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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

displayed in temples and tombs, and on statues. The best


Introduction
surviving illustration of a urological procedure is the
This review attempts to reconstruct the history of urology engraving depicting circumcision (discussed later); cir-
in ancient Egypt. It is logical to assume that people who cumcision is apparent on the phalli of statues of the
had achieved suBcient knowledge and skill in engineer- pharaohs.
ing to erect such structures as the Pyramids, and whose
mathematical knowledge involved the use of complex
Palaeopathology
calculations and acquaintance with the principles of
cubic capacity, angles, decimals and square roots, must One of the principal sources of knowledge of ancient
have been advanced in other fields of intellectual endeav- Egyptian diseases is the study of mummified tissues, i.e.
our, including medicine [1]. 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
Sources of knowledge of Egyptian medicine
treated the mummified tissues with a solution of an alkali
Most of the reliable knowledge of Egyptian medicine in (sodium bicarbonate) combined with a hardening reagent
ancient times has been derived from three sources: (i) (alcohol or formaldehyde). The mummified tissues, when
the medical papyri; (ii) the statues, engravings and immersed in this mixture, gradually swell to their former
paintings on the walls of temples; and (iii) palaeopatho- shape and regain their flexibility. RuCer identified and
logical studies. described the normal structures of the kidneys and the
testicles. He also discovered some pathological conditions,
e.g. urinary calculi, atrophic kidney, multiple renal
The Papyri
abscesses and schistosomal nephropathy [3].
Ancient Egyptian books were rolls of papyrus, made G. Elliot Smith discovered the first vesical stone taken
from the plant Cyperus papyrus, a sedge, that grows wild from a mummy, among the pelvic bones of a young
throughout Egypt. The stems were stripped of their outer person who lived during predynastic times (before 4800
rind and pith, cut into slices and arranged vertically and BCE) [1]. RuCer also described three vesical stones weigh-
transversely in overlaying rows. This was pressed into ing 30, 24 and 12 g and measuring 4.5, 3.4 and 2.5 cm,
one sheet. The horizontal fibres were on the recto side respectively. One stone was pear-shaped, one globular
and the vertical on the verso. There are only 10 papyri and one triangular; they consisted of mixed phosphatic
still extant which deal with medical matters: the Ebers, and uric acids, common enough in Egypt at that time
the Edwin Smith, the Berlin, the London, the Hearst, the [1]. Three other stones were discovered in a mummy of
Kahun, the Chester Beaty, the Carlsberg, the Zoega predynastic origin and found opposite the first lumbar
medial papyrus and the Ramasseum papyri [2]. Only vertebra; because of their position Badr assumed that
five of these papyri contain information about urology. these were renal calculi [1].

Statues, engravings and paintings The ancient Egyptian medical system


Statues depicting cretinism, poliomyelitis and various The ancient Egyptian medical system, although associ-
orthopaedic deformities are displayed in the Egyptian ated with religion, mysticism and priestly magic, is to
museum in Cairo, and in other museums worldwide. some extent similar to the modern medical system, in
Engravings of Egyptian patients with abdominal swell- that both depend upon the study of anatomy and
ings, umbilical hernia and scrotal swellings are also pathology, and provide clinical descriptions of diseases
and specific measures for treatment [1]. A study of
Accepted for publication 6 July 1999 Egyptian medicine shows that, even by the highest

© 1999 BJU International 755


756 A. A. SHOK EIR and M .I. HU SSE IN

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 a a a
inaccessible to analysis. The testimony of ancient sources Fig. 1. Hieroglyphic script of haematuria referring to schistoso-
refers to the Egyptians as the healthiest race of the miasis (ã-a-ã disease) as it appears in Kahun papyrus.
ancient world.
Herodotus, the ‘father of history’, noted the practice from the penis and in this case it is possible to represent
of specialization among Egyptian physicians, stating that haematuria [7]. To the ancient Egyptian physicians, the
‘the practice of medicine they split into separate parts, symptom was always regarded as the disease. As haema-
each doctor being responsible for the treatment of only turia is the chief symptom of urinary schistosomiasis,
one disease. There are, in consequence, innumerable Kamal assumed that it refers to this disease [8]. The
doctors, some specialized in diseases of the eye, others of disease was mentioned 50 times in the medical papyri, i.e.
the head, others of the stomach, and so on; while others, 28 times in the Ebers, 12 in the Berlin, nine in the Hearst
again, deal with the sort of troubles which cannot be and once in the London papyri. Kamal presumed that
exactly localized [2]’. In the tomb of an eminent man these frequent mentions indicated an endemic disease [9].
who lived at Saqqara during the time of the pyramids, A causal relationship to a verminous parasite named
we find his title, i.e. ‘priest of Selkis, goddess of magic, ‘hr wt’ is reported in prescription 62 of the Ebers papyrus
royal physician, and interpreter of a diBcult science’ [4]. (1550 BCE) [10]. The hieroglyphic script of that prescrip-
The court was served by a specialist who designated tion and its English translation is given in Fig. 2. Several
himself as ‘palace eye physician, palace physician of the clinical symptoms were mentioned for the disease in the
belly, one understanding the internal fluids, and a guard- Ebers and Berlin papyri, including haematuria, frequency
ian of the anus’. Egyptian physicians had ranks, e.g. of micturition, painful micturition, eCects on the anus,
generalist, specialist, chief of physicians, inspector of abdominal pain, diarrhoea and blood in the stool, cardiac
physicians, superintendent and ‘greatest physician’ of disturbances and mental weakness. These symptoms
Upper and Lower Egypt [5]. represent both urinary and intestinal bilharziasis. The
Case presentations, particularly in the Edwin Smith cardiac disturbances and mental weakness referred to in
Papyrus, are systematic and meticulous. Every case starts the papyrus possibly represent a picture of chronic
by the words ‘information regarding . . .’ suggesting the anaemia [11]. Engravings of Egyptian patients with
history of the disease, then an examination follows and abdominal swellings, umbilical hernia and scrotal swell-
starts with ‘if you examine a patient with . . .’, then the ings are displayed at the tombs of Ptah-Hetep and
physician expects the prognosis of the disease by writing Ankha-ma-Hor in Saqqara (Fig. 3). These probably rep-
one of the following expressions: ‘I will treat’, ‘I will resent the late manifestations of bilharzial hepatic fibrosis
fight’, or ‘I will not treat’, and finally the treatment is with ascites [6].
described [6]. Several drugs for the treatment of schistosomiasis were
Philologists have translated a few of the Egyptian described in the Ebers, Berlin and Hearst papyri. These
papyri that discuss medical subjects. These translations included palliative drugs, i.e. sedatives (Hyoscyamus),
confirm the existence of medical literature and a fairly antispasmodics (ammi-visnaga), diuretics (juniper and
extensive pharmacopoeia in ancient Egypt. Treatment beer) and colon evacuation (caster oil). In the Hearst
was oCered on a rational basis and it was in co-operation papyrus, prescription 83, antimony (inset) was men-
with nature, i.e. a diet was prescribed for the patient, tioned for the first time as a treatment for schistosomiasis
strict hygienic regulations were enforced and medic- [11] (Fig. 4). Ancient Egyptians also pioneered the pre-
aments were administered. When ordering a drug, the vention of this disease by discouraging people from
Egyptian not only gave the name of the drug, but polluting and contacting polluted water. One of the
stipulated the quantity needed and advised a method of confessions noted in the Book of the Dead reads: ‘I have
preparation. not waded water’ [12].

Egyptian knowledge of schistosomiasis Egyptian knowledge of bladder tumour


Schistosomiasis was first recorded in the oldest papyrus Ancient Egyptians were one of the first people to recog-
of Kahun (1900 BCE). It was named ã-a-ã disease, the nise urinary bladder tumours as disease entities called
hieroglyphic script of which is presented in Fig. 1. The ‘bn wt’, the hieroglyphic script of which is shown in
phallus symbol was used to represent any fluid emitted Fig. 5, as it appears in the Edwin Smith papyrus [13].

© 1999 BJU International 84, 755–761


U ROLOGY OF P HAR AONIC EG YP T 757

irrt/ m/for iht/useful


^ phrt/remedy
^ kt/other
prepare

sms/chams isw/rosseuisou ht/belly


^ n/for

ns/man wnm/eaten hrbyt/cooked


^ nw/ground
in honey

htf/his belly m/in hrwt/worm nwt/who


(has)

stn/ kma/produce â a â/haematuria n/it


they not (is)

nbt./all phrt/remedy
^ n/not 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 genitourinary tract [14]. However, Faulkner’s dictionary
Fig. 5 indicates the characteristic hardness of tumour of middle Egyptian (the recognized reference) translates
tissues in general, as well as its possible reference to the ‘bn wt’ as ‘hard sandstone’. Bladder tumours were also

© 1999 BJU International 84, 755–761


758 A. A. SHOK EIR and M .I. HU SSE IN

mentioned twice in the Chester Beaty papyrus [15]. The a


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].

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 reten-
tion of urine in an infant [1,10].

Enuresis and incontinence Fig. 3. a, Abdominal swelling and umbilical hernia in a boatman
(temple of Ptah-Hetep in Saqqara). b, Scrotal swelling in a farmer
The word ‘dja det’, used in connection with urinary (temple of Ankha-ma-Hor in Saqqara). From [11] with permission.
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 with painful micturition. This phenomenon is referred
treatment for ‘stopping the urine when it is very frequent’ to by the word ‘hdbw’. In such cases the urine was
[1,10]. Possibly this is the earliest mention of inconti- described as contaminated by mucus, pus and blood. A
nence in the history of medicine. The treatment varied, similar condition is described in the Hearst papyrus. The
but generally consisted of a combination of a vegetable treatments are referred to as ‘prescription for treatment
substance and a mineral salt in a fluid vehicle such as of ‘hab’ (burning) in the bladder’. In the Berlin papyrus,
water, beer or honey. In the Edwin Smith papyrus a prescriptions 143–147 apply to the ‘elimination of acute
case is described (passage 31) in which subluxation of a pain during micturition’; such pain was described as
cervical vertebra caused paralysis of the upper and lower violent and severe. Dawson suggested that the condition
limbs, incontinence and priapism [1]. referred to is prostatitis [17].

Cystitis syndrome Egyptian knowledge of urological anatomy


Three prescriptions in the Ebers papyrus are suggested The practice of embalming the dead aCorded the
to relieve burning pain in the bladder, which is associated Egyptians at least a superficial knowledge of the structure

© 1999 BJU International 84, 755–761


U ROLOGY OF P HAR AONIC EG YP T 759

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 the embalmer left the kidneys in the body, as for the
injure the internal organs, particularly the heart, which heart, indicating that special significance was attached
was regarded as the abode of the soul and the seat of to these two organs. If the kidneys were undesirable,
the intellect. The belief was that ‘no mutilated person they would have been removed with other viscera. Other
could enjoy the blissful life of the future world’. Egyptian authors believe that the kidneys were left behind in
knowledge of anatomy provided the basis for the proper ignorance, because their retroperitoneal location made
study by the Greeks. them inaccessible in the normal evisceration that was
A king-physician named Athotis, son of king Menes, part of mummification. The ureters (mt) were referred to
the founder of the first dynasty, and the author of a as vessels. The description 854n in the Ebers papyrus
manual on anatomy, but nothing is known of its contents reads: ‘there are two vessels which conduct urine to the
[6]. Professor J.H. Breasted, who first described the Edwin bladder’. There is no mention of a specific term for
Smith papyrus, maintains that this papyrus aCorded ureter. Every tube that carried a fluid or secretion was
evidence that anatomy was studied for its own sake and called a vessel [17]. As the Egyptian physicians knew
that this document is, in the true sense, a scientific that the ureters conveyed urine to the bladder, Kamal
medical book [13]. assumed that they also knew that the kidneys were the
Only a little was known about urological anatomy. source of that urine [9]. However, in most references it
The whole urinary tract was not specifically referred to is stated that the role of the kidneys was completely
as a system, but the individual parts of the tract were ignored.
mentioned in some way. There is no hieroglyphic word In paragraph 864 of Ebers papyrus, the bladder was
in the medical papyri for kidney. The words ‘depet’, definitely mentioned (chyptyt) and described as a separate
‘geget’, ‘geret’ and ‘gelet’ all signify loin. Some authors organ located in the frontal portion of the abdomen
support the opinion that the Egyptian physicians con- [18]. The urine itself was noted separately, named ‘moyt’,
sidered the kidneys to be very important organs, because and considered a clean fluid. One of the magical treat-
ments reads: ‘thou art a servant who cometh in vomitus;
thou art a noble who cometh in urine’ [1].

Egyptian knowledge of urological surgery


Mummies and statues occasionally show scars in the
Fig. 5. Hieroglyphic script of tumour (bn’wt) as it appears in the lumbar region, possibly indicative of previous surgery.
Edwin Smith papyrus. Operations to correct hernia and hydrocele were

© 1999 BJU International 84, 755–761


760 A. A. SHOK EIR and M .I. HU SSE IN

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 The stone is composed of carbonates of lime and an acid,
ancient surgical prowess can be seen in extant represen- such as vinegar. Upon contact between the stone and
tations of circumcision, an operation that was performed the moist skin, carbonic acid would be released and act
at least 2000 years before the reign of Rameses II. The as a local anaesthetic [9].
advantages of the procedure were first limited to mem- Ancient surgical instruments discovered in Egypt
bers of the priesthood but were later adopted by royalty include delicate scalpels, probes, forceps and knives. A
and the nobility. Still later, circumcision became a knowledge of urological surgery is indicated in the
universal practice, although the operation was not per- records stating that the Egyptians used bronze and tin
formed until the youth had reached puberty. The tech- for making catheters and this could have been as early
nique of the operation is best illustrated in a bas-relief as the third millennium BCE [19].
on the wall of the temple of Ankha-ma-Hor at Saqqara
(fifth dynasty, 2400 BCE) (Fig. 6). The scene on the right
Ancient Egyptian concepts of sex
depicts the preparation for the operation. The surgeon
is possibly anaesthetising the body of the penis of the Erotic life flourished at all levels of society and, contrary
adolescent boy standing before him. The patient supports to what is generally thought, it was recorded in words
himself by holding the surgeon’s head, saying, ‘rub and pictures [20]. The belief in an afterlife was all
properly what is there’. The surgeon answers, ‘I shall do important to the Egyptians; they believed that as the
what will be comfortable for you’, meaning that it will union of male and female was a necessity for the creation
not hurt. In the scene on the left, the hieroglyphics read of a new being, the erotic force also enables a person
‘circumcision by lector-priest’. The surgeon tells his who had departed from this life to continue existing in
assistant, who is standing behind the young man and the afterlife [2]. Therefore, the sexual power of the
holding him by the wrist, ‘hold him tightly, don’t let mummy had to be maintained and stimulated. This is
him faint.’ The assistant replies, ‘I shall do as you wish’. always visualized as pertaining to the mummy of a man,
It would be interesting to discover more about the never that of a woman. In Egyptian art the idea is
anaesthetics used and how they were administered. The expressed in a symbolic way which is straightforward
famous ‘Memphis stone’ could be the key to this secret. once the coded language is understood.

© 1999 BJU International 84, 755–761


U ROLOGY OF P HAR AONIC EG YP T 761

Baltimore: Karger Basel and University Park Press, 1973:


Sexual disorders 1–10
In prescription 663 of the Ebers Papyrus impotence was 8 Kamal H. Methods of diagnosing diseases by the ancient
mentioned as ‘grapo’ or ‘weakness of the penis’, and Egyptians. Proceedings of the Congress on International
Medicine and Tropical Hygeine. Cairo: Cairo University Press,
honey was among 37 drugs that were recommended for
1928; 2: 23
its treatment. Priapism was also described and prescrip-
9 Kamal H. The Ancient Egyptian Medicine (in Arabic). Cairo:
tions 658, 660 and 661 of the Ebers Papyrus described National Board for Books, Egypt, 1998
drugs for its treatment. Moreover, prescriptions 705, 10 Ebbell B. The Ebers Papyrus, the Greatest Egyptian Medical
706, and 707 of the Ebers papyrus described gonorrhoea Document. Copenhagen: Levin and Munksgaard, 1937
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University Books, 1960
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University of Chicago Press, 1930
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17 Dawson WN. The beginning of medicine and surgery in
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© 1999 BJU International 84, 755–761