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This paper summarises the common modalities that are available for researching ancient medicine and disease as well as explaining how some of these sources have survived to modern day. These are explained under the three broad headings of palaeopathology, artefacts, and texts. The descriptions use a variety of examples from ancient societies including in the Bronze Age, Babylonia and Assyria, ancient Egypt, ancient Greece, and ancient Rome to help explain these modalities. In addition, a review of the advantages and disadvantages of using these tools is included to help current and future historians in stimulating future research in this fascinating area.
All men and women share certain experiences. All are born, all suffer diseases and all die, whether from disease, degenerative processes, accident or violence. This situation has been an ever constant, but the causes of morbidity and their methods of treatment have varied throughout time. Knowledge on this subject in ancient societies has been gained through the collection and study of written and artistic sources, together with the practice of palaeopathology. The latter research tool was defined in 1910 by Sir Marc Armand Ruffer (1859–1917) as “the science of diseases whose existence can be demonstrated on the basis of human and animal remains”.1 This paper aims to show firstly how these sources have survived, and secondly their advantages and disadvantages for historical interpretation. A variety of examples from ancient societies have been used. Only by knowing about this can the medical historian first learn about the current knowledge of ancient disease and medicine and then go on to conduct research. This research has the possibility of advancing ancient medical knowledge, but by investigating subjects such as the differences in urban and rural health as well as individual conditions in our ancestors there may, with the advantage of hindsight, be information of direct relevance for the medical researchers of today.
The available sources of evidence for the palaeopathologist are skeletal and soft tissue remains. The former of these is most commonly used and is created when a buried corpse is subjected to biological decomposition from bacteria, moulds and invertebrates in conjunction with chemical breakdown from acidic groundwater.2 These processes remove the soft tissue but make slower progress upon the more decay resistant structures of bone and teeth. However, there are circumstances when the processes of soft tissue destruction are impeded to leave relatively well preserved, or “mummified” bodies.3 The most notorious instances have been the purposeful embalming by the ancient Egyptians with a naturally occurring salt called natron along with oils, resins and bitumen.3 The predynastic Egyptians also unintentionally mummified bodies when the corpse was buried in hot sand as desiccation proceeded faster than putrefaction to yield a dehydrated body. The same mechanism can transpire in the other climatic extreme to leave such bodies as the “Iceman” and those of Chilean mountain boys,3 which have provided invaluable access to the health of South Central Europeans in the Bronze age and in Inca cultural practices, respectively. Furthermore, discoveries have been found in the European anaerobic and antibiotic bogs where cases such as the “Lindow Man”, affectionately known as “Pete Marsh”, have permitted access to societies ranging from the Stone Age to those in the second millennium.3
Once the body remains are acquired, the palaeopathologist can start to perform a number of routine examinations on the material. This would normally first entail a macroscopic observation and description of the remains for all the abnormal and normal features, as this is a prerequisite to attempting a diagnosis of any disease process. This method can be supplemented by radiography, which is a quick and cheap methodology that can avoid the need for human contact with remaining flesh or for opening and destroying entombed bodies. This is extremely crucial as the 19th century practice of unwrapping and then conducting public autopsies on ancient Egyptian mummies damaged vast amounts of our current resources.4 Radiography manages to detect skeletal abnormalities but can also detect internal calcification, such as in arteries, the hepatobiliary system and the ova of Schistosoma (Bilharzia) haematobium in the kidneys of two mummies of the second dynasty.5 Significantly, radiographs also offer the advantage of detecting “Harris lines”. These are transverse lines seen in radiographs of long bones and signify bone regrowth after temporary cessation of longitudinal growth. Merely by measuring the sum total of these lines between the diaphysis and epiphysis of long bones, estimates on the malnutrition and disease status during the childhood of ancient populations can be made.6 Likewise, fertility figures of these populations can be relatively accurate from the appearance of Harris lines in the female pubic symphysis.
Technological advances in the latter part of the 20th century have further enriched the skills of the palaeopathologist. The endoscope has been applied to enable direct assessments on the internal organs of mummies and for microscopic tissues to be taken from them. Microscopy has allowed arterial atherosclerosis to be detected in human tissue as well as various intestinal parasites from human remains in Roman archaic latrines.6 Chemical tests straight from the medical laboratories can now measure calcium, strontium and phosphorus within bone tissue, which are useful indicators of health, as well as collagen, albumin and toxic substances.4 Interestingly, data on the toxic chemicals within soft tissue have resulted in the diagnosis of lead poisoning in an ancient potter.6 However, perhaps the most promising and extraordinary new techniques are the use of palaeo‐immunology and genetics to detect antibodies, antigens and DNA from body remains.1,6 These have great potential for studying population movements and many diseases previously unfound in ancient body remains. These techniques are further supported by the scanning electron microscope being able to identify blood cells, large organic molecules and pieces of nuclear chromosomal matter.4 These biological compounds can then be examined for the genetic make up of infection inducing pathogens, such as those in the malaria causing genus Plasmodium, without high levels of fear of contamination from normal flora and fauna.
Palaeopathology offers an immense quantity of material regarding diseases and medicine in the ancient world. Hypotheses regarding the origins and prevalence of congenital, traumatic, joint and neoplastic diseases have regularly been made and are likely to be joined by many more as alluded to earlier. Added to this is the possibility of a corpse revealing ancient methods of treatment, with the widely witnessed cranial holes from trepanation being one of many examples. Despite these uses, direct evidence for a particular disease or treatment is no longer the primary use of palaeopathology. In fact, evidence of the absence of a disease in ancient society, as is the apparent case with rheumatoid arthritis, can stimulate research into protective factors seen in ancient societies that can be of interest to both historical and modern medical fields.1 Furthermore, palaeopathology has developed a branch of historical demography known as palaeodemography, which attempts to determine the contraction and transmission of diseases in populations.4 This requires demographic data such as gender, age, ethnicity and population numbers, all of which palaeopathology can provide.
Unfortunately, several natural limitations with palaeopathological research have diminished the capability of its sources. Errors of diagnosis and interpretation are frequently encountered due to the existence of pseudopathology. This is when external conditions after death produce an appearance in the body remains that mimics a disease seen before death. Pressure, temperature, bacteria, plants, animals and both chemical and mineral agents have induced this.7 In addition, even if the effect of pseudopathology has been minimised, there exists the possibility that skeletal remains may have disappeared for any number of reasons. One study of a normal Roman burial ground found only 20% of the expected phalanges of the hands, feet, the carpals and the coccyx.2 A diagnosis of arthritis would be tentative at best. Ultimately, our ancestors have curbed our wisdom through Egyptian tomb raiders removing valuable objects from mummified remains throughout millennia and the ancient Greeks using the practice of cremating their dead. This has produced warped and fragmented bone remains, sometimes similar in appearance to that of osteogenesis imperfecta and rickets. However, understanding these factors and careful excavation and administration means that important research can be successfully conducted.
Ancient artefacts have survived to modern day due to beliefs surrounding the afterlife as well as the inherent properties of the materials. A lot of information on ancient Egypt has been recovered thanks to their belief that life in the after world was based upon the life led while on Earth. Central to this was the preservation of the deceased through mummification, as described earlier, yet the prevalence of grave robbery meant that a contingency substitute for the mummy was needed.8 This was performed through Serdaib and Ka statues as well as reliefs and paintings on the walls of the tombs depicting both the deceased member and his servants.8 However, materials have also survived purely because of their elevated opposition to breakdown. Metallic artefacts composed of gold are resistant to corrosion in all natural environments and those of copper alloys can offer partial resistance. Wood and textiles are both subject to biological and chemical decomposition, but preservation has sometimes been aided through their accidental storage in water or with metallic components respectively.9
Information on disease and medicine in the ancient world are numerous because of artefacts. The artistic depiction of human ailments, food, handicrafts and occupations has been depicted in the works of professional and amateur painters and sculptors throughout time.10 Therefore, it is unsurprising that the distinctive appearance of achondroplasia has been frequently portrayed in statuettes, tomb illustrations and even the Bayeux Tapestry. Furthermore, artefacts have helped reveal conditions that are regularly lost in body remains and hence obesity and some occupational diseases, among others, can be observed.8 Moreover, the greatest appliance of artefacts has been in exhibiting former medical treatments. A diminutive sample may include: the tomb door of Ir‐en‐akhty (First Intermediate Period) that depicts varying Egyptian practitioners8; Cypriot base ring juglets in the shape of an opium poppy that reveal importation of the same drug in the 18th dynasty8; copper alloy strainers that inform method of drug administration; the Asclepian temples in Tricca, Epidaurus, Lebena, Cos and Pergamum that reveal religious healing methods; and the Roman forts at Chester and Inchtuthil that show legionary hospitals and health spas.11 The amount of data in these cases alone can go a long way to explaining why artefacts are an important source for the disease historian.
The interpretation of artefacts is, however, fraught with pitfalls. The initial problem is that numerous representations of the apparently healthy or pathologically deformed individual may entirely have been an artistic convention to illustrate either idealised features or a particular state of a disease. Thus, the portrayal of obesity could perceivably have meant that a person was prosperous; similarly, the portrayal of a pharaoh as a perfect human specimen is likely to have been performed at the expense of physical blemishes. Nevertheless, there exists within the other sectors of ancient Egyptian and other societies the probable overrepresentation of deformities that had the uppermost impact in terms of mortality, personal disfigurement or social and economic disruption. This is because they were the conditions that evoked the greatest sympathy from society and the artists inside of them. The next problematic area in interpretation is that of seeing pathology when none exists and is something that has previously entangled distinguished scholars. The cesnola collection of Cypriot antiques contains an ex‐voto in the form of a woman's torso and an irregularity below the right breast was initially declared to have represented a cancerous lesion. In fact, they were the remains of a weathered bunch of grapes that were habitually used as a fertility symbol at the time.7 Avoiding falling into any of these aforementioned traps may prove arduous to any researcher but a combination of acquiring a high level of artistic knowledge and sensitivity together with obtaining a clear view of an object can help limit such errors.
Detrimental to knowledge acquisition from artefacts is the reality that many items have been fragmented or lost forever. Earthquakes ruined the Parthenon, Delphi and Olympia in Greece over many centuries and fires have long ago ravaged a number of temples and structures known as xaona because the structures were built with wood.12 Besides natural causes, there has been vast destruction by man, much of which was intentional. Bronze and marble were often consigned to the furnace for re‐use, and consequently a multitude of freestanding statues are irrevocable. Buildings from antiquity have also vanished to either make way for new or because the lead that helped protect the stabilising clamps before the advent of mortar were seized and re‐used elsewhere.12
Excavation of the early cities of Babylonia and Assyria has offered some of the oldest texts to date regarding medical procedures. Among the 30000 or so surviving clay tablets covered with cuneiform writing, there are about 1000 from the library of Assurbanipal on medicine that deal with diagnoses, medicines and their ingredients.13 These date from the 7th century BC although the Sumerian and Assyrian healing traditions that they record go back much further. The chief text is called sakīkū (The Treatise of Medical Diagnosis and Prognosis), comprising some 3000 entries on 40 tablets, and has helped inform about ancient healers in their era. These were the seer (bârû), a specialist in divination, a priest (âshipu), who performed incantations and exorcism, and a physician (âsû) who used drugs and performed bandaging and surgery.13 Tuberculosis is distinguished in the text but many of the entries are nothing more than fragmented syndromes or observations relating to an individual part of the body.
Insight into medical knowledge in ancient Egypt has been obtained from medical papyri. The most significant of these are seen in table 11 and have been preserved by similar mechanisms to those of the previously mentioned sources. Importantly, many papyri are missing as some were destroyed in tomb robbery, some were used as fuel, and a number were actually used to prepare magical remedies. The latter factor was described in the Ebers papyrus itself as a local application to the stomach to help children to pass urine required an “old book covered in oil” (Ebers 262).8 There are clear descriptions of treatments for a range of general and specialist branches of both medicine and surgery and the Edwin Smith papyrus is an excellent source of information for both diseases and their treatments. However, there have been justifiable criticisms of the papyri's historical use as many of them either reveal a pathology that is untranslatable today or they assume that a diagnosis has been made and simply leave a list of management instructions.
Numerous texts concern medicine in ancient Greece. The oldest work of Greek literature is Homer's Iliad, which he later followed with the Odyssey. These works describe a mythological world based upon a sound historical background. Within them are the circumstances surrounding the deaths of about 200 named individuals, the majority of which are ascribed to debilitating diseases, sudden death or by overt violence.6 Morbidities are also described and give evidence of mental aberrations, intoxication and the internal diseases of asthma (ásthma) and aphasia (amphasíē).6 Centuries later the Hippocratic corpus was assembled and is a collection of about 60 fairly heterogeneous medical treatises traditionally attributed to Hippocrates (ca 460–377 BC), the most prestigious member of the guild of Asclepiadae on the island of Cos. As well as the amount of detail on diseases that this collection brings, it is also of extreme use in studying how diseases have changed in frequency or of medical interest. One such example is diabetes mellitus. This is a disease with a genetic preponderance but in the Hippocratic era was a rarity, presumably because the pancreas was not tested by excess sugar or because it was being undiagnosed. The disease historian can, however, note that diabetes mellitus was the source of much medical writing by Celsus (fl. AD c.30), Aretaues (fl. AD 140) and Galen (AD 129–c.216) in the Imperial period.6 Therefore, by comparing the writings of the two periods debates can be stimulated regarding why such a change may have occurred.
Given the evidential problems associated with body remains and artefacts it is unremarkable to discover that several hazards are also seen in the literature world. Obtaining the sources is the first obstacle as the life of an ancient written text was precarious. This is especially true of the 700000 manuscripts that were once housed in the great Alexandrian library, the destruction of which—through riots sparked by Julius Caesar's arrival in 48 BC and the Muslim conquest of the city in the 7th century—has squandered educational material.13 The second obstacle is that a document may be indecipherable either because it is physically defective or because of our present inability to read many of the linguistic features, as in early Chinese manuscripts and some ancient Egyptian papyri. Then, even if there is no doubt about the translation of the word, its huge range of meaning in former times means that concise information is not gathered. The best example is the Greek word λεπρα, which is commonly translated as leprosy but in the classical period was used to embrace a wide range of skin disorders such as psoriasis, eczema, dermatitis and possibly a never accurate diagnosis of leprosy.7 Once these problems are diminished the task for the historian is never complete for they must understand that the original author may have made errors in transcription or only mentioned diseases incidentally, as subjects of casual concern or purely the symptoms. It seems that research is never simple.
There are many sources of information that have allowed historians to gain an insight into how ancient societies were affected by and dealt with diseases. This knowledge base is going to continue to increase with further discoveries both of actual sources and of means to examine them. This eventuality will be also be aided if meticulous care is taken with the pre‐existing sources, which will offer data to future generations. It would appear that disease historians are getting closer to our predecessors as every second passes, even if in reality we are hastily moving further and further away.
I am grateful to Miss Harriet Rollinson for reviewing the manuscript and for her suggestions.
Conflict of interest: nil