Tuesday, April 9, 2013

Maimonides as a Physician: Caring and Curing

Maimonides as physician: Caring and curing By JUDY SIEGEL-ITZKOVICH Tue Apr 2, 2013 11:33 am (PDT) . Posted by: "rufina" bernardetti Maimonides as physician: Caring and curing By JUDY SIEGEL-ITZKOVICH http://www.jpost.com/Health-and-Science/Maimonides-as-physician-Caring-a\ nd-curing-308369 An impressive English-language volume on the Rambam and his medical career has just been published, showing how he was way ahead of his time. [Maimonides] Maimonides Photo: Yair Haklai/Wikimedia Commons Centuries before the invention of the MRI and CT scans, x-rays, aspirin and antibiotics, the sphygmomanomter and even the thermometer, the medieval rabbi and philosopher Maimonides (Rambam) was a brilliant physician who treated the patient rather than the illness and espoused moderation and disease prevention. The great sage, especially during the last decade of his life as court physician to the sultan in Cairo, devoted himself to medicine and his patients and wrote 10 impressive works in Arabic including volumes on asthma, poisons and their antidotes, hemorrhoids and digestion, cohabitation and health promotion, and a glossary of drug names in Arabic, Syrian, Greek, Spanish, Persian and Berber. In recent decades, the Rambam's medical works were translated over nearly five decades into English by Jewish medical ethicist Prof. Fred Rosner of New York's Mount Sinai School of Medicine and the Albert Einstein College of Medicine in New York. Rosner, Prof. Samuel Kottek (emeritus professor of the history of medicine at the Hebrew University) and Prof. Kenneth Collins (medical historian of the University of Glasgow) have written and edited an excellent new book, Moses Maimonides and His Practice of Medicine. The 202-page, $30 hardcover Englishlanguage volume was published by the Maimonides Research Institute of Haifa and New York and includes chapters by 10 authorities on various aspects of the Rambam's medical work. It is a joy to read, not only for people in medicine but also the layman interested in health promotion, Jewish philosophy and history. Born in Cordoba in the Almoravid Empire (Spain) on the eve of Passover in 1135, Maimonides also lived for a time in Morocco and the Holy Land. He died in Egypt in 1204. His body was buried in Tiberias, on the shores of the Kinneret. Although he himself advocated regular and balanced meals, he worked so hard as a physician in the sultan's palace that he would arrive home in the nearby town of Fostat, exhausted and hungry, where, he said: "I would find the antechambers filled with gentiles and Jews... I would go to heal them and write prescriptions for their illnesses... until the evening... and I would be extremely weak." Some scholars have even suggested that his health declined and he died prematurely because of his endless work as a physician. Maimonides took up the profession at the age of 37 after the death at sea of his brother David, a merchant of precious stones. He needed the income to support himself and his family, including his sisterin- law and nephew, writes Britain's Chief Rabbi Jonathan Sacks in his foreword. "Why should the work of Maimonides in medical science continue to be of interest to contemporary physicians?" Sacks asks. "After all, the physics of Aristotle, and even his metaphysics, have long been surpassed, even if his writings on ethics still inspire and instruct. The first reason is his status and stature as a role model for Jewish doctors and medical scientists, indeed for all those who engage in the worked of healing as a religious act in the spirit of the biblical phrase `I am the Lord who heals you.' ...Second is the religious gravitas Maimonides ascribed to the calling of medicine. It was a strikingly bold move to include rules of health." The British chief rabbi adds that the Rambam wrote clearly why health is important to Jewish belief and practice of medicine: "Since, when the body is healthy and sound, one directs oneself towards the ways of the Lord – it being impossible to understand or know anything of the knowledge of the Creator when one is sick – it is obligatory on man to avoid things that are detrimental to the body and seek out things that fortify it." Just as a Jew must return a lost object to its owner, doctors should restore the good health of their patients, the Rambam argued. Sacks concludes that the most impressive part of Maimonides' work is its integration, the result of his unrivalled ability to "see life Creator and see it whole." Thus he was a holistic medical practitioner before the term became popular in the 20th century. MAIMONIDES LEARNED a lot about medicine and anatomy from the ancient Greek physician Hippocrates, who established medicine as a profession and whose doctors' oath the rabbi replaced for Jewish physicians; and from Galen, the prominent Greco-Roman physician, surgeon and philosopher. The Rambam called Galen "the greatest medical scientist who ever lived." Hippocrates recommended "the drawing off of noxious humors, that diarrhea benefits eye disorders and if bald people contract large varicose veins, their hair grows back." Both of these ancient physicians made numerous errors, such as thinking the human heart has two chambers and the liver five lobes. The Rambam was willing to change his views. He "would have understood a world where medical advancement is rapid and sometimes even theories that have seemed to be well validated are speedily discarded," Collins writes in the introductory chapter. "He never claimed certainty for his own views but only that they were likely to be so, given the methods he employed and and his adherence to a scientific outlook... Always challenging, and sometimes controversial, and with very modern attributes even from our contemporary perspectives, Maimonides has much to say to physicians today." While the Rambam hardly mentions surgery, he very often discussed plants – both fruits and vegetables – to treat his patients' ills. Some, like rhubarb, were used to purge the body of harmful humors, while others were used to treat migraines, asthma, cough and constipation. Among his collection of medications were dill, fennel, fenugreek, finger, hyssop, beet juice, borax, celery, cinnamon, quince, saffron, sesame, licorice and pine nuts. K o t t e k stresses the importance the Rambam gave to having a close relationship between the doctor and patient, taking psychology into account and being careful not to harm him. If the patient doesn't trust his doctor fully, the healing process won't get far, the Rambam believed, "For each sick individual feels his heart constricted, and each healthy person feels his soul wide-spread." By this, Kottek explained, the Rambam meant the existence or lack of anxiety. He also understood the importance of the environment on the patient: "In case the sick individual is poor and lives in a place that is harmful for his disease but has nowhere else to go, he [the physician] has to remove him to another place." He even realized that asthma involves air quality. Although bloodletting was commonly used by Arab physicians as treatment, Maimonides realized it could be dangerous and urged care in using it. Health promotion was no less important to Maimonides than caring for the sick, wrote Kottek. The Rambam gave advice on "how to eat, what may be eaten and what not, how to practice exercise, to bathe, to sleep and how to have sexual intercourse." Medicine, for him, was "an art." Prof. Carmen Caballero-Navas of the department of Semitic studies at the University of Granada, notes in her chapter that Maimonides did not seem to practice gynecology, even though he treated women from the Cairo palace for ills not connected to their reproductive organs. This is not surprising, she writes, because male Arab physicians usually did not treat women. Midwives delivered babies rather than male doctors. However, Jewish physicians and rabbis had more of an understanding of female anatomy due to the importance of "impurity" (nidda) in women's menstrual cycles and the halachic rules that relate to them. The Rambam does differentiate between men (as being warm and dry) and women (as being cold and wet) and discussed the theoretical nature of women's conditions, from amenorrhea, uterine "suffocation," "phlegm in the womb," pregnancy, miscarriage and childbirth. THE DISCUSSION of nutrition and lifestyle as seen through the Rambam's eyes is as relevant today as it was in the 12th century. Prof. Elliot Berry, director of the department of human nutrition and metabolism at the Braun School of Public Health and the Hebrew University-Hadassah Medical School in Jerusalem, discusses this aspect along with Reut Ben-Ami, a master's degree graduate at the Hebrew University. Maimonides wrote much about keeping clean the air we breathe, observing a proper diet, and "regulating emotions, exercise, sleep and excretions." He even noted the psychosomatic aspects of asthma and the holistic approach to the disease. Just moving from Alexandria to Cairo, with its better air, improved asthma, the Rambam wrote. People should not exercise in extreme cold or heat or immediately after eating. Famously, he urged people not to overeat by getting up from the table before being satiated. Whole grains, Maimonides advised, were better for digestion than white flour, and "thick meat" should be avoided, as its digestion is "hard on the stomach." He recommended poultry as well as small saltwater fish, but did not endorse consuming large amounts of fish – apparently because there were no refrigerators, so they were preserved in salt, which he identified as not promoting health. He recommended dairy products because they are digested easily, but thought them "harmful for those suffering from headaches." He strongly endorsed fruits and vegetables as a regular part of the daily diet and drinking cool water some two hours after eating, when digestion had already begun. Dr. Helena Paavilainen, a history of pharmacology researcher at the HUHadassah Medical School, listed the many plant products that the Rambam prescribed for treating asthma and noted that modern pharmacology has validated their efficacy for controlling respiratory spasms. "Maimonides' medical legacy, rooted in the experience of generations and augmented by his own clinical experience, would be a valuable starting point for further research. His deep understanding of psychosomatic and philosophical aspects of medicine is given the appreciation it deserves," she declared. Although leprosy is given in the Bible as a spiritual disease, Maimonides differentiated in his writings between that condition resulting from slander and the dermatological condition that today is treated with antibiotics. SURELY, THE Rambam erred with regard to some medical beliefs, such as female fetuses lying on one side of the uterus and males on the other. But his knowledge and ability to diagnose were amazing. He deserved the praise given him by Rosner, who called him "one of the greatest physician-theologian-philosophers that ever lived on this earth. May his memory be blessed!"

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