Global Nephrology

Rhazes attending to a patient

Nephrology in Persia - is this where it all started?

I’ve been visiting Dubai for the past few days and I wondered about what historical contribution this region had made to the study and treatment of kidney disease. It didn’t take much to dig around and come with the answer “a lot”.… and it began a long time ago!

In an interesting article published in the Iranian Journal of Nephrology in September 2011 titled “A Critical Review of the Works of Pioneer Physicians on Kidney Diseases in Ancient Iran” Saeed Changizi Ashtiyani and colleagues review the contribution of four early pioneers - Avicenna, Rhazes, Al-Akhawayni, and Jorjani. The report contains extensive biographical information about these physicians.

Avicenna

Avicenna, an Iranian philosopher and physician of the 10th and 11th centuries was born in 980 AD in a village near Bokhara (a city in old Persia) and died in 1037 AD in Hamadan, Iran. His most notable contribution was his book titled Al-Canon fi al Tibb (The Canon on Medicine). According to Ashtiyani et al Avicenna has a 30-page chapter in the Canon that describes in detail the collection of urine specimens, methods of examination, characteristics of urine (color, turbidity, consistency, odor, sediments, volume, presence of foam, etc), and urine characteristics in healthy and sick individuals. Avicenna also discusses other aspects about kidney disease. Here is a quote about oliguria:

“Oliguria can be due to the following causes: (1) drinking inadequate liquids; (2) body porosity; (3) effect of diarrhea on the body; (4) disability of the kidneys, resulting in impaired absorption of fluids; and (5) disability of the liver in separation of the fluid and sending it to the kidneys, so as in hepatic cirrhosis [sou of gonieh in Arabic] and dropsy state [estesgha in Arabic].”

Rhazes

Rhazes, also known as Ibn Zakariya, Al-Razi, and Razi, was born in Ray, a city a few miles south of modern Tehran, in 865 AD. Ashtiyani  writes: “Rhazes was not only one of the most prominent Persian physicians and philosophers of his era, but also the writer of the fundamental teaching texts in European medical schools for centuries.” The two major contributions of Rhazes in medicine are the Kitab al-Mansuri (Liber Al Mansuri) and Kitab al-Hawi (Liber Continens, meaning comprehensive book or encyclopedia). Ashtiyani  goes onto say “[Rhazes] was known as the most distinguished character in the world of medicine up to the 17th century.” Rhazes describes the discrimination between vesical and renal hematuria in a very scientific and up-to-date manner: “Sudden hematuria is due to a ruptured renal vessel but this cannot be the case in the bladder because it cannot be for a vesical vessel to rupture due to plenty of blood coming to it as it happens in the kidney. This is because blood is not filtered in the vessels of the bladder as it does in the vessels of the kidney. But, the amount of blood that comes to the bladder is only enough for its nutrition, while in the kidney, because blood is filtered in it, and then, large blood vessels and plenty of blood comes to it, far more than its need for nutrition.”

Hakim Jorjani

Esmail Jorjani was born in Jorjan, north-eastern Persia, in 1042 AD, and died in Marve, in 1136 AD. His most famous work is Zakhir-e-Kharazmshahi. He made important contributions about the bladder – both on the anatomy and physiology and proposed catheterization of the bladder for the treatment of patients with difficulty in urination.

The Hidayat

Al-Akhawayni is another famous ancient Iranian physician in this era. He was born, trained, and practiced in Bokhara, and hence, became known as Al-Bokhari. Bokhara, a city currently at the Republic of Uzbekistan, was located along the Silk Road, in the vicinity of the ancient Samarkand. His most substantial work was that of al-Bokhari, the Hidayat al-Mutallimin fi-al-Tibb (Learner’s Guide to Medicine) written in the closing decades of the 10th century. An article in NDT in 2007 describes his contributions to nephrology in detail. In Hidayat, he writes “The kidney is subject to diseases like any other organ including functional impairment [dysfunction], structural disorders and disruption, and some specific disorders like stones and inflammation, and renal weakness and atrophy, namely, hozal. Khoon Raftan [hematuria] and rim raftan [pyuria] are due to the inflammation involving the kidney, and [in which the pus] is excreted with the urine from the urethra and [there is] difficulty in urination [dysuria].”

In Hidayat, Al-Akhawayni also refers to renal atrophy (hozal), and suggests end-stage kidney disease with cachexia, polyuria, edema, and dropsy. He discusses the inflamed kidneys that might heal, form an abscess, or fail to heal and become “hard” which seems to suggest the small hardened kidneys of end-stage kidney failure. Credit for reference to hardened end-stage kidneys has been given to William Gulielmus of Saliceto when in fact it was described by Rufus of Ephesus in the 2nd century and re-stated 200 years earlier than Gulielmus by Al-Akhawayni.

For those with nephrolithiasis, Al-Akhawayni offers sage advice (for the time): “Beware that when the stone enlarges in the kidney it hinders the urine, causes intolerable pain, and may lead to mental confusion from pain. Each occasion of the pain is called an episode [the pain is intermittent]. During the episode of pain, the patient should sit in a tub of warm water in which the leaves of cabbage [Brassica oleracea], leaves of marsh-mallow [Althaea officinalis], chamomile [Anthemis nobilis], dwarf yellow [Astragalus hamosus], fenugreek [Trigonella foenum graecum], flaxseed [Linum usitatisimum], seed of mingwort [Artemisia absinthium], and star- thistle [Centaurea calcitrapa] have been brewed. And after getting out of the water tub, the back [of the patient] should be massaged gently with the oil of wallflower [Cheiranthus cheiri], and then he should jump [up and down] on one foot, or ride a horse trotting in place, or climb fast down a ladder until the stone comes out of there.”