Orthopedics in Ancient Egypt

INTRODUCTION Upper and lower Egypt was politically united around 3150 BC along the Nile River in northern Africa, establishing the ancient Egyptian civilization. It lasted for over 3000 years from 3150 BC to 30 BC.1 Ancient Egypt was the cradle of the first dawn of modern medical care, including bone setting and simple surgery.2 The current orthopedic practice depends on evidence-based medicine. The history of orthopedics in ancient Egypt is based on the following evidence found in mummified bodies, wall paintings, and hieroglyphics. The most thorough knowledge of ancient Egyptian medicine comes from two papyri (papyrus is an ancient writing material that was used extensively in ancient Egypt and other Mediterranean societies.): G. Ebers' massive medical papyrus and E. Smith's surgery papyrus. Smith's papyrus is interesting since it discusses ancient Egyptian surgery. In the Middle Kingdom, 1800–300 BCE, more than 40 papyri documenting medicinal methods for various ailments were found.3,4 There was even exceptional specialization for that period. Only one ailment was treated by each doctor. Doctors were everywhere. Some physicians treated the eyes, others the head, teeth, belly, and hidden diseases. Ancient Egyptians valued orthopedic surgeons. Broken bones and dislocations were prevalent in agrarian societies due to wars and accidents.5 TREATMENT OF FRACTURES IN ANCIENT EGYPT Edwin Smith's papyrus documented 48 occurrences of vertebral injuries and fractures of the clavicle, humerus, and sternum and includes thorough anatomical, clinical, and therapeutic information. This papyrus instructs the doctor how to examine the patient and look for signs of injuries. Each case was chosen whether to treat, contend, or not treat owing to a dismal prognosis. Case 31 was cervical dislocation with unconsciousness of his legs and arms (paralysis or quadriplegia) with dribbling of urine, a condition not to be treated.6,7 The frequency of long bone fractures, healing, and malalignment was investigated by visually inspecting 2287 long bones of 204 adult skeletons (112 males and 92 females) and taking anteroposterior and lateral radiographs. Of 2287 long bones tested, 45 had fractures (1.97%). Three fractures were malaligned, but most healed with good alignment due to effective treatment. However, 80% of fractures were in the radius and ulna, which were treated easily with hanging and splints. Finally, long bone fractures healed well, proving that therapy was effective.8,9 The lack of evidence of joint dislocation in ancient Egypt is surprising given the amount of fracture documentation. Only a famous artwork by a funereal artist showed a physician treating a dislocated shoulder, utilizing Kocher's 1870 technique. The earliest shoulder dislocation and reduction attempts are shown here.10 The Egyptian Orthopaedic Association's symbol depicts a shoulder reduction.11 Dislocated joint reductions are not well documented, according to other writers. The finding of an intramedullary fixation with an iron nail in a mummy's right knee in 1996 clarified surgical fracture management. On forensic medical evaluation, evidence of the right knee surgery was found. Investigations found that the device was implanted around the time of death.12 CONGENITAL DEFORMITIES AND SKELETAL DYSPLASIA Mummies, the time travelers of ancient Egypt, provide early evidence of congenital diseases. Genetics has improved our understanding of how inbreeding causes hereditary illnesses. The frequency of congenital illnesses may have grown due to consanguineous marriages at that time. The half-brother–sister marriage of Thothmus and Aahmes produced Queen Hatshepsut (18th Dynasty) (158–1350 BC). Her mother was the result of marriages in two successive generations between full brothers and sisters.13,14 The two stillborn children of King Tutankhamun were embalmed and placed in small coffins in his tomb. Both were females, 5–8 months of gestational age. Radiographs revealed scoliosis, spina bifida, and Sprengel deformity.15 Achondroplasia is one of the most well-known genetic abnormalities, however, the medical papyri did not include dwarfism since the ancient Egyptians did not consider it a sickness or illness. The "Badarian period" (4500 BCE) included the first biological evidence of dwarfism in Egypt. At the Museum of the Royal College of Surgeons in England, the almost complete skeleton was extensively researched.16 Dwarfs were employed as personal servants, linen overseers, animal tenders, jewelers, dancers, and entertainers, according to artistic evidence. In the Old Kingdom (2686–2190 BCE), numerous high-ranking dwarfs had exquisite tombs near the pyramids. Several Old Kingdom dwarfs were buried at the royal cemetery near the pyramids in spectacular fashion. Funerary sculptures or reliefs inscribed their names and titles. They were Seneb, Pereniankh, Khnumhotep, and Djeder. The father, the Seneb statue, was likely achondroplastic. His wife and kids are average sized. On a rectangular seat, Seneb sits as a scribe close to his wife. Two of their three children, a boy, and a girl, are under Seneb, placing their fingers to their mouths as was typical in ancient Egypt. Dwarfs were gods in ancient Egypt. The best-known dwarf gods, Ptah and Bes, used magic to protect the living and the dead.17 Poliomyelitis occurred in ancient Egypt. The late 19th dynasty mummy of Siptah (1342–1197 BCE) has a severely malformed Pes equinovarus-like left foot and shortened left leg, a polio deformity. The doorkeeper Ruma had a leg deformity that required a cane. Wasted and shortened limbs with foot equinus deformity were depicted. Pictures showed knee recurvatum, which can result from Polio and resultant muscular weakening.18,19 Egyptologists and academics agree that short persons were seen positively in ancient Egypt.20 Ancient Egyptian art offers a rich record of physical disability's role in daily life, particularly in the Old Kingdom. All physical infirmities were likely respected and publicly recognized in ancient Egypt. In addition, their disease was not physically limiting. Moral and wisdom teachings show ancient Egyptians' acceptance of physically disfigured people. Many old kingdom dwarfs received extravagant burials near the royal cemetery. Their hieroglyphic statues and expensive tombs demonstrate their exalted status.19 Ancient Egyptian teachings on morals and wisdom show their good view of the dwarfs. The New Kingdom Instructions of Amenemope, who reigned under Amenhotep III, describe ancient Egyptian principles. Amenemope advised respecting dwarfs and other handicapped people. The following was some of the instructions: do not jeer at a blind man nor tease a dwarf, neither interfere with a cripple, do not insult a man in God's hand, nor scowl at him if he errs.16,21,22 THE ORTHOPEDIC DISEASES OF ANCIENT EGYPT Early Egyptians had few arthritic disorders. Only mummified corpses of pharaohs, viziers, high priests, and nobility, who lived longer than the rest of the populace, show Osteoarthritis (OA).23 Medical-like whole-body computed tomography scanning was done on 52 ancient Egyptian mummies. A comprehensive examination of all major joints and the spine documented Osteoarthritis (OA) changes. Six (12%) of 52 mummies exhibited pathologic spine curvature. Modern society has substantially lower scoliosis rates. Twenty-five (48%) of our 52 mummies revealed spine degeneration with osteophytes and other anomalies indicative of current spinal osteoarthritis. Given the young predicted death age (mean 38.1 years), this incidence is greater than expected in a modern population. There were 13 mummies with acromioclavicular OA. Osteoarthritis alterations were less prevalent in the major joints of the hip (one case, 2%), elbow (one case, 2%), knees (four cases, 8%), and ankles (five cases, 10%), and ankle damage was not found.24 Several predynastic instances of spine tuberculosis were documented. Nesparehan, an Amun priest, recounted the most authentic example. A classic dorsal vertebral collapse with angular kyphosis and a large right iliac fossa psoas abscess.25 The human bones were inspected at the Deir el-Medina settlement, known to have been established to house the families of the Valley of the Kings tomb cutters and decorators. OA was detected in these too. OA frequency found by joint and sex in Deir el-Medina were: hip osteoarthritis was the most frequent in men and women (39% and 30%, respectively), followed by the knee (35% and 17%), and the ankle (31% and 8%). The proportion of components with OA at Deir El-Medina shows that males had higher knee and ankle joint strain than women or comparable populations of middle-class and elite Egyptians.26 Thus, workmen's treks may cause knee and ankle OA at higher rates than women from the village or other working areas. OA rates at Deir el-Medina are between those of other Egyptian working and elite populations, showing how the craftspeople there had good social access yet hard labor.27-29 CONCLUSION The ancient Egyptian civilization lasted for 3000 years and ended in 30 BCE. Orthopedics as a specialty was documented in ancient Egypt by the human remains the drawings, and the medical papyri. Fracture management was evident by the significant number of healed fractures. The old Egyptian tolerance for people with physical disabilities whether hereditary such as skeletal dysplasia, congenital deformities, or diseases such as polio was an example of respect for human rights.