Urology Doc Circumcision

BJU International (1999), 84, 755–761

HI S T OR I C A L R E V IE W

The urology of Pharaonic Egypt A.A. SHOKEIR and M.I. HUSSEI N* Urology and Nephrology Center, Mansoura University, and *Department of Psychiatry, Cairo University, Egypt

Introduction This review attempts to reconstruct the history of urology in ancient Egypt. It is logical to assume that people who had achieved suBcient knowledge and skill in engineering to erect such structures as the Pyramids, and whose mathematical knowledge involved the use of complex calculations and acquaintance with the principles of cubic capacity, angles, decimals and square roots, must have been advanced in other fields of intellectual endeavour, including medicine [1].

displayed in temples and tombs, and on statues. The best surviving illustration of a urological procedure is the engraving depicting circumcision (discussed later); circumcision is apparent on the phalli of statues of the pharaohs. Palaeopathology

Ancient Egyptian books were rolls of papyrus, made from the plant Cyperus papyrus, a sedge, that grows wild throughout Egypt. The stems were stripped of their outer rind and pith, cut into slices and arranged vertically and transversely in overlaying rows. This was pressed into one sheet. The horizontal fibres were on the recto side and the vertical on the verso. There are only 10 papyri still extant which deal with medical matters: the Ebers, the Edwin Smith, the Berlin, the London, the Hearst, the Kahun, the Chester Beaty, the Carlsberg, the Zoega medial papyrus and the Ramasseum papyri [2]. Only five of these papyri contain information about urology.

One of the principal sources of knowledge of ancient Egyptian diseases is the study of mummified tissues, i.e. palaeopathology. This study was first introduced by the French scientist Fouquet and was continued by G. Elliot Smith and F. Wood Jones [1]. Sir Marc Armond RuCer treated the mummified tissues with a solution of an alkali (sodium bicarbonate) combined with a hardening reagent (alcohol or formaldehyde). The mummified tissues, when immersed in this mixture, gradually swell to their former shape and regain their flexibility. RuCer identified and described the normal structures of the kidneys and the testicles. He also discovered some pathological conditions, e.g. urinary calculi, atrophic kidney, multiple renal abscesses and schistosomal nephropathy [3]. G. Elliot Smith discovered the first vesical stone taken from a mummy, among the pelvic bones of a young person who lived during predynastic times (before 4800 BCE) [1]. RuCer also described three vesical stones weighing 30, 24 and 12 g and measuring 4.5, 3.4 and 2.5 cm, respectively. One stone was pear-shaped, one globular and one triangular; they consisted of mixed phosphatic and uric acids, common enough in Egypt at that time [1]. Three other stones were discovered in a mummy of predynastic origin and found opposite the first lumbar vertebra; because of their position Badr assumed that these were renal calculi [1].

Statues, engravings and paintings

The ancient Egyptian medical system

Statues depicting cretinism, poliomyelitis and various orthopaedic deformities are displayed in the Egyptian museum in Cairo, and in other museums worldwide. Engravings of Egyptian patients with abdominal swellings, umbilical hernia and scrotal swellings are also

The ancient Egyptian medical system, although associated with religion, mysticism and priestly magic, is to some extent similar to the modern medical system, in that both depend upon the study of anatomy and pathology, and provide clinical descriptions of diseases and specific measures for treatment [1]. A study of Egyptian medicine shows that, even by the highest

Sources of knowledge of Egyptian medicine Most of the reliable knowledge of Egyptian medicine in ancient times has been derived from three sources: (i) the medical papyri; (ii) the statues, engravings and paintings on the walls of temples; and (iii) palaeopathological studies. The Papyri

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orthodox modern standards, it was highly advanced. However, it is clear that modern methods of investigation reveal only one aspect of Egyptian medicine, i.e. scientific. It is equally clear that Egyptian medicine was as much an art as a science and the secrets of this art are inaccessible to analysis. The testimony of ancient sources refers to the Egyptians as the healthiest race of the ancient world. Herodotus, the ‘father of history’, noted the practice of specialization among Egyptian physicians, stating that ‘the practice of medicine they split into separate parts, each doctor being responsible for the treatment of only one disease. There are, in consequence, innumerable doctors, some specialized in diseases of the eye, others of the head, others of the stomach, and so on; while others, again, deal with the sort of troubles which cannot be exactly localized [2]’. In the tomb of an eminent man who lived at Saqqara during the time of the pyramids, we find his title, i.e. ‘priest of Selkis, goddess of magic, royal physician, and interpreter of a diBcult science’ [4]. The court was served by a specialist who designated himself as ‘palace eye physician, palace physician of the belly, one understanding the internal fluids, and a guardian of the anus’. Egyptian physicians had ranks, e.g. generalist, specialist, chief of physicians, inspector of physicians, superintendent and ‘greatest physician’ of Upper and Lower Egypt [5]. Case presentations, particularly in the Edwin Smith Papyrus, are systematic and meticulous. Every case starts by the words ‘information regarding . . .’ suggesting the history of the disease, then an examination follows and starts with ‘if you examine a patient with . . .’, then the physician expects the prognosis of the disease by writing one of the following expressions: ‘I will treat’, ‘I will fight’, or ‘I will not treat’, and finally the treatment is described [6]. Philologists have translated a few of the Egyptian papyri that discuss medical subjects. These translations confirm the existence of medical literature and a fairly extensive pharmacopoeia in ancient Egypt. Treatment was oCered on a rational basis and it was in co-operation with nature, i.e. a diet was prescribed for the patient, strict hygienic regulations were enforced and medicaments were administered. When ordering a drug, the Egyptian not only gave the name of the drug, but stipulated the quantity needed and advised a method of preparation.

from the penis and in this case it is possible to represent haematuria [7]. To the ancient Egyptian physicians, the symptom was always regarded as the disease. As haematuria is the chief symptom of urinary schistosomiasis, Kamal assumed that it refers to this disease [8]. The disease was mentioned 50 times in the medical papyri, i.e. 28 times in the Ebers, 12 in the Berlin, nine in the Hearst and once in the London papyri. Kamal presumed that these frequent mentions indicated an endemic disease [9]. A causal relationship to a verminous parasite named ‘hr wt’ is reported in prescription 62 of the Ebers papyrus (1550 BCE) [10]. The hieroglyphic script of that prescription and its English translation is given in Fig. 2. Several clinical symptoms were mentioned for the disease in the Ebers and Berlin papyri, including haematuria, frequency of micturition, painful micturition, eCects on the anus, abdominal pain, diarrhoea and blood in the stool, cardiac disturbances and mental weakness. These symptoms represent both urinary and intestinal bilharziasis. The cardiac disturbances and mental weakness referred to in the papyrus possibly represent a picture of chronic anaemia [11]. Engravings of Egyptian patients with abdominal swellings, umbilical hernia and scrotal swellings are displayed at the tombs of Ptah-Hetep and Ankha-ma-Hor in Saqqara (Fig. 3). These probably represent the late manifestations of bilharzial hepatic fibrosis with ascites [6]. Several drugs for the treatment of schistosomiasis were described in the Ebers, Berlin and Hearst papyri. These included palliative drugs, i.e. sedatives (Hyoscyamus), antispasmodics (ammi-visnaga), diuretics (juniper and beer) and colon evacuation (caster oil). In the Hearst papyrus, prescription 83, antimony (inset) was mentioned for the first time as a treatment for schistosomiasis [11] (Fig. 4). Ancient Egyptians also pioneered the prevention of this disease by discouraging people from polluting and contacting polluted water. One of the confessions noted in the Book of the Dead reads: ‘I have not waded water’ [12].

Egyptian knowledge of schistosomiasis

Egyptian knowledge of bladder tumour

Schistosomiasis was first recorded in the oldest papyrus of Kahun (1900 BCE). It was named a˜-a-a˜ disease, the hieroglyphic script of which is presented in Fig. 1. The phallus symbol was used to represent any fluid emitted

Ancient Egyptians were one of the first people to recognise urinary bladder tumours as disease entities called ‘bn wt’, the hieroglyphic script of which is shown in Fig. 5, as it appears in the Edwin Smith papyrus [13].

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a

a

Fig. 1. Hieroglyphic script of haematuria referring to schistosomiasis (a˜-a-a˜ disease) as it appears in Kahun papyrus.

© 1999 BJU International 84, 755–761

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m/for

iht/useful

phrt/remedy

^

wnm/eaten

ht/belly

hrbyt/cooked in honey

m/in

hrwt/worm

kma/produce

nwt/who (has)

â a â/haematuria

phrt/remedy

^

nbt./all

n/for

nw/ground

^

htf/his belly

stn/ they not

isw/rosseuisou

^

sms/chams

ns/man

kt/other

^

irrt/ prepare

757

n/not

n/it (is)

mt/killed

Fig. 2. Prescription 62 of the Ebers papyrus showing the aetiology and intractability of schistosomiasis. As it reads (from right to left), it characterises the disease (haematuria), causative parasite (worm in belly), some herb therapy (chams and rosseuisou) and a comment on its intractability; (they are not killed by any remedy). From [11] with permission.

Badr assumed that the inclusion of an erect phallus in Fig. 5 indicates the characteristic hardness of tumour tissues in general, as well as its possible reference to the © 1999 BJU International 84, 755–761

genitourinary tract [14]. However, Faulkner’s dictionary of middle Egyptian (the recognized reference) translates ‘bn wt’ as ‘hard sandstone’. Bladder tumours were also

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mentioned twice in the Chester Beaty papyrus [15]. The ancient Egyptian words ‘dyjt’, meaning lower urinary tract disturbances, ‘hdbw’, signifying severe burning during micturition, and ‘nnw’, denoting marked dysuria in the male, may be understood as indicating vesical irritation caused by tumour [11,14,16]. RuCer, in his palaeopathological studies, described a tumour of the bony pelvis of a 20th dynasty mummy, and reported the possibility of it being metastatic from a primary tumour in the bladder [3].

a

Egyptian knowledge of nonsurgical treatment of some urological disorders Among the urological conditions described in the papyri are retention of urine, enuresis, incontinence and cystitis syndrome. b

Retention of urine Of the 24 paragraphs in the Ebers papyrus dealing with urological diseases, 10 are devoted to retention of urine, which was called ‘accumulation of urine’. The principal symptom noted was pain in the lower abdomen caused by the inability to pass urine. Various treatments were advised to regulate the act of micturition (Ebers papyrus 261, 262, 263, 270, 271 and 283) [10], and these prescriptions were described as preparations ‘to regulate or put in order the act of micturition’. Incomplete retention was also discussed and this condition was known to culminate in absolute retention. Prescription 262 of the Ebers papyrus details the treatment of retention of urine in an infant [1,10]. Enuresis and incontinence The word ‘dja det’, used in connection with urinary disease in an infant, implies continuing or ongoing, and Badr assumed that it means enuresis [1]. Prescriptions 273, 274 and 275 in the Ebers papyrus describe a treatment for ‘stopping the urine when it is very frequent’ [1,10]. Possibly this is the earliest mention of incontinence in the history of medicine. The treatment varied, but generally consisted of a combination of a vegetable substance and a mineral salt in a fluid vehicle such as water, beer or honey. In the Edwin Smith papyrus a case is described (passage 31) in which subluxation of a cervical vertebra caused paralysis of the upper and lower limbs, incontinence and priapism [1].

Fig. 3. a, Abdominal swelling and umbilical hernia in a boatman (temple of Ptah-Hetep in Saqqara). b, Scrotal swelling in a farmer (temple of Ankha-ma-Hor in Saqqara). From [11] with permission.

with painful micturition. This phenomenon is referred to by the word ‘hdbw’. In such cases the urine was described as contaminated by mucus, pus and blood. A similar condition is described in the Hearst papyrus. The treatments are referred to as ‘prescription for treatment of ‘hab’ (burning) in the bladder’. In the Berlin papyrus, prescriptions 143–147 apply to the ‘elimination of acute pain during micturition’; such pain was described as violent and severe. Dawson suggested that the condition referred to is prostatitis [17].

Cystitis syndrome

Egyptian knowledge of urological anatomy

Three prescriptions in the Ebers papyrus are suggested to relieve burning pain in the bladder, which is associated

The practice of embalming the dead aCorded the Egyptians at least a superficial knowledge of the structure © 1999 BJU International 84, 755–761

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Fig. 4. Prescription 83 of the Hearst papyrus, in which antimony (inset) is mentioned to treat schistosomiasis. From [11] with permission.

of the human body. The embalmer took care not to injure the internal organs, particularly the heart, which was regarded as the abode of the soul and the seat of the intellect. The belief was that ‘no mutilated person could enjoy the blissful life of the future world’. Egyptian knowledge of anatomy provided the basis for the proper study by the Greeks. A king-physician named Athotis, son of king Menes, the founder of the first dynasty, and the author of a manual on anatomy, but nothing is known of its contents [6]. Professor J.H. Breasted, who first described the Edwin Smith papyrus, maintains that this papyrus aCorded evidence that anatomy was studied for its own sake and that this document is, in the true sense, a scientific medical book [13]. Only a little was known about urological anatomy. The whole urinary tract was not specifically referred to as a system, but the individual parts of the tract were mentioned in some way. There is no hieroglyphic word in the medical papyri for kidney. The words ‘depet’, ‘geget’, ‘geret’ and ‘gelet’ all signify loin. Some authors support the opinion that the Egyptian physicians considered the kidneys to be very important organs, because

the embalmer left the kidneys in the body, as for the heart, indicating that special significance was attached to these two organs. If the kidneys were undesirable, they would have been removed with other viscera. Other authors believe that the kidneys were left behind in ignorance, because their retroperitoneal location made them inaccessible in the normal evisceration that was part of mummification. The ureters (mt) were referred to as vessels. The description 854n in the Ebers papyrus reads: ‘there are two vessels which conduct urine to the bladder’. There is no mention of a specific term for ureter. Every tube that carried a fluid or secretion was called a vessel [17]. As the Egyptian physicians knew that the ureters conveyed urine to the bladder, Kamal assumed that they also knew that the kidneys were the source of that urine [9]. However, in most references it is stated that the role of the kidneys was completely ignored. In paragraph 864 of Ebers papyrus, the bladder was definitely mentioned (chyptyt) and described as a separate organ located in the frontal portion of the abdomen [18]. The urine itself was noted separately, named ‘moyt’, and considered a clean fluid. One of the magical treatments reads: ‘thou art a servant who cometh in vomitus; thou art a noble who cometh in urine’ [1].

Egyptian knowledge of urological surgery Fig. 5. Hieroglyphic script of tumour (bn’wt) as it appears in the Edwin Smith papyrus. © 1999 BJU International 84, 755–761

Mummies and statues occasionally show scars in the lumbar region, possibly indicative of previous surgery. Operations to correct hernia and hydrocele were

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Fig. 6. Illustration of a bas-relief from temple of Ankha-ma-Hor in Saqqara showing the technique of circumcision (read from right to left).

described in the Ebers papyrus [9]. The best examples of ancient surgical prowess can be seen in extant representations of circumcision, an operation that was performed at least 2000 years before the reign of Rameses II. The advantages of the procedure were first limited to members of the priesthood but were later adopted by royalty and the nobility. Still later, circumcision became a universal practice, although the operation was not performed until the youth had reached puberty. The technique of the operation is best illustrated in a bas-relief on the wall of the temple of Ankha-ma-Hor at Saqqara (fifth dynasty, 2400 BCE) (Fig. 6). The scene on the right depicts the preparation for the operation. The surgeon is possibly anaesthetising the body of the penis of the adolescent boy standing before him. The patient supports himself by holding the surgeon’s head, saying, ‘rub properly what is there’. The surgeon answers, ‘I shall do what will be comfortable for you’, meaning that it will not hurt. In the scene on the left, the hieroglyphics read ‘circumcision by lector-priest’. The surgeon tells his assistant, who is standing behind the young man and holding him by the wrist, ‘hold him tightly, don’t let him faint.’ The assistant replies, ‘I shall do as you wish’. It would be interesting to discover more about the anaesthetics used and how they were administered. The famous ‘Memphis stone’ could be the key to this secret.

The stone is composed of carbonates of lime and an acid, such as vinegar. Upon contact between the stone and the moist skin, carbonic acid would be released and act as a local anaesthetic [9]. Ancient surgical instruments discovered in Egypt include delicate scalpels, probes, forceps and knives. A knowledge of urological surgery is indicated in the records stating that the Egyptians used bronze and tin for making catheters and this could have been as early as the third millennium BCE [19].

Ancient Egyptian concepts of sex Erotic life flourished at all levels of society and, contrary to what is generally thought, it was recorded in words and pictures [20]. The belief in an afterlife was all important to the Egyptians; they believed that as the union of male and female was a necessity for the creation of a new being, the erotic force also enables a person who had departed from this life to continue existing in the afterlife [2]. Therefore, the sexual power of the mummy had to be maintained and stimulated. This is always visualized as pertaining to the mummy of a man, never that of a woman. In Egyptian art the idea is expressed in a symbolic way which is straightforward once the coded language is understood. © 1999 BJU International 84, 755–761

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Sexual disorders 8

In prescription 663 of the Ebers Papyrus impotence was mentioned as ‘grapo’ or ‘weakness of the penis’, and honey was among 37 drugs that were recommended for its treatment. Priapism was also described and prescriptions 658, 660 and 661 of the Ebers Papyrus described drugs for its treatment. Moreover, prescriptions 705, 706, and 707 of the Ebers papyrus described gonorrhoea (chyn) and that it may cause narrowing of the tissue of the penis [9]. In addition to the organic sexual disorders, ancient Egyptians recorded some of the psychosexual disorders, e.g. homosexuality, necrophilia, bestiality, incest and gender identity disorders [2].

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Conclusions

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The written and pictorial evidence of the Egyptian knowledge of urology and other fields of medicine confirm that Egypt and not Greece was probably the original source of many of the medical ‘arts’. Ebbell [10] stated that ‘. . . Greek medicine is by no means original as people were formerly inclined to believe, but . . . a very great deal of it has been taken over from ancient Egyptians.’

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References 1 Badr MM. The history of urology in ancient Egypt. J Int Col Surg 1963; 30: 404–13 2 Hussien MI. Mental health and psychological medicine at the time of the pharaohs. MS Thesis, Department of Psychiatry, Faculty of Medicine, Cairo University, 1993 3 RuCer MA. Studies of Paleopathology of Egypt. Chicago: University of Chicago Press, 1921 4 Quibell JE. Excavations at Saqqara 1905–6, Cairo. Cairo: Societe Orientals de Publicite, 1907: 22 5 Ghalioungui P. The Physicians of Pharaonic Egypt. Cairo: Al-Ahram Center for Scientific Translation, 1983 6 Ghaliuongi P. Magic and Medical Sciences. New York: Baines and Noble Inc, 1965 7 Farooq M. Historical development. In Ansari N ed. Epidemiology and Control of Schistosomiasis. Chapt 1,

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Baltimore: Karger Basel and University Park Press, 1973: 1–10 Kamal H. Methods of diagnosing diseases by the ancient Egyptians. Proceedings of the Congress on International Medicine and Tropical Hygeine. Cairo: Cairo University Press, 1928; 2: 23 Kamal H. The Ancient Egyptian Medicine (in Arabic). Cairo: National Board for Books, Egypt, 1998 Ebbell B. The Ebers Papyrus, the Greatest Egyptian Medical Document. Copenhagen: Levin and Munksgaard, 1937 Badr MM. Schistosomiasis in ancient Egypt. In El-Bolkainy MN, Chu MN eds. Detection of Bladder Cancer Associated with Bilharziasis. Chapt 1. Cairo: Al-Ahram Press, 1980: 1–8 The Book of the Dead. The Hieroglyphic transcript and English Translation of Papyrus AN1. London: New Hyde Park University Books, 1960 Breasted JH. The Edwin Smith Surgical Papyrus. Chicago: University of Chicago Press, 1930 Badr MM. The history of tumors of the urinary bladder. In Elsebai I ed. Bladder Cancer, Chapt 1. Florida: CRC Press, 1984: 1–16 Jonkheere F. Le papyrus medical Chester Beatty. In La Medicine Egyptienne. Bruxelles: Fond. Egyptol. Reine Elizabeth, 1947 Gardiner AH. Egypt of the Pharaohs. New York: Oxford Press, 1966 Dawson WN. The beginning of medicine and surgery in ancient Egypt. Sci Prog 1972; 21: 86–96 Bakr ABA, Abadir FM. Disease in prehistoric Egypt. Therapeutic Notes 1955; 3: 43–9 Outwin EL. The development of the modern catheter. J Am Surg Tech 1955; 1: 87–94 Omlin J. Der Papyrus 55001 und seine Satirishe-erotischen Zeichungen und Inscriften Turin 21. Berlin: Berlin Akademie Verlag, 1973

Authors A.A. Shokeir, MD, PhD, Associate Professor of Urology. M.I. Hussein, Research Fellow. Correspondence: Professor A.A. Shokeir, Associate Professor of Urology, New Jeddah Clinic Hospital, PO Box 7692, Jeddah, Saudi Arabia.