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The name of Thomas Addis (1881-1949) is linked to several aspects of nephrological practice: from the "Addis count" of urinary elements, to the history of diet in chronic kidney diseases. He was accustomed to working with limited funds, and developed his theories with relatively simple means, combined with the careful, long-term observation of single cases. His political ideas were progressive; his outlook on life was optimistic. This is deeply reflected in his Glomerular Nephritis: Diagnosis and Treatment, a book worth reading in the era of chronic kidney disease (CKD), as it contains sharp analyses of the organizational aspects, and accurate comments on the role of the physician - all subjects of interest for the present times and challenges. One of Addis' ingenious ideas was to follow his patients throughout their lifelong disease, thus anticipating the theories of continuum of care and of therapeutic alliance between patients and physicians. He used to tailor his prescriptions and frequency of controls to each patient and phase of the disease, thus anticipating the tailored therapies and the patient empowerment presently considered as fundamental in chronic diseases. Furthermore, he suggested that physicians should work outside the hospital in small coordinated teams, in which volunteers, dietitians and laboratory technicians would play a crucial role. Patient-centered care and the importance of nonmedical team members are clear from the first lines of his book. As far as we know, he was the first physician to stress the role of volunteers in CKD, anticipating by decades nonprofit organizations such as the National Kidney Foundation.

Thomas Addis is an important figure in the history of nephrology. Born in Scotland and trained in Edinburgh, he came to San Francisco in 1911 to the new Stanford School of Medicine to run the clinical laboratory. Over the next 38 years, he made many contributions to renal physiology, the investigation of the structure and function of the kidneys in Bright's disease, and studies of kidney growth, hypertrophy and protein metabolism. Largely forgotten today, he was one of the first to use urea clearance as a measure of kidney function and was the first to systematize examination of the urinary sediment - the Addis count. He was also a leader in the use of diet and rest in the treatment of Bright's disease. Unknown to most nephrologists, before he came to the United States during the first 6 years following his graduation, he became one of the leading clinical investigators in hematology. His special interests were the mechanism of blood clotting and hemophilia. He was the first to transfuse fresh blood into a hemophiliac patient and show that this shortened the patient's clotting time. Addis was a great, if eccentric, personality as well as a great scientist. He was beloved by his many colleagues and students and was honored in his lifetime both in the United States and Great Britain.

Bright's work led to the recognition that coagulable protein in the urine indicated macroscopic kidney disease. After light microscopy was introduced, Simon, Nasse, Henle and Frerichs identified the major constituents of urinary sediment. By 1896, Senator had deduced that hyalin cylinders arise in the kidney tubules, and only the discovery of the Tamm-Horsfall protein in the next century separated him from the modern concept. Chemical analysis of urine also advanced greatly. Recognition of the pressure-volume relationship by Traube was probably the most brilliant achievement related to renal disease, and became the basis of the later pressure-natriuresis relationship. Traube also linked left ventricular hypertrophy with renal disease, recognizing that it maintained circulatory homeostasis at a higher level of pressure. The concept of nephritis changed considerably with technical progress, and Gluge was the first to see inflamed Malpighian bodies or glomeruli. The primary site of damage was disputed by many, including Henle, Pfeufer, Virchow, Reinhardt and Frerichs, but all these workers had to reconstruct the sequence of events leading to the autopsy findings. The term glomerulonephritis was first coined by Klebs, and the classification of nephritis adopted by Senator in 1896 led directly to the classic monograph of Volhard and Fahr (1914) on Bright's disease.

Pierre Rayer, in a day of purely descriptive medicine, devised a method for the scientific study of diseases affecting the kidney and urinary tract. He first assembled vivid illustrations of a wide range of disorders of the kidney found in specimens obtained at autopsy. The resulting Atlas won him widespread praise and is still often cited. His Treatise (Traité des Maladies des Reins et des Altérations de la Sécrétion Urinaire), in which he integrated data from pathological anatomy with urinary biology and clinical manifestations, was ahead of its time. Hence it was poorly understood and, like the work of many other innovators, was largely ignored. Nevertheless, his 2100 page Traité which begins with a description of his innovative and highly disciplined method of study, most unusual at this time, is by no means lacking in interest for today's nephrologists. Rayer's was a landmark contribution, affording, as it did, a comprehensive approach to the clinical problems of nephrology a century before the diseases themselves could be understood. Could a contemporary of Rayer tell that he was an inventor of scientific methodology before the proof of his rigorous demonstrations was carried out? That has been the achievement of clinical nephrology in the past forty years...one century later.

Within a few years of its occurrence, American clinicians became aware of the discovery by Bright in 1827 that albuminuria in edematous patients was associated with granular degeneration of the kidney. Yet, there was a paucity of important original observations in nephrology from American in the first half of the 19th century. By the mid-19th century, however, the primitive concepts of clinical nephrology, renal physiology, and renal pathology were becoming established in the United States, after enlightenment from Europe. Because of the dreadful course of anasarca and uremia and stimulated by the advantages of innovations in microscopy, renal disease began at that time to attract the attention of eminent American clinician-pathologists. Their early observations would add to the knowledge base on which later developments such as bacteriology, radiology, clinical chemistry, and other scientific advances would build.

Modern knowledge of renal physiology, kidney disease, and the body fluids in American medicine was established largely by Donald D. Van Slyke, Thomas Addis, John P. Peters, Homer W. Smith, and Alfred Newton Richards. Only two of these men were physicians, and through this group future nephrology was shaped by a dominant interest in metabolic problems and pathophysiology. Acute renal failure emerged as a new syndrome during World War II and fostered interest in hemodialysis and renal biopsy. Dialysis, when applied to chronic renal failure, eventually spawned an army of renal clinicians; and biopsy provided a specialist's nosology of what had once enjoyed the unity of "Bright's disease." A society and subspecialty board came late to nephrology and have been directed largely by renal academicians of the metabolic tradition. Nephrology is in the 1980s a bipartite subspecialty, its senior leaders still cherishing the metabolic-physiologic tradition, and a growing army of dialysis practitioners mostly looking after patients with chronic and acute renal failure.