London School: Willan and Bateman's Morphological Revolution

Introduction

The first of three major schools responsible for shaping the study of skin diseases into a formal specialty is known as the British School. In the eighteenth century, Britain was the home of two important surgeons in the early history of dermatology: Daniel Turner, whom many consider the first dermatologist, and John Hunter, the father of modern surgery. In 1792, the British physician Seguin Henry Jackson called for the establishment of the specialty in his groundbreaking text Dermato-pathologia. Two years prior to that landmark publication, the Medical Society of London awarded their prize, the Fothergill Gold Medal, to a 33-year-old physician named Robert Willan, who after nine years of medical practice had created a new system of organizing skin diseases.

After eighteen years of modification, Willan's arrangement emerged in a landmark publication, and his achievement would go down in history as the most significant publication in the history of dermatology. Prior to Willan, the language of dermatology was in total chaos. words leprosy, scurvy, herpes, scabies, dartres, and other appellations had become so indefinite as to be merely synonyms of cutaneous disease. particular terms such as lichen, psora, herpes, impetigo, porrigo, and scabies had been arbitrarily appropriated to very different genera of disease by successive medical writers.

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Georgian London and the Medical Context

Medical London in the Late Eighteenth Century

The Carey Street Public Dispensary, rich in cutaneous morbidity, was undoubtedly the best possible place for a physician like Willan to thrive for twenty years, gather his data, and develop his classification scheme. crowded vicinity of the dispensary, with its squalor and unhygienic citizens, must have been a breeding ground for skin disease. At least for English dermatology, the Carey Street Public Dispensary is where it all began.

London's major teaching hospitals of the era included St. Bartholomew's, St. Thomas', and Guy's Hospital, along with the Royal College of Physicians. However, it was the new Carey Street Public Dispensary, founded in 1782, that would become the birthplace of modern dermatology.

A public dispensary was a cross between an outpatient clinic and a pharmacy. It was not a hospital or infirmary, and the ill could not be housed there. As hospitals in London during this time primarily cared for the affluent, the dispensaries' main purpose was to relieve with advice and medicines the suffering and industrious part of the community, to whom the physician's fee or the apothecary's bill would be absolute ruin. dispensary movement in England grew out of a philanthropic impulse of the eighteenth century. Sixteen public dispensaries were established in London from 1770 to 1792, and approximately 50,000 lower-class citizens of London were cared for annually by the city's dispensaries.

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Robert Willan (1757 to 1812)

Architect of Modern Dermatological Classification

Robert Willan was born on November 12, 1757, near Sedbergh in the Yorkshire Dales of northwest England. He attended the Sedbergh School, where he became a Latin and Greek scholar, also excelling in mathematics. Because he was a Quaker, Willan could not matriculate at Oxford or Cambridge for medical school. Consequently, he attended the more progressive University of Edinburgh, and at 23 years of age, he received his doctorate.

Led by William Cullen, Edinburgh was a preeminent center of medical education in Europe, and Willan received an education based on the Enlightenment approach to the natural world with direct observation, classification, and analysis. He was influenced there by several educators: John Hope, an early supporter of Linnaean taxonomy; Alexander Monro, an anatomy professor; and Andrew Duncan, who worked at the Royal Public Dispensary of Edinburgh and once lamented that there was no satisfactory distinction of cutaneous diseases.

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Carey Street Public Dispensary

After two years of practice in Darlington, Willan moved to London, where he began working and teaching at the new Carey Street Public Dispensary in 1783. Employment at a teaching hospital in London was difficult to secure at this time, especially for Edinburgh graduates. Willan's Quaker upbringing and the influence of a Quaker physician named John Lettsom inevitably led to Willan's choice of a philanthropic career in medicine. He focused his efforts on caring for the poor and underprivileged rather than individual achievement or personal wealth.

The dispensary was located on Carey Street near Lincoln's Inn Fields in the center of London. It served the vicinity of Clare Market, Drury Lane, Temple Bar, Strand, Holborn, Fleet Street, Ludgate, and Black and White Friars. Records reveal that an average of 3,000 patients per year used its services.

During these early years on Carey Street, Willan took an interest in skin disease. By 1784 or 1785, he had reached his conclusions about primary skin lesions, the initial distinctive type of lesion that develops in the first stage of a skin disease. He noted that all skin diseases could be divided into categories based on these elementary forms. His biographer Thomas Bateman speculated it may have been Willan's own extreme accuracy that made him feel early and acutely the vagueness and confusion of language which universally prevailed in this department of medicine.

Morphological Revolution

Willan developed the idea to classify skin diseases in the same way one would organize plants, by their appearance. It was this early work that Willan submitted to the Medical Society of London and for which he received the Fothergill Medal in 1790. His system evolved during the 1790s, and by 1797, Willan had defined seven orders of skin diseases. He would later add an eighth.

The central insight was revolutionary: classify skin diseases by what they look like, not by speculative causes. While the idea to classify skin lesions by morphology was entirely Plenck's in origin, Willan never credited Plenck in his work. However, Bateman later corrected this omission, writing that it seems probable that Dr. Willan was indebted to this work of Professor Plenck for the groundwork of his classification. By reducing the number of orders to eight, Willan's system was stricter and leaner and followed the laws of classification more precisely.

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Willan's Eight Orders

Classification System

The simplifications enacted in Willan's arrangement proved to be a major improvement, and the system worked better than that of Plenck. system's greatest strength was not how the orders were arranged but the precision of Willan's definitions of the diseases. Willan was the first to emphasize clear and accurate characterizations of diseases, and from his studies, a uniform nomenclature was introduced. Virtually all of the 119 skin diseases he described, both old and new, were given first-rate updated definitions and descriptions.

Eight Orders and Their Genera

Example: Order Squamae

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Willan's Definition of Psoriasis

Willan was the first to accurately describe psoriasis as we know it today, under the term lepra vulgaris, characterized by scaly patches of different sizes but having nearly a circular form, which sometimes appears first at the elbow or on the forearm, but more generally about the knee. What Willan called lepra is the condition we today call chronic plaque psoriasis.

In the section that followed, under the heading Psoriasis, Willan listed eleven types of scaly tetters that are the variants of today's psoriasis, including guttate, nail, and erythrodermic forms. Thus psoriasis, derived from the Greek word psora meaning any itchy skin condition and unused since the writings of Galen, entered the nomenclature of the budding field of dermatology as the specific term for what we today know to be psoriasis.

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On Cutaneous Diseases (1798 to 1808)

Magnum Opus

Starting in 1798, Willan published installments, each containing one of his orders, over the next ten years in 1798, 1801, 1805, and 1808. This work was called Description and Treatment of Cutaneous Diseases. In 1808, Willan published On Cutaneous Diseases Volume 1, the first of two planned volumes, which was composed of the first four previously published installments. orders of cutaneous diseases contained within that volume were papulae, squamae, exanthemata, and bullae.

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It was a gorgeous quarto volume that presented color depictions of skin diseases, a novel idea, and Willan became the author of the first dermatologic atlas. Willan hired such famed artists of the era as Sydenham Teast Edwards, John Boyne, William Thomas Strutt, and Isaac Cruikshank for the copper engravings to illustrate his diseases.

Original Descriptions by Willan

Willan is remembered for writing original and accurate descriptions of numerous skin diseases:

Willan's Own Words: Purpose of His Treatise

In the introduction to On Cutaneous Diseases (1808), Willan articulated the four objectives that would guide all subsequent dermatological classification:

"In a systematical treatise on cutaneous disease, we should endeavour:

1. To fix the sense of the terms employed by proper definitions.
2. To constitute general division or orders of the diseases, from leading and peculiar circumstances in their appearance, to arrange them into distinct genera, and to describe at large their specific forms, or varieties.
3. To class and give names to such as have not been hitherto sufficiently distinguished.
4. To specify the mode of treatment for each disease."

Original Definitions of Technical Terms

Willan's definitions of lesion morphology, first published in 1808, established the vocabulary still used by dermatologists today. following are his exact definitions:

These definitions represent the birth of a standardized dermatological vocabulary that could be reproducibly applied by any trained observer, regardless of their theoretical orientation regarding disease causation.

Willan's Description of Lepra Vulgaris (Psoriasis)

Willan's clinical description of what he called "Lepra vulgaris" remains one of the finest observational accounts in dermatological literature:

"Lepra vulgaris at first exhibits small, distinct elevations of the cuticle which are reddish and shining, but never contain any fluid. Their surface, when examined through a magnifying glass, appears tense and smooth. Within 24 hours, however, thin white scales form on their tops. After three or four days the small elevations are flattened, and at the same time dilated by an extension of their bases to the size of a silver penny. These patches continue to enlarge gradually, till they become nearly the size of a crown piece. They always retain a circular or oval form, are covered with dry scales, and surrounded by a red border."

He further described the distribution pattern with remarkable precision:

"This species of Lepra sometimes appears first at the elbow, or on the forearm, but more generally about the knee. In the latter case the primary patch forms immediately below the patella. Within a few weeks several other scaly circles appear along the fore parts of the leg and thigh... If it does advance further, its progress is towards the hip and loins, afterwards to the sides, back and shoulders and about the same time to the arms and hands."

Regarding the disease course and nail involvement:

"In some cases of the disorder, the nails, both of the fingers and toes, are thickened, and deeply indented longitudinally. Either the whole or some part of each nail is harder and more prominent than usual."

Public Health Advocacy

Willan was a public health advocate and as a contemporary of Edward Jenner, he was an ardent supporter of vaccination. He deplored the living conditions of the poor in London and strove to correct the problem through public health initiatives. One such initiative was the establishment of a 15-bed fever hospital in 1802 to isolate and treat Londoners with typhus, as well as smallpox and scarlet fever.

Willan painted a grim picture of skin disease among the poor in London:

And how are the poor, without accommodations for the purpose at home, to clear their bodies from the dirt, dust, and unctuous or adhesive substances, which their various employments fasten on them? There being no provision in any part of the metropolis for washing and bathing, they quietly suffer the penalties annexed to the want of cleanliness, as disagreeable smells, perpetual irritation with chaps and fissures of the skin, boils, and eruptions of inflamed pustules, the Itch and the Prurigo, the Lepra, the dry Tetter, the running Tetter, the Dandruff, and the Scald-head.

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Thomas Bateman (1778 to 1821)

Faithful Successor

The legacy of Robert Willan would not have been fully delivered to posterity had it not been for the posthumous advocacy and support of Willan by his protege Thomas Bateman. Like Willan, Bateman was a native of Yorkshire and trained at Edinburgh. He arrived at the Carey Street Dispensary in 1802 and received a licentiate from the Royal College of Physicians in 1805. After Willan's departure, Bateman became a physician of the Dispensary and had the same special interest in skin diseases.

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After Willan's death, Bateman purchased the copyright of Willan's work as well as his watercolor drawings. In 1813, Bateman finished the task of publishing the second half of Willan's orders of diseases in a complete work entitled A Practical Synopsis of Cutaneous Diseases According to the Arrangement of Dr. Willan.

A Practical Synopsis (1813)

This slim volume is possibly the most critical text in the history of dermatology, with eleven editions issued before 1850 and translation into five languages. Its fame reached as far as St. Petersburg, where the tsar of Russia ordered several copies and rewarded Bateman with a valuable ring to symbolize imperial approval.

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In the preface of Practical Synopsis, Bateman made it abundantly clear that credit was due to Willan. He wrote that the work should not be considered as the completion of that original work but instead an abstract of the classification proposed by that respected author, together with a concise view of all the genera and species which he intended that it should comprehend.

Delineations of Cutaneous Diseases (1817)

Bateman followed up Practical Synopsis in 1817 with Delineations of Cutaneous Diseases, an atlas containing 70 color prints which also completed Willan's work from an illustration standpoint. Delineations is the first in a long line of impressive dermatologic atlases of the nineteenth century.

Original Contributions by Bateman

Bateman is credited with the original descriptions of several conditions:

The establishment of eczema as a dermatosis is the direct result of Bateman's presentation of Willan's views. Bateman was held by his contemporaries in the highest regard for his professionalism, judgment, integrity, and knowledge. He hosted many physicians at his clinic from all over Europe, readily sharing his knowledge with anyone who came to learn.

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London School's Influence

Geographic Spread

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For example, Bateman mentored Ireland's first dermatologist, William Wallace, who then returned to Dublin and established the Dublin Infirmary for the Treatment of Diseases of the Skin in 1818.

Enduring Terminological Legacy

Terms Still Used Today from Willan and Bateman:

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Limitations and Later Evolution

What Willan Could Not Know

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Despite these limitations, Willan's morphological approach remains clinically essential. Primary lesion identification is still the first step in dermatological diagnosis. categories of papulosquamous versus vesiculobullous persist. And morphology still guides algorithmic diagnosis.

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Legacy Assessment

Willan's Place in History

On Willan's magnum opus, the nineteenth-century French giant of dermatology Pierre Rayer wrote:

The great characteristics of Willan's writings are the impress they bear of the scientific spirit that guided him in his researches; the great precision, and the purity of his descriptions; the particular pains he takes to select well, and to use judiciously, his technical expressions; lastly, the sound judgment he displays in the interpretation of the ancients.

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The modern physician of any specialty could greatly benefit from studying the life and career of Robert Willan. In 1812, the year of his death, Willan was described in Gentleman's Magazine as one of the best and noblest of human kind, possessed of every virtue that can ennoble and adorn. In his profession he was beloved almost beyond example. He was a model of the perfect human character: a benevolent and skilful physician, a correct and sound philosopher, and a truly virtuous man.

Willan's Three Revolutions

1. Classification: Objective, reproducible system based on primary lesions
2. Visualization: Medical art as diagnostic tool through illustrated atlases
3. Professionalization: Establishment of dermatology as a legitimate specialty

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Next Chapter: The Paris School: Alibert and Biett