American Dermatology in the Nineteenth Century

Introduction

For most of the nineteenth century, medicine in the United States lagged behind medicine in Europe. Not until the post-Civil War era beginning in the 1870s, when economic prosperity in the United States allowed for sponsored improvements in universities, did American medicine become increasingly state-of-the-art and begin to rival that of Europe. Dermatology, up until this point a strictly European creation, was born in the United States either in 1869 with the foundation of the New York Dermatological Society; in 1871, with the appointment of the first professor of dermatology at Harvard; or in 1876, with the inauguration of the American Dermatological Association.

Prior to these three events, however, two figures had pioneered dermatology in the United States, laying the groundwork for what would become one of the most vibrant dermatological communities in the world.

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Timeline of American Dermatology

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Early Pioneers

Noah Worcester (1812-1846)

The first dermatological pioneer in the United States was Noah Worcester, the author of the country's first textbook on dermatology. Worcester, the son of a schoolteacher, was born in New Hampshire. At fifteen, he went to Harvard and graduated five years later in 1832. Inspired to enter a career in medicine by Reuben Mussey, professor of medicine, Worcester enrolled at Dartmouth Medical School.

After receiving his doctorate in 1838, Worcester moved to Cincinnati to start a practice. In 1841, Worcester went to Paris to seek additional training from Laennec in percussion and auscultation. During his eight months in Paris, Worcester, who was fluent in French, learned about skin diseases from Gibert and Cazenave at the most outstanding institution for skin disease in the world at the time, Hôpital Saint-Louis. He returned to Ohio as the best trained man in percussion and auscultation in America and was soon appointed professor of physical diagnosis and pathology at the Medical College of Ohio.

Tragically, Worcester contracted tuberculosis, possibly from his wife who died of the disease a year after their marriage in 1841, and at only 34 years of age, he himself was dead.

Worcester's Synopsis (1845)

While in the throes of tuberculosis, Worcester managed to author a treatise on skin disease, the first of its kind in the United States. In 1845, he published A Synopsis of the Symptoms, Diagnosis and Treatment of the More Common and Important Diseases of the Skin. 300-page tome contains 62 colored illustrations which were reproductions from European atlases.

The preface and introduction of Synopsis reveal that Worcester was not a frontier pretender but a science-minded, rational thinker, influenced by the brilliant minds of Europe. He saw his publication as filling a void in knowledge about this much neglected branch of medicine, lamenting that in many of our medical institutions, not a single lecture is given upon the nature, classification, and treatment of this interesting class of diseases.

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Worcester formulated a classification system adapted from the French Willanists in which he established the dichotomy of wet and dry dermatoses. In his method, the most proficient path to a diagnosis involved three steps: first, ascertain whether the eruption was initially dry or moist; second, look for the elementary (primary) lesion; and third, if the elementary lesion cannot be determined, try to learn from the patient or friends the appearance of the disease at first.

Although Synopsis appeared in two editions (1845 and 1850) and was an excellent book, it did not circulate well, failing to get the attention of the East Coast physicians who looked to Europe for knowledge, not to a western outpost like Cleveland. Therefore, because of geography and Worcester's professional disconnection with his eastern brethren, his impact on the foundation of the specialty was minimal.

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Bulkley Dynasty

Henry Daggett Bulkley (1803-1872)

The second American dermatologist from the first half of the nineteenth century—one whose impact was actually felt—was Henry Daggett Bulkley. Born in Connecticut, Bulkley went to Yale College and Yale School of Medicine, from which he received his doctorate in 1830. Like Worcester, Bulkley went to Paris to increase his medical knowledge, gravitating toward a career in skin disease after time spent with Biett and Cazenave at Hôpital Saint-Louis. He returned to New York City and started to practice medicine in 1832.

In 1836, Bulkley established the Broome Street Infirmary for Diseases of the Skin, the first facility in the United States for the treatment of skin diseases, which, like the Carey Street Dispensary in London, served the indigent and underserved. infirmary was one of the few such facilities for skin disease in the world at the time. In the first nine days of the infirmary, 246 patients were seen, 231 of whom were suffering from strictly cutaneous complaints.

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At the clinic, Bulkley began lecturing on skin diseases in 1837, the first formal training for skin disease in the United States, training which focused on the essential teachings of the French school. Because of the single-handed efforts of Bulkley, New York held an exceptionally high place in the development of dermatology.

In 1846, Bulkley produced an American edition of Cazenave and Schedel's Abregé pratique des maladies de la peau, known as Manual of Diseases of the Skin. Unlike Worcester's textbook, Bulkley's Manual was a bestseller and the most influential textbook on dermatology in the middle of the nineteenth century.

Lucius Duncan Bulkley (1845-1928)

Henry's son Lucius Duncan Bulkley followed in his footsteps with a career in dermatology. Born in Manhattan, Lucius went to Yale for college and Columbia University for medical school. After graduating in 1866, he journeyed to Europe for dermatologic training, where he met Hebra and Neumann in Vienna and Hardy in Paris.

Upon his return to New York in 1872, Lucius translated Neumann's Lehrbuch der Hautkrankheiten. Within a few years of beginning his practice, he started the Archives of Dermatology, a quarterly journal. He was a founding member of the American Dermatological Association in 1876. In 1882, he founded the New York Skin and Cancer Hospital to deal with the multitude of patients with unappealing skin diseases who were not welcome at general hospitals. This was the site of the earliest postgraduate training in dermatology in the United States. This facility would become a famous location for advances in dermatology in the next century, and still thrives today as the Department of Dermatology of NYU.

Lucius Bulkley was the first to describe pemphigoid gestationis. He was an outspoken advocate for specialization in medicine, writing that the science and practice of medicine was too vast for any one person to know all of it.

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Four Founders of American Dermatology

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James Clarke White (1833-1916)

Dermatology in the United States was officially recognized as a legitimate specialty in 1871 when James Clarke White of Maine, a graduate of Harvard College and the Harvard-affiliated Tremont Medical School, was appointed as Harvard's—and America's—first professor of dermatology.

After graduating from medical school in 1856, White went to the most famous medical school in the world, the one in Vienna, seeking higher learning to increase his competence to practice medicine. There he met the glorious triumvirate and later noted about Hebra:

He was an admirable teacher and no one could forget his clear and convincing method of presenting a subject, and the exhaustive use of abundant clinical material for instruction in diagnosis and therapeutics. It was the perfect system of object teaching given by a master of the keenest observation.

Hebra influenced White to embark on a career in dermatology. White returned to Boston in 1857 and opened a general medical practice. In 1860, he opened, along with Benjamin Joy Jeffries, the Eliot Street clinic in Boston that offered only dermatological and ophthalmological services. By 1863, White's restriction of his practice to dermatology was complete.

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In addition to his promotion of dermatology as a legitimate specialty, White advocated reform in medical education in general, which had been at the time a proprietary venture, benefitting teachers more than students who bought tickets to attend lectures. His campaign succeeded with the implementation of a three-year nine-month course with written exams and stricter entrance requirements. By the turn of the century, in large part because of White's efforts, medical education programs—now four years long—improved in the United States and began to resemble the programs in the fine medical schools of Europe.

White was a prolific writer during his tenure as professor of dermatology. His most significant work was Dermatitis Venenata: An Account of the Action of External Irritants upon the Skin (1887), the first complete work on contact dermatitis. James Clarke White was also the White of Darier-White disease, having described independently the condition known as keratosis follicularis a few months prior to Darier's announcement.

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Henry Granger Piffard (1842-1910)

If White was the master of dermatology in Boston, Henry Granger Piffard was at the same time the master of New York City after Henry Bulkley's death in 1872. Piffard was born in Piffard, a hamlet in western New York named after his ancestors who settled the area. He graduated from the University of the City of New York (now NYU) in 1862 and from the College of Physicians and Surgeons (now Columbia) in 1864.

Like Worcester, White, and Bulkley before him, Piffard went to Europe for postgraduate work in dermatology. He spent considerable time in Paris and Vienna, but most of his time was spent at the University College Hospital in London, under the mentorship of Tilbury Fox. It was there that Piffard met another Fox of no relation, George Henry Fox of New York.

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Piffard's energy, combined with his brilliant mind, earned him the nickname Brains and brought him international recognition. Piffard had diverse interests and countless hobbies, including ballistics, and he was a tinkerer and inventor. His photogenic (light-generating) pistol cartridges, used to facilitate photography of skin diseases, were among his most fascinating inventions. When exploded by a pistol, the cartridges would emit a magnesium light of great intensity, but momentary duration, allowing for instantaneous photography at night. One can only imagine the reaction of Piffard's patients as he pulled out his pistol to take a photo of their rashes.

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George Henry Fox (1846-1937)

Piffard's friend and colleague, George Henry Fox, was another important figure in early American dermatology. son of a veteran of the War of 1812 and the grandson of a veteran of the Revolutionary War, Fox was born in Saratoga County, New York. His undergraduate coursework was interrupted by his volunteering for the Civil War, with his service lasting two years.

He went to medical school at the University of Pennsylvania and received his MD in 1869. In 1870, Fox went across the Atlantic for dermatology training where he met Virchow in Berlin; Rokitansky, Hebra, and Neumann in Vienna; Bazin, Hardy, and Vidal in Paris; and Tilbury Fox in London. Fellow students in London included Henry Piffard, Radcliffe Crocker, and the young Canadian William Osler.

Fox returned to the United States in 1873 and joined the New York Dermatological Society. He was a founding member of the American Dermatological Association in 1876. Fox collected photographs of his patient's skin conditions, and by the end of the decade, he had a full assortment of pictures to create an atlas of dermatology.

Fox's Photographic Revolution

Fox was offered professorships in dermatology and settled into that role at the College of Physicians and Surgeons (now Columbia University) in 1880, where he remained for 26 years. In 1902, he described the underarm rash of young women known today as Fox-Fordyce disease, along with his colleague John Addison Fordyce.

George Henry Fox's long life spanned the entirety of dermatology's beginnings in the United States. His son, Howard Fox, was the founder and first president of the American Academy of Dermatology (1938) and a giant of twentieth-century dermatology.

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Louis Adolphus Duhring (1845-1913)

The greatest dermatologist of nineteenth-century America spent his career in Philadelphia. Louis Adolphus Duhring was born in Philadelphia, the son of a merchant who emigrated from Germany, and by hard work and discerning acuity, became one of the ten richest men in Philadelphia.

The young Duhring attended the University of Pennsylvania in 1861 but left in 1863 for a 90-day stint in the 32nd Regiment of Pennsylvania Volunteers when the southern portion of Pennsylvania was threatened by the Confederates. He received his doctorate in 1867. His first position after medical school was an internship at the Blockley Almshouse, a local hospital for the poor.

Blockley was for Duhring what Hôpital Saint-Louis was for Alibert, and what the AKH was for Hebra: a fertile ground for exposure to skin diseases and the development of ideas in a brilliant young physician's mind.

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Duhring went to Europe in 1868 where he spent two years—never vacationing, always working to receive additional training in dermatology. His first stop was Vienna where he met the master Hebra, who was so impressed with the young Duhring that he allowed him to accompany him on his dermatologic rounds. Duhring also went to Berlin, Paris, and London, and he studied Eastern diseases in Constantinople and leprosy in Norway.

Duhring's Greatest Contribution

Duhring's greatest contribution to the history of dermatology was not his textbook; it was the 18 articles he penned from 1884 to 1891 on the topic of dermatitis herpetiformis, a skin condition about which there was much confusion and debate at the time. Also known as Duhring's disease, dermatitis herpetiformis is an autoimmune blistering disease and one of the itchiest and most miserable skin conditions. Its association with gluten insensitivity and celiac disease was not known at the time.

Duhring posited that dermatitis herpetiformis could have papular, vesicular, and bullous presentations but that these presentations were just different forms of the same disease, not distinctly different entities. His opponents, led by Moriz Kaposi, argued that these forms were distinctly different diseases. Duhring's convincing argument, laid out over seven years of erudite scholarship, overcame the opposition, and the varied clinical presentation of dermatitis herpetiformis has been distinctly recognizable ever since.

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Personal Tragedy and Character

Duhring was a complex man. Around the time young Duhring left Blockley for Europe, he suffered a traumatic life event: his sweetheart and likely future wife died. Duhring underwent a complete change in temperament, from cheerful and sociable to the point that his colleague and friend, Van Harlingen, noted: I cannot recall any occasion when I have seen him smile or heard him laugh. His absorption in his work was absolute and complete.

Duhring remained a bachelor and a loner for the rest of his life, although he did enjoy on occasion a social life with a few intimate friends. An accomplished musician, he and his fellow interns at Blockley played in the Blockley Brass Sextette. In 1885, he developed neurasthenia (nervous exhaustion), which culminated in a nervous breakdown, causing five years of absence from his full-time duties.

Duhring resigned from all employment in 1910 and died in 1913, with an estate worth 1.25 million dollars, all of which he bequeathed to the University of Pennsylvania.

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Scope of Dermatology: Duhring's 1893 Address

In 1893, Duhring delivered a brilliant speech on The Scope of Dermatology at the 44th Annual Meeting of the American Medical Association. This address gives us the last word on dermatology in the nineteenth century and a fitting conclusion to the story of the origins of the specialty. following excerpts effectively summarize the state of dermatology at the end of the nineteenth century:

On how skin diseases were viewed throughout history:

Willan, especially, was an eminent general physician as well as a distinguished dermatologist. But the important questions of etiology and pathology were then for most diseases not at all understood. Affections of the skin were regarded mainly objectively, and were studied much as a model or a picture might be viewed. This method is in no way to be criticized, so far as it goes, but by itself and without the assistance of general pathology, it is far too restricted to meet the requirements of existing knowledge.

On the real value of dermatology:

The great value and importance of dermatology is that it should teach us to know the nature of various processes, as they affect not only the skin but the whole economy. Dermatology should be for the physician as a key with which the skin is made to reveal, in many instances at least, the nature of the process at work in the general system or in special organs, which without this aid might remain obscure.

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American Dermatology Comes of Age

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1907 International Congress

In 1907, speaking at the Sixth International Congress of Dermatology, held for the first time in New York, James Clarke White noted the advance of American dermatology to the point of equality with its international counterparts:

We have one hundred and twenty-five professors and teachers of dermatology. We have large and well equipped special laboratories and clinics, perhaps the largest and most magnificent medical school building in the world, and we have produced some admirable and exhaustive treatises and countless papers on dermatology. Most of our teachers have had the advantage of studying our subject with the most distinguished teachers of Europe, living and dead. You see, therefore, that you should find us very much the same as yourselves, and that we meet as equals.

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Summary

The four main founders of American dermatology were James Clarke White, Henry Piffard, George Henry Fox, and Louis Adolphus Duhring, with Duhring the greatest product of American dermatology in the nineteenth century. Noah Worcester and Henry Daggett Bulkley pioneered dermatology in the United States before it was formalized into a specialty, and these men cannot be forgotten.

By the end of the nineteenth century, American dermatology had achieved parity with its European counterparts. era of needing to travel to Vienna or Paris for proper training was ending, as American institutions could now offer world-class dermatological education. specialty was ready for the therapeutic revolutions of the twentieth century.

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Next Chapter: The 20th Century: Therapeutic Revolution