The Emperor of All Maladies. Siddhartha Mukherjee

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      Farber’s supply of folic acid for his disastrous first trial had come from the laboratory of an old friend, a chemist, Yellapragada Subbarao—or Yella, as most of his colleagues called him. Yella was a pioneer in many ways, a physician turned cellular physiologist, a chemist who had accidentally wandered into biology. His scientific meanderings had been presaged by more desperate and adventuresome physical meanderings. He had arrived in Boston in 1923⁷⁸, penniless and unprepared, having finished his medical training in India and secured a scholarship for a diploma at the School of Tropical Health at Harvard. The weather in Boston, Yella discovered, was far from tropical. Unable to find a medical job in the frigid, stormy winter (he had no license to practice medicine in the United States), he started as a night porter at the Brigham and Women’s Hospital, opening doors, changing sheets, and cleaning urinals.

      The proximity to medicine paid off. Subbarao made friends and connections at the hospital and switched to a day job as a researcher in the Division of Biochemistry. His initial project involved purifying molecules out of living cells, dissecting them chemically to determine their compositions—in essence, performing a biochemical “autopsy” on cells. The approach required more persistence than imagination, but it produced remarkable dividends. Subbarao purified a molecule called ATP, the source of energy in all living beings (ATP carries chemical “energy” in the cell), and another molecule called creatine, the energy carrier in muscle cells. Any one of these achievements should have been enough to guarantee him a professorship at Harvard. But Subbarao was a foreigner, a reclusive, nocturnal, heavily accented vegetarian who lived in a one-room apartment downtown, befriended only by other nocturnal recluses such as Farber. In 1940, denied tenure and recognition, Yella huffed off to join Lederle Labs, a pharmaceutical laboratory in upstate New York, owned by the American Cyanamid Corporation, where he had been asked to run a group on chemical synthesis.

      At Lederle, Yella Subbarao quickly reformulated his old strategy and focused on making synthetic versions of the natural chemicals that he had found within cells, hoping to use them as nutritional supplements. In the 1920s, another drug company⁷⁹, Eli Lilly, had made a fortune selling a concentrated form of vitamin B12, the missing nutrient in pernicious anemia. Subbarao decided to focus his attention on the other anemia, the neglected anemia of folate deficiency. But in 1946, after many failed attempts⁸⁰ to extract the chemical from pigs’ livers, he switched tactics and started to synthesize folic acid from scratch, with the help of a team of scientists including Harriet Kiltie, a young chemist at Lederle.

      The chemical reactions to make folic acid brought a serendipitous bonus. Since the reactions had several intermediate steps, Subbarao and Kiltie could create variants of folic acid through slight alterations in the recipe. These variants of folic acid—closely related molecular mimics—possessed counterintuitive properties. Enzymes and receptors in cells typically work by recognizing molecules using their chemical structure. But a “decoy” molecular structure—one that nearly mimics the natural molecule—can bind to the receptor or enzyme and block its action, like a false key jamming a lock. Some of Yella’s molecular mimics could thus behave like antagonists to folic acid.

      These were precisely the antivitamins that Farber had been fantasizing about. Farber wrote to Kiltie and Subbarao asking them if he could use their folate antagonists on patients with leukemia. Subbarao consented. In the late summer of 1947, the first package of antifolate left Lederle’s labs in New York and arrived in Farber’s laboratory.

       Farber’s Gauntlet

      Throughout the centuries⁸¹ the sufferer from this disease has been the subject of almost every conceivable form of experimentation. The fields and forests, the apothecary shop and the temple, have been ransacked for some successful means of relief from this intractable malady. Hardly any animal has escaped making its contribution, in hair or hide, tooth or toenail, thymus or thyroid, liver or spleen, in the vain search by man for a means of relief.

      —William Bainbridge

      The search for a way to eradicate this scourge⁸² . . . is left to incidental dabbling and uncoordinated research.

      —The Washington Post, 1946

      Seven miles south of the Longwood hospitals in Boston, the town of Dorchester is a typical sprawling New England suburb, a triangle wedged between the sooty industrial settlements to the west and the gray-green bays of the Atlantic to its east. In the late 1940s, waves of Jewish and Irish immigrants—shipbuilders, iron casters, railway engineers, fishermen, and factory workers—settled in Dorchester, occupying rows of brick-and-clapboard houses that snaked their way up Blue Hill Avenue. Dorchester reinvented itself as the quintessential suburban family town, with parks and playgrounds along the river, a golf course, a church, and a synagogue. On Sunday afternoons, families converged at Franklin Park to walk through its leafy pathways or to watch ostriches, polar bears, and tigers at its zoo.

      On August 16, 1947, in a house across from the zoo, the child of a ship worker in the Boston yards fell mysteriously ill with a low-grade fever that waxed and waned over two weeks without pattern, followed by increasing lethargy and pallor. Robert Sandler⁸³ was two years old. His twin, Elliott, was an active, cherubic toddler in perfect health.

      Ten days after his first fever, Robert’s condition worsened significantly. His temperature climbed higher. His complexion turned from rosy to a spectral milky white. He was brought to Children’s Hospital in Boston. His spleen, a fist-size organ that stores and makes blood (usually barely palpable underneath the rib cage), was visibly enlarged, heaving down like an overfilled bag. A drop of blood under Farber’s⁸⁴ microscope revealed the identity of his illness; thousands of immature lymphoid leukemic blasts were dividing in a frenzy, their chromosomes condensing and uncondensing, like tiny clenched and unclenched fists.

      Sandler arrived at Children’s Hospital just a few weeks after Farber had received his first package from Lederle. On September 6, 1947, Farber began to inject Sandler with pteroylaspartic acid or PAA, the first of Lederle’s antifolates. (Consent to run a clinical trial for a drug—even a toxic drug—was not typically required. Parents were occasionally cursorily informed about the trial; children were almost never informed or consulted. The Nuremberg code for human experimentation, requiring explicit voluntary consent from patients, was drafted on August 9, 1947, less than a month before the PAA trial. It is doubtful that Farber in Boston had even heard of any such required consent code.)

      PAA had little effect. Over the next month Sandler turned increasingly lethargic. He developed a limp, the result of leukemia pressing down on his spinal cord. Joint aches appeared, and violent, migrating pains. Then the leukemia burst through one of the bones in his thigh, causing СКАЧАТЬ