Depression and anxiety in Babylon

Introduction

Over the last 25 years, we have drawn attention to Babylonian descriptions, understanding and treatment of neurological and psychiatric disorders.^1–5

Although the Babylonians had no understanding of brain or psychological function, they were remarkably observant describers of many medical disorders and behaviours which we see today and for which they had their own interpretations and treatments. We began with the neurological disorders of epilepsy ¹ and stroke, including so-called Bell's Palsy,^2,3 and more recently we discussed psychiatric disorders, including psychoses of epilepsy ⁴ and obsessive compulsive disorder, phobias and psychopathic behaviour. ⁵ We turn our attention now to depression and anxiety in Babylon.

Sources, dates, terminology and guide to the text

There were two Babylonian Empires. Best known is the biblical or Neo-Babylonian Empire from 626 to 539 BC, associated with the famous Nebuchadnezzar (604–562). However, the great corpus of Babylonian medical texts we have studied are associated with the first Babylonian Empire initiated by King Hammurabi circa 1792 BC, i.e. in the first half of the 2nd millennium BC.

The present text is unusual in some respects. The tablet is a copy and the original date is unknown, although very probably of the 2nd millennium BC when there was a major activity in the collection and editing of medical texts. It was published by Köcher ⁶ as number 234 in the series known to Assyriologists by the initials BAM, i.e. Die babylonish-assyrische Medicin in Texten und Untersuchungen. It was subsequently edited with a translation and commentary by Ritter and Kinnier Wilson. ⁷ It includes an unusually long clinical description followed by its treatment, in this case a ritual.

The concept of ‘depression’ either as a symptom or as a clinical entity would not have been known to the Babylonians. Babylonian accounts of mental illness are notable for their objectivity and the absence of subjective feelings and thoughts. ⁵ Indeed, the concept of ‘depression’ as a clinical diagnosis is relatively new in the late 19th and early 20th centuries AD when the word ‘depression’ was substituted for the Greek word ‘melancholia’ as theories about ‘black bile’ were no longer thought to be relevant. ⁸ In the Babylonian language, there is a noun, ašuštu, with an associated verb, ašašu, which is generally understood to mean ‘distress’, which might perhaps include ‘depression’, but one cannot be certain about the exact meaning in a given instance. Some medical texts include the term, zikurrudû, a Sumerian loanword meaning literally ‘a cutting off (or shortening) of life’. This has been interpreted to mean ‘suicide’, ‘attempted suicide’ or ‘suicidal tendencies’, ⁷ which, if correct, could imply ‘depression’ in some instances. The Babylonians did recognize and describe fear, either as puluhtu or as a verb, iptanarrud, ‘he is constantly afraid’. This may be subtly different from hīp libbi, literally meaning ‘breaking of the mind’ and interpreted here either as ‘nervous breakdown’ or possibly ‘panic attacks’.

It is uncertain whether the clinical description in the text below referred originally to a single case involving one ‘head of the household’ or, in the usual Babylonian medical tradition, presents the complete clinical picture derived from observing many examples. Finally in the ritual treatment subsequently and briefly described below, the word māmītu means ‘oath’ or compulsion, which we have discussed in more detail elsewhere. ⁵ Here, the construction and burial of two figurines or anti-māmītu images are designed to break the oath or hold of the offended personal god and goddess. The appeal is to a higher deity, Shamash, the sun god and god of justice.

Text translation

If an awīlum (or specifically the head of a household) has had a (long) spell of misfortune – and he does not know how it came upon him – so that he has continually suffered losses and deprivation (including) losses of barley and silver and losses of slaves and slave-girls, and there have been cases of oxen, horses, sheep, dogs and pigs, and even (other) awīlū (in his household) dying off altogether; if he has frequent nervous breakdowns, and from constantly giving orders with no (one) complying, calling with no (one) answering, and striving to achieve his desires while having (at the same time) to look after his household, he shakes with fear in his bedroom and his limbs have become “weak”; if because of his condition he is filled with anger against god and king; if his limbs often hang limp, and he is sometimes so frightened that he cannot sleep by day or night and constantly sees disturbing dreams; if he has a “weakness” in his limbs (from) not having enough food and drink; and if (in speech) he forgets (cannot find)the word which he is trying to say; then, as for that awīlum, the anger of (his) god and goddess is upon him.

To release him, and so that he shall not be overcome by his “fears”:

(Procedure): You shall make two anti-māmītu images, male and female, of clay and potter’s clay, and you shall write their names on their left-hand sides. (The female figurine) you shall dress with a coat, wrap and headcloth of blue, black and white wool. A white stone you shall put round her neck. (The male figurine) you will (likewise) clothe with coat, wrap and headcloth and a girdle of white unspun wool you will [bind] on his loins.

Then before Shamash you will prepare the (customary) ritual. You will set up a libation vessel and provide (side) dishes of dates and emmer-meal. You will prepare a sacrificial sheep-offering which is pure and without blemish, and the right shoulder, (both) fat and roast, you will present to him.

You will then introduce the anti-māmītu images to Shamash, declaring their names (and saying):

(Incantation)

O Shamash, king of heaven and earth, lord of law and just reform,

To preserve (the lives of) my statues I have purified the potter’s clay,

I have given them their silver beads.

(As) in presenting them to you I honour (you) by them, I glorify (you) by them,

(So) let this his statue become a man,

Let this her statue become a woman.

O Shamash, lord most high and knower of everything,

I, So-and so, son of So-and-so, thy respectful servant,

From this day on do walk before you.

(So) as your great divinity shines forth upon me,

With regard to the māmītu-influences which have seized me, which pursue me night and day,

Which are wasting my flesh, and stand (ready) to cut off my life,

By the command of your great godhead

Allow it to these (images) to be a substitute for my flesh and person,

My substitute figurines let them be.

(Now) unto Ereshkigal, the great Queen of the Underworld,

The(se) substitutes of myself do I bury in the earth, (saying):

Long life and good health

Do you decree for me, do you open up for me!

Discussion

The modern psychiatrist will recognize a remarkably accurate description of an agitated depression with biological features including insomnia, anorexia, weakness (and probably weight loss), impaired concentration and memory. As in the case of obsessive compulsive disorder, ⁵ the author does not describe subjective thoughts or feelings, but does observe dejection, fear and agitation, possibly panic attacks, which led to the initial interpretation as an anxiety state. ⁷ The sufferer (or possibly other sufferers) is the head of a household, a wealthy land-owner with a large staff, somewhat equivalent to the ‘Lord of the Manor’ in feudal England. There were many provocative factors including loss of staff, animals, crops and income, together with personal frustrations and thwarted ambitions. This condition is serious, resulting from the anger of his personal god and goddess and requires the spiritual services of a priest (ašipu). ² The ritual involves the construction of two figurines who were buried underground with appropriate incantations to the god Shamash and to the Queen of the underworld, with a view to absorbing or breaking the hold of their anger by sympathetic magic. The early and longstanding theory that a condition might pass to or be absorbed by some other body or agent still lingers in the world today by the wearing of stone necklaces and amulets.

Although they recognized it as abnormal, the Babylonians did not have a single word or name to describe the behavioural disorder they observed and is recorded here. About a millennium later, from the 5th to the 3rd centuries BC, Greek medical and philosophical texts introduced the concept of ‘melancholia’ as a distinct medical entity, although their clinical descriptions were fragmentary and the authors did not leave a systematic discussion of the condition. ⁸ The word ‘melancholia’, derived from melaina chole, meaning black bile, was based on an entirely new physiological concept of some diseases resulting from imbalance between four key humours, of which black bile was crucial and dominant in this form of madness and some other physical diseases. Whereas the Hippocratic tradition emphasized the brain as the seat of the disorder, Aristotle (384–322 BC) and his followers continued to implicate the heart. The humoral theory of disease continued to evolve in Greco-Roman medicine, especially under Galen (131–201 AD).

Nevertheless throughout this period and for many centuries to come supernatural theories of madness, including melancholia, continued to dominate. The supernatural force might exert its influence from a distance or by entering the subject's body, sometimes capriciously or sometimes as a form of punishment for personal or family wickedness or sinfulness. The affliction might be visited by one of many gods, demons, departed or evil spirits, including, later, the Christian god or the devil.

The Greeks recognized four types of divine madness associated with particular gods, i.e. prophetic madness (Apollo), telistic or ritual madness (Dionysus), poetic madness (the Muses) and erotic madness (Aphrodite and Eros). ⁹ Melancholia overlapped with poetic madness due to the presumed association between being melancholy and a genius.

The Babylonians too had their deities but they did not blame them for otherwise unexplained diseases or abnormal behaviour, for which they invoked a variety of demons and evil spirits or, as in this case, the wrath of their personal god and goddess. The concept of the anger of a personal god and goddess, in contrast to the senior or communal gods, such as Shamash, does not appear in general medical therapeutic texts, but does in texts which are mainly concerned with mental conditions. As far as we know, personal deities did not have the power of the senior gods, which explains the appeal to Shamash, the god of justice, in this instance. The choice of Shamash may perhaps be based on the patient's sense of injustice in his or her misfortune.

More modern accounts and psychological concepts of melancholia began to appear from both physicians and ministers of the Christian Church in Europe in the 17th and 18th centuries.^10,11 Willis ¹² viewed melancholia as ‘a complicated Distemper of the Brain and Heart’, but he rejected any humoral theory. Subcategories of melancholia such as simple, delusional, hypochondriacal, religious, and, later, involutional, emerged. Gradually, the heart was dropped and apart from a brief interest in the spleen and vapours, was replaced by the mind. A new English word, ‘depression’, began to creep into clinical accounts. Derived from the Latin, ‘to press down’, examples included: ‘depression of mind’ (Whytt), ‘depression of spirits’ (Pinel) and ‘depressing passions’ (Haslam). ⁸ Subjective accounts of melancholy feelings and thoughts were now included. There was much debate about: (1) the use of the word ‘melancholia’ or ‘melancholy’ as a temporary and often understandable feeling; a serious but treatable medical or psychological illness; or an inherent temperament, and (2) the relationship of melancholia to other forms of mental illness, especially mania.

With the emergence of psychiatry as an independent medical discipline in the early 19th century, ¹³ these preliminary 17th and 18th century accounts and debates culminated in an explosion of descriptive accounts and nosological revisions of mental illness throughout the century. This 19th century descriptive psychopathology and nosology has been reviewed for the English, German, French, Spanish and Italian literature by Berrios ¹⁴ and Berrios and Porter, ¹⁵ and also for melancholia and depression in particular, by Jackson. ⁸ As the century progressed, the word ‘depression’ was increasingly used as synonymous with or a substitute for ‘melancholia’, for example by D.H. Tuke (mental depression and nervous depression), Griesinger (states of mental depression) and Kraepelin (depressive insanity and manic-depressive insanity). Finally in the 20th century, after two and a half millennia, patience with the use of the word ‘melancholia’, which implied an unbelievable black bile humoral theory, eventually ran out and it was gradually dropped from international classifications of disease, such as ICD and DSM and replaced by the more neutral word ‘depression’.

What is striking about the Babylonian clinical description we present here is how closely it corresponds to modern views of a depressive illness. What is missing, however, is any account of subjective feelings and thoughts, in this case of a depressive or anxious nature. This is true of other Babylonian texts of neuropsychiatric or behavioural disorders, for example, Obsessive Compulsive Disorder. ⁵ The Babylonians had no knowledge of brain or psychological function but they were remarkably accurate observers and objective describers of diseases and behaviours. Subjective accounts of emotional feelings, thoughts, ruminations, attitudes, etc., are a relatively new phenomenon in medical texts in the last 3 to 4 centuries, perhaps in part stimulated by the Romantic Movement. ¹⁴ Babylonian descriptions for example of various types of seizure or stroke also correspond closely with modern observations and descriptions.^1,2 Accurate clinical observations, descriptions and categorization are the first steps in the development of medical practice and understanding. It seems this process began with the Babylonians in the first half of the second millennium BC.