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III. The Edwin Smith surgical Papyrus
III. THE EDWIN
SMITH
SURGICAL
PAPYRUS
FELIX CUNHA, M.D. San Francisco,
I
N addressing a group of surgeons in Chicago in the nineties, John BiIIings said that although no modern surgeon possessed of all the knowIedge and resources avaiIabIe would discover any new technic or knowledge by a perusa1 of the methods the oId masters used, he was of the opinion that they couId read, compare and think; so doing it was fair to say that he would be a broader and wiser man, estabhshed on a better foundation. BiIIings acknowledged that there were a great many. men who had neither time nor accessibihty to search coIIections of origina materia1, and it was his opinion that short essays that did not take up too much time shouId be made avaiIabIe to these men by way of the surgical journaIs. It is with such a thought in mind that one justifies inflicting this sort of materia1 on an editor. By opening this series with a comment on the Ebers Papyrus one accompIishes a literary chore successfuIIy, namely, one can skip over a period of about 4,000 years before there is anything in surgica1 Iiterature which can be cIassed as specificaIIy informative. The art of surgery in these earIy days was sharply Iimited because of many surrounding environmenta factors. Before the time of Christ there was the Jewish abhorrence and aversion to blood. After Christ the religious shrank from doing anything to the body in the beIief that it interfered with God’s own handiwork. In most instances those who caIIed themseIves surgeons were afraid of venturing far, subconsciousIy frustrated by the inward knowIedge that they were not
June,
19~
California capabIe and did not know the way. Knowledge of anatomy, a necessary partner to was totaIIy Iacking. Therefore, surgery, is it any wonder that honest men were timid? During the Crusades the story is told of a certain grand duke, a member of a party making the piIgrimage. He was so fat that he tired too easiIy, thus holding up the progress of the expedition; in addition, he suffered excessiveIy from the heat. A surgeon accompanying the expedition was ordered to do something about it. He did. It was one of the earIiest actually recorded cases in which the operation was successfu1 but the patient died. The doctor cut into his noble patient’s beIly and removed a11 of the fat. The patient died that night. On another occasion a grand duke fell from his horse, with a resuIting compound fracture of the Ieg. After a few days it was a black, gangrenous leg. The surgeon accompanying this group would not amputate. Therefore, the duke placed a we11 sharpened battle axe across his Ieg beIow the hip and ordered his man servant to hit it and hit it hard with a heavy- hammer. Three bIows and the axe went through and the Ieg feI1 off. The duke died a few hours Iater. No word was mentioned about bIeeding. These were certainly the men of distinction of their day. To trace the story of surgery from the beginnings down through time is not onIy intriguing and inviting but is inspiring as weI1. It is a manifest testimonia1 of the ingenuity of the human mind. The paths of deviation in ideas and methods is, at est, a crooked one to trace because it is a
793
794
Cunha-The
Edwin
FIG. I. Osseous tumor of tibia taken from J. F-I. Breasted’s “The Edwin Smith Surgical Papyrus.”
story of humans, their fallibiIities, briIIiant minds and the neo-brilhant (those who have managed to shine through without any right to do so), great thinkers, humanists and phiIosophers and with it a11 just enough of a sprinkhng of crooks, quacks and many, many just pIain “nuts.” Surgery has had its peaks and vaIIeys in the point of estimation in the peopIes around it. Discredited and in disrepute at times, aImost extinct at various timesthat part of it which has been honest has survived. What hurdIes it has had to negotiate successfuIIy : crazy kings who narmade it go underground to survive; row-minded bigots in high pIaces who delighted in issuing edicts in attempts to strangIe it; eccIesiastic interferences for centuries either based on reIigion or on the sheke1; and superstition, increduIity, witches, medicine men, triba1 customs and what have you. In its time it has been the victim of of ignorance, of the IoftyinteIIigence, minded and cuItured, and of Iiars and
Smith
Papyrus
imposters, yet it has survived. How can the story of any parts of surgica1 progress possibIy be without interest to those in the tieId? How can it heIp but be stimuIating? We have made a beginning using the Ebers Papyrus as a sort of jumping off point because it represents the first actuaI recording we have and, therefore, material proof of the surgica1 art of the time approximateIy sixteen centuries before Christ. Before we transfer our attention to the great manuscripts, which is the next IogicaI step in tracing our way, there is one other great papyrus we couId hardIy afford to leave behind without mention. That is the Edwin Smith Papyrus. This was acquired by a Mr. Edwin Smith at Luxor or Thebes. The exact year is thought to be 1862. Smith was a Connecticut Yankee, one of the first of American EgyptoIogists, who took his work seriousIy enough to Iive in Luxor for twenty years. AIthough Smith was unquestionabIy famiIiar with the fact that he had acquired a fabuIousIy vaIuabIe piece of property, unlike Ebers, he made no attempt to se11 it. After he died his daughter presented it to the New York Historica Society. Egyptian writing was pureIy pictographic; a drawing or picture signified the Imagine the thing it meant to depict. Iabor of deciphering invoIved in a study, of page after page of such materiaI! The first great evoIutionary step forward in the fieId of surgery occurred when men recognized natura1 causes of disease rather then demons and spirits. From superstition to a scientific point of view was an absoIuteIy necessary change. The Edwin Smith Papyrus is of unknown authorship. Within it is, perhaps, the first attempt of man to write a clinica history. Under each case described a Iist is given of the objective signs or changes present as seen by the eye or paIpated by the hand. An attempt is made to marsha these facts in an orderIy manner so that the whoIe dovetaiIs together into an entity. AIong with this is an orderIy discussion on how these Iesions came about American
Journal
of Surgery
Cunha-The
Edwin
n-ith conclusions as to the cause of death and speculation on what might have been the antemortem picture leading up to death. Here then is the first recorded attempt at clinica diagnosis and the writing of a clinical history differing hardly any in format from that which we write today. There is a considerable amount of scattered blurring in the papyrus, thus eliminating possible valuable segments or sections. Some of this blurring was probably done by the original Egyptian scribe \vho \I-as trying for perfection and some was probnblyv done by Edwin Smith himself, also striving for perfection, whereb\- in trying to eliminate minor defects he only- increased them. 5Inn’s mind was yet primitive; the m>-steries of the human body baffled him because he had no pIausibIe explanation as to the why; he was unable to grasp at logical conclusions based on observed fact. %‘ithout entering controversy, the Smith Papyrus is presumably a work of the seventeenth century before Christ, and much of the material in it may be of as far back as a thousand years before that. Who compiled it, put it together? Nobody
*June, 1949
Smith
Papyrus
795
knows. Wishful thinking has desired to place it as the work of Imhotep, the earliest known physician, 1300 B.C., long before Hippocrates and long before Aesculapius. The surgeons of those days folIowed armies and did not have much civilian practice except as a side line. That is why so much of the material in this papyrus IS on fractures inflicted anywhere, in the skuI1, face, arms or clavicIes, by ingeniously designed, heavy, long-handled instruments for deaIing such blows as wouId produce such wounds. Tops of heads wouId IiteraIIy be knocked off; faces in all reaIity would be pushed into the occiput, not to mention eyes being knocked out any which way. The arrow wounds, show that apparently arrows were aimed more for the abdomina1 area where tissues were soft; or we would Iike to beheve that if a man were a particuIarIy good shot, he aimed for an eye. You can let imagination run Ioose in any direction here. These early days of surgery were the days of a science in the making. No technica1 terms existed; they had to be made up as the need arose. “Brain,” “fracture,” “compound fracture” had to be inxsented.
SMITH
SURGICAL
PAPYRUS
FELIX CUNHA, M.D. San Francisco,
I
N addressing a group of surgeons in Chicago in the nineties, John BiIIings said that although no modern surgeon possessed of all the knowIedge and resources avaiIabIe would discover any new technic or knowledge by a perusa1 of the methods the oId masters used, he was of the opinion that they couId read, compare and think; so doing it was fair to say that he would be a broader and wiser man, estabhshed on a better foundation. BiIIings acknowledged that there were a great many. men who had neither time nor accessibihty to search coIIections of origina materia1, and it was his opinion that short essays that did not take up too much time shouId be made avaiIabIe to these men by way of the surgical journaIs. It is with such a thought in mind that one justifies inflicting this sort of materia1 on an editor. By opening this series with a comment on the Ebers Papyrus one accompIishes a literary chore successfuIIy, namely, one can skip over a period of about 4,000 years before there is anything in surgica1 Iiterature which can be cIassed as specificaIIy informative. The art of surgery in these earIy days was sharply Iimited because of many surrounding environmenta factors. Before the time of Christ there was the Jewish abhorrence and aversion to blood. After Christ the religious shrank from doing anything to the body in the beIief that it interfered with God’s own handiwork. In most instances those who caIIed themseIves surgeons were afraid of venturing far, subconsciousIy frustrated by the inward knowIedge that they were not
June,
19~
California capabIe and did not know the way. Knowledge of anatomy, a necessary partner to was totaIIy Iacking. Therefore, surgery, is it any wonder that honest men were timid? During the Crusades the story is told of a certain grand duke, a member of a party making the piIgrimage. He was so fat that he tired too easiIy, thus holding up the progress of the expedition; in addition, he suffered excessiveIy from the heat. A surgeon accompanying the expedition was ordered to do something about it. He did. It was one of the earIiest actually recorded cases in which the operation was successfu1 but the patient died. The doctor cut into his noble patient’s beIly and removed a11 of the fat. The patient died that night. On another occasion a grand duke fell from his horse, with a resuIting compound fracture of the Ieg. After a few days it was a black, gangrenous leg. The surgeon accompanying this group would not amputate. Therefore, the duke placed a we11 sharpened battle axe across his Ieg beIow the hip and ordered his man servant to hit it and hit it hard with a heavy- hammer. Three bIows and the axe went through and the Ieg feI1 off. The duke died a few hours Iater. No word was mentioned about bIeeding. These were certainly the men of distinction of their day. To trace the story of surgery from the beginnings down through time is not onIy intriguing and inviting but is inspiring as weI1. It is a manifest testimonia1 of the ingenuity of the human mind. The paths of deviation in ideas and methods is, at est, a crooked one to trace because it is a
793
794
Cunha-The
Edwin
FIG. I. Osseous tumor of tibia taken from J. F-I. Breasted’s “The Edwin Smith Surgical Papyrus.”
story of humans, their fallibiIities, briIIiant minds and the neo-brilhant (those who have managed to shine through without any right to do so), great thinkers, humanists and phiIosophers and with it a11 just enough of a sprinkhng of crooks, quacks and many, many just pIain “nuts.” Surgery has had its peaks and vaIIeys in the point of estimation in the peopIes around it. Discredited and in disrepute at times, aImost extinct at various timesthat part of it which has been honest has survived. What hurdIes it has had to negotiate successfuIIy : crazy kings who narmade it go underground to survive; row-minded bigots in high pIaces who delighted in issuing edicts in attempts to strangIe it; eccIesiastic interferences for centuries either based on reIigion or on the sheke1; and superstition, increduIity, witches, medicine men, triba1 customs and what have you. In its time it has been the victim of of ignorance, of the IoftyinteIIigence, minded and cuItured, and of Iiars and
Smith
Papyrus
imposters, yet it has survived. How can the story of any parts of surgica1 progress possibIy be without interest to those in the tieId? How can it heIp but be stimuIating? We have made a beginning using the Ebers Papyrus as a sort of jumping off point because it represents the first actuaI recording we have and, therefore, material proof of the surgica1 art of the time approximateIy sixteen centuries before Christ. Before we transfer our attention to the great manuscripts, which is the next IogicaI step in tracing our way, there is one other great papyrus we couId hardIy afford to leave behind without mention. That is the Edwin Smith Papyrus. This was acquired by a Mr. Edwin Smith at Luxor or Thebes. The exact year is thought to be 1862. Smith was a Connecticut Yankee, one of the first of American EgyptoIogists, who took his work seriousIy enough to Iive in Luxor for twenty years. AIthough Smith was unquestionabIy famiIiar with the fact that he had acquired a fabuIousIy vaIuabIe piece of property, unlike Ebers, he made no attempt to se11 it. After he died his daughter presented it to the New York Historica Society. Egyptian writing was pureIy pictographic; a drawing or picture signified the Imagine the thing it meant to depict. Iabor of deciphering invoIved in a study, of page after page of such materiaI! The first great evoIutionary step forward in the fieId of surgery occurred when men recognized natura1 causes of disease rather then demons and spirits. From superstition to a scientific point of view was an absoIuteIy necessary change. The Edwin Smith Papyrus is of unknown authorship. Within it is, perhaps, the first attempt of man to write a clinica history. Under each case described a Iist is given of the objective signs or changes present as seen by the eye or paIpated by the hand. An attempt is made to marsha these facts in an orderIy manner so that the whoIe dovetaiIs together into an entity. AIong with this is an orderIy discussion on how these Iesions came about American
Journal
of Surgery
Cunha-The
Edwin
n-ith conclusions as to the cause of death and speculation on what might have been the antemortem picture leading up to death. Here then is the first recorded attempt at clinica diagnosis and the writing of a clinical history differing hardly any in format from that which we write today. There is a considerable amount of scattered blurring in the papyrus, thus eliminating possible valuable segments or sections. Some of this blurring was probably done by the original Egyptian scribe \vho \I-as trying for perfection and some was probnblyv done by Edwin Smith himself, also striving for perfection, whereb\- in trying to eliminate minor defects he only- increased them. 5Inn’s mind was yet primitive; the m>-steries of the human body baffled him because he had no pIausibIe explanation as to the why; he was unable to grasp at logical conclusions based on observed fact. %‘ithout entering controversy, the Smith Papyrus is presumably a work of the seventeenth century before Christ, and much of the material in it may be of as far back as a thousand years before that. Who compiled it, put it together? Nobody
*June, 1949
Smith
Papyrus
795
knows. Wishful thinking has desired to place it as the work of Imhotep, the earliest known physician, 1300 B.C., long before Hippocrates and long before Aesculapius. The surgeons of those days folIowed armies and did not have much civilian practice except as a side line. That is why so much of the material in this papyrus IS on fractures inflicted anywhere, in the skuI1, face, arms or clavicIes, by ingeniously designed, heavy, long-handled instruments for deaIing such blows as wouId produce such wounds. Tops of heads wouId IiteraIIy be knocked off; faces in all reaIity would be pushed into the occiput, not to mention eyes being knocked out any which way. The arrow wounds, show that apparently arrows were aimed more for the abdomina1 area where tissues were soft; or we would Iike to beheve that if a man were a particuIarIy good shot, he aimed for an eye. You can let imagination run Ioose in any direction here. These early days of surgery were the days of a science in the making. No technica1 terms existed; they had to be made up as the need arose. “Brain,” “fracture,” “compound fracture” had to be inxsented.