have lost any practical medical or scientific interest in them and only the human aspect of euthanasia can be considered.”45 Ernst Pütter, the ‘Verwaltungsdirektor’ (administrative director) of the Charité, would underline the need of the ‘IfK’ of patients in “the various stages of the disease” and therefore of a ‘Poliklinik für Krebskranke und Krebsverdächtige’ (Outpatient Clinic for Cancer Patients and Cancer Suspects).46 The ‘IfK’s’ wish was to be fulfilled in 1915.

Klemperer’s letter, quoted above, reveals a tension between the ‘Institut für Krebsforschung’ and the other specialist fields which were involved in care for the cancer patient, such as surgery, internal medicine and gynaecology. Klemperer hastened to state that the ‘IfK’ would never admit patients to its beds who were operable; these were to be referred for surgery immediately. But there were also many tumours which were inoperable, such as those from the pleura, the lungs, the liver, spleen, thymus, stomach and, to some extent, from the intestine, as well as patients who had already been operated upon but had suffered relapses (often cases of cancer of the breast or cervix). Klemperer was aware of the resistance an outpatient clinic would provoke in the other Charité clinics, but as he assured: “There would be no competition with the surgeons whatsoever. Our department would select internal, inoperable cases or inoperable relapses of external cancers.”47 (Emphasis as in the original.)

After Blumenthal had been put in charge of the ‘IfK’, the relationship with the surgeons was one of careful manoeuvring. In a letter to the ‘Minister für geistliche und Unterrichts-Angele- genheiten’ (Minister for Educational & Spiritual Affairs) Blumenthal wrote that a useful cooperation had been established between his institute and the Surgical Clinic. Those patients who

10 Scalpel or Rays? were operable were referred, while the surgical department “… sends us the tumours removed at operation, and we use them to prepare a vaccine with which we immunise the patients in order to induce their bodies to form antibodies against tumour relapses.”48 Although Blumenthal stated that the relationship with surgery was more or less harmonious, ‘Ministerialdirektor’ Naumann informed Blumenthal that the Charité was mounting fierce resistance against the institute. Briefly, the argument was: “The scientific research was done in other institutes, while the cancer patients could be treated at the appropriate clinics.” However, Blumenthal also experienced firm support from, e.g., Johannes Orth of the Pathological Institute, who had been Blumenthal’s supervisor when he started his career, as well as from Ernst Pütter — the ‘Ver- waltungsdirektor’ of the Charité — and from Naumann himself.49

For its research into the etiology and treatment of cancer, the ‘IfK’ thus needed patients in the early stages of the disease. On the other hand, even the desperate cases of inoperable cancer patients had to be offered some hope, otherwise they would seek help with quacks, homeopaths, and ‘Biochemiker’.50 Blumenthal held the opinion that one had to fight cancer by, in current terminology, a multi-modality regime in which surgery, chemotherapy, radiotherapy and immunotherapy each had their own contributions to make. For Blumenthal, cancer treatment had to be comprehensive, with local control of tumours being implemented by surgery and radiation. This was supplemented by the systemic and constitutional treatment of the disease, in which chemotherapy and immunotherapy were additional treatment modalities, to aid the patient’s convalescence. Except for smaller surgical manipulations, no substantial surgery took place at the ‘IfK’.51 Under Blumenthal’s directorship, radiotherapy became the foundation of the ‘IfK’ on the basis of which even the most desparately ill cancer patient could be offered a ray of hope for recovery and at least some form of relief. This, however, was to bring Blumenthal and the ‘IfK’ into conflict with those who used the scalpel as the main weapon against cancer.

That the ‘IfK’ applied radiotherapy to a substantial number of patients with malignant and benign tumours is apparent from the numbers listed below, covering radiotherapy at the ‘IfK’ over six years from 1922 until 1927.52

11 Ton van Helvoort

Table 1

Radiotherapeutic treatment at the Berlin ‘Institut für Krebsforschung’ from 1922-1927

I. Malignant tumours:

skin 159

larynx 82

lungs and bronchi 34

oesophagus 152

rectum 131

stomach 68

bones and joints 53

mouth and pharynx 183

cervix 258

mammae 708

other locations 686

II. Other diseases: 1,353

Total: 3,867

In spite of Blumenthal’s reassurance that there would be no competition between his institute and those clinics where cancer patients were traditionally taken care of, the above data show that such a tension was hardly inevitable. Furthermore, Blumenthal had a critical attitude towards operating on a cancer patient. Relapses after operations were commonly explained on the basis of the argument that surgery had apparently been performed in too late a stage or that not

12 Scalpel or Rays? all cancer cells had been removed. Blumenthal, however, held the opinion that the body was able to destroy metastasised cancer cells through its immune system. But a major operation would exhaust the body and shift the balance of the struggle towards the cancer cell53:

“It often seemed as if the operation actually provoked a generalisation of the disease. This could be explained by assuming that even before the operation, biologically latent cancer cells are distributed throughout the body, which are then stimulated to grow as the organism is weakened by the operation.”

Obviously, the numbers in the table above leave unanswered the question of the therapeutic effect of radiotherapy at the ‘IfK’, and how this compared with the efficacy of surgery. As was shown in Ilana Löwy’s review of ‘The culture of clinical experimentation in oncology’, strin- gent clinical trials are a relatively recent phenomenon. Unsurprisingly, most pre-World War II studies did not report comparative results.54

During the first decades of the twentieth century, surgery had a poor reputation and a diagnosis of cancer was perceived as a death sentence. One critic of surgery stated in the early 1930s: “In- stead of telling us tales of the Arabian Nights, the surgeons and gynaecologists should tell us frankly how many patients treated by them were still alive 5, 10, 15 years afterwards.”55 In 1933 the Würzburg surgeon Fritz König held a survey in which 60 hospitals were addressed and 33 responded. Three thousand patients were reported to be free of tumours after 5 years, most of whom had been operated upon, while only a few had received no other treatment but radiotherapy. König concluded that “... even the most obdurate pessimist cannot doubt the effecti- veness of surgery in cancer control”.56

The Festschrift of the ‘Institut für Krebsforschung’ at its 25th anniversary did not contain figu- res about the efficacy of radiotherapeutic treatment. There are obvious reasons for this, however. First, radiotherapy was still in its developmental stage, so the technique was changing rapidly over time. Secondly, in 1939 radiotherapist Otto Jüngling from Kiel had analysed why comparative studies were so difficult to perform: the therapists had to work along strict rules of statistics; furthermore, the patients in the different treatment arms had to be in a similar clinical stage. According to Jüngling, only centralised cancer institutes could satisfy such requirements: “Such exemplary reports are available from large centers in Stockholm, Paris and Zürich and from American authors.”57

The question about the best treatment modality for cancer — surgery or radiotherapy? — led to tensions between those who operated rays and those who used the scalpel. This was the case in

13 Ton van Helvoort

Germany as well as in other countries. However, the fact that X-ray and radium techniques were developed into expensive instruments, and the dangers of X-rays and radioactive substances, stimulated the centralisation of radiotherapy in large treatment centers, as well as the establishment of organisations for the administration of the radium supplies, the training of staff to hand- le X-rays and radioactive substances and the introduction of new legislation. The virtual non- existence of cancer charities and the strong opposition against the centralisation of radiotherapy by the medical specialists meant that radiotherapy took a different course in Germany than in many other countries.

5. PHILANTHROPY AND RADIUM THERAPY OUTSIDE GERMANY

This section presents a brief overview of the development of radium therapy in France, Sweden, the United States and Great Britain.58 In these countries, the costly radium played a crucial role in the control of radium and the centralisation of radiotherapy.

In France, the ‘Laboratoire Biologique du Radium’ (Biological Radium Laboratory) was established in 1906 under the auspices of Armet de Lisle, director of a radium factory, and in 1912 the ‘Radium Institute’ came into being. One year later a cooperation in the field of radiotherapy was established between the ‘University of Paris’ and the ‘Pasteur Institute’, for which three main reasons were given: (i) to link animal experiments with clinical research; (ii) to ameliorate the collaboration between surgeons and radiologists; (iii) because the new equipment was so costly that only cooperation could justify the large expenses.59 The research into radium and its application was strongly stimulated when in 1921 Marie Curie received from the American Women’s Movement a gift of 1 gramme of radium. Furthermore, she was lent several grammes of radium by the parent company of the Belgian ‘Mines du Haut-Katanga’ (Upper Congo Mi- nes). At Villejuif, a southern suburb of Paris, Gustave Roussy established a new cancer center in 1920, which initially was rather small but soon saw major expansion. In the 1920s, a department of ‘tele-curietherapy’ (‘Fernbestrahlung’, ‘Tieftherapie’, deep therapy) had been established here, headed by Simone Laborde, in which use was made of a ‘radium bomb’ containing 10 grammes. In the late 1920s, only six of these instruments, containing such a massive amount of radium, were operational and two of them were located in Paris, one in Villejuif and the other at the ‘Radium Institute’.60

In Sweden, Tor Stenbeck and Tage Sjögren were the founding fathers of radiotherapy. They started with self-made X-ray machines which were used for diagnostics as well as for therapy. One of Stenbeck’s pupils, Gösta Forssell, was to become the nestor of Swedish radiotherapy. He worked at the ‘Serafimer Hospital’, the university hospital in Stockholm, whose X-ray de-

14 Scalpel or Rays? partment moved to a separate house nearby in 1910. This was named ‘Radiohemmet’ (Radio Home). Subsequently, both the city of Stockholm and the state of Sweden became involved in radiotherapy. In 1916 a new building was opened, with 34 beds for patients.

For the history of radiotherapy in Sweden, 1928 was a crucial year. On the occasion of the se- ventieth birthday of King Gustav V, the Swedish people offered him a present of 6 million crowns. This gift was passed on to the Swedish organisation for cancer control and was used, among other things, to establish centralised cancer treatment institutions.61 Gösta Forssell became an important spokesman for those who defended the centralisation of cancer control as the most effective way of organising it.

In the United States, the availability of radium had improved after the mid 1910s, when the ‘U. S. Bureau of Mines’ and the ‘American Institute of Radium’ — founded by Howard Kelley, a gynaecologist from Baltimore, and the engineer James Douglas — set up a radium production plant in Denver. Until 1922, when uranium ores were discovered in the Belgian Congo, the main part of all radium in the world was won in the United States. James Douglas donated his share of the company — in the form of several grammes of radium — to the Memorial Hospital for the Treatment of Cancer and Allied Diseases in New York.62 Headed by the surgeon Henry H. Janeway and the physicist Gioacchino Failla, the Memorial became a centre of expertise for radium therapy.63 Besides the Memorial at New York, the Collis P. Huntington Memorial Cancer Hospital in Boston was also an important centre.

In England, N. S. Finzi, the author of the first 1913 textbook on radium therapy, brought together 600 mg radium for the treatment of a millionaire suffering from cancer of the bladder in 1911. During World War I radium was used in airplanes, for dials and indicators, and at the close of the war the Royal Air Force had a surplus of 5 grammes of radium, which was donated to the Medical Research Council. The MRC loaned the entire 5 grammes to the ‘Middlesex Hos- pital’ in London, predominantly for the treatment of cancer but also for experimental work. However, within two years the radium was split and divided over several clinical institutions. In 1929 the British ‘National Radium Commission’ was formed to control the distribution of radium a.o. over a dozen of regional cancer treatment centres.64

From this brief outline of developments in four countries, we can conclude that in the second half of the 1920s important cancer hospitals and cancer research institutions were set up in each of them. The role of philanthropy in the development of cancer control in each of these countries is most remarkable. The precious nature of radium and its scarcity were important factors in the centralisation of radium therapy at various levels. In centralised cancer institutes, surgeons and radiotherapists were more or less forced to cooperate. A chronicler of radiotherapy in

15 Ton van Helvoort

Sweden stated that because of the existence of consultative structures in that country “... there has never been any kind of a fight for the patient material between the different medical branches …”.65 Although such statements of friendly cooperation have to be viewed with a certain skepticism, it will become clear below that in Germany radiotherapy matured in a wholly different atmosphere.

6. BLUMENTHAL AND THE CENTRALISATION OF GERMAN RADIOTHERAPY, 1928-1933

In 1928, the ‘Institut für Krebsforschung’ celebrated its twenty-fifth anniversary. That year, Ferdinand Blumenthal was appointed extraordinary professor and from then on the ‘IfK’ was financed by the state (‘etatmässig’). Both the ‘IfK’ and Blumenthal himself were internationally recognised as prominent players in the field of cancer research and treatment, judging by the fact that he was one of the two German participants at the Cancer Control conference held at Lake Mohonk (N.Y.) in September 1926.66 Several employees of the institute, such as radiotherapist Ludwig Halberstaedter and haematologist Hans Hirschfeld, were among the most re- spected experts in their specialisms.67

The developments abroad which were outlined in the previous section highlighted the sore point of radium shortage in Germany. In the press this became known as the ‘Radium problem’. In order to delineate a policy regarding the future of radiotherapy in Germany, a commission of the ‘Deutsche Zentralkomité zur Erforschung und Bekämpfung der Krebskrankheit’ (‘DZK’, German Central Committee on Cancer Research and Control) visited some of the radiotherapy facilities in France and Sweden. Members of the committee were Ludwig Halberstaedter of the ‘IfK’, two of the founders of the journal Strahlentherapie — Richard Werner (Heidelberg) and Hans Meyer (Bremen) — and Walter Friedrich of the ‘Institut für Strahlenforschung’ (Institute for Radiation Research) of the Berlin University.68 The conclusions of this committee, laid down in a report ‘Bericht der Radiumkommission über ihre Reise nach Paris und Stockholm’ (Report of the Radium Committee on its Visit to Paris and Stockholm) were for the greater part adopted by the ‘DZK’, resulting in the following tasks being set for the control of cancer in Germany69:

— urging cancer patients to visit a doctor as soon as possible;

— further development and intensification of existing cancer research institutes;

— creation of centralised institutes, possibly linked to the cancer institutes at Berlin and Hei- delberg so that ‘Intensivbestrahlung’ could be effected (in all about 6 grammes of radium were thought to be needed);

16 Scalpel or Rays?

— establishment of smaller offices for cancer consultation and treatment for other forms of radiotherapy;

— centralisation of radium and mesothorium supplies, and organising a rational distribution of the capacity in radiotherapy;

— regulating the handling and use of radioactive substances such as radium and mesothorium, so that only trained personnel and therapists would be allowed to work with them.70

Similar themes were discussed on 31 May 1930 at a hearing organised by the ‘Landesgesund- heitsrat’ (County Public Health Board) on the future of cancer control. The debate was opened by contributions from Ernst Pütter (‘Verwaltungsdirektor’ of the Charité) and Ferdinand Blu- menthal.71 The latter pleaded for a centralised organisation of radiotherapy to make sure that education, training and quality control could be dealt with effectively. Blumenthal concluded that radiotherapy had been introduced too rapidly, so that there was insufficient supervision over a rather risky, not to say potentially dangerous, technique. He argued that capable surgeons were within reach for everyone but that things were different for radiotherapy in general, and radium therapy in particular: “It would be a gross underestimation of X-ray and radium treatment to believe that it would suffice to put enough radium into the hands of an otherwise com- petent physician to achieve satisfactory radiotherapy.”72

Subsequently, the aspects of the purchase of and control over radium and mesothorium were discussed and Blumenthal argued that this necessitated central institutions. ‘Fernbestrahlungen’ or deep therapy (as opposed to direct application, also known as brachytherapy) were not so often required that facilities had to be available everywhere. Blumenthal’s conclusion was that the developments abroad should be taken as an example: “We should therefore proceed along the same lines as in Sweden and France, i.e., concentrating the equipment for high-dosage tele- curietherapy in a few places, while most cases are treated with smaller doses in those same or other places.”73

Moreover, Blumenthal argued for the establishment of a ‘Prüfungskommission’ (Assessment Committee), which would have to monitor the expertise of those who were working in the field of radiotherapy. This had to result in better protection of patients as well as doctors and therapists against the harmful effects of radioactive rays. All this had to be laid down in legislation.

The work of the radium committee of the ‘DZK’ testifies to the importance radiotherapy had gained in the treatment of cancer. It was not only discussed whether or not regulation of radio-

17 Ton van Helvoort therapy should be introduced but also who would gain jurisdiction over the technique. Walter Stoeckel, head of the ‘Universitäts-Frauenklinik’ (University Gynaecological Clinic) of the Charité, warned against the consequences of attempts to centralise radiotherapy: “Founding centralised cancer institutes would provoke further the opposition from all sides, including specialists and specialised institutes. It would arouse the not unreasonable fear that a major part of their own work might be taken away from them.”74 He was referring to the surgeons, gynaecologists, dermatologists, oto-laryngologists and to a lesser extent orthopedists. These specialists claimed that cancer as a disease of a specific organ had to be treated by those who were experts in that particular medical domain. Thus, cancer of the cervix fell under the jurisdiction of gynaecologists. According to Stoeckel, this situation was the result of a historical process which was not to be interfered with by creating a new specialism encompassing different fields of expertise. Stoeckel clearly opposed the centralisation of radiotherapy striven for by Blumenthal, but the latter secured support from, for instance, the Cologne radiologist Werner Teschendorf, who openly advocated the establishment of special clinics for radiotherapy. Teschendorf claimed that much ‘cancer therapy’ was being lost through injudicious use.75

In 1931 Blumenthal and Teschendorf came under severe attack from the Medical Faculty of the University of Frankfurt am Main, an attack articulated by its dean, A. Loos.76 The immediate cause which brought the different points of view into the open was the formation of the ‘Reich- sausschuß für Krebsbekämpfung’ (State Committee for Cancer Control). The inauguration of the ‘Reichsausschuß’ on 25 February 1931 was a most important step, because from then on the government was going to participate in cancer control. And interestingly, chairman Bruno Dammann and secretary Félix Grüneisen of the ‘Reichsausschuß für Krebsbekämpfung’ seemed to opt for the centralisation of radiotherapy as Blumenthal had advocated.77

Dean Loos accused Blumenthal of attempts to withdraw the treatment of cancer patients from the disciplines that claimed jurisdiction over the diseased organs and to establish centralised cancer hospitals and institutes. This, he claimed, would be harmful for the training of doctors and specialists. Loos referred to an article written by Frankfurt’s Hans Holfelder, which defended local integration of radiotherapy with the surgical specialisms.78 Holfelder’s institute was, on the one hand, a centralised institute with large spaces for the megavolt X-ray devices, while on the other hand it was integrated with the university’s surgical clinic headed by Victor Schmieden. Holfelder stated that the X-ray department performed no surgery of whatever kind, as this was the proper domain of the Surgical Clinic.79

The criticism on Blumenthal became even sharper when Germany’s most prominent surgeons Hans Küttner (Breslau), Ferdinand Sauerbruch (Charité, Berlin) and Victor Schmieden (Frank- furt am Main) openly took sides in the conflict, claiming that surgeons were deliberately being

18 Scalpel or Rays? excluded from the formation of the ‘Reichsausschuß’.80 It was argued above that Blumenthal was critical about the legitimacy of cancer surgery in many cases, while the surgeons were most critical about the results claimed by the radiotherapists. The surgeons referred to patients who “… would develop into hopeless cases as a result of useless radiotherapy and so be lost to cure …”. In their view, the radiotherapist was only to be called in after the surgeon had given permission: “Generally speaking, the radiotherapist should only be called in after the possibilities for surgical treatment have been exhausted or have been rejected on good grounds.”81

In July 1932, the medical faculty of the Berlin University decided to cut the budget of Blumen- thal’s ‘Institut für Krebsforschung’ by M 20,000 of which one-fifth affected Rhoda Erdmann’s ‘Institut für experimentelle Zellforschung’. Although the latter was an independent institute, it still was financially tied to the ‘IfK’. Blumenthal wrote to Charité’s ‘Verwaltungsdirektor’ Al- fred Kuhnert that a budget cut of this magnitude would in fact imply the end of the ‘IfK’ as a research institute. In Blumenthal’s view, the attack on his institute was inspired by the competition between the ‘IfK’ and the regular clinics and institutes where radiotherapeutic devices for the treatment of cancer patients were also available. The argument of Blumenthal’s adversaries, he claimed, was that “… radiative treatment of cancer could just as well be performed and developed at the surgical clinics.”82 Blumenthal concluded that “… the independence of cancer research and cancer treatment in Germany [appeared to be] under attack from two different directions — pathology and surgery.”83

As mentioned above, Blumenthal devoted his experimental cancer research to a wide range of models. The conclusions drawn from these studies for the etiology of human cancer were un- acceptable to many clinicians and orthodox pathologists. To give an example, the surgeon Vic- tor Schmieden, co-author of the 1931 attack on Blumenthal, had written a few years before:

“It is alien to the clinician’s mode of thinking not to rely on conclusive evidence from human materials, but time and again to be referred to mammals, thence to birds, thence to cold-blooded animals and even to plants (sunflowers etc.). ... [W]e must warn against attaching too much value to comparative observations from the animal or plant kingdom.”84

This comment was written in response to the publicity that the research on cancer viruses had received in the mid 1920s.85 And in 1937 Ferdinand Sauerbruch, another co-author of the anti- Blumenthal article, would formulate his hesitation about animal experiments as follows: “Cli- nicians will be particularly apprehensive about simply transferring the results of animal experiments to human pathology and about generalising and overestimating the extent of their

19 Ton van Helvoort significance.”86 In summary, when Blumenthal wrote that independent cancer research was being attacked from pathology and surgery this concerned both his research program and the radiotherapeutic treatment of cancer patients.

The warm relationship between the chairman and the secretary of the ‘Reichsausschuß’ on the one hand and Ferdinand Blumenthal on the other had flagged and the ‘Reichsausschuß’ now established firm ties with the ‘Deutsche Gesellschaft für Gynäkologie’ (German Gynaecologi- cal Society) as well as the ‘Deutsche Gesellschaft für Chirurgie’ (German Surgical Society). Subsequently the surgeons, gynaecologists and other specialists succeeded in averting the centralisation of radiotherapy in Germany.

Blumenthal’s ‘Institut für Krebsforschung’ received the final blow with the introduction on 7 April 1933 of the ‘Gesetz zur Wiederherstellung des Berufsbeamtentums’ (Civil Law of April 7th, 1933) which banned persons of Jewish descent from entering into state service.87 Since Blumenthal and almost all of his staff and personnel were Jewish, he himself was forced to take early retirement; shortly afterwards he emigrated to Belgrade where he became professor, while Ludwig Halberstaedter and Hans Hirschfeld emigrated too.88 Hans Auler, Blumenthal’s personal assistent, was made acting director of the ‘IfK’.

7. CONFLICTING VISIONS ON THE CONTINUATION OF THE ‘INSTITUT FÜR KREBSFORSCHUNG’

After the almost complete dismantling of the ‘IfK’ in April 1933, the dean of the Medical Fa- culty of the University of Berlin, Hermann Gocht, tried to delineate new aims for the institute. He was the chairman of the ‘Deutsche Orthopädische Gesellschaft’ (German Orthopaedic So- ciety) and was greatly involved in the development of radiology because of the crucial role X- ray diagnostics played in his profession.89 Gocht sought advice from several experts, including the gynaecologist Walter Stoeckel (Charité), the surgeon Victor Schmieden (Frankfurt am Main) and the radiologists Gösta Forssell (Stockholm) and Hans Schinz (Zürich).

Walter Stoeckel of the Charité’s ‘Universitäts-Frauenklinik’ has been quoted several times already. In 1930 he had warned that attempts to centralise radiotherapy would meet with serious resistance from the medical specialists. And in his advice to Gocht he was also very outspoken against a centralised radiotherapeutic institute at the Charité:

“Whenever the founding of a centralised institute for radiotherapy or the establishment of a cancer hospital was discussed, the faculty has emphatically rejected the centralisation of either radiotherapy or cancer treatment. It is absolutely essential that each clinic retains the right and has the necessary equipment to irradiate pati-

20 Scalpel or Rays?

ents and treat cancers. This necessity derives especially from the fact that radiotherapists are insufficiently trained in either diagnostics or therapy to solve the problems that need to be solved with regard to cancer diagnostics and cancer therapy.” (Italics mine.)

Although Stoeckel admitted that radiotherapy had its place in the treatment of cancer, he felt nevertheless that the main responsibility was with the clinician: “It is only the clinician who is capable of assessing and implementing this kind of therapy, not the radiotherapist …”. Stoeckel did not object to a ‘IfK’ as a research institute, as long as it did not have therapy as its main objective.90

The Frankfurt surgeon Victor Schmieden, who with Küttner and Sauerbruch had criticised Blu- menthal openly, was asked for advice too. The view he defended was typically that of a surgeon: (i) the cancer patient had to be treated by the specialist with competence over the organ or organs affected; (ii) surgery had to be the first line of treatment; (iii) cancer treatment should never be based on a one-sided radiotherapeutic approach. Schmieden had always been offended by the ‘IfK’s’ pretending to be a therapeutic institute91:

“… I have also always resented the presence in the Luisenstrasse in Berlin of an institute which openly advertises itself to the public at large as a therapeutic institute for tumour diseases. … The real tumour diseases, especially cancer, however, are so intimately linked to the various clinical disciplines that it would be impossible to tear these types of disease away from internal medicine, surgery, gynaecology, la- ryngology, etc. and place their diagnosis and treatment under the responsibility of a special therapist who looks only at this aspect.”

Schmieden held the opinion that since surgery was in the vanguard of cancer treatment, the cancer patient should seek refuge in a combination of surgical and radiotherapeutic interventions “… but not in a purely surgical, nor in a purely radiological therapy.”92

Stoeckel and Schmieden represented the established disciplines, but radiologists were consulted too. Gösta Forssell, head of the ‘Sophiahemmets Röntgeninstitut’ at Stockholm, persevered in pleading for the centralisation of radiotherapy. He advised performing radiotherapy in an independent clinic with an outpatient department, although in “carefully organised collaboration” with the other clinics where surgery was practiced. He advised Gocht to transfer the experimental research to the Charité’s Pathological Institute.93

21 Ton van Helvoort

The second radiotherapist consulted was Hans R. Schinz, professor of medical radiology in Zü- rich and chairman of the Fourth International Congress of Radiology, held in Zürich in 1934. Schinz, quoted also in the introduction of the present essay, in his advice to Gocht, clearly expressed sympathetic feelings towards national-socialism, so a pro-Blumenthal position was hardly to be expected from him. He stated that now that the national-socialist revolution in Ger- many had succeeded, the country could catch up with such countries as Sweden with its ‘Ra- diohemmet’, the United States with its ‘Memorial Hospital’, Milan with its ‘Instituto del Cancro’ and Paris with its ‘Institut du Radium’. Schinz concluded that cancer surgery in Ger- many was well organised, unlike treatment by radiotherapy. Schinz held the view that centralisation would be inevitable: “All leading radiotherapists support the centralisation of radiotherapy.” In the Romance, Anglo-American and Scandinavian countries, centralised cancer institutes had been founded, as it was impossible for a radiotherapist to work efficiently “… in an institute which only functions as a nursing home for incurable cancer patients.” With regard to the situation in Germany, his judgement was most critical: “The decentralisation un- dertaken in most places in Germany has yielded disappointing results, and despite our great sympathy for Germany it must be said that, except as regards gynaecological radiotherapy, this has caused Germany, which has always marched at the forefront of science, to lag behind.” Schinz was familiar with the Berlin ‘Institut für Krebsforschung’ and held the opinion that the “… existing cancer institute should not only be continued but should be expanded into a radiotherapeutic cancer centre, which should primarily be led by a radiotherapist …”. In such an institute there was no need for extensive operations, as surgery and radiotherapy were independent disciplines: “A clear separation between these two treatment modalities should and can be made.”94 Summarizing, Schinz’s views on the Berlin ‘IfK’ were very similar to the ob- jectives set forth by Blumenthal. The consultations by Gocht resulted in the same division along party lines as had existed while Blumenthal was the director of the ‘IfK’. Radiotherapists strove for centralisation of treatment facilities, while the medical specialists defended their jurisdiction over the use of radiotherapy.

8. THE CONFLICT OVER CENTRALISATION CONTINUES

The discrepancy between radiotherapists and clinicians was also apparent during the 1934 Fourth International Congress of Radiology, chaired by Hans Schinz (in which, by the way, Blumenthal did not participate). Keynote lectures were given by Gösta Forssell and Ferdinand Sauerbruch and the theme was the organisation of radiotherapy.

With regard to specialisation and cooperation, Forssell took the following position: “It is no longer a matter of whether cancer treatment should be centralised, but of the extent to which

22 Scalpel or Rays? and the principles on which this is to be implemented.”95 In the case of treatment with radium, Forssell held that this was to be performed in central clinics for radiotherapy. Sauerbruch, who represented clinical medicine, showed understanding for the tension between surgery and radiotherapy. He saw it as a matter of course “... that there was initially a certain rivalry between the two sister disciplines, notwithstanding their great similarity in many fundamental respects. Roentgenology tried to contest the authority of the older surgical discipline, while the latter often out of prejudice denied or underestimated the prospects of radiology and hence rejected it.” And with reference to Forssell’s keynote address, Sauerbruch expressed his gratitude for the “… guidelines provided by his ground-breaking work, though certain details will have to be ad- apted to the circumstances.”96 But the crucial issue was of course what ‘details’ had to be ad- apted in order to meet the German situation.

The way Sauerbruch formulated the problem, it seemed as if the question was over which of the two techniques — the use of the scalpel or radiotherapy — was most beneficial to the cancer patient. But, as will have become clear from the above account, it was not so much a dispute over what constituted the best technique but under whose jurisdiction radiotherapy fell.

In view of the contradictory recommendations dean Hermann Gocht received in about the continuation of the ‘Institut für Krebsforschung’, it should cause no surprise that no firm decision was arrived at. Temporarily, Sauerbruch was appointed curator of the ‘IfK’, while Hans Auler was in charge of the day-to-day running of the institute. Under Sauerbruch, experimental cancer research entered new avenues. The experimental models studied by Blumenthal were almost all abandoned. Sauerbruch held the opinion that the course of a disease was determined by the body as a whole. This constitutional or pathophysiological notion of disease had become fashio- nable since the 1920s and had resulted in dietary studies and hormone research. Thus, Sauer- bruch and his co-workers had developed a dietary treatment for tuberculosis.97 In cancer, disturbances of the hormone balance, for example as a consequence of advancing age, were assumed to play a role. In his paper Die Bedeutung von Sexualstörungen für die Entstehung von Geschwülsten (The impact of sexual disorders for the genesis of tumours), Sauerbruch argued that the anatomical orientation had dominated cancer research too much, “… while general pathological disorders of the organism as a whole were neglected.”98 The physiological approach advocated by Sauerbruch was studied in more detail by Hans Auler, who did research on, for instance, the influence of climate on the genesis of cancer in laboratory animals.99

As was stated above, the ‘Reichsausschuß für Krebsbekämpfung’ was initially biased in favour of the centralisation of radiotherapy, a point of view that was abandoned under the pressure of the German Societies for Gynaecology and Surgery. In spite of this, the ‘Reichsausschuß’ urged the national-socialist government to create three professorships of radiology in 1935.100 They

23 Ton van Helvoort were situated in Hamburg, Cologne and Leipzig and it will be no surprise that Berlin was not included in the list.

In the late 1930s the conflict over radiotherapy in relation to the clinical specialisms was as hea- ted as it had been a decade before. At the last meeting of the ‘Deutsche Röntgengesellschaft’ (German Roentgen Society) before World War II, held in May 1939 at Stuttgart, the problem was addressed again. Hans Holfelder — who in 1931 had pleaded for local radiological institutes, integrated with surgical departments — now advocated the creation of centralised institutes for roentgenology, not only for radiotherapy but for X-ray diagnosis as well. Again, the representatives of the clinical specialisms objected strongly. Alfred Schittenhelm of the ‘Deutsche Gesellschaft für Innere Medizin’ (German Society for Internal Medicine) contended that the “… the various specialised clinics [should] be allowed to keep their own X-ray institutes”. Mar- tin Kirschner, representing the ‘Deutsche Gesellschaft für Chirurgie’, provokingly stated that roentgenologists were aiming “to establish for themselves a free territory to work in, without any competition”. And Heinrich Martius of the ‘Deutsche Gesellschaft für Gynäkologie’ claimed that the gynaecologist not only had to do his own X-ray diagnostics, but should also “retain control of his own radiotherapy”.101

In 1939 the X-ray department of Sauerbruch’s Surgical Institute merged with that of the ‘Insti- tut für Krebsforschung’.102 Meanwhile, the clinical department of the ‘IfK’ was deteriorating rapidly. After a complaint from a patient in 1942, the head of the ‘Gesundheitsamt Berlin-Mitte’ wrote the following report on the ‘IfK’: “In any case, the nursing ward of the institute in its present state is a disgrace and should be closed down by the police.”103 This meant an inglorious end to an institute that had been made internationally renowned by Ferdinand Blumenthal.

9. SCALPEL OR RAYS ?

The present essay has discussed how a new treatment modality for cancer, radiotherapy, was introduced and how this technique had to struggle for a niche of its own. It had to compete with orthodox therapy, i.e. surgery. The development of radiotherapy in Germany, and the history of the ‘Institut für Krebsforschung’ of the Berlin Charité in particular, constitutes an interesting case study because the establishment of radiotherapy took a different course than it did in the surrounding countries. Since centralised cancer institutes had been established in France and Sweden, Ferdinand Blumenthal strove for a similar role for his ‘Institut für Krebsforschung’; however, this met with vigorous resistance from the orthodox clinical specialisms.

That the struggle between medical specialists and radiotherapists, the latter trying to establish

24 Scalpel or Rays? an independent specialism of their own, was so intense and protracted was related to several specific characteristics of X-ray and radium technology, which applied not only in Berlin, in Germany as a whole, and in other countries as well. First, the introduction of therapeutic X-ray devices developed from X-ray diagnostics, the latter technique being of great importance to many medical specialisms. As the X-ray tube and related appliances were relatively cheap, X- ray diagnostics was widely available. When in the early twentieth century X-ray therapy of cancer was initiated, this seemed to be a change of degree rather than of kind. Secondly, like X- ray therapy, radium therapy was a technique which was highly ‘democratic’. Although radium and mesothorium were rather costly, in many cases some tens or hundreds of milligrammes were enough to produce excitingly high rates of cure. The situation changed when in countries such as England, France, Sweden and the United States impressive results were obtained by using ‘radium bombs’, which contained grammes of radium. The radium shortage which had been a problem in Germany from the beginning of the twentieth century was then acutely felt. Or, as Blumenthal said at a cancer conference in 1930: “… there is no other medical discipline, however, where this lack of funds has been so noticeable — I refer to the high price of radium — and where we have therefore been lagging behind other nations so seriously as in the research on and treatment of cancer.”104 In summary, radium was both a ‘democratic agent’ and a ‘centralising agent’, depending on the form of therapy, i.e. brachytherapy or ‘Fernbestrahlung’ (deep therapy).

Thirdly, another argument for centralising radiotherapy stemmed from the inherent hazards of radioactive rays, which constituted a health problem for the therapist as well as for the patient. This required several precautionary measures: (i) radiotherapists had to be educated and trained to prevent dilettantism; (ii) legislative regulations for handling radioactive substances were needed; (iii) the production and handling of such radioactive substances had to be restricted to spe- cially trained and certified staff.105 Of course these requirements would greatly enhance the professionalisation of the new subdiscipline of radiodiagnostics and radiotherapy. In the wake of this, professional associations and vocational training could be taken care of.

However, there were also fundamental differences between Germany and the other countries mentioned above. We have seen that the development of radiotherapy was influenced by national political as well as economic factors. Unlike the United States, Germany hardly possessed any uranium mines, nor did it have colonies where the minerals could be won, in the way that Belgium imported uranium ores from the Upper Congo. A further difference between Germany and countries such as Sweden, France and the U. S. was that philanthropy benefitting cancer research and treatment played a much smaller part in the former than in the latter countries. Alt- hough Blumenthal’s institute was supported financially by a bank and some industries and the Cancer Hospital at Heidelberg (‘Samariterhaus’) depended on private donations, these contri-

25 Ton van Helvoort butions were only a fraction of the donations received elsewhere, such as James Douglas’ donation of radium to the New York Memorial Hospital, the gift of radium from the U. S. to Marie Curie, and the donation of the birthday gift of the Swedish king to the Swedish organisation for cancer control. This philanthropy was a crucial factor in the ‘forced’ centralisation of radiotherapy in those countries.106

Moreover, the German authorities long remained aloof regarding the control of cancer, an attitude which altered only when the ‘Reichsausschuß für Krebsbekämpfung’ was installed. Alt- hough this committee had the centralisation of radiotherapy high on its agenda, it eventually withdrew its plans when the German specialists and their organisations opposed Blumenthal’s scheme for the organisation of radiology.

Blumenthal was a proponent of the concentration of cancer research in independent institutes because he felt that researchers at other institutes were too free of obligations with respect to the cancer problem107:

“The difference between the Universitätsinstitut für Krebsforschung at the Charité and all of these institutes, including the above-mentioned Kaiser Wilhem Institutes [of Biology and of Biochemistry, TvH], is that these institutes could switch to other subjects tomorrow, without any problem; for them, cancer is only a part of their research task, while the cancer institute is devoted purely to cancer research.”

An important aspect of the present case study is that it shows how a new medical technique and its proponents had to struggle for a niche within the network of tasks, instruments and techniques of the existing forms of cancer treatment. In this situation, the establishment was formed by surgeons, gynaecologists and internists, while, according to the formal hierarchy of German medicine, medical clinics and institutes were governed as if they were independent king- doms.108 From these powerful positions, their managers tried to retain their jurisdiction over the cancer patient by claiming competence over the new instruments for radiotherapy.

Those who applied the orthodox cancer therapies formulated the problem of the introduction of the new cancer intervention technique as if it was to be decided what therapy — surgery or radiotherapy — was the most effective for the cancer patient. Thus, their question was ‘Scalpel or rays?’, a question which they answered by saying that (i) surgery was the prime line of attack; (ii) operation and radiotherapy could best be applied together; (iii) those who were trained to use the scalpel also held the jurisdiction to use the new radiotherapeutic devices, or at least the latter should be used under their supervision. Although the discussion was presented as one

26 Scalpel or Rays? concerning the question what intervention technique was most effective, what was actually at stake was the jurisdiction over the cancer patient.

Thus, the present case study illustrates how a technological innovation was apparently discussed at the technological level. At the same time, however, the struggle was over the jurisdiction over the new technique and the competence to apply it. Certain circumstances which were specific to Germany, i.e. the radium shortage, the lack of a tradition of cancer philanthropy, the power of the German medical elite at the universities and the reticence of German government in cancer control, meant that the development of radiotherapy took a different course from that in other European countries and the United States.109 Moreover, this contributed greatly to the situation that cancer research as an independent specialism took longer to establish itself in Ger- many than elsewhere. This situation was not to be reversed until the 1960s.110

ACKNOWLEDGEMENTS

I would like to express my sincere thanks to my colleagues at the Faculty of Arts and Culture of Maastricht University, to Harmke Kamminga, Hans-Jörg Rheinberger, as well as the referees of this journal, for their constructive comments on earlier versions of this manuscript, and also to Jan Klerkx for his help in the translation work. Archival research for this study was done during a visiting fellowship at the Max-Planck-Institut für Wissenschaftsgeschichte in Berlin.

Abbreviations used: GStA I. HA: Geheimes Staatsarchiv Preussischer Kulturbesitz, I. Haupt- abteilung; HUA: Humboldt-Universität zu Berlin, Archiv; Char.-Dir.: Charité-Direktion; Med. Fak.: Medizinische Fakultät.

27 Ton van Helvoort

REFERENCES

1 See, for instance, Michael Peckham, Herbert Pinedo, and Umberto Veronesi (eds.), Oxford textbook of oncology, Oxford, Oxford University Press, 1995. For a ‘Landmark’-history of oncology see Michael B Shimkin, Contrary to nature — being an illustrated commentary on some persons and events of historical importance in the development of knowledge concerning cancer, Bethesda, MD, U.S. Department of Health Education, and Welfare, 1977; see also David Cantor, ‘Cancer’, in W F Bynum, and R Porter (eds), Companion encyclopedia of the history of medicine, vol. 1, London, Routledge, 1993, 537-61. On cancer therapy see also Caro- line C. S. Murphy, ‘From Friedenheim to Hospice: a century of cancer hospitals’, in L Grans- haw and R Porter (eds), The hospital in history, London, Routledge, 1989, pp. 221-41.

2 For a history of radiology in a broad sense of the term, i.e., including radiodiagnostics, see, for instance, E R N Grigg, The trail of the invisible light, Springfield, Ill., Charles C. Thomas, 1965; Ruth Brecher, and Edward Brecher, The rays: a history of radiology in the United States and Canada, Huntington, NY, Robert E Krieger Publ. Co., 1969; Ronald L Eisenberg, Radiology: an illustrated history, St. Louis, Mosby-Year Book, 1992; Richard F Mould, A century of X- rays and radioactivity in medicine, with emphasis on photographic records of the early years, Bristol, Institute of Physics Publishing, 1993. On the history of chemotherapy and immunotherapy see two recently published studies: Ilana Löwy, Between bench and bedside: science, healing, and interleukin-2 in a cancer ward, Cambridge, MA, Harvard University Press, 1996, and Stephen S Hall, A commotion in the blood: life, death, and the immune system, New York, Henry Holt, and Company, Inc., 1997.

3 Andrew Abbott, The system of professions: an essay on the division of expert labor, Chicago, University of Chicago Press, 1988.

4 Claude Regaud, ‘What is the value and what should be the organization and equipment of institutions for the treatment of cancer by radium and X-Rays?’, in American Society for the Control of Cancer, Cancer control, Chicago, Surgical Publishing Co., 1927, 116-40, p. 120.

5 On German radiotherapy see Hans-Peter Heilmann, ‘Radiation oncology: historical development in Germany’, International Journal of Radiation Oncology, Biology, Physics, 1996, 35: 207-17, pp. 207-9. See also Heinz Goerke, Fünfundsiebzig Jahre Deutsche Röntgengesell- schaft, Stuttgart, Georg Thieme Verlag, 1980, pp. 96-103.

6 Hans R. Schinz, Sechzig Jahre medizinische Radiologie: Probleme und Empirie, Stuttgart, Thieme, 1959, p. 223.

7 Hans-Heinz Eulner, ‘Röntgenologie’, in Idem, Die Entwicklung der medizinischen Spezialfä- cher an den Universitäten des deutschen Sprachgebietes, Stuttgart, Ferdinand Enke Verlag, 1970, 421-6, p. 425.

8 Gustav Wagner, and Andrea Mauerberger, Krebsforschung in Deutschland: Vorgeschichte und Geschichte des Deutschen Krebsforschungszentrums, Berlin, Springer-Verlag, 1989.

28 Scalpel or Rays?

9 On philanthropy see Lily E. Kay, ‘Rethinking institutions: philanthropy as an historiographic problem of knowledge and power’, Minerva, 1997, 35: 283-93.

10 For the role of surgery in cancer see, for instance, George J Hill, II, ‘Historic milestones in cancer surgery’, Seminars in Oncology, 1979, 6: 409-27.

11 Cf. Charles P Childe, The control of a scourge: how cancer is curable, New York, E P Dutt- ton, and Co., 1907.

12 Wolfgang Genschorek, Ferdinand Sauerbruch: ein Leben für die Chirurgie, Leipzig, S Hir- zel Verlag, 1981, p. 181.

13 Walter Stoeckel, Erinnerungen eines Frauenarztes, Leipzig, S Hirzel, 1979, pp. 109-10.

14 Gerald L’E. Turner, ‘Röntgen, Wilhelm Conrad’, in C C Gillispie (ed.), Dictionary of scientific biography, vol. 11, New York, Charles Scribner’s Sons, 1981, 529-31.

15 Bettyann Holtzmann Kevles, Naked to the bone: medical imaging in the twentieth century, New Brunswick, NJ, Rutgers University Press, 1997. This book discusses the impact of X-rays on man’s self-image and society in general.

16 This situation was recently expressed evocatively as follows: “… at the time of their discovery, radiographs were limited to small glass plates that reflected the organizational deconstruc- tion of medicine into specialties — each concentrating on the anatomical area covered by one small plate.” Ibid., p. 299.

17 Kurt-Achim Hinze, ‘Aspekte der Entwicklung der Röntgenologie an der Charité zu Berlin in den ersten drei Jahrzehnten nach der Entdeckung der Röntgenstrahlen’, PhD thesis, Humboldt- Universität Berlin, 1978, pp. 20-33. In the early 1930s it was attempted to unite the various X- ray departments into one independent unit, but this endeavour failed.

18 The idea that X-rays were selectively more destructive to tumour cells than to normal cells was not universally accepted, however; see David von Hansemann, ‘Krebsheilmittel in Theorie und Praxis’, Zeitschrift für Krebsforschung, 1914, 14: 139-50, pp. 143-4.

19 Hans Meyer, ‘Aus der Pionierzeit der Strahlenheilkunde: ein Lorbeerblatt auf das Grab von Bernhard Krönig, Freiburg i. Br.’, Medizinische Klinik, 1955, 50: 65-6, p. 66.

20 Stoeckel, op. cit., note 13 above, p. 86.

21 Carl J. Gauß, Hans Meyer, and Richard Werner, ‘Zur Einführung’, Strahlentherapie, 1912, 1: 1-3.

22 For a brief history of the cancer institute/hospital ‘Samariterhaus’ at Heidelberg, see Fried- rich Voelcker, ‘Zur Eröffnung des Institutes fur experimentelle Krebsforschung in Heidelberg’, Münchener Medizinische Wochenschrift, 1906, 53: 1919-21; and Vinzenz Czerny (ed.), Das Heidelberger Institut für experimentelle Krebsforschung. I. Teil. Geschichte, Baubeschreibung,

29 Ton van Helvoort wirtschaftliche Verhältnisse, Leistungen des Instituts, Aktensammlung, Tübingen, H. Laupp’schen Buchhandlung, 1912.

23 Vincenz Czerny, ‘Die Bedeutung der Strahlenbehandlung für die Chirurgie’, Strahlenthera- pie, 1912, 1: 4-5, p. 5.

24 Kurt Warnekros, ‘Zur Röntgentechnik der Carcinombestrahlung’, Verhandlungen der Ber- liner medizinischen Gesellschaft aus dem Gesellschaftsjahre 1913, 1914, 44: 416-23, p. 423. For a discussion of the widespread early use of radiotherapy in Northern America, see Charles R R Hayter, ‘The clinic as laboratory: the case of radiation therapy, 1896-1920’, Bulletin of the History of Medicine, 1998, 72: 663-88.

25 Unfamiliarity with the effects of radioactive rays also made many victims amongst radiotherapists themselves. Those who died as a consequence of immediate or protracted radiation were included in an Ehrenbuch (Book of honour); see Hermann Holthusen, Hans Meyer, and Werner Molineus (eds), Ehrenbuch der Röntgenologen und Radiologen aller Nationen, Munich, Verlag von Urban & Schwarzenberg, 19592.

26 Goerke, op. cit., note 5 above, pp. 103-5; Eisenberg, op. cit., note 2 above, pp. 492-7. See also Arne Hessenbruch, ‘The commodification of radiation: X-ray and radium standards, 1896- 1928’, PhD thesis, Cambridge University, 1995.

27 See, for instance, Alfred Romer, ‘Becquerel, (Antoine-)Henri’, in Gillispie, op. cit., note 14 above, vol. 1, 558-61.

28 On the discovery of radium, see Adrienne R Weill, ‘Curie, Marie (Maria Sklodowska)’, in Gillispie, op. cit., note 14 above, vol. 3, pp. 497-503; Jean Wyart, ‘Curie, Pierre’, in Gillispie, op. cit., note 14 above, vol. 3, 503-8; see also Eisenberg, op. cit., note 2 above, pp. 43-50.

29 Eisenberg, op. cit., note 2 above, pp. 481-510.

30 Ibid., pp. 511-26. See also Bernard Pierquin, ‘La radiumthérapie de sa naissance à sa mort. 1896-1976’, Cancer Radiothérapie, 1997, 1: 5-13. For the development of radium dosimetry, see Eisenberg, op. cit., note 2 above, pp. 523-5, and Hessenbruch, op. cit., note 26 above.

31 Letter by Paul Ehrlich; GStA I. HA Rep 89 nr. 24528, p. 57 e.v. (no date).

32 On the influence of chemists on the German Empire, see Jeffrey A Johnson, The Kaiser’s chemists: science and modernization in Imperial Germany, Chapel Hill, University of North Carolina Press, 1990.

33 Letter by Von Trott zu Solz, 11 September 1909; GStA I. HA Rep 89 nr. 24528, 54-56a.

34 Letter by August von Wassermann, 16 June 1913; GStA I. HA Rep 89 nr. 24528, 104-9.

35 Although clinics could actually purchase mesothorium, individual doctors were only allowed to hire it, in order to prevent monopolisation and speculation. See Verhandlungen der

30 Scalpel or Rays?

Deutschen Gesellschaft für Gynäkologie — Fünfzehnte Versammlung Abgehalten zu Halle a. S. am 14.-17. Mai 1913, Leipzig, Verlag von Johann Ambrosius Barth, 1914, p. 394.

36 Letter by Von Trott zu Solz, 22 September 1913; GStA I. HA Rep 89 nr. 24528, 110-15.

37 Ibid.

38 Letter by Walter Nernst, 31 August 1913; GStA I. HA Rep 89 nr. 24528, 124-7, p. 127.

39 Letter by Emil Fischer, 6 September 1913; GStA I. HA Rep 89 nr. 24528, 121-3, p. 123.

40 Ernst von Leyden, Kirchner, et al., Verhandlungen des Comités für Krebsforschung — Heft I. 1900-1902, Sonderabdruck aus der ‘Deutschen Medizinischen Wochenschrift’, Jahrgang 1900-1902, Berlin, G. Bernstein, 1902, 3-4.

41 Ernst von Leyden, and Ferdinand Blumenthal, ‘Die Abteilung für Krebsforschung an der I. medizinischen Universitätsklinik’, Charité-Annalen, 1904, 28: 36-44. Ferdinand Blumenthal defended his MD thesis in 1895 and completed his ‘Habilitation’ in 1899. Besides working at the ‘IfK’, Blumenthal was head of internal medicine at the Israelitic Hospital from 1902-1923.

42 See August von Wassermann, Franz Keysser, and Michael Wassermann, ‘Beiträge zum Pro- blem: Geschwülste von der Blutbahn aus therapeutisch zu beeinflussen’, Deutsche medizinische Wochenschrift, 1911, 37: 2389-91, and Anonymous, ‘Kleine Mitteilungen’, Ibid., 1911, 37: 2391-2.

43 This argument is elaborated in Ton van Helvoort, ‘A dispute over scientific credibility: the struggle for an independent Institute for Cancer Research in pre-World War II Berlin’, Studies in History and Philosophy of Biological and Biomedical Sciences, in press.

44 Matthias Kaiser, ‘Zur Geschichte des Deutschen Zentralkomitees zur Erforschung und Bekämpfung der Krebskrankheit (1900-1933)’, PhD thesis, Ernst-Moritz-Arndt-Universität Greifswald, 1989.

45 Georg Klemperer to Naumann, 22 May 1911; HUA Char.-Dir. nr. 949, 303-5, pp. 303-4.

46 Ernst Pütter, 22 December 1914; HUA Char.-Dir. nr. 950, 117-19, p. 117a.

47 Klemperer to Naumann, 22 May 1911; HUA Char.-Dir. nr. 949, 303-5, p. 303a, p. 304, respectively.

48 Blumenthal to the ‘Minister für geistliche und Unterrichts-Angelegenheiten’, 23 June 1915; HUA Char.-Dir. nr. 950, 150-8, p. 155. Immunotherapy, however, has now regained great interest, after having been out of favour for quite some time. See, for instance, Hall, op. cit., note 2 above. See also Martin Gore, and Pamela Riches, ‘The history of immunotherapy’, in M Gore, and P Riches (eds), Immunotherapy in cancer, Chichester, John Wiley & Sons, 1996, 1-9.

31 Ton van Helvoort

49 Ferdinand Blumenthal, Rhoda Erdmann, Ludwig Halberstädter, and Hans Hirschfeld, Zum 25jährigen Bestehen des Universitätsinstituts für Krebsforschung an der Charité, am 8. Juni 1928, Berlin, Julius Springer, 1928, p. 12, p. 5, respectively.

50 Ibid., pp. 7-9.

51 Ferdinand Blumenthal, ‘25 Jahre Krebsbehandlung’, Medizinische Klinik, 1925, 21: 533-36. Remarkably, arsenic compounds were used with the intention to improve a patient’s condition.

Those who conceived of cancer as a constitutional or systemic disease held the argument that surgery and radiotherapy were not aimed at the real cause of cancer; after all, cancer’s etiological agent had not been found. Therefore, these interventions were not cancer cures, they only prolonged life! See Hansemann, op. cit., note 18 above; and Otto Strauß, ‘Das Krebsheilungs- problem’, Zeitschrift für Krebsforschung, 1923, 19: 185-206.

52 Ludwig Halberstädter, ‘Die Bestrahlungsabteilung des Instituts für Krebsforschung’, in Blu- menthal, et al., op. cit., note 49 above, 28-36.

53 ‘Denkschrift über die wissenschaftliche Tätigkeit des Universitätsinstituts für Krebsfor- schung an der Charité in den Jahren 1917-1920’, 1 April 1920; HUA Char.-Dir. nr. 951, 56-65, p. 59a. Recent studies indicate that there may indeed be a mechanism that triggers latent tumour cells in the body after surgery. Presumably, this is not so much related to an impairment of the body, as to the fact that a tumour secretes one or more substances which suppress stroma formation elsewhere in the body. Such processes are now being studied under the concept of angiogenesis; see, for instance, Roy Bicknell, Claire E Lewis, and Napoleone Ferrara (eds), Tumour angiogenesis, Oxford, Oxford University Press, 1997.

54 Ilana Löwy, ‘The culture of clinical experimentation in oncology’, in Idem, op. cit., note 2 above, pp. 36-83.

55 Cited in Fritz König, ‘Die Chirurgie und Krebsbekämpfung’, Archiv für klinische Chirurgie, 1939, 196: 260-7, p. 263.

56 Ibid., p. 264.

57 Otto Jüngling, Allgemeine Strahlentherapie: Licht, Röntgenstrahlen, Radium, Stuttgart, Fer- dinand Enke Verlag, 1938, pp. 236-9, quotation on p. 236.

58 See also Jacques Bandaline, La lutte internationale contre le cancer — Première partie: la conception cancérologique à travers les siècles et la lutte contre le cancer en France — Deu- xième partie: organisation de la lutte contre le cancer dans les divers pays, Paris, Maloine, 1933; and Cantor, op. cit., note 1 above, pp. 547-52.

59 Patrice Pinell, ‘Naissance et développement de la radiothérapie en France’, Médecine Sci- ence, 1995, 11: 1596-9; see also Patrice Pinell, Naissance d’un fléau. Histoire de la lutte contre le cancer en France (1890-1940), Paris, Editions Métailié, 1992, and Bénédicte Vincent,

32 Scalpel or Rays?

‘Genesis of the Pavillion Pasteur of the Institut du Radium of Paris’, History of Technology, 1997, 13: 293-305.

60 In 1934 the cancer center at Villejuif became the French ‘National Cancer Institute’, known as the ‘Institut Gustave Roussy’ from 1948 onwards. For a history of radiotherapy in France, see Maurice Tubiana, Jean Dutreix, and Bernard Pierquin, ‘One century of radiotherapy in France, 1896-1996’, International Journal of Radiation Oncology, Biology, Physics, 1996, 35: 227-42.

61 Later, central cancer clinics were established at Stockholm (1937), Lund (1941) and Gothen- burg (1943). These were named ‘King Gustav V Jubilee Clinics’. For a history of radiotherapy in Sweden, see Elis Berven, ‘The development and organization of therapeutic radiology in Sweden’, Radiology, 1962, 79: 829-41.

62 For a history of radiotherapy in the United States, see Juan A Del Regato, ‘The unfolding of American radiotherapy’, International Journal of Radiation Oncology, Biology, Physics, 1996, 35: 5-14.

63 See, for instance, Gioacchino Failla, ‘Radium technique at the Memorial Hospital, New York’, Radium, 1920, 16 (November): 17-32.

64 For a history of radiotherapy in England, see J Michael Henk, ‘A brief history of British radiotherapy’, International Journal of Radiation Oncology, Biology, Physics, 1996, 36: 213-8. For a discussion of the control and regulation of radium for the purpose of experimental and clinical research before world war II, see David Cantor, ‘The MRC’s support for experimental radiology during the inter-war years’, in J Austoker, and L Bryder (eds), Historical perspectives on the role of the MRC, Oxford, Oxford University Press, 1989, pp. 181-204; see also Joan Aus- toker, A history of the Imperial Cancer Research Fund 1902-1986, Oxford, Oxford University Press, 1988.

65 Berven, op. cit., note 61 above, p. 837.

66 American Society for the Control of Cancer, op. cit., note 4 above.

67 On Halberstaedter, see Anonymous, ‘Halberstaedter, Ludwig’, in H A Strauss, and W Röder (eds), Biographisches Handbuch der deutschsprachigen Emigration nach 1933 — Band II, Munich, K. G. Saur, 1980, p. 452; on Hirschfeld, see Peter Voswinckel, ‘Von der ersten häma- tologischen Fachgesellschaft zum Exodus der Hämatologie aus Berlin’, in W Fischer, K Hier- holzer, M Hubenstorf, P Th Walther, and R Winau (eds), Exodus von Wissenschaften aus Berlin: Fragestellungen — Ergebnisse — Desiderate — Entwicklungen vor und nach 1933, Berlin, Walter de Gruyter, 1994, 552-67.

68 In 1914, the medical physicist Walter Friedrich went to Freiburg im Breisgau to cooperate with gynaecologist Bernhard Krönig (see section 2 of the present essay). In 1922, Friedrich was appointed director of the newly established ‘Institut für Strahlenforschung’ of the Medical Faculty of the Berlin University, an institute which was finished only in 1928. In Berlin, Fried- rich would no longer cooperate with clinicians as he had done at Freiburg. (By the way, Fried- rich was appointed rector of the East-Berlin Humboldt University in 1950.) See Walter

33 Ton van Helvoort

Friedrich, ‘Das neue Institut für Strahlenforschung der Universität Berlin’, Strahlentherapie, 1929, 34: 223-46; K. Eckoldt, ‘Walter Friedrich—Wissenschaftler, Humanist und Friedens- kämpfer’, Charité-Annalen N. F., 1984, 3: 289-95.

69 Report filed on 6 July 1929; GStA I. HA Rep 76, nr. 3852, 279-302. See also Kaiser, op. cit., note 44 above, pp. 21-4.

70 In 1931, Walter Friedrich stated that for Germany the most relevant solution for the ‘radium problem’ would be to follow the example of Great Britain, where a “middle course had been adopted between centralisation and decentralisation”. In London, two dozen hospitals had been provided with smaller or medium amounts of radium, while four ‘Central Cancer Institutions’ had been supplied with 1-2 g of radium; one of these had a radium bomb containing 4 g of radium for tele-Curietherapy. Over the whole of Britain, a dozen treatment centers held medium amounts of radium. See Walter Friedrich, ‘Die Beschaffung und Verteilung radioaktiver Sub- stanzen für die Krebsbekämpfung in Deutschland und im Ausland’, in F Grüneisen (ed.), Krebsbekämpfung: Jahrbuch des Reichsausschusses für Krebsbekämpfung 1930, Leipzig, Johann Ambrosius Barth, 1931, 86-90, p. 87.

71 Ernst Pütter, Ferdinand Blumenthal, et al., ‘Organisation der Krebsfürsorge [Bericht über die Sitzung eines zusammengesetzten Ausschusses des Landesgesundheitsrats am 31. Mai 1930]’, Veröffentlichungen aus dem Gebiete der Medizinalverwaltung, 1930, 32: 635-94.

72 Ibid., p. 651.

73 Ibid., p. 652.

74 Walter Stoeckel, contribution to the discussion in Pütter, et al., op. cit., note 71 above, p. 680.

75 Werner Teschendorf, ‘Zentralisation der Geschwulstbehandlung’, Zeitschrift für Gesund- heitsverwaltung und Gesundheitsfürsorge, 1931, 2 (2): 33-42, p. 36.

76 A. Loos, ‘Über die zweckmässigste Organisation der Krebsbekämpfung’, Deutsche medizinische Wochenschrift, 1931, 57 (ii): 1487-9. Apparently, Werner Teschendorf was spared further criticism. See, for instance, Goerke, op. cit., note 5 above, p. 100 and Teschendorf’s contribution ‘Zur Krebsbekämpfung’, in C Adam, and H Auler (eds), Neuere Ergebnisse auf dem Gebiete der Krebskrankheiten: 47 Vorträge, Leipzig, Verlag von S. Hirzel, 1937, 208-16.

77 See, for instance, Félix Grüneisen, ‘Ein Jahr Reichsausschuß für Krebsbekämpfung — 1. April 1930 - 31. März 1931’, in Grüneisen, op. cit., note 70 above, pp. 10-21.

78 Hans Holfelder, ‘Gedanken zur örtlichen Organisation der Krebsbekämpfung’, Deutsche Medizinische Wochenschrift, 1931, 57: 659-62.

79 Hans Holfelder, and Walter Körte, Das Röntgeninstitut der chirurgischen Universitätsklinik im Stäadtischen Krankenhaus Sachsenhausen in Frankfurt a. M., Leipzig, Georg Thieme-Ver- lag, 1929, p. 25.

34 Scalpel or Rays?

80 Hans Küttner, Ferdinand Sauerbruch, and Victor Schmieden, ‘Die Chirurgie des Krebses und die neuen organisatorischen Bestrebungen zur Krebsbekämpfung’, Medizinische Welt, 1931, 5: 981-5. In response to this, the chairman of the ‘Reichsausschuß’, Bruno Dammann, quickly involved the surgeons in the committee’s further activities. See Bruno Dammann, ‘Die Ziele des Reichsausschusses für Krebsbekämpfung’, ibid., 1931, 5: 986; for his earlier position, see Bruno Dammann, ‘Wege und Ziele der Krebsbekämpfung’, in Grüneisen, op. cit., note 70 above, 1-9. See also Kaiser, op. cit., note 44 above, pp. 22-30.

81 Küttner, et al., op. cit., note 80 above, pp. 984-5.

82 Blumenthal to ‘Verwaltungsdirektor’ Alfred Kuhnert, 25 July 1932; HUA Char. Dir. nr. 953, 246-53, p. 248.

83 Ibid., p. 248.

84 Victor Schmieden, ‘Infektion, Parasitismus und Gewächsbildung’, in G Schmorl (ed.), Ver- handlungen der Deutschen Pathologischen Gesellschaft: zweiundzwanzigste Tagung, gehalten in Danzig am 8.-10. Juni 1927, Jena, Gustav Fischer, 1927, 21-36, p. 30, p. 34, respectively.

85 Van Helvoort, op. cit., note 43 above; see also Idem, ‘Viren als Krebserreger: Peyton Rous, das “Infektiöse Prinzip” und die Krebsforschung’, in C Gradmann, and T Schlich (eds), Strate- gien der Kausalität: Konzepte der Krankheitsverursachung im 19. und 20. Jahrhundert, Pfaf- fenweiler, Centaurus-Verlagsgesellschaft, 1999, 185-226.

86 Ferdinand Sauerbruch, and Else Knake, ‘Bericht über weitere Ergebnisse experimenteller Tumorforschung’, Archiv für Klinische Chirurgie, 1937, 189: 185-90, p. 190.

87 See Andreas Fijal, ‘Die Rechtsgrundlagen der Entpflichtung jüdischer und politisch mißlie- biger Hochschullehrer nach 1933 sowie des Umbaus im nationalsozialistischen Sinne’, in Fischer, et al., op. cit., note 67 above, 101-15. See also Robert N Proctor, ‘The Gleichschaltung of German cancer research’, in Idem, The Nazi war on cancer, Princeton, N.J., Princeton Uni- versity Press, 1999, pp. 35-57.

88 See Michael Hubenstorf, and Peter Th Walther, ‘Politische Bedingungen und allgemeine Veränderungen des Berliner Wissenschaftsbetriebes 1925-1950’, in Fischer, et al., op. cit., note 67 above, 5-100, pp. 34-5; see also Anonymous, ‘Einleitung’, in Röder and Strauss, op. cit., note 67 above, Band I: Politik, Wirtschaft, Öffentliches Leben, pp. I-LVIII.

89 Gocht’s own position with respect to the ‘IfK’ did not become clear. Gocht was editor of the literature review Die Röntgen-Literatur — Zugleich Anhang zu ‘Gochts Handbuch der Rönt- gen-Lehre’, Stuttgart, Enke, 1911ff. On Hermann Gocht, see Holthusen, et al., op. cit., note 25 above, pp. 30-2; Goerke, op. cit., note 5 above, pp. 19-20; and Uwehorst Paul (ed.), 150 Jahre Berliner Orthopädie, Berlin, Humboldt-Universität, 1985, pp. 70-77.

90 Walter Stoeckel to ‘Dekan’ (Dean) Hermann Gocht, no date; HUA Med. Fak. 279, Bd 1, 100.

35 Ton van Helvoort

91 Victor Schmieden to ‘Dekan’ Hermann Gocht, 6 June 1933; HUA Med. Fak. 279, Bd 1, 27- 30, pp. 27-8.

92 Ibid., pp. 29-30.

93 Gösta Forssell to ‘Dekan’ Hermann Gocht, 7 June 1933; HUA Med. Fak. 279, Bd 1, 31-8, p. 34.

94 Hans R. Schinz to ‘Dekan’ Hermann Gocht, 7 June 1933; HUA Med. Fak. 279, Bd 1, 40-7, pp. 41-2, pp. 44-5, respectively.

95 Gösta Forssell, ‘Organisation der Krebsbekämpfung’, in H E Walther (ed.), IV. Internatio- naler Radiologenkongress Zürich 1934, Leipzig, Kommissionsverlag Georg Thieme, 1935, 56- 63, p. 61.

96 Ferdinand Sauerbruch, ‘Verhältnis der Chirurgie zur Radiologie’, in ibid., 63-8, pp. 65-6.

97 Ferdinand Sauerbruch, et al., ‘Die Bedeutung der von Sauerbruch, Hermannsdorfer und Ger- son angegebenen Diät bei der Behandlung der Tuberkulose — Bericht über die Sitzung eines zusammengesetzten Ausschusses des Landesgesundheitsrats am 28. Februar 1930’, Veröffent- lichungen aus dem Gebiete der Medizinalverwaltung, 1930, 32: 543-632; on research into constitutional aspects of disease in Germany see, for instance, Gerhard Koch, Die Gesellschaft für Konstitutionsforschung: Anfang und Ende 1942-1965, Erlangen, Palm und Enke, 1985, and also Proctor, ‘The Nazi diet’, in Idem, op. cit., note 87 above, pp. 120-72. For the further development of Gerson’s dietary therapy for cancer, see S J Haught, Censured for curing cancer: the American experience of Dr. Max Gerson, Bonita, CA, The Gerson Institute, 1991. The conflict between reductionist and holistic studies of the human cancer problem is discussed in Van Helvoort, op. cit., note 43 above.

98 Ferdinand Sauerbruch, and Else Knake, ‘Die Bedeutung von Sexualstörungen für die Ent- stehung von Geschwülsten’, Zeitschrift für Krebsforschung, 1936, 44: 223-39, p. 223; see, for instance, also Helmuth M Böttcher, Hormone: die Geschichte der Hormonforschung, Köln, Verlag Kiepenheuer & Witsch, 1963.

99 Hans Auler, ‘Geschäftsbericht des Deutschen Reichsausschusses für Krebsbekämpfung’, Zeitschrift für Krebsforschung, 1940, 49: 217-220, p. 220.

100 Heilmann, op. cit., note 5 above, p. 211. On the relationship between the ‘Reichsausschuß für Krebsbekämpfung’ and national-socialist ideology, see Félix Grüneisen, ‘Krebsbekämp- fung im nationalsozialistischen Staat’, Deutsche medizinische Wochenschrift, 1933, 59: 1498- 9; Hans Auler, ‘Die Aufgaben der Krebsbekämpfung im nationalsozialistischen Deutschland’, Fortschritte der Gesundheitsfürsorge, 1934, 8: 125-33; Max Borst, ‘Begrüßungsansprache’, Zeitschrift für Krebsforschung, 1940, 49: 216.

101 Cited in Goerke, op. cit., note 5 above, pp. 78-84.

102 Dagobert Müller, 250 Jahre Charité, Berlin, VEB Graphische werkstätten, 1960, pp. 257.

36 Scalpel or Rays?

103 Kaiser, op. cit., note 44 above, p. 73.

104 Ferdinand Blumenthal, ‘Krebskonferenz in Dresden vom 11.-13. Juni 1930’, Zeitschrift für Krebsforschung, 1930, 31: 632-6, p. 636.

105 Gösta Forssell of the Swedish ‘Radiohemmet’ also perceived such problems as important obstacles for the rational practice of radiotherapy: “The greatest obstacles that have so far stood in the way of cancer therapy have been the lack of professionalism in the implementation of radiotherapy and the fragmentation of its powers and its weaponry.” See Gösta Forssell, ‘Orga- nisation der Krebsbekämpfung’, in Walther, op. cit., note 95 above, 56-63, p. 57.

106 This is an example of how philanthropy and charitative organisations can influence the development of cancer control. Cf. David Cantor, ‘Contracting cancer? The politics of commissioned histories’, Social History of Medicine, 1992, 5: 131-42.

107 Blumenthal to ‘Dekan’ Von Eicken, 28 February 1929; HUA Med. Fak. 269, 12a.

108 Stoeckel, op. cit., note 13 above, p. 121.

109 On the role of German authorities and cancer control, see for instance, Proctor, ‘The campaign against tobacco’, in Idem, op. cit., note 87 above, pp. 173-247.

110 It was not until the second half of the 1960s that Karl Heinrich Bauer succeeded in mobi- lising enough support for a German ‘National Cancer Institute’. See Wagner and Mauerberger, op. cit., note 8 above.

37 A DISPUTE OVER SCIENTIFIC CREDIBILITY:

THE STRUGGLE FOR AN INDEPENDENT INSTITUTE FOR CANCER RESEARCH * IN PRE-WORLD WAR II BERLIN

Ton van Helvoort Maastricht University**

INTRODUCTION

Cancer and cancer research are high-profile topics in our society. Cancer is a very common disease, which means that many people are directly confronted with it. At the same time, there is a great deal of interest in the problem and substantial effort is being invested in attempts to solve it. This is reflected in the financial support for medical and basic research, as well as in the large number of cancer hospitals, cancer research centres and charitable institutions trying to combat cancer.1

In a carefully argued essay on the history of cancer and cancer research, David Cantor contended that the historiography of cancer is often based on the idea of an autonomous development of scientific knowledge on cancer, with ‘progress’ as the key word.2 In cancer historiography, societal influences such as social, institutional, professional, financial and political circumstances are usually regarded as preconditions which can accelerate or inhibit the progress of cancer research. Cantor concluded that no historiography of cancer had yet been published which had succeeded in linking internalist analysis with externalist historical description.

Until about twenty years ago, this state of affairs was characteristic of the historiography of science in general, which tended to focus on theoretical aspects of the development of science, while institutional historiography was seen as a separate specialism. This situation has changed over the past two decades. Scientific knowledge is now being analysed from the point of view that knowledge, equipment, resources and policy coincide in science; scientific facts are the result of a construction process in which each of these factors plays its role.3 A consequence of

* Will be published in Studies in History and Philosophy of Biological and Biomedical Sciences, vol. 31 (3/4), 2000. © 1999 Copyright Elsevier Science Ltd. ** Dr Ton van Helvoort, Maastricht University, Faculty of Arts and Culture, Department of History, P.O. Box 616, 6200 MD, Maastricht, The Netherlands. E-mail: [email protected]. Ton van Helvoort this point of view is that objects of experimental research no longer have a self-evident or objective, inherent relevance, but that we have to investigate why and how they are being legiti- mised. Current thought in the historiography of science analyses how ‘natural’ objects, such as rabbits, mice, flies, bacteria and viruses are given relevance and status as scientific objects.4 In this approach, it is a necessity to integrate the formerly separate domains of internalist and externalist historiography.

The present essay attempts to give a combined analysis of internalist as well as externalist developments in cancer research, based on the history of the Institut für Krebsforschung (Institute for Cancer Research; IfK) of the Berlin Charité Hospital, founded in 1903.5 This institute’s history lends itself very well to such an analysis, as it always faced severe criticism with regard to both its experimental methods and the therapeutic approaches to cancer patients. The history of this Berlin institute reflects developments in experimental cancer research and cancer therapy. During its existence the IfK was criticised particularly by the disciplines which were traditionally involved in cancer treatment, and it is their resistance which clearly reveals the processes used in the attempts to legitimise or de-legitimise experimental cancer research. It will be shown that the debate on the right to exist for the Institut für Krebsforschung was concerned with medical authority and scientific credibility. Its attempts to carve out for its experimental research a niche within the ecology of existing disciplines reveal both the internal and external factors, as well as their intimate interrelations.6

The first section of this paper outlines the state of cancer research around the turn of the century and describes the founding of the Institut für Krebsforschung by Ernst von Leyden, while the second section discusses the attempts by Emil Fischer and Georg Klemperer to treat cancer by means of chemotherapy. The failure of this research project almost led to the institute’s demise. Section three describes how Ferdinand Blumenthal managed to lead the IfK to new successes by making radiotherapy the institute’s main therapeutic modality. The next section deals with the experimental research which earned Blumenthal and his co-workers international recognition. They experimented with transplantation tumours, chemical carcinogenesis and cancers in chickens and plants, and studied tissue cultures. When, in 1928, the state took over the financial responsibility for the institute, the IfK appeared to have stabilised its position.

Section five discusses the criticism levelled at Blumenthal’s experimental approach by pathologists and clinicians. They challenged the relevance of the experimental systems used by Blu- menthal’s group for human cancer research. Section six outlines Blumenthal’s attempts to have radiotherapy in Germany regulated, and particularly to centralise the use of radium. As a result of these attempts, he now also came under attack from surgeons and gynaecologists, who felt that the use of radiotherapy came under their jurisdiction. In 1932, Blumenthal was confronted

40 A Dispute over Scientific Credibility: with a cut in his institute’s budget, which he interpreted as being the consequence of the criticism on his experimental and therapeutic approach by pathologists, surgeons and clinicians. When the National Socialists came into power, all staff members of Jewish descent were dismissed, which meant that the institute was virtually dismantled. Section seven shows how attempts were made to reposition the institute and give it a new lease on life, attempts which were thwarted by the lack of agreement on the future lines of development. The essay ends with a discussion of the human cancer problem and concludes that the confrontation between Blumen- thal’s approach to cancer research and the traditional clinical approach can be characterised as the persistent tension between a reductionist, laboratory approach and a more patient-oriented, holistic approach.

CANCER AND CANCER RESEARCH AT THE END OF THE 19TH CENTURY

At the end of the 19th century, cancer appeared to be on the rise as a problem in the Western world. One of the causes seemed to be the increasing life span of the population; over the first three decades of the twentieth century, average life span rose from 40 to 55 years.7 Another reason for the increased interest in the disease was that a number of famous persons died from the disease during the late 19th century. This included members of leading European dynasties such as the German emperor Friedrich III (1831-1888), who suffered from cancer of the throat and died after having reigned for only three months.8

There has been, and is, consensus that cancerous diseases have two general characteristics, i.e. the formation of tumours (swellings) and their malignancy. Malignant tumours are characterised by a loss of cellular coherence, which can morphologically be visualised by means of a microscope. A malignant tumour infiltrates the blood or lymph vessels and invades the surrounding tissue. Benign tumours, by contrast, exert pressure on the surrounding tissue, without de- stroying it. Clinically speaking, malignancy has only one outcome; if the cancer cannot be removed, it will inevitably lead to death.9 At the time when macroscopic signs can be observed in a patient, it is often too late to remove the tumour surgically. Therefore the physician in at- tendance needs to diagnose the disorder as early as possible, taking a biopsy of the tumour, which the pathologist studies under the microscope.

Because time is a crucial aspect in the prognosis of cancer, other means of diagnosis than biopsy were sought ever since chemical-bacteriological laboratories had become part and parcel of the hospital.10 At the turn of the century, attempts were made to diagnose cancer and other diseases via the chemistry of the blood.11 However, for the orthodox pathologist the microscopic image was the ultimate test for the diagnosis of a disease. In the words of one of the most renowned

41 Ton van Helvoort pathologists of those days, Hugo Ribbert: ‘In trying to establish the presence of the type of changes indicating these diseases, the decisive test is therefore the microscopic image. ... The microscope therefore retains its full diagnostic value in all circumstances, while chemistry often deceives us.’ Chemistry had been called in to establish that a pathological state existed, but it could not indicate which cells had changed. According to Ribbert, this discipline might yield impressive results with regard to histological microchemistry, but ‘it will never replace microscopic examination, will never outperform the latter. ... Histology is and will always remain the mainstay of pathology.’12

The problem was, however, that after decades of morphological research, pathology could offer little progress in the etiology of cancer, in contrast with the situation regarding infectious diseases. It was the successes achieved by Louis Pasteur’s and Robert Koch’s bacteriology, not the least of which was the finding of the tuberculosis bacillus by the latter, which at the start of the twentieth century seemed to offer a way out of the stalemate which appeared to characterise cancer research. This resulted in two, more or less opposing camps.

To orthodox pathologists, the etiological moment was to be found in Karl Thiersch’ Epithelial Theory or Julius Cohnheim’s hypothesis of so-called embryonal ‘cell rests’, which replaced Rudolf Virchow’s Connective Tissue Theory of cancer histogenesis.13 The opposing view came from bacteriology, which, although it had not yet managed to identify a cancer microbe, held great promise. Or, as stated by the chroniqueur of cancer research, Jacob Wolff, in 1929: ‘As, however, the achievements of bacteriology managed to clear up so much that had remained dark in the etiology of various diseases, people turned to this tool to elucidate the true nature of cancer.’14 Many clinicians, including the internist Ernst von Leyden, the surgeon Vinzenz Czerny, the gynaecologists Robert von Olshausen and G. Leopold as well as the French surgeon Eugène L. Doyen, assumed that cancer had a parasitic cause.15 Such hypotheses became known under the general heading of the Parasitic Theory of Cancer.16 According to the surgeon Victor Schmieden from Frankfurt am Main, this hypothesis of a cancer parasite was shared by numerous clinicians who ‘in their search for an explanation of the origin of cancer suddenly turned to the new science of microbiology, whose scientific triumphs seemed unlimited at the time.’ According to Schmieden, who refuted the hypothesis of a microbial cause of cancer, pathologists were ‘the fiercest enemies of this [microbial] theory’.17 In 1913, for instance, the le- gendary pathologist Ludwig Aschoff, speaking about the recurrent claims that potential cancer- causing agents had been isolated, told the New York surgeon Willy Meyer: ‘And if you should reach Methuselah’s age, you would not have lived long enough to see that happen ...’.18

After the successes of bacteriology during the latter quarter of the nineteenth century a closer study of the problem of the etiology of cancer was therefore deemed urgent. The year 1900 saw

42 A Dispute over Scientific Credibility: a German initiative for a review, or ‘Sammelforschung’, on the subject of cancer. A ‘Deutsches Zentralkomitee für Krebsforschung’ (DZK) was installed, chaired by Ernst von Leyden and ‘Ministerialdirektor’ Martin Kirchner, with George Meyer responsible for external communi- cations. At the same time the Zeitschrift für Krebsforschung was started as a channel for publi- cations.19

As stated above, Ernst von Leyden was an avowed supporter of a microbial cause of cancer. At the inaugural meeting of the abovementioned committee, he said: ‘The theory which is now gaining prominence, and to which I myself fully subscribe, is that of the parasitical nature of cancerous diseases. It is the only theory which is in sufficient agreement with the observations and with current biological views.’20

An important point of criticism on the parasitic theory of cancer was that clinical experience had shown cancer not to be infectious in person-to-person contacts. Like so many opinions in cancer research, however, this view was not universally accepted. The French physician Gueil- lot, for instance, had recommended in 1891 that the house of a cancer patient had to be disinfected after the patient’s death: ‘A house in which a cancer patient has succumbed is contaminated and must be disinfected.’21

Experiments on cancer in animals, however, seemed to indicate that cancer was not an infectious disease. At the 1909 international medical conference in Budapest, Ernst F. Bashford, director of the London ‘Imperial Cancer Research Fund’, stated that cancer was not infectious in animals. He based his opinion on the finding that experiments with some 200,000 mice had failed to produce any evidence of infection. Robert Behla, a prominent member of the DZK, coun- tered Bashford’s claim by saying: ‘Does this mean that the parasitical theory of cancer is dead, stone-dead? I dispute that view. [Ist etwa die parasitäre Krebstheorie dadurch tot, mausetot? Ich bestreite das.]’22 Behla saw himself as a new Luther attacking the orthodoxy of pathological anatomy represented by scientist Hugo Ribbert from Bonn: ‘What is there left to fear for an on- cologist who no longer fears the criticisms of the school of Ribbert, which has severed all ties with the progress party, which denies even the possibility of parasites and sticks to the view that any parasite must damage cells, even though many are simply symbionts. ... Even at the risk of being excommunicated by Bonn, I nail the following theses to the doors of the pathology institutes ...’. Behla then went on to suggest that cancer was caused by a Myxomycete which could be artificially cultured.23

43 Ton van Helvoort

THE FIRST DECADE OF THE INSTITUT FÜR KREBSFORSCHUNG (1903-1914)

Bacteriology, meanwhile, not only provided the Leitmotiv in the quest for possible etiological agents; it also contributed the techniques of active and passive immunisation for cancer. Ernst von Leyden, director of the Charité’s ‘I. Medizinische Klinik’, and his assistent Ferdinand Blu- menthal had ground up a spontaneous tumour obtained from a dog, and had injected the material into another dog. In this way they invoked immunity to further transplantation of tumors. They had also isolated bacteria from human tumours and suggested that the bacteria could form a vector for the transmission of a virus which could be involved in the development of cancer: ‘We felt it was definitely possible for bacteria to pick up a virus outside or inside a tumour, after which the virus would be cultured along with the bacteria. In our opinion, other microorganisms could also pick up the virus in question. This would mean that various parasites might acquire cancer-inducing capacity through such a virus.’24

To pursue the study of cancer and the search for potential cancer microbes on a more regular basis, Ernst von Leyden founded the Institut für Krebsforschung, appointing Blumenthal as the physician in charge of the clinic. It consisted of two wards for cancer patients (one for men, the other for women) and a laboratory. In his opening speech, Von Leyden indicated that physicians felt the need for action and that the parasitological/bacteriological theory offered them an opportunity for this: ‘Many of you might shake their heads and wonder how at my age I can find the courage to take up such a heavy task. ... It was particularly the new pathological insights provided by Louis Pasteur and Robert Koch. ... Many people expressed the opinion that this too had to be a parasitical disease. The struggle over these views continues today. Some important scientists still reject, if not actually combat, the parasitical view of cancer. I myself have adopted and defended this theory, not because I am always right but because this is the view to depart from if we are to take any action.’25 Just like the Berlin Institute, other institutes such as Ro- swell Park’s New York State Cancer Laboratory in Buffalo (N.Y.) (1899) and Vinzenz Czerny’s Institut für experimentelle Krebsforschung in Heidelberg (1906) were also conceived on the basis of a microbial cause of cancer.26

In the course of the first decade of the twentieth century, claims for possible cancer parasites were to fade. According to Jacob Wolff’s account of the history of cancer research, the parasites that had been isolated or observed were usually saprophytes or the products of cell degeneration processes.27 Ministerialdirektor Friedrich Althoff of the Prussian ‘Kultusministerium’, who had been involved on behalf of the state in the founding of Von Leyden’s cancer institute, is reported to have said that such a small-scale institute as this could easily be closed down again in case the microbial cause of cancer was not found ‘since it is on the basis of this view that it is being built.’28 After Von Leyden’s unexpected death as a result of a tragic accident in 1910,

44 A Dispute over Scientific Credibility: however, the institute was not closed down, even though no definite cancer parasites had been identified. By that time, experimental cancer research had become firmly entrenched and chemotherapy had emerged as a promising new approach to the treatment of cancer.

On the basis of experiments performed in the last two decades of the nineteenth century, in which spontaneous tumours in dogs had been transplanted (cf. the work by Von Leyden and Blumenthal), experimental cancer research was given a new impulse when Carl O. Jensen in Denmark and Leo Loeb in the United States independently reported on cancer transplantation experiments in mice and rats.29 The research by Jensen and Loeb had made the transplantation of tumours between rats and mice a routine laboratory model, offering opportunities for a sy- stematic study of the effects of chemical substances on tumours. Since Paul Ehrlich’s work on chemotherapy for, among other things, syphilis, research into the effect of chemical substances on infectious diseases had developed into an ‘industrialized’ search for a cancer cure. Hence, August von Wassermann’s observations on the effect of selenium compounds on tumours in mice created great excitement. Wassermann managed to cure transplanted tumours in mice by means of selenium-eosine.30

The influence of selenium on animal tumours had already been investigated by the chemist Emil Fischer, in collaboration with Georg Klemperer. They considered it possible that such a compound might destroy ‘the causative agent of cancer just as Hg [mercury] destroys Spiro- chaetes ...’.31 It was on the basis of these promising results that Fischer was put in charge of the IfK, with Klemperer as head of the clinic, allowing them to test the effect of such chemo- therapies on cancer patients. In his 1912 paper entitled ‘Der jetzige Stand der Krebsforschung’ (The State of the Art in Cancer Research), Georg Klemperer claimed that the future held a great deal of promise, ‘but nobody can tell whether the day of the harvest is near.’32

At the time, however, this chemotherapeutic approach failed to yield useful results in humans, which forcefully confronted researchers with the major differences between transplanted tumours in animals and cancer in humans. They were surprised to find how easily the transplanted tumours in animals could be influenced therapeutically. Active or passive immunisation, X- rays, adrenalin, trypsin and other fermentation products, all were able to destroy, or at least re- duce such tumours. But none of these had the same effect in humans, so that in 1911, Blumen- thal concluded that ‘there is a greater biological difference between cancer in animals and that in man than is often assumed.’33 Inevitably it was concluded that transplanted tumours in, e.g., mice had a fairly low level of malignancy.

In conclusion, by the beginning of World War I the expectation that a cancer microbe could be isolated had not been fulfilled. Fischer and Klemperer’s research was based on tests with ani-

45 Ton van Helvoort mals and, disappointingly, chemotherapy in man did not yield any effective anti-cancer therapy, whereupon around 1914/15 the demise of Von Leyden’s institute seemed imminent. Under the directorship of Johannes Orth (who was Rudolf Virchow’s successor as director of the Charité’s Pathological-Anatomical Institute), and the daily supervision of Blumenthal, however, therapeutic research at the institute took yet another turn, switching to radiotherapeutic treatment of patients. It was especially through this latter therapeutic perspective that the IfK gained a consi- derable reputation for itself.

RAYS OF HOPE: RADIOTHERAPY AT THE IFK FROM 1914 UNTIL 1928

By the time WW I broke out, bacteriology and chemotherapy no longer seemed to have much to offer to cancer research and therapy. Retrospectively, surgeon Ferdinand Sauerbruch, who was to be appointed curator of the IfK in the middle of the 1930s, summarized the situation after the first ten years of IfK as follows: ‘The nature of the disease was not recognised and no treatment modalities were found which were more effective than the old ones. It was recognised that practical experience was urgently needed to supplement the theoretical research, and conse- quently the cancer institute was extended to a treatment centre, which concentrated on radiotherapy.’34

Indeed, the IfK needed a supply of cancer patients. In 1911 Georg Klemperer had asked ‘Mini- sterialdirektor’ Naumann in writing for permission to open an outpatient clinic. In particular, there was a need for patients whose cancer diagnosis was not yet definitive, allowing the institute to test the latest diagnostic methods. It might take several weeks before a decision could be made as to whether a patient could be operated upon, and in the meantime they could be exami- ned on an outpatient basis at the IfK, after which they could undergo surgery at the appropriate clinic.35 Klemperer emphasized that so far, the IfK had been receiving mainly ‘hopeless’ cancer patients, a consequence of the fact that the institute did not have an outpatient clinic of its own, so that recruitment of patients did not take place through direct admission but through referrals from the Charité’s other institutes: ‘... that our patients come from clinics, which only allow them to come here after they have lost any practical medical or scientific interest in them and only the human aspect of euthanasia can be considered.’36

The 1911 letter by Klemperer already hints at the tension which was to persist between the IfK and the other branches of medical science which had until then catered for cancer patients, such as surgery, internal medicine, gynaecology, etcetera. He hastened to add that the IfK had no intention to admit patients who could be helped by means of an operation; such patients would be immediately referred. The traditional treatment of cancer consisted of the removal of the tu-

46 A Dispute over Scientific Credibility: mour by surgery, in which progress in anaesthesia and the development of aseptical techniques allowed for more complicated operations with better chances of survival. Nevertheless, in many cases tumours had progressed too far to be removed entirely or metastasis had already taken place. Thus, surgeons were often confronted with inoperable cases of cancer.

Klemperer was aware of the resistance which an outpatient clinic at the IfK would evoke, but, he asserts: ‘There would be no competition with the surgeons whatsoever. Our department would select internal, inoperable cases or inoperable relapses of external cancers.’37 (Emphasis as in the original.) Tumours not eligible for surgical treatment included those of the pleura and the lungs, the liver, the spleen, the pancreas, parts of the stomach and the intestinal tract, as well as those in patients who had been operated upon before and who had relapsed, often cases with cancers of the breast and uterus. The ‘Verwaltungsdirektor’ of the Charité, Ernst Pütter, also pointed out that the IfK needed patients ‘in the various stages of the disease’, necessitating the founding of a ‘Poliklinik für Krebskranke und Krebsverdächtige’.38 After this request the IfK was granted permission to open such an outpatient clinic.

When Fischer and Klemperer ended their chemotherapeutic experiments in 1914, the institute had ran into financial difficulties. Blumenthal was given the task to save the interesting animal tumour samples and was put in charge of the day-to-day running of the IfK. He had an influential ally in Ernst Pütter, who in 1915 wrote a letter of recommendation and support to Naumann of the Kultusministerium: ‘Professor Ferdinand Blumenthal is now incontestably the leading scientist, both at home and abroad, in the field of cancer research, and the unfruitful Fischer- Klemperer era has recently survived only thanks to Blumenthal’s research work. We are glad to see that he has now finally been promoted to director of the institute, a position which he de- served even before it was given to Klemperer, but which could not be granted to him because of the alleged discovery by Exzellenz Fischer [i.e. the chemotherapeutic treatment of cancer, TvH].’39

Even after Blumenthal had taken over the leadership of the IfK, the relationship with the surgical clinic led by Professor Axhausen remained one of careful manoeuvring. In a letter to the ‘Minister für geistliche und Unterrichts-Angelegenheiten’, Blumenthal writes that a pleasant cooperation has evolved between the IfK and the department of surgery. Patients eligible for operation were referred to the surgical department while the latter ‘sends us the tumours removed at operation, and we use them to prepare a vaccine with which we immunise the patients in order to induce their bodies to form antibodies against tumour relapses.’40 Although in this letter Blumenthal claimed that the collaboration with the other clinics was harmonious, ‘Ministe- rialdirektor’ Naumann reported ‘fierce resistance’ against the institute from the side of the Charité’s rival clinics and institutes. As Blumenthal retrospectively summarized, the argument

47 Ton van Helvoort was: ‘[The] scientific research was done in other institutes, while the cancer patients could be treated at the appropriate clinics.’41

The problem broached by Klemperer, viz. that the IfK was only given ‘hopeless’ cases to treat, lay not only in that fact that these patients were unsuitable as subjects for research, but also that as a consequence, the cancer institutes would come to be regarded as ‘houses of death’ and would be shunned as such.42 On the occasion of the 25th anniversary of the founding of the IfK, Blumenthal expressed this in the following words: ‘But cancer patients, like all patients, want to be treated and go to places where they believe that everything needed for such treatment is available; they lose confidence if they find that this is not the case.’43

As was expressed in Sauerbruch’s quote (beginning of this section), the second decade of the twentieth century saw the development of an alternative mode of treatment in addition to the surgeon’s knife, viz. radiation. The discovery of Röntgen rays, or X-rays, and other types of radiation, such as the radioactivity from radium, radon and mesothorium, together with the finding that these rays had a special destructive effect on dividing cells, offered an alternative treatment modality for cancer. This became known as ‘Strahlentherapie’ or radiation therapy.44

In Blumenthal’s view, pathology and surgery had made important contributions to cancer research and cancer treatment, but they had both come to a standstill: ‘[I]n the second half of the past century, pathology had founded and fully elaborated the science of the structure and clas- sification of malignant tumours, while surgery at the same time had not only developed but completely perfected the surgical methods to remove such malignant tumours, so that further progress in these areas could hardly be expected.’45 Blumenthal’s motto was that no patient should go untreated, and the use of radiation might be able to end the stalemate. However, he resisted a simplified view of radiation therapy: ‘It is not enough if someone just aims a Röntgen tube at the tumour.’46 According to Blumenthal, the treatment of cancer was a complex and intensive process, involving an operation, if possible, followed by radiation therapy, courses of arsenic (!) to boost the patient’s resistance and possibly serum and vaccination therapies. This meant that the scalpel was no longer the only succour for the cancer patient, and that the latter no longer had to abandon all hope when the tumour proved inoperable.47

The radiation department of the IfK was led by Ludwig Halberstaedter, who developed it into one of the most outstanding radiotherapeutic clinics in Germany.48 The IfK treated a substantial number of patients with malignant and benign tumours. During the six years from 1922 until 1927, 2514 cases of malignant tumours were treated with radiotherapy, as well as 1353 other conditions.49

48 A Dispute over Scientific Credibility:

After Blumenthal had taken over the day-to-day management of the institute in 1914, the ap- pointment of Johannes Orth as general director of the IfK in 1917 meant that an influential fi- gure was put in overall charge again. In actual fact, however, Blumenthal remained responsible for the institute’s policy. Four years later, Orth resigned and Blumenthal took over, being appointed general director the next year. After a financial crisis in 1924, which was averted by Blumenthal through private funding, the IfK seemed to have stabilised its position by 1928. In that year, Blumenthal was given an extraordinary chair in cancer research, and the institute was structurally funded by the state from April 1929 onwards.50 The radiation department had become the backbone of the Institut für Krebsforschung, shaping the institutional preconditions of a renewed experimental study of cancer by Blumenthal and his co-workers. But at the same time, as we shall see, radiotherapy became one of the main causes of the demise of the Charité’s Institut für Krebsforschung.

In September 1926, Blumenthal, summarizing the organized movement for cancer control in Germany, stated that the out-patient clinic of his institute was visited by more than 2,000 patients annually, while the radiation department treated 50 cancer patients a day with X-rays, radium and thorium X.51

EXPERIMENTAL RESEARCH AT THE INSTITUT FÜR KREBSFORSCHUNG FROM 1914 UNTIL 1928

Diagnosing the nature of a tumour was done on the basis of its morphological features, which were derived from its macroscopic behaviour as well as its microscopic appearance. Orthodox pathology regarded a malignant tumour as the outcome of a deranged cell, a hypothesis which was called the Cellular Theory of cancer. Important representatives of this orthodox pathology included Julius Cohnheim, Karl Thiersch, Hugo Ribbert and David von Hansemann.52

In 1919 Blumenthal stated that cancer was the ‘abnormal fermentative properties of the tumours ... [which] ... developed on the basis of a chemical change in the malignant cells.’ He concluded that the essential problem in the malignancy of a tumour was not a problem of growth but of metabolism.53 This same view was held by Johannes Orth, by then director of the IfK, who claimed: ‘These are undoubtedly primarily intracellular processes induced by external factors.’54 When a cell developed into a cancer cell, it had developed certain characteristics so that the cell which had gone astray could be seen as an ‘independent’ parasite infesting the body. According to Blumenthal this had inspired the search for cancer microbes: ‘It was probably this similarity which led many clinicians [including Ernst von Leyden and, initially, Blumenthal himself; TvH] to the idea that the etiology of cancer was that of an infection and made them insist on postulating a cancer agent, notwithstanding the failure of all attempts to find it. As a

49 Ton van Helvoort result, many physicians and laymen believed for decades that such an agent had to exist and that no real progress in cancer research and cancer treatment was to be expected until it had been found.’55

Unlike Hugo Ribbert who, as we have seen, valued morphology and microscopy higher than the results of the chemical/physiological laboratory, Blumenthal set greater store by chemistry, which ‘puts matters in a different light than mere morphological observation can produce.’56 Blumenthal favoured the chemical approach and he and Carl Neuberg reported abnormalities in proteolytic ferments which were specific to tumours. According to Hugo Ribbert and David von Hansemann, these were insignificant or postmortal phenomena.57

The notion that the secret of unrestrained multiplication of cancer cells was to be found in an aberration of their metabolism urged Blumenthal to study cancer in an experimental setting. This brought him in conflict with orthodox pathologists such as Ribbert and von Hansemann, but he had an ally in Johannes Orth: ‘While Ribbert, one of the most prominent pathologists of his day, held no hope that experiments could ever solve the problem of the etiology of cancer, his no less prominent counterpart Orth stated that such efforts should be continued with all force.’58

Blumenthal was not the only one who advocated the view that experimental research in the wi- dest sense had to be called upon to solve the riddle of cancer. The American plant pathologist Erwin F. Smith — author of the three-volume standard work Bacterial Diseases of Plants (1905-1914) — defended a similar view regarding the necessity of an experimental approach in cancer research after pathology had come to a standstill. In a lengthy paper on plant tumors in Science, Smith in 1916 forcefully attacked the morphological approach:

With some praiseworthy exceptions, the cancer specialists of to-day, following the lead of the Germans, and their English imitators, are lost in a swamp of morphology, and it is time that an entirely new set of ideas should be promulgated to rescue them from their self-confessed hope- lessness.

When a pathologist [David von Hansemann, TvH] can say: ‘Concerning the ultimate nature of neoplastic overgrowth we shall never have more than a descriptive knowledge,’ he has reached the end of the road in his direction and the limit of pessimism! I [Erwin F. Smith] do not care a rap whether I am called orthodox or heterodox, but I do care tremendously to keep an open mind and a hopeful spirit. One trouble with too many cancer specialists is that they are not biologists, whereas the cancer problem is peculiarly and preeminently a biological problem. These cancer morphologists have patiently cut and stained and studied hundreds of thousands of sections of tumors, fining and refining their definitions and distinctions and building up high walls of se-

50 A Dispute over Scientific Credibility: paration where nature has made none, all because they do not understand the plasticity of living, growing things. I do not mean to condemn the study of sections, but only to suggest that there are also other ways of looking at this problem, which is one of growing things. There is too much reasoning in a circle on the part of many of these writers, too much argument basing one assumption on another assumption as if the latter were a well-established and solid fact, too little clear thinking of a biological sort, too little first-hand knowledge of living plants and animals, too much dogmatism, too much orthodoxy, and not enough experimentation. Hence the pessimism and the discouragement. ... These strong men, chiefly morphologists, have dominated the situation for a generation, but they have not explained cancer and they can not explain it, and they must now give way.59 (Emphasis as in the original.)

By the time of Erwin F. Smith’s paper, cancer research had already entered a new phase. Rese- archers like Carl O. Jensen, Leo Loeb, Paul Ehrlich, Ernest F. Bashford, Carl Lewin and Leonor Michaelis studied the behaviour of spontaneous tumours transplanted to other animals of the same species. This resulted in transplantation or graft tumours which could be cultured (propa- gated) indefinitely, and unleashed a vast amount of experimental cancer work.60

Orth and Blumenthal distinguished between the etiological process in cancer and the behaviour of the tumour cell once it had become cancerous. Blumenthal still held open the possibility of cancer parasites playing a role in the etiology of cancer, but rejected a role for them during the further development of a tumour; the latter possibility had definitely been excluded by the many transplantation experiments in which no evidence of parasites was encountered. But he made allowance for a role for ‘neoplastic ferments’ in this process. In 1918, Blumenthal suggested the following mechanism for cancer formation: ‘It was assumed that these growth substances would normally be adequately suppressed by specific inhibitors, but that these inhibitors ceased to function in cancerous cells.’61

The transplantation tumour work, however, was very much frowned upon by orthodox pathology. In 1928, Blumenthal commented on this: ‘The work on cancerous animals at first encountered fierce resistance. Von Hansemann initially stated that the cancers of mice and rats were not real tumours which could be compared to those in humans. Others ignored animal cancers for a long time; Ribbert did so as late as 1911.’62 As late as 1909, Ribbert had prophesied that the artificial incitement of cancer would never be possible63, a contention that only a few years later would be belied by the technique of tar-painting or Teerpinseln.

In 1914, two Japanese researchers, Katsusaburo Yamagiwa and Koichi Ichikawa, reported on the Teerpinseln technique (tar painting) in which the prolonged application of tar to a rabbit’s ear resulted in a tumour. These Japanese workers made use of this particular tissue because na-

51 Ton van Helvoort tural tumours do not arise there. This meant that cancer formation by applying tar required no carcinoma-specific Anlage to result in a tumour.64 (To investigate the role of an Anlage or dis- positional factor for cancer, hereditary aspects of cancer were studied in rodent laboratory models, often on an industrial scale. This line of inquiry was not followed by Blumenthal and his co-workers.65) In Blumenthal’s laboratory, the potential of causing benign tumours by tar painting was confirmed by Ludwig Halberstaedter.66 The importance of such tar-induced tumours was in that it showed a strong analogy with cancer of the scrotum in chimney sweeps, caused by the coal-tar in chimneys.67

In a third animal model of cancer, the analogy with human cancer was felt to be more remote, and its relevance for cancer in man was therefore denied by many. This model was the chicken tumour discovered by the Rockefeller Institute researcher Peyton Rous in 1910. After trans- planting a tumour from one chicken to a chicken of related breed, Rous was able to isolate an ultrafilterable agent by which the tumour could be transmitted. Rous claimed that his ultrafil- trate contained no living cells. This contradicted the accepted knowledge that transmission of tumours could only be achieved when at least one intact, living cancer cell was transferred to the new host. After all, no definite parasitic cause — be it filterable or not — had so far been identified.68 The 1914 evaluation of the discovery of the Rous agent by the chairman of the ‘Cancer Commission’ of Harvard University, E. E. Tyzzer, may be seen as typical for the orthodox cancer worker: ‘Notwithstanding the interest which the work on fowl tumors aroused, in no instance has a similar infectious agent been demonstrated in tumors of mammals. We have at present, then, no grounds for believing that there is any specific infection associated with human tumors.’69

In the mid 1920s the work of the British cancer researchers William E. Gye and Joseph E. Bar- nard renewed the interest in Rous’s transmissible sarcomas. They reinvestigated the chicken tumours and claimed the existence of a filterable agent in mouse tumours as well.70 In 1926 Ernst Fränkel at the IfK also initiated studies of Rous chicken sarcoma and related tumours.71 Eva- luating the British work and the work by Fränkel in his own laboratory, Ferdinand Blumenthal concluded that the etiology of cancer could possibly reside in the attachment (‘das Anhaften’) of an invisible virus. He arrived at the same principal conclusion as Otto Teutschlaender of the Institut für experimentelle Krebsforschung at Heidelberg, who interpreted such an agent as an endogenous, chemical substance. Teutschlaender suggested a new name for such an entity, viz. ‘Ens malignitatis’. Blumenthal cared little whether such an agent should be called an autocata- lytic substance, an enzyme or an ‘Ens’; its origin was the most crucial aspect to him: ‘I too regard the cancer agent as something cellular, which, although it may occasionally enter the body from the outside, normally arises inside the diseased organism, i.e. endogenously. There is no need to assume that the agent is a parasite, or a ubiquitous virus, which until that moment lives

52 A Dispute over Scientific Credibility: a saprophytic life inside the body. ... In any case, the agent is not the exogenous parasite proposed by the old parasitic theory of cancer, which saw a causative agent as the sole cause of cancer.’72 (Emphasis as in the original.)

In addition to the animal models mentioned above, Blumenthal also approached the cancer problem by studying tissue cultures. In 1919 Rhoda Erdmann, who was introduced to this new in vitro technique by the American Ross G. Harrison, had started her study of tissue cultures at the IfK.73 Blumenthal offered her laboratory space after several requests to other laboratories of the Charité clinics had failed. Ultimately, Rhoda Erdmann would be given a separate Institut für experimentelle Zellforschung (Institute for Experimental Cell Research) but this was still tied to the IfK financially.74

Blumenthal’s laboratory studied yet another cancer model, besides transplantation tumours, chemical carcinogenesis, chicken tumours and tissue culture. In 1887 James Paget had already pointed out that similarities existed between plant galls and animal tumours. But probably the most important incentive to study plant galls in the context of cancer came from Carl O. Jensen, who had previously stimulated the study of transplantation tumours in mice. At the second In- ternational Cancer Congress, held in Paris in 1910, Jensen delivered a paper ‘Von echten Ge- schwülsten bei Pflanzen’ (On Real Tumours in Plants). He stated that the regular galls of plants were dissimilar to human cancer because they were more related to new growths caused by ‘Schmarotzer’ (parasites), for instance, the benign tumours of bilharzia. He also denied the true tumourous character of cabbage cancer, which was caused by a yeast. Only those plant tumours in which tumour growth was not preconditioned by continuing irritation by a micro-organism were to be regarded as relevant for cancer in animals. In this context he regarded the study of ‘Wurzelkropf der Rüben’ (crown gall of turnip) as of the utmost importance as ‘crown gall is not only a real neoplasm, but even a real tumour, which shows certain similarities to the malignant tumours in animals; I even tend to believe it could play a role in tumour research similar to that played at present by cancers in mice.’75

On what aspects did Jensen base his conviction that ‘crown galls’ represented a malignant tumour? On the one hand, on its continuing ability to proliferate, but on the other also on ‘the way it influences the growth of the turnip and its ability to relapse and be transplanted, as well as on the abnormal chemical conditions in its cells, [all of which] reminds us so much of the malignant tumours in animals that further research into the biological aspects of the tumour would doubtlessly be warranted.’76

Erwin F. Smith, who was quoted above as a proponent of experimental cancer research, was also an influential advocate of the relevance of ‘crown galls’ for the human cancer problem.77

53 Ton van Helvoort

However, Jensen and Smith diverged when it came to the bacterial cause of ‘crown galls’, B. tumefaciens, which was discovered by Smith. The latter held the opinion that the presence of this bacterium was a sine qua non for the growth of plant tumour tissue; Jensen on the other hand, who sometimes failed to detect the bacterium in crown galls, denied that the bacterium had to be present for tumour growth. Because of Smith’s claim that B. tumefaciens had to be present in order for a crown gall to growth, pathologists could deny that this was a case of a true tumour because parasites were not necessarily present in animal tumours.78

When Blumenthal succeeded Fischer and Klemperer in 1914/15, he equipped a ‘Abteilung zur Erforschung des Pflanzenkrebses’ (Department for the Study of Plant Cancer) in which crown galls of geranium, fuchsia and turnip were studied. He concluded that the plant cancers studied by him were certainly caused by parasites. He also thought this parasite to be identical to a bacillus found in infections of the epidermis as well as in cases with typhoid-like symptoms.79 In a publication in the early 1920s Blumenthal was quite aloof regarding the relevance of ‘crown galls’ for human cancer. His conclusion regarding B. tumefaciens and the tumour problem in man and animals was that ‘this example cannot alter the fact of the etiological diversity of cancer formation in humans and animals, whether it be parasitical or non-parasitical, and that it is therefore totally unsuitable for any attempt to derive a common cause for the problem of cancer.’80 According to Blumenthal the plant tumours were not similar to tumours in man and animals. They did not show the true characteristics of malignant tumours, i.e. their malignancy appeared to be weak and at best variable, and sometimes the tumour was not detrimental at all. Based on his research, he concluded that the bacillus caused the formation of daughter tumours, making the process one of infection rather than of genuine tumour formation. Blumenthal thought it therefore more reasonable to compare plant cancers with tumours resulting from tuberculosis or syphilis. Notwithstanding this conclusion, Blumenthal thought the study of plant cancers instructive ‘since this is a cellular neoplasm which develops in response to a bacterial stimulus, even though the biological characteristics of this neoplasm are not identical to those of cancers in animals and humans.’81

A few years later however, B. tumefaciens was again being studied vigorously by Blumenthal. His co-worker Paula Meyer had isolated ‘bacterial rods’ from human mamma carcinoma. It was especially the edges of the tumours and the softened parts which were closely studied. Meyer, Blumenthal and the latter’s personal assistant Hans Auler concluded that there might be a possibility that this B. tumefaciens-like bacterium could transmit a virus and thus cause cancer.82

What made the etiology of cancer so problematic was the multitude of possible causes; cancer could be caused by parasites, either specific as was discussed above or unspecific as described by the 1926 Nobel laureate Johannes Fibiger83, by chemical substances or by X-rays.84 Wha-

54 A Dispute over Scientific Credibility: tever the precise etiology of cancer, the continued suggestions that infectious agents could be involved in the causation of cancer unleashed almost emotional and certainly vehement reactions from those clinicians and pathologists who, on the basis of the non-infectious character of cancer, denied a direct involvement of parasitic, microbial agents. This resulted in the rejection of much of the experimental cancer research on animal and plant models. For them, this kind of work held little relevance for the greater problem of cancer in man.

We have seen that Ferdinand Blumenthal initiated studies using numerous new experimental systems, such as rabbit, rat and mice tumours, both in transplantation and in tar-painting experiments; chicken tumours; tissue cultures; and plant cancers. Blumenthal was a great advocate of the need for experimental cancer research and he expressed the opinion that special institutes were required for such research, since other research institutes were insufficiently committed to this area: ‘The difference between the Universitätsinstitut für Krebsforschung at the Charité and all of these institutes, including the above-mentioned Kaiser Wilhem Institute, is that all of these institutes could switch to other subjects tomorrow, without any problem; for them, cancer is only a part of their research task, while the cancer institute is devoted purely to cancer research.’85 But his choice of experimental models for solving the human cancer problem made him the object of severe criticism by orthodox clinicians and pathologists.

EXPERIMENTAL CANCER RESEARCH UNDER ATTACK

As was described above, chemotherapy and other treatment modalities were found to be highly successful in transplantated tumours in mice and rats, whereas such therapies yielded little or no effect in humans. It was this discrepancy which prompted August von Wassermann, one of the initiators of cancer chemotherapy, to observe: ‘Murine cancer is not the same as human cancer’.86

This statement touched upon the problem of the relevance of animal experiments for human cancer, a problem which still dogs experimental cancer research today. In 1929, Jacob Wolff discussed the problem explicitly in his review of cancer research under the heading: ‘Ist der Tierkrebs identisch mit dem Menschenkrebs?’ [Is animal cancer identical to human cancer?]. Or, in other words, ‘whether the malignant tumours in animals have the same clinical course as those in humans, whether they show the same anatomical, histological and biological characteristics as human cancer tumours ...’. Wolff claimed there were many similarities, and referred to Ernest Bashford of the ‘Imperial Cancer Research Fund’ as an important supporter of the relevance of tumours in mice for the problem of cancer. At the same time, however, there were many differences, which ‘preclude absolute identity and only allow analogy.’87

55 Ton van Helvoort

It could be argued that the transplanted or graft tumours in rodents — as opposed to tumours arising spontaneously — differed strongly from human cancer. For one thing, such transplanted tumours in mice could grew to incredible sizes; sometimes as large as the animal itself. At the same time, however, no cachexia, weight loss or wasting was observed, a phenomenon which was such a key characteristic of human cancers. In addition, these tumours showed so-called ‘circumscript growth’, which meant that they could be easily removed from the body (‘Aus- schälbarkeit’); this was another difference with human cancer, which was characterised by in- filtrative growth.88 Furthermore, metastasizing was rarely observed from graft tumours; by contrast, they often showed spontaneous resorption and healing, a process only sporadically seen in humans. A final remarkable difference was that transplantation of tumours could be effected more easily in young animals than in older ones, while spontaneous cancer arose mainly in older animals.

In view of this range of differences, it was perhaps not irrational to assume that graft tumours were a far cry from human cancer. Blumenthal also took a cautious position here. He concluded that ‘transplanted cancer develops in a different way from the natural disease. The former is nothing more than a daughter tumour of the original tumour, which finds better living conditions in young, rapidly growing tissue than in older animals. The conditions under which spontaneous cancer arises are very different from those for transplanted cancer tumours; this is not a matter of existing cancerous cells continuing their growth, but of normal cells of the body changing into cancer cells as a result of some specific stimulus.’89 Blumenthal felt justified in assuming that transplanted tumours were more like benign tumours, but he thought that much could be learned from this kind of tumours nevertheless.

Although many cancer workers ignored the studies of Rous’ sarcoma as being of little relevance to mammalian and human cancer, the work of Gye and Barnard put the parasitic theory of cancer in the limelight again, now dressed up as the Virus Theory of Cancer. In the United States, James Ewing, director of the New York Memorial Hospital for Cancer and Allied Disea- ses protested vigorously against this revival of attention for a theory of cancer parasites which he had pronounced dead two decades before.90 In the late 1920s, James Ewing claimed that Rous’s transmissible chicken tumours were more properly explained by James B. Murphy — a former co-worker of Rous — who now headed the cancer laboratory at the Rockefeller Institu- te. Murphy claimed that the extreme specificity of the agents discovered by Rous and himself constituted a fundamental and crucial argument against the involvement of living agents in the etiology of cancer. After all, every type of tumour had to be associated with its own specific causal virus. He thought it more probable that the filterable agent consisted of a transmissible mutagen, probably a principle with ferment-like properties.91 Ewing concurred with Murphy and concluded that the Rous agent ‘is in the nature of a ferment and not a living virus.’92

56 A Dispute over Scientific Credibility:

Research and speculations on chicken and plant tumours were anathema to the orthodox pathologists and clinicians, who rejected outright any ideas of cancer parasites or cancer viruses. In their view, the cause of cancer was in the nature of the cell; they defended the Cellular Theory in one form or another. In the homeland of pathology, Germany, pathologists also felt obliged to resist this reprehensible theory. The twenty-second annual conference of the Deutsche Pa- thologische Gesellschaft in 1927 was devoted to ‘Infektion, Parasitismus und Gewächsbildung’ (Infection, Parasitism and Tumour Development). Some saw this conference as the opportunity to finally settle the score with the parasitic theory of cancer; in their view, there was no such thing as a cancer parasite, whether microbial or viral in nature.

In the opening lecture, the influential Munich pathologist Max Borst claimed that there was a gradual transition between normal and malignant growth. And since normal growth could never be attributed to a parasite, cancer also had to be explained without recourse to such an agent: ‘we will have to try and explain the change toward malignancy from local circumstances or from a loss of general inhibitory factors.’93 In Borst’s opinion, the problem was that researchers limited their efforts to the cell, which made it a rather obvious idea to assume the existence of a cancer parasite. He himself felt that one had to look at tissues, organs and systems. In his view, the research into cancer parasites had yielded mainly artefacts, caused for instance by the effects of toxins, ferments, invisible viruses, etcetera. He also pointed out that many of the animal experiments basically involved an artificial situation: ‘But nearly all of our more or less firmly established knowledge of immunological processes in tumours has been derived from tumour transplantation experiments. ... No adequate basic information is available about spontaneous tumours.’94

Max Borst claimed that irrespective of whether blastomas grew expansively and only displaced other tissues (benign) or infiltrated and destroyed tissues (malignant), they always grew ‘aus sich heraus’ (Hugo Ribbert’s phrase), i.e. expanded by their own resources. Tumours never grew because something, of whatever kind, was passed on through contact. His interpretation was that this ruled out any parasitic cause: ‘Or else we would have to assume that some specific parasites are able to change normal cells into tumour cells, after which the altered cells continue their abnormal proliferation patterns without housing either the parasites or their metabolic products, that is, without showing any infectious properties.’95 Borst felt there were no grounds to assume that cancer was infectious: ‘Physicians, surgeons or pathologists do not become infec- ted through their contacts with tumour patients or with the tumours themselves.’ His overall conclusion was that ‘the infectious or parasitic theory of cancer lacks any firm foundation.’96 He stated that the mystery of cancer had to be solved by studying the causes of growth. Borst distinguished between exogenous factors (such as parasites) and endogenous factors, and felt that with respect to the latter ‘we are not yet even in the forecourt of the temple of knowledge.’

57 Ton van Helvoort

Nor was Otto Teutschlaender’s concept of ‘Ens malignitatis’ acceptable to him: ‘It seems to me that this is just the old riddle, dressed up in different, not even really new clothes.’97

At the same meeting, surgeon Victor Schmieden from Frankfurt am Main discussed the topic of ‘Infection, Parasitism and Tumour Development’. On the one hand, he blamed clinicians for the erroneous ideas about the parasitic nature of cancer: ‘We clinicians (though by no means only we surgeons) will therefore have to admit to being responsible for temporarily leading astray the entire cancer research.’ On the other hand, pathological anatomists had from the beginning been the most fervent opponents of this theory.98 In Schmieden’s view, the parasitic theory based itself ‘not on serious study of the question at hand but on mere impressions, on illogical conclusions from analogies, on worthless case histories and often simply on erroneous observations.’ He also claimed that no evidence had ever been found that cancer might be infectious: ‘There is no specific morbidity or mortality among physicians, nurses, researchers or the staff of pathology institutes and laboratories.’99 He felt that the parasitic theory could only be saved by assuming an ‘invisible ubiquitous virus’, but this might just as well, for example, be called a growth factor [‘Wachsstoffe’]. He concluded that parasites undoubtedly played some sort of role in the development of cancer, but that they never did so in a specific man- ner.100

Nor was Schmieden, like Borst, greatly impressed by the animal experiments, which he felt were too much concentrated on transplanted tumours. In fact, he was highly critical of all the model systems used: ‘It is alien to the clinician’s mode of thinking not to rely on conclusive evidence from human materials, but time and again to be referred to mammals, thence to birds, thence to cold-blooded animals and even to plants (sunflowers etc.). ... we must warn against attaching too much value to comparative observations from the animal or plant kingdom.’101 In his view, the tempting aspect of the parasitic theory was its therapeutic perspective: ‘The parasitical theory is a tempting one for the therapeutically minded practician, as it promises successful immune therapy and chemotherapy; that is why it is more welcome than the fateful and fatalistic theory of germ cell dislocation and heredity.’102

Victor Schmieden had no doubt that the parasitic theory had been conclusively disproved: ‘The strongest refutation of the parasitic theory probably resides in the observations on tar-induced cancer and on Röntgen-induced cancers in humans ...’.103 Since these techniques were able to induce tumour growth in all types of tissue, this meant that the cancer parasite had to reside in all healthy cells. He would only be willing to accept a cancer parasite if such an agent were to be found in humans and if it could be shown that the tumour disease had the typical clinical course and characteristics of an infectious disease, but this had not been observed so far. He therefore concluded: ‘As regards the parasitic theory; this is an abandoned hypothesis. There is no

58 A Dispute over Scientific Credibility: specific cancer-causing agent; cancer is not transmissible.’104 Borst concluded the 1927 conference of German pathologists with the words: ‘We have now buried the specific universal causative agent of cancer — hopefully forever.’105

Ferdinand Blumenthal, who wanted to keep an open mind on some sort of parasitic involvement, thereby became the object of fierce criticism from German pathologists and clinicians, who disagreed with these views. In this climate, the work at Blumenthal’s institute experienced resistance from pathological and clinical circles. The latter workers advocated the study of the problem of human cancer in the patient himself, as was also advocated by the leading American pathologist James Ewing, who concluded in 1935 that ‘the greatly improved outlook for the cancer patient has come from the combined efforts of clinical medicine in many departments, all directed to the more intelligent and detailed study of cancer in the human subject.’106 Alt- hough Ewing was rather sceptical about what could be expected from experimental cancer research, he was a fervent supporter of radiotherapeutic treatment of cancer in man and advocated biological studies of radiation.107 Blumenthal however, experienced criticism not only because of his experimental work but also because of the role he saw for radiation therapy in the fight against cancer. When he sought centralisation and regulation for radiotherapy in Germany in the early 1930s, opposition against these goals grew rapidly. Blumenthal then saw himself opposed not only by the pathologists but also by surgeons and gynaecologists, who rejected such centralisation of radiotherapy since this process would threaten their jurisdiction over this form of cancer treatment.108

THE CURTAILING OF BLUMENTHAL’S INSTITUTE

In 1928, Blumenthal and his institute finally seemed to receive the appreciation they had so long struggled to get. He was given an extraordinary professorship for cancer research, and the financial responsibility for the Institut für Krebsforschung was transferred to the state. Experi- mental research prospered and radiotherapy formed the institute’s legitimation as a cancer treatment center.

Blumenthal held the opinion that radiotherapy in Germany needed more strict regulation because of two structural problems, viz., radium bomb radiotherapy (tele-radiotherapy) and the un- controlled proliferation of radiotherapeutic practice. Therefore, a commission of radiotherapists and radiologists of the ‘Deutsches Zentralkomitee für Krebsforschung’ visited France and Swe- den to report on how radiotherapy and tele-radiotherapy were organized over there. This commission made a series of recommendations with regard to the concentration of radiotherapy in specialised centres, the control of radium and mesothorium as well as the judicial regulation of

59 Ton van Helvoort the profession of radiotherapists.109

In 1930, various initiatives tried to involve the state more closely in the fight against cancer. Thus the position of radiotherapy was discussed in the Landesgesundheitsrat.110 On 25 Febru- ary 1931, the ‘Reichsausschuß für Krebsbekämpfung’ (State Committee for Cancer Control) was established, with ‘Ministerialdirektor’ Bruno Dammann as chairman, Ferdinand Blumen- thal as deputy-chairman, and Felix Grüneisen as secretary. The primary tasks the ‘Reichsaus- schuß’ saw for itself included tackling the ‘radium problem’, the organisation of radiation therapy in general, and the training of radiologists. Proposals for legislation on handling radioactive materials were also made.111

These developments meant that the interests of the traditional disciplines were at stake, as be- comes clear from the following statement by A. Loos, dean of the Medical Faculty of the Uni- versity of Frankfurt am Main:

Until now, division of labour at the teaching hospitals was such that diagnostics, in particular the early recognition of individual types of cancer and the teaching of students and physicians in these areas was the task of the various specialist departments. This organisational structure not only reflects historical developments, but also corresponds best to the natural situation; only the specialist, who is completely familiar with the anatomy and functions of particular organs and organ systems under normal and pathological conditions and knows their peculiarities, is able to present to the students in a clear and emphatic fashion the early symptoms of cancer. In the interest of both patient care and teaching, it is absolutely essential that this traditional and reliable division is maintained.112

Such feelings and the criticisms on the work of the ‘Reichsausschuß’ meant that in the early 1930s, the climate in which Blumenthal had to work deteriorated rapidly. The centralisation of radiotherapy brought into the open a conflict which had actually been smouldering for the past three decades, viz. a struggle for competence between the IfK and those physicians who would traditionally be the ones to treat cancer patients, since they were suffering from tumours in organs which came under the responsibility of their disciplines. The activities of the ‘Reichsaus- schuß’ aroused resistance on the part of surgeons, gynaecologists and otolaryngologists, who felt excluded.113

In July 1932, the medical faculty cut the budget of the Charité’s Institut für Krebsforschung by RM 20,000, four fifths of which would have to be achieved by Blumenthal and one fifth by Rhoda Erdmann’s Institut für experimentelle Zellforschung, which, although an independent institute, was still financially integrated with the IfK.114 In a letter to the administrative director of the Charité, Blumenthal concluded that this budget cut basically meant closure of his in-

60 A Dispute over Scientific Credibility: stitute. He argued that the budget reduction had apparently been inspired by the fact that the traditional clinics claimed to have the expertise to administer radiotherapy to cancer patients themselves. Blumenthal felt that the motto of the campaign against the IfK was that ‘radiative treatment of cancer could just as well be performed and developed at the surgical clinics.’115

Blumenthal’s attempts to carry out radiotherapy in safe settings, to ensure adequate training of the specialists and to control the use of radioactive substances were frustrated by the resistance from the traditional medical disciplines. After the death of Bruno Dammann in 1933, Max Borst took over the chair of the ‘Reichsausschuß für Krebsforschung’, which thereby came to be led by someone who was highly critical of the animal experiments. Borst was primarily interested in the pathology of human cancer and at the above-mentioned 1927 Congress of the German Pathologists, Borst had stated: ‘Many of those who are searching for specific tumour-causing agents lack an overall view of the problem and tend to concentrate on details.’116

As we have seen, the resistance against Blumenthal did not only concern his radiation therapy. Cancer research as it was being practised in the pathological institutes had a descriptive, morphological character, while Blumenthal emphasised experimental research on animals and plants. This was characterised by the orthodox specialists as ‘artificial’ and hardly relevant to human cancer. Or as Blumenthal phrased it in his response to a letter by the dean of the medical faculty announcing the RM 16,000 budget cut: ‘In the early part of the present century, Hanse- mann and others attacked the new form of cancer research on animals and its laboratory findings, claiming that animal cancer was a different disease than cancer in humans. Up until the end of the first decade of this century, major pathology textbooks failed to mention cancer research on animals, or mentioned it only in passing. And it was as late as 1918 that the Bonn pathologist Professor Ribbert to a certain extent still claimed that it was a utopian dream to try and induce cancer experimentally, even though various methods for doing so had by then been developed.’117

Blumenthal, however, had always hoped that cancer research would inevitably become an independent line of research, just as bacteriological and chemical laboratories had been founded or had been set up in the context of the pathology laboratory. In other countries, he claimed, ‘the pathologists have long since given up their struggle against cancer research as an independent subject.’ He also pointed out that there were pathologists who were directors of cancer institutes, such as Johannes Fibiger in Copenhagen, James Ewing in New York and H. T. Deelman in Groningen, The Netherlands. In his opinion, the time for monopolising research branches and approaches was over: ‘[Cancer research] has long since overcome the limitations of mere morphological research ...’.118

61 Ton van Helvoort

In summary, it has been attempted to argue that Ferdinand Blumenthal’s dismissal and the trim- ming down of the Institut für Krebsforschung resulted from the traditional disciplines’ resistance against an innovative movement. Blumenthal once informally remarked that Von Leyden’s greatest mistake had perhaps been the small scale of the institute he had founded, which left it vulnerable to external attacks. Outside forces begrudged the IfK its successes in radiotherapy and also disputed the relevance of its experimental research, and so felt that the institute had to disappear or be cut down to size. It was with obvious regret that Blumenthal had to observe how centralised cancer institutes were being set up in many large cities abroad, while ‘the independence of cancer research and cancer treatment in Germany [appears to be] under attack from two different directions — pathology and surgery’.119

Blumenthal’s institute received its final blow when on 7 April 1933 the National Socialists decreed the ‘Gesetz zur Wiederherstellung des Berufsbeamtentums’ (Civil Service Law) by which all state personnel from Jewish descent were forced into early retirement or dismissed. Blumenthal was forced into early retirement and then emigrated to Belgrade, where he became a professor, while Hans Hirschfeld and Ludwig Halberstaedter were relieved of their posts and also emigrated.120

THE LOSS OF THE INSTITUT FÜR KREBSFORSCHUNG

Because of the dismissal of almost all the personnel of the IfK, only Hans Auler, who had been Blumenthal’s personal assistant since 1924, stayed on and he became the institute’s acting director. The discussions between Auler, the medical faculty and external advisers provide a more detailed picture of the general conflicts discussed above.121

With Ferdinand Blumenthal, the institute had come to be led by someone who had less authority than Von Leyden, Fischer or Orth, but who had enough entrepreneurial spirit to keep the institute afloat with the aid of external funding from, e.g., industry and banks.122 This resulted, however, in a kind of private institute, which led to friction within the Charité. Blumenthal had been employing, from private funds, various people outside the Charité’s staff. In a report on the IfK, Auler discussed the institute’s relations with other clinics. Because of the lack of beds at the IfK, Blumenthal had been using Landau’s private clinic, an intolerable situation in Au- ler’s view.123 It may be assumed that this situation, which had arisen during Blumenthal’s directorship, had always been a contentious issue. In a report, Auler wrote: ‘Even after the Institute was brought under public ownership in 1929, its character remained largely semi-private until 1 May 1933, in the sense that patients referred to the Charité were being treated at a private clinic (the Landau Clinic). This was an unlawful situation which was also uneconomical

62 A Dispute over Scientific Credibility: for the state. The same was true of the many smaller individual institutes within the Institute, in which physicians and technical staff worked on the basis of private contracts.’124 Auler acknowledged that the IfK had not been very popular: ‘For reasons which need not be elaborated here, the Institute was not very popular among the other clinics, and the same was true of the ‘Central Committee’ and the Zeitschrift für Krebsforschung, had close ties with the Institute. Experts claimed time and again that the Institute, the ‘Central Committee’ and the journal were superfluous. In short, the Institute did not, and still does not, enjoy a very good reputation.’ Au- ler then raised the issue of why the institute should be preserved. In his view, the main justifi- cation for its continued existence was the extensive body of knowledge on the cancer problem which had been built up at the IfK. He proposed to appoint a board of governors, consisting of representatives of various institutes, to assist the director.125

Felix Grüneisen of the ‘Reichsausschuß für Krebsbekämpfung’, who had earlier maintained good relations with Blumenthal, also expressed the need for a centre of expertise: ‘... if the cancer institute were a sort of nerve centre for the entire cancer problem at the Charité; ... as a centre which could integrate in a cooperative fashion the body of experience gained at the various clinics.’ The ‘Reichsausschuß’ wanted an institute that could develop a more global view and which could indicate ‘directions and targets to guide the scientific and organisational activities’. The IfK’s other functions could be transferred to other institutes: ‘The problem of radiotherapy is after all only a secondary task for the cancer institute. All individual aspects, such as cell research, animal research, serological and blood research and experimental therapy for serious patients could theoretically also be implemented at the Pathology Institute and at the various specialist clinics.’126 That did of course leave the question of the extent to which the centre of expertise could continue to function as such.

The dean of the medical faculty tried to form an opinion on the direction the institute should take by asking the advice of a number of external experts. Strikingly, their recommendations correspond closely to what might be expected on the basis of their particular discipline, in terms of the issues raised in the previous section.127 In view of the conflicting advice, it is not surprising that the Charité’s management failed to reach a decision on the future of the IfK.

In a letter from the dean of the medical faculty to the minister responsible it was stated that the present form of the institute was unsatisfactory, partly because the patient material consisted largely of hopeless cases referred by other clinics which also treated cancer patients. Since the city of Berlin’s ‘Hauptgesundheitsamt’ also wanted to assist in the treatment of cancer patients, the medical faculty’s proposal was to transfer the IfK to the Cäcilienhaus, under the administrative responsibility of Dr. Pickhan. This would mean a kind of judgment of Solomon: ‘The geo- graphical situation of the Cäcilienhaus, far removed from the university institutes, is also a

63 Ton van Helvoort favourable aspect, as it avoids conflicts regarding the patient material.’128 In a letter to Staats- minister Rust, Max Borst of the Munich Pathology Institute supported the idea of setting up a cancer therapy institute at the Cäcilienhaus. Borst had been asked to join the board of the scientific committee of the ‘Reichsausschuss für Krebsbekämpfung’, and this committee felt the need for a centralised institute as an operational base for research and information. Borst wrote that the Cäcilienhaus option would be useful, as the problems relating to the ‘collaboration with the Charité’s clinics and the other university institutes can easily be solved ...’.129

The ambiguous relationship between the Charité clinics and the IfK is evident from the institutes’ reactions to the idea of transferring the IfK. The clinics probably feared the loss of patients if the cancer institute turned out to be successful outside the context of the Charité, as the proposal to integrate the IfK with the Rudolf-Virchow Hospital was also rejected. Surgeon Ferdi- nand Sauerbruch — who was the co-author, with Hermann Küttner and Victor Schmieden, of the forceful attack on Blumenthal — expressed the view that the plans to transfer the cancer institute outside the Charité premises had to be rejected, as the ‘Krebsinstitut’ had to remain in ‘direct contact with the other Charité clinics ... [and] ... that it would be impossible to separate the cancer institute from the Charité, since that would mean that decades of close cooperation between the individual institutes would be disrupted and many important achievements would be lost.’ Sauerbruch proposed that the cancer institute should be led by himself and be linked to the surgical clinic. In his view, the purely radiotherapeutic approach would not always lead to the most suitable treatment modality, and such a one-sided approach would frequently result in poor treatment of the patients: ‘For instance, patients who would have had a chance of being cured by means of timely and adequate operations underwent useless radiotherapy. In other cases, radiotherapy was used for types of cancer which are known to be insensitive to radiation.’ As has been argued elsewhere, Blumenthal held the opposite view on the value of surgery in cancer treatment.130

Sauerbruch also recommended that other treatment modalities should be investigated, such as the ‘Ernährungsbehandlung’, a form of therapy which he had already applied to treat tuberculosis.131 Since the Charité’s surgical clinic already had a department of nutrition, integration would save expenses. Furthermore, the surgical clinic was already engaged in research on experimental tissue cultures. According to Sauerbruch, those departments of the surgical clinic and the cancer institute which were involved in scientific research would have to merge, and the resulting departments should limit their activities to research: ‘It would mean an improve- ment for both clinic and cancer institute to separate the research areas from the areas of treatment.’ Sauerbruch also proposed a new name for the ‘Krebsinstitut’; it should be known as the Abteilung für Geschwulstkranke (Department for Tumour Patients).132

64 A Dispute over Scientific Credibility:

In 1939, Hans Auler was given an associate professorship in cancer research, although some doubted his suitability. But since no other, more suitable candidate was available, the university’s rector felt Auler had to be given an opportunity to perform high quality research.133 As it turned out, however, Auler and his coworkers had to do their work in miserable circumstances during the final years of the 1930s and during World War II.134

THE HUMAN CANCER PROBLEM: CONCLUSION

Science is highly regarded in our society, particularly in the area of health care. The media re- gularly report on medical breakthroughs and expectations run high, especially when a problem like cancer is at stake. This is reflected in charitable fundraising activities for the benefit of scientific cancer research and in the plethora of laboratories for basic research in cancer hospitals and institutes.135 In the current state of the art, cancer is regarded as a genetic abnormality in cancerous cells and few people would contest that science is showing steady progress in this field.136

The institutionalisation of cancer research has meant that the process by which the relevance of research for the cancer problem was constructed has become ‘invisible’.137 Recent work on the history of science has tried to reveal these kind of processes. The present essay has analysed the specific case of the history of the Institut für Krebsforschung at the Berlin Charité until World War II, to show how cancer research and treatment were organised and legitimated. It was an attempt at institutionalisation which ultimately floundered, clearly revealing the resistance against the centralisation of German radiotherapy as well as the experimental approach to the cancer problem. The history of the Berlin IfK illustrates two aspects of cancer research in particular.

The first is the struggle for the availability of patients and patient materials suitable for research, in other words, the pursuance of medical authority to treat cancer patients. As Blumenthal emphasised, the IfK could only hope to have patients to work with if it could offer them a therapeutic perspective. He was able to offer such a perspective only in the form of radiotherapy, since surgery was the domain of the other Charité clinics, while chemotherapy and immunotherapy proved to be insufficiently effective. As I have briefly discussed here and more extensively elsewhere, it was Blumenthal’s attempts to regulate and centralise radiotherapy which became a major source of resistance against him and the IfK from the various Charité clinics and the specialist societies.138

A second aspect illustrated by the above history is the resistance against the experimental ap-

65 Ton van Helvoort proach to cancer study envisaged by people like Blumenthal, Orth and Smith, which is basically a dispute over scientific credibility. Orthodox pathologists contended that the experimental models these researchers considered relevant to the solution of the cancer problem, such as plant, chicken and rodent tumours, were too far removed from the main problem, cancer in man. They felt that the fundamental solution to the problem of cancer would be found in morphological, histological and constitutional research, and that until then, the best form of assistance one could offer to cancer patients was to improve existing treatment modalities.

Relations between the cancer clinic and the laboratory are inherently problematic, as recent historical studies have illustrated in detail and in particular for the case of immunotherapy.139 To give another example, a discrepancy between animal models and humans continues to dog the industrial-scale application of the results of genetic experiments in rodents to cancer prevention and treatment in humans.140

The history of the Institut für Krebsforschung reflects a remarkable confrontation between the experimental, reductionist approach to the cancer problem favoured by people like Blumenthal et al. and a holistically oriented approach favoured by people like Borst, Schmieden and Sau- erbruch. Recently there has been much interest in holistic appoaches in biomedicine.141 It has been pointed out by the medical historian Charles Rosenberg that twentieth century medical holism is hard to characterise with precision, but that it is best understood as an opposition to a mechanistic reductionism. It often manifests itself, he claims, as bedside oriented medicine as opposed to laboratory medicine.142

This dichotomy between reductionist and holistic approaches to medical problems is also reflected in a difference of opinions which has persisted in epidemiology for more than a century. In an earlier paper, Charles Rosenberg described how explanations of epidemics have histori- cally been marked by a distinction between two themes or schemes of thought, one based on the constitution of the persons or populations involved and one based on infection. He characterised these two views as follows: ‘The configuration theme is holistic and emphasizes system, interconnection, and balance, while the contamination theme foregrounds a particular disorde- ring element. The configurational style of explanation is interactive, contextual, and often en- vironmental; the emphasis on contamination reductionist and monocausal.’143

The history of the IfK illuminates a similar distinction between a reductionist, monocausal explanation of cancer and a configurational/constitutional explanation. Albeit that the prominent concept in oncology was not so much that of contamination — there was a level of consensus that cancer was not a contagious disease — but rather that of a monocausal, possibly subcellular agent.144

66 A Dispute over Scientific Credibility:

It may not be coincidental that the historical distinction between constitutional and monocausal explanations is particularly visible in Germany. It has been argued that the German pathologist Ludwig Aschoff — who was, as we have seen above, very strong-minded in rejecting a parasitic cause for cancer — strongly opposed the mechanistic theory of pathogenesis. Sauerbruch was strongly influenced by Aschoff’s ideas and Sauerbruch held that August von Wassermann’s ideas about diagnosing a patient on the basis of analyses of bodily fluids and excretion products were misleading: ‘A dangerous false track from bedside to laboratory has been taken’.145

Furthermore, Andrew Mendelsohn has shown that there was a great deal of support for the constitutional view of disease in that country.146 Mendelsohn mentions scientists like Hugo Rib- bert and Otto Lubarsch as representatives of this school of thought. Ribbert’s view of the origin of cancer has been referred to several times above, so a quote from Lubarsch may suffice to il- lustrate the latter’s constitutional explanation for the etiology of cancer: ‘Even if the existence of a causative agent of cancer could be irrefutably proved, other aspects, like chronic stimuli and the presence of cells displaced during the embryonic or postembryonic stage, should be regarded as having at least the same etiological importance as the parasite. ... It would become possible to find much more comprehensive solutions to the question of the propagation of the cancer (metastasis) and that of cachexia, as well as the relations with chronic stimuli, since anatomical examination of cases in which the cancer has apparently arisen spontaneously often reveals chronic inflammatory states representing prior alterations to the organs.’147

Accepting the distinction between constitutional/configurational and monocausal explanations as a fundamental characterisation of opinions in cancer research, it may be useful to return once more to the relation between clinic and laboratory. In a recent paper, Olga Amsterdamska described the controversy over experimental epidemiology between Leslie T. Webster and Simon Flexner on the one hand and W. C. C. Topley and Major Greenwood on the other. She argues that the latter used a configurational model, while the former used a contamination model. What is important in the present context is Amsterdamska’s argument that the transferral of Topley’s and Greenwood’s configurational model to the laboratory almost automatically gave rise to a contamination model: ‘In the laboratory, a configurational ideology seemed repeatedly to give way to a methodology embodying a contamination model. ... it was difficult, if not impossible, to maximize the advantages of the laboratory while upholding the configurational view. ... And even Greenwood’s and Topley’s ... commitment to configurational perspectives was not enough to overcome the reductionist and mechanistic consequences of standard bacteriological laboratory approaches and methodologies.’148 Thus, Amsterdamska argues that the laboratory approach is closely linked to the monocausal paradigm.

Although further study would be needed to substantiate this point, it seems reasonable to con-

67 Ton van Helvoort clude that much of experimental cancer research and its historiography is drenched in the re- ductionistic and monocausal view of the origin of cancer.149 Few scientists have been conscious of the fact that experimental cancer research has largely been structured on the basis of the monocausal, mechanistic principles for which nineteenth-century bacteriology was a prime source. Let me quote two of the few scientists who were aware of this precondition of cancer research, viz. G. W. de P. Nicholson, from 1933, and F. M. Lehmann, from 1964:

This judicial attitude towards morbid states in general and tumours in particular is a result of the truly mediaeval notions of causation by which pathology — dominated by clinical medicine — is informed. Paradoxical though it may sound, the fault lies largely with bacteriology, whose brilliant and incontestable demonstrations of cause and effect make life too easy and atrophy thought. For every time we say that a certain micro-organism is the ‘cause’ of the corresponding disease ‘in the medical sense’, do we not deceive ourselves with a half-truth? ... The living organism determines the disease and its form. ... Full knowledge of the extrinsic stimulus tells nothing of the essential nature of the intrinsic reaction: of the changes of the organism which are the being and coming to be of the effect.150 (Emphasis as in the original.)

Bacteriology had created a new concept of causality, which turned out to be very useful and became highly popular among physicians. The idea of bacteria as causative agents of diseases was so simple and plausible that it was soon generally accepted ... People first concentrated on the new etiological principle, starting a wild hunt for the microscopic causative agent of cancer. It is shocking to read some of the uncritical reports claiming the discovery of such causative agents, which appeared in all journals around the turn of the century. It is even more shocking to find that the search for an infectious cause of cancer, in the form of a ‘neoblastic virus’, continues to this day, and that even now millions are being spent on virus research, which in this respect is purely a laboratory artefact.151 (Emphasis as in the original.)

It has been pointed out that the artificial character of laboratory research, particularly in vitro research, is an inherent problem of cancer research.152 The history of the Institut für Krebsfor- schung illuminates the resistance that the experimental approach was to encounter, a tension that is much less visible nowadays, because experimental cancer research has become institutionalised. In this sense, reductionism has appeared as the winner of the confrontation between reductionist and holistic medicine, the former now being the dominant context for interpreting health and disease. However, Rosenberg has rightly stated that medical thinking ‘has been hi- storically organized around a number of mutually constitutive oppositions’.153 This means that the opposition between reductionist and holistic approaches in medicine will not whither away, because they are inherent in our interpretation of health and disease.

68 A Dispute over Scientific Credibility:

Abbreviations used: GStA I. HA: Geheimes Staatsarchiv Preussischer Kulturbesitz, I. Haupt- abteilung; HUA: Humboldt-Universität zu Berlin, Archiv; Char.-Dir.: Charité-Direktion.

Acknowledgements—Archival research for this study was done during a visiting fellowship at the Max-Planck-Institut für Wissenschaftsgeschichte in Berlin, Germany. I would like to express my sincere thanks to my colleagues in Berlin for their suggestions towards developing the argument of the paper, to Jan Klerkx for his help in the translation work and to Hans-Jörg Rheinberger for his continued interest in my work.

69 Ton van Helvoort

FOOTNOTES:

1 Peckham, Pinedo and Veronesi, 1995. For a ‘landmark’ history of cancer research, see Shimkin, 1977.

2 Cantor, 1993; see also Löwy, 1997.

3 Rheinberger and Hagner, 1997.

4 Clarke and Fujimura, 1992; Lederman and Burian, 1993; Kohler, 1994.

5 Kaiser, 1989; see also Salazar, 1986, pp. 51-60.

6 Cf. Abbott, 1988; Rosenberg, 1979; Star, 1995.

7 Kaiser, 1989, p. 22.

8 Kaiser, 1989, p. 4. The death of Friedrich III from cancer led to great fear of cancer amongst the public at large; see Römer, 1906, p. 79.

9 Blumenthal, 1919, pp. 11-14; Roussy, 1943, p. 26.

10 Cf. Cunningham and Williams, 1992.

11 For cancer diagnosis see, for example, Blumenthal, 1902; Blumenthal, 1910.

12 Ribbert, 1909, pp. 2-3. It was, however, precisely this supremacy of histology, morphology and microscopy which experimental cancer research was to attack.

13 Triolo, 1964; Triolo, 1965; Rather, 1978.

14 Wolff, 1929, p. 521.

15 Blumenthal, 1928, ‘Gründung’, p. 280; Schmieden, 1927, p. 21.

16 For a discussion of the Parasitic Theory of Cancer by a declared opponent of such a theory, see Ewing, 1941.

17 Schmieden, 1927, p. 21. As the New York surgeon Willy Meyer put it, quite a few clinicians and surgeons thought that finding a specific cancer microbe would not only be plausible, but also desirable ‘... because seemingly it would have simplified matters.’ See Meyer, 1931, p. 6. Together with William S. Halsted, Meyer was the first to develop the technique of radical mas- tectomy in breast cancer cases.

18 Meyer, 1931, p. 7. Years later Ludwig Aschoff said: ‘Younger colleagues can hardly imag- ine how strong the resistance by clinicians and leading bacteriologists used to be against the non-parasitic view of carcinogenesis which we pathologists have always advocated. I refer to

70 A Dispute over Scientific Credibility: the meeting at Karlsbad, where Feinberg read a paper. On one occasion, as I was saying good- bye to Von Leyden, he told me that pathologists could only, as it were, rehabilitate themselves by discovering the cancer parasite.’ See Schmorl, 1927, p. 126.

19 Kaiser, 1989, pp. 4-15; see also Salazar, 1986, pp. 31-50.

20 Von Leyden, Kirchner, et al., 1902, pp. 3-4. The results of the review, however, which were published a few years later, failed to substantiate the infection hypothesis. See Kaiser, 1989, p. 9.

21 Quoted in Wolff, 1929, p. 522.

22 Behla, 1910, p. 8.

23 Behla, 1910, p. 49.

24 Von Leyden and Blumenthal, 1902, p. 638. It should be pointed out that at that time the notion of (invisible and filterable) viruses was sufficiently vague for all kinds of properties to be attributed to them. Cf. van Helvoort, 1994.

25 Von Leyden, 1904, pp. 75-76.

26 Bainbridge, 1914, pp. 5-6.

27Wolff, 1929, pp. 702-21.

28 Blumenthal, 1928, ‘Entstehung’, p. 3. For literature and archival sources with regard to ‘Hochschulreferent’ Althoff’s influence on German scientific and educational institutions, see Schnabel, 1953.

29 Wolff, 1913. Rodents also became used to standardise genetic research into cancer. The 1910s also saw the advent of new models for experimental cancer research, such as chemical carcinogenesis, used e.g. in rabbits, rats and mice, as well as research on the role of viruses in chicken tumours. See Murphy, 1935.

30 Von Wassermann, Keysser and Wassermann, 1911.

31 Klemperer, 1912, p. 62.

32 Klemperer, 1912, p. 63. For ‘Ministerialdirektor’ Martin Kirchner, these findings showed that the experimental approach to the cancer problem was a useful one: ‘When Mr Von Leyden asked me to found the Committee for Cancer Research with him and Mr [G.] Meyer, we were initially ridiculed by many who felt that this research could never yield important results. If we see today how much progress cancer research has made in such a relatively short space of time, we can only feel pride and joy and recognise that Von Leyden was right at the time about the direction we had to pursue. Let us hope that our future efforts will yield further progress and that, if not we ourselves, at least our children may succeed in solving all remaining problems of cancer research.’ See Meyer, 1913, p. 416.

33 Blumenthal, 1911, p. 134.

71 Ton van Helvoort

34 Sauerbruch to ‘Ministerialrat’ Dr. Jansen, ‘Kultusministerium’, 20 February 1935, HUA Char.-Dir. No. 2572, pp. 260-266, especially p. 260.

35 Klemperer to Naumann, 22 May 1911, HUA Char.-Dir. No. 949, pp. 303-305, especially p. 303.

36 Klemperer to Naumann, 22 May 1911, HUA Char.-Dir. No. 949, pp. 303-305, especially p. 304.

37 Klemperer to Naumann, 22 May 1911, HUA Char.-Dir. No. 949, pp. 303-305, especially p. 304.

38 Pütter to Naumann, 22 December 1914, HUA Char.-Dir. No. 950, pp. 117-119, especially p. 117a.

39 Pütter to Naumann, 6 February 1915, HUA Char.-Dir. nr. 950, pp. 122-123, especially p. 122.

40 Blumenthal to the ‘Minister für geistliche und Unterrichts-Angelegenheiten’, 23 June 1915, HUA Char.-Dir. No. 950, pp. 150-158, especially p. 155.

41 Blumenthal, 1928, ‘Entstehung’, p. 12.

42 Blumenthal, 1919, p. 56.

43 Blumenthal, 1928, ‘Entstehung’, p. 8.

44 Cf. van Helvoort, submitted.

45 Blumenthal, 1919, p. 55.

46 Blumenthal, 1919, p. 54.

47 In the words of the British radiologist Stanford Cade: ‘One fact stands out very clearly: no patient, however ‘inoperable,’ should remain untreated. ... radium therapy abolishes or at least minimises, operative mortality and mutilation. It enlarges the field of ‘treatable’ cases beyond the limits imposed on purely operative surgery.’ Cade, 1929, pp. 1-2. This quotation also reveals the inherent tension between surgical treatment of tumours and radiation therapy.

48 On Ludwig Halberstaedter, see Anonymous, 1980.

49 Halberstaedter, 1928, p. 36.

50 Kaiser, 1989, pp. 72-73.

51 Blumenthal, 1927, p. 95. Blumenthal also stated: ‘It is difficult for the advocates of special cancer departments to carry on their campaign with a statement of the whole truth, namely, that for the X-ray diagnosis of malignant growths and for the application of an effectual therapy an amount of experience is necessary which cannot be acquired with the little material available in middle-sized towns of from twenty to a hundred thousand inhabitants, especially when the

72 A Dispute over Scientific Credibility: material is dispersed. ... I do not think that I exaggerate, when I assert that, while the surgical treatment of cancer is carried out nearly everywhere in Germany to practical perfection, the places are relatively few of which one can say that radiation is adequately done.’ Ibid., p. 96.

52 In 1928 Blumenthal outlined the position taken by the orthodox pathologists on the etiology of cancer as follows: ‘Der Krebs entstände nur durch Vererbung, indem irgendwelche ver- erbten, zur Krebsbildung disponierten Zellen eines Tages aus ihrem Schlummer erwachten und dadurch zu Krebszellen würden.’ See Blumenthal, 1928, ‘Ergebnisse’, p. 46.

53 Blumenthal, 1919, p. 371.

54 Orth, 1919, p. 382.

55 Blumenthal, 1919, p. 372.

56 Blumenthal, 1928, ‘Bekämpfung’, p. 4.

57 Blumenthal, 1928, ‘Ergebnisse’, p. 44.

58 Blumenthal, 1928, ‘Ergebnisse’, p. 46.

59 Smith, 1916, pp. 887-8. On the impact of Erwin F. Smith’s research on cancer research, see Rodgers III, 1952.

60 Woglom, 1913.

61 Blumenthal, 1918, p. 900.

62 Blumenthal, 1928, ‘Ergebnisse’, p. 44.

63 Blumenthal, 1931, p. 28.

64 Yamagiwa, 1924/5, p. 2.

65 See Löwy and Gaudillière, 1998.

66 Halberstaedter, 1923.

67 Shimkin, 1977, pp. 95-96.

68 For the New York surgeon Willy Meyer the importance of Rous sarcoma and its transmis- sibility by a filtrate was that ‘... the structurally intact cancer cell, the alpha and omega of the adherents of the cellular theory, had been totally eliminated.’ See Meyer, 1931, p. 18.

69 Tyzzer, 1914, p. 14.

70 Gye, 1925; Barnard, 1925. See also Austoker, 1988, pp. 95-99; van Helvoort, 1999.

71 Fränkel, 1927a; Fränkel, 1927b.

73 Ton van Helvoort

72 Blumenthal, 1928, ‘Ergebnisse’, pp. 64-65; cf. Teutschlaender, 1927.

73 On the history of tissue culture research see, for example, Russell, 1969; Harvey, 1975.

74 On Rhoda Erdmann’s work see Erdmann, 1930; Schneck, 1999. See also Hubenstorf and Walther, 1994, pp. 36-7.

75 Jensen, 1910, p. 245 and p. 248, respectively.

76 Jensen, 1910, p. 254.

77 Smith, 1916; Smith, 1925.

78 Braun, 1982, p. 169.

79 Blumenthal to the ‘Minister für geistliche und Unterrichts-Angelegenheiten’, 23 June 1915, HUA Char.-Dir. No. 950, pp. 150-158, especially p. 157a.

80 Blumenthal and Hirschfeld, 1922, p. 125. On Hans Hirschfeld, see Voswinckel, 1994.

81 Blumenthal, 1919, p. 42.

82 Blumenthal, Auler and Meyer, 1924. That these organisms were related to B. tumefaciens could not be corroborated by others; see Eggers, 1931, p. 997.

83 For a discussion of the work of Johannes Fibiger see, for example, Campbell, 1997; Petitho- ry, Théodorides and Brumpt, 1997.

84 See, for example, Ewing, ‘Lecture XII [On the Experimental Study of Cancer]’, in: idem, 1933, pp. 65-71.

85 Blumenthal to ‘Dekan’ Von Eicken, 28 February 1929, HUA Med. Fak. 269, p. 12.

86 Quoted in Klemperer, 1912, p. 16. See also Von Hansemann, 1912.

87 Wolff, 1913, pp. 316-340, especially p. 317 and p. 318, respectively.

88 Wolff, 1913, p. 330.

89 Blumenthal, 1919, p. 40.

90 Van Helvoort, 1999.

91 See, for example, Murphy, 1928.

92 Ewing, ‘Lecture XII [On the Experimental Study of Cancer]’, in: idem, 1933, p. 67. Al- though Blumenthal agreed with Otto Teutschlaender’s suggestion that the agent could also be a sort of ferment, many researchers referred to it as the Rous sarcoma virus. In an authoritative

74 A Dispute over Scientific Credibility: paper ‘Tissue transplantation and parasitism’ published in the Archives of Pathology H. E. Eg- gers concluded that ‘... all the work done in the search for a specifically causative parasite has been largely a chase after the will-o-the-wisp.’ See Eggers, 1931, p. 1013.

93 Borst, 1927, p. 7.

94 Borst, 1927, p. 11.

95 Borst, 1927, p. 12. In fact, Blumenthal thought this might be one of the possibilities.

96 Borst, 1927, p. 16 and p. 20, respectively.

97 Borst, 1927, p. 20.

98 Schmieden himself actually claimed never to have supported the parasitic theory. See Schmieden, 1927.

99 Schmieden, 1927, p. 27.

100 Schmieden, 1927, p. 22 and p. 27, respectively.

101 Schmieden, 1927, p. 30 and p. 34, respectively. It was common knowledge that cancer dis- position could to some extent be inherited. At the Lake Mohonk conference this was formulated as resolution 2: ‘Cancer itself is not hereditary, although a certain predisposition or susceptibil- ity to cancer is apparently transmissible through inheritance. This does not signify that, because one’s parent or parents or other members of the family have suffered from cancer, cancer will necessarily appear in other persons of the same or succeeding generation.’ See American Soci- ety for the Control of Cancer, 1927, p. 327.

102 Schmieden, 1927, p. 31.

103 Schmieden, 1927, p. 33.

104 Schmieden, 1927, p. 34.

105 Borst, 1927, p. 131.

106 Ewing, 1935, p. 6.

107 The New York Memorial Hospital became one of the world most outstanding radiotherapeutic centers. See Ewing, 1934; Del Regato, 1996.

108 See also van Helvoort, 1998.

109 Report decreed 6 July 1929, GStA I. HA, Rep 76, VIII B, nr. 3852, pp. 279-302 and Kaiser, 1989, pp. 21-24. See also van Helvoort, submitted.

110 Pütter, Blumenthal, et al., 1930.

75 Ton van Helvoort

111 Grüneisen (ed.), 1931; especially Grüneisen, 1931, in Ibid., pp. 10-21 and Friedrich, 1931, in Ibid., pp. 86-90.

112 Loos, 1931, p. 1488.

113 See, for example, Küttner, Sauerbruch and Schmieden, 1931. In 1939, surgeon Fritz König attributed the doubts about the efficacy of cancer surgery and the increased attention to radiotherapy of the early 1930s largely to the influence of the book Über Krebsverbreitung, Kreb- sbekämpfung und Krebsverhütung (On Cancer Occurrence, Cancer Control and Cancer Prevention) (Munich: Lehmann, 1932) by surgeon Erwin Liek, who had great doubts about the successes of cancer operations. See König, 1939, p. 260. On Liek see Proctor, 1999, pp. 22-26.

114 Blumenthal to ‘Verwaltungsdirektor’ Kuhnert, 25 July 1932, HUA Char.-Dir. No. 953, pp. 246-253, especially pp. 246-247a; see also Schneck, 1999.

115 Blumenthal, Ibid., p. 248.

116 Borst, 1927, p. 20.

117 Blumenthal to ‘Verwaltungsdirektor’ Kuhnert, 25 July 1932, HUA Char.-Dir. No. 953, pp. 246-253, especially p. 250.

118 Ibid., especially p. 252-3. But the orthodox pathologists did not surrender without a struggle, which is hardly surprising as is explained by the following statement by Robert Behla about the controversy over the parasitic cause of cancer. ‘It may be difficult for the current leaders in a particular discipline to suddenly have to change their entire view of the subject, and to see their published books become obsolete.’ See Behla, 1910, p. 48.

119 Blumenthal to ‘Verwaltungsdirektor’ Kuhnert, 25 July 1932, HUA Char.-Dir. No. 953, pp. 246-253, especially p. 248.

120 Hubenstorf and Walther, 1994, pp. 34-35; Fijal, 1994.

121 See also Hubenstorf and Walther, 1994, pp. 34-6, especially note 43.

122 Blumenthal, 1928, ‘Entstehung’; see also Kaiser, 1989, p. 18 and p. 66.

123 Auler to ‘Verwaltungsdirektor der Charité’, ‘Oberriegierungsrat’ Dr. Kuhnert, ‘Bericht über das Krebsinstitut der Charité’, 10 April 1933, HUA Char.-Dir. No. 2572, pp. 27-32, especially p. 31.

124 Auler, ‘Die zukunftigen Aufgaben des Institutes’, 19 June 1933, HUA Med. Fak. 279, Bd 1, pp. 50-53, especially p. 50.

125 Ibid., especially p. 50 and p. 50a.

126 Grüneisen to ‘Verwaltungsdirektor der Charité’, ‘Oberriegierungsrat’ Dr. Kuhnert, 25 April 1933, HUA Char.-Dir. No. 2572, pp. 62-63.

127 See van Helvoort, submitted.

76 A Dispute over Scientific Credibility:

128 ‘Dekan’ [Gocht] to ‘Minister für Wissenschaft, Kunst und Volksbildung’, 26 July 1933, HUA Med. Fak. 279, Bd 1, pp. 76-78, especially p. 77; see also Salazar, 1986, pp. 73-83 and pp. 90-101.

129 Borst to Staatsminister Rust, October 1933, HUA Med. Fak. 279, Bd 1, p. 83, especially p. 83a.

130 Sauerbruch to ‘Ministerialrat’ Dr. Jansen, ‘Kultusministerium’, 20 February 1935, HUA Char.-Dir. No. 2572, pp. 260-266, especially pp. 262-263; cf. van Helvoort, submitted.

131 A 1933 report by the acting director of the IfK, Hans Auler, shows that nutritional research had already become an important branch of research at the IfK; Sauerbruch may already have been influential here. See Auler to ‘Dekan’, 12 June 1933, HUA Med. Fak. 279, Bd 1, pp. 48- 49, especially p. 48.

132 Sauerbruch to ‘Ministerialrat’ Dr. Jansen, ‘Kultusministerium’, 20 February 1935, HUA Char.-Dir. No. 2572, pp. 260-266, especially pp. 265-266.

133 Auler’s capacities were evaluated as follows: ‘His own scientific work, however, has received a mixed reception.’ See ‘Dekan’ to ‘Reichsminister für Wissenschaft, Erziehung und Volksbildung’, 10 February 1939, HUA Med. Fak. 279, Bd 1, pp. 90-92, especially p. 91.

134 Cf. Kaiser, 1989, p. 73.

135 See, for example, Wagner and Mauerberger, 1989.

136 Varmus and Weinberg, 1993. But there are criticisms on the notion of progress in cancer control; see, for example, Greenberg, 1975; Bailar III and Smith, 1986.

137 Cf. Latour, 1987, pp. 258-259.

138 van Helvoort, submitted.

139 Löwy, 1996; Hall, 1997.

140 Löwy and Gaudillière, 1998. A successful example of the linking of cancer, human genetics and epidemiology is the isolation of the breast cancer gene, BRCA1; see Davies and White, 1996. But this finding has only limited relevance for breast cancer in general.

141 Lawrence and Weisz, 1998. For the specific case of holism advocated by German-speaking life scientists in the first half of the twentieth century, see Harrington, 1996; see also Weindling, 1989.

142 Rosenberg, 1998.

143 Rosenberg, 1992, p. 295.

144 Cf. van Helvoort, 1999.

77 Ton van Helvoort

145 See Benaroyo, 1998; and Sauerbruch, 1926, p. 1084. On Sauerbruch’s attitude to National Socialism, see Kudlien and Andree, 1980.

146 Mendelsohn, 1999. Regarding the constitutional notion of disease and the National-Social- ist ideology in Germany in the 1930s and 1940s, see Proctor, 1999.

147 Lubarsch, 1902, p. 50 and pp. 57-58, respectively.

148 Amsterdamska, 1999.

149 Cf. Gaudillière, 1998.

150 Nicholson, 1950, pp. 258-259.

151 Lehmann, 1964, p. 669.

152 See, for example, Dermer, 1994; cf. Löwy, 1997.

153 Rosenberg, 1998, p. 350.

78 A Dispute over Scientific Credibility:

REFERENCES

Abbott, A. (1988) The System of Professions: An Essay on the Division of Expert Labor (Chi- cago: University of Chicago Press).

American Society for the Control of Cancer (1927) Cancer Control (Chicago: Surgical Publi- shing Company).

Amsterdamska, O. (1999) ‘Standardizing Epidemics: Infection, Inheritance, and Environment in Interwar Experimental Epidemiology’, in J.-P. Gaudillière and I. Löwy (eds), Transmission: Human Pathologies between Heredity and Infection (Amsterdam: Harwood Academic Publishers), in press.

Anonymous (1980) ‘Halberstaedter, Ludwig’, in H. A. Strauss and W. Röder (eds), Biographi- sches Handbuch der deutschsprachigen Emigration nach 1933 — Vol. II (Munich: K. G. Saur), p. 452.

Austoker, J. (1988) A History of the Imperial Cancer Research Fund 1902-1986 (Oxford, Oxford University Press).

Bailar III, J. C. and Smith, E. M. (1986) ‘Progress against Cancer?’, New England Journal of Medicine 314, 1226-1232.

Bainbridge, W. S. (1914) The Cancer Problem (New York: The Macmillan Company).

Barnard, J. E. (1925) ‘The Microscopical Examination of Filterable Viruses Associated with Malignant New Growths’, Lancet ii, 117-123.

Behla, R. (1910) Die Bestätigung der künstlichen Züchtung des Krebserregers sowie weitere geschwulststatistische Mitteilungen über Familien-, Ehegatten- und endemischen Krebs (Ber- lin: Verlagsbuchhandlung von Richard Schoetz).

Benaroyo, L. (1998) ‘Pathology and the Crisis of German Medicine (1920-1930): A Study of Ludwig Aschoff’s Case’, in C.-R. Prüll (ed.), Pathology in the 19th and 20th Centuries: The Relationship between Theory and Practice (Sheffield: EAHMHP), pp. 101-113.

Blumenthal, F. (1902) ‘Die Beurteilung der Diagnose des Sitzes und der Prognose des Krebses durch die Untersuchung des Harns’, in E. von Leyden et al., Veröffentlichungen des Komitee’s für Krebsforschung —II. Ergänzungsband zum Klinischen Jahrbuch (Jena: Verlag von Gustav Fischer), pp. 17-22.

Blumenthal, F. (1910) Chemische Vorgänge bei der Krebskrankheit (Munich: Bergmann).

Blumenthal, F. (1911) ‘Innere Behandlung und Fürsorge bei Krebskranken’, Zeitschrift für Krebsforschung 10, 134-148.

79 Ton van Helvoort

Blumenthal, F. (1918) ‘Das Problem der Bösartigkeit beim Krebs’, Deutsche medizinische Wochenschrift 44 (ii), 899-903.

Blumenthal, F. (1919) Die Krebskrankheiten: Ihre Erkennung und Bekämpfung (Berlin: Verlag von Otto Salle).

Blumenthal, F. (1919) ‘Das Problem der Bösartigkeit beim Krebs’, Zeitschrift für Krebsfor- schung 16, 357-373.

Blumenthal F. and H. Hirschfeld (1922) ‘Beiträge zur Kenntnis einiger durch Bacterium tumefaciens hervorgerufenen Pflanzengeschwülste’, Zeitschrift für Krebsforschung 18, 110-125.

Blumenthal, F., H. Auler and P. Meyer (1924) ‘Über das Vorkommen neoplastischer Bakterien in menschlichen Krebsgeschwülsten’, Zeitschrift für Krebsforschung 21, 387-410.

Blumenthal, F. (1927) ‘The Organized Movement for Cancer Control in Germany’ (1927), in American Society for the Control of Cancer, Cancer Control (Chicago: Surgical Publishing Company), pp. 93-98.

Blumenthal, F. (1928) ‘Entstehung und Entwicklung des Universitätsinstituts für Krebsfor- schung an der Charité zu Berlin’, in F. Blumenthal, R. Erdmann, L. Halberstaedter and H. Hirschfeld, Zum 25jährigen Bestehen des Universitätsinstituts für Krebsforschung an der Cha- rité, am 8. Juni 1928 (Berlin: Julius Springer), pp. 1-16.

Blumenthal, F. (1928) ‘Über Ergebnisse der experimentellen Krebsforschung’, in F. Blumen- thal, R. Erdmann, L. Halberstaedter and H. Hirschfeld, Zum 25jährigen Bestehen des Univer- sitätsinstituts für Krebsforschung an der Charité, am 8. Juni 1928 (Berlin: Julius Springer), pp. 42-75.

Blumenthal, F. (1928) ‘Gründung und Aufgaben der Krebs-Institute’, Archiv für Soziale Hygiene und Demographie 3, 280-283.

Blumenthal, F. (1928) ‘Die Bekämpfung des Krebses’, Blätter des Deutschen Roten Kreuzes, Wohlfahrt und Sozialhygiene 7 (10), 3-9.

Blumenthal, F. (1931) ‘Entwickelung der Krebsbekämpfung in der Charité’, in F. Grüneisen (ed.), Krebsbekämpfung: Jahrbuch des Reichsausschusses für Krebsbekämpfung 1930 (Leip- zig: Johann Ambrosius Barth), pp. 22-30.

Borst, M. (1927) ‘Referat über Infektion, Parasitismus und Gewächsbildung’, in G. Schmorl (ed.), Verhandlungen der Deutschen Pathologischen Gesellschaft: Zweiundzwanzigste Tagung, gehalten in Danzig am 8.-10. Juni 1927 (Jena: Gustav Fischer), pp. 6-20 and p. 131.

Braun, A. C. (1982) ‘A History of the Crown Gall Problem’, in G. Kahl and J. S. Schell (eds), Molecular Biology of Plant Tumors (New York: Academic Press), pp. 155-210.

Cade, S. (1929) Radium Treatment of Cancer (London: J. & A. Churchill).

80 A Dispute over Scientific Credibility:

Campbell, W. C. (1997) ‘The Worm and the Tumor: Reflections on Fibiger’s Nobel Prize’, Per- spectives in Biology and Medicine 40, 498-504.

Cantor, D. (1993) ‘Cancer’, in W. F. Bynum and R. Porter (eds), Companion Encyclopedia of the History of Medicine — Volume 1 (London: Routledge), pp. 537-561.

Clarke, A. E. and J. H. Fujimura (eds) (1992) The Right Tools for the Job: At Work in Twen- tieth-Century Life Sciences (Princeton: Princeton University Press).

Cunningham, A. and P. Williams (eds) (1992) The Laboratory Revolution in Medicine (Cam- bridge: Cambridge University Press).

Davies, K. and M. White (1996) Breakthrough: The Race to Find the Breast Cancer Gene (New York: John Wiley & Sons, Inc.).

Del Regato, J. A. (1996) ‘The Unfolding of American Radiotherapy’, International Journal of Radiation Oncology, Biology, Physics 35, 5-14.

Dermer, G. B. (1994) The Immortal Cell: Why Cancer Research Fails (Garden City Park, NY: Avery Publishing Group Inc.).

Eggers, H. E. (1931) ‘The Etiology of Cancer: I. Tissue Transplantation and Parasitism’, Archi- ves of Pathology 12, 983-1013.

Erdmann, R. (1930) ‘Die Abteilung für experimentelle Zellforschung am Universitätsinstitut für Krebsforschung an der Charité, Berlin’, Methods and Problems of Medical Education 16, 95-102.

Ewing, J. (1933) Lectures on Tumor Pathology — Cornell University Medical School, Class of 1934 (New York: Barnes Press).

Ewing, J. (1934) ‘Early Experiences in Radiation Therapy — Janeway Memorial Lecture’, American Journal of Roentgenology and Radium Therapy 31, 153-163.

Ewing, J. (1935) ‘Some Results of Modern Clinical Cancer Research’, Bulletin of the American Society for the Control of Cancer 17 (August), 1-6.

Ewing, J. (1941) ‘The Parasitic Theory’, in idem, Neoplastic Diseases: A Treatise on Tumors, Fourth Edition (Philadelphia: W. B. Saunders Co.), pp. 113-127.

Fijal, A. (1994) ‘Die Rechtsgrundlagen der Entpflichtung jüdischer und politisch mißliebiger Hochschullehrer nach 1933 sowie des Umbaus im nationalsozialistischen Sinne’, in W. Fischer, K. Hierholzer, M. Hubenstorf, P. Th. Walther and R. Winau (eds), Exodus von Wissenschaften aus Berlin: Fragestellungen — Ergebnisse — Desiderate — Entwicklungen vor und nach 1933 (Berlin: Walter de Gruyter), pp. 101-115.

81 Ton van Helvoort

Fränkel, E. (1927a) ‘Untersuchungen über Rous-Tumoren’, Zeitschrift für Krebsforschung 24, 252-254.

Fränkel, E. (1927b) ‘Untersuchungen über die Roustumoren beim Huhn’, Zeitschrift für Krebs- forschung 25, 407-420.

Friedrich, W. (1931) ‘Die Beschaffung und Verteilung radioaktiver Substanzen für die Krebs- bekämpfung in Deutschland und im Ausland’, in F. Grüneisen (ed.), Krebsbekämpfung: Jahr- buch des Reichsausschusses für Krebsbekämpfung 1930 (Leipzig: Johann Ambrosius Barth), pp. 86-90.

Gaudillière, J.-P. (1998) ‘The Molecularization of Cancer Etiology in the Postwar United States: Instruments, Politics and Management’, in S. de Chadarevian and H. Kamminga (eds), Molecularizing Biology and Medicine: New Practices and Alliances, 1910s-1970s (Amster- dam: Harwood Academic Publishers), pp. 139-170.

Greenberg, D. S. (1975) ‘“Progress” in Cancer Research — Don’t Say It Isn’t So’, New Eng- land Journal of Medicine 292, 707-8.

Grüneisen, F. (ed.) (1931) Krebsbekämpfung: Jahrbuch des Reichsausschusses für Krebsbe- kämpfung 1930 (Leipzig: Johann Ambrosius Barth).

Grüneisen, F. (1931) ‘Ein Jahr Reichsausschuß für Krebsbekämpfung — 1. April 1930 - 31. März 1931’, in F. Grüneisen (ed.), Krebsbekämpfung: Jahrbuch des Reichsausschusses für Krebsbekämpfung 1930 (Leipzig: Johann Ambrosius Barth), pp. 10-21.

Gye, W. E. (1925) ‘The Etiology of Malignant New Growths’, Lancet ii, 109-117.

Halberstaedter, L. (1923) ‘Über Erzeugung von Geschwülsten mit Teer im Tierexperiment’, Zeitschrift für Krebsforschung 19, 381-392.

Halberstaedter, L. (1928) ‘Die Bestrahlungsabteilung des Instituts für Krebsforschung’, in F. Blumenthal, R. Erdmann, L. Halberstaedter and H. Hirschfeld, Zum 25jährigen Bestehen des Universitätsinstituts für Krebsforschung an der Charité, am 8. Juni 1928 (Berlin: Julius Sprin- ger), pp. 28-36.

Hall, S. S. (1997) A Commotion in the Blood: Life, Death, and The Immune System (New York: Henry Holt and Company, Inc.). von Hansemann, D. (1912) ‘Chemotherapeutische Versuche an tumorkranken Tieren: Anato- mischer Teil’, Berliner klinische Wochenschrift 49, 8-10.

Harrington, A. (1996) Reenchanted Science: Holism in German Culture from Wilhelm II to Hitler (Princeton: Princeton University Press).

82 A Dispute over Scientific Credibility:

Harvey, A. M. (1975) ‘Johns Hopkins — The Birthplace of Tissue Culture: The Story of Ross G. Harrison, Warren H. Lewis, and George O. Gey’, Johns Hopkins Medical Journal 136, 142- 149. van Helvoort, T. (1994) ‘History of Virus Research in the Twentieth Century: The Problem of Conceptual Continuity’, History of Science 32, 185-235. van Helvoort, T. (1998) ‘Radium und Röntgenstrahlen: Die Anfänge der Strahlentherapie in Deutschland’, Einblick: Zeitschrift des Deutschen Krebsforschungszentrums (4), pp. 6-9. van Helvoort, T. (1999) ‘Viren als Krebserreger: Peyton Rous, das ‘Infektiöse Prinzip’ und die Krebsforschung’, in Chr. Gradmann and Th. Schlich (eds), Strategien der Kausalität: Konzep- tionen der Krankheitsverursachung im 19. und 20. Jahrhundert (Pfaffenweiler: Centaurus-Ver- lagsgesellschaft), pp. 187-228. van Helvoort, T., ‘Scalpel or Rays ? The Struggle for the Cancer Patient in Pre-World War II Germany’, Medical History, submitted.

Hubenstorf, M. and P. Th. Walther (1994) ‘Politische Bedingungen und allgemeine Verände- rungen des Berliner Wissenschaftsbetriebes 1925-1950’, in W. Fischer, K. Hierholzer, M. Hubenstorf, P. Th. Walther and R. Winau (eds), Exodus von Wissenschaften aus Berlin: Frage- stellungen — Ergebnisse — Desiderate — Entwicklungen vor und nach 1933 (Berlin: Walter de Gruyter), pp. 5-100.

Jensen, C. O. (1910) ‘Von echten Geschwülsten bei Pflanzen’, in Anonymous, Travaux de la Deuxième Conférence Internationale pour l’Étude du Cancer Tenue à Paris du 1er au 5 Octobre 1910 (Paris: Félix Alcan), pp. 243-254.

Kaiser, M. (1989) Zur Geschichte des Deutschen Zentralkomitees zur Erforschung und Bekämpfung der Krebskrankheit (1900-1933) —Dissertation (Greifswald: Ernst-Moritz- Arndt-Universität).

Klemperer, G. (1912) Der jetzige Stand der Krebsforschung (Berlin: August Hirschwald).

Kohler, R. (1994) Lords of the Fly: Drosophila Genetics and the Experimental Life (Chicago: University of Chicago Press).

König, F. (1939) ‘Die Chirurgie und Krebsbekämpfung’, Archiv für klinische Chirurgie 196, 260-267.

Kudlien, F. and Andree, Chr. (1980) ‘Sauerbruch und der Nationalsozialismus’, Medizinhisto- risches Journal 15, 201-222.

Küttner, H., F. Sauerbruch and V. Schmieden (1931) ‘Die Chirurgie des Krebses und die neuen organisatorischen Bestrebungen zur Krebsbekämpfung’, Die Medizinische Welt 5, 981-985.

83 Ton van Helvoort

Latour, B. (1987) Science in Action: How to Follow Scientists and Engineers Through Society (Milton Keynes: Open University Press).

Lawrence, Chr. and G. Weisz (eds) (1998) Greater than the Parts: Holism in Biomedicine, 1920-1950 (Oxford: Oxford University Press).

Lederman, M. and R. M. Burian (eds) (1993) ‘The Right Organism for the Job’, Journal of the History of Biology 26, 235-367.

Lehmann, F. M. (1964) ‘Denkrichtungen in der Krebsforschung: Eine ideengeschichtliche Untersuchung’, Medizinische Klinik 59, 668-671 & 707-711. von Leyden, E., M. Kirchner, et al. (1902) Verhandlungen des Comités für Krebsforschung — Heft I. 1900-1902 [Sonderabdruck aus der ‘Deutschen Medizinischen Wochenschrift’, Jahr- gang 1900-1902] (Berlin: G. Bernstein). von Leyden, E., and F. Blumenthal (1902) ‘Vorläufige Mittheilungen über einige Ergebnisse der Krebsforschung aus der I. medizinischen Klinik’, Deutsche Medicinische Wochenschrift 28, 637-638. von Leyden, E. (1904) ‘Eröffnung der Abteilung für Krebsforschung an der I. medizinischen Klinik der Kgl. Charité zu Berlin’, Zeitschrift für Krebsforschung 1, 73-78.

Loos, A. (1931) ‘Über die zweckmässigste Organisation der Krebsbekämpfung’, Deutsche medizinische Wochenschrift 57 (ii), 1487-1489.

Löwy, I. (1996) Between Bench and Bedside: Science, Healing, and Interleukin-2 in a Cancer Ward (Cambridge, MA: Harvard University Press).

Löwy, I. (1997) ‘The Century of the Transformed Cell’, in J. Krige and D. Pestre (eds), Science in the Twentieth Century (Amsterdam: Harwood Academic Publishers), pp. 461-478.

Löwy, I., and J.-P. Gaudillière (1998) ‘Disciplining Cancer: Mice and the Practice of Genetic Purity’, in J.-P. Gaudillière and I. Löwy (eds), The Invisible Industrialist: Manufactures and the Production of Scientific Knowledge (London: Macmillan), pp. 209-249.

Lubarsch, O. (1902) Pathologische Anatomie und Krebsforschung: Ein Wort zur Verständi- gung (Wiesbaden: Verlag von J. F. Bergmann).

Mendelsohn, J. A. (1999) ‘The Body between Infection and Disease: Heredity, Etiology, and Constitution in European Scientific Medicine, 1890-1940’, in J.-P. Gaudillière and I. Löwy (eds), Transmission: Human Pathologies between Heredity and Infection (Amsterdam: Har- wood Academic Publishers), in press.

Meyer, G. (1913) ‘Verhandlungen des Deutschen Zentralkomitees zur Erforschung und Bekämpfung der Krebskrankheit, E. V.’, Zeitschrift für Krebsforschung 12, 401-416.

84 A Dispute over Scientific Credibility:

Meyer, W. (1931) Cancer: Its Origin, its Development and its Self-Perpetuation — The Therapy of Operable and Inoperable Cancer in the Light of a Systemic Conception of Malig- nancy: A Research (New York: Paul B. Hoeber).

Murphy, J. B. (1928) ‘The Nature of the Filtrable Agent in Chicken Tumours’, in British Empire Cancer Campaign, Report of the International Conference on Cancer, London, 17th- 20th July, 1928 (Bristol: J. Wright), pp. 33-36.

Murphy, J. B. (1935) ‘Experimental Approach to the Cancer Problem. I. Four Important Phases of Cancer Research. II. Avian Tumors in Relation to the General Problem of Malignancy’, Bulletin of the Johns Hopkins Hospital 56, 1-31.

Nicholson, G. W. de P. (1950) Studies on Tumour Formation (London: Butterworth).

Orth, J. (1919) ‘Aussprache über das Referat des Herrn Blumenthal’, Zeitschrift für Krebsfor- schung 16, 373-386.

Peckham, M., H. Pinedo and U. Veronesi (eds.) (1995) Oxford Textbook of Oncology (Oxford: Oxford University Press).

Petithory, J.-Cl., J. Théodorides and L. Brumpt (1997) ‘Un Prix Nobel Discuté: Johannes Fibi- ger, 1926’, Histoire des Sciences Médicales 31, 87-95.

Proctor, R. N. (1999) The Nazi War on Cancer (Princeton, N.J.: Princeton University Press).

Pütter, E., F. Blumenthal, et al. (1930) ‘Organisation der Krebsfürsorge [Bericht über die Sit- zung eines zusammengesetzten Ausschusses des Landesgesundheitsrats am 31. Mai 1930]’, Veröffentlichungen aus dem Gebiete der Medizinalverwaltung 32, 635-694.

Rather, L. J. (1978) ‘Cell Theory and the Genesis of Cells in Tumors, 1852-1900’, in idem, The Genesis of Cancer: A Study in the History of Ideas (Baltimore: Johns Hopkins University Press), pp. 118-179.

Rheinberger, H.-J. and M. Hagner (1997) ‘Plädoyer für eine Wissenschaftsgeschichte des Experiments’, Theory in Biosciences 116, 11-31.

Ribbert, H. (1909) Das Wesen der Krankheit (Bonn: Verlag von Friedrich Cohen).

Rodgers III, A. D. (1952) Erwin Frink Smith — A Story of North American Plant Pathology (Philadelphia: American Philosophical Society).

Römer (1906) ‘Über Krebsangst’, Zeitschrift für Krebsforschung 4, 75-82.

Rosenberg, C. E. (1979) ‘Toward an Ecology of Knowledge: On Discipline, Contexts and History’, in A. Oleson and J. Voss (eds), The Organization of Knowledge in Modern America, 1869-1920 (Baltimore: Johns Hopkins University Press), pp. 440-455.

85 Ton van Helvoort

Rosenberg, C. E. (1992) ‘Explaining Epidemics’, in idem, Explaining Epidemics and Other Studies in the History of Medicine (Cambridge: Cambridge University Press), pp. 293304.

Rosenberg, Ch. E. (1998) ‘Holism in Twentieth-Century Medicine’, in Chr. Lawrence and G. Weisz (eds), Greater than the Parts: Holism in Biomedicine, 1920-1950 (Oxford: Oxford Uni- versity Press), pp. 335-355.

Roussy, G. (1943) Der Krebs (Zürich: Rascher Verlag).

Russell, K. (1969) ‘Tissue Culture — A Brief Historical Review’, Clio Medica 4, 109-119.

Salazar, E. H. (1986) Krebsforschung und Krebsbekämpfung in Berlin bis zum Jahre 1945 (Berlin: Privately Printed).

Sauerbruch, F. (1926) ‘Heilkunst und Naturwissenschaft’, Naturwissenschaften 14, 1081-1090.

Schmieden, V. (1927) ‘Infektion, Parasitismus und Gewächsbildung’, in G. Schmorl (ed.), Ver- handlungen der Deutschen Pathologischen Gesellschaft: Zweiundzwanzigste Tagung, gehalten in Danzig am 8.-10. Juni 1927 (Jena: Gustav Fischer), pp. 21-36.

Schmorl, G. (ed.) (1927) Verhandlungen der Deutschen Pathologischen Gesellschaft: Zwei- undzwanzigste Tagung, gehalten in Danzig am 8.-10. Juni 1927 (Jena: Gustav Fischer).

Schnabel, F. (1953) ‘Althoff, Friedrich Theodor’ (1953), in Neue Deutsche Biographie. Vol. 1 (Berlin: Duncker & Humblot), pp. 222-4.

Schneck, P. (1999) ‘“… ich bin ja nur eine Frau, aber Ehrgefühl habe ich auch”: Zum Schicksal der Berliner Zellforscherin Rhoda Erdmann (1870-1935) unter dem Nationalsozialismus’, in K.-F. Wessel (ed.), Festschrift für Ilse Jahn, in press.

Shimkin, M. B. (1977) Contrary to Nature — Being an Illustrated Commentary on Some Per- sons and Events of Historical Importance in the Development of Knowledge Concerning Cancer (Bethesda, MD: U.S. Department of Health Education, and Welfare).

Smith, E. F. (1916) ‘Further Evidence that Crown Gall of Plants is Cancer’, Science 43, 871- 889.

Smith, E. F. (1925) ‘Some Newer Aspects of Cancer Research’, Science 61, 595-601.

Star, S. L. (ed.) (1995) Ecologies of Knowledge: Work and Politics in Science and Technology (Albany: State University of New York Press).

Teutschlaender, O. (1927) ‘Infektion, Parasitismus und Gewächsbildung’, in G. Schmorl (ed.), Verhandlungen der Deutschen Pathologischen Gesellschaft: Zweiundzwanzigste Tagung, gehalten in Danzig am 8.-10. Juni 1927 (Jena: Gustav Fischer), pp. 37-53.

86 A Dispute over Scientific Credibility:

Teutschlaender, O. (1928) ‘Die Roussarkome (Ihr Wesen und ihre Bedeutung)’, Zeitschrift für Krebsforschung 27, 241-252.

Triolo, V. A. (1964) ‘Nineteenth Century Foundations of Cancer Research. Origins of Experi- mental Research’, Cancer Research 24, 4-27.

Triolo, V. A. (1965) ‘Nineteenth Century Foundation of Cancer Research. Advances in Tumor Pathology, Nomenclature, and Theories of Oncogenesis’, Cancer Research 25, 75-106.

Tyzzer, E. E. (1914) ‘Report of the Director’, in Cancer Commission of Harvard University, Second Annual Report of the Collis P. Huntington Memorial Hospital for Cancer Research and of the Laboratories of the Cancer Commission of Harvard University, 1913-1914 (Boston, MA: Cancer Commission of Harvard University), pp. 11-18.

Varmus, H. E. and R. A. Weinberg (1993) Genes and the Biology of Cancer (New York: Sci- entific American Library).

Voswinckel, P. (1994) ‘Von der ersten hämatologischen Fachgesellschaft zum Exodus der Hämatologie aus Berlin’, in W. Fischer, K. Hierholzer, M. Hubenstorf, P. Th. Walther and R. Winau (eds), Exodus von Wissenschaften aus Berlin: Fragestellungen — Ergebnisse — Desi- derate — Entwicklungen vor und nach 1933 (Berlin: Walter de Gruyter), pp. 552-567.

Wagner, G. and A. Mauerberger (1989) Krebsforschung in Deutschland: Vorgeschichte und Geschichte des Deutschen Krebsforschungszentrums (Berlin: Springer-Verlag). von Wassermann, A., F. Keysser and M. Wassermann (1911) ‘Beiträge zum Problem: Geschwülste von der Blutbahn aus therapeutisch zu beeinflussen. Auf Grund chemotherapeu- tischer Versuche an tumorkranken Tieren’, Deutsche medizinische Wochenschrift 37, 2389- 2391.

Weindling, P. (1989) Health, Race and German Politics between National Unification and Nazism, 1870 — 1945 (Cambridge: Cambridge University Press).

Woglom, W. H. (1913) The Study of Experimental Cancer. A Review [George Crocker Special Research Fund No. 1] (New York: Columbia University Press).

Wolff, J. (1913) Die Lehre von der Krebskrankheit von den ältesten Zeiten bis zur Gegenwart. Band III: Erste Abteilung: Statistik. Tier- und sogenannter Pflanzenkrebs (Jena: Gustav Fischer).

Wolff, J. (1929) Die Lehre von der Krebskrankheit von den ältesten Zeiten bis zur Gegenwart. Vol. 1 — Second Edition (Jena: Gustav Fischer).

Yamagiwa, K. (1924/5) ‘Ein kleiner Rückblick auf unseren künstlichen Teerkrebs’, Gann: The Japanese Journal of Cancer Research 18, 1-25.