Hektoen International

A Journal of Medical Humanities

Renal reminiscences

Medical conferences are an opportunity to travel and to meet. During the early days when renal transplantation, dialysis, and biopsy revolutionized nephrology, I had the opportunity to meet many members of the new discipline. I once listened to Jean Hamburger lecture about kidney transplants. I heard Robert Schrier lecture on salt and water. One summer night, I walked to my hotel room with George Schreiner at three in the morning after a very prolonged renal dinner. Once standing before a poster on calcium metabolism, I heard a famous professor ask, “We know what they did in Sodom, but what did they do in Gomorrah?”

Bulky texts such as those of Strauss and Welt and of Douglas Black were coming into existence at the time. One met in wonderful places such as the Capetian castles on the Loire. In Stockholm the night was like the day, and during the day I heard Jonas Bergstrom talk about uremic toxins, sequential ultrafiltration, and continuous ambulatory peritoneal dialysis. At a meeting in Dublin, I was driven from the bus terminal to the hotel by horse and buggy. In sunny Athens the distinguished Gabriel Richet from Paris signaled his displeasure with the music as he opened the plenary session of the International Society of Nephrology by flinging his wine glass to the ground with an elegant flick of his wrist.

I attended meetings with Willem Kolff and Robert Kark and later with Robert Muehrcke, a kidney biopsy pioneer not recognized as a prophet in his own country. Working with Malcolm Milne, he had described the Muehrcke nails of renal failure. He later left academia, went to dialyze patients in the basement of a church, and established one of the largest dialysis groups in the United States.

In London at St Mary’s I met Roger Bannister, the young neurologist (not nephrologist!) who ran the mile in four minutes. At outpatients, I saw Stanley Peart listen for abdominal bruits in all hypertensives in the belief that most had renal artery stenosis. I remember Hugh de Wardener discussing his French Huguenot ancestors, heard Professor Max Rosenheim lecture on how most renal failure was due to infective chronic pyelonephritis, and saw Graham Bull and “Jo” Joekes, who popularized a low protein diet for advanced uremia. At St. Mary’s, Houghton and Pears were injecting patients with typhoid vaccine or prednisone to uncover occult chronic pyelonephritis. I also heard Denis Burkitt describe a new lymphoma that affected young persons in Uganda.

At the Hammersmith Postgraduate Hospital in London I met Professor John McMichael, who had recruited promising young people such as Christopher Booth. There was often talk about the brilliant young woman, Sheila Sherlock, who had come down from Edinburgh and diagnosed a case of Gaucher’s disease from X-rays. She took many brilliant young men with her to the Royal Free, including Stanley Shaldon, who later incurred her displeasure and was sent to an old fevers hospital to “do kidneys.”

There, Stanley Shaldon set up one of the earliest dialysis in the UK, with a Travenol tank, a Twin Coil that he flushed out and reused several times, regional heparinization, and catheters he made of brown Norwegian material, Teflon not yet available. He dialyzed patients twice weekly by femoral catheterization, including a young woman who ended up limping from a bleed into the iliopsoas muscle.

Professor Martini, a liver specialist from Hamburg, once came to the Royal Free and talked about so many women having cirrhosis of the liver as if vermouth was being sent from Italy through an underground pipe. Later, Dame Sheila Sherlock attended regularly the liver meetings in Chicago with her husband Geraint James, who frequently lectured on sarcoidosis. He often watched BBC war stories and would complain if British spies wore ties with stripes that slanted the right to the left, which would give them away to the enemy.

The hemodialysis and cadaver kidney transplantation unit at the Cleveland Clinic attracted many visitors. Belding Scribner came to show his arteriovenous shunt, and Thomas Starzl, the young suntanned transplant surgeon from Denver, said he was impressed with dialysis but not convinced! Harriet Dustan and Edward Frohlich were leading the research hypertension unit, but it had been founded in 1945 by Irvine Page of renin, angiotensin, and serotonin fame. He had recruited a young Willem Kolff who in an early paper referred to female dogs in the Dutch but not the American way. Page marked his paper with ink from top to bottom so that it had to be entirely retyped, and Kolff nearly burst into tears.

At the dialysis unit in Cleveland, patients with acute renal failure were treated by cannulating the femoral vessels, but the chronics received an external Scribner shunt of Teflon tips connected by a U-shaped Silastic loop that we learned to fashion over a flame into a perfect U-shape. At night we harvested cadaver kidneys in a plastic bag filled with “Nakamoto cocktail.” Satoru Nakamoto was an extraordinarily modest man. He once told me of his amazement when his wife of Japanese descent in Hawaii suggested they send their boy to Buddhist Sunday school, an institution unknown in Japan.

In those early days, patients with severe intractable hypertension were treated by bilateral nephrectomy, and I used to take the removed kidneys in a plastic bag to the Mount Sinai Hospital for renin determinations. There, I once found Victor Vertes and his entire team sitting on the floor and rolling up cellophane loops to make their dialyzers.

In Amsterdam, as an example of Dutch ingenuity, Mrs. William Drukker, wife of one of the founders of the European Dialysis and Transplant Association, served an entire dinner without ever having to get up by merely opening a little sliding door and reaching for the food arranged on a table in the kitchen. William Drukker once gave an example of true citizenship by sweeping the entire side of the street of his house with a broom.

Chicago, a frequent site of medical conventions, has a rich story of renal pioneers, not all teetotalers. At the first meeting of the American Society of Artificial Organs, one of its founding fathers threw a whiskey bottle out of the window from the 13th floor of the hotel, but when the police came to investigate, they denied any knowledge of this. Much later, a young nephrologist, wanting to impress his former chief, gave a sumptuous dinner, during which he produced a little booklet on wines. At which, his former chief observed that he certainly had learned much since the days when he only drank cheap red wine.

I remember Vittorio Bonomini of Bologna, who at the time was proposing that dialysis should be started as soon as the glomerular filtration rate dropped to 15 percent of normal. He invited me to lecture in Bologna but when I came he was away in Rome lobbying the senators to establish a second professorial unit in Bologna. He had me driven to Perugia in an elegant car that whizzed past Florence in no time. I attended a meeting in Assisi and went to Rome in a much slower train in the company of Professor Horst Klinkmann from Rostock, who said he had a professorship in Berlin where he sat in the chair once occupied by the great Leibnitz.

In Melbourne, when clouds from a bushfire darkened the whole town, I met Kirpal Chug, the doyen of Indian nephrology, who invited me to be a visiting professor in India. At the Calcutta Club, they seated me at the bar with a bottle of Kingfisher and argued for the next hour about who should become a member of the new college they were founding. In Khajuraho, I swam in a pool full of Italian tourists, and I admired the ancient indelicate statues of men and animals. In Chicago I drove to the airport professor Carmelo Giordano from Naples, famous for his low protein Giovanetti-Giordano diet. I lost my way in the maze under the convention hotel, and he almost missed his plane. He had tried to broker a peace between two dialysis journals, one Blue from Milano and one Yellow from Cleveland and Japan, both with the same editorial board.

I worked with the blue journal for the next 25 years, starting by reviewing a letter from New Guinea from doctors describing how they made their own peritoneal dialysis fluid to treat the natives who had got drunk on methyl alcohol when Queen Elizabeth visited Port Moresby. I got to love Milano and collaborated with my colleague Dr. Diego Brancaccio, a fan of Piero della Francesca, who took me on a tour to admire the paintings at Sansepolcro, the resort of Bagno Vignioni, the vineyards and lovely countryside of Tuscany, and the palace at Urbino.

At other meetings I met Marc De Broe from Antwerp and also Dimitrios Oreopoulos of peritoneal dialysis fame who later sent me his collection of photos from all over the world. I went to Ghent several times, collaborating with Severin Ringoir in a study of uremic middle molecules.

Among the many nephrologists I met in Chicago, I recall David Earle, who had studied post-streptococcal nephritis in the West Indies and graciously invited me to join his team to dinner in Atlantic City even though I was not on his faculty. His assistants at Northwestern, Francesco del Greco and Frank Krumlovski, also came to that dinner, held at the Crabhouseby the ocean in Atlantic City. Prominent nephrologists in Chicago at various times were Adrian Katz, who made the best Turkish coffee; Edmund Lewis, who made a potent Christmas punch; Todd Ing, who had trained with Oliver Wrong in London and did not drink at all; and Earl Smith, with whom I started dialysis by using an old Maytag washing machine. (See figure)

I once accompanied Jose Arruda from the University of Illinois to Brazil. He lectured on renal failure in Portuguese but with self-explanatory slides. I saw Fluminense play Botafogo at the enormous Maracanã football ground, which is surrounded by a wire fence for obvious reasons. We were fed exclusively meat at a traditional Brazilian restaurant and drank inexpensive beer at the Copacabana beach while watching girls play volleyball with their feet.

Traveling is often an opportunity to read a good book. I read Gibbon at Lautoka in Fiji, Emma at Carmel in California, and often Sir Thomas Browne. In his gorgeous style, he reminds us that generations come and go, and that the greater part of us must be content as though we had never been, to be remembered in the register of God but not in the record of man.

GEORGE DUNEA, MD, Editor-in-Chief

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.