The Emperor of All Maladies. Siddhartha Mukherjee

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СКАЧАТЬ common cancers. He was throwing down a gauntlet for cancer medicine. It was then up to an entire generation of doctors and scientists to pick it up.

       A Private Plague

      We reveal ourselves⁹⁶ in the metaphors we choose for depicting the cosmos in miniature.

      —Stephen Jay Gould

      Thus, for 3,000 years and more⁹⁷, this disease has been known to the medical profession. And for 3,000 years and more, humanity has been knocking at the door of the medical profession for a “cure.”

      —Fortune, March 1937

      Now it is cancer’s turn⁹⁸ to be the disease that doesn’t knock before it enters.

      —Susan Sontag, Illness as Metaphor

      We tend to think of cancer as a “modern” illness because its metaphors are so modern. It is a disease of overproduction, of fulminant growth—growth unstoppable, growth tipped into the abyss of no control. Modern biology encourages us to imagine the cell as a molecular machine. Cancer is that machine unable to quench its initial command (to grow) and thus transformed into an indestructible, self-propelled automaton.

      The notion of cancer as an affliction that belongs paradigmatically to the twentieth century is reminiscent, as Susan Sontag argued so powerfully in her book Illness as Metaphor, of another disease once considered emblematic of another era: tuberculosis in the nineteenth century. Both diseases, as Sontag pointedly noted, were similarly “obscene—in the original meaning of that word: ill-omened, abominable, repugnant to the senses.” Both drain vitality; both stretch out the encounter with death; in both cases, dying, even more than death, defines the illness.

      But despite such parallels, tuberculosis belongs to another century. TB (or consumption) was Victorian romanticism brought to its pathological extreme—febrile, unrelenting, breathless, and obsessive. It was a disease of poets: John Keats involuting silently⁹⁹ toward death in a small room overlooking the Spanish Steps in Rome, or Byron, an obsessive romantic, who fantasized about dying of the disease to impress his mistresses. “Death and disease are often beautiful,¹⁰⁰ like . . . the hectic glow of consumption,” Thoreau wrote in 1852. In Thomas Mann’s The Magic Mountain, this “hectic glow” releases a feverish creative force in its victims—a clarifying, edifying, cathartic force that, too, appears to be charged with the essence of its era.

      Cancer, in contrast, is riddled with more contemporary images. The cancer cell is a desperate individualist, “in every possible sense, a nonconformist,”¹⁰¹ as the surgeon-writer Sherwin Nuland wrote. The word metastasis, used to describe the migration of cancer from one site to another, is a curious mix of meta and stasis—“beyond stillness” in Latin—an unmoored, partially unstable state that captures the peculiar instability of modernity. If consumption once killed its victims by pathological evisceration (the tuberculosis bacillus gradually hollows out the lung), then cancer asphyxiates us by filling bodies with too many cells; it is consumption in its alternate meaning—the pathology of excess. Cancer is an expansionist disease; it invades through tissues, sets up colonies in hostile landscapes, seeking “sanctuary” in one organ and then immigrating to another. It lives desperately, inventively, fiercely, territorially, cannily, and defensively—at times, as if teaching us how to survive. To confront cancer is to encounter a parallel species, one perhaps more adapted to survival than even we are.

      This image—of cancer as our desperate, malevolent, contemporary doppelgänger—is so haunting because it is at least partly true. A cancer cell is an astonishing perversion of the normal cell. Cancer is a phenomenally successful invader and colonizer in part because it exploits the very features that make us successful as a species or as an organism.

      Like the normal cell, the cancer cell relies on growth in the most basic, elemental sense: the division of one cell to form two. In normal tissues, this process is exquisitely regulated, such that growth is stimulated by specific signals and arrested by other signals. In cancer, unbridled growth gives rise to generation upon generation of cells. Biologists use the term clone to describe cells that share a common genetic ancestor. Cancer, we now know, is a clonal disease. Nearly every known cancer originates from one ancestral cell that, having acquired the capacity of limitless cell division and survival, gives rise to limitless numbers of descendants—Virchow’s omnis cellula e cellula e cellula repeated ad infinitum.

      But cancer is not simply a clonal disease; it is a clonally evolving disease. If growth occurred without evolution, cancer cells would not be imbued with their potent capacity to invade, survive, and metastasize. Every generation of cancer cells creates a small number of cells that is genetically different from its parents. When a chemotherapeutic drug or the immune system attacks cancer, mutant clones that can resist the attack grow out. The fittest cancer cell survives. This mirthless, relentless cycle of mutation, selection, and overgrowth generates cells that are more and more adapted to survival and growth. In some cases, the mutations speed up the acquisition of other mutations. The genetic instability, like a perfect madness, only provides more impetus to generate mutant clones. Cancer thus exploits the fundamental logic of evolution unlike any other illness. If we, as a species, are the ultimate product of Darwinian selection, then so, too, is this incredible disease that lurks inside us.

      Such metaphorical seductions can carry us away, but they are unavoidable with a subject like cancer. In writing this book, I started off by imagining my project as a “history” of cancer. But it felt, inescapably, as if I were writing not about something but about someone. My subject daily morphed into something that resembled an individual—an enigmatic, if somewhat deranged, image in a mirror. This was not so much a medical history of an illness, but something more personal, more visceral: its biography.

      So to begin again, for every biographer must confront the birth of his subject: Where was cancer “born”? How old is cancer? Who was the first to record it as an illness?

      In 1862, Edwin Smith—an unusual character¹⁰²: part scholar and part huckster, an antique forger and self-made Egyptologist—bought (or, some say, stole) a fifteen-foot-long papyrus from an antiques seller in Luxor in Egypt. The papyrus was in dreadful condition, with crumbling, yellow pages filled with cursive Egyptian script. It is now thought to have been written in the seventeenth century BC, a transcription of a manuscript dating back to 2500 BC. The copier—a plagiarist in a terrible hurry—had made errors as he had scribbled, often noting corrections in red ink in the margins.

      Translated in 1930, the papyrus is now thought to contain the collected teachings of Imhotep, a great Egyptian physician who lived around 2625 BC. Imhotep, among the few nonroyal Egyptians known to us from the Old Kingdom, was a Renaissance man at the center of a sweeping Egyptian renaissance. As a vizier in the court of King Djozer, he dabbled in neurosurgery, tried his hand at architecture, and made early forays into astrology and astronomy. Even the Greeks, encountering the fierce, hot blast of his intellect as they marched through Egypt centuries later, cast him as an ancient magician and fused him to their own medical god, Asclepius.

      But the surprising feature of the Smith papyrus is not magic and religion but the absence of magic and religion. In a world immersed in spells, incantations, and charms, Imhotep wrote about broken bones and dislocated vertebrae with a detached, СКАЧАТЬ