Fourth Estate, £25, 571pp. £22.50 from the Independent Bookshop: 08430 600 030
The Emperor of All Maladies: A Biography of Cancer, By Siddhartha Mukherjee
Friday 18 March 2011
This is a story of pioneers and mavericks; of serendipity, risk-taking and wild leaps of faith; of meetings of minds that changed medical history and obsessive experiments conducted in solitude. It is a story of inspiration found in bathtubs, blizzards and on night-time walks; one in which the studios of Titian have their place: artists assisted student Andreas Vesalius in creating his atlas of anatomy that would tumble Claudius Galen's theory of humours, its "black bile" long considered the origin of cancer). As does a Japanese painter of birds and fish whose illustrations helped bring Greek cytologist George Papanicolaou's discoveries – as in the Pap smear - out of obscurity.
It is also a story of the early days of fund-raising, of love-ins and rifts with politicians; of the effects of war, of the specific "War on Cancer" declared in 1969 and its continuing war rhetoric; a tale of hopes, dreams and pincer-sharp disappointment. This is the story of cancer, that most "desperate, inventive, fierce, territorial, canny, and defensive" of illnesses.
Intricately entwined in our biology, built into our very genomes, cancer has been regarded as our shape-shifting doppelgänger, a dark mirror-image awaiting its chance to be triggered and to grow, cell after cell. "Omnes cellula e cellula", as Rudolf Virchow put it, upon discovering the proliferation of white blood cells in a patient in 1845: one of the first identified cases of leukemia.
At a time when there is scarcely a family unaffected by cancer (in some places, including the US, it is set to take over from heart-disease as the biggest killer), Siddhartha Mukherjee's stocktaking feels like essential reading. Medicine, the author writes, is also storytelling, beginning with a patient's narrative of suffering. In Dr Mukherjee, cancer has a master storyteller: a frank, compassionate, erudite and straight-talking guide through the history and into the present-day truths of Hippocrates's karkinos (crab).
For cancer, although often considered a "plague of modern times", is ancient. The Egyptian physician Imhotep first mentioned it in 2625BC; Atossa, queen of Persia, was also afflicted, as Herodotus wrote in 440 BC. Rather than seek advice, she cloaked her "shame" – a breast tumour – and had a Greek slave cut off the offending flesh. Her gratitude to him, allegedly, "launched a thousand ships" in the Greco-Persian wars.
While cancer was certainly present, it remained little understood in subsequent centuries. Treatments included "fox lungs, tortoise liver and crab's eyes". In the 18th and 19th centuries, advances in surgery emerged, with seeds of further knowledge sown.
One of the book's great strengths is the bringing to life of scientists: from the Scottish surgeon, Joseph Lister, who in 1865, inspired by Pasteur, discovered carbolic acid's vital role in surgery, to the morphine-addicted William Stewart Halsted. At the peak of his surgical career, in the 1890s, he learned from the "refined European techniques" of London, Paris, Berlin and Vienna in the medical version of the Grand Tour. His name will be forever linked to mastectomy. It moves from the Curies' discovery of radium in 1902 to wartime mustard gas informing "Four-Button Sid" Farber's experiments with antifolates in 1947, oncology's first achievement. The full palette of human nature is revealed here.
The development of treatments is explored: from radical surgery to early chemotherapy, increasingly lethal cocktails of chemicals, combination approaches, preventative innovations and the portrayal of palliative measures not as defeatist but as dignified. Mukherjee also considers the difficulties of trials in the search for the elusive "magic bullet" cure.
The book's six sections are well-balanced, spread between medical strides of the past (such as the near eradication of scrotal cancer among chimney sweeps when soot was discovered to be a carcinogen), more recent challenges (such as taking on the tobacco industry, with China and India its current prey), case studies, and current research. It is heartening, and daunting, to read of our deeper understanding of the cancer cell's biological make-up.
Mukherjee looks ahead with guarded optimism and avoids blithe promises. He contemplates whether more modest goals – the substantial prolongation of life by increasingly palatable treatments, rather than cancer's complete eradication – might be a more feasible, and still enormous, victory. De-mystifying the disease, rendering the science accessible, and wearing respect for the patients uppermost, The Emperor of All Maladies is the book that many will have been waiting for. This elegantly written overview allows us to look a once whispered-about illness squarely in the eye.
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