Neurosurg Focus 33 (2):E2, 2012 The journey of discovering skull base anatomy in ancient Egypt and the special influence of Alexandria ALI M. ELHADI, M.D., SamUEL KALB, M.D., LUIS PEREZ-ORRIBO, M.D., ANDREW S. LITTLE, M.D., ROBERT F. SpeTZLER, M.D., AND MARK C. PREUL, M.D. Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona The field of anatomy, one of the most ancient sciences, first evolved in Egypt. From the Early Dynastic Period (3100 BC) until the time of Galen at the end of the 2nd century AD, Egypt was the center of anatomical knowledge, in- cluding neuroanatomy. Knowledge of neuroanatomy first became important so that sacred rituals could be performed by ancient Egyptian embalmers during mummification procedures. Later, neuroanatomy became a science to be studied by wise men at the ancient temple of Memphis. As religious conflicts developed, the study of the human body became restricted. Myths started to replace scientific research, squelching further exploration of the human body until Alexander the Great founded the city of Alexandria. This period witnessed a revolution in the study of anatomy and functional anatomy. Herophilus of Chalcedon, Erasistratus of Chios, Rufus of Ephesus, and Galen of Pergamon were prominent physicians who studied at the medical school of Alexandria and contributed greatly to knowledge about the anatomy of the skull base. After the Royal Library of Alexandria was burned and laws were passed prohibiting human dissections based on religious and cultural factors, knowledge of human skull base anatomy plateaued for almost 1500 years. In this article the authors consider the beginning of this journey, from the earliest descriptions of skull base anatomy to the establishment of basic skull base anatomy in ancient Egypt. (http://thejns.org/doi/abs/10.3171/2012.6.FOCUS12128) KEY WORDS • Egypt • skull base anatomy • dissection • Imhotep • Alexandria • brain extraction • Herophilus • neurosurgical history HE earliest descriptions of the anatomy of the skull the earth, the giver of grain, bears the greatest source of base date to the ancient Egyptians and Greeks. It drugs, many that are healing when mixed, and many are has been claimed that anatomy was born in ancient baneful, there every man is a physician wise above hu- TEgypt or at least was practiced there somewhat systemati- man kind.”36 Many kings of other surrounding ancient cally, perhaps because of religious rituals involving prep- cultures sought medical advice from Egyptian physi- aration of the body and its organs for the next realm of life cians, often traveling far distances for personal attention. after death.12 Focusing on the earliest descriptions to the For example, Niqmaddu II, the king of Ugarit, asked the establishment of basic cranial, including the skull base, Pharaoh Akhenaten (1375–1334 BC) for an Egyptian phy- anatomy in ancient Egypt, this historical review tracks sician.21 King Hattusili III of the Hittites asked Ramses the very beginning of the anatomical journey that eventu- II to provide him a physician to cure his sister, and even ally formed the knowledge base underlying the success of Cyrus the Great, the ruler who united the Medes and the the neurosurgical specialty of skull base surgery. Persians, requested an Egyptian ophthalmologist to treat an eye injury.19 It appears that even though there might Ancient Egyptian Medicine have been ongoing international or cultural conflicts, such requests for services from an Egyptian physician Among the most ancient civilizations, the Egyptians were usually met with neutrality or immunity, even when became renowned for the practice of medicine combined a ruler would travel to Egypt or an Egyptian physician with what seems to be a lively inquiry into what might be would travel to another country. considered the science or philosophy of the day. The cali- According to Breasted,8 the ancient Egyptians estab- ber of Egyptian medicine is broadly recognized in nu- lished categories for their physicians. Some of these ranks merous references in both modern and ancient literature. are recorded in the Edwin Smith Papyrus. The swnw were In The Odyssey Homer wrote that “for there [in Egypt] the “doctors of the people,” while the wabw were “cer- Neurosurg Focus / Volume 33 / August 2012 1 Unauthenticated | Downloaded 10/05/21 06:46 PM UTC A. M. Elhadi et al. emonially pure.” The saw were guardians who obtained their education and training in the temple palace schools, some of whom reached the position that has been trans- lated as “great palace doctors.” A junior doctor was con- sidered a swnw. A senior doctor was called imy-r-swnw. The registrar was referred to as smsw-swnw. Consultants were called shd-swnw. Furthermore, each specialist had his own title. Importantly, a physician might reach a high rank or be highly regarded, but he was still expected to be available to the common people. The chief physician of the pharaoh was expected, more or less, to set the medical policy for the country. Head Anatomy in Ancient Egypt Preserved papyri include information that provides glimpses into Egyptian medicine. Egyptian physicians, at least those in roles of royal or ritual responsibility, seem to have been careful to record information on the diag- nosis and treatment of various conditions, including head injuries. Other information (for example, methods of ex- tracting the brain through the nose or mouth) appears to relate to the rituals of embalming, supporting a key part of the Egyptian view of the afterlife. Of the known pa- pyri, about 30 relate to medical and magical health. Other sources about such Egyptian information include ostraca, shards or tablets with inscriptions, writings on the walls of tombs (Fig. 1), analysis of mummies, and writings from FIG. 1. Upper: Photograph of ancient Egyptian drawings on the the Greek, Roman, and Arab civilizations.15 wall of the temple Kom Ombo showing surgical instruments: bifurcated probe, hooks, knife, knife blade, scoop probes, tooth forceps, flasks, Among the earliest Egyptian records are those from cupping vessel, sponge, double-ended probes, shears, male catheter, early 3100 BC, when Manetho, an ancient Egyptian his- saw blades, scalpels, and trivalve specula. Image available at http:// torian is said to have written, “Athothis [or Djer], his en.wikipedia.org/wiki/File:Kom_Ombo_Temple_Surgical_instruments. [that is, Menes’] son, for fifty-seven years built a palace JPG. ©Ad Meskens/Wikimedia Commons. Lower: Photograph of at Memphis and his anatomical works are extant, for he ancient surgical instruments found in the tomb of an Egyptian physician. was a physician.”32 According to Manetho, between 3100 Photograph provided by A. M. Elhadi, taken at and with the permission and 2890 BC, Djer (or Athothis) wrote some of the earli- of the Egyptian Museum, Cairo, Egypt, 2012. est records on medicine, for example, two works called Practical Medicine and Anatomical Book, which may be body, and a met to the left ear, where it was believed the the first practical and systematic studies of human anat- breath of death entered the body. omy. Although Manetho is consistently cited and what Compared with many cultures, ancient Egyptians he recorded is reputable, none of his works, like Djer’s, placed a high value on preserving the condition of the hu- has survived.32 Consequently, our knowledge of what the man body after death because they believed that the same Egyptians understood about anatomy is mostly drawn body would accompany them in the afterlife. However, this from surviving papyri and ostraca. For example, the Eb- belief created a barrier when it came to dissecting human ers papyrus, which includes paragraphs on anatomical bodies for study. Although their mission was purely ritual, structures referred to as metu (plural of met, which has no embalmers, apart from physicians, possessed knowledge equivalent in English but can mean arteries, veins, ducts, of human anatomy so they could remove the internal or- tendons, or even nerves), states that there are metu to the gans of the dead and preserve them for further use in the back of the head, to the forehead, to the neck, to the eyes, afterlife. Embalmers were trained to approach the human to the eyebrow, to the nose, to the temples, and to the head. organs with procedures that avoided disfigurement. In fact, Altogether, about 52 metu are described in this papyrus.32 Egyptian embalmers were the first individuals in history The Ebers papyrus also describes human anatomy to purposefully encounter and evaluate the brain through with more emphasis on the head (paragraph 854g). In this the nasal cavity without having to break through the hard section, 2 metu that supply the nostrils and 4 metu from bone of the skull and disfigure it (Fig. 2).19,35 This proce- the temples that supply the eye are well described. An- dure should not be interpreted as transsphenoidal surgery. other paragraph (856g) from the same papyrus mentions Rather, it was simply a transnasal or transbasal extraction that 2 additional metu independently supply the eyes, 1 of brain tissue. While some extractions of brain tissue ap- met for each eye. This statement could refer to the optic pear to have been accomplished through relatively small nerves because the small ocular vessels could easily have and refined approaches, such as through one nasal cavity, escaped notice. According to Egyptian beliefs, there was or off to the side of the maxillary region, others produced a met to the right ear, where the breath of life entered the large, more destructive holes at the skull base. 2 Neurosurg Focus / Volume 33 / August 2012 Unauthenticated | Downloaded 10/05/21 06:46 PM UTC Skull base anatomy in ancient Egypt because it was not part of their practice needs.