Further modifications have been introduced into this doctrine of parenchymatous nephritis by the contention that changes in the epithelium alone are not of inflammatory, but of degenerative, nature. Incidentally Cohnheim brings out well the point that with well-marked changes in the urine and constitutional symptoms we may find no structural changes in the kidneys; in other words, that the morbid changes in these kidneys must have been confined to the blood-vessels.
With Ziegler, Cornil, and others have come in an improved tech nique and an exact study of the changes in the kidney, which have given us a much more satisfactory knowledge of the lesions.
Although so much has been done in the study of the lesions of Bright's disease, it must be confessed that the ideas of the profes sion in general concerning it are still somewhat crude.
As regards acute Bright's disease, we often find the belief: That the kidneys are large, and either white or congested; that the chief change is in the epithelium of the tubes, which is swollen and detached and blocks up the tubes; that there is some change in the glomeruli which allows albumin to pass through the walls of the capillaries ; that the patients pass too little urine; that in consequence of this diminished production of urine there may be developed dropsy or cerebral symptoms; that the chief object of treatment is to make them pass more urine, or, failing this, to purge or sweat them.
As regards chronic Bright's disease, it is generally believed that there are two principal forms : one, in which the kidney is more or less large and white, while during life there is dropsy, and much al bumin in the urine; and one in which the kidney is more or less contracted and red, and there is little or no albumin in the urine, and little or no dropsy.
It has become evident to many careful observers that there is a group of persons who are more liable than are others to chronic pro ductive inflammation in different parts of the body. It may be the lungs, or the heart, or the arteries, or the liver, or the kidneys that are affected; and either one or several of these organs are involved at the same time.
The liability is most common after forty-five years of age, but is by no means infrequent in younger persons. Unquestionably many of these persons are gouty; in some there is a history of chronic alco holism; in some there is an hereditary history ; many of them suffer from disturbances of digestion; many of them have habitually an ex cess of urates, or oxalates, or occasional sugar, or albumin in the urine.
So great is the number of these cases, and so constantly are these persons under our observation, that it is often not difficult to recog nize that an individual belongs to this group before he has developed any one of the characteristic inflammations. We can predict before hand that a given individual will, at some time, develop emphysema, or chronic endocarditis, or endarteritis, or cirrhosis of the liver, or chronic nephritis.
Curiously enough it has occurred to some very intelligent physi cians that persons in this group are really all suffering from the same disease, and that they develop the characteristic lesions as the result of the disease. They propose to call this disease Bright's disease. According to this view a person can have Bright's disease while the kidneys are still normal. In this way have come in the terms of VOL. 1.-2 "renal inadequacy" and of the " pre-albuminnric stage of Bright's disease." There can be no question that this group of cases is a very im portant one, and it is quite true that most of them do have disease of the kidneys before they die. I do not know of any good name to designate all the cases of this kind, but I do not think we have any right to say that they are all examples of one disease. Much more probable is it that they all exhibit the effects of heredity, environ ment, and mode of life.
There is a well-marked disposition on the part of some authors to include cases of chronic inflammation of the arteries under the name of Bright's disease. This view of the matter is clearly stated by Mahomed in Guy's Hospital reports for 1880.
He says : " The object of this paper is to prove that in the earlier stages, and in most cases even to their final stage, the urine of what is generally known as chronic Bright's disease with red granular kid ney is most commonly perfectly normal. More than this, its object is to prove, either that chronic Bright's disease is not a renal disease, although it frequently gives rise to a renal affection, or else that another disease must be recognized which constantly precedes and prepares the way for Bright's disease, which may be called arterio capillary fibrosis, or any other name that may be preferred to it." The cases which Mahomed narrates in his paper seem to be cases of chronic arteritis, with more or less complicating nephritis.