eminent venereologists 4: jonathan hutchinson · andexcitementoflondon'smedical life...

Genitourin Med 1990;66:401-406

Eminent venereologists 4: Jonathan Hutchinson

J D Oriel138 Harley Street, London W1N 1AH, UK

"We older men who remember Sir Jonathan Hutchin-son well recall a tallish dark figure that changed verylittlefrom middle life to old age; dark eyes that seemedto look past you through his spectacles, black hair andbeard lengthening and growing grey with age, a suit ofblack broadcloth and a top hat that grudgingly gaveway to a wide-awake. We see him presiding at ourmedical meetings and addressing them in precise clear-cut sentences, rather solemn, without much sparkle, butfull ofmeat, andmade attractive by more than a trace ofYorkshire accent'

Hutchinson (fig) was one of the great figures ofVictorian medicine. He was bom in 1828 at Selby, in

Fig. Sir Jonathan Hutchinson by Spy.

Yorkshire, the second of a family of twelve children.His father had become prosperous in the flax trade,and both he and his wife were deeply committedmembers of the Society of Friends, both beingdescended from long lines of Quaker ancestors.Hutchinson was not sent to school, but received hisearly education from govemesses. The family atmos-phere was happy and secure but serious and pious,even the cut ofthe clothes or the width ofthe hat brimbeing regarded as important markers of religiousconformity.2 By the age of 17 years Hutchinson haddecided to become a missionary and persuaded hisfather to let him study medicine, which would be animportant asset in this work. Accordingly, in 1845 hewas apprenticed to Dr Caleb Williams, a Quaker witha large practice in York, for five years; during the lasttwo of these he also attended the small school ofmedicine at York. His letters at this time show him tobe hard-working and conscientious, but perhapsrather a prig.'

In 1850 Hutchinson went to London for clinicalinstruction at St Bartholomew's Hospital. The war-den of the students' hostel was then the surgeonJames Paget, who was to become his lifelong friendand mentor. He qualified the same year and returnedto York as House Surgeon, but he missed the interestand excitement of London's medical life and retur-ned there in 1851. Paget found him a junior positionat the City of London Hospital for Diseases of theChest. He lived frugally. His days were spent inhospital practice and coaching, and he was alreadycontributing case reports to medical journals. Hisevenings were devoted to philanthropic work in thepoorer parts of London. At first he was undecidedabout his future, but by 1853 his interest in medicinewas such that, as he explained in a letter to his father,he had given up the idea of missionary work anddecided to become a surgeon. There were alwaysstrong ties between father and son; in 1854 Hutchin-son yielded to his father's rooted objection to anyform of military service and refused the offer of asurgical appointment in the Crimea, where many ofhis colleagues were gaining valuable experience.However, in the same year he was appointed Surgeonto the Metropolitan Free Hospital, and soon afterjoined the staff of the Royal London OphthalmicHospital (Moorfields) and the Blackfriars Hospitalfor Diseases ofthe Skin. His most important appoint-ment came in 1858, when he became Assistant

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Surgeon at the London Hospital. At the time he wasnot a Fellow ofthe Royal College of Surgeons, but hepassed the examinations in 1862 and in the followingyear was appointed Surgeon to the London Hospitaland Assistant Surgeon to Moorfields.Hutchinson now had responsibility, as an operat-

ing surgeon, for 60 beds at the London Hospital,where he also lectured in surgery and ophthal-mology, as well as appointments at Moorfields, theBlackfriars Skin Hospital and the Metropolitan FreeHospital. He was deeply committed to teaching, andwrote voluminously. In addition to this formidablework load he had an expanding private practice ingeneral surgery, ophthalmology, dermatology, andparticularly in syphilis, a disease with which he wasfascinated all his life.

In 1856 Hutchinson married Jane Pynsent West, asensitive and artistic Quaker girl, and they settled in ahouse in Finsbury Square in the City of London,which was shared with three colleagues-the ophth-almologists Tay and Nettleship and the neurologistHughlings Jackson. The latter was to become Hut-chinson's most intimate friend. Like him he was aYorkshireman, and had studied under Paget at StBartholomew's. Hutchinson had persuaded him todevelop his interest in neurology, and later obtainedfor him a post as physician to the London Hospital,where he was to achieve great distinction; it has beensaid that Hughlings Jackson was Hutchinson'sgreatest contribution to medicine.2 Hutchinson andhis wife eventually had nine children (one of whomalso became a surgeon at the London Hospital). In1863 he had bought a property near Haslemere inSurrey, and the family spent increasing amounts oftime there. After his father's death in 1872 Hutchin-son could afford to buy a large country house andestate in Haslemere called Inval; this became thefamily's country home, Hutchinson himself spend-ing weekends and holidays there. In 1874 he movedfrom Finsbury Square to a more fashionable area inthe West End ofLondon, Cavendish Square. He hadbeen reluctant to move. His wife, writing to one ofher daughters, said: "Sir James Paget tells Papa hemust go, and give up all hope there of teaching andadvancing science, for it is time he attended to No. 1.He can do that there but nothing else. This quitescared Papa, and I can't help smiling at how advicewhich would attract most men disgusts him, and hethinks he had better stop here. We have not quitedecided yet."' The move was eventually made, anddespite Paget's prediction Hutchinson was able tocontinue his various activities as before.As time went by Hutchinson became a central

figure in British medical life. He was active inLondon's medical societies and was president in turnofmost of them. He travelled to hospitals in Europe,and in Paris became friendly with the great Frenchvenereologist Fournier. In due course he received

many honorary degrees. Although he was not a manto invite honours for their own sake, he was delightedwhen he was elected a Fellow of the Royal Society in1882. Having filled many offices in the Royal Collegeof Surgeons over the years, he was finally electedPresident in 1889. According to Johnston Abraham,4he refused a peerage offered him by Asquith, thePrime Minister; eventually, he accepted a knight-hood in 1908, at the age of 80.Hutchinson was a prolific author and editor. He

was secretary to the New Sydenham Society, whichpublished translations ofthe best modern continentalworks, during the whole of its existence, 1859-1907.He edited the British Medical Journal for a short timein 1869. His Illustrations of Clinical Surgery appearedin several volumes between 1878 and 1884, and asmaller Atlas in 1895. These publications provide amiscellany of plates and commentaries, mostly ofskin diseases and syphilitic lesions, but also ofcancers, diseases of joints, congenital malformationsand so on arranged in no particular order. Archives ofSurgery, which appeared between 1889 and 1900, isalong the same lines. The ten volumes of thisextraordinary work were written entirely by Hut-chinson. There are descriptions of interesting cases,many of them of syphilis, illustrations and commen-taries, and expressions of his opinions on a widevariety ofmedical and surgical subjects. It is perhapshis greatest work apart from his papers on syphilis.Osler wrote "When anything turns up which isanomalous or peculiar . .. I tell my students to turnto Mr Hutchinson's Archives of Surgery, as if it is notmentioned in them it is surely something very muchout of the common",5 and the medical historianGarrison believed that the work will "some day bestudied like the works of John Hunter".6 Hutchin-son's discursive style of teaching, based on the studyof individual case histories, is shown in the firstedition of his book Syphilis, which was dedicated toFournier and appeared in 1887.7 Only a fifth of thework is devoted to a systematic description of thedisease and its treatment, and the remainder to aseries ofcase reports with commentaries. The secondedition, largely rewritten, appeared in 1909;8 it is laidout on more conventional lines, without the com-mentaries.

Postgraduate teaching made a great appeal toHutchinson, and he was devoted to the idea of"objective teaching" by the use of specimens,models, diagrams and other illustrative material. In1868 he had suggested to the British MedicalAssociation that it should organise an exhibitiondemonstrating recent advances in medicine at itsannual meeting. This suggestion was adopted, andHutchinson prepared the first exhibition; they wereto become a feature of the annual meetings for manyyears. Hutchinson retired from the London Hospitalin 1883 with the intention of establishing a clinical

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museum of specimens, models, pictures anddiagrams, and this was subsequently expanded into a"Polyclinic", in effect a postgraduate medical centre,which opened in 1889. In addition to the museumthere were lectures, demonstrations and public con-sultations on poor patients who could not afford WestEnd fees. The project was very successful for a time,particularly with general practitioners, but wasregarded with hostility by the medical establishmentand the Polyclinic did not long survive Hutchinson'sretirement from it;' the large collection of illustra-tions was bought by Osler and taken to JohnsHopkins Hospital. Hutchinson was very disappoin-ted at the failure ofhis project, but he was ahead ofhistime. He had tried to amalgamate the Polyclinic witha general hospital, but there was to be no post-graduate hospital in London for thirty years after hisdeath.

Hutchinson's enthusiasm for teaching museumsdid not end with the Polyclinic. In 1883 he establi-shed at his home at Haslemere an EducationalMuseum; initially devoted to local natural history,this was gradually enlarged to become a museum ofmankind with fossils, drawings and specimens toillustrate the descent ofman and his achievements inscience and art. Hutchinson created an aviary andvivarium, and even provided at the entrance to themuseum little pots of wild flowers with accompany-ing notes.5 Nothing pleased him more than to escortgroups of friends through the museum, and he gaveweekend lectures to local inhabitants which rangedfrom natural science to evolution and poetry; hebelieved, he said, in a "mixed diet". An offshoot ofthese activities was the publication in 1897 of TheCenturies, a chronological synopsis of history withinterleaved blank pages for the reader's own notes.Hutchinson's museum survived for many years afterhis death. He established a similar museum in Selby,his birthplace, but it was not a success.Although not a countryman like Benjamin Bell,

Hutchinson enjoyed rural life. At Inval he and hiswife often entertained hospital colleagues andvisitors from abroad. They would be taken for walksthrough the beautiful Surrey countryside, with manya halt to discuss features of geological or botanicalinterest. Hutchinson himself was a good shot, butmany of his friends were not and the LondonHospital shooting parties were evidently ratherperilous affairs. After he retired from the hospitalHutchinson took a less active part in London'smedical life, his time being mostly devoted to hisprivate consulting practice and to his Polyclinic andeducational museum. His wife died in 1887 at the ageof 53, and after this he divided his time betweenCavendish Square and Haslemere. Eventually heretired to the country completely. He built a newhouse called "The Library"-he was a voraciousreader, not only of medicine and natural history, but

of biographies, poetry and novels-and there hespent the closing years of his life, looked after by hisdaughters, with Hughlings Jackson as his constantcompanion until his death in 1911. Hutchinsonhimself died in 1913 at the age of 85.

HUTCHINSON AND SYPHILISHutchinson's interest in syphilis began early in hiscareer. While he was at St Bartholomew's Hospital in1849 he described two cases of keratitis associatedwith congenital syphilis. Four years later he cameacross a case of "strumous" disease of the skull in ayoung man whose mother had syphilis; on perusingthe literature he realised that very little had beenwritten about congenital syphilis beyond the neo-natal period and decided to make a special studyof its later manifestations. He made a retrospectivesurvey of all the patients suspected of having"hereditary syphilis" who had attended BlackfriarsHospital for Diseases ofthe Skin and Moorfields EyeHospital, and gathered some new cases of his own.He published his results in a series ofpapers between1857 and 1863.He had noted a peculiar development of the

permanent teeth, particularly the upper incisors, insubjects who had suffered from syphilis in infancy.The teeth are small, short, and narrow towards theirfree edges, where they are notched vertically; they arediscoloured, and wear easily. Hutchinson had men-tioned this observation at a meeting of the Patho-logical Society, but since it had been greeted with"expressions of incredulity" he decided to publishclinical details of 13 cases, with illustrations.9 Thepatients were aged between five and 28 years, andmost of them had interstitial keratitis; a clear historyof syphilis in one or other parent, or of unequivocalneonatal disease, was established in every case. Aswas the custom at the time, this report was con-sidered by a committee of the Pathological Society.The hypothesis was thought to be interesting, butmore evidence was needed before it could be accep-ted. In due course this was forthcoming whenHutchinson published details of a further 70 cases.'0At the same time as these papers were appearing,

Hutchinson published the results ofhis studies oftheassociation between congenital syphilis and inter-stitial keratitis. He gave details of 64 cases." The oldterm "strumous corneitis", which implied a connec-tion with tuberculosis, was abandoned as meaning-less in this context. The reasons for regarding thedisease as a manifestation of syphilis were: (1) therewas a history ofeither parental or neonatal syphilis inall cases, (2) it is associated with the characteristicdental abnormalities already described, (3) itpreferentially affects the oldest living child in afamily, and (4) there is often a history of syphilis inother siblings. Hutchinson's conclusion that chronicinterstitial keratitis was due to syphilis was a new

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idea, and for many years was not generally accepted.It was contradicted by many ophthalmologists andpaediatricians, and as late as 1896, at a meeting oftheBerlin Medical Society, the majority spoke againstit.'

In 1858 Hutchinson read a paper at the annualmeeting of the British Medical Association in Edin-burgh on the recognition of "inherited syphilis" inadults, which was later published.'2 It gives a vividdescription of a patient with late congenital syphilis.There is a "bad, pale, earthy complexion, a thick andpitted skin, a sunk and flattened nose, and scars of oldfissures about the angles of the mouth ... the nails arestumpy and broken . . . and the hair is thin and dry."He goes on to describe the state of the teeth, and thefrequent destruction of the palate. Acute iritis canoccur in early congenital syphilis, although it isuncommon, but as the subject advances from child-hood to early adult life he becomes liable to inter-stitial keratitis. Having mentioned some rare signs ofthe disease, the author concludes that "it is not by anyone symptom that the diagnosis of hereditary syphiliscan ever be supported but by the careful estimation oftheentire group." Cases in which deafness was associatedwith congenital syphilis were mentioned in passing inseveral of Hutchinson's early works, but it wasevidently difficult to determine the structuresattacked, or indeed whether syphilis was reallyresponsible for the deafness. In 1861 Hutchinson andHughlings Jackson wrote a paper on the subject.'3 Of100 cases ofcongenital syphilis collected by Hutchin-son ten were deaf, but of these nine became so afterotorrhoea. The authors then describe a girl of 15 withunequivocal late congenital syphilis who developedbilateral tinnitus followed by total deafness, withoutantecedent otorrhoea. By 1863, when he publishedhis Clinical Memoir,'4 Hutchinson felt able to charac-terise deafness due to congenital syphilis more fully.It affects older children or adults and is eventuallybilateral. Although there may be a history of otor-rhoea, this is usually "trivial". He thought that thedeafness is due to disease of the auditory nerve orlabyrinth, and the prognosis for hearing is "veryunfavourable". Thus the eponymous triad was com-plete. D'Arcy Power, writing in 1926,1' stated thathardly anything had been added to our knowledge ofthese subjects since Hutchinson described them, andthis remains true today.Hutchinson was recognised as the foremost British

syphilologist of the 19th century. He used to say thathe was able to learn so much about the diseasebecause many of his patients belonged to the"educated classes"-they could give good histories,and it was possible to keep them under surveillancefor many years. In 1879 he gave a notable address tothe Lancashire and Cheshire branch of the BritishMedical Association on "Syphilis as an Imitator".'6He described how it could mimic not only a mul-

titude of skin diseases but eye conditions such asuveitis and retinitis pigmentosa and a variety ofneurological disorders. Hutchinson's ideas on thissubject influenced the teaching of generations ofmedical students, who were constantly warned neverto forget syphilis in differential diagnosis. With thedecline of syphilis this, advice has been largelyforgotten, but it may have to be re-learned one day.

In the 19th century, smallpox vaccination inEngland was mostly performned with vesicle fluidfrom a recently vaccinated child (called a "vaccin-ifer"). Arm to arm vaccination was a simple way ofmaintaining a source of virus, but in many Europeancountries was recognised as carrying a serious risk oftransmitting other infections, particularly syphilis.Hutchinson published a personal series of23 cases inwhich primary chancres had developed on the arm ofthe recipient,'7 giving for each case details of thevaccinifer, the vaccinifer's parents and the subjectsvaccinated from the same source; the amount ofworkin tracing and examining all these people must havebeen enormous. He proposed measures to prevent orat least minimise these infections, such as not using asvaccinifer a child who was unknown to the vaccin-ator, or a first-born child, but he was accused ofbeing"antivaccination". Great Britain was one of the lastcountries to adopt calf lymph for vaccination; thiswas initiated in 1881, but arm to arm vaccination wasnot banned until 1898.18Hutchinson believed that syphilis was a "specific

fever", differing from the others only by the prolon-ged intervals between its various stages. Althoughnever a laboratory worker himself, he was aware ofdiscoveries in the new science of bacteriology. Writ-ing in 1887, he stated: "[Syphilis] depends on a livingand specific microbe, and it is contagious or transmissibleonly so long as that microbe retains its vitality...considering the successes which the study of bacteria hasattained in late years, it is certainly surprising that no-one hasyet been able to demonstrate the specific microbeof syphilis."''9 This was written 18 years beforeTreponema pallidum was discovered by Schaudinnand HofEmann. While he did not exactly pooh-poohit, Hutchinson's reception of one of the most impor-tant events in the history of syphilology seems rathermuted: "We had but little to learn from the oculardemonstration of the parasite and the giving to it of aname. To those minds incapable of accepting as prac-tically proven anything not actually demonstrated, thediscovery is invaluable; and, at the same time, itfurnishes an important weapon of defence to those whofor themselves had long ago accepted its conclusions".2'Crissey and Parish2' have the impression that "herather resented the discovery of bacteria-he foundthem inconvenient and difficult tofit into his set ideas onpathogenesis." It had become apparent that T.pallidum was too large an organism to be conveyed byspermatozoa, as would be required for the direct

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infection of the foetus by its father. Paternal trans-mission had been believed by generations of ven-ereologists, including Hutchinson: " There is no doubtwhatever that syphilis may be inheritedfrom one or theother parent, but in English practice the great majorityof cases of infantile syphilis are ofpaternal inheritance.Comparatively seldom do we meet with cases in whichthe mother was the one who sufferedfrom syphilis."' Hewas reluctant to abandon on bacteriological groundsa concept which he regarded as a clinical fact: "Welisten with much respect to the arguments which thosewho propound these views urge in their support, butdecline to accord them that infallibility which they seemdesirous to claim". He struggled to explain how asyphilitic father and a "normal" mother could have achild with congenital syphilis, but to discover thetruth a serological test for syphilis was needed.Details of the "Wassermann test" were published in1906, but it came too late for Hutchinson; in thesecond edition ofhis book on syphilis he dwelt on thechances of error and on the need for more research,but within a few years ofhis death it had been shownthat the mothers of children with congenital syphiliswere infected,23 and the idea ofpaternal transmissionwas abandoned.Hutchinson advocated mercury for the treatment

of early syphilis; unlike many of his contemporaries,he believed that treatment should be startedimmediately the diagnosis was made and not deferreduntil there was evidence of secondary syphilis. Hefavoured continuous administration of "grey pow-der" (metallic mercury ground with chalk), in a doselow enough to avoid ptyalism, for a minimum of sixmonths. Inunction ofmercury ointment was restric-ted to special cases such as children with congenitalsyphilis. Iodides, often combined with mercury,were used for the treatment of late syphilis. Here, hewould continue treatment for two years and if therehad been no "reminders" he would regard the patientas cured. Many of his colleagues thought that hisviews on the prognosis of syphilis treated in this waywere too optimistic, but he would not shift hisground; as always, he referred to his clinicalexperience: "My own years having been unusuallyprolonged... I have been able to secure a kind ofexperience which falls to the lot of butfew. I have seenmany of those whom in their early vigour I had treatedfor syphilis, now in honouredgrey hairs and apt to boastof their grandchildren."` Organic arsenicals wereintroduced by Ehrlich in 1906, but Hutchinson wasdoubtful of their value. He regarded arsenic as toxicand potentially oncogenic, and continued to usemercury and iodides.

HUTCHINSON THE MANLike John Hunter, Hutchinson was a naturalist whotook to medicine. He was interested in all naturalphenomena and was gifted with great powers of

application and a remarkable memory. Althoughbrought up a Quaker, as an adult he developed adifferent set of beliefs based on scientific ideas,particularly the doctrine of evolution. He believedthat knowledge has the power to raise the standardsof life for both the individual and society in general.The accumulation of facts is thus not only essentialbut a duty.2 Throughout his long life he did this byreading and by his own observations; even after hispartial retirement from medicine he continued tostudy natural history at Haslemere. Nothing escapedhim, and he was an inveterate notetaker. Hirschbergrecorded a visit to Hutchinson's home: "While wetook a walk over the fields and hills he frequentlyremoved a large memorandum book from his coat andwrote notes. One was as follows: 'Haslemere, May1877. Dr Hirschbergfrom Berlin states that compulsorymilitary service represents an important aid in theeducation of the people.' '24

Hutchinson's phenomenal memory made himdevastating at clinical meetings. The presenter of anovel or unusual case could easily be told thatHutchinson had seen a similar or identical conditionperhaps 20 years ago, and he would produce detailsfrom his collection of case notes.25 He became recog-nised as a medical and surgical referee for thediagnosis ofobscure complaints and rare diseases. Hehad a logical mind, and was able to integrate apparen-tly disparate facts into a coherent whole, as wasshown in his studies ofcongenital syphilis. Like someother Yorkshiremen Hutchinson had no sense ofhumour, and he could stubbornly cling to fallaciousopinions which should have been discarded long ago.Until the end of his life he believed that leprosy wascaused by eating bad fish and nothing would shakehim, not even Hansen's discovery of the leprosybacillus.26Hutchinson regarded himself as a surgeon; in the

operating theatre he was safe, if not particularly deftor rapid.27 Although he often wrote on surgicalsubjects such as operative technique and Lister'santiseptic method, other branches ofmedicine-par-ticularly ophthalmology and dermatology-were ofequal importance to him. He had been called "theUniversal Specialist", and perhaps it was inevitablethat his interests should converge in his work oncongenital syphilis. It is by this work, a dozen papersin an enormous total output, that Hutchinson isremembered today. He was a natural teacher. "Nextto the ambition to discover something new", he said,"the desire to spread knowledge is the noblest aspirationof the human mind." Treves, a younger consultantsurgeon at the London Hospital, wrote that "Hutch-inson attracted a larger number of students to hisdemonstrations than any other surgeon of his time inLondon ... He was an admirable speaker. He was noteloquent... but adopted a slow, quiet, solemn andmodest manner which was very impressive."` Medical

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students were an unruly group in those days, butHutchinson was greatly respected by his large foll-owing. He was considered to be infallible, and hisstudents would pack the lecture theatre to "hear whatJonathan would say."Hutchinson took life very seriously. To a contem-

porary he was "not exactly genial or very approach-able, being originally ofa shy nature ... yet there was amagnetism about him, the magnetism of a man whollypossessedfor the searchfor truth.' He worked contin-uously and almost never took a holiday, his visitsabroad being for consultation with colleagues. Hewas never in a hurry, and seemingly never tired.Nettleship, the gentle and retiring ophthalmologistwho succeeded him at Moorfields, wrote: "Few couldsee much ofHutchinson withoutfeeling the attraction ofhis great power and balanced enthusiasm. It was

perhaps the quality, fullness and comprehensiveness ofhis information, coupled with his abiding sense that itwas his duty to teach what he was continuously learning,that gave to his personality an almost fearsomecharm.""` Like his friend Fournier, Hutchinson waswholly a clinician. "It is necessary to confess that Ihavefor manyyears worked but little in the post mortemroom and still less in the laboratory."5 His gifts lay inpatient observation leading to the accumulation andcollation of facts. Osler regarded him as "the greatestgeneralised specialist of his generation, the last of thepolymaths.""

Hutchinson wished his epitaph to be: "a man ofhope and forward-looking mind." He remained astudent and a seeker after truth to the end of his life,and the last glimpse we have ofhim is at Haslemere, afew days before his death. It was too cold to go out,and as he sat by the fire he was studying the logs in hiswood basket, comparing the tumours of trees withthose ofhumans-a naturalist to the last.

1 Godlee R. Sir Jonathan Hutchinson FRS, 1828-1913. Br JOphthalmol 1925;9:257-81.

2 Wales AE. Sir Jonathan Hutchinson. Br i Venereal Dis1963;39:67-86.

3 Hutchinson H. Jonathan Hutchinson: Life and Letters.London: Heinemann 1946:20-32.

4 Johnston Abraham J. In: Hutchinson H. Jonathan Hutchin-son, Life and Letters. London: Heinemann 1946:i-iv.

5 Klauder JV. Sir Jonathan Hutchinson. Med Life1934;41:313-27.

6 Garrison FH. An Introduction to the History ofMedicine, 4thed. Philadelphia and London: WB Saunders Co 1929:597.

7 Hutchinson J. Syphilis. London: Cassell & Co 1887.8 Hutchinson J. Syphilis. new ed. London: Cassell & Co 1909.9 Hutchinson J. Report on the effects of infantile syphilis in

marring the development of the teeth. Trans Pathol Soc1957;9:449-55.

10 Hutchinson J. A report on malformation of the teeth, asindicative'of diathesis. Trans Pathol Soc 1859;1O:287-99.

11 Hutchinson J. On the different forms of inflammation of theeye consequent on inherited syphilis. Ophth Hosp Rep andJ Royal Lond Ophth Hosp 1859;i:244;ii:54-105,258-83.12.

12 Hutchinson J. One the means of recognising the subjects ofinherited syphilis in adult life. Med Times Gazette; 11 Sept1858:264-5.

13 Hutchinson J, Hughlings Jackson J. Cases of deafnessassociated with syphilis. Med Times Gazette 1861;ii:530-1.

14 Hutchinson J. A Clinical Memoir on Certain Diseases of theEye and Ear Consequent on Inherited Syphilis. London;Churchill 1863:174-7.

15 Power, D'Arcy. Hutchinson's triad. Br J Surg 1926;14:1-8.16 Hutchinson J. An Address on syphilis as an imitator. Br Med

J 1879;i:499-501, 541-2.17 Hutchinson J. Vaccination-syphilis. Illustrations of Clinical

Surgery vol 1. London; J and A Churchill 1877:113-40.18 Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID.

Smallpox and its Eradication. Geneva;WHO 1988:264-7.19 Hutchinson J. op cit (7): Introduction.20 Hutchinson J. op cit (8): Introduction.21 Crissey JT, Parish LC. The Dermatology and Syphilology of

the Nineteenth Century. New York; Praeger Publishers1981:217-30.

22 Hutchinson J. The transmission of syphilis to the thirdgeneration. Med Press Circ 1906;82:110-2.

23 Craig CF. The Wassermann Test. London; Henry Kimpton1918:144-6.

24 Hirschberg J. Jonathan Hutchinson in Geschichte derAugenheilkunde (Englands Augenarzte). Handbuch derges Augenheil. Graefe-Saemisch-Hess 1914;14:234.

25 Obituary. Sir Jonathan Hutchinson FRCS FRS. Br Med J1913;i:1398-401.

26 Hutchinson J. On Leprosy and Fish-eating: a Statement ofFacts and Explanations. London; Constable 1906.

27 Nettleship E. Sir Jonathan Hutchinson FRS, LLD, FRCS.Opthalmol Rev 1913;32:225-30.

28 Treves F. Quoted by Hutchinson H, op cit (3): 77.29 Fox RH. The late Sir Jonathan Hutchinson (letter). Lancet

1913;ii:43-4.30 Nettleship E. Sir Jonathan Hutchinson. Opthalmoscope

1913;11:504-5.31 Cushing GH. Life of Sir William Osler. Oxford; Clarendon

Press 1925;i1:233.

Accepted for publication 30 May 1990.

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