From Observation to Diagnosis

Although it is well known that Ancient Egyptians were valuable medical doctors and surgeons, highly advanced in anatomy and surgery, few scholarly publications are focused on the method of examination, interpretation and treatment of illness.

by Primavera Fisogni This paper explores the first case included in the Edwin Smith Papyrus, the oldest surgical document in history of civilization, moving from the hieroglyphic text, in order to focus on both the medical glossary and the passage from observation to diagnosis.

The aim is both to sketch the intellectual method to practice medicine and to discuss the original hieroglyphic text. The doctor-patient relationship is made up of a number of established practices. For example, the doctor is expected to inquire about the patient’s conditions, symptoms, and to examine the general state of the person, listening to the heart and evaluating, for example, the respiratory function.

On the basis of these elements, through a phenomenological approach to the patient, the doctor can sketch a diagnosis. We probably do not realize that every medical examination summarizes several fundamental logical passages, through which information is acquired and organized. This process generates new knowledge through the examination, and correlation of multiple elements. A crucial step in the cognitive activity is the abduction or the inference through which, given a context of incomplete information (a cluster or symptoms), the subject (a medical doctor, a surgeon) introduces an element not present in the context, therefore “new”, which explains the data available (the diagnosis of the illness).

A plate from the Edwin Smith Papyrus (Wikipedia)

In short, what a medical observation reveals, on a strictly cognitive level, is the presence of a method for concretely dealing with the discomfort reported by the patient, so as to arrive at a fruitful treatment. It’s definitely a matter of method. A Greek term by origin, a method, always requires an intentional use of thinking, together with the awareness that - through reflection on the available data - it is possible to act, finding a way out of the problem. It is really surprising to notice how finely written and methodologically refined are the surgical cases collected by Papyrus Edwin Smith, the most ancient medical treatise of history, dated the seventeenth Century BC, from Egypt.

We probably do not realize that every medical examination summarizes several fundamental logical passages, through which information is acquired and organized.

Written in hieratic, a cursive hieroglyphic writing, it was translated and commented for the first time by James Henry Breasted, in 1930 (1). The text was probably much older, dating the sixth dynasty and, among the author, also the name of physician and architect Imhotep has been suggested. Reading the multifaceted cases examined by the papyrus, mostly severe traumas of the bones, we remain in awe of the effort of the authors to deal with the suffering of the wounded patients, whose injuries were primarily due to the battlefield or the critical conditions of workers in the building sites. Recently a renewed interest arouses from scholars of neurosurgery who found valuable insights in the way the Egyptian doctors were dealt with spinal injuries: «Although patient demographics, diagnostic techniques and therapeutic options considerably changed over time, the documented rationale on spinal injuries can still be regarded as the state-of-the-art reasoning for modern clinical practice» (2). From a logical point of view, all the cases examined in the papyrus show the same frame. The text generally starts naming the kind of injury occurred, then provide the readers (practitioners, surgeons, priests) with a close phenomenological description of the case in order to reach a possible explanation and a valuable treatment (3). Trauma in Ancient Egypt: a case history The first case of the 48 collected by the Edwin Smith Papyrus concerns an open fracture of the skull, where the trauma involved the gash of the bone. The title is, at all effects, a phenomenological description of the trauma.

Transliterated from hieroglyphs, it should be read: šsˁw wbnw m tp.f / ˁr n ḳš n dnn.t.f. Literally “Instructions (šsˁw) – Wound (wbnw, with the sign of the blood flow) in his head (m tp.f). / that penetrates (ˁr, verb also with the meaning of reaching, arriving, accompanied by wȝt, the sign of a path with greenery) in the bone (n ḳš) of his skull (dnn.t.f.). The understanding of the case is facilitated by the title itself, although the description is brief and the part of the head where the wound occurred is missing. It is interesting to note the dialogical character of the anamnesis, which seems to evoke two colleagues who are discussing about the case or a doctor/teacher and his students. In the following hieroglyphs it can be read: «if you examine – the passage begins – a man who has a wound in the head that penetrates the bone of his skull (but) without (that there is) a gash» (transliterated: ir ḫȝ.k s n wbnw m tp.f / ˁr n ḳš n dnn.t.f nn kf.t.f)”. We translate with the term “examine" the verbal construct ḫȝ.k, from ḫȝi ( , in abbreviated form ). It indicates the act of measuring, mainly in the sense of weighing (grain or other materials) or "pondering" something. The surgeon, therefore, observes by reviewing the object of the examination – the trauma – according to extension, depth, consistency, with an admirable exercise of intellectual comprehension (Lat. cum-prehendo, “I take together”) of the phenomenon. So, we read: «if you examine (literally: palpate) a man who has a wound in his head, / penetrating the bone of the skull (but) without a gash you must palpate his wound / (translation of the two lines of hieroglyphs above, ed), you should find his skull wounded without a perforation, fracture or blow in it.' The transliteration of hieroglyphs below, is to be read from the left, as follows: dˁr ḫr k wbnw.f / wd ḫr k ˁ k tp.f / gmm.k dnn.t.f wdȝ ti / n wn nt thm pšn spht ).

The verb "palpate", i.e., to perform an examination with fingers (dˁr) is in turn a modality of examining (ḫˁ.t), also used as a synonym of the same term. At this point, the Egyptian surgeon, an ambiguous profile between medicine and the science of divine, always suspended between critical observation and the help of goddess Sekhmet, had enough elements to formulate the diagnostic hypothesis. This passage was perceived as a culminating phase in the analysis of the injury, a prelude to the right solution of the case. We read: «You should say, concerning (him): 'He is one who has an open wound on his head. An ailment that I will cure’ ». Let’s move to the text. Hieroglyphs must be read from left to right.

Text from the Edwin Smith Papyrus edited by Breasted The transliterated Egyptian text sounds like this: dd in.k r.f ẖr yw bnw n kf.t m tp.f / smr iry; there is no reference to the prognosis, that’s to say: the author does not mention the likely course of the medical condition of the injured person. It’s easy to realize that the doctor made a true phenomenological effort to observe the data without prejudices, putting every possible suggestion well in brackets, before exploring the patient’s state – with the eyes and with the hands (in other cases of Edwin Smith Papyrus the sense of smell is also applied) – scrupulously. The formula ir ḫȝ.k s – if you examine – is the starting point of each case treated in the Edwin Smith Papyrus and a prelude to gmm.k – “you should find” formula (in hieroglyphic: the bird pecking the ground) –, as well as dd in.k, “you should say” formula. The properly diagnostic step starts with this utterance. The snake and the hand refer to the verb “to say”, the other sign, a leaf, followed by the movement of the water and the cup indicates the preposition “by” followed by the second person masculine pronoun “you”. There is therefore a precise logical consequentiality, in the analysis, which is also emphasised by language, which brings knowledge (sšmt) through šsˁw, or theoretical "instructions". According to Obenga the sšmt phase or “examination of the proof” is highly relevant in order to explore the logical texture of the pre-classical scientific method. «This is the review of the whole body of evidence or premises and rules that determine the validity of a solution. Such an examination of a logical proof always leads to a further conceptual generalization. Thus, the ancient Egyptians had the technique of forming concepts inductively» (4). A pre-classical idea of intention The relationship between the three phases of the medical examination - seeing-understanding-doing -, so peculiar to Egyptian thought, brings us back to the verb iri, to do/act, graphically rendered by the sign of the eye, to indicate the connection between cognitive and operational activity. It is worth noting the link between this Egyptian conceptual frame and the idea of intention, as it has been theorised by Anscombe in 1957 (5). Intention is a crucial component of the will. It is not just the act of bringing about some state of affairs, not a simple volition, but the kind of knowledge that allows to reach a goal. Anscombe writes (Proposition 8) that an intention belongs to class of «non-observational knowledge», the «class of movements known without observation».

If we reflect: when we say «I open the windows», I make a number of operations in order to perform that act. My act is intentional because I know all the passages that allow me to open that window. In other words, intention always needs the knowledge of the means to achieve the goal (to open a window). Sensing, in its grasping reality, for allowing will to consent, has a main role in defining the means. Egyptians had a clear insight of the fact that every intentional knowledge melts together thought and manipulation, the theoretical and the practical environment, the eye and the hands. This resounds astonishingly contemporary from the Edwin Smith Papyrus. In the last line of the hieroglyphic text the form iry.i indicates "I will cure" . We finally come to the treatment (srwḫ) of the wound, which consists in covering it with fresh meat (iwf wˁd), the first day, then carefully bandaging the injured part; later, it is suggested to treat it with fat (mrḥ.t) e honey (by.t), always securing it with gauze (ftt), until full recovery has been achieved. Probably, the surgical papyrus was also needed for the accident occurred to the vizier Uashptah who, visiting the construction site of the pyramid of the pharaoh Neferirkare (the third king of the 5th Dynasty), together with the sovereign, fell disastrously and died instantly from the consequences of the trauma, despite being rescued by the chief himself of the

court doctors.

«He was sent to look for a casket of medical books – Bresciani notes – but when arrived, they had to inform Her Majesty that the vizier was dead». (6) (Translation is mine) Conclusion While moving in an area very far from the modern idea of science, the surgeons of Ancient Egypt were certainly excellent phenomenologists and their approach to pathologies intuitively followed the master lines of that approach: observation, analysis and conclusion, putting in brackets pre-judgments and going to the essential features of the problem (7). Although in the text examined – the first within 48 cases of wounds, injuries and fractures studied (skull, neck, upper limbs, chest to the thoracolumbar spine) –, cannot be found a term that refers to “method”, however šsˁ.w , that can be translated with “instructions” belongs to the semantic area of the critical accuracy. The sign is expressed by the head of an antelope (a word that reads precisely šsˁ.w in its complete form), it refers to the term šsr, indicating both the grain and the arrow; two signs that clearly recall the act of counting and the sharpness of reasoning. In the second text from the medical Ebers Papyrus (line 48,1) dating back to 1550 BC (8, 9, 10), where one comes across formulas like the following:

The line is transliterated, from the left: «šsr(w) mȝˁ ḥḥ n sp». We translate as “True instructions from a million of years”, but it does not seem inappropriate even the hypothesis of a “Method that has been successful for a million years”, because a precise path is followed for obtain healing, consisting in the observation of symptoms, in the administration of a remedy and in the use of any prayers to the right gods. © Rekh Magazine References

1) Breasted JH (1930) The Edwin Smith Surgical papyrus (facsimile and hieroglyphic transliteration with translation and commentary, in two volumes) Chicago: The University of Chicago Press

2) van Middendorp JJ, Sanchez GM and Burridge AL (2010) The Edwin Smith papyrus: a clinical reappraisal of the oldest known document of spinal injuries, Eur Spine J., Nov; (19(11): 1815-1823; p. 1815

3) Fisogni P (2019). Nel segno del pensiero. Come pensavano gli antichi egizi, Cinisello Balsamo, Santelli

4) Obenga T (ed. K. Wiredu) (2004). Egypt: Ancient History of African Philosophy, in A Companion to African Philosophy, New York: London, Blackwell; p. 42

5) Anscombe GEM (1957). Intention, London: Blackwell.

6) Bresciani E (2016). Una rilettura di un testo biografico. La caduta mortale del visir Uashptah dalla piramide di Neferirkara, in Egitto e Vicino Oriente, Dipartimento di Civiltà e Forme del sapere dell’Università degli Studi di Pisa, XXXIX, 2016, pag. 5-6; p. 5.

7) Metwaly AM et al. (2021). Traditional ancient Egyptian medicine: A review, June 2021, June 2021, Saudi Journal of Biological Sciences; available at https://www.researchgate.net/publication/352539362_Traditional_ancient_Egyptian_medicine_

8) Wilson JA (1964). Medicine in Ancient Egypt Bulletin of the History of Medicine

Vol. 36, No. 2 (March-April 1962), pp. 114-123

9) BrYan CP (1930). Ancient Egyptian Medicine. The Papyrus Ebers, Chicago. Ares Inc

10) Jones A and Taub L (2018). Egyptian Medicine, Cambridge: Cambridge University Press