Sir Robert Christison was a professor of Medicine in Edinburgh for 50 years, and twice President of the Royal College of Physicians there. Despite this, few modern descriptions and assessments of either him or his work have been published. In particular, his major work in the field of renal disease, which allows him to be considered one of the fathers of nephrology, has been almost completely forgotten, even in Scotland. In this paper, Christison and his work in renal disease are described, trying to place his sometimes apparently paradoxial views and actions as a physician in the context of a man who lived across major changes in medicine.
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References
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College of Physicians Library, Edinburgh. File IYY: Letter from Christison to Dr Poole of East Broughton Place: under the signature is ‘written in Dr Traill’s indelible ink which no chemical agent whatever will remove ... ’
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The subsequent history of the family can be summarised: Alexander’s son Robert Alexander (1892–1945) became 3rd baronet, and in turn, Alexander’s second son, General Sir (Alexander Frank) Philip (1893–1993) the 4th baronet (Anon.: General Sir AF Philip Christison. Kemp T, Dalkeith 1974, for the Burma Star Association – I am grateful to Brigadier Nicholas Ridley, Christison’s great-great grandson, for the loan of this booklet). Although the latter studied medicine, he never qualified fully as a result of the First World War. He served with distinction in the Cameron highlanders, and was wounded and then decorated at Loos in 1915. Later in the Second World War as a Brigadier-General, he played a notable role in the Burma campaign of 1943–44. He outdid even his grandfather as a man of many parts: scholar, linguist (including Gaelic), singer musician, athlete, soldier, leader and diplomat, he lived exactly a century; there are many resemblances between grandfather and grandson. General Sir Alexander’s only son, John Anthony Alexander Christison (1918–42) was killed in action elsewhere in Burma without issue, so the title became dormant, as a baronetcy is inherited only through the male line. Three sisters survived him: Heather, who was the eldest (1916–1975), Alison (b. 1924) who now lives in Australia, and Fiona (b. 1932).
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It is of course possible that Christison was telling the truth, as he had access to the Queen on her visits to Scotland through his position as physican-in-ordinary, and was made a baronet only the following year; even so, quoting the Queen in a public University meeting did not display his usual caution – perhaps because he felt so strongly about the topic.
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Personal communication to the author from Mrs Alison James, great-grand-daughter of Sir Robert (2003).
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Pierre Louis’ great work (Louis PCA. Recherches sur les effets de la saignée dans quelques maladies inflammatoires, et sur l’action de l’émétique et des vésicatoires dans la pneumonie. Paris: JB Ballière) was published in Paris in 1835, but the use of bleeding persisted in some areas as far as the beginning of the twentieth century. It is curious that, with his contempt for Broussais, the great bloodletter and leech user, Christison still persisted with these treatments for so long.
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ChristisonR.Observations on the variety of dropsy which depends upon diseased kidney. Edin Med Surg J 1829; 32:262–91. It is worth noting that ‘Bright’s disease’ appears to be the first ever eponymous disease, certainly employed from 1834 onwards, especially in France (e.g. Constant: see ref.30). Many have remarked that a name attached to a disease indicates with near certainty that the person concerned was not the first to describe it, but (in some cases) the one who made it known, and the life of the medical eponym is only now drawing to its inglorious close. In Bright’s case, this criticism is scarcely justified, since elegantly he achieved both.
29.
Statistics are available for deaths from renal disease in the UK from 1840 onwards, and although their value is diminished by serial changes in definitions, the changes are so dramatic as to remain useful. From 1840 until 1900, the death rate remained relatively stable, but from about 1900 to 1970, deaths from ‘nephritis’ declined from over 600million per year to 134 million per year (from about 70,000 to approximately 7,000 per yearyear). Equally, in developing countries today, data for admission diagnosis of a nephrotic syndrome suggest an incidence up to 100 times higher than the 0.04 % in Western Europe and the US. Britain in 1840 was in a similar state to third world countries today, with life expectancy at birth of only 40 years. What drove, and still drives, these differences is open to speculation, but control of infections and ambient nephrotoxins such as lead, improved nutrition and immunity have all probably played a role. As a marker, amyloid secondary to infection shows similar patterns.
30.
Only in 1833 were children whose dropsy remitted described, first by Dr T Constant in Paris (Maladie de Bright. Gaz Méd Paris 1834; 1:105–7) and then by others in Paris. For details, see Cameron JS. The nephrotic syndrome: a historical review. In: Cameron JS, Glassock RJ. The nephrotic syndrome. New York: Marcel Dekker; 1988;3–56.
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At that time, only agents of vegetable origin such as squill, plus mercury in the form of calomel, were available as diuretics and were widely used. See Aliotta G, de Santo NG,Touwaide A. The diuretic use of scilla from Dioscorides to the end of the 18th century. J Nephrol 2004; 17:342–7.
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ChristisonR.On the cause of the milky and whey-like appearances sometimes observed in the blood. Edin Med Surg J 1830; 33:274–80.
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41.
The word ‘uremia’, derived from the ‘urée’ of Vauquelin and Foucroy was coined by Pierre Piorry (1794–1879) in 1847. (Piorry P. Traité de Médecine pratique, Vol II, Chapter XII, nos 4430–40). Would that he had rather named it ‘urinemia’ to emphasise that urea was not the only substance retained!
42.
Almost certainly Christison got the seeds of these ideas from his stay in, and continuing contact with, Paris in particular the lectures of Vauquelin. See: Fourcroy AF,Vauquelin N. Mémoire pour servir à l’histoire naturelle chimique et médicale de l’urine humaine. Mémoires de l’Insitut 1797; 2:431; Fourcroy AF, Vauquelin N. Premier mémoire pour servir à l’histoire naturelle, chimique et médicale, de l’urine humaine contenant quelques faits nouveaux sur son analyse et son altérations spontanée. Ann Chimie 1799; 31: 48–71; (see also: 1799; 32:150–5);Vauquelin suggested urea might be toxic from its retention (Fourcroy AF, Vauquelin N. Nouvelles expériences sur l’urée. Annales du Museum d’Histoire Naturelle 1808; 11:226), but in: Ségalas d’Etchepare,Vauquelin N. Sur de nouvelles expériences relatives aux propriétés médicamenteuses de l’urée. Lettre à M Magendie. Journal de Physiologie 1821–2; 2: 354, urea injection was shown to lead only to a diuresis. Nevertheless, they must have credit for first suggesting that retention of urinary solutes might be toxic, the idea which Christison developed.
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PrévostJLDumasJB.Examin du sang et de son action dans les divers phénomènes de la vie. Annales de Chimie et Physique, Paris 1823; 23:90–104 (report of meeting of 15th November1821 of the Société de Physiologie et d’Histoire Naturelle de Genève). See also: Mani N. La découverte de l’urémie expérimentale par Jean-Louis Prévost et Jean-Baptiste Dumas. Genève; 1821. Méd Hyg 1963; 21:408–9.
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Owen Rees G. Observations on the blood with reference to its condition in Morbus Bright. Guy’s Hosp Rep 1843; 8:317–30.
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ChristisonR.An inquiry on some disputed points in the chemical physiology of the blood and respiration. On the mutual action of blood and atmospheric air. Edin Med Surg J 1831; 94–103 (published also in German in Froriep Notizen 1831 col 81–88).
47.
Osler notes that in chronic renal failure ‘anaemia is more or less regularly present’ (Canadian Lancet 1881; 13:353–9) and Sir Nestor Tirard (a pupil of George Johnson’s) in 1899 passim (Tirard N. Albuminuria and Bright’s disease. London: Smith Elder; 1899; 148,153, 205, 212, 219, 327). Otherwise, little or no mention is made of anaemia even by the careful observer Samuel Wilks in his later articles in the 1880s and 1890s. See also: ref. 44, and especially Brown GE, Roth GM. The anemia of chronic nephritis. Arch Intern Med 1922; 30:817–40. Brown GE, Roth GM. Prognostic value of anemia in chronic glomerulonephritis. JAMA 1923; 81:1948–50; Parsons L, Ekola-Stromberg M. Anemia in azotemia. Am J Med Sci 1933; 185:181–90.
48.
ChristisonR.Properties of healthy urine; Functional disease of the kidneys; Gravel; Urinary calculus; Diabetes; Suppression of urine; Errors in the position and conformation of the kidneys; hypertrophy of the kidneys; Inflammation of the kidneys; Granular degeneration of the kidneys; Other chronic diseases of the kidneys; Diseases of the bladder and urethra. In: A system of practical medicine comprised in a series of original dissertations. Arranged and edited by Tweedie A. London: Whittaker; 1840; Vol 4;215–99.
49.
Alexander Tweedie (1794–1884) was a contemporary of Christison’s at Edinburgh as a student, and had been taught by Christison’s father. In 1822 he moved from Edinburgh to London, to work in the London Fever Hospital. In 1831–1835, he brought out the multi-author Cyclopaedia of Practical Medicine, to which John Bostock contributed a section on Physiology, followed by his Library of Practical Medicine in 1840. These two works were the first multi-author textbooks of clinical medicine in English.
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AbercrombieJ.Observations on ischuria renalis. Edin Med Surg J 1821; 10:210–22. This apparently is the earliest full description of intrinsic acute renal failure.
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CuminW.Cases of severe burns, with dissection and remarks. Edin Med Surg J 1823; 19:337–44. Cumin notes that such patients (his were mainly children) might develop anuria.
53.
John Charles Lever (1811–1859) of Guy’s Hospital is usually credited alone with the first description of albuminuria during eclampsia in 1843 (Guy’s Hosp Rep 1843; (2nd series) 1: 495–517), but almost simultaneously James Simpson in Edinburgh noted it as well (Edin Monthly J Med Sci 1843; 11:1015–22), as Christison says. One should also note that Rayer [see ref 20 above] described albuminuria during pregnancy, but did not associate it with an eclamptic syndrome.
54.
OslerW.The principles and practice of Medicine. New York: Appleton; 1909; 741–2. For more on the history of acute renal failure, see Eknoyan G. Emergence of the concept of acute renal failure. Am J Nephrol 2001; 22:225–30, although a full treatment is still awaited on this complex and interesting subject.
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ChristisonR. Bright’s disease of the kidneys (delivered 11 and 18March1851). Edin Monthly J Med Sci 1851; 12:551–73.
56.
JohnsonG.On the diseases of the kidney, with their pathology diagnosis and treatment with an introductory chapter on the anatomy and physiology of the kidney. London: John W Parker; 1852.
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WilksS.Cases of Bright’s disease with remarks. Guy’s Hosp Rep 1853; new series, 9:232–315.
58.
WilksS.Cases of lardaceous disease, and some allied affections, with remarks. Guy’s Hosp Rep 1856; 3rd series; 2:103–32. In this paper, Wilks notes two cases of what he called ‘simple amyloid’ without any preceding infection – 30 years before the usually credited description of primary amyloidosis by Carl Wild in 1886.
59.
FrerichsT.Die Bright’sche Nierenkrankheit und deren behandlung. Braunschweig:Vieweg; 1859.
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ValentinG.Repertorium für Anatomie und Pathologie. Bern St Gall: Huber; 1837; 11(2):290–1.
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FogazziGBCameronJS.Urinary microscopy from the seventeenth century to the present day. Kidney Int 1996; 50:1058–68.
62.
The first microscopical studies of the diseased kidneys were published by Valentin (see ref 35 above) in 1837, followed by those of Gluge (1839), Hecht (1839), Becquerel (1841), Bowman (1842) – who studied diseased kidneys as well as normal ones – Henle (1842), Quain (1843), Canstatt (1844), Eichholz 1844–5, Johnson (1846: see ref 40 above), Simon 1846, as well as Toynbee (1846) – who however made no sections, but used microdissection. The limitations of thick sections, and absence of tissue staining until the mid 1850s, held up progress in the area of histology for two decades. A history of early attempts to study renal histology has yet to be written.
63.
KlebsTAE.Handbuch der pathologische Anatomie. Berlin: August Hirschwald; 1870;644–8.
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JohnsonG.On the minute anatomy and pathology of the Bright’s disease of the kidney, and on the relation of the renal disease to those diseases of the liver, heart and arteries with which it is commonly associated. Med Chir Trans 1846; 29:1–24.
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von RokitanskyK.Handbuch der speciellen pathologischen Anatomie. Vienna: Braumiller &Seidel; 1842–46,Vol II; 417–24.
66.
It is strange that Christison was unaware of amyloidosis, which was so much more common in the nineteenth century in Europe than today, given the heavy load of chronic infection at all levels of the population, especially the poor. However Wilks’ excellent account (see ref 33 above) was five years in the future.
67.
ChristisonR.A dispensatory or commentary on the pharmacopoieias of Great Britain, comprising the natural history, description, chemistry pharmacy, actions, uses, and doses of the materia medica. Edinburgh:1842 (second edition 1848).
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JohnsonG.Lectures on the pathology, diagnosis and treatment of Bright’s disease. BMJ. 1873; i:1–3, 27–28, 81–83, 109–111, 161–164, 191–194, 275–277, 303–305, 527–529, 579–580, 605,606, 696–697,725–726. This series of articles was published separately as a monograph: Johnson G. Lectures on Bright’s disease etc. London:WT Elder; 1873.
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ChristisonR.Observations of the effect of cuca or coca, with supplement. BMJ 1876; i:527–31.
71.
ChristisonR.On the properties of the ordeal bean of Old Calabar,Western Africa. Edin Monthly J Med Sci 1855; 20:287–94. The Calabar, ‘ordeal bean’ or esere created great interest in the 1850s. The beans of this secret plant, later named ‘Physostigma venenosum’ were given to accused prisoners to prove guilt or innocence in parts of Nigeria. They contained an alkaloid, physostigmine named after the plant, which potentiates the activity of acetylcholine, inducing bradycardia and eventually cardiac arrest. Toxicity varied with the dose, and the outcome from recovery to death could in fact be determined in advance by how mature the beans were and how much was offered to the prisoner by the administrating judge. More recently, similar compounds have been used as antagonists including the toxic ‘nerve gases’ such as Sarin (see also ref 2 above, and Anon. Histories:The killer bean of old Calabar. New Scientist 2003; 178; 48–9).
72.
ChristisonR.On the capture of whales by means of poison. Proc Roy Soc Edin 1860; iv:270–1.
73.
R Christison, A Christison, D Christison. Report on medical statistics of the Standard Life Insurance Company. 1845–1880; Home department: Standard Life Insurance Company; 1884.
74.
CameronJSHicksJA.Frederick Akbar Mahomed and his role in the discovery of essential hypertension at Guy's Hospital. Kidney Int 1996; 49:1488–1506.
75.
CameronJSHicksJA.High blood pressure and the kidney: the forgotten contribution of William Senhouse Kirkes. Kidney Int 2000; 57:724–34.
76.
A further indication of how different the world Christison inhabited from ours, is his mention that, on coming up the Thames, the remains of publicly executed pirates were to be seen, hung in chains by the river as a deterrent.
77.
Nor, more surprisingly was there any notice in the Glasgow Herald! This may be the result of traditional inter-city jealousy.
78.
To contemporary eyes there appears to be interstitial expansion and glomerular alteration in this illustration; however, the material was probably examined unfixed and no illustrations of comparable normal kidneys are available, so this impression may be false. At best, the Valentin knife must have produced ‘sections’ of 100 microns thick or more.
79.
It is interesting to note that Christison, Johnson and Gull all received their knighthoods or baronetcies for personal services to the sovereign and her family, rather than purely for eminence in clinical medicine.The master himself, Richard Bright, died plain Dr Bright in 1858 – although he also served the Royal Family. As a dissenter, he lay somewhat outside the establishment of the day, and, of course, may have turned down an honour, which would have been in line with his character.
