Remembering Robert Willan: How one man forever changed the way we approach skin diseases

Until the 19th century, dermatology was a disorganized area of medicine with a clinical lexicon comprised of imprecise terms that were utilized inconsistently. Classifications of cutaneous diseases at the time were incomplete and relied upon unproven etiologic hypotheses. One physician, Robert Willan, is credited with addressing these issues, thereby enabling greater diagnostic accuracy and effective communication between practitioners.1Tilles G. Wallach D. Robert Willan and the French Willanists.Br J Dermatol. 1999; 140: 1122-1126https://doi.org/10.1046/j.1365-2133.1999.02894.xCrossref PubMed Scopus (18) Google Scholar His schema is the predecessor to our modern one, showing resemblance even 200 years later (Table I).Table IIn Willan's schema, skin conditions were divided into 8 groups based on primary lesion morphology. Several examples are shown using his paraphrased descriptions, accompanied by the modern categories in which each might be classifiedWillan's categoriesVesicularBullousPustularPapularScalyExanthemsTuberclesMacularExample conditionsChickenpox:Small shiny oblong red protuberances with a central transparent vesicle; these rupture within 10 days, leaving flat red marks.Pemphigus:Acute eruption of inflamed blisters on various body surfaces, sometimes in the mouth.Impetigo:Clusters of pustules with slight inflammatory border, which break and discharge fluid, resulting in thin yellowish scabs.Prurigo formicans:Large papules with intolerable itching. May be generalized but spares the face, palms, and soles. May have sensation of being stung by ants, or hot needles piercing the skin.Psoriasis guttata:Small distinct irregular patches, smaller than a sixpence [coin], with thin scale which leaves a shining red surface when detached.Ichthyosis:Harsh dry skin with flat large scales like tiles or fish scale, intersected with whitish furrows. Painful fissures on the palms and soles.Urticaria:Round, oval, or longitudinal elevations of the cuticle, usually denominated wheals which have a white top, surrounded by diffuse redness.Lupus:Ragged ulcers and scarring of the cheeks, forehead, eyelids, and lips; may be on the body.Nevi:Various discolorations of the skin, seen on any body part. Some are stain-like spots, others show slight thickening.Modern reaction patternsVesiculobullousPapulosquamousEczematousVascularDermalNeoplasms Open table in a new tab Willan was born in England on November 12, 1757; his father was a medical practitioner with no formal degree.2Booth C.C. Robert Willan MD FRS (1757-1812): dermatologist of the millennium.J R Soc Med. 1999; v92: 313-318https://doi.org/10.1177/014107689909200616Crossref Scopus (9) Google Scholar British law forbade Quakers like Willan from attending Oxford or Cambridge, so he enrolled at the University of Edinburgh. His professors of botany and medicine were leading scholars in the taxonomic principles of Carl Linnaeus.3Hare P.J. A note on Robert Willan's Edinburgh days.Br J Dermatol. 1973; 88: 615-617https://doi.org/10.1111/j.1365-2133.1973.tb08028.xCrossref PubMed Scopus (5) Google Scholar In 1783 Willan began general practice in a London dispensary where his patients were England's poorest, living in crowded and dirty quarters. This meant innumerable skin complaints would be evaluated there by Willan,2Booth C.C. Robert Willan MD FRS (1757-1812): dermatologist of the millennium.J R Soc Med. 1999; v92: 313-318https://doi.org/10.1177/014107689909200616Crossref Scopus (9) Google Scholar whose unusual scrupulousness in describing cutaneous lesions was noted by colleague Thomas Bateman.1Tilles G. Wallach D. Robert Willan and the French Willanists.Br J Dermatol. 1999; 140: 1122-1126https://doi.org/10.1046/j.1365-2133.1999.02894.xCrossref PubMed Scopus (18) Google Scholar Willan read dermatologic texts by Arabian, Greek, and Roman physicians, which he would later critique and synthesize in his own masterwork.4Willan R. On Cutaneous Diseases. Kimber & Conrad, 1809Google Scholar In 1790 Willan presented an essay to the London Medical Society proposing his classification of skin diseases. It refocused dermatology on the basic Hippocratic tenet of observability by clearly defining descriptive terms, de-emphasizing unverified etiologic hypotheses, and prioritizing lesion morphology as the critical step in diagnosis. His taxonomy was also modeled on Linnaean botanical principles: skin conditions sharing an observable trait composed an order, sequentially subdivided into classes and species according to additional physical details.1Tilles G. Wallach D. Robert Willan and the French Willanists.Br J Dermatol. 1999; 140: 1122-1126https://doi.org/10.1046/j.1365-2133.1999.02894.xCrossref PubMed Scopus (18) Google Scholar The Society recognized Willan's achievement with a medal and peers encouraged him to publish the work.5Booth C.C. Robert Willan, M.D., F.R.S., F.S.A..Br J Dermatol. 1968; 80: 459-468https://doi.org/10.1111/j.1365-2133.1968.tb11982.xCrossref PubMed Scopus (10) Google Scholar Willan was neither wealthy nor widely reputed, and may have encountered difficulty in finding a publisher willing to bear the financial risk of supporting his goal.5Booth C.C. Robert Willan, M.D., F.R.S., F.S.A..Br J Dermatol. 1968; 80: 459-468https://doi.org/10.1111/j.1365-2133.1968.tb11982.xCrossref PubMed Scopus (10) Google Scholar Between 1798 and 1808, the first half of his schema was published as 4 individual chapters that would become consolidated as the book On Cutaneous Diseases, which was widely celebrated.1Tilles G. Wallach D. Robert Willan and the French Willanists.Br J Dermatol. 1999; 140: 1122-1126https://doi.org/10.1046/j.1365-2133.1999.02894.xCrossref PubMed Scopus (18) Google Scholar This 420-page text was more than a mere list of definitions and categorization of diseases; it was a comprehensive manual on cutaneous practice. It contained therapeutics, case series, and contributions from numerous physicians. In the opening pages Willan wrote, “To complete adequately a plan so extensive must be considered an undertaking of much difficulty; and perhaps exceeding the powers of any individual.”4Willan R. On Cutaneous Diseases. Kimber & Conrad, 1809Google Scholar Sadly, Willan turned out to be correct, as he died of tuberculosis in 1812. The remaining 4 orders of his taxonomy were faithfully compiled and published posthumously by Thomas Bateman in 1813.2Booth C.C. Robert Willan MD FRS (1757-1812): dermatologist of the millennium.J R Soc Med. 1999; v92: 313-318https://doi.org/10.1177/014107689909200616Crossref Scopus (9) Google Scholar The Willanist doctrine spread throughout Europe due to its usefulness, despite criticisms from rival scholars.1Tilles G. Wallach D. Robert Willan and the French Willanists.Br J Dermatol. 1999; 140: 1122-1126https://doi.org/10.1046/j.1365-2133.1999.02894.xCrossref PubMed Scopus (18) Google Scholar Willan never occupied a prestigious hospital position and no diseases bear his name. But his doctrine still shapes the thought processes of cutaneous diagnosticians today, over 2 centuries after his death. Let us remember Dr Willan on November 12, and be inspired to always remain objective, articulate, and precise. None disclosed. I am indebted to Dawn Melberg and Melissa Spangenberg, exceptional medical librarians without whom this work would not be possible.