For Paulus Aegineta, cancer is an uneven swelling, rough, unseemly, darkish, and painful. It may appear either without ulceration (what the Hippocratic physicians called “cancer”), which worsens if operated upon, or with ulceration (the Hippocratic “carcinoma”), which occurs due to black bile, spreads with erosion, and appears in all body parts, but especially in the breasts and uterus of women. He believes that operating for uterus cancer is impossible and very dangerous, but in all “external” parts, such as the breasts, surgical treatment must be used. He disagrees with the methods used by other physicians, including cauterization or combination of mastectomy and cauterization of the area, agreeing only with Galen, who uses excision of the tumor and its roots and putrefaction for the discharge of the superfluous black bile.8
The study of ancient texts dealing with surgical treatment of cancer provides the reader with numerous conclusions that can be neither verified nor falsified. The Hippocratic physicians suggest that the most difficult cancers to treat are those of the axillae; the “difficulty” may lie either in distinguishing the tumors in the area or in the fact that tangible lymph nodes appear either in advanced cancers (especially of the breast) or in lymphomas, namely in situations that in that era and until recently were untreatable or treatable with very high morbidity. The Hippocratic physicians also advised not to treat surgically cancers that had not ulcerated, because they were thought to be incurable and any interference would lead to the death of the patient, while otherwise the patient might live for a long time. This conclusion could have been drawn by the observation of large benign tumors of the breasts, erroneously characterized as cancers, which do not ulcerate and have good prognosis, while any surgical intervention at that time would surely have high morbidity.
Archigenes of Apamea adds to the knowledge of the surgical treatment of cancer, which is advised only in case the patient is strong and has the power to cope with the operation; taking into consideration that there was no anesthesia or antibiotics at the time, this suggestion makes sense, since under these circumstances no surgical operation could be performed. Archigenes also describes various techniques that aim at the disruption of blood supply to and from the tumor. Ligature of the vessels surrounding the growth directly detaches the tumor from the vessels, while in combination with application of cold water, it induces vasoconstriction and, if applied for a long time, thrombosis of the small vessels. Additionally, the application of cups around the tumor possibly aggregates blood in the venal system of the tumor, further inducing stasis and thrombosis of the vascular bed. All these techniques seem to constitute the forerunner of embolization of the vascular supply of the tumors.9 Archigenes also suggests the use of instruments proportionate in size to the affected area, in such a way that the instrument may easily make a circular incision without any obstacles. Such a suggestion is reasonable, because the aim was to decrease the duration of the operation, thus decreasing operative pain and possibility of infection. Archigenes’ suggestion to move away any nerves from the perimeter of the wound could be reasonable based on avoiding postoperative pain and spread of the tumor to the surrounding tissues by perineural transmission. Finally, both Archigenes and Galen prefer using cauterization rather than ligation, probably in order to increase patient survival, although today we could explain it based on the fact that thermal energy has the additional ability to kill cancer cells, whereas ligation helps control hemorrhage without playing any oncologic role.
Galen believes that the cause of cancer is accumulation of “residues of black bile” created when the liver is weak, when the diet produces a large amount of thick blood and the spleen is weakly attracting the bile. Today, though, it is obvious that all those “causes” are in fact results of advanced carcinomas, which among others, provoke hypotrophy, diminished liver function, and immunodeficiency. Furthermore, Galen suggests, similarly to Archigenes, treating cancer only at its commencement, which is reasonable, bearing in mind that many benign tumors (such as cysts, fibroadenomas, lipomas, etc.) appear as small growths that were erroneously considered to be cancers. If therefore only such kinds of growths were operated upon, the prognosis was of course promising and the operation was considered as a successful one against “cancer.” Another important point in the Galenic texts is the advice he gives regarding ligation during operation, in fear of causing “affection of the neighboring parts by cancer.” Actually, poor surgical technique may indeed cause implantation of cancer cells to neighboring tissues, as in cases of imperfect resection. Moreover, he mentions the use of cauterization for the “burning of the roots of the tumor”; in advanced carcinoma of the breast, it was probably impossible at that time to radically excise the tumor or infiltrated neighboring structures (notably underlying muscles or bones). Cauterizing these parts possibly ameliorated prognosis through thermal destruction of the cells, which strongly resembles thermoablation, a very innovative treatment for cure of breast cancer.10
Taking into consideration the possible explanations provided in the ancient references to surgical treatment of cancer, one can only admire ancient medical practice. Even if most of the explanations were found in modern years, ancient physicians managed to use surgery with skills acquired through observation and experimentation in animals. Poor postoperative results taught the ancient physicians what they were able to do and what not, blaming though the nature of the tumor for any unfortunate prognosis.