- John Z. Wee
Cuneiform medical manuscripts are found in large numbers, mostly from 1st-millennium bce sites throughout ancient Mesopotamia. Included in the therapeutic tradition are pharmacological glossaries, herbal recipes with plant, mineral, and animal ingredients, and healing incantations and rituals. A Diagnostic Handbook created at the end of the 2nd millennium bce maps out a blueprint for medical practice that sketches out how a healer progresses in his knowledge of the sickness—initially interpreting bodily signs in ways reminiscent of omen divination, and only later arriving at a settled diagnostic verdict and treatment of the kind depicted in the therapeutic tradition. Mesopotamian aetiologies focused on malevolent agents external to the body, encouraging concerns for contagion, prophylaxis, and sanitation, while omitting significant roles for dietetics and exercise aimed at rectifying internal imbalances. Operative surgery was limited, because of the inadequacy of available analgesics and antiseptics. Suppliants seeking a cure visited temples of the healing goddess Gula in the cities of Isin and Nippur, while, among the professions, the “magician” and the “physician” were most associated with medical practice. After the 5th century bce, Calendar Texts and other astrological genres linked various ingredients to each zodiacal name, indicating certain days when a particular ingredient would become medically efficacious.
- Science, Technology, and Medicine
- Near East
Medical Text Objects and Historiography
Many hundreds of medical cuneiform tablets and fragments, most dating to the 1st millennium bce, have been discovered in Babylonian cities like Babylon, Borsippa, Sippar, Nippur, Uruk, and Ur in southern Mesopotamia, as well as Assyrian cities like Assur, Nineveh, Kalḫu (Nimrud), Dūr-Šarrukīn (Khorsabad), and Ḫuzirīna (Sultantepe) in northern Mesopotamia and Syria. One might regard with scepticism the claim by Herodotus of Halicarnassus that the Babylonians “had no use for physicians” (1.197), since the sick supposedly sought help from other laypersons with previous experience of the infirmity—though it is possible that the cuneiform record reflects a kind of text-based medicine practised among the scribal elite and not necessarily accessible to all. Unique to the historiography of Mesopotamian medicine is the significance of the text object. Medical manuscripts of papyrus, parchment, or paper undergo repeated copying and perhaps revision over the centuries, frequently by different cultures and even in other languages. By virtue of their durability, medical clay tablets from Mesopotamia lie closer to their contexts of composition, transmission, and usage, providing snapshots in time of how knowledge was “packaged” and employed in real-life scenarios.
Many cuneiform genres can be categorized as divinatory, consisting of omens that reveal the gods’ intentions and predict future events, or as remedial-apotropaic, which include magic spells, rituals, and prayers that appease the gods’ wrath, dispel malevolent agents, and mitigate personal guilt. To the latter category belong recipes of the therapeutic tradition, which provide lists of plant, mineral, and animal ingredients, with instructions on preparing them for the patient in the forms of elixirs, ointments, rinses, and dressings. Therapeutic texts regularly come with assurances that patients receiving these treatments will recover, and sometimes claim that certain medicaments were “tested” and endorsed by sages and kings of yore. Magico-medical tablets from the 81-7-1 collection at the British Museum give detailed descriptions of steps in preparing medicaments and the weights of ingredients.1 These details may be characteristic of introductory medical school texts, since most recipes elsewhere in fact omit such precise instructions and quantities, and probably served as only mnemonic aids for healers who had already learned the correct proportions and dosages from repeated practice. Early in the 2nd millennium bce, healing incantations reeled off a “skeleton list” of the most frequent sicknesses. By the 1st millennium bce, lengthier incantations were clustered together with therapeutic recipes—all grouped together around the theme of a common ailment. By declaring the name of a malady and its nature or mythic history, incantations assert mastery over it and invoke benevolent deities to expel it. On occasion, accompanying rituals transfer illness to a clay figurine acting as the patient’s substitute.
The therapeutic tradition presupposes that the healer, when using these texts during medical practice, already has knowledge or suspicion of the identity of his patient’s sickness. Sicknesses are identified by names such as “ašû,” “sāmānu,” and “ṣētu,” or by association with a particular body part, as in “sick lungs,” “sick muscle,” and “sick rectum.” Healers recognized that a single sickness could encompass several bodily signs, but did not consider therapy directed specifically at signs to be merely palliative, corresponding to what we call “symptomatic treatment.” Small cuneiform tablets, containing only a single or a few recipes for a certain sickness, came into relevance only after the healer had determined a match between this sickness and what ailed the patient. Large cuneiform tablets grouping together many recipes and incantations on the same or related ailments, likewise, ordered their contents based on sickness identity. The Assur Medical Catalogue reveals that, by the 1st millennium bce, such therapeutic contents had become systematized into extensive text series, organized head-to-foot according to the body part associated with sickness. Enumeration a capite ad calcem followed the practice of a lexical list titled Ugu-mu (“My Cranium”) from early in the 2nd millennium bce, reflected also in various literary, religious, and magic narratives. Pharmacological glossaries titled Šammu šikinšu (“Nature of the Plant”), Abnu šikinšu (“Nature of the Stone”), and URU.AN.NA record the ingredient’s purpose, its method of preparation, and, in some cases, its colloquial name or Deckname (“code name”) used to obscure its identity from the uninitiated.
The diagnostic genre is overwhelmingly represented by the Diagnostic Handbook, with its ancient title Sa-gig. Under the Babylonian king Adad-apla-iddina (1068–1047 bce), the scholar Esagil-kīn-apli is said to have rewoven older diagnostic material in new ways to create the handbook, consisting of forty tablets assigned to six chapters. The handbook in large measure succeeded in replacing its precursors, so that other diagnostic works are preserved in smaller numbers, mainly from the 2nd millennium bce and often from areas peripheral to the Mesopotamian heartland, such as Hattuša and Susa. Whereas therapeutic texts arrange their descriptions of sicknesses from head to foot and generally depict bodily signs without reference to time, the second chapter of the Diagnostic Handbook organizes medical signs in head-to-foot order and assigns them to the first day of the patient’s sickness. In this way, the handbook sketches out how a healer progresses in his knowledge of the sickness—initially attempting to discover and interpret bodily signs in ways typical of omen divination, and only later arriving at a settled verdict on the sickness’s identity and its remedy. The blueprint, therefore, paints a realistic picture of medical practice that runs through the handbook’s six chapters, which can be summarized as follows:
En route to the patient’s house, the healer encounters omen signs on whether the patient would recover (Sa-gig Chapter 1). Meeting the patient on the first day of sickness, the healer surveys the body from head to foot for medical signs (Chapter 2). He then learns how these signs develop beyond the first day and at different times, noticing as well other signs pertaining to the whole which he may have overlooked while focused on specific body parts (Chapter 3). Individual signs are recognized as manifestations of a particular sickness, which is identified using labels from the therapeutic tradition (Chapters 3–5) and treated with medicinal ingredients (Chapters 4–5). Since the stereotypical body so far is adult and male, conditions experienced by other bodies—such as pregnancy, childbirth, and postnatal confinement, and infant sicknesses—are discussed as addenda (Chapter 6).2
In the Diagnostic Handbook, the patient’s body is described as “eaten” by pain or “struck” by the malady, while sicknesses are said to “befall,” “touch,” “seize,” “douse,” and “overwhelm” the patient and, in cases of recovery, “leave” him behind. Ailments are attributed to the actions or “hand” of antagonistic agents, such as various named gods and goddesses, demons, ghosts, and even human witches and sorcerers. At times, the patient’s suffering is explained as punishment for adulterous sex with another man’s wife, or incestuous relationships with his own mother or sister, or as retribution for the violation of oaths, or the failure to offer tithes and cultic gifts. Prognoses foretell whether the patient lives or dies—but even verdicts of death were not inevitable, since they could be remedied by apotropaic means, and therefore are not equivalent to our notion of “terminal” illness. Some try to identify medical signs in the handbook with diseases known today, but such retrospective diagnoses are often unreliable—based on highly subjective interpretations of the ancient text, and underestimating the extent to which diseases can change (“pathomorphosis”) due to the evolution of human–microbial relationships, as well as the role of culture and society in defining disease.
Aetiologies and Implications
Whether addressed by healing incantations or caused by malevolent agents, sicknesses derive mainly from influences outside the human body. This recalls the depiction of illnesses as self-willed entities escaping from Pandora’s jar (see Hes. Op. 90–105), and beliefs that plagues are sent from the gods. Relatively little is said in Mesopotamian medicine, however, regarding the maintenance of balance within the body—an idea that features prominently in Alcmaeon (2) of Croton’s view that health requires an internal “equilibrium” (isonomia) of opposing qualities, and in Hippocratic practices that maintain correct proportions of bodily humours through regimens of diet and exercise, and through the expulsion of excess substances by means of clysters, emetics, and bloodletting (e.g., Salubr. 1–5; Nat. hom. 9). Mesopotamian aetiologies of sickness, therefore, did not naturally lead to significant roles for dietetics and regimen in order to regulate internal imbalances. While medical diets have been imagined as evolved from food adapted for sick constitutions (Hippoc. VM 3), medicinal ingredients in Mesopotamia also include metallic and non-metallic minerals and other materials not typically used as food, which implies that treatment requires exceptional measures, rather than merely adjustments to the usual quantities. A heightened sense of possible threats from one’s environment led to concerns about contagion and sanitation. Healers cast prophylactic spells on themselves before daring to approach the sick. Rabid dogs are described as carrying semen in the mouth and leaving behind offspring with every bite, in an allusion to the transmission of rabies through saliva. In folk etymology, the lavatory demon “Šulak” is said to spread its harm through “hands” (ŠU) that are “not” (lā) “clean” (KU3)—a concern also reflected in archaeological and textual evidence of lavatories and sewers for the disposal of excrement.
From the late Achaemenid city of Uruk (c. 4th century bce) comes a highly unusual cuneiform composition (SpTU I, 43) that may be described as a Systemic Etiology, which ascribes origins to sicknesses “from” four ancient organ systems: (a) “from the heart” = the psychic system, (b) “from the mouth (and/of) stomach” = the alimentary system, (c) “from the lungs” = the respiratory system, and (d) “from the kidneys” = a lower-body excretory and reproductive system.3 Rather than representing a radical break from earlier aetiological models, which situate the materials and agencies for sickness outside the human body, the aetiology is possibly concerned instead with pathological identities. So, for example, the “retention of (flatulent) wind” is said to be “from the kidneys,” because wind becomes a sickness due to obstructions within the body’s excretory system, even though the gaseous contents themselves are believed to be “blown into” the body from the outside.
While extispicy omens involved examining the internal organs of sheep, human dissections and post-mortems were not performed. Medical writings employ metaphors of physical subjugation for illness, but address actual physical injuries less frequently, probably because methods of treating cuts and fractures were learned manually rather than from texts. Uncertain evidence exists for trepanning and circumcision within Mesopotamia, though these practices are attested elsewhere in the ancient Near East. The Assyrians performed castrations on some criminals and to create eunuchs for important cultic and palace responsibilities. In order to ensure a low enough mortality rate for the latter, only the testicles rather than the entire genitalia may have been removed. Household implements like sieves, mortars, pestles, and various vessels could be adapted for surgical uses, in addition to specialized instruments such as spatulas, reed and metal pipettes, tweezers, blades, and plant thorns for stitching wounds. Wool was the most common material for bandages, dressings, slings, and tampons. Prescribed analgesics include wine, willow, mandrake, henbane, hemp, and the opium poppy, which could ease pain from a toothache or when applying anal suppositories, but are insufficient for use in operative surgery. Inadequate antiseptics also meant that invasive procedures came with high risks of fatal infections. The Laws of Hammurabi (nos. 218–220) famously recommend severe fines and bodily mutilations for physicians who perform botched operations, and such punitive attitudes would have discouraged attempts at and innovations in surgical practice.
Healing Deities and Professions
Early in the 2nd millennium bce, the divine names Gula, Ninisina, Ninkarak, Bau (or Baba), and Nintinuga had come to designate the healing goddess and patron of the city of Isin, whose symbolic animal was the dog. The Sumerian compositions Ninisina A and Letter Prayer of Nannamansum, the Gula Hymn of Bulussa-rabi, and the votive inscription A Dog for Nintinuga all portray the goddess as a healer—cleaning wounds and applying dressings and bandages, employing lancets and scalpels, or reciting incantations, sometimes joined in her healing activities by her son Damu. Suppliants petitioned and gave thanks for recovery in the goddess’s temples at Isin and Nippur, where performances of apotropaic rituals may be implied by the discovery of figurines in the form of dogs, alone or accompanying a human, and of humans with hands laid upon what one may assume to be the sick body part. The Isin temple—so far, the one better studied thanks to a series of excavations—probably also served as a resource library for medical texts, though, unlike the healing temples of Asclepius, it does not seem to be large enough to function as a hospital allowing long-term stays by many patients.
“Physician” (asû) and “magician” (āšipu or mašmaššu; also translated “exorcist”) are the two professions most associated with medical practice in ancient Mesopotamia, but there is much uncertainty in delineating their functions. Large private libraries belong to the magician family of Kiṣir-Aššur in the city of Assur (7th century bce) and to the Šangû-Ninurta and Ekur-zakir magician families in Uruk (late 5th–4th centuries bce), and magicians and the “magician arts” (āšipūtu) are referenced in cuneiform catalogues and colophons across a wide range of divinatory and remedial-apotropaic genres, including those of medicine and astrology. By contrast, no library belonging to physicians has yet been found, and physicians receive surprisingly few mentions in medical texts, appearing mainly in letters, laws, and administrative records. In any case, one should not assume that professional purviews remained static for millennia and across distant regions, or that individuals and individual families could not have retained traditional titles while specializing in disciplines or engaging in activities that broke with convention. Medical texts, in rare instances, also mention the “diviner” (bārû), “dream interpreter” (šā’ilu), and “scholar” (ummânu). Mostly omitted from the corpora of text-based medicine, the roles of “midwife” (šabsūtu) and “wet nurse” (mušēniqtu) are well known elsewhere, and it is suggested that the “barber” (gallābu) too may have performed minor surgeries.
The safeguarding of knowledge, skills, and library resources within professional families was characteristic of scribal education and apprenticeships in Mesopotamia during the 1st millennium bce —illustrated, for example, by the use of Decknamen to conceal the identities of therapeutic ingredients from those outside the in-group. Understandably then, a couple of literary narratives allude to the difficulty of verifying the actual competences of medical professionals: the scholastic tale Why Do You Curse Me? derides a high-ranking healer as, in fact, an ignoramus of Sumerian high culture, while the story of The Poor Man of Nippur suggests that a charlatan may easily pose as a physician. During the second half of the 1st millennium bce, when Mesopotamia fell under Persian and Hellenistic rule, temples grew in importance as patrons of traditional cuneiform scholarship. Professions with closer ties to temple institutions, such as the magician and the lamentation priest (kalû), appear to take on expanded roles. The so-called Exorcist’s Manual lists large numbers of diverse text series in which magicians were supposed to be experts. In the same vein, cuneiform commentaries on the Diagnostic Handbook—many of which belonged to magicians like Anu-ikṣur from the Šangû-Ninurta family—present medical language and ideas in scholastic conversation with an astonishing variety of lexical, astronomical, religious, magic, and literary compositions, as a pretext for affirming existing ways of perceiving and describing the sick body common in the therapeutic tradition.
Therapeutic recipes occasionally expose patients, medicaments, and substitute figurines to irradiation from stars and planets, whose rays are supposedly efficacious for healing. From shortly after the zodiac’s invention in the late 5th century bce, there appeared calendar texts and other new astrological genres, which divided each zodiacal sign into thirteen or twelve micro-zodiacal parts. Any given date, therefore, became linked to certain zodiacal and micro-zodiacal names, which in turn prescribed plant, mineral, and animal substances with healing properties for the day. The logic connecting such names with ingredients is sometimes self-evident—for example, Month 4 Day 7, which corresponds to Scorpio 19°, comes with the instruction to “smear (the patient) with the moulted skin of a scorpion.” Schemes that rely exclusively on calendar dates, however, did not sit easily with the tenet that therapy should be tailored to the specific sickness. Various solutions arose, which included sickness or human body parts as variables to be considered, and one of these probably led to the invention of the “Zodiac Man” (Homo signorum)—a pairing of zodiacal signs with regions of the human body, whose earliest description had been credited to Marcus Manilius (Astronomica 2.453–465//4.701–710), but is now also identified in a cuneiform tablet (BM 56605) on medical astrology.4
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Medical Texts in Modern Translation
Introductions to Topics
1. Irving L. Finkel, “On Late Babylonian Medical Training,” in Wisdom, Gods and Literature: Studies in Assyriology in Honour of W. G. Lambert, edited by Andrew R. George and Irving L. Finkel (Winona Lake, IN: Eisenbrauns, 2000), 137–223.
2. See John Z. Wee, Knowledge and Rhetoric in Medical Commentary: Ancient Mesopotamian Commentaries on a Handbook of Medical Diagnosis (Sa-gig) (The Netherlands: Brill, 2019), 40, 352.
3. John Z. Wee, “A Systemic Etiology of Sicknesses from Ancient Iraq: Organ Systems and the Functional Holism of the Babylonian Body,” in Holism in Ancient Medicine and Its Reception, edited by Chiara Thumiger (Studies in Ancient Medicine 53; Leiden, The Netherlands: Brill, 2021), 318–356.
4. John Z. Wee, “Discovery of the Zodiac Man in Cuneiform,” Journal of Cuneiform Studies 67 (2015): 217–233.