The neglected classic and the forgotten hero

By Richard Newell

Now that eponyms are out of fashion the term
‘ligament of Humphry’ falls less often on the ear.
It is a very small thing to remember him by, when
there is so much more.

- Professor E W Walls¹

In the year 1858 John W Parker and Son published the book Anatomy Descriptive and Surgical. Its author was the 31-year-old Henry Gray, Lecturer in Anatomy, St. George’s Hospital, London and Surgeon to the St. George’s and St. James’ Dispensary, Golden Square. The copious and high quality illustrations were wood engravings made from drawings by Gray’s colleague at St. George’s, Henry Vandyke Carter. The drawings were from dissections made ‘jointly by the author and Dr Carter’^2,3. Apart from a harsh and very critical anonymous review in the Medical Times and Gazette⁴, the book was well received and went on to become the classic and internationally famous text Gray’s Anatomy, now in its 42nd edition.

In the same year, Macmillan and Co. published the book A Treatise on the Human Skeleton (Including the Joints). Its author was the 38-year-old George Murray Humphry, Surgeon to Addenbrooke’s Hospital, Cambridge. The illustrations, again of very high quality, were lithographs “all drawn upon stone, from nature, by my wife; and, in most instances, from specimens prepared, for the purpose, by myself”⁵. I have been unable to discover any reviews of the book from its time of publication, but it was widely praised in the detailed obituaries and tributes paid to Humphry at the end of his long life. It was described as “one of the very best books in surgical literature”⁶ and “a most remarkable and original work… full of scientific inquiry and observation. No part of this book was of greater value than the sections treating of the joints and their mechanism, which he treated in a masterly and philosophic manner”⁷ . The Lancet obituarist felt that “His great work on the ‘Human Skeleton’ established for him a world-wide reputation as an anatomist of great learning and also of great originality”⁸. A memorial article in the St. Bartholomew’s Hospital Reports described “his profound and philosophical treatise on the Human Skeleton. No one can read this without a deep sense of the care and sagacity of the author, and of his truthfulness and learning”⁹. Rolleston (1932) in his history of the Cambridge Medical School said that the Treatise “was the outcome of many years” work. It was one of the earliest attempts to bring human anatomy into line with scientific morphology, made the dry bones live, and no doubt helped to secure his election as a fellow of the Royal Society in 1859”¹⁰ .

The book never went into a second edition, but Humphry’s own ‘working copy’ of the first edition, with his notes for a projected second, now resides in the rare books room of the Cambridge University Library.

Also in the year 1858, on June 25th, Sir Robert Jones was born, in Rhyl, North Wales¹¹.

The aims of this essay

Firstly, to stimulate a new interest amongst orthopaedic surgeons in George Murray Humphry’s major published text, A Treatise on the Human Skeleton (Including the Joints) – a neglected classic.

Secondly, to record and evaluate the contribution of Humphry to musculoskeletal clinical anatomy and to our understanding of joint function, and to restore to Humphry due recognition for his numerous and neglected original observations of importance to clinical orthopaedics today.

Thirdly, to consider the now little-recognised status of Humphry as a surgeon, as a clinical teacher and examiner, as a keen morbid anatomist, as a pioneer of university medical education and of efficient and effective hospital design, and even as an early advocate of the clinical importance of epidemiological studies.

Much appreciated and lauded in his time, George Murray Humphry is now a forgotten hero.

The structure of the essay

The essay will initially concentrate on a discussion of the content and the original contributions of the Treatise to orthopaedic knowledge and understanding – The Book.

It will then pass on to a short review of the professional life of Sir George Murray Humphry and an assessment of his place in the history of surgery, anatomy and medical education – The Man.

Finally we will bring together The Book and The Man and express the hope that both will recover their deserved recognition.

The Book

In his Preface to the Treatise, Humphry, referring to his habits when lecturing or teaching orally on the skeleton, says “I also added such information – physical, physiological, pathological, and practical – as I had been able to gather, from my own observation and researches, and which was likely to be useful and to excite an interest in the subject. The additional information, thus collected, forms, in great part, the material of the present volume;”¹²

In this essay we shall follow Humphry’s own groupings:

1. The physical - the anatomical contribution.
2. The physiological - its treatment of the physiology of joint function.
3. The pathological and practical - its many observations of clinical importance.

The anatomical contribution

In his Preface, Humphry points out that the volume “….is not…intended as a substitute for any of the existing manuals of anatomy; but is, rather, supplementary to them”¹³.

It is, nevertheless, a beautifully and elegantly written account of all aspects of skeletal anatomy, including embryological, developmental and comparative anatomy in each chapter, with a separate final chapter on the homology of the skeleton. The text is admirably complemented by the very clearly reproduced and conveniently placed lithographic illustrations.

The physiological content

The detailed function of all the major synovial joints, and indeed of some of the smaller ones, is I believe unprecedented in a textbook of this nature. This aspect will be further considered below in the section on the clinical importance of the work.

There is a separate chapter on ‘Standing, Walking and Running’ which contains an approach to gait analysis and joint dynamics little seen for another hundred years¹⁴.

The clinical importance

The book contains so many observations and correlations of clinical and pathological significance that it would be impossible in an essay of this length to list them all. They will therefore be considered and discussed under the regional anatomical groupings of Spine, Hand, Proximal Femur, Knee and Foot, taking examples from each region.

The spine

The chapter on the spine is comprehensive, dealing with everything from development and biomechanics to injuries and deformities. The illustrations include those of the developing spine at various ages: such illustrations do not appear in contemporary or later ‘standard works’ on human osteology^15,16.

In a footnote in the spinal section, Humphry described how while travelling in Germany he found four specimens in the Museum at Bonn “in which the arch of the fifth lumbar vertebra is separate from the articulating processes” and another in which “it is separate on one side, the spinous process being also cleft, so that one half of the arch is loose”. This note has been claimed to represent the first description of spondylolysis in English¹⁷.

Elsewhere in the chapter there are illustrated descriptions of the intervertebral discs including reference to fibre direction in the annulus and to their meagre and peripherally placed blood supply¹⁸.

Humphry discusses the pathological anatomy and deformity present in scoliosis ^19,20, emphasising the prime importance of vertebral rotation in producing the deformity. He is perhaps the first to suggest that the vertebrae are particularly subject to deforming forces in areas where they remain cartilaginous during growth and development.

The hand

Humphry was probably the first to describe the ‘tripartite hand and wrist’ as a functional entity²¹.

He described in detail the anatomy and the types of dislocation of the thumb and its joints, including the anatomy and pathology of the volar plate²².

He may also be the first in the English literature to draw attention to the high prevalence of enchondromata in the long bones of the hand²³.

The proximal femur

Humphry had a long-standing interest in the internal architecture of the proximal end of the femur. The trabeculae in the cancellous bone are clearly delineated in the Treatise²⁴. Koch (1917) credited Humphry as being the first to recognise the orthogonal relationship between the trabeculae²⁵. Andrew Dixon had observed as far back as 1910²⁶ that the generally accepted two-dimensional interpretations of proximal femoral architecture were simplified sectional profiles of three-dimensional structure. This seems to have been largely ignored at the time, but in the Treatise Humphry had already recognised the true directions and relationships of the bony plates which came together to form a series of supportive arches for the femoral neck^27,28. Both in the Treatise and in later work Humphry related the internal structure of the femoral neck to fracture in old age²⁹.

The knee

It is perhaps in the surgical anatomy, physiology and pathology of the knee joints that Humphry’s greatest and most neglected ‘orthopaedic contributions’ are found.

He discussed patellofemoral biomechanics³⁰ but his most prescient and original writings deal in particular with the four major ligaments of the tibiofemoral joint. In addition to meticulous anatomical description and detailed accurate illustrative records of his own dissections, Humphry recognised the individual and variously combined roles of the cruciate and collateral ligaments in knee function and especially in the control of rotation³¹. He describes his own individual investigations of the ligaments involving the effects of their section in anatomical preparations³². He was probably the first to recognise the presence and functional importance of separate bands of fibres within the anterior cruciate ligament³³. He gives the most detailed and well-illustrated descriptions to date of the menisci, and recognises the condition of ‘internal derangement of the knee’ (attributing the term to Hey in 1803) though he appears unaware that menisci could tear³⁴.

Finally it is in the knee that Humphry’s eponymous ligament is to be found. He describes it³⁵ as an attachment from the ‘external semilunar cartilage’ to the ‘posterior crucial ligament’, some of its fibres passing into the hinder part and others into the fore part of the ligament. The attachments are also illustrated in his Plate LIII. It is interesting that Humphry is describing a ligament passing both sides of the posterior cruciate and inserting into it. It is not clear how the eponym has become attached to only the anterior part of this ligament – now the ‘anterior meniscofemoral ligament’, while the posterior portion has acquired the eponym of Wrisberg. Current descriptions of both these ligaments describe their insertion into the lateral surface of the medial femoral condyle rather than into the posterior cruciate.

The foot

Here again Humphry gives his usual clinically applied consideration to individual bones and to the understanding of the arches of the foot³⁶, accompanied by an account of the anatomy and biomechanics of the subtalar complex³⁷. He also recognised the detailed structure of the midtarsal joint, with comments on the pathological anatomy of ‘flat foot’³⁸. Edmund Shephard only discovered the work of Humphry after publishing his 1951 paper on tarsal movements³⁹ and later told the author that he thought that Humphry had ‘almost said it all’⁴⁰.

At the very end of his chapter on the foot, Humphry gives what must be one of the earliest descriptions of hallux valgus with bunion⁴¹.

Accessibility of the Treatise

Some of the larger reference libraries and a falling number of medical school libraries still hold copies of the Treatise. As stated above, the ‘definitive’ copy (Humphry’s own, with his notes) is held by the Cambridge University Library. Copies sometimes appear on the antiquarian book market.

In 2015 a facsimile copy was published in the Classic Reprint Series by a company known as Forgotten Books⁴².

The Man

George Murray Humphry was born on July 18th 1820 in Sudbury, Suffolk. His father was a barrister, as was one of his brothers. Another brother became vicar of St. Martin’s-in-the-Fields. In 1836 he was apprenticed to JG Crosse, surgeon at the Norfolk and Norwich Hospital, said to be “one of the finest operating surgeons in England”⁸. In 1839 he went to St. Bartholomew’s Hospital, qualified MRCS Eng in 1841 and LSA in 1842. In the same year he was appointed Surgeon to Addenbrooke’s Hospital, Cambridge, at 22 the youngest hospital surgeon in Great Britain¹⁰. After his appointment he worked in and around Cambridge as a general practitioner/surgeon, reaching his patients on horseback. In 1844 he was elected one of the original fellows of the Royal College of Surgeons of England. In 1852 he passed the Cambridge MB, proceeding in 1859 to his MD. The Treatise was published in 1858, and Humphry became a Fellow of the Royal Society in 1859. The book “no doubt helped to secure his election”¹⁰.

In 1849 he married Mary McNab, a surgeon’s daughter who was an artist and illustrated the Treatise. They had a daughter and a son. Theirs was a happy and famously hospitable family home.

In 1866, while continuing his surgical practice, he was appointed the first Professor of Anatomy in Cambridge, a chair he held until becoming the (unpaid) first Professor of Surgery there in 1883. In Cambridge he became an honorary fellow of Downing in 1869 and a professorial fellow of King’s in 1884. He gave the Rede’s Lecture in 1880 (the only surgeon so honoured).

At the Royal College of Surgeons of England he was a Member of Council (1864-1884), a member of the Court of Examiners (1877-1887), Arris and Gale Lecturer in 1872 and 1873, and Hunterian Lecturer in 1879. He declined nominations for Vice-President and President because the appointments would have interfered too greatly with his work in Cambridge.

He was President of the British Medical Association, of the Anatomical Society of Great Britain and Ireland, and of the Pathological Society of London.

He was knighted in 1891, and died in Cambridge on September 24th 1896.

He was a slightly-built man with thick, dark hair and a substantial full beard. He was never in robust health, but worked extremely hard and became a charismatic and much loved and respected teacher of clinical surgery and of anatomy.

As a surgeon, he worked in Addenbrooke’s Hospital for 52 years. He undertook the standard operations of a 19th century district general surgeon. He was a pioneer of resection of the knee joint. He did not follow Lister; he managed wounds open or with soft dressings, and agreed with John Hilton – to whom he gave an eulogy at the end of his Hunterian lecture⁴³ – about the importance of rest and supporting natural healing. In January 1847 he performed the first operation under general anaesthesia at Addenbrooke’s (a finger amputation), only a few months after Liston. Humphry stressed thoughtful preparation in surgery. In his address ‘On taking pains’, given at a St. Thomas’ Hospital prizegiving, he said: “All great operators…consider beforehand the plan of the their operations, the instruments they will require, the difficulties they are likely to encounter, and the means they will employ to meet them”, giving Wellington and Nelson as exemplars of such an approach⁴⁴.

As a clinical teacher, he was a keen follower of Hunter, advising careful observation and thought in clinical practice. He introduced clinical lectures, bedside teaching and oral examination of his students. As an experienced examiner himself, Humphry was very aware of the current prevalence of facts without clinical relevance that students were forced to learn rather than observing and thinking for themselves. In teaching clinical diagnosis, Humphry’s own motto was “Eyes first and much, fingers next and less, tongue last and least”⁴⁵, – perhaps pre-empting Alan Apley’s principle of orthopaedic examination “Look, Feel and Move”. In the same address, after repeatedly emphasising the importance of ‘taking pains’, Humphry, paraphrasing Spinoza’s final words in his Ethics (1677), concluded “It is not easy to do anything well”.

Humphry established a Pathology Museum in Cambridge, often supplying it with material collected on his ‘holiday travels’ in Europe. Following Hunter, he recognised that “pathology is the keystone of surgery, resting upon a wide reaching study of physiology, on the one side, and careful clinical observation on the other”⁴³.

Humphry was an enthusiastic early advocate of the gathering of large groups of medical data to improve the understanding and treatment of disease – an early epidemiologist. Such work – on the ‘collective
investigation of disease’⁴⁶ – makes him a forerunner of Archie Cochrane⁴⁷.

Finally, due credit must be given to Humphry as the true founder and developer of the Cambridge University Medical School, and for establishing Addenbrooke’s Hospital as a clinical and surgical centre in the late 19th century. In both Rolleston’s The Cambridge Medical School¹⁰ and in Rook’s History of Addenbrooke’s Hospital, Cambridge⁴⁸ he is given a whole chapter under his name.

Summation

The main purpose of this essay is to encourage not only historians of medicine but working surgeons to give a new lease of life to an elegantly written and illustrated work, full of thoughtful and practical clinical observation as well as anatomical detail – a much neglected work, born in the same year as Gray’s Anatomy and as Sir Robert Jones.

Secondly it endeavours to celebrate the ground-breaking body of work in so many areas of medicine, its practice and teaching, accomplished by its author Sir George Murray Humphry, famous in his later career but now almost forgotten. Like Sir Astley Cooper and John Hilton, he was a true clinical anatomist, a memorable teacher and a working surgeon.

References

1. Walls EW (1966) Journal of Anatomy 100, 3.
2. Gray, H (1858) Anatomy Descriptive and Surgical. London: John W Parker and Son; title page.
3. Richardson, Ruth (2008) The Making of Mr.Gray’s Anatomy. Oxford: Oxford University Press.
4. Medical Times and Gazette (1859) March 5th, 241-244.
5. Humphry, GM (1858) A Treatise on the Human Skeleton. Cambridge: Macmillan and Co.; preface, p.vi.
6. ‘Two Great Surgeons’.(1896) Lancet Oct 3rd.
7. British Medical Journal (1896) Oct 3rd. Obituary: Sir George Murray Humphry p977.
8. Lancet (1896) Oct 3rd. Obituary: Sir George Murray Humphry p.965.
9. Lockwood CB (1897) In Memoriam, Sir George Murray Humphry. St.Bartholomew’s Hospital Reports XXXII pxxxi-xxxvii.
10. Rolleston Sir H (1932) The Cambridge Medical School: a biographical history. Cambridge: Cambridge University Press. p68.
11. Waugh W (1993) A History of the British Orthopaedic Association.London: The British Orthopaedic Association p47.
12. Humphry GM (1858) A Treatise on the Human Skeleton. Cambridge: Macmillan and Co. preface p.v.
13. Ibid. p.v.
14. Joseph J (1960) Man’s Posture. Springfield: Charles C. Thomas.
15. Holden L (1869) Human Osteology. London: John Churchill and Sons. 4th edition.
16. Frazer JE (1948) The Anatomy of the Human Skeleton. London: J & A Churchill Ltd. 4th edition.
17. Newell RLM (1995) Spondylolysis: an historical review. Spine 20:1950-1956.
18. Humphry GM (1858) A Treatise on the Human Skeleton. Cambridge: Macmillan and Co. pp 159,161.
19. Ibid. p 171.
20. Ibid. p 356.
21. Ibid. p 389.
22. Ibid. pp 432-436.
23. Ibid. p 397.
24. Ibid. Plate XXXVIII.
25. Koch JC (1917) The laws of bone architecture. Amer J Anat. 21:177-298.
26. Dixon AF (1910) The architecture of the cancellous tissue forming the upper end of the femur. J Anat Physiol. 44:223-230.
27. Humphry GM (1858) A Treatise on the Human Skeleton. Cambridge: Macmillan and Co. p474.
28. Newell RLM (1997) The calcar femorale: a tale of historical neglect. Clinical Anatomy 10:27-33.
29. Humphry GM (1889) Old Age. Cambridge: Macmillan and Bowes.
30. Humphry GM (1858) A Treatise on the Human Skeleton. Cambridge: Macmillan and Co. pp 478-480.
31. Ibid. pp 523-551.
32. Ibid. pp 537, 544.
33. Ibid. p538.
34. Ibid. p547.
35. Ibid. p546.
36. Ibid. pp 492-496.
37. Ibid. pp 561-567.
38. Ibid. pp 567-572.
39. Shephard E (1951) Tarsal movements. J Bone & Joint Surg. 33B:258-263.
40. Shephard E. (2001) Personal communication.
41. Humphry GM (1858) A Treatise on the Human Skeleton. Cambridge: Macmillan and Co. p577.
42. www.forgottenbooks.com.
43. Humphry GM (1879) Hunterian Oration. British Medical Journal Feb 25th p264.
44. Humphry GM (1891) On taking pains. British Medical Journal Oct 3rd p742.
45. Ibid. p743.
46. Humphry GM (1889) Old Age. Cambridge: Macmillan and Bowes.
47. Cochrane AL (1972) Effectiveness and Efficiency. Nuffield Provincial Hospital Trust.
48. Rook A, Carlton M, Cannon WG (1991) The History of Addenbrooke’s Hospital, Cambridge. Cambridge: Cambridge University Press. Chapter 13.