Renal Section, Department of Medicine, Baylor College of Medicine, Houston, Texas
Address correspondence to: Dr. Garabed Eknoyan, Department of Medicine (523D), Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030. Phone: 713-798-4748; Fax: 713-790-0681; E-mail: geknoyan{at}bcm.tmc.edu
The kidneys, always used in the plural (kelayot), are mentionedmore than 30 times in the Bible. In the Pentateuch, the kidneysare cited 11 times in the detailed instructions given for thesacrificial offering of animals at the altar. Whereas thoseinstructions were for purification ceremonies at the Temple,sacrificial offerings were made subsequently in seeking divineintervention for the relief of medical problems. In the booksof the Bible that follow the Pentateuch, mostly in Jeremiahand Psalms, the human kidneys are cited figuratively as thesite of temperament, emotions, prudence, vigor, and wisdom.In five instances, they are mentioned as the organs examinedby God to judge an individual. They are cited either beforeor after but always in conjunction with the heart as mirrorsof the psyche of the person examined. There is also referenceto the kidneys as the site of divine punishment for misdemeanors,committed or perceived, particularly in the book of Job, whosesuffering and ailments are legendary. In the first vernacularversions of the Bible in English, the translators elected touse the term "reins" instead of kidneys in differentiating themetaphoric uses of human kidneys from that of their mentionas anatomic organs of sacrificial animals burned at the altar.This initial effort at linguistic purity or gentility has progressedfurther in recent versions of the Bible, in which the reinsare now replaced by the soul or the mind. The erosion may havebegun in the centuries that followed the writing of the Bible,when recognition of the kidneys as excretory organs deprivedthem of the ancient aura of mysterious organs hidden deep inthe body but accessible to the look of God. At approximatelythe same time, Greek analytical philosophy argued that the brain,which is never mentioned in the Bible, was the most divine andsacred part of the body. This argument gained ground in thepast century, when the functions of the brain were elucidated,and ultimately established in the 1960s, when salvaging thekidneys for transplantation necessitated a change in the definitionof death as irreversible brain function. It is ironic that advancesin understanding kidney function and in nephrology that madekidney transplantation feasible may have contributed, albeitindirectly, to the gradual elimination of the metaphoric mentionof human kidneys in the Bible.
The mythical and metaphorical uses of the kidney in literatureand the arts in general remain a relatively unexplored subject(1,2). Information on its use in ancient times is even dimmer.There is not a single reference to the kidney in Frazer’s(1854 to 1941) seminal anthropologic work, The Golden Bough(3). By contrast, the figurative use of the kidney in the Biblehas been the subject of several articles and is dealt with,albeit briefly, in most general texts on medicine in the Bible,which are quoted in the references that follow. They have beenextremely useful in the preparation of this article, which isan attempt to interpret references to the kidney in the Biblewithin the historical context and prevailing social, medical,and religious customs of the times. The guiding principle indoing so has been the rabbinic saying, "There are seventy facesto the Torah" (Num. Rab 13:15), meaning that biblical textsare open to 70 different interpretations and this is just oneof them, but only as it pertains to the kidney. It is not meantin any way to undermine the sacredness of the quoted scripturesbut to add depth to their meaning by considering them in thecontext of the historical period in which they were incorporatedinto the inspired writings. Neither is it an attempt to trespassinto the domain of learned interpreters of the Bible, be theyscholars of religion or history, but rather an effort to incorporatethe historical evolution of our understanding of the kidneyand advances in nephrology in the clarification of the use ofthe kidney in the Bible.
Throughout the text, the term "Bible" is used to refer to theHebrew Bible or the Christian Old Testament. Where applicable,the term "New Testament" is used to refer to the added sectionsof the Christian Bible, and the term "Torah" is used to referto the Pentateuch, or first five books of the Bible. All scripturalverses quoted in the text are from the King James Version ofthe Bible.
A brief overview of biblical history is helpful in understandingits use of the kidney, which henceforth is used in the pluralas it appears throughout the Bible (kelayot, pl.; kolya, sing.).Its use in the plural has been interpreted to mean that theancients knew that there were two kidneys. They most certainlydid. However, their use in the plural also implies the kidneysin general, as reference to the heart is also made in the pluralon occasion (Psalms 7:8) but not invariably so as it is forthe kidneys. In doing so, the biblical authors were followingthe dialects of the ancient Semitic languages, of which Hebrewis one, spoken in the Middle East. The Akkadian use of the kidneysin the plural (kalte) appears in cuneiform texts from 1700 beforeCommon Era (BCE) or even earlier (1,4). Of interest is the explanationgiven for the presence of two kidneys in the Talmudic corpus,which reasons that there are in humans two kidneys, one to givegood and the other bad advice (5).
The Bible is a complex and exquisite work of literature becauseof the wondrous way in which it was created. Unfortunately,this also presents difficulties in its historical interpretation.Originally assembled from sources (oral to begin with and thenwritten as the alphabet was developed) composed in three languages(mostly old Hebrew, some in Aramaic, and few in Greek), it waswritten over a span of approximately 1000 years (ca. 1300 to400 BCE), during which the original texts were written and rewritten,copied and recopied, edited and reedited, and then collatedand redacted. The process of canonization was a long one, whichwas not completed until the end of the first or early secondcentury Common Era (CE). Written not as a chronicle but as atestimony of faith, the Bible is difficult to stratify and treatchronologically. Several events are recounted and appear indiffering versions and at variable time periods. Verificationis complicated by linguistic difficulties, presented by theuse of language written in consonants and without punctuationduring several distinct periods, compounded by the loss or survivalof only fragments of the original sources, because of the inherentfragility of the parchment and papyrus on which they were written(6–9). Nevertheless, in some ways, the Bible does holdin its pages reflections of real events, garbled perhaps bytime and recounting, but nevertheless of stories that occurredin real time. As such, the process of comparing biblical historywith mainstream ancient history in general and of medical historyin particular can be valuable, especially when it is done inthe broader context of evolving trends and regional customs,rather than specific dates and precise locations (8–10).
Considered in this broader context, the narrative of the Biblebegins toward the end of the Bronze Age and the start of theIron Age (Figure 1). This was a tempestuous era of human migrations,invasions, and devastations, during which emerging city-stateswere continuously warring and beginning to give way to organizedempires. As a result, the burden of human disease was changingfrom the stage of pestilence and famine of prehistory to thatof the receding pandemics brought about by fixed settlementsand close living in the evolving river civilizations of theMiddle East (11). It is on this stage that the primal figureof Abraham journeyed from Ur to Haran and by way of Canaan intoEgypt. In doing so, he was traveling the trade routes of theancient Middle East that extended from Mesopotamia through Syriaand Canaan into Egypt. Although Abraham’s sojourn in Egyptwas brief, the Patriarchal figures who followed him escapedthe famine, pestilence, and warring tribes of Canaan and wiselyelected to settle in the relatively richer, healthier, and morestable environment of pharaonic Egypt, where they dwelt forcenturies (8,12,13). As such, by the time Moses led the Hebrewsout of Egypt, they took with them many of the customs and conceptsthat they had acquired and assimilated during their stay inEgypt, including those pertaining to hygiene and medicine. Evenafter they settled back in Canaan, emerged as a nation, startedto interact with their neighbors to the east and north, andbegan composing some of the older original biblical texts, theyremained within the sphere of influence of Egypt for severalcenturies longer, before coming under that of the Babylonianand Persian empires in the seventh century BCE and thereafter,when the final version of the Bible began to be edited (7).By the time it was canonized, Alexander had conquered the MiddleEast, and Hellenistic science and philosophy were beginningto exert their influence on the thoughts and customs of theregion (Figure 1).
The Hebrews, unlike their neighbors, the Egyptians and Babylonians,left no medical literature, although the Bible contains manyreferences pertaining to medical subjects that consist mostlyof laws governing personal and social hygiene, limited referenceto external, possibly infectious, diseases (e.g., skin, eye,genital discharge, intestinal diarrhea) and some mention ofvarious body organs (13–18). By the time the Torah wascomposed, medicine had developed to a reasonable degree of sophistication(Figure 1). Beginning in the mystical origins of primitive medicine’smagical recipes, empirical observations had led to the accrualof a body of knowledge on the relative safety and curative propertiesof a disparate group of natural products for the relief of thesigns and symptoms of illness. Over time, several of these wereintegrated into folk medicine, whereas others were consolidatedinto the materia medica of medicine as it evolved graduallyfrom the priestly medicine of prehistory into the ancient world’searly professional physicians, whose therapy remained directedat signs and symptoms to relieve pain and suffering. The causeof illness was attributed to supernatural forces. Possessionby demons and malevolent spirits was considered the why andwherefore of disease, especially in Mesopotamia but also inthe relatively more sophisticated medicine of Egypt (12,19).Attributed to the pantheon of deities and demons that ruledtheir vision of the world, illness was perceived as a punitiveinstrument for transgressions against or breached promises toone of the divinities (10,19–21). As such, in both regions,medicine initially developed as ancillary to religion. Onlyin later periods did a special group of healers who were notmembers of priesthood arise (22). Even then, sickness continuedto be attributed to hostile spirits or the anger of a deity,so medications, no matter how powerful or effective, were expectedonly to alleviate symptoms. It was the incantations, spells,and prayers recited conjointly that could remove the cause ofthe disease and cure it (4,12,14,20). Minor ailments were acceptedas part of the normal pattern of life. Most illnesses were sufferedin silence and treated at home with folk medicines by membersof the extended family. Only when a disease was severe or prolongedwas health care sought from its priestly providers, usuallyin temples (18–21).
It was just about this transitional period from priestly toprofessional medicine that the Torah was written. It was thisgeneral concept of illness and its cure that was to formulatethe concept of disease in the Torah and to affect it in thebooks that followed: "I am the Lord your physician" (Exod. 15:26);"I kill and make alive. I wound and I heal." (Deut. 32:39) unequivocallydeclare the jealous Yahweh of the Torah. This divine monopolyon healing left no room in the Bible for the magical charmsand incantations of the healers of Mesopotamia and Egypt, whichaccounts for its hostile view of physicians, who are sanctionedand enjoined throughout most of the Bible (23–25). Thus,the kings of Judah, Asa (ca. 913 to 873 BCE) and Hezekiah (ca715 to 687 BCE), are faulted and reprimanded for seeking medicalcare from physicians for their respective diseases (2 Chron.16:12; 2 Kings 20), whereas Job, whose afflictions could notbe cured by medical men, characterizes them as " physiciansof no value" (Job 13:4). According to the Mishnah, "the bestof physicians are destined to go to hell" (Kidushin 4:14). Conversely,Jeremiah (ca. 626 to 582 BCE) was surprised that Gilead (a mountainousregion in Transjordan) had no physicians or balm left to treatthe children of Israel (Jer. 8:22), whereas Josephus (ca. 37to 100 CE) attributed to Solomon (968 to 928 BCE) a considerableknowledge of medicine (26). Legend has it that Hebrew medicinebegan with Solomon, who is said to have compiled a book of remediesthat was subsequently found and concealed by Hezekiah (23,24).Actually, this may not be a far-fetched likelihood, because"Solomon’s wisdom excelled the wisdom of all of the childrenof the east country, and all of the wisdom of Egypt" (1 Kings4:29). Surely that wisdom contained some medical lore, and ifit did, then so also must have that of Moses, who "was learnedin all of the wisdom of the Egyptians" (Acts 7:22). He was certainlyfamiliar with the art of apothecaries (Exod. 30:35). Moreover,it was Moses who at God’s command crafted a bronze serpenterected on a pole to relieve the effects of a plague of poisonousserpents (Num. 21:8 to 9). This or a copy of it later was placedin the Jerusalem temple, where it seems to have been used toheal disease, until Hezekiah destroyed it because of its implicationsof idolatry (2 Kings 18:4). This use of serpents for therapeuticpurposes reflects similar patterns of temple healings in Canaanthat survived well into the period of Greek rational medicine(25–27).
By the time the Bible was completed and canonized, Greek rationalmedicine had fully emerged and in the footsteps of Alexander’sconquests was permeating Middle Eastern medical thought (Figure 1).In fact, Alexandria, where Greek rational medicine flourishedunder the first Ptolemies, was a Jewish center of rabbinicalstudies with close ties and considerable influence on Jerusalemand the court of Judah (28). One impact of these changes wasthat seeking treatment from physicians gradually became acceptable,and in one of the Apocryphal Books of the Latter Prophets, seekingthe help of a physician is justified but then only as one whois God’s agent of healing for "the Lord hath created him"(Eccl. 38: 1 to 15).
As much as biblical medicine betrays to a great extent Egyptianand to some extent Mesopotamian influences, it differs fromthem in two ways. First is the inclusion in its chronicles ofthe pestilence and famine of prehistory and the receding pandemicsof the city-states and empires. Their mention is rare in themedical writings of Egypt and Babylonia (14). By sharp contrast,they are given center stage in the stories of the Bible, beginningwith the famine that drove the Patriarchs to Egypt, followedby the calamities that God wrought on the Egyptians to let hischildren return to Canaan and the concluding promise that, ifthe settlers would hearken to the voice of the Lord and followHis statutes and commandments, "I will put none of the diseasesupon them, which I have put upon the Egyptians, for I am theLord that healeth thee" (Exod. 15:26). The other differenceis that of reference to the kidneys approximately 30 times inthe Bible (2,29,30), whereas their mention in Egyptian medicaltexts is questioned (31) and in Babylonian ones superficial(32,33).
By far the most common mention of the kidneys in the Bible (11times) is about the parts of sacrificial animals that are tobe burned in Temple offerings. The authorship of these methodicalinstructions is attributed to P, whose central concern is Priesthood.It is the latest of the sources of the Torah and is consideredto have been composed between the sixth and fifth centuriesBCE (6,7).
The formulaic verse "And thou shalt take all of the fat thatcovereth the inwards, and the caul that is about the liver,and the two kidneys, and the fat that is upon them, and burnthem above the altar" (Exod. 29:13) is repeated monotonouslyin the instructions given for the sacrificial offering of bulls,rams, sheep, and calves and restated all over again as Mosesinstalls Aaron as high priest, who then makes the prescribedsacrificial offerings: "And he took the fat, and the rump andall that was upon the inwards and the caul above the liver,and the two kidneys, and their fat, and the right shoulder"(Lev. 8:16). This may be a custom acquired from the Egyptians.The kidneys and their surrounding fat as funerary offering isdocumented in a relief (ca. 2700 to 2200 BCE) from the tombof Tepemnkh (Figure 2). There is a reference to the kidneysas nourishment when in the recounting of God’s lovingactions on behalf of Israel, Moses recalls how the Lord foundJacob abandoned and fed him "butter of kin, and milk of sheep,with fat of lambs, and rams of the breed of Bashan, and goats,with the fat of kidneys of wheat; and thou didst drink the pureblood of the grape" (Deut. 32:14).
Figure 2. Relief from the tomb of Tepemnkh (Djadjaemankh), ca. 2700 to 2200 BCE. Louvre Museum, Paris, France. Reproduced with permission. Among the list of funerary offerings, fat around the kidneys is shown in the boxed hieroglyph.
Because only the best of everything must be offered to God,it is not unexpected that the kidneys and their surroundingfat would be part of the sacrificial offerings, and becauseit was believed that the Hebrew God did not eat like the statuesof human and animal gods of Egypt and Mesopotamia, the offeringswere not placed but burned at the altar so that smoke from theburned food would ascend skyward, where the spirit of Yahwehroamed. The blades used for sacrificial slaughtering seem tohave been considered blessed and used by God in the slaughterof the enemies of Israel: "The sword of the Lord is filled withblood, it is made fat with fatness and with blood of lambs andgoats, with the fat of the kidneys of rams; for the Lord hasa sacrifice in Bozrah, and a great slaughter in the land ofIdomea" (Isa. 34:6).
The Temple and its rituals had a distinct role in the deliveryof health care (34). Those who contributed to the Tabernaclewere promised protection from plagues to come (Exod. 30: 12).According to Josephus, sacrificial offerings were made for theexpulsion of disease (35). That sacrificial offerings, whichentailed the burning of kidneys and their surrounding fat, wereused for medical problems is illustrated in Figure 3, showingJoachim burning his offerings at the altar. It seems to havebeen favorably received as his wife Ann, who had been barrentheretofore, gave birth to Mary thereafter. This story fromone of the Apocryphal Gospels (Pseudo-Matthew 3:1 to 3) is reminiscentof the birth of Samuel, the first king of Israel (1025 to 1005BCE), following the petition for fertility of his childlessmother Hannah at the shrine of Shiloh (1 Sam. 1).
Figure 3. Joachim making a sacrificial offering at the altar, 1304 to 1306. Fresco by Giotto (ca. 1276 to 1337). Scrovigni Chapel (Arena Chapel), Padua, Italy. Reproduced with permission. Note in the foreground all of the sacrificial offering of animals of which the kidneys and their surrounding fat are individually cited in the books of Exodus and Leviticus. Burning on the altar are the remains of an entire kid, while the angel on the right announces the favorable reception of the offering and that Joachim’s wife Ann, who had been barren theretofore, would give birth to Mary in due time.
Allusion has been made that the burning of the inwards of sacrificialanimals was for economic reasons because they were not considerededible. This certainly is not applicable to the kidneys themselvesthat seem to have been consumed and those from a 3-yr-old calfconsidered a special delicacy (36). Besides, more than justthe inwards were used in offerings as the above quote aboutAaron indicates, and at times, the whole animal was burned (Figure 3).The use of the kidneys in sacrificial offerings may be relatedalso to their broader allegorical importance discussed in thesection that follows.
To differentiate between anatomic references to animal kidneysas body parts burned on the altar in the Torah from its subsequentfigurative use in later books authored by more poetic biblicalscribes, the translators of the King James Bible elected touse the term "reins" rather than kidneys in referring to thelatter instances, perhaps reflecting their stated commitmentto enrich the language with "civility and eloquence" (37).
The scriptures, much like the ancient literature of the MiddleEast, make figurative use of several internal organs as symbolsof wisdom, emotions, and vigor (1,38). The ancients did nothave a detailed psychologic vocabulary to make the fine linguisticdistinctions introduced in modern speech. The figurative useof organs, with their multilayered metaphoric implications,circumvented these limitations. It was their means to bringthe imagery of our recently acquired psychologic terms intoa series of manageable and easily visualized linguistic expressionsto discern the meaning of human experiences. As a book usedto teach the law and ethics to illiterate farmers and shepherds,this was a powerful tool, much like that of the imagery of thestained windows of cathedrals in the Late Middle Ages. The mostcommonly used organ for these purposes was the heart, as a symbolof intellect and wisdom, and blood, as a symbol of the lifeprinciple (18). Unlike most ancient literature, however, thekidneys receive special attention in the Bible as the seat ofconscience, emotions, desire, and wisdom. The broader regionof the loins, which according to the Oxford English Dictionaryis implied in the now archaic term "reins," is considered thesite of physical strength and prowess (Job 40:7; 2 Sam. 20:8).However, unlike the kidneys, reference to the heart as an anatomicorgan is extremely rare in the Bible (1 Sam. 25:37). Conversely,the liver, which is cited repeatedly as an anatomic organ alongsidethe kidneys in animal sacrificial offerings, is used only oncefiguratively in the Bible as the site of intense grief (Lam.2:11).
The kidneys are mentioned five times in the Bible as the organsexamined by God to pass judgment on a person. They are mentionedeither before or after but always in parallel with the heart,as for example, "I the Lord search the heart, I try the reins,even to give every man according to his ways, and accordingto the fruit of his doings" (Jer. 17:10), and, "Examine me,O Lord, and prove me; try my reins and my heart" (Psalms 26:2).All five mentions are in Jeremiah and Psalms, both of whichare poetic and epigrammatic in style and, hence, their freemetaphoric use of the kidneys and heart as the central essenceof a person, or, as we would call it now, the psyche of a person.
This metaphoric use of the heart and kidneys does not seem tobe due to transference from a specific anatomic meaning butto the survival of a more vague, more general, and earlier meaningof the deeper "inwards" of a person, a term also used in conjunctionwith the sacrificial use of the kidneys mentioned above. Boththe kidneys and the heart were internal organs, well hiddenfrom view but accessible to the look of God. This use of theheart and kidneys in parallel seems to have its roots in Egyptand Mesopotamia. Whereas the heart was the organ examined bythe gods in Egypt, the kidneys are mentioned alongside the heartin the Egyptian Book of the Dead: "Homage to thee, O my heart!Homage to you, O my kidneys!" but then only once (39). Attributionto Egyptian customs has been made on the ground that the heartand kidneys were left in place during mummification. This seemsto have been the practice during the early days of mummification,but there is evidence that later on, the kidneys or at leastfragments of them were removed, mummified, and placed back inthe abdominal cavity or stored in canopic jars alongside theother viscera (40). During their stay in Egypt, the Hebrewswere exposed to these procedures. Actually, the first use ofthe word "physician" in the Bible is when Joseph is said tohave employed "physicians to embalm his father" (Gen. 50:2)and had himself embalmed by them later on (Gen. 50:20). Temperamentswere also associated with organs in Mesopotamia, where the liverassumes the leading role with occasional mention of the kidneysand the heart cited in parallel with the liver as sites of emotions.In some instances, the kidneys replace the liver and were usedin parallel to the heart (1).
The kidneys are mentioned four additional times in the Bible,sometimes in direct connection with the heart, as the site ofemotions and intellect. Some of the attributes principally assignedto one of these two organs are at times credited to the other.Thus, whereas the heart is the organ considered to be the siteof wisdom and the governing center of rational processes, itis a function that is attributed also to the kidneys, as in,"I will bless the Lord, who has given me counsel; my reins alsoinstruct me in the night seasons" (Psalms 16:7). The Midrashon Genesis (Genesis Rabbah 61:1) tells that the illiterate Abrahamwas taught the law by his kidneys and then developed the recognitionof God from within himself (13,38). Conversely, whereas thekidneys are considered the site of affections, as in the versesof joy, "Yea my reins shall rejoice, when thy lips speak rightthings" (Prov. 23:16), and of faithfulness, "And righteousnessshall be the girdle of his loins, and faithfulness the girdleof his reins" (Isa. 11:5), they seem to share their positionas the site of affections with the heart as in the followingverse of grief: "Thus my heart was grieved, and I was prickedin my reins" (Psalms 73:21). No other internal organs of thebody are mentioned in parallel in the Bible as often as arethe heart and the kidneys.
Divine injury to the kidneys is mentioned three times in theBible. Job, lamenting his calamities (Figure 4), comments that"His archers compass me round about, he cleaves my reins asunderand doth not spare" (Job 16:13), and again, "Whom I shall seefor myself, and mine eyes shall behold, and not another; althoughmy reins be consumed within me" (Job 19:27), as does Jeremiah:"He hath caused arrows of his quiver to enter into my reins"(Lam. 3:13).
Figure 4. The Complaint of Job, ca. 1786 by William Blake (1757 to 1827). Reproduced with permission from the Museum of Fine Arts of San Francisco. Among Job’s complaints cited in the Bible are that the "physicians of no value" (Job 13:4) of the time could not provide relief when his "reins were consumed within me" (Job 19:27).
Conceptually, injury to the kidneys would be expected to resultin kidney disease, as has been suggested by some interpretersof these verses (29,30). It is possible also that they wereused for their more abstract metaphoric meaning to refer tointense suffering or deep sorrow felt in the "inwards," muchlike that of the current literal use of "you hurt me deep inside."
As a result of advances in medicine, psychology, and linguisticterminology, the biblical metaphoric attributes of the kidneysare now associated with the brain and the mind. Indeed, in recentversions of the Bible, the term "mind" is substituted oftenwhere the authors of the original text used the kidneys, yetthe brain is not mentioned in the original scriptures. It seemsthat the Hebrews, like the Egyptians, who discarded the brainduring mummification, did not consider the brain an importantorgan (40,41). Although this may be considered a speculativeassumption, the Hebrews during their centuries of residencein Egypt were familiar with the embalming customs of their hosts,and, as mentioned above, it was used at least by some of them,such as Joseph and his father.
Whereas it would be wrong to project our modern concepts anduse of language on that of the archaic biblical story tellers,there might well be more consciousness of a physical basis intheir metaphoric use of the kidney than there is in our continueduse of the metaphoric heart as we still speak of something being"the heart of the matter" or sing "I left my heart in San Francisco."Why then of the three principal organs used metaphorically inthe Bible the heart continues to be used to the present, whereasthat of the liver has been lost except for its residual in "melancholy"and that of the kidneys has disappeared without a trace? Theanswer lies in the gradual increase of Hellenistic influenceson Western culture since the closing centuries of the firstmillennium BCE (Figure 1).
In his account of the creation of man in Timaeus, Plato (428to 347 BCE) made the head the most divine and sacred part ofthe body, where it is placed at the very top and separated bythe neck from the trunk, which in its upper part contains themortal soul and is distinctly separated from the baser partof the trunk, which houses the appetitive organs (42). Platomade no mention of the kidneys in Timaeus. In essence then,the head, in its near-perfect geometric figure of a sphere,houses the brain and mind, now considered as the site of wisdomand essence of humans. There is no more need for God to lookat the "inwards" of the Egyptians, Mesopotamians, and Hebrewsof old; a mere glance at the mind and soul located in the headwould suffice. The ancient "inwards" and mysterious kidneyswere now relegated to mere supportive nutritive functions andaccordingly placed in the lowest part of the body, where theyare well separated from the rest of it by a strong diaphragm(42,43).
Parallel advances in medicine provided functional evidence forthis philosophical interpretation of the body, with its strongreligious overtones. Neither the Egyptians nor the Mesopotamiansconsidered the kidneys an excretory organ. Urine was thoughtto be formed in the bladder (44). Hence, the otherwise functionlessand well-hidden kidneys were given a spiritual role of vigor,strength, emotions, and wisdom. Whereas it was Galen (131 to200 CE) who provided conclusive experimental evidence that urinewas formed in the kidneys (44), the kidneys as the source ofurine long had been considered by his predecessors, after anatomicdissections revealed their connection to the bladder by theureters. Indeed, the first medical text on diseases of the kidneysand bladder by Rufus of Ephesus (ca. first century CE) was publisheda century before Galen (Figure 1), at just about the time thatthe Gospels were being composed (45). As such, the kidneys asmere generators of waste products could now be debased or evenneglected, as did Plato, because of their location in the abdomenalongside the nutritive organs.
Despite the absence of mention of the kidneys in the later booksof the Bible, the Hebrew use of the kidneys as the site of prudence,craftiness, and shrewdness persisted and permeated the biblicalteachings of the Christian era as in the explanation of theSyrian Father (later saint) Ephraem (ca. 306 to 373 CE) that:"In the kidneys are seated reasonings, and there dwells in themthe faculty of discernment; they distinguish truth from falsehood,and judge what is base and what is noble" (38). This may accountfor the single mention of the kidneys in the New Testament:"And I will kill her children with death; and all of the churchesshall know that I am He which searches the reins and the hearts:and I will give unto every one of you according to your works"(Rev. 2:23). To differentiate these noble allegorical functionsof the kidneys from their mundane physiologic function as excretoryorgans, the translators of the Bible into English, first JohnWycliffe (1330 to 1384) and his associates, elected to use "reenes"instead of "kidneris" in the 14th century, and subsequentlythe divines, who at the request of King James translated theBible in the first decade of the 17th century, decided to usethe reins rather than the kidneys (37,46). By the time thatthese translations into the vernacular were published, the functionof the kidneys as filters of waste products was well recognized.Nevertheless, the figurative use of the reins and kidneys seemsto have continued well into the 19th century as in, "They aregirdled about the reins with a curse," in an 1865 poem by A.C.Swinburne (1837 to 1901), a Victorian man of letters, and inan 1880 comment by his contemporary Disraeli (1804 to 1881):"It was a large and rather miscellaneous party, but all of theright kidney" (46).
The death blow, that was to prove Plato prescient, came in thelate 1960s, when improvements in resuscitation techniques andincreasing feasibility of organ transplantation provided a newstimulus to "salvage the kidneys," necessitating a new definitionof death as irreversible brain function (brain death) ratherthan the traditional cessation of respiratory and cardiac function(47). From the perspective of nephrology, it is unfortunatethat the biblical metaphoric use of the kidneys, which seemsto have survived Greek analytical philosophy and rational medicineduring the first centuries of the Common Era, was weakened afterthe Scientific Revolution, when the sensory-motor functionsof the brain were elucidated and ultimately lost because ofthe very success of nephrology in making kidney transplantspossible. It is not unexpected then that in recent translationsof the Bible, the "mind" and "soul" are substituted for theoriginal "reins" not only by Christians but also by Jews asin the most recent Tanakh Translation of the Torah, Nevi’imand Ketuvim (48). It will be unfortunate if future generationsare not able to appreciate the nuances and multilayered overtonesof the reins that the biblical authors intended and may havebeen one reason for their use as sacrificial offerings to theLord.
Acknowledgments
I thank Eberhard Ritz for the initial idea for this paper andWilliam G. Couser for inviting me to write this article, whosepreparation exposed me to vistas I had not fully appreciatedbefore, and Markham J. Geller for reading and commenting onan early draft of the manuscript.
Footnotes
Editor’s Note: With delivery of the December issue ofJASN we complete Volume 16 of the Journal and thereby its 16thyear of publication. Although invisible in the pages of JASNVolume 16, this year and volume span a period that has beena particularly turbulent one around the world and for nephrologistsand their patients in many areas. The tsunami in Thailand inlate 2004 was felt deeply in 2005, as were hurricanes Katrinaand Rita in the US, the terrorist bombings in London, the continuingwar in Iraq, and the earthquakes in Pakistan and India—allevents that challenged both the provision of optimal patientcare in affected areas and, by consuming scarce resources, theadvancement of renal science everywhere. As we enter this 2005holiday season for Christians and Jews, it is comforting tostep back from the travails and natural disasters of our timeover which we seem to have so little control and to take a broaderand more historic view of our discipline. In the following article,Dr Gary Eknoyan provides a unique perspective on kidneys andtheir role in human life and history as seen by the ancientsand described in the Bible, that ancient text that inspiresso many of our current holiday traditions and celebrations.As one reads the story one is struck by the important role playedby our organs of interest in nephrology, early exceeding thebrain and the heart in stature as the seat of "conscience, emotion,desire, and wisdom" in the ancient texts. The cover illustrationdepicts Joachim employing sacrificial offerings that entailedthe burning of kidneys and their surrounding fat to enhancethe fertility of his previously barren wife who later gave birthto Mary. The story and the picture both convey a remarkablesense of the distance we have traveled in renal medicine sinceancient times and tie the kidneys to a message of hope thatwe need to hear at this time of year and at this point in history.Enjoy the paper, and happy holidays from the JASN editorialstaff.
Published online ahead of print. Publication date availableat www.jasn.org.
Dhorme P: [The metaphorical use of names of body parts in Hebrew and Akkadian].
Revue Biblique32
:489
–517,1922
Maio G: The metaphorical and mythical use of the kidney in antiquity.
Am J Neprol19
:101
–106,1999[CrossRef]
Frazer JG: "Hearts and reins" and ideas of uncultured races.
J Manchester Univ Egyptian Oriental Soc1
:107
–108,1911
Geller MJ: Die babylonysch-assyriche Medizin in Texten und Untersuchungen 7. In:
Renal and Rectal Disease Texts, Berlin, Walter de Gruyten, GMBH & Co.,2005
Kottek SS: "The kidneys give advice"—Some thoughts on nephrology in the Talmud and the Midrash.
Korot10
:44
–53,1994
Friedman RE:
Who Wrote the Bible? New York, Harper Collins,1997
Friedman RE:
The Bible with Sources Revealed, New York, Harper Collins,2005
Romer L:
Testament. The Bible and History, New York, Henry Holt and Co.,1988
Bloom H, Rosenberg D:
The Book of J, New York, Grove Weidenfeld,1990
Dever WG, Gitin S, Eds:
Symbiosis, Symbolism and the Power of the Past. Canaan, Ancient Israel and their Neighbors from the Late Bronze Age through Roman Palaestina, Winona Lake, IN, Eisenbrauns,2003
Omran AR: The epidemiologic transition. A theory of the epidemiology of population change.
Milbank Mem Fund Q49
:509
–538,1971[CrossRef][Medline]
Baas JH:
Outline of the History of Medicine and the Medical Profession, Huntington, NY, Robert E Krieger Publishing Co. Inc.,1971
, pp13
–39
Preuss J:
Biblical and Talmudic Medicine, translated and edited by Rosner F, Northvale, NJ, Jason Aronson, Inc.,1993
Egar II:
The Origins of the Healing Art. A Psycho-Evolutionary Approach to the History of Medicine, New York, Philosophical Library,1978
Short AR:
The Bible and Modern Medicine, London, The Paternoster Press,1955
Levin SS:
Adam’s Rib: Essays on Biblical Medicine, Los Altos, Geron-X, Inc.,1970
Snowman J:
A Short History of Talmudic Medicine, New York, Hermon Press,1974
Smith CR:
The Physician Examines the Bible, New York, Hallmark-Hubner Press Inc.,2004
Dawson WR:
Clio Medica. The Beginnings: Egypt and Assyria, New York, Paul B Hoeber, Inc.,1930
Jastrow M: The medicine of Babylonians and Assyrians.
Proc Roy Soc Med7
:109
–176,1914
Jayne WA:
The Healing Gods of Ancient Civilizations, New Haven, Yale University Press,1925
Osler W:
The Evolution of Modern Medicine, New Haven, Yale University Press,1921
Gordon BL: Medicine among the ancients Hebrews.
Ann Med Hist4
:219
–235,1942
Allan N: The physician in ancient Israel. His status and function.
Med Hist45
:377
–394,2001[Medline]
Gordon MB: Medicine among the ancient Hebrews.
Isis33
:454
–485,1941[CrossRef]
Josephus:
Jewish Wars. Book VII. Cambridge, Loeb Classical Library, Harvard University Press,2001
Schouten J:
The Rod and the Serpent of Asklepios. Symbol of Medicine, Amsterdam, Elsevier Publishing Company,1967
Kottek SS: Alexandrian medicine in the Talmudic corpus.
Korot12
:80
–89,1996–1997
Kopple JD: The biblical view of the kidney.
Am J Nephrol14
:279
–281,1994[Medline]
Dvorjetski E: The history of nephrology in the Talmudic corpus.
Am J Nephrol22
:119
–129,2002[Medline]
Salem ME, Eknoyan G: The kidney in ancient Egyptian medicine. Where does it stand?
Am J Nephrol19
:140
–147,1999[Medline]
Geller MJ, Cohen SL: Kidney and urinary tract disease in ancient Babylonia, with translation of the cuneiform sources.
Kidney Int47
:1811
–1815,1995[Medline]
Geller MJ: Hippocrates, Galen and the Jews: Renal medicine in the Talmud.
Am J Nephrol22
:101
–106,2002[Medline]
Avalos H: Israel. The temple(s) of Yahweh. In:
Illness and Health Care in the Ancient Near East, Atlanta, Scholars Press,1995
, pp233
–404
Josephus:
Jewish Antiquities. Book III, Cambridge, Loeb Classical Library, Harvard University Press,2001
, pp429
–431
Rosner F:
The Encyclopedia of Medicine in the Bible and Talmud, Northvale, NJ, Jason Aronson Inc.,2000
, p67
Nicolson A:
God’s Secretaries. The Making of the King James Bible, New York, Harper Collins,2003
Hogg HW: "Heart and reins" in ancient literature of the Near East.
J Manchester Univ Egyptian Oriental Soc1
:49
–91,1911
Budge EAW:
The Egyptian Book of the Dead. The Papyrus of Ani, New York, Dover Publications Inc.,1967
, p313
Smith GE: Heart and reins in mummification.
J Manchester Univ Egyptian Oriental Soc1
:41
–44,1911
Leca A:
The Egyptian Way of Death. Mummies and the Cult of the Immortal, Garden City, NY, Doubleday and Company, Inc.,1981
, pp144
–146
Plato:
Timaeus, translated by Crawford FM, New York, Macmillan Publishing Co.,1959
Joubaud C:
Le Corps Humain dans la Philosophie Platonicieenne. Etude à partir du Timée, Paris, Librairie Philosophique J Vrin,1991
Eknoyan G: Origins of nephrology. Galen, the founding father of experimental renal physiology.
Am J Nephrol9
:66
–82,1989[Medline]
Eknoyan G: Rufus of Ephesus and his diseases of the kidneys.
Nephron91
:383
–392,2002[Medline]
Definitions of kidney and reins. In:
Oxford English Dictionary, CD-Version 2.01, Oxford, Oxford University Press,2001
A definition of irreversible coma: Report of the Harvard Medical School to examine the definition of death.
JAMA205
:337
–340,1968[CrossRef][Medline]
The Jewish Publication Society:
The Jewish Study Bible, Oxford, Oxford University Press,2004
This article has been cited by other articles:
G. Wolf A kidney from hell? A nephrological view of the Whitechapel murders in 1888
Nephrol. Dial. Transplant.,
April 11, 2008;
(2008)
gfn198v1.
[Abstract][Full Text][PDF]
Top
Abstract
Introduction
te) appears in cuneiform texts from 1700 before Common Era (BCE) or even earlier (1,4). Of interest is the explanation given for the presence of two kidneys in the Talmudic corpus, which reasons that there are in humans two kidneys, one to give good and the other bad advice (5). 
