A 120-year-old clinical challenge
Authors: Nick J. Levell
Journal: British Journal of Dermatology (2010)

Issues of the BJD dating back to 1892 (Vol. 4) are now available online (http://www.wileyonlinelibrary.com/journal/bjd; click on the ‘All Issues’ link in the left hand menu bar). The BJD was founded in November 1888, so this recent release of 27 years of back issues makes available most of the journal. This archive represents a great resource for scientists, epidemiologists and clinicians as well as for medical historians. The journal was founded as the British Journal of Dermatology and Syphilis by Malcolm Morris FRCS (Fig. 1), surgeon to the skin department at St Mary’s Hospital London and by Henry Grundy Brooke, physician to the Manchester and Salford Hospital for Skin Diseases.1 Victorian U.K. had had no dermatology journal for 18 years since the demise of the Journal of Cutaneous Medicine (1867–1870), a short-lived production edited by Sir Erasmus Wilson, which was perhaps doomed from inception by its editor’s opinionated and eccentric views – including a refusal to accept the pathogenic role of dermatophytes.2 Malcolm Morris: co-founder of the British Journal of Dermatology and Syphilis (now the BJD). Both Morris and Brooke were members of the Dermatology Society of London, founded in 1882.3 Although this Society initially had fewer than 30 members, it represented the voice of British dermatology nearly 30 years before the birth of the British Association of Dermatologists (BAD). This voice was muted, if not inaudible, as there was no journal to rival dermatology publications in France, Germany, Italy, Austria and America. British dermatology in the 1800s lacked the support from the British general medical profession, which was unwilling to accept the specialization developing in other countries. As a consequence in Britain, particularly in England, specialist posts and hospitals, in dermatology and other new specialities, were slower to develop and relied on exceptional contributions by talented enthusiasts. This unwillingness to accept the importance of dermatology perhaps still lingers in some corners of the British medical establishment. The fledgling journal was very different from the BJD we know today, soaring over the world of dermatological basic and clinical science. It contained mainly case reports and case series, with reviews of books and meetings. The transactions of the two British dermatology societies were published from 1897 until shortly after 1907 when they fused to form the section of dermatology at the Royal Society of Medicine. Despite the difficult working conditions of early dermatologists, basic science papers were published, for example relating to embryology of the skin,4 aetiology of atopic eczema,5 the genetics of xanthoma palpebrarum6 and the mycology of scalp ringworm.7 Initially the BJD was dependent on the generosity of a group of dermatologists who provided financial support to keep the journal afloat during difficult times over its first two decades.3 These newly released volumes online represent the fruit of their endeavours. In 1919 the BJD Editor Archibald Gray was inspired to form a professional society of British dermatologists to support the journal and hold an annual congress.8 Thus the BAD arose from the BJD’s editorial committee and on the 90th anniversary of the BAD this year, the link between the BAD and BJD remains strong. The journal contents from the earliest issues can present clinical challenges to the 21st century reader. The text box summarizes an epidemic disease characterized by a rash and a significant mortality which challenged British dermatologists in the early 1890s. Three papers describe the clinical presentation,9 bacteriology10 and histology.11 We challenge our readers to access the papers and provide us with the correct diagnosis. Comments or reflections may be submitted to BJD in the normal way as items of correspondence. Thomas Savill9 described an epidemic skin disease labelled as either ‘eczema’ or ‘pityriasis rubra’ which affected the infirmaries at Paddington and Marylebone in London in the summer and autumn of 1891. One hundred and sixty-three out of 846 inpatients at Paddington between July and October were affected and 28 died. Savill stated that the death rate was higher than the 10·85% death rate expected from scarlet fever or the 10% death rate expected from small-pox. The disease was evidently contagious spreading from bed to bed with a 9-day incubation period. It lasted for up to 6–8 weeks but could then subsequently relapse. It affected middle-aged and elderly people. The disease produced substantial malaise and erythroderma with conjunctival involvement. It progressed to exfoliation with intense itching and skin pain. There was associated hair loss and nail shedding. There was little fever, purpura is mentioned as a ‘vascular complication’, 50% had proteinuria and pulmonary and cardiac involvement occurred. Savill discussed the differential diagnosis: ‘It is possible that there are other diseases from which these cases ought to be distinguished, but I have purposely abstained from reading authorities lest my mind should become confused or biased in the observation, and prevented, by preconceived notions, from a realization of their true type’. (Trainees in dermatology: please do not follow this example.) Further papers describe the bacteriology10 and the histology11 (Fig. 2) of the disease. What is your diagnosis? Original histology slides of the epidemic skin disease of 1891.