Is Sin Dialyzable?
This is an old doc’s tale, something of a shaggy dog story, from long ago.
I was a young research fellow in the Nephrology research Laboratory at Washington University school of medicine, under a young and, in the field, well known principal investigator, the epitome of the cool straight-faced scientist, Neil Bricker. Our major function was basic research in kidney physiology in health and disease, and most of our time was spent experimenting on street dogs. But we also did clinical consultations, and, in emergencies, hemodialysis, and thereby hangs this story, a cluster of stories, actually.
Time out for a bit of medical history, no choice. I’m not going to explain and define everything, so best do your Wikipedia homework.
Hemodialysis, a procedure for ridding the blood of waste products when the kidney fails, was invented during WWII in 1943 and the Nazi occupation, by one of those peculiarly ingenious and unflappable Dutch physicians, Willem Johan Kolff, not because of the war but despite it. My story occurred in 1959.
Nowadays hemodialysis is as routine as draining dirty oil from a Chevy. Performed on patients with longstanding moderate or mild chronic uremia, dialysis uses very impressive automated machines, casually tended by a nurse or tech, at specialty facilities, or even at home. Not so in my day.
In theory simple, hemodialysis is the running of a uremic patient’s blood (containing, among the terrible plethora of other wastes not excreted by the failed kidney, excess urea – thus the adjective “uremic”) through a long tube of semipermeable membrane which keeps plasma protein inside, but allows, by a process known as osmosis, smaller molecules to pass through the tube into a special surrounding bath (we called it “dialysate”), if the concentration of a given substance is less in the bath than inside the tube. In hemodialysis the dialysate has a normal concentration of normal substances but lacks waste products, thus only wastes pass through the tube.
More than a decade after Kolff, the way we did dialysis, though unthreatened by Nazis, seemed to me still as primitive as Kolff’s way. Ingenuously improvised, his original semi-permeable membrane was simply cellophane sausage casing wrapped around a spool, the famous “Kolff Coil.” And likewise ours. As if it were a dirty overcoat, we immersed Kolff’s cellophane coil in the “bath,” and the whole business, coil and bath, into an ordinary household laundry tub affixed to the wall, and on completion simply pulled the plug and let the metabolic wastes drain into the Mississippi.
A surgical resident had done an arterial cutdown, through which the patient’s blood, his whole blood volume, was propelled by the patient’s blood pressure through the coil, which had been prefilled with a gallon or so of donor blood, all kept properly heparinized lest it clot in the coil like sausage, resulting in instant cessation of the patient’s circulation and death, or rupture of the coil and massive hemorrhage right into the tub, with shock and probably hemolysis and death.
Performed somehow always at night, all night, by the two of us research fellows surprised to be doing dialysis, and left to wing it by our chief, probably as surprised as we were to be involved with this strange thing, hemodialysis was, for us novices, formidable and awkward and tedious and risky. Thus dialysis was done only on acute very severely and acutely uremic patients, as a last resort.
Through the long night, I and Peter Morrin, the other fellow, did clotting times on the half hour, kept the heparin and IV going, watched the coil for clot or leakage, monitored the EKG (no other monitoring devices available back then) and vital signs, and I don’t remember what else. We were too busy to talk much – I could have learned about Ireland, where Peter was from, and discussed life and deep things, or catnapped.
This story of all this fortitude and pioneer struggle in the erstwhile utility basement is harrowing enough, but only the setting for the drama that follows.
On this particular night the patient we were dialyzing was Jessie, a thirty-something man who, while hunting in the Ozarks, had accidentally shot himself in the right thigh with his shotgun at close range, rendering his thigh muscles a huge mass of well shredded raw hamburger. Hamburger may be tasty to eat but is poison to the kidneys, shutting them down completely and allowing minuscule urine excretion, resulting in sudden (“acute”) uremia, more frequently fatal than not if left alone. However, if somehow the patient survives, the kidneys revive and are as good as new.
Termed “acute tubular necrosis” (ATN), and famously a result of massive tissue damage due to trauma, it has always been one of the most frequent causes war fatalities. It was so in WWII, but for the first time in history not in the Korean War, thanks to Kolff even if he never made it to TV's “MASH.”
Jessie, a casualty of the hunt rather than war, was now severely uremic, his BUN (blood urea nitrogen) approaching ten times normal. He needed amputation but his condition precluded it. No question, he would have to be dialyzed, tonight.
Jessie was known widely in the Ozarks as a model husband and father, exemplary citizen, and churchgoer, soft-tongued, virtuous, a deacon of the local Baptist church. But as his BUN rose higher and higher, he changed. He changed from being saintly to demoniac. Now he was screaming unintelligibly, mostly obscenities, many directed at his wife. Dumbfounded, she could only sob. Only after sedation and application of mild restraints could he be wheeled on a gurney to the makeshift basement dialysis area, while his sobbing wife waited at his bedside.
As the hours passed – blessedly uneventfully for Peter and me – Jessie seemed less restless, and come the dawn Peter and I wheeled him, in good condition and with a normal stat BUN, back to his room and wife, whom he greeted sleepily but lovingly, ardently, passionately. It was for joy that his wife was now weeping, and murmuring, “Miracle! Miracle! Miracl ” Exhausted, Peter and I readily agreed. For Jessie was his same sweet self again, with no memory of having been otherwise, and soon to be a cheerful and inspirational amputee and famous in his neck of the woods as the one-legged Psalm-singing hunter.
And with that happy denouement the story, the dramatic part, ends – for Jessie and his wife, and Peter and me. But for me another kind, not dramatic or action-packed but of meditation and many questions, was just starting. And over half a century later it isn’t over yet and won’t be as long as I and this earth last. Jessie’s transformation from saint to demoniac and his redemption -- by dialysis, -- what does it mean?
Is the devil dialyzable? Is the kidney, not the heart, where the devil resides? Is the devil simply urea, and every student of organic chemistry knows the formula, CO(NH2)2? And evil angels are alcohol, prescription or designer drugs, a legion of street psychedelic drugs smuggled across our membranous borders or synthesized in China? Is there more hope in rehab than in exorcism – or Christ? If so, what is sin other than a disadvantageous, and reversible, status, exactly as our secularists say, chuckling.
But I am no secularist. Nor do I see the devil or sin as whimsy. So what is that region somewhere deep in our brains, that is the domain of the subconscious and orbiting id and ego? However entertaining it looks by functional MRI, unformed brain perturbations and tenebrosities swirl down there, formlessly terrifying or enervating or, at most, surrealistic; a jangle of permutations of our glands and our parents, things long forgotten, contained and restrained down there like magma that, upon flowing normally upwards to the frontal cortex, solidifies and forms our conscious thoughts? Or perchance seeps up like Chthonic vapors to dance in our dreams or under hypnotism or in trance, and possesses us, or is liberated by rage or some designer drug or truth serum or wine, or uremia, bursting forth like lava from Mt. Vesuvius, burying us alive?
Is that place deep in our brains the seat of our will, freewill or enchained will claiming a greater freedom? Could it be the battleground of good and evil, where the great controversy between good and evil, God and Satan, is fought out on a personal rather than the cosmic level, where the decision for or against God, a decision that all of us must and shall make whether in structured or unstructured words, by unstopped sweat and tears or posthaste and whimsically? Is this the principle or perhaps only site of access by preternatural presences, either Christ's or Satan's, like the Tree of Knowledge in the Garden of Eden?
Or is this the barred cage where we compartmentalize Him and throw away the key, assuming, stupidly, that now He won't be pestering us all the time with His Commandments and conscious and offers of salvation? And congratulating ourselves, stupidly, that we haven't really actually killed Him, just locked him up. Out of sight out of mind. Maybe in a more convenient season we just might let Him out, if He has behaved.
But that’s way too poetic, isn’t it? Dr. Bricker, as cool a scientist-secularist as they come, would never talk like that. As he, looking poetically anguished, would admonish me, when coaching me for my presentation to the American Society of Clinical Investigation, “play it straight, Wes.”
So I’ll cut the tropes and talk in terms only of conscious and subconscious, as unsearchable as they are. We think of the subconscious as the source of the conscious, both being, therefore, like-minded, like the lump of clay and the finished vase. But in great issues, the subconscious, as near as we can tell, and the conscious, screaming clearly, seem in the greatest possible disagreement. Did Jessie’s cursings come from the conscious level, in grotesque disagreement with his sweet subconscious, or were his cursings because he had lost, thanks to uremia, all consciousness and cortical restraint, allowing cursings, previously locked up out of sight, to emerge?
I’ll play it straight – straight out of the Bible, where there is an answer, as close to an answer as we are to have in this life. It’s the story of the demoniac of Gadara, of whom I think as often as I rethink Jessie.
With convincing vehemence, the demonic cursed and rushed Christ. Had we been there, we would have taken the demoniac seriously and turned and fled. Without access to the subconscious, even our own, we cannot know, and must not, on the basis of what comes out another man’s mouth, whether cursings or pieties, judge what is deep down inside. But God can. And will, in the Great Judgment.
Christ did not turn and run. Being the Creator, and having Himself installed in mankind the subconscious deep brain and the conscious frontal cortex, Christ knows the true content of both. He knew that the devil – a legion of devils – had taken control of the Gadarene’s mouth and body. Was the devil also in control of his whole mind? That he was not, Christ could know. Christ could discern clearly that somewhere down deep there was the yearning, impossible for his mouth to utter, to be freed of the devils. Knowing that, Christ stood right there and by His word expelled the devils, cured the man, as we and Dr. Bricker would say. But when the Pharisees condemned Christ as vehemently as the demoniac had cursed Him, Christ knew their rejection of Him was monolithic all the way through, and He opened not His mouth.
I see the story of the demoniac, a true story, as parabolic of Jessie’s story. Yes, I say with a straight face, sin is dialyzable – by God; as dialyzable, as miraculously dialyzable, as urea. “Behold, I have caused thine iniquity to pass from thee.” Zechariah 3:4 KJV
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