Eruptions of the skin have interested both priests and physicians from the earliest of times1. Inevitably confusion reigned in those days: descriptions of the different patterns were indistinct, and the terms used by various writers were so vague that useful communication between them was impossible. Gray2, in his Harveian Oration, considered the early works of Galen (AD 130-200) and of Girolamo Mercuriale (1530-1606) who had published De morbis cutaneis in 1572. In England the two Copemans3, father and son, explored signs of interest in Tudor and the early Stuart times; events in Wales have been recorded by Hodgson4 and in Scotland by Walker and Percival5. This account begins in England with Daniel Turner.
Daniel Turner (1667-1740)6, born nine years before the death of Harvey, has been regarded as the "Father of Dermatology". He was apprenticed in London at the age of 17 for seven years, his mentors being Charles Bateman and Thomas Litchfield, Master of the Barber Surgeons. Turner was admitted to the freedom in 1691, and once elected to the livery could practice in London; he published the two volumes of his Art of Surgery in 1722 but his treatise, in English not Latin, on Diseases incident to the Skin had appeared in 1712. It came out in a French translation in 1742. His description of the skin's anatomy was accurate and his clinical accounts remarkable.
These efforts however, were belittled by the spite and envy of his contemporaries, and later generations tended to disregard his work, which had been carried out in isolation. There were no medical journals, no medical societies, and the College of Physicians in London seemed more concerned with disputes than the promotion of knowledge. His book, better appreciated on the Continent, ran to five editions and was translated into German and French.
Dissatisfied with the status of Surgeon, Turner turned to medicine, becoming a licentiate of the College of Physicians in 1711, but membership without a University degree was impossible. Nevertheless, he obtained a Doctorate from the newly founded Yale University, before they had a medical school, probably on the strength of publications he had donated to their library. However this American degree was not acceptable to the Royal College of Physicians so he remained without the coveted membership.
Two notable figures from Europe should be mentioned here as their work was to influence later British Dermatologists.
Anne-Charles Lorry (1725-1783) worked in France: his tractus de morbis cutaneis appeared in 17777 in Latin, being translated into German in 1799. Unpopular outside France, his writings bravely attempted to correlate the skin's functions with those of other organs.
J J Plenck8 (1735-1807), sometime Professor of Surgery and Obstetrics, had spent a busy life, largely in Vienna, writing on a variety of subjects including the skin and in 1776 he produced Doctrina de morbis cutaneis, a volume of 138 pages in Latin, basing his classification on the morphology of the dominant lesion. He listed 115 examples, which he divided into 14 categories. His work, though derided by some, was accepted and built upon by William and Bateman (see Bateman's Delineations of 1817).
Robert Willan (1757-1812) devised a dermatological classification, probably prompted by William Cullen, Professor of Medicine in Edinburgh; nosology was in the air, for Carl Linnaeus was doing just this, first with plants and then with diseases.
Willam, born in the Dales on North West Yorkshire, the birthplace of many learned physicians, was educated at Sedbergh, becoming a classical scholar and mathematician. A Quaker9,10 precluded from Oxford or Cambridge he entered Edinburgh University whence, after graduation, he moved to London at the suggestion of Dr John Fothergill, his father's friend, to work as his assistant. An unexpected and fatal illness was to overtake the doctor, prompting a brief return visit to Darlington before Willan finally and permanently settled in London.
In 1783, he was appointed Physician to the Carey Street Dispensary, a charitable institution lying between the cities of London and Westminster and catering for the sick poor. It was a time of great depression; Europe was an armed camp and England, equipped for war on land and sea, was ultimately to win the battles of Waterloo and Trafalgar. England's troubles were not confined to Europe, for the government had alienated and lost America. Ireland too remained a perennial problem, while George III, Head of State, his mind clouded with disease, seemed indifferent to outside affairs. It is scarcely surprising that charitable institutions were hard pressed in such a financial climate.
This was the background to Willan's work at Carey Street11. He was the physician working with Mr Pearson, the Surgeon, and Apothecary Nelson, who was as Assistant Surgeon to the Third Regiment of Foot Guards, was posted abroad in 1799. It was here that Willan began to study the contagious fevers - variola, varicella, measles, typhoid, scarlatina and their symptoms and signs, along with the more mundane skin eruptions affecting the impoverished sick.
Later, with his pupil Thomas Bateman, he developed a system of classification based on the morphology of the primary lesion; it was to be accepted and used by future generations. Both were Edinburgh graduates: the Royal Infirmary had been founded in 1729 (Royal in 1736), and was soon to be followed by a School of Medicine. These pioneers were later joined by others, notably Anthony Todd Thomson, then Richard Bright and Thomas Addison, all of whom worked with Willan; all were physicians and Edinburgh trained.
Immigrant Scottish graduates found appointments to general hospitals in England difficult to obtain - so strong was the influence of the London College of Physicians. As a result they would work at or even set up, dispensaries for the sick poor. In the larger hospitals skin care was still the province of the surgeons.
Willan's first treatise was published in 1798 in Breslau12, a celebrated University town of the Austro-Hungarian empire (now Polish Wroclaw); and was translated into German, the first section having appeared earlier in London. The illustrations, accurately depicting colour changes, were to revolutionise future publications, but the expense of engraving the plates was to delay future productions.
In 1798, work pressure had been increasing, especially in the winter, so Willan suggested that Assistants should be appointed. Two Swiss physicians, both Edinburgh trained, and who had studied at Carey Street, were selected; the arrangement did not prove successful. In fact one, Dr de la Rive, returned to practice in Geneva, while the other, Dr Alexander Marcet, entered Guy's, later being appointed to the staff. He is credited with the first clear description of renal colic and made a fortune in London before returning to Geneva as Honorary Professor of Chemistry. His portrait by Raeburn hangs in the Common Room at the Royal Society of Medicine.
In 1800 a new Assistant, Dr T A Murray had been elected, but he died of typhus after only two years; it was then that Thomas Bateman, whose appointment was to be far from straightforward, was taken on. The following year the Apothecary, the successor to Mr Nelson, died of smallpox. The governors, naturally concerned, then recommended that "in view of the increasing prevalence of contagious fevers amongst the poor the staff of the Charity do inoculate for the Cow Pox all recommended persons". The wards were to be whitewashed with hot lime and disinfected11,13.
In 1802 Willan opened a Fever Hospital in Grays Inn Road. Though commonplace in many provincial cities, London had nothing of the kind apart from the one smallpox hospital which had been erected at King's Cross in 1746. Willan produced On Vaccine inoculation in 1806, for he was a keen advocate of the technique and was reputed to have carried his recently vaccinated son round the smallpox wards to encourage the stricken inmates.
Over the years some 40 postgraduates were to study with Willan; in fact, dermatology was really the first postgraduate subject to be taught in London. Another pupil, also Swiss, was Laurent Biett. He had studied in Paris and later attended Bateman's Clinic in 1816; throughout he remained a dedicated supporter of the Willan system.
The theorising of Lorry in Paris did not appeal to Willan. He was concerned to evolve a classification based, like Plenck's, on the precise appearance of the primary skin lesion and this could well involve prolonged searching to identify the prototype. He introduced a nomenclature which, with modifications, became universally accepted. He tried to fix the sense of terms he used by exact definitions, as had Linnaeus, so as to constitute orders, and finally to arrange distinct genera. he attempted to classify and give names to cutaneous patterns that until then had not been clearly defined and for this work he was awarded in 1796 the Fothergillian Medal of the Medical Society of London. Ferdinand von Hebra was to propound, from his pathological viewpoint, a totally different approach to classification.
In Paris, L'Hôpital St Louis has, over the years, boasted many distinguished professors: Rayer, Gilbert, Biett and Cazenave, with Alibert14 as unquestioned chief, were around at this term. Alibert used the fanciful idea of a tree-trunk, branches and leaves, his arbre des dermatoses, to express the relationship between skin diseases, but many of his colleagues, influenced by Biett, preferred the Willan system. Nevertheless, it was generally agreed that Alibert's publications had superior illustrations.
Willan remained on the staff of the Carey Street Dispensary for 21 years, resigning in 1803 as private practice and tuberculosis took a heavy toll on his health. Throughout his years on the staff the Govereners had been "deeply impressed by his great attention to the patients" and obviously appreciated his special talents. However, his resignation was reluctantly accepted and they presented him with 50 guineas along with "a piece of plate of the same value" and made him Life Governer.
For a while, Willan developed a considerable private practice among the nobility; meanwhile his inquiring mind remained alert, for articles on measles and scarlet fever13, in which he described his attempts at immunisation, appeared in 1808. He took to entertaining friends at musical soirées with his wife and step-daughter Mary, his son Richard, and often his brother with whom he had always kept in touch. Summer holidays, with the grandees out of town, were spent in Edgware, enabling the house to be painted.
However, it was now obvious he was becoming increasingly ill, and in 1811 he left for Madeira with his family and Dr Ashby Smith. The voyage took 53 days from Blackwall; the Bay of Biscay was at its worst and the French fleet were ever a threat. Willan became iller, oedematous and ascitic; landing at Funchal on December 1st, he was a pitiable sight. However, at the home of a British merchant, James Gordon, he recovered enough to seek a cottage and start some medicinal treatment. By 1816 he began to lose his sight and his health further deteriorated, possibly the result of mercurial intake. In the eyes of some London physicians Medeira was a popular haven for tuberculosis and "chesty" patients but many emigrants were, in fact, to succumb in the steamy climate of Funchal.
Ashby Smith, to be his stepson-in-law, recounted how Willan continued to record the signs of his decline until three hours before death. He was buried in the English churchyard in Funchal, where his headstone15,16 remains intact. Mrs Willan prohibited Bateman from using her late husband's remaining papers; they were passed to Ashby Smith, who published them as The miscellaneous works of Willan.
Thomas Bateman (1778-1821) was born in Whitby. After three years apprenticeship in Yorkshire he moved to London, studying anatomy at William Hunter's School in Windmill Street and medicine at St George's Hospital. His Edinburgh MD thesis was titled De haemorrhoea petechialis. He became a pupil, then a friend and colleague of Willan in the Carey Street Dispensary and joined the staff in 1804. Earlier he had helped to establish the Edinburgh Medical Journal so he continued to contribute articles such as those on London's weather and current epidemics.
By 1812 only one volume of Willan's Cutaneous Diseases had appeared as the coloured engravings were proving prohibitively costly. In 1813 Bateman published his own Practice synopsis of Cutaneous Disease according to the arrangement of Dr Willan which ran to five editions before he died. It was to reach an eighth by 1849, the last being edited by Anthony Todd Thomson. On the strength of his publications Bateman received a diamond ring valued at 100 guineas from the Emperor of Russia with a request that he should send on all future publications. This could have been related to earlier smallpox in the Imperial Court when Thomas Dimsdale, Bateman's competitor for the Carey Street appointment had inoculated the Royal family and was ennobled by the Czar.
Bateman completed his own Delineations of Cutaneous Disease. It appeared from 1815 to 1817 in 12 sections; they were sold at a guinea each and incorporated 80 of Willan's original plates. A copy is in the library of the Royal College of Physicians in London. His atlas was republished after his death and again in 1875, with some embellishments by Tilbury Fox.
Bateman, now the principle authority in London, developed a lucrative private practice. His name is linked to many clinical entries - molluscum contagiosum, (for long known as Bateman's disease), lichen urticatus, ecthyma, purpura senilis, alopecia areata and erythema multiforme are all credited to him. He had indeed carried faithfully the mantle of Robert Willan, his friend and master.
After Willan and Bateman the Edinburgh ethos continued to permeate London.
Anthony Todd Thompson (1778-1849) the son of a Post-master General in the State of Georgia, and an Edinburgh graduate, returned home once the American Civil War had ended. By 1800 he was in his Sloane Street practice and helping to found the Chelsea Dispensary. Over his 20 years in London he gained a considerable reputation for skin expertise, he also lectured in botany and materia medica. In that capacity he was to join University College, then the University of London, as one of two Professors of Materia Medica. He was able to start a skin clinic at a Dispensary in George (now Gower) Street, where, until his death in 1849, he developed his clinical teaching.
When the new hospital building was completed, the clinic transferred there but was not officially recognised until it was taken over by his physician nephew, Edward Parkes, already on the staff. Parkes had earlier worked in his uncle's small laboratory and he completed Thomson's Practical Treatise on Diseases affecting the skin in 1850. Parkes was no dermatologist and was destined for a totally different though distinguished career. From the Crimea, where he set up a new military hospital, he went on to found the science of modern hygiene, becoming Professor at the Army Medical School and a Fellow of the Royal Society.
Thomas Addison (1793-1860), another émigré, had come from Newcastle to study at Edinburgh and graduated MD in 1815. He soon obtained a post in London at the Lock Hospital and this stimulated his study of the multifarious aspects of syphilis, always writing his notes in Latin. At the Hatton Garden Dispensary he worked with Bateman, he even joined the Carey Street staff for a while. In 1820 he entered Guy's17 as a pupil and, in 1824, against some opposition, was appointed Lecturer and Assistant Physician, becoming Demonstrator of Cutaneous Diseases in the School. He was a superb teacher, adding lustre to the new and independent school of physics at Guy's and outshining his contemporaries Brigh and Hodgkin. This shy, sensitive man did not seek publicity; his written works were published by Wilks and Dalby in one volume of the New Sydenham Society's Proceedings and this contains his descriptions of vitiligoidea or xanthoma, true keloid (morphoe) and melasma suprarenale, illustrated by several examples. His remarkable abilites were recognised by Trousseau who coined the famous eponym.
At this time an expanding printing industry stimulated a profusion of texts and atlases. Some that should be mentioned, as they went to several editions and were translated into French and German, were Plumbe's Practical Treatise on Diseass of the skin, published in 1824, with a 4th edition in 1836. Anthony Todd Thomson's Delineations of Cutaneous Disease in 1829, also an atlas, with the illustrations by his son. A Practical Compendium on Disease of the Skin by Jonathan Green appeared in 1835 and again in 1837.
Samuel Plube18 (1795-1837) was not a University graduate, he qualified MRCS in 1815 but he shared the Jacksonian Prize of the College of Surgeons for his essay on Diseases of the Skin.
After four years with the East India Company's Navy he settled to practice in London, becoming Surgeon to two Infirmaries. He worked on his own and, un-impressed with Willan's ideas, favoured the French teaching. He noted the primary pustule of sycosis barbae and clarified the relationship between Willan's "impetigo" and "eczema" (both being eczema). His Practical Treatise, an enlargement of his prize essay, published in 1824, ran to four editions. He was regarded as something of a "porrigo" expert, having coped with a stubborn ringworm outbreak amongst the "blue-coat boys" at Christ's Hospital.
Jonathan Green (1788-1864) after serving in the Royal Navy visited the St Louis in Paris where he witnessed the skilful extraction of a scabies mite on the point of a pin by one of Alibert's assistants. He was much impressed with their vapour baths and on his return to London established his own fumigating baths at 5 Bury Street: later they moved to 40 Great Marlborough Street, but in spite of his enthusiasm did not prove financially successful. He had become a firm disciple of Rayer and Biett and, somewhat ahead of his time, attempted a careful but unsuccessful study to relate specific skin eruptions to particular systameic diseases. In his Practical Compendium, he gives due credit to Lorry, Plenck, Willan, Bateman, Alibert and Rayer and clearly was a well-read, serious student.
Though Addison's name is indelibly etched in medical history, those of Green, Plumbe and Todd Thompson have become blurred in the lists of time. (The books of Plumbe and Green, bound together, are to be found in the Willan Library).
Up in Scotland the earliest records indicate that syphilis had been present, and its mode of transmission recognised since the 16th century. Leprosy had been widespread for longer; indeed King Robert I (the Bruce) in 1339 was an early victim and by the 12th century there were leper houses both in Scotland and in England19. Walker and Percival5 studying ancient archives and recording the development of dermatology up to the 18th century, noted that leprosy, syphilis, the "itch" and sibbens, an acute infection somewhat like yaws, made up the bulk of skin diseases. For a long time it was considered that a practice confined to such patients was not justifiable; the establishment view was that properly trained surgeons and physicians could readily cope.
The Edinburgh Infirary and Dispensarydates from 1729, the "new buildings" being opened in 1741. Clinical teaching, for which Edinburgh rightly was to become famous, was based on the pattern that Boerhaave had established at Leiden. When the disturbance of the Jacobite rising of 1745 had subsided, a combination of university education with clinical instruction in the hospital, unavailable elsewhere, became possible. Thus the Scottish capital became the new medical "Mecca", supplanting and finally eclipsing Leiden. It is hardly surprising that for a time, Englishmen outnumbered Scots amongst the undergraduate students.
By 1805, interest in dermatology was already apparent, and a Dr Kellie of Leith wrote on the Function of the Skin; understandably pride was also shown in the work of Willan and Bateman down in London. The writings of the French masters, like Alibert, were familiar to a few and some of the more adventurous spirits even travelled, often by foot, to London and across the water to Paris.
In 1824 Edward Duffin established a Skin Clinic in Edinburgh's Lawn-market where patients were seen twice weekly in rooms loaned to him by the Eye Institute. He used his own house to administer vapour and medicated baths but his attempts to develop a permanent clinic met with little interest or financial support; the project was doomed. Dejected and disillusioned, Duffin went off to London to try his hand at ophthalmology.
Joh Paget, graduating MD in 1831, studied in Paris with Alibert. He won a coveted prize at the St Louis in the face of considerable local opposition for an essay in which he tactfully expounded the views of his professor. He had seemed destined to be a foremost specialist in Scotland, but defied probability by succumbing to the charms of one Baroness Wesselanyi, a rich widow. Once married he looked after her estates, proving a fine landlord, an expert in the breeding of cattle and bringing science to viniculture.
Enquiring minds were also to be found in Dublin20. As in Scotland leprosy had been endemic for many years before syphilis appeared; for a long time the popular remedy for the latter, indeed for most other chronic diseases, was mercury in one form or another. The earliest description of mercurial skin eruptions - the mercurial lepra - came independently from three Irish physicians in 1804. Thomas Moriarty, George Burrowes and Whitley Stokes all claimed precedence. Thomas Bateman certainly, and Willan probably, suffered mercurial toxicity.
Abraham Colles, a name familiar to all, studied in Edinburgh for two years before journeying to London on foot. There he became a pupil and lifelong friend of Atley Cooper the Guy's surgeon. In 1837 he presented his Observations on the use of mercury for Venereal Diseases. He was well aware of the infectivity of secondary syphilis and in this was at variance with John Hunter, but he remained unclear about its relationship to the disease's later manifestations.
Another great Irishman was Arthur Jacob, born in 1790, and destined to be an ophthalmologist. He had earlier travelled to Edinburgh, London and finally Paris, all on foot. Back in Dublin, and on the staff of Sir Patrick Dun's Hospital, he recognised the rodent ulcer in 1827, describing it as affecting the eyelids and other parts of the face. For a long time it was known as Jacob's ulcer.
William Wallace (1791-1837), familiar with the writings to Willan and Alibert, was aware that no Dubliner could claim expertise in dermatology and, at his own expense, established the Dublin Infirmary for Skin Diseases. He arranged treatment for Scabies by sulphur vapour baths and introduced potassium iodide to the materia medica, finding it particularly effective fot tertiary syphilis. He agreed with Colles on the infectivity of secondary syphilis and made accurate observations on the incubation period. He died suddenly of typhus before he was able to train a successor to carry on his admirable work.
A Dublin Physician of interest was J M Neligan (1815-63). For years he had edited the Dublin Quarterly Journal of Medical Science and, though concentrating more on materia medica than on clinical practice, he found time to publish "A Practical Treatise on Diseases of the Skin" in 1852 and, in 1855 his "Atlas of Cutaneous Disease".
The First Dispensaries
Wallace's Dublin Infirmary and Duffin's Clinic in the Edinburgh Lawnmarket may well have been the first opened in the Kingdom. However, in all the big cities and especially in London, general dispensaries were founded throughout the 19th century. Often they catered for special classes of disease, those restricted to one system, such as the skin or the eye, and many were staffed by Scottish graduates. The founders of these institutions were individuals who might have been excluded from a conventional hospital appointment; some used their clinics to develop their special skills as Willan and Bateman had done, others saw an opportunity for financial gain. It was this aspect that helped to fuel the antagonism of the medical establishment, strongly supported by the Lancet, towards the idea of "specialism". It is true that a few of these early clinics were used to further the aims and fortunes of their founders but on the whole those did not survive for long. Others were to develop into respectable institutions, attracting many patients for whom no satisfactory provision had been made by the famous hospitals.
The Early Skin Hospitals
Rook21 found 12 existing in London from 1820. They, with the reputable dispensaries, must have trained the men who were to become the next generation of specialists. The Hospital for Diseases of the Skin opened at London Wall in 1841 as the London Cutaneous Infirmary and soon moved to Stamford Street, Blackfriars. It was founded by a Dr Startin22, who ran it single-handed for ten years. It became the only recognised centre in the city.
James Startin (1806-1872) was born at Mosley, Birmingham and spent some years as a student at St Bartholemew's, qualifying in 1827. After house appointments he returned to Birmingham as resident surgeon to the Town Infirmary and then set up practice. However a personal disaster with his bank, in which he had a share holding, forced him to sell up and move to France studying at Montpellier and Paris. There he was able to attend the St Louis where Biett, extolling the virtues of the "Willanists" over the "Alibertists", was lecturing.
Returning to England, and by now impressed with the prospects for developing dermatology in London, he gained the financial backing of Samuel Gurney, a Quaker banker, and the aristocratic patronage of two Royal Dukes, those of Cambridge and of Sussex. He was able to open the doors of his hospital in 1841 and later enticed onto the staff Thomas Hodgkin, the distinguished physician from Guy's, the anatomist A M McWhinnie from St Bartholemew's, and the surgeon George Burt.
Once Jonathan Hutchinson arrived as a pupil it was not long before Startin appointed him as another Surgeon and it was thus that the Hospital became a respected centre. Waren Tay, eye surgeon at the London Hospital, was his constant colleague and friend and Edward Nettleship, whose name is associated with the first description of urticaria pigmentosa23, was a long standing Assistant. J F Payne, Physician of St Thomas' and J H Stowers who became the main strength of St John's, were both to join the staff.
Startin gave a course of lectures which were published in the Medical Times in 1846 but it was on practicalities that he concentrated; his views were empirical but as a therapist he was widely regarded as adroit. He certainly made his mark as a clinical teacher and his greatest contribution was surely to interest, then to introduce Jonathan Hutchinson to the staff, for it was chiefly through Hutchinson that the hospital gained its fame and reputation.