Histologic Diagnosis of Inflammatory Skin Diseases

A. Bernard Ackerman, Almut Böer, Bruce Bennin, and Geoffrey J. Gottlieb

© 2002–2006 Ardor Scribendi, Ltd. All rights reserved.


Preface


In retrospect, it seems more than a tad audacious, but nearly 35 years ago, in early December, 1969, having only recently completed training in dermatopathology at Harvard and just six months into my first directorship of dermatopathology at the University of Miami, I walked up to the booth of Lea & Febiger ensconced in the exhibit hall at the annual meeting of the American Academy of Dermatology in the Palmer House hotel in Chicago and naively asked this question of the unprepossessing man manning the stall, alone: "Would you be interested in publishing a textbook of dermatopathology?" To my great surprise, the answer was encouraging: prepare a preface, come to Philadelphia, discuss the concept with the partners and other persons appropriate, and a contract might well be offered.

Why did I approach Lea & Febiger first when at least 10 other publishers of medical books had stands along the same row? For one, I knew of the company by reputation and intuited that because it was a small publishing house, compared to behemoths like Saunders, Lippincott, Mosby, and McGraw-Hill, it might be both more receptive to a first effort at construction of a book by a fledgling and more accessible in general to a novice like me. For another, I realized that Lea & Febiger not only had no book about dermatopathology on its list, but none about dermatology in general: that, too, might make it more receptive to what I was proposing.

What prompted me, a greenhorn whippersnapper, to venture to produce a textbook of dermatopathology? It was evident to me during my residencies at Columbia, the University of Pennsylvania, and Harvard, and during my fellowship in dermatopathology, that the three texts in English devoted to dermatopathology were inadequate for learning overarching principles and for grounding in a method for diagnosis. "Lever," "Montgomery," and "Pinkus" were devoid of organization logically, their table of contents was a hodgepodge of unrelated categories, and there was no attempt to unify what then constituted dermatopathology. Even a newly minted dermatopathologist such as I could see, on cursory reading, that all three texts were superficial and replete with misinformation. Last, hardly a single photomicrograph "shot" at scanning magnification could be found in any of those works, a circumstance that I deemed to be a major deficiency for teaching the subject effectively. I thought I could do better.

On inquiry, I soon learned that "preface" for a publisher of medical books was synonymous with "purpose," so, early in 1970, I began work on the first of what would prove to be more than 20 drafts of a preface to my seminal Arbeit. When that introductory statement was comprehensible sufficiently and purposeful manifestly, off it went to Lea & Febiger, followed soon thereafter by a visit from me to Philadelphia, where that venerable publisher of medical books, the oldest publisher of books of any kind in the United States, having been established in 1783 by the Irish immigrant Matthew Carey, was housed in a magnificent Georgian building situated on Washington Square, which was the home then, too, to W.B. Saunders, J.B. Lippincott, and F.A. Davis, all of them vaunted medical publishers. I met the partners, editors, and technical personnel of Lea & Febiger, discussed my aspirations for the volume I had in mind, and was promised a contract, which soon arrived in Miami and was signed immediately by me, without so much as a glance at it by an attorney, and returned to Philadelphia.

Within only a few months, it became all too apparent to me that forging a textbook dedicated to all of dermatopathology could take 25 years—and that simply was too long to postpone the gratification of holding the volume in my hands and too long to withhold from colleagues what I was learning, and synthesizing, daily. One morning, while in the shower and pondering grimly the reality of my fate, I had an epiphany: Why not limit the scope of the planned work to inflammatory diseases of the skin? That is what was lacking so egregiously from contemporary texts devoted to pathology in general and dermatopathology in particular, and what was the most engaging for me, being the dermatologist/dermatopathologist that I was. Before I reached for a towel, the decision had been made: The book would be Histologic Diagnosis of Inflammatory Skin Diseases. The subtitle, "A method based on pattern analysis," would come later.

The purpose of the undertaking was set forth clearly in the preface to the first edition of Histologic Diagnosis of Inflammatory Diseases (1978) and in these words:

...there is a need for a textbook that weds the gross and microscopic features of skin diseases and simultaneously provides a logical, systematic, and reproducible method of histologic diagnosis. This book endeavors to fill that need in part and to serve all students of skin disease, be they dermatologists, pathologists, surgeons, residents, or medical students...This book is intended to be of practical assistance in the histologic diagnosis of inflammatory skin diseases and is not a reference textbook for those interested in an exhaustive review of the literature about each subject.

The contents page looked like this:

If the fact that the book went through six printings is any indication, it seems that colleagues found the method that I advocated to be helpful.

The emphasis in the first edition was strongly on analysis of patterns formed by inflammatory cells as a vehicle to coming to diagnosis with specificity of inflammatory diseases of the skin. Some heed was paid to thinking algorithmically in order to achieve that desideratum, some attention was given to chronological sequence, that is, the life of a lesion as it played itself out over time, and some concern was directed at other matters pertinent to identifying a disease precisely, among those being clues to diagnosis (Sherlockian dermatopathology), differential diagnosis, exceptions, and pitfalls. The theme that dominated, however, was expressed in the heading, in toto, of it: Histologic Diagnosis of Inflammatory Skin Diseases: A Method by Pattern Analysis.

In an effort to rectify errors in the first edition and to alert to "new" patterns, in 1988 I created a 48-page supplement to that edition. I had no intention of embarking on a second edition of what by then had become known, universally, as "the gold book." For a variety of reasons (catalogued in the preface to the second edition), I changed my mind and did begin a second edition some 15 years after the first one had been born. One motivating factor for that change of heart, and the most compelling one, was my desire to do the job better and to correct much that I then perceived and conceived very differently than when I had sat down to write the very first draft of a preface more than 20 years before. A second factor was the exceedingly kind comments of colleagues about the work itself, they also inquiring, nearly invariably, when there would be a second edition (and, in the next breath, when I was going to do a volume about neoplastic diseases of the skin comparable to that devoted to inflammatory diseases). A third consideration was that instead of working alone, I would have a team of able, conscientious collaborators who would permit me to produce a completely new book, even though it would be called, officially, a second edition. The size was the same, that is, atlas dimension, but the color was platinum and the design of the cover, although retaining the symbol of an antique teaching microscope, was changed, too. Instead of a single author, six were listed, and all of them contributed energetically.

In the preface to the second edition of what now was titled Histologic Diagnosis of Inflammatory Skin Diseases: An Algorithmic Method Based on Pattern Analysis (1997), I shared with readers a hope for the new work predicated on what was considered by some to be a deficiency of the first edition. This is how I expressed it:

A limitation of this presentation [in the first edition] of a new method that relied mostly on pattern analysis, however, was that a single disease would appear in several chapters that pertained to different patterns...This situation was an inevitable consequence of the proclivity of the same cutaneous inflammatory disease to express itself differently histopathologically at different times in its chronologic course...In short, emphasis on pattern analysis facilitated diagnostic accuracy but did not allow integration of all the histopathologic findings in a disease based on the lives of lesions, the anatomic distribution of lesions, and the pace of evolution of lesions. That deficiency prompted me to rethink the subject in its entirety, with the result being a restructuring of the method that finds expression in this book. In short, the pattern remains the same, the emphasis is different.

What, then, was the special consideration that became the major thrust of the second edition? The answer was provided in the preface in this sentence: "By stressing algorithms based on analysis of patterns of inflammatory skin diseases, it also became possible to use the volume itself in algorithmic fashion." An effort was made in the second edition to base everything on logic applied sequentially, and nowhere was that exemplified better than in how the contents now were organized, which was very different from in the first edition, as is evident at a glance as follows:

Algorithms as vehicles to diagnosis histopathologically with specificity were present in profusion in the second edition, for example, in Chapter 5, titled "Basic patterns and analysis of them," where an algorithm for each of the nine basic patterns was constructed in skeletal fashion, and in Chapter 6, captioned "An algorithmic method for diagnosis that employs pattern analysis," in which sinews and flesh were added to each skeleton. Both the skeletal and the fleshed out versions of each of the patterns also were housed together in an atlas-sized booklet that accompanied the hard-bound text, which itself numbered 944 pages (the first edition was 863 pages). The algorithmic method that I propounded not only dominated Chapter 6, a segment of the volume dedicated to explaining and illustrating the utility of algorithms for diagnosis of cutaneous (and subcutaneous) inflammatory diseases, but it monopolized Chapter 9, titled "Nonspecific findings as vehicles to specific histopathologic diagnosis." That latter chapter was responsible for all of Part IV given to the matter of "Coming to specific diagnosis by another route," that caption meaning, in practice, turning on its head the system for diagnosis histopathologically espoused throughout the first and second editions; instead of beginning at scanning magnification to assess the basic pattern and then proceeding at progressively higher powers to specific diagnosis, adding findings crucial to diagnosis en route, a microscopist began by identifying at high magnification a "non-specific" change and then worked his/her way to scanning magnification, adding along the way findings essential for diagnosis with specificity, the last of those to be entered algorithmically being the basic pattern itself.

Photomicrographs throughout the second edition, except for the introductory chapters, and there were thousands of them, were printed in color and they, too, were set forth, consistently, in an algorithmic manner as follows:

Pattern at scanning magnification + Crucial findings at high magnification = Specific diagnosis (with comment addended)

Because of my satisfaction with the result achieved in the second edition, I had no intention whatsoever of launching a third edition. Several unexpected happenings incited me to change my mind. The first was that the publisher of the second edition [which was Lippincott/Williams & Wilkins, Lippincott having purchased Williams & Wilkins (the actual publisher of the second edition of record), which itself only recently having gobbled up a pathetically moribund Lea & Febiger] refused adamantly to authorize more than two printings of the second edition, despite 8,000 volumes of it having been sold out completely in less than two years (the first edition sold 13,500 copies). Appeal to logic, at first by me directly and then by my attorneys, was fruitless; Lippincott, in its wisdom, would not budge, even though salesmen for it were bombarded by requests for the book, especially at national and international meetings of dermatologists and pathologists, to say nothing of letters of supplication from students of the subject who sought fervently to obtain a single copy, all of that being for naught at various levels of authority at the headquarters of that aging institution in Philadelphia. So great was the demand for the second edition that at one point in 2002, Amazon.com was selling a copy obtained fortuitously for $1,200, nearly ten times the purchase price five years earlier. After nearly a year of wrangling with a host of "no-hopers" at Lippincott, I was able to "buy back" my work for $10,000. At last it was mine to do with as I pleased.

The second influence on my thinking about a possible third edition was the sentiment, expressed often by readers, that they preferred "the gold book" to its successor, the platinum one. No matter how many times I was told that, and it was often, I was staggered to hear it, unable to wed that message to my own sense of reality. In my mind, the first edition was nowhere near as substantial, profound, and instructive as the second, but as the refrain on behalf of "the gold book" came from many quarters whose judgment I regarded highly, there was no way that I could pay the message, so feelingly given, no heed, especially given the fact that, in the ultimate analysis, a work must serve optimally those who use it. I began to give thought to how a third edition might satisfy the needs of readers—and of me, too.

The stars, which all too often are crossed, happened to be in just the right alignment when, on July 1, 2003, without the intervention of a diviner or a visit to Delphi, I decided to invest, intellectually and spiritually, in a third and, this time, truly last edition. A third impact on my decision in that regard was a fortunate series of happenstances: exhortations that had come from my close co-worker, protégé, and successor as editor of Dermatopathology: Practical & Conceptual, Almut Böer. She was excited at the prospect of engaging a third edition with me; the dependability of Ying Guo, photomicrographer in color extraordinaire, who was now an associate of mine in dermatopathology at our Academy in New York City and, as always, was prepared to contribute her no small talent to the endeavor; and the enthusiasm of Bruce Bennin, practitioner of dermatology and mentor in dermatopathology to residents at Cook County Hospital in Chicago, who was the major architect of the algorithms in the second edition and was enthusiastic about having a go at innovating them in a third edition. To this remarkable team was brought Geoffrey J. Gottlieb, my most outstanding trainee in regard to diagnosis in dermatopathology, my most senior associate at our Academy, and the person who succeeded me on July 1, 2004 as Director of the Academy, he bringing to the undertaking a profound knowledge of immunodermatopathology, immunofluorescence in particular, that enriches the present work by making it an unparalleled resource of information, practically and conceptually, about that particular subject, one which complements magnificently the ballast provided by dermatohistopathology. His chapter on "Patterns of immunofluorescence for diagnosis of inflammatory skin diseases" is in synchrony with the dominant theme of the entire project, namely, patterns as vehicles to coming, with specificity, to diagnosis by microscopy of inflammatory diseases of the skin. And there was my slew of trainees in dermatopathology, fellows preparing during the course of one year to sit for the board examination in dermatopathology, visiting fellows who came from different parts of the world for six months or one year to gain knowledge of dermatopathology to be used benevolently on their return to their native countries, and various medical students and young physicians, usually ones desirous of becoming dermatologists, who, on an "elective," join us at a 27-headed microscope and participate, between 7:30 A.M. and 10:00 A.M., in discussions of issues germane to principles that govern and concepts that animate dermatopathology. The group for 2003–2004 was an exceptional one, and members of it were ardent about participating with me, and with passion, in the preparation of a third edition.

The last, and perhaps most dramatic "unexpected happening" was the impact on me of extraordinarily novel technologies in regard to communication, ones that have revolutionized, and continue to transform, in riveting fashion, the realm of publishing in general and of medical publishing in particular, all of this having transpired in the seven years since the second edition appeared. The impetus given by the Internet, globally, to this new age and the embrace of it as the prime source of information has provided possibilities never before imaginable for achieving aims pedagogical. Three individuals, in particular, were instrumental in instructing me, a person impaired technologically, in the ways of avant-garde communication, namely, Thane Kerner, President of Silverchair Science + Communications, Andy Zwick, Chief Executive Officer of Ardor Scribendi, Ltd., and also my nephew, and Betsy Peare, Managing Editor of Ardor Scribendi, Ltd. By virtue of their tutelage and our portal on the worldwide web, namely, Derm101.com, we, in this edition, can, and will,

Rather than give away the secret, here and now, of what distinguishes this third edition from the two editions that went before it, I merely will alert readers to the fact that this work, too, is a new book; fundamental changes seek to make it as beneficial as humanly possible to pathologists and dermatologists who want to master diagnosis by conventional microscopy of inflammatory diseases of the skin. That the material presented is housed in a volume whose front cover is gold and whose back cover is platinum should telegraph an all pervading theme, to wit, this third edition endeavors to catch up in itself the best, conceptually, of what was intended to be delivered in each of the prior editions. The "gold book" was meant to be read through from start to finish, and the "platinum book" was intended, in large measure, to serve as a source for reference; this, the third edition, is designed to be read through from the preface to the end of Chapter 9, and to be a resource for particular information and unconventional ideas in the chapters online, namely, Chapters 10 and 11. Readers need only browse through the pages, especially those that constitute the new Chapter 5, now richly illustrated in color and devoted to patterns basic to a method that utilizes algorithms, to recognize how extraordinarily different is this work from the previous two editions.

I will not divulge a word more about innovations in this third edition, not simply as a tease, but in order not to deprive a reader of the excitement and joy of discovering those novelties oneself. I feel compelled, however, to make an admission at the outset: I do understand that the syntax of the main title is not exactly correct; instead of Histologic Diagnosis of Inflammatory Skin Diseases it should read, properly, Diagnosis Histopathologic of Inflammatory Diseases of the Skin and Subcutaneous Fat. Surely readers, cognizant of my having promised a work that in so many respects is new, will forgive me for not having altered, after 25 years, and clumsily at that, the title of it.

A. Bernard Ackerman, M.D.
New York City
2005

© 2002–2006 Ardor Scribendi, Ltd. All rights reserved.