11.1 The Oldest Known Prescription

A prescription strictly defined is a physician's order to the pharmacist for medicinal substances. That order includes directions to the pharmacist for the prescription and directions for the patient's use of the medicine.

This article will describe and discuss the contents of a clay tablet from Nippur in the Middle East. The tablet was inscribed toward the end of the dynasty founded by Sargon the Great, some time during the last quarter of Third Millennium B.C. The prescriptions on the tablet can be divided into three classes in accordance with the remedies that were applied. This particular tablet is from ancient Sumer, between the Tigris and Euphrates in ancient Mesopotamia

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I. THE POULTICE PRESCRIPTIONS

Stated very simply, a poultice is a warm medicated dressing. The tablet first provides a list of simples to be utilized with each prescription. These are then pulverized and mixed with a liquid in order to form a paste. This is then fastened as a poultice to the 'sick' part of the body after it has been rubbed with oil. The rubbing with oil is done either for its intrinsic value or to keep the paste from clinging to the skin. You may find the following specific prescriptions to be interesting.

(1) Pulverize the branches of the thorn plant and seeds of the duashbur; pour diluted beer over it, rub with vegetable oil and fasten the paste over the sick spot as a poultice.

(2) Pulverize river mud, kneed with water, rub with crude oil, and fasten as a poultice.

(3) Pulverize the roots of the (?) tree and dried river bitumen; pour beer over it, rub with oil, fasten as a poultice.

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II. INTERNAL REMEDIES

This groups of prescriptions were intended to be taken internally. Here are two specific prescriptions.

(1) Pour strong beer over the resin of the (?) plant; heat over a fire; put this liquid in river bitumen oil, and let the sick person drink.

(2) Pulverize two simples and dissolve them in beer for the sick man to drink.

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III. THE COMPLEX THIRD GROUP

These prescriptions seem to be introduced by a difficult and enigmatic passage which reads, "arrange (?) the rushes over the hands and feet of the sick person. Following this, the operations consist primarily of washing the ailing organ with a specially prepared solution. This is followed immediately by the covering of the ailing organ with some substance that seems to include burnt ashes. In the next paragraph is described on the of four specific prescriptions.

"Sift and knead together, all in one, turtle-shell, the sprouting naga plant and mustard; wash the sick spot with quality beer and hot water; scrub the sick spot with all of the kneaded mixture; after scrubbing, rub with vegetable oil and cover with pulverized fir."

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The Sumerian physician went to botanical, zoological and mineralogical sources for his materia medica. His favorite minerals were sodium chloride (table salt), river bitumen, and crude oil. Animal sources were wool, milk, turtle shell, and water snake. Like their modern counterparts, most of the medicinals came from the botanical world. The plant sources included thyme, mustard, plum tree, pears, figs, willow, fir, pine and products such as beer, wine, and vegetable oil.

Very likely, the physicians practiced along empirical-rational lines. There is no evidence of magical spells and incantations which are often a feature of cuneiform medical texts of later days. (My note: cuneiform is a wedge-shaped writing system wherein a read was pressed into clay to make the characters. Much of the surviving text in surviving text is concerned with business and accounting.)

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Symbols that appear in the 'world's oldest prescription'

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V. EDUCATION IN ANCIENT SUMER

The ancient physician who prepared this medical tablet was not just a narrow practitioner of his profession, but was a cultured and educated humanist--a man of letters. In order to learn to write correctly and elegantly in the cuneiform writing format he had to spend much of his youth in the Sumerian school, or 'Academy'- known as the Edubba, or tablet house.

Here he studied and absorbed whatever 'scientific' and literary knowledge that was current for his day. The 'text books' consisted primarily of compilations of words, phrases, paragraphs, extracts, and whole compositions prepared by the ummias or professors of the Academy, which the student had to copy and recopy until he knew them by heart. These compilations which were consise, terse, and unadorned, were no doubt accompanied by oral explanations, or lectures.

This ancient pharmacopeia may well have been a compilations of this sort prepared by a practicing physician who was a lecturer on medicine at the Academy. If so, this tablet is a sort of 'page' from a textbook.

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VI. PRESCRIPTIONS IN THE 20th CENTURY

Most prescriptions today are simply orders for proprietary preparations which are ready made medicines sold under a brand name or generic equivalent. Seventy years ago, it was not uncommon for a physician to order a 'shotgun' polypharmacological monstrosity containing 20 or more ingredients.

Nowadays, virtually every prescription is for a commercially prepared product identified by name. Some pharmacists report that they can tell what detail man was calling on the doctors by the type of prescriptions that flow into their pharmacies.

One other interesting aspect of prescriptions is the issue of compliance. Depending on the variable studied and the strictness of definition, 15 to 95% of patients have been found NOT in compliance with the directions. Overall, 1/3 to 1/2 of patients make some error with their medications. These include incorrect dose, inaccurate timing, taking something else, or doing nothing. Patient compliance is often poor.

..... CJ '97

Resources

Goodman, L. & Gilman, A. The Pharmacological Basis of Therapeutics. New York: The

Macmillan Company. 1960.

Kramer, S. "The World's Oldest Known Prescriptions", an article received with the

purchases artifact from the University Museum, University of Pennsylvania.