Ophthalmology of the Pharaohs: Antimicrobial Kohl Eyeliner in Ancient Egypt

The bold eye makeup in the ‘60s, best exemplified by Sophia Loren’s winged ‘cat eye’ liner and Twiggy’s spidery eyelashes, had nothing on the ancient Egyptians and their gods. Their eyelids were heavily smeared with black kohl eyeliner, thick lines rimming the eyes, and the fashion was sported by everyone from peasants to pharaohs to effigies of the worshiped gods Horus and Ra. Though it may seem nothing more than a cosmetic fancy nowadays, kohl was considered to have potent magical powers and it has since turned out to possess unique pharmaceutical and antimicrobial properties. In fact, this deceptively simple beauty product may actually be one of the most ancient ophthalmological preparations known to man.

A piece of limestone pottery shows a woman nursing her child while a servant holds up a mirror and a crayon of khol. Dated from the 19th to 20th dynasty, 1285-1069 BCE, this shard is held at the Louvre, Departement des Antiquites Egyptiennes, Paris, France. Click for source.

Kohl served multiple roles in Egyptian antiquity. Egyptians of all social classes applied the eyeliner daily in veneration of the deities, satisfying both religious obligations and beautifying desires. Wearing the glossiest, highest quality kohl denoted one’s upper class status in society while the less wealthy adulterated their kohl with fire soot. Before the advent of Ray-Bans, it was applied liberally around the eyes to reduce the sun’s glare, to repel flies and to provide cooling relief from the heat. It also trapped errant dust and dirt, a simple remedy to curb the desert’s regular assaults on the body. Besides lining the eyes, the substance was also used to outline the eyebrows and enhance facial tattoos. In death, pouches containing the cosmetic and applicators were buried alongside the deceased, a testament to its importance not just in day-to-day living but also in the afterlife (1).

Kohl’s vast presence throughout history and across the globe testifies to its cultural, social, and hygienic purchase and evidence for its usage has been unearthed at the sites of ancient civilizations across North Africa, Central Asia, the Mediterranean and East Asia (2). It’s an incredibly old product, having been present since the Bronze Age (3500-1100 BC) and it’s usage has even been alluded to in the Old Testament, with two allusions at Kings II 9:30 and Ezekiel 23:40 to “painted eyes”.

An ancient Egyptian alabaster kohl pot dated from 1550 BC to 1070 BC. The opening was large enough to allow for a finger, feather or small stick to be dipped into the pot and then applied to the face. Image: Unknown. Click for source.

As with any product with a wide geographic distribution, it has picked up multiple labels. Arabs and modern Egyptians refer to it as “kohl”, while the Romans and Greeks named the product “kollurion”. The Iranians and those in the Indo-Pakistan region to this day call our eye-lining friend ‘surma” (2).

Kohl is predominantly composed of the mineral galena, a dark, metallic lead-based product that is also known by the chemical name lead sulfide (PbS). The mineral would be crushed and mixed  with several other ingredients such as ground pearls, rubies and emeralds, silver and gold leaves, frankincense, coral, and medicinal herbs such as saffron, fennel, and neem (1)(2). These compounds were then diluted in liquids such as oil, gum, animal fats, milk, or water to solubilize the lead and assist in its eventual facial smearing. Today we use galena for less prestigious and artistic purposes, in rechargeable batteries and as lead shot to fill shotgun shells.

A sample of the mineral galena, an ancient Egyptian source of lead sulphates. Image: Creative Commons. Click for source.

In 2010, French researchers analyzed samples from 52 kohl containers residing at the Louvre museum in Paris and found that the cosmetic contained trace amounts of four uncommon lead species: galena (PbS), cerussite (PbCO3), phosgenite (Pb2Cl2CO3), and laurionite (Pb(OH)Cl) (3). These last two compounds, the lead chlorides, are not naturally found in Egypt, which points to the possibility of deliberate manufacturing using lead oxide (PbO), rock salt (NaCl), natron (Na2Co3 and NaHCo3), and water. The authors of the study reckon that “it is clear that such intentional production remains the first known example of a large scale chemical process.” (4)

When researchers exposed skin cells to the lead sulfates found in kohl, they discovered that the lead ions elicited a profound immunological response. The cultured cells released one of the most important messaging molecules in the immune system, nitric oxide gas (NO); this gaseous molecule serves an activating messenger to bacteria-eating macrophage cells and stimulates blood flow by increasing the diameter of capillaries, encouraging rapid immune cell movement within the bloodstream (3). A 240-fold increase in NO production was sparked by the presence of lead ions, a bona fide tsunami of molecules flooding surrounding cells to respond to invading bacteria. This intense biochemical interaction suggests that kohl was more than just a beautifying cosmetic and the forefather of sunglasses, but also an important antibacterial ointment.

Why does it matter that the Egyptians were smearing black antibacterial gunk around their eyes? Aside from dastardly sandy winds introducing grit and irritating the sensitive eye region, infections of the eye were a serious and widespread concern (5). The desert conditions and annual flooding of the river Nile primed the eye for inflammations and bacterial infections. Antibacterial eyeliner seeping into the conjunctiva of the eye would activate an immune response, killing off pathogenic bacteria and preventing infections before they even started. The cosmetic’s regular usage could have cut down on the prevalence of ocular scarring, cataracts and blindness, nothing for an Egyptian living in antiquity to scoff at.

The Ebers Papyrus, a sort of medical textbook in ancient Egypt. It is considered to be one of the most complete and most exquisite of the medical papyri to be found. Click for source.

Perhaps it’s not all that strange that kohl has been found to have medicinal properties: the chemists and pharmacists in Egypt were considered quite knowledgeable by their Greek and Roman counterparts and their mastery of anatomy, diseases and pharmaceuticals were widely respected throughout the Mediterranean (3). We’re fortunate enough to actually have concrete evidence of this, in the form of several medical papyri scavenged by scrappy archaeologists in the late 1800s and early 1900s.

One of these is the Ebers papyrus dating from 1550 BC, the oldest known medical texts in existence (in existence, ladies and gentlemen!), and the hieroglyphic manuscript describes a plethora of ophthalmological multisyllabic quandaries including “blepharitis, chalazion, ectropion, entropion, trichiasis, granulations, chemosis, pinguecula, pterygium, leucoma, staphyloma, iritis, cataract, hyphaema, inflammation, ophthalmoplegia and dacryocystitis” (6). It contains detailed herbal preparations for eye drops, salves, ointments and even plaster dressings for the eyelids. Some of it seems to be clearly nonsense – beetle honey, anyone? – and in some unfortunate cases the papyrus recommends prayers and magical incantations to cure an ailment, another way of saying “You’re S.O.L., pal. Speak to my falcon-god-friend Horus here.” Aside from attendant ocular dilemmas, there are also remedies for gynecological, intestinal and dermatological issues and more.

A painted wood mask of an Egyptian face with kohl-lined eyes. Dated from 2000 BC, this object is located at the Swansea Museum, Swansea UK. Click for source.

The very existence of these papyri suggests a dedicated core of physicians and pharmacists collating their experiences, observations and empirical testing to create one of mankind’s first monstrously large medical textbook. Really, we contemporary humans are so damn lucky to have captured this surviving piece of ancient medical history, thanks to several original Indiana Jones-types from a century ago.

Kohl is still used today in North Africa and Central Asia, despite its considerable toxicity. I know what you’re thinking, “Now, a warning?” Heavy metals such as lead, mercury and arsenic often contaminate today’s product leading to cases of ‘saturnism’ or lead poisoning. This is particularly a serious issue with young children sporting the cosmetic as protection against the evil eye, as they are more likely to engage in hand-to-mouth behavior while learning about their environment (See here).

Even today, women mimic the application of kohl to enhance and brighten eyes but, sadly, there aren’t any therapeutic side-effects to expertly drawn winged cat-eyes. This idea of “cosmetics as medicine” that is vigorously pursued by the beauty industry in the form of “plumping” lipsticks, skin foundations embedded with minerals to combat acne, anti-aging creams and so much more was originally the province of Egyptian chemists. Maybe the secret to Cleopatra’s beauty wasn’t Maybelline but lead sulfate.

Note: The title of this article is derived from this short letter in the British Medical Journal: The Ophthalmology Of The Pharaohs. (1909) Brit Med J (2): 2543: 902. View it here on JSTOR.

Resources

Nothing’s safe from the FDA: Kohl, Kajal, Al-Kahal, or Surma: By Any Name, a Source of Lead Poisoning.

A group at Bard College completed an “interlinear transliteration” and English translation of parts of the Ebers Papyrus that they believe covered what we now know as diabetes mellitus. Neat, huh? Go here to check out their incredible work.

For a short but captivating read on kohl’s usages among women in North Africa in the early 1900s, download this pdf from Harquus, a website devoted to traditional women’s tattoos and facial markings.

References
(1) Cartwright-Jones C (2005) Introduction to Harquus: Part 2: Kohl as traditional women’s adornment in North Africa and the Middle East. Ohio: TapDancing Lizard Publications
(2) Mahmood ZA (2009) Kohl (Surma): Retrospect and Prospect. Pak. J. Pharm. Sci. 22(1): 107-122
(3) Tapsoba I et al (2010) Finding Out Egyptian Gods’ Secret Using Analytical Chemistry: Biomedical Properties of Egyptian Black Makeup Revealed by Amperometry at Single Cells. Anal. Chem. 82(2): 457–460
(4) American Chemical Society (2010, January 11). Ancient Egyptian cosmetics: ‘Magical’ makeup may have been medicine for eye disease. ScienceDaily. Retrieved April 18, 2012, from here.
(5) Finlaysonthe J (1893) Ancient Egyptian Medicine. Brit Med J. 1(1689): 1014-1016
(6) CN Chua. (Date unknown) A Historical Tour To Ophthalmology: The Ancient East. MRCOPTH. Accessed April 18, 2012, from here.

Tapsoba I, Arbault S, Walter P, & Amatore C (2010). Finding out egyptian gods’ secret using analytical chemistry: biomedical properties of egyptian black makeup revealed by amperometry at single cells. Analytical chemistry, 82 (2), 457-60 PMID: 20030333

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Buzz Kill: Blood-Borne Disease Transmission at the Hajj

With Hanukkah and Christmas just recently past and Chinese New Year fast approaching, it seems a suitable time to consider the topic of religious celebrations and infectious diseases, no? ‘Tis the spirit and all! I’ll be looking at one of most intriguing religious events in the world, the Islamic pilgrimage to Mecca known as the Hajj, and the special epidemiological event that accompanies it.

The Hajj is a powerfully sacred and social event for Muslims. The importance of the pilgrimage to the Saudi Arabian desert city and the communal celebration of the prophet Muhammed cannot be understated – it’s a profoundly holy journey and religious duty that every Muslim is urged to complete at least once in their lifetime. It is also unique from an epidemiological standpoint: two to three million people from 70 countries meeting in one tiny place is the siren call for respiratory, water-borne and blood-borne microbial diseases.

A Muslim praying at the Hajj with a backdop of thousands of pilgrims. Image: Hassan Ammar. Click for source.

So what does the Hajj consist of exactly? Depending on the lunar calendar, the Hajj may occur any time of the year; last year, the week-long event fell between November 4th to the 9th. The pilgrimage involves a series of performative rites that must be completed in the city of Mecca and its environs; these rites serve as a reenactment of the key historical events underpinning the birth of Islam. On the first day of the Hajj, pilgrims will walk counter-clockwise seven times around a rectangular building named the Kaaba located at the very center of Mecca. The Kaaba serves as an orientation point for Muslim prayer rituals and is considered the physical and spiritual nucleus of the Islamic religion. Pilgrims, also known as Hajjees will then run back and forth between the hills of Al-Safa and Al-Marwah a total of seven times and will end their day by drinking water from the holy Zamzam well.

A map showing the Hajj route and procession taken by pilgrims. Image: Creative Commons.

The second day is spent in vigil, praying to Allah and reciting the Quran at the granite hill of Mount Arafat, located just southeast of Mecca. The following day, pilgrims will gather in the thousands to perform a ritual enactment of the Stoning of the Devil by throwing pebbles at the three pillars of Jamarat in the small town of Mina. They then leave this area to shave their heads, perform a ritual animal sacrifice and go on to celebrate the religious holiday of Eid al-Adha. Their spiritual marathon is finally complete.

During this pilgrimage, Hajjees live in a spiritual state of purity called Ihram. Prior to entering this condition, pilgrims will ritually cleanse themselves, trim their nails and remove any unwanted body hair. From then on, men are dressed simply in two sheets of unstitched white cotton and a pair of plain sandals. Women wear the hijab, with their face and hands exposed. In this sanctified state, Hajjees are forbidden from shaving, trimming their nails, wearing scented toiletries, arguing or swearing along with a few other unbecoming behaviors.

The experience can be difficult for the heat-susceptible, agoraphobic, the frail or very young; Mecca during the Hajj is often stifling hot, humid and beyond overcrowded. Performing the rites  with millions of other people over a wide geographical area can be physically strenuous and quite exhausting. There have been several recorded cases of fatal stampedes and crowd crushes during the jam-packed Stoning of the Devil, sunstroke and heat exhaustion are not uncommon, cholera outbreaks have historically plagued pilgrims, and pneumonia, meningitis and food poisoning have repeatedly occurred. Really, it goes without saying that if millions of international travelers converge in one city for a physically active, overcrowded affair, one should consider oneself lucky not to catch a respiratory or diarrheal bug.

You certainly wouldn’t expect to come down with a blood-borne transmitted virus and nasty chronic disease.

Regrettably, that scenario may not be that unlikely for male pilgrims on the verge of exiting Ihram; contracting HIV or any of the unsavory gang of hepatitis viruses such as hepatitis B, C or D (HBV, HCV or HDV) is quite possible due to the unseemly practice of communal shaving.

A pilgrim bleeding while being shaved at the end of Ihram. Note the bare hands. Image: Unknown. Click for source.

Following the Stoning of the Devil and the completion of their religious rites, Hajjees migrate to Mina where hundreds of barbers await with razor blades to shave the scalps of male pilgrims and where women will trim a finger-length lock of hair. This last ritual seals the deal, so to speak, allowing pilgrims to compete their observance of the Hajj. Saudi officials require all barbers to be licensed though makeshift barbers still abound, waiting on roads for eager pilgrims with razors in hand (1). Pilgrims may also buddy up to shave each other’s scalps. These unlicensed barbers and pilgrims can often be found reusing unsterilized blades to communally head-shave Hajjees, a fabulous technique for transmitting blood-borne diseases (BBDs).

Indeed, physicians associated with the Saudi Arabian Field Epidemiology Training Program describe the practice of communal head-shaving at the Hajj as an ‘optimum focal setting for the spread of serious BBDs’ (2). There’s a considerable amount of hair-raising unhygienic behaviors going on – not only are unsterilized razors reused on multiple individuals, barbers often do not wear gloves, incur many abrasions on their hands and dispose of the razors improperly.

Only a few studies have looked at the demographics and practices of these barbers but they have yielded some insightful data. A study in 1999 examined 158 barbers recruited from makeshift shaving sites near Jamarat. Eight nationalities were represented but the majority stemmed from three impoverished countries – 72 from Myanmar, 27 from Egypt and 22 from Bangladesh. Most interestingly, two-thirds of the barbers worked seasonally. They were not licensed professionals, but rather opportunistic seasonal workers that had worked at the Hajj for a median of two to five years (2).

The barbers reported each shave as lasting roughly two to ten minutes (3); these rapid-fire, assembly line-like operations can increase the likelihood of accidental nicks and grazes. Twenty-one percent of barbers report using a blade more than once (3). When razors are finally disposed of 83% will discard them on a ground densely covered in shorn hair instead of in the rubbish bins provided by Saudi authorities (3). This is of crucial consequence considering the numbers of pilgrims who are barefoot or wearing sandals. The head-shaving event also occurs in a very short time-frame overall, within a few hours in a circumscribed geographical area, compounding the likelihood of a BBD swap meet.

The eye-opening video below shows some of these seasonal barbers at work.

Around 90% of male pilgrims will have their scalps closely shaved (4). And pilgrims do indeed get nicks and abrasions: two separate studies found roughly 60% of Hajjees incurred scalp cuts (5)(6). There aren’t any studies examining the incidence or rate of BBD transmission among pilgrims during the Hajj so we’re unable to know how frightful of a problem this is. But consider this: many pilgrims come from regions of the world with high endemicity of BBDs such as Pakistan, Nigeria, Egypt and Turkey (2)(3)(5). And there are barbers working at the Hajj who have tested positive for BBDs – a study conducted in 1999 found that 10% tested positive for HCV and there was a positive correlation between barbers infected with HCV and the length of time they had worked at the Hajj (5). Though the epidemiological data is thin on what could actually is going on here, we can still state with some certainty that razor recycling shouldn’t be going on.

Hepatitis viruses are patient predators. They’ll stake out on bloody scalpels, syringes and surfaces for four days (HCV) or up to a week (HBV) until an open wound allows them to slink into a new body (7). It is for this very reason that Hepatitis B was one of the most commonly acquired infections in hospitals among medical personnel before the advent of the hepatitis A/B vaccine. When razor are used frantically and repeatedly to shave pilgrim’s heads, accidents will naturally happen. Skin catches on the blade. A microscopic cut, a slight nick and a drop of blood beads. Maybe in the hubbub, in the physical and spiritual heat of the moment, a barber grazes his bare hands and fingers on that pilgrim’s blood droplet. Or accidentally smears his own fresh blood, precipitated by a slip of the blade on an earlier scalp. The blood blends, indistinguishable from the other. Was that barber or pilgrim infected; did a virus slip between the two? In any case, another eager, awaiting Hajjee sits down for a shave and the razor is used again. This happens over and over and over, until the razor blade is finally deemed blunt and useless.

A public health poster in a Saudi Arabaian hospital warning pilgrims of the dangers posed by shaving during the Hajj. Image: Uknonwn. Click for source.

It’s a perverse tragedy that pilgrims exiting a state of profound spiritual and physical holiness may find their very blood contaminated by a barber with unhygienic practices. Pilgrims can become infected with a fatal illness that is clinically asymptomatic in its early stages only to fly back home to their communities oblivious of their condition. Catching the flu or pneumonia at the Hajj is one thing but bringing home a deadly viral illness is quite another.

Clearly the provision of safe razor blades, screening and supervision of barbers and widespread education on this matter are desperately needed. In a study from 1998, 74% of Hajjees and 20% of barbers were unaware that diseases could be transmitted by used razor blades (3). Many pilgrims expressed more concern about the spread of visible skin diseases than anything else. The invisible nature of BBDs only helps to further conceal the potential for a BBD micro-epidemic at the Hajj.

Consideration of the provision of housing, sanitation and overall public health of these religious visitors is of enormous importance for Saudi Arabian officials planning for the Hajj, and they do a phenomenal super-human job of keeping millions of people safe and cared for by providing free health care, organizing the festivities and what not. Seven hospitals have been established to provide free medical services and can supply over 2000 beds for those requiring hospitalization (6). The Ministry of Health establishes infection control policies using current knowledge of ongoing global outbreaks, infectious disease epidemiology and established preventative medicine techniques (1)(5). By all accounts, they did a great job during the H1N1 flu pandemic in 2009 by requiring pilgrims to have flu shots, restricting visas for pilgrims from affected countries, setting up thermal sensors at airports to detect the feverish and deploying thousands of physicians throughout the pilgrim circuit (9). They also require all entering pilgrims to display certificates of vaccination for hepatitis A/B, meningococcal meningitis and yellow fever.

A pilgrim recieving a shave in a sanctioned barbershop during the Hajj. Image: Unknown. Click for sourece.

But keeping an eye on rogue unlicensed barbers can be difficult for officials considering the high crowd density and activity. Whatever may be the case, the seriousness of the matter can’t be ignored. A vigorous public health campaign as well as a serious crackdown on these barbers is needed in order to halt this hairy business. It’s been noted before that an epidemic of the flu, meningitis or cholera could easily bloom into a pandemic at the Hajj. Even so, the prospect of a multinational epidemic of BBDs spread by irresponsible hygiene practices is appalling. A hair-raising thought, indeed.

Recommended Reads

The hepatitis family, particularly the members B, C and D, is some real nasty shit. I didn’t go into any detail about their molecular biology but if you’re interested, please go here.

Go here to see the vaccinations required by the Saudi Ministry of Health for all visiting pilgrims.

For a list of every single conceivable disease you could catch during the pilgrimage, check out this baby.

An extremely helpful guide to how to handle oneself at the Hajj.

References

(1) ZA Memish. (2002) Infection control in Saudi Arabia: Meeting the challenge. Am J Infect Control. 30(1): 57-65
(2) The  Saudi Arabian Field Epidemiology Training Program (2000) Blood-Borne Diseases Among Barbers During Hajj, 1419 H (1999). Saudi Epidemiology Bulletin: 7(1). Accessed online on Dec 10, 2011. Link.
(3) Saudi Arabian Field Epidemiology Training Program (1998) Head-shaving practices of barbers and pilgrims to Makkah, 1998 Saudi Epidemiology Bulletin. 5(3): 18-19
(4) SM Rafiq, H Rashid, E Haworth & R Booy. (2009) Hazards of hepatitis at the Hajj. Travel Med Infect Dis. 7(4): 239-46
(5) Rashid H & Shafi S. (2006) Blood borne hepatitis at Hajj. J of Hep Mon. 6(2): 87-88
(6) Alrabeh AM, El-Bushra HE, Al-Sayed MO, et al. (1998) Behavioral risk factors for disease during Hajj: the second survey. Saudi Epidemiol Bull. 5(3). Accessed online on Dec 10, 2011. Link.
(7) CDC; Division of Viral Hepatitis. (2009) Hepatitis B FAQs for the Public. Accessed online on January 4, 2012. Link.
(8) Omar Sacirbey, 2009, Will flu epidemic slow the Hajj? Chron.com (Online). Accessed online on Dec 10, 2011. Link.

Memish ZA (2002). Infection control in Saudi Arabia: meeting the challenge. American journal of infection control, 30 (1), 57-65 PMID: 11852419