Concepts of Cancer from Antiquity to the Nineteenth Century
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History of Medicine Concepts of Cancer from Antiquity to the Nineteenth Century Margaret M. Olszewski, PhD (1T3), Faculty of Medicine, University of Toronto employed for conditions whose cause was less obvious, like in Abstract the case of headaches, where some scribes recommended rub - Theories about the origins of cancer and potential bing the head with the skull of a catfish, a treatment that fol - treatments for the disease can be traced back to several lowed the magical principle of “similia similibus” or like will be ancient papyri of Egyptian derivation that documented cured by like. 5 Egyptians thus interpreted physical conditions palliative treatment and surgical removal of tumours. within these parameters of belief. In the Greco-Roman period, Hippocrates explained It is generally accepted that the earliest known references to cancer using his humoural theory, arguing that an cancer are found in the Edwin Smith Papyrus, an Egyptian text on excess of black bile produced uncontrollable, crab-like trauma surgery dated to 1600 BCE. Attributed to Imhotep, vizier, cell growths. This theory would dominate explanations architect, physician and astronomer to the Pharaoh Djoser (who of cancer for the next millennia as it was promulgated presumably composed the text in 2500 BCE; the extant text is a by Hippocrates’ successor Galen. While there were copy), the historic collection of medical writings described forty- some additions to the medicinal understanding of can - eighty traumatic surgical cases, eight of which dealt with what cer in the Middle Ages, it was not until the nineteenth modern physicians believe to be incidences of tumours or ulcers 6 century that microscopic work by German pathologists of the breast. The following excerpt, describing the method of including Müller and Virchow, identified the cellular diagnosing tumours of the breast, is taken from the text: origins of cancer. This review considers some of the major contributions to cancer research and care from “... If you examine a man having bulging tumors on his ancient Egypt until the nineteenth century and out - breast, and you find that they have spread over his breast; if you place your hand upon his breast tumors and you find them to be lines the ways in which concepts of the disease have cool, there being no fever at all therein when your hand fells changed with the advancement of medical knowledge. him; they have no granulation, contain no fluid, give rise to no liquid discharge, yet they feel protuberant to your touch, you should say concerning him: ‘This is a case of bulging tumors I Introduction have to content wit h’.” 7 he history of cancer is a long and complicated one; Jacob Wolff’s lengthy volume The Science of Cancerous Disease from This description itself is quite vague and perhaps, not surpris - the Earliest Times to the Present is a testament to the disease’s ingly, it was common practice for a wide assortment of swellings, T 1 enduring and complex presence in medicine. Nonetheless, whether simply inflammatory or cancerous, as well as chronic there are a number of milestones in our current understanding ulcerations, to be classified as tumours during this period of the disease that can be traced from ancient times. This review because of the lack of understanding in human anatomy and article attempts to highlight these milestones, focusing on spe - physiology. 4 There were, however, distinctions made in treat - cific contributions that can be viewed as signposts in our evolv - ment depending on the presentation of the tumour: red, warm ing concept of cancer. As a historical review, this piece is not and pus-oozing masses were removed with cauterization using a intended to provide a complete history of the disease. Notable “fire drill,” while tumours that were cool to the touch and pus- omissions include perspectives on cancer in the Arab world and free were to be left intact. 8 One could also treat tumours with advances in cancer research in the twentieth century, topics that external applications. A number of these treatments are would warrant their own reviews. Instead, this article points out described in the Ebers Papyrus of about 1550 BCE. This text some important historical perspectives on cancer, how they have contained a far more comprehensive collection of medical evolved over time, and how they have set the stage for our mod - remedies – over 876 in total – and mentions some 500 different ern understanding of the disease. substances for the treatment of disease. 9 One such palliative approach for uterine cancer involved inserting a mixture of Ancient Egypt (3000 BCE – 500 BCE) fresh dates into the vagina to ease discomfort. 10 In ancient Egypt, magic and religion were strong influences While frequently cited in the literature on the history of cancer, on medical practice. 2 Priests were considered the ultimate care - these interpretations of cancer in Egyptian texts should be viewed takers of knowledge and it was thought that they received their cautiously, mainly because of the relative absence of tumours in wisdom directly from the heavens. In light of these beliefs, can - examined skeletal remains from the period, although some exam - cer, as well as other diseases, were mainly viewed as direct con - ples, like the discovery of an osteochondroma by Grafton Elliot sequences of the “will of the Gods.” 3,4 Spiritual and mystical ten - Smith and Warren Dawson, do exist. 11 Nonetheless, up until 2006, dencies were especially evident in the disease treatment, which only about thirty-nine malignant tumours had been identified in was based on perceived causes. Conditions were treated accord - Egyptian skeletal remains dating from various periods and places ing to their perceived cause. Pragmatic solutions were devised to in Egypt, although this number has recently been increasing. 12 treat conditions with obvious causes, such as bone setting for Furthermore, scholars such as Leonard Weiss have had trouble fractures and surgery for trauma, while magic was often reconciling the high frequency of male breast cancer in Egyptian UTMJ • Volume 87, Number 3, May 2010 181 History of Medicine Concepts of Cancer from Antiquity to the Nineteenth Century texts with modern statistics of the disease’s prevalence, estimated to be less than 1% of all cancer in men and less than 1% of all breast cancer diagnoses worldwide. 13 These scholars have thus tentatively concluded that these textual descriptions of Egyptian cancer cannot be confirmed. 14 On the other side of this argument there are those like Bendix Ebbell, translator of the Ebers Papyrus, who have suggested the word wenemet or “eating,” used frequently when describing swellings, was used unequivocally to describe cancer-like growths. 10 Despite these arguments, the remarkable lack of evidence to support the existence of malignant epithelial tumours is impor - tant when considered in light of recent increases in cancer inci - dence. Why did Egyptians suffer from cancer less frequently than modern society? A shorter life expectancy (thirty-nine years), a different diet and the existence of fewer carcinogenic agents in Egyptian times are a few of the reasons contemporary scholars have offered to explain this discrepancy. 10 The case of cancer in ancient Egypt provides an interesting case study for Figure 1. Hippocrates’s four humours (adapted from Magner, LN. A further epidemiological investigation. history of medicine. New York: Marcel Dekker, Inc.; 1992. 71-74 pp. ) Cancer in the Greco-Roman Period (500 BCE – 500 CE) healthy sexual activity was commonplace. Hippocratic physicians In the Classical Period, the Hippocratic School is thought to also recognized the natural healing process as critical in achiev - be the first to document Greek ideas about cancer. Comprised ing optimum health. Diseases were themselves natural and it was of some seventy books written by Hippocrates of Cos (460 BCE the physician’s responsibility to help nature achieve a cure. 17 – 370 BCE) and other contributing physicians, the Hippocratic How did this approach to medicine influence the way in which corpus was the first text to use the words karkinos and karkinoma the Greeks interpreted cancer? 21 The Hippocratic corpus con - to describe a non-healing swelling or ulceration and malignant tains eleven separate sections that approach the pathogenesis and non-healing tumour respectively. Hippocrates also introduced treatment of cancer. The clearest reference to cancer is found in 4 the word scirrhus to describe hard tumours. These learned the fifth book of Epidemics: “a woman from Abdera developed Hippocratic writings differed considerably from the equivocal carcinoma on the breast, and through the nipple there was sero- descriptions of cancer in the Egyptian period primarily because sanguinous discharge; when the discharge ceased she died.” 22 they were concerned with causation in health and disease and While this excerpt suggests that Hippocrates did not do much were grounded in an Aristotelian framework of rational knowl - about cancer, a number of other references throughout the cor - 15,16 edge acquisition. They adopted a natural philosophical pus indicate he did in fact distinguish between superficial, malig - approach to illness that was driven by a perceptible quest for a nant tumours that he called karkinoma apertus and deep tumours, naturalistic understanding of pathology and not just mystical or karkinoma occlusus , that he considered the overall condition of description . These writings contain a marked decrease in refer - the patient before diagnosis and that he was aware that some can - ences to magical or supernatural exclamations of disease. Belief cers favoured either the male or female gender or the elderly. in gods was still predominant but they were no longer consid - According to Hippocrates, an excess of black bile or atrabilis was 17,18 ered to be the direct cause of disease. the major cause of cancer. Imbalance of internal humours became the dominant expla - If tumours were superficial, Hippocrates advised that they be nation of disease in the Hippocratic era of medicine.