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Thomas Addis (1881—1949): Mixing Patients, Rats, and Politics

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Thomas Addis (1881—1949): Mixing Patients, Rats, and Politics View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Kidney International, Vol. 37 (1990), pp. 833—840 HISTORICAL ARCHIVE CARL W. GOi-FSCHALK, EDITOR Thomas Addis (1881—1949): Mixing patients, rats, and politics STEVEN J. PEITZMAN Department of Medicine, Division of Nephrology and Hypertension, The Medical College of Pennsylvania, Philadelphia, Pennsylvania, USA In the early decades of the twentieth century, with the threatat the Laboratory of the Royal College of Physicians of Edin- of epidemic infectious diseases already in decline, attentionburgh, one of Great Britain's pioneering medical research shifted to the chronic maladies: hypertension, atherosclerosis,enterprises, also supported by the Carnegie Trusts. obesity, cancer, diabetes—and nephritis, or Bright's disease. Ray Lyman Wilbur (1875—1949), dean of the young Stanford New chemical methods devised by Otto Folin (1867—1934) atMedical School in 1911, "thought it would be a good thing to Harvard and Donald D. Van Slyke (1883—1971) at the Rock-bring in a young scientist from Scotland if the right one could be efeller Institute Hospital empowered the investigation of renalfound who had been trained in German as well as British and metabolic disorders. Folin's colorimetric system provideduniversities, and who was likely to develop in some promising rapid measurement of creatinine, urea, and uric acid, while Vanfield of research" [3]. So Wilbur sent a cable of invitation to Slyke's gasometric analyses allowed quantification of urea andEdinburgh, and the young Scotsman accepted the unlikely total carbon dioxide. Also in the first decades of the twentiethposition: in 1911 Stanford was still a relatively isolated and century, the reform of medical schools provided new opportu-little-known medical school in San Francisco (the school moved nities for academic medical careers. The stronger and ambitiousto nearby Palo Alto in 1959). Why did Wilbur choose the young schools embraced the ideology of research, and sought full-timeScotsman—and why did Addis undertake the adventure? faculty members capable of good work in the laboratory. InWilbur himself had studied in Britain and Germany, and almost these contexts, we will examine the life and work of Thomascertainly saw in someone like Addis a faculty member whose Addis (1881—1949), whose career in the Department of Medicineeducation combined the best of the British clinical tradition at Stanford University School of Medicine in California waswith the most modern laboratory training in Germany. Avail- fashioned almost entirely from a lifelong study of kidneyable documents fail to fully answer the second question, but disease. A brilliant investigator and colorful human being, later in his life Addis wrote to Wilbur, "I never understood how Addis was probably the first American to become so fullyyou came to send it [the offer of a job at Stanford], but it gave identified as an authority in what only later became known as me a chance to work I should never have had if I had stayed nephrology. The author has uncovered many letters from Addis in various archival collections, so some of his own words willhome—that cable and your backing" [4]. Stanford did provide help tell his story. an opportunity not available to Addis in Britain. In the years Thomas Addis was born in Edinburgh on July 27, 1881, thebefore World War I, British medical schools lagged behind the son of a clergyman. He received his M.B. and Ch.B. in 1905,better American colleges in nurturing laboratory science. They then the M.D. in 1908, all from the University of Edinburgh. Hewere slow to appoint full-time (or whole-time) clinician-inves- served as Clinical Assistant in the medical outpatient depart-tigators who would combine practice, teaching and research [5]. ment of the Royal Infirmary of Edinburgh, and Medical Regis-And this is the kind of work Thomas Addis envisioned (Fig. 1). trar at the city's Leith Hospital. From 1908 through 1910 he was Addis, who already listed several publications, mainly in a Carnegie Research Scholar and Fellow; this supported addi-blood coagulation, was given charge of the clinical laboratory tional chemical training in Berlin and Heidelberg [1, 2] (theand the diabetic patients at Stanford, and joined Wilbur in some Scottish-American industrialist and philanthropist Andrew Car-studies of bilirubin metabolism. Wilbur in his Memoirs asserts negie in 1901 created a program to foster research in Scottishthat he encouraged Addis to "take up the study of the kidney," universities, the Carnegie Trusts for the Universities of Scot-[6] but another stimulus may have been the interest in renal land). Addis also investigated hemophilia and antimicrobial seradiseases of the professor of pathology, William Ophuls [71. In 1928, by which time his renal investigations were widely recognized, Addis received an invitation from Simon Flexner, Director of the Rockefeller Institute for Medical Research, to Received for publication January 1, 1989 spend a year "collaborating with Dr. Van Slyke in the studies and in revised form July 5, 1989 being carried out there on Bright's disease" [8]. Addis spent the Accepted for publication September 1, 1989 year in New York (though he worked for the most part © 1990 by the International Society of Nephrology independently on organ hypertrophy), "a great year,—the best 833 834 Peitzman:Thomas Addis (1881—1 949) V entire "system" comprising classification, diagnosis, and treat- ment. Addis entered medicine and the laboratory at a time when "functional diagnosis" dominated internal medicine. "Func- tional diagnosis" in the late nineteenth and early twentieth centuries referred to the attempt by laboratory-minded Euro- pean and American physicians to determine the functional deficits and compensations of diseased organs, rather than to examine only the morphological changes. Addis thought that functional analysis was no end in itself. Seeing himself in a tradition going back to the clinical-pathological methods of Richard Bright, Addis, writing in 1929, welcomed "the return of medicine from "function" to the straight and narrow road of morphology [which] was initiated in 1914 by the publication of Voihard and Fahr's book, Die Brightsche Nierenkrankheit. They again subjected clinical prediction to the test of correspondence with objectively ascertained struc- tural fact. .. andagain there came to workers in this depart- ment of medicine a sense that there was sure ground beneath their feet, and progress was possible and measurable however hard the way might be [11, pp. 4—5]." Addisbelieved that the category of structural disease in the kidneys could be discovered by properly looking at the urine— in it "is contained all the direct evidence as to the nature of the renal lesion" [11, p. 13]. But valid interpretation of the sedi- ment required knowing the nature and behavior of its elements, and the number of casts and cells in the urine of healthy persons and those with Bright's disease. This Addis accomplished. He found that some casts dissolve in alkaline pH, and that cells might burst in dilute urine. He standardized a method for - ti collecting a twelve hours' sample of urine during overnight water restriction. The concentrated, acidic sample was stirred and an aliquot processed in such a way that a count of the Fig. 1. Thomas Addis, M.D., F.R.C.P.E, (1881—1949), early in his formed elements might be done microscopically, providing a career at Stanford University School of Medicine (Courtesy of the Lane estimate of the number of red cells, casts, white cells and other Medical Archives, Stanford University Medical Center). objects excreted in twelve hours. A qualitative inspection I've ever had." The Rockefeller Institute, America's firstcomplemented the "Addis count." Addis emphasized the need important center for medical research, invited Addis to join itsto identify the deformed and ghostly red cells of nephritic staff permanently, and though tempted, he declined. "For oneorigin, and the importance of "renal failure casts" (broad thing," he wrote in 1930 to Rufus Cole, Rockefeller Institutecasts). Proteinuria was also quantified. Addis insisted again and Hospital Director, "I have collected a group of nephritics whichagain that the doctor must do much of this work himself if it is I have nursed along and watched over for the past ten years.to have meaning; it is too important to delegate to a technician. You know twenty years at least are needed to get anywhereFurthermore, he urged that the patient be present when the with prognosis .. ." [9].So he stayed at Stanford as Professordoctor performed the essential laboratory tasks, so that the of Medicine, "mixing patients and rats," as he put it, until 1948physician's eye and mind might travel between the patient and when he moved to the Institute for Medical Research of thethe urine or blood under examination, "striving to create a Cedars of Lebanon Hospital in Los Angeles. At Cedars oflarger and more inclusive picture .. ." [12]. Lebanon he collaborated briefly with a woman internist and Basing it largely on the quantitative and qualitative examina- researcher named Jessie Marmorston, and others, until histions of the sediment, Addis advanced a simplified "clinical death in 1949. classification of Bright's diseases" [13]. The plural form was Addis married Elesa Bolton Partridge in 1913 and the coupleintentional: Addis acknowledged that several entities made up had two daughters. He became a naturalized American citizenthe category "Bright's disease," a term that he still preferred in 1917. Addis served as president of the American Society forbecause it did not convey unwarranted assumptions about Clinical Investigation in 1930, was elected to the Nationalcause or pathological mechanism. By "clinical" classification Academy of Sciences in 1944 (to him, an "astonishing andhe meant one useful to doctors, not woven by pathologists from incomprehensible honor" [10]), and Fellow of the Royal Col-necropsies (there was no such thing as a percutaneous renal lege of Physicians of Edinburgh in 1945.
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