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Historical Perspectives

P. Beckley

Published 2022 in T&T Clark Handbook of Christian Prayer

ABSTRACT

In 1844, before a large medical audience in London, John Hutchinson demonstrated the use of measurements of pulmonary function to predict disease. In contrast to standard practice at that time, he conducted an epidemiological investigation that would have been acceptable by today’s standards, in which he examined over 2000 people and contrasted healthy and diseased cases. His data clearly indicated how, what he called, “vital capacity” predicted disease. Exploring the history of this young Victorian-era physician is both humbling and instructive for the modern epidemiologist, who has the advantages of the successes of ever more rapid, computerbased, technical approaches to evaluate existing data sources, and fewer opportunities to actually collect primary data from large number of patients using physiologic tools. (Epidemiology 2011;22: e1–e9) On 29 May 1844, with W. H. Bodkin, Esq., M.P., in the Chair, John Hutchinson presented to the Society of Arts a paper read by the secretary on the topic: “Pneumatic Apparatus for Valuing the Respiratory Powers.” This paper described a crude version of what we have come to know as the spirometer: 2 vertical cylinders, the outer one filled with water and the inner one designed to receive a tube that would convey the expired air. Three weeks later, at a meeting of the Statistical Society of London, John Hutchinson, Esq., M.R.C.S., lectured a room crowded with members of the medical profession “on vital statistics, embracing an account of a new instrument for detecting the presence of disease in the system.” Remarkably, he reported on a study of 1150 subjects, mostly men, and demonstrated most convincingly that expiratory volume (which he called “vital capacity”) was “singularly gratifying to him” in demonstrating the intimate relationship between capacity and height in normal subjects. At the time, physicians in London were trained by relatively brief apprenticeships; if they learned science or published at all, they either reported number of deaths or described abnormalities or curiosities among their last few patients. John Hutchinson’s studies stood out as a unique set of investigations and were highly praised during his lifetime. The subject of this paper is how this man, the first physician in his family, chose to pursue one area of human physiological science, founding what we now call respiratory disease epidemiology, and how his work helped develop respiratory physiology and epidemiology as well as medical screening. At the height of a successful but relatively short career (12 years) in London, Hutchinson gave it all up, for unclear reasons. The consequences of his departure from the field of respiratory disease epidemiology along with the dominance of tuberculosis (TB) in respiratory and general medicine were far reaching, and seem to have delayed further development in the use of field-based physiological measures of pulmonary function for almost 100 years. EARLY EDUCATION John Hutchinson was born in a village near Newcastleupon-Tyne on 14 January 1811. He was the only child of a coal fitter (or coal merchant) father and a mother whose family was of a higher social class. His father was a success as a merchant, owning or having part interest in a brewery and a public house and eventually acquiring some 142 acres of land. When his father died in 1832, John was left with a substantial estate, which permitted him to pursue his career in London. However, he continued to return to his origins both to lecture and testify about coal mine safety and diseases. The details of Hutchinson’s early education are unknown, but he was interested and directed toward a career in mechanical engineering, presumably because of his access to and interest in his father’s tools and workshop. He was said to have visited the coal mines of the area and claimed to have descended into the mines 200–300 times. He came to London in 1834, where he took up course work at University College and was exposed to the current thinking about medicine and specifically the impact of chronic diseases on mortality rates. At that time, London was home to several long-standing nonuniversity affiliated hospital-based medical schools. These were essentially independent operations with remarkably varying standards and teaching techniques. Professor Charles Bell, who came to London from Edinburgh as a recognized leader in medical education, was actively enFrom the Department of Medicine, Brigham and Women’s Hospital, Channing Laboratory, Harvard Medical School, Boston, MA; and Department of Environmental Health, Harvard School of Public Health, Boston, MA. Correspondence: Frank E. Speizer, Department of Medicine, Brigham and Women’s Hospital, Channing Laboratory, Harvard Medical School, 181 Longwood Ave, Boston, MA 02115. E-mail: frank.speizer@channing.harvard.edu. Copyright © 2011 by Lippincott Williams & Wilkins ISSN: 1044-3983/11/2203-0001 DOI: 10.1097/EDE.0b013e318209dedc Epidemiology • Volume 22, Number 3, May 2011 www.epidem.com | e1 gaged in discussions with the University of London in formulating University College Hospital Medical School, which made this hospital-based medical school one of the first in the city to grant university degrees. Previously, the only medical schools in England with formal connections to universities were Oxford, Cambridge, and Edinburgh; the first 2 did not include hospital-based teaching, although an Oxbridge degree qualified a man to be a Fellow in the Royal College of Medicine. Most physicians in London received some apprentice training, but few took course work from established professors at Universities. The Apothecaries Act of 1815 made mandatory at least a half-year’s experience in an infirmary, dispensary, or hospital. Thus, between 1800 and 1850, approximately 8000 university-trained men became physicians, which was more than in all previous history. Presumably, the 3 or 4 courses that Hutchinson was able to pay for and take at the new University College Medical School were sufficient to qualify him by 1837 to be elected as a member of the Royal College of Surgeons. Hutchinson attended lectures by and certainly read most of the publications of William Farr on vital statistics. In 1839, Farr was hired to develop a system for the Registrar General to collect and maintain death certification and tabulate such data to aid in public health decision making. In discussing the difference between prevention and therapeutics, Farr pointed out “In the application of hygiene it is the utmost importance to be able to distinguish the first aberration from health ....” The 2 men clearly knew each other and presumably worked together as is evidenced by the fact that in 1842 when Hutchinson was made a member of the Royal Statistical Society; he acknowledged the support given to him by Farr in his first major publication (1844, op.cit.). THE MEDICAL SCENE IN LONDON IN 1840S One of the predominant and important medical issues in London during the 1840s that must have been uppermost in the minds of most physicians at that time was the impact of TB (“consumption”) on the practice of medicine. In 1841, the population of England was approximately 15 million, with 2 million in the city of London. Over 25% of all deaths each year were attributed to pulmonary consumption, perhaps the most dominant chronic condition in London at the time. The cardinal symptoms and signs of the disease were loss of weight, diminished thoracic mobility, and abnormal breath sounds. Treatment for the disease was generally ineffective (nearly one-third of patients died once diagnosed), and was dominated by trying to reverse the weight loss, so dominant in association with mortality. As important as the disease was, from the perspective of public health between 1832 and 1854 local city authorities were forced to deal with repeated cholera epidemics, which acutely, although only intermittently, accounted for as many deaths as TB over a much shorter period of time. The first chest hospital in England was the Infirmary for Asthma, Consumption and other Pulmonary Diseases in Bishopsgate, later known as the Royal Chest Hospital, founded by Isaac Buxton in 1814. By the 1840s, the hospital functioned only as an outpatient dispensary. In fact, all hospital dispensaries were forbidden to admit patients with TB, since the prognosis was so poor. One of the major dispensaries to play a role in Hutchinson’s career was the West London Dispensary for Diseases of the Chest. This facility opened in 1839 and in its first year saw 224 patients who lived within a 1-mile radius. Most of the TB patients Hutchinson studied came from this facility. Meanwhile, as the result of the experience of Phillip Rose, a solicitor who was unable to find treatment for his clerk’s TB, an effort was undertaken that eventually would lead to the establishment of the Hospital for Diseases of the Chest, which opened its doors in 1846 as the Brompton Hospital and incorporated the West London Dispensary. The first annual report indicated that the hospital opened with 20 beds, examined 66 patients, and proudly reported that 19 were able to resume their usual occupations. By 1849, over 4350 patients had been admitted and treated. In 1850, Hutchinson was given an appointment at the Brompton Hospital as an Assistant Physician, a position he held until 1852. HUTCHINSON: PHYSICIAN, PHYSIOLOGIST, EPIDEMIOLOGIST EXTRAORDINAIRE With the completion of his formal medical training in 1837, Hutchinson began working at one of the local dispensaries. Perhaps more important, he became involved in the emerging life insurance industry. Although the first life insurance policies in England were sold as early as 1706, until about 1810 most insurance was devoted to fire and theft. The principal requirement for life insurance to become a viable business was the development of life tables that could be generalized to the public. Interested individuals constructed death registries fo

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