”The Emperor of all Maladies: A Biography of Cancer,” by Siddhartha Mukherjee. Scribner, 571 pages, $18 (paperback).
”The Emperor of all Maladies” is one of the best and most fascinating books of nonfiction that I’ve ever read. Right from the start, I would like to state strongly that readers - including those of the new Hebrew edition, translated from English by Yossi Milo; Am Oved) - should not be deterred by the fact that the book deals with cancer.
This book is optimistic, mainly thanks to the tremendous achievements that have been made in researching the disease. But the main reason not to be put off by it is that the book is not really only about cancer. At its center is indeed the accursed disease, but since cancer has a hand in everything and everyone has a hand in it, in its biography you can find not only researchers and physicians, nurses, psychologists and welfare workers, but also health maintenance organizations, pharmaceutical companies, the cigarette and food industries, insurance companies, marketing and advertising firms, inventors, politicians, legislators, heads of state and more. “The Emperor of all Maladies,” therefore, opens windows into history, mainly modern, in a manner that is new, surprising and staggering.
At the outset, Siddhartha Mukherjee, a cancer researcher and doctor at Columbia University, who won the 2011 Pulitzer Prize for general nonfiction, defines cancer as a wild and uncontrolled growth of cells. But cancer, to his mind, is also a metaphor with actual and dramatic implications. The cancerous cell, like modern man, is, according to Mukherjee, “a desperate individualist” - or, citing the surgeon-writer Sherwin Nuland, “in every possible sense, a nonconformist.” It expresses a state of absolute challenge, instability, loss of control, pathological excess. Are not these states an inseparable part of what characterizes modernity? Mukherjee wishes to see in cancer a metaphor for modern life. No doubt a discussion of this should be the subject of criticism, and perhaps even indulges in pathos, but there are diseases that are more than just diseases - diseases that are political, social and cultural phenomena in the broadest sense. Cancer, like AIDS, for example, has earned such a status.
The first description of cancer dates, apparently, back to 2500 B.C.E. It appears on an Egyptian papyrus inscribed with the teachings of a physician named Imhotep, who with regard to treatment for the disease wrote: “There is none.” Although “The Emperor of Maladies” has pretenses to describe the history of cancer from Imhotep’s day to our own, it focuses on the modern era, primarily on the 20th century. The reasons for this are varied. First is the absence of historical sources, as well as misdiagnoses by doctors. Second, many types of cancer manifest themselves at an advanced age, and as it is only in the modern era that we have witnessed a leap in life expectancy, the likelihood of developing a cancer rises with age.
Third, the 20th century brought progress in diagnostic capabilities, making it possible to attribute more deaths to cancer. Fourth, the change in the way we live has increased the frequency of several kinds of cancer. In 1900, tuberculosis was the main cause of death in America, and cancer ranked “only” seventh. By the 1940s, it had leapt to second place, right after heart diseases. The history of cancer is fascinating and it is staggering because of its extreme dynamism.
What at one time seemed a clear diagnosis and a self-evident method of treatment turned out at another time to be nonsense. Up until the 1950s, for example, no physician thought that cigarettes were carcinogenic, and advertisements for them regularly appeared in medical journals. Throughout the history of cancer we encounter “genius,” “mad” and “unconstrained” physicians, who on more than one occasion made a breakthrough at the price of killing their patients, alongside doctors who worked with the utmost caution. Sometimes someone wrote an article in a minor journal, and decades later that article turned out to describe one of the important breakthroughs in the field.
This is a history that contains periods of elation, of victory celebrations amid “the war on cancer” and periods of pessimism and despair. And sometimes the history of research in this realm is just an endless continuum of ordinary days. We owe the term “cancer” to Hippocrates, who, in around 400 B.C.E., called the disease by this name - karkinos in Greek, from the word for “crab” - because of the tumor’s appearance, which reminded him of a crab dug in the sand with its appendages spread out in a circle around it. “Oncology” was also coined by the Greeks; onkos means a mass or a burden. Cancer was perceived as a burden on one’s body. In Greek theater, the onkos was a tragic mask that was loaded down with a conical weight, which denoted the psychic load burdening the person down.
In 160 C.E., the Greco-Roman physician Galen claimed that cancer derives from black bile, and that it was pointless to remove it surgically. That perception held sway for centuries. As late as the 15th century, one of the era’s most prominent surgeons claimed: “In all my practice, I have never seen a cancer cured by incision, nor known anyone who has.” The remedies for cancer were, among other things, boar’s tooth, fox lungs, purgatives and laxatives and assorted ointments. Only at the turn of the 19th and 20th centuries, following the work of the London anatomist Matthew Baillie, did physicians begin to remove some tumors surgically. And what about inoperable cancers? One surgeon candidly recommending making due with “remote sympathy” for the patient.
Two dramatic developments from the mid-19th century - anesthesia and sterilization - enabled the next breakthrough. From that time and for many decades to follow, radical surgery ruled the roost. One of the first operations to remove a cancerous tumor took place in 1869, from the breast of Isabella Pim, sister of the surgeon Joseph Lister. It is worth noting here the gender aspect of this history. The efficacy of the most common and destructive operations performed on women’s bodies was not tested in any formal experiments until a very late period. In the 1960s, many women still refused to undergo radical mastectomy for that reason. In South Africa, uncontrolled experiments with bone marrow transplants were conducted on black women who were poor and ignorant. Children too were victims of irresponsible experiments - for example, involving chemotherapy. The hand that held the scalpel or injected the toxic chemical substances was, so it appears, less wary about taking action when it came to weak or, weakened groups like these.
In parallel to the great enthusiasm evinced over the possibilities offered by surgery, Wilhelm Roentgen discovered the X-ray. Many more years had to pass before it was possible to decipher the effect of radiation on the DNA of the cell. However, already in 1896, about a year after the discovery of X-rays, a 21-year-old Chicago medical student by the name of Emil Grubbe had the idea of using radiation on cancerous tumors. That same year a woman who had breast cancer underwent radiation with X-rays. And as always, at first the optimism knew no bounds. A Chicago doctor claimed in 1901 that he believed the innovative treatment was none other than the “absolute cure for all forms of cancer.”
But as always, the moment of disillusionment arrived: Focused radiation turned out to be no match for metastatic tumors. And what was worse, the radiation caused cancer in its own right. Galen was therefore wrong when he claimed that the disease was caused by black bile that blocks the body’s passages, though he was correct in his fundamental argument that the disease moves through the body, from one organ to another, along paths hidden from the eye. Mukherjee places the birthplace of chemotherapy, the treatment most identified with cancer, in the killing fields of World War I. Indeed, it was conceived on the night of July 12, 1917, when a barrage of mustard-gas shells was fired at British soldiers who were stationed near the Belgian town of Ypres. Some 2,000 of them died that night.
In 1919, two American pathologists studied the effects of that bombardment on its survivors. It turned out that the cells that manufacture normal blood cells had decreased dramatically; the bone marrow had been destroyed. Survivors of the attack suffered from anemia and required frequent blood transfusions. Their white blood cell count was low, and remained so. And even though mustard gas was a toxic chemical substance which took the lives of tens of thousands of soldiers, it damaged bone marrow cells specifically, wiping out only that population of cells.
In 1919 nobody was really interested in the article the pair of researchers had published. The following years were dedicated to rehabilitating Europe from the ruins of the war, and it would be some time before science took note of their discovery. Working on the basis of the idea that every remedy is actually poison in disguise, the American government’s Chemical Warfare Service - which studied the effects of war gases during World War II - developed a new method for treating cancer. They dubbed this method “chemotherapy.” Chemotherapy was based on the idea that a weakened version of chemical poison could be employed with the object of damaging malignant white cells. In 1942, mustard gas was injected directly into the vein of a 48-year-old jeweler from New York who suffered from lymphoma. He became the first chemotherapy patient. Thus, chemical warfare against the “external” enemy was directed this time at the enemy within. As a historian of Germany, I can add in this connection that during that same approximate period, certain groups in that country, Jews for example, began to be perceived as “a cancer in the body of the nation.”
In the mid-20th century, it became clear that without the allocation of public resources, humanity would not be able to defeat cancer. In early 1948, the first organization was founded to expedite research by deepening public awareness. This was the Children’s Cancer Research Fund, in Boston, which chose a skinny, fair-haired and blue-eyed boy with cancer named Einar Gustafson to be its poster child. His name was unknown, and the foundation also wanted to protect his identity, so it decided to call him by a catchier moniker – Jimmy – and thus was created the Jimmy Fund. Based on the assumption that promoting cancer care and research, and finding a cure for the disease, takes money, and lots of it, the staff of the new fund embarked on a veritable political campaign.
Lobbyists began raising money by any possible means: Using children, slogans, advertisements, cocktail parties and so on. More and more pressure groups and organizations joined in the journey that ultimately wound its way to Congress and the Oval Office, where on December 23, 1971, President Richard Nixon signed the National Cancer Act. Another parallel campaign marked out a different and no less important target. On January 1, 1971, at 11:59 P.M., the last-ever cigarette commercial was broadcast on American television.
Mukherjee’s book, as noted above, is truly exceptional in its ability to weave the story of cancer into general history. It has been a long time since I read such a broad, enriching and important work of history. Throughout, Mukherjee relates descriptions, sometimes verging on tears, of cases from his own clinic. Nevertheless, I fear the place of the cancer patients themselves is somewhat neglected here. In a monumental work such as this, which runs to more than 500 pages, it would have been proper in my opinion to devote a bit more room to the patients.
In the 1980s, in parallel to the research and medical breakthroughs, primarily in the fields of biology and genetics – and also in parallel to the realization that news of a miracle cure for the disease was not on the horizon – a field came into being that made allowances for the patient’s pain and suffering. That field, palliative care, in essence turned its back on the concepts and rhetoric of “war” and “victory” in the context of cancer, focusing more on the patient.
Mukherjee acknowledges the patients too little and too late. Just as he examined the history of the “war on cancer,” it would have also been interesting had he taken a historical look at patients’ responses to the disease, the ways they cope with it, society’s reactions to it and so forth. I can attest, from personal experience, and from the experience of many others, that both cancer itself and the metaphor “cancer” pose a genuine existential challenge to the patient.
Not only does cancer change the lives of those who suffer from it, many also decide to change their lives in its wake. And just as more room ought to have been devoted in this book to patients, space should also have been devoted to discussing the price paid by the treatment of other diseases and other patients that have enjoyed neither the resources nor the public relations that cancer has. After all, not every disease is “The Emperor of Maladies.”
Dr. Boaz Neumann is an associate professor of history at Tel Aviv University.