Portal de Periódicos da CAPES

Maimonides

2006; Elsevier BV; Volume: 55; Issue: 4 Linguagem: Inglês

10.1016/j.jaad.2006.05.058

1097-6787

Ada Ackerman,

Medicine, History, and Philosophy

What should a reader of a specialized journal, as is the Journal of the American Academy of Dermatology, expect from a reviewer of a book? At the very least, an effort should be made to capture the essence of what the author sought to convey. It is incumbent on a reviewer, further, to communicate whether, in his opinion, the purpose of the author was achieved and if not why not. A sense should be transmitted in such a survey critical for whether the volume under assessment would have interest for the particular audience for whom the reviewer is writing. Last, it is only fitting and proper for the analyst of a work to engage ideas spawned by the author and, if possible, to derive concepts independent of those ideas, some of which can be read between and beyond the actual lines, even sharing thoughts of his own triggered by what has been said, or not said, by the writer of them. That is my charge to myself as I appraise Maimonides by Sherwin B. Nuland, he being a clinical professor of surgery at Yale who has written 9 books previously about subjects medical/historical/biographical/philosophical/ethical, the best known and most enthusiastically received of those being How We Die; I am disposed especially favorably to The Doctor's Plague, an intriguing tale of the life, triumphs, and tribulations of the dogged, inflexible, but brilliant Hungarian physician of the 19th century, Ignatz Semmelweis, who discovered the cause specific for and advocated prevention effective of puerperal sepsis. Moreover, I want to convey to readers a sense for the style and the use of language with which Nuland seeks to give life to his subject, so that, wherever possible, I will let him speak in his own voice. This is what Nuland, in his own words, set out to accomplish in Maimonides: “What is presented in these pages is, as Maimonides himself might have put it, a guide for the perplexed—those many like me who have known of Maimonides all our lives and familiarized ourselves with just enough of him to believe, whether justified or not, that we have some modicum of understanding, but that it is never quite enough …. It is not a book for scholars. Its aims, like the Rambam's [the acronym for the real name of Rabbi Moses ben Maimon, Maimonides being an appellation Hellenized of it], are clarity and conciseness; its purpose is to make Maimonides accessible to myself and therefore to others.” Did Nuland achieve that desideratum? I can speak to that with confidence because I, like he, was well aware since childhood of the Rambam (ie, Maimonides), but my understanding of who he was and what he represented truly was deficient; in short, it was a blur. For me, Nuland achieved his aims admirably. I now have a sure sense of the man and of the reason for his influence profound on the Jewish people primarily, but also on other peoples diverse, as well as on practitioners of medicine from his own time until the present. The life of Moses Maimonides, as Nuland traces it, was remarkable in many ways. For one, it was lived physically in worlds different, the first 10 years having been peaceful in Cordoba, Spain, from the time of his birth in 1138 in the calendar Gregorian. His father, Rabbi Maimon ben Joseph, was a judge of the rabbinical court there. Cordoba at that time was under the rule of Muslims of the Umayyad sect. When Maimonides was 10 years old, the peninsula Iberian was taken over by the Almohads, which Nuland characterizes as a “violent fundamentalist Muslim sect originating among the Berbers of North Africa, under the leadership of their fanatical chief, Abdallah ibu Tumart,” it being hostile to those who were not practitioners of Islam—namely, Christians and Jews. The family left Cordoba for Almeria in southeastern Spain, which had yet to be occupied by the Almohads. When, 13 years later, those extremists took over Almeria, the Family Maimon departed by ship for Fez in Morocco, where, writes Nuland, “The persecution of Jews by the Almohads was at least as bad as it had been in Spain, but which provided certain advantages not obtainable on the road or in the Iberian towns.” Because the family was under surveillance by Muslim authorities, they fled Fez in 1165, doing so under cover of darkness, heading for the port city of Centa in Morocco en route to Acre in Palestine, the latter being a big disappointment to them, “a desolate land, with only small numbers of forlorn and generally impoverished Jews except for the few who were itinerant merchants or entrepreneurs.” The family soon set out by ship again, this time for Egypt, Alexandria first, Cairo next, and a suburb of Cairo, Fustat, last. In regard to their final stop, Egypt, Nuland comments that they “were on their way to a measure of liberty, ironically to be found in the place where their ancestors had lived in slavery and persecution.” Central to an understanding of Moses Maimonides is recognition of his absorption totally, in every fiber of his being, in his Jewishness, which itself derived from proscriptions divine entrusted to Moses on Mount Sinai. For another, Maimonides had two careers distinct and distinctive, although each complemented the other. The first was as Rabbi, he having been steeped deeply by his father in the Written Law of Judaism (ie, the Torah) and the Oral Law of the Jews (ie, the Mishnah). Nuland makes clear that during the family's time of homelessness, from Cordoba to Alexandria, Rabbi Maimon ben Joseph “had seen to it that Moses's education was never interrupted.” Once he had become a Rabbi himself, Maimonides served in Alexandria, where a “Jewish community of approximately 3,000 families made up a significant portion of the city's population of 50,000.” Because the Jews “enjoyed a large measure of civil autonomy,” they had their own “schools, religious institutions, communal functions, and systems of justice.” All of these were administered by a nagid, an officer appointed by the government. Nuland tells why Maimonides, even at age 27, was the person most qualified to be nagid and yet declined to be considered for that or any other position salaried: “Moses was encouraged by friends to apply for a formal paid position as a rabbi, but he refused. It was anathema to him that his learning and his religious leadership and counsel should be compensated with money …. Rejecting the common custom in Alexandria, Moses ben Maimon would not accept money for doing the work of God.” Once in Fustat, Moses took “an interest in the religious affairs of the 7,000 Jewish families who lived there and in Cairo,” he being so eminent a leader of the Jewish community that “the Muslim authorities were by this time referring to him as ra'is al-Yahud, the head of the Jews.” Some sense for the magnitude of those responsibilities is given by Nuland in this sentence: “During this period, the number of religious inquiries that were reaching him from local and distant rabbinical sources continued to grow.” That trend would eventually lead to Maimonides becoming “the spiritual leader of all Jews in Saladin's kingdom,” there then being many score thousand of them, a number that would swell to about three quarters of a million by 1948 at the time of the creation of the State of Israel and would shrink to meager in the entire Muslim world today. In addition to his engagement profound in the life of the Jewish community in Egypt and in the world beyond it, Maimonides was absorbed in his own works scholarly, the three of impact greatest on the Jewish people in his own day and in every generation subsequent being the Commentary on the Mishneh, the Mishneh Torah, and The Guide for the Perplexed. Nuland remarks that “a pattern of ceaseless literary activity […] would characterize his scholarship for the rest of his life.” In brief, in his Commentary on the Mishneh, an endeavor monumental that took Maimonides 10 years to complete, he chose “to use its composition as an opportunity to present his philosophy of Judaism and to expound on concepts that he believed to have long been misinterpreted, not only by ordinary people but by some of the rabbinical authorities themselves,” the focus of his work being “as much on moral and social responsibilities as […] on observance and ritual.” The text, when finished, was “infused with principles that we would now recognize as psychology and ethics” and with his “wide knowledge of Greek philosophy and its methods of reasoning,” as well as with “what was then known of the findings of science.” In the Mishneh Torah, an undertaking, formidable equally, to which he devoted another 10 years, Maimonides, in 14 volumes consisting of 86 monographs divided into 1000 chapters, endeavored to allow “readers to go directly to any subject of the Oral Law without having to deal with the abstruse, tortuous, unorganized, disputatious, and sometimes internally contradictory Talmud and later responsa and commentaries added by the geonim [plural of gaon, meaning renowned rabbinical leader] between the sixth and eleventh centuries, to which there is no order or system.” Because “Maimonides believed the arrival of the Messiah to be near” and with that event apocalyptic “the Jews were destined soon to return to Palestine under the leadership of a human descendant of the House of David,” the “Jewish nation would therefore need a set of precepts equivalent to a constitution, and it should be based on the Torah,” that constitution declaring “the principles of Judaism, classifying and codifying its laws.” For Maimonides, “The Mishneh Torah was meant to be that constitution,” being “written entirely in a form of Hebrew similar to that of the Mishnah itself.” Nuland summarizes the essence of the Mishneh Torah in these words: “Beyond strictly ritualistic matters, it is a treatise on ethics, as conceived by a mind steeped in religious law, classical philosophy, medical healing of body and mind, and a commitment to personal morality. It is a work of compassion redolent of the ancient Jewish commandment of tzedakah, charity in the broadest sense of beneficence to others.” In The Guide for the Perplexed, Maimonides sought valiantly to resolve the “seemingly unresolvable conflict between faith and reason that [he] faced throughout his own life.” Nuland paraphrases that perplexity as set forth by Maimonides thus: “Once a man has been exposed to the evidence of science and the methodology of logic, […] he will remain restless even though—in the interest of maintaining his religious convictions—he rejects what he has learned from the philosophers and observers of nature; his unease will annoyingly persist until he can find some concordance that will ease the niggling residuum of doubt from which he cannot rid himself.” The object of the treatise, as Nuland couches it, is this: “to enlighten a religious man who has been trained to believe in the truth of our holy Law… and at the same time has been successful in his philosophical studies, especially those of the Greek masters Plato and Aristotle.” That conflict causes such a person to be “lost in perplexity and anxiety.” In the judgment of Nuland, Maimonides, for all of his “learning and brilliance,” in The Guide for the Perplexed brought an “imperfect solution to the dilemma” of the conflict between faith and reason, Nuland ascribing that inability to the reality that a “perfect one will never be found.” Besides his dominant vocation as rabbi, Maimonides was a physician, taking up the study of medicine seriously in 1175 when he was 36 years old. His decision to embark on a career in medicine was motivated by factors pragmatic. In short, Maimonides and his family, consisting of a wife, a son, and a daughter, were supported largely by the profits of a successful business in precious stones that was managed by his brother David, nine years his junior. On a journey to India for purposes of trading in gems, the ship carrying David sunk in the Indian Ocean; all aboard drowned and all the gems were gone, too. Moses, “devastated by the loss of David… sank deeper and deeper into the grip of a depression so profound that he could barely function.” After the depression (a subject about which Maimonides later wrote a treatise) lifted at last, he was confronted with the problem of “How could he earn a living?” He realized that he had already acquired some education medical from books and from years of discussions “with physicians who were his friends” and he also was aware “of the high fees paid to doctors by members of the court and rich merchants, resulting in the accumulation of vast wealth,” often being the equivalent of tens of millions of dollars by standards of today. This is how Nuland makes clear the motivation of Maimonides in regard to a new career in medicine: “He now had to be very practical—with his undoubted skill, his great reputation as a scholar, and the connections he had made with prominent Muslim colleagues, there was a good chance that he might become physician to high-ranking members of the caliph's retinue, with all the financial compensation that came with such appointments.” And that is exactly what happened. Maimonides, in 1187, “was made physician to Saladin's court.” How ironic it is that Maimonides was adamant in his refusal to be a nagid because he would not accept payment for doing the work of God, but he chose to be a physician for reasons monetary as if the practice of medicine were not the work of God. Nuland presents a synopsis of the history of medicine prior to the time in which Maimonides lived, he doing that through those men medical who influenced thinking for millennia, among them Hippocrates and Galen in the world of the Greeks and Rhazes, Haly Abbas, Avicenna, Albucasis, Avenzoar, and Averröes in the sphere of the Arabs. He observes that “Without such a thorough and comprehensive understanding of the ancient and contemporary authors, Maimonides could not have produced the ten works that constitute his medical legacy,” some of those productions, all written in Arabic, being titled The Medical Aphorisms of Moses, Glossary of Drug Names, and On Sexual Intercourse. Nuland is not impressed with Maimonides as a thinker innovative in medicine. This is his view of the effect lasting of Maimonides' ten small works: “No aspect of medieval medicine was changed by it or by anything else he wrote, so in that sense his contribution to progress must be admitted to have been minimal.” Nuland elaborates on that thesis, but also pinpoints the character special of the art of medicine as practiced by Maimonides in these lines: “… Maimonides did not discover anything new. He was not a researcher, nor did he make original clinical contributions. He was, like so many eminent medical leaders of the period, a commentator on the art of medicine as it had been handed down to him by Hippocrates and especially by Galen, basing the commentary on his worldview and the experiences he had had when caring for his many thousands of patients. And his worldview embraced not only the clinical treatment of disease, but its psychological and spiritual aspects, as well as the ethical concerns that arose from his uniquely Jewish perspective and his uniquely compassionate nature.” Who, then, is likely to find Nuland's book about Maimonides instructive, illuminating, and pleasurable? The very audience that Nuland himself intended for it, namely, someone like him or me. This is not a text designed for one who seeks to learn the essence of Judaism with profundity or for one who anticipates being schooled in the influence of Maimonides on the corpus of medicine and on the mindset of physicians in centuries ensuing and in ones yet to come. In fact, the chapter given to “Maimonides Physician” begins on page 154 and ends on page 185, a mere 31 pages of a volume 215 pages in length. Probable it is that any reader of this extraordinary essay 215 pages long divided into chapters will be disappointed mightily to learn from Nuland that the prayer famed attributed to Maimonides actually was composed in the 18th century by a prominent Jewish physician of Berlin by name Marcus Herz. Nuland is “fair and balanced” in his estimation of the legend of Maimonides, giving full credit where deserved and advising of attributes mythic when appropriate, an example of the latter being the figure Samsonian of Maimonides in the history of medicine. Nuland makes no effort overt to alert a reader to how little things numerous have changed from the time of Maimonides and it was that that riveted me as I perused the pages infused with information pertinent to the biography. In closing this piece, I will extract for the benefit of readers a series of lines by Nuland that reinforce the rightness of the adage in French, “Plus ça change, plus c'est la même chose” (“The more it changes, the more it stays the same”). No comment by me will be necessary; the matters speak for themselves, but a brief quotation from another source contemporaneous will follow on each of the lines of Nuland and for the purpose of heightening perspective. “The unrest, which in fact existed throughout Egypt [in 1165], was complicated by a problem that has in one way or another form plagued Arab countries for centuries before that time and since. The Fatimids were Shiites, and the majority of their subjects were Sunni. Shiites reject the oral tradition of Islam, accepting only the written Koran; the Sunni, who are therefore considered more orthodox, accept both the oral and the written law.” “Iraq's political and religious leaders were engaged in a desperate effort last night to stop the country from sliding into civil war after a huge bomb shattered the golden-domed mosque in the city of Samarra, one of Shia Islam's most revered sites. At least six people were killed as demonstrations and armed clashes erupted across southern Iraq; and there were retaliatory attacks on Sunni mosques in Baghdad as thousands of furious Shia Muslims took to the streets. In an apparent reprisal attack, gunmen in police uniforms seized a dozen Sunni men suspected of being insurgents from a prison in the mainly Shia city of Basra and killed 11 of them, police and British forces said. “Iraq slips towards civil war after attack on Shia shrine.” The Guardian, digital edition Thursday, February 23, 2006 “A problem of the same sort [as Shiite versus Sunni] was causing difficulties in the Jewish community as well, due to the presence in Alexandria of a large number of Karaite families. Karaism, a movement that had its origins in Persia (and that still exists among small groups on Israel, Poland, and parts of the former Soviet Union), was analogous to Shiism in the sense of rejecting anything but the Hebrew Bible as the source of all divine law. Because it repudiated rabbinic Judaism, it was considered heretical by the regular Jewish congregations.” “Satmars [the largest Hasidic group in the United States based mostly in the Williamsburg section of Brooklyn] will marry each other and other Ungarishe, or Hungarian Hasidim, but never Lubavitchers [the second largest Hasidic group and also numerous in Williamsburg]. Lubavitchers are damaged goods, idolaters. They worship the Lubavitcher Rabbe, Menachem Mendel Schneerson, who was at that time hospitalized in Manhattan after suffering a stroke. It's not the rabbi's fault that his followers regard him as Moshiach, the Messiah, my hosts insist Satmars follow the issue closely. A recent New York times Magazine story on the Lubavitcher Rebbe was read and reread by virtually every Jew in Williamsburg [more than 100,000 of them].”From Boychiks in the Hood, by Robert Eisenberg San Francisco, Harper Collins Publishers, 1995; pages 14-5 “Most important for the Jews [living in the Muslim world in the 12th century] was the fact that as the ‘people of the Book,’ they and Christians were granted the status of dhimmis, those who were protected by Koranic law and allowed to practice their religion in recognition of submitting to Muslim authority. But protection does not mean equality, and tolerance is different from full participation. There were restrictions of privilege and access sufficiently restrictive that it has become customary to refer, and correctly so, to the ‘second class status of the dhimmis…Jewish and Christian schools [during the reign of the Islamic fanatic, Abdallah ibn Tumart] were closed, churches and synagogues given the option of conversion or death; emigration was forbidden for fear that the refugees might be of aid to rival leaders. Many of the Jews undertook a sort of pseudo-conversion … . To accomplish the goals he had set for himself, Saladin embraced the Islamic precept of jihad. Jihad is a campaign to advance the principles and hegemony of Islam, whether with one's own heart, by a relentless effort to convince others, or by doing battle with perceived enemies of the faith …. Though Christians and Jews were accorded special treatment because of the beliefs they shared with Islam, they nevertheless were considered infidels, and attempts were made to have them embrace the newer religion. Depending on the ruler—with the Almohads and Saladin personifying the two extremes—those who refused might be slaughtered or merely made to accept Islamic sovereignty and pay a special tax.” “[Condoleezza] Rice [U.S. Secretary of State] sought a ‘favorable resolution from [Hamad] Karzai [President of Afghanistan] for an Afghan man on trial for converting to Christianity from Islam. Clerics demanded his execution.”The Wall Street Journal, “What's News—” page 1, Friday, March 24, 2006 “Maimonides attitude toward Christians was that they were idolaters. They venerated images of Jesus, Mary, and a variety of saints, unlike the Muslims who worshipped the same universal God as the Jews. Not only that but the Jews of Jerusalem had been massacred along with the Muslims, as recently as 1148 by soldiers of the Second Crusade. There was plenty of reason for animosity and even contempt to be added to the trepidation that the travelers must have felt as they planned their escape [from Fez and other places of persecution in the Muslim world] to the Holy Land …. Expulsions, forced conversions, individual murders, and wholesale slaughter of entire ‘ghettoized’ communities were decimating the population of Jews living in the Christian countries.” “While there were moments in history when the Moslems turned upon the Jews, there was never the built-in hatred characteristic of Christian anti-Semitism, and by and large relations between Jew and Moslem [in some periods of Islamic rule in Europe] were on an almost compatible basis. But the Moslems had an implacable hatred of the Christian—the uncircumcised infidel—and the Christians hated Moslem power and regarded it as their first enemy.”From The Jews: Story of a People, by Howard Fast ibooks, 2006, page 141. “Only in Egypt [of the entire Muslim world] was there any measure of real freedom [for Jews], and even here dangers lurked, although of a very different kind. For awhile, the Jews prospered and practiced their religion unhindered, that very freedom had led to a laxity in observance and an erosion of scholarship and of the regard paid to rabbinical teachings and the law itself. Not only was the spiritual life of the Jews in danger, but their disappearance into a sea of assimilation and conversion was more than a remote possibility.” “Since at least the time of the ancient Greeks, a proportion of Jews have assimilated into the wider non-Jewish society around them, by either choice or force, ceasing to practice Judaism and losing their Jewish identity. Some Jewish communities, for example the Kaifeng Jews of China, have disappeared entirely, but assimilation has remained relatively low over much of the past millennium, as Jews were often not allowed to integrate with the wider communities in which they lived. The advent of the Jewish Enlightenment (see Haskalah) of the 1700s and the subsequent emancipation of the Jewish populations of Europe and America in the 1800s, changed the situation, allowing Jews to increasingly participate in, and become part of, secular society. The result has been a growing trend of assimilation, as Jews marry non-Jewish spouses and stop participating in the Jewish community. Rates of interreligious marriage vary widely: In the United States, they are just under 50%, in the United Kingdom, around 50%, and in Australia and Mexico, as low as 10%, and in France, they may be as high as 75%. In the United States, only about a third of children from intermarriages affiliate themselves with Jewish practice.”Population changes: AssimilationAvailable at: http://en.wikipedia.org/wiki/Jew “Since earliest times, amulets and charms were used to treat disease, sometimes along with incantations and prayer-like formulas written to enhance their efficacy. These were meant to function as a form of magic, and Maimonides railed against them in his teaching and writing as he did against any form of sorcery in treatment …. And yet this pragmatic physician would in rare instances violate his own dictum—when the disease was severe and he had little else to offer. A concession to popular superstition was permissible under such circumstances, he wrote ‘lest the mind of the patient be’ too greatly disturbed.” “Linus Pauling, PhD, was the only person ever to win two unshared Nobel Prizes. He received these awards for chemistry in 1954 and for peace in 1962. His recent death has stimulated many tributes to his scientific accomplishments. His impact on the health marketplace, however, was anything but laudable. Pauling is largely responsible for the widespread misbelief that high doses of vitamin C are effective against colds and other illnesses. In 1968, he postulated that people's needs for vitamins and other nutrients vary markedly and that to maintain good health, many people need amounts of nutrients much greater than the recommended dietary allowances (RDAs). And he speculated that megadoses of certain vitamins and minerals might well be the treatment of choice for some forms of mental illness. He termed this approach “orthomolecular,” meaning “right molecule.” After that, he steadily expanded the list of illnesses [including cancers] he believed could be influenced by “orthomolecular” therapy and the number of nutrients suitable for such use. No responsible medical or nutrition scientists share these views.”The Dark Side of Linus Pauling's Legacy Quackwatch Home Page, available at: http://www.quackwatch.org/01QuackeryRelatedTopics/DSH/colds.html.Accessed May 5, 2001 “Why is it, in fact, that so many Jews have become doctors? It is fitting to consider that question before embarking on a study of the life and thought of a man who personified the grand tradition, and whose teachings contributed so much to it …. The study of medicine is a religious activity …the physician is a messenger—or in certain ways even a partner of God …. ‘First choose life’ enjoins God …. The Hebrew word for doctor, rafe… means ‘to heal’ in the sense of repairing …. Among Jews, especially those of an intellectual bent, there is commonly a kind of restlessness, an anticipation of uncertainty, ambiguity, imperfection and the sense that one must do something about it even though the total solution will never be found …. Out of this restless dissatisfaction there arises a skepticism, a questioning of oneself, of one's place in the predominantly Christian world and, indeed, of the givens of that world, both great and small …. The practice of medicine… is applied skepticism, a dissatisfaction with the direction in which things are going, and a determination to do something about it, even though the doing may of necessity remain incomplete.” “At UCSF School of Medicine, Dr. Robert Stern, a professor of pathology, estimates that Jewish enrollment has dropped from roughly 20 percent when he started teaching there 27 years ago to 10 percent to 15 percent now [15% is more than 7 times the percentage of Jews in the United States, it being 2%].”“Fewer Jews Are Putting on the Stethoscope” by Abby CohnThe Jewish News Weekly, News Report, April 9, 2004 One last thought bears mention. Based solely on my reading of Maimonides as presented by Nuland, I have come to believe that perhaps the impact greatest of that polymath is implied in a statement in the “Epilogue” as follows: “Not only was it in the Rambam's conception of Judaism that it must be progressive, but that in its very progress lay one of the keys to its continuity.” This progressiveness of Maimonides influenced, in no small measure, the progressiveness of Judaism which itself contributed, immeasurably, to the survival of the Jewish people, that adaptability enabling formulation of new directions predicated always on old principles revelational, chief among those innovations in the West being Reform Judaism beginning in the 19th century and the Reconstructionist movement of the 20th century. If that assessment is correct, it represents an achievement phenomenal for a physician who departed this planet more than 800 years ago. BIBLIOGRAPHY Cohn A. “Fewer Jews Are Putting on the Stethoscope.” The Jewish News Weekly, News Report. April 9, 2004. The Guardian, digital edition, Thursday, February 23, 2006. Eisenberg R. Boychiks in the Hood. San Francisco: Harper Collins Publishers, 1995. pp. 14-5. Fast H. The Jews: Story of a People. Ibooks; 2006. p. 141. Nuland SB. Maimonides. Schocken: New York, 2005. Quackwatch Home Page. The Dark Side of Linus Pauling's Legacy. Available at: http://www.quackwatch.org/01QuackeryRelatedTopics/DSH/colds.html. Accessed May 5, 2001. The Wall Street Journal, “What's News—”, page 1, Friday, March 24, 2006. Wikipedia: the Free Encyclopedia Online. Population changes: Assimilation. Available at: http://en.wikipedia.org/wiki/Jew. Accessed June 13, 2006.