We know that Homo sapiens and others from our evolutionary tree cared for one another for hundreds of thousands of years, but little is known of their medical technology. We believe, for example, that our forebears used herbal and other natural remedies—that they ingested clay to absorb toxins and, topically, to fight infections and treat wounds. (Use of clay is not unique to humans as other primates and birds ingest clay.) Moreover, chimpanzees and other apes are known to eat trichome plants to combat parasites, and perhaps early humans did this as well. Certainly, there is evidence of prehistoric people using birch bark as a laxative and setting broken bones. Such simple physical measures were usually combined with spiritual intervention, which was overseen by the tribal medicine man or shaman.

A common intervention in human prehistory was trepanning, which involved cutting, drilling, or scraping a hole in the skull. An example of one such skull is shown in Figure 1.1. Trepanning was done, it is thought, to relieve cranial pressure after an injury as well as to treat mental illness, and it is believed to have been ritualistic in many cases, though little is understood of the context of such practices. Trepanned skulls have been found dating back 7,000 to 8,000 years.

Evidence of this remarkable medical procedure has been found in different locations scattered around the globe, including Europe, China, Siberia, North and South America, Africa, and Polynesia. The excavated skulls show that many of these trepanned “patients” survived, at least for a time; most are from men, perhaps because men were more likely to be injured in battle or otherwise. In any case, the surgical ability of our ancestors and the endurance of these patients should humble our own sense of medical prowess.

Egyptian medical practices spread beyond Egypt’s political reach as historical evidence shows. The borders of ancient Egypt varied over the millennia, at times including parts of what is now Sudan, South Sudan, and Israel, as shown in Figure 1.2. The Old Testament describes close ties between Canaan and Egypt. There is historical evidence to support this. Some medical practices may have spread. Circumcision, for example, was commonly practiced in ancient Egypt (as well as other cultures of the ancient Middle East including Mesopotamia), and this is thought to have been done at least partially for hygienic reasons. The practice has endured and remains widespread among Muslims and Jews.

Religion and medical care in the ancient Middle East were usually integrated to some extent, infusing healing and health with a spiritual overlay. Medicine was commonly taught in religious settings and healthcare providers remained tied to these communities. They were in some respects like “medicine men” in native American culture or “witch doctors” in southern Africa. Like them, the ancient Egyptians had hundreds of medical and health-related drugs and products. We know of such unguents and palliatives from translations of hieroglyphic writing on papyrus; thanks to the translations made possible by the Rosetta Stone (discovered in 1799), scholars were able to unlock the hieroglyphics, opening a window to medicine and health in the world of the pharaohs.

We have learned that the ancient Egyptians used copper salts and honey combined with grease as antiseptics. (Honey is quite resistant to bacteria.) They concocted mouthwashes with mint and other ingredients as a remedy for bad breath. They used aloe for burns, opium and thyme for pain, and even toothbrushes and toothpaste for oral hygiene. They also used adhesive bandages for wound care. Perhaps, the first great dentist of ancient Egypt was Hesy-Ra of the third dynasty; other notable dentists followed in what became a long tradition of Egyptian dentistry.

Mummification was an art as well as a science in ancient Egypt. Professionals who practiced it used specific medical compounds, special surgery, and wrapping and stitching techniques with great skill. This coincided with the development of surgical tools and advances in the understanding of human anatomy. So skillful were the experts in mummification, the remains of Ramses II are remarkably well preserved after more than 3,000 years, as shown in Figure 1.3.

The Greek physician Hippocrates (460–370 BC) is considered to be the father of Western medicine. He helped establish a scientific approach to medicine, which included a careful study of the manifestations of disease, the influence of diet and environment, and the use of clinical histories. It was doctors, Hippocrates maintained, not just the gods, who could understand and treat health issues and provide a prognosis for medical conditions. He performed early work on draining chest cavities as well as on treating hemorrhoids. An important early medical book, the Hippocratic Corpus, is associated with him (although it is believed to have multiple authors), and here is found the Hippocratic oath, a ritual that medical and other healthcare students routinely take upon graduation. It commits the graduate to a lifetime of ethical practice. One aspect, with important ramifications today, is a commitment to do whatever possible to improve patient health. Among the modern variations is the promise to “apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.” This can be interpreted as providing care when it is helpful but refraining when it is not. Nowhere in the oath, however, is the concept of economic efficiency stated, in which overtreatment is defined as excessive cost relative to benefit. From a modern perspective, this absence appears as a gaping hole in the ethical identification of how much care is too much. It is where healthcare providers and health economists commonly part company. In a world where healthcare institutions are becoming more market like, it is particularly problematic for those who are not prepared to use cost and economic criteria because markets do.

Even though the modern world owes much to early Greek medicine, the ancients had certain misconceptions that have had serious consequences. For example, the ancient Greeks and Romans believed in humorism, which entails belief in the importance of balance between bodily fluids: blood, phlegm, black bile, and yellow bile. These in turn were associated with air, water, earth, and fire, respectively. Treatments using the theory of humors might have recommended exercise and diet, quite benign measures, but others such as bloodletting, emesis, or use of enemas could be counterproductive. The theory of humorism in Western medicine continued through the 18th century and into the 19th century. George Washington’s death, in 1799, is sometimes attributed to misplaced humorism. To treat a bad sore throat, the ex-President’s chief aide called for his doctors, who were skilled at bloodletting. Washington died after they drained 40% of his blood.

Another great physician from the world of ancient Greece and Rome was Galen of Pergamon, who lived from 129 to around 210 AD. Galen advanced the understanding of human anatomy by means of dissections of monkeys and pigs—human dissection was generally frowned upon as the human body was considered inviolate. Such prohibitions persisted in Europe until the later Middle Ages. In Hellenic Alexandria, however, important advances in knowledge of human anatomy occurred, which provided physicians a better grasp of the nervous system, the eye, and the heart (with its component chambers and valves).

Galen also put forward a theory of blood circulation. But extrapolating from the dissection of animals to human structures and processes had its limits, and as a result, his theory contained errors. Blood circulation in humans was not really understood until the 13th century with the scheme of pulmonary circulation advanced by Ibn al-Nafis of Damascus. Galen also served as a physician to gladiators in Pergamon and acquired a reputation for great competence as only five gladiators died under his four years of service. He later served as a physician to Roman emperors Marcus Aurelias, Commodus, and Septimius Severus.

Some symbols of Hellenic medicine persist in the present day, such as the snake of Asclepius. The Greek god of medicine, Asclepius was the son of Apollo; his daughters included Hygeia, the goddess of cleanliness, and Panacea, the goddess of universal remedy. His snake-entwined staff, known as the Rod of Asclepius, is included in the World Health Organization logo, as shown in Figure 1.4.