At that point, more than 15,000 women were dying each year from cervical cancer. The Pap smear had the potential to decrease that death rate by 70 percent or more, but there were two things standing in its way: first, many women-like Henrietta-simply didn't get the test; and, second, even when they did, few doctors knew how to interpret the results accurately, because they didn't know what the various stages of cervical cancer looked like under a microscope. Some mistook cervical infections for cancer and removed a woman's entire reproductive tract when all she needed was antibiotics. Others mistook malignant changes for infection, sending women home with antibiotics only to have them return later, dying from metastasized cancer. And even when doctors correctly diagnosed precancerous changes, they often didn't know how those changes should be treated.

TeLinde set out to minimize what he called "unjustifiable hysterectomies" by doc.u.menting what wasn't cervical cancer and by urging surgeons to verify smear results with biopsies before operating. He also hoped to prove that women with carcinoma in situ needed aggressive treatment, so their cancer didn't become invasive.

Not long before Henrietta's first exam, TeLinde presented his argument about carcinoma in situ to a major meeting of pathologists in Washington, D.C., and the audience heckled him off the stage. So he went back to Hopkins and planned a study that would prove them wrong: he and his staff would review all medical records and biopsies from patients who'd been diagnosed with invasive cervical cancer at Hopkins in the past decade, to see how many initially had carcinoma in situ.

Like many doctors of his era, TeLinde often used patients from the public wards for research, usually without their knowledge. Many scientists believed that since patients were treated for free in the public wards, it was fair to use them as research subjects as a form of payment. And as Howard Jones once wrote, "Hopkins, with its large indigent black population, had no dearth of clinical material."

In this particular study-the largest ever done on the relationship between the two cervical cancers-Jones and TeLinde found that 62 percent of women with invasive cancer who'd had earlier biopsies first had carcinoma in situ. In addition to that study, TeLinde thought, if he could find a way to grow living samples from normal cervical tissue and both types of cancerous tissue-something never done before-he could compare all three. If he could prove that carcinoma in situ and invasive carcinoma looked and behaved similarly in the laboratory, he could end the debate, showing that he'd been right all along, and doctors who ignored him were killing their patients. So he called George Gey (p.r.o.nounced Guy), head of tissue culture research at Hopkins.

Gey and his wife, Margaret, had spent the last three decades working to grow malignant cells outside the body, hoping to use them to find cancer's cause and cure. But most cells died quickly, and the few that survived hardly grew at all. The Geys were determined to grow the first immortal human cells: a continuously dividing line of cells all descended from one original sample, cells that would constantly replenish themselves and never die. Eight years earlier-in 1943-a group of researchers at the National Inst.i.tutes of Health had proven such a thing was possible using mouse cells. The Geys wanted to grow the human equivalent-they didn't care what kind of tissue they used, as long as it came from a person.

Gey took any cells he could get his hands on-he called himself "the world's most famous vulture, feeding on human specimens almost constantly." So when TeLinde offered him a supply of cervical cancer tissue in exchange for trying to grow some cells, Gey didn't hesitate. And TeLinde began collecting samples from any woman who happened to walk into Hopkins with cervical cancer. Including Henrietta.

On February 5, 1951, after Jones got Henrietta's biopsy report back from the lab, he called and told her it was malignant. Henrietta didn't tell anyone what Jones said, and no one asked. She simply went on with her day as if nothing had happened, which was just like her-no sense upsetting anyone over something she could deal with herself.

That night Henrietta told her husband, "Day, I need to go back to the doctor tomorrow. He wants to do some tests, give me some medicine." The next morning she climbed from the Buick outside Hopkins again, telling Day and the children not to worry.

"Ain't nothin serious wrong," she said. "Doctor's gonna fix me right up."

Henrietta went straight to the admissions desk and told the receptionist she was there for her treatment. Then she signed a form with the words OPERATION PERMIT at the top of the page. It said:

I hereby give consent to the staff of The Johns Hopkins Hospital to perform any operative procedures and under any anaesthetic either local or general that they may deem necessary in the proper surgical care and treatment of: ______________________________

Henrietta printed her name in the blank s.p.a.ce. A witness with illegible handwriting signed a line at the bottom of the form, and Henrietta signed another.

Then she followed a nurse down a long hallway into the ward for colored women, where Howard Jones and several other white physicians ran more tests than she'd had in her entire life. They checked her urine, her blood, her lungs. They stuck tubes in her bladder and nose.

On her second night at the hospital, the nurse on duty fed Henrietta an early dinner so her stomach would be empty the next morning, when a doctor put her under anesthetic for her first cancer treatment. Henrietta's tumor was the invasive type, and like hospitals nationwide, Hopkins treated all invasive cervical carcinomas with radium, a white radioactive metal that glows an eerie blue.

When radium was first discovered in the late 1800s, headlines nationwide hailed it as "a subst.i.tute for gas, electricity, and a positive cure for every disease." Watchmakers added it to paint to make watch dials glow, and doctors administered it in powdered form to treat everything from seasickness to ear infections. But radium destroys any cells it encounters, and patients who'd taken it for trivial problems began dying. Radium causes mutations that can turn into cancer, and at high doses it can burn the skin off a person's body. But it also kills cancer cells.

Hopkins had been using radium to treat cervical cancer since the early 1900s, when a surgeon named Howard Kelly visited Marie and Pierre Curie, the couple in France who'd discovered radium and its ability to destroy cancer cells. Without realizing the danger of contact with radium, Kelly brought some back to the United States in his pockets and regularly traveled the world collecting more. By the 1940s, several studies-one of them conducted by Howard Jones, Henrietta's physician-showed that radium was safer and more effective than surgery for treating invasive cervical cancer.

The morning of Henrietta's first treatment, a taxi driver picked up a doctor's bag filled with thin gla.s.s tubes of radium from a clinic across town. The tubes were tucked into individual slots inside small canvas pouches hand-sewn by a local Baltimore woman. The pouches were called Brack plaques, after the Hopkins doctor who invented them and oversaw Henrietta's radium treatment. He would later die of cancer, most likely caused by his regular exposure to radium, as would a resident who traveled with Kelly and also transported radium in his pockets.

One nurse placed the Brack plaques on a stainless-steel tray. Another wheeled Henrietta into the small colored-only operating room on the second floor, with stainless-steel tables, huge glaring lights, and an all-white medical staff dressed in white gowns, hats, masks, and gloves.

With Henrietta unconscious on the operating table in the center of the room, her feet in stirrups, the surgeon on duty, Dr. Lawrence Wharton Jr., sat on a stool between her legs. He peered inside Henrietta, dilated her cervix, and prepared to treat her tumor. But first-though no one had told Henrietta that TeLinde was collecting samples or asked if she wanted to be a donor-Wharton picked up a sharp knife and shaved two dime-sized pieces of tissue from Henrietta's cervix: one from her tumor, and one from the healthy cervical tissue nearby. Then he placed the samples in a gla.s.s dish.

Wharton slipped a tube filled with radium inside Henrietta's cervix, and sewed it in place. He sewed a plaque filled with radium to the outer surface of her cervix and packed another plaque against it. He slid several rolls of gauze inside her v.a.g.i.n.a to help keep the radium in place, then threaded a catheter into her bladder so she could urinate without disturbing the treatment.

When Wharton finished, a nurse wheeled Henrietta back into the ward, and Wharton wrote in her chart, "The patient tolerated the procedure well and left the operating room in good condition." On a separate page he wrote, "Henrietta Lacks ... Biopsy of cervical tissue ... Tissue given to Dr. George Gey."

A resident took the dish with the samples to Gey's lab, as he'd done many times before. Gey still got excited at moments like this, but everyone else in his lab saw Henrietta's sample as something tedious-the latest of what felt like countless samples that scientists and lab technicians had been trying and failing to grow for years. They were sure Henrietta's cells would die just like all the others.

CHAPTER 4

The Birth of HeLa

Gey's twenty-one-year-old a.s.sistant, Mary Kubicek, sat eating a tuna-salad sandwich at a long stone culture bench that doubled as a break table. She and Margaret and the other women in the Gey lab spent countless hours there, all in nearly identical cat-eye-gla.s.ses with fat dark frames and thick lenses, their hair pulled back in tight buns.

At first glance, the room could have been an industrial kitchen. There were gallon-sized tin coffee cans full of utensils and gla.s.sware; powdered creamer, sugar, spoons, and soda bottles on the table; huge metal freezers lining one wall; and deep sinks Gey made by hand using stones he collected from a nearby quarry. But the teapot sat next to a Bunsen burner, and the freezers were filled with blood, placentas, tumor samples, and dead mice (plus at least one duck Gey kept frozen in the lab for more than twenty years after a hunting trip, since it wouldn't fit in his freezer at home). Gey had lined one wall with cages full of squealing rabbits, rats, and guinea pigs; on one side of the table where Mary sat eating her lunch, he'd built shelves holding cages full of mice, their bodies filled with tumors. Mary always stared at them while she ate, just as she was doing when Gey walked into the lab carrying the pieces of Henrietta's cervix.

"I'm putting a new sample in your cubicle," he told her.

Mary pretended not to notice. Not again, she thought, and kept eating her sandwich. It can wait till I'm done.

Mary knew she shouldn't wait-every moment those cells sat in the dish made it more likely they'd die. But she was tired of cell culture, tired of meticulously cutting away dead tissue like gristle from a steak, tired of having cells die after hours of work.

Why bother? she thought.

Gey hired Mary for her hands. She was fresh out of college with a physiology degree when her adviser sent her for an interview. Gey asked Mary to pick up a pen from the table and write a few sentences. Now pick up that knife, he said. Cut this piece of paper. Twirl this pipette.

Mary didn't realize until months later that he'd been studying her hands, checking their dexterity and strength to see how they'd stand up to hours of delicate cutting, sc.r.a.ping, tweezing, and pipetting.

By the time Henrietta walked into Hopkins, Mary was handling most of the tissue samples that came through the door, and so far all samples from TeLinde's patients had died.

At that point, there were many obstacles to growing cells successfully. For starters, no one knew exactly what nutrients they needed to survive, or how best to supply them. Many researchers, including the Geys, had been trying for years to develop the perfect culture medium-the liquid used for feeding cells. The recipes for Gey Culture Medium evolved constantly as George and Margaret added and removed ingredients, searching for the perfect balance. But they all sounded like witches' brews: the plasma of chickens, puree of calf fetuses, special salts, and blood from human umbilical cords. George had rigged a bell and cable from the window of his lab across a courtyard to the Hopkins maternity ward, so nurses could ring anytime a baby was born, and Margaret or Mary would run over and collect umbilical cord blood.

The other ingredients weren't so easy to come by: George visited local slaughterhouses at least once a week to collect cow fetuses and chicken blood. He'd drive there in his rusted-out old Chevy, its left fender flapping against the pavement, shooting sparks. Well before dawn, in a rundown wooden building with a sawdust floor and wide gaps in the walls, Gey would grab a screaming chicken by the legs, yank it upside down from its cage, and wrestle it to its back on a butcher block. He'd hold its feet in one hand and pin its neck motionless to the wood with his elbow. With his free hand, he'd squirt the bird's chest with alcohol, and plunge a syringe needle into the chicken's heart to draw blood. Then he'd stand the bird upright, saying, "Sorry, old fella," and put it back in its cage. Every once in a while, when a chicken dropped dead from the stress, George took it home so Margaret could fry it for dinner.

Like many procedures in their lab, the Gey Chicken Bleeding Technique was Margaret's creation. She worked out the method step-by-step, taught it to George, and wrote detailed instructions for the many other researchers who wanted to learn it.

Finding the perfect medium was an ongoing experiment, but the biggest problem facing cell culture was contamination. Bacteria and a host of other microorganisms could find their way into cultures from people's unwashed hands, their breath, and dust particles floating through the air, and destroy them. But Margaret had been trained as a surgical nurse, which meant sterility was her specialty-it was key to preventing deadly infections in patients in the operating room. Many would later say that Margaret's surgical training was the only reason the Gey lab was able to grow cells at all. Most culturists, like George, were biologists; they knew nothing about preventing contamination.

Margaret taught George everything he knew about keeping cultures sterile, and she did the same with every technician, grad student, and scientist who came to work or study in the lab. She hired a local woman named Minnie whose sole job was washing the laboratory gla.s.sware using the only product Margaret would allow: Gold Dust Twins soap. Margaret was so serious about that soap, when she heard a rumor that the company might go out of business, she bought an entire boxcar full of it.

Margaret patrolled the lab, arms crossed, and leaned over Minnie's shoulder as she worked, towering nearly a foot above her. If Margaret ever smiled, no one could have seen it through her ever-present surgical mask. She inspected all the gla.s.sware for spots or smudges, and when she found them-which was often-she'd scream, "MINNIE!" so loud that Mary cringed.

Mary followed Margaret's sterilizing rules meticulously to avoid her wrath. After finishing her lunch, and before touching Henrietta's sample, Mary covered herself with a clean white gown, surgical cap, and mask, and then walked to her cubicle, one of four airtight rooms George had built by hand in the center of the lab. The cubicles were small, only five feet in any direction, with doors that sealed like a freezer's to prevent contaminated air from getting inside. Mary turned on the sterilizing system and watched from outside as her cubicle filled with hot steam to kill anything that might damage the cells. When the steam cleared, she stepped inside and sealed the door behind her, then hosed the cubicle's cement floor with water and scoured her workbench with alcohol. The air inside was filtered and piped in through a vent on the ceiling. Once she'd sterilized the cubicle, she lit a Bunsen burner and used its flame to sterilize test tubes and a used scalpel blade, since the Gey lab couldn't afford new ones for each sample.

Only then did she pick up the pieces of Henrietta's cervix-forceps in one hand, scalpel in the other-and carefully slice them into one-millimeter squares. She sucked each square into a pipette, and dropped them one at a time onto chicken-blood clots she'd placed at the bottom of dozens of test tubes. She covered each clot with several drops of culture medium, plugged the tubes with rubber stoppers, and labeled each one as she'd labeled most cultures they grew: using the first two letters of the patient's first and last names.

After writing "HeLa," for Henrietta and Lacks, in big black letters on the side of each tube, Mary carried them to the incubator room that Gey had built just like he'd built everything else in the lab: by hand and mostly from junkyard sc.r.a.ps, a skill he'd learned from a lifetime of making do with nothing.

George Gey was born in 1899 and raised on a Pittsburgh hillside overlooking a steel mill. Soot from the smokestacks made his parents' small white house look like it had been permanently charred by fire and left the afternoon sky dark. His mother worked the garden and fed her family from nothing but the food she raised. As a child, George dug a small coal mine in the hill behind his parents' house. He'd crawl through the damp tunnel each morning with a pick, filling buckets for his family and neighbors so they could keep their houses warm and stoves burning.

Gey paid his way through a biology degree at the University of Pittsburgh by working as a carpenter and mason, and he could make nearly anything for cheap or free. During his second year in medical school, he rigged a microscope with a time-lapse motion picture camera to capture live cells on film. It was a Frankensteinish mishmash of microscope parts, gla.s.s, and 16-millimeter camera equipment from who knows where, plus metal sc.r.a.ps, and old motors from Shapiro's junkyard. He built it in a hole he'd blasted in the foundation of Hopkins, right below the morgue, its base entirely underground and surrounded by a thick wall of cork to keep it from jiggling when street cars pa.s.sed. At night, a Lithuanian lab a.s.sistant slept next to the camera on a cot, listening to its constant tick, making sure it stayed stable through the night, waking every hour to refocus it. With that camera, Gey and his mentor, Warren Lewis, filmed the growth of cells, a process so slow-like the growth of a flower-the naked eye couldn't see it. They played the film at high speed so they could watch cell division on the screen in one smooth motion, like a story unfolding in a flip book.