The Emperor of All Maladies: A Biography of Cancer (29 page)

Sorenson’s life had turned upside down. “I want to beat it to the end,” she had told me at first. We had tried. Through the early fall, we blasted her pancreas with radiation to kill the tumor cells, then followed with chemotherapy, using the drug 5-fluorouracil. The tumor had grown right through all the treatments. In the winter, we had switched to a new drug called gemcitabine, or Gemzar. The tumor cells had shrugged the new drug off—instead mockingly sending a shower of painful metastases into her liver. At times, it felt as if we would have been better off with no drugs at all.

Sorenson was at the clinic that morning to see if we could offer anything else. She wore white pants and a white shirt. Her paper-thin skin was marked with dry lines. She may have been crying, but her face was a cipher that I could not read.

“She will try anything, anything,” her husband pleaded. “She is stronger than she looks.”

But strong or not, there was nothing left to try. I stared down at my feet, unable to confront the obvious questions. The attending physician shifted uncomfortably in his chair.

Beatrice finally broke the awkward silence. “I’m sorry.” She shrugged her shoulders and looked vacantly past us. “I know we have reached an end.”

We hung our heads, ashamed. It was, I suspected, not the first time that a patient had consoled a doctor about the ineffectuality of his discipline.

Two lumps seen on two different mornings. Two vastly different incarnations of cancer: one almost certainly curable, the second, an inevitable spi
ral into death. It felt—nearly twenty-five hundred years after Hippocrates had naively coined the overarching term
karkinos
—that modern oncology was hardly any more sophisticated in its taxonomy of cancer. Orman’s lymphoma and Sorenson’s pancreatic cancer were both, of course, “cancers,” malignant proliferations of cells. But the diseases could not have been further apart in their trajectories and personalities. Even referring to them by the same name,
cancer
, felt like some sort of medical anachronism, like the medieval habit of using
apoplexy
to describe anything from a stroke to a hemorrhage to a seizure. Like Hippocrates, it was as if we, too, had naively lumped the lumps.

But naive or not, it was this lumping—this emphatic, unshakable faith in the underlying
singularity
of cancer more than its pluralities—that galvanized the Laskerites in the 1960s. Oncology was on a quest for cohesive truths—a “universal cure,” as Farber put it in 1962. And if the oncologists of the 1960s imagined a common cure for all forms of cancer, it was because they imagined a common disease called cancer. Curing one form, the belief ran, would inevitably lead to the cure of another, and so forth like a chain reaction, until the whole malignant edifice had crumbled like a set of dominoes.

That assumption—that a monolithic hammer would eventually demolish a monolithic disease—surcharged physicians, scientists, and cancer lobbyists with vitality and energy. For the Laskerites, it was an organizing principle, a matter of faith, the only certain beacon toward which they all gravitated. Indeed, the
political
consolidation of cancer that the Laskerites sought in Washington (a single institute, a single source of funds, led by a single physician or scientist) relied on a deeper notion of a
medical
consolidation of cancer into a single disease, a monolith, a single, central narrative. Without this grand, embracing narrative, neither Mary Lasker nor Sidney Farber could have envisioned a systematic, targeted war.

The illness that had brought Ben Orman to the clinic late that evening, Hodgkin’s lymphoma, was itself announced late to the world of cancer. Its discoverer, Thomas Hodgkin, was a thin, short, nineteenth-century English anatomist with a spadelike beard and an astonishingly curved nose—a character who might have walked out of an Edward Lear poem.
Hodgkin was born in 1798 to a Quaker family
in Pentonville, a small hamlet outside London. A precocious child, he grew quickly into an even
more precocious young man, whose interests loped freely from geology to mathematics to chemistry. He apprenticed briefly as a geologist, then as an apothecary, and finally graduated from the University of Edinburgh with a degree in medicine.

A chance event enticed Hodgkin into the world of pathological anatomy and led him toward the disease that would bear his name. In 1825, a struggle within the faculty of St. Thomas’ and Guy’s hospital in London broke up the venerable institution into two bickering halves: Guy’s hospital and its new rival, St. Thomas’. This divorce, like many marital spats, was almost immediately followed by a vicious argument over the partition of property. The “property” here was a macabre ensemble—the precious anatomical collection of the hospital: brains, hearts, stomachs, and skeletons in pickling jars of formalin that had been hoarded for use as teaching tools for the hospital’s medical students. St. Thomas’ hospital refused to part with its precious specimens, so Guy’s scrambled to cobble together its own anatomical museum. Hodgkin had just returned from his second visit to Paris, where he had learned to prepare and dissect cadaveric specimens. He was promptly recruited to collect specimens for Guy’s new museum. The job’s most inventive academic perk, perhaps, was his new title: the Curator of the Museum and the Inspector of the Dead.

Hodgkin proved to be an extraordinary Inspector of the Dead, a compulsive anatomical curator who hoarded hundreds of samples within a few years. But collecting specimens was a rather mundane task; Hodgkin’s particular genius lay in
organizing
them. He became a librarian as much as a pathologist; he devised his own systematics for pathology. The original building that housed his collection has been destroyed. But the new museum, where Hodgkin’s original specimens are still on display, is a strange marvel. A four-chambered atrium located deep inside a larger building, it is an enormous walk-in casket-of-wonders constructed of wrought iron and glass. You enter a door and ascend a staircase, then find yourself on the top floor of a series of galleries that cascade downward. Along every wall are rows of formalin-filled jars: lungs in one gallery, hearts in another, brains, kidneys, bones, and so forth. This method of organizing pathological anatomy—by organ system rather than by date or disease—was a revelation. By thus “inhabiting” the body conceptually—by climbing in and out of the body at will, often noting the correlations between organs and systems—Hodgkin found that he could recognize patterns within patterns instinctually, sometimes without even consciously registering them.

In the early winter of 1832, Hodgkin announced that he had collected
a series of cadavers, mostly of young men
, who possessed a strange systemic disease. The illness was characterized, as he put it, by “a peculiar enlargement of lymph glands.” To the undiscerning eye, this enlargement could easily have been from tuberculosis or syphilis—the more common sources of glandular swelling at that time. But Hodgkin was convinced that he had encountered an entirely new disease, an unknown pathology unique to these young men. He wrote up the case of seven such cadavers and had his paper, “On Some Morbid Appearances of the Absorbent Glands and Spleen,” presented to the Medical and Chirurgical Society.

The story of a compulsive young doctor putting old swellings into new pathological bottles was received without much enthusiasm. Only eight members of the society reportedly attended the lecture. They filed out afterward in silence, not even bothering to record their names on the dusty attendance roster.

Hodgkin, too, was a little embarrassed by his discovery. “
A pathological paper may perhaps be thought
of little value if unaccompanied by suggestions designed to assist in the treatment, either curative or palliative,” he wrote. Merely describing an illness, without offering any therapeutic suggestions, seemed like an empty academic exercise to him, a form of intellectual frittering. Soon after publishing his paper, he began to drift away from medicine altogether.
In 1837, after a rather vicious political spat
with his superiors, he resigned his post at Guy’s. He had a brief stint at St. Thomas’ hospital as its curator—a rebound affair that was doomed to fail. In 1844, he gave up his academic practice altogether. His anatomical studies slowly came to a halt.

In 1898, some thirty years after Hodgkin’s death
, an Austrian pathologist, Carl Sternberg, was looking through a microscope at a patient’s glands when he found a peculiar series of cells staring back at him: giant, disorganized cells with cleaved, bilobed nuclei—“owl’s eyes,” as he described them, glaring sullenly out from the forests of lymph. Hodgkin’s anatomy had reached its final cellular resolution. These owl’s-eye cells were
malignant
lymphocytes, lymph cells that had turned cancerous. Hodgkin’s disease was a cancer of the lymph glands—a lymphoma.

Hodgkin may have been disappointed by what he thought was only a descriptive study of his disease. But he had underestimated the value of
careful observation—by compulsively studying anatomy alone, he had stumbled upon the most critical revelation about this form of lymphoma: Hodgkin’s disease had a peculiar propensity of infiltrating lymph nodes
locally
one by one. Other cancers could be more unpredictable—
more “capricious,” as one oncologist put it
. Lung cancer, for instance, might start as a spicular nodule in the lung, then unmoor itself and ambulate unexpectedly into the brain. Pancreatic cancer was notoriously known to send sprays of malignant cells into faraway sites such as the bones and the liver. But Hodgkin’s—an anatomist’s discovery—was anatomically deferential: it moved, as if with a measured, ordered pace, from one contiguous node to another—from gland to gland and from region to region.

It was this propensity to spread
locally
from one node to the next that poised Hodgkin’s uniquely in the history of cancer. Hodgkin’s disease was yet another hybrid among malignant diseases. If Farber’s leukemia had occupied the hazy border between liquid and solid tumors, then Hodgkin’s disease inhabited yet another strange borderland: a local disease on the verge of transforming into a systemic one—Halsted’s vision of cancer on its way to becoming Galen’s.