History of Psychiatry

http://hpy.sagepub.com Notes on mental disorders in Pharaonic Egypt

Ahmed Okasha and Tarek Okasha History of Psychiatry 2000; 11; 413 DOI: 10.1177/0957154X0001104406 The online version of this article can be found at: http://hpy.sagepub.com

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413

Notes

on

mental disorders in Pharaonic

AHMED OKASHA and TAREK OKASHA*

Egypt

Introduction
The earliest recorded sources of medicine emanate from the two great centres of culture, Egypt and Mesopotamia. Of these the Egyptian records are very important, especially the information available from surviving

papyri. Herodotus, in the fifth century Bc, expressed his admiration for the health of the Egyptians, saying that they were the healthiest in the world: Egyptians are different from all other people ... they take their meals outside their homes, while they attend to their needs inside. Diodorus Siculus in the first century BC stated that the whole manner of life of the Egyptians was so wholesome that it appeared to have been arranged according to the rules of a learned physician rather than those of a legislator.1 A few authorities have attempted to summarize our knowledge of ancient Egyptian medicine. A medical perspective was presented by Prof. Ghalioungui at the Faculty of Medicine of Ain Shams University in Cairo.~ He posed various questions: what was the nature of that medicine? Was it sorcery or rational practice? What was valid in it? What influence did it exert on the
medicine of the Greeks who claimed to have borrowed from it? His book also draws several comparisons between the popular therapeutics actually practised in Egypt today, which are doubtless directly inherited from ancestors, and the treatments prescribed in hieroglyphic documents. The main sources for studying medical knowledge in ancient Egypt are the surviving papyri, which first required transliteration into modem languages. Furthermore, inscriptions on mummies, statues and paintings have been studied. Ancient Egyptian books were rolls of papyrus made from the plant Cyperus papyrus, a sedge that grows wild anywhere in Egypt. All these papyri

Address
Egypt.

for

correspondence:

Dt T. Okasha, Institute of

Psychiatry,

Ain Shams

University, Cairo,

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414

have been translated and annotated. Available medical

papyri

include the

following:

Egyptian beliefs

and health

Mans beliefs have always moulded his magical practices and his medical theories. The principles underlying Egyptian magical practices may be summarized as follows:
1.

Belief in the existence of an immaterial and impersonal force permeating the universe, a force that the magician could seize and subject to his own ends.

2.

The law of mystical participation. This asserts that mysterious ties in the universe holds all things together, and that any change in one part evokes responses in the whole.
A system of logic based on analogy and similarity, that deduces identity and solidarity between two things from a resemblance of form or name, e.g., the name given at birth influences destiny, the resemblance of a plant to an organ by its shape or name grants it power to heal that organ, etc.

3.

4.

The law of solidarity, which holds that a body remains forever linked to any fragment detached from it, hence it is possible to act on

5.

beings through nail clippings, used clothing, etc. The primitive conception still held by tribesmen today, that looks

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415

protracted sleep during which the deceased pursue lives, accomplish their usual activities or even their conjugal duties, like Osiris who after death fathered a child to Isis. The dead could also visit the living in the form of dreams by night and as ghosts by day.4
as a

upon death

their normal

In Ancient Egypt, the philosophy of life and death centred upon the idea that these were part of a continuous cycle, hence the belief in life after death demanded elaborate funeral ceremonies and complex rituals in preparation for it. This belief emphasized the psychology of the dead and the personality of the hereafter. The individual was considered to be composed of three integral parts. The Khat represented the body. The Ka was the soul of the individuals double, represented and symbolized by uplifted arms, whose main function was to protect the deceased body. The Ba, which was symbolized as a flying bird carrying the key of eternity, was believed to leave the body after death and reside in heaven, periodically visiting the burial place of the mummified

body.
had

Death, as opposed to life, did not exist in the Egyptian mind. His language no sign to express it. To him, death was nothing but a further step in life during which his soul or Ba could return from yonder to reinvest his body
and
resume

with it his interrupted life. The primary duty of preserving the of the deceased was to allow the Ba to recognize it before reanimating shape it. One of the worst outrages that could be inflicted on a dead man was to let his body decay, to erase his name, or to disfigure his body beyond

recognition.
The custom of embalming continued until the first centuries of the era. At first it was limited to Pharaohs, notables and priests, but it slowly spread among the people. The ceremony took forty days under the supervision of one or more priests, wearing gods masks and singing prayers. As much as Ancient Egyptians cared for the spirits of the dead, they also feared them. It was thought that diseases were either due to evil spirits or the wrath of the gods, but organic causes were also described. Hence the art of healing was part of the ancient religious practices. Among the Egyptian gods whose priests specialized in therapeutic practices was Sekhmet, the destroyer of mankind, the lion-headed divinity who could send disease upon men. At first she was worshipped for fear of her wrath and the supplicants prayed her to spare them the woes that were in her power to inflict, but she soon came to be considered as a benevolent deity. But the most important of the healing gods was Thoth, who was represented at times as a monkey, but generally as an ibis, or as a man with the head of an ibis surmounted by the solar disc and the lunar crescent, and often holding the seshet or inkstand and reeds, symbols of the scribe. He personified the moon and was related to the sun. Thoth was also called the

Christian

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416

measurer, and was held to be the inventor of the exact sciences, of mathematics, arts, theology, occult sciences and magic and the author of the secret healing formulae. He became the scribe of all the other gods and partook of their work, and, since he was also believed to be the owner of the secret books, he was considered to be the god of wisdom. He was revered as an author of books on medicine and served as physician to the gods and
ill. He was also credited with the invention of the that the ibis uses his curved beak to wash that from where it is essential for health that the residues of of his gut, part be evacuated. Master of words, he was as well versed in magic as digestion

protector of all who

enema,

were

according

to a

legend

Isis.

Isis, who practiced magic even before becoming a goddess, was always called the great enchantress, and was revered as the patroness of magicians. In the legend of Osiris, her husband, she succeeded by her indomitable perseverance in re-assembling his body, which had been dismembered by Seth and, by lying over his dead body, in conceiving Horus. She then resuscitated him by magic. As every Egyptians ambition was to become Osiris after death, this transmutation was the object of a specific funerary ceremony that comprised, among other rites, the opening of the mouth. Extending this idea, every sick person was also Osiris, and could be cured by Isis. On the other hand, Seth, who murdered his brother through his jealous love of Isis, was a symbol of evil and was a cause of sickness and epidemics. It is in this fertile soil that Freuds long-standing interest in Egyptology was rooted. Despite his childhood fascination with archaeology and ancient history, it is noteworthy that Freud did not begin collecting antiques until he was 40 and after the death of his father. Among the 2300 or so antiquities collected personally by Freud in his lifetime, some 600 objects are Egyptian. Out of 35 figures on the desk at the time of his death, 22 were Egyptian, mainly bronzes dating from 600 BC. It can be argued that pre-historical Egyptian imagery and configurations underpin Freuds own self-analysis, and are pivotal to both pre-Oedipal and Oedipal issues. That he chose to focus on Greek legends in his theoretical writing can be seen as a (defensive) function and a secondary process structure of historical Oedipal development. Freud clearly knew the details of the legend of Osiris and Horus since he possessed both volumes of Wallis Budges Osiris and the Egyptian Resurrection.8 Having related the Osirian story, we can compare it with Freuds Oedipal myth. The most striking surface difference is that whereas the Oedipal situation is triangular (mother/ father/child), the Osirian introduces a fourth term, that of the brother

(maternal/paternal
Medicine and its

or

sibling).

What may,

practice in Ancient Egypt perhaps, be the first hospital system

in the world

was

found

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417

relatively recently in the excavation at North Saqqara: a side gallery leading into a new wing consisting of a main passage with a vast maze of complicated lateral galleries branching off on either side. These side galleries, averaging 3 metres high by 2.5 metres wide, were completely filled with thousands of sealed pottery jars similar to those found nearby in 1964 which contained wrapped mummified ibises. The jars, however, proved to contain the mummies of falcons, many of them most beautifully shrouded. These were probably destined for worship and for the treatment of sick people lying in
separate
rooms.

The Heart There is

known physicians title in pharaonic times to suggest in mental diseases, although psychic and mental symptoms are mentioned in many clinical observations, mainly in the Book of the Heart. 10 In Ebbells translation of the Ebers papyrus, the words heart and mind occur in 14 prescriptions, but it must be added that whereas this author translated ib as mind and ha. t~ as heart, Grapow3 translated both as heart, so it seems that the heart and the mind meant the same thing in Ancient Egypt. Indeed, personality types were attributed according to the colour and shape of the heart, e.g., long-, short-, white-, and black-hearted. It also seems that the lay assumption of white-hearted individuals originated from Ancient
no

specialization

Egyptian beliefs.&dquo;
The heart was believed to be the centre of physical and emotional life, of the will and of the intellect.&dquo; The heart controlled actions of the arms, the legs and every part of the body, as well as such functions as vision, hearing and breathing. It made decisions and the tongue proclaimed what the heart had conceived. Wear and tear on this essential organ brought about senility. All the feelings, conditions of the soul, traits of character and temperament were expressed by various idioms referring to the heart. For example, being happy was described as long of heart and depressed as short of heart. A confident person was called he who fills the heart. To drown the heart meant to hide ones thoughts, and to wash the heart was to satisfy ones desire. Dryness of the heart referred to forgetfulness, which was said to be the result of thrombosis. The Brain
the Smith papyrus of about 1600 Bc, drew attention to what be the first reference to the brain itself used anywhere. &dquo; Until appears the earliest discussions of the brain had been found in Greek medical then, some two thousand years later. The Egyptian treatise describes documents, the external appearance of the brain as like the corrugations arising in metallic slag. Breasted also wrote that the earliest observations showing that the brain is a centre of nervous control are contained in the Smith papyrus. The surgeon
to

Breasted, in

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418

noticed that injuries to the skull and brain disturbed the normal control of various parts of the body as far away as the feet. &dquo; The same source also refers to convolutions of the brain, localization of functions within the brain, the brain as the source of control of movements, the connection of the brain with nervous system, and tetanus after brain injury. Dreams

temples were regarded in late Egyptian history as of such dreams were the lector priests. Some of the interpreters were in fact sanatoriums temples (e.g., Kom Ombo and Dandara). The were received and prepared by prayers, sacrifices, bathing and oiling patients and then left to sleep. Dreams were then interpreted and treated accordingly. Gardiner translated the earliest book of dreams, probably from the 12th dynasty (2000-1790 BC), which contains interpretations of all possible
Premonitory
orders. The dreams in

dreams. 15
Good dreams included a man seeing himself eating lotus, i.e., he will enjoy something; killing a serpent means that he will quench a controversy; crossing in a boat means that he will avoid controversy; climbing on a tree means the abolition of all his evils. Examples of bad dreams included a man seeing his bed on fire, which means that his wife will leave him, or pricking his body with a needle meaning he will tell a lie.

Hysteria
The oldest of the papyri, Kahun Papyrus - dating back to about 1900 BC deals specifically with the subject of hysteria. It is lamentably incomplete, only fragments having survived. The fragments were evidently part of a small treatise describing a series of morbid states, all attributed to the displacement of the uterus. Most of these diseases are defined clearly enough to be recognizable today as hysterical disorders: a woman who loves bed, she does not rise and does not shake it; who is ill in seeing, who has pain in her neck; pained in her teeth and jaws, she does not know how to open her mouth; aching in all her limbs with pain in the sockets of her eyes, she can not hear what is spoken. These and similar disturbances were believed to be caused by the starvation of the uterus by its upward displacement with a consequent crowding of other organs. As treatment, the genital parts were fumigated with precious and sweet-smelling substances to attract the womb, or evil-tasting and foul-smelling substances were injected or inhaled to repel the organ and drive it away from the upper part of the body where it was thought to have wandered. As a final measure to cause the womb to go back to its place, an ibis of wax was placed on charcoal and let the fumes thereof enter the vulva. This merits a special comment as it introduces a magicoreligious element to the otherwise entirely rational basis of treatment. The ibis was the symbol of the god Thoth. The use of these ordeals to repel or

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the uterus would suggest their belief in uterine displacement as a of these ailments, contrary to the statement that the idea of the wandering womb did not originate from Egypt.6 These methods were still carried out in recent times. Strong-smelling herbs such as Valerian and Asafoetida in the form of aromatics, sedatives and antispasmodics were still recommended as specifically anti-hysterical remedies in medical textbooks as recently as the beginning of the twentieth century.
attract
cause

Sadness and depression Depression was described in many tales. For example: He huddled up in his clothes and lay, not knowing where he was. His wife inserted her hand under his clothing ... She said: &dquo;My brother, no fever in your chest and the limbs, 2 but sadness of the heart.&dquo; 1,2 Despair in the darkest fashion is reflected in this dismal ode: Now death is to me like health to the sick, like the smell of a lotus, like the wish of a man to see his house after years of captivity.
In another poem:
Disease has sneaked into me I feel my limbs heavy I no longer know my own body Should the master physician come to me My heart is not revived by his medicines.

Suicide References to suicide are very rare in Ancient Egyptian sources and have not been dealt with in Egyptology more than marginally. Wilson, in his book The Burden of Egypt, quoted an Egyptian sage, Ipu-wer, who witnessed a period of common peril and disaster during the first and second Intermediate Period: Crocodiles sink down because of what they have carried off, for men go to them of their own accord. 17 One of the most difficult and interesting texts named The dialogue of a man with his soul, most probably from the same period, makes suicide the central question. The man argues with his soul that he would be much better off if he were to commit suicide. In the course of eloquent and beautifully composed arguments, the soul succeeds in convincing the man that suicide, and particularly the burning of the corpse, would mean disaster for both of them. By destroying the body (instead of having it embalmed according to traditions and nourished by offerings), the soul would lose the house into which, according to the Egyptian belief, it must return every night in order to be renewed and reborn the following morning at sunrise, so as to live

eternally.
Here
we are

confronted with the very

essence

of

Egyptian ethics. The

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not only the Ba (soul), but also the whole body and its under the responsibility of the gods and were the dwelling organs of the divine powers. The question whether suicide is sinful and thus places to eternal subject reprobation becomes irrelevant, if preserving the corpse by and it embalming supplying it with offerings suffices to keep the soul alive. It does not matter much if man reaches death by committing suicide apparently or by awaiting it deliberately, as long as the corpse itself is not extinguished by fire or drowning. Apart from Cleopatras suicide, this problem was not an issue in Ancient Egyptian literature.

Egyptians felt that

came

Aetiology of mental symptoms

for mental disorders was set out in the Ebers papyrus., It in significant that, an allegedly demoniac system of medicine, illnesses that were traditionally attributed to possession by evil spirits were often systematically traced to organic diseases. The mental or the demonic factor was not,
A system of
causes

is

however, ignored.
1.

Vascular

(mentioned in seven observations): (Eb. 855 e) As to faintness (the ib is faint): the heart does not speak or the vessels are dumb, there being no perception of the fingers; it arises through the air which fills them. These symptoms may suggest what we may now call negativism. (Eb. 855 J) As to the feeling of sickness (the ib is sick): it is debility of the heart through heat from the anus. (Eb. 855 k) As to the mind kneeling (breaking down): this means that
causes

the mind is constricted and the heart becomes small. It is that the heart is hot and weary and eats little and is fastidious (i.e.,

psychomotor retardation, probably of a depressive nature). (Eb. 855 l) As to drying up of the mind, it is that probably the blood coagulates in the heart. This drying up is equivalent to our present thought blocking, or poverty of thinking. (Eb. 855 x) As to him wheeling and falling on his heart: this means that he becomes faint, and that his mind becomes powerless. It is the overfilling of his heart with blood, which does it, that arises through drinking of water and eating hot fish. This can be interpreted as
stuporous
2.
or

catatonic conditions.

purulency: (Eb. 1, bis) As purulency falling thinking.

to

Due

855

to
on

the mind kneeling in the interior of his belly, the his heart, probably suggests degradation of

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421
3. Due
to

faecal matter:

(Eb. 855 g) As to his mind passing away, it is that the vessels of the heart carry faeces. This is equivalent to our present delirium or subacute delirious states.
4.

Due

mysterious toxin AAA: (Eb. 277) To expel a a a poison from the heart, expel fleeting forgetfulness and injury of the mind. This is what we now call
to a

dementia.
5.

Due

to

obscure

causes:

(Eb. 855 w) As to his mind being dark (i.e., melancholic and depressed) and his tasting his heart, this means that his mind is contracted, there being darkness in his belly and he makes the deep to consume his mind (i.e., he repents or he has fits of helplessness).
6.

Cause

not

mentioned: mind is can be

(Eb. 855 z) As to his mind being drowned: this means that his forgetful like one who is thinking of something else. This correlated with oneiroid or dreamy states.
7.

In

only

two

instances the

cause was

said

to

be demonic

or

spiritual:

e.g.,

(Eb. 855 u) Perishing of the mind and forgetfulness, it is the action of the priests breath that does it, it enters into the lungs several times and the mind becomes confused through it.

Psychological aspects of treatment Suggestion played an important part in all forms of treatment, even those that seem most rational to us. Religious people always felt that the daily bread they ate which sustained life and re-created it constantly, was a great mystery. And how much more mysterious were drugs?&dquo; Greek and Roman visitors were particularly impressed by the Egyptian cults and eagerly adopted them, the more so the less clearly they understood them. But one thing they did understand was that all these cults promised healing of mind and body. Magico-religious therapy was primarily aetiological, its aim being to remove the cause of the disease by driving out a demon or the ghost of a dead person, or by reconciling the patient with the
transcendental world.

Empirical-rational therapy,

on

the other hand,

was

for the

most

part

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422

symptomatic. The symptoms were considered were given or an incision was performed to

be the disease, and drugs relieve the sick person of a

to

symptom or a group of symptoms. One of the psycho-therapeutic methods used in Ancient Egypt was the incubation or the temple sleep. This was associated with Imhotep, the earliest known physician in history. I.em.ho.tep. - He who comes in peace was the physician vizier of the Pharaoh Zoser who built the Saqqara pyramid, 2980-2900 BC. He was worshipped at Memphis and a temple was constructed in his honour on the island of Philae. The temple was a busy centre for sleep treatment. The course of treatment depended greatly on the manifestations and contents of dreams, which were, of course, highly affected by the psycho-religious climate of the temple, or the confidence in the supernatural powers of the deity and on the suggestive procedures carried out by the divine healers.&dquo; When sleeping in the temple, the Egyptian could try and obtain contact with the gods by means of magic formulae, and interrogate them. His principal aims were knowledge of his future, of the dangers that threatened him, and of the evil spells that were following him. But he was also seeking a cure for his ailments. The principle of the healing dreams was attributed to Isis, although many other deities in Egypt also possessed the same powers.

Pharmacy
The prescriptions recommended in the Ebers and Hearst papyri include both those which specify accurately the quantities of drugs, and those which simply call for certain ingredients without specifying the amounts. Some prescriptions contain considerable detail regarding the methods of compounding and preparation. These details indicate a marked degree of skill in what has later come to be known as pharmacy. Identified plant remedies occurring in the old Egyptian medical papyri include acacia, anis, barley, cassia, castor-bean, coriander, cucumber, cumin, date, fennel, fig, fig-mulberry, garlic, gourd, juniper, leek, lettuce, lotus, peas, poppy-seeds, saffron, sunflower, styrax, terebinth, wheat, willow-buds, white thistle and wormwood. Also included in the old Egyptian medical writings are references to such mineral remedies as copper, feldspar, iron oxide, limestone, red ochre, sodium carbonate, sodium bicarbonate salt, stibnite, sulphur, and possibly arsenical compounds. Several beverages were included in prescriptions and often as vehicles for other medicaments. Beer, which was the popular drink, milk, wine and honey were all common vehicles for most of the prescriptions containing more than one ingredient. Fat and grease from various animals were frequently mentioned for incorporation in various prescriptions, both for oral administration and for application to the skin. Wax was extensively

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423

recommended in the Egyptian medical papyri for use as a vehicle or binding material in various ointments or preparations for application to the skin or
wound. Headache is a symptom often attributed to psychic or spiritual factors. In the Ebers papyrus there are nine prescriptions for it (Eb. 253-260 and 247) and two to cure migraine (Eb. 248, 250). In the Hearst papyrus, three of the first are repeated (H.75-77). Only the two remedies against migraine, which recommend rubbing the head with the head of a fish, imply the utilization of transfer. The rest are entirely pharmacological. In the Chester Beatty V papyrus, three spells are recommended against migraine.

Trepanation
The evidence

regarding the trephine operation in Ancient Egypt for therapeutic or surgical purposes is equivocal. Ghalioungui recorded the opinion of Mr T. D. Stewart of the Smithsonian Institute in Washington that the so-called trephine skull was a case of symmetrical reposition of the parietal bone as a result of old age. The older skulls are displayed in the museum of Anatomy in the Faculty of Medicine at Cairo. The first belongs to the Princess Horsiest Mertamer; the frontal bone is perforated by a circular hole with bevelled edges. The disc of bone that was removed was not taken out by means of a cylindrical trephine, nor by a punch, nor by drilling a row of small holes and later connecting them by sawing through. The easy slope of the bevel would suggest the use of a hammer and a chisel, or of a
convex

scraper with

wide radius.o

Conclusions

important lessons to be learnt from the examination of beliefs and practices relating to mental disorders that exist in various cultures throughout the world. In many non-western cultures, native practitioners, to whom modern psychiatry is unknown, treat emotionally disturbed persons. The examination of the emotional attitude and interpersonal elements in these various forms of psychological treatments offers the psychiatrist a broad perspective from which to understand the basic components of our own present day systems of psychiatry and psychotherapy.
There
are

REFERENCES
1. Ghalioungui, P. (1983), The Scientific Translation).

Physicians of

Pharaonic

Egypt (Cairo: Al Ahram Center for

2. 3.
4.

Ghalioungui, P. (1963), Magic and Medical Science in Ancient Egypt (Hodder & Stoughton). Grapow, H. (1954), Grundrisse der Medizin der alten Aegypter (Berlin: Akademie Verlag), Vol.
IV, 227. Lexa, F.

(1925), La Magique de lÉgypte Antique (Paris: Paul Genthner),

115.

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424
5. Harris, J. R. (1971), The Legacy of Egypt (London: Oxford University Press). 6. Bernfeld, C. S. (1951), Freud and Archeology, American Image, viii, 107-28. 7. Leff, J. R. (1988), Freud was an Egyptian. Read at the Annual Psychiatric Convention of the Egyptian Psychiatric Association, Cairo. 8. Budge, E. A. W. (1911), Osiris and the Egyptian Resurrection (London: Philip Lee Warner). 9. Emery, N. B. (1971), Preliminary Reports on the Exacerbation at North Saqqara 1960-1970, J. Egypt. Archeol., lvii, 3-12. 10. Ebbell, B. (1937), The Papyrus Ebers (Copenhagen: Levin and Munksgaard). 11. Bryan, C. (1930), Ancient Egyptian Medicine. The Papyrus Ebers. Translated from the German version (Chicago: Ares Publishers Inc.). 12. Posener, G. (1936), La Première Domination perse en Égypte, Bibl. Et., vol II, Cairo. 13. Breasted, J. H. (1930), in Ed. Smith Surg. pap. Vol. I, 12. 14. Breasted, J. H. (1934), The Dawn of Conscience (New York, London: Charles Scribners Sons). 15. Gardiner, A. H. (1934), Chester Beatty Papyrus; Hieratic Papyri in the British Museum, Vol.I (London: British Museum). 16. Merskey, H. and Potter, P. (1989), The womb lay still in Ancient Egypt, British Journal of Psychiatry, cliv, 751-3. 17. Wilson J. A. (1951), The Burden of Egypt, 2nd edn (1954), (Chicago, IL: Chicago University Press), 108-10. 18. Sigerist, H. E. (1951), A History of Medicine, Vol., I, Primitive and Archaic Medicine (New York: Oxford University Press). 19. Baasher, T. (1975), The Arab Countries. In: World History of Psychiatry. Howells, T. G. (ed.) (N.Y., London: Churchill Livingstone). 20. Batrawy, A. M. (1935), Report on the Human Remains, Mission Archeol de Nubie, 1929-1934 (Cairo: Bulac Gov. press), 186 and p. IXV, Fig.3.

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