The whitish or ashy, milky or creamy product, which may resemble albumen in its various degrees of coagulation, and consists of solitary and accumulated molecules, or of more or less globular fibrinous coagula and pus-corpuscles (Gluge), is an albumino-fibrinous substance, with a predominance of albumen; the amount in which it occurs is proportioned to the amount of granular degeneration.

The product may, as in simple inflammation, be deposited at every point of the renal parenchyma external to the vessels, but we find it more particularly in the Malpighian bodies (glands), and subsequently in the urinary tubuli; the granulations of Bright's disease are therefore in reality the Malpighian corpuscles charged with the above-named substance. The more the latter accumulates, the more it interferes with the circulation, hence the peculiar pallor or anaemic condition of the organ.

The cause of the peculiar character of the product is the more obscure, since the question is generally evaded. As the amount of reaction that takes place in the renal tissue does not suffice to explain it, we are led to seek the cause in an anomalous constitution of the blood, consisting in an excess of albumen, which may originate in a decomposition of the fibrine. This becomes the more probable, when we consider that the most frequent exciting cause (cold) appears peculiarly adapted to give rise rather to a change in the blood, than to a disease of the kidneys, and that the infiltration of the kidney, which we have examined as the eighth form, is evidently developed as a sequel of the cachexiae which we shall shortly investigate, and in complication with similar affections of other organs (liver, spleen). Although we might offer numerous observations on this connection, the real cause of the development of the renal disease from the crasis of the blood, which often takes place with such extreme rapidity, is to us an enigma. We look upon the anomalous condition of the blood in Bright's disease as the primary affection, which, from a peculiar relation to the kidneys, is followed by the secondary and visible disorganization of the renal tissue; this need not however always ensue, at all events it does not follow as rapidly as the structural disease of the kidney, consequent upon the vegetative disturbance that causes diabetes mellitus. By this means we explain how it happens that the two kidneys are generally attacked at the same time or at brief intervals. Graves is of opinion that the change of texture is induced by the free acids of the urine (phosphoric and nitric acids) coagulating the albumen as it passes into the urinary tubuli.

Bright's disease is distinguished in the dead and the living subject by the following symptoms: a. We may briefly enumerate the following as occurring in well-marked cases in the kidneys themselves, - increase in the size and weight of the organ, and especially of the cortical substance (the hypertrophy of French authors, a term which may easily give rise to a misapprehension); ansemia, pallor, laxness of the tissues, development of peculiar granulations, inflammatory sympathy of the renal fascia, on the one hand, and of the mucous membrane of the pelvis and calices, on the other.

/3. The so-called consecutive symptoms: a constant and considerable amount of albumen in the urine, accompanied by a diminution of its specific gravity (Gregory), a symptom considered by Bayer as belonging to the chronic form only; a reduction of the solid constituents, viz. the salts and urea, a milky turbid appearance, or if tinged with blood and blood-corpuscles, dark discoloration, eminent serosity of the blood arising from the removal of the albumen, and accompanied by a diminished specific gravity of the serum; dropsy, which is chiefly manifested as anasarca, marked pallor of the surface, and secondarily as serous effusion into the serous cavities, and especially of the pleura and peritoneum. Of the latter symptoms the albuminuria and the dropsy have long since been the special objects of explanatory attempts.

Albuminuria is considered by Gregory as pathognomonic only when the specific gravity is simultaneously diminished; it seems to ourselves to consist in a disturbance of the catalytic function of the kidney arising from the homologous infiltration of the renal tissue; albumen is in part deposited in the channels of the urinary tubuli themselves, as a product of the reaction. There is not, however, a proportionate relation between the degree of the albuminuria and the amount of renal disease, as we may even find the former existing without the latter.

Sabatier, whose views are not materially controverted by Bayer's objection, attributes the dropsical affections to an attenuation of the blood produced by the removal of the albumen. This crasis of the blood must, therefore, be viewed as secondary.

The lower degrees of Bright's disease are curable by resolution, without leaving any traces, like other moderate inflammatory processes. In the advanced stages a cure may be effected, but only with considerable alterations of texture, as manifested in atrophy of the kidney with a racemose surface, varicosity of the vessels, cellulo-fibrous condensation of the tissue, fibro-lardaceous thickening of the renal fascia, and contraction of the pelvis and calices, in induration of the product, and its conversion into a contractile callus. A fatal termination is induced, with a greater or less rapidity, by dropsy, and especially by serous accumulations in the large cavities of the body, by the slow or sudden supervention of serous effusion into the ventricles of the brain, into the cerebral substance, and into the pulmonary parenchyma, by anaemia, by the retention of urea in the blood, or by morbid conditions of other tissues and organs, which present accidental or essential complications with the renal disease and its predisposing cause.

In the case of retention of urea in the blood, the resulting symptoms are owing to the antagonism between the urea and the nervous matter; they consist in coma, delirium, convulsions, and tetanus, and are not un-frequently caused by urinous effusions within the cavity of the cranium.

The complications are chiefly dependent upon causes that operate suddenly or repeatedly, and for a considerable period, such as catarrhs, and particularly bronchial catarrh, rheumatism, with or without endocarditis, and their sequels; the complications may also originate in the secondary disorganization of the blood, and here again we meet with catarrhs, and also with extensive exudative processes, both on the mucous membranes (serous diarrhoea, pneumonia),1 and, more especially, on the serous membranes, the arachnoid, pleura, peritoneum, and internal coat of the blood vessels (phlebitis). Hemorrhage and apoplexy are of rarer occurrence. There is great difficulty in accounting for the complication with granular liver, and with the ascites resulting from the latter affection. The supervention of Bright's disease as a new complication may probably be accounted for by the greater liability of a previously diseased subject to the reception of noxious influences, whether operating continuously or temporarily; we allude more particularly to the abuse of spirituous liquors, and to cold.

The commonest and most evident cause of Bright's disease is cold, the sudden or constant influence of cold damp air, more especially; at all events, the occurrence of Bright's disease after scarlatina in children and adults, is most frequently due to this cause; the abuse of spirituous liquors is also considered as a cause, though chiefly in connection with the previously mentioned influences; diuretics, though they do not originate, undoubtedly promote the disease.

Numerous dyscrasic momenta are of considerable importance. We advert to the development of Bright's disease, subsequent to exanthe-matic fevers, particularly scarlatina, to typhus, to tubercular disease and tubercular suppuration, e. g. pulmonary phthisis, to cancerous diathesis, and to the affections which we are about to consider in connection with the eighth form.

The eighth form invariably sets in without reaction, and springs from inveterate scrofulous or rickety disease, but especially from syphilitic and mercurial taint. It presents itself as a constitutional infiltration of the kidney, and is associated with analogous affections of the spleen and liver, in the shape of lardaceo-albuminous infiltration; both the nature of this product and the anomalies of the blood and the urine as yet remain a perfect enigma. We have once noticed the complaint as a sequel of intermittent fever combined with a similar condition of the spleen.

1 [Qy. Bronchitis? - Ed].