THE FOUNDATIONS OF BRITISH DERMATOLOGY By H. HALDIN-DAVIS, M.D., OX., F.R.C.S., F.R.C.P.

LONDON, ENGLAND

T was towards the end of the 1. Maculae eighteenth century that there 2. Pustulae began to be felt among physi- 3. Vesiculae cians the necessity for a closer 4. Bullae Istudy of diseases of the skin, which up 5. Papulae to that time, although sufficiently 6. Crustae obvious to the naked eye, were even 7. Squamae less comprehended than other dis- 8. Callositates orders more deeply seated. The first 9. Excrescentiae cutaneae writer to give expression to this feeling 10. Ulcera cutanea was Plenck, who may be regarded as 11. I nsecta cutanea the man who ended the old order and 12. Vulnera cutanea began the new. He published his 13. Morbi unguium “Doctrina de Morbis Cutaneis” in 14. Morbi pilorum Vienna about 1780 and well describes There are no clinical descriptions of the preexisting state of affairs in his special cases, and a more serious preface. He says: defect, Plenck never attempts to The multitude of diseases which afflict define the terms he uses to describe the human skin, their variety, the obscur- the different conditions to enable those ity of the causes from which they spring, reading his descriptions of diseases to the consequent difficulty of curing them, know exactly what he meant. Plenck and their diversity have rendered this branch of medicine and surgery most was far from being a specialist; in the difficult to learners and almost incapable course of his long life—1732-1807— of explanation. The authors whom one he wrote on almost every branch of can consult are few, of whom some have medicine and surgery, from diseases but touched most cursorily upon a of the teeth to those of the female species of disease common at every age, genital organs, including a textbook while others have discussed their diag- of midwifery. He was first professor nosis in vague and uncertain terminology, of anatomy, surgery and midwifery at and have afforded but a doubtful basis of Bale, subsequently professor of chem- treatment. istry and botany at the Military The “Doctrina de Morbis Cu- Academy at Vienna, and had the taneis” is only a slim volume of 138 reputation of being one of the most pages, but it mentions all the then learned doctors of his time. He can- known skin diseases to the number of not be said to have made any great one hundred and fifteen, which are contribution to the knowledge of divided into fourteen classes. From dermatology, but in the little work, the brevity of the work it will be “Doctrina de Cutaneis Morbis,” he readily understood that the descrip- summarized what was known on the tions are terse in the extreme, and subject at the time. In fact, until the directions for treatment are very appearance of Willan, it obtained for meager. The fourteen classes are: its author the reputation of being the greatest authority on cutaneous medi- orders into which he had projected cine. It is evidently written by a clear- his classification, he only completed headed man, but does not bear much the account of the first four. His indication of patient work on the pupil Bateman, however, saved his subject; and there is no doubt that master’s doctrines from oblivion by Plenck, who was a voluminous writer the publication of “A practical synop- and who only produced this single sis of cutaneous diseases, according to short book on skin diseases, could the arrangement of Dr. Willan,” a have taken scarcely more than a book which had an instantaneous suc- passing interest in dermatology. cess, and ran through eight editions in Contemporary with Plenck but less about twenty years. Any inquiry into well remembered was a French physi- the state of dermatology at the begin- cian, Lorry (1725-1783). He pub- ning of the nineteenth century must lished quite a large volume on derma- therefore center around the figure of tology under the name “Tractus de Willan, although there are other indi- Morbis Cutaneis.” It has been sug- viduals who must not be forgotten. gested that his work was forgotten The main facts of Willan’s life are because it was written in Latin, but well-known, and although it is not so was Plenck’s little book. It is more the purpose of this paper to be an probable that it was too diffuse to be essay on Willan, it is as well to reca- useful and that owing to the confusion pitulate them. He was born in York- in terminology then prevalent those shire, educated at Sedbergh school, who attempted to read it found it very practiced in London, and died of obscure. The present writer who has phthisis at Madeira, on April 7, 1812, dipped into it certainly did. Quite in the fifty-fifth year of his age. He recently Lorry’s memory has been was not one of those who are only revived by Dr. Arne Kissmeyer who recognized after death, for he enjoyed has published a short monograph a great reputation among his contem- about him with quotations from his poraries; his pupil, Bateman, wrote writings, and with a preface by the a memoir of him in the Edinburgh celebrated modern French dermatolo- Medical and Surgical Journal, and he gist, Louis Brocq, written shortly has very properly been honored with before his death. Lorry is said to have an article in the ‘‘Dictionary of been the first physician to attempt to National Biography.” Here our pur- correlate the functions of the skin with pose is chiefly to indicate the more those of the other organs of the body. important effects which his writings Modern dermatology may be said had upon the progress of dermatology. really to have been brought into His first great work was the produc- existence by the work of Robert tion of a rational attempt at the Willan at the Carey Street dispensary. classification of skin diseases based A gestation of some eleven or more on characteristic lesions, a work which years culminated in the publication has influenced his successors prac- of Willan’s famous treatise, which was tically down to the present day. The first published in parts from 1798 original paper which embodied his onward, and appeared as a single classification was awarded the Fother- volume in 1808. Even then it was by gillian prize by the Medical Society no means complete, for of the nine of London in 1789, but no copy can now be found. This essay achieved Scurf, scale, scab, stigma, papula, the introduction of order into chaos. rash (exanthema), macula, tubercle, The defects of his predecessors are well wheal, vesicle, bleb (bulla), and pus- described in his own words in the tule. These terms with slight excep- introduction to the volume of cu- tions are used by all dermatologists, taneous diseases published in 1808: even to the present time. The excep- tions are: first the term stigma, They not only give various interpre- defined by Willan as a bright red tations of the accounts left us by the speck in the skin, without any eleva- ancients, but have perverted the sense of tion of the cuticle. This term has quite many passages, especially in the Greek dropped out of use, but he goes on to authors. They employ the same terms in say “when they coalesce, and assume very different significations. They also make artificial and often inconsistent a dark red or livid colour, they are arrangements, some reducing all the termed petechiae.” The term pete- diseases under two or three genera, while chiae is of course still in common use, others, too studious of amplification, but I am not quite certain that Willan apply new names to different stages or used it as a description of a purpuric appearances of the same complaint. lesion. The term tubercle as used by Willan is now obsolete. It is of course The objects set himself by Willan now exclusively employed as the name were: of the lesion which is the naked eye- 1. To fix the sense of the terms unit of tuberculosis, i.e., miliary tuber- employed by proper definitions. cle. As a general term, its place has 2. To constitute general divisions now been taken by the word nodule, or orders of diseases, from leading which is the exact synonym of the and peculiar circumstances in their Willanian “tubercle.” With these appearance, and to describe at large exceptions, the words used by Willan their specific forms or varieties. as the names of the various types of 3. To class and give names to such skin lesions are still current. He also as have not been hitherto sufficiently divided pustules up into four different distinguished. varieties: phlyzacium, psydracium, 4. To specify the mode of treatment achor, and kerion or favus. But these for each disease. Of these four objects, terms have not persisted with the the first and at that time the primary exception of favus, which is now of and urgent dermatological need of the course used to signify a definite moment, Willan accomplished in full. disease, not a type of lesion. I have He pointed out that all manifold examined the illustrations in Willan’s appearances exhibited by diseases of book, but it is difficult to make out the skin could be reduced to the per- exactly what he meant by these terms. mutations and combinations of twelve The second object of a systematic different types of lesion only. These treatise on skin diseases Willan also types accurately determined and de- carried out. He constituted general fined have become the dermatological divisions or orders of the diseases, alphabet for all subsequent physi- “from leading and peculiar circum- cians. Many diseases of the skin are stances in their appearances.” He still commonly described in Willan’s arranged them into distinct genera, terms. These comprise: and he described at large their specific forms or varieties up to a certain Bateman’s “Synopsis of Cutaneous point, but, as is well known, he never Diseases,” are the hair and nails ever lived to complete his work, the task mentioned. Nevertheless, it appears being taken up by his pupil, Thomas probable that Willan’s effort was an Bateman. The classification of skin improvement on Plenck’s, especially diseases Willan considered his great- in his omission of crustae and ulcera est work, and it was that from which cutanea as separate orders. Bateman he derived most credit from his makes the very just criticism that contemporaries. these may be developed from either He divided all cutaneous diseases pustules, vesicles, bullae or even squa- into nine orders: mae; hence the divers varieties of crustae and ulcera cutanea should be 1. Papulae separated from one another, and 2. Squamae grouped according to the primary 3. Exanthemata lesions from which they had arisen, 4. Bullae according as they arose from one of 5. Pustulae these more fundamental classes. Still 6. Vesiculae there is not a great deal to choose 7. Tubercula between Plenck’s classifications and 8. Maculae Willan’s; and yet Willan’s has had by 9. Dermal excrescences. far the greater influence, and was This classification as a matter of fact acclaimed even in his own day with a is not unlike Plenck’s. Of the nine welcome never granted to Plenck. orders of which it consists, no less than The reason for this lies not really in seven are identical with seven of the superiority of Willan’s classifica- Plenck’s first nine orders. The only tion, which as we have seen is some- differences are that Plenck has two what doubtful, but in the fact that orders, (6) crustae and (8) callositates, whereas the study of dermatology which are not mentioned by Willan; formed but a temporary incident in and Willan has (3) exanthemata and Plenck’s life, it was with Willan his (7) tubercula, not mentioned by ruling passion. When once Plenck’s Plenck. The miscellaneous collection little book had reached its second lumped together by Plenck in his edition in 1783, he seems to have lost orders (10) to (14) are also not given all interest in the subject, while by Willan. This can hardly be claimed Willan worked and wrote on it all his as a mark of Willan’s superiority, life. Nor did Willan’s reputation and because these conditions do not appear influence proceed alone from his writ- to have been considered by Willan at ings. He was not a very voluminous all, not even diseases of the hair and author, for he never wrote anything nails, provinces which have since been without long preparation. He exerted always appropriated by dermatology, his great influence, and largely no and which still form convenient, even doubt gained his great reputation if unscientific divisions, in most among his contemporaries by his modern classifications. Neither in Wil- clinical teaching, which he carried on Ian’s own “Treatise on Cutaneous at the Public Dispensary in Carey Diseases,” which as stated was never Street. This was in truth, as Dr. finished, nor in the many editions of Chaplin has pointed out, the first center for post-graduate study in and unmixed, but with the more pre- London, and it was through the pupils dominant appearance there is combined he taught there that his influence a partial eruption of another character; was spread over Britain and the conti- thus, with the papular Strophulus, with nent. It was there that he and suc- the rashes of Measles and Scarlet Fever, and with the pustular impetigo and ceeding generations of physicians first Scabies there is occasionally a mixture of began that patient clinical observation lymphatic vesicles . . . These circum- and study of the manifestations of stances constitute a series of natural disease upon the skin, which has impediments to every attempt at a elucidated what we know up to the methodical arrangement of cutaneous present of the problems of derma- diseases. tology, and which even at the present time can still be fruitfully pursued, Notwithstanding these more or less in- though there are many temptations evitable shortcomings, Willan’s classi- to follow the short cuts to knowledge fication was possessed of the great provided by bacteriology and its allied advantage that it was based on solid sciences. and obvious facts which all could The weak points of Willan’s classifi- observe for themselves, in a word, on cation are manifest and his critics the pathological appearances of skin were not slow to point them out. He diseases. Willan and his pupils always himself, a man of singular modesty, emphasized the importance of fixing was as well aware of them as anybody, on the primary lesions of diseases, not and perhaps the best criticism of his always an easy task in the case of system is to be found in the preface to multiform eruptions, hence numerous Bateman’s synopsis of “Skin discussions arose as to what was the Diseases,” a criticism written by a primary lesion in various dermatoses sympathetic observer and probably which are likely speedily to become inspired by Willan himself. It depends complicated by secondary lesions. In on the fact that diseases of the skin modified form discussions on these are notoriously multiform in their lines are still being continued. At all manifestations, and the same disease, events, to Willan must be given the e.g., scabies, syphilis, or eczema may credit of having introduced order into at different stages in its course give chaos and of having provided a basis rise to papules, vesicles or macules, on which most subsequent attempts hence at one time it will be placed at dermatological classification have according to Willan in one order and been based, and which has influenced sometimes in another. To quote the writings of all his successors. Bateman: But most modern systems of classi- fication are based on causation or . . . the diseases which commence with etiology, not as Willan’s classifica- one generic character are liable occasion- tions necessarily had to be, on patho- ally to assume another, in the course of their progress:—thus some of the papular logical appearances only. But as, even eruptions become scaly, and still more at the present day, our knowledge of frequently pustular if their duration be the etiology of skin diseases is lament- long protracted; . . . Moreover, it fre- ably deficient, except in the case of quently happens, that the characteristic a few infective agencies, we are still forms of eruptive diseases are not pure compelled largely to classify skin diseases according to their appear- The reason for this is that Willan ances. One great advantage we cer- founded his classification upon the tainly have over Willan, namely that facts which he could see with his we are armed with microtomes and own eyes, that is to say, the patho- microscopes, so that in our examina- logical anatomy of disease; while tion of the “leading and peculiar these other and more ambitious classi- circumstances of their appearance” fications were founded on transitory we are not limited to what we can see unstable and accidental resemblances with the naked eye, but can take the and differences in the symptoms and matter at least one step further, i.e., course of the conditions dealt with. into the realm of histology, which The classification of disease in general sometimes demonstrates the essential only began to become more satis- unity in cases where there is a super- factory with the growth of patho- ficial difference, and sometimes shows logical anatomy, firstly as far as it that conditions, which to the naked could be taken with the naked eye, eye are similar, differ radically in and subsequently by the advance of their microscopic anatomy. The at- histological methods. The final and tempts which have been made by logical classification of disease accord- writers since Willan’s time, notably ing to its cause, the etiological method, by Hebra, to classify skin diseases on has only become practicable since the a so-called pathological basis, would advent of bacteriology and proto- better be described as attempts at zoology, which have demonstrated to classification on the basis of micro- us the role of infection. scopic anatomy; for Hebra and others One eighteenth century physician, have had the advantages, denied to C. G. Selle, had the genius to see that Willan, of a knowledge of the micro- the classification of disease must be scopic appearances of the phenomena founded on their nature and causa- of inflammation and of new growth. tion, (or etiology). He put forward It is noteworthy that more or less this idea in his book “Rudimenta contemporary with Willan’s classifi- pyretologiae methodicae” (1789). But cation of skin diseases, many other knowing nothing of the causes of attempts at the classification of disease diseases he attempted to base his in general were made; for example, by classification on their behavior and Cullen and Brown into sthenic and reaction to the various therapeutic asthenic diseases, by Sydenham (a measures adopted for their treatment. century earlier) into a classification In fact he designed a therapeutic on botanical principles into orders, classification. But this basis of classi- genera and species. None of these fication proved quite inadequate and attempts led to any fruitful result, his ideas were never really seriously and they have all become matters of considered. mere antiquarian interest. Willan’s Apart from infections and certain classification is the only one the well-defined poisons, (e.g., lead and influence of which has persisted, and alcohol), an etiological classification even at the present day, although of of disease is still an impossibility, an course necessarily subjected to modi- impossibility shared both by derma- fication owing to the advance of knowl- tology and general medicine. Derma- edge, still is not absolutely out of date. tology has at least the distinction of being the first department of medicine meant to depict. Many of Willan’s into which a scientific as opposed to illustrations will pass this test, and a fanciful or imaginative method of if there are some which will not, it must classification was introduced. be remembered that even in the most modern works illustrations are still Ill us tra ti on to be found which fail to come up to It was only at the beginning of the this standard. nineteenth century, or at the earliest The claim made by Willan that during the last quarter of the eight- illustrations were a novelty in a book eenth, that the importance of illus- in skin diseases is supported by the tration in the description of diseases fact that after an extensive, (although of the skin first began to be realized. I will not say an exhaustive), search This advance we also owe to the among medical periodicals produced genius of Willan. His book, a “Trea- towards the end of the eighteenth tise on Cutaneous Disorders,” was century, I have only been able to find the first book on skin diseases to be one illustration depicting a skin dis- systematically illustrated. Willan him- ease. This illustration is to be found self claims the inclusion of illustra- in the London Medical Journal,1 and tions as a new idea; in fact in his formed the subject of a short paper introduction to the book, he writes of to the Historical section of the Royal it as follows: Society of Medicine.2 The case was one of pemphigus, an affection easier This method is new, and will be at- tended with many advantages, though at to portray than many affections of the same time subject to many imper- the skin, and the author, Mr. Thomas fections. Such drawings cannot suffi- Christie, was well aware of the impor- ciently represent the various degrees of tance of illustrating descriptions of opacity or clearness in pustules or vesicles, skin diseases, for he expressly writes: nor the quantity or quality of the matter “In cutaneous diseases plates ought discharged from superficial ulcerations; to be given for in such cases the most nor can they extend to every minute accurate description falls short of a circumstance in the course of a disease, good drawing.” being usually taken near its acme. The But the most interesting point in engravings, as auxiliaries to the verbal this paper is the footnote on page 367: description, will however be found useful in exhibiting the number, form, size and Since I wrote these remarks, I have colour of Papulae, Pustules, Tubercles, had the pleasure to find that Dr. Willan, Spots, etc, appearances which cannot be an ingenious physician of London, has always clearly communicated in words. taken up the same idea respecting the necessity of having drawings made of the It would indeed be difficult to sum appearance of skin diseases, which I up more clearly the advantages and have so strongly mentioned in this paper. limitations of illustrations to a derma- He has indeed proceeded a great way in tological work, and on the whole the executing this plan, and I hope will soon illustrations to Willan’s own book favour the public with a splendid work on must be accounted successful. The the subject. test of a good illustration is that it 1 Vol. 10: 361, 1789. should be possible to diagnose from 2 Section of History of Medicine, 1922, its inspection the disease which it is Vol. 15; pp. 34-36. This communication from Mr. the principles and practice of medi- Christie, therefore, is additional cine, but without much success. Sub- evidence that the practice of provid- sequently he received as pupils: ing works dealing with skin diseases with illustrations was only introduced . . . young physicians who had re- at or about the beginning of the cently graduated, and who were initiated into actual practice, under his superin- nineteenth century. tendence, among the patients of the Still additional evidence of the institution; a mode of tuition from which novelty of the idea is given by Alibert, they derived much practical knowledge, who in 1806 brought out the first and wrere gradually habituated to the parts of a large and important work on responsibility of their professional duties. skin diseases. The French dermatolo- Upwards of forty physicians, almost all gist says: “In order to facilitate the of whom have subsequently attained understanding of this monograph, I professional reputation, or now occupy have availed myself, the first in France, responsible situations both in this coun- of the help of the artist and engraver.” try and abroad, have received the benefit Alibert was undoubtedly familiar with of this instruction.1 Willan’s work, which he appreciated Of these forty disciples, the most to some extent, but criticized his celebrated was Marcet, who was a illustrations on the ground that they native of Geneva, and subsequently were drawn on too small a scale to became physician to Guy’s Hospital, give an accurate representation of the and a founder of the Medical and physical characters they were in- Chirurgical Society of London; he tended to depict. On the other hand wrote much, but not on dermatology. Bateman thought very little of Ali- Biett was another; he was a real bert’s treatise except for the illustra- dermatologist, who introduced the tions and goes so far as to say that classification of Willan into France, “The merit of his publication belongs where it speedily displaced that of principally to the artists, whom he has Alibert. He too was a native of had the good fortune to employ.” Switzerland, and returning to the And by common consent it also de- Hopital St. Louis, he soon became tracted from the usefulness of Alibert’s a formidable rival to his former work that the elaboration of the illus- master. The practical character of trations so enhanced the price that it his teaching made a more powerful was beyond the means of most phy- appeal to the younger generation sicians to purchase a copy. than the somewhat imaginative dis- Post -gr ad ua te Teac hin g sertations of the older master. Hardy, writing in 1885, exactly fifty years Dermatology enjoys the distinction after he had first become attached of being the first speciality which to St. Louis as an intern, remarks: afforded opportunities for post-gradu- “On s’amusait avec Alibert sous ate instructions, a point to which Dr. les tilleuls du pavilion Gabrielle; on Arnold Chaplin has drawn attention allait s’instruire dans les salles de in his Fitz Patrick Lectures. At the Biett, au pavilion de Saint-Mathieu, et, Public Dispensary in Carey Street, Willan began teaching as early as 1 Bateman, T. Biographical memoir of the 1786. At first he delivered lectures on late Dr. Willan. Edin. M. J., 8: 501-612, 1812. malgre les profondeurs de ses racines his own work was a mere extension I’arbe des dermatoses fut ebranle, of Willan’s principles. mais sans tomber cependant.”1 In this sentence, there is a witty Spec ial Dis eas es double entendre, for the classification In addition to the general considera- of skin diseases elaborated by Alibert tions already briefly dealt with, it and famous in its day, was on a will be interesting to examine the state botanical model, and he ultimately of knowledge existing at this period presented it in the form of a tree, with regard to certain well-known skin “I’arbre des dermatoses,” of which diseases. The first of these is: the normal skin constituted the trunk, Ringworm. It appears that it was while the larger branches became the only about the end of the eighteenth nosological families, the smaller ones or beginning of the nineteenth century the genera, and the leaves the species. that this disease began to be differ- Alibert was also in the habit of giving entiated. There are many allusions to his clinical demonstrations in the it in the medical journals around the open air, and actually under a tree year 1800. There is at first a certain which has only lately been cut down. amount of confusion between the The most famous of all Willan’s pupils various terms employed to describe it, was of course Thomas Bateman, who and also it does not seem at first to wrote in the Edinburgh Medical and have been by any means clearly Surgical Journal, the obituary notice differentiated from favus. Sometimes already quoted from, and who carried it appears to be called porrigo, which on his labors from the point where is more usually synonymous with Willan left them off. But apparently impetigo, sometimes tinea, and some- Bateman did not have the advantage times tinea appears to be confounded of the materials which Willan left with favus. One of the earliest refer- after his death, to work upon in the ences to it is in the Annals of Medicine, production of his book. It appears an Edinburgh publication edited by from the article on Bateman in “A Andrew Duncan. In the year 1798, Picture of the Present State of the there is an account of an inveterate Royal College of Physicians,” an case of tinea capitis successfully anonymous and very candidly written treated by the application of an work, published in 1817, that Willan’s adhesive plaster by Thomas Morison, widow refused to allow Bateman the surgeon of Dublin. This is an early, use of Willan’s collected material, but if not the original application of the handed it over to another editor. This “pitch cap,” a method of treatment second editor was no doubt Ashby used up to quite recent times for Smith, who published a collection favus, which may have been the entitled, “The Miscellaneous Works disease with which Morison was deal- of Willan,” a volume which is interest- ing. In the same volume a disease is ing, and of some dermatological sig- mentioned which is evidently the nificance. But Bateman never ceased dhobie itch, “the cutaneous disease to acknowledge his indebtedness to commonly known by the name of Willan, and always maintained that Ringworms, the Herpetic Serpigo of 1 Ann. de dermat. et sypb., lie Serie, Vol. Sauvages,” which Dr. Adam Freer 6: 634. records he has successfully treated with Cassunda vinegar. Dr. Adam x-rays were introduced. Mr. James Freer was a physician on the Bengal Barlow2 of Blackburn, Lancashire, establishment, an earlier form of the recommends the following prescrip- Indian Medical Service; it is tempt- tion: kali sulphurat (recens preparat'), ing to speculate that the name subse- sapo alb. hispan., aqua calcis, spirit quently became Freyer, and that this vini red miscae, fiat lotio pro tinea observer may be of the same family as capitis. He found it unnecessary to the late Sir Peter. At any rate, he must shave the head or even to cut off the have been his spiritual ancestor! hair. Several important papers on the Mr. William White3 writes some subject of ringworm of the head are to observations “On a species of porrigo be found in the Medical and Physical affecting the scalp in circular red Journal. Mr. Low1 writes that his patches.” This article gains additional attention has been drawn to it because interest from being communicated to up to the present it “has already the journal through Dr. Willan. Writ- excited very little of the attention of ing from Bath, the author states that medical writers, but also because its the disease had been prevalent there occurrence appears to be daily becom- for some time past, and that he had ing more and more common.” He not noticed any account of it. (He gives a fairly good clinical description evidently had not read Mr. Low’s of the disease, and notes the fact some- excellent article in the thirteenth times lost sight of even at the present volume.) He mentions that it particu- day, that adults are never affected. He cularly affects children in boarding thinks it was introduced from India schools, that it is generally discovered twenty or thirty years previously, because the hair falls off, and that it because Indian boys are more subject is scaly and obstinate, and that as to it than British. He says also “it has long as the red line is present it con- been asserted that animalculae under tinues to spread. He is rather pessi- the cuticle are the cause of this dis- mistic about the treatment, but thinks order, but a clergyman of my ac- that in some cases an alkaline lotion quaintance has failed to discover them in the form of the lotio saponacea of with the microscope.” The treatment the old “Edinburgh Dispensatory” he advocates includes both internal succeeds better than any other and external methods. The external application. He notices the tendency application favored by this author was to an accumulation of scales, which the unguentum hydrargyri nitratis differ from the usual porrigo to be applied to the shaved head at (impetigo) and may form a scab. But bedtime, and washed off the next he also notices that removal of the morning. He recognized the obstinacy scab does not cure the head. In of the affection, for he says that at Volume 26, on page 24, “Philan- least three or four months are neces- thropos” writes enquiring for a sary to effect a cure. The various remedy for ringworm, which, he says, remedies recommended by various “ infests the schools in the neighbor- authors for this disease have quite a hood of the metropolis, may truly be modern flavor. They show how little deemed an opprobium medicorum, from our treatment of it advanced until 2 Med. & Pbys. J., Vol. 14: 496. 1 Vol. 13: p. 24 et seq. 3 Med. & Phys. J., Vol. 21: 132-3. the difficulty with which it is kept unfortunate child was treated by his under, and its being scarcely ever father, (not, it may be noted with cured.” This article shows that the some satisfaction, by one of our nomenclature of the condition was by profession), on the advice of one of his no means settled at the time, for he neighbors, with the expressed juice of goes on to say that “Tinea capitis, dried tobacco leaf, which was applied a complaint almost equally common, as a sort of compress. The patient is more easily mastered.” So evidently died in three hours, and it was quite at that time ringworm and tinea were obvious from the account of the two different diseases, and probably symptoms and the post-mortem ex- the tinea of “ Philanthropos ” was our amination made by Dr. Cuming that impetigo. On the other hand Mr. the cause of death was acute nicotine Harrup, on page 203 of the same poisoning. Blindness, vomiting and volume, answers “Philanthropos” by involuntary evacuation of the bowels claiming the cure of two inveterate were the salient features of his short cases of tinea capitis, which to his illness. mind is apparently identical with Closely allied to ringworm of course ringworm, by shaving the scalp, wash- is the discoloration of the skin which ing it with soft soap and water, using we know as pityriasis versicolor, a lotion of sulphurated potash and and it may here be mentioned with lime water, while exhibiting internally propriety that pityriasis versicolor 8 to 10 grains of hydrargyri cum was accurately described by Willan.2 sulphidum twice daily, with two or He details its appearance, chronicity three doses of calomel and rhubarb. and resistance to treatment, and illus- He claims to have cured a nobleman’s trates it with a colored plate, which son and to have dealt successfully leaves no doubt that the condition with an outbreak of ringworm in a described by him is identical with that school. He puts great faith in the now known by the same name. He did exhibition of hydrargyrum cum sulphi- not of course know the fungus which dio. External applications alone he causes it, and hence he classes it next finds much slower. These early authors to psoriasis, “the dry or scaly tetter,” evidently employed much the same in Order 11, scaly diseases of the skin. mercurial preparations for the treat- Eczema. Although the term ec- ment of ringworm as are used even to zema is a very old one in medical the present time, and with much the literature, it is only since the begin- same success. At any rate, they were ning of the nineteenth century that it harmless, but some of the remedies has begun to take on the signification employed were not so innocuous. which is now commonly accorded to Dr. Ralph Cuming,1 claims the cure it. The first physician to use the word of a case by means of cantharides and appears to have been Aetius of Amida blistering. This was complicated by (a .d . 543), who described under this strangury, which, luckily, however, name hot and painful phlyctenulae passed off without much trouble. On which do not go on to ulceration, a the other hand, in Volume 14, page description which certainly suggests 305, the sad case of Thomas Mann, a condition consistent with our aged eight years, is reported. This modern notions of eczema. But the 1 Med. & Pbys. J., vol. 15: 43. 2 Manual of Cutaneous Diseases, pp. 196-7. same word as used by later writers, local dermatitis caused by the applica- seems to have been applied to boils tion of mercurial ointments is and carbuncles, while to conditions, occasionally seen. On the other hand, which judging from their description Willan undoubtedly failed to include a modern dermatologist would call as forms of eczema conditions to eczema, they give quite different which we certainly should give that names, e.g., achor (Johannes Gorae name. Examination of Willan’s Gorraeus, 1578), herpes (Sauvages, “Atlas” shows that lichen agrius and 1768), erysipelas (Fernelius, 1592), psoriasis diffusa, “peculiar to bakers,” etc. For an interesting discussion on are certainly forms of eczema, and so the ancient history of eczema, refer- also are certain conditions which he ence should be made to Hebra’s labels as varieties of porrigo. Never- “Diseases of the Skin”1 from which theless, to Willan must be given the indeed these remarks have been taken. credit of originating the first working For the now generally recognized definition of this puzzling disease, and meaning of the term we have again it is on the foundations laid by him to turn to the penetrating genius of that all subsequent dermatologists Robert Willan, who here once more have labored. For most of the nine- reduced the previous confusion of teenth century, the tendency was to ideas on the subject to order. Willan add to the number of conditions defined eczema as a non-contagious included under the term; recently the eruption of small closely-set vesicles pendulum has swung in another direc- and divided it into four species: e. tion. Norman Walker describes mercuriale, e. Impetiginosum, e. rub- eczema as the rubbish heap of derma- rum, e. e. solare. Almost all the subse- tology, and refuses to diagnose any quent work on eczema in which very condition by that name if he possibly numerous dermatologists of varying can help it. Certainly clinical and distinction and importance have taken bacteriological researches have suc- part, has consisted in the amplifica- ceeded in differentiating from the tion and correction of Willan’s original rubbish heap certain forms of derma- definition and description. On the one titis, especially of the extremities, as hand, of the four original species of manifestations of mycological infec- the disease described by him, one, tion. The first of these to be rescued eczema impetiginosum, identical with was the eczema marginatum of Hebra, impetigo, is no longer included under which was proved to be a form of the head of eczema at all, although it ringworm, and latterly many apparent was not until 1864 that the clinical cases of eczema of the fingers and toes genius of another British dermatolo- have been shown to be of a similar gist, Tilbury Fox, enabled him to dif- nature. Again, certain forms of what ferentiate impetigo as a distinct used to be considered chronic eczema disease sui generis; while eczema are now called Iichenification or “neu- mercuriale, in the form described by rodermatitis.” Before the time of Willan and Bateman, due to excessive Erasmus Wilson, lichen planus was dosing with mercury, is now practi- included in eczema. Still even yet cally a thing of the past, although there remains a vast collection of 1 Sydenham Society’s Translation, Vol. 11: cases of which it can only be said, PP- 75-79- that at any rate at one or other moment of their course they satisfy Andrew Baird from his success in the Willanian definition of eczema, and dealing with these cases. His success must still be labelled eczema although appears to have been due to the fact of their true nature we know very that he employed no poultices, but little more than Willan did himself. stimulating lotions instead most of which were largely composed of spirits Ulcer s of the Leg of wine, and were in point of fact It cannot be said that ulcers of the fairly strong antiseptics. His pathol- leg are rare even at the present time, ogy appears to have been based on although my impression is that they quite erroneous principles, but his are rarer than they were when I was a practical methods were sound. medical student twenty years ago. A literature of considerable dimen- But the modern practitioner has no sions exists on the subject of ulcers conception of their frequency and of the legs. One of the earliest writers importance at the beginning of the on this subject was Richard Wiseman; nineteenth century, and for many he produced his “Treatise on Ulcers” years after that. M. Parent Duchate- in 1676. This work deals with ulcers Iet1 states that in eleven years 3373 in general, and includes the considera- individuals were received into the tion of conditions which we now would hospitals of Paris suffering from atonic call tuberculous, syphilitic and malig- or varicose ulcers of the leg. He nant ulcers, but Wiseman’s classifica- further states that in one year, out of tion is by no means clear according to 1565 who sought admission, the half modern ideas. He recognized that of which were cases of a serious many ulcers were correlated with character, for want of room only 337 internal disorders, but pathology was could be received. We are not accus- not sufficiently developed in his time tomed to regard ulcers of the leg as a to enable him to distinguish between dangerous complaint, although un- different conditions and the differences doubtedly one which causes con- between the types of ulcer correlated siderable suffering and disability; but with them. This only came much at the period under discussion, owing later. It seems that the French derma- no doubt to ignorance of antiseptics, tologist, Alibert, deserves the credit they were not infrequently a cause of for distinguishing between syphilitic death. In 1806, 26 sailors in the and scrofulous ulceration. This was British Navy died from them, and not until after 1803, when he was they were a fruitful source of invalid- appointed to the staff of the Hopital ing. In fact, there appears to have St. Louis. In addition to these varie- been prevalent in the Navy a special ties, he described a third kind of ulcer type of ulcer which was called the under the epithet “dartreux.” Under “Ship, or contagious malignant this appelation were apparently in- ulcer.” This was so common that it cluded septic and varicose ulcers. caused much alarm. In 1803, 87 cases Wiseman’s chief contribution to the were admitted to Plymouth Hospital; surgery of ulcers was the introduction in 1894, 621; 1805, 377, in 1806, 505; of the laced stocking. He was the 1807, 346; in 1808, 223; and in 1809, first to recognize the importance of 220. Much credit was gained by Dr. giving firm support to the lower Ann. d’byg. publ., Vol. 28. limbs, and his device of the laced stocking, which enabled him to cure treating Old Ulcers of the Legs.” His many obstinate cases, was speedily new method was that of strapping the adopted by his contemporaries and ulcers by means of strips of plaster. their successors. Later writers fre- Baynton gives full directions for pre- quently refer to it with approbation. paring it: Other writers preferred the roller bandages to the laced stocking, and The plaster should be prepared for Underwood, writing in 1783, claims spreading by melting in an iron ladle credit for substituting flannel band- over a slow fire four ounces of common plaster or diachylon with half a drachm ages for linen, flannel being more of yellow resin; when melted, it should be elastic. Nevertheless, chronic ulcers stirred until it begins to cool, and then of the leg remained so difficult to cure, spread thinly upon slips of smooth that to save “face,” the profession porous calico of a convenient length and was driven to the somewhat discredit- breadth. able expedient of telling their un- fortunate patients that to cure their The strips were wrapped round the ulcers would be a dangerous proceed- leg with no dressing intervening be- ing; that through the ulcer poisonous tween them and the ulcer, and slightly humors were expelled from the system, overlapping one another. Some lay- which, were the ulcer cured, would ers of lint (cotton wool was then cause serious illness and perhaps unknown), were then placed over death. This doctrine is several times the plaster, and the whole bandaged mentioned in the old treatises, al- firmly with a roller of calico up to the though those surgeons who prided knee. The plaster was changed daily. themselves on their skill in the Baynton found that the plaster ad- management of ulcers of the legs take hered so tightly that sometimes when considerable pains to refute it. For being removed it brought away pieces the same reason the same doctrine of the skin with it. He therefore has also from time to time been put directed the patient to keep the whole forward with respect to chronic dressing constantly moist by pouring eczema, especially in infants, in whom over it cold clean spring water out of eczema is notoriously difficult to con- a teapot. This he found very beneficial. trol; and even within quite recent Baynton’s method of dealing with years, cases have been published of chronic ulcers was found to be a great sudden death after a cure of chronic advance over the older devices, and eczema, and in Germany the name Everard Home, who published a book Eczemtod has been given to this on ulcers in 1801, a book written in a catastrophe. more scientific spirit than any of the Another surgeon, Else, advocated other works on the subject which I the employment of thin sheets of have examined and a very interest- lead for compressing the limb, but this ing discussion of the whole subject, plan never seems to have been very goes so far as to say that “experience generally adopted. The greatest ad- has enabled me to give ample testi- vance in the therapeutics of chronic mony in its favour, and induces me to ulcers of the legs was made by Thomas consider it as one of the greatest and Baynton, a surgeon of Bristol, who in most useful improvements in modern 1797 published a “New Method of surgery.” It may also be interesting to quote Home’s summary of the were driven to most ingenious al- whole matter: though labored arguments to bolster No directions can be given respecting up the Hunterian theory. Benjamin which of these applications should be first Travers as late as 1830 maintained tried in indolent ulcers, as a great deal that a man by successive intercourse must depend on what had been used with a number of women infected before, without success; and in all cases of with gonorrhea could himself con- long standing, many medicines must have tract syphilis. His idea seems to be been previously employed; the surgeon that gonorrhea became converted into will therefore be guided by the history syphilis by a sort of quintessential of the case, when it can be procured. distillation of the original virus. This The adhesive plaster, the diluted nitrous is interesting as a doctrine which has acid, the solution of the argentum nitra- its modern analogy in the increase of tum, and the unguentum hydrargyri bacterial virulence by passing organ- nitrati, are the medicines on which it is reasonable to place the greatest depend- isms through a series of sensitive ence. animals. On the other hand, Howard writing as early as 1806, was already This summary almost equally well groping towards the truth, but was applies to the treatment of chronic overborne by the authority of Hun- ulcers at the present day. But there is ter. To the French school must un- one thing which the moderns have to doubtedly be given the credit of be thankful for, and that is that the establishing the essential distinction spreading or phagedenic ulcers, which between syphilis and gonorrhea, and sometimes arose de novo, and into the British only admitted the correct- which chronic ulcers were always ness of their views after very con- likely to develop, are now owing to siderable hesitation. But let us not our knowledge of sepsis and antisepsis, sneer at the theories of our profes- almost unknown. sional forefathers, which are now proved erroneous. As a great French Vene rea l Disea se scientist has said, nothing is so easy The whole position of the profession as to make the discovery of yes- at the beginning of the nineteenth terday, nothing so difficult as that of century with regard to venereal disease tomorrow. was vitiated by the Hunterian doc- The treatment of syphilis in vogue trine that gonorrhea and syphilis were at the beginning of the nineteenth merely diverse manifestations of the century is well known. It consisted same disease, a doctrine that was not almost entirely in drenching the pa- given up until near the middle of the tient with mercury, nor was the century. There are not many better surgeon satisfied unless copious saliva- examples of the paralyzing influence tion was obtained, which of course of authority. On reading the writings meant that the patient was thor- of surgeons of the time, to the modern oughly poisoned. In fact, frequently mind nothing is more obvious from it was impossible to tell whether the the carefully drawn up and accurately lesions of the sufferer were the result written case descriptions than that two of the disease or its treatment. Fatali- distinct conditions were being dealt ties were not very uncommon. Skin with. In many instances, the authors eruptions were so common that as mentioned before, Willan described is found in the account of a case of a special form of eczema: e. mercu- “pseudo syphilis” in the Edinburgh riale, due to zealous administration Medical and Surgical Journal, Oct., of the drug. The profession and their 1812, by William Stephenson Clark, patients owe their relief from this who had been Resident Surgeon of barbarous method of treatment prin- the Lock Hospitals, London, and cipally to Sir Jonathan Hutchinson. ought presumably therefore to have Mercury was usually given in liquid known something about his subject. form, but inunction was occasionally He details the history of a patient, practiced. I have come across an who after having been exposed to interesting case published by Wil- infection in January, passed through liam Nesbit1 of a case of “obstinate a severe illness of which every sign lues venera, attended with uncom- and symptom to the modern mind is mon eruptive appearances,” in which pathognomonic of syphilis, lasting the patient took mercury internally until September of the same year. with bad results, after which Mr. Nevertheless, Mr. Clark merely on Blair of the Lock Hospital was called the grounds that the sore “exhibited in consultation, and he then sum- little of the characteristic marks of a moned Dr. Willan to his aid, who true venereal chancre . . . and the suggested treatment by inunction. length of time that had elapsed be- No less than 50 oz. of mercury were tween the connection and the appear- inuncted during four months, and the ance of the sore,” and also that the patient was cured. It must be remem- secondary signs finally disappeared, bered that potassium iodide was not (although not until after the patient yet known as a remedy. Iodine was had had a most terrible illness), only introduced into medicine by Dr. without the administration of any Cointet of Geneva about 1830 for the mercury, published it as a case of treatment of goiter and scrofula. In “pseudo Syphilis.” Nevertheless, his original communication, Dr. Coin- when one considers how barbaric tet notices that some of the cases of was the method of treatment in scrofulous ulceration did well with it, vogue for syphilis in those days, while others were quite uninfluenced drenching with mercury to the point by it. Possibly some of his successful of salivation, commonly followed by cases were really syphilitic. But it the loss of all teeth, and occasionally was not until 1836 that William by a fatal termination, it is permissible Henry Judd employed it with intent to console oneself with the reflection against the advanced and inveterate that possibly he was not much worse symptoms of venereal disease. The off than he would have been if results then obtained must have treated in the orthodox fashion. seemed as magical as those we saw Measures for the prevention of ourselves in the first cases we treated venereal disease are commonly con- with Ehrlich’s 606. sidered a very modern development; Our professional forefathers were but it appears that the methods of far more reluctant to diagnose syphilis Metchnikoff were anticipated to some in doubtful cases than we are. A very extent as early as the first years of the remarkable example of this reluctance nineteenth century by T. M. Caton, 1 Lond. M. Rev., 5: 1800. a surgeon of the United Hospitals of Thomas’s and Guy’s. He published humid tetter, shingles, and among a practical treatise on the prevention diseases of infants, crusta Iactea, and cure of venereal disease, in which scald-head and papulous eruptions, he advocated for prophylactic pur- and pemphigus infantilis. Impetigo, poses the injection of a solution made crusta Iactea and shingles we still by dissolving a grain of muriate of know. Impetigo is usually taken as mercury in a pint of spring water. being identical with porrigo, but in For use a little of this is to be mixed some of Willan’s lists both these in a pint of spring water, and he adds, complaints are mentioned, so he evi- “if the mouth can bear this without dently drew some distinction between pain, it is fit for use.” He also recom- them; what that distinction was, it is mends covering the glans penis before very difficult to find out. Purpura or and after coition with a strong mercu- land-scurvy he himself explains is the rial ointment. Another interesting complaint “better known under the anticipation by the same writer is a appellation of Petechiae sine febre discussion of the connection between . . . An eruption of dark red spots tabes dorsalis and venereal disease. appears in the skin of the legs, arms, But here he strays a long way from the breasts, and abdomen. These spots right track, because he comes to the are precisely the same as the Pete- conclusion that tabes dorsalis is never chiae in Malignant Fevers.” But he due to venereal disease. In any case, quite clearly distinguishes them from the early speculations on this subject the more severe form of the disease are not very valuable, because under entitled purpura hemorrhagica, which the title tabes dorsalis were included is much more violent and dangerous. at that time many other nervous In one of his early reports he states diseases, which we now know are quite that he has himself never seen a case different from true tabes. of purpura hemorrhagica proving Many points of dermatological in- fatal, but in another of later date, he terest may be noted in a study of describes a fatal case in his own Willan’s “Reports on the Diseases of practice. The patient was a laborer at London,” which he published in the Deptford. It must have been a very Monthly Magazine and the Medical striking case, because “blood was not and Physical Journal, beginning in only discharged from the nose, mouth 1796, and which after his death were and fauces, but issued in large streams collected and republished among his from under the nails of his toes, from miscellaneous writings by Dr. Ashby small livid vesicles about the throat Smith. Every few months, Willan externally, also from similar vesicles wrote a report furnishing the names on the scrotum, thighs and other parts and numbers of various diseases met of the body.” A good description of with in his own practice both hospital this disease is also to be found in the and private, to which he added a few Edinburgh Medical and Surgical pages of remarks on any feature he Journal of 1813. considered worthy of special notice. Dry or scaly tetter is a synonym for The chief cutaneous disorders men- psoriasis, but Willan also mentions tioned in these lists are: lichen, itch, both in these reports, and in the and prurigo, purpura or land-scurvy, “Treatise on Cutaneous Diseases,” a dry or scaly tetter, lepra, impetigo or condition called lepra, or lepra Grae- corum, which from the illustrations is pathological facts, not as other obviously also psoriasis. It is however schemes, (notably that of Alibert), on only much later that psoriasis and theories to which the facts were to be lepra were recognised as identical. made to conform. Consequently, Wil- Pemphigus infantilis is evidently lan’s classification is not entirely the same as pemphigus neonatorum, obsolete even at the present day, while which we know now to be a strepto- the others have been completely swept away. As a clinical observer, his coccic infection. Every case seen by chief contribution was perhaps the \\ illan apparently terminated fatally establishment of the modern con- within seven or eight days. It is still ception of eczema. But his clinical very frequently fatal, but not so descriptions on the whole were far common. inferior to those of Alibert, whose Gutta rosea is acne rosacea. It is command of language, happy phrase- certainly not pityriasis rosea, which ology and dramatic presentment of was only recognized as a definite striking cases have enriched derma- clinical entity later by Gibert. tology with some classical similes. In this short survey of the art of One notable example is his comparison dermatology as it was practiced in of keloid with the claw of a crustacean Britain at the beginning of the nine- implanted in the skin, another the teenth century, something may be likeness of the tumors in mycosis fun- gathered as to how the foundations goides to tomatoes. Alibert had the were laid, which led to the develop- imagination of an orator and a poet, ment of this specialty as we see it while Willan possessed the penetration today. In truth, we end as we began, of a logician and an analyst. with Robert Willan. He was the first In other fields of medicine, Willan to guide his contemporaries and suc- also made his mark. This is not the cessors to a correct understanding of place to go into details concerning the problem before them by insisting them, but it may briefly be mentioned on a standard and constant terminol- that he was one of the earliest pioneers ogy wherewith to describe the mani- of Public Health. As a founder of the fold pathological changes which may House of Recovery from fevers, the make their appearance on the skin. original form of the London Fever We still employ his terminology Hospital, he was among the first to almost without change; and it is due realize the importance of isolating to him that one dermatologist can infectious disease, and he was also describe a morbid condition with the among the first to advocate the certainty that others will understand importance of fresh air and bodily what he means. But this would still cleanliness. Papers on these subjects hardly be possible were it not for are to be found in the previously Willan’s other great innovation, the mentioned volume of miscellaneous introduction of illustrations into works edited after his death by Dr. dermatological literature. His classi- Ashby. After him, the only outstand- fication of skin diseases, the achieve- ing figures are his pupils, Bateman ment which was applauded by his who carried on his work in England, contemporaries, was chiefly useful and Biett who did the same in France. because it was founded on hard Other dermatologists made useful con- tributions to the art by describing the advent of Hebra, Willan’s teaching particular diseases, or occasionally by dominated not only British but introducing a new remedy. But until European dermatology.

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