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A Short Historic View of Nephrology upto the 20th Century
Greydanus DE1, Raj VMS2 and Merrick J3-7*
1Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker MD School of Medicine and Ferris State University School of Pharmacy,
Kalamazoo, Michigan, USA
2Department of Pediatric Nephrology, Children’s Hospital of Illinois, University of Illinois College of Medicine, Peoria, Illinois, USA
3National Institute of Child Health and Human Development, Jerusalem, Israel
4Office of the Medical Director, Health Services, Division for Intellectual and Developmental Disabilities, Ministry of Social Affairs and Social Services, Jerusalem, Israel
5Division of Pediatrics, Hadassah Hebrew University Medical Center, Mt Scopus Campus, Jerusalem, Israel
6Kentucky Children’s Hospital, University of Kentucky College of Medicine, Lexington, Kentucky, USA
7Center for Healthy Development, School of Public Health, Georgia State University, Atlanta, USA
*Corresponding author: Joav Merrick, Medical Director, Health Services, Division for Intellectual and Developmental Disabilities, Ministry of Social Affairs and Social
Services, IL-91012 Jerusalem, Israel, E-mail: jmerrick@zahav.net.il
Received date: September 2, 2015; Accepted date: October 1, 2015; Published date: October 10, 2015
Copyright: © 2015 Greydanus et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
It is easy for a non-nephrologist to become lost in the complexities of renal physiology, diagnosis, and treatment
—i.e., to miss the forest for the trees. It is not unusual for one to “fall” into the loop of Henle (discovered by the 19th
century German anatomist, Friedrich Gustav Jakob Henle [1809-1885] and not return after being weighed down by a
seemingly skimble-scamble litany of renal sagacities. Thus, one can ask: “what is the role (“the forest”) of the
primary care clinician in the diagnosis and management of pediatric renal disorders (“the trees”)?” What is the forest
and what are the trees in this perspective? Certainly, seeking to stay current on basic principles of pediatric
nephrology is important such as fluid and electrolyte physiology and management of pediatric dehydration. In this
short review we summarize some of the pioneer work done in nephrology up till the 20th century.
Introduction
e study of life began with the emergence of Homo sapiens over
100,000 years ago [1]. Prior to the development of writing by the
Sumerians in 3200 BCE that emerged from earlier Neolithic proto-
writing, we can only guess at what ancient humans thought of the twin
bean shaped organs we now call kidneys (Middle English: kednei;
Scottish: nere, near; ancient Greek: nephrós) found in vertebrates. ey
were rst discovered in animals and used as food for esurient humans;
eventually cannibalistic ancient human carnivores found that human
kidneys were a satisfying source of nutrition and various mystical
myths arose about the pathetic fallacy power of these structures to
empower, enhance, and elongate life. Rudimentary knowledge of
medical conditions is traced to Mesopotamia (3100 BCE to 332 BCE)
that included Sumer and the Akkadian, Babylonian, and Assyrian
empires in modern-day Iraq. e word, Mesopotamia, is Greek for
“land between rivers” and indeed was between the Tigris and
Euphrates rivers—major waterways of both antiquity and our coeval
time. Scholars who have looked at cuneiform clay tablets of this
enchorial era identify references to descriptions reective of urinary
obstruction, urethritis (and urethral discharge), renal stones, and cysts
[2-4]. Archaic models of a kidney have been found such as that from
the 13th century BC found at an ancient temple in Kition, Cyprus; this
bronze artifact has been interpreted by scholars as an example of an
oering (“ex voto suscepto or from the vow made”) to the temple gods
by a person with kidney disease or as a teaching aid by the euhemerists
or priest doctors of the temple [5].
Babylonian physicians based diagnoses on the appearance of urine
(i.e., beet juice, wine, beer, paint, others) and therapy of renal or
genitourinary conditions was with local remedies from indigenous
plants or minerals and blowing chemicals into the urethra; also,
alcohol served as an anesthetic. In the spirit of 20th century French
explorer and researcher, Jacques Cousteau, these clinicians passed their
understanding of renal science on to the future clinicians in Greece
who ex post facto moved their tenuous knowledge of renal function
forward.
“What is a scientist aer all? It is a curious man looking through a
keyhole, the keyhole of nature, trying to know what is going on”
Jacques Cousteau: 1910-1997
Examination of Egyptian mummies reveals evidence of renal disease
including renal stones and cysts. An inaugural or eoan medical
enchiridion or vade mecum was the Ebers Papyrus (1550 BCE) from
ancient Egypt; it recommends a remedy for uid retention (dropsy)
that involves smearing on these patients a concoction made from
cooked old papyri documents in oil [2,6]. Unfortunately, there is only
exiguous documentation on renal disease available to modern scholars
from this time though there is some identied information about
urinary retention, frequency, dysuria, and particularly red urine.
Hematuria was etiologically linked, then, as now, in Egypt to
schistosomiasis particularly that from infection with S. haematobium
eggs implanted in the bladder wall [7]. e Egyptian “Book of the
Dead (1600 BC-1240 BC) was revered by ancient Egyptians to help
those in the aerlife and was an early work to link the kidney with the
heart [8]. e heart and kidneys were the only organs le in the
process of mummication.
“Homage to thee, O my heart! Homage to you, O my kidneys.!:
(Book of the Dead-8)
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Kidneys are identied ve times in the Old Testament Bible and
represent organs (called “reins”) examined by God to pronounce
judgment on humans [8]. Ancient Hebrew teaching was that the
kidneys provided the heart with advice and represented inner sources
of cognition and desire that were not available to humans but were
tested by God [8].
…”Examine me, O Lord, and prove me; try my reins and my heart.”
(Psalms 26:2—1000 BC).
“…I, the Lord, search the heart; I try the reins, even to give every
man according to his ways, and according to the fruit of his doings.”
Jeremiah [Yirmeyahu] 17:10—600 BCE
Hippocrates
Western civilization’s understanding of science is traced to the
Greek natural philosophers of the 6th Century BCE. Modern Western
medicine traces its roots to the famous Greek physician, Hippocrates
of Kos (460-370 BCE), who taught all future people of medicine to
emphasize the patient and powers of observation, and not the disease
itself or only rely on the leading of experience. e Hippocratic school
speciously linked health and disease to four bodily humors (black bile,
yellow bile, blood and phlegm). Its Corpus Hippocraticum was the
beginning of modern, Western, medicine and is a link between ancient
medicine and medicine of the 21st century. Hippocrates has been called
the (ancient) father of clinical nephrology as his statements on the
kidney (Greek: nephros) were unchallenged for over 19 centuries [5].
”Bubbles appearing on the surface of the urine indicate disease of
the kidneys and a prolonged illness…..colorless urine is bad…..the
sudden appearance of blood in the urine indicates that a small renal
vessel has burst…” Corpus Hippocraticum [2]
e preeminent Greek philosopher and physician, Aristotle
(387-322 BCE), in his text, De Partibus Animalium, wrote that the
kidney was not basic for life based on his observations in animals. He
described renal anatomy and wrote that urine was made at the bladder.
e purpose of the kidneys, concluded this Hellenic sage, was to
provide blood vessel support, but when found, they oen were lled
with stones, abscesses, and growths [9]. Perhaps this vacuous view of
the Aristotelian kidney encouraged limited progress in understanding
this organ for the next 2 millennia. However, other Greeks in the two
centuries aer Aristotle’s death identied the prostate gland and noted
the urine was actually made in the kidneys [10].
Roman physicians of the rst century, oen Greeks from Asia
Minor (Anatolia, now present day Turkey), began to advance the
ancient nescience of genitourinary medicine. Areteus of Capadocia
(81-138 AD), known for his descriptions of diabetes (“melting away of
esh into urine”), also commented on anemia from renal insuciency,
renal colic, hydronephrosis, and other renal pathology [2,11]. Pedanius
Dioscorides (40-90 AD) formulated the famous De Materia Medica
(Latin for “on Medical Material”) in about 60 AD that became the
standard encyclopedic pharmacopoeia of herbs and medicines from
the mid-rst century until the Renaissance period. In this ve volume
document this Greek physician, pharmacologist, and botanist wrote
about herbs to improve renal disease such as use of enemas with ptisan
or mallow for renal failure [2]. Other scholars of the rst century AD
mixed various drug conconctions, such as the Greek physician from
Crete, Andromachus the Elder (eriaca Andromach—
“Archiater”---60 AD), looking for theriacs or catholicons to cure the
ailments of mankind.
Galen of Pergamos (130-201 AD), father of modern and
experimental Western medicine, wrote about renal conditions and
concluded that the kidneys clear blood; in his capacity as a surgeon, he
showed that urine ows from the kidneys to the bladder by performing
ligation of the ureters [10]. Later in this rst millennium, Byzantine
physicians expanded our knowledge of the renal system and the term
“ureter” was rst used by Oribasius (326-403); he galvanized renal
physiology erudition by sagaciously suggesting that urine was
absorbed from the blood circulation by the kidneys [12].
e fall of the Roman Empire in 476 AD cast the Western world
into the Dark Ages (476 AD to 1000 AD) or European Middle Ages
(Medieval Period-- 5th century to 15th century) with loss of much
knowledge in medicine, other sciences, and the arts. Medicine,
including cognizance of renal disorders, was preserved and heightened
by Arab physicians of the 9th and 10th centuries including the Galen of
Islam, Rhazes (865-925), a musician turned physician, and Avicenna
(980-1037) whose work on describing urine foreshadowed the science
of uroscopy [2]. One of Avicenna’s renal advice involved urethral
insertion of a louse to improve urination [2,13].
e great Jewish scholar, Moses Maimonides (Rambam 1138-1204
AD) who was a noted physician (as well as rabbi, philosopher,
astronomer) expanded the understanding of urinalysis that included
descriptions of red urine (later identied by the eminent 19th century
English physician, Richard Bright MD as glomerulonephritis) and
black urine (later identied as a sign of malaria). is scholar who was
born in Cordova and carried for the sultan Saladin in Cairo, Egypt
commented on the realities of being a 12th century physician: “…I
have never seen anyone who urinated black urine who survived”
[2,14].
Renaissance
Modern nephrology perhaps can be traced to salient scientists and
paramount physicians of the Renaissance who began to unravel the
mysteries of the renal and genitourinary systems in the spirit of Sir
Issac Newton, standing on the shoulders of giants of the past. e
founder of pathological anatomy, Morgagni (Giovanni Battista
Morgagni: 1682-1771) described various renal disorders via autopsy
[2,15]. Paracelsus (eophrastus Bombastus von Hohenheim:
1493-1541), a famous and colorful physician from Switzerland, wrote
about proteinuria, hematuria, gout, and edema; his prevenient work
was the forerunner of using specic gravity in urinalysis [2,16]. Edema
(oedema) was originally called dropsy, a word rst recorded in the
penultimate decade of the 13th century and later connected to renal
disease in the 19th century (vida infra). e father of anatomy,
Andreas Vesalius (1514-1564), born in Brussels, Belgium, illustrated
renal anatomy in his seminal work, De Humani Corporis Fabrica
(1543) with convincing clarity that resonates into the 21st century
[2,17].
e father of microscopic anatomy, Marcello Malphighi
(1628-1694), identied the glomerulus (Malpighian corpuscle) and in
1666 published his observations on the kidney (and other organs) in
De viscerum structura exercitatio anatomica. He wrote about the
pyramids of the renal medulla and collecting ducts as well as other
microscopic aspects of the kidney; use of dye injection led him to
describe glomeruli as “…hanging like apples from the blood vessels,
which, swollen with the black uid, look like a beautiful tree” [2,18].
Other anatomic scholars continued to advance the knowledge of
this organ called the reins, such as the Italian Lorenzo Bellini
Citation: Greydanus DE, Sankar Raj VM, Merrick J (2015) A Short Historic View of Nephrology upto the 20th Century . Clinics Mother Child
Health 12: 195. doi:10.4172/2090-7214.1000195
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(1748-1795: Bellini’s ducts) in his Exercitatio Anatomica de Structura
Usu Renum (1662), the Russian Alexander Schumlansky (1748-1795:
De Structura renum in 1782), and the Englishman William Bowman
(1816-1892; e Physiological Anatomy and Physiology of Man-1857
with Robert Bentley Todd) [19], and many other sages of science and
medicine.
19th century pioneers
e 19th and 20th century brought forth a salmagundi of sempiternal
scholars, who, standing on the shoulders of previous giants, advanced
the eld of clinical nephrology to unprecedented levels. Perhaps the
beginning of modern nephrology can be traced to the Richard Bright
(1789-1858) who has been called the “greatest physician of his day and
one of ve or six great physicians of all time” [20]. He was one of the
famous triumvirate of London’s Guy’s Hospital in the Victorian era
along with omas Addison (1793-1860) and omas Hodgkin
(1798-1866). Each of these three medical paragons has diseases named
aer them.
Richard Bright made original advances in medicine including
nephrology and neurology (i.e., Jacksonian seizures, infantile seizures,
syringomyelia, brain arteries, and narcolepsy, others [21]. is father of
modern renal diseases concluded that the nding of albuminuria with
edema meant the patient had renal disease. e rst clinical mention
of proteinuria was in 1697 but it was Richard Bright who, standing on
the shoulders of giants, moved this observation further in 1827 [22].
is ingenious izzat established the rst medical research unit at his
hospital and provided a series of insightful, iatric descriptions of acute
nephritis, nephrotic syndrome, uremia, small and enlarged kidneys,
and a link between renal disease and enlarged ventricles of the heart
perhaps an a fortiori adumbration of the ancient Hebrew link of the
heart and the “reins” [23-28].
Richard Bright’s studies were oen post-mortem on patients with
advanced renal disease and his written observations are preserved in
the Gordon Museum at London’s Guy’s Hospital [24]. Analysis by late
20th century nephrologists revealed two had mesangiocapillary
(membranoproliferative) glomerulonephritis; one had a ve-year
clinical history and died from chronic renal failure with uremia while
the other died aer 3 to 4 months with severe nephrotic syndrome
[24]. Acute and chronic nephritis was called Bright’s disease long aer
his death that may have been caused by his own eponym.
Sir Robert Christison (1797-1882)
Another early pioneer and pharos in nephrology of the 19th century
was Sir Robert Christison from Edinburgh, Scotland who made
seminal advances in nephrology, pharmacology, and jurisprudence
[29]. He provided many contributions to the understanding of renal
disease including conrming the observations of Richard Bright,
expanded the understanding of uremia as well as anemia in renal
failure, discerned that albuminuria and edema might be reversible in
some situations, detailed microscopic studies of urine as well as the
kidney, and linked some cases of acute renal failure to toxins or
poisons [29,30]. He was a professor of medicine in Edinburgh for half a
century and was president of the Royal College of Physicians in
Edinburgh on two occasions. He remains one of the triumvirate
founders of clinical nephrology of the 19th century.
Pierre Rayer (1793-1867)
e First Triumvirate of ancient Rome was Julius Caesar, Pompey
(Gnaeus Pompeius Magnus) and Crassus (Marcus Licinius Crassus) in
60 BC and the Second Triumvirate was Antony (Mark Antony),
Lepidus (Marcus Aemilius Lepidus), and Octavian (Gaius Julius
Octavius) in 43 BC. e classic though unaliated triumvirate of 19th
Century Nephrology the fortuitous, feracious founders of modern
nephrology—were Richard Bright, Sir Robert Christison, and Pierre
Rayer. Pierre-François Olive Rayer (1793-1867) was a French physician
who contributed important, ingenious information to various elds,
including physiology, pathological anatomy, comparative pathology,
medical chemistry and parasitology [31].
Between 1837 and 1841 he published a 2,200 page, 3-volume treatise
on kidney diseases: Traité des maladies des reins [31,32]. is
masterpiece provided a clinical approach to renal disorders (uro-
nephrology) and was translated in to German but not into English.
is renowned clinical scientist represents themes oen repeated in
history a perspicacious paragon lost to the monolingual English-
reading population because of translation failure and one oen not
fully understood even in his own country [33,34]. He also expatiated
eloquently about skin diseases and eponyms associated with his name
include Rayer’s disease and Rayer’s nodules (xanthomas).
Claude Bernard (1813-1878)
A sagacious scientist whose works were translated into many
languages and who is acclaimed in his native country and beyond is
Claude Bernard, the most distinguished French physiologist of the 19th
century (and beyond!) [35]. He accomplished a gallimaufry of erudite
experiments in physiology that set the stage for sound scientic
methodology and is acclaimed as the father of modern physiology
[36]. He emphasized blind experiments to ensure scientic objectivity
and he performed now classic experiments on the pancreas’ function
(discovered the lipolytic function of the exocrine pancreas) as well as
the glycogenic function of the liver (with improvement in knowledge
of diabetes mellitus) [36-42]. He was the rst to describe homeostasis
or constancy of the internal environment (le milieu intérieur) and the
vasomotor system. is allowed future researchers to apply these
Promethean principles of perlustration to renal physiology. For
example, research in the rst half of the 20th century lead to the
disambiguation of electrolyte content of le milieu intérieur the
extracellular, intracellular, and interstitial uid compartments of tissue
elements that was unknown or confusing for eons of human life
[43-45].
”e living organism does not really exist in the milieu exterieur
(the atmosphere if it breathes, salt or fresh water if that is its element)
but in the liquid milieu interieur formed by circulating organic liquid,
which surrounds and bathes all tissue elements,…the stability of the
milieu interieur is the primary condition for freedom and
independence of existence; the mechanism which allows this is that
which ensures in the milieu interieur the maintenance of all conditions
necessary to the life of the elements.” Claude Bernard [43].
Francis Delaeld (1841-1915)
Contributions to clinical nephrology in the 19th century were by
European scientists and clinicians. Contributions from across the
Atlantic Ocean began at the end of this century with Francis Delaeld
(1841-1915) that foreshadowed an onslaught of American ingenuity in
understanding the kidney. He graduated in 1963 from New York’s
Citation: Greydanus DE, Sankar Raj VM, Merrick J (2015) A Short Historic View of Nephrology upto the 20th Century . Clinics Mother Child
Health 12: 195. doi:10.4172/2090-7214.1000195
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ISSN:2090-7214 CMCH, an open access journal Volume 12 • Issue 4 • 1000195
College of Physicians and Surgeons and continued his studies in
London and Berlin. Aer returning to New York he is acknowledged as
a panoptic pioneer in renal histology correlating renal symptoms with
kidney histological pathology [46]. Francis Delaeld developed
nosological classication of Bright’s disease (as it was called in his day).
He was the rst recognized renal expert from America and his beloved
city named a hospital aer him in 1948: the Francis Delaeld Hospital
which opened in 1950. Cardinal concepts in nephrology: the 20th
Century and the accession of American nephrologists It is not beyond
peradventure to note that, standing on the shoulders of giants from
other lands (ancient Mesopotamia, Egypt, Greece, Rome, Arab
countries, Renaissance Europe, 18th and 19th century Europe),
remarkable achievements in the understanding of renal physiology and
renal disease management resulted from the notable achievements of
American scientists and clinicians albeit in the 20th century [47]. Some
were Europeans transplanted to America and some were native born
Americans. ere are of course, more European clinicians of the 19th
century of neoteric note such as Ségalas’ and Wöhler’s work on extra
load of urea leading to diuresis, Ludwig’s studies on urine uctuations
due to hypertension, Ustimowitsch’s (with Falck and Richet) work on
urinary solutes and renal ow, Cushny’s work in 1900 on what was
later called osmotic diuresis, Friedrich von Muller’s work on what he
termed “nephrosis” in 1905 (as dierentiated from “nephritis”), and
many more savvy scientists [48]. However, a salient summary is now
presented of the American inuence in the 20th century and more data
will be provided in the Second Edition of this breviloquent megillah on
the history of the Pediatric kidney.
No human being is constituted to know the truth, the whole truth,
and nothing but the truth; and even the best of men must be content
with fragments, with partial glimpses, never the full fruition- William
Osler MD: 1849-1919
omas Addis (1881-1949)
is section of our wee, pensive synopsis begins with a Calvinist,
omas Addis, an innovative hematologist and researcher who was
born and trained in Scotland and moved his academic position in 1911
to USA’s Stanford School of Medicine to direct their clinical laboratory
[49]. He was recruited by Stanford’s rst dean of medicine, Ray Lyman
Wilbur. ough known to legions of cognizant clinicians because of the
Addis count of the urinary sediment, omas Addis’ contributions to
nephrology were immense and included physiology in Bright’s disease,
protein metabolism and renal growth (hypertrophy), and use of diet as
well as rest in management of renal disorder [49-52]. He studied blood
coagulation and haemophilia research that included transfusing fresh
blood into a patient with hemophila to shorten the clotting time. He
followed his patients throughout their life to better understand their
disease and precedently pioneered the concept of contributions from
nonmedical team members foreshadowing the benefaction of non-
prot organizations such as the National Kidney Foundation [52].
Alfred Newton Richards (1876-1966)
Born in Stamford, New York Alfred Newton Richards was an
eminent American pharmacologist involved in the discovery of the
mechanism of urine formation [47,53,54]. He led a group of scientists
at the University of Pennsylvania that meticulously established the
physiology of renal glomerular ltration and selective tubular
reabsorption. He was a president of the National Academy of Sciences
and one of his many honors was to have his beloved University of
Pennsylvania establish the Richards Medical Research Laboratories in
his honor.
Donald Dexter Van Slyke (1883-1971)
Dubbed the 20th century iatro-chemist, Donald Dexter Van Slyke
provided key concepts for scientists and clinicians in the 20th and now
21st century on cardinal concepts of acid-base balance. [55,56] is
allowed clinicians to more accurately understand diabetes and
nephritis with particularly reference to acidosis and alkalosis [57-63].
He published a brilliant paper on lung volume in 1918 but later
published his seminal work on amino-acids and the signicance of the
urea clearance in renal disease from the Rockefeller Institute for
Medical Research in New York [64-66]. is renowned Dutch-
American biochemist, who was a graduate of the University of
Michigan (as was his father), used his research at the Rockefeller
Institute Hospital (1907-1948) to help develop the eld of modern
quantitative blood chemistry that included seminal work on the
measurement of gas and electrolyte levels in tissues. He co-authored
the authoritative two volume text, Quantitative Clinical Chemistry
with another pioneer John P. Peters (vida infra). Among his many
honors were being the rst recipient of the American Medical
Association’s Scientic Achievement Award (1962) and the rst Van
Slyke Award in Clinical Chemistry (1957) by the American
Association of Clinical Chemists.
“Neither the urea clearance, nor any other physiological
measurement, should be asked to serve as the sole criterion to
discriminate between health and disease. e clinician using such a
test must evaluate the results in terms of all known causes of variation,
physiological and pathological.” - Donald D. Van Slyke, 1949 [66].
John P Peters (1887-1955)
John P Peters was an MD from Columbia College of Physicians and
Surgeons and completed a residency in internal medicine at Cornell
Medical College. He worked at the Rockefeller University Hospital
with Donald D Van Slyke PhD and others in biochemistry before
establishing his medical career at Yale University School of Medicine.
He was a master of both bedside medicine as well as biochemistry and
used these traits along with gied writing skills to establish clarity
regarding the human body’s chemistry for the foundation of modern
nephrology [47,67]. Research in the United States aer World War I
focused on diseases that disrupted homeostasis and John Peters was
able to use his Yale laboratory to study renal disorders in this manner
[68]. e emphasis was on improving knowledge in details of chemical
make-up of blood and urine as well as how these normal states were
disrupted by renal diseases as well as other disorders (i.e., liver, disease,
diabetes mellitus, others) [68]. He applied prominent principles of
physiology to his work including Starling’s law, the Donnan eect, the
Henderson-Hasselbalch equilibrium and others [67]. John Peters
established the importance of the ame photometer to accurately
measure sodium and potassium concentrations in small amounts of
serum or urine, utilized the balance technique in clinical research, and
was one of the most refulgent researchers who were able to integrate
raw research data into clinical applications of patients with severe renal
disease [67]. He was able to examine other researcher’s data better than
the original researcher and draw conclusions sometimes contrary to
the original study. He was able to combine his ideas with that of others
to formulate a better understanding of such issues as water balance in
health and disease [69]. He wrote about various organs but the reins
seemed to be his preferred one [67]. He researched and taught about
Citation: Greydanus DE, Sankar Raj VM, Merrick J (2015) A Short Historic View of Nephrology upto the 20th Century . Clinics Mother Child
Health 12: 195. doi:10.4172/2090-7214.1000195
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ISSN:2090-7214 CMCH, an open access journal Volume 12 • Issue 4 • 1000195
disease and metabolism, electrolyte and acid- base equilibrium,
nephritis, and water exchange. He co-founded the eld of quantitative
clinical chemistry with Donald Dexter Van Syle PhD (vida supra)
[70,71]. Dr. Peters was also an advocate for responsible social reform to
improve medical care for all [67,72,73]. e grateful students of this
rebellious son of an Episcopal minister went on to continue with
progress in nephrology in the 20th century for the benet of mankind
and they include Robert Petersdorf, Lawrence R. Freedman, Jack
Orlo, Arnold S. Relman, Franklin H. Epstein, Donald Seldin, and
others [67].
“A patient needs a doctor, not a committee….Doctors treat
individuals, not statistical averages…If you don’t examine the trees,
you may get lost in the woods... the proper study of mankind is man” -
John P. Peters, MD [67]
Homer W Smith (1895-1962)
Homer W Smith was an American investigator who was chair of
physiology at the University of Virginia but moved to New York
University in 1928 where he spent most of his illustrious career as
director of the NYU Physiology laboratories. His NYU time has been
called the Smithian Era of renal physiology for his monumental
research clarifying glomerular ltration, tubular absorption, and
secretion of solutes in renal physiology [48,74-77]. His work
established the concept that the kidney worked according to principles
of physiology both as a lter and also as a secretory organ. Twenty-rst
century clinical nephrology stems from his work and teaching on the
awareness of normal and abnormal functioning of the kidney. He
removed the then held belief of vitalism in renal physiology that life’s
processes are not subject to laws of physics and chemistry alone, i.e.,
life is in part self-determining. Dr. Homer W Smith spend many
summers at the Mount Desert Island Biological Laboratories (Mount
Desert Island, Salisbury Cove, Maine, USA) researching osteichthyes
and this work led to his famous book, From Fish to Philosopher, Man
and his Gods that has a foreword by Albert Einstein (1879-1955) [78].
He also authored his book on the kidney in 1951 that discussed various
issues of the Pediatric kidney (pages 461-491): Renal function in
infants and childhood; e fetal kidney; surface area as a basis for the
comparison of renal function in infants and adults; maturation of renal
function in infancy; relation of urine ow to ltration rate; urea
clearance; maintenance of salt and water balance in infancy [79]. e
American Society of Nephrology (founded in 1966) established the
Homer W. Smith award annually starting in 1964 to an outstanding
individual who signicantly advances knowledge in states of normal
and abnormal renal functioning.
Even then, a new branch of mythic thought had already grown
strong, one not religious in nature but no less perilous to mankind
exaggerated nationalism. Half a century has shown that this new
adversary is so strong that it places in question man's very survival. It is
too early for the present-day historian to write about this problem, but
it is to be hoped that one will survive who can undertake the task at a
later date. Albert Einstein in his foreword to Homer W Smith’s "Man
and his Gods", 1952 [78]
Pediatric Nephrology emerging from adult nephrology
ough there are many other giants who lead to current knowledge
of adult nephrology, this meditative epitome now turns to
consideration of the focus of this iatric issuance—the pediatric kidney.
e rst book on pediatrics in the Western world was published in
1544 AD by omas Phaer (1510-1560)—a truly assiduous
Renaissance man of sagacity---physician, lawyer, poet, philosopher,
and father of English paediatrics [79]. However, sustained interest in
diseases of children has come over the past two centuries as attention
before that was primarily, and certainly continues to be, with diseases
of adults [80,81]. Prior to this medical care for children was provided
by midwives, families, and family friends [80]. Research in diseases of
children was oen focused on infectious diseases in the 19th century
with attention given to the causes and management of diphtheria,
infant diarrheal illnesses, tuberculosis, streptococcal infections, and
others [82]. e era of vaccinology was ushered in by Edward Jenner
(1749-1823) in the waning years of the 18th century and then by Louis
Pasteur (1822-1895) in the latter part of the 19th century [83].
European clinicians and researchers began a nidus of interest on renal
disease in children in the penultimate decade of the 19th century with
writings on bladder extrophy, renal rickets, nephritis, and Henoch’s
purpura [84,85]. As adult nephrology was arising in the 20th century,
pediatric nephrology emanated later---analogous in the spirit of Greek
mythology as depicted by the dominant Danish artist Rudoph Tegner’s
(1873-1950) classic sculpture of Zeus giving birth to Athena; pediatric
nephrology emerged as a result of attempts to deal with uid and
electrolyte metabolism that was disrupted in diarrheal dehydration of
infants and children [84-86].
Conclusion
It is easy for a non-nephrologist to become lost in the complexities
of renal physiology, diagnosis, and treatmen i.e., to miss the forest for
the trees. It is not unusual for one to “fall” into the loop of Henle
(discovered by the 19th century German anatomist, Friedrich Gustav
Jakob Henle [1809-1885]) and not return aer being weighed down by
a seemingly skimble-scamble litany of renal sagacities [87]! us, one
can ask: “what is the role (“the forest”) of the primary care clinician in
the diagnosis and management of paediatric renal disorders (“the
trees”)?” What is the forest and what are the trees in this perspective?
Certainly, seeking to stay current on basic principles of pediatric
nephrology is important such as uid and electrolyte physiology and
management of paediatric dehydration [43].
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