Berger, L

Chaplin, S

Donoghue, HD

Pinhasi, R

Spigelman, M

English

M Spigelman

L Berger

R Pinhasi

HD Donoghue

S Chaplin

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John Hunter's post-mortem examination of George Grenville (1712–1770)

UCL Discovery

338The Hunterian Museum at TheRoyal College of Surgeons ofEngland contains approximately3,500 specimens of human andcomparative anatomy and pathologycollected by the surgeon, JohnHunter (1728–1793). A significantpart of the collection comprisespathological specimens. Theseinclude specimens removed duringsurgery or as incidental findingsfrom anonymous bodies beingdissected during anatomicalteaching. However, the majoritycomes from the bodies of patientson which Hunter performed post-mortem examinations. Theseinclude patients at St George’sHospital, where Hunter worked as asurgeon from 1768 until his death.A surprising number also comefrom the bodies of privatepatients.1,2 These were presumablyremoved with consent, at autopsiesthat would have taken place in thepatient’s own home and often withthe patient’s family or friendspresent.Ann R Coll Surg Engl(Suppl) 2008; 90:338–339Among the specimens are a calvaria, aportion of rib,t he distal part of the lefthumerus and the proximal third of theright femur from the former primeminister,G eorge Grenville,w ho died on13 November 1770 (RCSHC/P 844-7).Although details of many of these post-mortem examinations are included inHunter’s notes there is no record ofGrenville’s case.3 As a surgeon and at thatstage a relatively unknown practitioner,John Hunter is unlikely to have beenemployed directly by Grenville.I t ispossible that this case was one of severalin which John Hunter was asked toperform an examination at the request ofthe physician John Pringle (1707–1782).Pringle’s casebooks are preserved in theRoyal College of Physicians of Edinburgh.The collection has only recently beenopened to researchers and further studymay yet reveal a connection withGrenville’s case.Whatever the terms under which Huntercarried out the autopsy the resultsappear to have been widely disseminated.The Annual Register for 1770 recordedGrenville’s death, adding that ‘When hisbody was opened, the blood vessels inthe head were nearly empty; the ribbones on one side rotten, and two on theother side the same’.4 Hunter’s assistantWilliam Bell later prepared drawings ofthe calvaria, rib and humerus(RCSSC/HDB/4/1/361a-b). A noteappended to these drawings describesthem as ‘Bones of the HonourableGeorge G-’, adding that ‘many more werefound in the same condition uponopening the body,w here in place of thebone that was gone was a curdily [sic]substance’. It also records that thehumerus was fractured before death(RCSSC/HDB/4/1/360A).In contrast with modern practice,J ohnHunter appears to have had few qualmsabout revealing the identity of thepatients whose organs or tissues werepreserved in his collection. From 1785until his death Hunter’s collection wasdisplayed in a purpose-built museumbehind his house in Leicester Square.In1799 the collection was purchased by thegovernment and presented to theCompany (now the Royal College) ofSurgeons. During the 19th centuryHunter’s collection was enlarged throughthe addition of many thousands of newspecimens. As part of this process, thecollection was recatalogued andspecimens anonymised. Only recently hasa major recataloguing project helped torecover some of these hidden identities.The bones of George Grenville are stillpreserved and displayed in the College’sHunterian Museum.Morphologically the appearance of thebones suggests malignancy,w ith multiplemyeloma being the most likely diagnosisthough secondary deposits of a tumourcould not be ruled out with the primarybeing in the lung, prostate or any othertumour capable of spreading to bones;finally military tuberculosis was anotherdisease that could not be convincinglyruled out (Figure 1).The x-ray of the skull, which was done atthe Royal Free Hospital department ofradiology (Figure 2), was characterised bymany purely lytic punched-out lesions ofJOHN HUNTER’S POST -MORTEMEXAMINATION OF GEORGEGRENVILLE (1712–1770)M Spigelman1 Visiting ProfessorL Berger2 Consultant RadiologistR Pinhasi3 Lecturer in Prehistoric ArchaeologyHD Donoghue1 Senior Lecturer in MedicalMicrobiologyS Chaplin4 Director of Museums and SpecialCollections1Centre for Infectious Diseases andInternational Health, Department of Infection,Windeyer Institute of Medical Sciences, UCL,London2Royal Free Hospital London3Department of Archaeology, UniversityCollege Cork, Ireland4Hunterian MuseumSURGICAL HISTORY IDOI: 10.1308/147363508X337163John Hunterbulletin november 2008.qxp 14/10/2008 10:49 Page 338339THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BULLETINvariable size but with many uniformlysmall or raindrop lesions. These are afeature very commonly seen in myelomaand far less commonly in disseminatedmalignancy.T his taken with thewidespread morphologically similarlesions seen throughout the rest of theappendicular skeleton makes a compellingcase for the diagnosis of multiplemyeloma. The presence of so many bonelesions, especially in the absence ofpulmonary, renal or other soft-tissuedisease,m akes tuberculosis extremelyunlikely though it can occasionallyproduce disseminated bone lesions.In order to exclude military tuberculosisas a cause of this pathology we attemptedto find the DNA of the TB bacillus inthese bones. At the time of LordGrenville’s death, if the diagnosis ofmalignant myeloma is correct, it is highlylikely that he was immunocompromised.Therefore,he would have beenparticularly susceptible to tuberculosis,known as ‘the white plague,’ which hadreached epidemic levels in Europefollowing the Industrial Revolution, withdeath rates in London, Stockholm andHamburg approaching 800–1,000 per100,000 population a year.5Therefore,it was thought worthwhile toexplore the possibility and a small pieceof rib from Lord Grenville (P845) wasexamined for the presence of the DNAof the tubercle bacillus. The bone wascrushed in a sterile pestle and mortar and60mg of bone powder was used. Takingstringent precautions againstcontamination, the bone powder wasdemineralised in proteinase K and EDTA;incubated in lysis buffer based onguanidium chloride; subjected tosuccessive freezing in liquid nitrogen andthawing; and the DNA captured ontosilica using a commercial kit (NucliSENS®,bioMérieux UK Ltd, Basingstoke,UK).Eluted DNA was examined for therepetitive target sequence IS6110 by thepolymerase chain reaction, using primersspecific for the Mycobacterium tuberculosiscomplex. No evidence of tuberculosis wasobtained.We can now conclude that havingexcluded tuberculosis as a cause of thelesions, multiple myeloma was responsiblefor the death of Lord Grenville on13 November 1770.References1. Wood S. Two further letters of John Hunter and noteson Rockingham’s last illness from Hunter’s Case Book.Ann R Coll Surg Engl 1949; 5: 347–50.2. Dobson J. Some of John Hunter’s patients. Ann R CollSurg Engl 1968; 42: 124–33.3. Allen E, Turk JL, Murley R, eds. The Case Books of JohnHunter FRS.L ondon: Royal Society of Medicine; 1983.4. The Annual Register,o r a View of the History, Politics andLiterature for the Year 1770,6 th edn. London: Printedfor the executors of J Dodsley; 1803. p191.5. Daniel TM. The history of tuberculosis. Respir Med2006; 100: 1,862–70.Figure 1 Skull and rib showing typical myeloma lesions Figure 2 X-ray of skull and rib,c onfirming myeloma lesionsbulletin november 2008.qxp 14/10/2008 10:49 Page 339

Some of John Hunter’s patients.

The Annual Register,o r a View of the History, Politics and Literature for the Year 1770,6 th edn. London: Printed for the executors of J Dodsley;

The history of tuberculosis. Respir Med

Two further letters of John Hunter and notes on Rockingham’s last illness from Hunter’s Case Book. Ann R Coll Surg Engl

John Hunter's post-mortem examination of George Grenville (1712-1770)

John Hunter's post-mortem examination of George Grenville (1712-1770)

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