Book Review

Richard Bright 1789-1858: Physician in an Age of Revolution and Reform

N Engl J Med 1993; 329:1823December 9, 1993

Article

Richard Bright 1789-1858: Physician in an Age of Revolution and Reform
(Eponymists in Medicine.) by Diana Berry and Campbell Mackenzie. 296 pp., illustrated. London, Royal Society of Medicine Services, 1992. £12.95 (cloth); £7.95 (paper). ISBN: 1-85315-187-4

It is appropriate to bear in mind Fothergill's 1887 admonition that “so long as a disease carries a man's name it shows we know little about it.” Nothing can be truer than this contention when it comes to nephritis, which originally carried the designation “Bright's disease.” The eponym spread like wildfire to the Continent and to the Americas, for once Bright had pointed out the obvious, it was apparent that a major step forward had been taken in the understanding of the pathogenesis of dropsy (edema). The eponym has now been dropped, but nephrologists are no wiser today about the nature and causes of the disease that brings their patients to dialysis or transplantation than was Richard Bright more than a century and a half ago.

Berry and Mackenzie have produced a biography of Richard Bright that nephrophiles have been waiting for. It will be less appealing to hard-core medical historians, if only because its style is light, reverential, and enthusiastic and because brief chapter notes (including references) are used instead of footnotes. The charmed family and professional life of Richard Bright has been described previously by Pamela Bright in her book on her great-great-uncle, which appeared in 1983 (Dr. Richard Bright, 1789-1858. London: Bodley Head), and this aspect is amply covered in the present biography. However, the literature has lacked a comprehensive analysis of Bright's contributions to medical knowledge. Berry and Mackenzie rectify this deficit in a charming and eminently readable manner. Simple things, such as lists of Bright's contemporaries in medicine and the arts, a biographical sketch that parallels contemporary events, an appendix on therapeutic options in Bright's time, ample illustrations, and the breaking up of the text into subtitled sections, make the book appealing.

Bright is portrayed not only as the gentleman physician, artist, geologist, and peripatetic traveler that he was, but also as a determined and obsessive documenter of clinicopathological information. This description is used in preference to the term “clinician-scientist,” since Bright had no hypothesis to test and performed no experiments. His seminal observation that some cases of dropsy are associated with coagulable urine (“I have never yet examined the body of a patient dying with dropsy attended by coagulable urine in whom some obvious derangement was not discovered in the kidneys”) has been regarded by some as derivative. Both Wells (1812) and Blackall (1818) documented numerous cases illustrating the association of dropsy with coagulable urine. What they completely failed to notice, however, was the almost always consistent relation between these findings and pathological changes in the kidney. Noticing that connection was Bright's real contribution. It was first brought to wide attention with the publication of his magnificent illustrated book, Reports of Medical Cases etc, in 1827. One explanation for his ability to see the light where his predecessors had failed was that he performed his own autopsies and brought a professional artist into the postmortem room to depict the morbid anatomy. Combine this with a methodical documentation of the appearance of all the organs and body cavities and a fluid, appealing style of writing, and Bright's success and fame are easy to understand.

The authors describe his contribution to medical knowledge not only in relation to earlier writings, but also in a “renal portfolio” that depicts the post-Brightian haggling over nomenclature and therapy. Bright was broad-minded enough to modify certain of his earlier, more dogmatic statements as others started to look for flaws in his argument. He pointed out misinterpretations of his writings but acknowledged that, indeed, coagulable urine occasionally occurs without discernible renal pathologic effects, and conversely, some obviously diseased kidneys are discovered at autopsy when urinary findings were absent during life.

Toward the end of his professional life, Bright collaborated with a Dr. Toynbee in the investigation of the microscopical anatomy of diseased kidneys. Knowing that others were about to describe such findings, Bright dashed off a letter to the editor of the London Medical Gazette, pointing to the fact that his observations of nearly 1000 specimens allowed him to conclude that “one of the most interesting features of the morbid anatomy of this disease is to be found in the condition of the corpora Malpighiana” (the glomeruli). Toynbee later published the definitive data as the sole author. How ironic that today, other than being able to apply pseudoscientific names to the different appearances of the glomeruli, we have not advanced much beyond Bright's observations in our understanding of the basis of most chronic glomerular disease.

In his time Bright described a wide variety of diseases and syndromes, particularly in the first two volumes of Guy's Hospital Reports. These included the first lucid descriptions of hysteria, focal epilepsy, the thalamic syndrome, and many others. The authors emphasize the “extrarenal” interests to illustrate not only the breadth of Bright's writings, but also to paint the picture of an eminent London physician who, together with the likes of Addison and Hodgkin, ushered in an era of clinicopathological observation that formed the very basis of modern medical practice. Bright and Addison even had a go at publishing a textbook of medicine entitled Elements of the Practice of Medicine. Volume 1 appeared and was pronounced a disaster by reviews in the medical press. No further volumes were published. In contrast, nephrologists, physicians, and pathologists alike will enjoy the book by Berry and Mackenzie.

Leon G. Fine
Jennifer A. English
University College London Medical School, London WC1E 6JJ, United Kingdom