The ancient region of southwest Asia known as Mesopotamia is literally “between rivers”: the Tigris and Euphrates, which have their headwaters in the mountains of Asia Minor and ultimately merge as they flow into the Persian Gulf, nearly a thousand miles to the east. This fertile land, tilled for ten thousand years, also has been called the Cradle of Civilization. Here, about five thousand years ago, man first attempted to develop a system of writing, and here the first cities in the world were built.
In the course of the fourth millennium B.C., city-states developed in southern Mesopotamia that were dominated by temples whose priests represented the cities’ patron deities. The most prominent of the city-states was Sumer, which gave its language to the area and became the first great civilization of mankind. About 2340 B.C., Sargon the Great (c. 2360-2305 B.C.) united the city-states in the south and founded the Akkadian dynasty, the world’s first empire.
The next major civilization was centered on Babylon, and the most famous ruler of the Old Babylonian dynasty was Hammurabi (r. 1728-1686 B.C.), whose code of laws is the most prominent work of the period. Many thousands of inscribed clay tablets from this era still exist and make it one of the best-known cultures of Near Eastern antiquity.
The civilizations of Mesopotamia exerted powerful influences on their neighbors not only in their own time but also in subsequent centuries. Hebrew, Greek, Christian, and Islamic cultures owe many debts to ancient Mesopotamia. Some of the most famous early Bible stories have precursors in venerable Sumerian legend. The story of the Flood and Noah’s Ark is lent credence by the discovery of ancient Nineveh beneath eleven feet of silt, and the description of the Tower of Babel in the Bible seems to fit the ziggurat temple-form of early Sumerian city-states. Perhaps Mesopotamia’s most important contribution to the world was the introduction of a writing system, attributed to the Sumerians of about 3000 B.C. Although the Sumerian language itself did not long survive, the writing, called cuneiform, was adapted to Akkadian and its Babylonian dialect and was used to preserve the records and literature of Mesopotamia on clay tablets. Found by the thousands among the ruins of Babylon, Mari, and Nineveh, many of these tablets list representative plants, animals, and implements and provide a rudimentary zoological and botanical survey of the area. Others list the dynasties of rulers and major events which have enabled historians to work out a satisfactory chronology for the era.
Many other innovations came from the region of Mesopotamia: metallurgy, the wheel, the arch, clock dials, and uniform weights and measures. The sexagesimal system from which we derive our sixty-minute hour had its origins in Babylonian mathematics. The Chaldeans, a late Babylonian people, under Nebuchadnezzar developed extensive information on astronomy as well as concepts of astrology which were used in the medicine of Greco-Roman, Arabic, and medieval times. The earliest known regulations of the practice of medicine were found in the Code of Hammurabi (c. 1700 B.C.).
Ideas about Disease
Although the various Mesopotamian cultures had their differences, there was a certain basic agreement on cosmology. As among their primitive forebears, illness was a curse, a punishment by the gods which could be visited on the family and descendants as well as on the sinner who had knowingly or inadvertently violated a moral code. However, there was probably some realization of nonspiritual causes for illness since physicians were admonished, for ethical reasons, to avoid continuing treatment for hopeless cases.
There was a pantheon of numerous deities, some of them patrons of the local region or city-state. For the most part, the chief early Sumerian gods remained supreme throughout the era, either unchanged or mingled with the Semitic gods of later times. The three principal deities of Sumer were Anu, Enlil, and Enki. Enlil had a son, Ninib, who was a healing god. An important Babylonian god was Ea, Lord of Water and the first great cosmic ancestor of physicians, whose son Marduk became the most influential god in Babylonian worship. Marduk was the father of Nabu, who ruled over all science, including medicine, and to whom a temple was erected where a medical school developed. It is worth noting that one healing god, Ningishzida, has been pictured with a double-headed snake as his emblem, an indication of how long the snake has been a medical symbol. Indeed, in the early Sumerian epic of Gilgamesh, the search for the secret of immortality was thwarted when a snake stole and ate the plant of everlasting life. The snake immediately shed its skin and appeared rejuvenated, which qualified it as a symbol of regeneration and the cure of illness.
There were also evil demons who filled the spirit world. Each brought a different disease: Nergal gave fever, Ashakku debilitating consumption, Tiu headache, Namtaru throat ailments. Especially feared were the Evil Seven who wandered about afflicting the unwary. Because of them, physicians did not treat patients’ on the days of an illness divisible by seven.
Mesopotamian doctors depended on divination to uncover the sin committed by a sick person and to learn the expiation demanded by the gods, but they also observed a patient’s symptoms to estimate their seriousness. One method of divination particularly associated with Mesopotamian medicine was hepatoscopy (detailed examination of the liver, and other entrails, of sacrificed animals). Although the Mesopotamians seem to have had no overall idea of anatomy, they regarded the liver as the seat of life since it appeared to be the collecting point for blood. Clay models of livers have been found with markings that probably were used to instruct neophytes in the art of divination or to guide the priest himself.
Recitations, ceremonies, prayers, and sacrifices were common religious means of beseeching the gods for a cure; however, along with these a veritable pharmacopoeia of drugs was used regularly in the treatment of disease. In addition to clay tablets which report illnesses with their symptoms and diagnosis, prognosis, and treatment, others were found that list drugs and their appropriate uses. Hundreds of plants, minerals, and animal substances were the therapeutic agents. They were given by mouth in compositions, applied as salves and fomentations, blown into orifices, inhaled as vapors and fumigations, and inserted as suppositories and enemas. Oil was apparently the principal balm for open wounds, probably preventing the adherence of overlying dressings. The medications were administered according to rituals, the time of the day, and the positions of constellations.
No cuneiform tablets devoted exclusively to surgery have survived, but since virtually all of the medical rules in the Code of Hammurabi concerned the outcome of operations, we can be certain that surgical practices were common. Wounds, abscesses (especially of the eye), broken bones, sprained tendons, and brand marks of slaves were all clearly in the province of surgery. Furthermore, references to bronze lancets in the Code and elsewhere indicate the use of instruments in surgical operations, and there have been a few isolated archaeological recoveries of knives. A possible trephine has also been unearthed, but no examples of trepanned skulls have yet been found in the land “between rivers.” However, they have been uncovered in nearby Judea, which got its medical knowledge from Mesopotamia.
Medical practice appears to have been in the hands of three types of priests, only one of which was concerned exclusively with sick people. The baru as a diviner dealt with diagnosis and prognosis, but not only of illness. He also had to discover the causes and probable outcome of many other kinds of catastrophe. The ashipu, as an exorcist who drove out evil demons, was called on to rid a house, a farm, an area, and also sick people of occupying spirits. The asu apparently acted principally as a physician, employing charms and divination but also drugs and operations. The name of Biblical king Asa (Asa-El), “healer of God,” may have derived from the Babylonian asu.
The healing priests received their education in schools that were associated with the temples. The source of their learning, in addition to practical instruction, was the large number of texts available in the form of clay tablets. By the seventh century B.C., for instance, the library of Ashurbanipal contained over twenty thousand tablets, which were only discovered about a hundred and fifty years ago at the site of ancient Nineveh. They are still the most extensive source of knowledge about Mesopotamian society, including medicine, but recently tablets have been unearthed that date back to Sumerian times.
The priest-physician ministered mainly to the court, nobility, and upper classes; but apparently there were also barbers who performed some surgical procedures and did the branding of slaves. They also treated tooth disorders and did extractions. Veterinary practice may have been handled by either the low-class barber or the upper-class asu, but whether there were exclusive healers for animals, “doctors of oxen or asses,” is not known.
Medical practice, as well as other professional activity, was evidently regulated by well-defined laws. The Code of Hammurabi devotes ten short statements out of the 282 provisions to the fees due medical practitioners and their punishments for failure.
If a doctor has treated a freeman with a metal knife for a severe wound, and has cured the freeman, or has opened a freeman’s tumor with a metal knife, and cured a freeman’s eye, then he shall receive ten shekels of silver.
If the son of a plebeian, he shall receive five shekels of silver.
If a man’s slave, the owner of the slave shall give two shekels of silver to the doctor.
If a doctor has treated a man with a metal knife for a severe wound, and has caused the man to die, or has opened a man’s tumor with a metal knife and destroyed the man’s eye, his hands shall be cut off.
If a doctor has treated the slave of a plebeian with a metal knife for a severe wound and caused him to die, he shall render slave for slave.
If he has opened his tumor with a metal knife and destroyed his eye, he shall pay half his price in silver.
If a doctor has healed a freeman’s broken bone or has restored diseased flesh, the patient shall give the doctor five shekels of silver.
If he be the son of a plebeian, he shall give three shekels of silver.
If a man’s slave, the owner of the slave shall give two shekels of silver to the doctor.
If a doctor of oxen or asses has treated either ox or ass for a severe wound, and cured it, the owner of the ox or ass shall give to the doctor one sixth of a shekel of silver as his fee.
Although estimating relative monetary values in modern terms is difficult, one should compare the fees in the Code with the five shekels of silver yearly rent for a middle-class dwelling or the one-fiftieth of a silver shekel daily pay for an ordinary craftsman, which indicates a generally high schedule of medical fees. The severe punishments for a physician’s failures listed in the Code (such as cutting off the hands) should be matched against the punishments (which could include execution) meted out for the failures of other professionals and the transgressions of any person against another.
If a man has destroyed the eye of a patrician, his own eye shall be destroyed.
If a man has knocked out the teeth of a man of the same rank, his own teeth shall be knocked out.
If he has knocked out the teeth of a plebeian, he shall pay one-third of a mina of silver.
One may wonder whether under risk of such stringent penalties any practitioner could have had the nerve to perform an operation, but it may well be that the Code was not enforced to the letter. Indeed, earlier Sumerian writings recently discovered indicate that punishments were less severe than called for by the later Code.
One fact seems clear. Whatever may have been the restrictions and regulations, a goodly number of healers—whether priests or barbers—practiced medicine and surgery throughout the history of Mesopotamia. It is therefore difficult to account for the statement of the Greek historian Herodotus (fifth century B.C.) that: “They have no physicians, but when a man is ill they lay him in the public square, and the passersby come up to him, and if they have ever had his disease themselves or have known any one who has suffered from it, they give him advice, recommending him to do whatever they found good in their own case, or in the case known to them. And no one is allowed to pass the sick man in silence without asking him what his ailment is.”
Public Health and Hygiene
From the numerous instructions on clay tablets recommending religious and empiric methods of treatment, one can infer that the physician was called upon to treat a large number of ailments. They were not grouped together as disease entities, as they are today, but were listed and classified according to the location of the symptoms. For instance, in the head there were aches, eye and ear pains and swellings, and tooth abscesses. Chest problems were cough, pain, and the spitting of blood. Cramps, vomiting, and diarrhea were illnesses of the abdomen.
Epidemics must have occurred often; the many wars and invasions were likely events to foster pestilence. Certainly plagues of some kind were reported in the cuneiform tablets of the eighth century B.C., and fevers, probably of varying causes, were mentioned frequently in the medical texts. The shaking chills which Alexander the Great suffered in his last illness while campaigning in Mesopotamia in the fourth century B.C. may have been due to malaria.
A sick person of any rank was in a special category and was excused from work and even from service to the king. On the other hand, since disease was caused by spirits having possessed the body, the afflicted person was shunned as much as possible to avoid transference of the offending demon. This relative isolation was hygienically beneficial to the community although its purpose was based on religio-magical reasoning. The taboo against touching the sick was carried, over into Hebrew culture, where it became a key factor in a system of public hygiene—just one further example of Mesopotamia’s long-lasting influence on contemporary and later cultures.