Psychoses of epilepsy in Babylon: The oldest account of the disorder
Address correspondence to Edward H. Reynolds, Institute of Epileptology, Weston Education Centre, King's College, Denmark Hill Campus, Cutcombe Road, London SE5 6PJ, U.K. E-mail: firstname.lastname@example.org
We have previously published translations of Babylonian texts on epilepsy and stroke, which we believe to be the oldest detailed accounts of these neurological disorders from the second millennium BC. We now present a short Babylonian text, which clearly describes what are today known as interictal or schizophrenia-like psychoses of epilepsy. The text includes many of the classical symptoms of the syndrome, for example, paranoid delusions, hallucinations and mood disorders, as well as religiosity and hyposexuality, which have only been crystallized in the twentieth century. The Babylonians were remarkably good observers of human disease and behavior but had little or no understanding of pathology or brain function. Although they recognized many natural causes of disease, epilepsy and behavior disorders were attributed to supernatural, usually evil forces, the forerunner of the Greek concept of the Sacred Disease.
We have previously published a Babylonian neurological text on epilepsy based on a tablet in the British Museum, London, and a duplicate in the Archeological Museum at Ankara, Turkey (Kinnier Wilson & Reynolds, 1990, 1991). The epilepsy tablet is numbered 26 in a series of 40 tablets which comprise an early Babylonian treatise on diagnostic medicine known as Sa-gig (Sumerian) or Sakikku (Babylonian), which means “all diseases” (Kinnier Wilson & Reynolds, 1990, 1991; Stol, 1993). The exact date in the middle of the second century BC of the original compilation is not known, but a revised edition was composed during the reign of the Babylonian king, Adad-apal-iddina, between 1067 and 1046 BC and the two surviving tablets are copies, which have descended from that time.
The Babylonians were keen observers of neurological and medical disorders and the epilepsy tablet provides accurate descriptions of what we recognize today as tonic–clonic, absence, Jacksonian, complex partial and even gelastic seizures. However, they had little understanding of pathology and no understanding at all of the functions of the brain. Seizures were thought to be due to supernatural invasion of the body by demons, each seizure type associated with the name of a particular demon, the forerunner of the Greek concept of “the Sacred Disease” (Temkin, 1971).
A Babylonian Text on Epileptic Psychoses
The Babylonians were also accurate describers of human behavior and one of us (JKW) has identified a number of older tablets, which collectively suggest that they had a grasp of abnormal behavior amounting to the beginnings of modern psychiatry (Kinnier Wilson, 1965, 1967). Among these is a remarkable account of what today we call epileptic psychoses or schizophrenia-like psychoses of epilepsy (Slater et al., 1963; Trimble, 1991).
The relevant texts are AMT 96,7 (i.e., Assyrian Medical Texts in the British Museum) and its duplicate KAR 26 (i.e., Keilschrifttexte aus Assur Religiösen Inhalts published in Berlin), which can be traced back to the first half of the second millennium BC.
The key passage from these Babylonian texts has been published by Kinnier Wilson (1965). By way of illustration, we have included below the first few lines of the text, slightly abbreviated for the sake of clarity, which confirms its relevance to epilepsy. The lines read in transcription:
šumma amēlu antašubbû bēl ūri…qāt etimmi qāt māmîti…
eli-šu ibašši alû lemnu ireddi-šú…
and may be literally translated:
“If a man has been suffering from antašubbû, bēl ūri, qāt etimmi or qāt māmîti, and an alû lemnu then begins to inflict him with ideas of persecution…"
Of the terms mentioned, the first antašubbû, is a Sumerian loanword and has long been understood to mean “the falling disease,” that is, epilepsy characterized by major seizures. The term bēl ūri which follows means literally “the lord of the roof,” and was evidently the ancient term for an absence attack, the common rolling up of the eyes being caused, supposedly, by a demon lurking in such a position as the roof of a house. qāt etimmi means “the hand (power or influence) of a ghost,” and although it may have had a wider significance, we have suggested (Kinnier Wilson & Reynolds, 1990) that it refers to nocturnal epilepsy. The word māmîti in qāt māmîti literally means “oath,” but was used medically to denote conditions involving obsession or repeated action, as if the patient had sworn an oath to perform a certain action and could not be dissuaded from doing it. In the context of epilepsy, the term may readily be understood as referring to the automatisms of epilepsy or postictal confusion. The words alû lemnu translate, nonspecifically, to “evil demon.” For a more detailed discussion of the translation of Babylonian and modern words in relation to the various manifestations of epilepsy, see Kinnier Wilson & Reynolds, 1990.
Below we now present a translation of the text of the whole passage.
“If a man has been suffering from seizures, absence attacks, nocturnal epilepsy or automatisms, and an (or, possibly, the) evil demon then begins to inflict him with (ideas of) persecution so that he says—although no one will agree with him that it is so—that the finger of condemnation is being pointed at him behind his back and that god or goddess are angry with him; if he sees horrible, alarming, or immoral ‘visions’ and is (consequently) in a constant state of fear; if he engages in periodic outbursts of anger against god or goddess, is obsessed with delusions of his own mind, evolves his own religion, and says—although (again) they will not allow it—that his family are hostile towards him and that god, king, his superiors and (city) elders treat him unjustly; if all his muscles are subject to weakness, if his eyes are colored red, yellow and black, if he has a condition of speech such that he forgets what he wants to say, has no desire for female relationships and no inclination to pursue any activity (at all) …,” (details of the action to be taken by the ashipu, i.e. medical exorcist, follow, but the text is broken at this point).
In understanding the text from the Assyriological point of view, it is important to consider what is meant by the introductory, “If a man.” It is a general, and all-embracing, statement applying, as it were, to everyman, for the “textbook” manner of describing a disease with many symptoms was to present the total picture. This is also illustrated in other Babylonian psychiatric texts, for example, a detailed description of an anxiety state (Ritter & Kinnier Wilson, 1980). Some details in the present text bear out this conclusion. Thus, it should be realized that the phrase “god, king, superiors and (city) elders” is a stereotype phrase occurring numerous times in the psychiatric texts. It represents a summation of the several kinds of “enemies,” so familiar in paranoia, which might frustrate the patient's intentions or oppose his will. In line also with this comprehensive approach may be the discoloration of the eyes as indicated in the account. Ecchymosis around the eyes is quite rare in epilepsy, but nevertheless it claims its place in the physician's overall typology. Likewise, impairment of memory may also occur in the context of epileptic psychoses, but an alternative explanation for “forgets what he wants to say” may be thought block associated with his psychosis.
The association of epilepsy and insanity has been traced to the Greeks (Temkin, 1971). It was Hippocrates who suggested that epilepsy and madness were not supernatural but both arose in the brain. Both were thought to be influenced by the moon and in nineteenth century Europe epileptic patients were to a great extent treated and cared for in lunatic asylums. It was only in the late nineteenth and early twentieth century with the evolution of neurology from neuropsychiatry (Reynolds & Trimble, 1989) that it became clearer that most patients with epilepsy have normal mental states. Furthermore, in those patients who exhibit mental symptoms the latter can be classified into prodromal, ictal, postictal, and interictal disorders (Trimble, 1991). It was only in the mid-twentieth century that the concept of the interictal schizophrenia-like psychoses of epilepsy crystallized with the seminal studies of Slater et al. (1963). What is very remarkable about this Babylonian text is its close resemblance to present descriptions of schizophrenia-like psychoses of epilepsy, incorporating paranoid delusions of persecution, visual hallucinations, emotional instability and impulsive acts (e.g., fear, anger), negative behavior and even including such modern concepts as religiosity and hyposexuality. The latter behavioral features have only been recognized in the second half of the twentieth century as part of a wider interictal personality disorder occasionally associated with temporal lobe epilepsy (Lishman, 1987; Reynolds & Trimble, 1989; Trimble, 1991).
This account of epileptic psychoses again illustrates the very observant descriptions of disease by the Babylonians as we also noted in our earlier studies of the epilepsy tablet (Kinnier Wilson & Reynolds, 1990, 1991) and in an additional diagnostic tablet on stroke (Reynolds & Kinnier Wilson, 2004; Kinnier Wilson & Reynolds, 2007). Although the Babylonians understood that many medical conditions, such as dysentery, worm infections, lung and eye diseases, wounds and injuries, had natural causes, epilepsy, stroke, and behavior disorders were the result of supernatural or “‘hand of God” causes. The former were treated by an asû or medical practitioner, who used a wide range of plant and mineral products or surgical techniques, whereas the latter was the concern of the ashipu, or medical exorcist, who may be regarded at least in part as history's first psychiatrist (Kinnier Wilson, 1965, 1967). These earliest detailed descriptions from the second millennium BC suggest that the phenomenology of these disorders may have been remarkably constant over 3,000–4,000 years, although our understanding of their nature and treatment have changed profoundly.
Conflict of interest: We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. Neither of the authors has any conflicts of interest to disclose.