History of Medicine

GUY’S HOSPITAL AND MODERN MEDICINE

          In the years after the Napoleonic wars English medical graduates, forgetting their antipathy toward the French, rushed to Paris to study. There, they learned medicine at the bedside and followed their cases to autopsy, already a standard procedure to resolve clinical problems. Patients were examined with palpation, percussion, and auscultation, using the newly invented stethoscope. Old disease classifications based on symptoms were giving way to new terminology based on visible pathology.

Entrance to Guy's Hospital, 1820 (Wikipedia)

      Guy’s Hospital Medical School, in 1825, was considered the best in London. This was partly due to the influence of Sir Astley Cooper, a talented surgeon who taught anatomy and surgery, subjects that focused clinical teaching on local pathology. Guy’s was also blessed with three physicians who together, reflecting the French influence, catapulted the medical service into prominence: Thomas Hodgkin, Thomas Addison, and Richard Bright.

     Hodgkin, a Quaker, having studied in Edinburgh and Paris, arrived at Guy’s in 1825 as a clinical clerk. Focused primarily on pathology, he soon assumed charge of autopsies and directed

Thomas Hodgkin (Wellcome Library)

the anatomical museum. He introduced the stethoscope to Guy’s and he pushed for bedside teaching, not yet in vogue in London. His pathology studies culminated in a famous paper of 1832 describing seven cases of enlarged spleen and lymph nodes (an original illustration of one case, borrowed from the pathologist Robert Carswell, can be seen in: Arch Int Med 121: 288-90, 1968)). Only three or four of his cases would be labeled Hodgkins disease  today. He resigned from the staff at Guy’s in 1837 after a tense relationship with the hospital treasurer had cost him a promotion. He spent much subsequent time as a social reformer.

     Thomas Addison, another Edinburgh graduate, after working at the Carey Street Public Dispensary under Thomas Bateman (one of the fathers of dermatology), was appointed assistant

Thomas Addison (Wikipedia)

physician at Guy’s in 1824. At Guy’s he excelled as a lecturer, published on pneumonia, phthisis, fatty liver, and other subjects, and, having learned skin diseases from Bateman, started a department of dermatology. Of great importance was the publication, co-authored with Richard Bright, of volume one of a text entitled Elements of the Practice of Medicine, a book that the students devoured. Addison, who wrote most of it, described the pathology, including microscopic findings, of pneumonia and covered the clinical picture and pathology of appendicitis, a clinical entity not fully appreciated at the time. In 1855 he published a

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Patient with Addison's disease. Note copper skin (Wellcome Library)

book on the effects of disease of the adrenals, describing the full clinical picture of “Addison’s Disease”, a name actually coined by Armand Trousseau. In it he included some cases we now call pernicious anemia.

     Richard Bright came from a wealthy family, studied medicine at Edinburgh, and worked at the London Lock Hospital (a

Richard Bright (Wikipedia)

hospital for venereal disease), then at two other public hospitals under Thomas Bateman, from whom he also learned dermatology. He was appointed to the staff at Guy’s Hospital in 1820, preceding Addison’s appointment by four years and Hodgkin’s by five.

     Bright’s first important publication was in 1827, entitled Reports of Medical Cases Selected with a view of Illustrating the Symptoms and Cure of Diseases by a Reference to Morbid Anatomy. Inside were numerous case histories with autopsy findings, complete with numerous color illustrations. The latter included depictions of chronically diseased kidneys from patients who would thereafter be described as suffering from “Bright’s Disease”, or “Morbus Brightii” in those days.

Chronic kidney disease, mezzotint. From Bright's "Reports" (Internet Archives)

     The book was stunning. Nothing comparable had appeared in British medical literature since Matthew Baillie’s text on morbid anatomy of 1793 (that was still in print). Baillie’s book, though considered a landmark in pathology, contained no illustrations and no clinical histories, just descriptions of pathology. (In 1799 a volume with etchings to supplement the text was issued.) Bright’s manuscript included the clinical picture with the pathological findings. More striking were the color illustrations, for which Bright hired a father-and-son pair

of artists, one a mezzotint engraver. Mezzotinting was an expensive procedure but provided beautiful results. Bright, who was wealthy, presumably paid for the art himself. Overall, the two volumes contain 40 plates, 34 of which are mezzotints. The costly books were out of reach of medical students, and only 114 copies were sold in the first three years.

Ileal ulcers in typhoid fever, from Bright's "Reports" (Internet Archives)

     Bright also found that the urine of his renal patients contained albumin, which he tested for by holding a teaspoon of urine over a candle flame. Coagulation signified the presence of albumin. Others found urea in the blood of his patients, supporting the findings of Prevost and Dumas who had demonstrated urea in the blood of animals whose kidneys had been removed (1823), advancing the idea that a function of kidneys was to remove urea from blood.

     In time special beds were set aside for further study of patients with renal disease, complete with a small laboratory. It is thought to be the world’s first clinical research unit.

     Bright resigned from the staff of Guy’s Hospital in 1844 and entered private practice. He received many honors and was appointed Physician Extraordinary to Her Majesty Queen Victoria. His patients included John Snow (discoverer of the source of cholera) and Alfred Lord Tennyson. He died in 1858 after periods of angina and breathlessness.

     These brief and incomplete sketches only hint at the remarkable trio that was instrumental in introducing the new clinic-pathological approach to medicine in England. The introduction of chemistry into the study of renal disease and the use of microscopy in pathology were other contributions of this trio that have benefited us to this day.

SOURCES:

Rosenfeld, L. Thomas Hodgkin: Morbid Anatomist, Social Activist. 1993. Madison Books

MacKenzie, J C. “Dr. Richard Bright: A man of many parts - His bicentenary year. 1989; Brit Medico-Chirurg J 104: 63-67.

Peitzman, S J. “Bright’s Disease and Bright’s Generation: Toward exact medicine at Guy’s Hospital” 1981; Bull Hist Med 55: 307-21.

Keith, N M and Keys, T E. “Contributions of Richard Bright and His Associates to Renal Disease”. 1954; Arch Int Med 94: 5-21.

Pearce, J M S. “Thomas Addison (1793-1860)”. 2004; J Roy Soc Med 97: 297-300.

Dale, H. “Thomas Addison: Pioneer of Endocrinology”. 1949; Brit Med J Aug 13: 347-52.

Images of Hodgkin’s stethoscope and a model of Addison’s Disease are available at The Gordon Museum at King’s College London : https://www.kcl.ac.uk/gordon/collection/specimens - HodgkinsDiseaseSpecimen

Hodgkin, T. “On Some Morbid Appearances of the Absorbent Glands and Spleen.“ 1832; Medico-Chirurgical Transactions 17: 68-114.

Bright, R. Reports of Medical Cases Selected with a View of Illustrating the Symptoms and Cure of Diseases by a Reference to Morbid Anatomy. 1827; Longman, London.

Baillie, M. The Morbid anatomy of Some of the Most Important Parts of the Human Body. 1812 edition. Nicol and Johnson, London