Commentary

Abstract

Rayer divided his history of albuminous nephritis into four parts, corresponding to the various combinations of the three hallmarks of the condition, i.e. diseased kidneys at autopsy, dropsy in life and a finding of albumin in the urine. The accounts take us from the earliest writings, through the Renaissance period to the pre-Bright era and then onwards to the more contemporary studies immediately post Bright, which were mainly conducted in Rayer’s own department. The first part describes dropsy associated with diseased kidneys; the second part concerns the combination of albuminous urine and dropsy and also where urine low in urea and salts had been found; the third part brings the triad of albuminous urine, dropsy and renal lesions together. It is in this section that Bright’s work is critically examined and questioned. In the final part Rayer outlines his main recommendations and conclusions. In this commentary references have been omitted in favour of a Selected Bibliography that comprehensively covers the history of renal medicine, in particular the areas of controversy arising from Rayer’s text. Fundamentally, Richard Bright described three types of nephritic kidneys at post mortem associated with albumin in the urine and clinical dropsy during life; his work provided a benchmark from which all further research on the subject would evolve. In the eyes of the medical world his description finally separated renal dropsy as a clinical entity from that of cardiac or hepatic dropsy. Nevertheless, he could not have anticipated the frenetic activity that his publication would engender, not only in the medical schools of England, but also in those of Scotland, Ireland and France. Thus, Bright’s work provided not only the baseline, but also the stimulus, for his contemporaries, first to confirm the authenticity of his clinico-pathological triad, and then to add further, often egocentric comparative interpretations to his or their own findings. In fact, many of them did little to improve on Bright’s classical description. In order to get the text in perspective it is worthwhile casting a backward glance at several important areas which could explain some of the often acrimonious polemical debates that arose amongst researchers into nephritis in the immediate post-Bright period. Two factors had an essential bearing on the diagnosis of nephritis: the first being the precise body of knowledge relating to clinical syndromes, renal pathology, renal function, urine and urinalysis available to physicians in the mid-nineteenth century, and the second being the prevalent demography of that age which was critically important given that the pattern of diseases then was completely different and could at times obscure correct diagnosis. Both these points, plus the fact that diseases including dropsy were ineffectively treated and seen at a more advanced stage, make our modern assessment of the data fallible, even with the advantage of hindsight. Retrospectively, it is salutary to examine the pitfalls that might have been created by ignorance of up-to-date concepts available to present-day nephrologists and which led to misconceptions about what did or did not constitute nephritis at that time. As most of Bright’s original patients died, he attributed an overly grim prognosis to renal dropsy. This finding was challenged at an early stage by his contemporaries and could be explained by the lack of young patients suffering from