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Neurosurgical Classic-XVII
Edwin Smith Surgical Papyrus

Robert H. Wilkins, MD
Division of Neurosurgery, Duke University Medical Center,
Durham, North Carolina

Cases 47 and 48 in the Edwin Smith Surgical Papyrus
FIG. 1. Cases 47 and 48 in the Edwin Smith Surgical Papyrus. (Plate XVII from Breasted.l)


Hieroglyphic interpretation of Cases 47 and 48
FIG. 2. Hieroglyphic interpretation of Cases 47 and 48. (Plate XVIIA from Breasted.l)

General Resources The following article is reprinted with Dr. Wilkins' permission from Journal of Neurosurgery, March 1964, pages 240-244.

The Edwin Smith Surgical Papyrus, dating from the seventeenth century B.C., is one of the oldest of all known medical papyri.l-l2 Its differs fundamentally from the others in the following ways:

  1. The seventeen columns on the recto comprise part of a surgical treatise, the first thus far discovered in the ancient Orient, whether in Egypt or Asia. It is therefore the oldest known surgical treatise.
  2. This surgical treatise consists exclusively of cases, not recipes. The treatise is systematically organized in an arrangement of cases, which begin with injuries of the head and proceed downward through the body, like a modern treatise on anatomy.
  3. The treatment of these injuries is rational and chiefly surgical; there is resort to magic in only one case out of the forty-eight cases preserved.
  4. Each case is classified by one of three different verdicts: (1) favorable, (2) uncertain, or (3) unfavorable. The third verdict, expressed in the words, 'an ailment not to be treated,' is found in no other Egyptian medical treatise.
  5. This unfavorable verdict occurring fourteen times in the Edwin Smith Papyrus marks a group of cases (besides one more case) which the surgeon cannot cure and which he is led to discuss by his scientific interest in the phenomena disclosed by his examination."¹

It is of special interest to the neurosurgeon because it contains the first descriptions of the cranial sutures, the meninges, the external surface of the brain, the cerebrospinal fluid, and the intracranial pulsations. It also contains the first accounts of surgical stitching and of various types of dressings. Brain injuries are noticed to be associated with changes in the function of other parts of the body, especially the lower limbs, and hemiplegic contractures are described in Case 8. Changes in bodily functions are also described in association with injuries of the cervical spine. Case 31 contains the first description of quadriplegic, urinary incontinence, priapism, and seminal emission following cervical vertebral dislocation.

The Egyptologist who brought this manuscript to light, Edwin Smith, was born in Connecticut in 1822, the year that Egyptian hieroglyphic was first deciphered. In Luxor, Egypt, in 1862, Smith bought an ancient manuscript roll which lacked some of its outer portions. Two months later the same vandals sold him the remaining fragments glued onto a dummy roll. Although Smith recognized the fraud, pieced the two together, and made an attempt at translation, it was not until 1930 that James H. Breasted translated the treatise and established its importance. Breasted was then Director of the University of Chicago Oriental Institute, and had been requested by the New York Historical Society to translate the papyrus, which the Society had received in 1906 from Edwin Smith's daughter.

According to Breasted, the Edwin Smith Papyrus is a copy of an ancient composite manuscript which contained, in addition to the original author's text (3000-2500 B.C.), a commentary added a few hundred years later in the form of 69 explanatory notes (glosses). It contains 48 systematically arranged case histories, beginning with injuries of the head and proceeding downward to the thorax and spine, where the document unfortunately breaks off. These cases are typical rather than individual, and each presentation of a case is divided into title, examination, diagnosis, and treatment. There is a definite differentiation between rational surgical treatments and the much less employed medico-magical measures. Significantly, trepanation is not mentioned.

The scribe who copied the Edwin Smith Papyrus from the earlier document in the seventeenth century B.C. made many errors some of which he corrected in the margins. The beginning and end of the original document are missing from the copy, and the name of the author is not present.

"The scribe of over 3,500 years ago, to whom we owe our present manuscript, could have had little consciousness of the momentous decision he, or possibly some one for him, was making when he pushed aside the ancient Surgical Treatise, then already a thousand years old, while his own copy was still incomplete. He had copied at least eighteen columns of the venerable treatise and had reached the bottom of a column when, pausing in the middle of a line, in the middle of a sentence, in the middle of a word, he . . . laid down his pen and pushed aside forever the great Surgical Treatise he had been copying, leaving 15 inches (39 cm.) bare and unwritten at the end of his roll."¹

Of the 48 cases described in the Edwin Smith Papyrus, 27 concern head trauma and 6 deal with spine trauma.3 Of the 27 head injuries, 4 are deep scalp wounds exposing the skull, and 11 are skull fractures.

"The latter, according to our present day terminology would be classified as follows: two compound linear fractures; four compound depressed fractures; four compound comminuted fractures; and one comminuted fracture without external wound. The symptoms and signs of head injury are given in considerable detail. Feeble pulse and fever are associated with hopeless injuries and deafness as well as aphasia are recognized in fractures of the temporal region."5

The following thirteen cases are reproduced, in part, from Breasted's classic translation :¹*

* Reprinted in part from The Edwin Smith Surgical Papyrus. By James H. Breasted. Chicago: Univ.Chicago Press, 1930, 2 vols. With the kind permission of the University of Chicago Press.

Case Two
Title: Instructions concerning a [gaping] wound [in his head], penetrating to the bone.
Examination: If thou examinest a man having a [gaping] wound [in] his [head], penetrating to the bone, thou shouldst lay thy hand upon it (and) [thou shouldst] pal[pate hi]s [wound]. If thou findest his skull [uninjured, not hav]ing a perforation in it...
Diagnosis: Thou shouldst say regarding [him]: "One hav[ing a gaping wou]nd in his head. An ailment which I will treat."
Treatment: [Thou] shouldst bind [fresh meat upon it the first day; thou shouldst apply for him two strips of linen, and treat afterward with grease, honey, (and) lin]t every day until he recovers.
Gloss: As for: "Two strips of linen," [it means] two bands [of linen which one applies upon the two lips of the gaping wound in order to cause that one join] to the other.

Case Three
Title: [Instructions concerning] a gaping [wo]und in his head, penetrating to the bone (and) perforating his [skull].
Examination: [If thou examinest a man having a gaping wound in] his [head], penetrating to the bone, (and) perforating his skull; thou shouldst palpate his wound; [shouldst thou find him unable to look at his two shoulders] and his [br]east, (and) suffering with stiffness in his neck...
Diagnosis: Thou shouldst say [regarding] him: "One having [a gaping wound in his head, penetrating to the bone, (and) per]forating his skull, while he suffers with stiffness in his neck. An ailment which I will treat."
Treatment: Now [after thou has stitched it, thou shouldst lay] fresh [meat] upon his wound the first day. Thou shouldst not bind it. Moor (him) [at his mooring stakes until the period of his injury passes by]. Thou shouldst [tre]at it afterward with grease, honey, and lint every day, until he recovers...
Gloss: As for: "Moor (him) at his mooring stakes," it means putting him on his customary diet, without administering to him a prescription.

Case Four
Title: Instructions concerning a gaping wound in his head, penetrating to the bone, (and) splitting his skull.
Examination: If thou examinest a man having a gaping wound in his head, penetrating to the bone, (and) splitting his skull, thou shouldst palpate his wound. Shouldst thou find something disturbing therein under thy fingers, (and) he shudders exceedingly, while the swelling which is over it protrudes, he discharges blood from both his nostrils (and) from both his ears, he suffers with stiffness in his neck, so that he is unable to look at his two shoulders and his breast...
Diagnosis: Thou shouldst say regarding him: "One having a gaping wound in his head, penetrating to the bone, (and) splitting his skull; while he discharges blood from both his nostrils (and) from both his ears, (and) he suffers with stiffness in his neck. An ailment with which I will contend."
Treatment: Now when thou findest that the skull of that man is split, thou shouldst not bind him, (but) moor (him) at his mooring stakes until the period of his injury passes by. His treatment is sitting. Make for him two supports of brick, until thou knowest he has reached a decisive point. Thou shouldst apply grease to his head, (and) soften his neck therewith and both his shoulders. Thou shouldst do likewise for every man whom thou findest having a split skull...
Gloss: As for "(Until) thou knowest he has reached a decisive point," it means (until thou knowest whether he will die or he will live; for he is (a case of) "an ailment with which I will contend."

Case Five
Title: Instructions concerning a gaping wound in his head, smashing his skull. Examination: If thou examinest a man having a gaping wound in his head, penetrating to the bone, (and) smashing his skull; thou shouldst palpate his wound. Shouldst thou find that smash which is in his skull deep (and) sunken under thy fingers, while the swelling which is over it protrudes, he discharges blood from both his nostrils (and) both his ears, (and) he suffers with stiffness in his neck, so that he is unable to look at his two shoulders and his breast...
Diagnosis: Thou shouldst say regarding him: "One having a gaping wound in his head, penetrating to the bone, (and) smashing his skull, while he suffers with stiffness in his neck. An ailment not to be treated."
Treatment: Thou shalt not bind him (but) moor (him) at his mooring stakes, until the period of his injury passes by...

Case Six
Title: Instructions concerning a gaping wound in his head, penetrating to the bone, smashing his skull, (and) rending open the brain of his skull.
Examination: 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 therein throbbing (and) fluttering under thy 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 thy fingers until the brain of his (the patient's) skull is rent open-(and) he discharges blood from both his nostrils, (and) he suffers with stiffness in his neck...
Diagnosis: [Thou shouldst say concerning him]: "An ailment not to be treated." Treatment: Thou shouldst anoint that wound with grease. Thou shalt not bind it; thou shalt not apply two strips upon it: until thou knowest that he has reached a decisive point.
Gloss: As for: "Smashing his skull, (and) rending open the brain of his skull," (it means) the smash is large, opening to the interior of his skull, (to) the membrane enveloping his brain, so that it breaks open his fluid in the interior of his head....

Case Eight
Title: Instructions concerning a smash in his skull under the skin of his head. Examination: If thou examinest a man having a smash of his skull, under the skin of his head, while there is nothing at all upon it, thou shouldst palpate his wound. Shouldst thou find that there is a swelling protruding on the out side of that smash which is in his skull, while 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 him having that injury which is in his skull...
Diagnosis: Thou shouldst account him one whom something entering from outside has smitten, as one who does not release the head of his shoul fork, and one who does not fall with his nails in the middle of his palm; while he discharges blood from both his nostrils (and) from both his ears, (and) he suffers with stiffness in his neck. An ailment not to be treated. Treatment: His treatment is sitting, until he [gains color], (and) until thou knowest he has reached the decisive point....
Gloss: As for: "He walks shuffling with his sole," he (the surgeon) is speaking about his walking with his sole dragging, so that it is not easy for him to walk, when it (the sole) is feeble and turned over, while the tips of his toes are contracted to the ball of his sole, and they (the toes) walk fumbling the ground. He (the surgeon) says: "He shuffles," concerning it...

Case Twenty
Title: Instructions concerning a wound in his temple, penetrating to the bone, (and) perforating his temporal bone.
Examination: If thou examinest a man having a wound in his temple, penetrating to the bone, (and) perforating his temporal bone, while his two eyes are blood shot, he discharges blood from both his nostrils, and a little drops; if thou puttest thy fingers on the mouth of that wound (and) he shudder exceedingly; if thou ask of him concerning his malady and he speak not to thee; while copious tears fall from both his eyes, so that he thrusts his hand often to his face that he may wipe both his eyes with the back of his hand as a child does, and knows not that he does so...
Diagnosis: Thou shouldst say concerning him: "One having a wound in his temple, penetrating to the bone, (and) perforating his temporal bone; while he discharges blood from both his nostrils, he suffers with stiffness in his neck, (and) he is speechless. An ailment not to be treated."
Treatment: Now when thou findest that man speechless, his [relief] shall be sitting; soften his head with grease, (and) pour [milk] into both his ears.

Case Twenty-Two
Title: Instructions concerning a smash in his temple.
Examination: If thou examinest a man having a smash in his temple, thou shouldst place thy thumb upon his chin (and) thy finger upon the end of his ramus, so that the blood will flow front his two nostrils (and) from the interior of his ear having that smash. Cleanse (it) for him with a swab of linen until thou seest its fragments (of bone) in the interior of his ear. If thou callest to him (and) he is speechless (and) cannot speak...
Diagnosis: Thou shouldst say concerning him: "One having a smash in his temple; he discharges blood from his two nostrils and from his ear; he is speechless; (and) he suffers with stiffness in his neck. An ailment not to be treated."...
Gloss: As for: "Thou seest its fragments in the interior of his ear," it means that some of the fragments of the bone come away to adhere to the swab which was introduced to cleanse the interior of his ear.

Case Twenty-Nine
Title: Instructions concerning a gaping wound in a vertebra of his neck. Examination: If thou examinest a man having a gaping wound in a vertebra of his neck, penetrating to the bone, (and) perforating a vertebra of his neck; if thou examinest that wound, (and) he shudders exceedingly, (and) he is unable to look at his two shoulders and his breast...
Diagnosis: Thou shouldst say concerning him: " [One having] a wound in his neck, penetrating to the bone, perforating a vertebra of his neck, (and) he suffers with stiffness in his neck. An ailment with which I will contend."
Treatment: Thou shouldst bind it with fresh meat the first day. Now afterward moor (him) at his mooring stakes until the period of his injury passes by.

Case Thirty
Title: Instructions concerning a sprain in a vertebra of his neck. Examination: If thou examinest a man having a sprain in a vertebra of his neck, thou shouldst say to him: "look at thy two shoulders and thy breast." When he does so, the seeing possible to him is painful.
Diagnosis: Thou shouldst say concerning him: "One having a sprain in a vertebra of his neck. An ailment which I will treat."
Treatment: Thou shouldst bind it with fresh meat the first day. Now afterward thou shouldst treat [with] ywrw (and) honey every day until he recovers.
Gloss: As for: "A sprain" he is speaking of a rending of two members (although) it (=each) is (still) in its place.

Case Thirty-One
Title: Instructions concerning a dislocation in a vertebra of [his] neck. Examination: If thou examinest a man having a 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 bloodshot; it is a dislocation of a vertebra of his neck extending to his backbone which causes him to be unconscious of his two arms (and) his 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: As for: "A 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 joined together, when one has been severed from another.

Case Thirty-Three
Title: Instructions concerning a crushed vertebra in his neck.
Examination: If thou examinest a man having a crushed vertebra in his neck (and) thou findest that one vertebra has fallen into the next one, while he is voiceless and cannot speak; his falling head downward has caused that one verte bra crush into the next one; (and) shouldst thou find that he is unconscious of his two arms and his two legs because of it...
Diagnosis: Thou shouldst say concerning him: "One having a crushed vertebra in his neck; he is unconscious of his two arms (and) his two legs, (and) he is speechless. An ailment not to be treated."...
Gloss: As for: "His falling head downward has caused that one vertebra crush into the next," it means that he has fallen head downward upon his head, driving one vertebra of his neck into the next.

Case Forty-Eight
Title: Instructions concerning a sprain of a vertebra [in] his spinal column.
Examination: If thou examinest [a man having] a sprain in a vertebra of his spinal column, thou shouldst say to him: "Extend now thy two legs (and) contract them both (again)." When he extends them both he contracts them both immediately because of the pain he causes in the vertebra of his spinal column in which he suffers.
Diagnosis: Thou shouldst say concerning him: "One having a sprain in a vertebra of his spinal column. An ailment which I will treat." Treatment: Thou shouldst place him prostrate on his back; thou shouldst make for him....

References

  1. Breasted, J. H. The Edwin Smith surgical papyrus. Chicago: Univ. Chicago Press, 1980, 2 vols. (see 1: pp. xvi, 6, 480-485, 487-489, 446-448, 451-454, 466; 2: pi. XVII, XVIIA).
  2. Castiglioni, A. A history of medicine. E. B. 12. Krumbhaar, Transl. New York: A. A. Knopf, 1947, 2nd ed., xxx, 1192, lxi pp. (see pp. 55-57).
  3. Elsberg, C. A. The Edwin Smith surgical papyrus and the diagnosis and treatment of injuries to the skull and spine 5000 years ago. Ann. med. Hint., 1981, n.s. 8: 271-279.
  4. Elsberg, C. A. The anatomy and surgery of the Edwin Smith surgical papyrus. J. Mt. Sinai Hoop., 1945, 12: 141-151.
  5. Horrax, G. Neurosurgery. An historical sketch. Springfield, IL.: Charles C Thomas, 1952, xi, 185 pp. (see pp. 12-16).
  6. Kharadly, M. E. A. Surgery in ancient Egypt. J. int. Cod. Sury., 1957, 28: 491-500.
  7. Mettler, C. C. History of medicine. A correlative text, arranged according to subjects. F. A. Mettler, Ed. Philadelphia: Blakioton Co., 1947, xxix, 1215 PP. (see pp. 795-797).
  8. O-Connor, D. C., and Walker, A. E. Prologue. In: A history of neurological surgery. A. E. Walker, Ed. Baltimore: Williams & Wilkins Co., 1951, xii, 588 PP. (see pp. 1-22).
  9. Power, D'A. Some early surgical cases. I. The Edwin Smith papyrus. Brit. J. Surg., 1988, 21: 1 4.
  10. Power, D'A. Some early surgical cases. II. The Edwin Smith papyrus. Brit. J. Surg., 1984, 21: 885-887.
  11. Sachs, E. The history and development of neurological surgery. New York: P. B. Hoeber, law., 1952,168 pp. (see pp. 21-28).
  12. Wilson, J. A. Medicine in ancient Egypt. Bud. Hint. Med., 1962,86: 114-128.

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