Belding Scribner (known as 'Scrib' to almost everyone) made a technical advance in 1960 which has led to the saving of more than a million patients from death from chronic renal failure, for which work he received the Albert Lasker award in 2002 jointly with Willem Kolff. In addition, however, Scrib tackled the many medical, ethical, political and fiscal consequences of his innovation, and continued to explore these until his death, as well as doing much original work in electrolyte pathophysiology.
Scrib was born in Chicago, the son of an aeronautical engineer, Carleton Scribner, and an author, Mary Elizabeth Belding. He was educated at Williams College in Massachusetts and on the West Coast at the University of California in Berkeley, where he graduated AB in 1941. He obtained his MD from Stanford University Medical School in 1945, where the Scottish-American, Thomas Addis, inspired his interest in electrolytes and renal diseases. While a fellow at the Mayo Foundation from 1947 to 1951, he first heard of dialysis from a lecture by John Merrill.
He then returned to the West Coast, being recruited in 1951 to the faculty of the University of Washington, Seattle, as chief of nephrology, where he remained for the rest of his career, apart from a visit in 1957 to London to work with Malcolm Milne [Munk's Roll, Vol.IX, p.367]. It was during this visit to Europe that his attachment to collecting fine wines began.
Encouraged by Addis, Scrib had developed a bedside test to measure choride and, while at the Mayo Foundation, he developed similar tests for bicarbonate, total base and urea. These were combined in a bedside kit which became the basis for his teaching on the practical management of fluid and electrolyte balance problems, used by generations of medical students at the University of Washington.
His work on dialysis for renal failure began with studies of gastrodialysis and in 1958, in the first of his numerous papers on the subject of dialysis, he showed this technique to be inadequate alone to support patients in renal failure. He then turned to haemodialysis for the treatment of acute reversible renal failure but was frustrated - as all clinicians were at that time - by the fact that when such patients turned out to have chronic irreversible renal failure they inevitably died as access sites to their blood vessels were used up. The particularly tragic death of a young man from nearby Spokane in early 1960 was a turning point: someone who had been saved from certain death by dialysis had to be left to die again because no access was available.
Scrib conceived the idea of an external arteriovenous shunt which could be opened for each dialysis and re-used. (In fact, although he did not know it, the idea was not new, but had been frustrated previously by lack of non-thrombogenic materials.) A colleague, thoracic surgeon Loren Winterscheid, told him of the new PTFE (Teflon) tubing which he thought might be useful for chronic human vessel cannulation. Scrib recruited the engineer in charge of the hospital instrument shop, Wayne Quinton, to make an arteriovenous shunt from PTFE. The first three patients treated in March and April 1960 by Scribner, Quinton and surgeon David Dillard all survived for more than a decade using shunts: long-term haemodialysis was at last a reality.
Immediately the many dilemmas imposed by this successful, but expensive and basically palliative treatment for uraemia were obvious, and Scriber tackled them one by one during the years 1962 to 1964. Hypertension and sodium balance, peripheral neuropathy, anaemia, hyperphosphataemia and bone disease were and remained the main focus of his medical work, but perhaps even more importantly he recognised the human, psychological, ethical, financial and political problems created. The dilemmas posed by the shortage of both dialysis treatment and kidney transplants in the early 1960s led to the discipline of bioethics as we know it today, and Scribner played a crucial role in this development. His 1964 presidential address to the American Society for Artificial Internal Organs on 'ethical problems of using artificial organs to sustain human life' was a landmark in the development of bioethics.
He was a strong advocate that dialysis was best done outside the hospital environment and should not be done for profit. In conjunction with Albert Babb, professor of chemical and nuclear engineering at the University of Washington, he set up a team of engineers and physicians to facilitate and automate the process of dialysis, so making it the routine treatment it has become today. Babb's automation of dialysis fluid production facilitated dialysis in the home, which Scrib believed was its proper place, in order to encourage patient independence and quality of life. In addition, in 1962 he recruited the young Dutch physician Fred Boen from Amsterdam to work on peritoneal dialysis, and pioneered long-term treatment with this with the help of Henry Tenckhoff from Freiburg in Germany. Finally, along with many colleagues, he persistently lobbied the US Congress to make funding support for dialysis and transplantation available to any patient who required it. Legislation was eventually passed that did this, which remains unique in the world.
Over the years, Scribner's programme became a Mecca for students of dialysis, and trained numerous fellows from the United States and elsewhere who achieved distinction themselves, including Charles Mion and Bernard Charra from France, Alfred Blumberg and Bruno Truniger from Switzerland, Vincenzo Cambi from Italy, Robert Atkins and Charles Dawborn from Australia, Ulrich Graefe from Germany, Herman Aguirre from Chile, Stefan Angielski from Poland, and many others.
Scrib was a modest and delightful man, almost universally loved and respected by colleagues, trainees and patients. His minor eccentricities, such as living on a houseboat (from which he used to paddle to work at the hospital in a canoe) and his trademark red cap emphasised rather than distracted from his distinction. He grew with the new specialty of nephrology from 1960 to his death in 2003, and enhanced it in so many respects. He was president of the American Society for Artificial Internal Organs in 1964 and of the American Society of Nephrology in 1978. He received many honours in addition to the Lasker award, including the Hamburger award of the National Kidney Foundation, the John Phillips memorial award of the American College of Physicians and honorary degrees from the University of Goteborg and the Royal Postgraduate Medical School. But he was never so happy as when fly-fishing, flying model seaplanes from his houseboat, savouring wines from his collection, or welcoming old or new friends.
On 19 June 2003, he was found in the water, by his houseboat. For some time he had been physically frail from bone and cardiac disease, but his mind remained as sharp as ever, his last paper being published posthumously. In 1966, he and Ethel Hackett began a devoted and happy marriage. Scrib had four children from an earlier marriage and Ethel had three; but in truth Scrib has many more than a million children world-wide whose lives were saved or bettered by his work.
J Stewart Cameron
Christopher R Blagg
[Brit.med.J., 2003,327,167; The New York Times 22 June 2003]