Journal of Investigative Surgery, 23, 327–334, 2010 C 2010 Informa Healthcare USA, Inc. Copyright ISSN: 0894-1939 print / 1521-0553 online DOI: 10.3109/08941939.2010.515289
Ancient Egyptian Surgical Heritage Aly Saber Port-Fouad General Hospital, Port-Fouad, Port-Said, Egypt
ABSTRACT Egyptian medicine influenced the medicine of neighboring cultures, including the culture of ancient Greece. From Greece, its influence spread onward, thereby affecting Western civilization significantly. The oldest extant Egyptian medical texts are six papyri: The Edwin Smith Surgical Papyrus and the Ebers Medical Papyrus are famous. Keywords: ancient Egypt, Imhotep, Ebers Papyrus, Edwin Smith Papyrus, protosurgery, medical texts
INTRODUCTION
EARLY SPECIALIZATION
Driven by their deep-seated desire for eternal life in a healthy body, ancient Egyptians were one of the first civilizations to begin collecting and recording medical lore and medicinals that were effective for a healthy body [1]. Homer put in the Odyssey that of all the branches of science pursued in ancient Egypt, none achieved such popularity as medicine [2].
It may be significant that the oldest swnw we know, Hesy Re, who lived at the time of the legendary Imhotep (c. 2800 BC), was associated with the treatment of teeth, for specialization in single segments or functions of the human body seems a particular feature of the ancient kingdom [6].
That a well-developed and hierarchical medical profession existed in Pharaonic Egypt is without doubt as well as a recognizable surgical profession. Medical papyri and the treatises of the historians of antiquity provide a far more reliable source of information on surgical practice. They have indicated possible titles for surgeons and the types of instruments used [3]. The ancient Egyptian word for doctor is swnw. There is a long history of swnw in ancient Egypt. The earliest recorded physician in the world is also credited to ancient Egypt: Hesyre, “Chief of Dentists and Physicians” for King Djoser in the 27th century BC [3, 4]. The lady Peseshet (2400 BC) may be the first recorded female doctor and on a stela dedicated to her in his tomb she is referred to as imy-r swnwt, which has been translated as “Lady Overseer of the Lady Physicians” (swnwt is the feminine of swnw) [5].
Herodotus wrote, “Medicine is practiced among them (ancient Egyptians) on a plan of separation; each physician treats a single disorder and no more: thus the country swarms with medical practitioners some undertaking to cure diseases of the eye, others of the head, others again of the teeth, others of the intestines, and some those which are not local” [2, 7]. Specialists were a minority, and the majority did not record any specialization [6]. We know from records that the ancient Egyptians adopted a hierarchy system reminiscent of today’s health service [8] (Table 1). The Egyptians can claim credit for the first populations to have practicing physicians. Doctors in Egypt usually went through years of hard training at temple schools in the various arts of interrogating the patient, inspection or examination, palpation, and treatment [9].
SURGERY AS A SEPARATE PROFESSION Received January 01, 2010; accepted August 05, 2010. Address correspondence to Aly Saber, Consultant Surgeon, PortFouad General Hospital, 19 al-guish Street, Port-Fouad, Port-Said, Egypt. E-mail:
[email protected]
It was suggested and perhaps finally supported that surgeons were a separate group in ancient Egypt [6] (Figure 1). 327
A. Saber Table 1 Shows the adopted hierarchy system put by the ancient Egyptians reminiscent of today’s health service
Junior doctors (swnw). Doctors (imy-r-swnw). Senior doctors (wr-swnw). Registrar’s (smsw-swnw). Consultants (shd-swnw). Specialists in a given field, such as Sekhet-n-Ankh, a nose doctor.
INSTRUMENTS Many examples of proposed surgical instruments have been discovered. Some were undoubtedly used in the mummification process. The medical papyri contain many references to instruments and surgical tools that included knives, drills, saws, hooks, forceps and pinchers, scales, spoons, and a vase with burning incense [10] (Figures 2a and b). Some of the antique instruments used in traumatology, the general surgery and in cosmetic-plastic operations, are in a scarcely modified manner employed for the same purposes in modern surgical interventions nowadays (Figures 3 and 4). The surgical diagnostics and therapy of that time is demonstrated by the surgical instruments stock being in the possession of the Agyptisches Museum of the Staatlichen Museen zu Berlin [11–14].
2. removal of a tumor of fat (‘3t nt ‘d) (Ebers Papyrus, pp. 863–877). In Ebbell’s translation of the Ebers Papyrus, “then thou shalt go round it with a Ipt-knife to the limits of all”. . ., George Ebers further discussed the case of this instrument, referring to a different word, xpr. It appears that the function of Ipt, or xpr, was to debride a wound, and the most logical instrument would have been a curved scalpel [17] (Figure 3c). Blades made of iron and bronze came relatively late to Egypt. In some procedures, the blade would be heated until it glowed red and then used to make incisions. It would cut as well as seal up the wound to limit bleeding [18].
TREPHINATION The Egyptians invented the circular trephine, made by a tube with serrated borders, which cuts much easier by means of rotation and which was then extensively used in Greece and Rome, and gave origin to the “crown” trephine, used in Europe from the 1st to the 19th century [19]. The Ebers Papyrus (pp. 109, 876) discusses the use of the swt to treat “oozing in any limb,” probably a description of a hematoma. It would seem that the swrreed was akin to the modern surgical lancet for the relief of subcutaneous pressure points [20, 21]. Perhaps swt was composed of metal or ivory, and the reference to the reed simply implied its shape. Alternatively, the word may be the ancient Egyptian equivalent of the lancet [20–23].
SUTURES The first description in written history of suturing is found in the Edwin Smith Papyrus (pp. 225–233). Breasted thought that the word ydr stood for sutures [15]. Catgut and silk are known since antiquity as earliest written records date back to ancient India and Egypt, between 1600 and 1000 BC, when flax and hemp were used to close wounds. Since then many materials have been tried including the heads of giant black ants, catgut (sheep intestine), and tree bark [15, 16].
INCISIONS There are many references in the Ebers Papyrus to the undertaking of the “knife-treatment” (dw’), particularly for 1. opening of abscesses (‘3t nt ryt and ‘3t nt whdw) and 328
CAUTERIZATION Cauterization is first described in the Ebers Papyrus where instructions concerning a swelling of vessels, probably an aneurysm are given (pp. 108, 872 CVIII). Further, it is described in Edwin Smith Papyrus (Chapter 39 XIII3–12), describing “tumours or ulcers in the breast, perhaps resulting from injury”
PROPER MANAGEMENT OF SURGICAL PATIENT History and Examination of the Patient The Edwin Smith Papyrus (17th century BC) and the Ebers Papyrus (16th century BC) are an instructional system of the diagnosis and practice of medicine, which referred to audible signs of disease within the body and
Ancient Egyptian Surgical Heritage
FIGURE 1. Shows that surgeons were a separate group in ancient Egypt.
stated that the Egyptians were the first to systematically document the practice medicine [24]. The text instructs the physician to examine the patient and look for revealing physical signs that may indicate the outcome of the injury. Although in modern medicine we take for granted that the use of physical examination and rational thinking lead to an accurate conclusion, 5,000 years ago, the ancient Egyptians did this extraordinary act [24]. Probably the doctor would make a home visit if you could afford it. The first thing that he might do is examine your pulse, although it was never really clear what information the ancient Egyptians learned from this procedure. Then your physician would interrogate you, according to the Smith Papyrus, to find out about your general condition and symptoms, just as doctors do today.
The doctor might ask you if you had any enemies or did anything recently to incur anyone’s wrath. If you thought so, he might chant a spell to help rid the entity that was causing your cystitis. Alternatively, give you an amulet or healing charm to wear [25]. Then the doctor would examine you with a lot of hands-on observation, probing here, palpating there. He might ask for a urine sample to look at or test when he left your bedside. Finally, he would pronounce what he thought was wrong with you and what your treatment should be [25]. According to the Edwin Smith Surgical Papyrus, a doctor had three options when dealing with a sick patient: (a) to treat the illness (when he anticipated that a cure was likely or that the patient would recover regardless), 329
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FIGURE 2. (a) Shows the first known image of a doctor. Wooden relief of Hesyra, dating to the third dynasty, and found at Saqqara. The panel is now in the Egyptian Museum, Cairo. (b) Shows the image of the incised relief of the Wall of Temple of Kom Ombo. Many instruments are labeled according to medical use, but some do not have a clear purpose. Could the tube in the lower left corner of the relief between the cupping vessels and shears have been a hearing device used as a stethoscope?
(b) to contend with the illness (if a cure seemed unlikely but palliation was possible), or (c) to avoid treatment altogether (if the case seemed hopeless). (d) It was the physician’s call [26].
Ancient Egyptians were fully aware that accurate diagnosis of diseases and their symptoms was fundamental for effective treatment. These are the earliest surviving examples of observation and conclusion, the oldest known evidences of an inductive process in the history of the human mind. These read: [27].
Accurate Diagnosis
(a) “Until he recovers.”
The diagnosis is always introduced by the words: “Thou should say concerning him [the patient] . . .” and ends with one of three statements:
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(b) “Until the period of his injury passes by.” (c) “Until thou knowest that he has reached decisive point.”
(a) An ailment that I will treat.
Treatment
(b) An ailment with which I will contend. (c) An ailment not to be treated [25].
It is interesting to investigate the evidence we have for the existence of protosurgery in ancient Egypt
Ancient Egyptian Surgical Heritage
FIGURE 3. (a) Shows few examples of needles dated back to the early dynastic period, 3150 BC–2181 BC. (b) Shows a copper needle, a silver needle (missing the eye), and a copper pin with loop head. All are dated to the predynastic period. (c) Various instruments that were unearthed in Egypt. Dated to 3000 BC.
during the dynastic period (c. 3200–323 BC). Climate and chance have preserved medical literature as well as paleoarcheological specimens, and these artifacts along with extant Greek and Roman treatises appear to support the conclusion that protosurgery was practiced in ancient Egypt (the prefix proto designates an original or early form). Elements of protosurgical development included analgesia and sedation, the incision, trephination, protosurgery of trauma, and antisepsis, drawing on primary sources [28]. Although there is no evidence of surgical scars in any of the mummies so far found, the papyrus refer to the stitching of incisions and closing wounds by binding them with adhesive tape made of linen. The Smith Papyrus also indicates that the ancient Egyptians dissected human cadavers [29]. The following therapeutic accessories are mentioned in the Edwin Smith and Ebers papyruses: 1. Dressings for wounds (a) Lint (ftt) is of vegetable origin: it can be used dry to absorb secretions (on throat, Edwin Smith, case 28) or impregnated with medicaments for local application (in ear, Ebers 91, 767). (b) Linen: made of flax, is used in different forms (v.i.).
2. Sutures (Edwin Smith, case 10). 3. plints: three types (possibly 4) are described: (a) Brace of wood padded with linen (Edwin Smith, case 7) inserted into the mouth to help feeding the patient (vi). (b) Splint made of linen (Edwin Smith, case 35, fractured clavicle). (c) Stiff post-like roll of linen (Edwin Smith, cases 11 and 12). (d) it is possible that cartonnage was used, similar to our plaster of paris to splint fractures, also made of linen. 4. Cautery: either by means of the fire drill or with a heated scalpel [15–25, 30]. In many cases the treatment was beyond the capability of the time and the surgeon simply states that this is “. . . an ailment not to be treated”, i.e., with a very poor prognosis. Nevertheless, he meticulously described the physical findings [27].
Wound Care The treatment of acute and chronic wounds is an ancient area of specialization in medical practice, with a long and eventful clinical history that traces its origins to ancient Egypt and Greece. The Papyrus of Ebers, 331
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FIGURE 4. (a) This object is recognized to be an Egyptian toilet tool, but its function has not been uncovered. Dated to the 18th dynasty, 1570 BC–1293 BC. (b) These instruments were used to pull out the brain during the process of mummification. (c) Collection of ancient Egyptian medical knives, cupping cups, spatula, and forceps. Dated to about 4000 BC.
FIGURE 5. The Eye of Horus as an ancient Egyptian symbol of protection and royal power from the Gods.
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c. 1500 BC, details the use of lint, animal grease, and honey as topical treatments for wounds. The lint provided a fibrous base that promoted wound site closure, the animal grease provided a barrier to environmental pathogens, and the honey served as an antibiotic agent.
DECLARATION OF INTEREST
The Egyptians believed that closing a wound preserved the soul and prevented the exposure of the spirit to “infernal beings,” as was noted in the Berlin Papyrus [31].
REFERENCES
The ancient Egyptians were masters in applying and arranging bandages, and they recognized the cardinal signs of infection and inflammation. Egyptian drug therapy can be regarded as having evolved from a system rooted in magic and empirical observation [32].
The Eye of Horus The Eye of Horus or Eye of Ra was called the Udjat. It represents the right eye of the Sun God Horus (Figure 5). According to legend, the left eye was torn from Horus by his brother Seth. It was magically restored by Thoth, the God of Magic. The Eye of Horus was believed to have healing and protective power, using the mathematical proportions of the eye to determine the proportions of ingredients in medical preparations and to prepare medications. The eye of Horus has a very specific meaning. The eye is represented as a figure with six parts corresponding to the six senses: touch, taste, hearing, thought, sight, and smell [33–35]. The Egyptians did write prescriptions. Those prescriptions were first magical verses and then the real prescription. The Eye of Horus was an important part of the magical part of the prescription. With time the magical part became smaller and the real prescription more important. Eventually, all that was left of the magical verse was the Eye of Horus. It remained in prescriptions to this day as the R at the beginning of each prescription. Recently, it has been suggested that the symbol originates in the eye of Horus [36].
ACKNOWLEDGMENT To Mrs. Mervat Kamel for her help in writing and editing this report and my daughters Dr. Asmaa and Dr. Aya for their cooperation and preparation of the software of figures that made this work possible; really I feel indebted.
The authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper.
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