From certain death to chronic crisis: The medical and ethical history of kidney failure

“ We can keep the eyes closed for a few days, if necessary, without injury, and in fact often with benefit; or, we can abstain from food for some days, if need be, and let the stomach rest. But the kidneys cannot, with safety, cease their work. Their duty in ridding the blood of waste products, and of any foreign or poisonous material introduced, must be done not only faithfully, but continually, or the whole body at once suffers from the evil effects of the retained waste matters. ”

“ Every animal organism is constantly throwing off these extractives, such as urea, uric acid, creatinine, etc. The kidneys have no other function than the removal of poisons. If an animal is deprived of the use of its kidneys, it will diePg 58 of self-poisoning in a few days. When an animal is slaughtered and the blood ceases to circulate, this stream of urinary products on its way to the kidneys for excretion stops in the tissues, and is devoured by the consumer with the flesh. ”

“ The blood in the renal veins, having given up most of its impurities and still retaining its oxygen, is considered the purest blood in the body.
Urea is the most abundant solid constituent of the urine and is the chief waste product arising from the oxidation of nitrogenous substances in the body. Although secreted by the cells lining the uriniferous tubules, it is not formed in the kidneys. The secreting cells simply separate it from the blood where it already exists. The muscles also have been suggested as a likely source of urea, for here the proteids are broken down in largest quantities ”

“ If it fails to promptly fulfil its office, every vital function is interfered with; and in addition the fluid portion of the semi-liquid waste is re-absorbed directly into the circulation, redepositing in the very fountain of life, matter which the system has thrown off as worthless. Should the system be exposed to a chill, while in this condition, a congestion of the surface excretory vessels takes place; and practically the whole work of elimination is thrown upon the already hard-worked kidneys, frequently resulting in uraemic poisoning and death. ”

“ Any defect in their healthy activity leads to serious interference with the working of many organs, due to the accumulation in the body of nitrogenous waste products. If both kidneys be cut out of an animal, it dies in a few hours from blood-poisoning, due to the accumulation of waste poisonous [Pg 90] substances which the kidneys should have got rid of. Serious kidney-disease amounts to pretty much the same thing as cutting out the organs, since they are of little use if not healthy. It is always fatal if not checked, and often kills in a short time. ”

“ Uraemia is of toxic origin, and it is probable that the dropsy of renal disease is due to effects produced in the capillaries by the presence of abnormal substances in the blood. High arterial tension, cardiac hypertrophy and arterial degeneration may also be of toxic origin, or they may be produced by an attempt of the body to maintain an active circulation through the greatly diminished amount of kidney tissue available. ”

“ The effect upon the general health of the patient is not in any exact relation to the degree of the kidney lesion. These two facts render the prognosis of chronic diffuse nephritis very uncertain. The disease is always a very serious one, and terminates regularly in destroying life, but the length of time that will elapse before this fatal termination, and the precise way in which death will take place, are difficult to determine beforehand. ”

“ The possession of typically healthy kidneys is a rare circumstance in this climate. The excessive micturition so universal in infancy, occasioned by excess in diet, is the beginning of renal disease.
Dr. Bright immortalized his name by discovering the fact that, when a man’s last sickness is attended with a certain class of symptoms, as albumen in the urine, final suppression of the urine, and uremic poisoning, they are occasioned by a peculiar disease or degeneration of the kidney. ”

“ A new kidney has provided improved health, and the donation of a cornea has restored the miracle of sight. Unfortunately, however, many people still wait, and many people still die waiting for a suitable organ to become available. ”

“ Many thousands of Americans who suffer from irreversible kidney disease have obtained treatment through the End Stage Renal Disease (ESRD) Program. This program has assured that Americans affected with otherwise fatal kidney failure will have access to lifesaving dialysis or transplantation therapy. ”

“ The patient will very slowly lose flesh and strength, the appetite will be capricious, either mental or bodily exertion is an effort, but there are no positive symptoms, except that the urine is of rather low specific gravity, and in the evening urine there will be occasionally a trace of albumen. In this condition these patients may continue for years. They may improve very much under treatment, and finally die from some other disease without ever developing any renal symptoms. ”

“ Anaesthetics, that is, chloroform and ether, are not well tolerated when nephritis exists, and this adds to the danger of operation in such patients. No matter how simple or short the operation that is to be performed on a person suffering from kidney disease, if an anaesthetic is to be administered it would be well to prepare the patient for an untoward event that may occur.
Kidney disease is often extremely insidious. It may develop absolutely without the patient's knowledge, even though he might be deemed to be in a position to have at least some suspicion of its existence. ”

“ Certainly, in some cases, the "large white kidney" is an expression of a frail and feeble constitution, and has not always the same significance. A better level of general nutrition, directed in relation to the renal adequacy, may much aid in helping the kidneys to recovery. It is surely wrong to starve the patient while aiming only to rid him of his ailment. Of course, age, habits, constitution, and tissue-proclivity must be had regard to in all such cases.
The treatment of acute phases of dysentery by absolute milk diet I believe to be excellent ”

“ As an organ it is not easily injured by over work, but readily lends its function in an emergency in any effort to relieve other tired or diseased organs of the body. By vicarious action the skin is capable of performing much extra labor without injury to itself and can be harnessed temporarily for the relief of some vital part which has become crippled until its function can be restored.
A diseased kidney depends particularly upon the skin for succor more than any other organ. ”

“ In our Sanitarium, where we have had the advantage of our Turkish baths and other appliances, we have cured some cases in which the removal of the dropsical effusion reduced the patient's weight sixty pounds.
We cannot, In conclusion, too strongly condemn the general resort to strong diuretics so often prescribed by physicians for all forms of renal maladies, but which, by over-stimulating the already weak and delicate kidneys, only aggravate and render incurable thousands of cases annually. ”

“ It is often thought that medicine is the curative process. It is no such thing; medicine is the surgery of functions, as surgery proper is that of limbs and organs. Neither can do anything but remove obstructions; neither can cure; nature alone cures. Surgery removes the bullet out of the limb, which is an obstruction to cure, but nature heals the wound. So it is with medicine; the function of an organ becomes obstructed; medicine, so far as we know, assists nature to remove the obstruction, but does nothing more. ”

“ What is true of kidney changes applies also to corresponding changes in other organs, and there can be no question of any amount of will power bringing about the redintegration of organs that have been seriously damaged by disease or replacing cells that have been destroyed. ”

“ For the present, at least, the possibility of separating the secretion of one kidney from that of the other must be looked upon as depending chiefly upon accident, and in case of contemplated operation it is not possible to assure one's self of the integrity of the other kidney before the abdomen is opened. In many cases after opening the abdomen both kidneys may be examined before deciding upon further steps. Lawson Tait considers an exploratory incision distinctly indicated whenever abdominal disease not malignant threatens the life of the patient. ”

“ On the other hand, the onset may be so stormy or symptoms so terrifying, that we at once think of all the horrible conditions to which the genito-urinary tract is heir. But once our suspicion is aroused as to the possibility of tuberculosis of the kidney, the question of an exact diagnosis, the question of which kidney is involved, and the condition of the other kidney (on which naturally depend the course to pursue) are matters not always easy to decide. ”

“ A horseshoe kidney is usually discovered only after death, and with no special frequency in cases of renal disease.
Variations in the number of the kidneys possess this point of practical interest, that diseases affecting a single organ are more dangerous than if another exists which can take upon itself extra duty. Apparent absence of one kidney may be due to atrophy, attended with very small size of the renal vessels; in which case a small mass of connective tissue is found at the upper end of the ureter, which is usually illy developed. The other kidney is usually hypertrophied. ”

“ The treatment of uncomplicated wounds of the kidney consisted in the ensurance of rest, either alone, or with the administration of opium if the hæmaturia was severe. The after-treatment in the event of the development of hydronephrosis is on ordinary lines. Tapping, or incision followed by extirpation of the injured viscus, if the less severe procedures failed. I never saw a case where renal hæmorrhage suggested the removal of the kidney as a primary step, and much doubt whether such a case is likely to be met with, as the result of a wound from a bullet of small calibre. ”

“ A pyo-nephrosis naturally demands interference more peremptorily and more promptly than a simple hydro-nephrosis, because it exposes the patient to the dangers not only of its pressure and of its tendency to destruction of the renal substance, but to those more urgent ones of purulent infection or of perforation and perinephritic abscess. Removal is to be undertaken by the ordinary rules of laparotomy. ”

“ There is no TREATMENT known to be of value in cancer or sarcoma of the kidney, except so far as it may diminish pain or regulate the secretions. Surgically, removal of the diseased organ is the only expedient to be thought of. Although nephrectomy has been shown to be a perfectly practicable operation, and one that is usually well borne when the other kidney is sound, it has not proved very successful with malignant growths, even as a temporary expedient. ”

“ One hundred and ninety-eight times the kidney has been removed, and 105 human lives have been saved; 83 times abscesses in the kidney have been opened, and 66 lives saved; 17 times stones have been removed from the kidney without a single death—or, in all, in the last fifteen years, 298 operations, and 188 human lives saved. Besides this, as an extension of the operation in 17 cases, in which the kidney, having no such attachments as ought to anchor it in place, was floating loosely in the abdomen and a source of severe pain, it has been cut down upon and sewed fast in its proper place ”

“ From the right kidney, 14 cc. of urine, containing 2.4% urea, and a slight amount of pus; from the left kidney 3⁄4 cc. of urine, a very little urea and a large amount of pus. A nephrectomy of the left kidney a few days later revealed a small tubercular pyonephrotic kidney, with an apparently normal ureter.
In April, 1910, this patient was heard from directly for the last time. By virtue of his social status he was forced to lead a life which was not in conformity with his personal welfare, doing hard manual labor most of the time. ”

“ Incredible as it seemed, we could not but believe, for there was the apparatus before us working, apparently, as smoothly as a watch.
“It is a system devised recently by several very noted doctors at Johns Hopkins,” corroborated Leslie in a manner which showed that as a physician he would not have missed the opportunity of seeing the thing for thousands of dollars.
“Yes,” continued Kennedy, “when there is a toxin or poison in the blood, the kidneys naturally endeavor to eliminate it. But often, as in this case, an emergency arises and it is eliminated too slowly. ”

“ And it is precisely those elements that we want to reach. Yet by these delicate adjustments doctors can remove and discover any desired substance in the blood that is capable of elimination at all, in such a way.”
“I see,” agreed Sinclair. “It does in a way just the work that the kidneys do in elimination.”
Kennedy nodded.
“In fact this little apparatus, with its one hundred and ninety-two tubes,” he added, “has been found in practise to compare favorably with the kidneys themselves in removing even a deadly dose of poison. ”

“ Meanwhile, hundreds of kidney patients from Israel, which has its own well -developed, but under-used transplantation centers (due to ultra-orthodox Jewish reservations about brain death) travel in 'transplant tourist' junkets to Turkey, Moldova, Romania where desperate kidney sellers can be found, and to Russia where an excess of lucrative cadaveric organs are produced due to lax standards for designating brain death, and to South Africa where the amenities in transplantation clinics in private hospitals can resemble four star hotels. ”