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Nov 12, 2013 (3 years and 11 months ago)

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Concepts of Cancer From Antiquity to the Nineteenth Century


Margaret M. Olszewski, Ph.D. (1T3), Faculty of Medicine, University of Toronto

margaret.olszewski@utoronto.ca


ABSTRACT

Theories about the o
rigins of cancer and potential treatments for the disease can be traced
back to several ancient papyri of Egyptian derivation that documented palliative treatment and
surgical removal of tumours. In the Greco
-
Roman period, Hippocrates explained cancer usin
g his
humoural

theory, arguing that an excess of black bile produced uncontrollable, crab
-
like cell
growths. This theory would dominate explanations of cancer for the next
millennia as it was
promulgated by
Hippocrates’ successor Galen. While t
here were so
me additions to the medicinal
understanding of
cancer in the Middle Ages, it was not until the nineteenth century that
microscopic work by German pathologists including Müller and Virchow, identified the
cellular
origins of cancer
.
This review considers so
me of the major contributions to cancer research and
care from ancient Egypt until the nineteenth century and outlines the ways in which concepts of
the disease have changed with the advancement of medical knowledge.


KEYWORDS: history of cancer; humoural
theory; lymp
h node theory; blastema theory




Introduction

The history of cancer is a long and complicated one
; Jacob Wolff’s lengthy volume

The
Science of Cancerous Disease from the Earliest Times to the Present
is a testament to the
disease’s
enduring

an
d complex presence in medicine.
1

Nonetheless, there are a number of
milestones in our understanding of the disease that can be traced from ancient times until the
modern period. This review article attempts to highlight these milestones, focusing on specif
ic
contributions that can be viewed as signposts in the evolution of cancer as a medical concept. As
with any historical review, this piece is not a comprehensive history of cancer, but rather an
exploration of some important historical perspectives on the

disease. Notable omissions include a
thorough examination of conceptions of cancer in the Arab world and a look at advances in the
study of the disease in the twentieth century. The overarching aim is to provide the reader insight
into how scientific theo
ries evolve over time


how older ideas can be transformed, refined and
incorporated into newer ones and how accepted truths can be adapted in different ways when
novel approaches to nature are innovated. Familiarity with these origins and a sound knowledg
e
of how
revolution
s in concepts of cancer transpired are important for those grappling with
current ideas of the disease because, as this article demonstrates, this background could
potentially encourage researchers to consider how older concepts can be i
ntegrated into modern
approaches and ultimately lead to new concepts of cancer.


Ancient Egypt

(3000 BC


500 BC)

In ancient Egypt, magic and religion were strong influences on medical practice.
2

Priests
were considered the ultimate caretakers
of knowledge

and it was
thought

they received the
ir
wisdom directly from the heavens
. In light of these beliefs, cancer, as well as other diseases,
were mainly viewed as

direct consequences of

the “will of the Gods.”
3
,

4

Spiritual and mystical
tendencies were especial
ly evident in the treatment of disease. Conditions were treate
d according
to perceived cause. P
ragmatic solutions

were
devised to treat
conditions with obvious causes,
such as

bone setting for fractures and surgery for trauma, while magic was

often

employe
d for
conditions whose cause was less obvious, like in the case of headaches
, where the Ebers papyrus
recommended rubbing the head with the skull of a catfish, a treatment that followed the magical
principle of “similia similibus” or like will be cured by
like.
5


Egyptians thus interpreted physical
conditions within these parameters of belief.

It is generally accepted that

the
earliest known references to cancer are found in the
Edwin Smith Papyrus, an Egyptian text on trauma surgery dated to 1600 B.C. Attr
ibuted to
Imhotep, vizier, architect, physician and astronomer to the Pharaoh Djoser (who presumably
composed the text in 2500 BC; the extant text is a copy), the historic collection of medical
writings described forty
-
eighty traumatic surgical cases, eigh
t of which dealt with what modern
physicians believe to be incidences of tumours or ulcers of the breast.
6

The following excerpt
,

describing
the method of diagnosing
tumours of the breast
,

is taken from the text:



. . . If you

examine a man having bulgi
ng tumors on

his 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 cool, there being no fever at all therein when
your hand fells 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 have to content with
.


7


This description itself is quite vague and perhaps not surprisingly, it was common
pract
ice for a wide assortment of swellings, whether simply inflammatory or cancerous, as well
as chronic ulcerations, to be classified as tumours during this period because of the lack of
understanding in human anatomy and physiology.
4

There was, however, dist
inctions made in
treatment depending on the presentation of the tumour: red, warm and pus
-
oozing masses were
removed
with cauterization using a “fire drill,” while tumours that were cool to the touch and
pus
-
free were to be left intact.
8

One could also tre
at tumours with external applications. A
number of these treatments are described in the
Ebers Papyrus of about 1550 B.C.

This text
contained a far
more comprehensive
collection of medical remedies


over 876 in total


and
mentions some
500 different subs
tances

for the treatment of disease
.
9

One such palliative
approach for uterine cancer involved inserting a mixture of fresh dates into the vagina to ease
discomfort.
10

While frequently cited in the literature on the history of cancer, t
hese interpretations
of
cancer in
Egyptian texts should be viewed cautiously, mainly because of the relative absence of
tumours in examined skeletal remains

from the period
, although some examples, like the
discovery of an osteochondroma by
Grafton Elliot
Smith and
Warren
Daws
on, do exist.
11

Nonetheless, u
p until 2006, only about 39 malignant tumours had been identified in Egyptian
skeletal remains dating from various periods and places in Egypt
, although this number has
recently been increasing
.
12

Furthermore, s
cholars such as
L
eonard
Weiss have had trouble
reconciling the
high frequency of male breast cancer in
Egyptian 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 a
all breast cancer diagnoses wo
rldwide.
13

These scholars have thus tentatively concluded that
these textual de
scriptions of Egyptian cancer cannot be confirmed.
14


On the other side of this
argument there are those like
B
endix

Ebbell, tran
slator of the Ebers Papyrus, who have suggested
th
e

word
wenemet

or “eating,” used frequently when describing swellings, was used
unequivocally to describe cancer
-
like growths
.
10


Despite these arguments, t
he remarkable lack of evidence to support the existence of
malignant epithelial tumours is important

when considered in light of recent increases in cancer
incidence. 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 E
gyptian 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 further
epidemiological investigation.


Cancer in the Greco
-
Roman Period (50
0 B.C.


500 A.D.)

In the Classical Period, the Hippocratic School is thought to be the first to document
Greek ideas about cancer. Comprised of some seventy books written by Hippocrates of Cos (460
BC


370 BC) and other contributing physicians, the Hipp
ocratic corpus was t
he first text to use
the words
karkinos

and
karkinoma

to describe a non
-
healing swelling or ulceration and
malignant
non
-
healing tumour respectively.

Hippocrates also introduced the word
scirrhus

to
describe hard tumours.
4


These learne
d Hippocratic writings differed considerably from the
equivocal descriptions of cancer in the Egyptian period primarily because they were concerned
with causation in health and disease

and were grounded in an Aristotelian framework of rational
knowledge ac
quisition
.
15
,

16

They adopted a natural philosophical approach to illness that was
driven by a perceptible quest for a naturalistic
understanding
of pathology and not just mystical
description
. These writings contain a marked decrease in references to magica
l or supernatural
exclamations of disease
.

Belief in gods was still predominant
but they were not
considered to be
the direct cause of disease.
17
,
18

Imbalance of internal humours became the dominant explanation of disease in the
Hippocratic era of medicine.

The
humoural theory

stated that the human body was made up of
four basic substances or humours: blood, phlegm, yellow bile and black bile. Individuals were
healthy when these four elements were balanced but if there was too much of one element and
not eno
ugh of another, persons were ill.
19

Each of the humours was associated with a pair of
qualities: hot, cold, wet and dry. Each was also associated with a season and this lent many
diseases a seasonal quality; phlegm was cold and increased in the winter, blo
od increased in the
spring, yellow bile in the summer, and black bile in the autumn

(fig 1)
. Physical examination
was also emphasized in the Hippocratic writings


physicians were encouraged to take detailed
case histories that looked for physical signs a
nd symptoms, such as coughing, breathing and the
presence of tumours.
20















Black Bile

Blood

Yellow Bile

Phlegm

Hot

Moist

Cold

Dry

Fig 1. Hippocrates’s four humours (adapted from Magner, 1992).

Treatment of most diseases was aimed at restoring humoural balance. For example,
purging, laxative
s, bloodletting, emetics, diuretics and enemas were employed to rid the body of
excess humours. Preventive medicine in the form of advice on how to ensure a complete diet, get
adequate exercise and partake in healthy sexual activity was commonplace. Hippo
cratic
physicians also recognized the natural healing process as critical in achieving optimum health.
Diseases were themselves natural and it was the physician’s responsibility to help nature achieve
a cure.
17

How did this approach to medicine influence t
he way in which the Greeks interpreted
cancer? The Hippocratic corpus contains eleven separate sections that approach the pathogenesis
and treatment of cancer.
21

The clearest reference to cancer is found in the fifth book of
Epidemics: “a woman from Abdera
developed carcinoma on the breast, and through the nipple
there was sero
-
sanguinous discharge; when the discharge ceased she died.”
22

A number of other
references throughout the corpus suggest that Hippocrates distinguished between superficial
,
malignant t
umours which he called
karkinoma apertus

and deep tumours,

or
karkinoma occlusus
,

considered the overall condition of the patient before diagnosis and was aware that some cancers
favoured
either the male or female gender or

the elderly. According to Hippoc
rates, an excess of
black bile or
atrabilis

was the major cause of cancer. If tumours were superficial, Hippocrates
advised that they be removed by excision; if they were occult or internal, it was best to leave
them alone; “It is better not to apply any t
reatment in cases of occult cancer;” wrote Hippocrates,
“for, if treated, the patients die quickly; but if not treated, they hold out for a long time.”
10

For
Hippocrates, cancer was a systemic disease and as such it was best to let the disease take its
co
urse without surgery.
Some tumours could be treated with external ointments made from
copper, lead, sulphur or arsenic.
5

This limited knowledge of tumorous growths must be viewed
in light of the taboo surrounding human dissection. For it was not until the
third century B.C. that
human dissection was allowed in Alexandria and even then it

would soon become illegal
again
under Roman law.
23

As was the case in ancient Egypt, a limited understanding of human
anatomy hindered research into the pathophysiology of c
ancer and the primary explanation of the
disease was based on superficial observation and conjecture.


Little evidence survives about the history of cancer in the centuries that followed the
flourish of Hippocratic medicine.

Although there is evidence to
suggest that the Hippocratic
tradition in cancer care persisted.

Some recollections of later Roman medicine were preserved by
the medical encyclopaedist Aulus Cornelius Celsus (25 B.C.


50 A.D.). While not ostensibly a
physician, Celsus wrote profusely on

medical topics and summarized advances made in Greek
and Alexandrian medicine during the rise of the Roman Empire in his text
De Medicina
. This
work is important as it is one
of the only surviving texts to provide

a glimpse into medicine
during this perio
d.


A small portion of Celsus’ encyclopaedia describes cancer and its treatment. According to
Celsus, the organs most commonly affected by cancer were the face, the nose, ears
,
lips, and
breasts of women, as well as the liver and the spleen.
24

Tumours wer
e difficult to treat and it was
advised that as soon as they were perceived, one should use “caustic medicines”

to cure them.
Celsus
is
purportedly the first to classify breast cancer into four stages of progression: 1)
cacoethes (early
-
stage tumour), 2) c
arcinoma without skin ulceration, 3) carcinoma with
ulceration, and,

4)
“thymium,” an advanced exophytic and sometimes bleeding lesion
.
25


The work

of Hippocrates was

officially

revived

and expanded

by Gal
en of Pergamon
(129AD
-
199 AD), the acclaimed physic
ian and philosopher.
Throughout his lifetime, he wrote
profusely on medical topics as diverse as an
atomy, physiology and pathology. The knowledge
contained within these texts would dominate
medical
practice in
the West until the Renaissance.
The basis of G
alen’s approach was grounded in the Hippocratic course. Galen added to this by
performing limited anatomical experiments on animals.
17

It has been suggested that Galen
modelled himself to be a “scientific doctor”

that is, he used reason to localize disease
.

R
ational
and regional concepts of disease were borne from Galen’s practice.
26

Within this framework, Galen too contributed to knowledge about cancer. Galen was the
first to describe tumours using the word

“cancer” which derives from the Latin word “cancr
um”
or crab, because he believed tumours had a characteristic crab
-
like shape.
4

This definition can be
gleaned from one of his treatises,
“…and on the breasts we often saw tumo
urs resembling
exactly the anim
al cancer. And just as the animal’s legs are on e
ither side of

its body, so do the
veins stre
tched by the unnatural tumour resemble (the animal) cancer in shape.”
22

He also
introduced the term “sarcoma” to describe tumours that exhibited a “fleshy” cross
-
sectional
appearance.
4


While remaining faithful t
o Hippocrates’s humoural theory,
Galen extended Hippocrates’
definitions of cancer and classified tumours into three major types (fig. 2
).
4, 14



Fig. 2.

Galen’s Classification of Tumors



He maintained the humoural theory of cancer and argued that the di
sease was metabolic and
should be treated systemically rather than locally
;

cancer should be treated by attempting to
balance humours, using the same diet and purges that Hippocrates advised, and to remove
tumours surgically.

27

An illustrative description
of one such cancer treatment is included in one
of Galen’s texts:


If you attempt to cure cancer by surgery, begin by

cleaning out the
melancholic tumor by cathartics.

Make accurate incisions surrounding the
whole

tumor so as not to leave a single root. Le
t the blood


ow and do not
check it at once, but make pressure

on the surrounding veins, so as to squeeze
out the

thick blood. Then treat as in other wounds.

28


A skilled surgeon, Galen is supposedly also the first to have used surgical sutures to stitch up
wounds cau
sed by surgery as well as ligatures to tie off cut vessels and prevent further bleeding,
innovations that may have been inspired during his time as a the official physician for the Roman
gladiators.
4
Again, we see the importance of observation in diagnosin
g tumours and in
classification. Galen built upon the knowledge base established by Hippocrates in order to fine
tune Roman ideas about cancer.



The Middle Ages (500 A.D.


1450 A.D.) and the Renaissance
(1450 A.D.


1600 A.D.)

A long period of medical st
agnation followed the fall of the Roman Empire

in 476 AD
.
The Middle Ages witnessed a return to the amulets, magical spells and other superstitions that
dominated medicine in the time of the Pharaoh’s. This regression was largely due to the fact that
befor
e the founding of independent universities in Europe between the 10 and 13
th

cen
turies,
scholarship was
restricted to a small array of medieval monastic orders. This situation would
change when universities were established.
The major medicinal text to su
rvive the Middle Ages
was the work of Galen, which had been transcribed and
translated by Arabic scholars. As a
result, Galenic
-
cum
-
Hippocratic humo
u
ral theories were resurrected in the Middle Ages and
would influen
ce how physicians treated and viewed canc
er up until the last part of the
seventeenth century
.
4



In the late medieval period, there was a return to using the word

cancer rather broadly to
describe a range of afflictions, including swellings, gangrenes, tumours, abscesses, and herpes
sores. A mor
e concrete definition was provided by Guy de Chauliac (1300
-
1370), the le
arned
French surgeon, who defined

cancer as “a hard, round, veined, darkish, fast
-
growing, restless,
warm and painful tumour.”

14
,

29
,
30

As Luke Demaitre has observed de Cauliac’s defin
ition was
clearly rooted in Galenic principles and Greek ideas of temperature and spreading humours, an
observation that supports the conclusion that older Hippocratic
-
Galenic ideas still dominated
cancer aetiology in the middle ages.

31

Similarly, Egyptian

ideas of cancer “eating” and
“gnawing” the flesh continued to be used by some, such as Henri de Mondeville (1260
-
1320).
31
De Mondeville did considerable work on concepts of cancer in this period. He specified the
humoural theory of cancer by differentiati
ng between black bile produced in the liver, which he
thought contributed to hard tumours in the breast, and black bile produced as the breakdown
product of the three other humours, which resulted in true cancer. As with Galen, de Mondeville
recommended di
et and purging to redress humoural imbalance, as well as the extirpation of
tumors.
25

A review of the dominant medical texts of the period, including de Chauliac’s and de
Mondeville’s indicates that b
lack bile was still thought to be the primary cause of c
ancer.
It was
thought
humour became problematic when it was improperly cooked or burned, a process which
made it thick and stagnant and incapable of being expelled from pores or in the blood. Breast
cancer was common in light of this belief because menstru
ation prevented women from properly
cleansing their blood of black bile.
31

In the Renaissance, there was efflorescence in all areas of human life, including the arts,
literature and medicine. A renewed interest in the pursuit of intellectual activity and t
he
opportunity to explore the natural world unhindered by medieval mores allowed those who
studied medicine to rethink accepted traditions.
16
There was also a transition from Aristotelian
-
Galenic rationalism, based on metaphysical analysis to Baconian
-
New
tonian empiricism, which
took experiment as its starting point. The work of Andreas Vesalius (1514
-
1564), especially his
De Humani Corporis Fabrica

(1543) and the critical approach to anatomy contained within it,
would throw the long
-
revered definitions of

Galen into question. Vesalius’s dissections of human
cadavers would for the first time demonstrate the errors of Galen’s hypotheses, as these were
originally based on the anatomy of apes and pigs, not humans.
32

Others too, like the alchemist
Theophrastus P
aracelsus (1493
-
1541), were brazen enough to attempt to overthrow Galen’s
humoural theory, even though his own theory of cancer


that it occurred because of excess
mineral salt in the blood


was itself magical and imprecise.
1



The
Seventeenth and Eighte
enth Centuries


In the Age of Reason, thoughts about the origin of cancer shifted away from the humoural
theory toward the lymph node origin of the disease.
The French philosopher and physician René
Descartes (1596
-
1650) was the first to propose the lymph
theory of cancer.
16,
33

Among the
proponents of this idea
was Henry François le Dran (1685
-
1770), a Parisian surgeon who in 1757
argued that certain cancers, such as breast cancer, spread not
by humours but by the lymphatic
system
.
According to le Dran, t
um
ours began in localized areas
. T
he disease was than
transported to regional lymph nodes and eventually produced
systemic disease
throughout the
body.
34

In order to prevent spread, le Dran recommended complete excision of tumour
s as well
as nearby lymph node
s. Le Dran’s contributions were made possible thanks in large part to the
incremental discoveries made in the science of the human body. The Italian anatomist Gasparo
Aselli (1581
-
1626), for example, discovered the lymphatic system in 1622, while William
H
arvey (1578
-
1657) described the circulation of blood in 1628.
35
,

36


This eighteenth century
is particularly interesting for its
many contributors
to cancer
epidemiology. In the 1700s, curious physicians and men of science documented numerous links
between c
ancer and certain occupational and lifestyle choices. In 1713, for example, Bernardini
Ramazzini

(1633
-
1714)
, professor of medicine at the University of Padua, wondered about the
high rates of breast cancer and the virtual absence of cervical cancer in nun
s. He concluded that
the population’s celibate lifestyle must be the cause
,

suggesting that lack of sexual intercourse
diminishes
“disturbances in the uterus. Cancerous tumours are [then] very often generated in the
woman’s breast.”
37

In 1761,
the English p
hysician
John Hill (1714
-
1775) observed that snuff
users were more prone to developing nasal cancer,

an observation considered by some
the first
acknowledgment of external carcinogenesis.
38
,
39

In 1775, British surgeon Percival Pott (1714
-
1788) described an
association between scrotal cancer and the chimney sweep occupation,
presumably the first documented case of occupational cancer.
40



With the acceptance of human autopsy, a practice outlawed in earlier times for reasons of
religion and decorum, the gross p
athology of cancer could for the first time be observed without
criticism.
41
,

42

In 1761, Giovanni Battista Morgagni (1682
-
1771) laid the foundations of scientific
oncology with the publication of his
On the Sites and Causes of Disease
, a landmark text
consi
dered the first example of modern pathology.
16

In this work, Morgagni described cancers of
the breast, stomach, rectum and pancreas based on findings compiled from 700 autopsies, a
remarkable feat

made possible by the loosening of societal strictures on hu
man dissection
.
His
observations inspired him to be the first to attempt to disprove the Cartesian lymphatic theory
with experimental findings.
32

The study of cancer as an independent disease with its own
symptoms and treatments was enforced by the foundin
g of the first institutions set up to treat and
research the disease. The eighteenth century welcomed the
first cancer hospital
, LaLutte Contre
Le Cancer, which was founded in
Rheims, Fran
ce in 1740, and
the first cancer institute, where
studying the natur
al history of cancer was the primary cause,
which was
opened in Middlesex,
England in 1792.
43

In addition to suggesting the rising importance of cancer study, the ways in
which these institutions were managed illustrates some noteworthy eighteenth
-
century c
ancer
concepts. LaLutte Contre Le Cancer, for example, was moved away from the centre of Rheims in
1779 because it was presumed that cancer was a contagious disease.
16


The Nineteenth Century

In the nineteenth
century,
there was a marked shift away from th
e humoural theory of
cancer to a cellular theory of the disease. This was made possible by improvements in scientific
technology, namely the light microscope.
44

Invented by H. Jansen in the late sixteenth century,
and
used remarkably by Antony van Leeuwenho
ek (1632
-
1723)
and Robert Hooke between
1665 and 1678
to identify
microorganisms
,

the light microscope was improved further by
Charles Chevalier in 1824 allowing clearer visualization of microscopic specimens.
45
,

46

Johannes Müller (1801
-
1858),

German physio
logist and comparative anatomist, was among the
first to ob
serve cancerous tissue under the

improved achromatic lens of the new
microscope. In
1838
, he

The Edwin Smith
Papyrus describes 48
traumatic surgical
cases, 8 of which are
believed to be cases of
breast tumours.


Bernardini Ramazzini suggests a link
between abstinence and high rates of bre
ast
cancer/low rates of cervical

cancer based on
his
observations of nun
s.

The Ebers Papyrus
recommends the use of a
mixture of dates and other
natural substances to treat
tumours in the uteru
s
















Hippocrates explains cancer
using his humoural theory.
He believes that an ex
cess
of black bile or
atrabilis

leads to the development of
tumours.


Galen popularizes Hippocrates’
humoural explanation of cancer.
He

classifies tumours into three
main types.


The first cancer institute opens in
Middlesex, United Kin
gdom
.

2500 BC

1500 BC



400 BC

50 AD 199 AD

1300
-
1370


1543


1600


1713 1740 1761 1775 1792 1838 1858 1865

Aulus Cornelius Celsus
recommends caustic medicine and
cauterisization as treatment from
cancerous tumours

Guy de Chauliac defines cancer as “a hard, round, veined,
darkish, fast
-
growing, restless, warm and painful tumor”
during a period in medical history when the word was used
quite liberally to de
scribe a range of inflammations. Henri de
Mondeville distinguishes between the different types of bile
that can produce cancer


Galen’s interpretation of cancer,
favoured since its introduction, is
slowly overturned by the work of
Andreas Vesalius, who publishes
De Humani Corporis Fabrica
,
and other R
enaissance thinkers.


Rene Descartes proposes the
lymph theory of cancer.


Percival Pott describes an
ass
ociation between scrotal
cancer and the
chimney
swe
eps.

G
iovanni Battista Morgagni
records
anatomical

observations of human
cadavers.

John Hill remarks
on the relationship between
snuff and nasal cancer.


Johannes Mulller observes
cancerous tissue under a
microscope for the first time.
Based on his observations, he
postulates the blastema theory of
cancer.


The first cancer hospital
opens in Rheims, France
.

Rudolf Virchow disproves

the
blastema theory and confirms that
cancer develops
from
pre
-
existing
cells.


Karl Thiersch establishes that cancer is
spread by malignant cells.

Fig 3. Timeline of historical concepts of cancer, 2500
BC


1865.

verified that tumours were in fact made of cells and not clotted black bile or other unknown
substances.
47

While Müller confirmed the cellular heritage of cancer, from his observations he
extrapolated
what became known as
the blastema theory of
cancer, which stated that tumours
originated from a primitive body fluid or blastema by intracorporeal generation or crystallization

and not other cells
.
48

Blastemas were undifferentiated cell
-
like fluids that

originated between
tissues that made up an orga
n,

exuded from the blood and could develop into any tissue.

1

This
theory clearly echoed the ancient beliefs of Hippocrates humours, but nonetheless it founds its
champions in nineteenth
-
century medical men,
including
Julius Vogel (1835
-
1899), who
expanded

the theory in 1845 by proposing that each tissue had its own blastema (the law of
analogous blastemas).
16

S
ome were
, however,

still reluctant to accept that cancer developed from
a mysterious component of the blood.

One of Müller

s students, the German p
hysician and pathologist Rudolf Virchow (1821
-
1902), would provide the evidence needed to disprove this accepted truth. Using his principle of
cellular pathology, which stipulated that the cell was the smallest unit in which disease could be
located, Virc
how conducted pathological examinations of histological samples and concluded
that cancer arose in cells and not from body fluids or fibres.
49

Virchow’s revolutionary aphorism
omnis cellula a cellula

or “all cells are derived from cells” opposed the idea of

spontaneous
de
novo

generation and asserted that tumours did not develop from blastemas but from cells. In
18
58
, Virchow published his seminal text
Die Cellula Pathologie
in which he described the
microscopic details of cancer and highlighted the potentia
l for the disease to be diagnosed using
microscopic analysis of pathological tissue.
50

He proposed that cancer cells were generated by
either one of two methods: 1) a hereditary or constitutional predisposition or 2) from chronic
cellular irritation.
16

Desp
ite these revolutionary claims
Virchow, however, still believed that
cancer was spread by a liquid, rather than by malignant cells.
51

In 1865, the German surgeon
Karl Thiersch (1822
-
1925) verified that malignant cells spread cancer by studying metastasizing

epithelial tumours of the skin. Based on serial sectioning techniques, Thiersch concluded that
malignant cells in lymph nodes reached secondary sites by cellular embolism; toxic fluids were
released from malignant growths but cells were ultimately respons
ible for spread of the disease.
52

Karl von Rokitansky

(1804
-
1878) identified the two main cellular components of cancer to be
the cancer mass or parenchyma, composed of nuclei and nucleated cells, and the framework or
stroma, which was not considered neopla
stic. The qualities of these two components determined
the type of cancer; if the stroma was predominantly made of fibered trabeculae what was known
as a fibrous cancer developed while a medullary or gelatinous cancer formed when the
parenchyma predominate
d.
1

The work of Müller, Virchow and Rokitansky would formulate
modern classifications of tumours used in cancer pathogenesis, i.e. the type of cell that composes
the tumour, e.g. epithelial or mesenchymal, and whether they tumour is benign or malignant.
3

A
s
Diamanopoulos has observed, this system of classification is strikingly similar to the ancient
frameworks established by Hippocrates and Galen, i.e. a classification based on morphology and
behaviour.
4


Conclusion

This brief look at the history of cancer

from ancient Egypt until the nineteenth century
brings several facets about the evolution of science to the fore.
For one, it highlights how small
additions to the overall body of knowledge can have exponential effects on eventual
contributions


there is

a clear advantage to the steady
accumulation of knowledge over the
centuries.

The ideas of humoural imbalance and circulating toxic fluids, introduced by
Hippocrates and Thiersch, for example, still linger in contemporary theories of cancer.
53


This articl
e also demonstrates how scientific ideas are refined by improvements in
scientific method and scientific technology. Revolutions in thought following the stagnancy of
the Middle Ages facilitated a greater emphasis on observing the human body at the gross
a
natomical level. This allowed individuals like Paracelsus and Descartes to propose alternative
theories of cancer origin that opposed the long accepted humoural theory established by
Hippocrates and Galen. Enhancing the human senses to be able to visualize

the microscopic
transformed understanding of cancer pathology.

In the nineteenth century, the
improvement
of
the microscope,
for example,
allowed scientists like Müller and Virchow to conclude that
tumours were in fact made of cells

and not lymph or bile
.

A number of common themes weave throughout these earlier concepts of cancer. The
idea that cancer was transported in the body within some sort of fluid, be it black bile, lymph or
Virchow’s toxic liquid, is one such theme. The humoural theory, lymph theor
y and blastema
theory share this tenet. This belief facilitated the notion that cancer was a systemic disease
because the fluid allowed it to be transmitted to the entire body. There are also themes in cancer
treatment. Surgical removal of cancer was commo
n in all periods from ancient Egypt to the
nineteenth century. We also see how social norms, such as the prohibition of human dissection,
have shaped the ways in which science is made.

Modern cancer research too has been affected by accretions in knowledge
, advances in
practice and technology and these common themes. In the twentieth century, these preliminary
advances have been taken even further with the ability to see beyond the cell and into the
genome. Thus, we can conclude that modern theories of canc
er and our current understanding of
the disease have benefitted from these past theories by building on the knowledge they embodied
and by using them as the foundations for contemporary concepts of cancer.








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