A Short History of Disease

by Sean Martin

  Although ‘wekhedu of aaa’ and other terms remain a matter for scholars to puzzle over, we can make a few educated guesses as to what caused the Egyptian gastrointestinal diseases. Parasites like worms (also known as helminths) have been a health hazard in Egypt for millennia, and can infest the human body after infected water is drunk or under-cooked meat consumed, eating food with unwashed hands, or skin contact with larvae in contaminated soil. Worms such as S. mansoni and S. haematobium are likely to have caused schistosomiasis (bilharziasis), ‘still a major cause of chronic ill health in Egypt’.53 Infection is most likely to have been caused in ancient Egyptians by immersion in river water. The worms lay their eggs in the bladder and the rectum. The eggs are eventually ulcerated through the bladder, and passed in the urine. The main symptom is haematuria (blood in the urine). Centuries later, this disease was still very much in evidence: ‘Napoleon’s troops reported that Egypt was the land of menstruating men’.54 Other symptoms can include anaemia, lassitude, loss of appetite, and lessened resistance to other diseases. There may also be interference with liver function, and a possible link to bladder cancer. ‘Schistosomiasis of the rectum can be painful and may explain the high percentage of ancient Egyptian remedies for “cooling and refreshing” the anus’.55 It’s also speculated that penile sheaths shown in some murals were worn to prevent infection. It was thought the worm swam up the urethra.

  Given the prevalence of such afflictions, Herodotus commented ‘that the Egyptians were obsessed with their bowels’.56 It comes as no surprise to learn that part of the Ebers Papyrus constitutes the ‘Book of the Stomach’, which concerns itself with various obstructions of the stomach. Various diagnoses have been proposed for the diseases described in this section of the papyrus: obstruction of the lower end of the oesophagus, pyloric stenosis, carcinoma of the stomach, peptic ulceration, even faecal impaction. Even food poisoning is suggested by Ebers paragraph 207, which gives the earliest record of directions for a physician to examine a patient’s stools.

  After this are remedies ‘to cause the heart to receive bread’,57 and remedies for coughs and the gehew-disease. Both ‘bread’ and gehew remain unclear. The heart receiving bread could be a reference to a healthy circulation, while gehew disease could be in the domain of what modern doctors call ear, nose and throat complaints.

  The papyrus continues, discussing treatment of eye diseases, and is ‘our main source of information on treatment of eye disease in ancient Egypt’.58 This may be the ‘book of eyes’ referred to by Clement of Alexandria (150–215 AD), who believed that the ancient Egyptians had 42 books of knowledge, six of which were medical. (The other five covered anatomy, diseases, remedies, doctors’ instruments and women’s diseases.)

  Treatment of bites ‘both by man and crocodile’ is followed by diseases of the head, and what to do with burns, beatings and flesh wounds. But the papyrus returns once more into obscurity with a section dealing with general suffering in relation to ‘secretions’ (setja), and another section dealing with strengthening the metu.

  Metu is central to ancient Egyptian concepts of life and health. However, we’re not sure exactly what metu means. It seems to mean different things in different contexts: in some, metu seems to mean muscles, in others, the male member or impotence. In another case, ‘swelling of the metu’ sounds as though it could be a post-traumatic aneurysm. Heart disease is also attributed to the metu, as are liver diseases and our old friends, diseases of the anus. The Ebers and Berlin papyri (Ebers 856h and Berlin 163h) state that ‘all [metu] come to his heart… and unite at his anus.’59 This sounds like the Indian concept of the chakras, or the Chinese meridians, but remains guesswork.

  Ebers continues to treat diseases of the tongue; dermatology; teeth; ear, nose and throat; gynaecology.60 Before we are much the wiser on any of these, ‘the content then changes abruptly to a section on household pests.’61 The metu is then discussed again, followed by ‘what little is said about the cardiovascular system’. The final part ‘is of a more surgical nature’ similar to the Edwin Smith Papyrus.62 (This papyrus, also discovered by Edwin Smith – hence the rather imaginative name – dates from around 1550 BC, and is concerned for much of its length with describing medical procedures, rather than disease.)

  Cancer seems to have been relatively rare in ancient Egypt. As John Nunn speculates, this is probably linked with shorter life expectancy, genetic factors and environmental factors.63 However, ‘untreated cancer often produces large tumours before death, and it is therefore surprising that cancers are very rare, as in many ancient populations, in both mummies and skeletal remains.’64 The Ebers Papyrus contains a reference to ‘eating of the uterus’, which may refer to a tumour, although there is little scholarly consensus. Nunn does note however that ‘one could hardly deny that “eating” is a very graphic description of advanced malignancy.’65

  The skin diseases mentioned in Ebers could be leprosy. However, as might be expected, the terminology prevents us from making a definite identification. Ebers recommends, ‘If you examine a large tumor of Khonsu in any part of a man and it is terrible and it has made many swellings.’ The physician knew he was powerless to treat it. As the papyrus continues, ‘you shall say concerning it: It is a swelling of Khonsu. You should not do anything against it.’66

  As the great historian of medicine, Roy Porter, noted, leprosy ‘has a puzzling history. From as early as 2400 BC Egyptian sources contain references to a skin condition interpreted as leprosy, and 900 years later, the Ebers Papyrus mentions a leprous disease seemingly confirmed by Egyptian skeleton evidence.’67 The Bible appears to mention leprosy as well. Leviticus 13:2 reads, ‘When a man shall have in the skin of his flesh a rising, a scab, or bright spot, and it be in the skin of his flesh like the plague of leprosy; then he shall be brought unto Aaron the priest, or unto one of his sons the priests.’ In such a situation, the priest would have no option but to cast the person out of the camp, as leprosy was long believed to be highly contagious. (In fact, it isn’t, and is actually quite hard to contract. What seems to have inspired terror is the fact that leprosy can disfigure, especially the face.) Leviticus’s talk of leprosy – ‘living without the camp’ – was probably not leprosy in the modern medical sense (Hansen’s Disease) but could have been another dermatological complaint such as psoriasis. Nevertheless, the terror the disease inspired was real. Some Egyptian texts refer to the disease as ‘the death before death’, and lepers were cast out, being exiled to a place called the City of Mud.68

  Evidence from Mummies

  Skeletal evidence, as Roy Porter mentioned, is one of the other main sources for our knowledge of Egyptian disease, although mummies can be just as enigmatic as papyri when it comes to making firm assertions about disease.

  The mummy of the pharaoh Ramses V (d. 1145 BC) shows signs of what may be smallpox. Although the surviving medical papyri don’t mention anything that sounds like smallpox, Ramses’ mummy shows the disease’s telltale lesions on its pockmarked face and shoulders. If he did die of smallpox, he would be one of the earliest known victims of the disease. Evidence from other skeletons suggests tuberculosis of the spine, and more obvious deformities such as dwarfism, club foot and hydrocephalus. Guinea worm infestation has also been detected in one mummy, which was known to have caused dracunculiasis. Bones also show evidence of stunted growth, osteoporosis; dietary toxins include lead.69

  Other diseases have been conjectured, despite a lack of firm evidence from papyri, mummies, potsherds, funerary stelae or other sources. Malnutrition almost certainly afflicted the ancient Egyptians in years of famine. Polio appears to be depicted on some stelae – figures are depicted walking with sticks – and malaria would have certainly been a problem.

  There is no firm evidence of plague or tetanus, although both would eventually appear in Egypt.

  Disease in Ancient Greece

  A thousand years separates the Ebers Papyrus from the next important group of medical writings from western antiquity.
In The History of the Peloponnesian War, the Greek historian Thucydides gives a graphic account of the epidemic that struck Athens, his home city, in 430 BC:

  The plague first began to show itself among the Athenians. It was said that it had broken out in many places previously in the vicinity of Lemnos and elsewhere; but a pestilence of such extent and mortality was nowhere remembered. Neither were the physicians at first of any use, ignorant as they were of the proper way to treat it, but they died themselves in great numbers, as they visited the sick most often; nor did any human art succeed any better. Supplications in the temples, divinations, and so forth were found equally futile, till the overwhelming nature of the disaster at last put a stop to them altogether.

  He describes the symptoms, which included a terrible fever, livid patches on the skin, sore throat, a cough, vomiting, sneezing, fetid breath, convulsions, memory loss, exhaustion and severe diarrhoea. People were afraid to visit the sick, and the dead were buried without proper funeral rites. The death toll was so high – Athens lost a third of its population – that an air of lawlessness began to prevail, with widespread debauchery and crime:

  Fear of the gods or the law of man did not restrain them. As for the first, they judged it to be just the same whether they worshipped them or not, as they saw all alike perishing; and for the last, no one expected to live to be brought to trial for his offences, but each felt that a far severer sentence had been already passed upon them all and hung over their heads, and before this fell it was only reasonable to enjoy life a little.

  But what was the Plague of Athens? Thucydides records that there was talk the Spartans – with whom the Athenians were then at war – had poisoned the drinking water, but reserves final judgement. He does observe, however, that surviving the plague made one immune to it for life. Thucydides writes from personal experience: as a general in the war, he contracted the plague himself, but did not make the same mistake certain others did, of thinking they were then immune to all forms of sickness; no doubt they may well have succumbed to other ailments, rendering any celebration short-lived.

  Various pathogens have been proposed as the cause of the Plague of Athens, including bubonic plague, influenza, typhoid fever, measles, epidemic typhus, and smallpox, all of which display some of the symptoms described in The History of the Peloponnesian War. However, the jury is still out. Paleopathology has so far provided no conclusive answers and scholars are still arguing over the correct interpretation of Thucydides’ text. What we do know is that by the time Thucydides was writing, maybe ten to twenty years later, Athens had not only lost the war against the Spartans, but had been forever crippled as a major power. The golden age of Athenian democracy and culture was over, hastened to its grave by the plague – whatever it was.

  The Cult of Asclepius

  In the wake of the Plague of Athens and the crippling of the city-state’s power came the rise of the cult of Asclepius the healer. Its origins are obscure, but it could have been in existence while Thucydides was still writing his history of the war (while the war was still being fought). With the cult of Asclepius, magic maintained its prominence in Greek thinking about disease. The irony was perhaps not lost on Thucydides, who is often regarded as one of the founders of history as a discipline. He downplayed the role of the gods in human affairs, and as such, his work can be seen as a blueprint for later writings about diseases and medicine. But that would have given beleaguered Athenians little succour after losing so many of their kinsfolk to the plague and the lengthy war against Sparta.

  Asclepius was the son of Apollo and a mortal woman, reflecting the esteem in which doctors and medical practitioners were held in ancient Greece. Educated by the centaur Chiron, Asclepius used his learning to help humans with his medicinal know-how (plant remedies). So successful was Asclepius at this – indeed, he was said to be able to bring people back from the dead – that Hades, the god of death, complained to Zeus that the underworld was being deprived of its denizens. Zeus agreed that Asclepius had overstepped the mark, and promptly struck him dead with a thunderbolt. (Another version of the story has it that Asclepius was killed because he accepted gold for his services as a resurrectionist.)

  Subsequently elevated to the rank of god himself, Asclepius was worshipped as the tutelary deity of medicine, usually depicted as holding a staff around which a snake had coiled itself. This symbol – the caduceus – became synonymous with the healing arts. Asclepius was often shown with his daughters Hygeia (health) and Panacea (cure-all). His sons were known as the Asclepiads, supposedly the first physicians; this title was later bestowed upon all doctors, although it’s not certain whether it was a slang term, or one to designate membership of some kind of medical guild.

  The Asclepius cult spread during the fourth century BC, and by 200 BC, all towns of significant size in Greece had an Asclepion, or temple to Asclepius. Cos had perhaps the best-known Asclepion, although there were other notable examples at Epidaurus and Pergamon, birthplace of the Roman doctor Galen (for more of whom, see below). Rituals at Asclepia involved incubation, or temple sleep. The patient would sleep before an image of Asclepius, and hope that they would either be made well during the night by the god himself, or be given the cure in a dream (which sometimes required a priest to decipher it the following morning). People came to Asclepia seeking cures from blindness, paralysis, edema, tapeworms, abdominal abscesses, lice, headaches, wounds sustained in battle, infertility, gout, even baldness. If the patient was cured, the event would be commemorated on a plaque placed in the temple precinct: ‘Hermodikes of Lampsakos was paralysed in body. In his sleep he was healed by the god.’ But how did the gods heal? The experience of Alketas of Halika reveals something of their mysterious ways: ‘This blind man saw a vision. He thought that the god came up to him and opened his eyes with his fingers. The first things he saw were the trees of the Temple. At daybreak he left the Temple restored to health.’70

  The Hippocratic Revolution

  However, not all Asclepiads subscribed to the notion that disease had a divine cause. One doctor in particular caused a revolution that affected all subsequent medical practice: Hippocrates of Cos (c. 460 BC – c. 371 BC). Although Cos had a major Asclepion, Hippocrates, as Roy Porter put it, ‘plucked disease from the heavens and brought it down to earth.’71 Hippocrates was able to do this because of the relative openness of classical Greek culture, ‘a quality characteristic of Greek intellectual activity at large, which it owed to political diversity and cultural pluralism.’72 Unlike ancient Babylon, whose doctors were bound by the Hammurabic code, there was no regulation – to use modern parlance – of the medical profession. Theoretically, anyone could set up shop as a healer, shaman, doctor, exorcist or diviner – all of whose skills were known to have been sought out in ancient Greece to cure sickness.

  Little is known for sure of Hippocrates – he exists in the same realm of mythologised history as Homer, Hesiod and Pythagoras. Indeed, a genealogy was drawn up linking Hippocrates to Asclepius, and the famous Hippocratic Oath sworn by doctors begins ‘I swear by Apollo the physician, by Asclepius, by health (Hygeia) and all the powers of healing (Panacea), and call to witness all the gods and goddesses...’ But Hippocrates needed no dubious links to deities, whether by genealogy or oath, both of which were probably not written down until after his death. He stressed observation and reason over supernatural explanations, and the school he founded was to exert an immense influence. Known as the Hippocratic or Coan School, the collected writings of Hippocrates and his followers were brought together sometime during the third century BC. (Hippocrates was mysteriously able to continue writing books long after his death.)

  Although varied in style and substance due to the plethora of authors, the Hippocratic Corpus gives us a much clearer picture of what diseases the ancient Greeks suffered from. Interpretation of the Corpus involves the usual problem with ancient texts, in that definitions are sometimes imprecise, but modern doctors can assert with some confidence that Hippocrates an
d his followers knew of, amongst others, cholera, pneumonia (described as ‘a disease of the ancients’), meningitis, tonsillitis, epilepsy, septicaemia, various gastrointestinal disorders, tuberculosis, brucellosis, tetanus, malaria, and possibly influenza and polio.

  The writings on malaria are particularly interesting. Hippocrates was the first to describe the disease’s ability to produce fever on alternate days (tertian malaria), or every third day (quartan malaria); its effect on the spleen; its seasonal distribution; and its link to stagnant water. Hippocrates and his school were also aware of the seasonal and environmental risks of infection, as in the case of malaria; the human immune system’s tendency to produce fever and swelling as a reaction to infection; and the need to cook meat and fish properly to avoid diarrhoea and food poisoning. Above all, the Hippocratic Corpus attempted to treat every known disease in a systematic and reasoned manner.73

  Central to Hippocratic thinking was the theory of the four humours, based on the theory of the four elements. Formulated in the fifth century BC by the philosopher Empedocles (c. 490–430 BC), the theory held that all things were formed from earth, air, fire and water, and each of these elements had a defining characteristic: wet, dry, hot and cold respectively. From this, Hippocrates developed the idea that the body contained four humours, each comprising a pair of Empedoclean traits: black bile (cold and dry); yellow bile (hot and dry); blood (hot and wet); and phlegm (cold and wet).