French School: Alibert, Biett, and the Hôpital Saint-Louis

Introduction

Willanism spread from London to the mainland of Europe largely due to the efforts of one man, Laurent-Théodore Biett. Born in Switzerland and completing his medical education in Paris, Biett was asked by a wealthy French family in 1816 to accompany a young man, in a medical capacity, to London. As Biett was himself employed at a dispensary in Paris at the time, he toured the Carey Street Dispensary and there met Thomas Bateman, who taught him the Willanist doctrine. Impressed by some aspects of the system, Biett was the first to bring this doctrine to Paris, thus establishing a lineage of so-called French Willanists. Biett's pupils were all ears, but his famous mentor was not listening.

That mentor was Jean-Louis-Marc Alibert. passionate rivalry between Alibertistes and Willanistes would define French dermatology for the next half century, producing extraordinary advances in classification, treatment, and the elevation of dermatology as a cultural institution.

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Post-Revolutionary France and the Medical Renaissance

Transformation of French Medicine

The French Revolution and its dispersal of all religious orders forced fundamental changes in French society. Medical schools had been abolished in 1792 and were undergoing a period of reconstruction. Although the greatest scientist of the period, Antoine Lavoisier, was murdered by the revolutionaries in 1794, scientific pursuit eventually found its advocates within the French government. When the Napoleonic era ended and the Bourbons were restored to the throne of France in 1815, medicine in Paris underwent a remarkable transformation.

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Jean-Louis-Marc Alibert (1768 to 1837)

Visionary Founder

Born in Villefranche-de-Rouergue in Aveyron in the south of France, Alibert first embarked on a career in the priesthood. However, the French Revolution and its dispersal of all religious orders forced a change of plans for young Alibert. After a period of career uncertainty, Alibert did the natural thing a young man his age would do: head to Paris. Having been influenced by several prominent Parisian physicians, he settled on a career in medicine and entered medical school at an age later than was usual for his time, at twenty-seven.

While enrolled at the University of Paris, Alibert experienced an insufficient education due to the turbulence of the last decade of the eighteenth century, but he did cross paths with the great Philippe Pinel, to whom he dedicated his thesis on fevers in 1800. Although his grades for one of his terms revealed a weakness in external pathology, his inexperience with skin disease would soon be resolved.

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Hôpital Saint-Louis

Alibert's first professional appointment after medical school was adjunct physician at the Hôpital Saint-Louis in 1802, where he received the same level of exposure to skin pathology that Willan had received at the Carey Street Dispensary. Founded by Henry IV in 1607 and open since 1611, the 1100-bed, prison-like Hôpital Saint-Louis, which was originally ordered for sequestration of bubonic plague patients on the outskirts of Paris, had become by 1800 a facility for patients with chronic diseases.

With dermatologic therapeutics so ineffective at this time, a preponderance of patients with intractable skin diseases, such as syphilis, leprosy, cutaneous tuberculosis, scurvy, ringworm, scrofula, ulcers, and eczemas, occupied the hospital. Rather than request a less daunting assignment, Alibert sunk his teeth into the task and soon realized he had found his professional niche.

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Alibert was entering a deserted, uncharted territory of medicine, but he appeared nonetheless to relish the opportunity that a skin-disease hospital would afford him for fame and glory in a discipline that had yet to be formalized. He fancied himself as an explorer in the vast unknown land of skin diseases. Alibert approached his mission in dermatology with great zeal and equal pride. Inpatient dermatology allowed him to evaluate skin diseases as they changed from day to day, and he quickly became a master of not only diagnosis but also the course of the disease, which he considered equal in importance to the morphology.

Theatrical Educator

Alibert's career elevated Hôpital Saint-Louis to the preeminent facility for dermatological care in France and the birthplace of the French school of dermatology. To correct an overcrowding problem, Alibert quickly limited the admissions at Saint-Louis to only persons with skin diseases. Skin disease became the only concern of the hospital by order of the council of administration of hospices in Paris on November 27, 1801.

That same year, Alibert began to lecture on dermatologic topics in a small amphitheater on the campus of Saint-Louis. As his audience grew, he took his interactive lecture series outdoors to a courtyard under the lime trees. Depictions of skin diseases were suspended from the trees behind Alibert, and live patient presentations were offered when Alibert found interesting patients on the streets of Paris and invited them to the demonstrations. patients, displayed on platforms, bore the name of their disease in one-inch letters across the chest.

He once tried to impress upon his audience the extreme degree of scaling that occurs in exfoliative dermatitis by throwing a bucket of scales on the occupants of the front row seats. Alibert's dynamic teaching style brought him fame that soon spilled over into the general public, and laypersons, finding the lectures curious and then fashionable, attended these lectures with great zeal. Succeeding in making dermatology fascinating to anyone who would listen, Alibert was Mercurialis reborn.

Description des maladies de la peau (1806 to 1814)

His first of three masterpieces, Description des maladies de la peau, meaning Description of Skin Diseases, was published in twelve sections starting in 1806. work is historically significant, not only because it was written in French instead of Latin but also because of its stunning artistic impressions of skin disease.

The first edition, completed in 1814, was dedicated to Alexander I of Russia, as Alibert was a staunch supporter of monarchy in general, but not of Napoleon. book sold for 600 francs and was expensive to both produce and purchase and was almost financially ruinous, costing him his wife's entire dowry of 100,000 francs. When she died eight months after their marriage, he was compelled to return the money to her father. work was very well received by his peers, but it was too costly to be accessible for most.

Arbre des Dermatoses (1829)

Fully prepared to defend his beliefs, Alibert gave a presentation on April 26, 1829, in which he explained his entire understanding of skin disease. It was in this lecture that Alibert's method of organizing skin diseases was revealed to the world as the Arbre des Dermatoses, the Tree of Dermatoses.

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The Tree represents Alibert's attempt at a natural nosology: the smallest branches represent species, the next larger branches genera, and the largest branches orders. He brought the botanical basis of Linnaean classification to a whole new level and introduced a new nomenclature. His groupings were based not on a single criterion, such as morphology, but instead took into account cause, course, duration, appearance, and response to treatment, and how these diseases related to one another and how they affected the body as a whole.

According to Alibert, skin diseases could only be recognized after their complete development had been observed, not by the artificial approach of analyzing the elementary lesion. Upon completion of Alibert's presentation, the audience applauded, which brought Alibert to tears as he addressed them with great appreciation for supporting him and his doctrine.

Alibert's Contributions to Dermatology

Alibert's additional contributions to the nascent field of dermatology were numerous and varied. He described several new diagnoses in various publications throughout his career:

His descriptions were dressed up in a heavily stylized French that is difficult to render properly in English. Like Willan, Alibert promoted Jennerian vaccination and appreciated the risks of certain occupations on skin health.

Itch Mite Rediscovered

In contrast to Willan and Bateman and the Willanists who blamed the Itch on some contagion, Alibert was convinced that the rampant skin disease was caused by the sarcoptes mite. Recall that the discovery of the mite by Bonomo and Cestoni in the seventeenth century was forgotten and the writings about it lost at this time.

In 1812, the chief pharmacist at Hôpital Saint-Louis, Jean-Chrysanthe Gales, who was studying the Itch and the itch mite upon the recommendation of Alibert, claimed to have discovered the itch mite within vesicles of patients with the Itch, but no one could reproduce his findings. Twenty-two years later, one of Alibert's medical students at Saint-Louis, a Corsican named Simon Renucci, officially demonstrated in 1834 that the sarcoptes mite was the cause of what is now known as scabies, thus proving Alibert's conviction to be true.

This rediscovery of the scabies mite was the most crucial dermatological discovery in the first half of the nineteenth century, and it occurred in Alibert's domain; sixty percent of all skin disease patients in Europe at the time had the disease.

Man Behind the Legend

Alibert's personality afforded him success in life as much as his position and intellect did. His magnificent speaking ability, frequent use of similes and metaphors, and cheerful zeal for his craft made dermatology a fascinating subject for his audience. He was indefatigable, imaginative, brilliant, witty, and wise. He was an all-around kind and agreeable person, a social being, and fond of the finer things in life, including the arts, poetry, and in particular, beautiful women.

He, like Lorry, was a Catholic conservative of the ancien régime, most comfortable with the Bourbons in control. Pompous and proud, yet knowing when to be deferential, he respected his charity patients, his jewels, with courtesy and benevolence. His demeanor differed strikingly from his cold, somber, and practical counterpart, Biett.

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Laurent-Théodore Biett (1781 to 1840)

Practical Clinician

Laurent-Théodore Biett was born in Lausanne, Switzerland, and completed his medical education in Paris. In 1816, Biett's visit to London and his encounter with Thomas Bateman at the Carey Street Dispensary would change the course of French dermatology.

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Productive Rivalry

The Hôpital Saint-Louis to which Alibert returned in 1829 after serving as royal physician was a house divided, having been infiltrated by the cult of Willan. While Alibert was away, Biett had introduced Willan's system to the hospital.

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The Protestant introvert Biett delivered his own presentation a few days after the Catholic extrovert Alibert in 1829, and he argued in convincing fashion that the Willanist system was more precise, practical, and natural. Alibert, with his gift for rhetoric, did not falter, and the two men bickered contentiously with one another for eight more years until Alibert's death.

Biett's Contributions

Biett was not as forceful a character as Alibert, but his clear, concise, and practical manner, along with wise, calm, and deep-thinking demeanor, led some of his disciples to believe that Biett was the true founder of the French school.

He never had time for writing, but the book of his lectures by Cazenave and Schedel entitled Abrégé pratique des maladies de la peau, meaning Abbreviated Practice of Skin Diseases, published in 1828, became the bible of French Willanism and one of the most important dermatologic texts of the nineteenth century.

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French Willanists

Cazenave, Schedel, and the Second Generation

After Alibert's death in 1837, the Hôpital Saint-Louis continued as the headquarters of French dermatology, with the Willanists becoming even more influential there.

Pierre Louis Alphée Cazenave was to Biett what Bateman was to Willan. Cazenave explained the Willanist approach to the diagnosis of skin diseases in the preface to Abrégé pratique des maladies de la peau: first identify and recognize the elementary lesion; then compare the disease to other diseases with the same elementary lesion; next, observe the location, form, and evolution of the lesions; and finally, arrive at a diagnosis.

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Translated into many languages, Cazenave's and Schedel's text did more to advance Willanism in Europe and the United States than the work itself of Willan and Bateman. By the mid-nineteenth century, the leaders of dermatology in Europe generally agreed that the search for the elementary or primary lesion was the first step toward making the diagnosis.

Pierre Rayer and the Global Export of French Dermatology

Pierre François Olive Rayer was a true giant of mid-nineteenth-century medicine in France. Unlike the previous physicians discussed, Rayer never worked at Hôpital Saint-Louis. He was born in Saint-Sylvain and earned his medical degree in Paris in 1818. His varied professional interests included anatomic pathology, comparative medicine, and diseases of the kidney, the latter field of which he is considered a major forerunner.

Rayer's dermatological treatise, Traité théorique et pratique des maladies de la peau, first published in 1827 and accompanied by a forty-plate atlas in 1835, was considered one of the true classics in the history of the specialty. This combination of an encyclopedic text and a glorious atlas enjoyed a long stint as one of the most comprehensive texts on skin disease in the nineteenth century. It was Rayer's greatest dermatologic legacy: his expansion and modification of French Willanism into something uniquely his own, packaged into a masterpiece that became a global export.

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Ernest Bazin and the Diathesis Theory

Zenith of French Dermatology

The zenith of French dermatology in the nineteenth century was reached during the career of Pierre-Antoine-Ernest Bazin. Born outside Paris in a small community called Saint-Brice-sous-Bois, Bazin was a high achiever who entered a career in medicine following the footsteps of his father and grandfather. An intern at Hôpital Saint-Louis in 1834, Bazin attended Alibert's lectures and was an eager acolyte in Biett's clinics.

In 1850, Bazin was charged with the care of all patients at the hospital with scabies, which was generally hundreds of people at a time, as the condition was so miserable that the desperate populace turned to the hospitals for relief. Convinced that Renucci was correct about the scabies mite, Bazin showed that an ointment called Helmerich ointment applied to the skin from the neck down to the toes eradicated the mite and expedited the treatment protocol, which he had decreased from forty inunctions to two. By the mid-1850s, patients with scabies were no longer admitted to the hospital for this problem, thus freeing up much-needed beds for patients with other concerns.

Bazinical Tetralogy

Bazin differed from his contemporaries in that he viewed skin diseases as symptoms and believed that the principal task of the clinician was to determine the cause of the symptom by looking at the whole body. To Bazin, there was no such thing as diseases confined to the skin, only skin lesions, which he referred to as affections. As summed up by his students, Bazin believed the lesion is not the disease.

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This so-called Bazinical tetralogy was the centerpiece of his system, and Bazin argued that most of Willan's diseases were manifestations of one of these four diatheses. While his first two diatheses were reasonable constructs, the other two were products of his imagination, resulting in destructive, polemical criticism leveled against Bazin, especially from Devergie.

Bazin's Enduring Contributions

Despite the failure of his diathetic system, Bazin was the giant of mid-nineteenth-century French dermatology:

Bazin was a tall, cranky man who was self-made and lived a simple life in a modest home. A frank and outspoken person, if not abrasive and sarcastic, he freely criticized his colleagues, especially when irritated by their not accepting his views. He was kinder to his patients and his students than he was to his colleagues.

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Moulage Collection

Three-Dimensional Medical Art

One of the most spectacular legacies of the Paris School was the creation of life-sized wax models of skin diseases. Musée des moulages de l'hôpital Saint-Louis, developed by Devergie in 1867 and expanded by Charles Lailler, became world famous for its educational value.

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Jules Baretta, discovered by Lailler to be extraordinarily talented with artistic representations, was hired for the museum and contributed over 3,500 moulages. Having been designated a historical monument in 1992, one can still visit Musée des moulages de l'hôpital Saint-Louis today.

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Late Nineteenth Century Giants

Ernest Besnier (1831 to 1909)

Ernest Henri Besnier was born in Honfleur, France, and moved to Paris for medical school. For the first fifteen years of his career, he was both an internist and an epidemiologist of great repute. After Bazin retired, Besnier left behind his career in internal medicine and started a career in dermatology at Hôpital Saint-Louis on January 1, 1873.

Besnier was the most important early advocate in the French school for the implementation of histopathology as standard practice in dermatologic investigations. He invented the word biopsy, having written about the skin biopsy as early as 1879. His greatest legacy was his seminal description of atopic dermatitis in 1892, but his work with sarcoidosis and description of lupus pernio in 1889 was also masterful.

Louis Brocq (1856 to 1928)

Louis-Anne-Jean Brocq was born in the south of France and educated in Paris. In spite of suffering from the perpetual martyrdom of tuberculosis for the better part of his life, he simultaneously managed a huge private practice, hospital rounds, and scientific research.

Every present-day dermatologist is familiar with Brocq and his numerous descriptions and eponyms. He was the principal contributor to the monumental La pratique dermatologique along with Ernest Besnier and Lucien Jacquet. In addition, Brocq wrote 300 articles on dermatology covering parapsoriasis, bullous diseases, keratosis pilaris, pseudopelade, the first fixed drug eruption, congenital ichthyosiform erythroderma, and the herald patch of pityriasis rosea.

Some might argue that Louis Brocq was the greatest dermatologist whoever came out of France, if not the wider world. It is fitting to conclude with something Brocq once said of dermatologists: to be a good one, one must be a visualist, a patient and discerning analyst, a prudent clinician, a finished physician.

Jean Darier (1856 to 1938)

Ferdinand-Jean Darier's ancestors were French Protestants who fled France upon the revocation of the Edict of Nantes in 1685 and settled in Budapest, where Darier was born. He moved with his family to Geneva and then reclaimed his French ancestry in 1877 by moving to Paris for medical education.

Darier was gifted with a keen eye for observation, both clinically and microscopically. His greatest legacy was his demonstration of the value of the skin biopsy for dermatologists. His landmark discovery was the condition named after him and the American James White, Darier-White disease, also known as keratosis follicularis, on which he reported in 1889.

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Legacy of the French School

What Paris Gave Dermatology

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Three Great Schools Compared

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Next Chapter: The Vienna School: Hebra and Kaposi