The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukherjee
A book review.
Brief: The book is a scientific memoir of the disease that has been the biggest biological puzzle to humans in the 21st century.
Dr Farber
World War II
Embedded Files
Overall Flow:
Dr Bennet (1845) --> Dr Virchow (1847) --> American Association for Cancer Research (1907) --> Pernicious Anemia (1926) --> Dr Lucy Wills (Folic acid cures rare anemia in Bombay) (1928) --> National Cancer Institute (1937) --> Dr Farber (1947)A shorter version of the Book with all the Good Stuff (quoted) in italics😄
Prologue:
The first chapter is a short introduction to how it feels to be a 11 month old fellow of Oncology (a two year cancer training program) at a hospital. It deals with a 30 year old schoolteacher finding out she has acute lymphoblastic leukemia with a 30% chance of survival. It has some medical details of the condition but most of the matter is emotional focussing on the stress (undergone by physicians) related to the diagnosis, suffering and collapse of patients in their care. This sets the tone of the book, which gradually unfolds into a terrifying narration of the Emperor of All Maladies. It briefly touches upon how ancient physicians treated (suspected) cancer and how those choices effected the current form of the disease. The author stresses on his treatment of the subject (in this book) being driven by a study of the history of the disease and justifies his doing so.
Part I: Of Blacke Cholor Without Boyling
Meaning of the title of this part:
Chapter 1: The Suppuration of Blood (suppuration: suh·pyoo·ray·shn: inflammation/pus formation) (THE ORIGIN)
Etymology: White blood cells are the primary constituent of pus. Leukemia causes white blood cells to increase in number. This chapter deals with leukemia. One of its initial manifestations (1845) was inaccurately descirbed by Dr John Bennett as the combustion of blood into true pus, hence the title. Subsequently, Dr Virchow (1847) recongnized the inaccuracy as blood does not convert into anything but the blood itself is overpopulated by white blood corpuscules, which led him to name it leukamia (leukos is Greek for white). The author pointed out how similar renaming acutally helped improve the understanding of the disease in the case of AIDS (acquired immuno deficinency syndrome) renamed from GRID (gay related immune disease ).
Cell Disease: Dr Virchow really wanted to understand the disease and his learning approach was unconventional. He started off by eliminating each preconception about the disease. He tried to understand diseases in terms of cells (that he can see under the microscope), an idea that would lead to the cellular theory of human biology and revolutionize our understanding of diseases. This, however, was not some accidental genius and was mostly fuelled by his frustration at being unable to manuever the existing complex theory that described diseases based on unseen forces.
Experimental Treatment: The chapter starts with a scene set in the year 1947 at the Children's Hospitals' pathology laboratory centering around the doings of the pathologist, Dr Farber (born a year after Dr Virchow's death): who was called "doctor of the dead", impatient watching illness from its sidelines, analyzing tissues and cells, without ever treating a live patient decides to try treat leukemia in children, at a time when patients of this malady were eventually sent home to die. His choice to study the most hopeless breed of cancer was simple: to understand cancer, you needed to start in its basement. In trying to understand leukamia, he observed that contrary to other cancers, one could see it (blood) and hence one could measure (count) it. This actually gave a way to quantify the efficacy of treatments of leukamia. Thus he started experimenting with the treatment of cancer.
Chapter 2: A Monster more insatiable than the guillotine (THE ECONOMICS AND POLITICS)
Extirpations: This chapter presents a picture of the effect of the socio-economic conditions on the treatment of cancer (late 1940s) and how the discoveries of treatment of other diseases (during the time) influenced it. Post World War II, the boom in medical discoveries fuelled peoples expectations of treatment and mortality leading them to focus on other aspects of living like child care (the mid-20th century baby boom). However cancer was far from being conquered and there were political reasons behind it too. Specially, there were lack of funds for cancer research. As cancer rose into prominence, only under the favourable condition when the tumour would be strictly confined to a single organ/location such that it could be surgically removed (a process called extirpation) or the cancer cells destroyed via X-rays (radiotherapy), there was a hope for successful treatment. Still cancer remained something to be cut-off rather than treat with chemicals (as envisioned by Dr Farber in 1947).
Timeline of events:
1907: New Willard Hotel (Washington): American Association for Cancer Research group of cancer surgeons organise to lobby government for funds for cancer research.
1910: AACR convinced President Taft to propose to Congress a dedicated lab for cancer research -- Stalled due to lack of political support.
Late 1920's: Senator Matthew Neely observed the mortality of cancer peak from 70000 men and women in 1911 to 115000 in 1927. Matthew asked Congress to reward $5 mill. for "any information leading to the arrest of human cancer" -- people came up with rubs, tonics even blessed water! Congress was forced to give $50,000 towards Neely's Cancer Control Bill.
1937: Neely (re-elected to the Senate) with Senator Homer Bone and Representative Warren Magnuson led to a joint effort of the Senate-House crafted a bill to address the cancer funding issue which was later passed in July 1937 -- later president Roosevelt signed it -- National Cancer Institute Act which established a scientific unit called the National Cancer Institute (NCI) (which in 1944 became a subsidiary to NIH) to coordinate cancer research and education.
1938: The stage was set for the World War that was to begin in 1941 leading to a reordering of priorities. NCI wanted to convert the US Marine Hospital in Baltimore to a cancer centre. Instead, it was converted to a war hospital. Scientific research funding was due only to projects related to the war. -- cancer became the great unmentionable so much so that in 1950 when Fanny Rosenow, a breast cancer survivor wanted to post an ad in the New York Times for a support group for women with breast cancer she was to be met with : I am sorry Ms. Rosenow, but the Times cannot publish the word breast or the word cancer in its pages. Perhaps you could say there will be a meeting about diseases of the chest wall...
1947: Dr Farber entered the cancer scene, there was not much of a public outcry about cancer -- it had become politically silent -- which in a way helped him to concentrate on cancer by insulating him from public scrutiny. At the Children's Hospital doctors and patients fought their private battles against cancer, where Dr Farber would be fighting his with chemicals in the tunnels downstairs. Leukamia was unique, people had given up on finding a treatment for it, most people didnt even consider it as cancer before WWII. It was perhaps the closest to hematology -- the study of blood. So Farber concluded that he would have to study blood to find its cure. If he could find how blood cells are generated then he could possibly work back towards how to block the growth of abnormal leukemic cells, thus confronting cancer in reverse. Farber learnt of blood from George Minot under whom he had trained while at Harvard (1920s). Minot ran a laboratory off Harrison Ave. in Boston a few miles down the Children's Hospital.
1926 and Pernicious anemia: Every decade has a unique hematological riddle and for Minot's era it was pernicious anemia. Anemia is the deficiency of RBCs -- most commonly occurs due to a lack of iron. However, pernicious anemia (a rare variant) does not occur due to lack of iron. In 1926, Minot and his team demonstrated that pernicious anemia was caused due to a deficiency of vitamin B12 which won him and his colleagues the Nobel Prize in 1934.
A morally pernicious anemia: Mill workers in Bombay (who lived in poverty, malnourished, without medical care) particularly women after childbirth were severely anemic. In 1928 Dr Lucy Wills travelled to Bombay and realised that this kind of anemia could not be cured by vitamin B12 or any of Minot's concoctions. Instead she found that Marmite (a British bread spread!) could cure it. Just that she could not figure out what in Marmite could be the cure for this form of anemia. Turns out it was folic acid.
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