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Richard Bright—Physician Extraordinaire

2000; American Medical Association; Volume: 124; Issue: 9 Linguagem: Inglês

10.5858/2000-124-1262-rbpe

1543-2165

Venita Jay,

Medical History and Innovations

To their favorite teacher, Richard Bright, the students at Guy's Hospital offered not only their deepest respect but also their affection. One of the great men of Guy's, Bright's medical contributions were far reaching and his love for medicine and pathology all consuming. He is rightfully regarded as one of the founding fathers of nephrology, with his name immortalized in the eponym Bright's disease.There were other facets to this handsome scholar of medicine; Bright was also an accomplished artist, naturalist, linguist, geologist, traveler, and botanist. It has been said, "He wrote as no man had ever written before and as all who followed him were to attempt to write." Bright's extraordinary gift of observation was complemented by his detailed and exquisite illustrations.Born in Bristol, England, in 1789, Bright came from a wealthy intellectual family, which afforded him an excellent education and enabled him to travel. As a youth, he attended private school and later went to Edinburgh University. While at Edinburgh, Bright learned that the famous geologist Sir George Steuart Mackenzie was planning an expedition to Iceland. Bright and his friend Henry Holland accompanied Sir Mackenzie on this mission to study the volcanic geology of Iceland. When Mackenzie's book, Travels in Iceland in the Summer of 1810, was published, it contained Bright's sketches of the local flora and fauna, as well as shepherds and fishermen. As evidenced by his sketches, Bright's remarkable skills of observation and artistic talent were fully utilized on this trip. The sojourn to Iceland profoundly affected the young Bright, who nearly lost his life on a couple of occasions during stormy moments, including a narrow escape from shipwreck.After his Icelandic adventure, Bright embarked on his medical studies at Guy's Hospital in October 1810. He was profoundly affected by William Babington, who taught chemistry to medical students. Bright got his training at Guy's and in Edinburgh and graduated in 1813 with a thesis on Erysipelas, in which he stressed the contagious nature of this disease.After graduation, Bright was off again on another excursion in 1814. This took him through Holland, Belgium, Berlin, Vienna, and Hungary. A remarkable personal account of this trip appeared in a 762-page book, Travels from Vienna Through Lower Hungary, published in 1818. Once again, Bright's astute powers of observation and artistry were evident in this book and were not restricted merely to the sphere of medicine, but extended to history, art, archeology, religion, law, social conditions, the people, and the countryside. There were many maps and delightful sketches in the book, including depictions of a prison, gypsies, and a peasant cart.When Bright was appointed assistant physician to Guy's Hospital in 1820, research thrived in what was then called animal chemistry (today's clinical chemistry). Besides testing urine for proteins, research continued on the chemistry of the kidney, liver, and brain, as well as blood and urine constituents.Bright's work set the stage for correlating biochemical derangements and tissue pathology with clinical disease. Research on the chemistry of normal and pathological urine was well under way by investigators such as William Cruickshank, William Wells, John Blackall, and John Bostock. Bright was later assisted by his own students in conducting detailed examinations of urine specimens. In 1842, some beds in the clinical wards at Guy's were set apart for a semester of study of renal disease. This comprehensive and unique undertaking headed by Bright included a small clinical laboratory."One of the most ready means of detecting albumen is the application of heat by taking a small quantity of urine in a spoon and holding it over a candle," Bright explained. Thus he taught us more than 150 years ago that urine of patients with kidney disease and dropsy curdles when boiled over the flame of a candle. His epoch-making work on nephritis and the distinction between cardiac and renal dropsy established his reputation throughout Europe. Although cloudy urine had been discovered long before, Bright unified the stories of kidney disease, dropsy (generalized edema), and albuminuria.Hippocrates had noticed white clouds in urine, and the 13th-century Italian physician Saliceto provided a classic description of dropsy, scanty urine, and contracted kidneys. The preeminent Arab physician Rhazes had observed the association between damaged kidneys and dropsy. Albumin (or "albumen") in urine had been documented before Bright by several others, including Frederick Dekkers, Domenico Cotungo, William Wells, and John Blackall. But dropsy was still poorly understood until Bright, who put it all together with diseased kidneys and albuminuria and distinguished dropsies of renal origin from other etiologies.John King, a 34-year-old sailor, represented the first of the remarkable series of patients compiled by Bright and was a "well-marked example of granulated condition of the kidneys connected with the secretion of coagulable urine." Undoubtedly one of nephrology's most celebrated patients, King was admitted to Guy's Hospital under Dr Bright on October 12, 1825. He suffered from pain in the loins, scanty urine, hematuria, and generalized edema. When boiled in a spoon over the flame of a candle, King's urine coagulated. At the postmortem examination, "The kidneys were completely granulated … externally the surface rough and uneven; internally all traces of the natural organization nearly gone, except in tubular parts. …"In 1827, the first volume of Bright's renowned work appeared under the title Reports of Medical Cases, Selected With a View of Illustrating the Symptoms and Cure of Diseases by a Reference to Morbid Anatomy (also referred to as The Medical Reports). This volume focused on diseases of the kidney and its association with dropsy and albuminuria, as well as diseases of the liver with dropsy and afflictions of the lungs and intestines. Volume 2, which appeared in 1831, mainly dealt with the nervous system.Bright separated dropsies of renal origin from dropsies due to other causes, such as heart and liver disease. "One great cause of dropsical effusion appears to be obstructed circulation, and whatever generally or locally prevents the return of blood through the venous system, gives rise to effusions of serum more or less extensive." Bright recognized ascites due to cirrhosis of the liver with portal vein obstruction and ascites secondary to tubercular infection. But in cirrhosis, urine did not coagulate with heat, and kidneys were usually normal. Bright defined 3 basic pathologies at postmortem examinations in his cases, corresponding to the pale, large white kidney of nephrotic syndrome, the large red kidney of acute glomerulonephritis, and the small shrunken kidney of chronic glomerulonephritis.In Bright's writings, one finds a remarkably accurate clinical description of acute glomerulonephritis: "A child, or an adult, is affected with scarlatina … he finds the secretion of his urine greatly increased …tinged with blood …he awakes in the morning with his face swollen, or his ankles puffy. … [H]is urine contains a notable quantity of albumen. … [T]he urine is carefully tested …the quantity of urea is gradually diminishing. … [T]he swelling increases, the urine becomes scanty. … [H]e is suddenly seized with a convulsive fit, and becomes blind. … [W]orn out by convulsions, or overwhelmed by coma, the painful history of his disease is closed."Recognition of urea retention and the concept of uremia stemmed from Bright's observations. As his research in dropsy, coagulable urine, and diseased kidneys unfolded, Bright was struck by uremic manifestations, cardiac enlargement, a hard pulse (what would later be hypertension), and cerebral symptoms in his patients.On the subject of renal disease, Bright's most extensive observations appeared in the first volume of Guy's Hospital Reports in 1836. It consisted of 2 papers entitled "Cases and Observations, Illustrative of Renal Disease Accompanied With the Secretion of Albuminous Urine" and "Tabular Views of the Morbid Appearances in 100 Cases Connected With Albuminous Urine With Observations."Bright contributed frequently to Guy's Hospital Reports. The breadth and scope of his writings are quite bewildering, sparing virtually no organ system in the human body. His last publications were the important series of articles assembled later as Clinical Memoirs on Abdominal Tumours and Intumescence. These articles encompassed a broad range of conditions, including ovarian tumors, hydatid cysts, and other abdominal swellings. The list of clinical conditions described by Bright is indeed exhaustive, including diabetes, Jacksonian epilepsy, cerebral hemorrhage, malaria, peritonitis, whooping cough, scarlatinal middle ear infection, brain abscess secondary to ear infection, first accounts of laryngeal tuberculosis, and a host of neurological diseases. He was aware that pancreatic disease led to glycosuria. In his paper "Observations on Jaundice," he described fatty pale stools in obstructive jaundice due to pancreatic disease. The energetic Bright also wrote one volume of a medical textbook with Thomas Addison.Bright died in 1858, leaving behind an almost unparalleled legacy in medicine. Throughout his life, he exhibited an exemplary modesty and simplicity, untouched by his legendary medical feats. He won many accolades in his own lifetime and was appointed Physician Extraordinary to the Queen. Bright's writings and meticulous drawings continue to live on, inspiring generations of physicians.