Houston History of Medicine
March 2, 2011
Robert Rakel, M.D.
Good afternoon, and welcome to this month’s History of Medicine lecture. It is my pleasure to
introduce Sajid Haque, who is a member of the faculty here at M.D. Anderson as an assistant
professor in the Department of Critical Care. He is really a local, because he went to Rice as an
undergraduate,then to UTMB for medical school and to UT Houston for his residency and
fellowship.
The topic today is Medicine in Ancient Mesopotamia, which essentially is the Middle East. We
know a lot about activity in the Middle East these days but not 5000 years ago. So, Sajid Haque
will enlighten us.
Sajid Haque, M.D.
Medicine in ancient Mesopotamia. Why Mesopotamia? This is such a fascinating region. One,
because of current events that are going on there, but really, because this is the first place that
mankind ever developed civilization or complex society. So this is really the place where
humankind, or us as a species, really developed to form many of the things that we consider as
defining aspects of ourselves as a species. And it is very interesting to get the idea of what that
society was like and what medical practice at that time was like.
So what are we talking about, exactly? The Greek translation of Mesopotamia is “land between
the rivers,” and that is because it is located between the Tigris and Euphrates rivers, and that is
sort of the area we are talking about. It is interesting because of that location the area allowed the
civilization to thrive but also was prone to savage flooding, so as a result it is a region where we
get the stories of the Great Flood. It all sort of stems from this area, which has since become part
of many different religions and societies.
Just looking at our timeline briefly— As I mentioned, it is the first advanced civilization in
human history. So if you look at it—and these are other civilizations that were contemporary—
we have Egypt here, which we often think of as being a very old civilization. If we look here, we
have Rome and probably the golden age of Greece somewhere around here, and you can see that
as far removed as ancient Rome and Greece is from us now, that is how far this civilization we
will be talking about was removed from them, to sort of give you some idea or put it into
perspective. So roughly the initial group that lived in that area was the Sumerians. Initially there
was the Ubaid period, which was from about 5500 to 4000 B.C., then the Uruk period which was
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4000-2600 B.C. After that, although it is not clearly linear—a lot of these groups overlapped to
some degree—but then came the Acadians, the Babylonians, the Kassites, Assyrians, and then
the Persians, and then sort of the modern age that we know now.
So when we think about this, often you think of a civilization this old—and especially the first
time man is ever getting together and doing this sort of thing—you think how civilized or how
advanced could they be? But surprisingly, for it being the first time, they really were able to do a
pretty good job. In fact, in many ways they were so advanced that many aspects of their society
were not surpassed until just the past few hundred years. So it was a very intricate, cultured
society. There were multiple city-states. There were caravan trade routes that criss-crossed
through the city streets, and the streets were laid out in straight lines intersecting at right angles,
very much like many of our well-planned cities today. Manhattan comes to mind.
The architecture—especially considering what they had was mud and reeds and not a whole lot
else—they were able to develop surprisingly sophisticated architecture. They baked the mud and
reeds into sun-dried bricks and built houses and imposing buildings called ziggurats. This is an
example of one here. This was reconstructed by Sadaam Hussein in the eighties. The façade of
the ziggurat is new, but you can see the remains up here of the neo-Babylonian structure, which
in and of itself was a reconstruction—around 600 B.C., by King Nabonidus—of the original
structure from around 2100 B.C. And although these structures resembled the pyramids of Egypt,
they are more than just tombs for the kings; they are also ceremonial centers, places of worship
and sacrifice to the Gods. They also functioned as palaces and administrative centers.
This is a picture the ziggurat in the city-state of Ur as it may have appeared in about 2000 B.C. In
Sumerian it was called Etemenniguru, which meant “the house whose foundation creates terror.”
It was a pretty imposing structure, about 210 feet long, 150 feet wide, and over 100 feet high. It
was a shrine to the Moon God Nana, who was the patron deity of Ur. Most of the city-states had
a patron deity for each city. In fact, when we hear about the Biblical Tower of Babel, it was
probably referring to either this or a structure similar to this. Ur also happens to be—you hear
about Abraham in the major monotheistic religions—it is probably where he was from. So this is
a re-creation. You can see the ziggurat with the palace administrative complex here and the city
spreading out around it.
In addition to the architecture, they developed a very sophisticated irrigation and agriculture
system. Vegetation flourished with a lot of interconnected canals and irrigation systems. They
were able to grow wheat, grains, and dates in abundance. The combination of these two skills led
to one of the most famous structures ever built by man: the Hanging Gardens of Babylon. This is
actually a copy of the bas-relief from the reign of Sannacherib, about 700 B.C, and it depicted
royal gardens probably similar to the Hanging Gardens of Babylon, although we do not have
actual pictures of those. They are considered to be one of the original Seven Wonders of the
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Ancient World. They were built around 600 B.C. and later destroyed by several earthquakes
around the second century B.C. They actually may have been at Nineveh, based on tablets that
we found there, and it may have just been confused with Babylon. But you can see that
regardless of the location they were impressive structures. This is a depiction from the sixteenth
century, by a Dutch artist, about how they may have looked.
They had sophisticated use of machinery, as well, in these gardens, including an Archimedes
screw-type mechanism to pull water up into the gardens. The Greek historians Strabo and Philo
have provided descriptions of the gardens:
The garden is quadrangular in shape, and each side is four plethra [100 ft.] in length. It
consists of arched vaults, which are situated one after another on checkered, cube-like
foundations. The checkered foundations, which are hollowed out, are covered so deep
with earth that they admit of the largest of trees, having been constructed of baked brick
and asphalt. The ascent to the uppermost terrace roofs is made by a stairway; and
alongside the stairs there were screws through which the water was continually conducted
up into the garden from the Euphrates.
So this is a reconstruction of what that may have looked like. You can see the impressive
structures with fairly large plants being able to be put in there, stairways going up, and the screw
pulling water up inside it. So it was a very sophisticated structure for the time.
Also, not only their larger structures, but their houses and their aspects of daily life had a very
nice attention to detail. They had palaces and houses that were covered with ceramics, colored
tile works, enamels, engravings, mosaics, paintings, sculptures—very artistic civilization. This is
the Istar Gate; it is the eighth gate to the inner city of Babylon, built around 575 B.C. The reason
this is shown is because you can see the blue-glazed tiles that were alternating rows of sirrush,
which are dragons, and aurochs. It was originally one of the Seven Wonders of the World but
was replaced by the lighthouse of Alexandria in the sixth century A.D. This is actually a replica
of the gate in modern Babylon in Iraq, and this is how it may have looked at the time when it was
actually in place in use in the civilization. There are details kind of showing the degree of
artwork and detail that they had. This is part of the gate, but things like these have been found in
dwelling of residences as well. This is also a detail of a Sumerian prince from the third
millennium B.C., and you can see how finely crafted this is as well.
In addition to decorative tiling and statues, they also had, obviously as I mentioned before, a lot
of mud, which led to elegant clay pottery. This is a jar from the late Ubaid period, about 4500
B.C. So you can see, even at that time, very nice geometric detail to this pot. Interestingly, the
merchandise had clay tags inscribed with the merchant’s name for identification and delivery
purposes—precursors to UPS. So you can see with all of these beautiful objects that they had,
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they obviously dealt in buying and selling these things. And marketplaces were a big part of the
society as well. There were tourists and traders from all parts of the existing world at that time
that came together in these bustling marketplaces, and a whole array of foreign cultures,
costumes, languages. So you can really imagine what that civilization must have been like.
In addition to furnishing their houses well, they also took care of themselves, as people want to
do and we still do now. They weaved wool and turned leather from animal hides into attractive
clothing. In addition to dressing fashionably, they took frequent baths, used perfume and rouge
freely, and colored their gray hair with sage extract and vegetable dyes. So it is like an early Just
for Men commercial or something. Here is the earliest Sumerian king wearing a golden
headband. Not only were the houses furnished very well and decorated well, they also had a
surprisingly modern infrastructure, as evidenced by this ancient bathroom from the sixteenth or
seventeenth century B.C. It actually had a very effective drainage system, and we will get to that
in a bit when we talk about public health of the era.
Not only in their houses, but in the community itself, they had extensive facilities for the
population as far as school and education. A fair portion of the population was literate. There
were libraries with works on astronomy, botany, chemistry, geology, mathematics and, of course,
medicine. Schools for children, as well as for adults, were usually administered by the temples.
And there was special training in these schools for astronomers, engineers, judges, priests,
surveyors, and medical healers, which we will talk about a little bit more later.
These are clay benches in the school room of the second millennium B.C., excavated at the city
of Mari. So it was not all just work; they also enjoyed themselves. This is a harp from a royal
burial, but there is evidence that musicians played bells, cymbals, drums, flutes, harps, lyres,
oboes, tambourines, and trumpets.
So this surprisingly advanced civilization was responsible for many of the critical developments
and innovations which continue to influence us today and really have led us to where we are
today, in many ways: the city, metallurgy, the wheel, a system of numbering and uniform
weights and measures, clock dials, the arch, writing, and beer. We will talk a little bit more about
beer later, as it relates to medical care.
First, the city Uruk is generally thought to be the first city in the history of the world. It was
probably founded about 500 B.C. At its height, around 3000 B.C., it was about 500 acres in size
and had a population of 50,000-80,000. It was a pretty large city. In comparison, Athens, at its
peak in 500 B.C., was probably about half the size. You may have heard of Gilgamesh—there’s
the famous epic of Gilgamesh—and he was thought to have ruled Uruk in about the 27th century
B.C., to kind of put it in perspective. It is probably also in Biblical terms; you hear of Erech in
the book of Genesis, and that’s probably referring to this—to Uruk. The name Iraq is also
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thought to be derived from Uruk. This picture here shows a cylinder seal of the city of Uruk. The
cylinder seal was essentially a cylinder made usually of stone or fire-hardened clay with a design
on it which could be rolled in fresh clay, almost like a signature or a representation of a place.
You can see how here is the cylinder seal, and when it gets rolled into clay it looks like this. So
this is how Uruk may have appeared at the time—pretty extensive city-state. This is a depiction
of what a ceremonial procession at that time may have looked like. So you can see fairly
advanced architecture, advanced musical instruments, and nice, decorative works: vases, pottery,
domestication of animals—pretty intricate civilization.
The wheel—obviously we all know the value of that. This is an Assyrian cart. It is a restored
model, but from the third millennium B.C., indicating the early use of this wheel which was
invented here. A numbering system—they actually had a sexagesimal number system, which
means it was based on the number 60. Our current system of time actually may trace back to this
system, which is why we have the 60 seconds and minutes. There is actually evidence that they
developed the Pythagorean Theorem about 1300 years before Pythagoras. This is a Babylonian
tablet know as Plimpton 322, and it has columns of numbers that seem to have been used in
calculating Pythagorean triples. And then, of course, writing, which we are going to find is very
crucial to our understanding of medicine from that time, was developed in about the fourth
millennium B.C. Initially there were probably tokens used with simple symbols, probably since
around 8000 B.C. Those were used mostly for simple economic transactions, but a true system of
writing developed around the fourth millennium—one of the most crucial developments from a
medical standpoint, not only for us to understand what their system was like and how they
practiced, but to allow them to share medical knowledge amongst themselves and with later
generations. This is a sample of a Sumerian clay tablet and how it may have been used. Usually
the initial use of these was for economic transactions, and then later, more intricate things
developed.
So the medical texts that we refer to and we get most of our information from, a large part of
those come from the library of Ashurbanipal, who was the last great king of Assyria. His library
was buried with his palace when Nineveh was destroyed in 612 B.C. Ironically, the city was
destroyed, but the fire ended up baking the tablets to a consistency of stone, which is, in a large
part, what allows us to have the information that we have. So the destruction allowed
preservation of information. Many of the texts found were copies of documents, which even at
that time in 612 B.C., were thousands of years old. This is a statue of Ashurbanipal from around
the seventh century B.C.
These tablets—obviously someone had to collect them. A large portion of these were collected
by Campbell Thomson of Oxford. He collected 660 tablets relating to medicine. The largest
collection of these is called the “Treatise of Medical Diagnoses and Prognoses.” There are about
3000 entries on 40 tablets. They are not true medical books per se, with flowing text, but it is a
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list of diseases and prescriptions arranged from head to foot. We also have some knowledge from
bas-reliefs that give us some idea of their understanding of anatomic and physiologic correlation.
I will show you what I mean by that in a moment. There is also the oldest known medical text,
which is a Sumerian therapeutic handbook from about 2200 B.C. We also find an ancient
pharmacopoeia from the first millennium B.C., and I will talk a little bit more about these later.
The information that we get from these really gives us a good understanding of medical practice
in this society, all the way from public health to, again, as I mentioned, an evidence of their
knowledge of the correlation of anatomy and physiology, medical ideology that they had at the
time, the medical practitioners that were around at the time, prevalent diseases that people
suffered from, pharmacologic cures—they will debate whether they were useful or not—and the
medical procedures that they performed, as well as an intricate system of laws of medical
practice, which in many ways is similar to what we have today, and we will look at that a little
closer.
From the public health standpoint in this society, it was customary to wash your hands before
eating, and, in fact, they had forms of soap. So this probably contributed, in a large part, to
keeping the society fairly healthy. As I mentioned before, there were bathrooms. This is really
just the same image from the palace of Prince Zimrilim of Mari—again, the sixteenth or
seventeenth century B.C. here. They had basins for washing and emplacements for urination and
defecation. This was connected by an elaborate drainage system of terracotta pipes to
underground sewers and sometimes even to sump pits. As a result, they had a cleaner drinking
supply than probably London in 1850.
They also were aware of contagion. They isolated the sick. They engaged in frequent dressing
changes of wounds, and they burned bandages from certain patients after they were used. They
did not understand it in the sense of bacterial transmission; they thought it was probably that a
spirit had touched that person, and that spirit may be around that person, so that is the reason
they isolated. But they had some idea that disease spread from one sick person to another.
The interesting thing with these public health innovations that they had was that their lifespan
was actually fairly long. Forty years was considered a person’s prime; sixty was full maturity;
dying at fifty meant a short life, and seventy a long one; eighty was old age; ninety was extreme
old age. We actually have evidence: there was Adad-Guppi, who was the mother of King
Nabonidus, from around 547 B.C., and she lived to 102 years of age. That also means that when
the King came to the throne, he was probably middle-aged as well—fifties or sixties. So again,
lifespans of 50 to 60 years were not uncommon, even among slaves. It is pretty impressive,
considering that a lot of countries, even currently, do not have lifespans that long, and really the
world as a whole probably did not get back to lifespans that length until the past century or so.
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So the anatomic and physiologic correlations that we talk about—there are a few reliefs that give
us some idea. They did not talk specifically in their texts about anatomy and physiology and how
it is correlated, but we have some reliefs that give us some idea that they understood at least
some aspects of this. This relief is called the great hunt; it is from about the seventh century B.C.,
from the palace of Ashurbanipal II at Nineveh, and it shows paralysis of the lower extremities
from a spinal injury. So they had some understanding of that. This is a lion having blood coming
out of the mouth after a wound in the lungs, so there is some indication that that was
interconnected.
So what did they think about medicine, and what was their thought processes or their medical
ideology? Illness in Mesopotamia was believed to be caused by the intervention of extraneous
metaphysical forces such as demons, evil spirits, ghosts of the dead, or the wrath of the gods.
People became ill, it was thought, by committing a sin or just by bad luck, being victimized by
one of these agents—demons, spirits, ghosts of the dead. Particularly when someone died, the
family was supposed to keep providing sustenance for them at their gravesite to keep them in the
afterlife, and particularly if someone stopped doing that, it was thought that the ghosts might
come back. Or if they died in a particularly traumatic way, that they may come back and make
people sick. Or just the wrath of the gods, and as we will see here, and as I sort of mentioned,
there were a whole variety of gods that could do this—or demons.
As I mentioned, numerous deities existed, and some of them were patrons of a certain city-state,
so that would be the primary person that they would pray to in those cities. There were three
principal deities of Sumer: Enlil, who had a son named Ninib, who was healing god; there was
also Enki; and Anu. By and large, the chief early Sumerian god remained supreme throughout
the era.
As far as physicians go, another important god was Ea, Lord of Water, and the first great cosmic
ancestor of physicians. His son Marduk became the most influential god in Babylonian worship.
Marduk had a son named Nabu, and he ruled over all of science, including medicine. A temple
was actually erected to him, where a medical school developed.
There was one healing god named Ningishzida. He had a double-headed snake named Sachan as
his emblem. This is a ceremonial beaker from about 2000 B.C., and it is a dark green soapstone
beaker, so you can imagine it is probably much more beautiful than this picture gives us an idea
of. But this is to Ningishzida, the God of Healing. And again, this gives us some idea of the
origin of this symbol—and to how old it is—that we still find in common use today.
In addition to the gods, I mentioned the spirit world was filled with demons. Each of these was
thought to bring a different disease. Just for example, Tiu brought headache; Nergal, fever;
Ashakku, consumption; Namtaru, throat ailments. Pazuzu, who we see pictured here, was the
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demon of sickness. He brought famine and locusts, but he also was thought to drive away other
evil spirits. So in some instances he could be helpful, as well. This is again Pazuzu here, from
this figurine from about 1000-500 B.C. There was also the Evil Seven, which were a group of
demons who wandered around causing various afflictions, and they were so feared that
physicians did not treat patients on days of illness divisible by the number 7. It is kind of
interesting.
So what kind of people were practicing medicine at this time, or who were the medical
practitioners? The physicians at that time were well respected in society and well educated.
There were three main types: the Baru, who was sort of a diviner or seer; the Ashipu, who was
exorcists or a priest; and the Asu, who was the physician, probably most like what we consider a
physician today. They most likely worked together as collaborators rather than competitors. So
you have some evidence of a multidisciplinary approach that we are trying to foster, to get back
to today. They did not have hospital settings, per se, but they largely made house calls.
The Baru—again, he was the diviner or seer and interpreted omens and foretold the course of the
illness. Unfortunately they also had to discover the causes and probable outcome of many other
types of disaster. So they were probably pretty busy, not always dealing with medical issues. One
of the things they did do, though, for a sick person was they practiced hepatoscopy. In this
practice, what they did was a sick person breathed into the nostrils of a sheep, the animal was
sacrificed, and the Baru compared a coded clay model to the sheep’s liver to make a diagnosis.
And this is because the liver was considered the seat of the soul and the center of vitality. This is
one of those models of a sheep’s liver, from about 1800-1700 B.C. This was, again, used as a
reference for these guys when they were trying to figure out what was wrong by looking at the
liver of the sheep.
The next practitioner was the Ashipu. These were the exorcists or the priests, and they would
inquire about the nature of the offense to the gods. After discovering what the problem was, they
drove out the evil spirits with incantations, prayers, recitations, sacrifices, and ceremonial rituals,
beseeching the gods for cure. A typical invocation sounded like this:
Whoever or whatever you are, evil ghost or evil devil, evil god or evil fiend, or sickness
or death, or a phantom or wraith of the night, a fever or deadly pestilence, whatever or
whoever you are—get out! Take yourself off before me! Get out of this house! For I am
the priest of Ea, I who recite the incantation for the relief of the man who is sick. Be
exorcised by heaven! Be exorcised by Earth! Get out!
He refers to Ea, as we saw earlier, who is an important god for physicians. They also often had
amulets of protection. This is an Assyrian exorcism amulet from about 900 B.C. This is very
interesting detail; you see the sick person here in the center. These are two Ashipus dressed as
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fish, symbolizing Ea, the great God of Water, that we talked about. They are trying to induce the
female demon Lamashtu here to leave the patient. Lamashtu’s evil deeds usually included
causing harm to expectant mothers or children, often causing harm either during childbirth or
killing young children—unborns, neonates. So she is usually depicted with a lioness’s head with
donkey’s teeth and ears, and birds’ feet with sharp talons. She is also often shown standing or
kneeling on a donkey, nursing a pig and a dog, holding snakes. And then we see our old friend
here, Pazuzu, the Demon of Sickness, holding the amulet, and he was being invoked to protect
the birthing mothers and infants from Lamashtu. As I mentioned, he is invoked in protections
sometimes, as well.
Then we have the Asu, or the physician, who is most like the physician of today, probably. They
were educated in priestly administered schools that we saw earlier, associated with the temples,
and the students learned from recorded clay tablets and practical experience. Consistent with the
religious side of their schooling, the Asu worshiped Gula, the Goddess of Medicine, and her
husband Ninurta. Here is the Goddess Gula with her dog. This is a detail from a boundary stone,
from about 1000 B.C. Ninazu was the god of healing and the patron of physicians. His son we
saw earlier, Ningishzida, carried the staff and serpent Sachan. This is just a cylinder seal that
shows Ninurta, who is the husband of Gula. It also shows Ea over here, that we talked about
earlier. So how did these Asus practice? Surprisingly, we will see that in many ways it was
similar to what we do today. They began with a very careful history and exam. They knew
various ailments from the hundreds of clay tablets that had the recorded descriptions, so it was
kind of like their Harrison’s or whatever they had looked at. After the diagnosis the Asu
prescribed drugs and medications, performed surgery, set fractures, palliated visible sores, and
treated snake bites. For the cures that he came up with, there were more than 120 minerals, 250
medicinal plants, and 180 other drugs that were combined with alcoholic beverages, bouillon,
fats, milk in various forms, honey, wax, oils, and animal parts and products—very complicated
recipes. The ingredients were ground, strained, and filtered to make either ointments, plasters, or
other medications. External medical applications used solvents from bark, flowers, fruit, skins
and juices, plants, resins, sea kelp, seeds, or turpentine. These were dissolved in beer or milk and
mixed with wine, fats, and honey. The medicines were administered via laxatives, lotions,
enemas, ointments, pessaries, poultices, pills, powders, suppositories—so all kinds of different
modes of administration. Here we just see the Sumerian symbol for Asu.
So a prescription could literally sound something like, “Enveloped in the aroma of burning
feathers and liberally dosed with dog dung and pig’s gall.” So I am pretty glad I’m not practicing
in that particular time. It does not sound like the most pleasant or useful thing, but interesting
nonetheless. They did have mandragora, opium, hemp, and lolium temulentum, to provide
narcotic therapy. Mandragora, here, is a deliriant hallucinogenic. And lolium temulentum in Latin
means “drunk” and it can make someone feel poisoned or drunk.
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They also used fairly sophisticated medical instruments consisting of spatulas, bronze lancets,
metal tubes to blow medicine into various orifices, and tubes used as catheters. These were
excavated at Nineveh. Once they began practicing, the Asus would make their own cylinder seals
that we talked about earlier, like this one shown here. This impression of Dr. Urlugaledina’s
cylinder seal was found at Lagash, and it is from about 2000 B.C. The text reads, “O Edinmugi,
vizier of the god Gir, who attends mothers when they drop their young! Urlugaledina the doctor
is your servant.” So it is kind of like a business card of today.
We have a good idea of the diseases that the Mesopotamians may have suffered from, based on
all these clay tablet descriptions that we found and that were used by the Asu. The writings
correlate with a whole variety of illnesses, venereal disease, tumors, skin disease, rheumatism,
prolapse, plaque, nose and throat disease, intoxication, heart disease, gall bladder, fevers, cough,
constipation, colic, appetite control, abscesses, UTIs, kidney stones, edema, all kinds of things.
They also, as we mentioned earlier, were the inventors of beer. This is where it comes into play
with medical issues. The “Hymn to Ninkasi” is a prayer to the ancient Sumerian Goddess of
Beer, Ninkasi. It serves not only as a prayer, but as a way of remembering the recipe for beer.
This is a recipe for best beer from Ur, about 2050 B.C. It brings to mind the famous quote from
Homer, “To Alcohol—the cause of, and solution to, all of life’s problems.” You may have
figured out, it is not the Homer of the Iliad and the Odyssey, but our own Homer Simpson. You
will see it caused a lot of problems, which we will talk about, but it may have been the solution
to some of those as well.
Edema was likely present in ancient Mesopotamia, and the reason that we think that is, the
translation of Asu is actually “one who knows water.” It suggests that water and fluid overload
may have been a large component of what they dealt with. Some tablets, in fact, describe
symptoms consistent with volume overload: “If his neck throbs and his head keeps falling and
his hands and feet keep swelling up and he rubs them against the ground, the Demon Handmaid
of Lihu has seized him.” Other tablets describe possible Wernicke-Korsakoff Syndrome, which
manifests with confusion, amnesia, ataxia, nystagmus, and ophthalmoplegia and is brought on by
chronic alcoholism. “If a person drinks beer, and as a result his head continually afflicts him, he
continually forgets his words and slurs them when speaking, he is not in full possession of his
faculties, and that person’s eyes stand still...”
Another description suggests possible esophageal variceal bleeding: “If his temple afflicts him so
that he continually cries out and blood flows from his nose/mouth…” So these descriptions of
disease are interesting. They vividly demonstrate the diseases of the time, and they attest to skills
of close observation and documentation possessed by the ancient physicians. We can look at
these now and still essentially figure out what they are talking about. Again, these descriptions
probably dealt with complications from the invention of beer, but there are a few other
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descriptions that will follow here, that show that they had all kinds of other problems to deal with
as well:
“If a man has pain in the ‘flesh’ of his kidney, his hips or groin are affected, and his urine is
white like donkey urine, and later on his urine contains blood, that man suffers from musu
disease.” This was possibly pyelonephritis.
“The patient coughs constantly; his sputum is thick and sometimes contains blood. His
breathing is like a flute. His hand is cold, but his feet are hot. He sweats easily and his heart
is disturbed. If the sickness is violent, he suffers from constant diarrhea.” This suggests
maybe tuberculosis.
“When a man has fallen into the water and after being pulled out gets pains in his side which
radiate out according to how the breath goes.” This may be aspiration pneumonia.
“When the patient suffers from coughing, when his windpipe is full of noises in breathing,
when he suffers fits of coughing…” This may be asthma or other obstructive lung disease.
“When the body of a man is yellow and his face is yellow also and he suffers from loss of the
flesh…” This could be jaundice, related to alcohol as well.
“When a man eats and drinks until he is filled, and then feels pains in his stomach, as though
the skin inside were burning like fire…” This may be ulcer disease or gastritis.
“Fluctuating fever, weakness, loss of appetite, stiffness in the joints, ‘heat’ of the eyes,
blisters, chills, and earache.” That sounds a lot like Reiter’s Syndrome or manifestations of
lupus.
This last description actually is in reference to King Esarhaddon of Assyria, and this is a victory
stele of King Esarhaddon over the Egyptian pharaoh Tarharga, in 671 B.C. They always show
the people that they beat being a lot smaller than them. Of course when the Egyptians did the
same thing, it would be reversed. This guy would be small, and they have plenty of their own
documentation of their victories. In many cases, the disease processes and the descriptions of
them have not changed much over the millennia. Again, this emphasizes the importance of our
basic tenets of a careful and thorough history and physical examination.
So now that we have some understanding of the disorders that plagued ancient Mesopotamians,
we can examine the therapeutic measures that they used. One form of medical intervention was
pharmacologic, using the many ingredients and intricate methods of preparation that we talked
about earlier. The first mention of prescriptions like these can be found in the world’s oldest
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medical manuscript. We touched this earlier, but this is the oldest know medical handbook. This
Sumerian physician’s collection of empiric prescriptions is from around 2200 B.C. It is a small
clay tablet written in Sumerian and dated, by the style of writing, to the third dynasty of Ur. In
contrast, the oldest Egyptian papyrus, the Kahun Papyrus, was written in about 1850 B.C. So this
document has about fifteen prescriptions which are fairly understandable, despite the difficultly
of the text. One of these reads, “Pound together dried wine dregs, Juniper, and prunes; pour beer
on the mixture. Then rub the diseased part with oil, and bind on as a plaster.” Again, the beer
tends to be a recurring ingredient in many of the prescriptions. We talked about how it was the
cause of a lot of problems; we will talk a little bit about how it may have been the solution. They
invented and loved beer. They brewed at least 19 brands. There is a whole book on the subject.
Interestingly, brewers and tavern keepers were frequently female. You see here, a ceremonial
drinking scene from the great death pit at the royal cemetery of Ur. This is about 2500-2400 B.C.
The way they used to drink it was with straws because a thick sediment would form on the top,
so they would actually be able to get to the liquid by using the straws.
Although the alcohol content was probably fairly low, it probably had some antiseptic affect and
was probably a fairly good wash, especially when combined with hot water, as in this
concoction. “Pass through a sieve and then knead together turtle shell, ‘naga-si’ plant, salt, and
mustard. Then wash the diseased part with beer of good quality and hot water and rub with the
mixture. Then friction and rub again with oil, and put on [a plaster of] pounded pine.” So
although it caused a lot of problems, it could be the solution to certain other problems as well.
This is actually another image of the use of beer, probably from the second millennium B.C. The
thought is that this may be a depiction of part of the Epic of Gilgamesh, where this is Gilgamesh
and this is Siduri the tavern keeper, who was in this mountainous region he went and visited.
Another prescription for a Sumerian plaster reads, “Take some river sediment, pound it, knead it
with water, then rub the diseased part with mineral oil, and bind on as a plaster.” What is
interesting about this is that anthropologists have found that wounds in Iraq are still treated in a
similar way by some of the native people.
So you get some idea from the prescriptions that we have been talking about that the essence of
the Sumerian physician’s art—it used to be called bultitu—lay in developing the right kind of
bultu for each case. That bultu was a concoction of herbs and other ingredients which were
usually pounded, cooked, strained. The problem with these was that two bultu would almost
never be the same because the amounts were not really stated and probably were not measured.
There was also a large variety of fairly exotic items, like dung of lizard and marrow of long
bone, that may or may not have been easy to get. The other thing that we found, and I mentioned
this briefly earlier, is an ancient pharmacopoeia. This is a list of about 230 items that were found
on tablets in the remains of a drugstore from the first millennium B.C.
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Again, the effectiveness of ancient Mesopotamian drugs is difficult to determine. For a lot of
these things there is no identification, or the identification is uncertain. Most of the recipes have
one ingredient which cannot be identified at all. So then the questions that come to mind are,
“How did the Asu choose a certain treatment for these problems?” and “Were any of these drugs
actually useful?” The way they chose the treatment was simply for linguistic reasons, and the
name just punned with a given disease. It seems strange to us now, but at the time it seemed to
make sense to them because the name of an object was part of the essence of that object, so this
plan of therapy seemed reasonable. An example is found in a tablet from the Maklu series. It is
wished that the witch or agent of the disease be pierced, bound, lacerated by different plants. In
each case, the plant name puns with the verb, so an example of this is, “Like the shiklu plant [a
thorny plant] may her enchantment likshulu her [pierce her]…” or, “Like the sammu plant, may
her enchantment lisammu her [bind her].”
So you can see that because of their thought of the essence of the name, this seemed to be a
reasonable therapy at the time. Other times the choice is less clear, although it may be inferred
from other aspects of life at the time. For example, there is an Akkadian remedy which says, “If
a man, his head is full of sores, dissolve boiled dung in hot water, shave, cleanse until blood
issues…” I personally would not advocate doing that for any sores today, but if you view it from
the perspective of the Akkadians at the time, dung was an essential ingredient of daily life. They
brought it indoors as a fuel and probably had ammonium salt extracted from its soot after
burning it. It was used as an infusion for the bating of hides prior to tanning. The bating process
was used on a hide to reduce its swollen state by the action of the proteolytic enzymes. So it is
therefore possible that the Asu was attempting to reduce swelling with this particular bultu,
which looked at in that sense makes a lot more sense.
Then there is the question, Were any of the drugs actually useful? In many cases I have
mentioned it is impossible to tell, since we often do not know what was in the concoctions. We
do know, however, that Mesopotamia drug ingredients are composed of two main groups: plants,
and resins and spices. Occasionally a useful combination is found. Some of the plasters required
the heating of resin or fat with alkali obtained from burning certain plants like Salicornia
herbacea. The end result would be a type of soap, and this, as what we discussed earlier,
probably contributed to their good public health and the longevity that they had.
Beer and water wash, as we talked about, and frequent boiling in the recipes were probably
helpful and had some antiseptic benefit. Honey also probably has some antiseptic qualities.
Plants were probably effective as analgesics; they had some opium, Mandragora, lolium
temulentum that we mentioned earlier, and then Quunabu or Cannabis, which was used as an
analgesic. But also they used it for bronchitis, bladder trouble, rheumatic diseases, insomnia. The
resins and spices that they used—they had resins of pine, fir, and cedar—all may have had some
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antiseptic value. Frankincense they also had, from the Boswellia sacra tree, which we see here. It
possibly had some anti-inflammatory effect, and there is some evidence that it can relieve
depression and anxiety in mice; this is current evidence. Myrrh—there is some evidence that it
improves glucose tolerance in rats. It produced analgesia in mice subjected to pain by affecting
the opioid receptors, and it has shown to have decreased LDL and increased HDL in both rats
and humans. So there may have been something to the things that they were using.
It is easier to determine the efficacy of medical procedures since we are not hindered by the
various unidentified ingredients in the prescriptions. There is evidence of a variety of procedures
that they performed including thoracotomy, irrigation and drainage of an abscess, wound
dressings, packing for epistaxis, diuresis, and catheterization. Again, these are the instruments
that we saw earlier that were excavated at Nineveh.
There is one badly damaged but intriguing tablet—particularly as being in pulmonary critical
care, this is interesting for me—that suggests a possible thoracotomy. Three ribs, fourth rib cut
open, and fluid. Unfortunately it is pretty damaged, but it strongly suggests that the Asu is
performing some sort of a thoracotomy, presumably to drain some sort of an effusion. When we
look at this, the fourth rib seems high, but it is possible the Mesopotamians counted the ribs from
the bottom up, rather than the way we count them. And this actually correlates with ancient
Greek medicine. The Hippocratic work called On Internal Disease describes chest incision for
plural empyema as, “Incise over the third rib, beginning from the last.” So that would make more
sense with draining an effusion from the lower aspects.
Another procedure appears in the collection called Prescriptions for Diseases of the Head:
If the ailment mentioned above [the above part is lost, unfortunately] is painless, and the
very surface of the flesh is intact; if, when you open, pus squirts out and keeps flowing:
the name of this disease is “little she-fly.” [We do not really know that that means either.]
If the wind has blown onto the patient, it is a case of Pabil-sag the god: you can operate
it. To remove it, attack this disease with the point of the knife. After cutting it open, grind
boiled plaster, salt of ammonia, and powder of [some unknown mineral]. Apply all this
onto the diseased surface and make a dressing of it. If the disease has reached the bone,
cut all around, scrape and remove [the diseased bone].
So it suggests irrigation and drainage of an abscess to thoroughly get all of the diseased tissue.
Another tablet has this description:
Wash a fine linen in water, soak it in oil, and put it on the wound. Bring powder of acacia
and ammonia salt, and put it on the wound; let the dressing stand for 3 days. When you
remove it, wash a fine linen in water, soak it in oil, put it on the wound, and knot a
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bandage over it. Leave the dressing 3 more days…thus continue the dressing until
healing ensues.
So we see pretty sophisticated wound dressing and frequent changes, like we mentioned earlier,
and likely the Mesopotamian oil was sesame oil. This may have some antibacterial effect. There
is some data from Kekessy, in Geneva, that shows rapid killing of staphylococci in sesame oil. It
also likely prevented adherence of the bandage to the wound.
They also refer to epistaxis and packing for it. This is a reference to treatment for epistaxis in a
letter from around 680 B.C. to King Esarhaddon, who we saw with the Reiter’s or lupus, from
his Rab Asi or chief physician. This also gives us some indication there may have been a type of
hierarchy in physicians, although we’re not entirely clear on that. But this refers to a chief
physician, Arad-Nana. This regards an episode of epistaxis. So he writes,
In regard to the patient who had a hemorrhage from the nose, Rab-Mugi [a high official
charged with the care of horses and chariots, possibly the Rabmag of Jeremiah] reported
to me: “Yesterday toward evening much blood ran.” That is because the dressings that I
had prescribed are applied without knowledge. They are placed over the nostrils, so that
they only obstruct the breathing but come off when there is bleeding. They should be
placed within the nostril: then they will stop the breath and hold back the blood.
So it shows some understanding of actually packing for this disorder.
The ancient nephrologists also had some tricks up their sleeve. For kidney stones we find, “If a
man…suffers from a stone, which does not come out…during 3 days, he has a stone in the
urethra. That man must drink beer and the stone will be passable. If that man doesn’t drink beer
but drinks a lot of water, he will be assigned to his fate.” So here, again, we see a therapeutic use
for beer as a diuretic agent.
Catheterization— Another tablet reads, “If a man’s urine constantly drips and he is not able to
hold it back, his bladder swells and he is full of wind, his urine duct is full of blisters; in order to
cure him, take puquttu, [we do not know what that is] crush it in pressed oil, and blow it into his
penis through a bronze tube.” Since puquttu is unknown, we do not know if this cure was
pharmacologically useful, but if the bronze tube used to administer it were inserted far enough, it
many have served to catheterize the patient.
Now we have some idea of what the society was like, what diseases they suffered from, who
treated these diseases, and how they treated them. One other very interesting aspect of this
society was that they had a very intricate system of laws of medical practice. Most of the
precepts regarding medical practice were actually outlined in the Code of Hammurabi from
around 1700-1800 B.C. And that is the one that we all are familiar with, but it is interesting to
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find that there were many earlier concepts that can be traced back to clay tablets by Urukagina of
Lagash, about 2400 B.C.; Eshnunna from 2100 B.C.; and Lipit Ishtar of Isin, about 1800 B.C.
Isin was actually, by the way, one of the city-states that was thought to be one of the most
sophisticated centers of medical practice. This is actually a depiction of a fragment of an
inscription from Urukagina. So these older sets of laws did not deal as much with medical
practice, but you could see that the Code of Hammurabi, which we hear about as being the most
extensive, had some antecedents to it that may have led to its development.
So who was Hammurabi? He was the Babylonian king who had a 43 year reign, from about 1792
B.C. to 1750 B.C.—again, evidence of the longevity that some of these people had. He was the
sixth king of Babylon, and he developed one of the first and most extensive codes of law in
recorded history. He also was pretty effective at advancing his empire. This is sort of the region
he took over with, and this is what he ended with at the end of his reign. So the Code of
Hammurabi is actually a very beautiful artifact that we have. It is polished black diorite, and it is
a pillar found near Susa. It has the Code of Hammurabi inscribed and a bas-relief at the top,
showing the king receiving laws from the Sun God, Shamash. So the king is getting the laws.
Some people interpret this as Shamash giving Hammurabi the circle and scepter as an insignia of
the king’s authority in mandating the Codex. It is almost eight feet high and six feet in
circumference at the base, tapering to five feet in circumference at the top. It is engraved with
282 laws on various subjects. We will talk a little bit about these laws in a second, but to
understand them, the Code used a sliding fee reimbursement scale—which is interesting—for
medical services based on social class.
Just briefly, we will mention the different social classes. The three main social classes were: the
awīlum, the upper class—that was business men, feudal lords, free men of some wealth,
gentlemen, large landowners, military leaders, palace officials, professionals, and temple priests;
the muškēnum or middle class were free men who were less well-off, poor or middle-income
commoners who owned small properties, tenant farmers, craftsmen, merchants, hired laborers,
and even former slaves; then the lower classes were the wardum, who were mainly the male and
female slaves.
So interestingly, regardless of a person’s social class, access to medical care was unrestricted at
the time. A fee schedule for provider health care services was also established, along with patient
rights, and satisfaction and quality control through malpractice penalties. It is a very advanced
system. The following lines from the Codex describe reimbursement:
If a physician set a broken bone for a gentleman [the awīlum that we mentioned] or cure
his diseased bowels, the patient shall pay 5 shekels of silver to the physician. If he be a
freeman [or a muškēnum], he shall give 3 shekels of silver. If it be a man’s slave [or
wardum], the owner of the slave shall give 2 shekels of silver to the physician. If the
physician has made a deep incision in the body of a gentleman [or awīlum] with a lancet
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of bronze and saves the man’s life, or has opened a caruncle in the eye of a man with a
lancet of bronze and saves the eye, he shall take 10 shekels of silver. If the patient is a
freeman, [or muškēnum]…5 shekels… If the patient is a slave, [or wardum] the master of
the slave shall give 2 shekels of silver to the physician.
So the interesting thing about this is that the slaves or wardum sort of had a health plan because
their owners were paying for the medical services that they might need. The physician of the
time also had to be cost conscious since the established fee caused him to absorb any additional
expenses of treatment beyond the set fee. This is a lot like some of the current payment schedules
we encounter now; it is amazing how similar it is. So physicians were reimbursed actually fairly
well for their services. To get some idea of the value of a shekel, a free craftsman had to work
about one year to earn 10-14 shekels. A middle-class dwelling rented for about 5 shekels a year.
So before we become too indignant about how little we currently make, the malpractice penalties
were pretty severe also:
If a physician operate on a man for a severe wound with a bronze lancet and cause the
man’s death, or opened an abscess in the eye of a man with a bronze lancet and destroy
the man’s eye, they shall cut off his fingers. If a physician operate on the slave of a
freeman for a severe wound with a bronze lancet and cause his death, he shall restore a
slave of equal value. If he open an abscess in his eye with a bronze lancet, and destroy his
eye, he shall pay silver to the extent of one half his price. [The average prices for male
slaves were 16 to 30 shekels.]
So if we went back in time, internists probably would not fair as badly under this malpractice
system as surgeons.
The Mesopotamian concept of disease, as we mentioned previously, was that if someone became
ill, it was either because he had sinned or because he was the victim of a god or evil spirit. So a
physician was not really held liable for any of those causes. But a wound caused by a man
through surgical intervention with his bronze lancet was unfortunately his responsibility. Here
we see sort of the outcome-based fee schedule—wealthier people, down to the slaves, and
depending on the procedure, the amount of reimbursement, and then unsuccessful operations
losing a hand, which is a pretty steep price to pay.
In conclusion, hopefully this glimpse into the first civilization of mankind has been entertaining
and instructive, and particularly I hope it has given some insight into the very earliest roots of
our profession. Although medicine has obviously changed enormously in the past 5000 years, it
is fascinating to see how integral facets, such as close observation, attention to detail, meticulous
record keeping, even reimbursement and malpractice protocols have persevered and have
retained a lot of similarity to that time, from the very dawn of civilization.
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