Thomas Addison

We thank Thomas Burns for correcting errors concerning Addison's month and year of birth, and his place of death, in the original entry.

Thomas Addison was the son of Sarah and Joseph Addison, a grocer and flower-seller in Long Benton, Northumberland. He attended the local village school and then went to the Royal Free Grammar School in Newcastle-on-Tyne, and learned Latin so well that he made notes in that language and spoke it fluently. This may have led to his habitual exactitude of diction in whatever he wrote or spoke in after life.

His father had wished him to become a lawyer, but in 1812 he entered the University of Edinburgh as a medical student. He graduated in 1815, at the age of twenty-two, and on August 1 that year was conferred doctor of medicine with the thesis "Dissertatio medica inauguralis quaedam de syphilide et hydrargyro complectens – Concerning Syphilis and Mecury.

In 1815, Addison moved to London where he took up his residence at Skinner Street, Snow Hill, and became house surgeon at the Lock Hospital. He moved to Hatton Garden. Addison was also a pupil of Thomas Bateman (1778-18821) at the public dispensary. He commenced practice, while at the same time he was physician at an open ward reception on Carey Street. Thanks to his superiors he became specially interested in diseases of the skin, an interest which prevailed his whole life through. This interest most probably led to him being the first to describe the changes in skin pigmentation typical of Addison's disease.

Addison's brilliant career as a physician and scientist began in 1817 when he was enrolled as a physician pupil at Guy's Hospital in London. Guy's Medical School book records his entrance: "Dec. 13, 1817, from Edinburgh, T. Addison, M.D., paid pounds 22-1s to be a perpetual Physician's pupil." He obtained his licentiateship in the Royal College of Physicians on 22 December 1819 and was elected a fellow on July 4, 1838.

On January 14, 1824 he was promoted to assistant physician, In 1827 he was appointed lecturer of materia medica. At that time, when medical students paid fees for separate courses of lectures, they sought throughout the metropolis for the most attractive teachers. Armstrong then drew a large class to the Webb Street school by his instruction in the practice of medicine; most of his pupils remained to listen to Addison, and so great was the attendance that his lecture-fees must have amounted to £700 or £800 a year.

In 1835 Addison was joint lecturer with Richard Bright on practical medicine, and in 1837 Addison became a full physician at Guy's Hospital. When Bright retired from the lectureship in 1840 Addison became sole lecturer. He held this position until either 1854 or 1855.

Addison was a brilliant lecturer and diagnostician but a rather shy and taciturn individual, and, as a result had a small practice, at a time when physicians of his position evidently all had large practices.

He was one of the most respected physicians at the Guy's Hospital where he excerted a great deal of influence and taught in a dogmatic and forceful manner, devoting himself almost wholly to his students and patients. He was described as the type of doctor who is always trying to discover the re-arrangement in a piece of machinery rather than one who, like Benjamin Guy Babington (1794-1866), regarded his patients as suffering, sensitive human beings.

Addison's disease
The adrenal glands were described by Eustachius in 1714, but it was many years before their function was elucidated. Indeed, the offer of a substantial prize for an essay on adrenal physiology, made by the Académie des Sciences de Bordeaux in the eighteenth century failed to elicit any significant entries.

The story of Addison's disease begins with Addison's first description in a short note in an article in the London Medical Gazette entitled Anaemia - disease of the suprarenal capsules in which the disease is not distinctly separated from a new form of anemia.

This article was followed up in his monograph On the Constitutional and Local Effects of Disease of the Suprarenal Capsule which was published in London in 1855 and represented the beginning of the study of the endocrine glands. This work was much debated in England and Scotland and largely discounted, John Hughes Bennett (1812-1875) in Edinburgh denying the existence of the disease. Armand Trousseau (1801-1867) in Paris, however, was quick to recognise adrenal failure and gave it the eponym Addison's disease.

In his book Addisons points out that it was really under his attempts at elucidating the base of a peculiar form of anaemia that he happened to find pathological changes comprising both suprarenal glands. He maintains that the disease of the adrenal glands could not be connected with the anaemia, as he had previously thought. His descriptions of the symptoms of the eleven patients with enlarged adrenal cortex collected by himself and his younger associate Samuel Wilks is worth quoting:

"The leading and characteristic features of the morbid state to which I would direct your attention are, anaemia, general languor and debility, remarkable feebleness of the heart's action, irritability of the stomach, and a peculiar change of the colour in the skin, occurring in connection with a diseased condition of the suprarenal capsules . . .
The discoloration pervades the whole surface of the body, but is commonly most strongly manifested on the face, neck, superior extremities, penis, scrotum, and in the flexures of the axillae and around the navel."

One of the eleven patients in the monograph is of special interest. This patient had been treated by Bright, who had noted pigmentation of the skin, the irritability of the stomach, the emaciation, and the asthenia which quickly lead to the petient's death. He also described the characteristic changes: the very enlarged adrenal glands with deposits of a "scrofulous kind", and partial deterioration of the glands with deposits of pus.

Bright seems to have been confused by the fact that the patient also had tumors of the chest and a swelling of parotis, and he did not connect the subsequent classic symptology with the changes of the adrenal glands. This description came many years before Addion's monograph and, if Bright had understood the connection his name, not Addison's, would have been attached to the disease.

Addison's comment to Bright's account tells something of why Addison enjoyed modest popularity:

"It did not appear that Dr. Bright either entertained a suspicion of the disease of the capsules before death, or was led at any period to associate the colour of the skin with the diseased condition of the organs, although his well-known sagacity induced him to suggest the probable existence of some internal malignant disease. In this as in most other cases, we have the same remarkable prostration, the usual gastric symptoms, the same absence of any very obvious and adequate cause of the patient's actual condition together with a discoloration of the skin, sufficiently striking to have arrested Dr. Bright's attention even during the life of the patient."

The disease now known as Addison's anaemia was first described in detail by Addison in 1849 in a lecture in the South London Medical Society, but it was apparentlyt not published in an ordinary way. He is also said to have lectured on the disease already since 1843. It appears from these accounts that what Addison called "this remarkable form of anaemia" was probably pernicious anaemia.

An overlapping of the two diseases on the side of Addison, who tried to unite "his" diseases into one entity, coloured the struggle about priority to the idiopathic or pernicious anemia. In a leader of The Medical Times and Gazette of London in 1874, one could read that Biermer in Zurich ha described a new type of anemia, "idiopathic anemia", and that this disease was not yet described in England. The paper adds: "... no doubt there will soon be many observers on the lookout for it." This caused Samuel Wilks seven days later in a letter to British Medical Journal to inform that the disease was well known in England as Addison had lectured on it in 1843.

In this context it is interesting to notice that "idiopathic anaemia" had been described already in 1822 by James Scarth Combe in the Transactions of the Medico-Surgical Society of Edinburgh. Combe remained anonymous until his death in 1883, and apparently never took part in the struggle for priority of this new disease, pernicious anaemia.

It has also been suggested that the author Jane Austen gave the first account of the disease in her letters describing the disturbance causing her death in 1817.

Today Addison's discoveries are regarded as fundamentally significant in the study of endocrine glands and the treatment of pluriglandular diseases. His book On the Constitutional and Local Effects of Disease of the Supra-Renal Capsules is one of the truly remarkable medical books of the nineteenth century. Addison describes here for the first time two chronic diseases of the adrenal gland: Addison's disease and pernicious anaemia (Addison-Biermer anaemia), the most important primary disease of the blood.

With Bright he was to write a textbook of medicine, Elements of the Practice of Medicine (1839), but only one volume was written and that by Addison. This joint undertaking by two of the most famous physicians in nineteenth-century Europe is quite scarce. It was intended as a "work at once elementary and practical to which teachers might refer their pupils as a companion and assistant during the period of their studies".

This book contains if not the first, then the most lucid and complete description of "Inflammation of the caecum and appendix vermiformis" - from the earliest symptom to the buildup of abcess and death in peritonitis, of course with pregnant autopsy findings.

With Sir William Whitey Gull (1816-1890), Addison described xanthoma diabeticorum, and he also first described morphea, or circumscribed scleroderma (Alibert’s keloid syndrome), which is sometimes called Addison's keloid.

Addison took a great interest in diseases of the lungs and in 1843 described the pathology of pneumonia, which so far in accordance with René-Théophile-Hyacinthe Laennec (1781-1826) had been considered an inflammation of the interstitial tissues of the lungs. Addison followed the fine bronchial branches to their very end, and found that the inflammation consisted of "pneumonic deposits in the air cells", the alveolars.

Addison's lifelong interest in dermatology is evident from some of his writings with great news value. One article specially deserving to be mentioned is "On a certain affection of the skin, vitilogoidea plana tuberosa", in which he presents the first account of xanthoma planum et tuberosum, which is so common with hypercholersterolaemia. He founded the Department of Dermatology at Guy's in 1824 and his influence is still evident in the collection of wax models of skin disorders which were prepared under his supervision.

Addison was at his best at the bedside, always moving to one side since he was slightly deaf in one ear. He used to tell his students that if he could not reach a diagnosis in a patient he would think of alle the possible explanations for his patients symptoms on his way to and from the hospital. His abilities to sift evidence and come up with a diagnosis were unrivalled in his day, but he did noe devote the same energies to alleviation or cure.

Thomas Addison's time at Guy's entailed a reorganisation of medicine to which also Bright contributed. It is evident from literature that Addison and Bright were among the first to introduce scientific principles in the diagnostisation of diseases, demanding that the physician should try to correlate physiological findings during life with the observations done at autopsy, something which was still quite rare at the time. This dawn of a new era was initially met with cynicism and resistance to changes amongst the establishment - a situation all to familiar to many scientist of our time. The old school even protested against the use of the stethoscope, which had been introduced by Laennec, whom Addison admired so much. Bright's superior even used the stethoscope as a flower vase.

Once, when called in to see a patient he spent a long time in finally arriving at the diagnosis of an abdominal cancer. He discussed this with the attending doctor and the patients friends and relatives and was leaving when he was reminded that he had not written a prescription. He asked what he was already being given and when told "a magnesium mixture" he said "a very good medicine, go on with it". This probably explains why his practice was not as big as it might have been.

Both marital happiness and fame came came late to Addison. In September 1847, at the age of 52 years, he married Elizabeth Catherine Hauxwell at Lanercost Church. They were childless, although she had two children by her first marriage. His membership in the Royal College of Physicians, invitation to lecture at the Royal Society, to be physician to the court, honorary titles, etc, all came later, often decades later, than what would have been "normal" for a medical scientist of his importance. He must have been pleased to read the following recension in The Medical Times and Gazette:

"We believe that Dr. Addison has made a discovery which is the most important practical medicine has produced for many years, and one in every way worthy of the untiring zeal and energy in professional persuits which has characterised his life."

After ill-health forced him to leave Guy's Hospital Addison received an admiring letter from one of his pupils, and answers it with a deep concern for the welfare and future of the hospital. He is considered by many to be the greatest of the triumvirate Addison-Bright-Hodgkin, "so that every Guy's man during the 30 or 40 years of his teaching, was a disciple of Addison holding his name in the greatest reverence and regarding his authority as the best guide to the practice of the profession.

The following statement in the medical press adds to the picture:

"He is a fine, dashing, big, burly, busting man, proud and pompous as a parish beadle in his robe of office. Dark, and of sallow complexion, an intelligent countenance and noble forehead, he is what the ladies would renounce a fine man. He had mentally and physically a tall idea of imself. Every sentence is polished, is powerful: he prefers the randiloquent. Slow and studied are his opening sentences, studied the egularity of his intonations. The advantages of his tall and graceful person are artfully employed to add to the favourable impression; his attitudes, tones and manner are studied and systematic."

Maybe this somewhat ironic statement to some degree explains the onspicuous absence of real affection?

Depression and suicide
Addison had a number of episodes of severe depression which he greatly feared. He retired in 1860 because of an incipient cerebral disorder depression and wrote to his students: "A considerable breakdown in my health has scared me from the anxieties, responsibilities and excitement of my profession; whether temporarily or permanently cannot yet be determined but, whatever may be the issue, be assured that nothing was better calculated to soothe me than the kind interest manifested by the pupils of Guy's Hospital during the many trying years devoted to that institution."
Three months later, on June 29, 1860, he committed suicide. On July 7, 1860, The Medical Times and Gazette published a note of Addison's death, but neither the Lancet nor the British Medical Journal recorded it, something that was considered almost obligatory. He was buried in Lanercost Abbey, Cumberland, near his childhood home.

In his memory the university placed a bust of him in the pathological museum, named a hall of the new part of the hospital after him, and perpetuated his memory with a marble wall table in the chapel.

"Dr Addison, formerly a physician to Guy`s Hospital, committed suicide by jumping down the area (i.e. the space between the front of the house and the street) of 15 Wellington Villas, where he had for some time been residing, under the care of two attendants, having before attempted self-destruction. He was 72 years of age (sic), and laboured under the form of insanity called melancholia, resulting from overwork of the brain. He was walking in the garden with his attendants, when he was summoned in to dinner. He made as if towards the front door, but suddenly threw himself over a dwarf-wall into the area - a distance of nine feet - and, falling on his head, the frontal bone was fractured, and death resulted at one o`clock yesterday morning"
Brighton Herald of the 30th June 1860
The quotation was taken from the website of Charles Douglas Wehner, http://www.wehner.org./

On Thomas Addison:
"The personal power which he possessed was the secret of his position, much superior to what Bright could ever claim, and equal, if not greater, than that of Sir Astley Cooper.”
Sir Samuel Wilks (1824-1911)

Quotation by Thomas Addison:
«Were I to affirm that Laënnec contributed more towards the advancement of the medical art than any other single individual, either of ancient or of modern times, I should probably be advancing a proposition which, in the estimation of many, is neither extravagant nor unjust.»
Collection of Published Writings, «Diseases of the Chest.»

• De Syphilide et Hydrargyro. Doctoral thesis, University of Edinburgh, 1815.
  "Concerning Syphilis and Mecury"
• An Essay on the Operation of Poisonous Agents upon the Living Body. Written with John Morgan (1797-1847). London, Longman Rees, 1829.
  First book in English on the action of poisons on the living body.
• Observations on the Disorders of Females Connected with Uterine Irritation. London 1830.
• Observations on Fatty Degeneration of the Liver.
• Elements of the Practice of Medicine.
  Written with Richard Bright (1789-1858). 3 parts, London, 1836-1839.
• On the influence of electricity, as a remedy in certain convulsive and spasmodic diseases.
  Guy’s Hospital Reports, London, 1837, 2: 493-507.
  First therapeutic employment of static electricity.
• Observations on the Anatomy of the Lungs.
  1840. In: Collected Writings, London 1868.
• Observations on Pneumonia and its Consequences.
  In: Guy's Hospital Reports, 2nd Series, 1843, 1: 365-402.
• On the Pathology of Phthisis.
  Guy's Hospital Reports, London 1845, 3: 1-38.
• Chronic Suprarenal Insufficiency, Usually due to Tuberculosis of Suprarenal Capsule.
  Addisons’ disease. 1st announcement in: London Medical Gazette, n.s. 1849, 43: 517-518.
• On a Certain Affection of the Skin, Vitilgoidea - a. plana, b. tuberosa. With remarks. Written with William Gull.
  Guy's Hospital Reports, London, 2nd Series, 1851, 7: 265-276.
• On the Constitutional and Local Effects of Disease of the Supra-renal Capsules. London 1855.
• Elements of the Practice of Medicine.
  Written with Richard Bright.
  Issued in three parts from 1836 to 1839.
• On the keloid of Alibert, and on true keloid.
  Medico-Chirurgical Transactions, London, 1854, 37: 27-47.
  Addison described two forms of keloid, that described by Alibert, and the ”true keloid” (the skin disease morphoea), ”Addison’s keloid”.
• A Collection of the Published Writings of Thomas Addison. Edited by Dr. Wilks and Dr. Daldy.
  239 pages. London, the New Sydenham Society, 1868.
  Dr. Wilks is Sir Samuel Wilks, 1824-1911.
• F. M. Sutherland:
  Nova et Vetera. Thomas Addison 1793-1860.
  British Medical Journal, London, 1960, 5194: 304-305.