INTRODUCTION
History of medicine forms an infrastructure on which modern dermatology is based. Evidence of disease is found in the earliest Egyptian literature, the Ebers Papyrus and then in Grecian, Roman and Arabic medicine. The history of dermatology can only be distinguished from the history of medicine at the beginning of the 19th century, when dermatology like the other specialities began to be recognised as a special branch of medicine.
ANCIENT HISTORY
Ebers Papyrus is the oldest and most important medical papyrus of ancient Egypt. It was written in about 1536 BCE, it is a compilation of medical lore going back to about 3000 BCE. The Papyrus devotes a considerable amount of space to skin diseases, leprosy is frequently mentioned. Healing was an art addressed on many levels. Turmeric powder and henna were used to treat open wounds. Acacia and aloe vera were employed for skin ailments. Remedy was evolved for removal of guinea worm by wrapping it round a stick and then slowly pulling it out, this method was still used as a standard treatment till recent times. The magicians and priests would drive away the evil demons. Cleanliness, bathing, shaving hair from the scalp were as significant for treating disease as were dietary restrictions such as eating raw fish unclean animals.
Other early writings from Mesopotamia come from the clay tablets, which have description of disease of ears, eyes, skin, heart and various venereal diseases. Mention is made of a child born with a birthmark was called ‘spotted evil’ which predicted a misfortune or even the death of a king.
Hippocrates (460–370 BCE) is said to have freed medicine from the shackles of magic, superstitions and supernatural phenomenon. He initiated the theory of four humors, but actually this concept is found in Cretan and Mycenaean medicine. According to this theory the body consists of four humours: blood yellow bile, black bile and phlegm. An imbalance of the humours caused disease and the physician's role was to restore health by correcting the imbalance and restoring harmony to the humours. Skin being a vehicle for the excretion of humours. The equilibrium could be disturbed by climate, environment and nutrition.
Hippocratic writings contained a number of passages which refer to cutaneous disorders. He divided skin diseases into two types: local (those with an independent existence) and constitutional (those that occur due to elimination of disease). Hippocrates made an astute observation “Eunuchs are 2not subject to gout, nor do they suffer from baldness”, wisely reflecting on his own alopecia.
Aristotle (384–322 BCE) too was aware of the hormonal association of baldness. He noticed that neither normal women nor eunuchs went bald and that both were unable to grow hair on their chest. Aristotle mentions “akari” a kind of a tiny animal that may be applied to the mite of scabies-acarus. Aristotle also described lice, nits and bed bug. The cautery was effectively used by the Greeks to treat infection, wounds and tumors.
Cornelius Celsus (25 BCE–50 CE) of Rome, although a layman, he wrote books on agriculture, law, military science, philosophy and medicine. Only eight books comprising his “De Medicine” have survived. The sixth book is devoted chiefly to skin diseases. He called attention to the dangers of a carbuncle on the face. He also described patterns of alopecia, “Area Celsi” perhaps was alopecia areata, cradle cap was called mothers crust, thought to be due to the disturbance of humours by the mother's milk. Celsus recognised the common wart as “thymion” and “myrmecia” was another term used by Celsus for the deeper and broader variety of warts of the palms and soles. He is best known for the four signs of inflammation—calor, rubor, tumor and dalor.
Pedanius Dioscorides (40–90CE) was a celebrated Greek physician, pharmacist and botanist wrote “De Materia Medica”, a precursor of all modern pharmacopeias. He found that the fig could be used for a number of skin diseases its juice could bleach freckles, while an unripe fig was used for treating warts, and when mixed with honey and salt it was used to treat oozing sores. Radish in a decoction with honey could remove the black and blue marks around the eyes.
Claudius Galen of Pergamon (131–201CE) was an eminent physician, he was born in Greece and later settled in Alexandria. His writings acquired a canonical status during the Middles Ages, but fell into dispute during the renaissance, as Galen's writing were based on animal anatomy, human dissection was legalised later. Galen distinguished skin diseases into those of the hairy parts of the body and those of the non-hairy parts, a classification that existed until the 18th century. Galen also advanced the theory of humours to linking them with the temperaments of the human body, sanguine, choleric, phlegmatic and melancholic.
Methods of prevention of disease have also been used since ancient times. Long before Jenner introduced the vaccination against smallpox, some tribes in Africa protected themselves against smallpox by inserting the fluid of smallpox blisters under the skin. In some parts of Asia, smallpox swabs were moistened in water and then pricked under the skin. Chinese were known to blow powdered scabs of smallpox into the nostrils. Wooden patens were worn in Sudan to prevent against guinea worm infection.
THE MIDDLE AGES
Al-Razi (865–925CE) was a Persian physician and philosopher. He wrote a number of books on medicine. The most popular one was “The Comprehensive Book on Medicine” (Kitab Al-Hawi Al-Tibb). In his treatise, he described smallpox 3and measles, diseases not described by Hippocrates. Al Razi's interest was exanthemata. Al Razi was also the first physician to relate hay fever with the smell of roses.
Ibn-Sina (Avicenna 980–1037CE), was also a Persian scholar, well versed in philosophy, medicine, music and mathematics. His book “The Canon of Medicine” became the leading medical encyclopedia for centuries. It was the first book which dealt with experimental medicine and evidence-based medicine. Avicenna stressed on testing of drugs before its use on the human body. Avicenna's medical philosophy was based on the theory of four humours similar to that of Hippocrates and Galen. Avicenna laid stress on the pores of the skin as a route to eliminate the excess of humours for cure of disease. He mentioned that exercise clears the pores of the skin and bathing dilates the pores, which help in the maturation of abscesses. Avicenna also wrote good descriptions of anthrax, carbuncle, and lesions on the head and neck. Avicenna was an authority on skin diseases in the Middle Ages.
Moses Ben Maimon (1135–1204) better known as Maimonides was a Jewish philosopher of the 12th century. He was born in Spain and eventually settled in Egypt. He was an outstanding Talmudic scholar and the first person to write a systematic code for all Jewish law. Maimonides also achieved fame as a physician, writing a number of medical treatises. His work on medical ethics has great depth.
Many contagious diseases were introduced into Europe by the returning crusaders. Epidemics of typhus, leprosy, smallpox and other diseases can be directly traced to the returning crusaders, but the most notorious epidemic to be imported from the East was that of Black Death or bubonic plague, which killed about 25 million people in the 14th century. Nostradamus, the famous French astrologer had studied at the medical school in Montpellier, he later settled as a practitioner at Agen. His healing powers soon spread throughout France and to neighbouring countries, where he was called to treat plague. Nostradamus is also famous for his prophecies.
After the crusade wars (1095–1291), new nursing and hospital orders were developed. The order of Lazarus, which was devoted to the care of the lepers, was found at the beginning of the 12th century. Leprosy was endemic in Europe, but with the return of the crusaders, the number of lepers increased considerably.
Leprosy patients were subjected to total ostracism from society, which was strictly enforced by the government. Leprosy was considered as a punishment of sin from God, the people considered that even a touch of a leper would result in death. Distinctive clothing was mandatory, as was segregation in places of public assembly and even worship. However, the order of Lazarus was so sympathetic to the care of the lepers that thousands of leprosoria were soon built throughout Europe.
MODERN AGE
Girolamo Fracastoro (1478–1553) was an Italian physician, a scholar in mathematics and geography, a poet and an astronomer. Fracastoro proposed 4the scientific germ theory of disease, more than 300 years before Louis Pasteur and Robert Koch. His book “De Contagione” also gives the description of typhus.
The name for syphilis is derived from Fracastoro's epic poem, written in three books. Syphilis was the name of a shepherd boy, who insulted a Sun god. He was punished by the god with a terrible disease, which had the features of the disease syphilis. The poem suggests its cure by mercury and guaiaco.
Girolamo Mercuriale (1530–1606) born in Italy and educated in Bologna, Padua and Venice. Mercuriale wrote many books on medicine, including one on skin diseases, “De Morbis Cutaneis et Omnibus Corporis Humani Excrementis Tractatus”, this was published in 1572. In 1585, he published “De Decoratione”, which deals what may be called cosmetic dermatology including plastic surgery.
Bernardino Ramazinni (1633–1714), an Italian physician is known as the “Father of Occupational Medicine”. While still a medical student his attention was drawn towards the disease of working places. He would visit workplaces, observe workers activities and discuss their illness. His writings include “De Morbis Artificum Diatriba” (Disease of workers). Ramazinni described cutaneous ulcers in men working with mercury and contact dermatitis in men working with animal hides. Perhaps this was the beginning of the awareness towards industrial dermatology.
Percival Pott (1714–1788) reported that chimney sweepers had ragged sores on their scrotum. Most of the other doctors of the time thought it was some venereal diseases. But Pott was astute and said that it was skin cancer, caused by the lodging of soot in the rugae of the scrotum. The observation was a clinical milestone. It was the first cancer described caused by an external agent. The cancer was called the “chimney sweepers cancer”, a classic in industrial medicine.
John Hunter (1728–1793) was a Scottish surgeon, who moved to London at an early age of 20 years. He inoculated himself with the secretion from a case of gonorrhoea. As the patient was suffering from both gonorrhoea and syphilis, Hunter developed syphilis and he thought that both the diseases had a common origin. He died 20 years later of syphilitic heart diseases. Philippe Record (1799–1889) later established the independent existence of syphilis and gonorrhoea.
James Currie (1758–1805) a Scottish physician, sparkled a renewal of interest in hydrotherapy. He used cold water to treat some contagious fevers in Liverpool. In 1777, he made public his views on experience in hydrotherapy. The spas of England were popular for the sufferers of gout and other metabolic diseases. Psoriasis is treated today at the Dead Sea Clinic in Israel, Swiss Alps and in the North Sea Islands
PIONEER DERMATOLOGISTS
Austria
Joseph Plenck (1735–1807), the Viennese protodermatologist is considered to be the forerunner of modern European dermatology. Plenck introduced the systematisation of dermatovenereological diseases, based on their 5paradigmatic differences. He wrote many treatises including dermatology and venereology. He also compiled a book which enlisted 800 plants with medicinal uses.
Ferdinand Ritter von Hebra (1816–1880) (Fig. 1), the “Father of the New Vienna School of Dermatology” was the first to specialise entirely in skin diseases. He established in the Vienna School of Medicine, a centre of dermatological training and research. He trained scholars from Europe and America.
He began his career working with Joseph Skoda who was the head of the department of chest diseases; Skoda saw Hebra's interest in skin diseases and supported him in opening a division of dermatology in the hospital. Hebra experimented on himself with the scabies mite. He transferred the mite on his skin and then observed the primary and secondary lesions of scabies. He also experimented on various chemicals on the skin and saw that it produced contact dermatitis.
These findings led him to prove that cutaneous diseases were due to agents acting on the skin itself. Skin was not only a mirror for the manifestation of internal disorders or a route for the excretion of humours. He discarded the theory of four humours. Von Hebra classified skin diseases in 12 categories based on their morphological and microscopic appearance. These were hyperaemia, anaemia, anomalies of secretion, exudations, haemorrhage, atrophy, hypertrophy, benign new growths, malignant new growths, ulcers, neurosis and parasitic disorders. His treatment was therefore directed at the local problems, rather than the abnormalities of the humours, which were still considered the primary source of disease.
Dermatology lends itself as a playground for artists, because skin diseases are visible to the naked eye. In Hebras atlas a whole spectrum of dermatological diseases are covered.
Hebra trained several men who rose to eminence; some of them were Kaposi, Kobner, Neumann, Pick, Duhrling and Auspitz. His students were not only from Austria, but also from other countries in Europe and America.
In his 40 years of service as a dermatologist, he had endeared to him the entire population of Vienna. On his death in 1880, his funeral was attended by the royalty, the nobility and the citizenry. Such a concourse had never before been witnessed in Vienna.
After the great Hebra were Kaposi, Austipz, Kobner, Hansen and Unna.
Moritz Kaposi (1837–1902) was the son-in-law and successor of Hebra, he married his daughter Martha Hebra. Kaposi was credited with the description of xeroderma pigmentosum. His atlas on skin diseases was extensive and most valuable at his time. Kaposi's name entered in history when he described Kaposi's sarcoma of the skin. The sarcoma was discovered in five elderly patients and Kaposi initially called it “idiopathic multiple pigmented sarcoma”. More than a century later it was seen in gay men of New York.
France
French dermatology has been represented by so many brilliant minds, to name a few: Alibert, Lorry, Bazin, Virchow, Hallopeau, Brocq and Darier. Most of them were trained at the Hospital Saint Louis.
J L Alibert (1768–1837) (Fig. 2) laid the foundation of dermatology at the Hospital Saint Louis. Alibert first wanted to be a priest, but later took medicine as a career. He is called the “Father of French Dermatology”. He classified skin diseases in 12 categories and likened his classification to a tree. An imaginary tree was drawn an on its branches were his classification. He is said to have taught dermatology to his students under a lime tree in the hospital, till his department was established.
Anne Charles Lorry was called the first French dermatologist; he had two special fields of interests, dermatology and mental diseases. He conceived the idea that the skin was an organ with its own blood vessels, nerves and lymphatics, but after being appointed as a physician to Louis XVI, he had to leave his interest in skin diseases. Similar was the case with Jean Louis Alibert.
Ernest Bazin (1807–1878) recognized the important role that parasites play in skin diseases. His revolutionary work in the treatment of scabies and fungal infections established him the chief at St Louis School.
United Kingdom
The pioneer English dermatologists were Daniel Turner, Robert Willan, Sir Erasmus Wilson, Tilbury Fox, Sir Jonathan Hutchinson and John James Pringle.
Daniel Turner (1667–1740) came into medicine as a Barber –Surgeon, but he was dissatisfied with it because of the lack of glamour in the profession. He then moved on to medicine, he was accepted as a licentiate of the College of Physicians in London. Turner showed a considerable practical knowledge of dermatology and had a considerable concern for the welfare of skin patients. He wrote the first dermatological text in English entitled “A treatise on Diseases Incident on the Skin”. The book was translated into both German and French. He also wrote a book on syphilis. Turner should be regarded in a minor way as the founder of British Dermatology.
Robert Willan (1757–1812) (Fig. 3) a Yorkshire born physician practiced at the Public Dispensary in London. He is the accepted founder of British Dermatology. Willan was a general practitioner, but had a special interest in dermatology; his greatest achievement was the modified Plenk's classification of skin disease. He grouped skin disorders in eight categories, based on the morphology of skin lesions. Willan described the morphology of skin disease in detail, such as type of lesion, the shape and size, presence or absence of umbilication, redness, colour, consistency, pattern of distribution, etc. Willan elected to publish his findings in sections, four of which appeared between 1798 and 1808.
The four sections were under the title “On Cutaneous Diseases”. This work was completed later by Thomas Bateman, his student.
Thomas Bateman (1778–1821) completed Willans classification, later published his book “Practical Synopsis of Cutaneous Diseases”. The book was a very successful work, it went through eight editions in 20 years. Bateman generously described his work to be merely an extension of Willan's work. Bateman died at the age of 43 after an illness associated with partial blindness. Had he not died prematurely, he would have added much more to the knowledge of dermatology.
Sir Erasmus Wilson (1809–1884) was one of the greatest dermatologists of his time. His book “Diseases of the Skin” ran through six volumes. Sir Erasmus Wilson was also known for his philanthropy. An extensive traveler and Egyptologist, he brought back from Egypt the monument known as the “Cleopatra's Needle” and set it on the Thames Embankment, at a cost of then £10,000. Altogether, his contributions towards arts and sciences were about £30,000. It is indeed a unique accomplishment among medical men. Erasmus Wilson was knighted in 1881.
United States
Dermatology in the United States began with two men who studied skin diseases briefly in the clinics of Paris in Europe. Henry Daggett Bulkley (1804–1872) a Yale graduate on return from Paris, established the first dispensary for the treatment of skin and venereal diseases, the Broome Street Infirmary for Skin diseases, and a year later delivered a series of lectures on dermatology, the first ever in North America.
Noah Worcester (1812–1847) a Dartmouth graduate after studying in the Parisian clinics joined the faculty of the newly founded Medical School of Ohio. Dr Noah Worcester published the first American textbook on skin diseases in 1845, “A Synopsis of the Symptoms, Diagnosis and Treatment of the More Common and Important Diseases of the Skin”. Dr Worcester's early death from tuberculosis was a setback for American dermatology.
Most of the early American dermatologists travelled to Europe for postgraduate training, Vienna was the favourite place for most of them. James Clark White after postgraduate studies in Europe became the first professor of dermatology at Harvard in 1871. Other early American dermatologists were Louis A Duhring, Henry Granger Piffard, George Henry Fox, John T Bowen and William Allen Pusey. Duhring was a student of Hebra, his article on dermatitis herpetiformis ran through 18 papers. Duhring acquired large fortune and was second only to Erasmus Wilson in his benefactions.
This chapter is only a small tribute to the pioneers of medicine and dermatology great doctors and scientists have contributed to the history of dermatology, only a few have been listed above. We are living today in an age of great development and progress, but our past should not be forgotten. Winston Churchill addressing the Royal College of Physicians in March 1944 said, “The further you look back, the further you can look forward”.
FURTHER READING
- Aliotta G, Capasso G, Strumia S, et al. Joseph Jacob Plenck. (1735–1807). Am J Nephrol. 1994;14(4-6):377–82.
- Crissey JT, Parish LC. Two hundred years of dermatology. J Am Acad Dermatol. 1998;39(6):1002–6.
- Holubar K, Frankl J. Joseph Plenck (1735–1807). A forerunner of modern dermatology. J Am Acad Dermatol. 1984;10(2):326–32.
- Jackson R. Historical outline of attempts to classify skin disease. Can Med Assoc J. 1977;116:1165–8.
- King JM. Historical review of early dermatology. South Med J. 1983;76(4):426–36.
- Lyell A. Daniel Turner, and the first controlled therapeutic trial in dermatology. Clin and Exp Dermatol. 1986;11:191–4.
- McCaw IH. A Synopsis of the history of dermatology. Ulster Med J. 1944;13(2):109–22.
- O’Malley CD. Dermatological origins. Arch Dermatol. 1961;83(2):204–13.
- Parish LC, Parish JL, Parish DH. Bibliography of secondary sources on the history of dermatology: 1. Journal articles in English supplemented through 2010. Clin Dermatol. 2011;29(4):469–74.
- Potter BS. Bibliographic landmarks in the history of dermatology. J Am Acad Dermatol. 2003;48(6):919–32.
- Sutton RL. Diseases of the skin: Mercurialis. Arch Dermatol. 1966;94 (6):763–72.
- Zaidi Z, Wahid Z, Kapadia N. The History of Dermatology. Specialist. 1999;15(1):157–64.