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Galen on Tumors
© 1989 by Ralph W. Moss, Ph.D.
The Greek phyisican and writer Galen (129 C.E.-ca 199) was well acquainted with tumors. The index to Kühn's edition lists over a hundred references to tumors (onkoi) and another hundred or so to cancer per se (karkinos). 1 These references are generally short allusions scattered over twenty volumes. For instance, in his work on medical definitions (Horoi iatrikoi) Galen differentiated among `skirros, ' `karkinos' and `karkinoma.' At Kühn XIX: 393 he refers to cancer as a malignant state, kakoethes. There is also a discussion of cancer in the influential Methodi Medendi (Therapeutikes methodou).2 In this paper, however, I shall mainly discuss the one work which Galen wrote specifically on the topic: De tumoribus praeter naturam (peri tôn para physin oncôn).
By general agreement, this is not a major opus. Even Jeremiah Reedy, his modern English translator, calls it "admittedly one of Galen's minor works."3 He believes its interestlies primarily in the fact that it is a "concise example of the application of the doctrine of the humors to pathology." 4
Nevertheless, I believe that De tumoribus has far greater historical significance. It is the only work of antiquity specifically devoted to tumors, cancerous or non-cancerous. This alone warrants an important place in medical history. And while it may be ill-organized, schematic and derivative (especially the Hippocratic corpus) it did codify the influential notion that cancer is caused by an excess of black bile (`atrabilis' or `melanchole'). This idea survived intact through the Middle Ages and Renaissance and was only superseded (by the lymph theory) at the end of the eighteenth century. In fact, Jacob Wolff, in his authoritative four-volume history of cancer, characterized the all pre-modern thinking about cancer as, "Die Theorie von der Atra bilis." And Wolff writes, "Denn die schwarze Galle ist die Ursache des Krebses und diese Theorie hat bis spät in das 18. Jahrhundert als ein Dogma gegotten." 5.
The Greek title of De tumoribus is itself instructive. The word onkos meant any kind of mass, such as a "heap" of wood or a woman's "bun" of hair. Galen begins his treatise in a neutral tone: "One of the things that happen to bodies is what is meant by the word oncos." It is simply any "extension in length, breadth, and thickness." Para means bypassing something or going against or contrary to something.6 "Para physin" is thus something abnormal, unnatural, hence prone to disease.
The general topic of this work is swellings, not specifically cancer and the first kind of swelling dealt with is the most familiar: obesity. According to Galen the obese (as well as the emaciated) are in a category somewhere between health and disease. They are still kata physin but not yet para physin:
"...the obese have grown beyond what is natural in breadth and thickness; nevertheless, they are not yet contrary to nature (7). They represent a third state. By contrast, a man with a swelling caused by dropsy may look the same as an obese man but is in fact contrary to nature. The difference is that the contrary to nature state is marked by its "harmfulness to function" (hê blabê tês energeías). This distinciton shows an emphasis on functionality in understanding physiology and disease."
Galen catalogues an enormous number of conditions that can cause an unnatural increase in the size of the body. The first is inflammation, defined as a large swelling of the fleshy parts that occurs with "tension, resistance, throbbing pain, heat, and redness" (30.16-17). According to Reedy, this is the locus classicus for the famous four symptoms of inflammationrubor, dolor, calor, and tumor. 8
Galen admits the medical profession's ignorance of the cause of inflammation. "Why these symptoms develop is not known even by all physicians themselves, let alone by the masses." He faults doctors for not making a "systematic investigation" (zetesis); they simply pronounce their opinion" (doxa) (section #3.4). But after this admirable appeal to the scientific method, Galen pronounces his opinions on the matter. His explanation consists of variations on the theory of the four humors and the four elements. Inflammations occur when a part of the body is "suffused with much heat and is boiling hot...air is not seen in the inflamed parts." "If the inflamed part is cut, a large quantity of blood can be seen flowing out." The color of the inflammation, red, is proper to blood, "for no other parts or humors of the body is red except flesh and blood".
Galen emphasizes the importance of color as a diagnositic tool and one often meets with red blood, black bile, yellow bile, etc. in his work. "Color...is an indication of the quality of a substance," Galen explains (#31.25). After a long discursus on polysarcia Galen returns to his previous discussion of inflammation and concludes that it is brought about by an increase of the bloody humor.
Although Galen was not associated with a particular medical sect (and is praised for rising above them) one still finds something sectarian about this discussion. He is out to destroy the theory of an unnamed opponent that air is responsible for inflammations. 9 His counter-argument is that all inflammations result from a disturbance of the blood. In Galen's system heat is involved. So, too, is "some substance from without." Galen combines various theories in a highly assertive way. This has been put it in less complimentary terms, however: he has been called an "eclectic dogmatist."10.
In De tumoribus Galen often finds an apt analogy. Thus, he compares inflamed tissue to "soaking-wet sponges" (hoi diabrocchoi spongoi). At times he argues from first principles pertaining to the physical world. Blood is "unlike pitch, resin, and wax," in that "it does not thicken when cooled, and it is always rather warm by nature" (p.33.22-23). Polysarcia on the other hand cannot be caused by an increase in blood because: The original color is not heightened in anything which increases in its substance. If it were, snow would become whiter, pitch blacker, and gold yellower.11
Galen, the philosopher, is associated with the development of logic and one can transform this argument into syllogistic form:
Inflammation is far and away the most important topic in De Tumoribus. It takes up nearly a third of the text. But Galen procedes to treat many other types of growths which are contrary to nature. These include, in addition to the above-mentioned polysarcia, abscesses, suppurations (empyemata or diapyemata), etc.. In a good example of realistic thinking, he chastises his wordy colleagues:
"As I have always said, one should be concerned about names only so that what is meant is clearly expressed. A person must be eager to discover the things themselves which are under discussion so that not one of them remains hidden. All these matters are but preparations for the therapeutic method with which we cure the conditions, not their names." 12
Again: "Their controversy is about the name; it would be better to know the origin of the symptoms and disregard the name."13 But he then procedes to catalog the names of 61 such illness and to propose treatments for almost none of them.14
Some of these conditions are familiar, such as erysipelas, fistula, carbuncles, gangrenes, herpes, and leprosy. Elephantiasis; boils; tubercules; and buboes are there, as is satyriasis or priapismus, a condition we might not think to include in a modern textbook on `tumors.' In other cases, however, his meaning is obscure. We are told that achor is "a small ulcer on the skin of the head." But what exactly are atheromata; steatomata; melicerides; pnematoses; ecchymomata and melasmata; pelidna; psoras; myrmeciae; achrochordones psydraces; epinyctides phygethlon; struma; sarcocele; hydrocele; epiplocele; enterocele; enteroepiplocele and so forth. Some of these are "conditions," he assures us, "known to everyone".15
At the end of the essay Galen writes "now it is time to put an end to this treatise, since there does not remain any type of swelling which is contrary to nature that has not been discussed."16 This is technically true, although the book has turned out to be more of a catalog of swellings, than an analysis of any particular condition.
Galen on Cancer
Galen's discussion of cancer per se is quite short. It takes up a total of only one page out of twenty-eight in the text. Nevertheless, this is the first book we know of to deal with tumors, including cancer, in a systematic way and the last one until Giovanni Ingrassia's 1553 book of the same name.17
Cancer (karkinos) is mentioned six times in the text. It was Hippocrates who named cancer "karkinos" 18 after the crab. According to legend, it was so called because this disease "has the veins stretched on all sides as the animal the crab has its feet, whence it derives its name." 19
Galen adopted Hippocrates' basic theory of cancer as an excess of black bile (melancholia or atra bilis). But in expanding this concept, he writes:
Black bile without boiling causes cancers and, if it happens to be rather acrid, cancers with a sore. For this reason they are blacker in color than inflammations and are not at all hot. The veins on them are fuller and more extended than in inflammations, because the humor that causes cancer does not run out as much from the vessels to the surrounding flesh because of its thickness.20
Galen's physiology includes not just four humors, but four conditionswarm, cold, moist and dry. The condition in turn determines the various drugs used in the treatment of disease.21 Thus cancer is caused not just by an excess of black bill but by a cool, black bile. It can be either acrid or not, giving rise to different kinds of cancers. It is the thickness of the cancer which gives rise to enlarged veins. This keeps the humors from running out and causing an inflammation.
The veins are not red, as in inflammation; they are like the humor that is causing distress, 22 i.e. black. After a digression into gangrene, Galen returns once more to the question of cancer. He has introduced the concept of dregs (ilus, literally, mud, slime or dirt). There are two kinds of black dregs, he says. One is what Hippocrates calls black. "The other is likewise black, but it has its own nameblack bile. Cancers come from the latter."23 Some of the characteristics of cancer are thus "a swelling that is larger than natural, painless and hard." The origin," he tells us, "is sometimes from the beginning, sometimes from a mutation either of an inflammation or of erysipelas or of edema when they have been cooled excessively."24
Black bile comes in various degrees of strength: thus, in chapter 12 we learn it can be either "biting" (daknodes) or "milder" (metriotera). The biting type "attacks flesh...it eats the surrounding skin and causes an ulcer." The milder type "causes cancer without ulceration." All ulcers, cancerous or not, "are products of an unhealthy state of the humors, either of some bitter bile, or of black bile, or of bile in some way poisonous and vicious because it is nourished by a major disorder" (p. 45). The languageek diaphthoras meizonos hypotrapheíses(22.5-6) is ominous in Greek since hypotrapheises carries with it the connotation of a secret nuturing, while diaphthora also means destruction, ruin or death.
Although Galen makes no categorical distinction between malignant and benign tumors, he shows an understanding that some growths are particularly catastrophic. Internal cancers were largely unknown to him 25 but cancer was believed to arise from a systemic condition: we might paraphrase this as `a major disorder nourished in secret by an unhealthy state of the humors.' And for Galen, what could be more serious than an unhealthy state of the humors?
Influence of the Text
The dogma of black bile as the source of cancer prevailed for over 2,000 years. It reigned for over 1500 years after De tumoribus. How influential was this particular work? It would be easy to overstate its importance. Undoubtedly, the major reason for the longevity of the theory was the general prestige of Galen's name and theories in the Middle Ages. For various reasons, the basic notion of four humors prevailed, and the black bile theory of cancer was accepted as part of that schema.
Nevertheless, a study of the work's transmission and early publishing history shows that De tumoribus was known, copied and preserved in several centers of medieval learning. It also was well-known in Syriac and Arabic traditions, was printed and enjoyed a considerable vogue in the sixteenth century. But with the development of alternative paradigms of cancer it fell into almost total obscurity.
There are eight mss. of the text preserved. All but one, the vellum Marcianus, are on paper. Most date from the fourteenth century.26
Through standard techniques of linguistic analysis, especially of textual errors, Reedy concluded that four of these manuscripts were derived from a hypothetical "a" ms., the other four from "b." At some point in the past, both a and b were copied from a single parent text, called "w."
De tumoribus, like so many other Greek mss., was preserved in the Arabic world, although we have no direct evidence that it made its way back to the West through Islam. Hunain ibn Ishaq, a ninth century physician, wrote that he himself made a synopsis in Syriac of this work. He also stated that Ayyub ar-Ruhqwi al-Abrash (who flourished in the early ninth century) translated it into Syriac. Arabic translations were done by Ibrahim ibn as-Salt, a contemporary, and by Hubaish, a nephew of Hunain.27
A word-for-word Latin translation by Nicholò da Reggio (1280-1350) is especially important, because it appears to be derived from a text earlier than all the extant mss.28
The first printed text of De tumoribus was the Aldine edition of 1525 (vol. III, folios 83r to 85r), which appears to have been derived from the "a" tradition.
The apogee of influence forDe tumoribus appears to have been in the sixteenth century when it was repeatedly translated into Latin and three European languages 29:
The work was the subject of a disputatio in Strassburg in the early seventeenth century, although the German translation of P. Richter did not appear until 1913. 30 With the overthrow of the Galenic humoral theory of cancer, there was an equal decline in studies and translations of this work. The Basel edition, published in 1538, and those of Charterius (1679) and the monumental work of Kühn, including text and Latin translation (1824) were all "little more than apographa of the Aldine edition."31 Jeremiah Reedy's critical edition, with English translation, done as a 1968 Ph.D. dissertation, was the first to make a first-hand study of all the manuscript sources. Reedy discovered more than 50 errors in Kühn's edition.32 It was the first English translation in almost four hundred years.
To understand Galen's thinking on cancer it is necessary to know something about his general medical background. He was born at Pergamum c. 129 and died 199. (Singer gives his dates as 131-201). He had a "spectacular career."33 He studied at Smyrna, Corinth and Alexandria and at the age of twenty-eight returned to Pergamum, where his practice included dietetics and surgery. He was a physican at a gladiatorial school and went to Rome in 161 or 162 AD. There he won fame as a physician and "remarkably good" teacher.34 His earliest writings were probably the philosophical ones. In this field, he followed Aristotle, with elements of Plato and Stoics mixed in. Galen was summoned by Marcus Aurelius to serve in the Army and eventually became the Emperor Commodus's personal physician. Galen left Rome in 193.
In all, he wrote 500 works, the main one the Ars Magna, "the bible for medical practice for centuries" to come.35 Galen's work is considered the "culmination of the development of Greek biology."36
Galen excelled at comparative anatomy and performed detailed dissections, correcting results of earlier generations. These were not of man, like Herophilus and Erasistratus, but of animals including barbary apes, which he considered closest to man. Galen showed that arteries as well as veins carried blood. His physiology was entirely adequate for the system he proposed. He reinterpreted Hippocrates to fit his own system. He has been called a polemicist who engaged in "violent diatribes"37 and an "eclecitic dogmatist,"38 in fact the "greatest eclectic."39 Galen's personality dominates all his references to others. (For instance, in De tumoribus there are more references to himself than any other physician. In fact, Hippocrates is the only other physician he mentions by name.)
Galen's physiology was based on the familiar four humors, although he neither invented these humors nor named the temperamental types--sanguine, melancholic, choleric, and phlegmatic.40 This portion of his work, it is said, was "most strongly influenced by speculative ideas."41 It called for a complicated balance of elements, humors and qualities. Pneuma, a spirit derived ultimately from air was critical to his whole system and was borrowed from Herophilus.42 Environmental factors were also taken into consideration. But central to all was the role of digestion and nutrition. Everything depended on how the system functioned. Galen believed blood had its origin in chyle, which was brought from the alimentary canal through the portal vessel, to the liver. There it was turned into blood.43 "The system determined what treatments would be necessary."44
Drugs ("galenicals") were also important in his system. He classified them by their affinity to humors. He classified drugs into four "degrees" of one or more of the qualities warm, cold, moist, and dry.45 A drug, thus, might be warm in the second degree and moist in the third degree. "This gave him a rough idea of the type and severity of the disease which the drug might treat."46 This has been called an early attempt at quantification in medicine.47 Theriac, the famous panacea he concocted, contained 70 ingredients in an opium base. He used this, and Mithridates, in the treatment of cancer.48 He also employed various folk remedies and urged cancer patients to avoid certain substances. Because of his humoral base, bleedings, purgatives and diuretics were also basic to his therapy.
Basically, however, (following Hippocrates) he believed in prevention through nutrition and other methods. He was enormously influential in later times because:
While the biological works of Aristotle and Theophrastus "lingered precariously in a few rare manuscripts in monasteries of the East" and the entire output of the Alexandrians and Pergamenes was utterly destroyed, the "vast, windy, ill-arranged treatises of Galen saturated the intellectual world of the Middle Ages."52
He made the "great biological and medical synthesis of antiquity,53 and this can be seen in the cancer of tumors. This system lasted until Vesalius in the 16th Century A.D. In cancer, it was not superceded until the blood and lymphatic systems were known. Cancer was then thought to be a disease of the lymph. Galen's example gave a conceptual framework to a very puzzling phenomenon. He fought the sectarianism of earlier days and to laid the basis for a scientia aeterna, "a science in which all scientists equally share and on which all of them unanimously agree."54
1 Galen, Opera Ominia, ed. C.G. Kühn, Voll. I-XX, C. Cnobloch, Leipzig, 1821-1833.
2 Kühn, op.cit. vol. X. A large work. Most of the cancer references can be found in 975 sq.
3 Reedy, Jeremiah, "Galen on Cancer and Related Diseases," Clio Medica. vol. 10(3) 227-238 (1975), p. 227. The same translation as in Reedy (1968) below, with a short commentary.
4 Reedy (1975).
5 Wolff, Jacob. Die Lehre von der Krebskrankheit. Four volumes. Gustav Fischer: Jena, 1907. vol. 1., p. 11. Wolff 's standard history of cancer theories and treatments should be supplemented with Shimkin, below. The first volume of Wolff is now available in an English translation as "The Science of Cancerous Disease from Earliest Times to the Present. English translation by Barbara Ayoub. Introduction by Saul Jarcho, M.D. Published in the U.S. by Science History Publications/U.S.A., a division of Watson Publishing International, but printed in India.
6 Para with the accusative. With the dative it has another meaning. A healthy state, hygeia, is by contrast kata physin. The preposition kata (with the accusative) means "according to" or "answering to". Kata physin is regular Greek for "naturally."
7 Galen, `De tumoribus praeter naturam,' a critical edition with translation and indices, The University of Michigan, Ph.D. (University Microfilms #68-13,387: 1968) p. 29.
8 Reedy (1975).
9 This may have been based on observations of emphysematous, or "gas," gangrene, which occurs when a wound is infected with various anaerovic, spore forming bacteria, especially C. welchii.
10 Edelstein, "Galen," Oxford Classical Dictionary (Oxford: 1970).
11 Reedy (1968), p. 31.
12 Reedy (1968), p.37-38. Surprisingly, Galen has nothing to say about the treatment of tumors in this treatise. We learn from Wolff, op.cit., that this included purgatives with aloe, rhubarb and cassia, as well as the use of two compound medicines: Theriac (70 substances) and Mithridates (54 substances). He also recommended "das alte Volksmittel, Gaenseblut, trinken." Many substances, such as wine, rabbit flesh and old cheese were also forbidden to the cancer patient (p. 14).
13 Reedy (1968), p. 41.
14 Giovanni Fillippo Ingrassia (1510-1580) extended the list to 287 varieties of tumors according to Michael Shimkin, Contrary to Nature, Washington, D.C.: Superintendent of Document, DHEW Publication No. (NIH) 79-720, p. 51.
15 Reedy (1968), p. 47.
16 Reedy (1968), p. 50.
17 Celsus deals with cancer in De medicina V.28, but this is part of a larger and more general work. See Shimkin, Contrary.
18 Shimkin, Contrary, p.23. The phrase karkinodes helkos , `cancerous condition,' also appears once.
19 Paul of Aegina, 7th Century AD, quoted in Shimkin, op.cit., p. 35.
20 Reedy (1968), chapter 720, p. 43.
21 Leicester, Henry M. Development of Biochemical Concepts from Ancient to Modern Times. Cambridge: Harvard University Press, 1974.
22 Reedy (1968), p. 43.
23 Reedy (1968), p. 43.
24 Reedy (1968), p. 43.
25 "Der Krebs innerer Organe war ihm nicht bekannt." Wolff, Lehre, p. 13.
26 Reedy (1968), intro., for stemma and a discussion.
27 Reedy (1968), p. xiii. Also G. Gabrieli, "Hunan Ibn Ishaq," Isis VI (1924) pp. 282-292, M. Meyerhof, "New Light on Hunain ibn Ishaq and his Period," Isis VIII (1926) pp. 685-724 and G. Bergstraesser, "Hunain ibn Ishaq Ueber die Syrischen und Arabischen Galen-Uebersetzunge," Abhandlungen fuer die Kunde des Morgenlandes, Band 17: 2 (1925) p. 25.
28 L. Thorndike, "Translations of Works of Galen from Greek by Niccolo da Reggio," Byzantina Metabyzantina I (1946) pp. 213-235.
29 J. Reedy (1968) p. xiv. See R.J. Duirling, "A Chronological Census of Renaissance Editions and Translations of Galen," Journal of the Warburg and Courtland Institutes 24 (1961) ppp. 230-305.
30 Melchior Sebizius, "Liber Galeni de Tumoribus Praeter Naturam in theses redactus et in inclyta Argentoratensium Academia publice ac solenniter ad disputandum propositus," Strassburg, 1633.
31 Reedy (1968), p. xiii.
32 Thus confirming Edelstein's judgment that Kühn's text is "unreliable." Ludwig Edelstein, "Galen," in Oxford Classical Dictionary, (Oxford, 1970).
34 Ibid. Edelstein
35 McGrew, Roderick M., Encyclopedia of Medical History. New York: Macmillan, 1985. p. 121.
36 Leicester, Development , p. 32.
37. McGrew, Encylcopedia, p. 121.
38. Edelstein, OCD.
39 Leicester, Development, p. 32.
40 A concept attributed to Honorius of Autun in the 12th century. Cf. Leicster, p. 32.
41. Edelstein OCD
42. Singer, Charles. A Short History of Scientific Ideas to 1900. New York: Oxford University Press: 1959.
43 Singer, Short History, p.99.
44 McGrew, Encyclopedia, p. 121.
45 Leicester, Development, p. 32.
46 Ibid. See also F. Kremers and G. Urdang, History of Pharmacy, 3rd ed. rev. by G. Sonnedecker, Philadelphia: Lippincott, 1963, p. 16.
47 Shryock, R.H., "Quantification in Medical Science," Isis 52 (1961), p. 217.
48 Wolff, Lehre, p. 13
49 Ibid. McDrew
50 Singer, Short History, p. 101
52 Ibid. p. 100.
53 Ibid. p.98.
54 Edelstein, OCD.