Lumleian Lectures on Bright's Disease
Authors: R. Southey
Journal: BMJ (1881)

IN I863, Rosenstein's work on Kidney-Disease was issued from Berlin.Like Frerichs, he regarded Bright's disease as one essentially uniform pathological process, encountered in various stages, according as life was cut short or prolonged; the kidney at the time of death presenting different aspects, according to the stage reached, and the particular tissue at that time predominantly altered.But his synonym for it was " difluse nephritis", by which he implied that every element in the kid- ney-tubes, blood-vessels, and matrix-tissue-were involved.He separated various renal affections, in which albumen occurred in the urine, from Bright's disease: i.The congested kidney of passive hyperoemia; 2. Tne slighter catarrhal forms of nephritis, in which albuminuria was often a very temporary affair; and 3. Amyloid dege- neration.*His conception and his description of the mode of com- mencement of diffuse nephritis, however, entirely corresponded with those changes in the renal epithelium, to which Virchow had assigned the name of parenchymatous inflammation.He says: The renal cells and the matrix-wall of the tubes swelled up simultaneously in the first stage of hyperermia; in the second stage, exudation took place, not on the bare surface, but into the renal cells themselves, which distended the tubuli and encroached upon the intertubular spaces, and squeezed the blood out of the cortical capillaries.Two courses were now open (the third stage); either the epithelium might decay, the secreting tubes atrophy and spontaneously collapse (as Dr. Johnson had surmised) ; or the inflammatory changes might extend to the interstitial matrix-tissue of the glands, which became, either locally or generally, the scene of cellular hyperplasia.There is a good deal here, of course, taken at second hand from the pathological authorities of the time; and there is no particular advance, except in interpretation of the facts observed, upon Frerich's ideas; but the description of the symptoms was, and is still, admirable ; and the b)ook continues to be in Germany the best text-book of renal diseases.In I86o-6z, Dr. Dickinson published two papers in theAMedico-Chtitzirgical Triansactions, vol.43, page t44, based upon clinical records and necropsies at St. George's Hospital.He divided Bright's disease into two varieties: I.The tubular disease, primarily a catarrhal affection of the renal tubes, leading to the large, smooth, white, or mottled kidney ; and, in cases which lived long enough, advanced to some degree of atrophy.2. The intertubular disease, in which he surmised that an exudation, thrown out between the tubes, finally starved and involved both secretory tubes and Malpighian bodies in gradual destruction- this process leading ultimately to the formation of the atrophied granular kidney.Dr. WVilliam Roberts, in his Prdctical Treatise on Renal Disease, published in I865, treats the subject, as he writes (page 296), "rather from a clinical than an anatomical point of view".A good many new anatomical features in the kidney were just then being brought to light by Henle and Schweigger-Seidel.He classified Bright's disease under tsvo main heads, as acute or chronic.The former corresponded to the inflammatory dropsy of the old physicians; the desquamative nephritis of Johnson; the first stage of Frerichs; the parenchymatous nephritis of Virchow; the acute diffuse nephritis of Rosenstein; and the acute tubular disease of Dickinson.The chronic Bright's disease was a less satisfactory group, involving, as it did, relapsed or protracted acute cases, and others which had been chronic from the beginning.He pronounces himself promptly on the subject of fat in the renal substance, and in the epithelium of the tubes, as an alteration associated with most varied pathological changes, and special to no one type of renal degeneration (page 297).He recognises three types of chronic Bright's disease : I. Large white kidneys, lapsed acute cases; 2. Cases chronic from the beginning, red granular contracting kidney; 3. Lardaceous or amyloid kidneys.* Rosenstein also separates tlse fat kidney, like the fatty liver, wholly fromBright's disease, and from amyloid degeneration.This is the kidney which Rokitansky described as "steatosis".I am by no means clear what kidney is here intended.One case after poisoioing by phosphorus is included in this chapter.