Bloodaxe's Realm     The Medieval World  




      Figure 1. Stele of Hesy Re
      The Egyptians had a long and apparently deserved reputation as physicians (swnw -- sounou).* Homer speaks of Egypt in Book IV of the Odyssey:

       

      "In that country the fertile soil produces all kinds of juices which may have a good or bad effect. There everybody is a physician and surpasses in experience all other men; because verily they are from the family of Pćon."**

      Cyrus the Elder (Cyrus the Great), king of Persia, sent a message to Amasis in 560 BCE requesting an ophthalmologist who "should be the best in all of Egypt". The personal physicians of King Darius I were Egyptian as well.***

      That Egyptian medicine was apparently sacradotal does not mean that superstition held sway over common sense -- despite some modern views to the contrary. An excellent example is their custom of diagnosing pregnancy by having a woman urinate on grain (wheat and barley) held in a net bag. If the grain sprouted the woman was pregnant and likely to have a boy if the wheat sprouted first. Modern (1933) testing of this technique finally put to rest the notion that this was all hocus-pocus -- it worked in 40% of the test cases.[3] There have been numerous other examples of seemingly "magical" thinking shown to be valid. Not the least of these is the employment of honey to treat burns.[4]

      The first Egyptian physician of record was a chap named Hesy Re (2600 BCE), who may also have been a dentist (Figure 1). The most ancient ophthalmologist known to have existed was Iry, a Royal Oculist who lived during the 6th Egyptian Dynasty (2400 BCE). His stele, a large limestone slab, was discovered in a tomb near the Great Pyramid of Cheops (Figure 2). He was not only physician to the Pharaoh but chief of the court medical corps. In addition to being the "palace eye-physician", he was also the "palace stomach-bowel-physician", bearing the titles: "one understanding the internal fluids" and "guardian of the anus." This last was an important position because of the stress the Egyptians placed on purgatives and their believed ability to cleanse the body of noxious elements -- the concept of the whdw (ukedhu) -- the "rotten stuff par excellence".†† This notion remained a viable part of medical practice until well into the 19th century.


      Figure 2. Stele of Iry. First known
      ophthalmologist

      We know a great deal about these people because they left behind a written record carved either upon living stone or inscribed upon a slightly less durable substance -- papyrus scrolls. The relative continuity of the Egyptian empire and the dryness of their climate has preserved much of this record for us. The earliest known Egyptian medical papyri date from about 1700 BCE, and refer to the teachings of Imhotep, Grand Vizier to King Djoser (Zoser), physician, magician and architect of the first pyramid -- the Step Pyramid complex at Saqqara (Figure 9) -- who had lived some 1000 years earlier and who was subsequently deified as the Egyptian God of Medicine. Typically these papyri begin as does the Berlin Medical Papyrus:

      "...found in ancient writings in a chest containing documents under the feet of Anubis in Letopolis in the time of the majesty of King Usephais, deceased; after his death it was brought to the majesty of King Sened, deceased, because of its excellence ... It was the scribe of sacred writing, the chief of the excellent physicians, Neterhotep, {who made} the book."

      Similarly the London Medical Papyrus states:

      "This book was found in the night, having fallen into the court of the temple in {Khemmis}, as secret knowledge of this goddess, by the hand of the lector of this temple. Lo, this land was in darkness, and the moon shone on every side of this book. It was brought as a marvel to the majesty of King {Khufu}."[5]

      This was probably done in each case to give the work a cachet or confer on it more importance as having been "touched by a god".


      Figure 3. Portion of the oldest surgical treatise known.

      Edwin Smith Surgical Papyrus

      That we are able to glean anything at all from the writings of the ancient Egyptians is due to an ophthalmologist -- Thomas Young -- who, in 1819 provided the key that permitted Champollion to decipher the Rosetta Stone. Young was a remarkable man who contributed greatly to our understanding of the eye and the natural world and of whom we will hear more in this treatise (see also Basic Optics).

      The Edwin Smith surgical papyrus (Figure 3) was written about 1700 BCE but is based on writings of the Old Kingdom (2640 BCE) -- the time of Imhotep. Now in the library of the New York Academy of Medicine, it contains some reference to external diseases of the eye. As such it is the oldest existing record which can qualify as an ophthalmological document -- though the Ebers document is more complete and thorough. Moreover, most of the material appears to be a manual on treating wounds and may have been carried by an army surgeon.††† The content of this papyrus refutes -- res ipsa loquitor -- the commonly held belief that the Egyptians were not familiar with anatomy. How else would it be possible without such knowledge or dissection or autopsy that a depressed skull fracture resembles "a puncture in a pottery jar" -- as one example? The papyrus demonstrates an advanced understanding of wounds of all types and their treatment including the use of adhesive tape, suturing, and plaster casting of fractures as well as the application of surgical techniques.[5] The author of this work was quite astute as to expectations, advising: "leave him moored at his mooring stakes" meaning putting the patient at his customary diet without administering any medications and waiting.

      It is quite possible that the original text of this papyrus was written by Imhotep himself though the breadth of knowledge contained therein makes it hard to believe that it sprouted de novo from one mind. Only six or seven other significant "medical" papyri are known to exist.‡‡ However, an Old Kingdom inscription describes the existence of other books on medical science in the age between 3000 and 2500 BCE -- the time of Imhotep. Unfortunately, none of these have come down to us nor has any other collateral material surfaced referencing them.

      Ebers Papyrus

      The Ebers Papyrus (1500 BCE) is much more complete than the Smith Surgical Papyrus and reveals a depth of ophthalmological experience which could only have been attained after many years of observation and empirical practice.[6-7] In this papyrus a section is devoted to diseases of the eye and appears mostly to be a pharmacopić with advice on treatment of various ocular problems. There are few anatomical references, such as that four vessels from the temples supply blood to the eyes. However, large numbers of pathological conditions are described and their treatment suggested -- blepharitis, chalazion, ectropion, entropion, trichiasis, pinguecula, leucoma, staphyloma, iritis, ophthalmoplegia, dacryocystitis, and so on.

      One treatment has to do with curing "stupid vision" (amblyopia?) -- a mixture of mysticism and empiricism:

      "Take the water (humor) contained in pigs eyes, take true antimony, red lead, natural honey, of each 1 Ro (about 15 cc); pulverize it finely and combine it into one mass which should be injected into the ear of the patient and he will be cured immediately. Do and thou shalt see. Really excellent! Thou shalt recite as a spell: I have brought this which was applied to the seat of yonder and replaces the horrible suffering. Twice."

      It should not be assumed that the presence of incantations in some of the remedies makes the Egyptian practice of medicine "dominated by the demoniac theory of disease" as some have stated.[8] The structure and content of both the Ebers and Smith Papyri mitigate against this conclusion.‡‡‡ Spells are only recommended in a few cases (12 out of 49 cases and 877 remedies in the Ebers papyrus, only one in the Smith Papyrus) and there is no direct evidence that the physicians applying the treatments believed that the diseases were demoniacal in origin. Some appear to have been recommended for their moral support value alone. Thus a prayer to Isis would be quite meaningful and uplifting to a patient who believed in that goddess.

      Cataract

      It is equally strange but held as fact by some medical historians that despite the sophistication of Egyptian medicine and the evidence that operations were performed on other parts of the body -- because nothing was written of surgery on cataract (indeed even upon the eye itself) -- that therefore no such surgery was performed. So some say.

      It is remarkable that this condition could have existed, but the explanation for this may lie in the fact that medicine in Egypt was a very old science and steeped, perhaps even hide bound, in tradition. Clemens from Alexandria, a Greek, who studied the Egyptian civilization in some depth, claims that medicine in the Nile valley developed there independently. Albeit, they seem to have been a rather eclectic people, borrowing good ideas from all of the cultures they had contact with. Quick learners, they absorbed sufficient knowledge of warfare, including the use of the chariot, to rout their Hyksos conquerors and invade and conquer them in return. During the same period they used Hyksos ideas to improve their irrigation systems.

      Medicine, however, being more closely associated with the temple, may not have been so easy to change. The priests were a more iconoclastic lot and perhaps this, coupled with a degree of religious arrogance, caused them to dismiss input from other cultures.§

      It is difficult to credit the statements that because we have not seen anything written -- that they didn't know about or didn't operate on cataract. It just doesn't fit with the rest of what we have discovered about that culture. There is a telling comment made by Hirschberg in his monumental work, "The History of Ophthalmology", referring to Euclid's "Opera Omnia": "According to our present conception, this Greek scholar must have learned a great deal from the Egyptians before he could write his principles of geometry in which he erected the foundations of a new science, optics."[9] It has also been assumed that even before Euclid there were books on optics. Democrites wrote one called "Aktinographia" around 430 BCE but nothing of these books survives today. Still, the evidence is strong that ocular surgery per se, was unknown in Egypt.

      The Egyptians did speak and write of a condition called "dark pupil" or "the rising of the water" of the eye. Ointments and spells were used in treating this affliction -- which was probably a cataract.[3] The Romans called cataract "suffusio". Galen says in his 10th book of The Use of the Parts: "The first stage consists of visual disturbances; the second one is called the descending of the water, sometimes of the drops (gutta); the third or final stage is the cataract, because it prevents vision, like a sluice of a mill or like water falling from heaven will obscure the sun...".

      The Arabs, who took their medicine from the Greeks (who in turn had inherited it from the Egyptians) call the condition of cataract the "white water" or "the stabbing of the water which descends into the eye". In the ninth book of Rhazes we find that the following terms are synonymous for this condition: cataracta, the downpour of water, water which has descended into the eye, gutta and suffusio. Fabricius Aquapendente in the Middle Ages said: "Cataract is like a water descending into the eye obscuring vision...".

      This similarity of usage is undoubtedly a coincidence if we are to believe some medical historians. However, as physicians we are trained not to believe in coincidences -- therefore we are forced to conclude that cataract was a problem recognized by the Egyptians. But what of surgery for cataract?


      Figure 4. (1) knives; (2) drill; (3) saw; (4) forceps or pincers;
      (5) censer; (6) hooks; (7) bags tied with string; (8, 10)
      beaked vessel; (11) vase with burning incense; (12) Horus
      eyes; (13) scales; (14) pot with flowers of Upper and Lower
      Egypt; (15) pot on pedestal; (16) graduated cubit or papyrus
      scroll without side knot (or a case holding reed scalpels);
      (17) shears; (18) spoons. The instruments to the left of the
      spoons are not identified but they look to the author to be
      sounds. And what are the devices next to the hooks? Some
      say that these implements are too large to be surgical
      instruments but the Egyptians did not carve reliefs to
      scale. Furthermore, this collection is located in an area
      with other reliefs showing medical motifs including the
      queen giving birth.

      It seems a workable conclusion that the Egyptians tended not to record everything "known to all" or considered to be common knowledge. The Ebers Papyrus itself is a good example because not all diseases are completely described or named -- certain familiarity with the subject is assumed. Surgical methods are not discussed in any great detail within the Edwin Smith Surgical Papyrus nor are instruments described. The transcriber of the original Smith Papyrus did, however, feel compelled to add a glossary of terms to explain some of the concepts obviously not familiar to the expected reader of the treatise some 1000 years later. We have examples of what are believed to be some of their surgical instruments but they left no drawings or descriptions of them so we cannot be certain. Yet if they did surgery (and there is evidence that they did) -- they had to have had the instruments to do it with. Figure 4 shows a portion of a wall at Kom Ombo. This relief purports to show some surgical instrumentation of the period. If true, this is the only example of its kind and as such is subject to some controversy.

      Thus the question is still open: "Did the Egyptians operate for cataract?" Probably not, else the Greeks, who grabbed the best of every culture they had contact with, would surely have mentioned it before 300 BCE (see The Greek Era).

      Likewise, while there is evidence of the use of magnifying lenses by lapidaries in Nineveh (see The Babylonians), such usage is not described in extant Egyptian writings but may have been known and kept as a guild secret. But nothing resembling spectacles has been found either in inscriptions or with any mummies. The early Greeks were familiar both with the magnifying as well as the heating potential of a water filled glass globe. Albeit, it is not clear whether such knowledge came from other cultures or originated with the Greeks themselves.

      In fact, there appears to have been no real advances in Egyptian medicine from about 2000 BCE on. This should not surprise us. By that time the culture was already ancient and medicine overlaid and steeped in mysticism and dogma. In fact some of the early Greek writers maintain that an Egyptian physician could be put to death for instituting therapy outside that which was considered "correct" or "by the book".[10] Only after four days of no response to the "correct" treatment could other means or methods be applied.[11] To say that this stifled innovation, experimentation and creativity is an understatement. There is a lesson to be learned here which many of our legislators and other members of society would do well to heed. These same strictures are being promulgated today, but under assumed names.§§

      These ancient people left an indelible mark upon medical history nonetheless. Despite assertions to the contrary, it was not the Hippocratic authors who first recognized the power of nature to heal spontaneously. The Old Kingdom swnw who recommended that patients be "be left at their mooring stakes" was a far earlier advocate of the vix mediatrix naturć. Excerpts, allusions, and derivations of the Egyptian papyri appear frequently in Arabic works and medieval manuscripts. Some drugs from the Nile valley could still be found in pharmacopeias until the early 1900's -- stibium is still being used to treat trachoma. The whdw itself was alive and well until the late 19th century along with the advice that "purges are chiefly to prevent any putrid matter from entering the habit".

       

 

 

      * At least that was true in the past. Their reputation has taken a beating in modern times.

      ** Pćon was the ancient Greek god of physicians.

      *** Though it was a Greek physician, Democedes, who successfully treated Darius' badly dislocated ankle. Whereupon the king, who had found relief from amongst his slaves, almost had the Egyptians impaled. Wrathy fellow was Darius.

      This last can also be translated as "guardian of the lower intestinal tract".

      †† Aristophanes (c. 410 BCE) ridicules the Egyptians because of their use of this therapy ad libitum, ad nauseum. In one play a character says: "Sell the helmets speedily to the Egyptians, then they can use them to measure their purgation."

      ††† More likely a physician at a construction site judging by the wounds treated.

      Thus employing "tincture of time" the most ancient and effective of remedies.

      ‡‡ Edwin Smith Surgical; Ebers; Kahoun; Beatty; Ramesseum III; Westcar, Brugsch, and Turin papyri.

      ‡‡‡ We must keep in mind that the persons doing the translations lacked medical training and insight. Unfortunately, no physicians (except Young) were involved in the original translations and it would seem that few if any have been consulted in these interpretations.

      § This is probably one of the earliest examples of the NIH (Not Invented Here) syndrome which we will encounter again. It is heartening and at the same time ironic to discover that out current problems are nothing new.

      §§ The entire quote from Siculi is as follows: "If the Egyptian physicians following the dogma and rules of the holy book cannot save the patient, they will remain unpunished and nobody can accuse them. If they, however, act contrary to the holy book, they can expect the death sentence because the legislator is convinced that the old therapy which has been observed for so long and has been collected by the best experts, should not be replaced by a new individual wisdom."