The Emperor of All Maladies - Part One Summary

The book begins with the story of Carla Reed, a 31-year-old kindergarten teacher and mother of three who experiences headaches, strange bruising, white gums, and exhaustion. The author learns about Carla as he is heading into work at Massachusetts General Hospital in Boston. His beeper informs him to see a patient with leukemia when he arrives. Leukemia, a cancer of the white blood cells, is “breathtaking” with regard to its pace and acuity. Ten months into his two-year fellowship in oncology, the author already feels drained and inured to the death around him.

Nothing in Mukherjee’s training could have prepared him for this work. He thinks about Aleksandr Solzhenitsyn’s novel Cancer Ward, in which the protagonist, diagnosed with cancer, experiences the erasure of his identity. The author feels stunned, almost to the point of incoherence, about the decisions he must make about his patients each day.

Following his experience, the author is motivated to learn more about the history and ongoing war against cancer. He knows the biology of the disease, which he describes as “the uncontrolled growth of a single cell,” and he notes that cancer cells, which grow better than other cells, “are more perfect versions of ourselves.”

As Part One progresses, Mukherjee’s writing feels less like the history of the disease and more like a biography of cancer. His presentation of cancer feels much more like a person than a disease, with leukemia serving as one of main characters. We learn that cancer is an ancient disease, first documented by an Egyptian physician called Imhotep in ~ 2500 BC. Paleopathologists have confirmed the ancient nature of cancer, with the oldest cancer case confirmed in a mummy dating back to 400 AD. However, he notes that historically cancer was much rarer and only as we have extended our life spans has cancer become the common disease faced today.

We are then introduced to and provided a historical background for the methods of treating cancer that still persist today including surgery, radiation and chemical drugs. The ancient greek doctor Galen attributed cancer to one of the four humors of the body, black bile. Galen did not recommend surgery for cancer patients and his medical assessment was followed for an extended period. As our scientific understanding of anatomy and physiology improved thanks to Andreas Vesalius and Matthew Baillie, the concept of black bile was disproven and an era of treating cancer with surgery was born. Initially, the surgeries themselves were more deadly to patients than cancer. As surgery survival rates improved thanks to the development of anesthesia and improved wound care, cancer surgery was transformed by Dr. Halsted. Dr. Halsted pioneered the radical surgery which involved removing as much tissue around a tumor as possible. The data didn’t support the success of such an invasive surgery, but nonetheless a generation of surgeons were created who essentially disfigured patients to treat cancer. Over time, the extreme surgeries were altered to more closely resemble the surgery a cancer patient may receive today.

While surgical interventions were being developed, important scientific discoveries were made that would eventually lead to radiation therapy. Röntgen, a german scientist, discovers x-rays. Following the discovery of X-rays, Pierre and Marie Curie discover radium. Initially, the dangers of radioactive substances and x-rays were not recognized but quickly the damage done to cells by radiation was understood. Emil Grubbe, a young medical student, was the first person to attempt to treat cancer using radiation. Radiation therapy was born, with varying success, since radiation had the power to both reduce the severity of cancer and cause cancer. The dangers of radiation and radiation therapy coincided with an increase in the desire to discover a chemical treatment for cancer. 

Dr.  Ehrlich was one of the first doctor’s to attempt to treat cancer with chemicals. In the early 1900s, a boom in synthetic chemistry provided an array of chemicals to test. Despite his extensive efforts, Dr. Ehrlich was unable to find a chemical that was successful at treating cancer without being too toxic. As it turned out, the precursor for one of the first affective chemicals was mustard gas used during World War One. It would take years until a connection between the ability of mustard gas to decimate white blood cell populations and the potential to treat cancer would be made. In 1948, a chemical similar to mustard gas called 6-MP was discovered to cause leukemia remissions. As chemicals were being tested to discover 6-MP,  Dr. Farber, an unpopular pathologist, was also trying to treat cancer with drugs. After some initially disastrous first trials with children, Dr. Farber successfully induced a short lived leukemia remission in a young boy using an antifolate drug. Dr. Farber’s success combined with his knowledge of 6-MP inspired him to pursue the creation of a children’s cancer hospital. The hospital was top of the line, but required huge funds and could only offer limited treatments that resulted in short term remission. Part one leaves us with knowledge of the earliest cancer treatments and at the cusp of the “war on cancer.”

Andi DeRogatis is a graduate student at UC Davis in the animal biology graduate group. She is currently studying how the avian immune system is influenced by the process of molt. She loves all things birds and is passionate about getting others excited about birds as well! You can follow her on Twitter @andiderogatis.

Lindsey Mooney is a graduate student in the UC Davis Psychology Department. You can follow her on Twitter @Linz_Mooney.

For more content from the UC Davis science communication group "Science Says", follow us on Twitter @SciSays.