The Emperor of All Maladies. Siddhartha Mukherjee

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      The most striking finding, though, is not that cancer existed in the distant past, but that it was fleetingly rare. When I asked Aufderheide about this, he laughed. “The early history of cancer,”¹¹¹ he said, “is that there is very little early history of cancer.” The Mesopotamians knew their migraines; the Egyptians had a word for seizures. A leprosy-like illness¹¹², tsara’at, is mentioned in the book of Leviticus. The Hindu Vedas have a medical term for dropsy and a goddess specifically dedicated to smallpox. Tuberculosis was so omnipresent and familiar to the ancients that—as with ice and the Eskimos—distinct words exist for each incarnation of it. But even common cancers, such as breast, lung, and prostate, are conspicuously absent. With a few notable exceptions, in the vast stretch of medical history there is no book or god for cancer.

      There are several reasons behind this absence. Cancer is an age-related disease—sometimes exponentially so. The risk of breast cancer¹¹³, for instance, is about 1 in 400 for a thirty-year-old woman and increases to 1 in 9 for a seventy-year-old. In most ancient societies, people didn’t live long enough to get cancer. Men and women were long consumed by tuberculosis, dropsy, cholera, smallpox, leprosy, plague, or pneumonia. If cancer existed, it remained submerged under the sea of other illnesses. Indeed, cancer’s emergence in the world is the product of a double negative: it becomes common only when all other killers themselves have been killed. Nineteenth-century doctors often linked cancer to civilization: cancer, they imagined, was caused by the rush and whirl of modern life, which somehow incited pathological growth in the body. The link was correct, but the causality was not: civilization did not cause cancer, but by extending human life spans—civilization unveiled it.

      Longevity, although certainly the most important contributor to the prevalence of cancer in the early twentieth century, is probably not the only contributor. Our capacity to detect cancer earlier and earlier, and to attribute deaths accurately to it, has also dramatically increased in the last century. The death of a child with leukemia in the 1850s would have been attributed to an abscess or infection (or, as Bennett would have it, to a “suppuration of blood”). And surgery, biopsy, and autopsy techniques have further sharpened our ability to diagnose cancer. The introduction of mammography to detect breast cancer early in its course sharply increased its incidence—a seemingly paradoxical result that makes perfect sense when we realize that the X-rays allow earlier tumors to be diagnosed.

      Finally, changes in the structure of modern life have radically shifted the spectrum of cancers—increasing the incidence of some, decreasing the incidence of others. Stomach cancer, for instance, was highly prevalent in certain populations until the late nineteenth century, likely the result of several carcinogens found in pickling reagents and preservatives and exacerbated by endemic and contagious infection with a bacterium that causes stomach cancer. With the introduction of modern refrigeration (and possibly changes in public hygiene that have diminished the rate of endemic infection), the stomach cancer epidemic seems to have abated. In contrast, lung cancer incidence in men increased dramatically in the 1950s as a result of an increase in cigarette smoking during the early twentieth century. In women, a cohort that began to smoke in the 1950s, lung cancer incidence has yet to reach its peak.

      The consequence of these demographic and epidemiological shifts was, and is, enormous. In 1900, as Roswell Park noted, tuberculosis was by far the most common cause of death in America. Behind tuberculosis came pneumonia (William Osler, the famous physician from Johns Hopkins University, called it “captain of the men of death”¹¹⁴), diarrhea, and gastroenteritis. Cancer still lagged¹¹⁵ at a distant seventh. By the early 1940s, cancer¹¹⁶ had ratcheted its way to second on the list, immediately behind heart disease. In that same span, life expectancy among Americans¹¹⁷ had increased by about twenty-six years. The proportion of persons above sixty years—the age when most cancers begin to strike—nearly doubled.

      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.

       Onkos

      Black bile without boiling¹¹⁸ causes cancers.

      —Galen, AD 130

      We have learned nothing¹¹⁹, 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 bile¹²⁰. It’s bad habits. It’s bad bosses. It’s bad genes.

      —Mel Greaves, Cancer: The Evolutionary Legacy, 2000

      In some ways disease¹²¹ 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 medieval 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, СКАЧАТЬ