Introduction:

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It took man centuries and millennia to build our present medical knowledge that we all take for granted. Medicine is the most respected and the oldest profession on earth. It had and still has a profound impact on human life and comfort. It is important for both physicians and laypeople to review the ancient roots of modern medicine.
Some readers may consider the title, Arabian Gulf: Cradle of Medicine, provocative.
It should not be. 
The reason I refer to the Arabian Gulf as the cradle of medicine is that the Gulf (Fig.1) is the region where human civilization began. 
There is no disagreement among historians that the north of the Gulf was the site of early civilization in human history.
The first human settlement was far south of present Iraq, which is now covered by the Gulf sea after the melting of the Ice Age (1). 
Historians agree that the Sumerians in the north of the Gulf, which is actually the south of present Iraq, were the first civilized people.

 

 

 

 

 

 

 

 

                                                                           Fig.1. The Arabian Gulf

Samuel Kramer, a well-known authority on Sumerian history, chose a dramatic title to one of his books: History Begins at Sumer (2).
The word civilization is related to urban settlement and cities and derives from Latin civitas (city). So civilization means "city-dwellers".
Archaeological discoveries have proven the existence of prehistoric societies from 58000 – 3000 BC. The Sumerian culture has been dated from 3000 BC in the city of UR. This coincides with the invention of writing by the Sumerians, which is the beginning of history. Prehistory is time before the invention of writing.
Some primitive societies still practice medicine exactly as they were carried out over thousands of years. Examples of such practices are witchcraft, exorcism, cautery, and bloodletting. Most of Arabian Gulf traditional medicine that is still practiced on a limited scale is inherited from the Mesopotamians. In fact, some of the Babylonian heritage is preserved not only by the Arabs but also by non-Arab Moslems (see table 1). Islam did not forbid all pre-Islamic traditions.

 

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Table 1. Babylonian Heritage

1. Eating pork was prohibited.

2. An eye for eye and tooth for a tooth.

3. Adultery was punishable by death (woman)

4. Polygamy was permitted.

5. Taking interest in a money loan was a sin.

6. Bath after sexual intercourse was a must.

 

Causes of Illness

The causes of Illness in Arabian Gulf traditional medicine were thought to be due to genii, The causes of Illness in Arabian Gulf traditional medicine were thought to be due to genii demons and witchcraft. The Gulf Arabs believed that disease is punishment by God for sins. These beliefs are, no doubt, Babylonian in origin. For thousands of years, the Gulf Arabs believed in the bad eye as a cause of disease. The bad eye concept as a cause of the disease is so prevalent, especially among the older generation of our society, that it is unlikely to vanish for years to come. The bad eye concept is well-explained by the Babylonians. They believed that a spirit may enter a person’s body, and it may leave through his eye, without his attention or knowledge, to possess another person when the former looks at the latter, the victim.
We frequently use the term Babylonian to indicate not only the Babylonian era, when Babylon was the capital of Mesopotamia, but also the entire history of Mesopotamia from its Sumerian origins to the Assyrian period, just as when we say Egyptian, we refer to the whole period of Pharaonic history.
The Babylonians achieved great progress in mathematics, astronomy and a variety of first inventions in history. It is beyond the scope of this article to discuss other than their medical history. Table 2 lists some of their scientific achievements.

 

 

Table 2. Babylonian Scientific achievements

1. Spinning, dyeing, and weaving. 

2. The use of gold (4000 B.C.). They also used bronze and iron.

3. Manufactured glass.

4. Prepared soap (3000 B.C.).

5. Invented a water clock.

6. Mathematical tables for the calculation of square, square roots, cube roots…

7. Number 60: the basis of hours, minutes and circle degrees

8. Measurements:weight (menu), length(elbow), distance and load.

9. Calendars.

10. Artificial pollination of palm trees

 

Before there were humans there was a disease

 

Disease forms have remained essentially the same throughout the millennia. There is no doubt that before there were humans there was a disease. But unfortunately, proof of the existence of diseases in prehistory can not the reasons for such practice is still speculative and explanations have ranged from treatment for epilepsy, headache, to venting for increased intracranial pressure; or an avenue for the devil to exist!
Trepanned skulls have also been found dating as early as 5000 BC in Mesopotamia.
be traced except through bones. Flesh decays fast and no traces of it could be found for analysis. Archaeologists have unearthed the skeleton of an individual dated 60,000 years ago in Shanidar cave, north Iraq. The skeleton was given the name Shanidar I, after the cave in which it was found. Shanidar I had multiple traumatic injuries, healed fractures and degenerative bone disease. He could not have survived such deadly injuries alone without someone caring and providing food for him (3). His story proves the existence of "humane" care in early societies.

 

The first physician

 

Since the Sumerians are credited with the earliest human civilization, it is not surprising that excavations in that region reveal the existence of a Sumerian physician seal as early as 3000 BC. That seal is the earliest proof of the existence of physicians during that era (Fig 2).

 

 

 

 

 

 

 

 

 

 

 

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Besides the invention of the wheel and writing, the Sumerians are also credited for the preparation of drugs and cosmetics and brewing of barley beer.CardiologystatedThey even had veterinarians and they called them, "healers of beef and ass."
The practice of medicine was not restricted to male physicians only. There is a single mention of a woman physician in an old Babylonian text from Larsa (5).
, "Writing on a baked clay tablet a physician recommended the addition of potassium nitrate to a number of medical cures" (4).

 

 

 

 

 

 

 

 

 

 

 

 

 

Fig. 3. Oldest known Sumerian medical book. 2200 B.C.

 

The first medical text

The oldest medical text was written by a Sumerian physician in the 3rd millennium BC on a clay tablet (Fig 3). This medical text is now at the University of Philadelphia Museum (6). Most Babylonian medicineClay tablets have been found mentioning liver, eye, respiratory diseases,
came from the botanical world. Their favorite mineral preparation was sodium chloride and potassium nitrate. fever

and gonorrhea. They showed some knowledge of night blindness, otitis media, renal calculus, stroke, and Babylonians administered drugs in every possible way short of injections: mixtures, potions, inhalation, ointment, liniment,
scabies. (7).enemas

and limited physical examination was carried out by the Babylonians. The temperature of the skin was tested in several parts of his body, the rhythms of the
suppositories. (6).pulse

wasThe discoloration of the skin and the color of the urine was noted. (5).
apparently recognized. 

Mesopotamian Disease theory

Unfortunately, the supernatural was the fundamental feature of ancient medicine such as Babylonian medicine. They also believed that disease was a punishment inflicted by the gods upon men for their sins.

 

The Mesopotamian Disease theory can be summarized as follows:

 

• Numerous gods and goddesses controlled health and disease.

• The disease was punishment for sin.

• When gods retract their protection, a man falls prey to disease-bearing devils and ghosts, which swarmed around Mesopotamia.

• The illness was essentially a moral and ethical defect, a black mark, a condemnation. Such an ailment called for a moral cure.

• Treatment: mostly magical and religious.

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There were, in ancient Iraq, true physicians who believed in the supernatural origin of most diseases, but who also recognized the causative action of natural agents such as dust, dirt, food or drink, and even contagion. Babylonian medical and philosophical beliefs.

 

The Babylonians had their own medical and philosophical beliefs. The following are some of their enduring beliefs (6):

 

1. The heart is the seat of the mind.

2. The liver is the seat of emotion.

3. The stomach is the seat of courage.

4. The uterus is the seat of kindness.

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These beliefs survived for thousands of years. They still exist, not only in Arab culture but also in many cultures around the world. In Muslim and Christian Holy Scriptures, the heart was the center of thoughts. The concept that the heart is the center of love is almost universal. Some ancient Arab poets associated both the heart and the liver with love. In the West, people still say, "he has guts", when they mean courage. Most people are not aware that the origin of such terminology goes back to the ancient Babylonians.

The medical team

There was teamwork among the ancient healers of Babylon as in modern medicine.

1. Baru-priest, or diviner, finds out the hidden sin responsible for the divine anger. The demons were exorcised by the Ashipu-priest using magical rites and incantations. The gods were appeased through prayers and sacrifices.

2. Ashipu made the diagnosis and prognosis. It was assumed that the patient's fate depended largely on his findings. His task was to perform the rites required for driving out an evil spirit from the body and for reconciling the patient with his god.
If the disease was obvious, it was the work of a certain devil and no further diagnosis was necessary!
In more complicated cases, the priest recited a long list of possible sins to the patient, hoping that he might be able to choose from them the sin that had caused his disease. If both methods failed, divination entered the scene (7).

3. Asu was the real   He provided rational medicine. In later society.  He had spent years at school learning the basic sciences of his time. A professional man belonging to the upper-middle class of the Assyro-Babylonian physician. He was neither a priest nor a witch-doctor, but a period however, the asu was superseded by the ashipu (5).

We have learned how an asu looked like from a humorous Babylonian story, The physician (asu): clean-shaven and carrying the two insignia of his calling – a libation   (alcohol) jar and a censer(incense burner)(5).  

In other descriptions, he carried a bag of herbs.

         Methods of Divination (prognosis) 

The Babylonian priests predicted the course of the disease using the following methods:

1. Astronomy & astrology: The Babylonians mastered this science. They watched the stars and calculated their movements with precision. They predicted eclipses with accuracy. Eclipses were considered bad omens. They consulted the stars to predict the course of a battle or the outcome of a disease. The prognosis was linked with the constellations of the stars and planets. The widespread practice of astrological medicine in Medieval Europe originated with the Babylonians.
   They made accurate calendars far ahead of their times. Much later on in history, a Roman emperor had to send for a Babylonian astronomer to make a calendar for the Roman empire.

2. Hepatoscopy: They examined the liver of sacrificed animal to foretell the course of the disease or other future events (Fig 4).

  3. Dreams: They believed that some dreams carried messages about the future

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Amulets

Amulets are written prayers or poems or parts of animals or plants or statuettes carried by individuals as protection to drive away evil spirits. The following is a poetic amulet (7):

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Seven are they,

seven are they,

In the Ocean Deep seven are they,

Evil are they,

evil are they,

Seven are they,

Twice seven are they!

 

By Heaven be ye exorcised! By Earth be ye exorcised. The Babylonians invented the concept that the last day of the week is for resting. They considered it a day of bad omen that may bring disaster. They stayed home as a preventive measure. The Jews adopted the Babylonian concept of resting the last day of the week but instead of a bad omen, they considered it holy.

Nowadays, germs have replaced spirits as causes of disease and immunization has replaced amulets for the prevention of disease.

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Preventive medicine and hygiene

It is not surprising that the Babylonians perceived that some diseases are contagious. They must have had experience with major contagious diseases such as the plague or minor diseases like the common cold.

One of the Mesopotamian kings, Zimri-Lim, King of Mari (I780 B.C.) wrote to his wife Shibtu:

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"I have heard that the lady Nanname has been taken ill... Now then, give severe orders that no one should drink in the cup where she drinks, no one should sit on the seat where she sits, no one should sleep in the bed where she sleeps. She should no longer meet many ladies in her house. This disease is contagious."(6).

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The original Babylonian word for contagious was Sabtu, which literally means "catching." The notion of contagion, isolation of lepers, and regular rest days, which came into modern culture seem to have been of Mesopotamian origin (7). Pouring water on hands before and after meals was a Babylonian custom. Urination in rivers was a sin (8). The Babylonians had an admirable sewage system and 4000-year-old water closets have been dug out by archaeologists.

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Medicine in Hammurabi’s Code of Law

Hammurabi, in his Code of Law (c.1695 BC), made the first declaration of human rights in history:

"To cause justice to prevail in the land..., that the strong may not oppress the weak. . ."

The practice of medicine was regulated by the state. Malpractice was recognized and was punishable by law. Hammurabi's Code of Law specified:

"If a surgeon performs a major operation on an 'awelum' (nobleman), with a bronze lancet and caused the death of this man, they shall cut off his hands".

However, there is no proof that such a punishment was ever carried out. Hammurabi also specified fees for lifesaving operations: "Ten shekels of silver for ‘awelum’, five shekels for ‘mushkenum’ (poor man) and two shekels for a slave" (6). Some features of Babylonian medicine are enumerated in table 3.

 

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Babylonian therapeutic challenge

Heart disease

We have no real proof that the Babylonian physician knew how to treat heart disease. However, there is a description of the treatment of "stricture of the lungs".The term "stricture" was a literal translation by a non-medical scholar. That term might have been pressure or squeeze sensation over the chest, which might have been angina or myocardial infarction. The prescribed treatment reads:

"Take . . . sheep kidney; dates, firtree, turpentine, Pinetree turpentine, laurel, opopanax, the resin of galbanum, mustard, cantharis ...Grind these in a mortar with fat and dates. Pour the mixture on a gazelle’s skin. Fold the skin. Put it on the painful area and leave it in place for three days. During that time the patient shall drink sweet beer. He shall take his food very hot and stay in a warm place. On the fourth day, remove the poultice...." (6).

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The prescription instructions indicate that there may have been chest pain since the patient was instructed to apply the preparation "on the painful area", which must be the chest area. The patient who was tied to gazelle skin might not be free to be active and that may have kept him resting in

bed for 3 days; the beer most likely relieved his pain. It appears that the Babylonians knew that three days was adequate bed rest for acute myocardial infarction, whereas we modern cardiologists practiced it only in the last decade! The patient was also advised to stay warm. Perhaps they also knew that cold weather aggravates angina!

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Urinary retention

Urinary retention was treated as follows:

"Crush poppy seeds in beer, make the patient drink it. Grind some myrrh, mix it with oil and blow it into his urethra with a tube of bronze" (6).

The treatment was effective. The opium (poppy) and the beer relieved the pain while the tube drained the urine. The insertion of a tube into the urethra indicates that they practiced invasive therapeutic interventions.

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Treatment of Alcoholic Intoxication [Withdrawal]

"If a man has taken strong wine and his head is affected and he forgets his words and his speech becomes confused, his mind wanders and his eyes have a set expression. To cure him, take licorice... beans, oleander. . to be compounded with oil and wine before the approach of the goddess Gula ..and in the morning before sunrise and before anyone has kissed him let him take it, and he will recover" (9).

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The above quotation is described as Treatment of Alcoholic Intoxication but it sounds like treatment of withdrawal. It is logical to add wine in the treatment of withdrawal but not in the treatment of intoxication.

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Tooth abscess

The Babylonians were very skilled in treating tooth abscess. Historians mention that an Egyptian king sent for a Babylonian dentist to treat his tooth abscess when his Egyptian dentist failed. They described their methods of treatment using herbs and oil to massage the gum so vigorously “until

blood comes out”. They must have learned from experience that the best treatment for an abscess is to drain it, as we do today.

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Origin of the association of snake and medicine

The Epic of Gilgamesh is the most famous of the Babylonian myths and is considered the father of epic literature. Gilgamesh sought immortality that was granted only to the gods. The snake ate the plant of immortality and shed its skin. The shedding of the skin was a sign that the snake possessed the power of regeneration and rejuvenation, hence the snake in the epic of Gilgamesh may have been the origin of its association in medicine. Ninazu, "Lord of Physicians", was an important healing deity and the emblem of his son, Ningishzida, was a double-headed snake (9). A double-headed snake ceremonial beaker (Fig 5) is another proof that the link between the snake and medicine is of Babylonian origin before the Greeks adopted the concept.

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King Esarhaddon and his doctors

The Assyrian king Esarhaddon was an interesting character: He Killed his father for the throne; he occupied Egypt; he had psychiatric disturbance and suffered from rheumatism. He had a substitute king 4 times. The substitute king was installed when a fortuneteller warned the king that he would be killed on a certain day. On that day the poor substitute was killed and Esarhaddon returned to the throne.

An Asu (physician) sent a letter to the Assyrian king Esarhaddon:

"Replying to what the king my lord wrote me, ‘send me your true diagnosis": I have given my diagnosis to the king my lord in one word: ‘Inflammation.’ He whose head, hands and feet are. . . inflamed, owes his state to his teeth: his teeth should be extracted. On this account, his insides are inflamed. The pain will subside, the condition will be most satisfactory" (9).

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King Esarhaddon was impatient. He repeatedly said to his physician:

"Why do you not recognize the nature of this illness of mine, Why do you not bring about its cure?" (9).

Whereupon Arad-Nana ‘sealed and sent a letter to the King’:

"If it is agreeable in the sight of the king my lord, let a magician perform an exorcism. Let the king take this bath: immediately his fever will leave the king, my lord. That anointing with oils should be done two or three times for the king my lord. That disease is in the pus. They should bring liquorice to the king. Exactly as they have done twice already, they should massage (him) vigorously. I intend to come and give instructions. At once the perspiration of the king will come. I am sending to the king my lord a concoction (?) of those things; let him apply it to the flesh of his neck. May the king anoint himself on the appointed day with the liniment which I am sending." (9)

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Esarhaddon, however, consulted not only his asu, but also his ashipu, his exorcist. He complained:

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"My arms (and) legs are limp, and I cannot open my eyes. I am smeared (with liniments) and abed with fever, it burns my very bones." (9)

The priest answered:

"At (the root) of this there is no sin. Ashur, Shamash, Bel, (and) Nabu will bring about the recovery. His illness will leave, (his condition) is truly most satisfactory." (9)

It was common in those days to try drugs on slaves before giving them to the royals. Adadshum-user, crown prince's asu wrote:

"Concerning the medicine about which the king my lord wrote (me), it is perfectly safe. As the king my lord has commanded, we shall give it to those slaves to drink. Afterward, the crown prince may drink. . . The king’s commands shall be fulfilled as are those of a god." (9)

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Exchange of Physicians

It was normal for Mesopotamian kings to send their physicians for consultations when the Egyptian king was sick and vice versa. It was a friendly gesture with a political motive to strengthen their relations. So, at foreign courts, Babylonian and Egyptian physicians competed.

In 1300 B.C. the Egyptian physician Pareamakhu was in Anatolian courts and a Babylonian Raba-sha-Marduk was at the Hittite court and in 1280 B.C. the king of Babylon sent a physician to the Hittite monarch Hattusil (9).

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Evolution of Medical History

Both the Mesopotamian and Egyptian lands witnessed a fruitful exchange of medicine with Europe over thousands of years. First, Mesopotamian medicine was transmitted in part to the Greeks, and together with Egyptian medicine, it paved the way for the great Hippocratic reform of the fifth century B.C. Then, during the rise of the Arab Empire (8th -10th century), Greek medicine was translated into Arabic. The Arabs preserved Greek medicine when most of the original works were lost from Europe. The Arabs improved on Greek medicine as well as made new discoveries over several centuries. In the 13th and 14th century Greco-Arab medicine was transferred to Europe again from Arab capitals such as Cordoba in Andalusia, Spain, and Baghdad in Iraq. It is true that not only medicine but human civilization started north of the Arabian Gulf, but neither medicine nor civilization belongs to one nation on earth. Nations as well as civilizations borrowed from each other medicine, science, arts, and technology over centuries of human development. Fortunately for us, in the field of medicine, the same trend is continuing in the medical sciences. No country has a monopoly on medical science today. With the present vast publications and fast communications via the internet, medicine is becoming a global science. In fact, the whole world is becoming a village on a small planet in our universe.

Medical history shows us the evolution of medicine, how medical therapies come and go, and how useful procedures become not so useful. Some of us may laugh at the diagnostic and therapeutic methods used by the ancient Babylonians. But to be fair we should credit the Babylonians and ancient Egyptians for starting the foundations of medicine with their trial and error. Through such trial and error, they laid down the foundations of medicine upon which this field

progressed. They deserve our admiration. Modern medicine with its scientific theories has its roots in the "old" theories of the past. Many of today's medical facts and theories sprang out from yesterday's myths and errors. Today's truth might also become tomorrow's myth.

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References:

1. Michael R. Cultural Atlas of Mesopotamia and The Ancient Near East. Equinox (Oxford) Ltd. 1990:20.

2. Kramer SN. History begins at Sumer. University of Pennsylvania Press. 1956.

3. Trinkaus E, Shipman P. The Neandertals. Pimlico. 1993.

4. Am. J Cardio. Packer M. Hormone-Electrolyte interactions in congestive heart failure. Lessons from a 4000-year-old Sumerian tablet. 1990;65:(Suppl): 1E-3E.

5. Joan Oates. Babylon. Thames and Hudson Ltd. London 1979.

6. G Roux: Ancient Iraq. George Allen & Unwin Ltd 1964.

7. Ackerknecht E H. A Short History of Medicine.The John Hopkins University Press. 1982.

8. Al Badri A. Min’ Al Tib Al Ashuri. Iraq Science Society Press 1979.

9. Sigerist HE. A Story of Medicine, vol.1. Oxford University Press 1951.

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