It is important to note that itch is usually not described in a straightforward manner in medical literature composed before the nineteenth century, but is usually found in the context of a localised disease with which it was associated, or sometimes in a chapter dealing specifically with dermatoses. Often one has to rely on textual searches, which makes terminology a major issue.

In classical Latin, the term pruritus refers to itching, irritation or sexual excitement and is thus nearly interchangeable with prurigo, perhaps surprisingly given the modern understanding of ‘prurigo’ as describing the specific group of papular dermatoses to which the term is applied today. The Greek term knêsmos and related words denote itch, in an irritating or pleasurable sense (tickling). Metaphorical meanings reach from irritation to titillation. From an etymological point of view, knêsmos and related words are associated with the notion of scraping or scratching (Weisshaar et al. 2009b).

At the same time, the names of clinical conditions used today have often evolved from the terms employed by ancient authors. However, translations can create a misleading picture of ancient clinical observation. For example, a typical translation of a sentence from the Corpus Hippocraticum could run as follows: ‘Leprosy, pruritus, scabies, lichen, vitiligo and alopecia arise from phlegm and are mere blemishes rather than diseases’ (Affections 35) (Hippocrates 1988). A more detailed analysis of the terms used in describing itch and related skin lesions through the centuries remains to be addressed in depth elsewhere. This applies especially to the terms pruritus and itch, which we have used synonymously (Bernhard 1994).

Cures for itch were sought from the early days of mankind and are documented in sources even more ancient than those of Greek antiquity (e.g. Papyrus Ebers, dating from approximately 1550 BC). The earliest attempt at understanding the mechanisms underlying the complaint, however, was made in Greece around the fifth century BC. Hippocrates is generally seen as the first to introduce rational science into medicine. The Corpus Hippocraticum was compiled from the fifth century BC onwards and completed around the tenth century AD. Itch is mentioned in various places in the Corpus Hippocraticum. The development of a certain skin lesion is vividly described as follows: ‘Serous fluids appeared in the skin. Having coalesced, they became warm and caused itching. Then they erupted like burn blisters caused by fire, and they seemed to smoulder underneath the skin’ (Epidemics 2.1.1). Elsewhere it is noted that a symptom only seen in the Perinthian women suffering from ‘summer fevers’ was ‘roughness of the skin, furfuraceous, similar to the bites of gnats, not very itchy at all’ (Epidemics 2.3.1). An extensive case history is documented for a certain Andreas, who ‘before the rising of the Pleiades, displayed shivering, fever, and vomiting’, until among other symptoms, ‘efflorescences appeared on his skin, itching a little, but hot as if caused by fire’ (Epidemics 7.43) (Hippocrates 1994). In the Aphorisms, a collection of concise clinical observations probably intended for teaching, Hippocrates states that ‘extensive efflorescences’ generally cause less itching (Aphorisms 6.9).

In the competitive milieu of Ancient Greek medicine, it was a crucial skill for a doctor to predict the development of a disease. In this, itch served as a prognostic criterion, as can be read in the Coan Prenotions containing an extensive sketch of bedside prognostics. Itching of the body preceded by constipation in a patient with consumption is said to bode ill (Coan Prenotions 432). Likewise, ‘in all patients, itching will be followed by black stools, and vomiting of curdled masses’ (Coan Prenotions 626) [Weisshaar et al. 2008). As the Corpus Hippocraticum is based on the concept of humoural pathology, itch was mostly explained from this point of view which also involved, besides the humours of the body, the influence of external factors such as the weather. Thus, in the Humours, it is said that ‘certain forms of leprosy (leprê) and joint pain are itchy when rain is impending’ (Humours 17).

The Alexandrians succeeded the Hippocratics in the Hellenistic period. The focus of their research shifted to investigative and experimental aspects. Aulus Cornelius Celsus, an encyclopaedist from the first century AD, observed what he calls scabies: ‘quite hard, with ruddy skin’ and causes pustules, some of which are ‘rather moist, others more dry’. They emit a serous discharge and proceed to exulcerate, causing itch. The rougher the skin, and the more intense the itch, the more difficult it is to cure. ‘Therefore, the Greeks call this form of scabies “agria”, that is, “the savage one”’. For this disease, Celsus prescribed a salve ‘composed of sublimed zinc oxide, saffron, verdigris, white pepper and a preparation made from unripe grapes’ (Celsus 5.28.16a) (Weisshaar et al. 2009b). Aretaeus of Cappadocia, a Greek physician of the first or second century AD, connected generalised itch to icterus when he discussed two types of jaundice—one ‘light and saffron-coloured’ and the other ‘greyish and dark’—saying that in both, ‘the whole body is itchy’ (Aretaeus 1958).

In the second century AD, Galen of Pergamon developed a synthesis of the medical knowledge of his time and thus became a crucial figure in medical research and practice until the Renaissance and even later times. In his work, On the Preservation of Health, Galen explained how to assess a patient’s medical history as an important part for differential diagnosis. Among other things, ‘it is essential to determine whether the patient is one of those who by nature tend to accumulate unhealthy humours. You can find this out by asking him whether he has suffered from a predisposition to scabies (psôrôdês diathesis), leprosy (leprôdês), whiteness (alphôdês) or itching (knêsmôdês), or from erysipelas, herpes, the elephant disease (elephas), the snake disease (ophiasis), the fox disease (alôpekiasis), many blisters, ulcerous efflorescences, night rash or any one at all of the symptoms that arise from, or are worsened by, an unbalanced state of the humours’ (Galen On the Preservation of Health 4.4.5) (Galen 1823).

The Byzantine period (fifth to fifteenth century AD) is marked by a tendency to compile ancient sources. Alexander of Tralles, writing in the sixth century AD, recommended a remedy for scabby and serous conditions of the head: ‘Crush rue and alum in honey and use them to anoint the shaven head. When the skin has peeled off, boiled leaves of the olive tree should be applied with honey as a poultice’ (Alexander Trallianus Therapeutics 1.6). In a fascinating testimony to the broadness with which terms like scabies (psôra) were used before systematisation in dermatology, Alexander states that ‘bladder scabies’ (psôriasis kysteôs) is present if ‘furfuraceous sediment appears in the urine fluid. This must be distinguished from that carried in the blood vessels’ which arises from excess heat in the body. ‘When the urine is of thin consistency and very acrid, conclude that the furfuraceous sediment has come from the blood vessels. But when the urine is of a thick consistency, conclude that it is bladder scabies’ (Alexander Trallianus 11.5).

In terms of leprosy (lepra) and scabies (psôra), Paul of Aegina from the seventh century AD states that ‘these diseases have in common the rough appearance together with itching and scratching of the body, which originates from a proneness to black bile’ (Paulus Aegineta 4.2.1). In comparison with leprosy (lepra), scabies (psôra) is said to be ‘more superficial, adopting various forms, and rendering furfuraceous particles. It is necessary to resort to phlebotomy, if the patient seems strong enough; if not, cleansing should nevertheless be achieved by purging with substances that expel black bile’. Later, he adds an extensive description of drugs for external application (Paulus Aegineta 4.2.3–5), listing plants, other organic ingredients, metallic components and also some ingredients less familiar for the modern reader, such as goat droppings, which were not uncommon in ancient pharmacopoeias.

Both Paul and Theophanes Nonnos report that ‘the itch that comes about in old age’ cannot be cured but can be alleviated by a number of procedures and remedies including phlebotomy, baths and salves (Paulus Aegineta 4.4.2–3; Theophanes Nonnos 237) (Paulus Aegineta 1921; Theophanes Nonnus 1794). As these chapters are devoted specifically to itch (knêsmos), they may be viewed as an early attempt to define pruritus as a disease in its own right.

After the end of the Byzantine empire, ancient medical knowledge continued to be transmitted in the Muslim world and in the Latin West. The tradition of handbooks in Arabic medicine reached its climax in the tenth and eleventh century AD. The physician, Haly Abbas, owes much to the characteristic blend of Byzantine tradition with Persian influences. Scabies and itching arise from ‘a mixture of salty phlegm with bilious blood’. If this mixture is ‘thin and fine’, it soon brings about an itch to promote healing, but if it is coarse, it will ‘cause persistent dry itching and scabies’. Especially ‘those who do not take warm baths and on whose skin soot accumulates’ suffer from itching. Also, ‘itch in old age often arises from the weakness of the skin and because salty liquids come about in their bodies’. Haly Abbas adds that ‘the characteristic of scabies are intense itch and small nodules, which are first reddened, then suppuration occurs. Scabies is found between the patients’ fingers, on their hands, elbows, and on the coccyx’ (Weisshaar et al. 2009b).

Another influential author is Avicenna whose medical knowledge is contained in Kitāb al-Qānūn fi at-Tibb. He assumes that salty water causes itch and scabies, arguing that it dehydrates the body, draining it of all vigour. First, its effect is cleansing, but later on, it leads to constipation, as it is dry by nature. It spoils the blood and produces itch and scabies. Furthermore, southern winds can promote the curing of itch, for ‘they relax the body and open the pores, stimulating the humours and expelling them’, and at the same time, however, ‘they cause paucity of spirit, festering of wounds, and recidivism. They drain the body of all vigour, promoting ulcers, gout, headaches, dizziness and itching’ (Avicenna 1562).