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** This is an archived, static copy of the Casebook messages boards dating from 1998 to 2003. These threads cannot be replied to here. If you want to participate in our current forums please go to https://forum.casebook.org **
Medical round table: Nephrology: Lusk Kidney: Bright's disease
Casebook Message Boards: General Discussion: Medical / Forensic Discussions:
Medical round table: Nephrology: Lusk Kidney: Bright's disease
Author: Thomas Ind
Saturday, 22 January 2000 - 08:02 am |        | I have communicated with CMD on this topic and it is probably time that I give the information I have discovered out on a post.
The first question must be 'What is Bright's disease?'. Regrettably an index of nearly 20 modern day pathology books does not contain it as the disease does not exist anymore. The term Bright's disease has been superceded in part by the term Glomerulonephritis. However, there are many different variants of glomerulnephritis all of which form different clinical scenarios. The diagnosis today is made by renal biopsy and microscopic analysis and immune studies. The causes are wide ranging and include infective causes, poisoning, chronic anaemia, and autoimmunity (immunity to oneself).
I have found a description of Bright's disease in the same 1901 pathology book. It says this;
'But the era of real knowledge was inaugurated by Richard Bright (1789 – 1858), of Guy’s Hospital, who, in his Report of Medical Cases, published in 1827, and in articles in Guy’s Hospital Reports of 1836 and 1840, laid the foundations upon which all subsequent work in the diseases of the kidney is based. He brought the clinical symptoms and the urinary changes into relation with the morbid anatomy of the kidneys, and it has been customary since his day to speak of nonsuppurative inflammation of the kidney as Bright’s disease.'
In other words non-suppurative (not pussy) inflammation of the kidney (nephritis). So nearly all forms of nephritis can be considered as Bright’s disease and in view of the varying aetiologies and social conditions surrounding East London in the 1880s it must have been very common indeed.
So the next question is this, is Brown's description of Eddowes remaining right kidney, consistent with what we know about the macroscopic appearance of a Kidney with Bright's disease?
I will expand in my next post. |
Author: Thomas Ind
Saturday, 22 January 2000 - 08:29 am | | In Borwn's post-mortem report of Eddowes he describes the right kidney as 'bloodless with slight congestion at the base of the pyramids.'
I understand that Nick Warren attributes this statement as conclusively supporting the presence of Bright's disease. Now I haven't read his article in the Criminologist in 1989 and would love to if I have time to find it but I am not so certain of his conclusions.
In the A-Z it states that he was (is) FRCS(Eng) and FRCS (Edin). And that as a student he did an elective with Profsor James Cameron. Well I am not entirely sure that I can remember anything from my elective years and as a surgeon he is no more qualified than I am medically to comment on this. Don't be fooled by the FRCS (Eng) & FRCS(Edin). When taking surgical exams people used to take both exams incase they failed one. He is clearly a very eminent surgeon and has clearly contributed greatly to the subject but he (like me) is not a forensic pathologist if his qualifications cited in the A-Z are correct.
I asked an eminent Professor of histopathology in a London teaching hospital what a kidney with glomerulonephritis would look like. Please excuse me for not giving his name as this was a very off hand conversation and he is not a Ripperologist. He stated that the most distinctive feature was red dots on the surface. I then looked at GN kidneys in our pathology museum and they did indeed have numerous red dots on. At this point I was very excited as from what I saw in the museum the red dots were so obvious that they could not have failed to have been mentioned by Brown in his detailed post-mortem. Furthermore, I concluded that the abscence of a description of this categorically disproves that Eddowes had Bright's disease.
I now feel differently and will explain in another post to split things up a bit. |
Author: Thomas Ind
Saturday, 22 January 2000 - 08:53 am | | One reason my opinion changed was as a result of my search for macroscopic descriptions of GN kidneys in the text books. What struck me the most is the pausity of macroscopic descriptions. Even a three volume book on the pathology of the kidney had only four lines. The vast mojority of the books had no macroscopic descriptions and pages and pages of microscopic details. In fact, today GN is only diagnosed microscopically.
Here are some of them;
'In acute glomerulonephritis the kidneys are normal in size or enlarged and oedemtaous, and the surface of the kidney may show punctate haemorrhages. In longstanding progressive chronic glomerulonephritis the kidney may be normal in size or small finely granular cortical scarring.'
In Clinical Medicine 4th edition Kumar & Clark WB Sauders 1998
'A diagram of a kidney with acute diffuse proliferative glomerulonephritis;
Kidney enlarged
Cortex broad, pale, without markings
Medullary rays congested
Glomeruli just visible as grey avascular dots'
In Pathology Illustrated 4th edition Gowarn, Macfarlane & Callender Churchill Livingstone 1995
'The kidneys are simetrically enlarged, in some cases up to a twice normal size, although an increase in some 50% is more usual. The general appearance is pale, the cut surface bulges because of interstial oedema and the main thickening is in the cortex. Glomeruli may stand out as grey, translucent dots'
Pathology of the kidney (forgot to write down author and publisher) 1983
Don’t worry yourself about the discrepancy between red and grey. Although they sound like different colours completely if I showed you the specimens you would agree that they could be described as both red and grey. Furthermore, stored tissue has a very different colour to fresh tissue and this could also account for the discrepancy. However, ‘….may show….’, ‘…….just visible……. ‘, and ‘……may stand out as…….’ seems to me very different from saying if a kidney isn’t described as have red or grey spots on then it can’t have glomerulonephritis.
My professor's comment about red spots being the most distinctive feature I now interpret as being the one feature that a kidney may have that would make you look at it and say ‘that kidney is from someone with glomerulonephritis’. The kidney’s in the museum are clearly those with the best example of these red spots.
So what about older texts? The 1901 book refers to the pathological anatomy of ‘Acute Parenchymatous or Degenerative Nephritis (Synonyms: Acute Tubular or Tubal Nephritis; Desquamative Nephritis, Catarrhal or Croupous Nephritis; Acute Bright’s disease)’ as follows;
'Although at some times normal in size, the kidney is usually somewhat enlarged and paler than normally; the capsule is tense and thin, and strips readily. On section the surface is pale and less translucent than normally, the organ looking as if it has been cooked. The cortex is sometimes marked with reddish striae or reddish dots; its width is increased and it bulges a little, so that halves of the kidney cannot be brought into complete apposition. The pyramids are usually darker than the cortex. The consistence is diminished and the organ is more friable than normally.'
So when you bear in mind all these descriptions, then that of Brown isn’t altogether inconsistent with a description of Bright’s disease as it was known in 1901. However, from what we know about the life in Whitechapel in 1888 then there are all the aetiological factors to suggest that Bright’s was very common indeed.
One final comment of caution comes from the 1983 book;
'Until recent years, our knowledge of the pathology of acute glomerulonephritis was derived from autopsy material. This of necessity raised the question of whether fatal cases showed the same pathological changes as occurred in patients who recovered.'
That does raise the question as to whether the medical profession as a whole could make a diagnosis of Bright's disease on a woman who died from other causes.
My next question will have to be this, what would a kidney look like in woman who died of haemorrhage. It can be assumed that it would look pale and bloodless. What about the pyramids? Unfortunately the description 'bloodless' and 'congested' are not on the surface consistent. When I gave this description to my professor of pathology (who is not afraid to state his beliefs strongly) he said something like this;
"Well he's a bloody fool. How can it be both 'bloodless' and 'congested'".
Well I think the answer can be found in the description of a GN kidney in Illustrated Pathology. The pale cortex and congested medulla could be consistent with GN. The major vessels could have been bloodless?
Either way, I find no conclusive evidence that Eddowes had Bright's disease. The only evidence available is not good evidence to support it but does not rule it out completely. Arguments againsts it having Bright's disease are the abscence of spots and abscence of other reported pathology that would be consistent with someone suffering from renal disease such as anaemia, peripheral oedema and heart disease.
Brown's description of her kidney could been associated with any pathology the aetiologies of which were so common in the East end of London in 1888 that it could have been considered as normal. As yet, I have no information on what a kidney would look like following death from haemorrhage. I suspect that the macroscopic descriptions I find will have a similar discrepancy to the descriptions of Eddowes kidney as I have found for Bright's disease. |
Author: Christopher-Michael
Saturday, 22 January 2000 - 09:48 am | | Tom -
Nick Warren is listed in the "A-Z" as asserting that Eddowes had Bright's Disease, but I do not know whether this is in his published work on the subject or from private conversation. In any event, he does not make the confident identification of Bright's Disease in his "Criminologist" article (which I will forward to you). It comes under a discussion of 7 points of identification for the kidney, which Warren prefaces as follows:
"They [the police] duly approached three medical authorities; Dr Gordon Browne, who performed the autopsy; Dr Openshaw, a pathologist and Curator of the London Hospital Museum; and Mr Henry Sutton, Senior Surgeon to the London Hospital. After due consideration, which included a microscopic examination of the postal kidney, they were able to suggest no less than seven points to identity between this organ and that retained in Eddowes' body."
Then, under point no 6, he writes:
"6) The kidney was severely affected by Bright's disease. This was not uncommon among the London poor of 1888, but is at the very least a remarkable coincidence. As a point of identification it remains entirely valid, even though at first Dr Gordon Browne appears to have had some reservations as to the thoroughness of his autopsy He is quoted by the 'Daily Telegraph' as saying:
'Conclusions based on the CONDITION (author's italics) of the right kidney may very well prove misleading.'
Whether the 'condition' of the kidney was due solely to Bright's Disease or had the additional diagnostic features of being a 'ginny kidney' as a result of chronic gin taking, appears to have confused every writer on this subject to date. As stated earlier, gin is now known to be harmless to the kidney. . ."
Now, my problem with the above - as I have said before - is the inclusion of Henry Sutton. I have never seen a reference to Sutton's preparing a report on the Lusk Kidney outside of the pages of Major Smith, and certainly no book I have ever read on the subject brings forth his comments. Therefore, I am left to conclude that:
- Smith was lying or misremembering;
- Sutton did make a report and it has been lost;
- Sutton's conclusions were included in Dr Brown's now lost report on the kidney.
In any event, only in Smith's pages is the bilateral diagnosis of Bright's Disease in the LK and Eddowes made. Unfortunately, Mr Warren does not give any reference as to where he found the seven points of identity, and may, in fact be creating it as a composite of all the medical statements attributed to Openshaw, Brown and Sutton. I still believe there is not enough extant evidence to credit the LK with Bright's Disease. It will be interesting to follow this discussion and see whether a different determination of the pathological condition of Eddowes' right kidney can be made.
CMD |
Author: Thomas Ind
Saturday, 22 January 2000 - 10:24 am | | | I think the comment 'severely' affected by bright's disease is interesting. Should we therefore expect my red spots? Are there any descriptions as to what it looks like? |
Author: Thomas Ind
Saturday, 22 January 2000 - 10:27 am | | | A-Z states that Openshaw was an orthopaedic surgeon not a pathologist. Is this true? I have got the Royal Society of Medicine doing a literature search on him to see what he has written but I will have to wait another week for that. |
Author: Thomas Ind
Saturday, 29 January 2000 - 12:30 pm | | I thought I would share some information related to some research I am doing. I am currently looking into Thomas Openshaw. One of the books I have located is the 'London Hospital: Descriptive catalogue of the Pathological Museum., London 1890.'
There is a section that may in part help us with our questions about a 'Gini kidney'. Specimens 1822 to 1825 are under the heading of 'Granular Cirrhotic Nephritis'. As I have stated in a previous post, a pathology text book from the era has suggested that nearly all forms of nephritis came under the category of Bright's disease. The catalogue does not use the term Bright's disease. I am not sure what what is mean't by 'Cirrhotic Nephritis' as in modern times liver cirrhosis is not just the domain of alcoholic liver disease but more commonly caused by viral hepatitis. However, I have never heard the term 'cirrhosis' applied to a kidney before and it may be that certain changes in the kidney were attributed to alcohol disease or 'gini kidney'.
We currently dispute this description as Openshaw denied it in his letter to the Times (so I understand), furthermore Smith's tale is thought inaccurate (or at least tarnished with a bit of bullshit). However, this evidence (which needs to be looked at further in a search for 'cirrhotic kidney') and a the contents of my early 20th century pathology book which describes poisons as an aetiological factor for glomerulanephritis suggests that there may have been renal changes that were attributed to Gin in 1888.
If we look at the descriptions of these four 'cirrhotic kidneys' they do not match that of Eddowes remaining kidney as described by Brown ('pale, bloodless, with slight congestion at the base of the pyramid'). They are as follows;
1822 - A small pale contracted granular kidney (injected).
1823 - Half a kidney showing similar changes, with the vessels dissected. Presented by Mr Eve.
(No I don't know who Mr Eve was)
1824 - A small granular kidney with numerous cysts, and thickened vessels.
1825 - An injected specimen of contracted granular kidney, showing opaque white uninjected areas into the pyramids.
So what I have to find out now is whether the term 'cirrhosis' related to a kidney implies alcohol or if it is a term describing the granular nature of the kidney. Fat deposits in the kidney are common in Nephotic syndrome which aften follows glomerunephritis (Bright's disease). |
Author: Thomas Ind
Saturday, 29 January 2000 - 12:47 pm | | On a final note. If you are wondering if the LK is sitting on the London Hospital. The answer is still possibly but I would have to look at the specimens to see how many fit the description. Specimens above could all fit in addition specimens 1819 - 'A thin section of a large white kidney (injected) showing a swollen cortex and other results of chronic parenchymatous nephritis' and specimen 1820 - 'A large pale granular kidney, the result of chronic tubal, with interstitial, nephritis'.
So my next repeated question is this. A longitudinal incision, is this so that the front and back halves are separated or the medial and lateral halves?
My final question is this? I remember a while back there were some questions relating to the word 'phthisis'. To save me searching through the posts what did we conclude that this mean't and in relation to what were we questioning it? Specimen 1827 is 'one half of a granular kidney with cysts from a case of phthisis.' |
Author: A.M.P.
Saturday, 29 January 2000 - 01:17 pm | | The only reference found by the text search in the last month was from the General Discussion/New Suspect board on 20th January 2000.
phthi·sis
Pronunciation: 'thI-s&s, 'tI-, 'fthI- or with i for I
Function: noun
Inflected Form(s): plural phthi·ses /-"sEz/
Etymology: Latin, from Greek, from phthinein to waste away; akin to Sanskrit ksinoti he destroys
Date: 1526
: A progressively wasting or consumptive condition; especially : pulmonary tuberculosis. |
Author: Thomas Ind
Saturday, 29 January 2000 - 01:21 pm | | | Thanks AMP |
Author: Jon Smyth
Saturday, 29 January 2000 - 07:33 pm | | Tom
Seeing as how Websters Medical dictionary describes 'cirrhosis' as:
Inflamation of an organ characterized by degenerative changes, particularly the liver.
Are we to understand this can be a general degeneration which has more than one cause, in more than one organ?
So, on that basis we might include kidney in 'organ', and alchohol in 'cause'?
Regards, Jon |
Author: Thomas Ind
Saturday, 29 January 2000 - 08:07 pm | | Jon, YES.
That was the point I was trying to make. I disagree with the exact wording of Webster (as you quote) but do agree that the true meaning of the term cirrhosis does not imply alcohol. However, lay and medical people alike use the term in relation to alcohol.
This may have been in relation to a famous article in the Lancet in 1975 about the incidence of liver cirrhosis in doctors and relating it to alcohol. I have never heard the term cirrhosis applied in modern medicine to anything other than the liver. Many people use the term in relation to alcohol. What I need to know now is if the term used in the catalogue in relation to the kidney implies alcohol. I will find that out soon by reading another pathology book of that era that I hope to lay hands on via the RSM.
I suspect, that the term was used in this instance to imply alcoholic fatty degeneration that would fit with a 'Ginny kidney'. Even if it didn't, the you can imagine a reasoning for Reed's interpretation (perhaps from the word). However, it may apply to what we call now, nephrotic syndrome which can produce fatty streaks when examining a kidney macroscopically. I will keep you informed but as a medic and academic, I don't keep things to myself and share what I have found as I find it. |
Author: Jon Smyth
Saturday, 29 January 2000 - 08:34 pm | | Your turning stones, Tom.......keep digging !!!
By Gadd, we'll crack this case yet !!! :-)
Jon |
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