De atra bile: An (auto)biography of cancer

Calloway Scott // Look at a recent history of cancer and you might learn something like the following: in the ancient world, cancers were rare. This is owing to shorter lifespans of the population and more limited environmental, occupational, and habitual exposure to carcinogens. It is also very probable that you will learn that the venerable medical theorists of Graeco-Roman antiquity, namely Hippocrates and Galen, identified the pathological agent of malignant cancers as melancholos or atra bilis—black bile. You can readily find this historical fact in peer-reviewed medical journals as well as publications of popular science like Siddartha Mukharjee’s magisterial Emperor of All Maladies. Unfortunately, this is not true. Or, at least, it is not the whole truth. The Hippocratics never identified black bile as the cause of cancer, although Galen did. I know this generally as a historian of ancient medicine interested in the transmission, manipulation, and misinterpretation of ideas over time, places, and cultures. But I know it specifically because, when I was handed a world-dissolving cancer diagnosis a couple of years ago, looking back to the past was the only way to make sense of my body and myself in the present.

Over the course of the summer of 2016 I was diagnosed with a grade-3, anaplastic astrocytoma. This is a kind of malignant tumor which emerges in the star-shaped glial cells of the brain where it can metamorphose into its deadlier cousin, glioblastoma. Astrocytomas are relatively rare and our understanding of their etiology and even epidemiology is still poor. One of the few things I was assured of by my oncologists was that the cause of the unchecked proliferation of cells within my head would never be known. It could really only be thought of as a matter of statistical infelicity: a case of cosmically bad-fucking-luck. I would never be able to pinpoint a moment when, be able to identify an event or environment that caused the cancer. It just was: a simple fact of biological processes, the slow accretion of DNA transcription errors, nothing more and nothing less. A thing was growing inside of my brain that, genetically speaking, was part of me in the most profound sense, yet also completely and totally alien, a paradox for which I lacked wholly a perspective to begin to make sense of. I had no language or means to account for the origin of my cancer in a way that could make it fit into any kind narrative I could tell about myself, my choices, or my life.

To fill the gap, I started reading what I could on the history and historiography of cancer, seeking out familiar places where meaning inhered, where sense could be made. And this is how I came to find that Hippocrates had deemed black bile the cause of cancer—a fact which, for a variety of reasons, struck me immediately as off. So, I decided to assemble the passages in which the Hippocratics did have something to say about cancers and track down how we have come to believe that Hippocrates (as an authoritative figure from the past) supposed that melancholos was its cause.

With any attempt to correlate ancient perceptions of disease with our own, we are first of all confronted with the problem of retrospective diagnosis. On the one hand, the limited paleopathological evidence available to us seems to confirm the lower rates of cancers which leave identifiable traces on bones. Looking to texts, especially those from the 5thcentury BCE, is a trickier business. First of all, there is the problem of vocabulary. There are several words for “tumor” in ancient Greek. Karkinos, “crab” (whence the Latin cancer) is attested for both malignant and benign growths. Some later authorities explained this curious etymology by likening the red and swollen veins present in some breast cancers to the claws and legs of the crab; others to the tenacity and inextricability of tumorous tissue which was like a crab’s grip. But there were other less colorful words, like phuma, which broadly indicated any kind of concentrated swelling in the body. It is extremely difficult for us to disambiguate all the cases we would class as cancer, then, and this is a salutary reminder that the taxonomies and phenomenology of disease (and so the language and media used to represent it) in the ancient world is rarely commensurate with our own. (I will henceforth, then, keep the emic term karkinoi to render Greek thinking about the disease.)

The number of passages within the Hippocratic corpus which reference such karkinoican be counted on two hands. Some, like two passages from the Epidemics (Epid. 2.6.22 and 5.1.20) underscore the difficulties of interpretation, as the latter speaks of a karkinos which supervenes in cases of bloody hemorrhoids, while the former describes karkinoi caused by upset stomachs or heavy cough. We are clearly closer to the mark in other instances such as Aphorisms (6.38.1). Here we are informed “For those with hidden karkinoi, it is better not to treat them. For, if they are treated, these patients die more quickly; those who do without it live longer in the end.” Still others note the fact that non-congenital karkinoi do not strike young adults (Coan Prenontions 505) or, similarly, that the majority of karkinoi occur in the very young or those over 60 (Prorrhetic 2.11). Importantly, however, no passage of the texts known to us as Hippocratic ever mentions a humoral origin of the disease, let alone connects it specifically to pathological accumulations of black bile.

For this, it seems, we have Galen to thank, who, in his De atra bile (On Black Bile) declares “karkinos especially is caused by the black bile” (K 5.116.13). To be sure, many of the medical authorities in the intervening 600 years appear to have approached the topic in their writings. The first century CE Methodist physician Soranus, in for instance, made observations about cervical cancers, and Pedanius Dioscorides described helpful botanical therapies for them in his massive compendium of pharmacology De Materia Medica. But, so far as I am aware, it was Galen who appears first to have discussed karkinos within a framework of humors which he claims were established by “Hippocrates.” In this he is referring to the Hippocratic text On the Nature of the Human Being (De Natura Hominis), the only Hippocratic text to enumerate the four humors as blood, phlegm, yellow and black bile. For Galen, Nat. Hom. was the truly canonical Hippocratic text against which all others were to be measured, providing antique authority for his etiological schemes. In the various passages where Galen discusses the causes of karkinoi (e.g. De Placitis Hippocratis et Platonis 8.4.33, De Morborum DifferentiisK 6. 874.15; De Crisibus IIIK 9.693.5) he regularly does so by citing Hippocrates as the source for humoral theory, but he never credits his master with the notion that black bile is the causal agent. This, it appears, is Galen’s ‘discovery,’ one made possible by the conceptual tools “supplied” him by Hippocrates. Thus, nowhere in the Hippocratic Corpus is black bile linked to origin of karkinoi nor does Galen ever attribute that belief to his

We can take the history of the misidentification, I think, one step further to one of its possible sources. Paul of Aegina, an early Byzantine epitomizer of ancient medical opinions and steeped in the works of Galen, informs us that “some [karkinoi] do not have visible lesions, which ones Hippocrates calls ‘hidden’…” Paul immediately follows this by paraphrasing Galen’s opinion that “their origin comes from black bile….” (Epitome 6.38). So, although Paul never gives Hippocrates as the authority for the second claim, one can easily imagine a reader supposing that this was good, Hippocratic doctrine given the proximity. Indeed, it is not even clear that this is not what Paul actually thought. And so, I suggest, it was through Paul of Aegina’s reading of Galen that we received something like the modern orthodoxy implicating Hippocrates in the atrabilious cause of cancer.

In the grand scheme of things, in the great sweep of medical and intellectual history, does this story about black bile matter? Probably it does not. But to me it mattered, and  it continues to matter. Unlike the implacable and inscrutable stuff unfolding itself inside my head, this was a problem that could be confronted. It could be queried and tracked in ways that returned me to myself and my familiar mental habits. In short it gave me structure and meaningful fulfilment in a time I needed it most. And so, too, writing this is a happy reminder that disease is not limited to its physicality or its biochemistry, but is embodied experience accruing and recreating meaning in the process of its telling and in the act of its sharing.

Some Bibliography:

Hajdu, S.I. 2004. “Greco-Roman thought about cancer,” Cancer 15;100(10): 2048-51.

Karpozilos, A. and Pavlidis, N. 2009. “The Treatment of Cancer in Greek Antiquity,” European Journal of Cancer 40, 14: 2033-41.

Riddle, J. 1985. “Ancient and Medieval Chemotherapy,” ISIS 76: 319-30.


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