November 1, 2010

IT IS US:

Cancer World: The making of a modern disease (Steven Shapin, November 8, 2010, The New Yorker)

Cancer has always been with us, but not always in the same way. Its care and management have differed over time, of course, but so, too, have its identity, visibility, and meanings. Pick up the thread of history at its most distant end and you have cancer the crab—so named either because of the ramifying venous processes spreading out from a tumor or because its pain is like the pinch of a crab’s claw. Premodern cancer is a lump, a swelling that sometimes breaks through the skin in ulcerations producing foul-smelling discharges. The ancient Egyptians knew about many tumors that had a bad outcome, and the Greeks made a distinction between benign tumors (oncos) and malignant ones (carcinos). In the second century A.D., Galen reckoned that the cause was systemic, an excess of melancholy or black bile, one of the body’s four “humors,” brought on by bad diet and environmental circumstances. Ancient medical practitioners sometimes cut tumors out, but the prognosis was known to be grim. Describing tumors of the breast, an Egyptian papyrus from about 1600 B.C. concluded: “There is no treatment.”

The experience of cancer has always been terrible, but, until modern times, its mark on the culture has been light. In the past, fear coagulated around other ways of dying: infectious and epidemic diseases (plague, smallpox, cholera, typhus, typhoid fever); “apoplexies” (what we now call strokes and heart attacks); and, most notably in the nineteenth century, “consumption” (tuberculosis). The agonizing manner of cancer death was dreaded, but that fear was not centrally situated in the public mind—as it now is. This is one reason that the medical historian Roy Porter wrote that cancer is “the modern disease par excellence,” and that Mukherjee calls it “the quintessential product of modernity.”

At one time, it was thought that cancer was a “disease of civilization,” belonging to much the same causal domain as “neurasthenia” and diabetes, the former a nervous weakness believed to be brought about by the stress of modern life and the latter a condition produced by bad diet and indolence. In the eighteenth and nineteenth centuries, some physicians attributed cancer—notably of the breast and the ovaries—to psychological and behavioral causes. William Buchan’s wildly popular eighteenth-century text “Domestic Medicine” judged that cancers might be caused by “excessive fear, grief, religious melancholy.” In the nineteenth century, reference was repeatedly made to a “cancer personality,” and, in some versions, specifically to sexual repression. As Susan Sontag observed, cancer was considered shameful, not to be mentioned, even obscene. Among the Romantics and the Victorians, suffering and dying from tuberculosis might be considered a badge of refinement; cancer death was nothing of the sort. “It seems unimaginable,” Sontag wrote, “to aestheticize” cancer.

Cancer is “the modern disease” not just because we understand it in radically new ways but also because there’s a lot more cancer about. For some cancers, the rise in incidence is clearly connected with things that get into our bodies that once did not—the causal link between smoking and lung cancer being the most spectacular example. But the rise in cancer mortality is, in its way, very good news: as we live longer, and as many infectious and epidemic diseases have ceased to be major causes of death, so we become prone to maladies that express themselves at ages once rarely attained. At the beginning of the twentieth century, life expectancy at birth in America was 47.3 years, and in the middle of the nineteenth century it was less than forty. The median age at diagnosis for breast cancer in the United States is now sixty-one; for prostate cancer it is sixty-seven; for colorectal cancer it’s seventy. “Cancer has become the price of modern life,” an epidemiologist recently wrote: in the U.S., about half of all men and about a third of women will contract cancer in their lifetime; cancer now ranks just below heart disease as a cause of death in the U.S. But in low-income countries with shorter life expectancies it doesn’t even make the top ten.

The cancers of the past were visible on the body’s surface; now we have visual access to the enemy within at a micro level. Modern technologies—advances in microscopy, histological staining, biopsies, X-rays, computed tomography (C.T.) and magnetic resonance imaging (M.R.I.) scans—have given us new possibilities for understanding cancer, but also a new vocabulary of fear. In “The Illness Narratives,” the psychiatrist and anthropologist Arthur Kleinman recorded conversations between cancer victims and their physicians. A dying patient with metastasized rectal cancer told his doctor about his feeling that “there is something not me in me, an ‘it,’ eating its way through the body. . . . These cancer cells are me and yet not me.” The more science tells us about the cancer cell, the more it resembles us.


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Posted by Orrin Judd at November 1, 2010 5:53 AM
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