Tuesday, November 27, 2007

Maimonides and Western Medicine

Moses Maimonides (1138-1204) was born in Cordova, Spain, the heart of the intellectual and economic Umayyad state known as Andalusia. In the twelfth-century, Cordova was dramatically different than the rest of Europe; religion was less a reason for intolerance than an inspiration for craft and art, leading to a kind of renaissance unseen elsewhere in Europe for another century. It was in this environment that Maimonides was educated and trained, not only in the Torah (as precursor to becoming a Rabbi), but also in the art of medicine. The reason behind this training was purely practical, as “until rather late in the Middle Ages, rabbis were not paid for their services…for that reason, Maimonides like any other rabbi had to adopt a profession in the world, and like many intellectually gifted medieval rabbis he became a physician.” (1)

The state of western medicine in the late 12th century was one of stasis. “In an age when the voice of authority was the most significant influence in determining belief, philosophy, and the understanding of nature, the persisting ghost of a single man loomed over medical thought like an overpowering colossus. That man was the second-century C.E. Greek physician Galen of Pergamon.” (2) To a large extent Galen’s death left medicine in a 1500-year state of perpetual doldrums. The great Arab thinker Avicenna (980-1037) changed that somewhat; his work The Canon was perhaps the most important medical writing to come out of the Arab medical system in the middle ages, and became the standard textual work in medical schools of Europe until the 18th century. But despite even his towering achievements, Galenic medicine was persistent juggernaut that stymied even the most brilliant minds.

Did Maimonides change this? Did he challenge the supremacy of Galen? To a certain extent yes, but even Moses was unwilling to completely tap the empirical keg when confronted with the sheer volume and historical march of Galen’s work. Sherwin B. Nuland’s biography Maimonides looks at this very question, of whether the Rabbi deserves membership in the pantheon of western physicians…"What was the contemporary state of “the theory and practice of medicine” in the twelfth century, and how was it affected by Moses’s teachings and his daily round of patient care? Did he add to the general sum of knowledge? Did he make any new discoveries? At his death, were the “theory and practice” of medicine of “the time” significantly different than they might have been had he never lived? And most important for posterity, did he leave a heritage that succeeding generations of physicians could look to as a model of the grand tradition of their art and science?" (3)

To be succinct, the purpose of this short essay is to bring some clarity to those questions. I intend to explore three areas in which Maimonides could be considered to have contributed greatly to the continuance and evolution of the western medical tradition. This essay will explore those three contributions, and make a case for their relevance and importance to the present state of the Great Art. Those three areas of influence are: First, a challenge and clarification of the work of Galen; second, an insistence to the separation of religion and medicine; and third, a prescient understanding of the necessity of preventative medicine. It is for the last that he is considered truly brilliant, and deserving of the title The Prince of Physicians.

Though Maimonides is less known for his work as a physician than he is for his commentary on the Torah and his Guide to the Perplexed, he remains a highly respected author and thinker even into the modern age, and it could be said that his work “Mishneh Torah, the fourteen volume systematization of all Jewish law from Scripture to his own day” remains unsurpassed. It has been suggested that to get Judaism right, one must first get Maimonides translation right, because it was he who honed and clarified the disparate parts of his faith. Though that was separate from his work in the field of medicine, I begin with it for the reason that it was the same brilliance that found him a leader in Judaic thought that underlies his work in medicine.

Maimonides challenged Galen generally through most of his medical work, but specifically in his Medical Aphorisms, a collection of 25 treatises on healing and medicine within which were approximately “1,500 passages culled mainly from Galen, with critical comments, providing the physician with a handy desk manual, reducing Galen’s 129 books to one.” (4) The heading under the 25th Treatise (last in the book) suggests an alternate title for the last chapter, “which may be called ‘The Holy War for Independent Scientific Investigation Against Galen.” (5) It is an ominous way to begin a chapter, and precludes any thought that the content will spill praises toward Galenic thinking. Indeed, “in medicine, as in other fields, Maimonides strived to reduce complexity to system and order. He chafed under Galen’s prolixity and reduced the Roman physician’s massive literary output to a single book of extracts that a physician could carry around in his pocket.”(6) Thus a clear picture arises of Maimonides challenging the status quo. Part of his influence on the western medical tradition derives from this simplification and clarification, and his bold challenges against the supremacy of Galenic thought. Maimonides contests the “arrogant presumption” of Galen, writing that he “considers himself more important than he really is.” (7) The following passage perhaps elucidates the point at hand, written by Maimonides himself.

"If anyone declares to you that he has actual proof from his own experiences, 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. Do not allow your mind to be swayed by the “novelties” which he tells you, but look well 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 without letting yourself be easily persuaded. And this is true whether the person is notable or one of the people. For a strong will may lead a man to speak erringly—especially in disputation. I offer this in order to awaken your interest in the statements of that wise men, that prince, Galen." (8)

It is this challenge of Galen, the juggernaut of western medicine, which sets apart Maimonides as truly unique. This uniqueness sprang from an independence of thought, and an insistence on rational inquiry and historical skepticism. “Maimonides was among the first to point to the feet of clay that would eventually crumble sufficiently to bring down the entire icon.” (9) Maimonides challenged Galen, and got away with it.

Though Maimonides was a Talmudic Rabbi, better known for his religious contributions than his scientific ones, his “medical writings contain no references to Talmudic medicine, nor is there a hint of magic, superstition, or astrology, widespread at the time in medical practice.” (10) The rabbi was a natural scientist when it came to the understanding and treatment of disease. It could be said, in a sense, that he was Aristotelian, that he implicitly understood the process of scientific rationality. “In principle, Maimonides divorced medicine and science from religion,” (11) which brings me to my second point.

Certainly there was much need for this in the medieval age, a time when the monks were the practitioners of medicine (though this was the case primarily in Europe). There is a story of Maimonides, when, after becoming a physician at the court of Sultan az-Sahir Ghazi (son of the great Saladin), he prescribed a medical treatment (wine and music) that went against Islamic law. When asked why he would recommend this, his answer falls in line with his rigid insistence on maintaining the independence of medical authority: “The physician, qua physician, must advocate a beneficial regime regardless of the religious law, and the patient has the option to accept or decline. If the physician does not prescribe what is medically beneficial, he deceives by not offering his true counsel.” (12)

At a time when the lines of demarcation between scientific inquiry and religion were at best obscured, Maimonides provided the physician with ammunition to defend his profession. In contrast, St Bernard of Clairvaux (1090-1153), a famous Christian cleric and near contemporary of Maimonides, “asserted that ‘to consult physicians and take medicines befits not religion and is contrary to purity’ – and it was a popular gibe that ubi tre physici, dui athei (where there are three doctors, there are two atheists).” (13) Of course this was hyperbole from the most dogmatic of churchmen, but it gives an understanding of the confused nature of medical thought at the time, and the necessity of the separation Maimonides insisted on. To be fair, Maimonides (being first and foremost a man of god) argued that the reason for good health was ultimately desired not for an end in and of itself, but for the great praise of the almighty. One cannot praise God in a state of disease and sickness. He commented in the Mishneh Torah that “since, when the body is healthy and sound one directs oneself toward 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 which are detrimental to the body and seek out things which fortify it.” (14) This though is not a negation of separation or an affront to the authority of medical practitioners, but a conclusion as to why one would want to maintain optimal health. As such, it does not discount his original insistence on the independent authority of physicians. This then is the second great offering of Maimonides to the history and evolution of western medicine, manifested through his insistence on the supremacy of physicians in all things medical.

The third contribution of Maimonides to western medical tradition is perhaps the most important, and certainly is what he is most remembered for (within medical history). It is a cogent and surprisingly modern idea, though in his time perhaps not so much. It is a simple concept, lacking in his day, of the necessity of preventive medicine. One needs look no further than his Aphorisms for support of this revolutionary idea. In the seventeenth treatise, titled Aphorisms Pertaining to General Rules of Health, he lays out the argument. “Immobility is as great a detriment to the maintenance of health as activity is of benefit.” (15) He continues by adding “one’s attention should first focus on the maintenance of natural [body] warmth, before anything else. That which best insures this is [the performance of] moderate physical exercise, which is good both for the body and soul (soma and psyche)”. (16) He prescribes for the elderly a daily regimen of walking, something that has an uncannily modern ring to it. Likewise, Maimonides posits the benefits of massage and touch as a means of stimulating the innate ‘heat’ of the body, insofar as it rejuvenates the body naturally.

As part of his preventive medical techniques, Maimonides also intuited modern medical procedure by noting the beneficial effects of positive thinking, leading to an early form of psychosomatic medicine. Whether certain amulets or trinkets were anathema to his practice was often overlooked when the needs of the patient were at hand. He was “committed to the thesis of the mind’s effect on the body, [and] it was permissible to discard even the most cherished of medical convictions in the interest of a patient’s psychological needs.” (17) Case in point was the mental stability of the person during medical treatment, in which case amulets and other such pagan paraphernalia were permissible “lest the mind of the patient be to greatly disturbed.” (18) It was this flexibility that served Maimonides in his work as a physician, and gained him the trust and respect of his peers.

Though it may be said that Maimonides didn’t necessarily advance any of these three points to a degree that they were ultimately reality changing for western culture, he represents a marker in the road to modern medical techniques. Perhaps none of his work was truly original, but he, and to a lesser extent his Arabic counterparts al-Rhazi and Avicenna, represented a slow chipping away at the immense fa├žade that had come to be understood as Humoral Theory. Each in their own way advanced the art, each chiseled another chip from the concrete theories of Hippocrates and Galen. As for Maimonides it may be said, “of the several aspects of the Ramban’s genius, the one that was surely most appreciated by readers in his time and later was his extraordinary ability to separate wheat from chaff and to collect, classify, and correlate needed information into a helpful, compact, and easily remembered whole.” (19) This perhaps more than any other thing made Moses a genius, a polymath not unlike Galen.

In considering the above conclusion, it can also be stated that it wasn’t Maimonides’ original intent to advance the art of medical practitioners. Certainly his most profound work was in the area of Judaic law and Talmudic revision, and even to a certain extent the formation and dissemination of what is known today as the Kabbalah. Nevertheless, his work in the court of Saladin, and of course his few medical writings, earned him a hallowed place in the annals of the western medical profession. He exhibited a prescient mind; his work at separating religious and medical law, his challenging Galen, and finally his work in the field of preventative medicine, all combined exhibit an intuition of the direction and future of western medicine. As suggested above, he is more a beacon in the road than an individual who diverted the traffic, but that fact doesn’t make his work less special. He is remembered today primarily for his Guide to the Perplexed, but that is perhaps only because he is less studied as a pioneer in medicine than as a giant in Judaism.

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Footnotes:
  1. Neuhaus, Richard John, ed., The Second One Thousand Years. Cambridge: Wm. B. Eerdmans, 2001. p. 16.
  2. Nuland, Sherwin B., Maimonides. New York: Random House, 2005. p. 155.
  3. Ibid.
  4. Seeskin, Kennith. Ed. The Cambridge Companion to Maimonides. New York: Cambridge University Press, 2005. p. 39
  5. Rosner, Fred. Muntner, Suessman. Eds. The Medical Aphorisms of Moses Maimonides. New York: Bloch Publishing Company. p. 171
  6. Seeskin, Kennith. Ed. The Cambridge Companion to Maimonides. New York: Cambridge University Press, 2005. p. 39
  7. Nuland, Sherwin B., Maimonides. New York: Random House, 2005. p. 167
  8. Id. at 168
  9. Id. at 169
  10. Seeskin, Kennith. Ed. The Cambridge Companion to Maimonides. New York: Cambridge University Press, 2005. p. 39
  11. Id. at 40
  12. Ibid.
  13. Porter, Roy. The Greatest Benefit To Mankind. New York: W. W. Norton & Co, 1997. p. 110
  14. Nuland, Sherwin B., Maimonides. New York: Random House, 2005. p. 176
  15. Rosner, Fred. Muntner, Suessman. Eds. The Medical Aphorisms of Moses Maimonides. New York: Bloch Publishing Company. p 41, Volume II
  16. Id. at 42
  17. Nuland, Sherwin B., Maimonides. New York: Random House, 2005. p. 179
  18. Ibid.
  19. Id. at 173
D. Reese Zollinger, 2007
(fair use of above material)

Happy slogging!

2 comments:

Shari Zollinger said...

Reese, your essays have become very clear, succinct and well executed. I
am impressed. Funny, I am reading Thoreau's Economy lately and it sounded uncannily similar to the part on preventative medicine, particularly body warmth and walking.
Fascinating.

rr said...

Great work Reese.