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Nephrology and Urinalysis in the Writings of Moses Maimonides
NEPHROLOGY: HISTORICAL PERSPECTIVES
Nephrology and Urinalysis in the Writings of Moses Maimonides Fred Rosner, MD, FACP • Moses Maimonides, renowned medieval Rabbi, philosopher, theologian, astronomer, and physician, wrote 10 medical treatises. These include extracts from Greek medicine and a series of monographs on health in general and several diseases in particular. This essay describes Maimonides' knowledge of nephrology as found in his writings and presents an English translation of an entire chapter from his Medical Aphorisms dealing with urinalysis. © 1994 by the National Kidney Foundation, Inc. INDEX WORDS: Nephrology; urinalysis; Maimonides.
M
OSES MAIMONIDES was born in Cordoba, Spain, on March 30, 1138. His mother died in childbirth and, consequently, his father Maimon raised him. Persecution by the Almochades (Almoravids), a fanatic Moslem group from North and West Africa, forced the Maimon family to flee Cordoba in the year 1148. The family wandered through southern Spain and northern Africa for the next 10 years and finally settled in Fez, Morocco. Little is known of Maimonides' early life and medical education. There are no sources indicating that Maimonides had any formal medical education. In his Medical Aphorisms (see below), he mentions "the elders before whom I have read," one of the few allusions to some semiprivate study of medicine. A few times he mentions the son of Ibn Zuhr, from whom he heard teachings of the latter's illustrious father (the great physician Abu Merwan Ibn Zuhr), whom Maimonides held in great esteem. Maimonides must have been an avid reader since his medical writings show a profound knowledge of ancient Greek authors in Arabic translations as well as of Moslem medical works. Hippocrates, Galen, and Aristotle were his Greek medical inspirations and Rhazes of Persia, Al Farabi, and Ibn Zuhr the Spanish-Arabic physician are Moslem authors frequently quoted by Maimonides. From the Department of Medicine, Mount Sinai Services at Queens Hospital Center, Jamaica. NY; and the Department ofMedicine, the M Ollnt Sinai School ofMedicine, New York, NY. Received November 5, 1993; accepted in revisedform March 1, 1994. Address reprint requests to Fred Rosner, MD, FACP, Queens Hospital Center, 82-68 164 St, Jamaica, NY /1432. © 1994 by the National Kidney Foundation, Inc. 0272-6386/94/2402-0011$3.00/0 222
The Maimon family left Morocco in 1165, traveled to Palestine, landing in Acco, and from there to Egypt where they settled in Fostat (old Cairo). Maimonides turned to medicine as a livelihood only after the death of his father in 1166 and the death of his brother in a shipwreck shortly thereafter. Maimonides was left with his brother's wife and child to support and, after a year's illness following his father's death, entered into the practice of medicine. In 1174, at the age of 39 years, he was appointed court physician to Visier AI-Fadhil, Regent of Egypt during the absence of the Sultan, Saladin the Great, who was fighting in the Crusades in Palestine. It was at this time that Richard the Lion-Hearted, also fighting in the Crusades, is reported to have invited Maimonides to become his personal physician, an offer that Maimonides declined. His reputation as a physician grew in Egypt and neighboring countries, and his fame as a theologian and philosopher became worldwide. Maimonides was also the spiritual leader of the Jewish community of Egypt. At the age of30 years, in the year 1168, shortly after settling in Fostat, he completed his first major work, the Commentary on the Mishnah. In 1178, 10 years later, his magnum opus, the Mishneh Torah was completed. This monumental work is a 14-book compilation of all biblical and talmudic law and remains a classic to this day. In 1190, Maimonides' great philosophical masterpiece, the Guide for the Perplexed was completed. Maimonides died on December 13, 1204, and was buried in Tiberias. Legend relates that Maimonides' body was placed on a donkey and the animal set loose. The donkey wandered and wandered and finally stopped in Tiberias. That is the site where the great Maimonides was buried. Maimonides was a prolific writer. His famous trilogy consists of the Commentary on the Mish-
American Journal of Kidney Diseases, Vol 24, No 2 (August), 1994: pp 222-227
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nah, the Mishneh Torah, and the Guide for the Perplexed. Each of these works alone would have indelibly recorded Maimonides' name for posterity. However, in addition to these, he also wrote a book on logic (Ma'amar Hahigayon), a book of commandments (Sefer Hamitzvot), an epistle to Yemen (Iggeret Teman), a letter on apostasy (Iggeret H ashmad), a treatise on resurrection (Ma'amar Techiyat Hametim), commentaries on several tractates of the Talmud, and over 600 Responsa. Several additional works, including the so-called Prayer of Maimonides, are attributed to him but are, in fact, spurious, the prayer having been written in 1783. 1 Over and above all these books, Maimonides also wrote 10 medical works, which have been summarized elsewhere. 2 More extensive information about Maimonides' medical writings can be found in the numerous essays by Kroner, Muntner, Meyerhof, Leibowitz, Rosner, and others as cited in extensive bibliographies on Maimonides the physician. 3,4 The present essay deals with nephrology and urinalysis as found in the medical writings of Maimonides. This subject was addressed briefly by a modern urologist in a series of articles published between 1967 and 1976. 5- 8 Maimonides was quite knowledgeable about the anatomy and pathophysiology of the urinary tract, as will be shown. ANATOMY
Maimonides describes two kidneys from which distilled urine passes through the "two vessels" (ureters) in the "reservoir" (urinary bladder), where it is kept until the sphincter relaxes and the urine is excreted through the urethra. He also describes the testicles, the scrotum, the penis, and the uterus. Maimonides quotes Galen, who wrote that "a man whose right testicle is larger than the left has male children whereas a man with a large left testicle has female offspring." The same applies to a woman's breasts. In his major medical work, entitled The M edical Aphorisms of Moses,9 Maimonides quotes Galen, who states that the "right kidney is somewhat higher than the left" and that "the urinary bladder receives vessels to nourish it and has a tube [urethra] to remove wastes." The bladder is said to be "a type of muscle." Although the membranes of the kidneys contain small nerves, "the bladder receives a large nerve so that its sen-
sation is finer and stronger. The penis, the genitals and uterus have an abundance of nerves necessary for sensation during cohabitation." PATHOLOGY
In his legal code known as Mishneh Torah, Maimonides describes defects and diseases in animals that render them terefah, or nonkosher. lO For example, if a kidney is exceedingly small, or if it is afflicted with disease (that is, if its flesh is like dead flesh that has putrefied after several days, so that if one grasps it at one end it disintegrates and falls to the ground), and if this disease has progressed as far as the white matter inside the kidney, the animal is terefah. Likewise, if secretion (even if not malodorous) or turbid or malodorous liquid is found in the kidney, it is terefah: if clear liquid is found in it, the animal is permitted. An exceedingly small kidney probably represents end-stage renal disease from chronic nephritis. The other disorders may represent benign and malignant tumors or cysts, renal abscesses, or other diseases. One cannot be certain. PATHOPHYSIOLOGY
Maimonides accurately describes the symptoms oflower urinary tract obstruction, including hesitancy, a narrow stream, dripping, and urinary retention. He distinguishes between urinary retention in the elderly and anuria, a condition in which "no urine reaches the reservoir because the kidneys cease to function." In his Commentary on the Aphorisms of Hippocrates,11 Maimonides quotes Hippocrates, who says that diseases of the bladder and kidneys in the elderly are difficult to heal. He also speaks of patients who discharge copious amounts of thick white urine (?pyuria) or who urinate blood or pus. Fleshy substances or hair-like substances (?filaria) in the urine are said to come from the kidneys or the bladder. Maimonides also describes urinary sediments resembling "pistachio hearts." Fat in the urine, he asserts, is evidence of the dissolution of the kidney. Strangury occurs because of weakness of the bladder or sharpness of the urine. The former is due to a bad constitution or inflammation that develops there. Sharpness of the urine occurs because of the admixture of stinging humor. An inflammation in the uterus or rectum damages the bladder because
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of its proximity. A tear in the bladder or kidneys, according to Maimonides, is not always fatal. In describing urine in various diseases, Maimonides states that "Most patients with fever have thin urine at the beginning of the illness. The closer they get to the end, the thicker the consistency of the urine. . . . Sometimes the urine resembles lime and is sparse at the beginning of the illness. The reason for the sparseness is that it traverses the kidneys with difficulty. When the major part of the bad humor has been evacuated and the remainder thereof cooked, the patient urinates thinner urine and in large amounts. . . Transparent urine is the furthest away from being cooked and it indicates that the illness will be protracted . . . Urine is turbid only if the heat of the fever acts on the thick substances in, and the copious amounts of the urine; or if it acts on the substances alone. If the heat is extraordinarily great, gases are produced so that the urine becomes thick and turbid like wax or pitch or cinnabar resin. The thick gases and the heat rapidly ascend to the head and headache is produced. Sometimes it occurs during the micturition of the turbid urine; at other times it occurs earlier, and at yet other times it occurs later."
Regarding illnesses, Maimonides speaks of bladder stones and describes renal colic, calculi, and abscesses. Thick chymes are said to cause pain in the kidneys (?nephritis). Kidney disease is present if the patient micturates rusty, thin urine. In his medical book entitled The Art of Cure: Extracts from Galen,12 Maimonides states that stones form in the kidneys when the latter contain a coarse viscous humor that was warmed and burned. In his Treatise on Asthma, 13 Maimonides again speaks of pain in the kidneys, stones in the kidneys, and urinary retention. DIABETES
The word "diabetes" in Hebrew letters (diabetia) is present in the original Arabic manuscript of Maimonides' Medical Aphorisms as well as the medieval Hebrew translations. Maimonides must have taken the word directly from the Greeks. The Greeks used the word "diabetes" to refer to a disease characterized either by excessive passage of urine or the passage of sweet urine. Maimonides discusses both polyuria and glycosuria in his Medical Aphorisms. 14 For example, in chapter 6, he quotes Galen who postulated the cause of diabetes to be in the kidneys and bladder: "Individuals with sweet white humors are very somnolent [?hyperglycemia or ketoacidosis]. Those with an excess
of sour white humor are hungry [?hypoglycemia]. If an excess of salted white humor prevails, they are extremely thirsty. When the white liquid is neutralized, the thirst disappears. "
Later, in chapters 8 and 24, Maimonides again quotes Galen, who said that diabetes is rare and that he only saw two cases of this disease. Maimonides, however, claims that in the warm climate of Egypt, he saw 20 patients with diabetes and postulates that the sweet waters of the Nile may play a role in the causation of the disease. He also states that the disease is due to the prevailing heat that spreads over the kidneys. THERAPY AND PREVENTION
Maimonides usually advocates conservative management of genitourinary ailments, with the exception of renal abscesses, for which he advises early surgery to evacuate the pus. He states that drinking radish juice cleanses the kidneys and bladder and that diuresis should not be induced in healthy people but only in patients with certain illnesses. 13 Diuretics should not be given when bleeding occurs from the kidneys or bladder. Wounds in the bladder or kidneys are treated with honey and other substances that make the urine flow. If a patient with continuous fever and putrefaction of humors excretes ripe material in his urine, the fever will spontaneously resolve completely in 11 days. Hectic fever and consumption may follow a sickness in the uterus or kidneys. To cure such illnesses, it is necessary to empty the putrefying wastes by stimulating urine flow and bowel emptying. Catheters or tubes to collect urine from the bladder are described. Some kidney sicknesses are treated by bloodletting. Diuretics should be avoided for "hot tumors" of the bladder, penis, or kidneys. One who eats coarse foods forms stones in his kidneys. 12 In his three treatises on the regimen of health, 15 Maimonides states that it is not proper to exercise until one has cleansed oneself from superfluities, that is to say urine and feces. He also says that wine is not only nourishing and rapidly digested but is a good diuretic. People who drink cold water on leaving the bath may develop chilled kidneys. In his legal code known as Mishneh Torah 16 Maimonides states that if one interrupts urinati~n or defecation, one may develop very serious and dangerous illnesses. He does not specify the na-
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ture of these illnesses, but the talmudic assertion on which his statement is based is more explicit: "withholding feces brings on dropsy, and keeping back urine brings on jaundice."!7 URINALYSIS
In Maimonides' major medical work, his Medical Aphorisms, the entire fifth chapter is devoted to examination of the urine in health and in disease. Maimonides seems to allude to hemoglobinuria when he states that "black urinary sediments signify either fiery heat or extreme cold . . . every urine which turns black is extremely malignant. I have never seen anyone who urinated black urine who survived. . ." The final aphorism in this chapter is a concise outline by Maimonides of Galen's views on the four basic types of urine. The reader must bear in mind the medieval concept of disease production. Disease was thought to be due to disruption of the normal equilibrium between the four body humors: blood, phlegm or white bile, choler or yellow bile, and melancholy or black bile. These humors were supposed to represent various combinations of the four basic elements that compose the human organism: fire, air, earth, and water. Each of the latter had two qualities: fire warms and dries, air warms and moistens, earth cools and dries, and water cools and moistens. In blood these elements are equally distributed; in phlegm water predominates, in yellow bile fire predominates, and in black bile earth predominates. Each human being is born with a particular combination of or mixture of these elements. Any change or disruption in this equilibrium was thought to result in ill health. Ancient and medieval physicians frequently wrote in the form of aphorisms. This custom can be traced to Hippocrates, who was followed in this regard by many illustrious physicians, such as Galen, Rhazes, Alfarabi, Ibn Zuhr, and Maimonides, among others. I present below my English translation of chapter 5 of the Medical Aphorisms of Moses Maimonides. Each aphorism concludes with a citation of the source on which it is based, all works of Galen. Latin, rather than Greek titles of Galen's works are given for ease of reading by the English reader. Words in brackets are my own additions to clarify the meaning of certain
phrases; they are not included in the original. I hope the reader will thus gain additional insight into medieval medicine and the medical genius of Moses Maimonides. The term "cooking," which recurs throughout this chapter, is translated literally from the original and probably refers to body humor metabolism with resultant formation of urine that has different qualities, as described in the text. THE FIFTH TREATISE contains aphorisms pertaining to the examination of the urine.
1. It is obligatory to perform tests and to examine the urine during any fever because fevers are sicknesses in arteries. Therefore, in pleuritis, first examine the sputum and afterwards examine the urine because pleuritis is not ordinarily one of the fever-producing illnesses. Similarly, if there is a disease in the abdomen accompanied by fever, first examine the stool and then look at the urine. If there is no fever, only examine the stools. De Crisiblls VI 2. The most propitious sediments of those which settle in the urine in patients with fever due to sepsis are those which arise from the humor which already became putrefied by the arteries which contained it. From this, evenly distributed white sediments develop in the urine without detestable odors. De Febribus I 3. If the particles of the urinary sediment are all equal in appearance and in substance, it signifies the dominance of nature over the illness and its rule over it. Urine in which foam accumulates is caused by a cold humor and therefore shows the chronicity of the illness. Comment. Aphorismorwn VII 4. The most favorable urine in ill people and the one which most closely resembles the urine of healthy individuals and the maximally "cooked" urine in very healthy people is urine which is even in thickness and whose yellowness leans to a tinge of redness to deepen the yellow color because some moisture of blood and red bile become mixed into it. De Crisibus I 5. The most propitious type of urine has a good appearance and contains white turbidity which is smooth and even. If it settles to the bottom of a vessel, it is the best. If [it settles] in the middle, it is less favorable than the first. If it floats on top, it is less favorable than the second. These three types indicate the [degree of] "cooking." Of
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the other types of urine, some show the opposite of cooking and some herald a catastrophe. De Crisibus I 6. The evenness of sediments and their settling down set forth two conditions. One is that sediments should not be dispersed and diffuse but remain compact, and the second is that they should remain so at all times. Sometimes the urine is clear at a certain time but at another time it contains settlings and sediment. In such a case, the observed sediment is not one of the favorable ones since it indicates that cooking was not completed. De Crisibus I 7. The most favorable urines are those of patients whose urine, when excreted, shows completely favorable sediments which are fully cooked because this signifies that nature has already triumphed over the illness and has begun to excrete the illness-producing humors. After this in propitiousness is a urine which is micturated turbid but which settles out favorable sediments after standing awhile since this signifies that nature has commenced the activity of cooking and will soon complete this activity. After this second type in propitiousness is a urine which is micturated thick but then clears and in which no sediment forms at all. This signifies that the cooking time is far off even though nature has initiated efforts in this direction. De Crisibus I 8. A sediment always occurs in the urine of those ill with fever which developed from complete rest and relaxation and in those who increase their food intake at the end of the illness. However, in those who develop fever from work and toil, the illness often terminates without any sediment at all developing in the urine. They rapidly complete the cooking with the appearance of a white, flat and even turbidity in the upper part of the urine or suspended in the middle. De Crisibus I 9. Ifillnesses occur secondary to favorable humors, urinary sediments are plentiful. If these [illnesses], however, originate from red humors, no sediments at all form or only very few. Comment. Prognostikon II 10. The most unfavorable of all urines in sick people is the thin, clear one which resembles well water and is clear and translucent. It is the furthest possible from being cooked. Somewhat less dangerous is the urine which is excreted thin and clear but a short time later becomes cloudy since
FRED ROSNER
this signifies that nature, although behind in its task, will soon perform it. Less favorable than the second is the urine which is micturated cloudy and remains cloudy because this shows that nature is as yet undecided and, although attempting to cook [the urine], has not yet clarified the matter. De Crisibus I 11. Among kidney ailments is one in which the patient micturates rusty, thin urine similar to the early excretion of a sick liver and this one is slightly more bloody than the other. De Locis Affectis VI 12. If the urine is of an oily bile type, it is a sign of the dissolution of the fat from the heat of the fever. If the urine is actually fatty and its appearance and consistency is that of oil, it is a bad [sign] and leads to death by dissolving flesh because the heat which melts the flesh is more dangerous than the heat which [only] dissolves oil. Commentarius Epidemiarum III 13. Urine resembling water that is micturated repeatedly as occurs in people with the illness diabetes is the most unfavorable of all uncooked urines and occurs because of the death of two powers: the natural power of metabolism and the retention power. De Crisibus I 14. Black urinary sediments signify either fiery heat or extreme cold. They occur in association with what resembles the death of the natural powers. Ashen-appearing sediments, however, occur only secondary to cold. De Crisibus I 15. Every urine which turns black is extremely malignant. I have never seen anyone who urinated black urine and survived. Black sediments [in otherwise clear urine] signify a less dangerous situation. A black cloud suspended in the middle of the urine is even less dangerous than black sediments. A black cloud floating on top of the urine is even less dangerous than one suspended in the middle. De Crisibus I 16. If a cloud or black sediments, either black in appearance or which actually contain particles resembling "groat kernels" or beaten-out plates, float on top of white urine which is thin as water, these are fatal signs. The same is true of a foulsmelling urine or fatty urine which is called oily, all of which are fatal. These [types of] urines indicate that the patient has in his nature a serious life-threatening situation. De Morborum Temporibus VI
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17. Every appearance of urine except white, dark yellow or red is a sign of [imminent] death. The same [is true] of what is excreted in the urine except for sediments which settle or suspended turbidity or a favorable cloud floating on top of the urine. All three [occurring simultaneously] are a bad sign or an indication of death. De Crisibus I 18. If the illness is oflong duration and [healing] activity is delayed and the patient is micturating thin urine for a prolonged period, the crisis usually ends with the excretion of an abscess. But if thick urine is excreted, favorable sediments develop which settle [in the urine] and begin to slowly cook the illness. No crisis occurs during the excretion of the abscess. De Crisibus III 19. If the urine contains particles resembling peeled barley flakes or lentil kernels, this shows that [the illness] comes from the liver. If these particles resemble flesh, it signifies they originated in the kidneys. If they resemble beaten-out plates, it shows they came from the urinary bladder. Particles which resemble groat kernels in size and hardness and are not white indicate the melting of flesh and nerves. Black particles signify the dissolving of splenic fat. Urine which resembles donkey urine indicates an excessive accumulation of raw humors called chyme. Commentarius Epidemiarum VI, 5 20. Moses says: The implication in the words of Galen in his [book] On Crises is that the most favorable of all urines of sick patients is the one in which favorable sediments are seen. This is called the first type because nature has already completed its activity and has cooked the illnessproducing material. The next in order of propitiousness is the urine which is micturated cloudy but after being excreted becomes clear through the settling of favorable sediments since this signifies that nature has already commenced its work and will soon complete its task. This is the second type of urine. After this in propitiousness is that which is nearly cloudy and then becomes clear but where sediments do not settle since this demonstrates that nature has already begun its work but is not even close to the time of cooking. This is the third type. After this in propitiousness is one which is micturated turbid and remains turbid since this one is further away from being
cooked than the previous one. This is the fourth type. Following this is the one which is urinated clear and thin and later becomes turbid because this indicates that nature has not yet begun its activity but will shortly do so. The most unfavorable of all is urine which is micturated thin and remains very thin since this shows the complete absence of cooking, not at the present time nor in the near future. End of the fifth treatise.
REFERENCES I. Rosner F: The physician's prayer attributed to Moses Maimonides. Bull Hist Med 41:440-454. 1967 2. Rosner F: The medical writings of Moses Maimonides. NY State J Med 73:2185-2190. 1973 3. Rosner F: Maimonides the physician: A bibliography. Bull Hist Med 43:221-235. 1969 4. Rosner F: Maimonides the physician: A bibliography. Clio Med 15:75-79, 1980 5. Kook H: Genito-urological items in the scripts of Rambam. in Koroth, vol 4 (#5-7). Jerusalem. Israel, Israel Society of the History of Medicine and Science and the Jerusalem Academy of Medicine. 1967. pp 448-451 6. Kook H: Genitourinary items in the writings of Maimonides. in Koroth, vol 6 (#3-4). Jerusalem. Israel, Israel Society of the History of Medicine and Science and the Jerusalem Academy of Medicine. 1973, pp 216-221 7. Kook H: Maimonides the physician as seen by a modem urologist. in Koroth, vol 6 (#7-8). Jerusalem. Israel, Israel Society of the History of Medicine and Science and the Jerusalem Academy of Medicine, 1974. pp 489-496 8. Kook H: Maimonides as seen by a modem urologist. Int Surg 61 :390-392. 1976 9. Rosner F. Muntner S: The Medical Aphorisms of Moses Maimonides. vol I. New York. NY. Bloch Publishing. for Yeshiva University Press, 1970 10. Maimonides M: The Book of Holiness, Laws of Ritual Slaughter. Chapter 8. section 26. New Haven, CT, Yale University Press. 1965. p 298 II. Rosner F: Maimonides' Commentary on the Aphorisms of Hippocrates. Haifa. Israel. Maimonides Research Institute. 1989 12. Barzel US: Moses Maimonides' The Art of Cure-Extracts from Galen. Haifa. Israel, Maimonides Research Institute. 1992 13. Rosner F: Moses Maimonides' Treatise on Asthma. Haifa, Israel. Maimonides Research Institute. 1993 14. Rosner F: Medical Aphorisms of Moses Maimonides. Haifa. Israel, Maimonides Research Institute, 1989 15. Rosner F: Moses Maimonides' Three Treatises on Health. Haifa. Israel. Maimonides Research Institute. 1990 16. Maimonides M: Mishneh Torah-Hilchot Tefillin, chapter 4. section 20. New York, NY, Moznaim Publishing, 1990. p 94 17. Epstein I (ed): The Babylonian Talmud. Tractate Berachot. Folio 25a. London. UK, Soncino Press, 1948. p 149
Nephrology and Urinalysis in the Writings of Moses Maimonides Fred Rosner, MD, FACP • Moses Maimonides, renowned medieval Rabbi, philosopher, theologian, astronomer, and physician, wrote 10 medical treatises. These include extracts from Greek medicine and a series of monographs on health in general and several diseases in particular. This essay describes Maimonides' knowledge of nephrology as found in his writings and presents an English translation of an entire chapter from his Medical Aphorisms dealing with urinalysis. © 1994 by the National Kidney Foundation, Inc. INDEX WORDS: Nephrology; urinalysis; Maimonides.
M
OSES MAIMONIDES was born in Cordoba, Spain, on March 30, 1138. His mother died in childbirth and, consequently, his father Maimon raised him. Persecution by the Almochades (Almoravids), a fanatic Moslem group from North and West Africa, forced the Maimon family to flee Cordoba in the year 1148. The family wandered through southern Spain and northern Africa for the next 10 years and finally settled in Fez, Morocco. Little is known of Maimonides' early life and medical education. There are no sources indicating that Maimonides had any formal medical education. In his Medical Aphorisms (see below), he mentions "the elders before whom I have read," one of the few allusions to some semiprivate study of medicine. A few times he mentions the son of Ibn Zuhr, from whom he heard teachings of the latter's illustrious father (the great physician Abu Merwan Ibn Zuhr), whom Maimonides held in great esteem. Maimonides must have been an avid reader since his medical writings show a profound knowledge of ancient Greek authors in Arabic translations as well as of Moslem medical works. Hippocrates, Galen, and Aristotle were his Greek medical inspirations and Rhazes of Persia, Al Farabi, and Ibn Zuhr the Spanish-Arabic physician are Moslem authors frequently quoted by Maimonides. From the Department of Medicine, Mount Sinai Services at Queens Hospital Center, Jamaica. NY; and the Department ofMedicine, the M Ollnt Sinai School ofMedicine, New York, NY. Received November 5, 1993; accepted in revisedform March 1, 1994. Address reprint requests to Fred Rosner, MD, FACP, Queens Hospital Center, 82-68 164 St, Jamaica, NY /1432. © 1994 by the National Kidney Foundation, Inc. 0272-6386/94/2402-0011$3.00/0 222
The Maimon family left Morocco in 1165, traveled to Palestine, landing in Acco, and from there to Egypt where they settled in Fostat (old Cairo). Maimonides turned to medicine as a livelihood only after the death of his father in 1166 and the death of his brother in a shipwreck shortly thereafter. Maimonides was left with his brother's wife and child to support and, after a year's illness following his father's death, entered into the practice of medicine. In 1174, at the age of 39 years, he was appointed court physician to Visier AI-Fadhil, Regent of Egypt during the absence of the Sultan, Saladin the Great, who was fighting in the Crusades in Palestine. It was at this time that Richard the Lion-Hearted, also fighting in the Crusades, is reported to have invited Maimonides to become his personal physician, an offer that Maimonides declined. His reputation as a physician grew in Egypt and neighboring countries, and his fame as a theologian and philosopher became worldwide. Maimonides was also the spiritual leader of the Jewish community of Egypt. At the age of30 years, in the year 1168, shortly after settling in Fostat, he completed his first major work, the Commentary on the Mishnah. In 1178, 10 years later, his magnum opus, the Mishneh Torah was completed. This monumental work is a 14-book compilation of all biblical and talmudic law and remains a classic to this day. In 1190, Maimonides' great philosophical masterpiece, the Guide for the Perplexed was completed. Maimonides died on December 13, 1204, and was buried in Tiberias. Legend relates that Maimonides' body was placed on a donkey and the animal set loose. The donkey wandered and wandered and finally stopped in Tiberias. That is the site where the great Maimonides was buried. Maimonides was a prolific writer. His famous trilogy consists of the Commentary on the Mish-
American Journal of Kidney Diseases, Vol 24, No 2 (August), 1994: pp 222-227
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nah, the Mishneh Torah, and the Guide for the Perplexed. Each of these works alone would have indelibly recorded Maimonides' name for posterity. However, in addition to these, he also wrote a book on logic (Ma'amar Hahigayon), a book of commandments (Sefer Hamitzvot), an epistle to Yemen (Iggeret Teman), a letter on apostasy (Iggeret H ashmad), a treatise on resurrection (Ma'amar Techiyat Hametim), commentaries on several tractates of the Talmud, and over 600 Responsa. Several additional works, including the so-called Prayer of Maimonides, are attributed to him but are, in fact, spurious, the prayer having been written in 1783. 1 Over and above all these books, Maimonides also wrote 10 medical works, which have been summarized elsewhere. 2 More extensive information about Maimonides' medical writings can be found in the numerous essays by Kroner, Muntner, Meyerhof, Leibowitz, Rosner, and others as cited in extensive bibliographies on Maimonides the physician. 3,4 The present essay deals with nephrology and urinalysis as found in the medical writings of Maimonides. This subject was addressed briefly by a modern urologist in a series of articles published between 1967 and 1976. 5- 8 Maimonides was quite knowledgeable about the anatomy and pathophysiology of the urinary tract, as will be shown. ANATOMY
Maimonides describes two kidneys from which distilled urine passes through the "two vessels" (ureters) in the "reservoir" (urinary bladder), where it is kept until the sphincter relaxes and the urine is excreted through the urethra. He also describes the testicles, the scrotum, the penis, and the uterus. Maimonides quotes Galen, who wrote that "a man whose right testicle is larger than the left has male children whereas a man with a large left testicle has female offspring." The same applies to a woman's breasts. In his major medical work, entitled The M edical Aphorisms of Moses,9 Maimonides quotes Galen, who states that the "right kidney is somewhat higher than the left" and that "the urinary bladder receives vessels to nourish it and has a tube [urethra] to remove wastes." The bladder is said to be "a type of muscle." Although the membranes of the kidneys contain small nerves, "the bladder receives a large nerve so that its sen-
sation is finer and stronger. The penis, the genitals and uterus have an abundance of nerves necessary for sensation during cohabitation." PATHOLOGY
In his legal code known as Mishneh Torah, Maimonides describes defects and diseases in animals that render them terefah, or nonkosher. lO For example, if a kidney is exceedingly small, or if it is afflicted with disease (that is, if its flesh is like dead flesh that has putrefied after several days, so that if one grasps it at one end it disintegrates and falls to the ground), and if this disease has progressed as far as the white matter inside the kidney, the animal is terefah. Likewise, if secretion (even if not malodorous) or turbid or malodorous liquid is found in the kidney, it is terefah: if clear liquid is found in it, the animal is permitted. An exceedingly small kidney probably represents end-stage renal disease from chronic nephritis. The other disorders may represent benign and malignant tumors or cysts, renal abscesses, or other diseases. One cannot be certain. PATHOPHYSIOLOGY
Maimonides accurately describes the symptoms oflower urinary tract obstruction, including hesitancy, a narrow stream, dripping, and urinary retention. He distinguishes between urinary retention in the elderly and anuria, a condition in which "no urine reaches the reservoir because the kidneys cease to function." In his Commentary on the Aphorisms of Hippocrates,11 Maimonides quotes Hippocrates, who says that diseases of the bladder and kidneys in the elderly are difficult to heal. He also speaks of patients who discharge copious amounts of thick white urine (?pyuria) or who urinate blood or pus. Fleshy substances or hair-like substances (?filaria) in the urine are said to come from the kidneys or the bladder. Maimonides also describes urinary sediments resembling "pistachio hearts." Fat in the urine, he asserts, is evidence of the dissolution of the kidney. Strangury occurs because of weakness of the bladder or sharpness of the urine. The former is due to a bad constitution or inflammation that develops there. Sharpness of the urine occurs because of the admixture of stinging humor. An inflammation in the uterus or rectum damages the bladder because
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of its proximity. A tear in the bladder or kidneys, according to Maimonides, is not always fatal. In describing urine in various diseases, Maimonides states that "Most patients with fever have thin urine at the beginning of the illness. The closer they get to the end, the thicker the consistency of the urine. . . . Sometimes the urine resembles lime and is sparse at the beginning of the illness. The reason for the sparseness is that it traverses the kidneys with difficulty. When the major part of the bad humor has been evacuated and the remainder thereof cooked, the patient urinates thinner urine and in large amounts. . . Transparent urine is the furthest away from being cooked and it indicates that the illness will be protracted . . . Urine is turbid only if the heat of the fever acts on the thick substances in, and the copious amounts of the urine; or if it acts on the substances alone. If the heat is extraordinarily great, gases are produced so that the urine becomes thick and turbid like wax or pitch or cinnabar resin. The thick gases and the heat rapidly ascend to the head and headache is produced. Sometimes it occurs during the micturition of the turbid urine; at other times it occurs earlier, and at yet other times it occurs later."
Regarding illnesses, Maimonides speaks of bladder stones and describes renal colic, calculi, and abscesses. Thick chymes are said to cause pain in the kidneys (?nephritis). Kidney disease is present if the patient micturates rusty, thin urine. In his medical book entitled The Art of Cure: Extracts from Galen,12 Maimonides states that stones form in the kidneys when the latter contain a coarse viscous humor that was warmed and burned. In his Treatise on Asthma, 13 Maimonides again speaks of pain in the kidneys, stones in the kidneys, and urinary retention. DIABETES
The word "diabetes" in Hebrew letters (diabetia) is present in the original Arabic manuscript of Maimonides' Medical Aphorisms as well as the medieval Hebrew translations. Maimonides must have taken the word directly from the Greeks. The Greeks used the word "diabetes" to refer to a disease characterized either by excessive passage of urine or the passage of sweet urine. Maimonides discusses both polyuria and glycosuria in his Medical Aphorisms. 14 For example, in chapter 6, he quotes Galen who postulated the cause of diabetes to be in the kidneys and bladder: "Individuals with sweet white humors are very somnolent [?hyperglycemia or ketoacidosis]. Those with an excess
of sour white humor are hungry [?hypoglycemia]. If an excess of salted white humor prevails, they are extremely thirsty. When the white liquid is neutralized, the thirst disappears. "
Later, in chapters 8 and 24, Maimonides again quotes Galen, who said that diabetes is rare and that he only saw two cases of this disease. Maimonides, however, claims that in the warm climate of Egypt, he saw 20 patients with diabetes and postulates that the sweet waters of the Nile may play a role in the causation of the disease. He also states that the disease is due to the prevailing heat that spreads over the kidneys. THERAPY AND PREVENTION
Maimonides usually advocates conservative management of genitourinary ailments, with the exception of renal abscesses, for which he advises early surgery to evacuate the pus. He states that drinking radish juice cleanses the kidneys and bladder and that diuresis should not be induced in healthy people but only in patients with certain illnesses. 13 Diuretics should not be given when bleeding occurs from the kidneys or bladder. Wounds in the bladder or kidneys are treated with honey and other substances that make the urine flow. If a patient with continuous fever and putrefaction of humors excretes ripe material in his urine, the fever will spontaneously resolve completely in 11 days. Hectic fever and consumption may follow a sickness in the uterus or kidneys. To cure such illnesses, it is necessary to empty the putrefying wastes by stimulating urine flow and bowel emptying. Catheters or tubes to collect urine from the bladder are described. Some kidney sicknesses are treated by bloodletting. Diuretics should be avoided for "hot tumors" of the bladder, penis, or kidneys. One who eats coarse foods forms stones in his kidneys. 12 In his three treatises on the regimen of health, 15 Maimonides states that it is not proper to exercise until one has cleansed oneself from superfluities, that is to say urine and feces. He also says that wine is not only nourishing and rapidly digested but is a good diuretic. People who drink cold water on leaving the bath may develop chilled kidneys. In his legal code known as Mishneh Torah 16 Maimonides states that if one interrupts urinati~n or defecation, one may develop very serious and dangerous illnesses. He does not specify the na-
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ture of these illnesses, but the talmudic assertion on which his statement is based is more explicit: "withholding feces brings on dropsy, and keeping back urine brings on jaundice."!7 URINALYSIS
In Maimonides' major medical work, his Medical Aphorisms, the entire fifth chapter is devoted to examination of the urine in health and in disease. Maimonides seems to allude to hemoglobinuria when he states that "black urinary sediments signify either fiery heat or extreme cold . . . every urine which turns black is extremely malignant. I have never seen anyone who urinated black urine who survived. . ." The final aphorism in this chapter is a concise outline by Maimonides of Galen's views on the four basic types of urine. The reader must bear in mind the medieval concept of disease production. Disease was thought to be due to disruption of the normal equilibrium between the four body humors: blood, phlegm or white bile, choler or yellow bile, and melancholy or black bile. These humors were supposed to represent various combinations of the four basic elements that compose the human organism: fire, air, earth, and water. Each of the latter had two qualities: fire warms and dries, air warms and moistens, earth cools and dries, and water cools and moistens. In blood these elements are equally distributed; in phlegm water predominates, in yellow bile fire predominates, and in black bile earth predominates. Each human being is born with a particular combination of or mixture of these elements. Any change or disruption in this equilibrium was thought to result in ill health. Ancient and medieval physicians frequently wrote in the form of aphorisms. This custom can be traced to Hippocrates, who was followed in this regard by many illustrious physicians, such as Galen, Rhazes, Alfarabi, Ibn Zuhr, and Maimonides, among others. I present below my English translation of chapter 5 of the Medical Aphorisms of Moses Maimonides. Each aphorism concludes with a citation of the source on which it is based, all works of Galen. Latin, rather than Greek titles of Galen's works are given for ease of reading by the English reader. Words in brackets are my own additions to clarify the meaning of certain
phrases; they are not included in the original. I hope the reader will thus gain additional insight into medieval medicine and the medical genius of Moses Maimonides. The term "cooking," which recurs throughout this chapter, is translated literally from the original and probably refers to body humor metabolism with resultant formation of urine that has different qualities, as described in the text. THE FIFTH TREATISE contains aphorisms pertaining to the examination of the urine.
1. It is obligatory to perform tests and to examine the urine during any fever because fevers are sicknesses in arteries. Therefore, in pleuritis, first examine the sputum and afterwards examine the urine because pleuritis is not ordinarily one of the fever-producing illnesses. Similarly, if there is a disease in the abdomen accompanied by fever, first examine the stool and then look at the urine. If there is no fever, only examine the stools. De Crisiblls VI 2. The most propitious sediments of those which settle in the urine in patients with fever due to sepsis are those which arise from the humor which already became putrefied by the arteries which contained it. From this, evenly distributed white sediments develop in the urine without detestable odors. De Febribus I 3. If the particles of the urinary sediment are all equal in appearance and in substance, it signifies the dominance of nature over the illness and its rule over it. Urine in which foam accumulates is caused by a cold humor and therefore shows the chronicity of the illness. Comment. Aphorismorwn VII 4. The most favorable urine in ill people and the one which most closely resembles the urine of healthy individuals and the maximally "cooked" urine in very healthy people is urine which is even in thickness and whose yellowness leans to a tinge of redness to deepen the yellow color because some moisture of blood and red bile become mixed into it. De Crisibus I 5. The most propitious type of urine has a good appearance and contains white turbidity which is smooth and even. If it settles to the bottom of a vessel, it is the best. If [it settles] in the middle, it is less favorable than the first. If it floats on top, it is less favorable than the second. These three types indicate the [degree of] "cooking." Of
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the other types of urine, some show the opposite of cooking and some herald a catastrophe. De Crisibus I 6. The evenness of sediments and their settling down set forth two conditions. One is that sediments should not be dispersed and diffuse but remain compact, and the second is that they should remain so at all times. Sometimes the urine is clear at a certain time but at another time it contains settlings and sediment. In such a case, the observed sediment is not one of the favorable ones since it indicates that cooking was not completed. De Crisibus I 7. The most favorable urines are those of patients whose urine, when excreted, shows completely favorable sediments which are fully cooked because this signifies that nature has already triumphed over the illness and has begun to excrete the illness-producing humors. After this in propitiousness is a urine which is micturated turbid but which settles out favorable sediments after standing awhile since this signifies that nature has commenced the activity of cooking and will soon complete this activity. After this second type in propitiousness is a urine which is micturated thick but then clears and in which no sediment forms at all. This signifies that the cooking time is far off even though nature has initiated efforts in this direction. De Crisibus I 8. A sediment always occurs in the urine of those ill with fever which developed from complete rest and relaxation and in those who increase their food intake at the end of the illness. However, in those who develop fever from work and toil, the illness often terminates without any sediment at all developing in the urine. They rapidly complete the cooking with the appearance of a white, flat and even turbidity in the upper part of the urine or suspended in the middle. De Crisibus I 9. Ifillnesses occur secondary to favorable humors, urinary sediments are plentiful. If these [illnesses], however, originate from red humors, no sediments at all form or only very few. Comment. Prognostikon II 10. The most unfavorable of all urines in sick people is the thin, clear one which resembles well water and is clear and translucent. It is the furthest possible from being cooked. Somewhat less dangerous is the urine which is excreted thin and clear but a short time later becomes cloudy since
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this signifies that nature, although behind in its task, will soon perform it. Less favorable than the second is the urine which is micturated cloudy and remains cloudy because this shows that nature is as yet undecided and, although attempting to cook [the urine], has not yet clarified the matter. De Crisibus I 11. Among kidney ailments is one in which the patient micturates rusty, thin urine similar to the early excretion of a sick liver and this one is slightly more bloody than the other. De Locis Affectis VI 12. If the urine is of an oily bile type, it is a sign of the dissolution of the fat from the heat of the fever. If the urine is actually fatty and its appearance and consistency is that of oil, it is a bad [sign] and leads to death by dissolving flesh because the heat which melts the flesh is more dangerous than the heat which [only] dissolves oil. Commentarius Epidemiarum III 13. Urine resembling water that is micturated repeatedly as occurs in people with the illness diabetes is the most unfavorable of all uncooked urines and occurs because of the death of two powers: the natural power of metabolism and the retention power. De Crisibus I 14. Black urinary sediments signify either fiery heat or extreme cold. They occur in association with what resembles the death of the natural powers. Ashen-appearing sediments, however, occur only secondary to cold. De Crisibus I 15. Every urine which turns black is extremely malignant. I have never seen anyone who urinated black urine and survived. Black sediments [in otherwise clear urine] signify a less dangerous situation. A black cloud suspended in the middle of the urine is even less dangerous than black sediments. A black cloud floating on top of the urine is even less dangerous than one suspended in the middle. De Crisibus I 16. If a cloud or black sediments, either black in appearance or which actually contain particles resembling "groat kernels" or beaten-out plates, float on top of white urine which is thin as water, these are fatal signs. The same is true of a foulsmelling urine or fatty urine which is called oily, all of which are fatal. These [types of] urines indicate that the patient has in his nature a serious life-threatening situation. De Morborum Temporibus VI
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17. Every appearance of urine except white, dark yellow or red is a sign of [imminent] death. The same [is true] of what is excreted in the urine except for sediments which settle or suspended turbidity or a favorable cloud floating on top of the urine. All three [occurring simultaneously] are a bad sign or an indication of death. De Crisibus I 18. If the illness is oflong duration and [healing] activity is delayed and the patient is micturating thin urine for a prolonged period, the crisis usually ends with the excretion of an abscess. But if thick urine is excreted, favorable sediments develop which settle [in the urine] and begin to slowly cook the illness. No crisis occurs during the excretion of the abscess. De Crisibus III 19. If the urine contains particles resembling peeled barley flakes or lentil kernels, this shows that [the illness] comes from the liver. If these particles resemble flesh, it signifies they originated in the kidneys. If they resemble beaten-out plates, it shows they came from the urinary bladder. Particles which resemble groat kernels in size and hardness and are not white indicate the melting of flesh and nerves. Black particles signify the dissolving of splenic fat. Urine which resembles donkey urine indicates an excessive accumulation of raw humors called chyme. Commentarius Epidemiarum VI, 5 20. Moses says: The implication in the words of Galen in his [book] On Crises is that the most favorable of all urines of sick patients is the one in which favorable sediments are seen. This is called the first type because nature has already completed its activity and has cooked the illnessproducing material. The next in order of propitiousness is the urine which is micturated cloudy but after being excreted becomes clear through the settling of favorable sediments since this signifies that nature has already commenced its work and will soon complete its task. This is the second type of urine. After this in propitiousness is that which is nearly cloudy and then becomes clear but where sediments do not settle since this demonstrates that nature has already begun its work but is not even close to the time of cooking. This is the third type. After this in propitiousness is one which is micturated turbid and remains turbid since this one is further away from being
cooked than the previous one. This is the fourth type. Following this is the one which is urinated clear and thin and later becomes turbid because this indicates that nature has not yet begun its activity but will shortly do so. The most unfavorable of all is urine which is micturated thin and remains very thin since this shows the complete absence of cooking, not at the present time nor in the near future. End of the fifth treatise.
REFERENCES I. Rosner F: The physician's prayer attributed to Moses Maimonides. Bull Hist Med 41:440-454. 1967 2. Rosner F: The medical writings of Moses Maimonides. NY State J Med 73:2185-2190. 1973 3. Rosner F: Maimonides the physician: A bibliography. Bull Hist Med 43:221-235. 1969 4. Rosner F: Maimonides the physician: A bibliography. Clio Med 15:75-79, 1980 5. Kook H: Genito-urological items in the scripts of Rambam. in Koroth, vol 4 (#5-7). Jerusalem. Israel, Israel Society of the History of Medicine and Science and the Jerusalem Academy of Medicine. 1967. pp 448-451 6. Kook H: Genitourinary items in the writings of Maimonides. in Koroth, vol 6 (#3-4). Jerusalem. Israel, Israel Society of the History of Medicine and Science and the Jerusalem Academy of Medicine. 1973, pp 216-221 7. Kook H: Maimonides the physician as seen by a modem urologist. in Koroth, vol 6 (#7-8). Jerusalem. Israel, Israel Society of the History of Medicine and Science and the Jerusalem Academy of Medicine, 1974. pp 489-496 8. Kook H: Maimonides as seen by a modem urologist. Int Surg 61 :390-392. 1976 9. Rosner F. Muntner S: The Medical Aphorisms of Moses Maimonides. vol I. New York. NY. Bloch Publishing. for Yeshiva University Press, 1970 10. Maimonides M: The Book of Holiness, Laws of Ritual Slaughter. Chapter 8. section 26. New Haven, CT, Yale University Press. 1965. p 298 II. Rosner F: Maimonides' Commentary on the Aphorisms of Hippocrates. Haifa. Israel. Maimonides Research Institute. 1989 12. Barzel US: Moses Maimonides' The Art of Cure-Extracts from Galen. Haifa. Israel, Maimonides Research Institute. 1992 13. Rosner F: Moses Maimonides' Treatise on Asthma. Haifa, Israel. Maimonides Research Institute. 1993 14. Rosner F: Medical Aphorisms of Moses Maimonides. Haifa. Israel, Maimonides Research Institute, 1989 15. Rosner F: Moses Maimonides' Three Treatises on Health. Haifa. Israel. Maimonides Research Institute. 1990 16. Maimonides M: Mishneh Torah-Hilchot Tefillin, chapter 4. section 20. New York, NY, Moznaim Publishing, 1990. p 94 17. Epstein I (ed): The Babylonian Talmud. Tractate Berachot. Folio 25a. London. UK, Soncino Press, 1948. p 149