MBS Review
SULZBERGER ON MILITARY DERMATOLOGY ALFRED M. ALLEN, M.D., M.P.H.
tion in which he served. He and coinvestigators had conducted fundamental researches into the causes, treatment and prevention of common, potentially disabling dermatoses, among them fungal infections,^-'' scabies,^ reactions to irritants and contact sensitizers,'' and burns caused by vesicant gases used in chemical warfare.' In addition to this, clinical investigations he carried out on Cuam during the last few months of the war confirmed the association between prickly heat and tropical anhydrotic aesthenia,** provided data that suggested miliaria is due to obstruction of the sweat duct orifice by keratin plugs,^ and established in the literature a previously undescribed entity under the term "tropical acne."'" A preoccupation during the war years was the "urgent necessity for predicting with utmost possible rapidity and accuracy just what certain old and newly introduced materials would do to the skins of the millions of our service men and women who would regularly be exposed to the effects of these materials."'' This led to the popularization by Sulzberger and co-workers of the paired comparisons experimental design, which they dubbed the "method of simultaneous symmetrical paired comparisons."2- Insistence on application of this and other scientific principles and methods helped introduce rigorous standards to the der-
From the Department of Dermatology Research, Letterman Army Institute of Research, San Francisco, tOalifornia
As a relatively inexperienced US Naval medical officer at the onset of World War II, Lieutenant Commander Marion B. Sulzberger was able to capture the essence of military dermatology with the verbal clarity and force that is characteristically his. "The principal problems of military dermatology," he wrote in 1941, "are those of prevention and of reducing the morbidity due to common skin diseases. . . . It is the task of the military dermatologist to see that the modern methods are standardized and applied in routine fashion throughout. . . ."' He also prophetically recognized the area in which he would make his principal contributions to military dermatology: "the controlled conditions obtainable in military organizations often offer unparalleled opportunities for statistical and comparative studies regarding the practicability and effectiveness of competing methods."! Thrust of his Wartime Investigations By war's end in 1945, a senior and experienced Captain Sulzberger could look back on 4 progressively triumphant years for himself and the military organiza380
No. 5
MILITARY DERMATOLOCY
matologic invesfigations of fhe postwar period. Use of the paired comparison design in a paired foot study of various agents thought to have antifungal properties provided strong evidence that undecylenic acid was the best of the lot.^-t Other applications of extreme importance during the war years were "to find out as rapidly as possible which of the many formulas for anti-gas ointments was the most effective and the least damaging; which of the many insect repellent preparations was the least unpleasant, least irritating, and active for the longest period; under which form of topical application thermal and chemical burns would have the most rapid healing, the lowest incidence of infection, and the least irritation and retractile scarring; (and) which sun-protective cream or flash-burn protective ointment was the best and likely to be the least irritating to the skin. . . ."'' Wartime Publications Much of the scientific work done by Sulzberger and associates during World War II was classified secret or confidential; therefore, the many reports (more than 100) to the National Research Council and to the US Army and US Navy were never made public. An inkling of the extensive work in skin sensitization to vesicant agents of chemical warfare is contained in a report published in the lournal of Investigative Dermatology after the war.' Although historical in nature, the published report gives an indication of the enormous problems experienced by wartime investigators, who were suddenly confronted by the need to find cutaneous protection against such agents as mustard gas, nitrogen mustards, and lewisite. An interesting offshoot of the studies on protection against war gases was the development of an agent, chloroamide.
Allen
381
which when incorporated into a topically applied ointment offered significant protection against a common peacetime problem, poison ivy.^' Perhaps the most memorable of all Sulzberger's contributions to dermatology during World War II was his coauthorship with Pillsbury and Livingood of the Manual of Dermatology, published under the auspices of the National Research Council in 1942.^2 This small book, which was deliberately made compact, rugged and pocket-sized, became the dermatologic "Bible" to thousands of physicians pressed into military service all over the world. Its practical, straightforward, no-nonsense approach to communication of basic medical information made it a favorite for many years after its publication. The "close-out" World War II contribution to dermatology in the US Navy appeared in the form of a chapter entitled "Dermatology" by Sulzberger and Novy, which was published in The History of tbe Medical Department of tbe U. S. Navy in World War in^ in 1953. The chapter is a convenient summary of the common dermatologic problems faced by the Navy during the war and the scientific investigations mounted to conquer them. Later Military-Oriented Work Though retired from Naval service in 1946, removal of the uniform did not end Captain Sulzberger's keen interest in the dermatologic problems of the military; nor did it more than temporarily stem the flow of militarily oriented professional publications. In 1954 a paper appeared under his name with the title "The Fitness for Military Service of Patients with Certain Chronic Dermatoses."' * This was only a prelude to what was to come. In 1961, a year after retiring as Professor and Chairman of the Department of Dermatology at New York University, Sulz-
382
INTERNATIONAL JOURNAL OF DERMATOLOCY
berger joined the US Army Medical Research and Development Command in Washington, DC, as a full-time Technical Director of Research. In this position he was frequently called upon to articulate the need for, and the goals of, military research, especially that involving the skin and its diseases. With characteristic lucidity, he showed how basic research can meaningfully be differentiated from applied research,'^ how military medical research is unique and necessary,"• and how vital it is for the military to find new and better ways to enhance the protective capabilities already built in to the wondrous natural form of body armor called the human skin.''' The year 1954 marked the beginning of a department of dermatology research at an offshoot of the Letterman Army Hospital in San Francisco, California, now called the Letterman Army Institute of Research. Sulzberger moved west to assume the position of Scientific Advisor to the Institute, and as a charter member had a great deal to do with charting the course of the fledgling dermatology research component. Under his direction and guidance, the research unit concentrated its efforts on the effects of heat and humidity on the skin, with emphasis on 4 specific problem areas, namely blisters, miliaria, insect repellents, and factors that alter the permeability of the skin.18 Papers on these subjects written by Sulzberger and others followed in due course.'^' 20 The war in Vietnam provided ample confirmation of the importance of skin diseases to the military.^' It also created a heightened awareness of the need for a practical manual on the management of common skin diseases by physicians or paraprofessionals with little or no formal training in dermatology. Although it does not bear his name, Sulzberger was a coauthor of the booklet prepared to fill this need, the Army Field Manual Manage-
June 1977
Vol. 16
ment of Skin Diseases by Company Aidmen in Tropics, published in 1969.^2 AJI of the foregoing should make it clear that Sulzberger's contributions to military dermatology were so many and varied that he could be called 'the man for all seasons" in this respect. He has left a model to follow for the dermatologist who wishes to make the greatest possible professional contributions during terms of military service. References 1. Sulzherger, M. B., MacClatchie, L. K., and Parsons, R. P.: Military dermatology and syphilology. Med. Clin. N. Am. 25:1677, 1941. 2. Sulzberger, M. B., Shaw, H. C , and Kanof, A.: Evaluation of measures for use against common fungous infections of skin: Screening tests by means of paired comparisons on human subjects. US Naval Med. Bull. 45:237, 1945. 3. Sulzberger, M. B., and Kanof, A.: Comparative evaluation of preparations for the propbylaxis and treatment of fungous infections of feet. US Naval Med. Bull. 46:822, 1946. 4. Sulzberger, M. B., and Kanof, A.: Undecylenic and propionic acids in the prevention and treatment of dermatophyfosis. Arch. Dermatoi. Syphilol. 55:391, 1947. 5. Carpenter, C. C , Hemlein, J. A., Sulzberger, M. B., and Baer, R. L.: Scabies and pediculosis treated with benzyl benzoate, DDT, benzocaine emulsion. J. Invest. Dermatol. 7:93, 1946. 6. Sulzberger, M. B., Baer, R. L., Kanof, A., and Lowenberg, C : Methods for the rapid evaluation of the beneficial and harmful effects of agents applied to the human skin. J. Invest. Dermatol. 7:227, 1946. 7. Sulzberger, M. B., Baer, R. L., Kanof, A., and Lowenberg, C : Skin sensitization to vesicant agents of chemical warfare. |. Invest. Dermatol. 8:365, 1947. 8. Sulzberger, M. B., Zimmerman, H. M., and Emerson, K., jr.: Tropical anidrotic asthenia (thermogenic anhidrosis) and its relationship to prickly heat. J. Invest. Dermatol. 7:153, 1946. 9. Sulzberger, M. B., and Zimmerman, H. M.: Studies on prickly heat II, Experimental and histologic findings. J. Invest. Dermatol. 7:61, 1946. 10. Sulzberger, M. B., Addenbrooke, E. E., Joyce, S. J., Greenberg, S., and Mack, A. C : Tropical acne. US Naval Med. Bull. 46:1178, 1946.
No. 5
MILITARY DERMATOLOGY
11. Sulzberger, M. B., Baer, R. L., and Kanof, A.: Chloramide containing ointments in prevention of experimental poison ivy dermatitis. ). Invest. Dermatol. 7:145, 1946. 12. Pillsbury, D. M., Livingood, C , and Sulzberger, M. B,: Manual of Dermatology. Philadelphia, W. B. Saunders, 1942. 13. Sulzberger, M. B., and Novy, F. C , Jr.: Dermatology in The History of the Medical Department of the United States Navy in World yVar II. Vol. I. Washington, DC, Govt. Printing Office, 1953, pp. 299-314. 14. Sulzberger, M. B.: The fitness for military service of patients with certain chronic dermatoses. US Armed Forces Med. J. 5:968, 1954. 15. Sulzberger, M. B.: On basic and applied research. Milit. Med. 127:468, 1962. 16. Sulzberger, M. B.: Progress and prospects in idiophylaxis (built-in individual self-protection of the combat soldier). Proceedings of
17.
18,
19,
20. 21,
22.
Allen
383
1962 Army Science Conference, West Point, NY, 1962. Sulzberger, M. B.: Theme of the month: body armor. Army R&D News Magazine 3:2, 1962. Sulzberger, M. B.: The effects of heat and humidity on the human skin. Arch. Environ. Health 11:400, 1965. Sulzberger, M. B,, and Griffin, T. B,: Induced miliaria, postmlliarial hypohidrosis, and some potential sequelae. Arch, Dermatol. 99:145, 1969. Akers, W, A., and Sulzberger, M. B.: The friction blister. Milit. Med. 137:1, 1972. Sulzberger, M. B., and Akers, W. A.: Impact of skin diseases on military operations. Arch. Dermatol. 100:702, 1969. FM 8-40: Management of Skin Diseases by Company Aidmen in the Tropics. Washington, DC, Headquarters, Department of the Army, 1969.
-x: y "My Alter Ego," by Tobias R. Funt, M.D,, Fort Lauderdale, FL. Third place watercolor from the 1975 art exhibit of the American Academy of Dermatology.
SULZBERGER ON MILITARY DERMATOLOGY ALFRED M. ALLEN, M.D., M.P.H.
tion in which he served. He and coinvestigators had conducted fundamental researches into the causes, treatment and prevention of common, potentially disabling dermatoses, among them fungal infections,^-'' scabies,^ reactions to irritants and contact sensitizers,'' and burns caused by vesicant gases used in chemical warfare.' In addition to this, clinical investigations he carried out on Cuam during the last few months of the war confirmed the association between prickly heat and tropical anhydrotic aesthenia,** provided data that suggested miliaria is due to obstruction of the sweat duct orifice by keratin plugs,^ and established in the literature a previously undescribed entity under the term "tropical acne."'" A preoccupation during the war years was the "urgent necessity for predicting with utmost possible rapidity and accuracy just what certain old and newly introduced materials would do to the skins of the millions of our service men and women who would regularly be exposed to the effects of these materials."'' This led to the popularization by Sulzberger and co-workers of the paired comparisons experimental design, which they dubbed the "method of simultaneous symmetrical paired comparisons."2- Insistence on application of this and other scientific principles and methods helped introduce rigorous standards to the der-
From the Department of Dermatology Research, Letterman Army Institute of Research, San Francisco, tOalifornia
As a relatively inexperienced US Naval medical officer at the onset of World War II, Lieutenant Commander Marion B. Sulzberger was able to capture the essence of military dermatology with the verbal clarity and force that is characteristically his. "The principal problems of military dermatology," he wrote in 1941, "are those of prevention and of reducing the morbidity due to common skin diseases. . . . It is the task of the military dermatologist to see that the modern methods are standardized and applied in routine fashion throughout. . . ."' He also prophetically recognized the area in which he would make his principal contributions to military dermatology: "the controlled conditions obtainable in military organizations often offer unparalleled opportunities for statistical and comparative studies regarding the practicability and effectiveness of competing methods."! Thrust of his Wartime Investigations By war's end in 1945, a senior and experienced Captain Sulzberger could look back on 4 progressively triumphant years for himself and the military organiza380
No. 5
MILITARY DERMATOLOCY
matologic invesfigations of fhe postwar period. Use of the paired comparison design in a paired foot study of various agents thought to have antifungal properties provided strong evidence that undecylenic acid was the best of the lot.^-t Other applications of extreme importance during the war years were "to find out as rapidly as possible which of the many formulas for anti-gas ointments was the most effective and the least damaging; which of the many insect repellent preparations was the least unpleasant, least irritating, and active for the longest period; under which form of topical application thermal and chemical burns would have the most rapid healing, the lowest incidence of infection, and the least irritation and retractile scarring; (and) which sun-protective cream or flash-burn protective ointment was the best and likely to be the least irritating to the skin. . . ."'' Wartime Publications Much of the scientific work done by Sulzberger and associates during World War II was classified secret or confidential; therefore, the many reports (more than 100) to the National Research Council and to the US Army and US Navy were never made public. An inkling of the extensive work in skin sensitization to vesicant agents of chemical warfare is contained in a report published in the lournal of Investigative Dermatology after the war.' Although historical in nature, the published report gives an indication of the enormous problems experienced by wartime investigators, who were suddenly confronted by the need to find cutaneous protection against such agents as mustard gas, nitrogen mustards, and lewisite. An interesting offshoot of the studies on protection against war gases was the development of an agent, chloroamide.
Allen
381
which when incorporated into a topically applied ointment offered significant protection against a common peacetime problem, poison ivy.^' Perhaps the most memorable of all Sulzberger's contributions to dermatology during World War II was his coauthorship with Pillsbury and Livingood of the Manual of Dermatology, published under the auspices of the National Research Council in 1942.^2 This small book, which was deliberately made compact, rugged and pocket-sized, became the dermatologic "Bible" to thousands of physicians pressed into military service all over the world. Its practical, straightforward, no-nonsense approach to communication of basic medical information made it a favorite for many years after its publication. The "close-out" World War II contribution to dermatology in the US Navy appeared in the form of a chapter entitled "Dermatology" by Sulzberger and Novy, which was published in The History of tbe Medical Department of tbe U. S. Navy in World War in^ in 1953. The chapter is a convenient summary of the common dermatologic problems faced by the Navy during the war and the scientific investigations mounted to conquer them. Later Military-Oriented Work Though retired from Naval service in 1946, removal of the uniform did not end Captain Sulzberger's keen interest in the dermatologic problems of the military; nor did it more than temporarily stem the flow of militarily oriented professional publications. In 1954 a paper appeared under his name with the title "The Fitness for Military Service of Patients with Certain Chronic Dermatoses."' * This was only a prelude to what was to come. In 1961, a year after retiring as Professor and Chairman of the Department of Dermatology at New York University, Sulz-
382
INTERNATIONAL JOURNAL OF DERMATOLOCY
berger joined the US Army Medical Research and Development Command in Washington, DC, as a full-time Technical Director of Research. In this position he was frequently called upon to articulate the need for, and the goals of, military research, especially that involving the skin and its diseases. With characteristic lucidity, he showed how basic research can meaningfully be differentiated from applied research,'^ how military medical research is unique and necessary,"• and how vital it is for the military to find new and better ways to enhance the protective capabilities already built in to the wondrous natural form of body armor called the human skin.''' The year 1954 marked the beginning of a department of dermatology research at an offshoot of the Letterman Army Hospital in San Francisco, California, now called the Letterman Army Institute of Research. Sulzberger moved west to assume the position of Scientific Advisor to the Institute, and as a charter member had a great deal to do with charting the course of the fledgling dermatology research component. Under his direction and guidance, the research unit concentrated its efforts on the effects of heat and humidity on the skin, with emphasis on 4 specific problem areas, namely blisters, miliaria, insect repellents, and factors that alter the permeability of the skin.18 Papers on these subjects written by Sulzberger and others followed in due course.'^' 20 The war in Vietnam provided ample confirmation of the importance of skin diseases to the military.^' It also created a heightened awareness of the need for a practical manual on the management of common skin diseases by physicians or paraprofessionals with little or no formal training in dermatology. Although it does not bear his name, Sulzberger was a coauthor of the booklet prepared to fill this need, the Army Field Manual Manage-
June 1977
Vol. 16
ment of Skin Diseases by Company Aidmen in Tropics, published in 1969.^2 AJI of the foregoing should make it clear that Sulzberger's contributions to military dermatology were so many and varied that he could be called 'the man for all seasons" in this respect. He has left a model to follow for the dermatologist who wishes to make the greatest possible professional contributions during terms of military service. References 1. Sulzherger, M. B., MacClatchie, L. K., and Parsons, R. P.: Military dermatology and syphilology. Med. Clin. N. Am. 25:1677, 1941. 2. Sulzberger, M. B., Shaw, H. C , and Kanof, A.: Evaluation of measures for use against common fungous infections of skin: Screening tests by means of paired comparisons on human subjects. US Naval Med. Bull. 45:237, 1945. 3. Sulzberger, M. B., and Kanof, A.: Comparative evaluation of preparations for the propbylaxis and treatment of fungous infections of feet. US Naval Med. Bull. 46:822, 1946. 4. Sulzberger, M. B., and Kanof, A.: Undecylenic and propionic acids in the prevention and treatment of dermatophyfosis. Arch. Dermatoi. Syphilol. 55:391, 1947. 5. Carpenter, C. C , Hemlein, J. A., Sulzberger, M. B., and Baer, R. L.: Scabies and pediculosis treated with benzyl benzoate, DDT, benzocaine emulsion. J. Invest. Dermatol. 7:93, 1946. 6. Sulzberger, M. B., Baer, R. L., Kanof, A., and Lowenberg, C : Methods for the rapid evaluation of the beneficial and harmful effects of agents applied to the human skin. J. Invest. Dermatol. 7:227, 1946. 7. Sulzberger, M. B., Baer, R. L., Kanof, A., and Lowenberg, C : Skin sensitization to vesicant agents of chemical warfare. |. Invest. Dermatol. 8:365, 1947. 8. Sulzberger, M. B., Zimmerman, H. M., and Emerson, K., jr.: Tropical anidrotic asthenia (thermogenic anhidrosis) and its relationship to prickly heat. J. Invest. Dermatol. 7:153, 1946. 9. Sulzberger, M. B., and Zimmerman, H. M.: Studies on prickly heat II, Experimental and histologic findings. J. Invest. Dermatol. 7:61, 1946. 10. Sulzberger, M. B., Addenbrooke, E. E., Joyce, S. J., Greenberg, S., and Mack, A. C : Tropical acne. US Naval Med. Bull. 46:1178, 1946.
No. 5
MILITARY DERMATOLOGY
11. Sulzberger, M. B., Baer, R. L., and Kanof, A.: Chloramide containing ointments in prevention of experimental poison ivy dermatitis. ). Invest. Dermatol. 7:145, 1946. 12. Pillsbury, D. M., Livingood, C , and Sulzberger, M. B,: Manual of Dermatology. Philadelphia, W. B. Saunders, 1942. 13. Sulzberger, M. B., and Novy, F. C , Jr.: Dermatology in The History of the Medical Department of the United States Navy in World yVar II. Vol. I. Washington, DC, Govt. Printing Office, 1953, pp. 299-314. 14. Sulzberger, M. B.: The fitness for military service of patients with certain chronic dermatoses. US Armed Forces Med. J. 5:968, 1954. 15. Sulzberger, M. B.: On basic and applied research. Milit. Med. 127:468, 1962. 16. Sulzberger, M. B.: Progress and prospects in idiophylaxis (built-in individual self-protection of the combat soldier). Proceedings of
17.
18,
19,
20. 21,
22.
Allen
383
1962 Army Science Conference, West Point, NY, 1962. Sulzberger, M. B.: Theme of the month: body armor. Army R&D News Magazine 3:2, 1962. Sulzberger, M. B.: The effects of heat and humidity on the human skin. Arch. Environ. Health 11:400, 1965. Sulzberger, M. B,, and Griffin, T. B,: Induced miliaria, postmlliarial hypohidrosis, and some potential sequelae. Arch, Dermatol. 99:145, 1969. Akers, W, A., and Sulzberger, M. B.: The friction blister. Milit. Med. 137:1, 1972. Sulzberger, M. B., and Akers, W. A.: Impact of skin diseases on military operations. Arch. Dermatol. 100:702, 1969. FM 8-40: Management of Skin Diseases by Company Aidmen in the Tropics. Washington, DC, Headquarters, Department of the Army, 1969.
-x: y "My Alter Ego," by Tobias R. Funt, M.D,, Fort Lauderdale, FL. Third place watercolor from the 1975 art exhibit of the American Academy of Dermatology.
