Philosophy as Prologue
What is the meaning of life? The question has been asked for as long as Homo sapiens has been on the planet, and it has always been a vexing one. The answer remains elusive. Who among us is able to offer an insightful, incisive, comprehensive, reflective, and compelling answer to the question of the meaning of one’s own life, let alone the meaning of the life of another person, especially a life as multifaceted as that of Paul Gerson Unna, a complex, intriguing, iconoclastic, singular, admirable man (Fig. 1). Is there meaning to life and, if there is, what might it be? Among the possible answers are these (Fig. 2):
Paul Gerson unna (circa 1885)
“The meaning of life.”
If, scores of years ago, we had been able to speak to Unna, it would have been interesting to ask him: “What do you conceive to be the meaning of your life?” Which of the four answers just proposed might he have given? In order to even begin to speculate about what his response might have been, it is necessary first to review Unna’s life and his accomplishments.
The Life of Unna
Paul Unna was born in Hamburg on September 8, 1850, the son of the highly respected Jewish physician, Moritz Adolf Unna. His mother, Ida Gerson, also came from a family of doctors. Paul Unna had such a high esteem for his mother’s father that, before he had reached the age of 20, he asked the Senate of Hamburg for permission to take the name of his maternal grandfather, Gerson, as his own middle name. In 1870, Paul Unna became Paul Gerson Unna. In the same year, he followed in the footsteps of his father and grandfather by embarking on the study of medicine. Shortly after having moved to Heidelberg to begin his medical studies there, the Franco-Prussian War broke out and Unna volunteered with patriotic zeal for the Prussian medical corps. Just three weeks before the armistice in early May 1871, in the fighting at Le Mans, he was wounded severely by a French rifle ball that shattered his thigh. His father rushed to the battlefield, retrieved him, and brought him home to Hamburg where it took months for him to recover from his injuries. Henceforth, as a person disabled by war, Unna received a moderate pension that he eventually used for sponsoring research endeavors in dermatology and for other specific purposes.1
The war ended with a crushing defeat of the French, who were forced to transfer Alsace to the Germans. Shortly thereafter, in order to revivify his new province, the German Kaiser reopened the University of Strassburg and endowed it with an outstanding faculty. It was in Strassburg that Unna resumed his study of medicine. At the same time, he pursued other interests, for example, philosophy, an inclination toward which was maintained by him for the rest of his life. His first publication, at age 24, was an essay on conscience. Later he became a devotee of Monism and eventually founded and edited a journal devoted to that philosophy. Unna named the journal “The Century of Monism” (“Das Monistische Jahrhundert”).
Unna’s most important teacher at the University of Strassburg was the chairman of anatomy, Wilhelm von Waldeyer (Fig. 3), who is still remembered today because of several anatomical structures that bear his name and for having introduced hematoxylin for staining sections of tissues. In Waldeyer’s department, Unna wrote his doctoral thesis about “The development and anatomy of the human skin and its adnexa” (“Entwicklungsgeschichte und Anatomie der menschlichen Haut and ihrer Anhangsgebilde”). He chose this subject because, as he explained later, “He who cannot learn anything from the skin, which lies open before him, will learn even less from any other organ.”1 By employing new stains, such as picrocarmine, Unna was able to identify different parts of the epidermis. He characterized the stratum basale as the regenerating zone, defined the stratum spinosum and stratum granulosum morphologically, noted that the spinous zone did not participate in regeneration, and specified four parts of the stratum corneum on the basis of the way each of them took the stain.2 The faculty of the university was not at all pleased by the provocative and revolutionary aspects of Unna’s thesis. Felix von Recklinghausen, whose name is linked indelibly to neurofibromatosis, rejected Unna’s thesis outright and in these words: “It is not in keeping with the principles of science to draw conclusions from tissue sections that have been smeared with dyes.”3 Unna was instructed to revise his dissertation immediately, but, although he made some changes, he refused steadfastly and adamantly to alter his conclusions. Even at this relatively young age, Unna demonstrated that he clearly was his own man. His physical appearance was described by John Crissey, the leading contemporary historian of dermatology, as being “on the chunky side, although not excessively so. He had a noble forehead, bright eyes, and a square-cut, chest-nut colored beard that was prematurely touched with grey.”4 Although his stature was short, he was little more than 5 feet 4 inches tall, he could not be intimidated (Fig. 4). Unna had self respect, independence, and courage. Those were to be his most notable personal characteristics for the rest of his days.
Wilhelm von Waldeyer (1836-1921)
Malcolm Morris, Henry Radcliffe-Crocker, and Paul Gerson Unna at a meeting in England in 1896. Even with his tophat, Unna is smaller than his British colleagues.
Because of the decidedly unfavorable reaction to his doctoral thesis, Unna gave up his dream of an academic career and elected to join his father in the private practice of medicine. Before returning to Hamburg, however, he spent three months in Vienna in order to hone his clinical skills. What transpired during this period was what prompted him to pursue dermatology as a career. At that time, von Hebra’s skin clinic was the center of dermatology in the world, and there Unna was impressed not only by the master himself but by Heinrich Auspitz (Fig. 5), whom he referred to as a “genius.”5 Auspitz was a Jew who readily acknowledged being Jewish and, unlike Kaposi and Neisser, did not convert to Christianity in order to advance his career. As might be inferred from that decision alone, Auspitz was very much his own person, an indomitable free spirit, and a rebel who assaulted the concepts of the Vienna school of dermatology and did not shrink from their, or any, authority. Unna, still upset by the unpleasant circumstances that surrounded his thesis, and the response to it by von Recklinghausen, saw in Auspitz a kindred spirit and chose him as mentor and model. Together with Auspitz, Unna performed a comprehensive study of histopathologic findings in the chancre of syphilis, a project so satisfying that it contributed to his decision to become a dermatohistopathologist.6
On his return to Hamburg, Unna acquired practical experience during a year with Julius Engels-Reimers, the director of dermatology at the St. Georg Hospital. Some professional pique on the part of Engels-Reimers, who did not engage in scientific work and was less renown than his younger assistant, induced Unna to leave St. Georg and to enter general practice.1.4
In 1879, Unna married Elisabeth Foerster, who was not Jewish, and with her had four sons and one daughter. His was a loving family life that was enriched by cultural events like little concerts at home in which Unna himself participated as a skillful cellist (Fig. 6).7 What might have been a life devoted mostly to both family and a busy practice of general medicine was changed by the strong attraction of Unna to dermatology. Because of being consulted by increasing numbers of patients with skin diseases, Unna founded his own private clinic in 1881 and, shortly thereafter, decided to give up the practice of general medicine in favor of dermatology. Although that decision was without precedent in Germany, Unna’s clinic immediately became a success.1 His pupil, Alfred Hollander, recalled that “Unna’s quiet but convincing attitude so effectively influenced people. When necessary, he sat down with the patient and spent ample unhurried time discussing and explaining the problem and, in most instances, succeeded in relieving anguish.”7
Family concert at Unna’s home. From left to right: Elisabeth, Eugen, Karl, Georg Wilhelm, Paul, and Paul Gerson Unna.
Because patients flocked to Unna’s clinic, the building that housed it soon became too small and, in 1883, he purchased a property in Eimsbüttel that was like a park (Fig. 7). There he built a new skin clinic with separate buildings for inpatients, laboratories, and his own family. When these teaching facilities became too small, he added yet another building, the “Dermatologikum” (Fig. 8). Before long, Unna had created his own private university that, in regard to the scope of its activities, soon surpassed all departments of dermatology in long established famous universities. This man, little in size, had a big brain from which sprung big ideas. The concept of a “Dermatologikum” would be revolutionary even today, let alone 100 years ago!
Park of Unna’s clinic in Eimsbüttel
In an effort to improve treatment of skin diseases, Unna collaborated closely with his friend, Paul Beiersdorf (Fig. 9), whom he described in his autobiography as an “ingenious, scientific, and generously thinking pharmacist.”5 That Unna himself was also generous is reflected in his autobiography in lines such as these: “The powerful emergence of Beiersdorf’s factory into a world-renowned firm is generally known, but only few know that, in our first contract, the condition for my cooperation was that the firm would not try in any way to reimburse me materially for my spiritual work. . . . The only reimbursement for which I asked and which I always obtained was that the firm would carry out the experiments necessary for the production of my preparations without charge and they granted me the right always to control my preparations.”5
Paul Beiersdorf (1836-1896)
The crucial word in this quotation for the understanding of the meaning of life for Paul Gerson Unna is “spiritual” in regard to his work. Unna was inspired by his work, and what motivated him was not money, medals, or material reward of any kind. He was an exemplar of the Latin precept, Ars Gratia Artis – art for the sake of art – and that alone. It is that mentality that gave meaning to Unna’s life, and lack of it left so many of his physician contemporaries, and leaves so many physicians today, bereft of gratification that sustains and is sustaining.
The topical preparations that Unna created for Beiersdorf were symbolic of his seemingly limitless capability to spawn ideas. Together with Beiersdorf and his coworkers, Unna developed so many new compounds that he came to perceive the need for a journal devoted to practical aspects of dermatology. In 1882, Unna, his school friend, Oskar Lassar (Fig. 10), and Ferdinand Hebra’s son, Hans von Hebra (Fig. 11), founded the Monthly Journal for Practical Dermatology (“Monatshefte für praktische Dermatologie”), whose name was later changed to Dermatologic Weekly (“Dermatologische Wochenschrift”). Among the therapeutic innovations published in this journal were compounds that still are used today, among them cignolin for the treatment of psoriasis, a plaster that became known as “Leukoplast,” and eucerin, known worldwide today as “Nivea Crème.”
Oskar Lassar (1849-1907)
Hans von Hebra (1847-1902)
In 1891, Unna, together with Henri Leloir of France, Malcolm Morris of England, and Louis Duhring of the United States, founded the International Atlas of Rare Skin Diseases. The purpose was to show examples of cutaneous maladies so instructive that they would be ideal for teaching teachers, not simply for enlightening students. Among the diseases described for the first time in that short-lived publication were angiokeratoma of Mibelli and acanthosis nigricans.9
Of Unna’s innumerable articles on clinical dermatology, the most important was his original account of seborrheic dermatitis (Fig. 12). It was based on a lecture given by him in 1887 at the International Medical Congress in Washington, D.C.10 Even more important than his contributions to clinical dermatology and dermatologic therapy, however, was Unna’s work on histopathologic aspects of the skin. From the time of his medical studies, Unna had experimented with various dyes, and he was the first to recognize that those dyes reacted chemically with particular elements of tissue. Among the stains that Unna developed was polychrome methylene blue that enabled him, in 1887, to conclude that the infiltrate of urticaria pigmentosa was made up of mast cells. In 1891, using the same stain, Unna was able to see, and for the first time to describe, plasma cells. He maintained his interest in specific chemical reactions of elements of tissue throughout his life and summarized his experience in a book titled, Histochemistry of the Skin (“Histochemie der Haut”) that was published in 1928, one year before his death.11
“Seborrhoeal eczema,” picture from Unna’s original article in 1887.
Of all of Unna’s contributions, his most substantial and influential was a textbook of dermatopathology that was part of a multivolume Textbook of Special Pathologic Anatomy, edited by the pathologist Johannes Orth of Göttingen. When, in 1889, Orth asked Unna to write the volume on skin diseases, Unna accepted reluctantly because he understood immediately the perils of the twin ogres that confronted him. This is what he considered to be his options then: “There were two methods open to me. I might either content myself with simply repeating the different statements, critically sifting them, and endeavoring to disentangle the great literary confusion. . . . Or, I might attempt . . . to work once more through the whole of cutaneous pathology – a labor certainly beyond the power of one individual in the short period of five years.”12,13 Unna decided to adopt the latter method, and the intensity of his preparation for the textbook resulted in several new observations about basics, among them spongiosis, ballooning (Fig. 13), and reticular alteration (Fig. 14) in vesicular dermatoses, and the epidermal origin of so-called nevus cells, and “dropping off” of them into the dermis in melanocytic nevi. The phenomenon of “Abtropfung” was set forth comprehensively by him in 1893.14
“Ballooning degeneration of epithelia (varicella),” from Unna’s textbook, Die Histopathologie der hautkrankheiten, 1894.
“Reticular degeneration of epithelia (variola),” from Unna’s textbook, Die Histopathologie der hautkrankheiten, 1894.
One year later, in 1894, Unna’s monumental textbook was published under the title, Histopathology of Skin Diseases (“Die Histopathologie der Hautkrankheiten”) (Fig. 15). At that time, dermatopathology was still embryonic, the only two texts about it having been published 46 years earlier by the dermatologists Simon and von Bärensprung. In his preface to the book, Unna expressed his mission in regard to the volume in these words:
“A summary of the literature soon made it evident to me that there was no real histopathology of the skin, that there was but little harmony between clinical and histological detail, and that to the clinician, microscopical observation had been more troublesome than useful. It is indeed not to be wondered at that very eminent dermatologists, even those whose clinical experience is of the utmost value, turn with impatience from present day histopathology, where all the inflammations of the skin seem to be alike microscopically. The fact that in most dermatological text-books the microscopical anatomy is merely a sort of ornamental addition is but too well justified, for when two skin diseases, clinically distinct, give microscopically the same appearances . . . it is clear that something needs elucidation.”12,13
Frontispiece of Unna’s textbook, Die Histopathologie der hautkrankheiten, 1894.
The elucidation came through a textbook more than 1200 pages in length that covered almost all skin diseases known at that time. Unna’s method was to first provide a brief clinical summary followed by a detailed description of histopathologic findings. Readers today would find the book difficult to use and the language of it ponderous. The table of contents was not organized in a consistent, logical manner, but was a hodgepodge of categories as dissimilar as “traumatic inflammations” and “neurotic inflammations” (Fig. 16). Furthermore, there were very few drawings of histopathologic findings, and the descriptions of those findings were long and tedious, replete with irrelevant details that often were given more attention than criteria essential for coming to specific diagnosis.15 Nevertheless, the book was an instant success and at last put dermatopathology on a firm foundation. Two years after its publication, Unna’s work was translated into English by Norman Walker of Edinburgh, who wrote that, as a consequence of the textbook, Unna had become “the best known dermatologist in the world.”13
Page of the table of contents of Unna’s textbook, Die Histopathologie der hautkrankheiten, 1894.
Unna’s fame led not only to his being invited to international medical congresses, but to his attracting to Hamburg many students from all over the world. In 1886, Unna began postgraduate courses, and shortly thereafter one of his admirers in New York City, Prince Morrow, in his Journal of Cutaneous and Genito-Urinary Diseases, published a notice that must have been written by Unna, somewhat immodestly, himself:
“Dermatological Instruction Abroad. – The advantages of Professor Unna’s instruction is offered to those who wish to take a complete and thorough course in dermatology. Under his personal supervision, physicians and students are instructed in the microscopical, bacteriological, clinical, and therapeutical investigation of skin diseases. His course comprises not less than six months’ study, and it is to be commended as possessing decided advantages over the four weeks’ courses given in Berlin and Vienna. To those contemplating dermatologic study abroad, all requisite information can be obtained by addressing Dr. P.G. Unna, Hamburg.”4
In short, Unna was much appreciated throughout the world for his scholarship, accomplishments, and contributions, but much less so in Germany. The reason was not only the biblical adage that “a prophet is not honored in his own community,” but more important the fact that Unna had not paid homage to the hierarchy of academe. He was the quintessential academic outside a university – uncontrolled and unrestricted, uncontrollable and unrestrictable. Despite the title Professor bestowed on Unna in the advertisement in Prince Morrow’s journal, Unna was not a professor and had no faculty rank, yet he dared to give courses that were said by him to be better than those given at the universities in Berlin and Vienna. It is little wonder that the academic establishment in Germany was less than sanguine about him.
Unna himself contributed further to the antipathy by giving his opponents ample opportunity to attack him. Many of his concepts were fanciful and even wrong; for example, much of his work on the chemistry of the cell. He conceived of a cell, simplistically, as consisting of zones of oxidation and reduction that, in his view, were composed of acidic and basic proteins that he claimed were responsible for different properties of staining. In order to explain all kinds of staining reactions, however, he advanced a complicated model that he called “The three stories of cellular proteins” (Fig. 17). In brief, he compared the cell to a small building in which three floors were reserved for the storage of different groups of proteins, which he named by such opaque terms as “plastin” and “mesoplastin” for the nuclear proteins and “spongioplasma” and “granoplasma” for the cytoplasmic proteins. Neither the terms nor the concept were ever accepted, and justifiably.11
“The Three Stories of Cellular Proteins,” from Unna’s textbook, Histochemie der Haut, 1928.
Unna, however, never capitulated or even so much as retreated. Although his tenacity and fearlessness are much to be admired, his tendency to persist defiantly and unflaggingly sometimes verged on stubbornness and obstinacy akin to arrogance. Unna was not known for his willingness to admit error. For another example, when Unna characterized seborrheic dermatitis, he insisted that the condition was caused by a “morococcus.” In his Histologic Atlas on Pathology of the Skin, published in sections between 1897 and 1910, he captured accurately the features of seborrheic dermatitis, e.g., mounds of parakeratosis at lips of follicular ostia, but his causative “morococcus” appeared wrongly in every drawing (Fig. 18). That bacterium was said by Unna to be responsible not only for seborrheic dermatitis, but for all kinds of “eczema.”16 And for a third example, there is the story of the plasma cell. In 1891, Unna identified plasma cells for the first time, but until his death, despite all evidence to the contrary, he insisted that they were derived from spindle cells in connective tissue, that they always were products of disease, and that they divided to give rise to lymphocyte-like “daughter plasma cells” (Fig. 19).5 Unna clung to his hypotheses in a manner that later was described by his friend of many years, Jean Darier (Fig. 20), in this way:
Histopathology of “seborrheal eczema.” from Unna’s Histologischer Atlas zur Pathologie der Haut, 1910.
“Development of plasma cells – plasma daughter cells. The plasma cells of granulation tissue.” from Unna’s Histologischer Atlas zur Pathologie der Haut, 1910.
Jean Darier (1856-1938)
“It was with the temperament of the wrestler that he confronted the opposition and the obstacles with which his path was strewn throughout his life. Nor was he an easy man to argue with; it was hardly ever possible to bring him round to see the pros and cons of a subject or indeed to consider an opinion that did not coincide exactly with his own. Without giving ground to any significant degree he continued to hang on to his convictions and yet made no great effort to win you over, depending rather on the passage of time and the force of truth which to his mind were certain to bring about the downfall of all opposition.”4
For all these reasons, Unna was skewered often by colleagues and was even the object of ridicule by them. As but one example of that hostility to him is a vicious dog in the clinic of Albert Neisser, chairman of dermatology at the University of Breslau. Neisser named the dog “Unna” and as something other than a term of endearment.8 In Vienna, Unna was no less despised than in Breslau. When Eduard Láng and Hans von Hebra proposed in March 1894 that Unna be made an honorary member of the Vienna Dermatological Society, Moriz Kaposi declared publicly that he would leave the society immediately should that happen.17 In the first two decades of the 20th century, the most important journal of dermatology worldwide, the Archiv für Dermatologie und Syphilis, honored several dermatologists by devoting a Festschrift to them. Among those dermatologists were Moriz Kaposi, Filipp Josef Pick, Caesar Boeck, and Julius Caspary, but not Paul Gerson Unna. When Unna’s pupil and friend, Ernst Delbanco (Fig. 21), organized a Festschrift on the occasion of Unna’s sixtieth birthday in 1910, leading dermatologists from abroad contributed to it, but not a single dermatologist from Germany.
Ernst Delbanco (1869-1935)
Toward the end of Unna’s career, however, the fierce opposition to him abated, and at long last he was given the recognition he deserved for his many contributions (Fig. 22). He was made an honorary member of many dermatological societies, including the American Dermatological Association and the societies of the cities of Paris, Rome, Vienna, Berlin and, after Kaposi’s death, even Vienna. After having been treated successfully with ichthyol, a compound introduced by Unna, the German Chancellor, Otto von Bismarck, wanted to confer on Unna the title “Professor,” but Unna declined because he considered the circumstances surrounding it to be inappropriate.1 He accepted that title in 1907, however, when he received it from the Senate of Hamburg 12 years before the University of Hanburg was founded, and as the first physician ever who was not in the official employ of the city. Together with the title of “Professor,” Unna was given a small dermatology unit at the hospital in Hamburg-Eppendorf. In 1920, following the founding of the University of Hamburg, Unna’s “Dermatologikum” was granted the status of a university hospital as long as that institute remained under his personal aegis.18
Paul Gerson Unna (circa 1925)
Unna never received an honorary doctorate of medicine. In 1927, however, the chairman of dermatology at the University of Bonn, Erich Hoffmann (Fig. 23), secured for Unna an honorary doctorate of the faculty of philosophy at that university, an honor that Unna appreciated more than any other that came to him. Marion B. Sulzberger, who attended the ceremony, recalled the awarding of the degree thus: “With pomp and fanfare, Unna was called to the platform to receive his honor. Unna stood immobile while his praises were being intoned and the Diploma of Doctor of Philosophy Honoris Causa was handed to him. When the loud and long applause subsided, Unna marched back to his seat without a word of acknowledgement.”19 It is probable that Unna did not speak because he was choked with emotion.
Erich Hoffmann (1868-1959)
On January 25, 1929, Unna revised the manuscript of a brief autobiography. Four days later, at the age of 78, he died from an attack of influenza. Hardly a nook or cranny of dermatology had not been influenced by his creative genius.