Book Review: The Emperor of All Maladies

The Emperor of All Maladies: A Biography of Cancer
by Siddhartha Mukherjee
Scribner, 2010.

In The Emperor of All Maladies, oncologist Siddhartha Mukherjee has written what surely will be the definitive popular history of cancer medicine. The author credits Richard Rhodes’ monumental account of the Manhattan Project, The Making of the Atomic Bomb [read my review], for inspiring the writing of this book. In subject matter, though, this book is more along the lines of Horace Judson’s The Eighth Day of Creation. Indeed, the history of cancer is also the history of medicine. As other human diseases were conquered by vaccination (18th century), antisepsis (19th century), and modern pharmaceuticals (20th century), cancer remained resistant to the primitive onslaughts of early medicine. The ancients knew just enough about cancer to pronounce it incurable, and only recently have we discovered enough about cancer biology to mount a direct attack against it.

The book is subtitled “A Biography of Cancer,” reflecting its largely chronological organization as well as the author’s desire to write a “biography” of a living being, rather than a “history” of a disease. But I found the clever conceit of anthropomorphism to be more of a distraction than a useful tool, for it does not really add much to an already fascinating story. Indeed, Mukherjee largely abandons it after the first hundred pages or so, returning to it only briefly and sporadically until the final chapter. Perhaps it was a device that helped warm him up and get into the groove of writing.

Perhaps, too, it reflects on the author’s literary leanings, for the book is peppered with references to writers from Sontag to Solzhenitsyn. Apparently, Dr. Mukherjee was forced to memorize a lot of poetry while attending a Catholic high school in his native India. Let it not be said that poetry is useless to a physician, for the lingering effects of his literary training show up in this book’s eminent readability and some rather inspired word choices. For example, in describing his own emotions when a patient dies, he writes of the “astonishing, punctuated clarity of a gunshot in winter.” (p. 305) That phrase is so crisp that you can feel it leap off the page.

Dr. Mukherjee draws not only on the usual historian’s repertoire of personal interviews, archival papers, and other works. As a practicing oncologist, he also cites the original papers in the medical literature that announced notable breakthroughs. Endnotes comprise 69 of the book’s 571 pages, and I do believe he read every single one of those books cover to cover! With his training in oncology and gift for explaining complex medical topics, the author helps the reader to appreciate the significance of each advance: both the excitement of discovery and the numerous disappointments that often followed.


Intriguingly, Mukherjee also uses cancer as a springboard to explore related topics: hematology, anatomy, genetics, molecular biology, genetic engineering, the AIDS crisis, even the dye industry. You see, the dye industry grew alongside textile mills in the first wave of industrialization, and it was thus critical in the formation of the chemicals industry. Success in textiles built up Imperial Germany into a world power, and success in dyes also led Germany to develop chemical weapons as it tried to force a decision on the Western Front of World War I. Mustard gas turned out to have a longer-term effect on its victims, killing white blood cells and thus depleting the bone marrow. Experiments with nitrogen mustard during the Second World War then anticipated Sidney Farber’s later pioneering work in chemotherapy.

After all, Dr. Mukherjee is a man who attended Stanford for undergrad, then Oxford as a Rhodes Scholar, followed by Harvard Medical School and an oncology fellowship at Mass General, and is now married to a MacArthur Award winner. [How Cancer Acquired its Own Biographer, The New York Times, November 8, 2010.] He does not stop his in-depth research of a topic until he feels he has fully understood the content, the context, and the history. Rarely have I ever encountered a book that so telepathically anticipated the interested reader’s questions. And the author does not shove them into footnotes, either. Rather, he explores the most relevant connections in the body of the text, for if they are worth explaining at all, then they are surely worth explaining well. This is a man who celebrates his daughter’s birth by running off to the lab with the umbilical cord, harvesting stem cells in anticipation of future therapeutic usage. Meanwhile, he’s pointing out to the reader that the newborns are housed right next to the cancer ward in the hospital, for the newborns were most nearly aseptic and thus posed the lowest risk of infection to the immunosuppressed cancer patients.

He’s not content just to introduce notable personages with brief biographical sketches, but also seeks to understand their career path and personal circumstances. Sidney Farber, for example, went to the University of Buffalo for undergrad, then went to medical school in Germany at Heidelberg and Freiburg before returning home as a second-year medical student at Harvard Medical School. Now, that’s strange. Why the detour in Germany on the way to Harvard? Because, Mukherjee explains, the prestigious mainline American medical schools of the day had strict Jewish quotas.

Likewise, Yella Subbarao, who supplied Farber with anti-folates, found work at a pharmaceutical company after being denied tenure at Harvard, despite his groundbreaking work on purifying ATP and creanine. Indeed, Subbarao arrived in the United States penniless, and had to work for a time as a night porter at Brigham and Women’s Hospital before obtaining more suitable employment in the biochemistry laboratories. It was a time when such rags-to-riches stories were commonplace. Dr. George Papanicolaou also arrived in American penniless, and worked as a (very unsuccessful) carpet salesman before landing a research position studying the menstrual cycle of guinea pigs. Since these pigs do not bleed during their menstrual cycle, Papanicolaou worked out how to time their cycle by scraping off cervical tissue and smearing it on a slide — resulting in the Pap smear.