The History of Albuminous Nephritis (review)

The first modern laboratory test effectively entered medical practice in 1827, when the English physician and pathologist Richard Bright published his results of checking the urine for albumin using heat or nitric acid. He showed that among persons with the common symptom dropsy (now called edema, or anasarca), some showed heat-coagulable urine (albuminuria)—and these, if they came to autopsy, turned out to have distinct pathological alterations in the kidneys. The condition soon came to be known as "Bright's Disease," and among the physicians, pathologists, and medical chemists who followed Bright's lead was Pierre-François Rayer.

Rayer was a prominent French physician and authority on skin diseases, with an interest as well in morbid anatomy. In 1840 he published his immense three-volume Traité des maladies des reins, which actually extended beyond the kidneys to the entire urinary system and included a magnificent colored atlas of the pathological findings. For the second volume he wrote a detailed "Historique" of past knowledge of the albuminous form of renal disease, proving himself capable of reading Latin, English, German, and other languages. Several British enthusiasts for the history of renal medicine recently came together to translate this historical section of Rayer's magnum opus, and they have added useful supplementary material.

Rayer's extensive review can be summarized here only briefly. Of course, he identifies the "precursors" of Bright's work, and proves that here and there other physicians associated dropsy, albuminous urine, and abnormalities in kidneys seen at autopsy. As he reaches the period of Richard Bright, he centers on the debates concerning the "new" disease and its urinary sign. What substances in the urine might also congeal on application of heat, or of acid, and give a false indication? In what conditions other than renal disease might a physician encounter transient proteinuria? Bright portrayed, in text and plates, basically three pathological varieties of grossly altered kidneys—but were these three diseases, or three stages of one process? Rayer shows himself an active but fair-minded reviewer: he analyzes and critiques, clearly but not harshly pointing out, for example, how this or that author has generalized from one or two patients. As the translators promise, his review provides readers with all they could want in order to understand the state of knowledge of one form of renal disease in 1840. It is astonishing that Rayer could uncover so much literature over time and space—how did he do it without Medline?

The supplementary material comprises a concise biography of Rayer; some "commentary" on the essay, highlighting many of Rayer's conclusions; and biographical sketches of many of the individuals he cited. There follow some reproductions (alas, not in color) of illustrations of diseased kidneys from the Bright-Rayer period, and notes on how such plates were made. Professional historians (should any find the need to read this volume) will find the "commentary" irritatingly "presentist," whereas clinician readers will find the retroactive interpretations plausible and of interest.

That several collaborators came together to produce the volume attests to the fact that there does now exist a small community of individuals, most of us nephrologists, who are cultivating the history of this relatively new specialty. It is a specialty with a good deal to claim historically—arguably the first widely used laboratory test (as noted above); numerous demonstrations of the interaction between "basic science" and the clinic; and rapid proliferation of two remarkable therapies of the twentieth century: a life-sustaining artificial organ (dialysis), and the first routinely successful major organ transplantation. The present volume's "introduction" wishes to place the History of Albuminous Nephritis within the course of a developing history of medicine in Europe, and perhaps this is justified in context—that is, in 1840...