Karl Holubar, MD FRCP,
Institute for the History of Medicine, University of Vienna, Vienna, Austria
An unpublished lecture given at the International Society of Dermatopathology Annual Meeting, , Orlando, FL, USA, 26 February 1998.
Ladies and Gentlemen
I am supposed to speak to you on the history of European dermatopathology, a story that could start off at several points in time between Hippocrates and dermatopathology board certification in recent years.
Firstly, when speaking on the history of European dermato-pathology in its early phases this entails speaking on the history of world dermatopathology. This may be said without undue eurocentrism.
Secondly, due to the fact that sometime ago an excellent and extensive review appeared in the Journal of this society by Petra Milde and Bernie Ackerman in 17 successive articles, a plethora of detailed information is at hand for everybody. Therefore much of what I could possibly tell you, you know by yourselves already. I cannot do better than Milde and Ackerman, I can do it only differently. Consequently, I will focus more on the early period of development, i.e. up to the fin-de-siècle period and the turn of the last century and I will pay particular emphasis on the role of Vienna dermatopathology. This because at one point of time during mid last century it became the driving force on the world scene notwithstanding the fact that over the last two centuries it was German dermatopathology which developed the greatest momentum in the field.
Thirdly, dermatopathology, in the old days is synonym to dermato-anatomy and dermato-pathology.
Skin has been in focus for reasons of attraction, blemishes, color and for reasons of punishment since time immemorial. Homer used the word o crwV (ho chros ), crwtoV (chrotos) rather than the more familiar to derma (derma) . The former alludes to chroma, color, more than the latter, the root of which is der, an Indo-European root also signifying to flay, i.e. carrying the connotation of pain. Preparing the hide of an animal as much as flaying provided some insight into what the skin is like in its texture, in anatomical terms, and allowed to glean about the skin´s extraordinary resilience and strength. „Derma" remained with us since Hippocrates.
Skin as an outer envelope of the body did not draw enough attention of researchers to its microstructure through many centuries, probably also by virtue of its two-dimensional character as compared to the socalled parenchymatous organs, viz. liver, heart, kidney, brain etc. Only the systematic exploration of the human anatomy by Vesalius and his successors paved the way for more detailed observations. Mercurialis in 1572 still speaks of the purpose of skin to hold everything together, thereby repeating the teachings of Hippocrates and Galen, and further, cumque nullam aliam actionem utilem habeat, sed solum excrementorum sit receptaculum. Haffenreffer´s writings in 1630 echo the same ideas and repeat the ancient partition of skin into four parts, partes eius sunt quattuor, epidermis, cutis vera, pinguedo and membrana carnosa.
Much more into details of skin anatomy leads us the ten-page introduction of Daniel Turner´s treatise (mostly the 1736 edition is quoted because the first editions of 1714 and 1717 are quite rare). I just want to mention that he described what may be interpreted as the Auspitz phenomenon, long before Hebra and Devergie (page iv, 1736 ed.). Speaking about a patient seen recently, he wrote „on the inside of whose Knee a large Lichen, or impetiginous Eruption, was seated, accompanied with great itching: Whence, upon rubbing, a Scale would throw off, and a fresh one regenerate in few Days. For Curiosity sake, I raised one of these, near the Compass of an half Crown; in one part it adhered to that subjacent, and forcing the same off with the Edge of my Spatula, several small specks of Blood appeared underneath..."
Other authors of the settecento, particularly Lorry in his 700-page volume (1777) add admirably detailed studies of the aspect of healthy or sick skin, much of which reads as if it were observed with a magnifying lens and not a microscope. Skin was called by Lorry (Annaeus-Charles, 1726-1783) an organ for the first time (caput primum, p.2). But there were no biopsies made yet, no microscopic diagnoses performed; this was still to come.
"Dermologie" and "dermatologia" first surfaced in 1764 & 1777, „dermato-pathologia" in 1792.
Often a (sub)discipline is already in the process of development and no term for it has been agreed upon, sometimes however, the term has been coined already, but the (sub)discipline had yet to grow and eventually be named such. Orthopaedics and dermatopathology are examples of the latter type of development. Nicolas Andry coined the term in 1741, well over a century before the clinical specialty of orthopaedics started to emerge; „dermatopathology" was coined by Henry Seguin Jackson in 1792, about onehundred years before the days of P G Unna (1850-1929), a point of time when we may justifiedly speak of such a field existing in medicine.
Jackson wrote in his introduction
before I enter upon a branch of medicine, too long and too often considered as of chirurgical importance only; a branch, which I have seriously undertaken to throw some light upon....and which perhaps founded on the principle of an arterio-muscular pathology, could be established on the plan of Sauvages´ nosologia methodica; might be properly enough denominated cachexiaelogia dermatica et epidermatica vel dermato-pathologia;..
What we should focus on, is probably the remark „arterio-muscular pathology", because this phrasing alludes to microanatomy of skin, of vessels, muscles, connective tissue and their changes.
The terms „dermologie" and „dermatologia" as quoted above, at the time referred not only to skin but also to other membranes of the body, in anatomy and pathology alike.
The star under the anatomists of the turn of the 18th century, Marie-François-Xavier Bichat 1771-1802 extensively covers anatomy of dermis and epidermis, describes the influence of cold, heat, air, water, acids, etc. on both, but still does not attempt to make anything like a biopsy of various diseases, does not separate dermatology as an area of medicine in which skin diseases are dealt with. He does however comment on aetiology of skin lesions and differentiates between diseases which penetrate the intact epidermis (.e.g. the plague, in his view) and others which necessitate lesions (e.g. rabies) (page 692, vol 4). Later books present the same approach, extensively covering the anatomy of skin and its reaction to various stimuli: e.g. Conrad Heinrich Fuchs 1840, Louis-Victor D. Duchesne-Duparc 1859. Thereby many details of pathology as evident to the naked eye, are presented, worth being re-read by any student of dermatopathology; but still no systematic attempt is made to use the microscope.
We should be aware that there is a sloping transition from an era in which skin was conceived as a four-layered envelope of the body, a concept as old as medicine itself, into a period when any textbook of medicine was to be understood as one of anatomy, pathology and clinic. and covered in its general parts, an increasing number of anatomical and physiological details, of experimental data, and of anecdotal observations also on skin. The treatises of Turner at the beginning, and Bichat at the end of the 18th century are proof of it. Only very slowly authors started to correlate clinical conditions of skin with pathological processes, e.g. PFO Rayer in 1826, LA Struve in 1829 and F Hebra in 1845. Still there were no biopsies yet. If one looks to the national origin of the authors or the places where they resided, it is always London, Paris, Vienna and Berlin, like a merry-go-round. In 1844, Julius Rosenbaum (1807-1874) in his short but remarkable treatise, dated in memory of Edward Jenner on the anniversary of his death, i.e. the 26th of January, spoke the first time of "Dermatopathologen", dermatopathologists. With regard to the performance of microscopic studies he quoted the Frenchman Gilbert Breschet (1794-1845), in 1839
Si on parvenait à localiser les maladies de la peau, et nous en concevons la possibilité, c'est-à-dire si l'on pouvait, prenant pour guide l'anatomie, indiquer le siège de chaque maladie cutanée, ce serait un veritable progrès pour la médecine et pour l'anatomie pathologique.
Rosenbaum gave a well documented summary of late 18th and early 19th century essays on the subject of skin pathlogy and physiology, worth looking into for any student of the historical depths of our field. In the perspective of today, the shortcoming of his text is the conclusion that the Plenck-Willan system of morphological diagnosis is unsuited as a basis to explain skin pathology.
Bärensprung and Gustav Simon, so well described in the Milde-Ackerman articles must be seen as direct successors to this tradition in Berlin. (I will not be repetitive in this regard and remain short).
Now we have reached the point of time when we really touch upon the core of the field: Gustav Simon (1810-1857) and Felix von Bärensprung (1822-1864) show up on the scene. In Berlin, in the physical and spiritual neighborhood of Virchow, no wonder. For the first time „anatomy" and „pathology" are displayed in the respective titles, and relate to diseases of the skin. Suffice it to say that both authors were aware of the other´s work.
Simon dated the preface of his book April 1st, 1848 and wrote (p. vi and vii) that much has been achieved by meticulous clinical description of diseases of the skin but now attention has to be given to the „Bestandtheile des so zusammengesetzten Hautorgans bei den einzelnen Krankheiten", that is, attention to the „parts of which the skin is composed in different diseases", with the aid of anatomo-pathological investigations. His treatise comprises of 400-odd pages and on some matters gives admirably detailed descriptions and sketches. His most important discovery, which made him an immortal of dermatopathology, was the discovery of the demodex folliculorum, the acne mite, in 1842. The coverage of the different areas of dermatopathology was very unbalanced, John Crissey, our grand master of dermato-history has remarked on that. We should keep in mind, however, that sections were made by hand, i.e. with a knife and not by microtome, and there were no stains yet. Especially the epidermal hypertrophies and neoplasms, the blisters of the skin and the parasites were well covered. Unfortunately, Simon died in his 47th year, otherwise we might have much more to comment about.
Felix Wilhelm von Bärensprung, a dozen years his junior, we may see as Simons physical and spiritual successor in the Charité in Berlin and in the emerging field. Bärensprung was personally acquainted with Rudolf Virchow. This acquaintance must have had a profound influence on his thinking, so much both gentlemen within a short time became bitter political enemies, Simon being an arch-conservative, Virchow an ardent republican.
Bärensprung´s book was more limited both in volume and in scope than was Simon´s. He extensively dealt with epidermal hyperplasias, corns, condylomata, verrucae, ichthyoses, naevi, comedones and cysts, hardly with inflammatory conditions The same reservations as to the technique of tissue processing hold for him of course. The arguments in the preface read remarkably similar to Simon´s. Skin diseases are chracterized by a great diversity of clinical lesions, but contrary to many other areas of the body where microscopic pathological investigations have been performed already, skin diseases were left behind, he said. With regard to acute inflammatory conditions he mentions the rapid decomposition of tissue post mortem. This again points not in the direction of systematic biopsies, planned or performed in vivo, and to the lack of proper fixation techniques. As in Simon´s oeuvre, illustrations are in the form of drawings still.
Bärensprung died age 42, of syphilis. His atlas was finished by Hebra who had provided the author with illustrations and was familiar with his plans. Ironically, the last years of Bärensprung´s life were filled with works on syphilis, probably due to the personal connections he had to Paris and Saint-Louis, especially to PLA Cazenave, and his familiarity with the works of Philippe Ricord and Léon Bassereau. Let me demonstrate to you some of the drawings in the books by Gustav Simon and Bärensprung. (I must say Gustav Simon because there was also an Oscar Simon, from Breslau, Wroclaw of today, only few years later upon whom I will not comment).
In Vienna there was a void in dermatology-to-be, early in the 19th century. Plenck had died 1807, a prolific writer to the last day, but nobody succeded him with any further forays into the field of skin diseases. Other attempts to start clinical teaching in this respect failed repeatedly and it took three decades till Carl Rokitansky 1804-1878, Carl Wedl 1815-1891 and Ferdinand Hebra 1816-1880 were around. Particularly Wedl, a general pathologist had special interest in pathology of the teeth and the skin. He had been in France, England and Germany and was familiar with the above developments. His pupils, Isidor Neumann 1832-1906, Salomon Stricker 1834-1898, Heinrich Auspitz 1834-1885, Moriz Kaposi 1837-1902, Salomon Ehrmann 1854-1926, became the torchbearers of developing dermatopathology in Vienna. Auspitz in particular, must be given credit, think only of the phenomenon bearing his name, even if he was not the first to observe it, but the first to introduce it into clinical use, think of acantholysis, which he discovered and named, think of Unna who became one of his and Stricker's pupils. Isidor Neumann published a detailed study on senile skin in 1869 (Über die senilen Veränderungen der Haut des Menschen) where he speaks of metamorphoses which occur only in some areas, e.g. in the face and neck, which increase with age, are present in various degrees beyond the 50th year, and are consequences of external influences e.g. temperature. He did not create a special term, e.g. Seemannshaut, sailors' skin or farmers' skin, but he meant exactly the same as Unna, who coined these terms 25 years later. Unna became the father of German dermatopathology; his textbook appeared in 1894.
Another offspring of the Wedl-Neumann-lineage of the Vienna School was the oeuvre of Salomon Ehrmann and Johann Fick, a book which had its first edition in 1905. Another was Joseph Kyrle (1880-1926), pupil of Neumann's successor Ernest Finger, who was the first to edit a histoBIOLOGY of skin, in 1925, foreshadowing the „Montagna Series" of the fifties. The Vienna lineage ended with Kyrle.
From the German School the followers of Unna´s were the books of Walter Friboes in 1920 and of Oscar Gans in 1925. Gans was also entrusted with the respective chapter on histopathology of the skin in the Jadassohn Handbook, printe in the early thirties.
In France, where so much was published in the early phases of the growth of dermatopathology, the slump in continuity of development occured in the second half of the 19th century. Eventually, it was Jean Darier 1856-1938, who became the father of modern dermatopathology in France. He and Jules Brocq elaborated their encyclopedic volumes and later the précis de dermatologie, in the first years of this century. Few people know that Darier´s parents were married in Vienna und he himself was born in Budapest and he was bilingual (French-German) from his childhood. At the time of the first world congress in Paris, in 1889, Darier began the series of dermatopathologic treatises with which he gained world fame.He started to see the biopsy as an indispensable tool for dermatologic diagnosis. After all, the term was created by his teacher Ernest Besnier (1831-1909) in 1879, saying that the new technique of biopsy, a word also created anew and proposed by Besnier, is of considerable importance in diagnosis. The magnificent éloge on Darier by Achille Civatte held on 9 March 1939, offers proof of all important details on his life. On account of the familiarity of all the above with the French and German languages, it is futile to speculate who was the leader and who the follower. Perhaps due to the strength of the optical and chemical industries (stains!) in Germany, the Germans had a slight edge over both the French and the Austrians.
JMH MacLeod 1870-1954 was the father of British dermatopathology, clearly a pupil of Unna's, his book entitled practical handbook of diseases of the skin, first printed in 1903. At the time, the center of gravity was on the continental side of the Channel without any doubt. Whimster, Rook, Wilkinson, were the followers.
On the world scene it was German dermatology which influenced American dermatology more than any other. With regard to dermatopathology, it was Oscar Gans who infused the latest knowledge into the U.S. when he delivered his series of lectures at Mayo in the late twenties (upon the invitation of Paul O'Leary who then headed the Section of Dermatology at Rochester, Minnesota). The overtures of the holocaust and the rising power of Hitler in Europe finally brought over to the United States the flower of dermatologists and investigators of the German School, e.g. Alexander and Walter Lever, Felix and Herman Pinkus, the Epsteins, Erich Urbach, Stephan Rothman, to name just a few. With this exodus and transfer of brain power, Europe lost its leading role to never again retain it.
US-American dermatopathology proper, started with the first edition of Walter Lever's book, 1949. The first words of the introduction are paradigmatic of the new style, even from the pen of a German: It is important to select a proper site for biopsy... no flowery formulations, no baroque retrospect, no, - Anglo-Saxon simplification triumphed, "Brevity is the soul of the wit", as Shakepseare said in Hamlet. Here we got it. A new era in new world was to be born.