The Emperor of All Maladies: A Biography of Cancer Read Online Free PDF Page B

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 some
thing
but about some
one
. 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 character: 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, sterile scientific vocabulary, as if he were writing a modern surgical textbook. The forty-eight cases in the papyrus—fractures of the hand, gaping abscesses of the skin, or shattered skull bones—are treated as medical conditions rather than occult phenomena, each with its own anatomical glossary, diagnosis, summary, and prognosis.
    And it is under these clarifying headlamps of an ancient surgeon that cancer first emerges as a distinct disease. Describing case forty-five, Imhotep advises, “If you examine [a case] having bulging masses on [the] breast and you find that they have spread over his breast; if you place your hand upon [the] breast [and] find them to be cool, there being no fever at all therein when your hand feels him; they have no granulations, contain no fluid,