close

Вход

Забыли?

вход по аккаунту

?

000168739

код для вставкиСкачать
Early Contributors to Nephrology
Am J Nephrol 1994; 14:307-312
Division of Nephrology. Department of
Medicine, The University of Southern
California School of Medicine,
Los Angeles. Calif., USA
Key Words
Maimonides
Body homeostasis
Nephrology
Uroscopy
Maimonides:
Physician and Nephrologist
Abstract
Maimonides (Moses ben Maimon) was born in 1135 in Cordoba, the son of a
Jewish rabbi. After a seminomadic upbringing in Spain and North Africa dur­
ing the rule of the Almohades, Maimonides settled in Fostate (Old Cairo),
where he became renowned as a physician, eventually being appointed as
court physician to Saladin and his son. Maimonides wrote both religious and
medical treatises, the latter including the Medical Aphorisms o f Moses in
which he deals with almost all aspects of health and disease. His aphorisms on
urine and the kidney were influenced by Galen, to whose contributions he
added new dimensions. His aphorisms dealt with a variety of renal diseases
recognized today.
Introduction
In the 12th century, the Almohades (A1 Muahhidin),
i.e. Unitarians, ruled what is now known as North Africa
from the Atlas Mountains to the borders of Egypt and
Spain. The Almohades were Islamic zealots who perse­
cuted believers of other faiths. They destroyed churches
and synagogues and offered the Jews 3 options: they could
convert to Islam (real convert), they could accept publicly
that Muhammad was the Prophet but could then practise
their Jewish laws in secret (pseudoconvert), or they could
leave for other lands. Jews who defied the Almohades,
refused to accept any of these options and continued to
practise Judaism in public were imprisoned, tortured and
executed.
The Life of Maimonides
In these oppressive and terrifying times for Jews, there
lived in Cordoba, Spain, the family of Rabbi Maimon, a
scholar and judge, who apparently was a descendent of
King David. On 30 March 1135 (the Passover eve of the
Hebrew year 4895), Rabbi Maimon had a son whom he
called Moses. His mother died at birth. Later the Rabbi
had another son, David, from a second wife.
Moses is now known as Maimonides, which is the
Greek word for ‘son of Maimon’. In the Hebrew language
the word ‘ben’ stands for the English word ‘son’, and so
Maimonides is known among the Jews as RMBM (pro­
nounced Rambam), an acronym for Rabbi Moses ben
Maimon. The Arabs called him Abu Amram Musa ibn
Maimon (fig. 1).
The Almohades conquered Cordoba in 1148 when
Maimonides was 13 years old. The Maimons remained in
Cordoba under the rule of the Almohades for a short time
and practised their Judaism secretly at their home. They
thus lived a double life which was worrisome, irksome
and dangerous. The Maimon family left Cordoba and
wandered into southern Spain and North Africa to finally
settle in 1160 in the city of Fez, Morocco. It is not clear
why they chose Fez, as it was also ruled by the Almohades.
It is possible that they believed that Fez would be a safer
place to live because they were strangers and their reli­
gious disguise would not be detected. Another reason
might have been the desire of Rabbi Maimon that his chil­
dren study with and be tutored by the great scholar of the
time, Rabbi Judah ibn Shoshan. When this teacher was
Shaul G. Massry, MD
Division of Nephrology
University of Southern California School of Medicine
2025 Zonal Avenue
Los Angeles, CA 90033 (USA)
© 1994 S. Karger AG. Basel
0250-8095/94/0146-0307
$8.00/0
Downloaded by:
Vanderbilt University Library
129.59.95.115 - 10/26/2017 8:56:35 AM
Shaul G. Massry
1
2
Fig. 1. A portrait of Maimonides, with
his name in Hebrew. With permission from
the New York Academy of Medicine.
Fig. 2. The tomb of Maimonides in Ti­
berias. The inscription in Hebrew says:
‘From Moses unto Moses, there was none
like Moses
Here rests the dust of the Great Eagle
The Giant of the Bible, understanding
and medicine.’
308
Massry
In 1187, at the age of 52 years, Maimonides had a son,
Abraham from a late marriage. Abraham grew to be a
Jewish scholar and a physician. Maimonides died on
December 13, 1204 (Tebeth 20 of the Hebrew year 4965).
He is buried in Tiberias, Israel, on the shores of the Sea of
Galilee (fig. 2). It is not clear why his burial site is so dis­
tant from the place of his death. A legend claims that his
family and friends could not decide where to bury him
because he did not leave instructions. They therefore
placed the coffin on the back of a camel and let it loose.
The camel walked without stopping for 7 days and 7
nights across the Sinai desert and then northward toward
Tiberias where it stopped. This was taken as a sign that
Maimonides wished to be buried in Tiberias and his wish
was fulfilled. It is also said that Maimonides wanted to
spend the last years of his life in the Holy Land. He died
before his wish could be realized, but his remains were
brought from Egypt for burial in Tiberias.
The Writings of Maimonides
Maimonides wrote both religious and medical treatises.
His religious writings were in Hebrew, while his medical
treatises were in Arabic. He produced 7 religious contribu­
tions (table 1). The most important among them is Mish­
neh Torah (Commentary on the Mishneh). The Mishneh is
Maimonides: Physician and Nephrologist
Downloaded by:
Vanderbilt University Library
129.59.95.115 - 10/26/2017 8:56:35 AM
arrested and executed in 1165 by the Almohades for prac­
tising Judaism, the Maimon family fled to Palestine and
settled in Acre.
Their stay in Acre was brief, and at the end of 1165
they moved to Egypt. During this journey, or shortly after
their arrival in Egypt, Rabbi Maimon died and his two
sons, Moses and David, settled in the city of Fostate (Old
Cairo). The desire of Rabbi Maimon was that David
should engage in commerce and be the breadwinner, so
that Moses could devote his time to scholarly endeavors
related to the study of Judaism and the Bible. David did
indeed become a merchant and dealt in precious stones, a
business that provided him with the means to support his
own family as well as his brother Moses. Not long after
their arrival in Fostate, however, David died in a ship­
wreck in the Indian Ocean while on a business voyage.
Maimonides was then faced with the task of supporting
his brother’s family and earning his own living. He
refused to receive payment for his religious services as a
rabbi, and instead began to utilize his knowledge in medi­
cine to practise the art of healing. His medical endeavors
were very successful. They brought him recognition and
fame and led to his appointment as court physician to the
famous Muslim military leader Saladin, as well as to his
son A1 Afdal, thereafter. He was offered the post of physi­
cian to Richard Coeur de Lion of England, but he
declined.
Table 1. Religious writings of Maimonides
Original name (Hebrew)
English translation
M ishneh Torah
M orahe N ibokhim
M a am ar Hahigayon
Safer H a-m itzvot
Iggereth H ashm ad
M a 'amar Techiyath H a-m ethim
Commentary on the M ishneh
Guide for the Perplexed
Book on Logic
Book of Commandments
Epistle to Yemen
Treatise on Resurrection
Table 2. Medical writings of Maimonides
Original name (Arabic)
English translation
A l M ukhtasart
Fusul M u s a fi a1 Tibb
Sharh Fusai Abuqrat
The Extracts
The Medical Aphorisms of Moses
A Commentary on the Aphorisms of
Hippocrates
On Coitus
On Hemorrhoids
A Discourse on Asthma
A Book on Poisons and the
Protection against Lethal Drugs
Fi al Jim a 'a
Fi al Bawasir
M aqalah f i al R abu
K ita b a lS u m u m W a a l
M etahhariz m in al
Adiwiya al Qilialah
Sharh A sm a al Uqqar
Fi Tadbir al Sihhah
Maqalah f i Bay an Ba ’d al
A 'rad W a-alJawab anha
fbrotogno.
k _
CT Hcp'a-*! ap!*jof«nir*crlîrWfi<Tim» Raí»
fir
umJum dtKsrinjm ua'ircj mccu.uni'r p tapi».
I
i
N nomicdf’ p*1« w ír n ton,i» cum cîi-'.ui:uup»rr
Air Mí»\íc* film» frru«ii à r ifrxrlttKu« t r ’Juhrfi»
mult.» • »púíór» lójr.’auciTmul;: fapicmu u j jphy
rftnoni mdruofi» ip ru r m furm t/rurr pecnt%
-+ '
kjc um nJr^rt fu firu mrr.ipi iru r cue ítcc(
tv n fit di'4!. !•* que ad uirr!!r«ni;fuur funr tt uifff«irtrr pí»iíí
tf.iiCi q«*» id f 0^iUî<«rTr fur»r ioni Jitul fuñí alwur ferait: c
>J ortufu|tfcuoiú fíi tjffttdb&uUsnM oui* ad fftsl&tqtjctnr
f r 0 * divurti opertrt fa* c f. in
fcmi> hol’frf untEunc e n tra
W ip-tim fp.Vu cu« i mdiirJtrc p*. vtt : f_ r. j J err* tú r T
- A » « y rárnfVocirfiuit pioe.ru cflMm nú ¿rt.r.c:: ú ic w aîituuif
H e JOfciópiMiúnr» u u ip !rn ín c J (¿psatr fuut focli» ccftni
\ A * tú«* c: r¿:rrtt¿ufi.*duAU> fr^JiiifndjTîiftrrt.iud^m nutrí
\
ría» mvcfTanj»íuti4ii:iuituddifrrntc. IroM tunct-im \prj
^ »rute» p'rrtpuu» mfJupru ccpbutf fud iiHiú di«u!pjtui:> de
*¿>aonfmi% .timuía C liala rr.rdkcrú *fynUum.t pefr mm te
itemet era»urlngu .tprjsnlmcs of
R j ITt ¿íuul
,¿*r. a aj»;.otifcri 'uis.r.Jpixinfrri leltm.in Mrfur Danu'
ixtaií f l d w
írljam cui! .tftproiitJrmii preuitV
u e m ú c ] M . ,-p«Iav* rápiba^ ir.ip orilrro«. «n loé
tu altqtu ron
fr» udut íufht irte* t¿ <Aptfhc:idcncá
«mac»arti*»atine* :fcJrelurwldevri’c» afu^iciffc» m roete
m cópthtfaiiLi jJcíphm denduo nutrí w \ mulu* erdierrfíí
nca>¿ft jJ e n inmemoiñ retnédum. fccw funm\»efifil¿ser
•yateurque ccpduutr jtpi>onfmo» ná pefuir pip r<H omr.iionc
íant cetfíTaru fue fam oc« Non vpocra» m « i oaftrtf fui»
urr óbaiTa? ¿Ifaraldi in onmiha» l u» .ue oÁpiuuit vra apfco'
rtfaofü nec allí<pu rrtnort* íUt» fu a r . H ecyrro pnmíti -td
rTvuftfxcmlioniAphohrmeraein» ■triili m pfrr.r. ( Ltorof
cCfjnoA^.necA^omf cempT^íTe frd dr^iíTcquú collr^íeci
Ct vf^*‘* G ilc z de Albas Iibrt» futft rfc* eíu»
Que dif
x it p vtmic6píex»oni\ ín exyoíuóc I lu o r ú y p x iiii.N rc c o
-nc«o rnr in tatafmodi aplionfmii fic\« fea mlibio raí freí
I
A Commentary on the Names of
Drugs
On the Regimen of Health
A Treatise in Elucidation of Some
Accidents and the Response
First Page o f the First Edition of the Aphorism t of Maimonides, Bologna, 1489
(From the copy in Dr. Fricdcnwald s collection)
Fig. 3. The 1st page of the 1st edition of the Latin translation of
the Medical Aphorisms of Maimonides, Bologna, 1498. With per­
mission of Dr. Friedenwald.
is in the Medical Aphorisms o f Moses that the contribu­
tion of Maimonides to the origins of nephrology can be
found. FusulM usafi al Tibb was composed between 1187
and 1190, written in Arabic and translated into Hebrew
and Latin. It contained 1,500 aphorisms, most of which
are derived from Galen.
Maimonides the Physician-Scientist
It is not known where and how Maimonides gained his
knowledge in medicine. It is accepted, however, that he
acquired the foundation of the art of healing in the West,
309
Downloaded by:
Vanderbilt University Library
129.59.95.115 - 10/26/2017 8:56:35 AM
an authoritative postbiblical collection of Jewish oral laws,
compiled by many scholars over the first 2 centuries AD.
Thus, the Mishneh represents Torah Baal Peh. the Hebrew
oral law. A parallel to Torah Baal Peh is found in Islam and
is called the Hadith. the ‘conversation’. The Mishneh was
codified in the 3rd century AD by Judah ha-Nasl; it was
then subjected to intensive study both in Babylon and Jeru­
salem. These studies produced a wide range of critical notes
called Gemara, which means ‘completion’. The Mishneh
and the Gemara make the Talmud. Thus, although there
are 2 Talmuds, a Babylonian and a Jerusalem Talmud, they
contain 1 Mishneh but 2 Gemaras. The Mishneh Torah of
Maimonides includes important, critical commentary on
the Mishneh and remains a classic even today.
Maimonides wrote 10 medical contributions (table 2).
The most important of them is Fusul Musa f i al Tibb, or
the Medical Aphorisms o f Moses (fig. 3). This treatise
dealt with almost all aspects of health and disease, and it
‘Man should believe nothing which is not attested (1) by rational
proof as in mathematical science; (2) by evidence of the senses; or
(3) by the authority of prophets and saints.’
He further declared:
‘Do not allow your mind to be swayed by the novelties which he
tells you, but look into his theory and his belief, just as you should do
concerning the things which he declares that he has seen; look into
the matter he declares that he has seen; look into the matter without
letting yourself be persuaded. And this is true, whether the person in
question is notable, or one of the people. For a strong will may lead a
man to speak erringly, especially in disputation.’
He continues:
‘In this aphorism, it is my purpose to bring before you something
well deserving your examination and belief: if anyone declares to you
that he has actual proof, from his own experience, of something
which he requires for the confirmation of his theory, even though he
be considered a man of great authority, truthfulness, earnest words
and morality, yet, just because he is anxious for you to believe his
theory, you should hesitate.’
Maimonides was a dedicated physician and worked
extremely hard in the service of patients. He described his
day as follows:
‘I dismount from my animal, wash my hands, go forth to my
patients, and entreat them to bear with me while I partake some light
refreshment, the only meal I eat in 24 hours. Then I go to attend my
patients and write prescriptions and direction for their ailments.
Patients go in and out until nightfall, and sometimes until 2 hour and
more in the night. I converse with them and prescribe for them even
while lying down from sheer fatigue. When night falls, I am so
exhausted that I can hardly speak.’
310
Massry
Maimonides the Nephrologist
The aphorisms of Maimonides on medicine and health
and those related to urine and the kidney, and thus to
nephrology, were influenced by Galen. He added new
dimensions, however, to the contributions of Galen. He
was praised by one of the authorities of his time in com­
paring him with Galen:
‘I deem Galen's medicine fit for the body,
But Abu Imran’s [Maimonides] for both body and mind.
Had the medicine of the time on him come to call.
Through knowledge he would have cured it of ignorance ills.’
Maimonides was also influenced by the medical apho­
risms of the Old Testament and the Jewish prayers. Fig­
ure 6 provides the original Hebrew text of a Jewish morn­
ing blessing and its English translation. This blessing
speaks of the life-threatening consequences of excessive
and severe urinary losses or diarrhea and of urinary or
intestinal obstruction. It ends by thanking God for acting
‘wondrously’. This is interpreted to indicate the wondrous
coordination of body function, and in medical lexicon,
‘body homeostasis’. Two of the aphorisms of Maimonides
deal with the same issues presented in the Jewish morning
prayer. First:
‘Bodies whose excretory passages are patent, their health status is
more permanent. When they become ill, they heal very easily. The
bodies whose passages are obstructed have opposite conditions pre­
vailing.’
In this aphorism, Maimonides recognizes the impor­
tance of a patent urinary tract for health and emphasizes
the danger of urinary obstruction. In the second aphorism
he states:
‘Elimination of excessive moist liquid occurs in one of three man­
ners: either through diarrhea, through the sweat, or in the urine.
Nature will push these fluids from whichever site we desire and will
seal off the other two sites. Therefore, should a crisis be near while
the patient is constipated or in urinary retention, then of necessity,
shivering should be induced and profuse sweating will ensue through
which the patient will lose his bad humor.’
This is an interesting description of how to maintain
fluid balance of the body and certainly describes body
homeostasis. It should be mentioned that even in modern
times, sweating has been used to treat uremic patients.
In the aphorisms of Maimonides, the word ‘cooking’ or
‘cooked’ is often encountered. Cooking means that the
organs of the body are doing their tasks adequately, and
complete cooking indicates successful achievement of
Maimonides: Physician and Nephrologist
Downloaded by:
Vanderbilt University Library
129.59.95.115 - 10/26/2017 8:56:35 AM
i.e. Spain and Morocco. This concept is based on certain
statements made in the writings of Maimonides, e.g.:
‘This is what we have received from the Elders of the Art’
and ‘This we have seen the outstanding Elders do in the
land of Andalusia’, though he did not mention the names
of those Elders. It has been said that he might have
learned medicine from 2 famous physicians of the time,
Abu Marwan ibn Zuhar (Avenzoar, 1091-1162, fig. 4)
and Ibn Rushd (Averroes, 1126-1198, fig. 5). It should be
mentioned that there is nothing in the writings of Mai­
monides to attest to this claim.
Maimonides was very critical in his medical thinking
and practice and demanded the same from others. He was
a true scientist. His medical thinking and writings were
governed by 3 principles that he detailed as follows:
Fig. 4. Abu Marwan ibn Zuhar (Avenzoar).
Fig. 5. Ibn Rushd (Averroes). A lithograph by Vigneron, in the
collection of the Wellcome Foundation, with permission.
Fig. 6. Jewish morning blessing. Both the Hebrew text and the
English translation are provided.
‘Blessed are you our God, King of the Universe, who fashioned
man with wisdom and created within him many openings and many
cavities. It is obvious and known before your Throne of Glory that if
but one of them be opened excessively or but one of them were to be
blocked, it would be impossible to survive and stand before you. You
are our blessed God who heals all flesh and acts wondrously.’
He provides several aphorisms on the value of urine
examination in diagnosing various illnesses. He states:
‘If the urine is fatty and its appearance and consistency as that of
oil. this is a bad [sign], causing death by dissolving the flesh because
heat [disease] which melts the flesh is dangerous’ ... ‘urine in which
foam [protein] accumulates reflects the chronicity of the illness.’
‘Maximally ‘cooked’ urine in the healthiest people is urine which
is even in thickness and whose yellowness leans to a tinge of redness
to deepen the yellow color. This urine may have white turbidity in it
which is flat and even and should settle to the bottom of a vessel.’
This description probably reflects the lipiduria and
proteinuria seen in nephrotic syndrome.
In another aphorism he describes macroscopic hema­
turia and (probably) acute glomerulonephritis. He states:
This sediment described by Maimonides is most prob­
ably urate. He recommends that urinalysis be done in all
patients with fever because the character of the urine may
provide information on the illness. This ancient advice by
Maimonides is commonly practised today.
‘There is a type of kidney ailment in which the patient micturates
rusty, thin urine similar to early excretions of a sick liver, and this
one contains more blood than others.’
He also describes the character of the urine in blackwater fever or hémoglobinurie fever:
311
Downloaded by:
Vanderbilt University Library
129.59.95.115 - 10/26/2017 8:56:35 AM
these objectives. It also indicates that nature has already
triumphed over the illness and has begun to excrete the
illness-producing liquids. Hence, the description that the
excretions of various organs are ‘maximally cooked’ re­
flects healthy conditions.
Maimonides defined normal urine as follows:
Body homeostasis
Kidney function
Obstruction of the urinary tract
Polyuria of diabetes mcllitus and/or diabetes insipidus
Nephrotic syndrome
Hemoglobinuria and/or blackwater fever
Proteinuria as an indication of the chronicity of illness
Macroscopic hematuria as an indicator of glomerular diseases
Use of sweating as a therapeutic modality in conditions with urine
retention*
* Sweating has been used in the treatment of uremia even in mod­
em times.
Further Reading
312
‘Black urine and black sediment are extremely malignant and
indicate serious illness. They occur in association with what resem­
bles the death of natural resources.’ ... T have never seen anyone who
urinated black urine who survived.’
He also warns about the dangers of polyuria:
‘When urine resembling water is micturated repeatedly as occurs
in people with the illness diabetes, this is the most unfavorable of all
uncooked urine.’
The word diabetes in this aphorism may indicate ei­
ther diabetes mellitus or diabetes insipidus.
It is apparent that the medical writings of Maimonides
contain many statements related to nephrology and de­
scribe many of the nephrologic concepts and renal dis­
eases known today (table 3). The name of Maimonides
should be added to the list of scholars who contributed to
the origins of nephrology.
Bar-Sela A, Hoff HE. Faris E: Moses Maimonides'
two treatises on the regimen of health. Trans
Am Philos Soc 1964;54:3-50.
Brodie A: The moral philosophy of Maimonides. J
Med Ethics 1988:14:200-202.
Posner F, Muntner S: Studies in Judaica. The Med­
ical Aphorisms of Maimonides. New York, Yeshiva University Press, vol 1,1970.
Posner F, Muntner S: Studies in Judaica. The Med­
ical Aphorisms of Maimonides. New York. Yeshiva University Press, vol 2, 1971.
Posner F. Muntner S: Moses Maimonides’ apho­
rism regarding analysis of urine. Ann Intern
Med 1971;71:217-220.
Posner F: The medical writings of Moses Maimon­
ides. N Y State J Med 1987,87:656-661.
Massry
Maimonides: Physician and Nephrologist
Downloaded by:
Vanderbilt University Library
129.59.95.115 - 10/26/2017 8:56:35 AM
Table 3. The medical writings of Maimonides on nephrology.
References to these functions and conditions are found in his writ­
ings
Документ
Категория
Без категории
Просмотров
0
Размер файла
1 390 Кб
Теги
000168739
1/--страниц
Пожаловаться на содержимое документа