In the latter half of the 19th century while specialist hospitals were developing throughout the land, a number of individual heroes were to emerge. Two pioneers appeared in Scotland, McCall Anderson in Glasgow and Allan Jamieson in Edinburgh; they were outstanding. Both had the advantage of a period of study in Vienna with the incomparable Ferdinand von Hebra, whose classification of skin diseases was formulated on the new and wholly admirable basis of his own pathological findings. The other pioneers were to be found in London.
William James Erasmus Wilson (1809-1884)24 born in London, was the son of a naval surgeon and destined for a surgical career. He won prizes for anatomy and physiology at the Aldersgate school, forerunner of St Bartholomew's, and became a pupil of the Quain brothers. For a while he supplemented his income by demonstrating anatomy with great skill and making high quality dissections. This grounding stood him in good stead for later he was made a Fellow of the Royal Society largely on the strength of his anatomical publications, and admitted in 1843 as a foundation Fellow of the Royal College of Surgeons.
Through his father, now retired from the navy and running a private lunatic asylum in Denham, Erasmus Wilson met Thomas Wakley, the Middlesex Coroner and founder of the Lancet (who like Willan was to die of tuberculosis in Madeira). This meeting changed the direction of Wilson's interest when it was arranged that he should coach the Wakley boy in anatomy, for young Thomas studying medicine at Oxford, wished to move to the new University College in London which had assembled a superb array of professors. Wakley, the father, variously described as forceful, outstanding or even outrageous, saw a bright future for Wilson; indeed he used him on the Lancet for a while as an Assistant Editor, and this provided a useful entrée into the medical publishing world.
Wakley was also conscious of an opening in London, one that might possibly be filled by Wilson as there was no expert in diseases of the skin practising in the capital. Willan had left the scene, Bateman had died in 1821, the hospitals directed their skin patients to surgeons, quacks had a restricted appeal and the dispensaries catered for the sick poor. There was surely room for an impressive consultant, who could speak on equal terms with the nobility and smart London society.
As an avid reader, Wilson was able to learn as he went on. He had no effective hospital appointment so his experience was gleaned totally from his own practice. Self-confidence and an industrious nature were his assets and he gradually amassed a fortune. Publications flowed from his pen - Diseases of the Skin appeared in 1842. Having taught anatomy and physiology for five years at the Middlesex Medical School, he produced The History of the Middlesex Hospital, a digest of the Board's Minutes with no pertinent observations of his own. He wrote a variety of pamphlets such as - A scamper through the spas of Belgium, The Eastern or Turkish Bath and The art of prolonging life.
Although self-opinionated, and critical of the writings of others, he must have been an astute observer, for lichen planus, exfoliative dermatitis and naevus araneus are all credited to his name. The Journal of Cutaneous Medicine and Diseases of the Skin were published quarterly; it appeared in 186725 and Wilson was founder, editor and chief author. At first it had some exceptional contributions notably from Tilbury Fox, McCall Anderson and Jonathan Hutchinson, but the editor's enthusiasm seemed to wane and the journal to wither once he achieved his self-endowed Chair at the Royal College of Surgeons; there he is still honoured as a major benefactor.
He had become the one person in London whose name the public associated with diseases of the skin. He was also well recognized in France, for Hardy, in a retrospective address at the Vienna congress tracing progress made since Willan and Bateman, listed the French heroes of the early 19th century, Alibert and Biett, adding " the next stage in the history of the science is marked by the names of Bazin, Hebra and Erasmus Wilson".
Philanthropy was in his nature. Practice was profitable and his investments shrewd. He distributed his gifts widely and would even forgo a fee from a deserving patient. A Chair of Pathology was endowed at Aberdeen University26 in memory of his father, an ex-graduate. A protagonist of bathing and washing, then unpopular with all social classes, he was a generous benefactor of the Seabathing Hospital at Margate, which became popular for the treatment of tuberculous patients. He was knighted for his good works by the Queen and honoured by the Masons.
On one occasion he rescued a lady from drowning in the Regent's Park Canal, gaining a medal from the Royal Humane Society. He gave evidence at the inquest on a soldier who had died some time after a judicial flogging. Wakley had suggested that the famous dermatologist had an exceptional knowledge of anatomy and would be an appropriate expert. Wilson concluded that the severe punishment had provoked the soldier's death and after ten adjournments the jury finally agreed with his views; this led to the abolition of flogging in the services. The transportation of Cleopatra's needle at his own expense, from Alexandria to the Thames embankment was a flamboyant act27. Breaking loose in the wild seas of the Bay of Biscay, the obelisk, encased in iron, was retrieved much later 90 miles north of Ferrol and towed to London. Two sailors were drowned in the enterprise.
He had his portrait painted many times. Stephen Pearce, a fashionable artist, was a personal friend and produced at least six canvases. A small one hangs in the Willan Room and there is a three quarter length portrait in the Medical Society of London, presented by Wilson at the end of his Presidency. It is recounted, probably apocryphally, that on a later visit he was horrified to find his picture languishing in the basement. In a fury he rescinded his plans, so the monies destined for the Society were redirected elsewhere, probably to the College of Surgeons. There are sculptural likenesses by Thomas Brock, his marble bust stands in the rebuilt library of the College of Surgeons, and his bronze figure outside the Margate Seabathing Infirmary.
Lyell26 concluded - "he will be seen as an exotic epiphyte on the tree of dermatology, rather than as part of its trunk; and he will be remembered as a remarkable man, whose work as a dermatologist was eclipsed by what he did for dermatology". Be that as it may, he was surely from the mould of men who, in that expansive Victorian era were to make Britain great. Ernest Besnier wrote - Au dessus de tout, il avait ce rare merite devenu trop rare a l'epoque actuelle, d'etre medicin en même temps que dermatologist". (Above all, he had that quality, all too rare today, of being a doctor as well as a dermatologist).
More biographies have been written on Erasmus Wilson than on any other British dermatologist to date; those remote from our scene seem to have accorded him the greatest respect. Exuberant, extrovert or not, he certainly put dermatology "on the map" in the eyes of the world at large.
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Some 20 years younger than Erasmus Wilson was Jonathan Hutchinson, a polymath28 whose seminal influence on dermatology was matched by his interests in other spheres of medicine, surgery and medical education. His various capabilities were seemingly superhuman.
Jonathan Hutchinson (1828-1913) was a surgeon, eye-surgeon, neurologist, syphilologist and dermatologist, writer and teacher. Born a Quaker at Selby where his father was a merchant, he served his medical apprenticeship with Caleb Williams in York before moving in 1850 to St Bartholomew's in London to complete his training. After a brief return to York for his House Surgeon's post he came back to London, studying ophthalmology at Moorfields and striving to learn "all he could in all branches of medicine". For a while medical journalism was his only source of income; by 1855 he was on the staff of the Medical Times and Gazette, the main competitor of the Lancet and edited by Thomas Spencer Wells.
He put up his plate at 14 Finsbury Circus in the year he married (1856), and became the paid Secretary of the New Sydenham Society. It was through this Society that he published his atlases of Skin Diseases and Drug Eruptions. In 1859 he was appointed Assistant Surgeon to the London Hospital, achieving the FRCS three years later and in 1863 was promoted to full surgeon.
Though his surgery was mainly conducted at the London, he was an eye surgeon at Moorfields and neurology and ophthalmology both intrigued him. Earlier he had studied with James Startin at his newly founded Skin Hospital at Blackfriars and once on the staff, it provided his centre for dermatology and syphilology. Soon he became pre-eminent and Blackfriars emerged as the postgraduate skin centre.
He edited the British Medical Journal for one year and from 1877 to 1888 produced the two volumes of his Atlas Illustrating Clinical Surgery. His "one man" publication - the Archives of Clinical Surgery (to be seen today in the Willan library) - appeared from 1889 until 1900 and is well worth a look. He claimed he had no time to write any systematic book, but he made meticulous notes, and incomparable data are available on his numerous patients, many of dermatological interest. Scadding29 referred to these Archives while pursuing the earliest recognition of sarcoidosis; he found that Mrs Mortimer's Malady had been termed by Hutchinson "lupus vulgaris multiplex non-ulcerans".
Hutchinson's amazingly retentive memory, coupled with his genius for teaching, enabled him to fascinate large audiences on a multiplicity of subjects. He attained a unique status. With his tall, stooping frame, his untidy black beard and his slow speech he presented an austere, seemingly humourless figure. It might seem amazing that such a solemn man could enthral his audiences but this is precisely what he did. In 1893 he opened, at his own expense, a Clinical Museum at 1 Park Crescent, and transferred it to a house in Chenies Street in 1898. The notice outside read: "The Medical Graduate College and Polyclinic; lectures to be given at 5.15 pm". It can be regarded as the fore-runner of London's Postgraduate Medical School. His collection of drawings and memorabilia, later established as a museum at his home in Haslemere, was sold to William Osler, transported across the Atlantic, and presented to the Johns Hopkins Medical School in Baltimore.
An incomparable Syphilologist, he described his triad of notched incisor teeth, labyrinthine deafness and interstitial keratitis, and so provided a firm diagnosis long before the Treponema pallidum or the Wassermann reaction were recognized. It was well-known to all students.
He was elected President of the London (Third) International Dermatological Congress in 1896 and his Presidential address is quoted in full in the eighth volume of his Archives (October 1896). A perceptive extract is:- "If we ask how the most rapid development has come about the answer must be: By the aid of cheap printing and cheap travelling. We are now able to communicate easily one with another and to make mental use of each other's brains. A six hour journey will now enable a Londoner to visit, what I may fairly claim to be the Cradle of Dermatological Science - the Hôpital St Louis."
His presence was the one redeeming feature of this international meeting, which otherwise brought London little kudos, as our own high-class academics were so sparse and our facilities so inadequate.
He recognized an array of entities - varicella gangrenosa, the tabetic or Hutchinson's mask, Summer eruption (hydroa vacciniforme), angioma serpiginosum, notched incisor teeth, corneal salmon patch, choroiditis and circinate retinopathy.
He staunchly maintained his theory about the cause of leprosy which he attributed to the consumption of decaying fish, this even after the causal organism had been demonstrated. It was his one "blind spot"; nevertheless he remained a good friend of Gerhard Hansen, the Norwegian leprologist at Bergen. His book on Leprosy and fish eating was published in 1906.
Founder member of the Dermatological Society of London, he became President of the Royal College of Surgeons in 1889 and was elected a Fellow of the Royal Society. He was knighted in 1908 having earlier refused a Baronetcy. He retired in 1911, dying a month before his 85th birthday in 1913. His wife had died in 1886 having produced six sons, three becoming doctors, as well as three daughters.
Malcolm Morris, in Montreal, in his commemorative address concluded - "he brought to the study of pathology of the skin a knowledge of disease in general such as probably no other dermatologist has ever possessed".
Perhaps as dermatologists we can not rightly claim this legendary figure as one of our own, but we can bask in his reflected glory. On his gravestone his own words are inscribed - "A man of hope and forward-looking mind".
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In London, University College was beginning to set a pattern of forward-thinking30. Anthony Todd Thompson and his nephew Edward Parkes, who later went to the Crimea to establish a new military hospital, have already been noted. William Jenner, an able physician destined to become Professor of Clinical Medicine, took over the skin clinic and in 1859 was able to persuade the Hospital to form a special department for skin diseases, retaining control himself. After two years, Thomas Hillier, a contemporary of Tilbury Fox, was deemed ready to take over. He was by now a general physician at Great Ormond Street and must have been lucky to be appointed ahead of Fox, for although he wrote a Handbook of Skin Diseases especially for students, dermatology was not his full-time commitment. It proved a short tenure, for Hillier died aged 37, after only seven years in post. This gave Tilbury Fox the chance to return home and assume his proper role.
William Tilbury Fox (1836-1879) was born in Broughton, Hants into the large family of a surgeon, Luther Owen Fox. He came early to the newly founded University College where he proved to be a brilliant student, winning the gold medal. His entry to dermatology was circuitous for his initial aim had been obstetrics. An interest in fungal infections led him to write a treatise on "The skin diseases of parasitic origin" in 186330. He even attempted some cultural experiments on himself. William Jenner, his Professor and chief, was so impressed with such enthusiasm that he suggested this change in Fox's plans.
Tilbury Fox must have known Erasmus Wilson and could well have been in awe of such an overbearing man. The independent Wilson had no time for the views of others and using his vast clinical experience and innate intelligence had developed a personal form of classification and of treatment. He must have been a difficult man with whom to work. At one stage Fox, without any hospital appointment, accepted an invitation from the Earl of Hopetoun to join him as personal physician on a voyage to the East. This did nothing for Fox's health, but he made good use of the experience, producing pamphlets on the spread of cholera and on the state of dermatology in Egypt. On his return he was appointed to the Charing Cross Hospital but after only two years University College beckoned him back. Then, in his rightful home, Fox set about acquiring out-patient space, installing baths and developing the subject by teaching and example. A physician both by training and instinct, he would take long and detailed histories. He was industrious, able, virtuous and popular, and the first full-time dermatologist to be in charge of skin diseases at any English teaching Hospital.
Tilbury Fox complained that skin care at other hospitals was in the hands of "men already overworked, who have in some instances no claim but that of seniority, or who conveniently stop a gap and do the work in a dilettante fashion". By 1875 things were little better and the Lancet produced this infamous piece:-
"Our opinion against the increase of specialism, especially against the narrow specialism of dermatology is well known. Specialists can not as a rule be said to be among the best educated of the profession and the exclusive practice of some small speciality tends to perpetuate and increase ignorance, if it do not already deprave professional morals".
There followed a more graceful conclusion -
"Be this as it may, we are always ready to welcome work on special subjects from Physicians and Surgeons".
A devotee of Willan and Bateman, Fox found Hebra's teaching indigestible; nor was he attracted to the current French view of blaming constitutional states for the specificity of an eruption. For him the presentation and clinical features of the primary lesion were all-important.
His description of impetigo contagiosa appeared in Wilson's Journal; this was followed by pompholyx, hydroa pruriginosum (dermatitis herpetiformis) and "dysidrosis", an idea which has since baffled many a dermatological tyro. His thoughts on lichen urticatus were way ahead of Rupert Hallam's and his understanding31 of fungal infections was outstanding. He refuted the idea that microbes or fungi could be generated by the skin whereas Erasmus Wilson refused to accept that fungi could in any way be pathogenic.
Prone to angina, Tilbury Fox died aged 43. He had introduced his brother Colcott to dermatology and for a while they worked together at University College Hospital. Adamson24 regarded Tilbury as a shining light in London, but his brother Thomas Colcott may have shone even more brightly. Findlay32 regarded Tilbury as sincere but intellectually timid; but we should remember that he was working in a hostile environment, newly appointed to a specialism hardly recognized and still largely in the hands of surgeons. In a more forgiving vein, Findlay adds "thanks to Tilbury Fox, dermatology had become respectable, a worthy pursuit to attract other celebrated men into its fold".
Three Celtic Pillars
Thomas McCall Anderson (1836-1908), physician at the Glasgow Western Infirmary, later to be Regius Professor of Medicine, was keenly interested in dermatology for he had studied in Paris with Bazin and in Vienna with Hebra. Deploring the absence of any specialist hospitals in Britain, he helped to found the Glasgow Hospital for Skin Diseases in John Street (1861), and did most of his dermatological work there. In 1874 he took charge of the skin patients at Glasgow Western Infirmary and in 1878 the Skin Hospital opened in Elmbank Street. The subsequent developments at the Western Infirmary and of the Glasgow Royal Infirmary have been recorded by Alexander33.
Anderson was an excellent teacher both at the bedside and in the lecture room, being able to combine a general physician's approach with his well-informed skin appraisal. He wrote on parasitic diseases, eczema, syphilis, psoriasis, porphyria and on the related alopecia areata, Addison's Diseaseand vitiligo. He produced a successful Treatise on Disease of the Skin and was knighted in 1905.
William Allan Jamieson (1839-1916) in Edinburgh was, with McCall Anderson, the mainstay of Scottish Dermatology. He was the son of a minister and had studied the arts before setting off to the Queensland for two years. It was then that he decided to take up medicine and returned home to qualify in 1865. After eleven years in general practice he came back to Edinburgh with the idea of becoming a general physician, but two friends, one of them being Douglas Argyll Robertson, persuaded him to consider dermatology, which seemed to be attractive; plans were changed and he was soon away to Vienna to study with Ferdinand von Hebra.
Back home he tried to persuade the Royal Infirmary to make a dermatological appointment, but it was not until 1884 that he was elected Extraordinary Physician for Diseases of the Skin. His teaching became popular and "Saturday Skins" always filled the theatre. The allocation of the famous "small dark room" for his own use, and two wards of 12 beds shared with the otologist, was his reward.
From 1899 he was a University Lecturer, and his clinic was to become the foremost in the United Kingdom5. Thus the teaching of dermatology, originally dependent on the hobbies of individual professors, was now, thanks to Jamieson, placed on a sure foundation. He was joined in 1892 by Norman Walker, fresh from Vienna and where he had translated Unna's Histopathology of the Skin The Edinburgh reputation rightly stood high.
Jamieson worked from an impregnable base of general medicine, and was elected President of the Edinburgh Royal College of Physicians in 1877. A popular President of the Dermatological Section of the British Medical Association's Edinburgh meeting in 1887, he was a fine upstanding figure, tall, handsome and heavily bearded. He was an enthusiast for archery at which he showed great skill and gained many prizes. Greek scholar and man of culture, he had a variety of interests and was remembered by his many devoted patients as a kindly and gentle physician.
Henry Samuel Purdon (1843-1906)34 from a remarkable medical family, pioneered dermatology in Belfast. A Glasgow graduate and pupil of McCall Anderson, his zeal was such that in his early twenties he arranged a public meeting to consider providing facilities for the care of skin patients; in 1865 he was able to open the "Belfast Dispensary for Diseases of the Skin" in rented accommodation in Academy Street. Henry Purdon, with his uncle Thomas Purdon, took charge. By 1868, with increasing use, a move to Regent Street was arranged; facilities there were said to be "commodious and up-to-date". The Hospital flourished until it was rebuilt in 1875 in Glenravel Street, but was destroyed during an enemy air-raid in 1941. Never rebuilt as such, its spirit flourishes in the Skin Department at the Royal Victoria Hospital.
Henry Purdon was energetic, studying, lecturing, writing and travelling, he was well known in London. He became a corresponding member of the New York Dermatological Society and in 1870, when Erasmus Wilson's Journal of Cutaneous Medicine was proving too burdensome for the founder to sustain, the editorship was offered to Purdon. He was able to produce a few more numbers before publication finally ceased.
Two More London Pillars
In London, two pupils of Tilbury Fox came to stand out at a time when very few in Britain could devote themselves exclusively to a medical speciality. Both were physicians by instinct and training, dedicated, industrious and with fine intellects; it is notable that neither Radcliffe Crocker nor Colcott Fox had travelled abroad to study in Paris or Vienna, the two famous centres.
H Radcliffe Crocker (1845-1909) was born in Brighton and educated privately. A man of indefatigable energy and patience he had a fine physique and a bluff manner. He spent his early years apprenticed to a general practitioner in a colliery district before returning to University College where he held various posts in the department of medicine; he then became the dermatological protégé of Tilbury Fox and joined him in 1876 as Assistant Physician, taking over the clinic on his death.
Crocker was undoubtedly a giant of his time; the foremost in English dermatology, he was to be compared with Besnier in Paris, for both had a formidable experience of general medicine which predated their interest in the skin. Meticulous observation, methodical recording and critical analysis enabled him to produce two great, indeed monumental, works. His "Treatise on Diseases of the Skin, their Description, Diagnosis and Treatment", was dedicated to Tilbury Fox, and published in 1888. A second edition appeared in 1895, and a third in 1903. It was based on his own 15,000 cases and was widely regarded as the most original and most authoritative text in the English language. His "Atlas of Diseases of the Skin" (1896) proved equally popular. Both Whitfield and Macleod stressed that Crocker had established the streptococcal cause of impetigo contagiosa, the evidence for this appearing in the first (1888) edition of his Treatise at a time when bacteriology was in its infancy. Impetigo had first been defined clinically by Tilbury Fox in Erasmus Wilson's journal.
An avid reader, with highly developed powers of observation and a photographic memory, Crocker stands out as a beacon. Contemporary physicians, so critical of specialization and especially of dermatology, did at least credit him and Tilbury Fox with "bringing some semblance of order to the subject".
He was most active in the Dermatological Society of London, of which he was an original member, and was always a remarkable contributor to the meetings. As well as producing his own books and writing sections for Quain's Dictionary and Allbutt's System of Medicine, his name is associated with an extraordinary list of clinical entities that he had observed and defined - dermatitis repens, the telangiectatic form of lupus erythematosus, erythema elevatum diutinum, myoma multiplex, recurring winter/summer eruption, tylosis palmaris/plantaris, granuloma annulare and xanthoerythroderma perstans. The first and last have now lost their individual status.
Crocker, who gave the Lettsomian Lectures in 1903, was an immensely busy man with a large private practice. His seemingly robust physique belied appearances for his health was in fact poor, though it seemed to improve in later years when his wealth ensured a more comfortable life style. He died suddenly when on holiday in Switzerland.
Thomas Colcott Fox35 (1849-1916) was the younger brother of Tilbury, with whom he was closely associated in the early years. He too had been born at Broughton, the eighth son of the surgeon Luther Owen Fox. From Queenswood he went to London's University College and thence with a scholarship to Peterhouse, Cambridge where he rowed in the college first eight. He was a countryman at heart enjoying most country pursuits, playing cricket for Hampshire and the Incogniti (no mean feat for an oarsman) he was also reputedly a good skater and a proficient golfer.
At University College his brother was in charge of the Skin Department and "Tommy" benefited from fraternal guidance and teaching. He proved to be a model student, a careful observer and later became an exceptional diagnostician. Like Crocker, he wrote articles for Quain's Dictionary and for Allbutt's System of Medicine. The brothers co-operated on the third edition of the Epitome of Skin Disease which was published in 1876.
His first appointment was to the Victoria Hospital for Children, a post he relinquished on moving in 1883 to the Westminster Hospital where he was to stay for 30 years. He observed his cases with meticulous care and had an uncanny ability to identify a cryptic primary lesion. His abiding interest was in children and their diseases; this never wavered and it was to prompt his particular study of fungal infections of the skin and hair. He described granuloma annulare, the "ringed eruption", along with Crocker and it was he, simultaneously with Thibierge in France, who incriminated tuberculosis as the cause oferythema induratum.
Private practice had no attractions, it was hospital work and mycology that he found absorbing. Though he wrote many fine papers he never embarked on his own textbook. He followed Radcliffe Crocker as President of the Section in the newly formed Royal Society of Medicine and he proved an admirable chairman; his profound knowledge of the literature and his own considerable experience brought him great respect. His devoted disciples included Graham-Little, Adamson, MacLeod and Whitfield. The latter deemed him ideal as a man and as a teacher, "the rock upon which the modern English School of Dermatology is founded". More robust than his brother, he made the greater impact.
Humorous, modest, and without a shred of pomposity, he loathed humbug and never courted popularity. His knowledge of the literature was remarkable for he was an omnivorous reader. Inheriting his brother's library, and adding to it, he formed a unique collection. He was held in respect by Professor Besnier in Paris, who was once overheard to say "we think the world of Dr Fox".
Childless, he had been devoted for years to his Aberdeen terrier, tragically to be killed by a passing bus. Losing his sight meant learning Braille: then he reluctantly had to forsake his Harley Street house for a quieter home but where he could still enjoy the visits of old friends and colleagues bringing him the latest news of the world he had graced for so long.