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We celebrate the fiftieth anniversary of an event that helped to change descriptive, morphologic dermatology into the experimental, investigative discipline that is so evident in the high-quality scientific papers we are privileged to hear today.
These symposia were the creation of a single, singular man, William Montagna, an extraordinary scholar, teacher, and scientist, whose life passion was skin, arguably the most fascinating organ of the body. He was not a dermatologist as many suppose but a Ph.D. in biology whose far-ranging studies of mammalian skin brought him the honor of being elected President of the Society of Investigative Dermatology, previously restricted to M.D.s.
He came upon the scene in mid-century, a watershed time in biomedical science, corresponding to the founding of the National Institutes of Health in Bethesda, Maryland.
This epochal time also marked the end of a long period that I have called paleodermatology, dominated by European masters mainly interested in classification and clinical descriptions of dermatologic diseases. Mid-century, about 10 y after the founding of the Society of Investigative Dermatology, marked the beginning of neodermatology, based on Galilean principles of experimental science, requiring evidentiary proof, replacing the pontifical pronouncements of the professoriate.
Bill Montagna came to this country at age 13 from Calabria, Italy, malnourished, skinny, and half-starved, part of a huge wave of desperately poor immigrants seeking a better life. He did not have a word of English, a language in which he later became a master of literary style and grandiose prose.
Through talent and hard work he became in early adulthood an associate professor of biology at Brown University, in Providence, Rhode Island. In those days, the term biology encompassed a great range of subjects, relating to all living things, whose practitioners were generally known as natural philosophers. Biologists could roam anywhere and Montagna did just that. His main interests were anatomy, ornithology, botany, and zoology, in all of which he had extensive knowledge, which spilled out of him so generously and spontaneously that he was widely regarded as a genius. To take a walk in the woods with Montagna was a fantastic, delightful experience. He could identify every bird within a half-mile merely by watching its movements. Every few feet he spotted an interesting plant that he could instantly name by its Latin genus and species. He saw and appreciated the majestic beauty of all living things.
It was in the field of anatomy that he reached lofty heights, bringing him international fame but very little money. His salary at Brown was $ 4000 annually, a sum that was supposed to enable him to raise four children! Here too his choice was exemplary, taking the vows of poverty in order to pursue his scientific passions. His first connection with medicine was in teaching cat anatomy to medical students.
His early descriptions of the hair cycle in murine skin are masterpieces of clarity, beauty, and penetrating observations, matching the great observations of his Italian forebears – Malpighi, Corti, Golgi, Scarpa, and others. Later, Montagna's uncontrollable curiosity expanded into disquisitions on philosophy, music, and poetry; he even wrote a book on anthropology! His immense knowledge on so many subjects would, in former times, have earned him the sobriquet of a “polymath”, a term applied to formidable scholarly minds, like a Plutarch or a Luther.
The story of Montagna's liaison with the dermatologic community is illustrative of his capacity to exert great influence in fields beyond his own expertise. He was a great proponent of interdisciplinary research. His lectures at Brown University on ornithology and anatomy were extremely popular, always oversubscribed by captivated students. Bill was an inspiring lecturer, who could simultaneously educate and entertain, using theatrical gifts descended from Italian grand opera. His hands were always in dramatic motion accompanied by facial expressions that reflected his deep love of learning and his joy in sharing that passion with his students. Love of gaining and sharing knowledge is of course the secret of all great teaching. He was superbly eloquent and a joy to listen to.
The only way not to be affected by his enthusiastic sermons was to fall asleep, which his full-throated, stentorian oratory completely prevented. To describe the wonders of skin he thought that the term “perfect” was an understatement, requiring upgrading to the latinized term “plu-perfect”. As a good showman he effusively quoted timeless Latin aphorisms to show his direct descent from the Roman classicists.
He thought that modesty was hypocritical pretension and never allowed it to inhibit his theatrical performances.
When skin became his dominant interest, news of his dramatic lectures began to diffuse into the surrounding dermatologic community. A prominent dermatologist, Dr. Walter Lobitz, at the nearby Hitchcock Clinic in New Hampshire, soon began regularly putting in an appearance, spreading the word to east-coast dermatologists that a powerful educational force was elevating the study of skin to majestic new heights. A steady stream of research papers awakened dermatologists to new opportunities in the study of living anatomy. An informal liaison soon developed among young east-coast dermatology investigators and the Brown School, led by Montagna and Herman Chase. This was the crucible in which the Biology of the Skin Symposium was forged.
A few words about the first symposium in Providence will show how much things have changed, from pauperism to plushness. We stayed at the University Club at Brown University, at the handsome fee of $4.00 per night. A steak dinner, including one large pitcher of bathroom gin per table of six, cost $3.50. Bill supplied lush applies and lunch without cost to the participants who were thrilled to be founding members of these lively symposia, always called to order by Bill's shrill finger-whistling, which could be heard a mile away. A confirmed atheist, he always ended each day's presentation with a hearty “God Bless”!
Industry support soon came on line, providing funds for travel of speakers from all over the world. Mention should be made of Dr. Harvey Blank who persuaded Squibb, by whom he was employed at the time, to support the symposia with serious monies.
DERMATOLOGY AT MID-CENTURY
Academics who currently occupy chairs of dermatology will probably conclude that the following account is a classical example of Kligmania, the musings of a senescent brain whose reflections of the past bear little resemblance to reality. I submit nonetheless that no physician born after 1950 can imagine the primitive, pathetic state of dermatologic practice and knowledge that existed at the half-century mark.
The teachings of the leading professors were closer to the precepts of Galen than to modern science. Medieval empiricism, largely derived from the European masters of descriptive and morphologic dermatology, was standard fare. Knowledge descended in one direction from above to below, phrased in recondite, pedantic, ostentatious Greek–Roman terminology that delighted in such jaw-breaking, tongue-twisting descriptions as “perifolliculitis capitis abscedens et suffodians” (now happily condensed to “dissecting cellulitis of the scalp”). Nomenclature was supernumerary, dominated by small-minded splitters. For example, there were 12 subtypes of parapsoriasis and eight varieties of mycosis fungoides. Memorizers outnumbered thinkers by at least 10 to one!
As regards therapy, the emphasis was on the art of medicine, displayed by affable bedside manners and paternalistic style rather than anything resembling scientific knowledge. The emphasis on the art was unavoidable because the truth is there was damned little science!
Dermatologists were not considered doctors by mainstream medical men and were the butt of denigrating, disparaging jibes and jokes, in wide circulation among the laity as well as professionals. I offer up some choice examples.
As regards therapy, we had sulfur on the outside and arsenic on the inside.
If it's wet, dry it! If it's dry, wet it!
The skin game was a great commercial enterprise; skin patients never died and never got well.
Topical therapy was characterized by the three Ss:
The preparation must stink (like sulfur).
It must sting (like alcohol).
It must stain (like gentian violet).
You could always tell when you approached the dermatology ward. It was brightly colored by the brilliant red of Castellini's paint and the nose was assailed by the stench of sulfurous concoctions. Patients knew they were being treated through these sensory assaults.
The low esteem in which dermatology was universally held was clearly evidenced by the applicants for residency training. They came from the bottom of the class academically, vying with psychiatry for last place. The candidates often were quite frank about their choice of dermatology. They saw dermatology as an undemanding, comfortable way to make a nice living, without night calls, rare hospitalizations, and avoidance of the frantic pace of general practice. After all, most rashes get better in 3 wk or 21 d, regardless of one's expertise! Nice work if you could get it! There were only four M.D.–Ph.D.s in the whole country: Aron Lerner, Al Kligman, Tom Fitzpatrick, and Walter Shelley. The fact that all are alive and still functioning professionally is testimony to the epidemiologic evidence that dermatology is a life-extending specialty, with the lowest level of depression and suicide!
Things have changed dramatically. Nowadays, a residency in dermatology is the most sought after career choice, there being only three or four slots per 100 applicants in our most prestigious institutions. Only top students need apply! Incredibly, about a third of the applicants already possess an M.D. and a Ph.D.
My professor of dermatology was John Stokes, a world-renowned dermatologist, whose life work has been swept into the dustbin of history, leaving not a trace of his teachings or activities. He belonged to the old school of teaching by intimidation and humiliation, based on the belief that students were both lazy and resistant to enlightenment.
He was a bombastic, dogmatic, egotistical, eloquent showman who taught absolute nonsense. We were obliged to learn hundreds of obscure and exotic clinical “signs” that would point to a diagnosis (and of course exhibit one's immense knowledge of trivia). Patients were dichotomously characterized as “parasympathetic” or “sympathetic” types depending on their responses to a battery of psychologically oriented questions. None of us took this seriously. It was simply a proof that dermatology was a wayward specialty, lampooned and deplored by mainstream medicine. No one dared question the pronouncements of this famous man, who was thus enabled to live his entire life in a state of exalted ignorance.
Such a blatant demogogue would not be tolerated today. I am happy to state that his successor, Donald Pillsbury, represented the exact antithesis to his chief. He was not only a gentleman but was the first to understand the importance of investing in investigative dermatology, which has brought us to our current position of excellence in dermatologic science.
Will anyone believe what actually happened to me on the first day of my residency at Penn? I was assigned to assist Dr. Herman Beerman in the treatment of a patient with pemphigus. Dr. Beerman withdrew 50 ml of venous blood and injected it into the man's buttocks, which caused him to jump uncontrollably in great pain, requiring my young muscles to subdue him. Astounded by this performance, I asked Dr. Beerman what this was all about. He said: “This treatment is called autohemotherapy”. When I inquired about evidence of efficacy, he was quite puzzled by my skepticism, replying that autotherapy had been successfully employed in European centers for more than a century! Empirical practice was enough proof. Of course no one at the time ever heard of a double blind, randomized, controlled study. Statistics was mainly a sport for mathematicians.
The early meetings of the Society for Investigative Dermatology in the 1950s can be viewed benignly as quaint and even amusing. There was one small lecture hall accommodating perhaps 50 persons. There may have been two or three women (probably secretaries or mistresses) and no blacks. It is a proud and noteworthy feature of our specialty today that it is absolutely color blind, totally free of racism and gender bias. The organizers had great difficulty in finding enough presenters to take up a whole day! Compare that to today's huge meetings with six concomitant sessions, 1000 posters, and 10 applicants for each spot on plenary programs.
The early presentations were mainly clinical as there was no funding for basic research. What sometimes passed for science was really quite incredible. I remember a paper (unpublished) that claimed that plants could develop allergic contact dermatitis to pesticides and fungicides. I became oriented toward dispelling these preposterous beliefs, earning a reputation as an impudent iconoclast. One of my earliest works was a refutation of the claim by a well-known dermatologist that the serum of pemphigus patients inhibited the development of the cotyledons of beans. We not only suffered from a lack of knowledge but much worse was the fact that much of our knowledge was bad.
The investment in investigative dermatology has paid off handsomely. Dermatology is now in the forefront of biomedical science with distinguished representatives in every field, including genetics, molecular biology, immunology, epidemiology, biochemistry, etc. It is possible nowadays for a newcomer to attend a meeting of the Society for Investigative Dermatology without becoming aware that the central focus is dermatology.
People my age (85) like to reminisce about the good old days, usually decrying how much has since been lost. To which I say: those good old days were really quite bad. The good times are today and the best times lie in the future.
Finally, the Brown Symposia became known as the Oregon Symposia when Bill moved to Portland, Oregon, to become Director of the Primate Center. All honor to Dr. David Norris, who permanently enshrined Bill's name in the annals of dermatologic science by calling these symposia the Montagna Symposia on the Biology of the Skin.