J Med Biogr OnlineFirst, published on July 4, 2014 as doi:10.1177/0967772014533055
Original Article
The Paget Bicentenary: An Australian perspective
Journal of Medical Biography 0(0) 1–7 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0967772014533055 jmb.sagepub.com
Nadeem Toodayan
Abstract The year 2014 marks the bicentenary of the birth of Sir James Paget (1814–1899), the celebrated English surgeon and pathologist. Although best known for his work on bone and breast disease, Paget also played an important role in the institution of Australia’s first medical school. In this article, that involvement and Paget’s other antipodean influences are summarised. The naming of Paget’s disease of the bone is also discussed.
Keywords Sir James Paget, bicentenary, antipodean influences, Australian medical education, Paget’s disease of the bone, Paget eponyms
Not by the lips, but by the life, are men influenced in their beliefs1 – Sir William Osler, 1904. On 11 January 2014, members of the profession gathered to commemorate the life and achievements of Sir James Paget (Figure 1). His presence was felt especially in his birth town of Great Yarmouth in Norfolk, UK, where the hospital that bears his name celebrated his life in a well-crafted clinical conference.2 Speakers that day lectured on topics ranging from Paget’s contributions to breast cancer and bone disease to his influence on medical education and clinical surgery. His great grandson, Sir Julian Tolver Paget, 4th Baronet (b. July 1921), delivered a warm account of Paget’s family life and a dinner was held for 200 in Great Yarmouth’s newly refurbished Town Hall. Next morning a civic service was held at Yarmouth Minster where both medical professionals and town locals gathered. Altogether, the Paget bicentenary celebrations were orchestrated by Dr Hugh Gerard Sturzaker (b. 1940), a retired surgeon, Lead Governor to the James Paget University Hospital and long-time partisan of the Paget tradition (Figure 2). In anticipating the Paget bicentenary, Dr Sturzaker wrote the new biography Sir James Paget: Surgeon Extraordinary and His Legacies.3 On 17 January Dr Sturzaker again formally recapitulated Paget’s life and influence at Great Yarmouth’s Time and Tide Museum in his talk titled Sir James Paget: 200 years young. Professor Harold Ellis, who had also presented at the Paget bicentenary conference, lectured on 4 March in Paget’s memory at the Royal
Figure 1. Sir James Paget (1814–1899) in 1881. Photograph by George Milner Gibson Jerrard (1848–1918). Courtesy of the Wellcome Library. Associate Lecturer, University of Queensland School of Medicine, Southern Clinical School; Brisbane, Australia Corresponding author: Nadeem Toodayan, University of Queensland School of Medicine, Southern Clinical School; Brisbane, Australia. Email: [email protected]
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Sir James Paget Timeline
11th January 1814: Born in Great Yarmouth at 59 South Quay. 9th March 1830: Commences surgical apprenceship under Mr. Charles Fisher Costerton (1790-1852). October 1834: Enters St. Bartholomew's Hospital medical school. November 1834: First book published, 'Sketch of the Natural History of Great Yarmouth and its Neighbourhood'. 2nd February 1835: Discovers Trichinia spiralis. 13th May 1836: Passes membership examinaon for the Royal College of Surgeons. April 1837: Appointed curator of St. Bartholomew's Hospital Pathology Museum. 1839: Becomes demonstrator of Morbid Anatomy at St. Barts. 14th April 1841: Elected Surgeon to the Finsbury Dispensary. 1842: Begins to catalogue the pathological secon of the Hunterian Museum at the Royal College of Surgeons. 30th May 1843: Appointed Lecturer in Physiology at St. Barts.
1872: Elected Fellow of The Linnean Society. 1874: 'On Disease of the Mammary Areola Preceding Cancer of the Mammary Gland' published in St. Bartholomew's Hospital reports. 1875: Elected President of the Royal College of Surgeons and the Royal Medico-Chirurgical Society. 14th November 1876: 'On a Form of Chronic Inflammaon of the Bones (Osteis Deformans)' paper presented to the Medico-Chirurugical Society. 13th February 1877: Hunterian Oraon. August 1881: President of the 7th Internaonal Medical Congress in London (when the above photo was taken).*
8th August 1843: First warden to Student College at St. Barts. November 1843: Elected Foundaon Fellow of the Royal College of Surgeons. 23rd May 1844: Married to Lydia North (1826-1895) aer a prolonged 8 years of engagement. January 1847: Elected Professor of Anatomy and Physiology at the Royal College of Surgeons. Arris and Gale lecturer from 1847-1852. February 1847: Becomes Assistant Surgeon at St. Barts. 1849: Completes pathological catalogue of the Hunterian museum. 1851: Elected Fellow of the Royal Society. March 1858: Appointed Surgeon Extraordinary to Queen Victoria (1819-1909). 24th July 1861: Becomes full surgeon at St. Bartholomew’s. 1863: Appointed Surgeon in Ordinary to Albert Edward (1841-1910) the Prince of Wales. April 1869: President of the Clinical Society of London. 1871: Knighted.
* “A thrill of pride must have filled the breast of every Englishman present, at the thought of having, as the representave of the naon, such a gied man” 4 – Sir William Osler on Paget’s presidenal address at the IMC in 1881.
13th December 1882: Inaugural Bradshaw Lecture 'On some Rare and New Diseases'. April 1883: Elected Vice Chancellor of London University. April 1886: Appointed Chairman of the Pasteur Commiee. 1887: President of the Pathological Society of London. 1889: Appointed to Royal Commission on Vaccinaon. May 1894: James and Lydia celebrate their Golden Wedding anniversary; Lydia dies early next year. April 1897: Awarded Honorary Gold Medal of Royal College of Surgeons; the highest honour conferred by the society. 30th December 1899: Dies peacefully at home, a day shy of the new century. 4th January 1900: Funeral at Westminster Abbey; laid to rest by his wife at East Finchley Cemetery.
The Paget Bicentenary 11th January 2014
Timeline. Images reproduced courtesy of the Wellcome Library and East Finchley Cemetery.
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Figure 2. Dr Hugh Sturzaker (left), Sir Julian Tolver Paget (right, aged 92) and Henry Paget (centre) stand for a photograph in Yarmouth minster on Sunday 12 January 2014 during the Paget Bicentenary civic service. They gather around a replica of Sir Joseph Edgar Boehm’s (1834–1890) bust of Sir James Paget, which was produced for the Royal College of Surgeons in 1885. This copy resides in the James Paget University Hospital Museum. Reproduced with permission from Dr Hugh Sturzaker.
College of Surgeons in London; his talk was titled Sir James Paget: Surgeon, Teacher and Clinical Observer. Both Great Yarmouth Minster and the Burrage Centre at the James Paget University Hospital exhibited Paget memorabilia for more than a week and a blue plaque was unveiled on 6 January at the site of Paget’s birthplace at 59 South Quay. Meanwhile in Brisbane, Australia, another personalised tribute was taking form; this time in an educational video titled ‘The Paget Bicentenary’ which was uploaded to Youtube. The timeline summarises significant events defining Paget’s long life and the table displays his most important clinical contributions (Table 1).
Paget’s Antipodean influences The first-ever official medical school in Australia was inaugurated by the University of Melbourne in the first quarter of 1862. The school was established against the odds of disinterest on part of the government, gross opposition from members of the profession and much financial difficulty.6 In fact, it has been said that its inception was made possible only through the iron-willed determination of its founder, Sir Anthony Colling Brownless (1817–1897), himself a physician and then Vice Chancellor of Melbourne University. Brownless had been a student of Paget at St Bartholomew’s Hospital in 1840 and emigrated to Australia in 1852. Knowing firsthand of Paget’s exceptional teaching facility, Brownless eagerly sought his guidance when drafting the foundations for the new faculty. And so it happened that when Hugh Culling Eardley Childers
(1827–1896), ex-Vice Chancellor of the University, left for England in March of 1857, Brownless had him interview Paget in order to attain directly his advice on modelling a world-class medical curriculum. When the two did meet, Paget promised to detail his suggestions in a letter to be addressed to Childers in the near future. Although somewhat postponed in its formulation, the letter eventually was despatched on 9 April 1858 from Paget’s private doors in London at 1 Harewood Place in Hanover Square. Specified in its contents were the prerequisites needed to enter, the length of professional study, the specific subjects to be included and the course of student examinations to be incorporated. By the end of May the letter had been fast-tracked to Melbourne University where the council, now headed by Brownless, thanked Paget for his ‘highly valuable communication’. Based on Paget’s suggestions and Brownless’ dogged determination, the Melbourne Medical School took form in March of 1862. Soon afterwards Paget was again summoned when Brownless wrote to him on 26 March 1862, this time seeking a highly qualified Professor to occupy the Chair of Anatomy, Physiology and Pathology, at the new medical school. As before, Paget was keen to cooperate and, with the assistance of zoologist Sir Richard Owen (1804–1892), proceeded to interview applicants for the important position. The two men endorsed the application of the distinguished English anatomist and physiologist George Britton Halford (1824–1910) who then was to become Melbourne University Medical School’s first full-time lecturer. The medical faculty at the University of Sydney also once sought Paget’s directions but his involvement in the genesis of Sydney Medical School was only brief. The Faculty of Medicine at Sydney University, founded in June of 1856, predates even that of Melbourne University.7 At this time there was no medical school but the institution preserved the right to award both Bachelors’ and Doctors’ degrees in medicine. Plans to erect a medical school were discussed and discarded on more than one occasion. On one of these occasions Sir Alfred Roberts (1823–1898), a distinguished Englishborn Australian surgeon and founding member of Sydney’s Royal Prince Alfred Hospital, personally contacted Paget in a bid to gain approval for a new scheme of medical education at the university. In his letter dated 6 August 1872, Roberts put forth the proposal that a cost-effective medical school could be founded on the principle of one-way student exchange whereby Sydney’s medical students would complete their final two years of training in England.8 The programme would greatly benefit the colony and help facilitate a full-time medical school in the future. In two separate letters Paget replied in the affirmative and suggested the
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Table 1. Summarising many of Sir James Paget’s most important contributions to clinical medicine, listed somewhat in order of importance. Contribution
Year
Summary
Paget’s disease of the bone
1876
A common chronic localised metabolic bone disorder characterised by a rapid turnover rate and disorganised remodelling of bony tissue. Paget named the disease ‘Osteitis Deformans’ when he presented five cases to London’s Medico Chirurgical Society in November 1876. Save the somewhat obvious increased incidence of fractures, little has been added from the clinical side since Paget’s original description.
Paget’s disease of the breast
1874
A rare form of breast cancer characterised by eczematous changes in the skin of the areola and periareolar regions. This usually occurs in the presence of underlying ductal carcinoma in situ or invasive breast cancer. Paget thought the skin changes preceded and produced the malignancy in the breast and, although this is now thought to be incorrect, the importance of Paget’s clinical observation lies in the recognition of the association.
Trichinella spiralis
1835
The parasite that causes trichinosis. Paget discovered the organism as a first year medical student at St Bartholomew’s Hospital while dissecting a cadaver. He noted that the ‘minute whitish specks’, which were often disregarded as bony ‘spiculae’ in the muscle tissue, were in fact ‘cysts containing small worms’. The discovery was aided by Robert Brown’s (1773–1858) microscope. Sir Richard Owen (1804–1892) further detailed the discovery and named the parasite ‘Trichina spiralis’ (which eventually became Trichinella spiralis).
Carpal tunnel syndrome
1853
A compressive neuropathy of the median nerve due to entrapment in the carpal tunnel. Paget was the first to describe the phenomenon in his famous Arris and Gale lectures which were first published in 1853 as his ‘Lectures on Surgical Pathology’.
Osgood-Schlatter disease
1891
Tibial tubercle apophysitis. A common cause for knee pain in preadolescents that is caused by repetitive micro-fractures and tendinous inflammation secondary to repeated traction injury at the level of the tibial insertion of the patellar ligament. Paget gave an unmistakably accurate account of the condition in his final text ‘Studies of Old Case Books’ which was first published in 1891. This was more than a decade before Robert Bayley Osgood (1873–1956) and Carl Schlatter (1864–1934) independently called wider attention to the condition in 1903.
Extramammary Paget’s disease
1874
A rare and often non-invasive intraepithelial adenocarcinoma that usually affects the anogenital region and is histologically very similar to Paget’s disease of the breast. In the same paper, where he described rawness of the mammary areola and breast cancer, Paget briefly commented on ‘a persistent rawness of the glans penis’ preceding cancer of the penis. The actual concept of ‘extramammary Paget’s disease’ was first introduced by Henry Radcliffe Crocker (1846–1909) in 1889.
Paget-Schroetter syndrome
1866
Spontaneous or effort-induced thrombosis of the axillary or subclavian veins causing pain and engorgement of the affected arm. Paget first described the clinical features of this condition in 1866. In 1901, Leopold von Schroetter (1837–1908) suggested that the condition occurrs secondary to occlusive thrombosis of the deep veins of the upper limb.
Osteochondritis dissecans
1870
A relatively uncommon disease of the joints that occurs in the setting of subchondral bony infarction. This causes subsequent fragmentation of articular cartilage and surrounding bony tissue. Loose bodies may enter the joint space causing pain and locking of the joint. In 1870 Paget was the first to suggest a vascular insult in the development of the condition. He called it ‘quiet necrosis of the bone’. The term ‘osteochondritis dissecans’ was introduced by Franz Konig (1832–1910) in 1887.
Causalgia
1864
In February of 1864 Paget was the first to allude to the painful ‘glossy fingers’ occurring in partial nerve injury of the upper limb. Weir-Mitchell described the condition more fully in the same year and introduced the term ‘Causalgia’ in 1867.
Paget’s recurrent fibroid tumour
1853
Slow-growing spindle-cell sarcomas that tend to recur after resection. Paget described several cases of the condition in 1853. His histological findings suggest spindle-cell tumours.
Paget’s residual abscess
1869
In a paper produced in the fifth volume of the St Bartholomew’s Hospital Reports, Paget introduced the term Residual Abscess to call wider attention to ‘abscesses formed in or about the residues of former inFammations’.5 Although the term is somewhat outdated, it may continue to be used loosely as an adjunct to more descriptive terminology, at least for historical reasons.
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institution of a barrier exam before a transfer was made. He was fully supportive of the idea and wished Roberts ‘all encouragement and help’. Unfortunately, due to lack of funds the scheme did not come to fruition and had to be abandoned. It would take the generous endowment of John Henry Challis (1806–1880), a highly successful merchant and philanthropist, and the brilliant resourcefulness of a bright young Scottish professor, Sir Thomas Peter Anderson Stuart (1856– 1920), to bring the Sydney Medical School to life in 1883. As in Melbourne, a full-time five year curriculum was initiated and plans for a grand new medical school building soon emerged. Completed in 1889, the Anderson Stuart building, as it later became known, was adorned with beautiful coloured stained glass windows illustrating important historical figures in medicine. The building’s southern doorway, donated through the philanthropy of the English-Australian naturalist and physician Dr George Bennet (1804– 1893), is embellished from the inside with coloured glass apertures depicting the coat of arms of a select group of celebrated 19th century medical practitioners.9 The third window to the right commemorates Paget by name and escutcheon (Figure 3). Like many 19th century practitioners, Sir Thomas Anderson Stuart held Paget in high esteem. In 1881 he had the good fortune to hear Paget’s Presidential Address at the 7th International Medical Congress in London and in 1891, during another trip to England, Anderson Stuart found himself dining with Paget at Sir Andrew Clark’s (1826–1893) residence.10
Australian plants
Figure 3. The Paget and Jenner Window in Sydney University Medical School’s Anderson Stuart Building is a pleasant reminder of Paget’s influence on Australian medicine. Image supplied and reproduced with kind permission of Clive Jeffrey (Sydney University Anatomy Teaching and Technical Support Unit).
Beyond Australia’s medical schools, Paget is further commemorated in a special group of Australian plant species found in the rainforests of Eastern Australia.11 The eponymous Pagetia species presents a group of small to medium subcanopy trees that inhabit an area from Cape York to north east New South Wales. Pagetia trees were first discovered and named in 1866 by the famed German-Australian physician and Botanist Sir Ferdinand Jacob Heinrich von Mueller (1825–1896), himself an ardent admirer of Paget. The genus he named Pagetia is taxonomically synonymous with Bosistoa and consist of three species – P. monostylis, P. dietrichiae and P. medicinalis (Figure 4); each may serve as an enduring reminder of Paget’s horticultural interests. Paget became a fellow of the Linnean Society in 1872 and attributed many life successes to his early pursuit of botany. In 1885 he donated some 800 plants from his private collection that now make up the Paget Herbarium at the Norwich Castle Museum.12 A further 29 of his specimens are on display in the Geldart
Herbarium at the same institution. Pearn11 has summarised Paget’s botanical legacy in A Doctor in the Garden. Another Australian doctor who came to be involved with Paget’s legacy was Shirley Dallas Roberts-Nelson (1927–2011) of Melbourne, Victoria (Figure 5).13 As Director of Radiology at Prince Henry’s Hospital (1962–1987), she effectively transformed its little known radiology department into a highly skilled and efficient unit, comparable to Melbourne’s leading teaching hospitals. Later in her career she took to writing biographies. Her second book, Sir James Paget: The Rise of Clinical Surgery, was published by the Royal Society of Medicine in 1989 as a part of their Eponymists in Medicine series. The biography was illustrated with exclusive images and further ornamented with excerpts from the unpublished Paget family history: The Paget’s of Great Yarmouth, 1800 to 1850, written by Alfred Tolver Paget (1818–1862), James’
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Figure 5. Shirley Dallas Roberts-Nelson (1927–2011), radiologist from Melbourne, Victoria, wrote a biography of Sir James Paget.
Figure 4. The leaves and flowers of the appropriately named Australian plant, Pagetia medicinalis, make part of Paget’s Australian legacy and remind us of his botanical bent.
younger brother and fourth birthday present! Only two other Paget biographies have been found – Stephen Paget’s (1855–1926) Memoirs and Letters (1901) and Sturzaker’s bicentennial biography (2014).
Who named Paget’s disease of the bone? Ellis14 faced this question in his well-received Hunterian Lunchtime Lecture on 4 March 2014 – That’s a very good question, that’s something that’s well worth researching. Serendipitously, this author found an answer in Sir Jonathan Hutchinson’s (1828–1913) 1888 Bradshaw Lecture on the importance of museums in medical education; in relation to rare diseases, Hutchinson states: ‘I will adduce as an instance of this a new disease which has had the good fortune to be observed by one to whom clinical surgery was already under untold obligations, and to be described by him in two essays which are models for us all, not only in the art of seeing and describing what has been seen, but of zealous effort in bringing to a focus all the light that can be got from the
researches of others. I allude, of course, to Osteitis Deformans, a malady which, were it not that the brow of its discoverer wears already so many laurels, we might be tempted to propose should be known as Paget’s disease’.15 Hutchinson’s words were originally cited by Walter Reginald Bett (1903–1968) in 1956.16 Bett was a distinguished physician and medical historian who founded the prestigious Osler Club of London in alliance with Alfred White Franklin (1905–1986) and others in the late-1920s.17 Reading Hutchinson’s suggestion alone, we cannot be sure when the eponym Paget’s disease came into general use but even as early as 1916 Elliot Carr Cutler (1888–1947) spoke of ‘Paget’s disease’ as if the eponym were well established at that stage.18 He even compared it to such legendary eponyms as Addison’s, disease, Parkinson’s disease and Hodgkin’s disease. In the early 1850s Jonathan Hutchinson was one of Paget’s favourite students at St Bartholomew’s Hospital; later, his teacher described him as ‘one of the most industrious observers of cases that I ever knew’.19 No doubt Hutchinson reciprocated his respects and when Paget’s obituary article for the British Medical Journal was due in the first days of 1900, Hutchinson contributed heavy praise in dear memory of his late mentor and friend.
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Conclusion Sir James Paget was a courteous and honourable man. He exemplified exceptionally high standards in both moral and medical spheres and made important contributions to Australian medical education. His influence on Australian medicine has been preserved in antipodean relics, each of which may now be added to his ongoing legacy.
10.
11.
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References and notes 1. Osler W. The Ingersoll lecture 1904: science and immortality, part IV: the Teresians. Boston and New York: Houghton, Mifflin, and Company, 1904, p.37. 2. Personal correspondence with Dr Hugh Sturzaker December 2013–January 2014. Dr Sturzaker kindly sent the author the program schedule and further updated him after the event. 3. Sturzaker H. Sir James Paget: surgeon extraordinary and his legacies. London: New Generation Publishing, 2014, pp.153–161. Dr Sturzaker’s book gives a well-summarised synopsis of Paget’s medical contributions. 4. Osler W. The International Medical Congress. Canada Medical and Surgical Journal 1881; 10: 121–125. 5. Paget J. On residual abscesses. In: Andrew and Callender (eds) St Bartholomew’s Hospital Reports. Vol. V, London: Longmans, Green, and Co, 1869, pp.73–79. 6. Russell KF. The Melbourne Medical School 1862–1962. Carlton: Melbourne University Press, 1977, pp.xi, 15, 16, 25, 26, 206–208. 7. The University of Sydney (2002–2014) Sydney Medical School Online Museum and Archive; Sydney Medical School from 1856 to 1900, http://sydney.edu.au/medicine/ museum/mwmuseum/index.php/ Sydney_Medical_School_Online_Museum_and_Archive. 8. Nixon WJ. The Prince Alfred Hospital; Correspondence with Sir James Paget, Bart., upon the proposed Medical Education scheme. The Sydney Morning Herald, Friday 12 September 1878. 9. McKenzie B. Stained glass and stone: the Gothic buildings of the University of Sydney. Marrickville: Southwood
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Press, 1989, p.110. Published for Sydney University. The Anderson Stuart building’s East window was uncovered only recently. Epps W. Anderson Stuart M.D., physiologist, teacher, builder, organizer, citizen. Sydney: Angus & Robertson, 1922, pp.44, 71. Professor Jonathan Stone of the University of Sydney drew attention to this publication. Pearn JH. A doctor in the Garden, Nomen Medici in Botanicis, Australian Flora and the World of Medicine. Brisbane: Amphion Press, 2001, pp.294–296. Personal correspondence with Dr Tony Irwin, Senior Curator of Natural History at Norfolk Museums and Archaeology Service. Fabrikant H. Obituary: Shirley Dallas RobertsNelson (11 August 1927–20 July 2011). Journal of Medical Imaging and Radiation Oncology 2012; 56: 123–124. Ellis H. Sir James Paget: Surgeon, teacher and clinical observer. Hunterian Museum Lunchtime Lecture delivered 1 pm on Tuesday 4 March 2014 at the Royal College of Surgeons. The audio and transcript of the talk are available online: http://www.rcseng.ac.uk/ museums/hunterian/events/lunchtime-lectures-andevening-talks. Hutchinson J. The Bradshawe Lecture on museums in their relation to medical education and the progress of knowledge. British Medical Journal 1888; 2: 1257–1265. The quote can be found on the bottom left hand of page 1263. Bett WR. Osteitis deformans before and after Paget. Annals of the Royal College of Surgeons of England 1956; 19: 390–393. Lella JW. The Osler Club of London, 1928–1938: young medical gentlemen, their heroes, liberal education, books, and other matter. Canadian Bulletin of Medical History 1995; 12: 313–338. Cutler EC. Sir James Paget and Paget’s disease. Boston Medical and Surgical Journal 1916; 174: 187–192. (Cited by Bett, ref 13). McManus I. Sir James Paget’s research into medical education. Lancet 2005; 366: 506–513.
Author biography Dr Nadeem Toodayan is a resident medical officer from Brisbane, Australia. He enjoys sharing his interest in medical history, which was born of a passion for medical eponyms.
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Original Article
The Paget Bicentenary: An Australian perspective
Journal of Medical Biography 0(0) 1–7 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0967772014533055 jmb.sagepub.com
Nadeem Toodayan
Abstract The year 2014 marks the bicentenary of the birth of Sir James Paget (1814–1899), the celebrated English surgeon and pathologist. Although best known for his work on bone and breast disease, Paget also played an important role in the institution of Australia’s first medical school. In this article, that involvement and Paget’s other antipodean influences are summarised. The naming of Paget’s disease of the bone is also discussed.
Keywords Sir James Paget, bicentenary, antipodean influences, Australian medical education, Paget’s disease of the bone, Paget eponyms
Not by the lips, but by the life, are men influenced in their beliefs1 – Sir William Osler, 1904. On 11 January 2014, members of the profession gathered to commemorate the life and achievements of Sir James Paget (Figure 1). His presence was felt especially in his birth town of Great Yarmouth in Norfolk, UK, where the hospital that bears his name celebrated his life in a well-crafted clinical conference.2 Speakers that day lectured on topics ranging from Paget’s contributions to breast cancer and bone disease to his influence on medical education and clinical surgery. His great grandson, Sir Julian Tolver Paget, 4th Baronet (b. July 1921), delivered a warm account of Paget’s family life and a dinner was held for 200 in Great Yarmouth’s newly refurbished Town Hall. Next morning a civic service was held at Yarmouth Minster where both medical professionals and town locals gathered. Altogether, the Paget bicentenary celebrations were orchestrated by Dr Hugh Gerard Sturzaker (b. 1940), a retired surgeon, Lead Governor to the James Paget University Hospital and long-time partisan of the Paget tradition (Figure 2). In anticipating the Paget bicentenary, Dr Sturzaker wrote the new biography Sir James Paget: Surgeon Extraordinary and His Legacies.3 On 17 January Dr Sturzaker again formally recapitulated Paget’s life and influence at Great Yarmouth’s Time and Tide Museum in his talk titled Sir James Paget: 200 years young. Professor Harold Ellis, who had also presented at the Paget bicentenary conference, lectured on 4 March in Paget’s memory at the Royal
Figure 1. Sir James Paget (1814–1899) in 1881. Photograph by George Milner Gibson Jerrard (1848–1918). Courtesy of the Wellcome Library. Associate Lecturer, University of Queensland School of Medicine, Southern Clinical School; Brisbane, Australia Corresponding author: Nadeem Toodayan, University of Queensland School of Medicine, Southern Clinical School; Brisbane, Australia. Email: [email protected]
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Sir James Paget Timeline
11th January 1814: Born in Great Yarmouth at 59 South Quay. 9th March 1830: Commences surgical apprenceship under Mr. Charles Fisher Costerton (1790-1852). October 1834: Enters St. Bartholomew's Hospital medical school. November 1834: First book published, 'Sketch of the Natural History of Great Yarmouth and its Neighbourhood'. 2nd February 1835: Discovers Trichinia spiralis. 13th May 1836: Passes membership examinaon for the Royal College of Surgeons. April 1837: Appointed curator of St. Bartholomew's Hospital Pathology Museum. 1839: Becomes demonstrator of Morbid Anatomy at St. Barts. 14th April 1841: Elected Surgeon to the Finsbury Dispensary. 1842: Begins to catalogue the pathological secon of the Hunterian Museum at the Royal College of Surgeons. 30th May 1843: Appointed Lecturer in Physiology at St. Barts.
1872: Elected Fellow of The Linnean Society. 1874: 'On Disease of the Mammary Areola Preceding Cancer of the Mammary Gland' published in St. Bartholomew's Hospital reports. 1875: Elected President of the Royal College of Surgeons and the Royal Medico-Chirurgical Society. 14th November 1876: 'On a Form of Chronic Inflammaon of the Bones (Osteis Deformans)' paper presented to the Medico-Chirurugical Society. 13th February 1877: Hunterian Oraon. August 1881: President of the 7th Internaonal Medical Congress in London (when the above photo was taken).*
8th August 1843: First warden to Student College at St. Barts. November 1843: Elected Foundaon Fellow of the Royal College of Surgeons. 23rd May 1844: Married to Lydia North (1826-1895) aer a prolonged 8 years of engagement. January 1847: Elected Professor of Anatomy and Physiology at the Royal College of Surgeons. Arris and Gale lecturer from 1847-1852. February 1847: Becomes Assistant Surgeon at St. Barts. 1849: Completes pathological catalogue of the Hunterian museum. 1851: Elected Fellow of the Royal Society. March 1858: Appointed Surgeon Extraordinary to Queen Victoria (1819-1909). 24th July 1861: Becomes full surgeon at St. Bartholomew’s. 1863: Appointed Surgeon in Ordinary to Albert Edward (1841-1910) the Prince of Wales. April 1869: President of the Clinical Society of London. 1871: Knighted.
* “A thrill of pride must have filled the breast of every Englishman present, at the thought of having, as the representave of the naon, such a gied man” 4 – Sir William Osler on Paget’s presidenal address at the IMC in 1881.
13th December 1882: Inaugural Bradshaw Lecture 'On some Rare and New Diseases'. April 1883: Elected Vice Chancellor of London University. April 1886: Appointed Chairman of the Pasteur Commiee. 1887: President of the Pathological Society of London. 1889: Appointed to Royal Commission on Vaccinaon. May 1894: James and Lydia celebrate their Golden Wedding anniversary; Lydia dies early next year. April 1897: Awarded Honorary Gold Medal of Royal College of Surgeons; the highest honour conferred by the society. 30th December 1899: Dies peacefully at home, a day shy of the new century. 4th January 1900: Funeral at Westminster Abbey; laid to rest by his wife at East Finchley Cemetery.
The Paget Bicentenary 11th January 2014
Timeline. Images reproduced courtesy of the Wellcome Library and East Finchley Cemetery.
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Figure 2. Dr Hugh Sturzaker (left), Sir Julian Tolver Paget (right, aged 92) and Henry Paget (centre) stand for a photograph in Yarmouth minster on Sunday 12 January 2014 during the Paget Bicentenary civic service. They gather around a replica of Sir Joseph Edgar Boehm’s (1834–1890) bust of Sir James Paget, which was produced for the Royal College of Surgeons in 1885. This copy resides in the James Paget University Hospital Museum. Reproduced with permission from Dr Hugh Sturzaker.
College of Surgeons in London; his talk was titled Sir James Paget: Surgeon, Teacher and Clinical Observer. Both Great Yarmouth Minster and the Burrage Centre at the James Paget University Hospital exhibited Paget memorabilia for more than a week and a blue plaque was unveiled on 6 January at the site of Paget’s birthplace at 59 South Quay. Meanwhile in Brisbane, Australia, another personalised tribute was taking form; this time in an educational video titled ‘The Paget Bicentenary’ which was uploaded to Youtube. The timeline summarises significant events defining Paget’s long life and the table displays his most important clinical contributions (Table 1).
Paget’s Antipodean influences The first-ever official medical school in Australia was inaugurated by the University of Melbourne in the first quarter of 1862. The school was established against the odds of disinterest on part of the government, gross opposition from members of the profession and much financial difficulty.6 In fact, it has been said that its inception was made possible only through the iron-willed determination of its founder, Sir Anthony Colling Brownless (1817–1897), himself a physician and then Vice Chancellor of Melbourne University. Brownless had been a student of Paget at St Bartholomew’s Hospital in 1840 and emigrated to Australia in 1852. Knowing firsthand of Paget’s exceptional teaching facility, Brownless eagerly sought his guidance when drafting the foundations for the new faculty. And so it happened that when Hugh Culling Eardley Childers
(1827–1896), ex-Vice Chancellor of the University, left for England in March of 1857, Brownless had him interview Paget in order to attain directly his advice on modelling a world-class medical curriculum. When the two did meet, Paget promised to detail his suggestions in a letter to be addressed to Childers in the near future. Although somewhat postponed in its formulation, the letter eventually was despatched on 9 April 1858 from Paget’s private doors in London at 1 Harewood Place in Hanover Square. Specified in its contents were the prerequisites needed to enter, the length of professional study, the specific subjects to be included and the course of student examinations to be incorporated. By the end of May the letter had been fast-tracked to Melbourne University where the council, now headed by Brownless, thanked Paget for his ‘highly valuable communication’. Based on Paget’s suggestions and Brownless’ dogged determination, the Melbourne Medical School took form in March of 1862. Soon afterwards Paget was again summoned when Brownless wrote to him on 26 March 1862, this time seeking a highly qualified Professor to occupy the Chair of Anatomy, Physiology and Pathology, at the new medical school. As before, Paget was keen to cooperate and, with the assistance of zoologist Sir Richard Owen (1804–1892), proceeded to interview applicants for the important position. The two men endorsed the application of the distinguished English anatomist and physiologist George Britton Halford (1824–1910) who then was to become Melbourne University Medical School’s first full-time lecturer. The medical faculty at the University of Sydney also once sought Paget’s directions but his involvement in the genesis of Sydney Medical School was only brief. The Faculty of Medicine at Sydney University, founded in June of 1856, predates even that of Melbourne University.7 At this time there was no medical school but the institution preserved the right to award both Bachelors’ and Doctors’ degrees in medicine. Plans to erect a medical school were discussed and discarded on more than one occasion. On one of these occasions Sir Alfred Roberts (1823–1898), a distinguished Englishborn Australian surgeon and founding member of Sydney’s Royal Prince Alfred Hospital, personally contacted Paget in a bid to gain approval for a new scheme of medical education at the university. In his letter dated 6 August 1872, Roberts put forth the proposal that a cost-effective medical school could be founded on the principle of one-way student exchange whereby Sydney’s medical students would complete their final two years of training in England.8 The programme would greatly benefit the colony and help facilitate a full-time medical school in the future. In two separate letters Paget replied in the affirmative and suggested the
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Table 1. Summarising many of Sir James Paget’s most important contributions to clinical medicine, listed somewhat in order of importance. Contribution
Year
Summary
Paget’s disease of the bone
1876
A common chronic localised metabolic bone disorder characterised by a rapid turnover rate and disorganised remodelling of bony tissue. Paget named the disease ‘Osteitis Deformans’ when he presented five cases to London’s Medico Chirurgical Society in November 1876. Save the somewhat obvious increased incidence of fractures, little has been added from the clinical side since Paget’s original description.
Paget’s disease of the breast
1874
A rare form of breast cancer characterised by eczematous changes in the skin of the areola and periareolar regions. This usually occurs in the presence of underlying ductal carcinoma in situ or invasive breast cancer. Paget thought the skin changes preceded and produced the malignancy in the breast and, although this is now thought to be incorrect, the importance of Paget’s clinical observation lies in the recognition of the association.
Trichinella spiralis
1835
The parasite that causes trichinosis. Paget discovered the organism as a first year medical student at St Bartholomew’s Hospital while dissecting a cadaver. He noted that the ‘minute whitish specks’, which were often disregarded as bony ‘spiculae’ in the muscle tissue, were in fact ‘cysts containing small worms’. The discovery was aided by Robert Brown’s (1773–1858) microscope. Sir Richard Owen (1804–1892) further detailed the discovery and named the parasite ‘Trichina spiralis’ (which eventually became Trichinella spiralis).
Carpal tunnel syndrome
1853
A compressive neuropathy of the median nerve due to entrapment in the carpal tunnel. Paget was the first to describe the phenomenon in his famous Arris and Gale lectures which were first published in 1853 as his ‘Lectures on Surgical Pathology’.
Osgood-Schlatter disease
1891
Tibial tubercle apophysitis. A common cause for knee pain in preadolescents that is caused by repetitive micro-fractures and tendinous inflammation secondary to repeated traction injury at the level of the tibial insertion of the patellar ligament. Paget gave an unmistakably accurate account of the condition in his final text ‘Studies of Old Case Books’ which was first published in 1891. This was more than a decade before Robert Bayley Osgood (1873–1956) and Carl Schlatter (1864–1934) independently called wider attention to the condition in 1903.
Extramammary Paget’s disease
1874
A rare and often non-invasive intraepithelial adenocarcinoma that usually affects the anogenital region and is histologically very similar to Paget’s disease of the breast. In the same paper, where he described rawness of the mammary areola and breast cancer, Paget briefly commented on ‘a persistent rawness of the glans penis’ preceding cancer of the penis. The actual concept of ‘extramammary Paget’s disease’ was first introduced by Henry Radcliffe Crocker (1846–1909) in 1889.
Paget-Schroetter syndrome
1866
Spontaneous or effort-induced thrombosis of the axillary or subclavian veins causing pain and engorgement of the affected arm. Paget first described the clinical features of this condition in 1866. In 1901, Leopold von Schroetter (1837–1908) suggested that the condition occurrs secondary to occlusive thrombosis of the deep veins of the upper limb.
Osteochondritis dissecans
1870
A relatively uncommon disease of the joints that occurs in the setting of subchondral bony infarction. This causes subsequent fragmentation of articular cartilage and surrounding bony tissue. Loose bodies may enter the joint space causing pain and locking of the joint. In 1870 Paget was the first to suggest a vascular insult in the development of the condition. He called it ‘quiet necrosis of the bone’. The term ‘osteochondritis dissecans’ was introduced by Franz Konig (1832–1910) in 1887.
Causalgia
1864
In February of 1864 Paget was the first to allude to the painful ‘glossy fingers’ occurring in partial nerve injury of the upper limb. Weir-Mitchell described the condition more fully in the same year and introduced the term ‘Causalgia’ in 1867.
Paget’s recurrent fibroid tumour
1853
Slow-growing spindle-cell sarcomas that tend to recur after resection. Paget described several cases of the condition in 1853. His histological findings suggest spindle-cell tumours.
Paget’s residual abscess
1869
In a paper produced in the fifth volume of the St Bartholomew’s Hospital Reports, Paget introduced the term Residual Abscess to call wider attention to ‘abscesses formed in or about the residues of former inFammations’.5 Although the term is somewhat outdated, it may continue to be used loosely as an adjunct to more descriptive terminology, at least for historical reasons.
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institution of a barrier exam before a transfer was made. He was fully supportive of the idea and wished Roberts ‘all encouragement and help’. Unfortunately, due to lack of funds the scheme did not come to fruition and had to be abandoned. It would take the generous endowment of John Henry Challis (1806–1880), a highly successful merchant and philanthropist, and the brilliant resourcefulness of a bright young Scottish professor, Sir Thomas Peter Anderson Stuart (1856– 1920), to bring the Sydney Medical School to life in 1883. As in Melbourne, a full-time five year curriculum was initiated and plans for a grand new medical school building soon emerged. Completed in 1889, the Anderson Stuart building, as it later became known, was adorned with beautiful coloured stained glass windows illustrating important historical figures in medicine. The building’s southern doorway, donated through the philanthropy of the English-Australian naturalist and physician Dr George Bennet (1804– 1893), is embellished from the inside with coloured glass apertures depicting the coat of arms of a select group of celebrated 19th century medical practitioners.9 The third window to the right commemorates Paget by name and escutcheon (Figure 3). Like many 19th century practitioners, Sir Thomas Anderson Stuart held Paget in high esteem. In 1881 he had the good fortune to hear Paget’s Presidential Address at the 7th International Medical Congress in London and in 1891, during another trip to England, Anderson Stuart found himself dining with Paget at Sir Andrew Clark’s (1826–1893) residence.10
Australian plants
Figure 3. The Paget and Jenner Window in Sydney University Medical School’s Anderson Stuart Building is a pleasant reminder of Paget’s influence on Australian medicine. Image supplied and reproduced with kind permission of Clive Jeffrey (Sydney University Anatomy Teaching and Technical Support Unit).
Beyond Australia’s medical schools, Paget is further commemorated in a special group of Australian plant species found in the rainforests of Eastern Australia.11 The eponymous Pagetia species presents a group of small to medium subcanopy trees that inhabit an area from Cape York to north east New South Wales. Pagetia trees were first discovered and named in 1866 by the famed German-Australian physician and Botanist Sir Ferdinand Jacob Heinrich von Mueller (1825–1896), himself an ardent admirer of Paget. The genus he named Pagetia is taxonomically synonymous with Bosistoa and consist of three species – P. monostylis, P. dietrichiae and P. medicinalis (Figure 4); each may serve as an enduring reminder of Paget’s horticultural interests. Paget became a fellow of the Linnean Society in 1872 and attributed many life successes to his early pursuit of botany. In 1885 he donated some 800 plants from his private collection that now make up the Paget Herbarium at the Norwich Castle Museum.12 A further 29 of his specimens are on display in the Geldart
Herbarium at the same institution. Pearn11 has summarised Paget’s botanical legacy in A Doctor in the Garden. Another Australian doctor who came to be involved with Paget’s legacy was Shirley Dallas Roberts-Nelson (1927–2011) of Melbourne, Victoria (Figure 5).13 As Director of Radiology at Prince Henry’s Hospital (1962–1987), she effectively transformed its little known radiology department into a highly skilled and efficient unit, comparable to Melbourne’s leading teaching hospitals. Later in her career she took to writing biographies. Her second book, Sir James Paget: The Rise of Clinical Surgery, was published by the Royal Society of Medicine in 1989 as a part of their Eponymists in Medicine series. The biography was illustrated with exclusive images and further ornamented with excerpts from the unpublished Paget family history: The Paget’s of Great Yarmouth, 1800 to 1850, written by Alfred Tolver Paget (1818–1862), James’
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Figure 5. Shirley Dallas Roberts-Nelson (1927–2011), radiologist from Melbourne, Victoria, wrote a biography of Sir James Paget.
Figure 4. The leaves and flowers of the appropriately named Australian plant, Pagetia medicinalis, make part of Paget’s Australian legacy and remind us of his botanical bent.
younger brother and fourth birthday present! Only two other Paget biographies have been found – Stephen Paget’s (1855–1926) Memoirs and Letters (1901) and Sturzaker’s bicentennial biography (2014).
Who named Paget’s disease of the bone? Ellis14 faced this question in his well-received Hunterian Lunchtime Lecture on 4 March 2014 – That’s a very good question, that’s something that’s well worth researching. Serendipitously, this author found an answer in Sir Jonathan Hutchinson’s (1828–1913) 1888 Bradshaw Lecture on the importance of museums in medical education; in relation to rare diseases, Hutchinson states: ‘I will adduce as an instance of this a new disease which has had the good fortune to be observed by one to whom clinical surgery was already under untold obligations, and to be described by him in two essays which are models for us all, not only in the art of seeing and describing what has been seen, but of zealous effort in bringing to a focus all the light that can be got from the
researches of others. I allude, of course, to Osteitis Deformans, a malady which, were it not that the brow of its discoverer wears already so many laurels, we might be tempted to propose should be known as Paget’s disease’.15 Hutchinson’s words were originally cited by Walter Reginald Bett (1903–1968) in 1956.16 Bett was a distinguished physician and medical historian who founded the prestigious Osler Club of London in alliance with Alfred White Franklin (1905–1986) and others in the late-1920s.17 Reading Hutchinson’s suggestion alone, we cannot be sure when the eponym Paget’s disease came into general use but even as early as 1916 Elliot Carr Cutler (1888–1947) spoke of ‘Paget’s disease’ as if the eponym were well established at that stage.18 He even compared it to such legendary eponyms as Addison’s, disease, Parkinson’s disease and Hodgkin’s disease. In the early 1850s Jonathan Hutchinson was one of Paget’s favourite students at St Bartholomew’s Hospital; later, his teacher described him as ‘one of the most industrious observers of cases that I ever knew’.19 No doubt Hutchinson reciprocated his respects and when Paget’s obituary article for the British Medical Journal was due in the first days of 1900, Hutchinson contributed heavy praise in dear memory of his late mentor and friend.
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Conclusion Sir James Paget was a courteous and honourable man. He exemplified exceptionally high standards in both moral and medical spheres and made important contributions to Australian medical education. His influence on Australian medicine has been preserved in antipodean relics, each of which may now be added to his ongoing legacy.
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References and notes 1. Osler W. The Ingersoll lecture 1904: science and immortality, part IV: the Teresians. Boston and New York: Houghton, Mifflin, and Company, 1904, p.37. 2. Personal correspondence with Dr Hugh Sturzaker December 2013–January 2014. Dr Sturzaker kindly sent the author the program schedule and further updated him after the event. 3. Sturzaker H. Sir James Paget: surgeon extraordinary and his legacies. London: New Generation Publishing, 2014, pp.153–161. Dr Sturzaker’s book gives a well-summarised synopsis of Paget’s medical contributions. 4. Osler W. The International Medical Congress. Canada Medical and Surgical Journal 1881; 10: 121–125. 5. Paget J. On residual abscesses. In: Andrew and Callender (eds) St Bartholomew’s Hospital Reports. Vol. V, London: Longmans, Green, and Co, 1869, pp.73–79. 6. Russell KF. The Melbourne Medical School 1862–1962. Carlton: Melbourne University Press, 1977, pp.xi, 15, 16, 25, 26, 206–208. 7. The University of Sydney (2002–2014) Sydney Medical School Online Museum and Archive; Sydney Medical School from 1856 to 1900, http://sydney.edu.au/medicine/ museum/mwmuseum/index.php/ Sydney_Medical_School_Online_Museum_and_Archive. 8. Nixon WJ. The Prince Alfred Hospital; Correspondence with Sir James Paget, Bart., upon the proposed Medical Education scheme. The Sydney Morning Herald, Friday 12 September 1878. 9. McKenzie B. Stained glass and stone: the Gothic buildings of the University of Sydney. Marrickville: Southwood
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Press, 1989, p.110. Published for Sydney University. The Anderson Stuart building’s East window was uncovered only recently. Epps W. Anderson Stuart M.D., physiologist, teacher, builder, organizer, citizen. Sydney: Angus & Robertson, 1922, pp.44, 71. Professor Jonathan Stone of the University of Sydney drew attention to this publication. Pearn JH. A doctor in the Garden, Nomen Medici in Botanicis, Australian Flora and the World of Medicine. Brisbane: Amphion Press, 2001, pp.294–296. Personal correspondence with Dr Tony Irwin, Senior Curator of Natural History at Norfolk Museums and Archaeology Service. Fabrikant H. Obituary: Shirley Dallas RobertsNelson (11 August 1927–20 July 2011). Journal of Medical Imaging and Radiation Oncology 2012; 56: 123–124. Ellis H. Sir James Paget: Surgeon, teacher and clinical observer. Hunterian Museum Lunchtime Lecture delivered 1 pm on Tuesday 4 March 2014 at the Royal College of Surgeons. The audio and transcript of the talk are available online: http://www.rcseng.ac.uk/ museums/hunterian/events/lunchtime-lectures-andevening-talks. Hutchinson J. The Bradshawe Lecture on museums in their relation to medical education and the progress of knowledge. British Medical Journal 1888; 2: 1257–1265. The quote can be found on the bottom left hand of page 1263. Bett WR. Osteitis deformans before and after Paget. Annals of the Royal College of Surgeons of England 1956; 19: 390–393. Lella JW. The Osler Club of London, 1928–1938: young medical gentlemen, their heroes, liberal education, books, and other matter. Canadian Bulletin of Medical History 1995; 12: 313–338. Cutler EC. Sir James Paget and Paget’s disease. Boston Medical and Surgical Journal 1916; 174: 187–192. (Cited by Bett, ref 13). McManus I. Sir James Paget’s research into medical education. Lancet 2005; 366: 506–513.
Author biography Dr Nadeem Toodayan is a resident medical officer from Brisbane, Australia. He enjoys sharing his interest in medical history, which was born of a passion for medical eponyms.
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