Click on the link at the bottom for further information about The Ministry Model and the material that we will explore together …
For further information, click HERE.
Click on the link at the bottom for further information about The Ministry Model and the material that we will explore together …
For further information, click HERE.
… or must it enlist the heart?
Snow was on the ground. Old Hark was standing out to the side of his cabin, scattering handfuls of cracked corn and scratch to the birds all around him. Now and then he sniffed the air. It smelled like more snow was coming.
A solitary figure bundled in a great bearskin coat trudged along the forest path to the old man’s cabin.
He stopped in front of the cabin and shifted a large ledger out from under his arm. The burly figure opened it to a page, looked at the cabin and then to the page again, and walked out toward the old man.
“Good day,” said the stranger.
“Howdy,” said Old Hark, brushing his hand on his coat. “Your face is easy, but I can’t recollect the name. We met?”
“Not in any formal way,” said the stranger. “But I’ve passed this way before. Maybe you’ve caught a glimpse of me. I’m Death.”
The old man straightened his back and held the feed bag a little closer to his chest.
“Death, eh? Well, you got the wrong place.”
“No,” Death said, opening the ledger. “You’re Old Hark, aren’t you?”
“Maybe, and maybe not,” said Old Hark, turning his back and scattering a handful of feed.
“Well, certainly you are,” Death said, taking a pen from his pocket. “It’s all right here in the book.”
“Don’t give a dang what’s in the book,” said Old Hark. “I ain’t going. Come again in the spring.”
Death sighed, and took the cap off the pen. “How tiresome, ” he said. “Everyone tries to put it off, and all it amounts to is making a little check mark after your name. He poised the pen above the book.
Old Hark turned. “I ain’t afraid of you.”
“No?” Death said, looking up.
“Come again in the spring. I won’t hinder you none then. But you see all these birds? Come winter time, they depend on me to feed them. They naturally ought to fly south in the fall but don’t, reason that I been feeding ’em all winter since I was no bigger ‘an a skip bug. They’d die if I was gone – they ain’t real wintering birds. But you come back in the spring, and they’ll know I won’t be here next winter and have enough sense to go south.”
“Oh, that wouldn’t do at all,” Death said. “The book is all made up in advance. Why, rescheduling you into the springtime would take a good week’s work. Erasures would have to be made, new entries, changes of address, causes of departure . . . very complicated, no trifling matter at all, I assure you. No, it really won’t do at all.”
“Don’t know about that,” Old Hark said, “but I ain’t going.” He took a few steps away. Death followed him.
“See here,” Death said persuasively, “you’re really getting quite old and feeble, you know, quite past the age I usually visit people.”
“Ain’t going,” Old Hark said. Death saw that the old man was resolute, not at all in the correct state of mind for the business at hand. He considered that he might cause a tree to fall on the old man’s head. He consulted his book. Next to Old Hark’s name was written: “Means of departure: Quiet, gentle, peaceful.” So violence was out of the question.
Death turned a page in the book and studied the entries. “Now, look,” Death said. “I can give you another day. I can fit you in for tomorrow, but then you’ll have to come quietly, gently, and peacefully. Even so I’ll have to stay up half the night juggling these entries, but I’ll do it as a special favor. “
“Not tomorrow, either,” said Old Hark. “Come again in the spring.”
Death was getting impatient. “You’re so old now and so feeble and your memory is so shabby you won’t even remember me by then, and we’ll have to go through all this again. “
“There ain’t nothing wrong with my memory.”
“Isn’t there, now?”
Death smiled. “If you think so, let me make you a wager.”
“Let’s hear it,” said Old Hark.
“It’s this,” said Death. “Just so I can be sure you’ll remember me next spring, let’s make a test. If I can ask you a question about something that happened in your life and you can’t remember, then you must come with me tomorrow.
“Agreed,” said Old Hark. “Ask away.”
Death closed the ledger and put his pen away. He smiled again and asked, “On your second birthday, your mother baked up a special treat. What was it?” Then Death turned and walked off toward the forest path.
“Good day, ” he called. “I’ll see you tomorrow.”
It began to snow. Old Hark returned to his cabin, kicked the snow off his boots and went inside. He put on some coffee to perking and sat back in his rocking chair. He sat there for hours, remembering many things, many smells, and tastes, and sounds, and people, but of course he couldn’t remember what his mother baked special on his second birthday.
Some birds chirped outside the door. The snow had stopped. Old Hark got a handful of feed, opened the door and chucked it out. The birds made a fuss of noise, but just as Old Hark closed the door, he heard one chirp above and unlike any of the others, a very strange chirp.
It sounded exactly as if one of the birds had said, “Plumcakes. “
It snowed most of the night. Next morning, Old Hark made his rounds to the bird feeders and scattered plenty of feed. He got his shovel and a ladder out then and climbed up to shove some of the snow off the roof of the cabin.
While he was up there, Death came around with his ledger under his arm. He stood next to the ladder and shouted out a cheery “Good morning!” Old Hark looked down. He put a finger to one of his nostrils, blew his nose
in the snow, and then said, “Plumcakes,” and turned back to his work.
That was a surprise for Death. He had spent half the night working on the book. He was tired, and now he was angry and was tempted to pull the ladder out from the old man. But he remembered the words in the book, “Quiet, gentle, peaceful,” and he got hold of himself.
“Very good,” Death said. “I don’t think there’s one man in a thousand who could have remembered that far back. But of course it might have been luck. Perhaps you just made a guess at it.”
“l didn’t guess,” Old Hark said.
“But you couldn’t do it again,” Death said.
“I reckon I could.”
“Then just to be absolutely positive it wasn’t a guess,
let’s try it one more time.”
“One more time,” Hark agreed. “Ask away.”
“Very well,” said Death. “The question is this: On your first birthday, your mother picked some wild flowers and put them in your crib with you. What kind of flowers were they?” And he walked away up the forest path.
After clearing the roof, Old Hark took his shovel to work on some drift that was leaning onto his fence. Now and then he threw some feed out of his pocket to the birds that followed him about. They were singing and chirping around the fence, and as he finished up and headed back to the cabin, Old Hark heard in back of him an unusual chirp, loud and clear.
It sounded exactly as if one of the birds had said, “Buttercups. “
Next morning when Death came around, Old Hark was under his lean-to splitting wood.
“Good morning,” Death said lightly, although actually he was feeling grouchy because he had been up half the night fixing his book to fit the old man into a new place.
Old Hark spit on his hands and took a fresh grip on his splitting maul. “Buttercups,” he said, and swung the maul.
Death swallowed hard to keep from crying out. It was impossible. He would have liked to have Old Hark’s wedge jump up and crack his skull, but of course that wasn’t in the book. Slowly, Death got control of himself.
“Amazing,” Death said. “I can scarcely believe it. What a memory. I’m astounded, really I am. You don’t suppose you could possibly do that again? I hardly believe you could.”
Old Hark took a breath and leaned on the butt of his splitting maul. “I reckon I just might,” he said. “But supposing I do? Then you got to let me be all the way into next spring.”
“Agreed,” Death said. “Agreed. Then it’s a wager. One more question. If you can answer, then I won’t come again until next spring. If you can’t answer … well, then … Death made a check mark in the air.
“Ask away,” said Old Hark.
“The question is this,” said Death. “On the day you were born, when the midwife held you up in the air, what were the first words your father said?” Death cocked his head, smiled, and walked away.
After splitting the wood, Old Hark filled all the bird feeders and broke up the ice in the cistern. All the while he was paying close attention to the birds which always fluttered nearby, but he heard nothing out of the ordinary in their chirping. Then he went inside. He stoked up the fire, made coffee, took a nap and puttered with some harness. But every now and then he opened the door and threw out some feed, and listened carefully. just ordinary singing and chirping. He was feeling especially tired and went to bed early with no answer to the question.
Now the reason the birds could tell him nothing was this. Old Hark had been born in that very cabin, and generations of birds had known him and everything about him, and because of their love for the old man they had passed on many memories of him, and so they knew the answers to the other questions.
But on the day the old man was born, in the very bed in which he now lay, the window was closed and the curtain was drawn, so the birds knew nothing of what his father’s first words were upon seeing his newborn son. They could not help him.
Old Hark woke late, which wasn’t like him. His bones hurt, and he felt tired. It took him much longer than usual to get his chores done, and the wind seemed to chill him to the heart. Still, he listened carefully to the birds. They said nothing special. Early in the afternoon, without coffee or even a bite to cat, he undressed and got back into bed. He had never felt quite so tired in his life. Through his half-closed eyes, he watched the birds on his windowsill hopping about, but he was too tired even to crack the window a bit so he could hear them sing. Now and then he fell asleep.
Death knocked on the door in the late afternoon.
“Come in,” Old Hark whispered.
“Hello,” Death said, opening the door. Then he saw Old Hark laid out in the bed and understood at once that the old man had no answer to the question.
“Well, well,” Death said, taking a chair next to the old man’s bed and opening his book on his lap. “Now isn’t that’s more like it, yes indeed. Ha, ha. You old rascal, I’ve been up half the night again on your account, you know, but it’s quite all right now, yes indeed. It’s good to see you lying there so quiet and gentle and …” Death glanced at the book. “ … so peaceful.”
Old Hark paid him no attention. He was watching the birds playing on the windowsill.
“Now,” said Death, taking out his pen. “I’ve managed to fit you in for sunset. Oh, you should appreciate that. It’s a choice spot, really. Very appropriate, very … fitting to the occasion, you know. Daylight ending, the sun going down, darkness coming on…. Ah, yes, a choice spot – we usually reserve it for poets.” Death ran a finger down the page. “Here we are,” he said cheerfully. He took the cap off his pen and moved to make a check mark after Old Hark’s name. Then he paused.
“0h, yes,” Death said. “It’s a formality, but I must ask you so as to make it all strictly legal. As I recall then, the question was this: On the day you were born, when the midwife held you up in the air, what were the first words your father said?”
But Old Hark had not even been listening. He was looking at the birds, and he said to Death, “Open the window.”
Death thrust his head forward and clutched at his pen.
“What did you say?”
“Let the birds sing.”
“NOOOOoooooooo!” Death bellowed. He flung his arms about hysterically, splattering ink, then screamed out again and fell off his chair in a fit. He got up in a rage and pitched his book through the window.
Birds flew in, singing. Death grabbed a handful of his coat front and threw himself out the window and went stumbling up the forest path.
Old Hark leaped out of bed and watched Death disappear into the forest. He was feeling much better. He put on a wool shirt and got some coffee to perking, then cut himself some cheese and bread. In a short time he figured out what all the commotion had been about.
Of course what it was, is this: Death had lost the wager and must leave Old Hark to live until spring, for his father’s first words on seeing his newborn son had been “Open the window! Let the birds sing!”
Until one is committed there is hesitancy, the chance to draw back, always ineffectiveness. Concerning all acts of initiative and creation, there is one elementary truth, the ignorance of which kills countless ideas and splendid intentions: that the moment one definitely commits oneself, then Providence moves too. All sorts of things begin to occur to help one that would never otherwise have occurred. A whole stream of events issues form the decision, raising in one’s favor all manner of unforeseen incidents and meetings and material assistance, which no person could have dreamt would have come their way.
If Margaret Mead, the American anthropologist, and the German poet, Goethe had been able to collaborate, they might well have written this:
Whatever you can do, or dream you can,
Begin it together with a small group of
Bold, thoughtful, committed citizens.
Never doubt that the genius, power and
Magic of such a group can change the world.
In fact, it is the only thing that ever has.
As someone who has been painstaking in my desire to avoid labels and category classifications, since I believe they contribute to “the illusion of separation,” for professional reasons I have nevertheless decided to temporarily relent and come up with something to call myself. The moniker I have finally settled upon is: transpersonal neurobiologist. Turns out I’m the only such creature currently on planet earth. Do a Google search (You’ll have to disregard my colleague Jamal Granick if your search turns him up. When I contacted Jamal about the label, he had no idea he was one).
So what is a Transpersonal Neurobiologist? Very simply it’s someone who studies both Transpersonal Psychology and Neurobiology and tries to weave them together into some sort of coherent, meaningful, useful body of knowledge.
Transpersonal Psychology, while first introduced in the early 1900s in a lecture by William James at Harvard, evolved mostly in the late 1960s as a natural progression of the research findings of Abraham Maslow, who was primarily interested in peak human experiences. Here’s what Wikipedia has to say about the field:
Transpersonal psychology is a sub-field or “school” of psychology that integrates the spiritual and transcendent aspects of the human experience with the framework of modern psychology. It is also possible to define it as a “spiritual psychology.” The transpersonal is defined as “experiences in which the sense of identity or self extends beyond (trans) the individual or personal to encompass wider aspects of humankind, life, psyche or cosmos.” It has also been defined as “development beyond conventional, personal or individual levels.”
Issues considered by transpersonal psychology include spiritual self-development, self beyond the ego, peak experiences, mystical experiences, systemic trance, spiritual crises, spiritual evolution, religious conversion, altered states of consciousness, spiritual practices, and other sublime and/or unusually expanded experiences of living. The discipline attempts to describe and integrate spiritual experience within modern psychological theory and to formulate new theory to encompass such experience.
Neurobiology, on the other hand, is a pretty mainstream, rigorous science. Here’s how MIT scientists thinks about it:
Neurobiology is geared towards understanding how the remarkable diversity in neuronal cell types and their connections are established and how changes in neurons and their connections underlie learning and thinking. A number of groups are identifying and characterizing genes involved in specifying neuronal cell fate in vertebrates and invertebrates. Others are analyzing molecules involved in guiding axons to their correct targets. Additionally, efforts are underway to understand the physiological and biochemical changes in neurons that are involved in learning and memory, and the changes underlying neuropathology.
When I put the two together, what I find myself most interested in is how structural and developmental vulnerabilities of the human body and brain operate in ways that prevent us from attaining our highest human potential. It’s kind of like left brain and right brain attempting to weave both study categories into some sort of a coherent whole. Out of this attempt will hopefully come insight into how the structural vulnerabilities of the body and brain end up contributing to much of the pain, suffering and chaos in the world. Few of us appear to be as fully “operational” as we might be and a transpersonal neurobiologist would argue that it’s not our fault – we’re not to blame. But we’re still on the hook for doing what we can to make things better for ourselves and everyone else. It’s called being an imperfect human being in an imperfect world. And it’s good to try and do our own work with as much kindness, understanding and compassion as we can muster.
Next time you hear the terms transpersonal neurobiologist think, “Oh, that’s someone who studies how structural and developmental vulnerabilities of the body and brain contribute to human suffering. And then tries to do something to address them.”
There are numerous emotional and physical disorders that have been linked to stress including depression, anxiety, heart attacks, stroke, hypertension, immune system disturbances that increase susceptibility to infections, a host of viral linked disorders ranging from the common cold and herpes to AIDS and certain cancers, as well as autoimmune diseases like rheumatoid arthritis and multiple sclerosis. In addition stress can have direct effects on the skin (rashes, hives, atopic dermatitis, the gastrointestinal system (GERD, peptic ulcer, irritable bowel syndrome, ulcerative colitis) and can contribute to insomnia and degenerative neurological disorders like Parkinson’s disease. In fact, it’s hard to think of any disease in which stress cannot play an aggravating role or any part of the body that is not affected. This list will undoubtedly grow as the extensive ramifications of stress are increasingly being appreciated.
1. Frequent headaches, jaw clenching or pain
2. Gritting, grinding teeth
3. Stuttering or stammering
4. Tremors, trembling of lips, hands
5. Neck ache, back pain, muscle spasms
6. Light-headedness, faintness, dizziness
7. Ringing, buzzing or “popping sounds
8. Frequent blushing, sweating
9. Cold or sweaty hands, feet
10. Dry mouth, problems swallowing
11. Frequent colds, infections, herpes sores
12. Rashes, itching, hives, “goose bumps”
13. Unexplained or frequent “allergy” attacks
14. Heartburn, stomach pain, nausea
15. Excess belching, flatulence
16. Constipation, diarrhea, loss of control
17. Difficulty breathing, frequent sighing
18. Sudden attacks of life threatening panic
19. Chest pain, palpitations, rapid pulse
20. Frequent urination
21. Diminished sexual desire or performance
22. Excess anxiety, worry, guilt, nervousness
23. Increased anger, frustration, hostility
24. Depression, frequent or wild mood swings
25. Increased or decreased appetite
26. Insomnia, nightmares, disturbing dreams
27. Difficulty concentrating, racing thoughts
28. Trouble learning new information
29. Forgetfulness, disorganization, confusion
30. Difficulty in making decisions
31. Feeling overloaded or overwhelmed
32. Frequent crying spells or suicidal thoughts
33. Feelings of loneliness or worthlessness
34. Little interest in appearance, punctuality
35. Nervous habits, fidgeting, feet tapping
36. Increased frustration, irritability, edginess
37. Overreaction to petty annoyances
38. Increased number of minor accidents
39. Obsessive or compulsive behavior
40. Reduced work efficiency or productivity
41. Lies or excuses to cover up poor work
42. Rapid or mumbled speech
43. Excessive defensiveness or suspiciousness
44. Problems in communication, sharing
45. Social withdrawal and isolation
46. Constant tiredness, weakness, fatigue
47. Frequent use of over-the-counter drugs
48. Weight gain or loss without diet
49. Increased smoking, alcohol or drug use
50. Excessive gambling or impulse buying
See more at: http://www.stress.org/stress-effects/
by Sherwin Nuland
The Malevolence of Cancer As early as the days of Hippocrates and even before, the ancient Greek physicians had a clear understanding of the ways in which a malignant growth so often pursues its inexorable determination to destroy life. They gave a very specific name to the hard swellings and ulcerations they so commonly saw in the breast or protruding from the rectum or vagina; they based that name on the evidence of their eyes and fingers. To distinguish them from ordinary swellings, which they called oncos, they used the term karkinos, or "crab," derived, interestingly enough, from an Indo-European root meaning "hard." Oma being a suffix referring to "tumor," karkinoma was used to designate a tumorous growth that was malignant. Centuries later, the Latin word for "crab," cancer, came into common usage. Oncos, meantime, came to be applied to tumors of any kind, which is why we call a cancer specialist an oncologist. Karkinoma was said to be due to the stagnation within the body of an excess of a hypothetical fluid called black bile, or melan cholos (frommelas, "black" and chole, "bile"). Since the Greeks did not dissect the human body, the cancers they saw were ulcerated malignancies of the breast or skin, and those of the rectum and female genital tract which had grown so large that they protruded through body openings. Accordingly, the fanciful explanation was supported by the common observation that cancer patients were indeed melancholy, and for obvious good reason. The origin of karkinos and karkinoma was based, as were so many Greek medical terms, on simple observation and touch. As Galen, the foremost interpreter and codifier of Greek medicine, put it in the second century a.d., the appearance of this creeping, infiltrating stony mass, ulcerated at its center, which he so often saw in the breasts of women, is "just like a crab's legs extending outward from every part of its body." And it is not only the legs that are digging farther and deeper into the flesh of its victim — the center, too, is eroding its way directly through her. The likeness is to an insidious, groping parasite, attached by sharp-clawed tentacles to the decaying surface of its imperiled prey. The clawing extremities ceaselessly extend the periphery of their malign grip, while the loathsome core of the burrowing beast eats silently away at life, able to digest only what it has first decomposed. The process is noiseless; it has no recognizable instant of beginning and it ends only when the despoiler has consumed the final remnants of its host's vital forces. Until after the middle of the nineteenth century, cancer was thought to do its killing by stealth. Its lurking force lay under the cover of hushed darkness, its first sting felt only when murderous infiltration had strangled too much normal tissue to restore the overwhelmed defenses of its host. The perpetrator regurgitated as malignant gangrene the life it had noiselessly chewed up. We know better now, because we have come to recognize a different personality when our old enemy is seen through the microscope of contemporary science. Cancer, far from being a clandestine foe, is in fact berserk with the malicious exuberance of killing. The disease pursues a continuous, uninhibited, circumferential, barn-burning expedition of destructiveness, in which it heeds no rules, follows no commands, and explodes all resistance in a homicidal riot of devastation. Its cells behave like the members of a barbarian horde run amok — leaderless and undirected, but with a single- minded purpose: to plunder everything within reach. This is what medical scientists mean when they use the word autonomy. The form and rate of multiplication of the murderous cells violate every rule of decorum within the living animal whose vital nutrients nourish it only to be destroyed by this enlarging atrocity that has sprung newborn from its own protoplasm. In this sense, cancer is not a parasite. Galen was wrong to call it praeter naturam, "outside of nature." Its first cells are the bastard offspring of unsuspecting parents who ultimately reject them because they are ugly, deformed, and unruly. In the community of living tissues, the uncontrolled mob of misfits that is cancer behaves like a gang of perpetually wilding adolescents. They are the juvenile delinquents of cellular society. Cancer is best viewed as a disease of altered maturation; it is the result of a multistage process of growth and development having gone awry. Under ordinary conditions, normal cells are constantly being replenished as they die, not only by the reproduction of their younger survivors but also by an actively reproducing group of progenitors called stem cells. Stem cells are very immature forms with enormous potential to create new tissue. In order for the progeny of the stem cells to progress to normal maturity, they must pass through a series of steps. As they get closer to full maturity, they lose their ability to proliferate rapidly in proportion to the increase in their ability to perform the functions for which they are intended as grown-ups. A fully mature cell of the intestinal lining, for example, absorbs nutriments from the cavity of the gut a lot more efficiently than it reproduces; a fully mature thyroid cell is at its best when it secretes hormone, but it is much less inclined to reproduce than it was while younger. The analogy with the social behavior of a whole organism, like us, is inescapable. A tumor cell is one that has somewhere along the way been stopped in its capacity to differentiate, which is the term used by scientists for the process by which cells go through the steps that enable them to reach healthy adulthood. The clump of immature abnormal cells that results from the blocking of differentiation is called a neoplasm, derived from the Greek word for a new growth or formation. In modern times, the word neoplasm is used synonymously with tumor. Those tumors whose cells have been blocked closest to the attainment of the mature state are the least dangerous and are therefore called benign. A benign tumor has retained relatively little of its potential for uncontrolled reproduction — it is well differentiated; under the microscope, it looks a lot like the adult it was close to becoming. It grows slowly, does not invade surrounding tissues or travel to other parts of the body, is often surrounded by a distinct fibrous capsule, and almost never has the capacity to kill its host. A malignant neoplasm — what we call cancer — is a different creature entirely. Some influence or combination of influences, whether genetic, environmental, or otherwise, has acted as the triggering mechanism to interfere so early in the pathway of maturation that the progress of the cells has been stopped at a stage when they still have an infinite capacity to reproduce. Normal stem cells keep trying to produce normal offspring, but their development continues to be arrested. They do not attain a sufficient level of adulthood to do the work they were meant for or to look more than just a little like the grown-up forms they were intended to be. Cancer cells are fixed at an age where they are still too young to have learned the rules of the society in which they live. As with so many immature individuals of all living kinds, everything they do is excessive and uncoordinated with the needs or constraints of their neighbors. Being not completely grown-up, a cancer cell does not engage in some of the more complicated metabolic activities of mature nonmalignant tissue. A cancer cell of the intestine, for example, doesn't help out in digestion as its adult counterpart does; a cancer cell of the lung is uninvolved in the process of respiration; the same is true of almost all other malignancies. Malignant cells concentrate their energies on reproduction rather than in partaking in the missions a tissue must carry out in order for the life of the organism to go on. The bastard offspring of their hyperactive (albeit asexual) "fornicating" are without the resources to do anything but cause trouble and burden the hardworking community around them. Like their progenitors, they are reproductive but not productive. As individuals, they victimize a sedate, conforming society. Cancer cells do not even have the decency to die when they should. All nature recognizes that death is the final step in the process of normal maturation. Malignant cells don't reach that point — their longevity is not finite. What is true of Dr. Hayflick's fibroblasts does not apply to the cellular population of a malignant growth. Cancer cells cultivated in the laboratory exhibit an unlimited capacity to grow and generate new tumors. In the words of my research colleagues, they are "immortalized." The combination of delayed death and uncontrolled birth are malignancy's greatest violations of the natural order of things. These two factors in combination are the main reasons a cancer, unlike normal tissue, continues to enlarge throughout its lifetime. Knowing no rules, cancer is amoral. Knowing no purpose other than to destroy life, cancer is immoral. A cluster of malignant cells is a disorganized autonomous mob of maladjusted adolescents, raging against the society from which it sprang. It is a street gang intent on mayhem If we cannot help its members grow up, anything we can do to arrest them, remove them from our midst, or induce their demise — anything that accomplishes one of those aims — is praiseworthy. There comes a point at which home turf is not enoughs — offshoots of the gang take wing, invade other communities, and, emboldened by their unresisted depredations, wreak havoc on the entire commonwealth of the body. But in the end, there is no victory for cancer. When it kills its victim, it kills itself. A cancer is born with a death wish. Cancer is, in every possible sense, a nonconformist. But, unlike some nonconformist individuals about whom there is much to admire, the nonconforming malignant cell has not a single redeeming feature. It does everything it can not only to disassociate itself from but even to destroy the community of cells that has given it life. As though to make certain that it is not confused with the conformist adult members of its original family, the cancer cell retains an immature and different appearance and even shape. This characteristic of malignant growth is called anaplasia, from the Greek term meaning "without form." The anaplastic cell gives birth to anaplastic offspring. But try as it may, only an unusual cancer is composed of cells that have changed their appearance completely enough to become unrecognizable as members of their own original tribe. Except in extreme cases, a careful look down the barrel of a microscope at a bit of the diseased tissue will suffice to reveal its ancestral lineage. Thus, a bowel cancer can be identified as what it is because it still has some characteristic features that betray its intestinal origin. Even far away from home, as when the bloodstream has carried its cells to the liver, the cancer's face, almost no matter the degree of anaplasia, will usually give it away. Even cancer, that remorseless renegade that ran away to join the biological equivalent of Murder, Inc., retains some dimly recognizable traits of its old family and its old obligations. The twin characteristics of autonomy and anaplasia define the modern understanding of cancer. Whether they are to be thought of as "ugly, deformed, and unruly" or more academically as "anaplastic" and "autonomous," the cells of a cancer are wicked in ways far beyond what is implied by the scientific connotation of the word malignant. Malevolent, in fact, says it better, because it bears the implication of an element of ill will. The deformity and ugliness of the individual cancer cell are most manifest in the irregularities of its distorted shape. Whereas the appearance of a normal cell in normal tissue differs hardly at all from that of its normal neighbors, the forms and dimensions of the individuals in a cancer's cellular population are usually neither uniform nor orderly. They may bulge, flatten, elongate, round themselves out, or in some other way demonstrate that each is created as though with a mind of its own — it is an independent agent. Cancer is a state in which a breakdown has occurred in the communication and mutual interdependence between cells. That sequence of events noted above has taken place, in which the genetic characteristics of the malignant cell become altered, and everything else about the disease follows from that fact. Some of the environmental, lifestyle, and other causes of the alterations are known, some are being studied, and some are no doubt still unsuspected. Though chaotic in appearance and inconsistent in size, the community of malignant cells is not necessarily always anarchic. In a few forms of cancer, in fact, all individuals are found to choose a specific uniform shape that suits a shared element in their willfulness. Such malignancies exist as though to demonstrate an obstinate refusal to conform to the accustomed disharmony expected of them; their cells reproduce myriads of virtually identical selves, like so many millions upon millions of little poisonous apples, boringly similar to one another but quite different from their tissue of origin. Even the predictability of malignancy's unpredictability is unpredictable. The central structure of the cancer cell, its nucleus, is larger and more prominent than that of mature relatives and is often as misshapen as the cell itself. Its dominance over the protoplasm surrounding it is intensified by the enhanced avidity with which it takes up standard laboratory stains, a characteristic that gives it a darkened, ominous look. The evil-eye nucleus reveals its disordered independence in yet another way: Instead of dividing neatly into two symmetrical halves during the process of reproduction known as mitosis, the chromosomes (the components of the nucleus that carry the DNA) align themselves in bizarre patterns, attempting with varying degrees of success to multiply, figuratively head over heels, without any element of precision or accountability. The rate of mitosis of some cancers is so rapid that a quick look through the microscope will catch many times the number of cells in the act of trying to reproduce as are found in mature normal tissue, and every one of them seems to be doing it in its own haphazard way. Small wonder that the surviving offspring are ill-suited to their surroundings in the ordered, consistent tissue of the organs of which they were originally meant to be a part. So pugnaciously "other" are the new masses of cells, in fact, that they not only invade but also push their law-abiding grown-up neighbors out of the way as they infiltrate and preempt surrounding territory. In a word, cancer is asocial. Having escaped the constraints that govern nonmalignant cells, the newly formed tissues pursue uncontrolled and domineering relationships with their host organs and cannot be made to restrict their encroaching margins to the foci that gave them birth. Unrestrained and patternless growth enables a cancer to force its way into nearby vital structures to engulf them, prevent their functioning, and choke off their vitality. By this means, and by destroying the organs from whose stem cells they are made, the masses of cancer cells kill the gradually sickening person after feasting on the nutrients that were to have sustained him Although it begins as a microscopic phenomenon, the process of malignant growth, once properly established, inevitably continues until it can be seen with the naked eye or felt with the exploring hand. For a while, the growing mass may remain too small or confined to produce symptoms, but in time, the cancer's victim will sense that something untoward is happening to him. By that point, the malignancy may have grown so large that it is beyond cure. Particularly in certain solid organs, a cancer may reach considerable size before it makes its host aware of its presence. It was for this reason, of course, that the disease achieved its legendary reputation as a noiseless killer. A kidney, for example, may be found to harbor a perfectly huge growth when it first reveals its advanced state of disease by spilling visible blood into the urine or causing a dull ache in the flank. If an operation is done at that point, the surgeon's efforts will be defeated by the wide extent of involvement of surrounding tissues. The otherwise-symmetrical brown smoothness of the organ will be found to have been eaten away in one large area by an ugly, lobulated protrusion of coarse gray hardness that has forced its way through to the surface, invaded the adjacent fat, and drawn all nearby tissues into it, the misbegotten whole forming one great puckered grotesquerie of bunched-up aggression. Of all the diseases they treat, cancer is the one that surgeons have given the specific designation of "The Enemy." The visible structure and invasiveness of a cancer are only two of its many forms of unruliness. One of the most duplicitous of malignancy's misbehaviors is the way in which it seems to elude the defenses ordinarily mounted by the body against tissue it perceives as not belonging to it. Theoretically at least, cells that have become cancerous should be detectable as foreign or "other" by an intact immune system and then killed, much as is a virus. This actually does happen to an extent; some researchers believe that our tissues are continually making cancers, which are just as continually being destroyed by this kind of mechanism. Clinical malignancies would then develop in those rare instances when the surveillance system fails. An example of support for such a thesis is to be found in the prevalence in people with AIDS of tumors such as lymphoma and Kaposi's sarcoma. Overall, the incidence of malignancies in immunocompromised individuals is some two hundred times that found in the general population, and for Kaposi's the figure is more than twice what it is for the average tumor. One of the most promising fields of today's biomedical research is the study of tumor immunity with a view toward strengthening the body's responses to the antigens that cancers may produce. Although there have been some promising results, the target cells continue, for the most part, to outwit the scientists. Normal cells require a complex mixture of nutrients and growth factors in order to continue functioning and retain viability. Throughout all tissues of the body, they are bathed in a life-giving nutrient soup called extracellular fluid, which is constantly being restored and cleansed by exchanging substances with circulating blood. The blood's plasma, in fact, amounts to one-fifth of the body's extracellular fluid; most of the other four-fifths lies between the cells, and is called interstitial. The interstitial fluid accounts for approximately 15 percent of body weight; if you weigh 150 pounds, your tissues are soaking in 22 pints of the salty stuff. The nineteenth-century French physiologist Claude Bernard introduced the term milieu interieur to name and describe the function of this internal environment in which cells live within us. It is as though the earliest groups of prehistoric cells, when they first began to form complex organisms in the marine depths from which they drew sustenance, brought some of the sea into and around themselves so that they might continue to be nourished by it. Among the unique features of malignant tissues is their reduced dependence on the nutritional and growth factors in the extracellular fluid. Their lessened need for sustenance from the surroundings enables them to grow and invade even those areas beyond optimal supply lines. No matter that each cellular unit can get along with less, the helter-skelter increase in population soon accumulates so many malignant cells that the requirements of the aggregate tend to outstrip whatever supplies are available. As a result, a total tumor mass will often develop an increased demand for nutrition, even though each individual within it may require less than a normal amount of it. If growth is rapid enough, blood supply after a time will be insufficient to restore used-up nutrients, especially because new vessels usually do not appear rapidly enough to keep pace with the needs of the whole expanding tumor. The result is that a portion of an enlarging tumor may die, literally of malnutrition and oxygen lack. It is for this reason that cancers tend to ulcerate and bleed, sometimes producing thick, slimy deposits of necrotic tissue (from the Greek nekrosis, meaning "becoming dead") within their centers or at the periphery. Until mastectomy became a common operation less than a hundred years ago, the most dreaded complication of breast malignancy was not death but the fetid running sores it produced as a hapless woman's chest wall was digested away. This is precisely why the ancients referred to karkinoma as the "stinking death." In the late eighteenth century, Giovanni Morgagni, the author of a landmark text of pathological anatomy, said of the cancer he saw in his patients and at their autopsies that it was "a very filthy disease." Even in relatively recent times, when much more was known, malignant tumors continued to be viewed as repugnant sources of self-loathing and decay, a humiliating abomination to be concealed behind euphemisms and lies. Many are the stories of women with breast cancer who withdrew from friends, secluded themselves at home, and lived their final months as recluses, sometimes even from their own families. As recently as the period of my training, just over thirty years ago, I saw a few such women who had finally been prevailed upon to come to the clinic because their situations had become intolerable. Of the several reasons we still hesitate to utter the word cancer in the presence of a patient or family assaulted by it, the residual heritage of its odious connections is the one most difficult for our generation to expunge. Not enough that a rapidly growing cancer may so infiltrate a solid organ like the liver or kidney that insufficient tissue remains to perform the organ's functions effectively; not enough that it may obstruct a hollow structure like the intestinal tract and make adequate nourishment impossible; not enough that even a small mass of it can destroy a vital center without which life functions cannot go on, as some brain tumors do; not enough that it erodes small blood vessels or ulcerates sufficiently to result gradually in severe anemia, as it often does in the stomach or colon; not enough that its very bulk sometimes interferes with the drainage of bacteria-laden effluents and induces pneumonia and respiratory insufficiency, which are common causes of death in lung cancer; not enough that a malignancy has several ways by which it can starve its host into malnutrition — a cancer has still other ways to kill. Those just mentioned refer, after all, only to potentially lethal consequences of encroachment by the primary tumor itself, without its ever having left the organ where it first arose. These are the kinds of damage cancer does in its own neighborhood. But it has an additional way of killing that takes it out of the category of localized disease and permits it to attack a wide assortment of tissues far from its origin. That mechanism has been given the name metastasis. Meta is a Greek preposition meaning "beyond" or "away from," and stasis connotes "position" or "placing." Introduced as early as the Hippocratic writings to indicate a change away from one form of fever to another, metastasis later came to be applied specifically to migration of bits of tumor. In modern times, this one word, metastasis, has come to articulate the defining feature of malignancy — cancer is a neoplasm that has the potential to go beyond its home and travel to some other place. A metastasis is, in effect, a transplant of a sample of the primary tumor to another structure or even a distant part of the body. Cancer's ability to metastasize is both its hallmark and its most menacing characteristic. If a malignant tumor did not have the ability to travel, surgeons would be able to cure all but those that involve vital structures, which cannot be removed without compromising life. In order to travel, the tumor must erode through the wall of a blood vessel or lymph channel, and then some of its cells must become detached and pass into the flowing stream. Either individually or clumped into an embolus, the cells are then carried to some other tissue, where they implant and grow. Determined by the route of blood or lymph flow as well as other still-unclear factors, various cancers have a predilection to be deposited in certain specific organs. For example, a breast cancer is most likely to metastasize to bone marrow, lungs, liver, and, of course, the lymph nodes in the armpit, or axilla. A cancer of the prostate commonly travels to bone. Bones, in fact, along with the liver and kidney, are the most common sites for metastatic deposits, regardless of the malignancy's organ of origin. In order to take root in a distant location, tumor cells need to be hardy enough to resist destruction while on their journey. The simple mechanical dangers of traveling through the jolting circulation complicate the possibility of being killed by the host's immune system during the course of the passage. If they survive the voyage, the cells must then establish a new home and be provided a reliable source of nutrition. This means a priori that the transplanted bit of cancer cannot create a viable colony on the newly reached distant shore unless it is capable of stimulating the growth of tiny new blood vessels to supply its needs. So difficult is it to satisfy all of these requirements that very few of the migrating cells ever do manage to colonize some far-flung site. When tumor cells are experimentally injected into mice, only one-tenth of 1 percent survive beyond twenty- four hours; it is estimated that only one of each 100,000 cells entering the bloodstream lives to reach another organ, and a far smaller proportion successfully implant themselves. Were it not for obstacles such as these, massive numbers of metastases would appear as soon as a cancer becomes sufficiently large to shed many cells into the circulation. By the twin forces of local invasion and distant metastasis, a cancer gradually interferes with the functioning of the various tissues of the body. Tubular organs are obstructed, metabolic processes are inhibited, blood vessels are eroded sufficiently to cause minor and sometimes major bleeding, vital centers are destroyed, and delicate biochemical balances are deranged. In time, a point is reached at which life can no longer be sustained. In addition, there are less direct ways for cancer to take its toll on those in whom its growth is unchecked, and they are usually the result of the debilitation, poor nutrition, and susceptibility to infection that come with the malignant process. Nutritional depletion is so common that a term has been devised to designate its effects: cancer cachexia. Cachexia is derived from two Greek words meaning "bad condition," which is exactly the situation in which advanced cancer patients find themselves. It is characterized by weakness, poor appetite, alterations in metabolism, and wasting of muscle and other tissues. Actually, cancer cachexia is sometimes present even in people whose disease is still localized and relatively small, so it is clear that factors account for it other than a tumor's gobbling up of its host's resources. Though a tumor is capable of depriving its host of some essential nutrients, the concept of parasitizing may be, in fact, a simplistic way of looking at far more complicated causes of its ability to deplete resources. Changes in taste perception, for example, and local tumor effects such as obstruction and swallowing problems sometimes contribute to inadequate intake, as do chemotherapy and X-ray treatment. Numerous studies of people with malignancies reveal various kinds of abnormalities in the utilization of carbohydrates, fats, and proteins, the causes of which are uncertain. Some tumors even seem capable of increasing a patient's expenditure of energy, thereby contributing to the inability to maintain weight. To add to the problem, certain malignancies and even some of the host's own white blood cells (monocytes) have been shown to release a substance appropriately given the name cachectin, which decreases appetite by direct action on the brain's feeding center. Cachectin is not the only such agent. It is likely that tumors of all sorts are capable of secreting various hormonelike substances which produce generalized effects on nutrition, immunity, and other vital functions that until recently were attributed to the parasitizing effects of the growth itself. Malnutrition causes problems far beyond weight loss and exhaustion. The healthy body adapts to ordinary starvation by using fats as its main energy source, but this process is not effective in cancer, with the result that protein must be utilized. Not only does this and the lessened food intake cause muscle wasting; the decreased protein levels contribute to the dysfunction of organs and enzyme systems, and may significantly affect the immune response. There is evidence that one of the substances released by tumor cells further depresses immunity. Although this may, at least theoretically, enhance cancer growth, that untoward effect seems much less important than the fact that depressed immunocompetence, especially when magnified by chemotherapy and radiation, increases susceptibility to infection. Pneumonia and abscesses, along with urinary and other infections, are frequently the immediate causes of death of cancer patients, and sepsis is their common terminal event. The profound weakness of severe cachexia does not permit effective coughing and respiration, increasing the chances of pneumonia and the inhalation of vomitus. The final hours are sometimes accompanied by those deep, gurgling respirations that are one of the forms of the death rattle, quite distinct from the agonal bark of a James McCarty. Near the end, a decreased volume of circulating blood and extracellular fluid not infrequently leads to a gradual decrease in blood pressure. Even if this does not proceed to shock, it may cause organs such as the liver or kidney to fail because of chronic lack of sufficient nutrients and oxygen, although they are not directly involved with tumor. Since many people with cancer are in an older age group, the various forms of depletion often induce stroke, myocardial infarction, or heart failure. Of course, the presence of a generalized disease of metabolism, like diabetes, complicates the problems enormously. Thus far, only those cancers have been mentioned that begin as tumors originally localized to a specific organ or tissue. A smaller group of malignant diseases have a more generalized distribution from the very beginning, or arise in multiple sites of a particular kind of tissue, specifically the blood and lymph systems. Leukemia, for example, is a cancer of the tissues responsible for the production of white blood cells, and lymphoma is a malignancy of lymph glands and similar structures. Patients with leukemia and lymphoma are particularly prone to infection, and it is a leading cause of death in those malignancies. One of the common forms of lymphoma is Hodgkin's disease. I cannot mention Hodgkin's disease without calling attention to a remarkable accomplishment that is in many ways exemplary of the biomedical achievements of the last third of the twentieth century Thirty years ago, virtually every patient with Hodgkin's disease died of it, unless claimed by something else in the several-year interval between diagnosis and the terminal phase. Since then, improved understanding of the way in which the disease distributes itself in the lymph glands, and its responsiveness to appropriate programs of chemotherapy and supervoltage X-ray, have resulted in five-year disease-free survival of approximately 70 percent, which is as high as 95 percent for patients whose disease is discovered when its extent is still limited; recurrence rates after this period are low and decrease with each year. Not only Hodgkin's disease but lymphomas in general are now among the most curable of all cancers. The changed outlook for people with lymphoma is only one example of extraordinary progress in treating cancer. Another is childhood leukemia. Four out of five children with this disease have a form of it called acute lymphoblastic leukemia, previously fatal in every case; today, the five-year rate of continuous remission of acute lymphoblastic leukemia is 60 percent, and most of these youngsters will be cured. Although there have thus far been only a few other success stories of the sheer magnitude of these two, the general trend in the campaign against cancer is favorable enough to justify cautious optimism. Basic research, new ways of interpreting the clinical phenomena of disease, innovative applications of pharmacology and the physical sciences, and the willingness of informed patients to enroll in large-scale trials of promising treatments are among the reasons for the vast changes over the past few decades. In the year I was born, 1930, only one in five people diagnosed with cancer survived five years. By the 1940s, the figure was one in four. The effect of modern biomedicine's research capacity began to make itself felt in the 1960s, when the proportion of survivors reached one in three. At the present time, 40 percent of all cancer patients are alive five years after diagnosis; making proper statistical allowances for those who die of some unrelated cause, such as heart disease or stroke, 50 percent survive at least that long. It is well known that those who reach the five-year milestone free of disease face greatly decreased odds of eventual recurrence of their malignancy. Virtually all of the progress has been made possible by a combination of earlier diagnosis and the improved treatment resulting from the factors listed in the preceding paragraph. Improved treatment and the possibility of success of the constantly appearing innovative approaches to advanced disease bring hope to today's cancer patient. Paradoxically, and sometimes tragically, that kind of hope is the very thing that has led to some of the most error-fraught dilemmas that patients and their doctors are compelled to face today. My clinical career encompasses a period during which a realistic expectation first began to be felt in the scientific community that malignant disease would prove amenable to treatment based on an understanding of cellular biology rather than the ages-old oversimplifications of surgery. As more was learned about the cancer cell, new and increasingly effective ways were developed to combat its unchecked ravages. With the optimism born of therapeutic successes came a determined cockiness that sometimes goes beyond reason; it finds expression in the philosophy that treatment must be pursued until futility can be proven, or at least proven to the satisfaction of the physician. The boundaries of medical futility, however, have never been clear, and it may be too much to expect that they ever will be. It is perhaps for this reason that there has arisen the conviction among doctors — more than a mere conviction, it is nowadays felt by many to be a responsibility — that should error occur in the treatment of a patient, it must always be on the side of doing more rather than less. Doing more is likely to serve the doctor's needs rather than the patient's. The very success of his esoteric therapeutics too often leads the physician to believe he can do what is beyond his doing and save those who, left to their own unhindered judgment, would choose not to be subjected to his saving.