THE PRESIDENT’S ADDRESS BEFORE THE American Dermatological Association at the Twenty-first Annual Meeting at Washington, May 4, 1897. JAMES C. WHITE, M.D. Reprinted from the Journal of Cutaneous and Genito-Urinary Diseases, For August, 1897. [Reprinted from Journal of Cutaneous and Genito-Urinary Diseases, August, 1897.] THE PRESIDENT’S ADDRESS BEFORE THE American Dermatological Association at the Twenty-first Annual Meeting at Washington, May 4, 1897. JAMES C. WHITE, M.D. Gentlemen:—It may be claimed as a proper justification for my addressing you a second time from the president’s chair that it is good custom when a child comes of age that one of the seniors, who was present at the birth, should preside at the celebration and say some words fitting for the occasion. So I, who had the great honor of serving as the chief official sponsor at the foundation of this So- ciety, may not inaptly venture to speak for it again when it has attained its majority. This is the twenty-first annual meeting of the American Der- matological Association, the oldest national association of its kind in the world. Twenty years ago it was my high privilege to welcome the charter members at their first gathering—twenty-nine in num- ber, of whom but eleven are still with us—and to present the sketch of a plan for the future conduct of the Society. The purposes and scope of such an association therein suggested, and subsequently adopted, have been, in the main, faithfully followed, and we may well pause at this turning-point in its career and, looking backward, inquire what has been accomplished of the bright promises of its infancy. Such a retrospect may best be brief, however, for several of my predecessors in this Chair have, from time to time, reviewed what has been done for dermatology by this Society. In that first address I expressed the hope that the dermatologists of this country, who lived widely apart, and had been working with- out meeting one another, some of them for twenty years, would find great advantage in forming a mutual personal acquaintanceship, and comparing and reconciling their individual opinions, often previously of unfortunate variance. Certainly we may congratulate ourselves that this most desirable aim has been completely fulfilled; that it is a sincere delight to us to meet one another at these yearly gather- ings ; that our respect and esteem for each other has been constantly strengthening during all these years, and that we express and criti- cize our individual observations and beliefs with the utmost frank- ness without jarring in any measure our bonds of good-fellowship; and this was not always so, as some of us remember. Another object we hoped to attain was the elevation of our specialty to its proper rank among the departments of medicine, and a great advance has been accomplished in this direction.1 Some eighty medical schools in this country are now teaching dermatology especially, where scarcely more than ten then gave instruction in it. In some of them its character must still, no doubt, be capable of im- 1 Dr. Morrow’s address to this Society in 1890. 2 Transactions of the provement, but in some of them it rivals the best schools of Europe in the quality of the teachers, the size of their clinics, and its stand- ing as a requisite part of medical education. The practice and wri- tings of American dermatologists to-day, it may be claimed without boasting, are on a plane as high as those of their European col- leagues. The profession at large, too, recognizes more generally than formerly the importance of the independent position of the der- matologist, although we all still meet now and then, no doubt, the practitioner who claims absolute ownership of his patients, and de- nounces all specialists as needless or worse. The lamentable igno- rance of such physicians, too often, concerning cutaneous pathology deserves open exposure. Strange to say, the country doctor more generally and modestly appreciates the limitations of the individual intellect, and rarely claims such omniscience. In one other respect the relation between the exclusively dermatological practitioner and the family physician are not yet upon a wholly satisfactory basis, even when the former is called in consultation, or is asked to suggest a plan of treatment by letters after a single visit from the patient. It is absolutely necessary, if any important results are to follow such advice, that the case should remain under the immediate observation of the specialist in the majority of affections, for thus only will the directions, how- ever carefully expressed, be carried out with that particularity so essential to success, and in certain diseases the ever-changing nature of the process demands as frequent a modification of the original advice under trained oversight. It is my custom to inform students that the second visit is often of more importance to the patient than the first; that the errors in treatment resulting from failure to carry out the instructions given may be corrected. I have known a physi- cian to continue the use of an ointment advised for three days in a case of scabies for a whole year without interruption, and the com- mon remark then to be made: “Oh, it does no good to consult a specialist.” Are we not all continually meeting with such experi- ence? Patients have yet to learn their independent rights in relation to special professional practice. Another highly important purpose of the Society has been the gathering of data concerning the prevalence and character of diseases of the skin on the North American Continent. Here, as in no other country of equal civilization, exist the most extreme variation in the physical conditions of life and the greatest diversity in the eth- nical features of its population. Here new types or modifications of cutaneous affections might well be looked for. The work accom- plished by our standing committee on statistics in this direction can- not be overestimated. Under the careful and persistent efforts of its accomplished chairman, Professor Hyde, there has been collected an enormous material bearing upon the prevalence of diseases of the skin under the observation of skilled dermatologists, such as exist in no other part of the world. By its agency we have discovered the previously unknown amount and locality on this continent of lep- rosy, for example, so essential to its necessary control. Much has been done by the Association also to advance our American Dermatological Association. 3 knowledge concerning the character of skin diseases among us. During these twenty years 327 papers, containing the valuable re- sults of the observations of its members, have been presented to this Society, and have been thoroughly discussed at the annual meet- ings. These studies and comparisons of individual opinions, so freely expressed, have been of great benefit to the progress of der- matology. And some mention may well be made here of other and larger contributions to the literature of our specialty by members of this Association during this period. At the time of our foundation but one or two books on general dermatology written by them were in existence. Since then four general treatises and six or more impor- tant works on special subjects have been published by them, not to mention several extensive collaborative publications, to which they have made noteworthy contributions. Several excellent atlases of illustrations have also been issued by them. Nor should I neglect to give due credit to that praiseworthy periodical, the Journal of Cutaneous Diseases, which has been conducted in so self-sacrificing spirit by successive editors of our number, and to which we have been greatly indebted, both as a Society and as individuals. It is to be regretted that a journal devoted to the interests of dermatology alone should not meet with sufficient support in this great country, and that it must needs be associated with another specialty, with which it has no natural affiliation. One other desideratum the Association has had in view from the first, viz., the adoption of some system of classification and nomen- clature for purposes of registration and mutual understanding. This most desirable object has received the serious consideration of sev- eral able committees, but by no means such attention on the part of the Society as it deserves. The construction of an acceptable classi- fication on any stable foundation in these days of ever-shifting pa- thology may, indeed, be of Utopian prospect, but there is no excuse for our neglect of the question of a system of nomenclature, how- ever artificial or arbitrary. A truly Babelian confusion now charac- terizes our returns. Nor should mention be omitted here of the annual publication of the list of writings of members of the Association. Its length and great diversity of subjects bear witness to the activity of our col- leagues, and in connection with the exhaustive reports of Dr. Duhr- ing in his two presidential addresses, and the carefully prepared work of Dr. Jackson, forms an invaluable bibliography of modern dermatology. Such were the chief aims of the Association as recognized at its foundation, and they have been, in the main, satisfactorily adhered to and fulfilled. They have received the support of the distinguished members who have graced this chair—sixteen in number—and other valuable suggestions have been made by them from time to time, with regard to the conduct of the Society, which have deserved seri- ous consideration. Some of them have been adopted to our great advantage. To one of them, first proposed by Dr. Hyde, I again 4 Transactions of the ask your attention, as I regard it as a matter of material importance to ourselves, and of fairness to the dermatologists of the United States who are not connected with this Association. We have at present forty members. Now, I would not lower the high standard of qualification we have hitherto maintained as essential to admission to the Society in the least, but it may well be questioned if there be not a considerable number of physicians who devote themselves ex- clusively to the study and practice of our specialty, whose position as teachers and whose published writings show them to be fit candi- dates for this Association. I met such men at the International Congress of Dermatologists in London last summer. It is possible that in this vast country of ours there are many more of them than we have knowledge of. Under our present system, proposals for membership come mostly from those of us who are especially inter- ested in some person through friendship or other affiliation. It is no one’s business to look over the field and see to it that some most deserving dermatologist, not thus favorably circumstanced, is not neglected on our part, to our detriment and his own. He would not be likely to present his own claims. It would be well, in my judgment, if a standing committee were established, whose duty it should be to keep a record of all prominent physicians in our specialty on this continent, of their home-work and standing, of their published writings, of their time passed in practice, and of other facts bearing upon their fitness for fellowship with us, and to present them to us at proper time for consideration. Such a committee, representing various parts of our country, would not be swayed un- fairly by personal feeling or local influences, and their recommenda- tions would carry great weight. At present the Council, to which all chance nominations are referred, is a constantly changing body, and with little time .at our busy meetings to give them proper inves- tigation. All nominations for membership should be referred to such a committee one year before action could be taken upon their report by the Society. Such a plan, if adopted, would require an alteration of the Constitution. There was another subject referred to at some length in the first presidential address, which I regarded as of preeminent importance to the welfare of American dermatology, and which occupies to-day, I regret to say, largely the same deplorable position as then. I refer to the establishment of hospitals or wards for the care of patients with skin diseases under the exclusive charge of dermatologists. I can hardly state the necessity of such more strongly than at that time, but must repeat that, under existing conditions, instruction in dermatology in this country is most seriously handicapped, and that its medical schools in this particular must continue to occupy a far inferior position to those of Europe, and our students must still be forced abroad to acquire in sufficiency this important part of their professional education. If anyone thinks this statement overdrawn, let him look about him for any approach to the opportunities afforded for the study of cutaneous diseases by the St. Louis Hospital in Paris or others in smaller capitals which might be mentioned. American Dermatological Association. 5 There remains one other matter of general interest to the Asso- ciation, and within our own control, which I cannot refrain from speaking of, though not in words of praise, viz., our published trans- actions. They have been far from creditable to us. The twenty volumes are not uniform in appeasance, they contain serious errors arising from improper revision, misrepresentations of statements, trivial summaries of important communications, and disjointed and meager reports of discussions. They are wholly unworthy of this Association, in my opinion, and their further publication in any such shape had better be discontinued. It would be impossible to publish an annual volume containing all communications, discus- sions, and reports in full in proper form without largely increasing the yearly assessment upon members, doubling the present rate, possibly; and unless the Society will agree to this method of raising the necessary fund, we had better content ourselves with the simple publication of our proceedings in some medical journal by the secre- tary. The alternative should be the foundation of a new series of our transactions in complete and appropriate shape under the man- agement of a standing committee on publication. Its success might by assured by the establishment of a permanent fund for this pur- pose, raised by voluntary contribution, in addition to some increase of the annual assessment. May I ask the serious attention of the Council, under whose control all publication of papers and proceed- ings lies, to this important subject. And now beyond these immediate interests connected with our own career may we not appropriately at this notable era look back- ward briefly at the changes which have marked the progress in our specialty during these twenty years? How much more do we know than when first we met together? We should know much more, because the means of learning have been immensely enlarged. For- merly we got our knowledge from a few books, and fewer teachers, and the observation of patients too often through glasses selected by the former. We have grown to be independent of such methods and all dicta. Then the teachers have become broader and more progressive, and the greatest of them have learned the great lesson that they can never stop going to school themselves, and that this school is limited by no racial or geographical boundaries. They meet their own immediate colleagues frequently in local dermato- logical clubs and societies, once a year their national co-workers in wider fields, and every four years in an international congress their fellows from all the countries of the world. They learn in this way how small a fraction of knowledge is any one man’s portion. In such a congress there is no seat for the dictator in medicine, and this is, perhaps, the most important object of its being. Every teacher should return home from such a gathering a more modest man, a humbler student. The teacher who is contented with repeating the doctrines expressed from his chair, or in his book, twenty or even ten years ago, and ignores the work of other and later observers of every nation, cannot retain the title of great. That is the highest school of dermatology which is the most liberal and cosmopolitan in 6 Transactions of the its views and sources of inspiration, and any national school which in these days remains unreasonably subservient to the dicta of any one man, dead or living, deserves no longer an international follow- ing. And besides these public schools of learning, these associa- tions and congresses, the great leveling places of personal equations, there have arisen the laboratories, where the all-important founda- tions of scientific medicine are being laid so quietly at last beneath our old superficial structures, based hitherto almost wholly on clin- ical observation and arbitrary deduction. It is not only an exact pathology which they are surely establishing, but a reasonable therapy as well, and any moment a discovery of a nature to revolu- tionize our control of the gravest diseases which afflict mankind may be flashed from their portals. How far-reaching have been the results of the investigations made within them in our epoch upon our specialty: The demonstration of the bacillary nature and the unity of all forms of cutaneous tuberculosis, formerly regarded as distinct affections, and of their intimate clinical relations with pul- monary forms of the disease; the discovery of the cause of leprosy, and the vast importance of this explanation of its real nature upon all its etiological relations and its future extinction. The recognition of the germ of syphilis stands next in succession, let us hope, although this confirmation of our foreknowledge will have little effect, except possibly in the direction of therapeutics. Studies in staphylococcia have practically abolished one of our best known lesions, the pustule, as a primary or integral expression of the inflammatory process in cutaneous pathology, and the role of para- sitism as the essential factor in the etiology of skin affections has been enormously magnified. Modern methods of investigation have also greatly extended our knowledge of the multiplicity of plant forms in our longer known fungus diseases. The practical outcome of all these scientific studies is becoming immediately apparent, so that the bacteriological, as well as the histological laboratory, has become as important a part of the equipment of a department of dermatology as the clinical ward or out-patient service. They should be intimately associated in every school of medicine. A great advance has been made, too, in a closer discrimination in the gross features of disease, so that conditions formerly consid- ered a unity, have been separated from one another, and given an independent position on our list. Among the more notable examples of these newly constructed or newly recognized affections, are: Acantholysis, or epidermolysis bullosa; acanthosis nigricans; actinomycosis, in its more generalized cutaneous manifestations; angioma serpiginosum ; dermatitis exfoliativa, in forms not previously comprised in Hebra’s pityriasis rubra; dermatitis hepetiformis of Duhrmg; dermatitis gangrenosa; dermatitis papillaris capillitii; der- matitis medicamentosa and venenata, of which our knowledge has been greatly extended; erythrasma; erytheme indure des scrofuleux; granuloma fungoides; hydrocystoma of Robinson; hydroa vaccini- forme; keratoma; multiple benign cystic epithelioma; myoma; myx- edema; psorospermosis of French, or keratosis follicularis of Amer- American Dermatological Association. 7 ican writers; pemphigus vegetans; pityriasis rubra pilaris; porokera- tosis; syringomyelia; urticaria pigmentosa; xanthoma diabeticorum. A comparison of the earliest statistical returns of the Association with those of the last few years will show a great addition to our list of real or pseudo-titles. On our first form for statistical returns, issued in 1878, there were one hundred titles. On the blank now in use there are one hundred and thirty-six titles, and in the supple- mentary table printed in our last published returns, seventy-six additional titles are given, although these are largely synonyms. The selection of the term prurigo as the first topic for open discus- sion in the late meeting of the International Congress of Derma- tology, and the diversity of opinions there presented, demonstrate, as an example, on how unstable and unsatisfactory a basis our noso- logical system rests. The introduction of absolutely new physical influences among mankind is also creating hitherto unknown tissue changes in the skin of those exposed to them. The Roentgen-rays, for instance, have shown their capability of producing a powerful destructive action upon the hair and nails, a dermatitis of peculiar type, and a deep necrosis of the cutaneous structures, followed by prolonged and inex- plicable impairment of the process of repair. Let us hope that they may be possessed of as powerful curative possibilities to be isolated and controlled. Again, the introduction of a strange plant from the remote deserts of China to our household flora gives rise to a novel type of cutaneous inflammation, and the invention and use of new remedies is continually starting up fresh forms of dermatitis medica- mentosa to be recognized. And with our great advance in knowledge of the nature of dis- eases of the skin, thus briefly and imperfectly sketched, what gain have we made in means of cure ? Very little as yet, it must be said, but we are beginning to discover as the result of etiological research the basis of a rational system of cutaneous therapeutics. Our small list of specifics should be greatly lengthened when we are no longer obliged to search for them along a line of purely empirical experi- mentation. Let us hope that the time is soon coming when we shall not have our efforts in this direction characterized by a trial of every new chemical product which the ingenuity of the synthetical chemist can devise, and heralded as of prodigious potentiality against this and that affection by the professional trumpeter of the manufacturing firm, but rather avail ourselves of every hint emanating from those engaged in studying the natural history of the germs which cause disease, and the action of reagents upon their vitality under culture. I see no limit to the hopes which may be ultimately realized from such research. The accomplishment of immunity by inoculation of the products of specific germs or modified serum against such affec- tions as leprosy, tuberculosis, and syphilis is a perfectly reasonable expectation. The fact which Jenner determined by accident and shrewd observation has been converted into a scientific principle by Pasteur and Koch, and the imagination can hardly be too daring in forecasting its possible benefits in preventive and curative medicine. 8 Transactions of the Some of you will live long enough, let me trust, to see every child immunized by inoculation against all infective diseases as regularly as now against variola. So much for the past of our Association and for the progress of dermatology during its existence. And now a few words more as to its future. Can we in any way make it more useful than it has been? I can see but little room for improvement in the objects and methods we have so uniformly and successfully adhered to thus far. They are those which have been followed mainly by all the many similar asso- ciations which have been founded since our own. In one or two directions, however, a change might be made with advantage. I think an effort should be made, as already stated, to make our mem- bership broader and more national, without lowering the high stand- ard of requirement higherto observed; and, secondly, that we should introduce into the conduct of our meetings a feature which gave to the late International Congress at London so distinguished a success. There, in addition to the usual program of papers without num- ber, which were hastily discussed by a few of the several hundred dermatologists and syphilographers in attendance from all parts of the world, who all returned home probably with their individual views on every subject considered unchanged or more fixed than before, was arranged a great exhibition of all the means of illustrating the pathology and pedagogy of diseases of the skin. Portraits, photo- graphs and models, microscopic sections and bacteriological cultures, in enormous numbers, were brought together from near and far, and constitued a marvelous object lesson in dermatology. The work of our most distinguished colleagues with which we were previously familiar only by description, was there before us for examination and comparison. There was collected an hour or more before each session a wonderful series of cases, examples arranged in groups of the rarest and most interesting affections of the skin. Hundreds of such patients gathered from all parts of Great Britain and its various colonies were thus shown, many of them of extraordi- nary character. In their presence the most renowned masters and diagnosticians should have felt helpless. Surely every one there, the most accomplished and experienced, must have felt how much remains to be learned in our department of medicine, and how vast the privileges of our English confreres with such opportunities for observation. Now, although we may not hope to rival such an unprecedented exhibition, we can certainly bring together every year much material of a similar character, which could not fail to add greatly to the interest and value of our meetings. We are all constantly meeting with cases of extraordinary character, as the experience of our local dermatological clubs proves, which might be discussed on this broader meeting-ground with undoubted advantage to all of us, and occasionally to some one of us is vouchsafed a unique example of dermatosis, which might never be known to the rest of us, unless presented in this way. We have all of us, no doubt, upon our existing lists cases such as we know our fellow members would like to see here. The Council has thought it advisable to make the American Dermatological Association. 9 attempt this year to introduce such a clinical feature upon our pro- gram, although Washington is over far from the great centers of professional activity to warrant any expectation of a full success at this Congress. Indeed, it may be doubted if these triennial meetings conduce to the best interests of our society. If the Association favor the future development of such a clinical exhibition, it may well determine the selection hereafter of the place of meeting in our large cities, and a local committee should be annually appointed to have charge of it. Ido not see how it could fail of being a most attractive and valuable addition to our program. Then, too, we have accomplished microscopists and bacteriologists among our members, and the results of their valuable work would be better appreciated by us if it were submitted to our direct inspec- tion. They certainly deserve the assignment of a fixed opportunity for such a demonstration upon our card. Some of our papers could be presented in much more complete form, if illustrated by such a supplementary display. And we should have our annual gallery exhibition, to which every member should contribute all additions of his personal collec- tion during the year of drawings, photographs, paintings, and models, representing any case of unusual interest. To the question of the permanent adoption of all these additional measures for ma- king our meetings more attractive and instructive, I beg your serious attention. Let us not neglect any means of keeping our society in the highest rank of kindred associations. Death has dealt lightly with us during our first twenty years, but another double decennium can carry to its end but few of our orig- inal members. Let us hope that our successors will transmit the Association to theirs with purposes as high and record as honorable as those we commemorate to-day.