The Emperor of All Maladies: A Biography of Cancer (10 page)

But the rarity of ancient cancers notwithstanding, it is impossible to forget the tumor growing in the bone of Aufderheide’s mummy of a thirty-five-year-old. The woman must have wondered about the insolent gnaw of pain in her bone, and the bulge slowly emerging from her arm. It is hard to look at the tumor and not come away with the feeling that one has encountered a powerful monster in its infancy.

Black bile without boiling
causes cancers.

—Galen, AD 130

We have learned nothing
, therefore, about the real cause of cancer or its actual nature. We are where the Greeks were.

—Francis Carter Wood in 1914

It’s bad bile
. It’s bad habits. It’s bad bosses. It’s bad genes.

—Mel Greaves,
Cancer:
The Evolutionary Legacy
, 2000

In some ways disease
does not exist until we have agreed that it does—by perceiving, naming, and responding to it.

—C. E. Rosenberg

Even an ancient monster needs a name. To name an illness is to describe a certain condition of suffering—a literary act before it becomes a medical one. A patient, long before he becomes the subject of medical scrutiny, is, at first, simply a storyteller, a narrator of suffering—a traveler who has visited the kingdom of the ill. To relieve an illness, one must begin, then, by unburdening its story.

The names of ancient illnesses are condensed stories in their own right. Typhus, a stormy disease, with erratic, vaporous fevers, arose from the Greek
tuphon
, the father of winds—a word that also gives rise to the modern
typhoon.
Influenza
emerged from the Latin
influentia
because medi
eval doctors imagined that the cyclical epidemics of flu were influenced by stars and planets revolving toward and away from the earth.
Tuberculosis
coagulated out of the Latin
tuber
, referring to the swollen lumps of glands that looked like small vegetables. Lymphatic tuberculosis, TB of the lymph glands, was called
scrofula
, from the Latin word for “piglet,” evoking the rather morbid image of a chain of swollen glands arranged in a line like a group of suckling pigs.

It was in the time of Hippocrates, around 400 BC, that a word for cancer first appeared in the medical literature:
karkinos
, from the Greek word for “crab.” The tumor, with its clutch of swollen blood vessels around it, reminded Hippocrates of a crab dug in the sand with its legs spread in a circle. The image was peculiar (few cancers truly resemble crabs), but also vivid.
Later writers, both doctors and patients
, added embellishments. For some, the hardened, matted surface of the tumor was reminiscent of the tough carapace of a crab’s body. Others felt a crab moving under the flesh as the disease spread stealthily throughout the body. For yet others, the sudden stab of pain produced by the disease was like being caught in the grip of a crab’s pincers.

Another Greek word would intersect with the history of cancer—
onkos
, a word used occasionally to describe tumors, from which the discipline of oncology would take its modern name.
Onkos
was the Greek term for a mass or a load, or more commonly a burden; cancer was imagined as a burden carried by the body. In Greek theater, the same word,
onkos
, would be used to denote a tragic mask that was often “burdened” with an unwieldy conical weight on its head to denote the psychic load carried by its wearer.

But while these vivid metaphors might resonate with our contemporary understanding of cancer, what Hippocrates called
karkinos
and the disease that we now know as cancer were, in fact, vastly different creatures. Hippocrates’
karkinos
were mostly large, superficial tumors that were easily visible to the eye: cancers of the breast, skin, jaw, neck, and tongue. Even the distinction between malignant and nonmalignant tumors likely escaped Hippocrates: his
karkinos
included every conceivable form of swelling—nodes, carbuncles, polyps, protrusions, tubercles, pustules, and glands—lumps lumped indiscriminately into the same category of pathology.

The Greeks had no microscopes. They had never imagined an entity called a cell, let alone seen one, and the idea that
karkinos
was the uncon
trolled growth of cells could not possibly have occurred to them. They were, however, preoccupied with fluid mechanics—with waterwheels, pistons, valves, chambers, and sluices—
a revolution
in hydraulic science originating with irrigation and canal-digging and culminating with Archaemedes discovering his eponymous laws in his bathtub. This preoccupation with hydraulics also flowed into Greek medicine and pathology. To explain illness—all illness—Hippocrates fashioned an elaborate doctrine based on fluids and volumes, which he freely applied to pneumonia, boils, dysentery, and hemorrhoids. The human body, Hippocrates proposed, was composed of four cardinal fluids called humors: blood, black bile, yellow bile, and phlegm. Each of these fluids had a unique color (red, black, yellow, and white), viscosity, and essential character. In the normal body, these four fluids were held in perfect, if somewhat precarious, balance. In illness, this balance was upset by the excess of one fluid.

The physician Claudius Galen, a prolific writer and influential Greek doctor who practiced among the Romans around AD 160, brought Hippocrates’ humoral theory to its apogee. Like Hippocrates, Galen set about classifying all illnesses in terms of excesses of various fluids. Inflammation—a red, hot, painful distension—was attributed to an overabundance of blood. Tubercles, pustules, catarrh, and nodules of lymph—all cool, boggy, and white—were excesses of phlegm. Jaundice was the overflow of yellow bile. For cancer, Galen reserved the most malevolent and disquieting of the four humors: black bile. (Only one other disease, replete with metaphors, would be attributed to an excess of this oily, viscous humor: depression. Indeed,
melancholia
, the medieval name for “depression,” would draw its name from the Greek
melas
, “black,” and
khole
, “bile.” Depression and cancer, the psychic and physical diseases of black bile, were thus intrinsically intertwined.) Galen proposed that cancer was “trapped” black bile—static bile unable to escape from a site and thus congealed into a matted mass. “Of blacke cholor [bile], without boyling cometh cancer,” Thomas Gale, the English surgeon, wrote of Galen’s theory in the sixteenth century, “and if the humor be sharpe, it maketh ulceration, and for this cause, these tumors are more blacker in color.”

That short, vivid description would have a profound impact on the future of oncology—much broader than Galen (or Gale) may have intended. Cancer, Galenic theory suggested, was the result of a
systemic
malignant state, an internal overdose of black bile. Tumors were just local outcroppings of a deep-seated bodily dysfunction, an imbalance of physiology that
had pervaded the entire corpus. Hippocrates had once abstrusely opined that cancer was “
best left untreated
, since patients live longer that way.” Five centuries later, Galen had explained his teacher’s gnomic musings in a fantastical swoop of physiological conjecture. The problem with treating cancer surgically, Galen suggested, was that black bile was everywhere, as inevitable and pervasive as any fluid. You could cut cancer out, but the bile would flow right back, like sap seeping through the limbs of a tree.

Galen died in Rome in 199 AD, but his influence on medicine stretched over the centuries. The black-bile theory of cancer was so metaphorically seductive that it clung on tenaciously in the minds of doctors. The surgical removal of tumors—a local solution to a systemic problem—was thus perceived as a fool’s operation. Generations of surgeons layered their own observations on Galen’s, solidifying the theory even further. “
Do not be led away and offer
to operate,” John of Arderne wrote in the mid-1300s. “It will only be a disgrace to you.” Leonard Bertipaglia, perhaps the most influential surgeon of the fifteenth century, added his own admonishment: “
Those who pretend
to cure cancer by incising, lifting, and extirpating it only transform a nonulcerous cancer into an ulcerous one. . . . In all my practice, I have never seen a cancer cured by incision, nor known anyone who has.”

Unwittingly, Galen may actually have done the future victims of cancer a favor—at least a temporary one. In the absence of anesthesia and antibiotics, most surgical operations performed in the dank chamber of a medieval clinic—or more typically in the back room of a barbershop with a rusty knife and leather straps for restraints—were disastrous, life-threatening affairs. The sixteenth-century surgeon
Ambroise Paré described charring tumors
with a soldering iron heated on coals, or chemically searing them with a paste of sulfuric acid. Even a small nick in the skin, treated thus, could quickly suppurate into a lethal infection. The tumors would often profusely bleed at the slightest provocation.

Lorenz Heister, an eighteenth-century German physician, once described a mastectomy in his clinic as if it were a sacrificial ritual: “
Many females can stand the operation
with the greatest courage and without hardly moaning at all. Others, however, make such a clamor that they may dishearten even the most undaunted surgeon and hinder the operation. To perform the operation, the surgeon should be steadfast and not allow himself to become discomforted by the cries of the patient.”

Unsurprisingly, rather than take their chances with such “undaunted”
surgeons, most patients chose to hang their fates with Galen and try systemic medicines to purge the black bile. The apothecary thus soon filled up with an enormous list of remedies for cancer: tincture of lead, extracts of arsenic, boar’s tooth, fox lungs, rasped ivory, hulled castor, ground white-coral, ipecac, senna, and a smattering of purgatives and laxatives. There was alcohol and the tincture of opium for intractable pain. In the seventeenth century, a paste of crab’s eyes, at five shillings a pound, was popular—using fire to treat fire. The ointments and salves grew increasingly bizarre by the century: goat’s dung, frogs, crow’s feet, dog fennel, tortoise liver, the laying of hands, blessed waters, or the compression of the tumor with lead plates.

Despite Galen’s advice, an occasional small tumor was still surgically excised. (Even Galen had reportedly performed such surgeries, possibly for cosmetic or palliative reasons.) But the idea of surgical removal of cancer as a curative treatment was entertained only in the most extreme circumstances. When medicines and operations failed, doctors resorted to the only established treatment for cancer, borrowed from Galen’s teachings: an intricate series of bleeding and purging rituals to squeeze the humors out of the body, as if it were an overfilled, heavy sponge.

Rack’t carcasses
make ill Anatomies.

—John Donne

In the winter of 1533, a nineteen-year-old student from Brussels, Andreas Vesalius, arrived at the University of Paris hoping to learn Galenic anatomy and pathology and to start a practice in surgery. To Vesalius’s shock and disappointment, the anatomy lessons at the university were in a preposterous state of disarray. The school lacked a specific space for performing dissections. The basement of the Hospital Dieu, where anatomy demonstrations were held, was a theatrically macabre space where instructors hacked their way through decaying cadavers while dogs gnawed on bones and drippings below. “
Aside from the eight muscles
of the abdomen, badly mangled and in the wrong order, no one had ever shown a muscle to me, nor any bone, much less the succession of nerves, veins, and arteries,” Vesalius wrote in a letter. Without a map of human organs to guide them, surgeons were left to hack their way through the body like sailors sent to sea without a map—the blind leading the ill.

Frustrated with these ad hoc dissections, Vesalius decided to create his own anatomical map.
He needed his own specimens
, and he began to scour the graveyards around Paris for bones and bodies. At Montfaucon, he stumbled upon the massive gibbet of the city of Paris, where the bodies of petty prisoners were often left dangling. A few miles away, at the Cemetery of the Innocents, the skeletons of victims of the Great Plague lay half-exposed in their graves, eroded down to the bone.

The gibbet and the graveyard—the convenience stores for the medieval anatomist—yielded specimen after specimen for Vesalius, and he compulsively raided them, often returning twice a day to cut pieces dangling from the chains and smuggle them off to his dissection chamber. Anatomy came alive for him in this grisly world of the dead. In 1538, collaborating with artists in Titian’s studio, Vesalius began to publish his detailed drawings in plates and books—elaborate and delicate etchings charting
the courses of arteries and veins, mapping nerves and lymph nodes. In some plates, he pulled away layers of tissue, exposing the delicate surgical planes underneath. In another drawing, he sliced through the brain in deft horizontal sections—a human CT scanner, centuries before its time—to demonstrate the relationship between the cisterns and the ventricles.

Vesalius’s anatomical project had started as a purely intellectual exercise but was soon propelled toward a pragmatic need. Galen’s humoral theory of disease—that all diseases were pathological accumulations of the four cardinal fluids—required that patients be bled and purged to squeeze the culprit humors out of the body. But for the bleedings to be successful, they had to be performed at specific sites in the body. If the patient was to be bled prophylactically (that is, to
prevent
disease), then the purging was to be performed far away from the possible disease site, so that the humors could be diverted from it. But if the patient was being bled therapeutically—to
cure
an established disease—then the bleeding had to be done from nearby vessels leading
into
the site.

To clarify this already foggy theory, Galen had borrowed an equally foggy Hippocratic expression,
και ιειυ
—Greek for “straight into”—to describe isolating the vessels that led “straight into” tumors. But Galen’s terminology had pitched physicians into further confusion. What on earth, they wondered, had Galen meant by “straight into”? Which vessels led “straight into” a tumor or an organ, and which led the way out? The instructions became a maze of misunderstanding. In the absence of a systematic anatomical map—without the establishment of normality—abnormal anatomy was impossible to fathom.