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softer than Thames water. Water can never contributean excess of calcium to a diet beyond physiologicaltolerance. It must be emphasised that McCarrison (1927),in his. experimental production of stone in the bladderof rats, used a highly artificial mixture of foods devoid ofvitamin A and with a great excess of calcium. No naturaldiet possesses this combination.,

Swift Joly (1929), in his great review of the distributionof bladder stones throughout the world, has shown thatin Western Europe and in the the United States ofAmerica there has been an enormous change in theincidence of vesical calculi since the 17th and 18thcenturies, when the great itinerant lithotomists flourished.Bladder stone in childhood is now a rare disease. That anall-round improvement in the diets of children has beenan important general factor in this decline is not improb-able. But the absence of a factor of proven prophylacticvalue need not by itself cause the onset of a disease. Thewidespread distribution of deficiency diseases throughoutSouth-East Asia contrasts with the restricted foci ofbladder stones and makes a direct causal relationshipunlikely. , A similar argument applies to climate effects.Ubon, like other stone areas, such as parts of the Punjaband Persia, has a hot dry season. Urinary outputs mustinevitably be reduced and some concentration of urinaryconstituents result. This might predispose to stoneformation. But most hot countries are free from stoneand in the past it has been common in such places asIceland.

An interesting speculation is that a positive noxiousfactor in the diet might be the responsible agent.Undoubtedly the children of Ubon province eat manystrange foods. One such, consumed only on occasions,might contain a poison which upsets the delicate balanceof urinary colloids which, as Butt and Hauser (1952)show, help to keep the supersaturated electrolytes insolution. An interference with surface tension within thebladder might follow and allow the stone to form. An

up-to-date review of thip work has appeared in theLancet (1953). - ..

Another possible mechanism is that a poison mightinterfere -with either the production or the excretion ofcitric acid by the kidney. Shorr (1945) has broughtforward the claim that " citric acid is not a waste productbut a useful urinary constituent by virtue of its capacityto enhance calcium solubility." He has shown that incertain circumstances, notably in hyperparathyroidism,there is a close parallel between levels of urinary calciumand urinary citric acid. CEstrogens are also able to raisethe urinary output of citric acid. Further, Scott et al.{1943) report that " non-infected recurrent renal stoneformers excrete subnormal amounts of citric acid in theirurine." That’plant poisons can upset citric acid metabolismis well known. The poisonous South African plantGifblaar is responsible for the deaths of sheep and cattle.Its botanical name is Dichapatalum cymosum. The

poison in the plant is potassium fluoracetate and thisexerts, its lethal action by preventing the kidney fromremoving citric acid, which accumulates in that organin concentrations 56 times above normal (see Peters 1949).Might- not another plant poison prevent the normalexcretion of citric acid in the urine and so break up ’amechanism for keeping supersaturated salts in solution But this is pure speculation..That stone formation in the bladder is due to the

disturbance of a complicated biochemical mechanism iscertain. The nature of this mechanism awaits discovery.Should any clues with a practical consequence be forth-coming from biochemistry laboratories, the children inthe villages of Nong Kai Nog and Loa Bog in North-EastThailand provide suitable material for testing their

validity. Until such a biochemical advance takes place,these children must continue to rely upon their surgeonto relieve them of their pain and suffering.

I owe a great debt to Dr. Chovit Chutikom and Dr. AmaraChandrapananda. Without their ready and cheerful assistanceit would have been impossible for a stranger to undertakethese field studies.

REFERENCES

Butt, A. J., Hauser, E. A. (1952) New Engl. J. Med. 246, 604.Joly, J. S. (1929) Stone and Calculous Disease of the Urinary Organs.

London.Lancet (1953), i, 332.McCarrison, R. (1927) Brit. med. J. i, 717.Pendleton, R. L. (1943) Geogr. Rev. 33, 15.Peters, R. A. (1949) Advanc. Sci., Lond. 6, 257.Pyn Muangman (1940) J. Thailand Res. Soc. nat. hist. suppl.

12, 203.Scott, W. W., Huggins, C., Selman, B. C. (1943) J. Urol. 50, 202.Shorr, E. (1945) Ibid, 53, 507.Zimmerman, C. C., Vaidhyakara, P. C. (1933) Metron, 11, part 3,

p. 179.

Special ArticlesDERMATOLOGY IN LONDON

Past and PresentFROM A CORRESPONDENT

THE year 1714 is one which commands no little spacein the larger history books. In its early months thematter of the Hanoverian succession had been settled,and clinched by a proclamation (June 23) which warnedthe citizens that if the son of James II arrived in Englandhe was to be apprehended forthwith. Early on July 28,John Arbuthnot, the friend of Swift and Pope, andphysician extraordinary to Queen Anne, was summonedto the Palace, and on Aug. 1 the Queen thankfullyrelinquished forever the cares of her great office. " Sleepwas never more welcome to a weary traveller than deathwas to her." ..

Possibly, as Arbuthnot penned these words, therewas in his room a copy of the new book De MorbisCutaneis, a Treatise of Diseases Inc-ident to the Skinwritten by his colleague, Daniel Turner, of the Collegeof Physicians, London. For Arbuthnot was at leastas much interested in literature as he was in medicine;the written work of a colleague was always of interestto him ; and this was the first attempt in English tobring some order to the chaos of dermatology.A portrait of Turner shows a man about forty years

of age, with a firm mouth and well-moulded chin, a largenose, wide-set eyes, and a lofty brow. He looks resoluteand stern. Obviously he was not a man to be trifledwith ; pioneers seldom are. His book was widely readin England and the Colonies. A second edition was

published in 1723. In the same year -he received fromYale College the first medical.degree given in English-speaking North America.

In 1757 Robert Willan was born. It is said that hecame to London in 1782 and the next year was appointedto the Public Dispensary in Carey Street, where heestablished the bedside method of teaching. Doubtlessit is a mistake to compare the portraits of two men in anattempt to judge their characters, but we can say thatWillan had more kindly lineaments than Turner. Thechin was less pronounced, the lips more full, more readyto smile, the nose aquiline, the eyes larger but the gazevery direct, the brow broader but less high; a veryintelligent face tinctured with understanding andkmdliness. This was the man who, in 1785, submittedto the Medical Society of London a plan for the classifica-tion of skin diseases, for which five years later he receivedthe Fothergillian medal. In 1808 the first volume of hiswork On C2ctaneous Diseases was published by J. Johnsonof St. Paul’s Churchyard.As Pusey has written, " Willan’s reputation-cannot be

separated from that of his faithful associate, ThomasBa-teman (1778-1821) " ; for when WiJIan died; at theage of 55, before his treatise could be completed, hiswork was continued by the man who had been hiscolleague for ten years at the Public Dispensary. Bate-man published an important work entitled A Practical

641

Synopsis of Outaneous Diseases, the sole purpose of whichwas to present an abstract of Willan’s classification ofskin diseases and to elabora,te that work ; some seven

editions of this book were printed and it was translatedinto French, German, and Italian. He also publishedDelineations of the Cutaneous Diseases comprised in theOlassifioation of the late Dr.Willan, which contained alarge number of coloured plates.

THE LONDON "SCHOOL"

It was through the’ work of these three-Turner,Willan,. and Bateman-that many years ago Englandachieved an international reputation for the clinical

study of skin diseases. There followed men such as

W. C. Dendy, Jonathan Green, A. T. Thompson, andSamuel Plumbe, and later Erasmus Wilson, TilburyFox, Jonathan Hutchinson, Colcott Fox, and RadcliffeCrocker. Thus, starting with the impetus conferred

by the work of Turner and Willan, there came into beingwhat we may loosely term a school of dermatology,which was not only, particularly English but particularlyof London ; and in saying this we do not wish to belittlethe brilliant work performed at other centres in theUnited Kingdom-by, for example, J. N. Neligan ofDublin, H. G. Brooke of Manchester, W. A. Jamiesonof Edinburgh, and T. McCall Anderson of Glasgow.As is well known, the teaching of dermatology in

London during the latter half of the 19th century,though competing with the work of Hebra in Vienna,Unna in Hamburg, and the flourishing French schoolat the St. Louis Hospital in Paris, influenced the practiceof that specialty in many parts at home and abroad.The influence of the London school was fostered by

the action of Erasmus Wilson in establishing a Journalof Cutarseous Diseases in 1867, the foundation of the

Dermatological Society of London in 1882, and the

inauguration of the Dermatological Society of GreatBritain and Ireland in 1894. These societies merged toform the dermatological section of the Royal Society ofMedicine in 1907 ; and it would be difficult to over-estimate the importance of the frequent meetings ofthat body in moulding clinical opinion in dermatologyin this country.In 1921, largely on the initiative of Dr. A. M. H.

{now Sir Archibald) Gray, the British Association of

Dermatology and Syphilis was founded, its first meetingbeing held in London, whence its journal has alwaysbeen published. The association meets annually ina different town in Britain, not infrequently in London.Membership tends to be restricted to those who havebecome established and have made some mark in thespecialty.The London Dermatological Society was founded in

1912 and was renamed the St. John’s Hospital Dermato-logical Society in 1926. This society also has muchinfluence; its meetings are well attended, its discussionsare often lively, and its annual oration has been givenby many distinguished men, both from at home andabroad. In -1934 Dr. R. Prosser White bequeathed asum of money to finance this oration, which was renamedthe Prosser White oration.The particular genius of London dermatology has

lain in a flair for diagnosis, on which visitors from abroadhave always commented ; on integrity in the assessmentof therapeutic measures, which more enthusiastic practi-tioners have found ruthless and chilling ; and on acapacity for rapidly-assimilating advances made elsewhere.

. On the Continent, dermatology and venereology

are usually combined in practice, and ample provisionin hospital beds and in laboratory space and equipmentis made for the two subjects in a single department.In London this arrangement is not considered rationalor desirable, and few hospital beds and little laboratoryspace, except for histopathology, have been given to

dermatology alone. This major defect may perhapsexplain why London dermatologists have hithertotended to regard the practice of dermatology as all-

important and have failed to attract research-workersto a subject in which they are much needed.

POSTGRADUATE TEACHING

For many years, postgraduate students have come toLondon from far-distant countries, as well as from theuniversities at home, to absorb the practical teachingwhich London dermatologists could give. In this post-graduate migration, St. John’s Hospital for Diseasesof the Skin, with its associated London School of Dermato-logy, played a large part. The school was founded in1923. Instruction in the form of lectures and clinicaldemonstrations was conducted by the (then) honorarystaff of St. John’s Hospital and the heads of the skindepartments of the London undergraduate teachinghospitals, a department of special pathology beingdirected by Dr. J. M. H. MacLeod.

In July, 1948, the Institute of Dermatology, an

institute of the British Postgraduate Medical Federation,was constituted on the foundations of this London Schoolof Dermatology, remaining attached to St. John’sHospital, which was designated a postgraduate teachinghospital under the National Health Service Act. TheInstitute of Dermatology is now under the control of adirector ; the -pathology department has been extendedto include sub-departments of medical mycology andbiochemistry, in addition to histopathology; a- largeand expanding museum of " maulages," photographs,and coloured drawings has been added, and a libraryhas been included. Besides arranging for postgraduateteaching on the widest scale, the institute providesfacilities and encouragement for clinical investigationand scientific research. An annual prize (the Chesterfieldmedal), which was founded in 1895, is awarded on theresults of an examination.The inpatient department of St. John’s Hospital having

been destroyed in 1940, a new one has been opened inNorth London, where the teaching activities of the Insti-tute will be further extended. In addition, postgraduatesat the Institute may sometimes obtain facilities to

enlarge their experience considerably by visiting theskin departments of the general teaching hospitals ;and here they may witness various methods of under-graduate instruction. Overseas students who havefollowed this course in the past have often said that,owing to its wealth of material and variety of teaching,London is in their opinion the most valuable dermato-logical teaching centre in the world. Outside the circleof schools associated with the University of London,visitors are likely to be made welcome at the LondonSkin Hospital and at the Skin Hospital at Blackfriars.

* * *

Though brief, these notes will perhaps suffice to showthat the dermatologists of London today are endeavouringto continue the tradition founded by Turner, Willan,and Bateman, and have much to offer the postgraduatestudent who possesses ability and who is willing to dohis best.

SYMBIOSIS AT HILL END

SOME ACHIEVEMENTS AND OPPORTUNITIES

DURING the war, Hill End Mental Hospital, atSt. Albans, was called on to provide out-of-Londonwards for St. Bartholomew’s ; and the partnershipthus begun has persisted. Hill End was vast enoughto give such hospitality-a rambling Victorian structure,as able to accommodate guests as a Victorian house.The simile, however, must not be stretched too, far;for Victorian houses were often solidly comfortable andconvenient, whereas Victorian hospitals seem to have