Fifty Years OF DERMATOLOGY.

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    AUGUST 3, 1929.

    Fifty YearsOF

    DERMATOLOGY.

    A MALCOLM MORRIS MEMORIAL LECTURE

    Delivered on May 16th, 1929, under the Auspices of theChadwick Trust,

    BY SIR NORMAN WALKER, M.D., LL.D., F.R.C.P.,CONSULTING PHYSICIAN FOR DISEASES OF THE SKIN TO THE

    ROYAL INFIRMARY, EDINBURGH.

    THOSE who decided that the Malcolm MorrisMemorial Lectures (of which this is the third) shouldbe concerned alternately with dermatology and publichealth made a very wise and far-seeing decision. Thesubjects are closely interwoven, and to both of themMorris gave of his best.

    I propose to sketch the progress of dermatologyduring the last 50 years, during most of which MalcolmMorris was an active force. When, after qualifyingas a Member of the Royal College of Surgeons ofEngland in 1870, and after a period of study in Vienna,Morris commenced practice in Goole, I questionwhether there were many inhabitants of the EastRiding who had ever heard the word dermatology. ISkin diseases were, at that period, commonly attri-buted to dirt (and my native country had an unenvi-able reputation in that respect), to some mysterioushumours which no one could satisfactorily explain,or to gout, which, being a fashionable complaint ofthe better classes, was itself sufficient for the climbersof those days. It is so nearly 50 years since I com-menced the study of medicine that I make no excusesfor using that as another reason for the round figure.Nor, I think, do I need to make any when I beginthese reflections with special reference to Edinburgh.

    DERMATOLOGY IN EDINBURGH.In 1880, dermatology in Edinburgh was in a state

    of hibernation. In the middle of the nineteenthcentury it had had quite an active period. HughesBennett, whose name is best known as a physiologistand as a physician, and to whom belongs the creditof having been the first to introduce the use of themicroscope into the teaching of clinical medicine inEdinburgh, took an active interest in dermatology,and his writings on many dermatological subjects arestill well worthy of perusal by even the youngest ofour craft. He was not alone in his interest, for hiscolleague, Laycock, the Professor of Medicine, wasalso, to use the quaint wording of the Anatomy Act," addicted " to dermatology. In those days, everyprofessor in the Faculty of Medicine had the right to ashare in the medical wards of the Royal Infirmary,for the purpose of giving clinical instruction to hisstudents. But as there were not enough wards to goround there was an in-and-out arrangement, underwhich each took charge for periods of three months.Chance brought it about that the charge of the wardsallocated to the diseases of the skin alternated betweenLaycock and Hughes Bennett, and I have heardfrom many old friends, now passed to their rest, ofthe enjoyment of the students who had the oppor-tunity of going round with each when he took overcharge from the other, and of hearing very candidaccounts of the blunders in diagnosis and theinadequate treatment which had occurred during hisabsence. They had no direct followers and when Ibegan medicine in 1880 there were no skin wards inour new Royal Infirmary. There was, however, oneward in which there were usually some skin cases.I alluded a few minutes ago to the fact that anyprofessor in the faculty could claim opportunities forteaching clinical medicine, and that in the past theseopportunities had been exercised by occupants ofthe chairs of botany, chemistry, anatomy, pathology,materia medica, physiology, and medical juris-prudence. In the days I speak of the last of these

    chairs was occupied by Sir Douglas Maclagen, amember of a famous Scottish family which suppliedsoutherners with an Archbishop of York. Sir Douglas,before he was appointed professor, had served histime as an ordinary surgeon to the infirmary but,curiously, the privileges granted to the physicianswere not extended to the surgeons. In his youth,Maclagen had spent a good deal of time in post-graduate study in Paris, then the Mecca of derma-tology and, on his return to active duty as a physicianin the infirmary, he filled many of his beds with skincases, and when his turn came round to give a clinicallecture he usually selected his subject from some ofthem. Several of the ordinary physicians and surgeonstook some interest in skin diseases and it was my goodfortune to commence clinical work-as Chairmanof the Examination Committee of the General MedicalCouncil I should almost blush to confess it-in myvery first year under one whose personality is knownthe whole world over, thanks to Sir Arthur ConanDoyle, as Sherlock Holmes. Dr. Joseph Bell wasthe last of a long line of Bells, surgeons in Edinburgh.To his out-patient clinics came patients with allsorts of diseases, not a few of them dermatological,and no one would have appreciated more intelli-gently the detective skill which Joe Bell showed ininvestigating these cases than Malcolm Morris. Itwas from Bell that I first learned to distinguishbetween lupus and rodent ulcer, a distinction notmade and not regarded as seriously important by someof his colleagues. A happy inspiration led me to askthe clerk of the Royal College of Surgeons of Edinburghto search the minutes of the College, and I learnt withgreat interest that Malcolm Morris was proposed forthe Fellowship of the College in 1882 by Sir JosephFayrer and seconded by Dr. Joseph Bell. Morrisoften used jokingly to refer to the fact that a partof his success was to be attributed to the fact that,owing to his Christian name and to the fact that hewas a Fellow of the Royal College of Surgeons ofEdinburgh, some people assumed that he must be aScotsman and therefore capable.When Morris commenced practice in London the

    dominant personalities were Erasmus Wilson, JonathanHutchinson, and Tilbury Fox. In many hospitalsthe skin appointment-if there was one-was heldby some member of the staff-usually the juniorstaff-in addition to his ordinary duties, and he hadto make his own opportunities for investigation. Ihave a vivid recollection of a day spent with my oldfriend, Colcott Fox ; we lunched at the NationalLiberal Club, went to Westminster Hospital at 2oclock, and from then until nearly 7 he saw a constantstream of patients and I know that, long before theend, my mental capacity was exhausted 1 Two orthree students looked in at various periods during theafternoon and, no doubt, picked up somecrumbsfrom Foxs sage comments. While much yet remainsto be done, the contrast in the present day is veryremarkable. It no longer remains a chance whetherthe person whom circumstances put in charge of theskin department was interested or whether he regardedit as a duty to be discharged in order to get back tohis own job. Almost every teaching school in thecountry is now supplied with a well-trained derma-tologist, and the students of to-day get regular, careful,systematic instruction.My own immediate chief in Edinburgh was Allan

    Jamieson. He had a career interestingly like that ofhis friend Morris, for they met at Hebras feet inVienna and lit their torches at his altar. They eachspent some useful years in general practice in a seaporttown-as a residence, I should place Berwick-on-Tweed before Goole-and each, having spent sometime in study abroad, settled as a general practitionerin the town where he was educated. In these largerfields they found more scope for their special interests.Their experience and their influence grew, and eachplayed a notable part in forwarding the art of derma-tology. Jamieson had at first one-later extended totwo-out-patient days in the week and his Saturdayclinics were often attended by as many as 300

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    students. Now the department has a staff of sixand 22 beds, and the out-patient department is opendaily ; it needs to be ! There are still lecture demon-strations to as many as 200 students, but the groupsfor clinical teaching are limited to 15.

    If I were to endeavour to allocate the beatitudesamong my friends, I would not put Morris among the" meek." But I would put him high among the " peace-makers." The path of dermatology in these 50 yearshas not been one of uniform smooth progress. Therehave been obstacles to circumvent and morasses tocross. In the overcoming of all these difficultiesMorriss counsel was always wise, and the harmoniousrelations now existing in our ranks owe not a little to him.

    I think my best plan to illustrate the progress ofdermatology in the half century is to contrast theposition of certain diseases as they were 50 years agowith their position now.

    RODENT ULCER.I begin with rodent ulcer, with which subject

    Morris had a very interesting connexion. Of thatdisease we older dermatologists have memories whichone hopes can never again be put on record. Thereused to arrive at our out-patient departments miserablewretches with half their faces eaten away and storiesof how they had for years been carefully applyingthis, that, or the other ointment. Rodent ulcer has.always been a fascinating subject for the youngdermatologist and many have done their first originalwork on the investigation of its pathology. In amoment I shall refer to modern methods of treatment,but these would be of comparatively little avail wereit not that increasing knowledge and more abundantopportunities of demonstrating the early stages ofthe disease to students had resulted in the earlierappearance of cases at hospital. I can remember, inmy student days, watching with bated breath the lateProf. Annandale, a plastic surgeon of the very firstrank, cutting away extensive ulcers and leaving gaps Iwhich seemed to us students impossible ever to fill. I,Others treated these extensive cases with caustics,

    I

    but the number successfully treated by any methodwas small and the patients mostly died a miserabledeath. One of the most interesting events of the earlydays of X ray therapy was Sequeiras accidentaldiscovery that rodent ulcer responded to X rays, andmany of the later ulcerated cases were cured by thismeans. Then came the radium treatment, which wasquite dramatically successful, as I can testify frompersonal -experience. The interest aroused and theattention drawn to it has had the effect that sufferersare now almost invariably advised of the position andof the right methods of treatment at a stage when theprognosis is almost entirely favourable. If the newhopes of more abundant supplies and more adequateorganisation of the use of radium in other forms ofcancer are fulfilled, the pioneer success of radium inrodent ulcer should stand as a landmark.

    Lupus.In referring to tuberculosis of the skin, it would

    be a crime to omit reference to what Morris did forthe campaign against tuberculosis in general. His- organising powers, his ready pen, and his fearless.ourage were important factors in the promotion ofthe campaign against tuberculosis, for he had the

    happy knack of the journalist in interesting the publicin whatever subject he took up. But here I am-concerned with tuberculosis of the skin, or lupus-the wolf. I can vividly remember the old days when- patients with lupus might attend almost any depart-ment of a hospital and were, I fear, generally regardedas very uninteresting cases. In Edinburgh they fellmainly under the care of the surgeons, who had oneremedy, or perhaps I might say two : the sharp spoonand the cautery. I remember, as a young man, oneof the surgeons to the Royal Infirmary showing tothe Medico-Chirurgical Society a case which he hadscraped 77 times ! The patients were scraped,remained sufficiently long in hospital for healing tocommence, and were then discharged, to return six

    months, 12 months, or 18 months later, worse thanthey were before, to undergo the same treatmentagain. I sometimes think that insufficient credit isgiven to the work of Unna, of Hamburg, who popu-larised the use of salicylic acid. I use the word" popularised " because I believe Unna was not thefirst to use it and that the credit for the originalobservation of its good effects on lupus is due to aYorkshire house surgeon whom I have never beenable to identify. This was the method in vogue andbeing carried out when I was appointed assistant toAllan Jamieson in 1892. The method still has itsplace in the treatment of exceptional cases, but itspart in advancing matters at that stage was the demandit made for more frequent attendances and closerobservation. Of course other caustic methods werein use and some teachers, notably one of my ownmasters-Prof. Pick, of Prague-used it with greatfreedom. I saw much of it for he was good enough tosay that I worked the thermo-cautery better thanany other of his assistants! I was not, however, soimpressed with its good effects as to use it much whenI had personal charge of patients.With the introduction of tuberculin arose great

    hopes for the treatment of lupus, and it was myprivilege to be attached to Picks wards in Praguewhen that treatment was at its very beginning. Largedoses were given at very brief intervals, severereactions resulted, and I saw many of the cases aday or two later in the pathological department, whereI was then working with Chiari. The results weresuch that only the very stern-hearted could perseverewith the treatment, and it soon fell into desuetude.So far as I know there were only two leading derma-tologists who did not discontinue it ; these wereMcCall Anderson, of Glasgow, and Neisser, of Breslau.They were never addicts of the large dose, but pre-ferred small doses and long intervals. For some yearsI treated a large number of patients by that method ;many of them benefited, and I think much of thebenefit was due to the tuberculin, but I am nowconvinced that quite as much was due to the factthat the fortnightly injection was introducing moremethod into the management of the cases, and thatof course we did not restrict our treatment to tuber-culin alone.The next great step forward came when Finsen

    got to work. He began, it will be remembered, withstudies on the effects of red light in the treatment ofsmall-pox, and the extension of his experiments, andhis application of light in various forms to otherdiseases, is an instance of how work commenced onpurely scientific lines, often leads to importantpractical results. While the method of Finsen, bothin its old and in its newer forms, still is probably thebest of all methods of treatment for a few cases oflupus, our greatest debt to Finsen is not the methodof treatment but the fact that he taught the need ofperseverance. He organised the treatment of lupusand taught us that steady, persistent, daily treatmentwas essential in the cure of this obstinate disease.The enormous expense of his apparatus hindered itsuse in most centres in this country, and it had com-paratively little trial in America-not because of theshortage of money, but because of the shortage ofcases. Many an American visitor has told me thathe has seen more cases of lupus in one day in myclinic than he had seen in the rest of his life.Next came X ray therapy, and few of us can look

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