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Paleopathologic findings and examination of ancient mummies indicate that cancer occurred in prehistoric time but to my knowledge the first written description of cancer is found in the Edwin Smith Papyrus and the Ebers Papyrus.1, 2 These papyri are based on what was known in surgery and medicine up to 3000 BC and 1500 BC, respectively. The Edwin Smith Papyrus contains the earliest description of breast cancer, with the conclusion that there is no treatment.1 In the Ebers Papyrus, enlarged thyroids; polyps; and tumors of the skin, pharynx, stomach, rectum, and uterus are described.2, 3

Although cancer was not a prevalent disease in antiquity (because most people did not live to old age), it is of interest that in ancient writings breast cancer is mentioned far more often than any other malignancy. Once the diagnosis of cancer was made, treatment was administered with cautery, knife, or salts of lead and sulfur or arsenic paste. The latter was in use as “Egyptian ointment” until the 19th century.3, 4

Hippocrates (460–375 BC), a native of Greece and contemporary of Socrates (469–399 BC) and Plato (427–347 BC), was a skillful diagnostician. He separated medicine from superstition and religion and made it a science.5 The writings attributed to Hippocrates were first printed in Rome in Latin in 1525, and several Greek editions later were published in Venice (Fig. 1). In the Hippocratic writings there are many references to cancer.6 Hippocrates classified diseases according to the principal symptoms and came to the conclusion that all diseases, including cancer, originate from natural causes.5, 6 Hippocrates noted that growing tumors occur mostly in adults and the growths reminded him of a moving crab, which led to the terms carcinos (a tumor), carcinoma (a malignant tumor), and cancer (a nonhealing malignant ulcer). The hard tumor, the scirrhus, was different from carcinos and carcinoma.3, 7

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Figure 1. Title page to the writings of Hippocrates, printed in Venice in 1588. (Reprinted from author's private collection.)

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According to Hippocrates, tumors were caused by an imbalance of the four humors: blood, phlegm, yellow bile, and black bile. The black bile was particularly bad. Hippocrates wrote of dark, beef glaze-like vaginal discharge in association with enlargement and ulceration of the uterus. He recognized cancers of the skin, mouth, breast, and stomach. He knew about anorectal condylomas and polyps and recommended examination with a speculum if they were higher up in the colon.4, 6, 7 Hippocrates described breast carcinoma with bloody discharge from the nipple and called attention to the danger of bloody ascites.6 He observed scirrhous tumor of the cervix, which was associated with bleeding, emaciation, and dropsy, and caused death. He mentioned superficial and deep-seated tumors in the armpit, groin, and thigh in older people.6, 7

Hippocrates summed up his recommendation for treatment by writing that tumors that are not cured by medicine are cured by iron (knife), those that are not cured by iron are cured by fire (cautery), and those that are not cured by fire are incurable.6, 7 For occult or deep-seated tumors, he advised not to use any treatment because if treated, the patient would die quickly. If not treated, the patient could survive for an extended period.3, 7

After Greece became part of the Roman Empire in 146 BC, Greek physicians began to emigrate to Rome. In 46 BC, a new law was passed, at the recommendation of Julius Caesar (100–44 BC.), that granted Roman citizenship to all Greek physicians in Rome. Among the new citizens was a highly educated and ambitious young man named Aulus Cornealius Celsus (25 BC–AD 50). Celsus, a native of Greece, received most of his medical education at the best medical school at the time, which was located in Alexandria, Egypt. Celsus was a proud citizen of his adopted Rome and made Latin the language of medicine for the first time. He wrote, in Latin, his De Medicina, an encyclopedic listing of advances made since the time of Hippocrates. His written notes resurfaced in the 15th century and first were printed in book form in 1478 in Florence using the new type printing, making it the first medical book published by printing. This first printing was followed by additional editions (Fig. 2).

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Figure 2. Title page of the 1687 Amsterdam edition of De Medicina by Celsus. (Reprinted from author's private collection.)

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Celsus continued the Hippocratic tradition by comparing cancer with a crab, because it adheres to surrounding stuctures in a manner similar to how the crab holds on to anything in its claws.8 Celsus distinguished several varieties of cancer. He knew about superficial cancers of the face, mouth, throat, and penis but he also mentioned cancers of the liver, spleen, and visceral organs such as the colon.9 In De Medicina, Celsus introduced the first classification for breast carcinoma. He distinguished early carcinoma, carcinoma without ulceration, and ulcerated fungating carcinoma.8, 9 He recommended aggressive surgical therapy but he believed that only at the early stage could these tumors be removed. He cautioned that even after excision, and when a well-healed scar is formed, breast carcinomas may recur with swelling in the armpit and cause death by spreading into the body.9, 10 He found no use for bloodletting in terminal cases.

According to Celsus, superficial carcinomas should first be treated with a topical application of cabbage, a salted mixture of honey and egg white, or ripe fig.8 As an aside, Celsus described the four cardinal signs of inflammation (redness, heat, swelling, and pain), but he did not draw a distinct line between inflammatory and neoplastic lesions.3

The third Greek physician of fame is Claudius Galen (131 AD 200). He also studied in Alexandria, and after he completed his studies he settled in Rome. Shortly after his arrival, he became famous by demonstrating to the Romans that aphonia occurred after cutting across a nerve (the accessory nerve) in the neck of animals.3 For his skills in surgery, he was appointed as a salaried physician of the gladiators.

Galen was a theorist and a prolific writer but, despite the fact that he practiced in Rome and his spoken language was Latin, he used Greek in his writings. He penned some 500 medical papers, including 100 notes concerning tumors and cancer. His collected writings, Opera Omnia, first appeared in book form in 1490 in Venice, which was followed by additional editions (Fig. 3).

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Figure 3. The frontispiece to the collected works of Galen, printed in Venice in 1625. (Reprinted from author's private collection.)

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Galen followed Hippocrates and his humorist theory and ignored Celsus, his immediate predecessor in Rome. He adopted the black bile theory of Hippocrates and believed that black bile caused severe, ulcerated, and incurable cancer, whereas thin bile was responsible for nonulcerated and curable cancer.4, 11 Although he also compared cancer with the crab and advised surgery by cutting into healthy tissue around the border of the tumor, he accepted the Roman prejudice against surgical procedures. He believed that the best surgeon was the one who operated only as a last resort.3, 4, 10 Galen held that cancer was a constitutional disease that afflicts the sick, particularly those with a melancholic disposition, and that the overall goal should be to prevent the accumulation of black bile by using purgatives.4, 11 Parenthetically, he also believed that black bile caused hemorrhoids and the suppression of menstrual bleeding. With regard to pain in terminally ill individuals, he recommended ointment made from poppy heads.10, 11

After the fall of the Roman Empire in AD 476 (Table 1), Celsus, the first Roman physician of excellence, was forgotten but Galen's rigid humoral theory and authorative reasoning that left no questions unanswered were promoted. His thinking well suited the Christian theology as well as Byzantine and Arabic teachings. Galen's canonical theories obstructed progress in medicine and delayed advances in understanding cancer until the end of the 18th century.

Table 1. Chronology of Events
YearMedical historyYearWorld history
3000 BCEdwin Smith Papyrus is written3000 BCConstruction at Stonehenge begins
1500 BCEbers Papyrus is written1500 BCThe Hebrews are in bondage in Egypt
  509 BCRoman Republic founded
460 BCHippocrates is born
375 BCDeath of Hippocrates
25 BCCelsus is born399 BCDeath of Socrates
AD 50Death of Celsus30 BCCleopatra commits suicide
AD 130Galen is bornAD 42St. Peter is the first pope
AD 200Death of GalenAD 122Construction of Hadrian's Wall begun in Britian
AD 399Death of Fabiola, the first female surgeon of RomeAD 476Fall of the Roman Empire

REFERENCES

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  2. REFERENCES
  • 1
    Breasted JH. The Edwin Smith Surgical Papyrus. Chicago: University of Chicago Press, 1930.
  • 2
    Ebbell B. The Papyrus Ebers: the greatest Egyptian medical document. Copenhagen: Levin and Munksgaard, 1937.
  • 3
    Pemberton O. Observations on the history, pathology and treatment of cancerous diseases. London: J. Churchill, 1858.
  • 4
    Wolff J. Die Lehre von der Krebskrankheit von den ältesten Zeiten bis zur Gegenwart. Jena: Gustav Fischer, 1907.
  • 5
    Laennec RTH. Propositions sur la doctrine d'Hippocrate, relativement a la médecine-pratique. Paris: L'imprimerie de Didot Jeune, 1804.
  • 6
    Littré E. Oeuvres complétes d'Hippocrate. Paris: Bailliére, 1846.
  • 7
    Adams F. The genuine works of Hippocrates. New York: W. Wood, 1886.
  • 8
    Constantini R. Aur. Corn. Celsi de Medicina libri octo. Amsterdam: Joannem Wolters, 1687.
  • 9
    Spencer WG. Celsus De Medicina. London: Heinemann, 1935–1938.
  • 10
    Park R. An epitome of the history of carcinoma. Bull Johns Hopkins Hosp. 1903: 14: 288294.
  • 11
    Kühn CG. Opera omnia. Lipsiae: C. Cnobloch, 1821–1833.