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| by | Prof. . M. KAMEL HUSSEIN | M. Ch., F.R.C.S. |
|
The subject of this study is an Ancient Egyptian medical papyrus known as the Edwin Smith Papyrus . Mr. Edwin Smith , an Egyptologist who lived in Egypt for nearly twenty years , bought the papyrus in 1862 . His heirs gave it to the New York Historical Society which entrusted its study and translation to Prof. . J. Breasted . When the Brooklyn Museum bought the Egyptian Collection of the Historical Society in 1949 it was stipulated that the Papyrus which had acquired universal fame , would be handed over to the Academy of Medicine . This was done in a formal ceremony in which Prof. . F. Beekman , President of the New York Historical Society , took part . Edwin Smith himself did not attempt to study the papyrus but he must have had an idea of its subject . It was left for Prof. J. Breasted to make a full study of it . He gave a lecture in the Egyptian Faculty of Medicine , Kasrel-Aini Hospital in 1923 in which he announced to an astonished audience the existence of this very remarkable surgical treatise . He had just begun its translation and he chose Case No . 6 as an example which showed the general character of the document . He was handicapped by the difficulty of the text and by its more or less technical character but , even from a mere superficial study he realized the extreme importance of that papyrus as a landmark in the development of human thought . Professor Breasted has since published an exhaustive study of the Papyrus which is a model for all investigators . It is a wonderful example of vast knowledge and conscientious methodical examination of facts which is not to be wondered at from an author of Breasted’s standing , but which is nevertheless a striking demonstration of the scientific methods which characterize great Egyptologists . I can give only a very imperfect idea of the greatness of Breasted’s work , I have to refer the reader to the book itself , otherwise I shall spend all my time talking about Breasted Suffice it to say that we are very lucky that such work was entrusted to so competent an investigator . He asked the help of a medical man to aid him in understanding the subject matter more fully , but he admitted that a correct estimation of the old surgeon’s knowledge of the medical sciences was beyond his competence. This is what I shall try to do . I have also been actuated by a keen impelling desire to express my unlimited admiration of that Ancient Egyptian doctor who represents , at least to myself , the prefect example of a certain type of intellect which has become a great friend , almost a personal friend , of mine more living to me than living authors . I am sure that he will be so to many of his colleagues among us who care to read him with sufficient interest . The papyrus is a roll written in hieratic with a small piece missing at the top . The text comes to an abrupt termination which obviously . can not be the end . The present papyrus is a copy made by a scribe for some purpose or other possibly for the use of a surgeon , from an older manuscript , Breasted imagines the poor scribe , innocent of any medical knowledge or any suspicion as to the great value of the work , plodding through what was to him a very tedious task until he was definitely bored and tired , yawned and cursed his fate and laid aside the original and the copy which he left in the middle of a sentence , in the middle of a word never to resume it again little realising the great loss he caused us by this untimely winding up of his work . The psychology of the scribe and its importance in clearing up some of the difficulties of the text are among the fascinating points about Breasted’s study . The present papyrus was written about the seventeenth century B.C. and the original manuscript is estimated for several reasons to have been written about the about the time of the great Pyramid , a fact of considerable importance to which we shall refer later . There is definite method about the whole work , It is a series of cases described and treated , all written according to a clear and definite plan and arranged in a very logical fashion . There are 48 cases in all , starting with injuries of the head , then those of the face , temporal region , mandible and chin , cervical vertebrae . clavicle , humerus and sternum . In every group of cases such as the eight cases of the head he starts , with the simpler , more superficial and less dangerous cases going on to describe lesions which are deeper , more complicated and more dangerous . The writer was undoubtedly endowed with a rare talent for classification . We shall give the entire text of one case as an example . Title ; Instructions concerning a dislocation in a vertebra of his neck . Examination ; If thou examinest a man having dislocation in a vertebra of his neck, shouldst thou find him unconscious of his two arms and his two legs on account of it , while his phallus is erected on account of it and urine drops from his member without his knowing it , his flesh has received wind ; his two eyes are blood-shot ; it is a dislocation of a vertebra of neck extending to his back-bone which causes him to be unconscious of his two arms and two legs . If , however , the middle vertebra of his neck is dislocated , it is an emissio seminis which befalls his phallus . Diagnosis ; Thou shouldst say concerning him ; "One having a dislocation in a vertebra of his neck , while he is unconscious of his two legs and his two arms , and his urine dribbles , an ailment not to be treated . Gloss A. As for "dislocation in a vertebra of his neck , he is speaking of a separation of one vertebra of his neck , from another , the flesh which is over it being uninjured ; as one says it is wnh" concerning things which had been severed from another . Gloss C. As for "while his urine dribbles" it means that urine drops from his phallus and cannot hold back for him . We see from this example the general plan of most of the cases . He starts with what can be described as a title , followed by a detailed clinical examination of the mandible . Then follows the expression "thou shouldst concerning him (one having so and so) an ailment which I shall not treat . This is a part of the case which Breasted found difficult to describe . He called it Diagnosis but he says that very often it is only a repetition of the title with some symptoms being added . He , quite rightly , remarks that it is only recently , since Sydenham , that the labels we call diagnosis became known . He often calls it the verdict , a sort of prognosis as well as diagnosis , a verdict and an advice as to the attitude that should be taken by the treating doctor . He evidently think that the repetition of a few symptoms is an attempt , not a very successful one , at making a diagnosis . I find it of absorbing interest to watch our old surgeon choosing among the signs and symptoms enumerated in the examination the one or two essential signs which to him were the most important for prognosis , diagnosis or treatment . They are what we would call pathognmonic or diagnostic or prognostic . This choice of the fundamental facts to be stressed is most remarkable . We find it difficult to get the modern student to develop the power of distinguishing just those signs . It is the highest achievement of the fully developed medical brain to be able to tell from the mass of irrelevant or contradictory data just the significant signs . This talent is shown to a remarkable extent by our author we have seen his gift for classification and now we see his talent for the significant which rarely fails him throughout . This is the hall mark of the born artist whose intuition tells him at a glance what his reason may not appreciate in years . In the case under discussion we notice that he repeats only the paralysis of his two arms and two legs and the incontinence of urine and these are just the two characteristic features : which distinguish this most dangerous lesion . He leaves out the erection , the tympantitis , the bloodshot eyes . These signs are left cut by the author because he realises that although they occur in these cases they have little to do with the decision he is going to give about the case , an ailment not to be treated . After the diagnosis comes the treatment , even in certain cases where he says they are not to be treated , a real doctor’s attitude in front of cases which he realises as hopeless and which he nevertheless treats according to the best medical ethics . Breasted sees , quite rightly , in this detailed study of hopeless cases a real interest in pure science and love of search after truth for its own sake . I can add that medical men all over the ages show this extraordinary interest in the worst cases and it is interesting to see the same weakness in the earliest surgeon whom we can analyse more or less successfully . When the case is of doubtful prognosis he examines it as much as four times or more when necessary , until the case takes on a definite turn to the better or to the worse. The is all that the very ancient author wrote . Some time , later , however , the terms used became too technical for later readers and had to be explained . This was done by a commentator who explained certain terms ; in case 31 e.g. he explained dislocation , emissio seminis , and dribbles . These comments on the text are most valuable , for without them much of the text would be impossible to understand and the explanations intended to help students twenty centuries later have been of the greatest help to us , We shall say one word more about the case under discussion now before we look through the whole series . The last sentence of the examination is not very clear but it probably means that only dislocations about the middle of the neck or higher do produce erection and emission . This is quite a correct statement . The first eight cases deal with head injuries and contain a considerable amount of information . The first case had to be reconstructed by comparison with the case that followed for the beginning of the first column of the papyrus has been lost . Fortunately we have a gloss for this case which is not valuable for it explains the word examine which apparently was a special word meaning to count . The commentator goes on to say that the word has some relation to counting the pulse to know the action of the heart from which vessels go to every limb , hands and feet . Here we have the earliest knowledge of the heart and
pulse and the method of knowing the action of the heart through feeling
the pulse ; facts which were never known to Hippocrates and which only became popular through the late work
of the doctors of Alexandria . The commentator goes to say "if a priest of
Sekhmet or any other physician put his hands or fingers upon head or hands
and measures the heart etc. . thereby describing a picture of the medical
man by the bedside which has remained the most characteristic attitude of
the physicians throughout the ages .
|
| Case 2: |
| describes a wound of scalp reaching bone , an ailment which he treats by binding fresh meat over it on the first day . Later on he approximates the edges of the gaping wound by applying two strips of linen and still later he dresses the wound with grease and honey to be changed every day until he recovers . The two strips of linen are explained as being for the purpose of bringing the edges together , the earliest use of adhesive strapping . We recognize also the rational order in the treatment ; he applies fresh meat and when the wound suppurates (in a later case he describes signs of inflammation) he uses honey which probably acts as a hypertonic sugar solution and grease which prevents the sticking of the dressing to the wound . Quite apart from the efficiency of the treatment the marvelous fact is his keen observation of the wound and his change of treatment according to the stage of development of the wound . |
| Case 3: |
| describes a compound fracture of skull . "Thou shouldst palpate the wound." Digital examination of wounds is advised quite often . Meat is put on it the first day we are not to bind . We can explain the danger of binding (possibly strapping is meant) by the possibility of its keeping back infected discharges in compound fractures . We are advised to "moor him at his mooring stakes" explained in the commentary , as meaning keeping him on ordinary diet until period of injury passes . Later on he is treated with grease and honey . In the gloss attached to this case the word penetrating is explained as meaning "contracting a smash through his incurring a break like a puncture of a pottery jar , a very apt description of fissured fractures of the skull . |
| Case 4: |
| This is the first of the more serious cases . It describes a gaping wound of scalp and fractured vault and base . "If thou examinest a man having a gaping wound of his head , splitting his skull , thou shoulldst palpate his wound . Shouldst thou find something disturbing under the finger and he shudders exceedingly while the swelling over it protrudes ; he discharges blood from both nostrils and ears : he suffers from stiffness of his neck ... An ailment with which I will contend" We notice here a change of tone , the verdict is no longer certain , he will contend with it . In the treatment he keeps his patient on ordinary diet , he sits him up supported by two bricks and his head is not bound "until thou knowest that he reached a decisive point" . Obviously he knows that the prognosis is not certain but is likely to be good . A very similar case is case 6 which we shall come to presently but in the latter the prognosis is definitely bad . The main difference between the two is that in the former there is pulsation of the brain while in the latter it is absent . The ancient surgeon realised that the presence of pulsation at the bottom of the wound excludes compression of the brain which we know is the most serious early complication of head injuries |
| Case 5: |
| describes depression of the fracture and comminution , we notice here that , the verdict is definitely an ailment not to be treated . he is quite sure the case is grave although it differs from the preceding one only in the depression . He waits , avoiding bandaging until patient reaches a decisive point . |
| Case 6: |
|
is a very precious one . "If thou examinest a man having a gaping wound in his head , penetrating to the bone , smashing his skull , and rending open the brain of his skull , thou shouldst palpate his wound . Shouldst thou find that smash which is in his skull like those corrugations which form in molten copper , and something there in throbbing and fluttering under the fingers , like the weak place of an infant’s crown before it becomes whole ; when it has happened there is no throbbing and fluttering under the fingers until the brain of his skull is rent open ; he dischages blood from both nostrils ; he suffers from stiffness of his neck . Thou shouldst say ... An ailment not to be treated , Thou shouldst anoint his wound with grease . Thou salt not bind it , thou shall not apply two strips upon it , until thou knowest that he reached a decisive point" . Here is mentioned for the first time in history the brain and the meninges , the gyri are described and compared to molten copper , pulsation is observed and its absence recognised as a very serious sign and . The description is unmistakably that of serious compression of the brain and the verdict an ailment not to be treated is quite justified . The comment on this case explains that the membranes are ruptured and that "it creaks open his fluid in the interior of his skull . He does not say blood and this can only mean cerebrospinal fluid . |
| Case 7: |
|
is the longest in the papyrus and is a little puzzling . Taking the signs mentioned in the diagnosis as the most important ones we are forced to lay great stress on the cords of the mandible being contracted associated with signs of fractured base and stiffness of the neck . The first idea that we get about the case is that it is one of tetanus . This is supported by the necessity that the surgeon finds of putting , a wooden brace to open patient’s mouth so that he may take diet . Difficuities in this diagnosis arise . The incubation period of tetanus is a week to ten days and it is not likely that our surgeon would have mentioned this in the first examination together with the discharge of blood frcm both nostrils . This mention of bleeding from nostrils is repeated in case 8 which is undoubtedly a chronic but case 8 is one of simple fracture which could be missed at the beginning and only the history of the bleeding can be got . In case 7 the lesion could not pass unnoticed . Another objection to the diagnosis of tetanus in this case is the relief which the patient gets from simple remedies . We are advised to make for him something hot until he is comfortable do that his mouth opens . I think that our author or his followers were for once not quite clear , I should imagine that the second examination where he mentions fever from the wound , TY (untranslatable) from the wound - still stressing the wound condition -- clammy sweat , tense ligaments of neck , ruddy face , bound mouth , and anxious face as if he wept , all this probably describes a case of meningitis secondary to sepsis in the wound and that the third examination which is treated with the wooden brace in the mouth may have been real tetanus . In this case the first description must be that of a case of compound fracture of vault and base possibly affecting some of the cranial nerves as evidenced by the expression "spittle hanging at his lips" and which he would contend until the case developed meningitis or tetanus some days later . The insistence on the trismus would then be overdone just for once . Breasted translates wooden brace although he mentions the possibility of its being a wooden tube which would serve for the feeding of an exhausted man whether tetanic or otherwise . We are quite unlucky to have the word "ty" unexplained and also in the fact that the scribe omitted the word which described the back and teeth which would have helped us considerably in identifying the case . Were it used to describe only the back we might hasard the guess that it meant arched which is an important sign of tetanus and is not likely to have been missed by our surgeon . We have to leave this case
unsettled . It is the richest in comments having ten gloss to explain
various terms . |
| Case 8: |
|
is on the contrary a beautifully clear one . It is one of simple comminuted fracture of skull . "If thou examinest a man having smash of his skull under skin of his head palpate his would Shouldst thou find that there is swelling protruding on the outside of that smash which is in his skull , his eye is askew because of it on the side of him having that injury which is in his skull , and he walks shuffling with his sole on the side of the injury , Thou shouldst recognise him as one whom something has smitten from outside as who does not release his shoulder fork and who does not fall with the finger nails in the middle of his palm . He suffers from stiffness of neck and bleeds from ears and nostrils . An ailment not to be treated. Sit him up till he regains colour and until he reaches a decisive point. Second examination continues exactly as case 6 verbatim . Not to be treated . This is a clear of hemiplegia after injury to the
head with conjugate deviation of eyes . Our surgeon knew the relation of
brain to body and he realised the relationship between the side of brain
which was injured and the side of body which was paralysed . In the
diagnosis the author leaves the usual formula "thou shalt say concerning
him" and starts like this "thou shouldst recognise him as one whom
something from outside has smitten etc." . Breasted is impressed by the
deviation from the usual formula and he sees in it a belief in the nature
of disease being due to material causes and not to supernatural and
demoniac influences as must have been the belief current in his days . I
am inclined to put another construction on the expression used which may
make it even still more important from the point of view of pure medicine
and from the fact that our author shows nowhere any tendency to
theoretical considerations . I am inclined to believe that my explanation
probably fits in with the mentality of our surgeon . We notice that in the
commentary gloss D explains that something from outside has smitten him as
meaning not due to the intrusion of something which his flesh engenders .
If the translation is exact the passage clearly means that our surgeon
knew that these symptoms could be caused by internal disease and not
necessarily by injury and he makes haste to warn his colleagues not to mix
the two cases, This is a wonderful attempt at differential
diagnosis . His interest in this
distinction may be for pure love of knowing but it can certainly be
attributed to the fact that he may have known that medical hemipegia
improve better . Dr. Luckhardt in a special note about this case is at
great pains trying to explain the reference to fact that patient falls
with his finger nails in the middle of his palm and he prefers this to the
statement in the original text which says he does not fall with his finger
nails in the middle of his palm . I prefer the negative form . We must
remember that he describes a case of hemiplegia with spastic leg and
adducted arm . If we read "his finger nails do not fall in the middle of
his palm" we get a very clear and exact description of the attitude taken
by the hand in hemiplegia where the fingers are kept extended and
approximated and the thumb held rigidly in contact with them . Although
the verdict is not to be treated he examines the patient again and he
describes a condition identical with case 6 . This necessitates the
presence of a wound through which the pulsation of the brain could be
examined and the question arises whether the surgeon operated on the case
in the meantime with that object in view i.e. in order to expose the brain
and notes its throbbing "when the brain of his skull is rent open" . We
can only offer this as a possibility . |
| Case 9: |
| We now come back to our papyrus . Leaving the head cases we come to a group of less serious ones . An injury to the forehead is treated with the egg of an ostrich and a charm . This is the only case of the kind in the papyrus and there is plenty of evidence , even from its style and language to show that it is quite foreign to our papyrus . |
| Case 10 : |
| is a simple wound of eyebrow . Here we are advised to stitch the wound and when stitching gets loose (obviously due to infection) the edges are to be brought together with two strips of linen, grease and honey are applied until recovery takes place . This is a rational and quit modern conception of the treatment of wounds . |
| Case 11: |
| "If thou examinest a man having a break in the column of his nose , his nose is disfigured and there is a depression in it while the swelling over it protrudes and he bleeds from his nostrils. Thou shouldst clean it with two plugs of linen . Thou shouldst place two other plugs of linen saturated with grease in the inside of his nostrils . Thou shouldst place two stiff rolls of linen by which his nose is held fast" . |
| Case 12: |
| is very nearly the same except that he notices the creptius while examining the case and in the treatment he actually sets the fracture and he mentions that the cleaning of the nostril is for removal of worms of blood . It is easy to see that even now we can add nothing to the excellent treatment indicated . What more do we do for a case of fractured nasal bones ? We clean the nose to remove blood clots , we reduce the fracture , we pack the nose with gauze soaked in Vaseline (he uses which serves exactly the same purpose and we put stiff splints on the outside to keep it position, which is identical with the treatment recommended in the papyrus. |
| Case 13: |
| is more serious for it describes fracture of the nose associated with fractured base and the verdict is that it is not to be treated . |
| Cases 14,15 and 16: |
| are wounds of soft tissues of the nose and cheek. |
| Case 17: |
| is a serious
fracture of maxilla which crepitates but is associated with fractured base
and is not to be treated . |
| Case 18: |
| a wound without any bone injury . |
| Case 19: |
| shows injury to the bone with when patient is asked to look at his shoulders and subconjunctival haemorrhage on the side of the injury only and is given good prognosis . |
| Case 20: |
| is a be describing fractured base with
bleeding from nostrils and in both eyes . He adds that patient wipes his
eyes with the back of his hand like a child and knows not that he does so
; a beautiful description of a very characteristic attitude diagnostic of
cerebral irritation . Another sign of the same condition occurs in the
next case where patient is pained when he hears speech . |
| Case 21: |
| is simpler for haemorrhage is from one ear . |
| Case 23: |
|
the last of this series is a serious smash of temple and base . patient is speechless and is not to be treated . He cleans the ear with a swab which brings fragments of bone out , obviously a very serious injury . It is in this case that the ramus of the mandible is likened to the claw of a bird . Now we come to less serious cases , A wound in the ear is treated by stitches and when they get loose the back of the ear is padded . |
| Case 24: |
| A fracture of the mandible with crepitus is described , with a wound over it , and fever . It is pronounced as not to be treated . Our surgeon does not hesitate in giving the worst prognosis for cases of compound fractures , a statement which remained true till long after Lister’s days . |
| Case 25: |
|
is a gem . "If thou examinest a man having dislocation of his mandible and mouth is open , thou shouldst put thy thumb upon the end of the rami of his mandible and your two claws under his chin and thus reduce his dislocation . There never was and never will be any other method for reducing this dislocation . The following two cases describe wounds of chin and lips . |
| Case 28: |
| is a wound of throat piercing to the gullet , if he drinks he chokes and it comes out of his wound which is inflammed and feverish . Wound is stitched and re-examined and is given a doubtful prognosis . |
|
The next four cases are vertebral injuries of which we have studied case 31 the most important , In this series we learn that sprain is a "rending of two members although each is still in its place" , a very important and exact definition and very modern in its conception of the pathology of the condition . we also get an explanation of the displacement of a vertebra as follows . "A vertebra sinking to the interior of another as a foot settles into cultivated ground". He must have been a true Egyptian fellah ( farmer ) to give such a description . Here we also get the statement that one vertebra crushes into another through falling with head downwards which is perfectly true . We then come to a very accident which must be considered due to an unusually severe trauma , dislocation of the two clavicles . He replaces them and fixes them with rolls of stiff linen . If the soft tissues over them are uninjured the verdict is serious . It is in the gloss of this case that we get the remark that behind there are two canals leading to the lungs one on right and one on left of throat and bosom . This is not quite right as a description of the trachea and bronchi but we have to remember that the commentator though displaying great knowledge and careful observation does not show the same precision as the original author . |
| Case 35: |
|
describes fracture of the clavicle and is a very precious one "If thou examinest a man having a break in his collar bone and shouldst thou find his collar short and separated from its fellow . I will treat . Treatment . Place him prostrate on his back with something folded between his shoulder blades ; thou shouldst spread out with his two shoulders to stretch apart his collar bone until break falls in its place . Place two splints of linen one on the inside and the other on the underside of his arm . This is undoubtedly the best treatment ever devised for restoration of the normal length and shape of the clavicle , the sort of treatment which we do not often do for it is needlessly exacting . The same treatment is advised for fractures of the humerus . Traction in abduction with two side splints to support the side of the fracture remains the essential principle of fractured arms up till now . The advice of putting something folded between the shoulder blades to let the fractured clavicle fall in position is the most astonishing single statement in the whole papyrus . |
| Case 37: |
|
Compound fracture of the humerus with crepitus is to be treated but a second examination is made and if blood is issuing from the wound which pierces through to the interior of the injury the case is not to be treated . This is the second example of our surgeon’s firm belief that compound fractures with fever are serious because of the wound for there is no difference between the two cases to make one safe and the other dangerous except the presence of a wound penetrating to the site of the injury .
|
| Case 40: |
| , complete in every detail. It describes the various stages of its development . Treatment is also instructive. cool applications (leaves of trees) are applied in the very early cases , followed by applications to dry up the wound and lastly hot applications are recommended in the stages. Here we find the gloss explaining the gloss explaining the word inflammation "Wound is sluggish without closing, high fever comes forth from it , lips are red and its mouth open." |
| Case 47: |
| follows a wound in shoulder from beginning to end through five examinations. It is stitched on the first day and fresh meat applied. On the second examination the stitches are found loose and strips of linen are applied to the edges with grease and honey until he recovers . If the wound really gets inflamed the surgeon does not bandage it . The condition either becomes worse (fourth examination) or it takes a turning to the better . |
| Case 48: |
|
is the last case. A sprain of a spinal vertebra obviously dorsal or dorso-lumbar causing pain when legs are extended. "Thou shouldst place him prostrate on his back, thou shouldst make for him .... And we shall never know what . The papyrus comes to an abrupt termination in the middle of the sentence , the author’s voice will never be heard again . Let us now summarize his knowledge of the medical sciences . It is interesting to see how much anatomy he knew . He probably dissected and did postmortems independently , I think , of embalming . He knew about the brain , and its meninges , its gyri are compared to molten copper . His knowledge of the vascular system is very good for the age in which he lived . The canals leading from the heart to every member suggested to me actual dissection for it is difficult to guess the fact that blood vessels are canals without having seen them . His description of one vertebra crushing into another like the imprint of a foot in cultivated ground shows that he must have done autopsies , for the appearance can in no way be suggested by the clinical appearance of the neck ; he must have actually seen the injured vertebrae . The ramus of the mandible is likened to the claw of a bird . He mentions , as we have already ; seen , two canals on either side of the throat leading into the lungs . It is to be noticed that most of this knowledge is derived from the glosses which were written by a later author . The original text being mainly clinical does not stop to explain though we feel certain that such facts must have been known to the ancient author for the inferences from them are there . This knowledge must have been available at the time and it is only is at a later date that the explanation of the terms became necessary . His knowledge of physiology is mainly derived from clinical observation and is naturally limited . He knew about injuries to the brain causing paralysis on the same side , contre-coup effect. He knew about conjugate deviation and he felt the pulse to know the action of the heart . His pathology is much richer . His eager statement in case 8 that certain symptoms are caused by something from outside smiting him , which can be construed as meaning a denial of demoniac influences , is interesting , for such beliefs in the supernatural harmful influence of a fell still exists in certain parts of Egypt. We have offered above another possible explanation for this unique passage . He knew about inflammation and described its signs well , redness, swelling and heat. He recognised the seriousness of compound fractures associated with fever . He knew about the mechanism of fracture-dislocation of the spine being usually a fall with the head downwards . A sprain is beautifully defined , (Case 30) such definition showing the comprehension of a state of affairs around joints consistent with the teaching of modern pathology . He knew about compression of the brain , realising that the principal difference between a safe and a dangerous case was the presence or absence of pulsation in the brain . We have or be content with these salient points to avoid repetition of many facts detailed in the description of cases . his clinical knowledge is really vast . He is endowed with that most precious and rare talent of memorizing cases as entities so clearly as to be able to recall them at will and classify and compare . He had no statistics to help him , he probably had to depend entirely on his vivid memory , the most important power that should be cultivated by medical men . His means of examining cases are varied and numerous . he asks patients several questions which are always to the point , he wants them to move neck and shoulders and to look at breast to see whether the movement is painful or difficult . He notices the patients’ irritability , and their attitude as in the case of the man who puts his hand in his eye like a child and he knows not that he does so . He palpates wounds to see whether the underlying bone is injured or not , to note pulsations , heat , depression of the fracture and crepitus . Measuring the pulse (counting) is extraordinary . Could he have used a time measure or did he simple compare it with the normal as the experienced physicians do without a watch ? Trismus , stiffness of neck , subconjountival heamorrhage , bleeding from ear nostrils are mentioned . Quadriplegia , hemiplegia, incontinence of urine , priapism . seminal emission , tympanitis and several other signs are mentioned and correctly appreciated . His clinical observation is of a very high order . His therapeuses is very often rational and in places most efficient and shows an understanding of the indications for the various lines of treatment . He reduces dislocations and fractures , he applies splints of stiff linen as supports . He uses a sort of wooden wedge for feeding tetanus patients . He uses cauterization , he stitches wounds and he is quite familiar with the fate of the stitches which become loose and then grease and honey are applied . Strips of linen are used to approximate the edges of wounds not the first day and never when wound is inflamed or when there is danger in keeping back discharges . Bandaging is naturally quite well known to him he avoids using it in cases of compression of the brain or in badly infected wounds while in the very earliest stages of inflammation he uses cooling applications (leaves of trees) . his use of fresh meat on the first day is not easy to explain unless it be for stopping hemorrhage which is sometimes done even now . If it were so it would add one more to the already long list of most precious facts known to our surgeon . His treatment of fractured nose and clavicle are beyond all praise . We have now to mention of the theories about the papyrus before attempting to describe the mentality of the author or assests its value . Breasted, and his authority on the subject is very great thinks that original text dates about the fourth dynasty and that the present copy is some thousand years younger . We have no guess as to the ago of glosses added to the cases , Dr. Meyerhof told me that the language of case 9 shows that is not of the same age as the rest of the papyrus . Breasted goes one step further and suggests , admittedly as pure conjecture and with slight evidence , that , corresponding in time with the great Imhotep , he might have been the author . I would not have quarreled with the suggestion if I had not happened to from quite a definite opinion about the author which we shall discuss very shortly . Imhotep , whatever he might have been , was a half-divine healer , with some supernatural powers such as the priests were supposed to have and a good deal of knowledge of magic and priestly culture. Our author is human to back-bone , quite a firm believer in ordinary causes and effects . He never soars higher than what he sees. I feel sure that surgeon would have never been so clear headed had gone through the customary medical or priestly learning of his days . He could hardly have rid himself of that influence so definitely as to show no trace of it whatsoever . His knowledge would be considered in those days as the dignity of the learned physician . Up till quite recently medicine was hardly considered among the learned professions and certainly surgery was looked upon as a manual sort of practice not to be compared with the wisdom of physicians or lawyers or the clergy or the classical scholars . His science however must have been appreciated for his work was copied for thousands of years . To such a work must be attributed the wide reputation of Egyptian medicine about which Herodotus tells us so much, for it is incredible that such reputation could be built on the recipes described in the other papyri . Breasted also puts forward the theory that he must have followed an army, He is impressed by the frequency of cases of wounds . I think that the vast majority of cases can be as well or better described as falls from a height . The fourth dynasty was not the most warlike of dynasties . They were rather builders and chiefly pyramid builders . The would give our surgeon the best chance any body ever had of studying injuries due to falls from a height. Our surgeon is undoubtedly one of vast experience , he must have seen tens and hundreds of cases of each type to be able to individualise , examine and compare , and prognose them with such ability and confidence . Among the 100.000 workers who labored for thirty years he would just the unique chance for studying those injuries , a chance which has not repeated itself since . No army of ancient history even with the usual exaggeration could afford the necessary experience , such leisure at contemplating the cases or such careful treatment as is shown in this papyrus , I feel that the only experience in the history of the world which would give this information must be pyramid building . There are a few points about our author which may help us to estimate his real value . It is customary in examining unique achievements of this kind to describe them as the work of a genius or to assume that they must have been preceded by a high scientific medical culture which culminated in the present text. Both statements can be right and can be wrong in this case . If we mean by genius the power to rise above the prejudices and conceptions of one’s age or has a right to the description . But by genius we also understand the power to achieve what most people would be unable to do . To my mind the beauty of our text is that it can be written by any normal human intelligence with a correct technique of thinking . It has been said that it is not difficult to be anything out of the ordinary . I should have thought it very difficult to be really ordinary , what the medical people call normal which represents health . Our surgeon would have not been a good surgeon if he were a genius , for surgery is too much a matter of hard facts to be a work for supermen . Then again I question the statement that this must be the outcome of a preceding advanced identical culture . These are the observations of intelligent man endowed with certain talents, who had a unique experience and who profited by it , but he need have learnt nothing from any predecessor . It is difficult to create a work of such importance without a certain high general culture of the age . Yet it is needless to assume that it is the combined experience of several men . There is nothing impossible or even unlikely in attributing to one man the credit of having observed all these facts by himself . Then again I cannot imagine our author as a priest ; he is too solid in his knowledge , too remote from the admission of any powers but the wordly natural forces . He has no pretentions to any supernatural power . He has no pretentions to any supernatural power . He examined his cases too well and he dealt with material which priests would not care to master . He certainly was not an erudite , his style is far from being elaborate , his similes are all quit naturally suggested by ordinary experience . He naturally give no sign of philosophical , no attempt at generalization or the discovery of formulae governing the various phenomena observes . All that interests him is that similar cases which have similar appearances will progress in a similar manner and should be treated similarly. The fact that he mentions no rationale does not mean that he had none and the concise style is not due to the hiero glyphics . There are texts in that language which irritate by their redundancy . This is what our author was not . Where then is his superiority ? He was a born medical scientist . His science may be questioned . It is suggested that without theoretical consideration surgery is simply a handicraft . This is a mistake Medical men , will realise that such a treatise is the height and essence of medical science . Medical science is essentially the keen observation of facts, their classification , the correct estimation of their value and their correct application in similar cases . This we find beautifully exemplified in our papyrus . Our science dose not allow of unlimited flights into the infinite or the transcendental nor does it allow of deep insight into the origin of things . We have a definite aim which always brings us back to earth, the cure of a patient or at least his relief . We should not lose sight of this at any time . It is up to medical men
to realise that it takes a scientist of the highest class to do what our
author has done . Greek medicine has stood in the way of our progress for centuries chiefly owing to the premature development of theorizing and generalizations . There is too much deductive reasoning , too much of ideas like the humoral theory and too much of what Herodotus says about certain Greeks , the desire to acquire reputation for cleverness a fault of which our surgeon is singularly free. Modern medicine has ignored the Greek method altogether and has gone back to the way of the ancient Egyptian author i.e. compilation of the largest number of correctly observed facts and their classification . Our author is distinguished by his practical , his logic of facts ; the relation which he finds between facts is their natural dependence , their inevitable sequence and not their being grouped one word or one title or one formula . His crystal clear brain, his vivid memory , his talent for breathing order into chaos, his sense of the significant put him among the perfect examples of human intelligence . And then his style , sharp , concise , clear and dogmatic inspires perfect confidence later . His ability to discern vital facts shows the inspired scientist while his evaluation of these facts shows the born artist . It is easy to value this unique treatise on its priority . It is the first specialized thesis on a special subject , the first to show a rational order of exposition, the first to use terminology which would not be intelligible to laymen , the first example of correct inductive thinking in history , and several other claims . But I go further and say that any body , at any age , writing of any subject with that mastery , has a claim to immortality . I may be allowed to imagine him as a gray haired man who had seen the Great Pyramid grow and who had seen people fall and die and recover and who remembered them all and who told his younger colleagues of what was going to happen and it fell invariably as he had told them and they marveled and they were filled with admiration and they wrote down his sayings recognising thereby a |
