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              I. I-em-hotep and Ancient Egyptian Medicine

                   II. Prevention of Valvular Disease




                                  THE
                            HARVEIAN ORATION


   DELIVERED BEFORE THE ROYAL COLLEGE OF PHYSICIANS ON JUNE 21, 1904


                                   BY
                     RICHARD CATON, M.D., F.R.C.P.
       EMERITUS PROFESSOR OF PHYSIOLOGY, UNIVERSITY OF LIVERPOOL;
                 CONSULTING PHYSICIAN, ROYAL INFIRMARY


                        With Seven Illustrations


              PRINTED AT THE UNIVERSITY PRESS OF LIVERPOOL

                      LONDON: C. J. CLAY AND SONS
          CAMBRIDGE UNIVERSITY PRESS WAREHOUSE, AVE MARIA LANE
                                  1904
                          ALL RIGHTS RESERVED


                                   TO
             Sir WILLIAM SELBY CHURCH, Bart., K.C.B., M.D.
                             THE PRESIDENT
                                 AND TO
                              THE FELLOWS
              OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON
                       THIS ORATION IS DEDICATED
                           WITH MUCH RESPECT




                                  THE
                            HARVEIAN ORATION
                                  1904


Mr. President and Gentlemen, The officials fellows and friends of this
college assemble to-day, as we and our predecessors have assembled year
by year for two-and-a-half centuries, to commemorate the services which
William Harvey has rendered to mankind, and in order to keep alive in
our own minds the wise counsels which he addressed to us, the memory of
which he desired us ever to renew at the festival which he founded. We
are to honour our great profession, to continue in mutual love and
affection among ourselves, and to search and to study out the secrets of
nature by way of experiment in order to prevent suffering and to
ameliorate human life.

In commencing the pleasing duty which the kindness of our President has
placed in my hands it is needful to comply with the desire of our
founder that we commemorate the names of benefactors of this college.
The lengthy and honourable roll was so fully dealt with by the learned
orator of last year that I shall merely add to his recital the names of
those who since that time have given of their substance for the
advancement of medicine. Dr. Horace Dobell of Parkstone Heights, Dorset,
gave the sum of £500 to encourage research into the ultimate origin,
evolution, and life-history of bacilli and other pathogenic
micro-organisms; Dr. George Oliver, Fellow of this College, of
Harrogate, and Farnham, Surrey, has given £2,000 to found the
Oliver-Sharpey lectureship or prize in memory of William Sharpey of
University College, and to encourage the application of physiological
knowledge for the prevention and cure of disease and for the
prolongation of life; and Lady Clark has presented to us a bust of our
revered and lamented former president, Sir Andrew Clark.

No student of the works of Harvey can fail to bear in mind the great
loss we have sustained this year in the decease of Sir Edward Sieveking,
who in his Harveian Oration drew special attention to the Prelectiones
Anatomiae and in conjunction with Dr. George Johnson and other Fellows
of this College arranged for the admirable autotype reproduction of
Harvey’s manuscript which we possess.

Desiring to render this address as little wearisome as may be I propose
to divide it into two parts: the first archaeological, dealing with
Egyptian medicine, the medicine god, and the earliest inquiries known to
have been made concerning the circulation and circulatory diseases—viz.,
those of the physicians of ancient Egypt, a department of pre-Harveian
work, and perhaps the only one, which has not been dealt with in this
room. Secondly, I wish to speak with great brevity on the more practical
subject of the preventive treatment of certain forms of circulatory
disease.




                                   I
          Egypt and the Earliest Researches on the Circulation


To all who love our venerable and beneficent profession the spectacle of
our predecessors in early ages striving in darkness and difficulty to
acquire that hidden knowledge to which we have partially attained is
interesting and should awaken our sympathy. As was remarked by the
learned Harveian Orator of 1896: ‘The past is worth our study and ever
more so the further we advance.’[1]

The information which archaeological research has of late afforded,
though in a fitful and partial manner, as to the earliest history of
medicine, and particularly in regard to that department in which our
founder laboured, is not unworthy of our attention.

The first evidence of definite inquiry, in any degree worthy to be
called scientific by a body of men specially educated for, and devoting
their lives to medical service, occurs in the early history of Egypt.
The ability, learning, and artistic skill shown during the early
dynasties, which all Egyptologists recognize, are paralleled by the
remarkable interest then manifested in medicine. Works on anatomy and
medicine are stated to have been written even by the early sovereigns of
Egypt. Athothis, the son of Menes, who lived six thousand years ago,[2]
is stated in the Berlin papyrus to have written a book on medicine, and
I shall soon have to quote from the anatomical writings of the Pharaoh
Usaphais, one of his successors; Semti, the seventh monarch of the same
dynasty, pursued similar investigations. It is clear that, like the
Greeks, these men in the childhood of the world believed that ὑγιαίνειν
µὲν ἄριστον ἐστιν, sanitation was to them the first of the sciences.

    [Illustration: PLATE I
    Ancient bronze figure of I-em-hotep, the Egyptian God of Medicine
    (By the kind permission of the Committee and Curator of the
    Liverpool Museum)]


The Medicine God I-em-hotep

During the third dynasty, about the year 3,500 B.C. there lived a
learned physician (probably a priest of Ra, the sun-god) the founder of
a cult, whose eminence was such that in course of ages he is deified and
becomes for later generations the special god of medicine. His temples
were places of healing for the people. His name is I-em-hotep, meaning
‘he who cometh in peace.’ According to ancient inscriptions he was the
son of a certain architect named Kanofer, but when raised in popular
esteem to the rank of a demi-god he is called the son of the supreme god
Ptah, the Hephaistos of Egypt, and he becomes one of the great god-triad
of Memphis. I-em-hotep is described as ‘the good physician of gods and
men, a kind and merciful god, assuaging the sufferings of those in pain,
healing the diseases of men, giving peaceful sleep to the restless and
suffering’; he is called ‘the creative god who giveth life to all men,
who comes unto them who call upon him in every place, and who gives sons
to the childless.’[3] He was great in magic and all learning. He and his
followers had to do with the embalming of the body, and he protected the
soul of the dead man from all spiritual enemies after it had left the
body. In the ritual of embalmment the dead man was encouraged by these
words, ‘Thy soul uniteth itself to I-em-hotep; while thou art in the
funeral valley thy heart rejoiceth because thou dost not go into the
dwelling of Sebek, but thou are like a son in the house of his
father.’[4]

From the testimony of temple inscriptions and papyri, as well as from
the writings of Manetho, it is clear that the cult of the medicine-god
I-em-hotep was established first in early times at Memphis. In, or
adjacent to, some temple—perhaps that of Ra—I-em-hotep and his assistant
priests gave advice and medical aid to multitudes of the sick and
ailing. It is evident that he gained great renown for his skill and
learning. When at length he died he was buried in or near the temple.
The priests whom he had taught continued there the work of healing,
always in association with his name. Just as the Greeks came to
Epidaurus to be healed by Asklepios, so did the Egyptians, many
centuries earlier, visit Memphis to seek help from I-em-hotep. It seems
probable that in course of time the temple formerly dedicated to some
well-known Egyptian god ceased to be known by his name, and in popular
speech became the house of I-em-hotep. There is the clearest evidence of
the existence of an important temple in later times dedicated to
I-em-hotep at Memphis.

A hieroglyphic inscription describes I-em-hotep appearing in a vision to
the high priest of Memphis, and addressing him thus:—‘I desire that a
great building be erected in the holy place at Anche-tewej (a part of
Memphis), where my body is hidden, for building it I will give thee the
reward of a son.’[5] We know this temple was built. Later again, similar
temples were erected elsewhere; doubtless priest physicians were
transferred from Memphis to new centres, just as to Greece and Magna
Graecia Epidaurus sent forth trained priests to establish Asklepieia at
Athens, Cos, or Pergamos.

As the centuries and millenniums passed on the cult of I-em-hotep seems
to have become more and more popular. In later times, when Greek
colonists appeared in Egypt, they gave him the name Imouthes, and
applied to his temples the Greek term ‘Asklepieia,’ clearly regarding
him as alike in kind to the Greek Asklepios and his temples as hospitals
for the sick. The following phrase occurs in the Serapeum Greek
papyrus:—

                                   ‘τὸ πρὸς Μέµφιν µέγα Ἀσκληπιείον’[6]

The great temple stood outside the eastern wall of Memphis close to the
Serapeum. We may reasonably hope that a careful examination of the site
may yet reveal to us traces of the temple and perhaps even the tomb and
remains of I-em-hotep himself. Some of those who are present to-day when
visiting the site of the temple of I-em-hotep have been impressed by the
thought that on this spot, long before Asklepios, the source, or
Hippocrates, commonly called the father of medicine, were born, probably
before the Homeric poems were written, before the Israelites were in
Egypt, before the Stone Age had passed, learned men here devoted
themselves to the consideration of the nature of human life, strove to
prolong it, to assuage suffering, and to cure disease. They studied and
treated many of the ailments familiar to us, such as tubercle, leprosy,
plague, anaemia, and other diseases prevalent in Egypt to-day. Near the
site of this temple, securely sealed in an earthen vessel which had been
hidden in the sand, was found one of the medical papyri from which I
shall quote some passages; doubtless it belonged to an early physician
who sought, perhaps during the invasion of Ethiopian or other
barbarians, to preserve for mankind the precious knowledge that seemed
in danger of extinction.

As we should naturally expect in the case of one so eminent, the
Egyptian artists made many drawings and bronze figures of I-em-hotep;
they usually represent him as a man rather than as a god, with few
mystic or metaphorical emblems excepting those related to learning or
human life. He is represented in art as a bald-headed man, usually in a
sitting posture, bearing on his knees an open papyrus scroll, and
sometimes holding in his hand the symbol of life.[7]


Testimonies as to I-em-hotep

I-em-hotep rises before us as one of those intellectual giants who take
all knowledge for their province. In his comprehensiveness he surpasses
Leonardo da Vinci or our own Linacre; he is distinguished as a
physician, a minister of the king, a priest, a writer, an architect, an
alchemist, and an astronomer—great in all, but greatest in medicine; so
eminent that in the view of Egypt he is a god.

    [Illustration: PLATE II
    The Temple of Edfu
    The earliest portions of which are believed to have been built by
    I-em-hotep.]

    [Illustration: PLATE III
    The Step-pyramid of Sakkara
    Supposed to have been built by I-em-hotep for the Pharaoh
    Tosorthros.]

In the reign of Tosorthros, of the third dynasty, five or six thousand
years ago, we meet with the wise I-em-hotep in an inscription referring
to the seven years of famine which befell Egypt in consequence of a
succession of low Niles. He is there the adviser of Pharaoh; to him the
king applies in his trouble for counsel and help.[8] In the inscriptions
in the temple of Edfu[9] he is described at length as the great priest
I-em-hotep, the son of Ptah, who speaks or lectures.[10] Perhaps his
discourses or lectures were on medicine. Elsewhere he is described as
the writer of the divine books. It may here be remarked that probably
Ebers’ papyrus was one of the six divine books attributed to Thoth
ceremonially, but not improbably in large part the work of I-em-hotep.
Manetho, while speaking of his eminence as a physician, refers to him
also as an architect, the first to build with hewn stone.[11] Not
improbably he built the step pyramid of Sakkara, the tomb of his patron
Tosorthros.[12] Manetho also suggests that I-em-hotep improved and
completed the hieroglyphic script of Egypt. In the Hermetic literature
he is famed for his knowledge of astronomy or astrology; the Westcar
papyrus describes him further as an alchemist and magician.[13] These
powers were always associated with medicine, and even to-day in the
popular view they are not entirely dissociated from it. What share
I-em-hotep may have had in those early discoveries of the movement of
the blood, to which I am about to advert, we do not know. It does,
however, seem clear that either through the labours of I-em-hotep or of
other priest physicians, the Egyptians had discovered certain elementary
facts and knew as much as the Greeks, as much as we find in the
Hippocratic writings, or in those of Aristotle and the later Alexandrian
school, and the hypothesis seems a natural one that the knowledge
possessed by the Greeks was acquired from Egypt.


Necropsies made by the Egyptian Priests

It is of some interest to note that these priests of I-em-hotep,
themselves learned men, not only saw and prescribed daily for vast
numbers of sick persons but also performed innumerable necropsies. They
removed the heart, large blood-vessels, viscera, and brain from the
bodies of deceased persons, also from the bodies of sacred animals,
prior to embalmment; the heart was placed in a separate jar by itself
and the remainder of the viscera in a larger vessel. We are told by
Pliny that in later times an examination of the body was made after
death in order to ascertain the nature of the disease which was the
cause of death.[14] Thus these men had an opportunity of learning
something of anatomy and pathology. They may have gained some insight
into the intricate problem of the action of the heart, the movement of
the blood, and the changes of heart and vessels produced by disease; no
nation of antiquity had such opportunities. Did they discover anything?
I think I can demonstrate to you that they did obtain a partial
knowledge of the circulation; they did not solve the problem, but they
approached it as nearly as did the Greeks, and probably from them the
Greeks obtained such knowledge as they possessed in early times.


References to the Circulation in the Medical Papyri

Certain of the contents of the medical papyri are at present almost
incomprehensible, partly on account of the difficulty of translating
technical terms; these parts I shall not refer to at all; those portions
which are more easily understood still present difficulties, and
translations must necessarily be free and at times vague. It must be
remembered that the hieratic script was not a good medium for the clear
and definite statement of facts, also that the modes of thought and
forms of expression of the time were far removed from our own, even far
remote from those of the Hellenes. We enter a different world when we
try to comprehend the beliefs and conceptions of the ancient Egyptian,
the platform of thought on which he built is imperfectly known to us.
Furthermore, the philosophic conceptions which the Greeks gave to
mankind and their lucidity of expression had not then come into
existence.

In addition to these negative aspects of difference there are positive
ones. The Egyptian believed himself to dwell in a universe peopled by
spirits and demons, good and evil, whose influence must be propitiated
or averted by charms and spells. It will, therefore, be understood that
a hieratic papyrus is vastly more difficult to interpret than a Greek
manuscript.

The references in various papyri to the circulation, though somewhat
vague, are not without interest. Where the sense is important I have had
the help of one or two learned living Egyptologists, and here I must
express my acknowledgments to Dr. Budge, Professor Kurt Sethe, Dr.
Brugsch, Dr. Joachim, Dr. Leemans, Dr. Withington, Dr. Grant Bey, Dr.
Sandwich, Mr. Garstang, Professor Carrington Bolton, Professor Flinders
Petrie, Mr. Percy E. Newberry, and others, for help orally, or from
their writings, without which, in my ignorance, I should have done
little. I am especially indebted to Professor Kurt Sethe’s work on
‘Imhotep’ and to Dr. H. Joachim’s ‘Papyros Ebers.’

Let me read you one or two extracts from the work of the Pharaoh
Usaphais quoted in Ebers’ papyrus[15]: ‘Man hath twelve vessels
proceeding from his heart which extend to his body and limbs; two
vessels go to the contents of his chest, two vessels go to each leg, two
to each arm, two vessels go to the back of the head, two to the front of
the head, two branches go to the eyes, two to the nose, two vessels go
to the right ear, the breath of life goes through them, two go to the
left ear, and through them passes the breath of death; they all proceed
from the heart.’ The concluding sentence is the earliest example I know
of the ancient superstition that the left side of the body is sinister
and evil. This is very early anatomy, professing to be at least six
thousand years old; we must not expect it to be quite accurate.

Turning to a comparatively recent period, I shall quote from other parts
of Ebers’ papyrus; the only existing copy of this papyrus (found in a
tomb at Thebes) was written in or before the sixteenth century B.C. No
doubt most, if not all, its contents are much older than that date.[16]
The extracts which I am about to read commence thus: ‘From the secret
book of the physician, a description of the action of the heart and of
the heart itself. From the heart arise the vessels which go to the whole
body ... if the physician lays his finger on the head, on the neck, on
the hand, on the epigastrium, on the arm or the leg, everywhere the
motion of the heart touches him, coursing through the vessels to all the
members’ [the reference is clearly to the pulse]; ‘thus the heart is
known as the centre of all the vessels. Four vessels go to the nasal
chambers, of which two convey mucus and two convey blood. There are four
vessels within the temples or skull, from these the eyes obtain their
blood.... The four vessels divide inside the head and spread towards the
hinder part.’ The Berlin papyrus speaks of the division into thirty-two
vessels within the skull, and implies that air traverses, at any rate,
some of them.

Returning to Ebers’ papyrus[17]—‘When the breath enters the nostrils it
penetrates to the heart and to the internal organs, and supplies the
whole body abundantly.’ This idea that certain of the vessels convey
air, you will observe, is identical with the Greek conception and
probably was its source. ‘Three vessels traverse the arms and extend to
the fingers, three vessels also pass down the leg and are distributed to
the sole of the foot, a vessel goes to each testis and one to each
kidney. Four vessels enter the liver, conveying fluid and air; these may
be the seat of various diseases as they are mixed with the blood; four
vessels convey fluid and air to the intestine and spleen; two go to the
bladder and from them the renal secretion is produced. Four vessels
convey fluid and air to the lower abdomen, going to the right and left
sides; from them is formed the alvine excretion.’[18] These vessels here
described are clearly the iliac arteries and veins. ‘When the heart is
diseased its work is imperfectly performed: the vessels proceeding from
the heart become inactive, so that you cannot feel them’ [no doubt this
is a reference to changes in the pulse], ‘they become full of air and
water.... When the heart is dilated the vessels from it contain effete
matter. If a suppurative or putrefactive disease occur in the body’
[abscess, I imagine, for which various sites are suggested] ‘then the
heart causes it’ [_it_ being probably purulent or septic material] ‘to
traverse the vessels, fever or inflammation of various kinds occur in
the body, the heart is in a morbid state while the fever continues.’ [It
may be noted in passing that the septic infection is asserted to enter
the body by the _left_ eye]. ‘In heart disease there is either
disturbance of the action of the heart or the heart is congested or
overfilled with blood, the heart is moved downwards, comes nearer the
praecordia, and weakness and nausea occur....[19] When the disease
affects the basic region or lower mass of the heart there is shortness
of breath, the heart is displaced on account of the volume of blood from
the abdomen’ [probably the old idea of the rush of blood entering the
heart from the liver]. ‘There may be fever or inflammation of the
heart.’ At this point comes a passage of some therapeutic interest. ‘The
heart during such disease must be made to rest to some extent if it be
possible.’ Here we have wise advice from the ancient Egyptians, advice
the importance of which we have scarcely as yet recognized, and which we
may to-day follow with advantage. ‘If the heart is atrophied (or wastes
itself) there will be an accumulation of blood within it. When the
disease of the substance of the heart is accompanied by dropsy there is
a lessening’ [in strength probably] ‘in the ventricle or cavity.... When
the weakness of the heart is due to old age there is dropsy. When there
is raising or increase of the heart it presses towards the left side, it
is increased by its own fat, and is displaced; there may be much fat
contained within its covering or pericardium. If in a suppurative
disease the heart is pushed forward it floats or sinks in the fluid and
is displaced.’ Here we surely have a reference to pericardial
effusion.... ‘If the heart trembles or palpitates, has little power, and
sinks downwards, the disease is advancing. When there is much beating at
the praecordia, with a feeling of weight, when the mouth is hot and
languid, and the heart is exhausted the disease is a fever or
inflammation.’ In another place (folio 102) the heart is spoken of as
being full of blood which comes or flows from it again. In folio 39,
after a description of symptoms, follows a statement to the effect that
the heart is distended, the sick man is short of breath because the
blood has stagnated and does not circulate. This is an interesting
expression, but judging from other parts of the papyrus the word
translated circulate can only have a vague meaning, implying movement to
and fro, just like the expression ‘περίοδος αἴµατος’ in the Hippocratic
writings, which seems to imply the circuit of the blood, but in reality
has only a similar indefinite meaning. It is evident that the Egyptians
knew that blood flowed from the heart, but, like the Greeks, they never
seem to have realized that the heart is a pump, nor did they recognize
valves.

The Leyden medical papyrus speaks of a paralysis or disturbance of some
sort in the blood-vessels of the head, causing blindness and disorder in
the body and in the limbs; this seems to be a description of the results
of cerebral haemorrhage. Remedies are suggested to subdue the vascular
activity occurring in certain diseases.[20]

The Passalaqua papyrus is rather interesting. It was found in an earthen
jar at Thebes, and deals largely with leprosy (which prevailed greatly
in ancient Egypt). This papyrus appears to date from the time of
Mencheres of the fourth dynasty, and for many centuries was enclosed in
a case or box beneath the feet of the figure of the god Anubis, and
forgotten for ages. It was rediscovered in the reign of a later monarch,
and recopied on to a new roll of papyrus.[21] The British Museum papyrus
dates back, as regards the major part of its contents, to the time of
Khufu or Cheops the pyramid builder. It bears some evidence of Semitic
influence. In the section on the treatment of wounds it contains the
following prayer:—‘Oh Ra, creator of the gods, pass ye me along, renew
ye me, avert from me all evil things, all evil maladies, all wounds in
the flesh of these limbs.’[22] In earlier times these prayers are much
more common than during the later dynasties, when the physician seems to
have relied more upon treatment.

The various papyri from which I quote deal of course with practical
medicine and not with physiology; no distinct definition as to structure
or function is to be looked for in them; only as associated with
diagnosis, prognosis, or treatment do we get statements as to the nature
of the heart, the vessels, and the movement of the blood.


Importance of the Medicine and Sanitation of Ancient Egypt

It is clear from the study of these medical papyri that medicine
advanced considerably amongst the Egyptians, and from them medical and
sanitary knowledge has descended to us by two channels—namely, by the
Greeks and through the Jewish race, while probably much of it was lost
irrecoverably. Josephus quotes from Manetho a statement that Osarsiph,
who Josephus says was the great Hebrew leader Moses, was a priest at
Heliopolis, where medicine was taught.[23] It is highly probable that
the sanitary laws of the Jews were derived from the Egyptians. Just as
the Jews remembered the diseases of Egypt (Deut. xxviii, 60) so they
also remembered the sanitary and remedial measures they had learnt
there. Those of us who have seen in the later excavations at Knossos the
evidences of sanitary knowledge of a somewhat high type, possessed by
the Cretans at a remote period, exemplified among other things by
drainage pipes, scarcely excelled by our own to-day, knowing as we do
the close connexion between Crete and Egypt, may well believe that here
we have an example of sanitation derived from Egyptian sources.

In England we have overlooked the importance of Egypt as a primary
source of the science and art of medicine. If we regard with reverence
the dim traditional form of Asklepios as a founder of our art, and the
Asklepieia where throughout Greece and Magna Graecia medicine was
practised and taught, in greater degree should we reverence the much
more venerable I-em-hotep and view with interest the primaeval medicine
temples and hospitals of Egypt. The evidence of this priority from
Egyptian sources is absolutely conclusive, but in addition we have
corroborative evidence from European authorities.

In the ancient writings of the pseudo-Apuleius Hermes is described as
speaking to the youthful Asklepios as follows[24]:—‘Thine ancestor, the
first discoverer of medicine, hath a temple consecrated to him in the
Libyan mountains near the Nile, where his body lies, while his better
part, the spiritual essence, hath returned to the heavens, whence he
still by his divine power helps feeble men as he formerly on earth
succoured them by his art as a physician.’

In the Cairo Museum probably many of the present audience have seen the
sepulchral stele of Shemkhetnankh, a great physician of the fifth
dynasty, who was contemporary with King Sahura, and who is described in
the stele as the principal physician of the Royal Hospital. His name,
which is doubtless a title given to him by the monarch, means ‘He who
possesses the things that give life.’ It is interesting to find that
five thousand years ago a hospital should exist associated with, and
under the patronage of, the Pharaoh and having its own staff of
physicians. And it is manifest that our calling held a distinguished
position at the time when art and learning in Egypt were at their
zenith.

    [Illustration: PLATE IV
    Plan of part of Eastern Colonnade of Philae with temple of
    I-em-hotep and courtyards adjacent.]

Few of the temples of I-em-hotep remain. When viewing the ruins of
Heliopolis, the ‘On’ of the Bible, the visitor naturally wonders in what
part of the wide area the great halls were situated in which Horus was
healed after being wounded by Typhon, those halls which, as Ebers tells
us, had from mythical times been used for clinical purposes by the
celebrated faculty of medicine of Heliopolis. A small temple of
I-em-hotep still exists at Philae, with certain adjacent courtyards,
which were probably employed for medical purposes. I subjoin a ground
plan and three photographs of these remains at Philae.

This temple is contemporary with the earlier Ptolemies; the
hieroglyphics are of the date of Ptolemy IV, but the inscription in
Greek on the cornice of the southern door (see Plate VI) is later,
dating from the reign of Ptolemy Epiphanes, two centuries before the
Christian era.[25] The colonnade (Plate V) and also the courtyard in
front of the temple appear to be still later additions. Since the Coptic
houses and much accumulated rubbish have been cleared away, and certain
necessary restorations made by Captain Lyons, on behalf of the Public
Works Department of Egypt, all details of the temple can be examined
with ease.

From the colonnade a door marked _e_ on the plan (Plate IV) leads into a
square courtyard, the north side of which, marked _ad_ in the plan, is
formed by the façade of the temple proper. Here some of the hieroglyphs
refer to I-em-hotep and his work (Plate VI). In the centre of this
façade a door marked _f_ leads into the larger anterior chamber of the
temple. From this the door _g_ communicates with the inner sanctuary.
The eastern wall of the courtyard has a curious elongated recess, many
yards in length but only a foot-and-a-half in depth, marked _ac_ in the
plan, a narrow door, _b_, gives access to it. Between _a_ and _b_ a
small aperture in the wall marked _x_ communicates with this curious
recess, and the remains of a second aperture exist further to the left.
It is difficult to understand the purpose of this structure.[26] Plate
VII represents the wall _ac_ with the doorway and apertures referred to.
A door marked _h_ leads into a larger courtyard which again communicates
by three doors on its western side with the colonnade.

Whether this further courtyard was a portion of the purlieus of the
temple is uncertain, no doubt a considerable space would be required for
the medical work of the priest physicians.

Plate V represents the west wall of the temple (shewing a mediaeval
Coptic doorway broken through into the sanctuary), also a part of the
colonnade. To the left is a portion of the great pylon of the temple of
Isis.

    [Illustration: PLATE V
    Eastern Colonnade, Island of Philae, with entrance (on right) to
    courtyard of temple of I-em-hotep. The western wall of the temple
    (with mediaeval Coptic doorway) occupies the centre of the picture.]

I am indebted to the courtesy of the Egyptian Public Works Department
and to Captain Lyons for the privilege of reproducing these views of the
temple of I-em-hotep at Philae.[27]


Methods Employed by the Egyptian Physicians

I may mention in passing that, although the medical papyri which have
come down to us are no doubt only an insignificant fraction of those
possessed by the Egyptians, we, nevertheless, find in them abundant
reference to medicine and surgery. In the Kahun papyrus obstetrics is
dealt with. Gynaecology, also ophthalmology, materia medica, diseases of
the ear, tongue, and nerves, also dentistry, are the subjects of others,
and even veterinary medicine was treated of in a papyrus, a fragment of
which was found by Professor Flinders Petrie.

According to Herodotus, Egyptian physicians specialized to a
considerable extent, ‘Each physician applies himself to one disease
only.’ ‘Some,’ he says, ‘are for the eyes alone, others for the head,
others for the teeth, others for diseases of the abdomen, others again
for special internal diseases.’[28] As to dentistry it may be remarked
that the ancient Egyptians were probably the first to stop decayed teeth
with gold. I may add that Ebers states that twenty distinct diseases of
the eye are referred to in the papyri, and Dr. Grant Bey asserts that
the operation for cataract was practised in ancient Egypt.[29]

As regards materia medica the Egyptians possessed the following
drugs:—lactuca, various salts of lead, such as the sulphate, with the
action of which in allaying local inflammation they were well
acquainted; pomegranate and acanthus pith as vermifuges; peppermint,
sulphate and acetate of copper, oxide of antimony, sulphide of mercury,
petroleum, nitrate of potash, castor oil, opium, coriander, absinthe,
juniper (much used as a diuretic), caraway, lotus, gentian, mustard,
ox-gall, aloes, garlic, and various bitter infusions; mandragora,
linseed, squills, saffron, resin, and various turpentine products;
cassia, certain species of cucumis, cedar-oil, yeast, colchicum,
nasturtium, myrrh, tamarisk, powdered lapis lazuli, vinegar, indigo; the
oasis onion, mastic and various gums, mint, fennel, hebanon or
hyoscyamus, magnesia, sebeste (a tonic and a cough medicine), lime,
soda, iron, and a great number of other agents, the names of which no
one can at present translate.

    [Illustration: PLATE VI
    Front of the temple of I-em-hotep, Island of Philae]

    [Illustration: PLATE VII
    Eastern wall of courtyard of temple of I-em-hotep, Philae; showing
    door and apertures into narrow wall chamber]

In reading this very imperfect list one does not wonder that Homer
speaks of ‘the abundant herbs of Egypt, healing and baneful, used by men
more skilled in medicine than any of human kind.’[30] The Berlin Medical
papyrus alone mentions fifty medicines of vegetable origin. Some of the
prescriptions in Ebers’ papyrus are stated to have come from the great
medical temples of Sais and Heliopolis. The copy of Ebers’ papyrus has
evidently been in use by the priest physicians, for various notes have
been added on the margin by later hands in reference to the
prescriptions—‘Good,’ ‘Very good,’ ‘Try this,’ etc.

It is an interesting fact that upon the walls of some of the ancient
temples hieroglyphic records have been cut referring to medicine, and
containing, in some instances, prescriptions; in other cases
descriptions of various chemical processes; some of the temples seem to
have had laboratories attached to them. The hieroglyphic name for the
land of Egypt was Khami, whence are derived the words ‘Alchemy’ and
‘Chemistry.’[31]

Surgical instruments and the actual cautery were in use, also steam
inhalations, massage, ointments, plasters, poultices, suppositories,
injections, and emetics, and the importance of temperature in disease
was to some extent recognized.

Prescriptions were written out in due form and sometimes at great
length, fully equalling those of the most enthusiastic therapeutist of
our own day. Some hundreds of prescriptions have come down to us in
papyri. The longest prescription which I have read contained thirty-five
ingredients. To read it was a formidable task; to take it I should think
a much more formidable one. Some prescriptions are wise and rational, a
few strange and repulsive, and some are associated with charms and
spells.

Human nature is the same in all ages; hence one was not surprised to
meet with hair invigorators, hair dyes, cosmetics, pain killers, insect
powders, and a soothing syrup for small children containing opium in use
three thousand five hundred years ago. It was rather interesting to find
that the symbol for a half tenat often used in their prescriptions is
identical with that indicating a drachm with us, though the amounts are
not the same. I trust that the drachm will soon be as obsolete as the
tenat.

The writings of Dr. Grant Bey contain the information that during the
Hyksos period a law was enacted to the effect that if any physician
adopted a method of treatment not authorized by the sacred books and in
case the patient died under that treatment, the life of the physician
should also be forfeited. It is to be hoped that a principle so
absolutely fatal to all progress was not permitted long to remain in
operation.[32]




                                   II
   A Suggestion in Regard to Preventive Treatment of Valvular Disease


I have referred to certain facts, mostly of recent discovery, bearing on
the existence of our profession in the remote past and in reference to
the partial knowledge to which the priests of I-em-hotep attained as to
the circulation of the blood, a subject not without a certain interest,
but the advances of that knowledge made subsequently, which have on more
than one occasion been dealt with in this room, those now making, and
those yet to be made in the future are of more practical importance to
us.

The genius and the marvellous industry of Harvey first clearly unfolded
the great secret of the course of the circulation, thus opening a wide
door for the work of others, physiological and therapeutic. A
recognition of the principles of blood pressure, and of the action of
vasomotor nerves, and other advances have followed. We have attained to
a larger, though I believe as yet only to a partial and provisional,
hold of truth in these matters. As such we shall regard our knowledge if
we are wise. The great mistake in all times has been that of believing
that the truth already attained is the whole and that nothing remained
behind.

Our Egyptian and our Greek predecessors seem to have believed that they
had attained to absolute and final knowledge on these subjects. While we
smile at their error, let us be humble in estimating our own position
and ever remember that we ourselves may be yet barely on the threshold.

Our father, Harvey, has exhorted us ever to search and to study out the
secrets of nature by the way of experiment. Will you pardon me if I
devote the remainder of this paper to an account of a humble attempt to
carry out his mandate, if I narrate briefly an experiment dealing with a
yet unsolved problem in the pathology of the circulation, to which I
have devoted twenty-five years of my life?

I may plead the usage of speakers and writers who follow a tale or
narrative by a moral or practical application, and perhaps I may also be
allowed to say that the discovery that ancient Egyptian physicians
advocated rest in certain forms of heart disease suggested to me the
propriety of supporting this doctrine by a brief narration of my own
experience in the same direction.

As the Egyptians were probably ignorant as to the action of the valves
of the heart, they can only have known the fact that rest was
beneficial, but not the reason.

Valvular defect is one of the most important and perhaps the most common
of circulatory diseases. It is one which probably we shall never be able
to cure, and is thus likely to remain one of the opprobia of medicine.
Is it possible to treat it by prevention? This is the problem upon which
I wish to speak a few words. I am the more encouraged to do this because
I know that various Fellows and Members of this College hold similar
views to those which I desire to unfold.


Joints recover: Why does the Endocardium fail to do so?

There are in this audience many who have treated cases of acute
rheumatism and cases of valvular disease in hundreds of instances. We
are all aware that in acute rheumatism, however severe the joint lesion
may be, however great the swelling, the pain, the local pyrexia, and the
effusion, in the large majority of cases, after the usual treatment all
these grave symptoms subside, or if they linger in any joint many of us
know how certainly they will vanish if we stimulate the trophic and
vasomotor nerves by small blisters applied to the adjacent skin, the
final issue in most cases being the restoration of every joint to a
normal condition. But, alas, we also know that when the endocardium
covering the mitral or aortic valve cusps is in like manner attacked, a
like restoration does not take place spontaneously excepting in few and
rare instances. When regurgitation through the valve, shown by an apex
bruit with accentuation of the second pulmonary sound, has occurred in
acute rheumatism, if after treating the rheumatism we leave the affected
heart to its own course, and the patient to his, persistent bruit,
persistent pulmonary accentuation, hypertrophy, dilatation—in fact,
life-long heart disease and its train of attendant evils follow in a
large majority of cases, and mar or shorten life. Why should the
rheumatic heart be so much more intractable than the rheumatic joint?


The Rheumatic Joint rests, but not the Rheumatic Heart

No doubt the reason is that the joint can rest. The merciful influence
of pain in the part affected insures repose for each affected joint.
Suppose it were otherwise. Imagine pain absent and conceive for a moment
that we could flex and extend an acutely rheumatic knee or elbow sixty
or eighty times per minute continuously, what would be the fate of the
joint? Is there any probability that restoration to the normal condition
would follow? Few of us, I think, would expect it, for it is a
physiological law that repair in a diseased organ cannot coincide with
full functional activity. When the endocardium and valve cusps are
inflamed pain does not give the signal for rest, for, indeed, pain or no
pain, the toiling heart cannot intermit its labours.


Disastrous results of Valvulitis if not specially treated

During my thirty-five years of experience as a hospital physician and in
private I have watched with special interest the fate of the numerous
cases of endocarditis which came under my charge, endeavouring as far as
possible to trace the later history of such cases for a lengthened
period. During the earlier years I merely treated the rheumatism,
believing, as I had been taught, that little or nothing could be done to
prevent disaster to the heart. I had the pain of discovering that many,
indeed most, of these cases merged into permanent valvular disease. This
distressing experience induced me to experiment on various methods of
preventive treatment. Of these, one has proved successful and has been
constantly employed by me for twenty years.


The work of the Rheumatic Heart must for a time be minimised

The method is very simple; it is merely to give the heart the same
advantages, the same opportunities for repair, so far as we can, that
the joints enjoy; in other words, by every means in our power we lessen
the work to be done by the heart. The most absolute quiet is enjoined,
the patient lies with his head at a low level, pain and fever are
subdued, no excitement is permitted, the patient is made as comfortable
as we can make him, and sleep is encouraged—in fact, we seek to attain
physiological rest. We follow the precept of our ancient Egyptian
brother, declared so many thousand years ago: we give the ailing heart
the nearest approach to rest that is practicable. In addition we
administer sodium or potassium iodide, partly to help in the absorption
of morbid exudations but chiefly to lower vascular tension, just as we
give these drugs in cases of internal aneurism. Lastly, we endeavour to
influence the cardiac vasomotor and trophic nerves reflexly by gentle
and almost painless stimulation of those cutaneous nerves which we know
from physiological data, and from the evidence of the referred pains of
angina to be in close relation with the heart—viz., the first four
dorsal nerves.

I believe, however, that by far the most important factor in the
abortive treatment of endocarditis is rest, rest for many weeks, the
slowing of the heart, the lengthening of the diastole, which is the only
rest-time possible, the careful avoidance of high blood pressures, which
the weakened and softened valve cusps cannot sustain without peril, and
the diminution of the volume of the blood to be moved.

Only then, when functional activity is minimised, can we hope for repair
of mischief, re-formation of destroyed endothelia and absorption of
effusion in the valve cusps. Moreover, repair is only possible during
the early stages of endocarditis; later the mischief is permanent,
unalterable by any form of treatment. The method fails if from any
reason it is found impracticable to slow down the heart, for example, if
asthma, bronchitis, or pneumonia, or great nervous excitability
co-exist.

I submit that these measures are rational, their objects being by
affording rest to give opportunity for the exercise of the _vis
medicatrix naturae_ which is our sheet anchor, nay, indeed, to stimulate
that natural reparative process which alone can effect restoration.


Two Objections to the Proposed Method

It may be objected that there are two difficulties in our path. First,
in regard to diagnosis, how are we to distinguish the signs of
commencing endocarditis from those of mere dilatation? In the great
majority of instances in which marked and continuing bruit occurs,
endocarditis is present and not mere dilatation, but I admit that in
some cases discrimination is difficult. The wisest course is, if in
doubt, to treat as endocarditis. Secondly, some physicians complain, as
those at the Johns Hopkins Hospital have recently done, that they find
difficulty in inducing private and hospital patients to submit to a
sufficiently long period of rest. Occasionally that is so in the case of
foolish or thoughtless persons, but in general, if the danger to which
the heart is exposed be calmly and plainly stated to the patient, and
also if the hope of perfect recovery be held out to him through the
agency of prolonged rest, he will agree to give this method a fair
trial. Such, at least, has been my experience.


Successful Results obtained

For twenty years continuously this method has been carried out. The
results have been striking. The comparative absence of permanent heart
disease after endocarditis has been in marked contrast to its frequency
prior to the adoption of the treatment by rest. So striking indeed is
the change that I confess it now seems to me that it would be an immoral
act on my part to omit these measures in any recent case of endocardial
disease.

If we make it a rule to watch carefully for incipient valvulitis and if,
when we find it, we secure for the heart prolonged rest, I believe that
it is in our power to diminish, in a most material degree, the frequency
of chronic valvular disease of the heart.




                               FOOTNOTES


[1]Dr. Payne, Harveian Oration, p. 51

[2]In all estimations of date I have taken the lower limit, thus
    probably much understating the remoteness of the events recorded.

[3]Hieroglyphic inscription on Temple of I-em-hotep at Philae. See
    Brugsch, _Thesaurus_, p. 783

[4]Maspero, _La Mythol. Egypt._, p. 80

[5]Brugsch, _Thesaurus_, V, 923

[6]Peyron, _Acad. Sc. de Torino._, Ser. II, Tom. III, 1841, p. 40

[7]See Plate I

[8]Maspero, _His. Anc. de l’Orient_, I, 240

[9]See Plate II

[10]De Rougé, _Insc. du Temps. d’Edfou_, II, 89

[11]Eusebius on Manetho; Lauth, _Manetho und der Turiner Königspapyrus_,
    144

[12]See Plate III

[13]Erman, _Die Märchen des Papyrus Westcar_, I, S 22

[14]Pliny, _Nat. Hist._, xix, 5

[15]Fo. 103

[16]Fo. 99

[17]Fo. 99

[18]Fo. 100

[19]Fo. 101

[20]Leeman, _Mons. Egypt du Musee. d’Antiq. Leiden_, 1839

[21]Brugsch, _Recueil de la Mon. Egypt_, I

[22]Birch, _Zeitschr. für Ægypt Spr. and Alterthum_, 1871, S. 61-64

[23]Josephus C. Apionem I, 26

[24]_Pseudo-Apul._, _Asklepios_ C, 37

[25]Budge, _Gods of the Egyptians_, p. 523

[26]Is it possible this was a drug store or dispensary; the prescription
    being passed in at the one aperture and the medicine given out from
    the other?

[27]_A Report on the Island and Temples of Philae_, by Capt. G. H.
    Lyons, R.E., Public Works Department, Egypt.

[28]_Euterpe_, 84.

[29]Dr. Grant Bey, _Ancient Egyptian Medicine_. A paper prepared for
    Internat. Med. Congress, 1894

[30]_Odyssey_, IV, 227

[31]Dr. Grant Bey, _Loc. Cit._

[32]Dr. Grant Bey, _Loc. Cit._


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                          Transcriber’s Notes


—Silently corrected a few typos.

—Retained publication information from the printed edition: this eBook
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—In the text versions only, text in italics is delimited by
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