by Es Will

Introduction

As detailed in his bibliography, the late Stewart Cameron contributed extensively to the history of interest in the kidney.^B That body of work encompassed both technical advances and biographical accounts of significant individuals. He was drawn into the intellectual histories of several of those who had not achieved the professional prominence of, for example, his Guy’s Hospital predecessor Richard Bright.^B11,20,23,28  It is a particular inversion then to delve into the opposite, the intellectual background that underpinned his professional dominance in UK and international nephrology. He made several video autobiographies that expressed the preoccupations that he recognised in his career, although no doubt even he would have valued a more distanced commentary. Whilst any external assessment is bound to be coloured by current fashions and prejudices, it should be useful to add a carefully considered, wider and more distant perspective.^8,10 That conclusion is impressed personally on all of us, from our experience of ageing. What was deliberately intended or unwillingly obliged can, in time, be more readily distinguished from given circumstances or, at least, their interactions can be part-discerned. The search for a plausible account, a Grasp, of the incompletely perceived conditions of the past, the Reach, is History in a nutshell?²⁰

Several sources are available on the  UK Kidney  History website to allow us an attempt at such an account.

The celebratory event at Guy’s Hospital (April 19^th 2024) was designed to allow his colleagues and associates to express their personal appreciation of his contribution to nephrology. However, the meeting was only incidentally an enquiry, through his products and admirers, into his lifelong intellectual interests. Whilst reputation is as a rule rather enhanced by some obscurity of origins, historical explanation may be possible beyond the easier default to innate genius or ‘common sense’. It is sometimes possible to ‘join up the dots’. By contrast, we should be careful, because ‘(traditionalists) by the sheer force of their veneration of the past (may) invent it’.⁴ With one or two exceptions, Stewart was adamant that his activities had been given shape by random events, which had offered him the opportunities of a butterfly, rather than a penetrating worm, allowing numerous incomplete contributions in his transit: a Da Vincian-style polymath.^B10 However, the events, the circumstances, and his opportunism, are an inevitable part-substrate of his contribution.

The extensive bibliography assembled by John Feehally emphasises Stewart’s remarkable energy and pressure to communicate. It holds clues to the drivers of his intellectual effort and expresses both the triumphs and pitfalls of his sustained curiosity. The arc of his career was confluent with an intermediate phase of the development of medical interest in the kidney, as he explained; the interval between the exploration of the whole organ, through anatomy and physiology, and developments in modern cell biology/genetics.¹⁴ He did not much participate in the study of renal physiological inputs and outputs (except for urate metabolism), nor endocrine activity much beyond renal anaemia and Erythrocyte Stimulating Agents (ESA, a term he claimed to have created). His was a clinically-oriented exploration of the diagnosis and treatment of renal disorders, accompanied by a generous description of serial enabling developments, investigatory techniques and treatments.

There were contributions to other medical, social and political areas, of course, which spilled over from his enthusiasm and intellectual ‘fun’. A future treatment of his laboratory and technical interests will require additional expertise, quite apart from his contributions to renal replacement medicine and surgery. However, it seems pertinent to explore some gaps in our understanding of the early prompts and the context of his contributions, the conditions of his career. That analysis serves to extend the appreciation of his personal efforts, beyond the obvious reputational simplifications.

Guy’s Hospital culture as a cradle of clinical investigation

In the course of his historical investigations Stewart himself came to wonder why Guy’s had been so productive of clinical developments, across the 19^th century in particular.^B9 During his own  medical education the interest at Guy’s in the legacy of Bright was prominent and multidisciplinary. The 1958 volume (number 107) of Guy’s Hospital Reports carried sixteen articles relating to Bright and kidney disease – a veritable symposium. They included a biography of Bright by HC Cameron, the retired (1945) Guy’s paediatrician, and, more curiously, HCC’s own obituary (mentioning his artistic side and sojourn at Pembury alongside Arnold Osman – vide infra).⁶ He had written historical biographies late in life. Other still active paediatricians were prominent, as well as philosophical physicians and histopathologists. The results of renal biopsy examinations, especially glomerular, were a solid feature, as well as Acute Renal Failure (ARF) and its management (contemporaneous with Frank Parsons’ publications from Leeds and without mention of established US dialysis experience during and after the Korean War).³⁴ The focus was on careful dietary management of ARF, except possibly dialysis for ‘gross distortion of the chemical structure of the ECF’ (an uncalibrated hint of the threatening catabolic cascade of trauma, sepsis or surgery). Also advertised were the scientific strands of vascular pathology and cardiac hypertrophy. Those had led to the progressive recognition of renal arteriosclerosis and hypertension, through the 19^th century Guy’s trio of Wilks, Gull and Mahomed.^B7,9,15/31 The historical patterns of a senior clinical career, especially renal, were well established, then, as traditional Guy’s interests.

Incidentally …

Bright was very ambitious about publishing volumes that would cover the entire organ system in the form of Reports, only two of which he managed in his early career, 1827 and 1831. Unlike, say, Brunel, or for that matter Brunelleschi, his barely limited ambition was not pursued to a comprehensive conclusion – he retired in 1843. As a gentleman scientist, in the event well heeled by virtue of investment in the slave trade, he was not especially different at a distance of two centuries from, say, Robert Boyle. He turned his style of reportage into the enduring journal Guy’s Hospital Reports, ‘with the help of the Treasurer’, and published two papers in Volume 1, in 1836. The 1958 Guy’s Hospital Reports were topped off with a Bright Bibliography. He was a role-model in waiting for an enthusiastic communicator.

Medical Research and Clinical  Science at and beyond Guy’s 1959-1962

The greatest intellects must develop in some social context, and lifelong preoccupations  may be derived from early influences, whether planned or incidental. At Guy’s in the late 1950s there were few luminaries to kick-start a clinical scientific career, and Stewart described exploring the potential of alternative institutions and facilities. However, in the Professor of Experimental Medicine, John Butterfield (JB), there was a patron of experience and influence. His supportive mentorships continued for at least a further decade at Guy’s (author’s experience). We can assume that JSC, after one of the first Guy’s BScs and productive, collaborative work on diabetes/insulin as a lecturer, was recognised as a promising candidate for further development. Notably, he achieved first author status on a series of publications as a junior researcher.^I,J1 The London research environment was positive, in the tradition of the Medical Research Society. Clinical Science or Guy’s Hospital Reports offered ready dissemination. However, the USA was the go-to stepping stone towards a UK career in secondary care and clinical science.

Stewart described his 1962 BTA (Been To America) year at Cornell, sponsored by JB, as deliberately designed to train in renal medicine and replacement, while at Guy’s technical homework for haemodialysis was in hand. He seems to have been widely engaged in the US renal scene.^G1

His US departmental head at Cornell was Professor E. Lovell Becker. Becker (from the German ‘bakker’) was a polymath, with already developed interests in most of the areas that Stewart subsequently explored.¹ For example, they wrote an early history paper together, concerning Bright’s publication history.^B1 Becker was deeply into nephrosis, proteinuria, lupus, medical history and nomenclature. Stewart was already interested in the latter. His 1967 Guy’s Gazette essay on Words even mentioned the need for an historical understanding of renal syndrome labels (text available on request).^{B2, J3} One of Becker’s interests may have been the residual, ‘sleeper’, idea behind a late article on the visit of John Keats to the Isle of Mull in 1810, although of course there were enough plausible sources for that interest in both Scotland and Guy’s.^A13 Becker had written a travelogue concerning Richard Bright visiting Iceland in a similar vein.³ The shape of some of Stewart’s preoccupations can then plausibly have derived from the early exposure to Becker’s; they might have been ‘baked’ in?! They had, after all, written that history paper together, mentioned uniquely in his Festschrift of 1996, which hinted at picking up the torch of a preoccupation with medical history from Becker as well as Guy’s?¹⁰

An ever-present awareness of historical trajectory was a subsequent feature of Stewart’s relation to all the facets of Nephrology.

The fact that Becker did not reference JSC when discussing Glomerulonephritis or Proteinuria in, say, 1970 is noteworthy, and there was a reciprocal blank.² It may be relevant to mention that Richard Bright was publicly generous to collaborators and trainees, which was uncharacteristic of his times. That was well known to Stewart in 1964, as the last comment in the paper with E.Lovell Becker, before his senior career took off.^B1

The main stroke of luck

After the technical tinkering of the 1950s, which established extracorporeal acute renal support as practical, haemodialysis became an option for the maintained palliation of established renal failure in the mid-1960s.³⁰ The national decision to fund regional dialysis facilities of 1966 fell perfectly into the JB/JSC strategy – here was the timely task, the funding, the kit and the personnel. It took advantage of Guy’s preparation, with dialysis started already by Victor Parsons and Jo Joekes for acute renal failure. It should be noted that specialty-nominated physicians did not exist at Guy’s at that time, and it was a further decade before the specialty style of appointments was adopted, for example in Cardiac Services (Edgar Sowton 1970) and Gastroenterology (Hermon Dowling 1974). Stewart offered the titles Renal Physician or Physician in Renal Disease variably in his  publications of the late 1960s. Although he was only a lecturer when initially empowered at Guy’s (albeit an MD 1964-5), he did not become ensnared in career formalities, like Frank Parsons  He was adequately credentialled to move from Lecturer to Senior Lecturer in Medicine and then specialty Professor, despite bureaucratic reservations about academic appointments at Guy’s. Successful careers are typically permitted by the avoidance of bad luck, at least, but the regional dialysis remit was a clear, supercharging, win-win event; his energy, interest and research experience was given access to practical potential. What is more it came near the beginning of an active medical career. It was possible to incidentally usurp a core NHS function, offering medical capacity to underpin interdisciplinary clinical research.

In retrospect …..

It is interesting that the subsequent, early Guy’s approach to acute renal failure was not haemodialysis but well publicised peritoneal dialysis, even for catabolic patients – clinical practice did not follow the developmental pathway of dialysis there, at least.^D2,3

The cultural role of renal replacement techniques

It has been asserted elsewhere that it was renal replacement techniques that put and kept nephrology on the clinical specialty map, and the Guy’s pursuit of dialysis and transplantation can be used to support that contention.³⁵ The modern, widespread commercialisation of maintenance renal support, especially in the USA, has demonstrated a possible re-separation of sub-specialty clinical interests, where in some developed health care systems the nephrologist is pacing the hospital corridors, giving good advice but de-departmentalised.⁹ The historical pattern is then of the fusion of renal replacement and clinical renal disease in the 1960s and its tendency to come apart in a modern market society. The ultimate 1968 acceptance by the RA of the clinical dialysing enthusiasts of the mid-1960s consolidated the role of renal replacement activity in the development of nephrology in the UK, when academics were still a dominant feature. It may be no accident that the Royal College of Physicians of London had accepted Renal Medicine as a specialty in 1967.

Renal replacement was also the functional, everyday, ballast of a research career in renal disease. Stewart explored the issue comprehensively through the history of renal biopsy, in particular.^B12,13,16 He was able to successfully straddle the renal replacement-renal disease binary of clinical and academic disciplines early in his career, which others found less feasible regardless of their ultimate contributions to nephrology. He was a lifelong advocate of clinically related technologies, as the means of extending diagnosis and clinical management.^{B19,33 G8,43,44}

A gregarious social model

The attempt to create a family or team ethos was a persistent feature of Stewart’s career, in each of the several settings he found himself. The basis of those intentions he ascribed in particular to John Butterfield, an avuncular, charismatic patron (with a voice as characteristic as Kenneth Horne on the wireless). The significance of that claim is that Stewart was comfortable with admitting the profound influence of a mentor when he was a freshly-minted lecturer (vide infra).

In considering the ethos of the post-1966 renal unit at Guy’s, he seems to have celebrated the intimacy of patients and staff, describing an egalitarian exchange of information and treatment possibilities, free of hierarchy. That was no doubt easier when unselfconscious intellectual gifts  and wide clinical awareness created social confidence in the medical staff. There can be subtle and comfortable submission in any group in response to the well-advertised indulgence of an effortless superior. Who would not respond well to benevolent authority, committing itself to the social group? That was the effective social exchange of the 16th century Elizabethan monarchy, in court and country, according to compelling accounts.¹⁶ JSC seems not to have volunteered any element of his relaxed sociability that might have been derived from his upbringing.

As far as staff were concerned, a pragmatic delegation of tasks to nurses was a response to the scale of demand. It required informal cross-professional recognition and a major extension in the practical role of nurses. The scale of the renal services hub may have facilitated personal relations, approximating the ca. 150 of Dunbar’s number.¹¹ It was of obvious importance for him to free-up medical capacity for basic work in renal diseases, while relying day to day on more clinically engaged colleagues. Similar role adjustments took place across the UK as the new regional dialysis units were established, paving the way for non-medical, routine supervision of haemodialysis satellite units, for example.

The unit egalitarianism must have been given a rude shock by the Guy’s Hepatitis B outbreak of 1969, which could be laid partly at the door of informal contact and relaxed hygiene. There had been episodic renal unit outbreaks after 1965, in Manchester and London, but it was the fatalities in Edinburgh in 1969 that brought home the unacceptable risks of haemodialysis programmes as then established.^12,13 The Guy’s outbreak was the largest in the UK at 89 staff and patients.^D14

The attempt to transplant dialysis patients ‘out of trouble’ foundered on the impossibility of further avoidance of blood products and graft rejection in early renal transplant immunosuppressive regimens. As an anecdote, Guy’s offered an outreach renal transplant facility to Liverpool.²² The irrepressible Mr Mick Bewick, with a post-infected house-officer (the author), travelled by train to the isolation caravans of the patients there, on a limited surgical rescue mission. The full national epidemiological consequences were compiled in the Rosenheim Report. The Jeremiahs of the time forecast the end of UK renal replacement, but control of the risk was ultimately effective,  through isolation sub-units and improvements in technology.

Another negative consequence of an intuitive family approach in dialysis units was more subtle. A protective instinct, born of comprehensive medical intimacy, meant that scientific clinical investigation of dialysis populations, especially randomised studies, became suspect, as possibly leading to patient harm. That may account partly for his regretted tardiness of randomised controlled trials in UK nephrology; the earliest controlled studies were of outpatients.^{C1 14}

These intentions and consequences still bear on the lively debates about the place of empathy in contemporary medical education and practice.

As an aside ….

The recognised need for specialty-dedicated ‘doctors and nurses’ was a feature of Stewart’s 1997 biography of the first UK, and Guy’s-related, ‘nephrologist’, Arthur Osman.^B11 That article also raised the issues of the need to ‘sell’ one’s ‘innovative ideas’ and to cultivate successors, aspects which he pursued intuitively and worked hard to enact. He repeatedly returned to his satisfaction with the unit’s impressive trainee programme, for example. It is interesting that Osman’s career had a number of similarities to Stewart’s, adopting paediatric patients and publishing prolifically, as well as recognising the need for renal medicine to be a clinical specialty. Osman also manifested a deep, published, interest in Richard Bright.

The family analogy was probably behind Stewart’s attitude to the specialty in general, which was given greater scope as later appointments drew him into playing roles on the international stage. His typical,  somewhat ambivalent, use of ‘we’ and ‘us’ suggested a comprehensive, even parental, approach to the specialty. The suggestion of inclusiveness was an encouragement to colleagues and trainees that was intrinsic to any conversation with him. The typical exchanges carried an implication of joint, immediate, personal interest and participation in a shared universal search for nephrological and/or scientific understanding. In several of his historical papers he dwells on the reasons for the poor reputational outcome of renal pioneers, the lack of followers being one important element that he identifies. The example of JB, as a confident extrovert, must have been an additional asset. Latterly, Stewart was aware of the importance of salient individual contributions.^B19

Paediatrics

One dimension obviously begging medical development in the 1960s was childhood renal disease, in both parenchymal disorders and renal replacement. The referral of young, deserving, patients was an obvious prompt to involvement, and the resources of Guy’s, both in facilities and personnel, may have allowed what was simply not possible elsewhere nationally. The pre-existing focus on nephritis and nephrosis, together with a sudden vacuum in senior paediatric supervision, must have increased his regular exposure to children compared to renal adult physicians nationally. The fact that he had young children at home has not been mentioned.

To offer the investigation of children with nephrotic syndrome was something of a sales opportunity for nephrology, and personal reputation, that he did not overlook. The south east was a practical area of operations for a peripatetic renal biopsy-er and that visiting incidentally advertised the newly cohering specialty.^{C1 11} Thankfully, there was no demand for detailed clinical supervision from the activity, just diagnosis and treatment advice. The  children were outside the national, MRC, nephrosis studies in adults (1967), which were also focussed on steroid treatment, and that separation offered a useful sub-specialist topic for early publication from Guy’s.^{C1 11}

The development of paediatric nephrology also offered a novel outlet for his gregariousness, through sharing the establishment of the European Society of Paediatric Nephrology (ESPN). It was one of the historical events to which he returned with pride and photographs. He was a prominent proponent of specialist renal services for children and maintained a comprehensive interest in their rehabilitation.^{D9,13,23 G17,22,33}

The glomerulus as picturesque

Richard Bright is said to have declared to being ‘fond of seeing’. His major publication in 1827 was floridly illustrated, with colourful, hand painted mezzotints of histological material. This has been interpreted as part of a medical continuity with the style of Victorian natural historians. They carried an expectation of detailed illustration (in their ‘astonishing intellectual stamina’).³¹ A picture has always been ‘worth a thousand words’ but it is also a device that delights ‘the eye’ and draws attention to the content. As microscopy developed after Malpighi (1761), serial visual evidence of renal structure was predominantly about the glomerulus and its components. The glomerular tissue elements could display a variety of inflammatory appearances, which offered a promise of differential diagnosis that seduced the medical intelligence of several generations of thoughtful clinicians. The interstitium was banal by comparison. Journal articles of the 1960s and 70s are full of glomerular images with which molecular pathways and graphs simply could not compete visually.^C1 Added to that, the multiple tissue components of the glomerular ‘clew’(ball) were arguably a powerful stimulus to any physician’s well-rehearsed faculties of discriminating clinically anomalous features and dealing with uncertainty. As a consequence, the glomerulus was, and remains, the strongest candidate for the visual representation of any kidney-related topic, the totem of nephrology. Glomeruli are balloons on the gate of any nephrological party!

A strong, youthful artistic proclivity (‘seeing’) was mentioned by Stewart as having indicated a possible alternative career path. In the event, the 1960-1970s excitement over the glomerular appearances in tissue sections from nephritic renal biopsies eclipsed the earlier implications of interstitial pathology.^18,19,28 The glomerulus took centre stage in the differential diagnosis of nephritis for twenty years.^C1 Ultimately, it was the visual identification of the cells and fibrosis of the interstitium, through histology and the development of monoclonal specifiers, which promoted the crucial importance of their dull histological appearances for renal clearance.^{C2 68/5, 23-26} The possible disconnect of glomerulus and interstitium for GFR had been known in diabetic nephropathy and amyloidosis, for example, as had the relation of proteinuria to the degree of interstitial abnormality.^27,29 Illustrations of the variably altered glomerulus had typically encouraged the plausible inference that tubular changes were merely a sequel to pathology ‘upstream’.¹⁵

A similar allure, of diverting detail and enigmatic function, was repeated in the late awareness of the prognostic significance of total proteinuria. Bright had asserted that the severity of renal disease and proteinuria were unrelated. The protein selectivity that had permitted investigation and the more logical treatment of nephrosis in the 1960s was overtaken ultimately by the appreciation of unselective proteinuria as prognostic of outcome in all nephritides; the basis of the binary staging, with eGFR, of chronic renal disease today. Stewart came to regret the fact that particular perception had not been advertised in formal publication. Other than a vascular, ischaemic correlation he worried that a clear scientific connection between glomerular inflammation and renal fibrosis had not yet been elucidated.

These two examples point up the inapparent prompts for clinical scientists to attend to and investigate only some, ‘attractive’, topics. The glomerulus can be seen as  ‘marketing’ itself as a suitable case for attention, almost the rose in a bouquet. Similarly, the revelation of protein selectivity was a validating token of effective clinical science. Both enabled the marketing of nephrology through a kind of intellectual come-on, a glitz.²⁹

Other than glomerular charisma

The modern social environment of marketing and instant communication has allowed many, typically political, abuses of extroversion, profitably allied to self-seeking. In contrast, the early thespian instincts to which Stewart admitted were put to excellent, more generous use throughout his career.²¹ They were apparent in presentational panache, frequent topical asides, continuous public conversation, historical anecdotage and language that was colourful, even sometimes extreme. His early renal transplant patients did not just die from excess of immunosuppression but were ‘destroyed’, for example. The account of his hepatitis B illness was especially dramatic but was experienced in similar form by numerous others. They also thought that their time might have come, but kept that to themselves.

An early flamboyance of dress expressed his self-confidence and was noteworthy to contemporaries. It was unmissable at Guy’s. It was possibly one reason he became involved in an early television study aimed at doctors, joining with the established Charles Fletcher in designing a series of trial medical programmes for the BBC. The decade earlier ‘Your life in their hands’ advertising dialysis was not mentioned in his BMJ report of 1968.^J2 The broadcasts were otherwise carefully considered, with follow up ‘questionaries’. Presumably he was felt by the BBC to represent a desirable, very modern, young contributor. He did not take the bait that was offered for a possible career in the media; we may conclude that he was recognised as usefully provoking attention, at least.

And by the way …..

As another Cameron-esque aside, it is tempting to put his lifelong egalitarianism and extroversion together, as two sides of a single psychological coin. Was it perhaps the former that made the latter instinct publicly comfortable? The sharing of his joie de vivre, on one side implicit and on the other explicit, makes a lot of sense, and balanced the exceptionalism of his early flamboyance.

Abstractions

His introduction to nephrology of Kaplan-Meier plotting of clinical outcomes and Venn diagrams to illustrate overlapping clinical features were critical steps in expressing and simplifying the fundamentals of renal research. The other applications of abstract theory in modern IT do not seem to have been a major part of his interest, although he claimed some responsibility for the timely creation of the UK Renal Registry and collaborated in the UK production of EBM-provoked standards, rather than guidelines, in  the mid 1990s (he was conscious of a need to blunt the quality:cost pressures of the 1990s NHS purchaser-provider reorganisation). He toyed with data presentation and the structure of clinical effort as those new issues evolved.^B17 Of course, his whole career was based on science-derived evidence applied to the clinical context, although a popular, catchy-enough, term for that did not surface until the late 1980s as part of Evidence-based Medicine (EBM).

His generation, practicing in an era when much was traditional and unspecialised in clinical medicine, could still see the application of science as collateral rather than central to practice. He adopted that transition as a motivating, piecemeal, mission. There was little prompt for a more general term, like EBM, when it was being practiced comprehensively, avant la lettre. Likewise,  the eternal vocational instinct towards improved patient care did not prompt the need for a high-level expression, like Continuous Quality Improvement (CQI). In the event, these well-placed slogans from North America clarified vocational aspirations usefully, as well as provoking intellectual and technical progress in medical practice. They commodified the specialty, in a way that the early Stewart might have envied as a means to promote his aspirations. The commodification and acronyms did not stop there. Nephrology itself has been restructured subsequently through the graduated categories of AKI and CKD, although perfectly sensible, if narrower, terms were available in ARF and CRF. The latter had been forged from the past, expressing the extreme, largely developed, presentations of renal disease.  For him, the process of progressive semantic redesignation was apparent in the types and categories of glomerulonephritis, at a yet lower taxonomical level, but challenging enough at the time.

As for other technological abstractions, the substantial 1980s UK renal contribution to clinical IT was not recognised as a significant topic when he organised the disrupted London ISN meeting of 1987, a missed opportunity. Unfortunately, that oversight was compounded by the loss of the first clinical computer section in the programme of the EDTA annual meeting, in the course of the shift from established annual Proceedings to the first EDTA journal, Nephrology, Dialysis and Transplantation (a development that he also claimed to have originated, albeit in a triumvirate).^B31 Neither was organised clinical IT ever adopted as a separate topic by a Renal Association under his influence, compared with the fortunate 1968 incorporation of his enthusiastic, dialysing colleagues. Informatics necessarily resurfaced in the RIXG group of 2007. It is unclear whether he would have shown more interest in IT had he not retired earlier than anticipated in the mid-1990s. We can imagine his interest in current, specialty-wide, IT-based patient consultation and participation, as a mature continuation of his instinct for egalitarian organisation and patient emancipation.

Comment

Any dip into the intellectual currents of a career is bound, then, to involve collateral elements like character and circumstances. That aggregation comes to convey a complex professional achievement that begs assessment. Expressing the consequence of any given individual for a complex historical context is challenging, but can be attempted if they are examined as more than just immaculate legendary heroes.^7.21 One means of assessing personal contribution is to contrast peers who had similar opportunities and, in this case, made significant scientific contributions. There were and are a few such individuals in UK nephrology, who point up the personal characteristics that Stewart brought to the specialty.

Conclusion

It seems that Stewart fostered a series of preoccupations throughout his career, some possibly drawn from early exposure to mentors, traditional Guy’s culture and even Richard Bright himself. His social, artistic and thespian inclinations could all be usefully mobilised towards career development. He came to represent the whole of Nephrology and shaped it as a communal, international intellectual exercise, with both academic and practical strands. He was able to find a way to a sustained reputation among his peers and successors.³³ His remarkable energy could be applied through fortunate opportunities, although even he became aware of at least two, much delayed, clinical truths in renal disease, the importance of the renal  interstitium for renal clearance and  proteinuria in prognosis. The oversights can be seen as due to diversions of research interest over many decades, through inadvertent, covert, branding; one price of unconstrained investigatory enthusiasm, perhaps? He communicated and dignified the historical origins of nephrology, through the study of progressive individuals and methodologies. He was well aware of the foundations of reputation. In that, he exemplified his own intellectual trajectory, of a career-long effort to understand (another Grasp) the revelations of new investigatory techniques (another Reach). His hard work and intense focus are a guide to achievement, even when personal capacities less impressive than his are deployed.

John Keats is reported to have declared that ‘every mental pursuit takes its reality and worth from the ardour of the pursuer – being in itself a nothing’.¹⁷ That comment from early 19th century Romanticism can be taken to sum up the special quality of Stewart’s energetic engagement with, and effective broadcast of, nephrological clinical science.

 

Griffiths T,  Hughes SP. John Keats: The Doctor’s Poet?

 ‘Beauty meant a deep acceptance of this – not an intellectual acceptance alone but, from
infancy, the developing and developed capacity within the self to bear the experience of
contradiction and, also in medical practice, to accept uncertainty. For Keats, men of ‘genius’
possessed in abundance the capacity to bear contradiction and he struggled to develop it
himself, to hold the tension between opposing poles, to remain open – fully – to the other.
He thought about Leigh Hunt’s theatre reviews where he wrote about ‘passive capacity’ and,
later, the work of William Hazlitt on Shakespeare and his emphasis on ‘gusto’ – intensity –
Keats’s version of which he described in a letter to his friend, Benjamin Bailey: ‘every mental
pursuit takes its reality and worth from the ardour of the pursuer – being in itself
a nothing’’

References

JSC Bibliographic references are given as alphabetic category (A to J) followed by the number (category C has two sections). The following references are given in superscript by plain number.

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2. Becker EL b. Proteinuria in renal disease. Bull NY Acad Med 1970;46(10):830-837.
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13. https://edren.org/ren/unit/history/important-events-in-dialysis-in-edinburgh/#The_Edinburgh_hepatitis_outbreak.
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22. Risdon RA, Sloper JC, De Wardener HE. Relationship between renal function and histological changes found in renal-biopsy specimens from patients with persistent glomerular nephritis. Lancet. 1968 Aug 17;2(7564):363-6. doi: 10.1016/s0140-6736(68)90589-8.
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Author: Es Will

First posted: 30th September 2024

 

 

 

 

 

 

Last Updated on October 3, 2024 by John Feehally