ADDRESS DELIVERED BEFORE THE American Dermatological association, BY THE PRESIDENT, EDWARD WIGGLESWORTH, M.D., AT THE Tenth Annual Meeting, August 25th, 1886. BOSTON: 1886 ADDRESS DELIVERED BEFORE THE AMERICAN DERMATOLOGICAL ASSOCIATION, BY THE PRESIDENT, EDWARD WIGGLESWORTH, M.D., AT THE Tenth Annual Meeting, August 25th, 1886. BOSTON: 1886 ADDRESS. Gentlemen, — Just ten years ago, in the University of Pennsylvania, at Philadelphia, I had the honor of calling to order the first public meeting for the organization of this Association. The opportunity was furnished by the meeting on that day, of the Section of Dermatology and Syphilology of the International Medical Congress, and the setting apart of this Sec- tion, the first national acknowledgment of the specialty, as such, was due, let me here state, to the personal influence of our respected ex-President, Dr. Duhring. What was, at that time, and what is, the condition of American Der- matology ? Prior to the last quarter of a century the field of American Dermatology was a desert. Then, for fifteen years, the pioneers of the coming regiment of scientific workers alone occupied the field and led a guerrilla warfare, fighting each for his own hand. For the last decade, these veterans, and other younger recruits, enrolled together as one of the regiments of the great medical army, have marched steadily from one victory to another over bigotry, error and ignorance. The original chaos was vivified by the rays of the great Viennese lumi- nary, and the fields are already bringing forth fruit. But this fruit is still to be greatly increased in quantity and improved in quality. More special- ists are needed in our branch ; more official positions, enabling such special- ists to instruct students in medical schools ; and, finally, for the sake of humanity, greatly increased opportunities and facilities, by means of wards in hospitals, for the proper treatment of those afflicted by the diseases belonging in this department of medicine. The remark, in this connection, of our honored first President, at our first annual meeting, cannot be im- proved upon. “ Every day we see in the out-patient department and else- where, cases which we know are requiring attention they will not, cannot 4 receive at home, cases which without restraint and peculiar management last indefinitely and spread disease, cases which entail horrible conse- quences upon others ; all of them sure of more rapid and certain recovery if they could receive such hospital care, some of them as surely doomed to years of misery and even speedy death, because they do not obtain it. Those who, from love to their fellow men, or pity for their bodily woes, have left large endowments for their care in sickness, they who make gen- erous appropriation from the wealth of States and cities for the treatment of disease among the poorer classes of society, certainly have intended no such arbitrary distinctions. It is not they who have ordained that a fever and a fracture shall have the best chance of recovery by proper nursing and the most eminent professional attention — while an inflammatory or de- structive process of the integument shall be debarred from both. There is neither reason nor justice in such action, and they who control the govern- ment of such institutions have much to answer for, for such unequal distri- bution of hospital charity.” The line of progress for us in the future should be in the direction of the establishment of hospital wards for special treatment and special clinical instruction. “ As now managed nearly everywhere amongst us, these insti- tutions refuse to a large class of sick persons the benefit of hospital resi- dence either wholly, or offer them, if received, not, we may fairly say, the best medical skill it is in their power to procure.” If, in this direction, the progress of the last ten years has been less marked than in others, we may at least console ourselves with the thought that this is precisely the field in which our personal efforts avail the least, and the condition of affairs is de- pendent upon outside influences rather than upon our own endeavors. And in spite of everything, there has been progress even here. New York has her skin and cancer hospital, and two wards for skin diseases at the Charity Hospital. Boston established a ward for skin diseases at the Massachu- setts General Hospital, though it is at present, we trust however, only tem- porarily, discontinued. In Philadelphia the sole special clinic for skin diseases, with beds, ten years ago, was at the University Hospital. Now there are two in addition, one at the Philadelphia Policlinic, the other at the City Hospital. Many also of the smaller hospitals in our larger cities have appointed dermatologists as consulting physicians for such cases of diseases of the skin as they admit; notably the Presbyterian and the Mi- chael Reese hospital in Chicago. That the workers are ready, as soon as they shall have opportunity, is evident. Ten, even nine years ago, our officially recognized representa- tives among the great body of medical instructors in the United States were reported by our President as follows, viz.: Professors, 4 ; Clinical Professors, 5; Instructors, 1; Lecturers, 6; Total, 16 At present New York has added two professors and two instructors at New York Policlinic, 5 a professor at the Post-Graduate School, and a lecturer at the New York Hospital Boston has added one special instructor at the Harvard Medi- cal School, and one clinical lecturer at the Policlinic, or extra-mural school. To the clinical professorship of the University of Pennsylvania, the only one existing ten years ago, Philadelphia has added one at the Medico- Chirurgical College, and one at the Jefferson Medical College, as well as an instructor at the University of Pennsylvania, one at the Policlinic, and a lecturer at the Woman’s Medical College of Philadelphia. Baltimore appointed in April, 1877, a “lecturer on the diseases of the skin” in the College of Physicians and Surgeons. This followed our organization, although prior to our first meeting. In April, 1879, the University of Maryland appointed its first clinical professor in this speciality, and the lecturer at the College was promoted to the professorship of hygiene and clinical dermatology. In January, 1884, the “Baltimore Policlinic and Post-Graduate School of Medicine,” was formed, with a chair of skin dis- eases St Louis possessed, nine years ago, only a single lectureship for skin diseases. To-day she has, in addition, three professorships and some four clinics. In Kansas City there are two professorships of derma- tology, recently established. Chicago has added to her professorship at Rush Medical College, one at the College of Physicians and Surgeons and one at the Woman’s Medical College, together with a lectureship at the Rush Medical College and one at the Chicago Medical College. The Medical College at Albany has promoted its lecturer on dermatology to a professorship The Detroit Medical College has done the same. The Minnesota College Hospital of St. Paul has a professorship. At Toronto, Canada, one of our members is professor at the School of Medicine. Nash- ville has a professorship at the University of Tennessee The University in Buffalo and the Niagara University have also established lectureships. While unwilling to assert that no omissions have occurred in this list, I can at least say that there has been no intentional neglect, except that the specialty of genito-urinary surgery has, in accordance with my settled convictions, been excluded from this consideration of our advance in pure dermatology. The two specialties are entirely distinct, one being largely medical, the other largely surgical. I would here express my sincere thanks to all the gentlemen who have aided by furnishing information, and my indebtedness to Dr. G T. Jackson’s article upon “The Present Con- dition of Dermatology in the United States” in the Monatsheft f Prakt. Dennatologie iox )wx\z, 1885. While the limited number of our medical schools limits of course the number of our members who bear official titles, the actual amount of clini- cal instruction given by the same specialists, or their assistants, or others, in the various hospitals, and in the numerous and rapidly multiplying dis- pensaries, has greatly increased ; new dispensaries having come into exist- 6 ence, as well as classes in dermatology in already existing institutions. In Philadelphia the number of cases treated yearly in these clinics by recog- nized specialists, has risen from about 800 in 1878, the first year reported, to nearly 1400 in the present year, and elsewhere commensurate progress has been made. The contributions of the members of the Association to the literature of dermatology during its first decade of its existence, need not be enumer- ated, as they have been regularly appended to the successive annual reports of transactions. Suffice it to say, that they include the best treatises, hand-books, and atlases, the only periodicals, and some of the bast monographs of the time, in the English language. The New York Dermatological Society continues the sole local organiza- tion which we possess, but the good work which it has already done is con- stantly increasing, while the publication of its Proceedings adds ever to medical knowledge and to the credit of American Dermatology. Two honorary and three of the active members of the original Associa- tion have passed away since its organization. Twelve active members, all living, have been added to its ranks. And now what else has been done, during this third of a generation that we have been together, to promote the objects of the foundation of our Association, as suggested in the inaugural address of our earliest Presi- dent? One of these objects was “ a more intimate personal acquaintance- ship amongst American Dermatologists.” Gentlemen, when I cordially and heartily bid you all welcome here to-day as a band of workers, with a common object, it is also as a band of mutual friends, without so far as I know a single feeling of ill-will existing in the breast of any one of you against any other member present. Certainly, I may say personally that my regard, as well as my respect, for each member individually has from the beginning steadily increased with a more extended acquaintanceship. That there exists to-day a harmony and good feeling among us, which, but for the personal acquaintanceship, resulting from the formation of this Asso- ciation, never would have existed, no one I think will be inclined to deny. Have we not come into better accord as to the “ nature and treatment of skin diseases ” ? Does not our increased membership, relatively large though actually too limited, prove that this Association is “ held as a place of aspiration,” and has it not encouraged “ independent work in our department” as a means for the acquirement of such membership? Has not the “systematic work” of our standing committee upon statistics already furnished valuable data for the comparison of diseases of the skin as they occur in America with those occurring elsewhere? Nor have such data been confined solely to the “comparative prevalence of individual dis- eases”; as is shown by this committee’s excellent reports upon “ Leprosy in America.” 7 Have we not by concerted and official effort done much to repress the rank luxuriance of growth of dermatological nomenclature, and to furnish a “ uniform and simple system ”? And yet, while great progress has been made, the classification and nomenclature adopted the 29th of August, 1878, and revised the 28th of August, 1884, stand already in need of re-revision, thanks to the rapid advance of knowledge in the province of diseases of the skin. To this fact I propose to call the attention of the Standing Committee at its next meeting. But while much has been accomplished, much still remains to be done. The idea of specialism, already rooted, is to be nurtured and trained in the minds of the profession and of the public, and the practical development, socially, of our specialty itself is to be elaborated in many minor details. Those of us entering practice twenty years ago found men plying medicine as a trade, regarding patients as the physician’s private property, not to be trespassed upon by strangers, often controlling such patients by appeals to their ignorance, fears and prejudices, and substituting in their own persons an acquaintance with the weaker side of human nature, useful for financial purposes, for an exact scientific acquaintance with disease, to be used for the benefit of their race. The specialist was the pioneer into this latter realm, and, like all such, was, too frequently, a martyr to his cause. But he represented that majority which consists of one with truth upon his side, and, like all other such majorities in the history of the world, he has finally won his way to victory. The “ elaborate division of labor ” is “ as useful and successful in a learned profession as it is in the mechanic arts,” for the whole matter is a relative question of height of standard. General medi- cine itself is too often only special attention to such diseases as may prove rapidly fatal ; and neglect, or often worse than neglect, of all other mala- dies. It is itself merely an abnormal, ill-defined specialism, substituting multa for multum, and, like the young cuckoo, insisting upon the sole con- trol of its illegally-held habitation. Specialism substitutes quality for quantity, which substitution is the distinguishing mark of the civilized man from the savage ; nay more, the essential criterion of advancement in civili- zation itself. The standard of specialism is nothing short of perfection, and that in every direction, resulting therefore in the general perfection of medicine as a complex whole, which is merely the sum of all its parts. What is science but exact knowledge ? What is medicine but that knowledge specially directed to the physical welfare of mankind as distinct from the rest of nature ? and what is specialism in medicine but further subdivision, rendered necessary by the very various parts composing the indi- vidual, and possible by the extension of our opportunities for studying these same parts, due to increase of mechanical means for enlargement of the field of our hitherto unaided senses? As the astrologer has given place to the astronomer, as the alchymist has yielded his place to the chemist, so must 8 the old-fashioned, cure-all doctor fade away before the exact knowledge of the modern scientific physician, who has sense enough to recognize that the world has made progress, and that to-day no one can, wisely, “ take all knowledge to be his province.” The rising sun of truth is already scatter- ing the ghosts and awaking the “ Rip Van Winkles.” Who of us does not meet continually the case of the patient with a mistaken diagnosis of early syphilis, with the mistaken treatment by potassic iodide, with the eruption due to the drug attributed to the disease, and consequently followed by its increased administration, until in despair the poor sufferer applies to the specialist, is told to do simply nothing, and is in a few days a well man ? Who of us is ignorant of local lesions errone- ously diagnosticated, erroneously supposed, even upon that presumption, to need caustic, and more erroneously still, treated consequently by that non-caustic irritant, nitrate of silver, with most lamentable results ? Who of us escapes cases of acute eczema rendered more violent, and even sub sequently chronic, by the early use of tar, because “ tar is good for eczema ” ? It is high time that such treatment should be recognized as punishable mal-praxis, for the specialist has raised the average standard of require- ment too high to longer admit the pardoning of such errors as these, and the world consequently has made too many steps onward. It has been sarcastically called the “sole duty now-a-days of the family doctor to decide what specialist shall be summoned.” The error lies in the use of the word “sole.” It certainly is his duty, and a very important one, as a man of honor, to decide whether any one, and if so, who, can probably accomplish that wherein he admits that he himself has failed. Too often pride com- pels him to assert, of light cases, that “they will get well of themselves,” a falsehood ; or fear hurries him, in fatal ones, often after it is too late, to lay the burden of his error upon the shoulders of the specialist, a suicidal confession ; but most frequently it is the cases not fatal but chronic, and bad enough to tire out the physician and to exasperate the patient, in which, often against his will, the family doctor calls in the aid of the specialist. The successful treatment, as far as new recipes go, is filed away and used in future in all similar cases as an infallible specific, until, at all events, a case is encountered which refuses to yield to its potency. And do we not see such physicians opposing as unnecessary the hospital appointments and private practice of the very specialist to whom they flee at once for the treatment of themselves or of the members of their families? But, as the first and great commandment is “ to recognize one’s limita- tions,” so the second is like unto it, namely, “to be in harmony with one’s environments,” and the specialist in turn, debating between appearances common to several diseases, and remembering that these also occur at times as mere symptoms of some grave general malady, or, surprised by the co-existence of severe disease outside his province with that for which 9 he has been summoned, may find himself only too sorely in need of the aid of the “general physician,” that is, the specialist in dangerous diseases. Furthermore the sending to the general practitioner by the honest specialist, of patients who have made their own and an erroneous diagnosis, but, in accordance with it, called upon, as they think, the proper person, is a matter of “ ter die" occurrence. Both members of the profession are needed, though specialism rises, as the latest and highest evidence of progress, upon the foundation of general medicine at St. Peter’s upon the soil of Rome. Science does not culminate in a jack at-all-trades, least of all in one whose conscience has become anaesthetized by custom, who confounds his own limitations with “the limitations of human understand- ing,” and his own ignorance with “ the immaturity of medicinal therapeu- tics.” The specialist builds his own boundary-wall, and cannot poach upon the preserves of others. He “ distinguishes what he can do from what he cannot,” thus filling the old definition of “ the best physician.” He cannot maltreat a patient, and, when compelled to confess ignorance and seek superior wisdom, charge the wronged sufferer another, and a still higher fee for a “consultation,” which is in reality a confession. We are told that “the human body is made up of parts and functions so thoroughly interdependent that it cannot be parcelled out into defined and isolated regions.” Of course it cannot, and specialties are not so con- structed. What scientist divides a country into square miles and attempts to become thoroughly conversant with every atom existing in one of those miles ? The special divisions of study are the flora, the fauna, the geologi- cal strata, etc., though all these may pervade identically every mile of the region. Proper investigation by suitable specialists in due season would obviate many “appalling pathological conglomerates,” consisting of aggre- gated effects of original causes which lacked proper “general medical treatment.” Not only “ conglomerates,” but single lesions, are often very variously diagnosticated by different general physicians. The aforetime “consulting physician” meant one who, “in addition to his general acquirements, knew more about some particular thing than any one else,” and we may be sure that his “ general acquirements ” had to pay the penalty. But even this involved greater mental ability than that of his fellows. He was a confessed superior. To-day no one has mental ability enough to add to the greatly extended knowledge necessary to the thoroughly qualified general physician, the intensified fundamental acquaintance with detail needed by the specialist. Life is too short for the ablest intelligence to exhaust even any one specialty. The physician may, like Kepler, “think the thoughts of God after him,” but the thoughts of the Infinite upon the smallest molecule of matter call for more than the limits of a finite exist- ence. Could the able general physician add one specialty, a still abler might add two, and so on, till that monstrous combination of folly and 10 fraud, the modern “ universal specialist,” might acquire a theoretical justi- fication for his actual baneful existence. In the light of experience, this is a reductio ad absurdum. Per contra, the specialist might also be a general physician. But the former yields this point, and why should not the latter concede to the specialist his specialty, instead of, while decrying “the poor man’s one ewe lamb,” nevertheless attempting to rob him of it. One able physician of mature age and large experience is to-day practically as good as another. The true “consulting physicians” are the specialists, and that not from superior ability, but from superior experience in a particular direction. Specialists should, therefore, receive this title at the hospitals with which they are connected, while those ex-physicians at present called “consulting,” but never consulted, should receive their true and proper title of “ Emeriti.” But enough of the “idea of specialism.” The public will in time appre- ciate the absurdity of being content with inferior results in one branch of medicine, because forsooth there are so many others in which their medical adviser is equally or more at home.- It will reason rather that he who “insists upon doing the work of ten men, manifests a quality of mind which we can only call arrogance, and which challenges for his work severe criti- cism.” Versatility will not atone for imperfect work. While absolute perfection is, of course, unattainable, no one can honestly furnish work which they know to be crude and incomplete, and justify it by “ lack of time, hurry of life, keenness of competition, or financial necessity,” while delighting, with “brazen self-assertion, not so much in doing the thing well as in showing how well he can do it.” Believing in the ultimate achievement of all possibilities, and in the progress of truth, I have no doubt as to the future of specialism if we are honest and earnest. Not infinite omniscience, but infinite morality, is the duty of the specialist, and this, conscientiously carried out, will blunt the sharpest dart of the hostile “general practitioner.” While visions of what yet remains to be accomplished might well lead us almost to despair, a mere glance at the generally prevailing ignorance, on the part of both physicians and their patients, shows conclusively that we and our work are imperatively demanded. But, as said before, enough of specialism in the abstract. Now as to our duties in the future as individuals, for the development of the specialty in which we believe. We must, as said before, first of all labor for the estab- lishment of skin wards in all our general hospitals. The incisive and broad minded words of our first President, ten years ago, are unfortunately still imperatively called for. “ Skin diseases form a large portion of the ordinary affections of mankind, and general hospitals are bound to provide proper accommodation and the best medical skill within their reach for the sake of justice and humanity. On broader principles a hospital board 11 which cannot rise above the petty jealousies of individuals or cliques, which in these days of wonderful advance in special medicine can see no wider field of usefulness than its antiquated divisions of medical and surgical service, with their restricted modern signification, offer ; which fails to per- ceive its duty to develop means in every practical direction, for the ad- vancement of progressive medical education, is open to the criticism of the profession at large and should receive it. Until such reform is effected we shall have in this country no hospitals worthy the name of general or great. Let it be our most constant endeavor to create the sentiment in the public and profession which shall make such a reproach no longer possible.” Our next object should be the simplification of our nomenclature and classification. While deprecating too frequent revisions, it seems to me that certain changes are already called for ; and, since our object is perfec- tion, and our pupils look to us for exactness in all directions, I would have the proper pronunciation, or accentuation at least, of every word employed in our nomenclature suitably marked in the committee’s next report, or an appendix added with such pronunciations. Then again, our annual reports of transactions are susceptible of im- provement, the general appearance, dimensions and typography of different reports having thus far varied one from another owing to their various sources of publication. For one, I should be glad to see also the metric or international decimal system exclusively adopted in our reports. Every- thing which tends to draw closer the bonds of universal brotherhood pro motes the progress of humanity by lessening that isolation to which alone most of the mutual misunderstandings of nations, as of individuals, is due. Thus far, also, the reports have been issued without, I think, sufficient re- vision on the part of our individual members. Finally, the statistics, while valuable, have not been what they might be, provided all members would freely and honestly contribute their private as well as public cases. One other thing : I should be glad if a committee might be appointed charged with the furnishing of information as to the value of such new remedies as might have been brought forward during the year which had elapsed. We have amongst us very able botanists and chemists, and some also, fortunately, who possess the advantage of presiding over special wards in general hospitals. Among these such a permanent committee could be selected to make annual reports embodying the results of their investiga- tions. Many of you w ill remember my request in waiting, some years since, for information as to the value of a highly-puffed specific for the treatment of syphilis, one brought out under the patronage of a great name in medi- cine ; and your universal response that it was “ worthless.” While such specifics are vaunted and disseminated to the detriment of the public, there exists a field for the labors of this proposed committee. The question of fees is one which we might also well consider a little. 12 “ The exclusive practice of dermatology is more poorly paid than that in any other department of medicine, and we should be justified in raising our fees for attendance to some proper and equalizing scale of compensa- tion.” While a concurrent tariff of prices in different cities may be impos- sible, there are yet certain general principles as to which, harmony might perhaps be established. Thus the general practitioner in America repre- sents the medical attendant in England ; the specialist here, the consulting physician there. But such “physicians” there, receive an exact, unvarying fee, receive it “cash down,” and in advance. Here, apart from quarterly bills never paid, individual visits are daily made by persons, who having received advice worth ten or fifteen dollars and occupied the time of patients who do pay those fees, pull from their pockets two dollars and say that that is all they have, and they supposed that was the price; and that too, when perhaps the fee-table lies upon the table in the reception-room. Again, the day has gone by for remitting fees to clergymen or even to other physicians. The necessity for such a condition of things, due to the mutual relations of the single parson and the two physicians of country villages, a century ago, has gone forever. The members composing the medical profession furnish to-day a gratuitous clientele enough to occupy the whole time of the best specialist, who is naturally the adviser selected, and thus to ruin him financially. If he does not in return ask advice from each of those he has treated, and he cannot, even if he would, of all,— then where is the quid pro quo upon which the whole absurdity is based ? The particular one whom he does select as his family physician makes naturally more visits to the family of the specialist than the latter is likely to return, and should be remunerated accordingly. Business is business and exactness in money matters promotes good feeling. In Boston, I rejoice to say, the specialist pays his family physician and feels for him a warmer regard and a more cordial appreciation in consequence, while at the same time preserving his own self-respect. A consistent schematic plan or skeleton for reports of cases is another thing which would seem desirable, thus condensing general into special, and consequently more exact, considerations, and giving them in logical sequence, by which means the articles are more easily read, more readily recollected and more collectively valuable. Such a scheme might be some- thing like the following: I. The history of the disease, generally speak- ing. II. Its definition and seat. III. Its varieties. IV. Etiology. V. Course. VI. Pathological Anatomy and Histology. VII. Diagnosis and differential diagnosis. VIII. Prognosis. IX. Treatment. X. Summary of the whole paper. XI. Bibliography. Pursuance of such a plan would bring out each point more clearly and also prevent desultory wandering from the special subject under consideration. If our long articles are to do good they must be read by those most needing them. For this end a 13 summary should always be appended. That is of course read first, if at all, and leads if approved, even to the reading of the paper in full. In our oral teachings also, we must — speaking as those who have authority — discourage polypharmacy, and instruct our pupils as to the value of hygiene and the necessity, if they would succeed in practice, of instructing their patients as to its every minute detail. (Thus, in Boston, printed diet-lists, suggestive though not inflexible, are given to patients, often with the best results as to dyspepsia, constipation, etc.) We must show our pupils the need of apostolic work in the direction of medical instruction of tbe people, teaching them simple rules by means of which the causes of their symptoms may be not only removed, but permanently pre- vented, rather than temporarily benefited. Where explanation can be sub- stituted for command, it always is a pleasure, as presupposing a superior mind and consequently one which will best profit by our instructions; deriving itself the most benefit therefrom, and redounding the most to our credit. Before concluding, I would call your attention to the fact that there has been received a communication from the Secretary of the American Surgi- cal Association, proposing a union of all the special medical Associations of America, to meet together annually or biennially, at the same time, and at some appointed place, the first meeting to be at Washington. This plan, advocated by many, I shall submit to you for discussion at the proper time. And now, gentlemen, with heartiest congratulation upon the past history and present standing of our Association, and with the warmest wishes for its and your prosperous futures, I welcome you to our tenth annual con- vention, and sincerely requesting your kind cooperation and support in the discharge of the duties of my office, I now declare our annual meeting for 1886 open, and ready for business in accordance with the programme before you.