eMJA: Magee, Arterial disease in antiquity

History

Arterial disease in antiquity

The study of papyrus writings and of mummified human remains provides an insight into the diseases and the practice of medicine in ancient times. Paleopathology, developed in the latter part of the last century and now incorporating modern technology and diagnostic techniques, has shown that arterial disease was not uncommon and that the arterial lesions of 3000 years ago were no different from those we see today.

Reginald Magee

MJA 1998; 169: 663-666

Introduction - Ancient Egypt - Vascular disease - Conclusions - References - Authors' details
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Introduction

In today's society there is a general awareness of arterial disease and its consequences. People know about coronary occlusions and strokes, and cholesterol has become a household word. In the press there are articles, almost daily, about diets, vitamins, forms of alternative medicine, the dangers of smoking and the advantages and disadvantages of consuming alcohol. Healthfood shops abound. The stresses of modern living have been implicated in arterial disease. While once senior executives worried about developing ulcers, now the concern is about coronary vessels and blood cholesterol.

While we cannot be certain that the stresses we are subject to in our time are any greater than the stresses on primitive peoples and those who belonged to ancient civilisations, we do know they are different. Thus, in a context of different stresses, different lifestyles and different diet, it may be interesting to examine the occurrence of arterial disease in the past. Human remains in many countries have been examined by scientists, but those from ancient Egypt have probably been examined in the greatest detail. This article presents an overview of these studies in relation to arterial disease.

Ancient Egypt

In the 19th century there was an increasing interest in the ancient history of Egypt. Studies of ancient Egyptian writings, such as the Papyrus Ebers and Papyrus Edwin Smith (well known works on medical conditions and their treatment, written between 1500 BC and 2000 BC), and drawings and statues showing malformed people (Figure 1) have taught us much about disease and the practice of medicine in that civilisation. However, more direct information about diseases was obtained by the careful examination of skeletons and preserved tissue from unwrapped mummies. The unwrapping (or "unrolling", as it was often referred to) of mummies became a fashionable occupation in the last century. A number of mummies were investigated in 1834 by Thomas Pettigrew (surgeon to the Duke of Kent, whose chief claim to fame was that he vaccinated Queen Victoria). His efforts, however, made little contribution to the knowledge of disease in ancient Egypt as his unrollings were done rather hastily and the examinations were relatively superficial. It was in the latter part of the last century and the early part of this century that interest in the study of mummified tissue was regenerated with the development of paleopathology. This science was defined by Sir Marc Armand Ruffer, Professor of Bacteriology at Cairo Medical School, as "the science of diseases which can be demonstrated in human and animal remains of ancient tissues."^1,2 Other notable workers in the field included Elliot Smith (Australian anatomist and anthropologist), Wood Jones (English-born professor of anatomy in Australia and Manchester), and the Egyptologist Margaret Alice Murray.

Figure 1: Egyptian statue from the Old Kingdom (2686-2181BC of a person with exophthalmos.

Embalming and mummification

Ancient Egyptians believed that it was necessary to maintain the corpse in as lifelike a condition as possible, as the departed spirit would eventually return to the body. Thus, embalming was considered important and embalmers held some status within society. Today, we can preserve bodies by injecting fluid into the blood vessels, deep freezing and freeze drying. As these methods were not available to the embalmers of ancient Egypt, others had to be employed. The overwhelming evidence is that natron, a naturally occurring substance consisting mainly of sodium carbonate and sodium bicarbonate, was the main agent used. Three embalming methods (varying in thoroughness and in price^1,3) are described in the writings of Herodotus (5th century BC) and Diodorus Siculus (1st century BC). These methods are summarised in Box 1.

The study of mummies showed that embalming did not facilitate the opportunity for anatomical examination as the organs were removed roughly through a relatively small incision.

1: Embalming methods, in order of thoroughness and price, described in the writings of Herodotus (5th century BC) and Diodorus Siculus (1st century BC)

The most expensive method involved physical removal of the internal organs (the brain by an iron hook passed up through the nose and the intestines and thoracic contents through a cut in the left flank, although the heart was often left as it was considered to be the seat of the mind), which were stored in Canopic jars and later may have been wrapped and returned to the body cavity. This was followed by cleansing of the cavities with palm wine and powdered aromatics, and filling of the body with myrrh, cassia and spices to add fragrance. The incision was either left, covered with a plate or occasionally sewn up. Muscles were removed through multiple small incisions and then the body was covered in natron for 70 days, then washed, wrapped in linen bandages and smeared with gum. Finally, it was returned to the relatives, placed in a case and kept in a sepulchral chamber.
The next-most-expensive method was to fill the body cavity with cedar oil injected through the rectum and to cover it with natron for 70 days. On the last day the oil (which liquefies the inner parts) would be allowed to escape, leaving only skin and bone. The body would then be returned to the family.
The cheapest method was simply to wash the body with a salt solution, embalm it with natron for the usual period and return it to the family for burial.
Any extra filling required for the cleared body cavities was done with rags, sawdust or mud.

Vascular disease

Aortic calcification in two Egyptian mummies was first described by Czernak in 1852.⁴ The Australian Elliot Smith described tortuous calcareous temporal arteries in the mummy of Pharaoh Rameses II (XIX Dynasty, reigning 1279-1213 BC), and extreme calcareous degeneration, with the formation of large bone-like plaques, in the aorta of Pharaoh Mernephtah (XIX Dynasty). A sample of this aorta was sent to the curator of the museum at the Royal College of Surgeons, who made sections from it which he showed at a meeting of the Royal Society of Medicine in 1909.⁵

Ruffer^2,6 developed a method for preparation of the tissue sampled from mummies and examined a number of specimens from the XVIII to the XXVII dynasties (1580 BC - AD 527). In his article on arterial lesions, he commented on the extensive mutilation during the embalming process, when all of the viscera and most of the muscles were removed, so that it was only by accident that the whole or portion of the aorta or one of the large arteries was left behind.² Thus, it was only the peroneal artery (and occasionally the arteries of an untouched arm or leg, remaining when the embalmers had not done their work properly) that was usually available for examination.² He produced and published drawings of the gross and microscopic appearances of the specimens, some examples of which are shown in Box 2.

2: Coloured illustrations reproduced from Ruffer²

a. Pelvic and thigh arteries completely calcified.

b. Calcified patches in an aorta.

c. Calcified atheromatous lesion in a subclavian artery.

d. Section through an almost completely calcified peroneal artery (van Gieson stain).
* Remnants of endothelium and fenestrated membrane;
† Calcified patches

In 1972, Rosalie David, Keeper of Egyptology at the Manchester Museum, revived interest in the subject and involved many other scientific specialists in a study which became known as the Manchester Mummy Project.⁷ A range of multidisciplinary techniques were used in the examination of mummies, including radiology, computed tomography and magnetic resonance imaging, histological examination, electron microscopy, carbon dating, serological tests, DNA studies, fingerprinting, dental studies and scientific facial reconstruction. The team also pioneered the use of virtually non-destructive techniques, such as endoscopy, to obtain tissue samples. A mummy tissue bank has now been established at Manchester University's School of Biological Sciences to store samples from Egyptian mummies held in collections worldwide.

In 1975, Aidan Cockburn and co-workers published the findings of an autopsy on the mummy known as Pum II (Pennsylvania University Museum mummy number II).⁸ The wrappings, resins and tissues were all examined in great detail. The aorta was found to contain large and small atheromatous plaques, and other vessels in organs returned to the body cavity in visceral packages showed some intimal fibrous thickening consistent with arteriolar sclerosis.⁸

Paleopathological studies of the vascular system of human remains preserved outside Egypt include those by Chinese pathologists examining the Mawangtui mummy, which was dated about 1120 BC.⁹ This was a mummy of a 50-year-old woman which had been immersed in a solution containing mercury salts, and sealed hermetically so that the fluid was still present. The arteries of this mummy, in particular the coronary arteries, showed atheromatous plaques and arteriosclerotic changes. Further, Zimmerman examined naturally frozen Alaskan mummies, the oldest of which (dated about AD 400) was of a 53-year-old Inuit woman who had moderate aortic and coronary atherosclerosis.¹⁰

More recently, the discovery of the body of a man estimated to be about 5000 years old near the Austrian-Italian border -- the "Ice Man" -- has become the subject of a book which describes the condition of the hair, skin and teeth.¹¹ Although radiological studies have been done, macroscopic or microscopic studies of the internal organs have not yet been reported.

There has been no study of arterial disease in Australian Aboriginal remains. This is, firstly, because their burial rites (which varied, but included often more than one of interment, mummification, cremation, platform exposure, delayed burial and burial in hollow trees) would have left little soft tissue for examination and, secondly, because of cultural sensitivities. It would, of course, be interesting to know to what extent arterial disease affected such an isolated and distinct race whose diet was simple, but characterised by indulgence at times of seasonal abundance.¹² Unfortunately, paleopathological studies of Aboriginals have been limited to the study of skeletal remains which showed evidence of osteoarthritis, osteomyelitis and metastatic malignancy.¹³

Investigation of vascular disease

Radiological examination of the mummies examined by the various pathologists showed calcification of the aorta, femoral and carotid arteries.^7,8,10 High resolution computed tomography of the head of the Ice Man,¹¹ whose estimated age was 35-40 years, showed "slight hardening of the arteries", presumably some calcification seen in the walls of the vessels, at the base of the brain.

Macroscopic examination of mummies showed evidence of calcification of the arterial wall, which varied from isolated spots to bone-like plaques to rigid calcified tubes which would break when dissected out.^2,6-9 Ruffer illustrated a specimen of subclavian artery which showed almost complete obstruction at its origin by thick calcified plaque. He also described arteries which appeared to be thickened and fibrous, rather like whipcord, but not calcified.²

Microscopic examination showed appearances of arteriosclerosis, atheroma, lipid deposition and medial calcification. Degeneration of the muscle coat and replacement by fibrous tissue was present in some specimens, and spots of calcification could also be seen.^2,6-8,10 The elastic tissue could be easily demonstrated with such stains as phosphotungstic acid-haematoxylin and Heidenhain's iron haematoxylin, and among the degenerative changes seen was reduplication of the internal elastic lamina. Lipid could be demonstrated in plaque with such stains as Sudan 3 and 4 and Sudan black. Atheromatous lesions in mummy arteries have sometimes shown sectorial clefts, giving the impression of dissecting aneurysm.¹⁴

Figure 2: Section of a popliteal artery from a Ptolemaic mummy which shows that good tissue definition can be obtained, and that the intima media and adjacent fat are distinguishable, although intracellular details are not. Collagen and elastic tissues are the best preserved (courtesy of J T Rowling).

Documented evidence of aneurysm

Degenerative changes have been found in the aorta, coronary and peripheral arteries, but aneurysm has not been reported, probably because of the efficiency of the embalmers. However, Ghalioungui¹⁵ noted a description of aneurysm in the peripheral arteries in the Papyrus Ebers:

"...a swelling of vessels ... it is hemispherical and grows under thy fingers at every going [ie, it pulsates], but if separated from his body it cannot become big and not come out [ie, diminish] ... it is a swelling of a vessel ... and it arises from injury to a vessel." (Eb 872)

A cirsoid aneurysm (and the magic used to treat it) was also described:

"...its appearance in growing on account of serpentining of the serpentry and they have formed many knots ... it is a swelling of vessels. Thou shalt not put thy hand to such a thing ... what is spoken is its effective spell 'flow out thy vessel ... that jumps in the midst of these limbs'." (Eb 873)

It would appear that the lesions seen in the ancient Egyptians were no different from those we see at the present time in vascular surgery and morbid histology.

Rowling, in his presentation to the Royal Society of Medicine in 1961,¹⁶ cited the mortuary inscription of Weshptah, the Architect, Vizier and Chief Justice of Pharaoh Neferirkere (2494-2345 BC), which suggested that he died of a cerebral haemorrhage. He also said that in the Papyrus Ebers there was reference to hemiplegia, and another to an association between disease of the vessels of the thigh and foot conditions which may have been gangrene. Rowling considered that it may have been fortuitous that the ancient Egyptians made this association. However, to read into this ancient text that disease of the vessels of the thigh was associated with gangrene would seem highly conjectural.

Conclusions

In his writings on Egyptian mummies, Ruffer speculated on the causes of vascular disease.² He eliminated tobacco and syphilis, as neither was known in ancient Egypt. Although the Egyptians consumed both beer and wine, and did get drunk, as shown in ancient artworks, Ruffer's contemporary experience of over 800 autopsies in Muslim abstainers indicated to him that alcohol was not the cause of arterial disease. He considered meat consumption as a factor, but, while admitting that mummies represented the wealthier classes who may have eaten more meat than others, emphasised that the diet was mainly vegetable and, judging from dental wear, rather coarse. Ruffer also dismissed the stress of everyday life, as he did not consider the life of the ancient Egyptians to be any more arduous than at the time of his writing. His conclusion was that the causes of the degenerative disease were just as obscure in ancient times as they are now.²

Disease has always been a part of life. Evidence of it has been found in the remains of reptiles of the Permian period through to the time when ancient human civilisations began to record it. It is clear that atherosclerosis is an ancient process, and its pattern has always been the same regardless of race, diet and the stresses of survival. However, in these days, modern man in may some ways encourage atherosclerosis by smoking and consuming foods with a high fat content.

References

Sigerist HE. Primitive and archaic medicine. Oxford: Oxford University Press, 1967.
Ruffer MA. On arterial lesions found in Egyptian mummies. J Pathol Bacteriol 1911; 15: 453-462.
Garner R. Experimental mummification. In: David AR, editor. Manchester mummy project 1979. Manchester: Manchester University Press, 1979.
Sandison AT. Degenerative vascular disease in the Egyptian mummy. Med History 1962; 6: 77-81.
Shattock SG. Microscopic sections of the aorta of King Mernephtah. Lancet 1909; 1: 319.
Ruffer MA. Remarks on the histology and pathological anatomy of Egyptian mummies. Cairo Scientific J 1910; 4: 3-7.
David AR, editor. Manchester mummy project 1979. Manchester: Manchester University Press, 1979.
Cockburn A, Barraco RA, Reyman TA, Peck WH. Autopsy of an Egyptian mummy. Science 1975; 187: 1155-1160.
Cockburn A. Miscellaneous mummies. In: Cockburn A, Cockburn E, editors. Mummies, disease and ancient cultures. Cambridge: Cambridge University Press, 1980.
Zimmerman MR. The paleopathology of the cardiovascular system. Texas Heart Inst J 1993; 20: 252-257.
Spindler K. The man in the ice. Guernsey, Channel Islands: Guernsey Press, 1995.
Mulvaney DJ. The prehistory of Australia. Melbourne: Pelican Books, 1975.
Webb SG. Paleopathology of Aboriginal Australians. Melbourne: Cambridge University Press, 1955.
Sandison AT. Diseases in ancient Egypt. In: Cockburn A, Cockburn E, editors. Mummies, disease and ancient cultures. Cambridge: Cambridge University Press, 1980.
Ghalioungui P. Medicine in ancient Egypt. In: Harris JE, Wente EF, editors. An x-ray atlas of the royal mummies. Chicago: University of Chicago Press, 1980.
Rowling JT. Pathological changes in mummies. Proc Roy Soc Med 1961; 54: 409-415.

Authors' details

Princess Alexandra Hospital, Brisbane, QLD.
Reginald Magee, FACS, FRACS, Senior Visiting Vascular Surgeon.

Reprints: Dr H R Magee, "Alexandra", 201 Wickham Terrace, Brisbane, QLD 4000.

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