Nonetheless, the original authorship remains a controversial issue [ 9 ]. Although his translation of the Edwin Smith papyrus is still regarded as a masterpiece, Breasted encountered several problems in his interpretation of the text. After the publication of his translation in , several other Egyptologists and physicians suggested alternative interpretations of a number of hieroglyphs and fragments written in the original text [ 10 — 16 ].
For the clinical appraisal of the spinal injury cases, this latter translation was used for the current review. Before going into detail on the spinal injury cases, it is important to appraise the style and perspective the papyrus was written in.
The papyrus includes 48 cases of wounds, injuries and fractures topographically ordered from the skull, neck, upper limbs, chest to the thoracolumbar spine. The text of the last case case 48 comes to an unexpected end in the middle of a sentence. This suggests that the writer or writers was about to write down more cases dealing with wounds and injuries to the thoracolumbar spine, sacrum and lower limbs. The papyrus is astonishingly well structured.
Besides the mentioned topographic structure of the scroll, all cases are documented in a similar form. It has been suggested that the cases described in the papyrus predominantly concern patients who sustained their injuries during battles or construction work [ 10 , 15 , 17 — 19 ]. From this perspective, one may assume that the cases under study deal with relatively young, healthy male patients. This means that other prognostic factors than the diagnosis under study were not considered in the treatment decision-making.
This order of provided information suggests that the documented cases are not chronological descriptions of the diagnostic work-up of an individual case, but rather accurate, post hoc descriptions of the most significant signs and symptoms of the diagnosis under study. Another interesting aspect is that none of the cases include differential diagnoses. Nonetheless, since a number of unique cases were documented for most of the regions, i.
Six of the cases documented in the papyrus primarily deal with injuries to the spine cases 29—33 and 48 , see Table 1. The translations of each of these cases are presented in the Appendix [ 9 ]. The diagnostic descriptions and therapeutic verdicts of the six spinal injury cases as reported in the Edwin Smith papyrus, based on the Sanchez and Burridge translation [ 9 ].
In one case other information than the signs and symptoms belonging to the diagnosis under study have been documented as well:. Case " it is his fall head-downward which caused a vertebra to crush into its counterpart. In no other case, the mechanism of injury has been described. In fact, this is the only case presenting information acquired from history taking or, more likely in this case, heteroanamnesis. In the head injury cases, neck stiffness is attributed by the Egyptian physicians to what amounts, in our terms, meningismus from traumatic subarachnoid hemorrhage.
The inability to rotate or flex the neck is described in seven cases cases 4, 5, 7, 19, 29, 30 and 32 , of which three cases deal with spinal injury. In case 48, the only case dealing with a lumbar spinal injury, a unique type of physical examination is reported. The patient, presumably lying in supine position, is asked to extend and contract the legs. Interestingly, this is the only clinical symptom reported in this case. Although others hypothesized that this case represents the first description of non-traumatic low back pain [ 20 ], this case most likely covers the diagnosis of a symptomatic traumatic lumbar intervertebral disc injury [ 21 , 22 ].
The papyrus includes two cases with spinal cord injury cases 31 and It is noteworthy that in these two cases significant symptoms related to injuries of the spinal column, e. All of the reported signs and symptoms are related to the spinal cord injury. The use of the term unawareness in this context is intriguing. It implicates that both motor and sensory functions are completely absent. After carefully reading case 31, we can conclude, however, that the accuracy of this description of neurological deficit leaves room to speculation.
The following text, which is perhaps one of most interesting fragments of the entire papyrus, explains why:. If however, the middle vertebra of the back of neck is dislocated, ejaculation arises from his penis.
Based on the second sentence, we cannot do otherwise than to conclude this case concerns a spinal injury located at the lower part of the cervical spine resulting in a low cervical tetraplegia [ 1 , 3 , 6 ]. From a modern perspective, we know that the motor and sensory tracts to the proximal parts of the upper limbs myo- and dermatomes C5 would likely had have been intact in such a case.
The papyrus contains the first known descriptions of autonomic dysfunction in spinal cord injury, including: priapism, urinary incontinence and abdominal distention case The bloodshot eyes case 31 , stupor and aphasia case 33 are not related to the spinal cord injury as these signs are most likely the result of an inaccurately described closed head injury. As mentioned, the papyrus excels by its topographic structure. The categorization of anatomical regions is also observed within the group of spinal injuries.
Furthermore, the cervical spinal injury cases can further be categorized in open case 29 and closed cases 30—33 wounds. Each of the four closed cervical spinal injury cases concerns a unique diagnosis of the injured spinal column. An additional explanation on the diagnosis is provided by the writer in each case see Appendix.
Case 30 represents the least disabling type of spinal injury and has previously been interpreted as a whiplash injury [ 24 ]. Case 31 concerns a more severe injury with separation of one vertebra from another. However, the extent and direction of the displacement injury remain speculative issues. In contrast, the explanation on the vertebral compression fracture accompanying case 32 includes a highly illustrative metaphor:.
The detailed description of the crushed fracture in case 33 suggests that post-mortem examinations were performed [ 26 , 27 ]. The same counts for the documented pathologic anatomic relation between the dislocated vertebra and spinal cord in case Other Egyptologists, however, do not support the suggestion of postmortem examinations being performed in Egypt before the fourth century b. Another question that remains is how the writer accurately determined the diagnoses of cases 30 and 32 in surviving subjects.
Although the signs and symptoms of spinal cord injuries reported in cases 31 and 33 are not entirely similar, the author did not clearly categorize the neurological deficits of these two cases into different entities.
However, case 31 includes a very interesting remark:. The writer describes a hypothetical alternative clinical presentation: a more cranial injury to the cervical spinal column would result in a different type of neurological sequelae, namely priapism and spermatorrhea. Although it is evident that the ancient Egypt physicians had great knowledge about human physiology and anatomy see next paragraph , with the currently available knowledge we can say that the documented causal relation between the level of injury and mentioned neurological sequelae is an inaccurate one.
Nonetheless, after reappraising the alternative scenario documented in case 31 we may conclude that, referring to the level of injury, the papyrus includes the oldest known categorization of SCI in history! Clearly, the author of the papyrus was a learned physician and anatomist. Besides the accurately documented diagnoses and their significant symptoms, the scroll also includes the first ever known reporting of causal relations in spinal injuries [ 26 ].
Four causal relations are described in the spinal injury cases. In case 33, the mechanism of injury is related to the type of spinal column injury:. This sentence demonstrates that even in ancient times, physicians were aware of the effects of excessive axial loadings on the integrity of the vertebral bodies of the spinal column.
One of the most fascinating fragments of the papyrus concern the documentation of the inexplicit causal relation between the injury of the spinal column and spinal cord in cases 31 and These two causal descriptions illustrate that more than 3, years ago physicians already had substantial knowledge about human physiology. They knew that injuries to the spinal column had the potential to result in motor, sensory and functional deficits.
Without doubt, it can be stated that the ancient Egyptian physicians were already aware of the vital functions of the spinal cord.
In this case, the writer describes a rational explanation for the pain which is evoked by physical examination. The statements on the treatability of the spinal injury cases are summarized in Table 1. Two of the six spinal injury cases are considered untreatable; cases 31 and 33, the only two cases with a documented spinal cord injury.
The writer considers the remaining three cases cases: 30, 32 and 48 as treatable by non-operative means. To recapitulate, the Edwin Smith papyrus is a unique treatise containing the oldest known descriptions of signs and symptoms of injuries of the spinal column and spinal cord. The papyrus excels in rationality, even more so when considering it originated at the time when written language itself was a recent invention and medicine was at its birth.
The cases covered by the papyrus are not likely to represent individual ancient cases, but rather a series of accurately described clinical scenarios based on the clinical knowledge of highly experienced and educationally minded Egyptian physicians. Although the first documented signs of spinal column injuries are—from a modern perspective—fairly non-specific, symptoms of spinal cord injuries have been documented accurately in the scroll. The papyrus contains the first known categorizations of spinal column and spinal cord injuries and covers important clinical prognostic factors which were considered in the treatment decision-making process as reported by the writer.
While all of the spinal injury cases in the papyrus cover injuries to the spinal column, two cases focus on the signs and symptoms of concomitant injury to the spinal cord.
Interestingly, in these two cases significant symptoms related to injuries of the spinal column are not described at all.
Given the devastating effects of spinal cord injury on survival outcomes, details about injuries to the spinal column and their prognostic value were apparently not considered significant enough to be reported. A possible explanation for this is that patients with spinal cord injury usually had a poor prognosis.
Most of the patients died a relative short period after the injury because of pneumonia, urinary tract infections or other complications related to autonomic dysfunction.
It was not until the first half of the twentieth century when survival rates increased dramatically because of the introduction of specialized care, prevention of complications and the discovery and use of antibiotics [ 29 — 32 ]. When compared with ancient Egypt, the contemporary diagnostic work-up of spinal column injuries has improved considerably. With the breakthroughs in medical imaging by Roentgen in X-rays and Hounsfield and Cormack in computed tomography physicians became able to estimate the severity of closed spinal column injuries [ 33 , 34 ].
Instead of history-taking and physical examinations, imaging techniques became the reference standards in the diagnostic work-up of spinal column injuries. It is, however, painful to conclude that more than 3, years after the first known documented categorization of spinal column injuries, no reliable, accurate and validated spinal injury classification system has been introduced and globally endorsed to date [ 35 , 36 ].
In contrast, contemporary classifications of spinal cord injuries are characterized by their high methodological standards. Since the ancient Egyptian times, the number of effective treatment options for spinal column injuries improved considerably [ 40 — 42 ].
Whereas natural history and treatment outcomes are hardly documented in the papyrus, current spinal trauma literature is actually focused on treatment outcomes of both operatively and non-operatively treated patients. It is fascinating to see the shift of treatment goals over time. Whereas ancient Egyptian triage medicine considered the likelihood of survival as the most important outcome of interest, nowadays the quality of life and functional outcome measures are of primary interest [ 43 , 44 ].
Despite all recent scientific efforts, a cure for spinal cord injury still does not exist. With a number of causal relations described in the spinal injury cases the Edwin Smith papyrus excels in rationality. Moreover, the most significant symptoms were explicitly considered as important prognostic factors in the postulation of the treatment verdicts.
Although injuries reported in the papyrus still occur today, the distribution of spinal injuries now ranges from children to octogenarians, with the latter group readily increasing [ 45 ]. Because of this demographic switch of spinal injuries, physicians are nowadays facing more complex diagnostic and therapeutic work ups.
Nonetheless, whereas demographics, diagnostic techniques and therapeutic options changed over time, the diagnostic, prognostic and therapeutic rationale documented in the oldest known treasure on spinal injuries can still be considered as the state-of-the-art reasoning for modern clinical practice.
This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author s and source are credited. Title Treatment instructions concerning a knife wound in a vertebra in the back of his neck. He has found he is unable to look at both his shoulders and his chest. Treatment You should bind it over fresh meat the first day. Treatment You have to bind it over fresh meat the first day.
Afterward, you should treat with powdered alum and honey every day until he recovers. Title Treatment instructions for a dislocation in the vertebral column of the back of the neck. Examination If you should examine a man for a dislocation in the vertebral column of the back of his neck, and you find him unaware of both his arms and his legs, as a result of it, while his penis is stiff because of it and urine drips from his penis without him knowing it and his internal organs have become gaseous and both his eyes are bloodshot, it is a dislocation of the vertebral column of the back of his neck extending to his thoracic spine, that causes him to be unaware of both his arms and his legs.
His penis is stiff and subject to emission from the end of his phallus. That is to say, the penis remains stationary, it does not move down to the genital region, moreover, neither can it lift upward. Title Treatment instructions for a subsidence in a vertebra in the back of his neck. Then he finds he is unable to turn his face.
He can look to neither the front of his chest nor his two shoulder joints. You have to loosen his bandages, and you then apply ointment to his head as far as the back of his neck. You have to bandage it over alum and you should treat him afterward with honey every day. Title Treatment instructions concerning a crushed vertebra of the back of his neck.
Examination If you should examine a man having a crushed vertebra in the back of neck and you find him with one vertebra fallen into its counterpart, and now he is stuporous and he does not speak. It is his fall head downward which caused a vertebra to crush into its counterpart and you find he is unaware of both his arms and his legs because of it.
Then he must extend it. He has to contract it immediately because of the pain that it makes in the vertebral column of his back from which he suffers. Joost J. Gonzalo M. Sanchez, Email: ten. Alwyn L. Burridge, Email: ac.
National Center for Biotechnology Information , U. Journal List Eur Spine J v. Eur Spine J. Published online Aug Sanchez , 2, 3 and Alwyn L. Burridge 4. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Received May 20; Accepted Jul This article has been cited by other articles in PMC. Abstract Dating from the seventeenth century b.
Keywords: Papyrus smith, Medical history, Spinal injuries, Spinal cord injuries. Introduction Dating from the seventeenth century b. A brief summary of the history and translation of the papyrus After lying in a tomb in Thebes, Egypt, for over 3, years, the papyrus Fig. Open in a separate window.
Breasted's attention, and finally under his close scrutiny has revealed itself as the oldest known scientific treatise surviving from the ancient world, is described in the Introduction to one of the most illuminating glimpses we have ever had into the astonishingly developed medical knowledge of ancient Egypt. Both to the medical profession and to the lay reader the Surgical Papyrus will be of intense interest. It contains, for example, for the first time in human speech a word for "brain.
Repeatedly the surgeon, because of his scientific interest in the observable facts, discusses cases of injured men whom he has no hope of saving. Volume 1 contains a historical introduction to the document, followed by translation and commentary. Volume 2 contains collotype facsimiles of the Papyrus, which originally was in a continuous roll but for the sake of convenience has now been cut into columns of text.
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