The history of medicine records a complex evolution of ideas regarding health, disease and its possible causes and remedies. In our Western culture, there seems to be an artificial time-line describing this evolution from Mesopotamia, through Egypt, Greece, and Rome, passing through the alchemy and witchcraft of the Middle Ages to the introduction of the scientific method during the Renaissance and, finally, through the accelerated 17th-century developments up to our own time.

Unfortunately, we tend to disregard advancements in other cultures because we feel they had little bearing in our current conception of Medicine. However, other civilizations indeed developed their particular and different ideologies; thus their own Medicine. However, we ignore them and classify them as magic or superstition because they do not follow our beliefs; yet, these ideologies are relevant today.

As the world becomes globalized, we “westerners” are encountering these ideas, which may be very different from our conceptions, but no less valid, important and useful in understanding other peoples and cultures. For instance, the Oriental tradition has brought us in contact with acupuncture, therapeutic massage, and herbology; concepts not associated with our current concepts of medicine but extensively used in our time.

In our continent, we know very little of the Medicine practiced in pre-Hispanic (pre-Columbian) America but the offspring resulted from the fusion between indigenous and European medicine is still present every day in much of the Spanish-speaking countries.

Pre-Hispanic medicine and ophthalmology

Two main areas in America were the backdrops for the development of civilizations and cultures advanced enough to develop a philosophy and systematic knowledge known as medicine: the coastal area of northern Peru and Mesoamerica.

Mesoamerica is an area roughly comprising from the Tropic of Cancer in northern Mexico to present-day Nicaragua. It was the setting for the development of several of the most complex civilizations that appeared in this continent and the world during 3,000 years, starting with the Olmec culture around 1,200 BCE on the coast of the Gulf of Mexico and ending with the Spanish conquest of the Aztec Empire in 1522.

Most of the great civilizations that inhabited Mesoamerica reached their zenith around the year 200 BCE. Great cities were built; enormous efforts were made in advancing and documenting their exploits, science, and culture. Although these societies were literate, we have very little first-hand information about their conception of the world, their place in it, their philosophy and their medicine. By the time of the Spanish conquest, most of the Mesoamerican civilizations were in rapid decline or had all but disappeared. The Mexica (or Aztec) was the dominant culture at the time of Cortes’ arrival. They spoke the Nahuatl language and had inherited most of their culture and medical traditions from earlier inhabitants of the Valley of Mexico, including the Teotihuacan and Toltec cultures.¹

Most of the accounts regarding native customs and traditions were written by either Spaniards educated in Europe or by American Indians educated in the recently established Spanish schools: people trained with a late medieval-early renaissance mindset, and heavily embedded with catholic and Aristotelian ideas. Their observations and accounts were filtered through this mentality, written through “European” eyes for European ears, so they might not be entirely unbiased.

One of the most valuable documents we have is an account written by Bernardino de Sahagún, a Franciscan friar who is considered the father of American ethnology. He arrived in America as an evangelizer in 1529 and dedicated his life to the research and documentation of the native religion, culture, and language in his posthumously published General History of Things of the New Spain.^2,3

Other sources of information are provided by codices, documents painted on tree bark or animal skins describing stories, mythology or illustrating different events through time. Some of them were made during the early colonial period to document the lifestyle of the indigenous population. Regrettably, overzealous catholic priests, considering them an “instrument of the devil” destroyed most of them.

The codex “de la Cruz-Badiano” —or known by its Latin name Libellus de Medicinalibus Indorum Herbis— is of particular medical interest because it is a pharmacopeia of medicinal herbology compiled in 1552 in the tradition of European pharmacopeias of the time (Figure 1).⁴

Written in Nahuatl by Martin de la Cruz, a converted American Indian “physician”, who worked at Santa Cruz de Tlatelolco convent, where Fray Bernardino de Sahagún was a teacher. The codex was translated into Latin by Juan Badiano.⁴

Another important document was written by Francisco Hernández, a Spanish physician sent by King Philip II of Spain, in 1572, to document and discover the natural richness of his newly conquered territory.⁵ His Historia Natural de Nueva España (The Natural History of New Spain) illustrates close to 2,000 plants, many of them of medicinal use. He conducted many interviews of “medicine men” recording the customs and uses of many of these plants. Sadly, the text remained as an unpublished manuscript until the late th18th century. Although profusely illustrated, most of the drawings were lost in the fire.

Fray Toribio de Benavente “Motolinia” was one of the first evangelizers to arrive in the newly conquered territories. He documented his life-long observations in a text called Historia de los Indios de la Nueva España (History of the Indians of New Spain) part of a major work he never got to finish. In it, he describes many of the customs observed by the native population. All these texts attempt to describe aspects of the indigenous peoples' lives but fail to delve into the complex philosophical structure supporting these beliefs and traditions.⁶

Mesoamerican cultures developed intricate religious beliefs, philosophy, literature, astronomy, mathematics, and medicine. In their “Cosmovision” three parts form the universe: sky, earth, and the underworld. The world is divided into opposite, complementary pairs: hot and cold, earth and sky, male-female. Man is a reflection of this universe, an entity that participates in its order, and opposes it. Man creates and consumes energy, feeds the gods with his blood and heart. Thus, man and gods have an intimate relationship. Each one depends on the other for his life and sustenance. Man, at birth, was assigned three “souls” or anemic entities nestled in the head, heart, and liver. These “souls” were related to the three parts of the universe and determined occupation, health, and fortune. Their qualities depended on his date and time of birth.^1,5,7,8

Medicine and religion were indivisible. The disease was thought to represent a break in the equilibrium of the individual’s three anemic entities either due to the introduction of some supernatural being or object or because of the decline of one of them.^3,5 Different gods were related to specific diseases. The Mexica pantheon was not scarce. The goddess in charge of health and medicine was Tzapotlatenan who had several lesser gods under her command. Specific gods were responsible for certain types of diseases; for example, several kinds of “rheumatism” and muscular spasms were blamed on Ehecatl, lord of the wind. Of particular interest to us is the god Xipe-Totec (the dark-skinned one) who was responsible for diseases of the skin and eyes.^5,9

The religious calendar also played an important role in pre-Hispanic cultures. The day and time of birth could determine physical and mental characteristics as well as occupational orientation, health and life expectancy. There were 20 days in the religious calendar “month”, each with its associated sign, (similar to our zodiac) and deity. These signs were associated with certain body parts based on certain similarities (Figure 2).

For instance, the calendar sign for movement (ollin) was associated with the tongue; the right foot with the sign for deer and the eyes and tears to the day-sign of rain (quiahuitl) and the sun god (Tonatiuh).^3,7 It is curious to note that Patecatl, god patron of healers, ruled one of the days. His day-sign was “grass”, a symbol of the intertwining of the three “souls” whose imbalance was considered the origin of the disease. Therefore, the religious and calendar systems were very complex and highly interdependent.

Diseases were also classified according to “humors”. It is not clear if this was a European (Hippocratic/Aristotelian) interpretation of an indigenous classification or there are overlaps in this line of thought. Illness could be hot or cold, wet or dry, which had a direct bearing on the therapeutic considerations, as we will explain later. Maintaining health was a matter of moderation, equilibrium, and fulfillment of one's obligations with the body, community, and deities.^5,8

In Mesoamerican cultures, pathophysiology had mostly a divine origin. There were “good” and “bad” diseases; diseases of divine, human or natural origin. “Good diseases” were caused by particular gods. If the person died from one of them, he accompanied the god in his daily celestial voyages. These were probably seen as an honorable way to die since the deceased became a servant to the god. Men caused “bad” diseases: witches, sorcerers, spirits or the “evil eye”.³

Physicians or ticitl were well-known and had a well-specified occupation. Both men and women could practice medicine. Education was, for the most part, transmitted from father to offspring and included knowledge regarding diagnosis as we understand it today but also divination, astrology, astronomy, and religion to better understand not only the nature of the disease but what circumstances or entities were responsible for its appearance.⁵

Therapeutics included the practical knowledge of bone-setting and suturing as well as herbology, mineralogy and zoology, incantations, metaphysical transformations and ways of contacting the gods. It is recorded that on asking what makes a good physician, Sahagún was told that: “A healer has to have the expertise, know the secrets of medicines, heal the sick, know the medicinal plants, know how to set broken bones, bleed, purge, cut and suture […], take care of ulcers and gout, heal the sickness of the eyes and cut the growths that come out of them”.^3,5

Physicians were very observant. Several descriptions of diseases are accurate enough for us to have a clear idea of what they were referring to. Many examples of clay figurines depicting different diseases have been found. There is an ongoing debate among archeologists whether these were used as “snapshots” documenting what people looked like or were used for ritualistic purposes, the physical anomaly being associated with a particular deity. Nonetheless, the existing illustrations give us a glimpse of their observational capacities (Figure 3).

One of the more widely spread figurines illustrates the ritual of head deformation and strabismus. Fray Motolinia described methods used by the Mayas to produce head deformation and strabismus in the infant by pressing the cranium between two wooden tablets and placing a pebble in front of their eyes to force convergence.⁶

There is ample evidence that head deformation worked and was widely practiced all over Mesoamerica, across social, economic and cultural strata (Figure 4).

No evidence exists for the strabismus. It is believed that children born with strabismus were considered special, with a direct line to deities, especially Tlaloc (the rain god), thus able to better communicate with them. Like this pathology, some diseases were considered as especially associated with certain deities. These were tended by special physician-priests dedicated to these gods who had their secret methods of healing taught at the priest schools.

Physicians were fairly knowledgeable in anatomy, probably due to the availability of human and animal material from sacrifices. This is shown in the nomenclature for various body parts. The naming of the parts of the eye and adnexa was somewhat elaborate (Table 1).⁸ Diagnoses were fairly accurate for the time but they also come to us filtered through European thought.

They had names for entities such as pterygium, cataract, chalazion, leucomas, and conjunctivitis (Table 2), but naming the disease was not enough for a diagnosis.

The type of humor imbalance producing it and the responsible deity or sorcerer behind it had to be uncovered. The physician had to consider the calendar for dates of birth, dates the disease appeared and under what circumstances. He might even take a “trip” to “other worlds” with the help of hallucinogens to discover the identity of the culprit. Only then could a suitable remedy be given consisting of the proper incantations, spells, exorcisms, and offerings accompanied by topical herbal infusion, plasters and ritual baths.

A few of the medical incantations have survived thanks to the work of Hernando Ruiz de Alarcón, a zealous priest who compiled them so they could be identified as medical procedures thought to be ”inspired by demons” and combat them. Here are a few regarding eye diseases¹⁰:

Spells to rid the eyes of pain, redness or disease*

I

Dare come

One Serpent, Two Serpent

Three Serpent, Four Serpent.

What do you do to the magic mirror,

The magic eye?

Put yourself somewhere.

Move yourself someplace.

If you do not obey me

I will call the one with the jade skirt

The one with the jade shirt

Because she will scare you away

She will spill you,

Spill you quickly on the prairie.

II

I am the priest

I am the master of transformations.

I brought you, venerable one with the hair of mother-of-pearl.

Search for the green pain,

Search for it, venerable hair of mother-of-pearl.

What god, what potentate

Wishes to harm now our magic mirror?

Dare come, priest from the land of medicine,

Green from the land of medicine.

Dare come, the one knocked against the rocks in seven places.

Dare come, priest from the land of medicine.

What god, what potentate

Wishes to harm now our magic mirror?

III

Dare come, nebulous herb.

Dare come and pick the dust from the earth;

Dare come clean what is damaged,

Our magic mirror.

Dare come,

Uncles of ours, the priests,

The ones from five destinies, from a single courtyard.

Dare accompany the nebulous herb,

Dare come white woman

Dare come and clean our magic mirror

*These spells are translated by the author from texts mentioned and translated into Spanish in the book by Lopez-Austin and compiled by Hernando Ruiz de Alarcón in 1629 in his book Tratado de las Supersticiones y Costumbres Gentilicias que oy viuen entre los Indios Naturales desta Nueva España.¹⁰

For infusions and plasters, the Mexica pharmacopeia was very rich. It included the use of different parts of plants, animal and mineral components (Figure 5).

Many of them were chosen by what was considered their physical characteristics: hot or cold, wet or dry, to counter opposite sickness.¹¹

Herbs from all over the region could be found in the large markets but availability was severely limited in smaller villages with access only to local remedies; thus, the wide variety of treatments developed. Most of them have been difficult to match their modern names but some have been identified and proven to have real therapeutic effects by modern pharmacologic techniques.^12-14 Several have endured as folk remedies and still used in modern Mexico.

Pain was a given in the life of the native population. Psychotropic plants were used for sedation during some procedures and even in case of human sacrifices. Peyote and toloache^5,6,13 were wildly used as an analgesic and hallucinogenic as well as certain mushrooms.

The Mexica people, being a war-prone culture, was well versed in surgical procedures. There is evidence of the setting of broken or dislocated bones with immobilization. Cranial trephinations were probably performed for ritualistic reasons but burial findings show evidence of bone healing confirming the survival of the “patient”. Regarding the eyes, pterygia were removed using a cactus thorn to pull the growth off the cornea and excised with a sharp obsidian knife. The wound was then treated with “woman’s milk” and infusions of chichicaquiolitl and iztaquiltic to control inflammation.¹² This was considered necessary for proper healing (unfortunately many of these plants are not identifiable today).

Leucomas were also treated by scraping the corneal opacity with a sharp shell or obsidian knife and applying topical infusions. There is no evidence for the surgical management of cataracts. Lid, lip, and face skin wounds were sutured using human hair and thin cactus thorns or fish bones as needles. If an ear or nose were beyond repair, prosthetics made of clay could be fashioned to improve cosmesis.⁵