History of Medicine

SKIN DISEASE IN OLD VIENNA

     Imagine a king roaming around his realm in disguise to better know the problems of his subjects. It’s the stuff of a fairy tale, but it actually happened – in Vienna, where the Habsburg emperor Joseph II ruled from 1780-90. A liberal but impulsive monarch inspired by enlightenment ideas, he established in 1784 the Allgemeines Krankenhaus (General Hospital) as part of a larger program to deal with the sick and poor streaming into the city since the start of industrialization.  The hospital that Joseph created, using his own funds, was a makeover of an old almshouse built around several courtyards, redesigned to house about 2000 patients.

Allgemeines Krankenhaus (Wikipedia)

     In the decade 1836-46, under the influence of the enlightened vice-director of the faculty, Ludwig Baron von Türkheim, the medical school attached to the hospital was substantially reformed. Josef Skoda, the great diagnostician, was given his own chest service, and Carl Rokitansky created a pathology department (he eventually performed some 30,000 autopsies). Other specialty divisions were established, making the “second” Vienna Medical School one of the most advanced in the world, drawing on many thousands of patients seen each year at the hospital.

     Patients with skin diseases, before the 1840s, were generally placed in medical departments. Most skin conditions were thought to result from attempts of poisons or “corruptions” from within the body to escape through the surface. Thus skin lesions were often left alone so as not to impede this process. At the Allgemeines Krankenhaus the skin ward was next to Skoda’s chest ward, and Skoda asked one of his brightest graduating students, Ferdinand von Hebra, to take charge of the ward.

     Ferdinand Ritter von Hebra was born in Brünn, Moravia, in 1816. He attended high school at a monastery in Styria, then

(Wikipedia)

medical school in Vienna, graduating in 1841. Josef Skoda arranged for Hebra to be his assistant. Noticing that Hebra took an interest in the neglected dermatology patients Skoda urged him to study the patients, and supplied him with books.

      Hebra absorbed existing literature intensively - in particular the writings of two English physicians, Robert Willan and Thomas Bateman, and the Frenchmen, Jean Louis Alibert and Laurent-Théodore Biett, all of whom had attempted to bring some order out of the confusion of skin lesions. Alibert’s classification took the form of a tree, with the trunk representing the epidermis and dermis, and the branches various groups of diseases. All these classifications fell short, partly due to inadequate knowledge.

Arbre des Dermatoses by Alibert - illustrating
his classification (Wikipedia)

     Over time Hebra concluded that many skin ailments were of local origin and not expressions of poisons escaping from the inner body. This was most evident in the case of scabies, perhaps the most common disease he encountered (he is said to have seen 60,000 cases by 1860). The causative mite, Sarcoptes scabiei, though suspected for many years, had proved difficult to find. It was not until a student of Alibert, Simon Francois Renucci, in 1834 demonstrated the mite consistently (by looking between vesicles rather than inside them) at the St. Louis Hospital, Paris. His demonstration even survived a 300-franc bet that he was wrong.

     Hebra enlarged upon Renucci’s work by infecting himself several times and charting the course and cure of the disease. He did away with bleedings, laxatives, and most medicines taken internally, treatments reflecting the belief of internal disease as a cause. Instead he applied sulfur, in an ointment made from lard and potassium bicarbonate, and noted the necessity of treating all skin but the head. He acknowledged that “quacks and old women” had more sense than doctors in their use of topical therapies.

Vienna Medical Faculty
Hebra(second from left, rear), Skoda (second from left, front),
Rokitansky (center, front) ( from Google Books)

     Hebra’s work on scabies carried great weight in conveying the idea that the skin should be considered a separate organ subject to its own disorders, though he recognized that some skin problems were indeed manifestations of generalized disease. Soothing baths, oils, and sometimes more caustic applications were used, many of them tested systematically, and most internal remedies discarded.

     Hebra advanced the description and organization of dermatologic lesions. Terms such as erythema multiforme, lichen planus, impetigo herpetiformis, and rhinoscleroma are largely due to him. He began lectures on skin disease in his second year and was an exceptionally good lecturer, combining clarity, abundant

Erythema multiform (from Hebra: Atlas
der Hautkrankheiten, Google Books)

material, and a ready wit. The lectures attracted students from home and abroad. He could also, in Sherlock Holmes fashion, tell a patient's occupation by examining their hands or feet. In 1845 Hebra’s ward was separated from Skoda’s to become an autonomous dermatology service, a moment considered by some as the “birthdate of dermatology” as a specialty. He published many articles and a few books, including a famous atlas of skin diseases. The latter was a collaboration with the artists Anton Elfinger, who was also a successful political cartoonist, and Carl Heitzmann. 
     Heitzmann had studied medicine under

From Atlas der Descriptiven Anatomie des Menschen
by Carl Heitzmann. (Hathi Trust)

both Hebra and Rokitansky and was even being considered as a successor to Rokitansky as chair of pathology. He never had formal art training but nevertheless published a surgical pathology text for medical students and later a two-volume human anatomy text with 600 illustrations that went through 9 editions. After failing to succeed Rokitansky he emigrated to New York where he practiced dermatology, published more papers, and was a founding member of the American Academy of Dermatology.

     An assistant to Hebra was Moritz Kaposi, whose name is

Moritz Kaposi (Wikipedia)

associated with a formerly rare but now common malignancy seen in HIV patients. Kaposi was gifted and hard-working, and finished volume 2 of Hebra’s Handbook of Dermatology after Hebra’s death. He also married the boss’ daughter.

     Ferdinand von Hebra died in 1880 of “dropsy”. A funeral procession a mile and a half long followed his coffin to its final resting place next to Carl Rokitansky. Von Hebra brought dermatology into the modern world, freeing it from many misconceptions and opening it to modern research methods.

SOURCES:

Crissey, J T. and Parish, L C. The Dermatology and Syphilology of the Nineteenth

         Century. 1981, Praeger Scientific. Especially chapter 4.

Lesky, E. The Vienna Medical School of the 19^th Century. 1976, Johns Hopkins Univ

        Press.

Finnerud, C W: “Ferdinand von Hebra and the Vienna School of Dermatology”. AMA

        Arch Derm Syph.  1952, 66(2): 223-32.

Everett, M A: “Jean Louis Alibert: The Father of French Dermatology”. Int J Derm

       1984, 23: 351-6.

Neuburger, M. “Die Lehre von den Hautkrankheiten vor Hebra”. Wien Med Wochen 

          1928, 78: 641.

Friedman, R: “The Story of Scabies II”. Medical Life 1934, 41: 426-76. 

Friedman, R: “The Story of Scabies III”. Medical Life 1935, 42: 218-71.

Hackstock, I: “Carl Heitzmann (1836-1896): physician and illustrator”. Int J Derm

         1938, 37: 235-40.

Shelly, W B, and Crissey, J T: Classics in Clinical Dermatology, with Biographical

        Sketches. 1953, Charles Thomas.
Lesky, E. Meilensteine der Wiener Medizin. 1981, Verlag Wilhelm  
        Modrig.