Thank you, Owen Purdue. Who is next?

Onkos

Immediately what stands out to me in this chapter, (as they do in most) are the beginning quotations. Mukherjee’s prolific use of quotations in the book is one of my favorite things about his work. They pull you in, make you think deeply. Anyways, the ones at the beginning of ‘Onkos’ are very good. We have Galen, the famous follower of Hippocrates’ ‘four humours’ theory. He said this in 130 AD: Black bile without boiling causes cancers. It’s hard to understand what he means, and I was left with a lot of questions after reading this quotation: what is black bile? How does it form into cancer? In any case I moved on.

The next quotation is much more poignant. We have learned nothing, therefore, about the real cause of Cancer or its actual nature. We are where the Greeks were. That last statement is highlighted simply because it is so poignant. Francis Wood said this in 1914, over two millennia after Hippocrates and the first description of Karkinos. That statement, in its beautiful simplicity, tells us of the unknowably complicated mechanisms of cancer. Cancer is so intricate, so huge and massive and unknowable, that even in the 20th century we were only at the tip of the iceberg in our understanding of it. That statement again makes cancer real to the reader.  

Mukherjee hits hard with a final, poignant statement: In some ways disease does not exist until we have agreed that it does- by perceiving, naming, and responding to it. This quotation confirms the inevitable, that confirmation bias (denying bad news) is human nature. It makes me think about what I would do if I was diagnosed with cancer. I would probably try to deny it as long as I could. This is not my fault. I, after all, am only human.

On to the actual text, where we are forced to confront the question ‘what’s in a name?’ Well, in a name is precisely this: potential. If it’s a person, it could be the potential to smile at old memories or frown in disgust. The same goes for just about anything….Except illnesses. There are famous names in the world of medicine: HIV/AIDS, influenza, ebola, smallpox, (yes it has been eradicated, but who of us hasn’t considered an apocalyptic resurgence?) and of course, cancer.

These are the names that send chills down the spine, names that give meaning to the word fear. And as Mukherjee tells us in the opening paragraph of the chapter, to name an illness is to give it literary weight. A great piece of wisdom here: A patient, long before he becomes the subject of medical scrutiny, is, at first, simply a storyteller, a narrator of suffering. Quite awesome.

Mukherjee then takes us on an etymological tour of medicine. We see here how much we really owe to the romans and greeks. Tuberculosis, influenza, and now cancer: we all see what’s behind their names. In telling us about the origins of these names, Mukherjee uses his signature device to keep us interested in the story: he changes the time in history. The last chapter was all about the beginning, and discovery of cancer: this one seems to be about the naming of the disease and its very first scientific hypothesis. And if you’ll flip the page back, you can see we left off first in 1990 with Aufderheide and then in 1940, as cancer ‘ratcheted its way to second on the list’. Now, here we are again, back in 400 BC with Hippocrates and the genesis of the four humour theory. We learn in this chapter the reason there’s a crab on the cover of the book: to the first man who described it, Hippocrates, cancer was the sharp, rough shell of a crab, and the tumors not single, isolated metastasized outcroppings but legs reaching out around the body. And so it was, that here today in 2014 there is a crab on the cover of the book. The title of the chapter is credited to the Greek word for ‘mass’ or ‘load’: onkos, from which the modern discipline of oncology takes its name. Mukherjee reminds us, though, that Hippocrates description covered not just cancer, but included every other tumor: lumps lumped indiscriminately into the same category of pathology. There was a bit of english magic at the beginning of this clause, did you notice it? Hopefully.

Next we hear of the ‘four humors’ hypothesis, theorized by Hippocrates and picked up by Galen a couple centuries later. For every illness there was a liquid explanation, but for cancer, there was one perfectly in synch more with the future than the past: that cancer was a malevolent, evil disease; that it came hand in hand with depression, darkness, and death. Here is a metaphor with some of the deepest roots in all of medical history. It tells us that the chill we feel when we think of cancer is the same one that has been chilling people for all of human history. This may be a short chapter, but there is a lot of material here. It’s also worth mentioning that we get the name of the section (Of Black Cholor, Without Boyling) from a quotation by Thomas Gale, english surgeon, describing the cancer hypothesis of Galen.

But perhaps because of the humor theory, the treatment of cancer took a step back. Because tumors were now believed to be caused by black bile, the potential of successfully excising them was...Next to nothing. ‘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.’ And that is where we leave cancer research for a long, long time. Almost 1500 years will pass before the humor theory is finally discredited. Mukherjee throws in some of his trademark visuals here, describing the painful tradition of medieval surgery, and gives us part of the reason cancer treatment was left to a standstill for a millenium and a half: that surgery was often life-threatening.

Suddenly, on the last page, we are met with a flurry of one of the rhetorical devices Siddhartha Mukherjee loves best: anaphora. With little restraint he lists off a dozen or so of the medieval ‘cures’, showing us just how far medieval patients would go to find a cure for their tumors. What is the purpose of this veritable apothecary? Perhaps to tell us exactly the lengths patients exhausted before succumbing to their diseases or the operation of a surgeon. Indeed, it’s really only a sampling of the amount of drugs available to people now and the ones that were available to them then.  Mukherjee ends the chapter with a final metaphor: that the human body with its surplus of ‘black bile’ was like an overfull sponge. It’s a metaphor that’s eerily reminiscent of Mukherjee’s description of leukemia at the beginning of the book: much like black bile, white blood cells saturate the leukemic body with cancerous ‘blasts’. Maybe Galen wasn’t so far off the mark after all?

Vanishing Humors

Info:	Significance:
- In 1533, a student named Andreas Vesalius arrived at the University of Paris.	- He hoped to learn Galenic medicine, but would end up disproving Galen entirely.
-When he arrived, he found that the University’s surgical program was neglected and in disarray.	- He resolved to teach himself the principles of anatomy without the help of the university.
-Vesalius began to visit graveyards around Paris, looking for subjects...	-From which to make his own anatomical map.
-He began to chart out arteries, veins, and nerves.	-Soon, though, he was forced to confront a major hole in Galen’s hypothesis. Galen had mentioned to the readers of his works that in order to cure disease one would have to bleed patients from the arteries that led ‘straight into’ the tumor. But what defined ‘straight into’?
-Because of that question, Galen set out sketching every nerve and artery in the human body.	- Soon he was charting out the nerves and many other systems. Nowhere, however, could he find the ‘Black bile’ of cancer. Though he would succeed in his mission of mapping out the body, he would never formally declare himself against Galen’s principles. The fact that black bile didn’t exist, however, always lurked in the back of his mind.
- 250 years later, in 1793, Matthew Baillie would publish a counter to Galen’s study, in which instead of showing healthy anatomy, he drew the anatomy of the ill.	-Here was the finale of the search for Galen’s black bile. Surely, if black bile was present, it would be present in something it was supposed to have caused, cancerous tumors.
-Baillie sketched out several types of cancer. But none of them contained black bile.	-It was concluded by the scientific community that black bile, and Galen’s four humor hypothesis, did not exist.