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Pharaohs and the first prescriptions

Almost 1,500 years before the Magi brought gifts of frankincense and myrrh to Bethlehem, the ancient Egyptians included them among their vast materia medica. Some 2,000 prescriptions are recorded.

Egyptian prescribing

Source: Mary Evans Picture Library/Hubertus Kanus

Many possess therapeutic merit and have enough detail to make them reproducible today. Ironically this wealth of information was unknown until archaeologists discovered ancient Egyptian documents in the 19th century and only in the early 20th century came the first indication that the ancient Egyptians practised a credible form of medicine 1,900 years before Galen.

In the past five years scholars have verified the materia medica and efficacy of prescriptions recorded from the time of Amenemhet III (1842–1797 BC) to Ramses III (1182–1151 BC), a period pivotal to the history of pharmacy.

History attributes rational medicine to Hippocrates (ca 460 BC) and medical origin to Thales of Iona (624–554 BC). Before Thales, medical history resided in mythology, which attributed drugs from plants to the centaur Chiron and medical practice to the Greek god Asclepius.

Asclepiades (ca 100 BC) brought Hippocratic doctrine to Rome, while Celsus (ca 40 AD) recorded the materia medica. Dioscorides (ca 50 AD) wrote the first pharmacopoeia and Pliny the Elder (23–79 AD) produced an encyclopaedic account of medicinal plants. Claudius Galenus (ca 130–200 AD), subscribing to Hippocratic doctrine, laid the foundations of pharmacy, but transmission of his knowledge, influencing medicine for 1,500 years, pursued a tortuous route, from Ancient Rome to the Byzantine Empire and then Persia.

In the 5th century AD, the Byzantine period, Oribasius translated Galen’s texts into Syriac and within 200 years, Islam having united the near east, adopted Galen’s teachings to influence Persian medicine until the time of Avicenna (ca 980–1037 AD).

Combining Galenic protocol with Persian medicinal tradition, Avicenna’s ‘Canon of medicine’ was brought to Salerno, from where it was transmitted to Moslem Spain. The 12th century Jewish exodus brought his knowledge to England influencing medicine into the 16th century, when contemporary medicinal herbals became the precursors of modern pharmacopoeias.

However, the medical papyri translated after the decoding of the Rosetta Stone indicate not only that Egyptian medicine predates Hippocrates but suggest the ancient Egyptians practised pharmacy.

Ancient Egyptian medical records

The materia medica is recorded in 12 medical papyri written in hieratic script, a shorthand development of hieroglyphs, detailing the ailments and treatments endured in ancient Egypt. Translated into Latin, German or English, they illustrate the relative sophistication of medicine in ancient Egypt, continuity of practice and longevity of remedies. Most significant pharmaceutically are:

•The Kahun Papyrus (ca 1850 BC) dating to Amenemhet III (this was found by archaeologist Flinders Petrie at the workman’s village in the Fayoum, and contains 33 gynaecological remedies)

•The Edwin Smith Surgical Papyrus (ca 1550 BC), detailing 48 cases of physical traumata

•The Ebers Papyrus, dating to Amenhotep I (1546–1526 BC), found in the Valley of the Kings and containing 877 remedies

•The Chester Beatty Papyrus found at Deir el Medina, dating to Ramses III (1150 BC) and specialising in colorectal conditions

The format of remedies is consistent and formulaic. They commence “a treatment for” and detail the drug, formulation, preparation and dosing regimen. For example, in the Ebers Papyrus, there is “a treatment to empty the belly to eliminate disease”. The ingredients are colocynth and honey and the instructions are to ground finely and eat with sweet beer.

One prevailing problem is the reliability of translation, particularly with respect to drug identification. Scholars have endeavoured to reconcile a translation with a particular plant, rarely finding independent attestation to the unique vocabulary. The Linnaean system of classification was not introduced for another 3,000 years. Consequently, plants are cited by common name, which varies.

The materia medica, of ancient Egypt includes 134 plants, 90 drugs derived from 24 animals, 28 minerals, nine vehicles and 12 dressings Among them are plants significant to pharmacy in the past century, including:

  • Acacia nilotica
  • Balanites aegyptica
  • Ceratonia siliqua
  • Phoenix dactylifera
  • Juniperus phoenicea
  • Pisatccia terebinthus
  • Punica granatum
  • Oleo terebinth
  • Salix fragilis
  • Hordeum vulgare
  • Cyperus esculentis
  • Linum usitassimum
  • Coriandrum sativum
  • Anethum graveolens
  • Cuminum cyminum
  • Artemisia absythum
  • Aloe vera
  • Ammi visnaga Styrax benzoin
  • Ricinus communis
  • Citrullus colocynthus
  • Boswelia carteri
  • Hyoscyamus muticus
  • Commiphora myrrha
  • Apium graveolens
  • Allium sativum
  • antimony
  • copper
  • alabaster
  • natron
  • honey

Formulation and preparation Ancient Egyptian prescriptions show awareness that formulation not only influenced efficacy but determined route of administration. The ancient Egyptians used creams, draughts, enemas, extracts, eye preparations, ointments, infusions and inhalations.

They had linctuses, liniments, lotions, mixtures, mouthwashes, ointments, pastes, pessaries, pills, poultices, powders, solutions and suppositories.

Formulations were characterised by the active ingredient, a vehicle in which it was carried, flavouring and a demulcent or, possibly, a secondary drug. Unusual formulations include animal dung and nutritious foodstuffs.

Instructions for preparation were specific, affording reproducibility. Drugs were ground, sieved, powdered or infused in water, alcohol or fat. The leaf, seed, fruit, root, bark, juice or resin was specified indicating concept of pharmacognosy.

Remedies deployed capacity based on the ro. This is considered to be 15 ml by most scholars but some recent work proposes it as 60 ml. However, this variance would only be significant in the dispensing of the poisonous laxative colocynth.

Almost 25 per cent of prescriptions detail measurements. Another 25 per cent of prescriptions can be estimated by precedent. For example, frankincense was usually being dispensed in a constant 0.5 ro dose. Topical remedies were without measurement.

Administration Oral formulations were taken immediately for a day or, more commonly, for four days (but rarely longer), heated, cold or “finger warmth”. Laxatives were administered as a single dose before retiring, suppositories used on rising. Topical, non-systemic preparations were rubefacient, demulcent, cooling or emollient. Poultices relieved pain or brought infection to a focus.

Rectal preparations were prescribed to stimulate defecation, administer drugs or as demulcents. For example, remedy 134 from the Ebers Papyrus is “a treatment to cool the anus”. It was a mixture of balanite oil, carob water, oil and honey and “injected” into the anus.

A treatment for a cough (remedy 326), contains orpiment, bitumen, s’m (an unknown ingredient) and fat. Instructions are to heat seven stones on a fire, place the ingredients on a hot stone, place a perforated vessel on the top and a reed in the vessel then to inhale the smoke through the reed and, afterwards, to eat fat or oil.

For a congested nose, the nostril was to be filled with date wine (Ebers Papyrus remedy 761) and instructions to remove an ear infection (remedy 768) are to:

Remove infection with a knife
Place oil and honey in ear with seed wool
Place strip of linen (bandage) in ear

Vaginal drugs were administered to bring the medicament into close contact with the mucous membranes. Aural, nasal and ophthalmic preparations including powders, ointments and drops, contained antibacterial agents and biocides mixed in any vehicle that would facilitate application.

Drug sources

The renowned agriculture industry of ancient Egypt was the pharmaceutical provider. As early as 2800 BC a picture develops of an increasingly organised agricultural system, harnessed to the needs of a population with a common objective of transforming a narrow, arid plain into productive fields. The annual flood water was channelled into the fields by a basin system of irrigation.

Barley, emmer and flax, sown in November when the Nile flood receded, provided alcohol, fibre, oils, demulcents and emollients. Dates were harvested with carob pods, figs and pomegranate, yielding stabilisers, laxatives, antiseptics, astringents and anthelminthics. The acacia flowered from October, followed by the pod, used medicinally.

In January, gum was scraped from acacia stems and stored as chips to be used as stabilisers and demulcents, while onions and garlic were sown. In April, sycamore figs and cereals were harvested as melons, cucumbers and colocynth ripened, each with pharmaceutical properties. Young flax was harvested for fine cloth and bandages, with the dried seed heads providing linseed oil in May.

Cumin, dill seed and garlic were harvested in June. July brought the annual flood and a second harvest of sycamore figs. In August, water lily flowers were harvested and dried; their centres ground, made into bread and used pharmaceutically.

Grapes were harvested. Their wine was used to an extraction medium and, when soured (acidic), used as an antiseptic. Onions, plums and juniper berries were picked and all used in ancient Egyptian remedies for antiseptic, laxative and birth inducing properties, respectively.

Egyptian marsh dwellers expressed oil from ricin seeds and its many medicinal uses were recorded in the Ebers Papyrus. By October, the Nile’s rich silt initiated the agricultural cycle again when olives, zizyphus fruit and a third crop of sycamore figs were gathered, each with laxative, diuretic or astringent properties.

Frankincense, cedar and coriander were acquired through trade with the Near East, Nubia, Libya and the southern Mediterranean. Animal products originated from husbandry or hunting, while minerals came from mining, smelting, building and jewellery industries. Drug availability probably paralleled food availability, being subject to the same threats.

Forensic evidence of diseases

Knowledge of diseases in ancient Egypt arises from the forensic work of a team at the University of Manchester, led by Rosalie David. Radiology has revealed skeletal traumata, tuberculosis, spinal deformities, spondylitis, herniated lumbar discs, arthritis, osteoporosis, degenerative changes, atherosclerosis and infestation.

Dental disease resulted from attrition and abrasion of the teeth, caused by eating bread contaminated with grains of sand (during milling). Child mummies indicate the fragility of life for the young and Harris lines (growth arrest lines) on their bones indicate illness and physical demise.

Evidence exists of the guinea worm, schistosomiasis and tape worm. Endoscopy has provided access to internal tissues, histology revealing sand pneumoconiosis and anthracosis from smoky fires. Intestinal infestation from stongyloides, ascaris, eccinococcus and trichinella has been revealed. Famine during pregnancy also manifests itself in bone histology.

Ancient Egyptian remedies

 

Colocynth was used as a laxative

Source: Produced with permission of The Royal Botanic Gardens Kew

Colocynth was used as a laxative

Laxatives dominated the Egyptian remedies and ingredients included fresh carob, aloe, castor oil and colocynth, bulk laxatives of bran, figs, fruit and lubricants of fat and oil.

Calcium carbonate was used as an antacid, and figs, barley, soured milk and honey were used as digestants. Aggressive purgatives were mixed with anticholinergics, such as hyoscyamus, or carminatives (eg, cumin or coriander).

Carob and gypsum were effective antidiarrhoeal remedies.

Heart conditions were less well treated because the ancient Egyptians had difficulty differentiating between the heart and stomach. They prescribed aloe, mustard, willow, hyoscyamus, pomegranate and ammi variously containing glycosides or useful vasodilators. Diuretics included celery, honey, beer, carob and powdered dates.

Analgesics were few and restricted to carminatives or anti-spasmodics. There were effective antipyretics (eg, salt, alum and willow) but there is no evidence of the use of narcotics until the Roman period (30 BC) or indeed other sedatives, despite hemp being used in daily lives.

Musculoskeletal disorders were treated topically with warm bandages, poultices or rubefacients containing turpentine, mustard, juniper and frankincense. Celery seed was used by the Egyptians for painful joints and is now advocated for its antirheumatic properties. Saffron used for back ache in ancient Egypt, has long been acknowledged for its antirheumatic properties but is seldom used today because of side effects.

Gynaecological remedies controlled labour, conception, infection or predicted birth. Absinthe was used for menstrual disorders and pessaries of crocodile dung served as a barrier contraceptive, its acidity probably spermicidal. Pessaries of juniper oil, now known to stimulate uterine contraction, were inserted to initiate labour.

The ancient Egyptians would not have known that schistosomiasis caused the haematuria they described, but treatment was symptomatic, with demulcent preparations of barley water, acacia and biocidal antimony. Impotence is cited but the 39-ingredient remedy in the records would have had no efficacy.

Anthelminthic remedies based upon pomegranate, absinthe, thyme, and antimony, followed by a purgative, controlled tapeworms and round worms. Ancient Egyptian antiseptics and germicides were effective. Their phenols were thymol and bitumen; alcohols were beer and fermented wine and their acids were soured wine. Zinc, antimony and copper were used as astringents, mixed in any vehicle that would afford even distribution.

Coughs were treated with mixtures of honey, acacia and antimony; congestion with a nasal wash or aromatic inhalation. The plant Ammi visnaga, with its bronchodilator khellin, was used to treat respiratory conditions thought to be asthma.

Ophthalmic remedies were placed on the eye lid, margin or in the eye. Infections were treated with antiseptics of copper, honey, and child’s urine. Acacia, carob and milk were used as demulcents. Antimony was used as we formerly used mercury (ie, as a biocide).

Mouth washes were of acacia, carob and milk, mixed with antiseptic yellow ochre, cumin and copper. Mouth ulcers were eased by chewing anaesthetising celery seed and nasal congestion by a nose plug of fragrant gum. Malachite, honey and oil were placed in the ear on gauze for infections, while drops of warmed balanites oil improved hearing.

Acacia gum and plant mucilage were used as skin demulcents. Balanites oil, castor oil and goose fat were used as emollients and to control infection they were mixed with salt, frankincense, malachite, ochre or lead and used in bandages. Ladanum treated dandruff but baldness was treated with fats, oils and, symbolically, with hedgehog quills. For burns, an antibacterial mixture of turpentine, copper, oils and honey, was applied.

Pharmacopoeia

There is no evidence of any formal regard to toxicity or contraindications in the prescriptions, but the prescribing, formulation, preparation and dosage indicates awareness of potential benefits and dangers. An Egyptian physician could only deviate from the formatted remedy after four days of treatment, indicating a remarkable level of protocol.

There is no evidence that the ancient Egyptian physicians had a pharmacopoeia save an isolated monograph on ricin. Instead, the papyri fulfilled the role of a formulary. However, the remedies reflect the use of alcohols, antacids, anthelminthics, antipyretics, anticholinergics, demulcents and expectorants, none being central or respiratory stimulants.

The ancient Egyptians had dermatological agents and described exfoliators. Cardiac glycosides were few, prescribed subtherapeutically and there were no cardiac stimulants.

They used disinfectants and antiseptics but had no concept of sterilisation, being unaware of the causes of sepsis. They used frankincense for fumigation. Their embalming agents of myrrh, frankincense and pine resin were effective antiseptics as were onions, garlic and honey. Their only halide was sodium chloride.

Natural diuretics were deployed subtherapeutically and bile salts of mammalian origin were used. Oral preparations were flavoured, with honey, sweet beer or fruit countering bitter products.

Body and leg ulcers were treated with honey and the dressings changed daily. Hypertension is not described but dom palm fruit and balanites oil are antihypertensive. Haemostatics were represented by fresh meat or sprouting barley (hordenine).

There was little pain relief or anaesthesia. Chief among their natural stabilisers and suspending agents were acacia and carob. Essential oils were cumin, celery, thyme, dill, juniper and coriander. Mustard oil, pine oil and turpentine were used for warming properties. Fixed oils include castor, linseed, olive and safflower oils. Ointments and suppositories incorporated wax. Their most potent purgative was colocynth.

Of the materia medica of ancient Egypt, 59 plants, 18 mineral and 15 animal sources were cited in British Pharmaceutical Codex until 1958 and the British Herbal Pharmacopoeia contains a further 35 ancient Egyptian substances and 20 ingredients have nutritional worth.

Moreover, 25 per cent of drug substances cited in the BPC 1911 were used in ancient Egypt. The remaining 75 per cent originate from India and the Americas, which were not Egypt’s trading partners ca 1500 BC. Consequently the ancient Egyptians were without caffeines, narcotics, anaesthetics, antimalarials, anticonvulsants, antidepressants, vaccines and immunological agents.

Hormones were not available to them but they specified that ass urine (high in progesterone and oestrogen post partum) be used. Homer refers to poisons known to the ancient Egyptians but they are not evident. Mandrake is depicted artistically, but is not identified in any recipe. Moreover, the ancient recipes are curative not sinister.

There is a view that the placebo effect of drugs used in ancient Egypt exceeded their therapeutic value. What is known of pharmacy in ancient Egypt indicates a society cognisant of the need for health care and treatment, utilising a diverse range of plant, animal and minerals to this end.

Religion influenced all aspects of daily life in ancient Egypt, so it was intrinsic to medical practice and treatment. Although the importance of prayer and incantation is recognised, well documented rational treatment predominates endorsed by prayer.

 

Page 2 of the Kahun papyrus

Source: The Petrie Museum of Egyptian Archaeology, UCL, London

Page 2 of the Kahun papyrus

Users The Kahun Papyrus was probably written for the midwife and the Edwin Smith Papyrus for military physicians. The Ebers Papyrus is multifunctional, perhaps being the notes of a physician, as with the BNF. Celsus (40 AD) is attributed with writing the first materia medica for use by non-medical people, but credit probably lies with the Chester Beatty Papyrus, which originated from a private household over 1,200 years earlier.

Pharmacy did not exist as an independent profession in ancient Egypt but there is compelling evidence the Egyptians adopted professional protocols and standards. Restricted by their limited knowledge of physiology, they based their treatments conceptually.

Remedy 420 in the Ebers Papyrus is an eye ointment, to be made by Chui the Venerable, the high priest of Heliopolis. He did not have the title of pharmacist, but he probably practised the art. Moreover, the remedy had some efficacy.

Perhaps three wise men 2007 years ago knew of the pharmaceutical legacy of the ancient Egyptians and gave its most valued medicaments — gifts fit for a pharaoh.

ACKNOWLEDGEMENTS Rosalie David, director of the KNH Centre for Biomedical Egyptology, The University of Manchester, and the Leverhulme Trust’s Pharmacy in Ancient Egypt Project, Judy Adams, John Denton, Judy Miller and Angela Thomas, all at the University of Manchester, and John R. Campbell, pharmacy adviser.

Citation: The Pharmaceutical Journal URI: 10005731

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