Fifth Form

The kidneys are enlarged or of the normal size, or they may be reduced in size; their surface is granular and racemose, or whilst certain portions present the nodulated and prominent appearance, others are irregularly furrowed, indented, and cicatriform. The cortical tissue is coarsely granulated, looser in texture, very vascular and congested, and the vessels are varicose; or else we find it, as in the case of a diminution of the organ, of pale-yellow or ashy hue, exsanguineou3, of coriaceous density, and mainly of a fibro-cellular texture; the indentations at the surface here and there present a similar tissue, of a whitish or slaty color. We also not unfrequently see cysts, containing the most various substances, and varying in size from that of a poppy-seed to that of a pea or nut and more, scattered through the cortical structure.

In the former case the attachment of the fascia propria is slight, in the second it is more intimate: the fascia is thickened, and the adipose layer indurated. The pyramids are small and atrophied, of increased density, and generally of a dirty brown color; the calices and pelvis are slightly contracted.

Sixth Form

The organ is but little increased in size and weight, the cortical substance only presents a few undefined patches of a paler color, and the prevailing hue is either pale red, or it is found on closer examination to offer transitions of a pale red, a white, yellow, or ashy color. It is infiltrated with inspissated matter, resembling thick cream or coagulated albumen; and not only does not present greater laxity of texture, but is of the normal or even of increased consistency.

The fascia propria is but slightly less adherent at these points than in the healthy condition, and the pyramids, as well as the calices and pelvis, are normal.

Seventh Form

The increase of size is commonly trifling; occasionally there is partial atrophy and diminution. There is increase of density and consistency. As in the last variety, the cortical substance only presents patches of a dull white color, which have no defined borders, and are often very extensive; it arises from a coagulated, albuminous, larda-ceous-looking substance, in which no trace of the renal tissue remains. We here find considerable swelling of the kidney, owing to the copious deposition of the morbid growth; or the organ otherwise seems shrunk, and presents the appearance and consistency of fatty cartilaginous tissue. One or more of the pyramids occasionally undergo a similar metamorphosis. The fascia propria is agglutinated to the diseased portions of the kidney, and thickened; the lining membrane of the calices and pelvis is tumefied.

Eighth Form

The kidney presents but a slight increase of size, or is of normal dimensions, but always considerably indurated. The general hue is a dirty red or brownish-yellow, and the cortical substance presents a fatty waxy gloss, is unusually hard and brittle, and infiltrated with an albuminous, lardaceous, and transparent substance. Occasionally a whitish flocculent deposit is seen in the tissue, of the shape of fine granular dots and lines, giving to the surface and sections a marbled appearance.

We have thus enumerated the forms which, in a general point of view, we think it proper to class under Bright's disease. The first seven forms undoubtedly belong to the latter, if the totality of the symptoms, as they appear in the living subject, be considered: they also occur complicated with one another, and the second, third, fourth, and fifth forms more particularly represent Bright's disease and Christison's granular degeneration of the kidney. In the latter form the disease is generally chronic, though with an acute tendency and occasionally exacerbations; the second, third, and fourth forms represent progressive stages of degrees of the metamorphosis occurring in Bright's disease: they vary in duration, and pass from one to the other either gradually or, as is frequently the case, with very tumultuous symptoms. Each of these stages may prove fatal. The fifth form is the last link of the metamorphosis; with it the process becomes retrograde, and the disorganized tissue of the viscus presents the condition of secondary atrophy. The different varieties are not un-frequently complicated with one another; and we thus find the first degree (second form) attacking one kidney, or a section of one kidney, whilst the other kidney, or the other sections, present the metamorphosis of the third or fourth degree (third and fourth form). The peripheral layer of the cortical substance is generally in a more advanced stage than the deeper-seated layers.

The sixth and seventh forms represent the less frequent or chronic varieties of the disease; the latter (the seventh) must be looked upon as the terminal point of the metamorphosis, as the product of the disease is retained in a state of condensation and organization, and subsequently shrivels up. It is sometimes complicated with the varieties previously spoken of.

The first form is extremely rare, and runs an acute course; on the occurrence of powerful exciting causes, very tumultuous symptoms are sometimes induced, which speedily reach their climax, and may terminate fatally on the fourteenth day.

The eighth form is invariably chronic; we shall for the present exclude its consideration from the following remarks, and advert to it subsequently, for reasons that will then be apparent.

The nature of the disease, and the scientific exposition of its characteristic symptoms, have been the subject of numerous discussions, and we neither venture to assume that our remarks will add great weight to the arguments of those who consider it inflammatory, nor do we wish to anticipate further investigations and statements of depth and originality.

We consider the nature of Bright's disease to consist in an inflammatory process, which proceeds from a stage of hyperaemia to one of stasis, and then gives rise to a product, which is not only remarkable by its peculiar character, but which, in well-marked cases, by its excessive accumulation, causes a singular alteration in the appearance and structure of the kidney. It commonly runs, as we have already stated, a chronic course, with occasional exacerbations, but it is sometimes acute. In the latter very important cases, in which, from the tumultuous violence of the exudation, the product is mixed with a large amount of serum, and is generally reddened by the coloring matter of the blood, and in which the characteristic milky or creamy or coagulated substance of well-marked Bright's disease is not formed, we should be obliged to consider the condition as one of very acute simple inflammation of the kidneys, were it not that the characteristic general symptoms and the constitution of the urine established it as a case of Bright's disease.