X. Sierra, MD
Read also The dermatological heritage in danger in Madrid by J. Calap
Dermatology in Spain did not have such an early awakening as in France, England, or Austria. There had been some early work carried out in this field, such as that of Alfaro, who in 1840 published a book which basically followed Alibert's ideas1 (although his classification is closer to Rayer's2), but, in general, the attempts at studying skin diseases had been timid and inconsistent.
José Eugenio Olavide was born in Madrid in 1836. He studied medicine at the old San Carlos Hospital, and, on finishing his studies, went to Paris, where for 2 years he worked with eminent physicians, such as Alfred Velpeau, Armand Trousseau, and Jacques Maissonneuve.
On his return to Madrid, in 1860, he secured a place as doctor at the San Juan de Dios Hospital. This old hospital of Madrid was founded in 1552 under the name of Antón Martín, with the aim of serving "the wounded poor". Sufferers of skin diseases and venereal diseases were confined here.3 This hospital was renowned for the treatment of sexually transmitted diseases, and the satirical poet Francisco Quevedo (17th century) made reference to it in this sense in some of his poems. Olavide was in charge of 120 beds for cutaneous patients, fueling his growing interest in dermatology, until then a neglected speciality in Spain.
Soon Olavide had at his disposal a group of associates, with whom he began classes or sessions in the aforementioned hospital. This may be considered as the first educational activity in dermatology that took place in Spain (1864). It is true, however, that some years before, in 1850, there had been a failed attempt to establish a Chair of Dermatology in Madrid, for which Don José Calvo had been nominated, but this project only lasted a year and never came to fruition.
The continuous observation of cutaneous diseases in the wards of San Juan de Dios Hospital, and the need to retain in his memory the clinical details of the cases seen by him, led Olavide to have illustrations made of skin diseases. His first intention was to keep the illustrations in a kind of small private museum. He also made clinical annotations, helped by his associates Hernando de Benito and Castelo. This is how he achieved a classification of dermatologic diseases.
He then had the idea of publishing these experiences and teachings in the form of a book, which would organize the material forthcoming from his personal observations with the aim of contributing towards a better comprehension of dermatologic diseases. The treatise was entitled "General Dermatology and Atlas of the Iconographic Clinic of Skin Diseases or Dermatoses", and appeared in instalments between 1871 and 1880 4. This worthy piece of work, which comprised two volumes, consisted of a text book and a rich iconographic atlas, and stands out as one of the best publications of its time on the subject of clinical dermatology. The illustrations, drawings and lithographs by Acevedo showed cutaneous injuries in detail and sith accuracy. This iconographic richness and the large size of its pages (in folio) substantially raised the price of this work, which made it impossible to acquire for many of its potential readers, such as do students of medicine5. Had it not been for the official support of the Minister of Public Works and Economy, Ruiz Zorrilla, it would never have been published. The instalments continued to appear, albeit at an irregular pace and with interruptions, between 1871 and 1880. Although this book, because of its magnitude and luxurious edition, met with certain difficulties in distribution, it became the most emblematic work in Spanish dermatology and has been a compulsory point of reference since its publication.
Olavide viewed dermatology as a branch of pathology which studied skin disorders, whether produced by internal or external cause, and whether a local disorder or part of a systemic disease. In Olavide's work, it is easy to recognize the influence of the French school of Alibert and, above all, Bazin. He declared that the mere description of symptoms was not enough and tried to explain the cause of the disease, attempting to "link pathogenesis with the anatomy and pathologic physiology towards the philosophic explanation of the symptoms".
Attention should be drawn to the consideration he gave to functional diseases and to disorders which he called "sympathetic", in other words, those which coincided with localized complaints in other organs. This set the precedent, in his time, of considering the cutaneous expression of systemic pathology6, which corresponds fully to the concept of diathesis defended by Bazin and Hardy. He also considered some diseases without an objectifiable morphologic base as is the case with sensitive or subjective disorders.
Olavide would have preferred to disregard the elemental lesions described by Willan, although that was not entirely possible. For this reason, he tried to make his own classification of elemental lesions, insisting that these may superimpose themselves or coincide, a dynamic concept, considering the epoch, similar to that proposed later by Devergie.
The treatise classified dermatoses into three large groups: parasitic diseases, natural diseases, and artificial diseases.
The parasitic diseases, which were contagious, were produced by external agents, such as animals (lice, scabies) or cryptogams (tinea). Amongst the latter, he also included chloasma and pityriasis.
Those which he called natural diseases were local, general, or constitutional deformities. Olavide here included complaints of the following types: syphilitic, herpetic, rheumatic, scrofulous, scurbutic, leprous, pellagrous, glanderous, carbuncular, tuberculous, fibroid, and cancerous. This is where we can most clearly see the influence of Bazin and his theory of diathesis, in which the personal factor is essential and explains the constitutional predisposition of an individual towards suffering from the disease.
Finally, he considered the artificial diseases which were caused directly or indirectly.
As can be seen, the "more botánico"* classifications of notorious influence in European dermatology had no such effect on Olavide, probably due to his readings and almost exclusive relations with the French school. Olavide did not know the work of Hebra, since he did not speak German. It is also unlikely that he knew the work of other schools, which had made little impact in Spain. We should also remember that the works of Willan and Bateman were not translated into Spanish, nor that of Rayer; Plenck's work was, but very belatedly; Biett's work archieved only a sparse distribution7.
The causes of diseases were also of interest to Olavide. In the line of etio-pathogenic thought, he suggested five causes of dermatosis: contagion, heredity, internal constitutional diseases, exterior influences, and causes through individual predisposition. He defined three types of contagion: the parasitic (scabies, phytoparasitic), the miasmatic (ferments), and the virulent (purulent or serous liquids).
Olavide was as a strong supporter of the microscope as a means of research and diagnosis. A display of his early interest in microbiology was the study in 1872 of the ambient air of the hospital service, conducted by Ezequiel Martín de Pedro, with the aim of examining the germs found there. Three years later, in 1875, Olavide gave a speech before the Royal Academy of Medicine of Madrid entitled "Parasitism or vegetable morbidity before reason and the facts". A little later he published a similar pamphlet 8. In these works, he considered cutaneous parasitism, parasitism of mucous membranes, and also parasitism in a general sense.
The presence of microscopic plant matter on the skin was generally accepted in these times, but its etiologic role was more debatable. It is true that Remack and Schönlein had already described the producing agent of favus, which they called Achorion schönleinii (today Trichophyton schönleinii), Gruby had carried out many demonstrations of fungal producers of diseases, and the producing agent of pityriasis versicolor had already been described (Eichstedt, 1846); however, the role of microscopic fungi as etiologic agents was still not universally accepted. Admitted by some, as was the case with Bazin and Hardy, it was still disputed by others, such as Cazenave, who maintained that fungi "were no more than ilusions of micrography". The skepticism of this prestigious dermatologist doubtless influenced the opinion of a large number of doctors of the epoch.
In spite of this controversy, Olavide clearly defended the etiologic role of fungi in the case of transmissible dermatosis, rebuffing those who considered parasites to be mere co-adjutants in the production of diseases:
"In spite of how irrational the idea may be, there have been and there still are men of science who are not content to look on diseases as the accidental cause of the production and the development of parasites, but rather they consider them to be an efficient cause, which has been mistakenly called spontaneous generation (...) we must distinguish between those cases in which the parasites are the cause of the disease and others in which they are a coincidence or complication".
This was a disguised allusion to opinions such as a those of Cazenave or Devergie, who showed themselves unwilling to recognize the etiologic role of fungi. Olavide considered contagion to be a seed and the individual to be the land in which it was sown 9, recognizing these disorders within the phytoparasitic group: thrush, favus, herpes, alopecia areata, and pityriasis versicolor. He appeared very keen to explain the different forms of contagion considering them to be direct or mediate, by air and by transplantation. The latter form of contagion gave cause for various experimental works:
"In this way we have transplanted tinea from man to various animals".
Some of the illustrations of his book attested to he results of various studies of experimental dermatology: tinea reproduced in dogs and carts, rats, cockerels, etc.
He also extensively considered scabies, to which he had already dedicated other studies 10. He defined it as:
"a parasitic disease and therefore contagious, produced by an arachnid..., called Sarcoptes hominis".
He then went on to defend the concept that all parasitic diseases have existed since time immemorial, although they have been confused with other diseases, such as syphilis and leprosy. After describing in detail the acarus, he refuted the idea of spontaneous generation and scabious predisposition. As treatment, he suggested the use of creosote and phenic acid.
Although he made some errors, such as denying the contagiousness of leprosy, he showed himself to be farsighted in other senses. It is surprising, for example, to note his conviction that syphilis would one day be explained as a "parasitism".
As can be seen, Olavide fully accepted the concept of etiology. As a consequence of this etio-pathogenic mentality, in 1881 he created a micrographic laboratory in the hospital under the direction of his associate Antonio Mendoza. Here, histologic and microbiologic work and research were carried out lending their efforts a special scientific rigor.
Olavide was also the founder of a museum of wax moulages in which, in some way, his initial idea of collecting clinical illustrations survived, and from which his treatise finally came forth. The wax moulages allowed the reproduction, in three dimensions and in a form quite similar to the original, of the various pathologic alterations of the skin, and constituted a regular recourse in the larger educational centers of the era, until the introduction of photography made them unnecessary. In this sense, we should recall the wax museum of the Saint-Louis Hospital in Madrid. Now, San Juan de Dios Hospital no longer exists; it disappeared in 1965. Its heir, the existing Gregorio Marañón Hospital, Madrid, preserves the wax moulages of Olavide's museum in boxes in a store-room, and lamentably they cannot be seen by the public. Let us hope that, in the near future, this anomalous situation will be rectified.
All things considered, José Eugenio Olavide deserves to be recognized as the founder and instigator of Spanish dermatology. On his death, in 1901, his book survived in Madrid with his followers, amongst whom Juan de Azúa (1858-1992) stands out. Olavide's influence in Barcelona was well known, especially on Joan Giné i Partagàs (1836-1903), who recognized Olavide in his book11. Olavide's treatise, a true banner of Spanish dermatology, marks its starting point, and can be considered the solemn consecration of this medical speciality in Spain, comparable with the works of Alibert in France, Willan in England or Hebra in Austria.
^ 6 Gómez-Orbaneja J. Historia de la dermatología en Madrid, en el siglo XIX y primer tercio del XX. In: Calap J, Rodríguez-Murillo JA, eds. Aspectos Históricos de la Dermatología Médico-Quirúrgica y Venereología Española. Barcelona: Isdin, 1985.
^ * "more botánico". Latin phrase used in the early 19th century referring to the medical classification of skin diseases, as had been performed previously by botanists when classifying plants (e.g. linneus).