Chapter Dermatopathology Lyn M. Duncan and Martin C. Mihm Jr. he history of dermatopathology at role of pathological investigation was doubtless Tthe Massachusetts General Hospital (MGH) imparted to Dr. White during his time in Vienna. is a rich and long one, dating back to the second Dr. White returned to Boston, and his versatility half of the nineteenth century and continuing as a physician is illustrated by the fact that he to the present day. It features close interaction began his career at MGH as a clinical chemist, between the Dermatology and Pathology depart- serving in that capacity from 1863 to 1872; but ments, beginning in Dermatology and then he was interested primarily in dermatology and becoming a specifi c Dermatopathology Unit in devoted his practice to it after 1872. Once he had the department of Pathology in the 1960s. Th e opened the outpatient clinic, he began a two-year history includes luminaries in the fi eld, such as debate with other MGH physicians and surgeons Drs. James C. White, John T. Bowen, Walter F. on the need for a special “Skin Ward”; this special Lever, Wallace H. Clark Jr., and Martin C. Mihm ward was formed, but it closed in only a year, Jr., and major discoveries, perhaps most notably and Dr. White was appointed to the Out-Patient in the area of skin neoplasia. A number of epony- Department, as Physician to Out-Patients with mous skin diseases and tumor staging systems are Diseases of the Skin. He was a prolifi c writer, associated with individuals who worked at the served as an Editor of the Boston Medical and Sur- MGH, attesting to the infl uential role of MGH gical Journal (the precursor to the New England Dermatopathology over the years. Journal of Medicine), and was the fi rst professor of dermatology in the United States (at HMS). The Early Years: White and Bowen In keeping with his training under von Hebra, Th e roots of dermatopathology at MGH can be some of his works contained detailed descrip- traced to its companion clinical discipline, der- tions of cutaneous pathology (34). His family matology, which itself dates to 1869 at MGH, would also go on to prominent positions at the when Dr. James Clarke White began an outpa- MGH, his son Charles J. White (see below) serv- tient clinic for patients with diseases of the skin ing as Chief of Dermatology and his grandson, (fi gure 18.1). He graduated from Harvard Medi- also named James C. White, becoming Chief of cal School (HMS) in 1856 and then studied in Neurosurgery. Vienna with the great dermatologist Ferdinand One of Dr. White’s trainees was Dr. John Tem- von Hebra. Von Hebra is considered the fi rst pleton Bowen (fi gure 18.2). Dr. Bowen had gradu- person to bring careful pathological study to ated from HMS in 1884 and studied in Germany diseases of the skin, and an appreciation for the and Vienna before returning to the MGH in 1889 251 pathology_chap18.indd 251 8/16/11 10:22 AM Keen Minds to Explore the Dark Continents of Disease Figure 18.1 James Clarke White Figure 18.2 John Templeton Bowen as Assistant Physician to Out-Patients with Dis- much preferred this type of life to the public area eases of the Skin. He went on to become the fi rst of hospital practice and teaching” (32). In a his- Edward Wigglesworth Professor of Dermatology torical sense, therefore, Dr. Bowen can justifi ably at HMS in 1907 and was Chief of the Derma- be considered the fi rst dermatopathologist at the tology Service at MGH from 1911 to 1913. Dr. MGH. Bowen did seminal and extremely careful work in After Dr. Bowen’s tenure, Chiefs of Dermatol- understanding the microscopic pathology of skin ogy included Drs. Charles J. White (son of Dr. diseases, the most notable being his descriptions James C. White; 1913–1927), Harvey P. Towle of in situ squamous cell carcinoma (3), known (1913–1925, with Dr. White), E. Lawrence Oli- subsequently as Bowen’s disease. He collaborated ver (1927–1936), and C. Guy Lane (1936–1947). and published with pathologists, including Dr. Some of these individuals did clinicopathologi- S. Burt Wolbach, the Chair of HMS Pathology, cal correlations of dermatological disease and and was a member of the American Association published interesting case reports on a variety of of Pathologists and Bacteriologists. Indeed, some conditions. For example, Dr. White published felt that this quiet man may have liked his micro- an article with Dr. Oscar Richardson of Pathol- scope better than his patients. According to Dr. ogy (chapter 3) on cutaneous leprosy in 1909 that Charles J. White, “Dr. Bowen was by nature a included detailed histopathological and bacte- student. He loved quiet: he loved his microscope, riological examinations and that acknowledged and he loved to ponder over things—to ‘mull’ Dr. Bowen’s help with the case (33). A promi- over them was a frequent word on his lips. He nent MGH dermatologist from 1921 to 1937 was 252 pathology_chap18.indd 252 8/16/11 10:22 AM Dermatopathology Arthur M. Greenwood, who also worked at New England Deaconess Hospital. He published a number of papers that had dermatopathological correlates, including ones with the MGH Pathol- ogy department and on the skin of diabetics with Dr. Elliott Joslin (chapter 3). His papers refl ect close interactions with MGH Pathology, such as his acknowledgment in a 1922 paper on heman- giosarcoma of the skin of “indebtedness to Dr. J. Homer Wright and to Dr. Charles J. White for their valuable suggestions and aid in interpre- tation of the sections” and his reference to Dr. Wright in the text (14). Dr. Wright himself had also published on dermatopathology, including one of the detailed early histological descriptions of cutaneous leishmaniasis, an article in which he acknowledged his close interactions with Dr. White on the case (36). The Lever Era Walter F. Lever was born on December 13, 1909, in Germany and obtained his medical degree in Leipzig (fi gure 18.3). His father, Alexander Lever, Figure 18.3 Walter F. Lever was a prominent dermatologist in Germany. In the 1930s Walter Lever became one of many phy- together he agreed to it. In working with him in sicians who left Germany in an exodus to the dermatopathology I learned a great deal of gen- United States because of the rise of Nazism. He eral pathology. With only brief interruptions the joined the MGH in 1936 as a research fellow and Pathology Laboratory at the Massachusetts Gen- resident on the Dermatology Service. In that year eral Hospital was a ‘second home’ to me for more Guy Lane had become Chief of Dermatology than 20 years” (19). and had expanded the training program to two Dr. Lever was appointed to the Dermatology years and doubled the number of residents, giv- faculty in 1944, and he continued his close rela- ing Dr. Lever “some spare time” that he “spent in tionship with Pathology, reviewing the skin biop- the Pathology Laboratory” (19), thus beginning sies with the residents. He is best known for his his long association with MGH Pathology. His widely read textbook, Histopathology of the Skin, description of his early interactions with Pathol- originally published in 1949 and now in its ninth ogy attests to the novelty of a dedicated dermato- edition (20). Th is successful text is a refl ection pathologist: “Th e members of the Pathology Lab- of Dr. Lever’s important role in the forging of oratory were not used to seeing a dermatologist a strong relationship between the departments among them. Th ey frankly admitted that their of Pathology and Dermatology at the MGH. In know-how in dermatopathology was not exactly 1949 this close bond was portrayed in the pref- overwhelming. When I suggested to Ben Castle- ace to the fi rst edition of his textbook: “I wish to man [who was fi nishing his pathology training express my deep gratitude to Dr. Tracy B. Mallory in the mid-1930s] that perhaps we might learn it and Dr. Benjamin Castleman of the Pathology 253 pathology_chap18.indd 253 8/16/11 10:22 AM Keen Minds to Explore the Dark Continents of Disease Laboratory at the Massachusetts General Hospi- and M.D. in 1947 from Tulane University, where tal for the training in pathology they have given he continued to work, rising to become Professor me. It has been invaluable to me. Th eir teaching of Pathology before his move to Boston. Upon is refl ected in this book.” joining the MGH in 1962, with the support of Dr. Lever was also known for his original work the Chief of Dermatology, Th omas B. Fitzpat- in the fi eld, including his description of bul- rick, Dr. Clark set up an electron microscopy lous pemphigoid in 1953 (21). In 1959 Dr. Lever research laboratory on the Dermatology fl oor left the MGH to become the Chairman of the of the Warren Building. His work in this facility Department of Dermatology at Tufts Univer- yielded descriptions of dermal-epidermal separa- sity Medical School; despite this move, he was tion in bullous pemphigoid, dermatitis herpeti- retained as a consultant to the MGH and Hon- formis, and erythema multiforme, as well as the orary Dermatologist for more than 20 years. Dr. ultrastructural mechanisms of melanin synthesis. Lever had an infectious enthusiasm about derma- Dr. Clark’s contributions to clinical dermatopa- topathology diagnosis and teaching. He was con- thology over the next seven years included the sidered by many in Boston to be a type of Red publication of the fi rst classifi cation of mela- Baron: he attended and supported the citywide noma and the identifi cation of histopathologi- dermatopathology review sessions, driving his cal prognostic factors, including the anatomical open convertible in the winter, a red scarf fl ut- extent of invasion, now termed the Clark level.