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Series Introduction
During the past 25 years there has been a vast explosion of new information relating to the art
and science of dermatology, as well as fundamental cutaneous biology. Furthermore, this
information is no longer of interest to only the small but growing specialty of dermatology.
Clinicians and scientists from a wide variety of disciplines have come to recognize both the
importance of skin in fundamental biological processes and the broad implications of under-
standing the pathogenesis of skin disease. As a result, there is now a multidisciplinary and
worldwide interest in the progress of dermatology.
With these factors in mind, we have undertaken this series of books specifically oriented
to dermatology. The scope of this series is purposely broad, with books ranging from pure basic
science to practical, applied clinical dermatology. Thus, while there is something for everyone,
all volumes in this series will ultimately prove to be valuable additions to the dermatologist’s
library.
The latest volume in the series (No. 38), by Lim, Hönigsmann, and Hawk, presents a com-
prehensive and current review of photomedicine by world renowned authorities. The role
of photobiology in medicine has received increased emphasis in the past decade as a result
of considerable new information regarding the molecular biological effects of ultraviolet
light, its effect on the immune system, its role in the promotion of skin cancer, and its
abuse by profiteers who market suntan parlors. It is, therefore, critically important that
dermatologists, physicians in general, biologists, and public health scientists remain current
in photomedicine. I believe that Dr. Lim and his coeditors have produced a timely and
critically important addition to our series, which is both timely and comprehensive.
Alan R. Shalita, MD
Distinguished Teaching Professor and Chairman
Department of Dermatology
SUNY Downstate Medical Center
Brooklyn, New York, U.S.A.
Preface
Within the past 30 years photomedicine has developed from empiricism into one of the most
exciting fields in biomedical research. Studies on the effects of visible and ultraviolet radiation
on skin have led to a fruitful collaboration between basic scientists and clinicians. The success-
ful use of the new ultraviolet techniques for the treatment of skin disease, along with a rapidly
increasing understanding of the pathogenesis of photodermatoses, thereby markedly improv-
ing their treatment, have been the driving force for the development of a new subspecialty of
photodermatology. This now encompasses the diagnosis and treatment of sunlight-induced
disorders; all aspects of phototherapy, including the use of such new modalities as photody-
namic therapy for skin tumors and other diseases; as well as photoprotection, which continues
to evolve with the development of new generations of ultraviolet filters. In the past decade,
therefore, very significant advances have occurred throughout this novel subspecialty, particu-
larly in photoimmunology, molecular biology, and genetics. In more detail, these include better
recognition and understanding of:
. Acute and chronic effects of ultraviolet radiation on the skin: in vitro studies, animal
models, photoaging, and epidemiology of skin cancers;
. Clinical manifestation of photodermatoses: actinic prurigo, pin-head papule form of poly-
morphous light eruption, novel genetic mutations in porphyrias, and so on;
. Pathophysiology and treatment of photodermatoses: polymorphous light eruption, actinic
prurigo, chronic actinic dermatitis, xeroderma pigmentatosum, photo-exacerbated derma-
toses, and so on;
. The science of photoprotection: new ultraviolet filters, photoprotection by clothing, photo-
protection by oral agents, and so on;
. Phototherapy: narrowband ultraviolet B, ultraviolet A1, visible light;
. Topical photodynamic therapy;
. Medical and cosmetic applications of laser and similar radiation sources; and
. New insight on the use of laser and radiation sources on people of color.
In planning for this book, our vision as editors was to create a book that is comprehensive
and up-to-date, yet is user-friendly to its intended readers who are busy, practicing dermatol-
ogists, photodermatologists, and trainees in dermatology. The editors are pleased that recog-
nized experts from many parts of the world willingly put in the effort and contributed most
informative chapters for this book.
The book consists of six sections. Section I is on history and basic principles, followed
by the effects of ultraviolet radiation on normal skin in Section II. Section III covers all the
photodermatoses, while Section IV and V discuss photoprotection and ultraviolet and visible
radiation therapy. Section VI is a practical description of testing methods used in photoderma-
tology and guidelines of setting up a phototherapy and laser center.
The three of us work in the United States, Europe, and the United Kingdom. We have
taken great care to make sure that materials covered in this book reflect an international
point of view. For example, international coverage is done on actinic prurigo (commonly
seen in Central and South America), photoprotection (different ultraviolet filters available in
different parts of the world), light sources and laser, and many other topics. It is our hope
that the readers will find that this book provides a good perspective on the worldwide scope
of photodermatology.
vi Preface
On a personal note, the three of us have been colleagues and friends for many years; all of
us have separately published books in photodermatology in the early and late 1990s. It has
been a real pleasure to combine our experience and to work on editing this book together.
We do hope that the readers will enjoy this book as much as we have enjoyed writing and
editing it.
Henry W. Lim, MD
Herbert Hönigsmann, MD
John L. M. Hawk, MD
Acknowledgments
Henry W. Lim would like to thank his parents, for providing him the opportunity to succeed,
and his wife Mamie, for her unending patience and support.
Hebert Hönigsmann would like to thank his wife Xandi, for tolerating the lack of care
and attention to the family during the preparation of this book.
John L. M. Hawk would like to thank his wife, Lorna, for her continuing tolerance and support,
as ever previously, throughout the preparation of this book.
The editors would like to thank Sandra Beberman and her team at Informa Healthcare for
working with us to produce this book.
Contents
Series Introduction Alan R. Shalita, MD iii

Preface v
Acknowledgments vii
Contributors xiii
Section I: History and Basic Principles

1. History of Human Photobiology 1
Rik Roelandts
2. Basic Principles of Photobiology 15

Brian L. Diffey and Irene E. Kochevar
3. Radiation Sources and Interaction with Skin 29

Harvey Lui and R. Rox Anderson
Section II: Effects of Ultraviolet Radiation on Normal Skin

4. The Molecular and Genetic Effects of Ultraviolet Radiation
Exposure on Skin Cells 41
Marjan Garmyn and Daniel B. Yarosh
5. Photoimmunology 55
Thomas Schwarz and Gary M. Halliday
6. The Acute Effects of Ultraviolet Radiation on the Skin 75

Lesley E. Rhodes and Henry W. Lim
7. The Chronic Effects of Ultraviolet Radiation on the Skin: Photoaging 91

Mina Yaar
8. The Chronic Effects of Ultraviolet Radiation on

the Skin: Photocarcinogenesis 107
Antony R. Young and Norbert M. Wikonkál
9. The Epidemiology of Skin Cancer 119

Luigi Naldi and Thomas Diepgen
Section III: Photodermatoses

Part A: Basic Principles
10. Evaluation of the Photosensitive Patient 139
Henry W. Lim and John L. M. Hawk
x Contents
Part B: Immunologically-Mediated Photodermatoses

11. Polymorphous Light Eruption, Hydroa Vacciniforme,
and Actinic Prurigo 149
Herbert Hönigsmann and Maria Teresa Hojyo-Tomoka
12. Chronic Actinic Dermatitis 169

John L. M. Hawk and Henry W. Lim
13. Solar Urticaria 185

Takeshi Horio and Erhard Hölzle
Part C: Drug and Chemical-Induced Photosensitivity

14. Drug and Chemical Photosensitivity: Exogenous 199
James Ferguson and Vincent A. DeLeo
15. Cutaneous Porphyrias 219

Gillian M. Murphy and Karl E. Anderson
Part D: DNA Repair-Deﬁcient Photodermatoses

16. Xeroderma Pigmentosum and Other DNA
Repair-Deficient Photodermatoses 239
Mark Berneburg and Kenneth H. Kraemer
Part E: Photoaggravated Dermatoses

17. Photoaggravated Dermatoses 251
Victoria P. Werth and Herbert Hönigsmann
Section IV: Photoprotection

18. Photoprotection 267
Henry W. Lim and Herbert Hönigsmann
19. Novel Developments in Photoprotection: Part I 279

Uli Osterwalder and Henry W. Lim
20. Novel Developments in Photoprotection: Part II 297

André Rougier, Sophie Seite, and Henry W. Lim
21. Public Education in Photoprotection 311

Cheryl Rosen and Mark Naylor
Section V: Ultraviolet and Visible Radiation Therapy

22. Phototherapy with UVB: Broadband and Narrowband 319
Michael Zanolli and Peter M. Farr
23. Ultraviolet-A1 and Visible Light Therapy 335

Jean Krutmann and Akimichi Morita
24. Psoralen Photochemotherapy 347

Warwick L. Morison and Herbert Hönigsmann
25. Extracorporeal Photochemotherapy (Photopheresis) 359

Robert Knobler and Peter W. Heald
Contents xi
26. Photodynamic Therapy 369

Sally H. Ibbotson and Rolf-Markus Szeimies
27. The Principles and Medical Applications of Lasers and Intense-Pulsed Light in
Dermatology 389
Iltefat Hamzavi and Harvey Lui
28. Lasers and Energy Sources for Skin Rejuvenation and Epilation 401
Robert A. Weiss and Michael Landthaler
29. Laser Treatment on Ethnic Skin 417

Henry Hin Lee Chan and Brooke Jackson
Section VI: Appendices

Appendix A. Phototesting 433
Peter M. Farr and Robert S. Dawe
Appendix B. Photopatch Testing 441

Percy Lehmann, Frank C. Victor, and David E. Cohen
Appendix C. Guidelines for Setting Up a Phototherapy Referral Center or an

Office-Based Phototherapy Unit 449
Michael Zanolli and Roy Palmer
Appendix D. Guidelines for Setting Up a Laser Center 457

Macrene R. Alexiades-Armenakas and Jeffrey S. Dover
Index 463
Contributors
Macrene R. Alexiades-Armenakas Department of Dermatology, Yale University School of

Medicine, New Haven, Connecticut, U.S.A.
Karl E. Anderson Department of Internal Medicine, Division of Gastroenterology and

Hepatology, University of Texas Medical Branch, Galveston, Texas, U.S.A.
R. Rox Anderson Wellman Center for Photomedicine and Department of Dermatology, Harvard
Medical School, and Massachusetts General Hospital, Boston, Massachusetts, U.S.A.
Mark Berneburg Department of Dermatology, Eberhard Karls University, Tuebingen, Germany
Henry Hin Lee Chan Division of Dermatology, Department of Medicine, University of

Hong Kong, and Department of Medicine and Therapeutics, Chinese University of
Hong Kong, Hong Kong, China
David E. Cohen Ronald O. Perelman Department of Dermatology, New York University

School of Medicine, New York, New York, U.S.A.
Robert S. Dawe Department of Dermatology, Ninewells Hospital and Medical School,

Dundee University, Dundee, Scotland, U.K.
Vincent A. DeLeo Columbia University, St. Luke’s– Roosevelt Hospital Center, New York,
New York, U.S.A.
Thomas Diepgen Department of Clinical Social Medicine, Occupational and Environmental

Dermatology, Heidelberg, Germany
Brian L. Diffey Department of Regional Medical Physics, Newcastle General Hospital,

Newcastle, England, U.K.
Jeffrey S. Dover Department of Dermatology, Yale University School of Medicine, New Haven,
Connecticut, and Dartmouth Medical School, Hanover, New Hampshire, U.S.A.
Peter M. Farr Department of Dermatology, Royal Victoria Infirmary, Newcastle upon Tyne,
England, U.K.
James Ferguson Photobiology Unit, Ninewells Hospital, Dundee, Scotland, U.K.
Marjan Garmyn Department of Dermatology, University of Leuven, Leuven, Belgium
Gary M. Halliday Dermatology Research Laboratories, Melanoma and Skin Cancer Research
Institute, University of Sydney, Sydney, Australia
Iltefat Hamzavi Department of Dermatology, Henry Ford Hospital, Detroit, and Hamzavi
Dermatology, Port Huron, Michigan, U.S.A.
John L. M. Hawk Photobiology Unit, St. John’s Institute of Dermatology, St. Thomas’ Hospital,
King’s College of London, London, England, U.K.
xiv Contributors
Peter W. Heald Department of Dermatology, West Haven VA Medical Center, Yale University
School of Medicine, New Haven, Connecticut, U.S.A.
Maria Teresa Hojyo-Tomoka Departamento de Dermatologia del Hospital General Dr. Manuel
Gea González, Tlalpan, Mexico City, Mexico
Erhard Hölzle Department of Dermatology and Allergology, Klinikum Oldenburg, Oldenburg,

Germany
Herbert Hönigsmann Department of Dermatology, Medical University of Vienna, Vienna, Austria
Takeshi Horio Department of Dermatology, Kansai Medical University, Osaka, Japan
Sally H. Ibbotson Department of Dermatology, Ninewells Hospital and Medical School,

University of Dundee, Dundee, Scotland, U.K.
Brooke Jackson Skin and Wellness Center of Chicago, Chicago, Illinois, U.S.A.
Robert Knobler Division of Special and Environmental Dermatology, Department of Dermatology,

Medical University of Vienna, Vienna, Austria, and Department of Dermatology, College of
Physicians and Surgeons, Columbia University, New York, New York, U.S.A.
Irene E. Kochevar Wellman Center for Photomedicine, Massachusetts General Hospital,

Harvard Medical School, Boston, Massachusetts, U.S.A.
Kenneth H. Kraemer Basic Research Laboratory, Center for Cancer Research, National Cancer
Institute, Bethesda, Maryland, U.S.A.
Jean Krutmann Department of Dermatology and Environmental Medicine, Institut für

Umweltmedizinische Forschung (IUF), Heinrich-Heine University, Düsseldorf, Germany
Michael Landthaler Department of Dermatology, University Clinic Regensburg, Regensburg,

Germany
Percy Lehmann Klinik für Dermatologie, Allergologie und Umweltmedizin, HELIOS-Klinikum

Wuppertal, Universitätsklinikum der Universität Witten-Herdecke, Wuppertal, Germany
Henry W. Lim Department of Dermatology, Henry Ford Hospital, Detroit, Michigan, U.S.A.
Harvey Lui Department of Dermatology and Skin Science, Vancouver Coastal Health Research
Institute, University of British Columbia, Vancouver, British Columbia, Canada.
Warwick L. Morison Department of Dermatology, Johns Hopkins University, Baltimore,

Maryland, U.S.A.
Akimichi Morita Department of Geriatric and Environmental Dermatology, Nagoya City

University Graduate School of Medical Sciences, Nagoya, Japan
Gillian M. Murphy Department of Dermatology, Beaumont Hospital, Dublin, Ireland
Luigi Naldi Centro Studi GISED, Ospedali Riuniti, Bergamo, Italy
Mark Naylor University of Oklahoma, Tulsa, Oklahoma, U.S.A.
Uli Osterwalder Ciba Specialty Chemicals, Basel, Switzerland
Roy Palmer Photobiology Unit, St. John’s Institute of Dermatology, St. Thomas’ Hospital,
London, England, U.K.
Rik Roelandts Photodermatology Unit, University Hospital, Leuven, Belgium

Contributors xv
Lesley E. Rhodes Department of Dermatological Sciences, Photobiology Unit, University of

Manchester, Salford Royal Foundation Hospital, Manchester, England, U.K.
Cheryl Rosen Division of Dermatology, Toronto Western Hospital, University of Toronto,

Toronto, Ontario, Canada
André Rougier La Roche-Posay Pharmaceutical Laboratories, Asnières, France
Thomas Schwarz Department of Dermatology, University of Kiel, Kiel, Germany
Sophie Seite La Roche-Posay Pharmaceutical Laboratories, Asnières, France
Rolf-Markus Szeimies Department of Dermatology, Regensburg University Hospital,

Regensburg, Germany
Frank C. Victor Ronald O. Perelman Department of Dermatology, New York University

School of Medicine, New York, New York, U.S.A.
Robert A. Weiss Department of Dermatology, Johns Hopkins University School of Medicine,

Baltimore, and Maryland Laser Skin & Vein Institute, Hunt Valley, Maryland, U.S.A.
Victoria P. Werth Department of Dermatology, University of Pennsylvania, and Philadelphia V.A.

Medical Center, Philadelphia, Pennsylvania, U.S.A.
Norbert M. Wikonkál Department of Dermatology, Semmelweis University, School of Medicine,

Budapest, Hungary
Mina Yaar Department of Dermatology, Boston University School of Medicine, Boston,

Massachusetts, U.S.A.
Daniel B. Yarosh Applied Genetics Incorporated Dermatics, Freeport, New York, U.S.A.
Antony R. Young Division of Genetics and Molecular Medicine, St. John’s Institute of
Dermatology, King’s College London, London, England, U.K.
Michael Zanolli Division of Dermatology, Vanderbilt University Medical Center, Vanderbilt

University, Nashville, Tennessee, U.S.A.
Section I: HISTORY AND BASIC PRINCIPLES
1 History of Human Photobiology

Rik Roelandts
Photodermatology Unit, University Hospital, Leuven, Belgium
B Study on visible light was first published by Newton in 1672, and study
on action spectrum of ultraviolet light was published by Hausser and
Vahle in 1922.
B Relationship between sunlight and skin aging was first published by

Unna in 1894, and relationship between sunlight and skin cancer was
published by Dubreuilh in 1907.
B First description of a photodermatosis (eczema solare) was in 1798 by

Wilan.
B First commercially available sunscreen (benzyl salicylate and benzyl

cinnamate) was in 1928 in the United States. The concept of SPF was
developed by Greiter in 1974, and adopted by the United States Food and
Drug Administration in 1978.
B Modern day phototherapy started with Goeckerman in 1925 and PUVA

with Parrish in 1974.
2 Roelandts
THE BEGINNING OF A SCIENTIFIC INTEREST

he endless chain of days and nights since life began must have been an important source
T of imagination during history. This may explain why the Egyptians saw the Sun God Re
sailing the heaven in a boat and why the Greeks saw Apollo driving a chariot through the
sky. The Aztecs even offered beating human hearts to the Sun God, to give him enough
strength to reappear the next day. In nearly every civilization, people have adored the sun.
It was not only a question of religion but also of necessity. The sun is the universal source
of light and heat, and without the sun it would be dark and cold forever. This has nothing
to do with science. However, from early humankind on, people realized that the sun is extre-
mely important for life and it was, therefore, a topic of major concern. Stimulating people’s inter-
est is the beginning of science. Apart from this, there is also human experience. In many
civilizations, people realized that the sun could have a beneficial effect on certain diseases and
this, of course, had a stimulating effect on people’s imagination. It can take a very long time
before imagination evolves into a critical and structured approach, and in many cases this is a
step-by-step process.
The beginning of a real scientific interest in the solar spectrum dates from the 17th
century. One of the most important steps forward was the discovery of the visible spectrum
of the sun by Isaac Newton in England. He published the results of his experiments in 1672,
whereby the visible spectrum of the sun was fractionated by a prism into the different colors
of the rainbow (1). When Newton projected green plus red light on a wall, no green or red
light appeared, but only yellow light. When he added blue light, no green, red, or blue light
appeared, but only white light. To make white light, Newton did not need all colors, but
only red, green, and blue—the three basic colors.
In 1800, William Herschel, again in England, did some experiments with a thermometer to
evaluate which colors of the visible solar spectrum had the highest temperature. He noted that the
thermometer registered a higher temperature above the red visible light and, thus, discovered the
infrared spectrum of the sun (2).
The discovery of ultraviolet rays came a year later and can be attributed to the German
Johann Wilhelm Ritter. This discovery was partly based on previous experiments, by Carl
Wilhelm Scheele in Sweden, which had already been published in 1777 (3). Scheele could
show that paper strips dipped in a silver chloride solution became black after exposure to
the sun, because of a reduction of the silver, and that silver chloride did not become black in
the dark. Later on, this became the principle of analogous photography. Scheele could also
show that this was more pronounced with blue light than with red light. Ritter, a young scien-
tist, was convinced that invisible rays not only existed beyond the red end of the visible spec-
trum, as Herschel had demonstrated, but he also believed a similar invisible spectrum must
exist below the visible blue end of the spectrum. He first started his experiments with a ther-
mometer as Herschel did. Because he could not find a further decrease in temperature below
the visible blue as compared to the blue, he changed to Scheele’s method of using paper strips
dipped in silver chloride. He started measuring below the visible blue, where Scheele had
ended, and noted that the paper strips became even darker when exposed to invisible wave-
lengths shorter than the visible blue light. He, thus, discovered in 1801 the ultraviolet spectrum
of the sun, which he called “infraviolet” (4,5). Ritter died, unhappy, at the age of 33, without
ever realizing the importance of his discovery (6).
It took many years before the importance of ultraviolet rays became clear. After Ritter’s
death it was still a common belief that sunburn was due to heat damage. This changed with the
experiments of Everard Home in England in 1820 (7). Home wondered why the skin of black
people living in a hot climate was better protected than white skin, although black was absorb-
ing more heat. Therefore he exposed one of his own hands to the sun and covered the other one
with a black cloth. He developed sunburn on the exposed hand although a thermometer regis-
tered a higher temperature on the hand under the black cloth (8). Information at that time was
not so easily available as it is nowadays, which is illustrated by the fact that Moriz Kaposi, as
late as 1891, still believed that solar-induced erythema, and also pigmentation, were due to the
heat of the sun (9). Another illustration is the fact that Niels Finsen in Denmark, as late as 1900,
repeated Home’s experiment, independently, unaware of the previous experiment.
History of Human Photobiology 3
Although the damaging effects of ultraviolet radiation became gradually better known, it
took a few more years before real action-spectrum studies were undertaken. During Word War
I, Karl Hausser was the chief radiation physicist for Siemens AG in Germany. While working
near the battlefields, he got pulmonary tuberculosis and was sent to Davos in Switzerland for
heliotherapy. He took long walks in the mountains and noted that sunburn occurred easier at
noontime than in the afternoon hours (10). As a result, he and Vahle made the first detailed
action-spectrum studies for erythema and pigmentation of human skin. They could show
that erythema and pigmentation depend upon the wavelengths of the ultraviolet radiation
and that the effect is mainly due to wavelengths shorter than 320 nm (11). In 1922, they pub-
lished the action spectra for the induction of erythema and pigmentation in human skin
using a monochromator and an artificial mercury lamp.
During the Second International Congress on Light in 1932 in Copenhagen, Denmark,
William Coblentz proposed to divide the ultraviolet spectrum of the sun into three spectral
regions: UVA (315 –400 nm), UVB (280 – 315 nm), and UVC (,280 nm) (9).
Measuring the intensity of solar irradiation was another problem. Many different systems
were available (12). Although cadmium cathodes were already used in Potsdam in Germany
and in Davos in Switzerland as early as 1910, the first integrating analog meter was developed
by Rentschler in the mid-1930s, using a zirconium photodiode (11). However, these photo-
diodes showed great individual variability and temperature sensitivity. In addition, good
amplifiers were not available at that time. In the mid-1950s, Robertson developed a UVB
detector with a stable cold cathode thyratron to amplify the weak detector output (11). This
detector was later redesigned and became the popular Robertson-Berger meter.
ERYTHEMA, PIGMENTATION, AND NATURAL PHOTOPROTECTION

The concept that sun exposure is responsible for sunburn is known since early humankind. In
1799, Johan Christoph Ebermaier in Germany noticed different degrees of sunburn depending
on the time of exposure, whereby paler skin types reacted more severely than darker skin types
(13). However, until the experiments of Home in 1820 and even much later, it was commonly
believed that the heat of the sun was responsible for sunburn. The first to show that solar-
induced erythema is really induced by ultraviolet rays was Jean Martin Charcot in France in
1858. He noticed severe sunburn and keratitis in two scientists working with electric arcs
(9,14). This is also the first medical publication about accidental UV exposure. In 1877,
Arthur Henry Downes and Thomas Porter Blunt in England could show that sunlight also
may have a bactericidal action (15).
For a long time, it was a common belief that the heat of the sun was also responsible for
tanning, induced by sun exposure. In 1808, the German Placidus Heinrich noticed that the light
and not the heat of the sun was responsible for tanning (16). In 1829, John Davy from Scotland
first described immediate pigment darkening (9). It was only in 1885 that Paul Unna of
Germany suggested that the violet end of the solar spectrum, and thus the ultraviolet radiation,
was responsible for the pigmentation of the skin (17). A few years later, in 1889, Erik Johan
Widmark proved experimentally in Sweden that sunburn and tanning were due to the ultra-
violet rays and had nothing to do with heat (9,18). As soon as this was generally accepted,
research started into the mechanism of pigmentation. In 1917, Bloch published his experiments
on the mechanism of melanin formation in human skin and discovered dopa-oxidase (19).
Around the same time, Riehl reported a particular form of hyperpigmentation on both
cheeks and on the lateral parts of the neck after chronic sun exposure (20).
In 1928, Jean Saidman of France, published an interesting textbook, Les rayons ultra-violets
en thérapeutique, in which he describes how the minimal erythema dose (MED) may vary
according to the individual pigmentation, the site of the body, and age. He also describes vari-
ations in the MED in the case of certain skin disorders and in the case of oral intake of certain
drugs (12). He even made a device with a timer and several diaphragms to determine the MED,
automatically.
That sun exposure could induce an increase in skin thickness was already reported in
1799 by Ebermaier in Germany (13). In 1900, Magnus Möller reported that sun exposure
could induce a double protection mechanism in the epidermis, an increase of the stratum
4 Roelandts
corneum thickness, and an increase in pigmentation (21). In 1931, Guido Miescher of

Switzerland noticed an increase in thickness of all layers of the epidermis after sun exposure,
thus reducing the intensity of the penetrating radiation (22).
SKIN AGING AND SKIN CANCER

Gradually, it became clear that sun exposure could not only induce short-term but also long-
term skin changes. In 1893, Robert Bowles of England had already suggested that
sunlight could be responsible for skin cancers: “If the sun’s rays will produce sunburn,
erythema, eczema solare, inflammation, and blistering, it is clearly capable of producing
deep and intractable ulcerations of a low and chronic nature” (23). One year later, in 1894,
Paul Unna in Germany discovered the relationship between sun exposure and skin aging,
by studying sailor’s skin (24). He also associated the severe degenerative changes on the
exposed areas of sailors’ skin with the development of skin cancer (11). Around the same
time, in France, Dubreuilh noticed that people working in the vineyards around Bordeaux
had more skin cancers than people living in the city (25). He was the first to establish a
clear-cut relationship in 1906 –1907 between skin cancer and solar exposure (26). Both con-
ditions were dose-dependent. Skin aging was, therefore, more pronounced in the neck of
people working outside, which resulted in the description of cutis rhomboidalis nuchae by
Jadassohn and Nikolsky in 1925 (27).
In 1928, George Findlay reported that daily irradiation of mice with ultraviolet light from a
mercury arc could induce skin cancer (28) and that the interval time was reduced if tar were used
before the ultraviolet exposure. The first action-spectrum studies of skin photocarcinogenesis were
published by Angel Roffo from Argentina in 1939 (29), where he showed that window glass can
prevent the induction of skin cancer by both mercury arc radiation and by natural sunlight.
Shortly afterward, Harold Blum, Kirkby-Smith, and Grady, in the United States, conducted a com-
prehensive series of experiments on photocarcinogenesis in mice and were able to obtain highly
reproducible ultraviolet-induced skin cancers (30). These experiments were the beginning of a
large number of experiments on animal photocarcinogenesis during the following decades.
PHOTODERMATOSES
Probably the first to describe a photodermatosis was Robert Willan in 1798. He called the
disease eczema solare (31). The same condition was again described in 1887 by Veiel. What
they called eczema solare was, most likely, what we currently consider as polymorphous or
polymorphic light eruption. The name polymorphous light eruption was first used by Rasch
in Copenhagen, in 1900 (8). The same condition had also been described as prurigo aestivalis,
by Jonathan Hutchinson in 1878 (32). In 1919, Haxthausen used the term polymorphous light
eruption as a collective name for eczema solare and prurigo aestivalis, because it was not pos-
sible to differentiate between the two conditions (33).
Hydroa vacciniforme was first described by Bazin in 1860 (8). Later on, this term became
more confusing because it was not only used to describe hydroa vacciniforme, as it is known
currently. Some authors used the same terminology to describe what is, presently, called con-
genital erythropoietic porphyria.
Moriz Kaposi was the first to describe xeroderma pigmentosum in 1870 (8), but he did not
make the relationship with solar exposure or light, which was only done many years later by
Paul Unna (24).
The symptoms of congenital erythropoietic porphyria have been described under differ-
ent names such as pemphigus leprosus by Schultz in 1874 (34), xeroderma pigmentosum by
Gagey in 1896 (35), hydroa vacciniforme by M’Call Anderson in 1898 (36), hereditary syphilis
by Vollmer in 1903 (37), hydroa aestivale by Ehrmann in 1905 (38) and Linser in 1906 (39), until
Günther described the condition, in 1911, as a porphyria (40). One of the first symptoms of this
disease is the dark coloration of the urine, which was already noticed in the first description by
Schultz in 1874 (34), whereas M’Call Anderson was the first to recognize in his description of
1898 that the disease was caused by light (36). That the lesions resulted from the sensitization of
the skin to light exposure by porphyrins, was first suggested by Ehrmann, in 1909 (41). The
name Günther’s disease, to describe congenital erythropoietic porphyria, dates from a later
period. Even in 1926, Rasch still proposed to call the disease M’Call Anderson’s disease (8).
The same year the same author published a case report of a patient with porphyrinuria
and blisters on the back of both hands (8). Rasch did not make use of the terminology por-
phyria cutanea tarda, till that time, but he clearly made the link with alcoholism. The name
porphyria cutanea tarda was first used in 1937 by Waldenström, who also extensively
studied acute intermittent porphyria (42). The other porphyrias were described later, even
after World War II.
While the previous photodermatoses have mainly been described for the first time in the
19th century, solar urticaria has been described at the beginning of the 20th century. Probably
the first report of the induction of urticaria by sunlight is the one reported by Merklen, in 1904
(43). He was the first to consider urticaria, caused by light, to be a distinct clinical entity. A year
later in 1905, Ward, for the first time, provoked urticaria by means of sun exposure under con-
trolled conditions (44). The name “solar urticaria” was suggested by Duke in 1923 (45), and in
1928, Wucherpfennig could quantify the urticarial response by phototesting with increasing
doses of different wavelengths (46). In 1942, Rajka reported the passive transfer to normal
volunteers by an intradermal injection of serum from a person with solar urticaria (47).
The history of topically or systemically-induced photosensibilization starts earlier.
The first reports of systemically-induced photosensibilization were mainly due to occasional
intake of plant extracts. Already, in the 16th century, skin reactions have been observed in
animals after eating buckwheat followed by sun exposure (48). Similar observations have
been made in the 18th century in Sicily and in Napels in Italy, where white sheep showed
severe skin reactions after eating Hypericum, while the black sheep did not (49).
Between 1908 and 1910 Hausmann discovered that hematoporphyrin can photosensitize
animal skin and that the responsible wavelengths are in the green visible light around 500 nm
(50). The first clinical proof that some substances can photosensitize human skin in combination
with sun exposure dates from 1912, when our colleague Meyer-Betz injected himself with hema-
toporphyrin and exposed himself to the sun (51). By doing this he could demonstrate that the
combination of a photosensitizing substance and sun exposure can induce a skin reaction that
each of these two components separately would not induce, which is the definition of a photo-
sensibilization. Another example of a systemic photosensibilization in human skin is the “eosin
disease,” which was seen in patients treated with oral eosin for epilepsy or for other reasons (50).
In 1939, Stephen Epstein could demonstrate in human volunteers, using sulfanilamide as
the photosensitizer, that two mechanisms are involved: a dose-dependent phototoxic reaction
and a nondose-dependent photoallergic reaction (52).
It was first reported in 1913 by Louis Lewin, that topically applied agents can photosen-
sitize in workers using coal tar pitch (53). In 1916, Emanuel Freund reported phototoxic reac-
tions to eau de cologne, which was the first description of a berloque dermatitis, and he
concluded that oil of bergamot was most probably the photosensitizing substance (54). The
first description of a phytophotodermatitis dates from 1920 by Moritz Oppenheim (55). Hans
Kuske could show that the photosensitizing substances in these plants were furocoumarins,
and that their action spectrum was mainly between 334 and 366 nm, which was the first deter-
mination of an action spectrum for the furocoumarins (56). The photopatch test was introduced
in 1941 by Burckhardt (57).
PHOTOPROTECTION
It has always been part of human nature to protect the skin against sunburn by avoiding sun
exposure or by wearing appropriate clothes. During history, many substances have probably
been tried out as photoprotectors. As far as we know, the first scientific reports date from
the end of the 19th century. In 1878, Veiel reported the use of tannin as a photoprotector, but
its use was limited because of its staining potential (58). In 1891, Friedrich Hammer of
Germany even published a monograph, probably the first large monograph on photobiology,
discussing photoprotection and experimenting with different topical agents, to prevent
sunburn (9,59).
6 Roelandts
When Hausser and Vahle, in 1922, reported that sunburn in human skin is caused by a
specific part of ultraviolet spectrum between 280 and 315 nm (60), one realized that the skin
could be protected by filtering out these specific wavelengths. This resulted in a growing inter-
est in sunscreen agents. The first commercially available sunscreen appeared on the market in
1928, in the United States, as an emulsion containing benzyl salicylate and benzyl cinnamate
(61). During the subsequent years, sunscreens were not widely available and were not used
on a large scale. In Germany the first commercial sunscreen became available in 1933 (62)
and in France, in 1936 (63). The German product was an ointment. The French one was an
oil preparation and became a great success, because it was launched the same year that paid
holidays were granted.
During World War II, there was a real need for good sun protection for soldiers engaged
in tropical warfare. One of the most practical and effective agents for sun protection turned out
to be Red veterinary petrolatum, and was used as standard equipment (64). After the war,
styles were changing in many countries and a number of filters were synthesized, tested,
and marketed. In many cases these were less effective oil preparations, apparently with the
sole purpose of promoting tanning. During the 1970s, holiday travel to sunny areas steadily
became more popular, resulting in an increasing demand for sunscreens with better and
broader protection. This became possible by incorporating UVB filters into milks and creams
instead of oils. In 1979, real UVA filters became available and a further advance was the intro-
duction of micronized inorganic powders such as titanium dioxide since 1989, and zinc oxide
since 1992 (65).
With the increasing use of sunscreens, there was also an increasing need to find a good
method to evaluate their protection. In the early years, the usual way was to determine the
absorption spectrum of the sunscreen. In 1934, Friedrich Ellinger in Berlin proposed to use a bio-
logical method by determining the MED in protected and unprotected skin, using both forearms
and a mercury lamp (66). He concluded that the method of choice was the way in which the MED
could be decreased. He was right, but the right irradiation source was not yet used. In 1956,
Rudolf Schulze in Germany proposed to test commercially available sunscreens by giving
them a protection factor (67). The idea was to divide the exposure time needed to induce erythema
with sunscreen by the exposure time needed without sunscreen. He used a series of Osram-Ultra-
Vitalux lamps to apply a series of increasing ultraviolet doses (40% increases), in both protected
and unprotected skin. The light source he used was more similar to the solar spectrum than the
light source used by Ellinger. The method was further improved in 1974 in Austria by Franz
Greiter, who developed the concept of the sun protection factor (SPF) (68). In 1978, this method
was adopted by the Food and Drug Administration (FDA), in the United States (69) and
became internationally accepted. At that time sunscreens were mainly used to prolong the
exposure time in order to tan, and at the same time to avoid sunburn.
THE BEGINNING OF A THERAPEUTIC INTEREST

Over the centuries, sunlight has been used in the treatment of many diseases in different
countries such as ancient Egypt, Greece, and Rome, but the records are mostly anecdotal. In
addition, many believed that the therapeutic effect was due to red light and the heat of the
sun, because there was no notion of ultraviolet rays.
Gradually, and especially in the second half of the 19th century, more and more people
became interested in heliotherapy. In 1855, Arnold Rikli from Switzerland opened a thermal
station in Veldes Slovenia for the provision of heliotherapy (70). In 1856, Florence Nightingale
in the United Kingdom protested against the orientation of the Royal Victoria Hospital in
Netley, near Southampton, observing that no sunlight could enter its wards (71). In 1877
Downes and Blunt showed that sunlight could kill anthrax bacilli and, thus, had a bactericidal
action (15). In 1890, Palm from Edinburgh suggested that the sun could play a therapeutic role
in rachitis (72).
At the end of the 19th century, many people started to realize that ultraviolet rays of the
sun were the most important wavelengths for its therapeutic effects. This resulted in the use of
filtered solar radiation and of artificial light sources. In 1893, Niels Finsen in Denmark
used filtered sunlight in the treatment of lupus vulgaris. At a time when no antibiotics or anti-
inflammatory agents were available, Finsen’s phototherapy was more than welcome. Because a
treatment session with filtered natural sunlight could take several hours, and because natural
sunlight was not always available in Denmark, Finsen became logically interested in more
powerful artificial irradiation sources. In 1894, Heinrich Lahmann in Germany was probably
the first to use an artificial light source in the treatment of skin diseases (70), although he
was not the first to construct such a lamp. The first to make a (mercury) lamp was, probably,
Way around 1856 to 1860 (12).
In April 1896, Finsen founded the “Lysinstitut” or Medical Light Institute (later Finsen
Institute), in Copenhagen, where he continued to use filtered natural sunlight; but from 1897
onward he also used a new carbon arc lamp in combination with quartz filters (73).
Around the same time, in 1898, Willibald Gebhardt published what is probably the first
book on phototherapy, Die Heilkraft des Lichtes (74). A major problem when using a carbon
arc lamp to irradiate human skin was the high temperature. Finsen et al. developed a water-
cooling system and an irradiation unit where four patients were irradiated at the same time.
This irradiation source became internationally known as the Finsen lamp. After Finsen in
1901 published his therapeutic results with lupus vulgaris, treated by concentrated UV
doses from a carbon arc lamp, he received the Nobel Prize for Medicine in 1903, the only
Nobel Prize ever to be awarded for dermatology (73). From this time on the Finsen lamp
was used in all major dermatology departments inside and also outside Europe in the treat-
ment of lupus vulgaris. Finsen also wrote the foreword in the first French textbook on photo-
therapy, Photothérapie et Photobiologie, written by Leredde and Pautrier and published in 1903
(75). In 1904, a smaller lamp was constructed by Finsen and Reyn, the Finsen-Reyn lamp,
which allowed therapist to irradiate one single patient and which was more convenient in
smaller treatment centers. All these lamps were used only for localized irradiations. In the
same year, 1904, the Schott Company in Jena, Germany, was able to construct an ultraviolet
tube (9), using the low-pressure mercury lamp developed by the American Peter Hewitt in
1902 (76), and using a new type of glass containing barium sulfate.
About the same time, the first experiments started with the use of photosensitizers and
visible light in the treatment of skin cancer that became the principle of photodynamic
therapy, nearly a century later. During the winter of 1897 and 1898, Oscar Raab, in Munich,
had already noticed that the death of the paramecia, which he was studying, not only
depended upon the concentration of the dye acridine but also on the intensity of the light
in the laboratory (77). In 1905, Albert Jesionek and Hermann von Tappeiner could cure
three out of five basal cell carcinomas they had treated with intralesional eosin and light
exposure (78).
A lot of research was done in the construction of new phototherapy equipment. In
1906, Hans Axmann in Germany constructed a horizontal treatment cabin equipped with
a series of low-pressure mercury tubes, allowing total body irradiations (9,79). Unfortunately,
the output of these lamps was not high enough to obtain a sufficient therapeutic effect in
lupus vulgaris and, therefore, could not compete with the Finsen-Reyn lamp. In 1906 also,
Richard Küch in Hanau, Germany, made the first quartz lamp. By using quartz instead of
lead glass, he was able to develop a high-pressure mercury lamp with a higher output
(80). In the beginning these lamps were only used to illuminate streets and warehouses,
where they gradually replaced the carbon arc lamps, which had a lower output and
higher running costs (9). Soon after, the high-pressure mercury lamp was also used for thera-
peutic purposes, because of the same reasons. In 1908, Carl Franz Nagelschmidt made a table
model of the high-pressure mercury lamp for total body irradiation, but this was nothing
more than a prototype. After Hugo Bach constructed his own quartz lamp in 1911, this
“Höhensonne” lamp was modified many times and was used for almost 50 years for total
body irradiations (9). When in 1912 Ernst Kromayer in Berlin made a quartz lamp with a
high UV output, and improved the lamp by using a water cooling system, it became possible
to treat different skin diseases (81,82). Kromayer commercialized his lamp in 1906, and it
became one of the most popular treatment lamps in dermatology for decades. It was not
only used in Europe but also in Asia and the United States, although it could only be
used for localized irradiations.
8 Roelandts
In 1919, the pediatrician Kurt Huldschinsky published his therapeutic results with high-
pressure mercury lamps in the treatment of rachitis (83). This again was a very interesting
indication for the use of phototherapy in medicine. Its success was greatly due to the use of
the new radiography technique as a way to control the evolution of the disease.
Lupus vulgaris was not the only indication for the use of phototherapy in dermatology.
William Henry Goeckerman, in the United States, started testing different photosensitizers in
the treatment of psoriasis in order to improve the therapeutic effect of the sun. In 1925, he
published his results using coal tar in combination with ultraviolet exposure from a high-
pressure mercury lamp (84). This treatment became very popular worldwide and was used
for decades to treat psoriasis. Later on, John Ingram in the United Kingdom combined this
treatment with dithranol (85).
In 1927, Erich Uhlmann could induce repigmentation in vitiligo patients combining
bergamot oil and exposure to natural sunlight or to a Kromayer lamp (86).
In 1947, a new type of lamp was born, the high-pressure xenon lamp. In contrast to the
high-pressure mercury lamp, this lamp had a continuous spectrum ranging from the ultra-
violet to the infrared spectrum, similar to the natural solar spectrum. Because this lamp was
more costly to use it did not become popular for therapeutic purposes but was only used for
research and phototesting.
In 1958, the use of blue light phototherapy (420 – 480 nm) was reported for the treatment
of newborns with jaundice, after a nurse noticed that the yellow pigmentation in jaundiced
babies faded away after sun exposure (87). Apart from its use in pediatrics to treat jaundice
in newborns, heliotherapy and phototherapy were done on an organized scale to treat tubercu-
losis, leg ulcers, and skin diseases.
HELIOTHERAPY FOR TUBERCULOSIS

In 1903, Rollier in Leysin, Switzerland, opened the first hospital to treat lung tuberculosis
and rachitis by sun exposure. In 1914, he published his therapeutic results in a book, La
Cure du Soleil, which unfortunately was published in French at the start of World War I
and therefore had no great effect outside Switzerland (88). When in 1923 his book was trans-
lated and published in English under the title Heliotherapy, the use of sun exposure in the
treatment of tuberculosis became increasingly popular (82). It was only when the first tuber-
culostatics became available, in 1946, that the use of sun exposure in the treatment of lung
tuberculosis and the use of phototherapy in the treatment of lupus vulgaris became part
of history.
HELIOTHERAPY AND PHOTOTHERAPY FOR LEG ULCERS

Another application of an organized use of sun exposure and phototherapy was in the treat-
ment of leg ulcers. The first to report a therapeutic effect of sun exposure in the treatment of
ulcers was Larrey, Napoleon’s private physician. He noted, during Napoleon’s campaign in
Egypt, in 1798 and 1799, that the soldiers’ traumatic ulcers healed more quickly after sun
exposure (89). In 1904, Bernhard in Switzerland described heliotherapy as a treatment for
skin ulcers (89,90). Later on, this was confirmed by other authors (91,92) whereafter the treat-
ment of wounds with sunlight gradually gained ground, especially in Switzerland, Germany,
and France. During World War I from 1914 to 1918, ulcers were treated by exposure to natural
sunlight or to quartz lamps in Germany, the United Kingdom, France, and Italy. During World
War II from 1940 to 1945, this “open-air treatment” with sunlight or with quartz lamps was
still being used. When the first antibiotics became available, however, interest in using
phototherapy for wound healing faded.
PHOTOTHERAPY FOR SKIN DISEASES

Heliotherapy with natural sunlight was mainly used in thermal stations to treat tuberculosis
and in wartime to treat leg ulcers. However, both indications became part of history. This
was not the case with the use of phototherapy in the treatment of skin disorders. During history
and up to the present, several skin disorders have been treated with heliotherapy or
phototherapy.
Before the end of the 19th century its use was more anecdotal. Probably the first report of
the use of sunlight in the treatment of skin disorders dates from about 1400 BC , when plant
extracts followed by sun exposure to treat vitiligo was used in India (93). The same treatment
was also used in ancient Egypt. The anecdotal use of heliotherapy during the centuries changed
at the end of the 19th century with Niels Finsen. He was the first to use sun exposure in a more
standardized way on a large scale for a specific indication, with a detailed account of its thera-
peutic results. He was also the first to switch from heliotherapy with natural sunlight to photo-
therapy with artificial lamps, making it more practical. The Nobel Prize he won in 1903 had a
booster effect on phototherapy. Probably a similar effect happened at the end of the last century
with the development of phototherapeutic UVA (PUVA) treatment or photochemotherapy.
Photochemotherapy has a long history (94). It started with the use of plant extracts
and sun exposure to treat vitiligo and resulted in the use of oral 8-methoxypsoralen
(8-MOP) and total body UVA-irradiation cabins to treat psoriasis. Many different steps
have been involved. The first step was the use of certain plant extracts to treat vitiligo
(95). The next step was the isolation of the active ingredients in these plants as 8-MOP
and 5-methoxypsoralen (5-MOP), in 1947, and the first trials with 8-MOP and sun exposure
in vitiligo patients (96 –99). Later, the action-spectrum studies were introduced (100,101).
These were followed by the topical use of 8-MOP in combination with UV irradiation to
treat psoriasis (102) and in 1967 by the oral use of 8-MOP to treat psoriasis (103). The
next step was the use of “blacklight” UVA tubes in combination with topical 8-MOP in
the treatment of vitiligo (104). One year later, in 1970, Mortazawi used the same type of
UVA tubes in a total body irradiation cabin, using topical 8-MOP to treat psoriasis
(105,106). The use of UVA tubes in a total body irradiation cabin was new. Although
the UVA output of these tubes was effective when the 8-MOP was used topically, it was
insufficient when administered orally. In 1974, Parrish et al. reported the use of a new
type of a high-intensity UVA tube in combination with oral 8-MOP in the treatment of psor-
iasis (107). This approach was more effective and was the real start of PUVA therapy, which
revolutionized dermatological treatment.
The history of UVB phototherapy is not as old as the history of photochemotherapy, and
was started at the end of the 19th century with the work of Niels Finsen on lupus vulgaris. In
1923, Alderson recommended the use of a mercury quartz lamp to treat psoriasis. In 1925,
Goeckerman associated tar with UV irradiations in the treatment of psoriasis, and this
remained for about half a century as the most popular form of phototherapy in dermatology
(84). The main drawback of this treatment was the low output of the lamps. In 1958,
Zimmerman in the United States described an irradiation cabin, using fluorescent UVB
tubes (108). Later, several other total body irradiation sources were described (109,110). After
a successful start of PUVA treatment, Wiskemann suggested, in 1978, using an irradiation
cabin with broadband UVB tubes (111). During the subsequent years, broadband UVB photo-
therapy became an alternative for PUVA treatment. Because broadband UVB phototherapy
was less efficient for psoriasis than PUVA therapy, it never achieved its popularity.
This changed in 1988 when narrowband UVB phototherapy was introduced in the treatment
of psoriasis by van Weelden et al. (112) and Green et al. (113). This was more efficient than
broadband UVB phototherapy.
In the meantime, other types of phototherapy have been developed such as extracorpo-
real photopheresis for cutaneous T-cell lymphoma (114), high-dose UVA1 phototherapy for
atopic dermatitis and localized scleroderma (115), and topical photodynamic therapy with
visible light for actinic keratoses and superficial basal cell carcinoma (116).
JOURNALS, SOCIETIES, AND MEETINGS

The first real journal dealing exclusively with photobiology and photodermatology was prob-
ably the Transactions from Finsen’s Medical Light Institute, which were published in Danish
10 Roelandts
and German. The journal appeared from 1900 until 1904, when Finsen died. In 1912, Hans
Meyer in Germany started the new journal Strahlentherapie, dealing not only with phototherapy
but also with radiotherapy. Because phototherapy became less important after World War II,
this journal is no longer a photobiological or photodermatological journal.
In 1927, the Deutsche Gesellschaft für Lichtforschung (German Society for Research on
Light) was founded (9). The first president was Hans Meyer, editor of the journal Strahlenther-
apie. One year later, in 1928, the first international society was founded by a group of French
colleagues, called Comité International de la Lumière, with Axel Reyn as the first president. Reyn
was Danish and a pupil of Finsen. The First International Congress on Light was held in 1929
in Paris, France, with Jean Saidman as its president. The second congress was in Copenhagen,
Denmark, in 1932 and the third one took place in Wiesbaden, Germany, in 1936. In 1937, the
decision was made to attribute a prize—the Finsen medal—during each congress to an out-
standing cutaneous photobiologist. The next congress was again held in Paris, France, in
1951. At that time, the name of the society became the Comité International de Photobiologie
and the name of the congress changed to the “International Congress on Photobiology” (9).
In 1962, Douglas McLaren started the first journal in English, named “Photochemistry
and Photobiology: An International Journal.” The American Society of Photobiology was
founded in 1972 (11) and the Japanese Society for Photomedicine and Photobiology in 1978.
In 1984, Christer Jansén from Finland and Göran Wennersten from Sweden started another
international journal in English, named “Photodermatology clinical and experimental,” the
name (and size) of which changed in 1990 to “Photodermatology, Photoimmunology & Photo-
medicine.” The Photomedicine Society in the United States was founded in 1991 and the Euro-
pean Society for Photodermatology in 1999.
In 2004, another journal was launched, named “Photodiagnosis and Photodynamic
Therapy.” Apart from these journals several other journals are available dealing only partly
with cutaneous photobiology and photomedicine, such as the “Journal of Photochemistry and
Photobiology. B: Biology,” which started in 1987 as part of the “Journal of Photochemistry.”
BUILDING ON THE PAST

The history of human photobiology is as old as humankind. During the centuries a lot of people
were involved. Some of them had the bright ideas and others had the merit of putting them into
practice. The result is a beautiful example of how science is built up stone by stone. In this
period, when we have the idea that we can realize everything, we often forget that we are
just building on the foundations laid out by others before us. History therefore is a good
lesson in modesty.
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visited the mission school of Dr. Happer, located at the port, and also
went up to Canton to visit the hospital conducted by Dr. Parker, who
had been a lecturer in the University of Pennsylvania when he was a
student there. On Feb. 7, the party for Siam took passage on the
John Bagshaw, Captain Dare. After a call at Hong Kong they had a
quiet passage southward through the China Sea, and on the 23rd
reached Singapore, the maritime capital of the South China Sea.
Here they were fortunate in finding in the harbour the native-built
trading vessel Lion, Captain Dupont, owned by the King of Siam.
Although the ship was modeled after western vessels, it was of the
rudest native workmanship, without conveniences for occidental
travellers; and even the orientals who took passage had only deck
space allotted to them. For these three Westerners one small cabin
was made available and had to serve them day and night for the
twenty-four day voyage, a sail cloth being suspended in the middle
as a concession to foreign ideas of privacy. Provisions had to be
secured at Singapore and the Chinese cook of the vessel paid to
prepare them.
The passage from the South China Sea into the Gulf of Siam
proved to be the climax of the whole trip. A violent and prolonged
storm was encountered which not only added greatly to the misery of
the ship’s company but imperiled their lives:
“For nearly three days,” writes Dr. House, “we have not
had one cheering glimpse of the sun. Squall after squall of
rain has burst in its fury upon us; indeed it has been
almost one incessant rain, and the wind all the time from
the most unfavourable quarter has at last increased to a
gale, driving the ship from her course towards we know
not what islands and rocks.... The waves are rolling wildly,
scowling rain clouds begird the horizon and shut out the
sky above us and the view before us. It is now three days
since the captain has been able to get an observation, and
the dead reckoning is in these seas little to be depended
upon, owing to the strong currents. Our situation is no
more safe than it is agreeable.... Every wave rolls us also
to and fro, so that if one sits or stands he is obliged to be
continually bracing himself, now this way, now that, to
keep the center of gravity; and every now and then is
pitched by some sudden lurch against the nearest object
so that sides and arms and elbows fairly ache with the
bruises.... And all this time there is in your ears the
creaking of the rudder chains and the dismal splashing of
the great waves as they surge up under the stern
windows. But a greater annoyance yet remains to be
spoken of. The deck over us (the roof of our cabin) leaks
in a hundred different places upon us, not in drops but in
streams. In my compartment there is but one dry place,
and that is the mattress; and even that is not wholly dry,
for now and then it drops down upon the pillow. The floor
is as wet as if being mopped; wet trunks, wet books, wet
baskets lie around. The chairs are too wet to sit upon, and
so the bed is the only place for rest.”
WELCOMED BY OTHER MISSIONARIES

Fortunately the voyage of twenty-four days was not all like this,
and after the storm had abated there was much to make the days
interesting. At length came the first sight of Siam:
“Friday, March 19. The first sight of Siam. Thy people, O
Siam, shall be my people; but my God shall be their God.
Here would I die and here would I be buried.... Henceforth
I would live for Thee, my God. Thou art a kind Master; and
oh, Thou hast bought me, every power and faculty; Thou
hast bought me by Thy precious blood. Let me henceforth
shrink from nothing—but sin and remissness in Thy
blessed service. With the beginning of my missionary life I
give myself anew, tremblingly but trustingly to do Thy will
O God, my Creator, Guide and Redeemer.”
The following day, Saturday, March 20, 1847, Dr. House landed in
Bangkok. The arrival of the new missionary party met with a most
cordial welcome by the small group of fellow Americans already
engaged in the work. At that time Siam was occupied by two
American missions, besides French Catholic missions. The
American Board was then represented by Rev. Jesse Caswell and
Rev. Asa Hemmenway with their wives; while the Baptist Board was
represented by the following men and their wives: Revs. J. T. Jones,
Josiah Goddard, and E. N. Jenks, and Mr. J. H. Chandler, a lay
missionary.
“Early on the morning of the 20th of March, just eight
months to a day from the time of our leaving New York, we
found ourselves at the bar which obstructs the entrance of
the great river of Siam.... I was despatched with the
captain in a swift, but alas open, boat that I might, if the
ship was unable to get over the bar, make arrangements
with friends to send down for Mr. and Mrs. Mattoon. After a
rather broiling row of some twenty miles along a river far
more beautiful than I had been led to suppose, arrived at
the outskirts of this truly great city about sundown. We had
still some three miles or more before we reached the
residence of the missionaries of the A. B. C. F. M., and it
was then dark. Was most kindly welcomed by Mr. Caswell
and Mr. Hemmenway, the only missionaries of that Board
now left; and glad indeed they appeared to see me.”
On Monday the ship came up to the city and by that time plans had
been made to house the newly arrived missionaries in two of the
vacant houses in the mission compound where they had been
welcomed.
The relations between the three sets of missionaries were most
cordial. So far as economy of effort made it wise they co-operated in
their undertakings. It was the dispensary of the A. B. C. F. M. that Dr.
House re-opened. The tracts used by the three missions were
printed by the press of the Baptist mission. Members of each of the
missions took turns at the tract house maintained in the bazaar.
Although the Presbyterians had previously been engaged in work in
Bangkok they held no property there; and for the present it was
neither advisable nor possible for the newcomers to obtain a location
for themselves. It was arranged that they should live in the A. B. C.
F. M. compound until there was time to obtain a desirable site.
The compound contained several houses built after the native
style; set high upon posts, with an open space beneath, a verandah
on all sides, no windows but openings for air. In one of these houses
Dr. House lived for the first two years, having a servant to take care
of the house but taking his meals with the Mattoon family. This
arrangement entered upon temporarily continued by force of
circumstances for three years until the return of Rev. D. B. Bradley,
M.D., with another physician, when a readjustment of housing was
necessary. Thereupon Dr. House moved to one of the “floating
houses” moored in front of the compound, and this continued to be
his abode for more than a year until a permanent site was secured
for the mission.
The members of the three missions held a common service of
worship each Sunday morning and afternoon. At the morning service
the sermon was in Chinese or Siamese, while the afternoon service
was wholly in English. It is interesting to learn that an “original”
sermon was unusual, the preacher of the day commonly reading a
published sermon of some well-known divine. On Wednesdays there
was an informal conference for all workers and servants. On
Saturday evenings there was a prayer meeting for the missionaries
only. Later a “monthly concert of prayer for missions” was
established. When the number of Chinese increased a separate
service was held for them, and likewise a Sunday school for the
Siamese pupils of the day school.
Occasionally there would be in attendance on worship some
officers from any English vessel in port and then in turn one of the
missionaries would visit the vessel and conduct a preaching service
for the crew. After the treaty of Great Britain, in 1855, the number of
English families increased very rapidly, and while at first many of
these attended the services at the mission, their number soon
warranted the erection of a chapel for their own use.
IV
RELATIONS WITH ROYALTY AND
OFFICIALS
Soon after their arrival Dr. House and Mr. Mattoon were taken by
their fellow missionaries to call upon two princes who had
manifested a friendly interest in the westerners. The acquaintance
thus formed proved to be of large influence both to the mission and
to the Siamese nation. One of these princes was entitled Chao Fah
Yai, which signifies “The older brother of the king,” while his brother
was entitled Chao Fah Noi, meaning “The younger brother of the
king.” As Chao Fah Yai later became King of Siam and his brother
the Vice-King at the same time and as this new king played a
momentous part in the opening of Siam to intercourse with the
western nations as well as showed much favour to the mission work,
it is essential to give a sketch of that important personage.
When, in 1824, the throne was made vacant by the death of the
royal father of these two men, the older son had expected to
succeed to the throne. Apparently this had been the father’s
intention, for he had given this son the name “Mongkut,” meaning
“crown prince.” Through intrigue, however, the crown went to a half-
brother who, under the title Phra Chao Pravat Thong, was the
reigning king when Dr. House reached Siam. Chao Fah Yai, having
been thwarted in his aspirations towards the throne, entered the
priesthood and retired to a watt, doubtless as the safest way to avoid
the royal displeasure towards a rival,—a course which the custom of
the country made possible for him.
The princely rank of this priest made him the leader of the
Buddhist religion in Siam; and his great wealth enabled him to make
his watt one of the most notable and influential in the country. He
was a man of enlightened mind beyond his generation. In marked
contrast to the king, he was interested in foreign affairs and amicably
disposed towards the few foreigners living in Bangkok, especially
towards the missionaries, because of their education and culture.
Having already learned Latin from the French priests, in 1845
(then about forty years of age), he invited Rev. Jesse Caswell, a
missionary of the American Board, to become his tutor in English. To
secure the services of Mr. Caswell he offered in return a reward
which he perceived would be more prized than any fee of gold he
could propose. He offered Mr. Caswell the privilege of using a room
in one of the buildings connected with the watt for preaching the
Christian religion and distributing tracts, and granted permission to
the priests of the watt to attend if they wished. Mr. Caswell accepted
the invitation and continued for three years, until his death, to teach
English to the chief Priest of Buddhism in his own temple, and to
preach Christianity to all who cared to listen. The esteem of the
Prince for his tutor is evidenced by the fact that in 1855, when Dr.
House was returning to America on furlough, he made the doctor the
bearer of a gift of one thousand dollars to Mr. Caswell’s widow in
token of appreciation of her husband’s services, and again in 1866,
by the same agent, he sent a gift of five hundred dollars. He also
caused a monument to be erected, in memory of his tutor, at the
grave of Mr. Caswell.
The more one contemplates the terms made by Chao Fah Yai with
Mr. Caswell the more astonishing it appears. Here is the most
influential priest in all Siam, the recognised head of the Buddhistic
cult in Indo-China, inviting into his watt an uncompromising teacher
of the Christian religion notwithstanding the known antipathy of the
king to the westerners and their religion, and in return for instruction
in the English language he grants him freedom to teach the moral
and religious doctrines of Christianity within the precincts of
consecrated ground and permits novitiates and priests under his
authority to listen to that doctrine.
This broadmindedness of Chao Fah Yai is further shown by an
incident which he related to one of the Protestant missionaries.
Sometime previous to the engagement of Mr. Caswell a young priest
of the watt became a Roman Catholic. The prince was urged to flog
the young man for abandoning the religion of his country. To this
suggestion the prince said he replied: “The individual has committed
no crime; it is proper for every one to be left at liberty to choose his
own religion.” On a later occasion the Governor of Petchaburi,
having forbidden the distribution of books by the Roman Catholic
priests in his province because he said they sought to shield their
converts from the authorities when accused of crime, conferred with
Chao Fah Yai as to whether he should place the same ban on the
books of the Protestants; but the Priest-Prince was able to explain to
him the difference of policy between the Roman Catholics and the
Protestants and to dissuade him from forbidding the distribution of
Protestant literature.
From his intercourse with Mr. Caswell, Chao Fah Yai was
quickened with an interest in Western learning, especially the
sciences. By his association with these missionaries and the
discussion of the evidences of Christianity he came to recognise that
his own religion had accumulated a mass of unauthenticated
teachings, the accretion of centuries of priestly fancy; and he
perceived that this accretion must be sloughed off if his religion was
to meet the pressure of foreign civilisation, which he foresaw could
not be forever excluded. Accordingly he became the leader of a new
party in Buddhism which rejected the uncanonical writings which had
accrued to the extent of some eighty-four thousand volumes and
held only to the authentic teachings of Buddha. As the leader of this
new sect the Prince-Priest was doubtless responsible for the
reinvigoration of the religion of Siam, enabling it better to meet the
contest of time.
The interest of Chao Fah Yai in the American missionaries was
more on account of their intellectual culture than on account of their
religion. On one occasion in conversation with Dr. House he frankly
said that while he did not believe in Christianity he thought much of
Western science, especially astronomy, geography and
mathematics. His interest in these subjects was very keen and
practical. From the study of navigation he was led into the subject of
astronomy, and took interest in the calculation of time, and was
especially proud that his own calculation of an eclipse of the moon
was almost identical with the Western almanac. His conversation
showed considerable intelligence of the late developments in
science. He was also a student of languages, and had a knowledge
of several languages of eastern India, such as Singhalese and
Peguan; he was familiar with Sanscrit, which had been a contributor
to the Siamese language, and had studied Latin because he said he
had been told that it was like the Sanscrit; besides these he was an
expert student of the Pali, the sacred writing of Buddhism. The
prince was also the first native prince of Farther India to procure a
printing press, which he obtained from London, with fonts of English
and Siamese type, and an alphabet of Pali of his own devising.
Apparently Chao Fah Yai approached the subject of Christianity as
a vigourous mind approaches any ponderous subject that presents
itself; he considered it philosophically. Every religion studied
philosophically presents insuperable difficulties; a religion may be
rightly judged only by its practical adaptation to life and its effects on
the human heart. Had he attempted to study Christianity in a
practical manner as he did the science of the West his conclusions
would doubtless have been different. One evening the prince called
at the home of Mr. Caswell just as the weekly prayer meeting was
assembling and, upon invitation, remained to the meeting. His
questions afterwards showed that he had given attention, for he
inquired the meaning of such words as “redemption” and
“Providence,” which he had heard used.
While it is a fact that on several occasions the prince emphatically
disclaimed belief in the Christian doctrines, nevertheless the
arguments of the missionaries were not without effect upon his mind,
for he felt himself called upon to do an entirely new thing—to publish
an apologetic for Buddhism in the points where the Christian
arguments were most aggressive. In another manner also he gave
evidence that the Christian arguments were pressing upon his
conscience. The Baptist mission for some years had printed an
annual almanac filled with Christian truth and containing, besides
other items of civil information, a list of officials of the government
and of the watts. In 1848, for the first time, Chao Fah Yai took
exception to the religious character of the almanac in which his
name appeared as head priest of his watt. He wrote to the editor of
the almanac, expressing a “wish to have added to the description of
myself in the English almanac ‘and hates the Bible most of all’; we
will not embrace Christianity, because we think it a foolish religion.
Though you should baptise all in Siam I will never be baptised.... You
think that we are near the Christian religion; you will find my disciples
will abuse your God and Jesus.”
Concerning his attitude to Christianity a comment from Mrs.
Leonowens’ book, An English Governess at the Siamese Court,
casts a little light:
“He had been a familiar visitor at the houses of
American missionaries, two of whom Dr. House and Mr.
Mattoon, were throughout his reign and life gratefully
revered by him for that pleasant and profitable
conversation which helped to unlock for him the secrets of
European vigor and advancement, and to make straight
and easy the paths of knowledge he had started upon. Not
even his Siamese nature could prevent him from
accepting cordially the happy influence these good and
true men inspired. And doubtless he would have gone
more than half way to meet them, but for the dazzle of the
throne in the distance which arrested him midway
between Christianity and Buddhism.”
This was the Priest-Prince upon whom the newcomers made their
first call of respect. The acquaintance formed at this time ripened
into a friendship that continued warm and true to the end. Dr. House,
in his journal, carefully records the details of the call:
“His Royal Highness was somewhat unwell, but he
would come down. A servant was sent to ask if we would
not take some refreshments. Soon a plate of stone-fruit
was presented, resembling in flavour our peach; also a
plate of Chinese cakes, white and thin, with a bowl of dark
Chinese jelly and sugar. Knife, three-pronged fork and
teaspoon were brought and we made an excellent tiffin.
“I looked around the room; Bible from A. B. Society, and
Webster dictionary stood side by side on a shelf of his
secretary, also a Nautical Tables and Navigation. On the
table a diagram of the forthcoming eclipse in pencil with
calculations, and a copy of the printed chart of Mr.
Chandler....
“This man, if his life is spared, is destined to exert an all-
powerful influence upon the destinies of this people. He
must possess a vigour of mind and much energy of
purpose thus to commence the study of a new language
at the age of forty. Indeed he seems Cato-like in other
things....
“Soon the Prince-Priest appeared with two or three
following, dressed in yellow silk robes worn as a Roman
toga. His manners were rather awkward at introduction,
and his appearance not prepossessing at first, though we
became more interested in him as we saw him more. He
seated himself on a chair by the center table, and asked
our names and ages and whether married. Wished to
know if I could cure sick as Dr. Bradley did. Whether I
could cure the dropsy, for there was a case in the watt. He
understands English when he reads it, but cannot speak it
well yet.
“We asked to see his printing room; several young
priests and servants on bamboo settees folding books.
One composing type, one correcting proof. They gave us
a copy of a book published in the Prince’s new Pali
alphabet—it was the Buddhist ten commandments and
comments on them. Mr. Caswell had previously told him of
the present of a keg of printing ink we had for him from our
friend G. W. Eddy, of Waterford. He asked who it was
from, and if ‘they had heard of him in America’; and was
evidently well pleased to find that he was known. Upon
taking leave, he promised to call in return upon his guests
in a few days.”
This call of the new missionaries was returned by the priest, and
on several occasions afterwards he visited the Doctor in his house.
Occasionally he would send notes by his servants requesting various
favours, medical attendance upon inmates of the watt, loan of books.
On a second visit, when Dr. House went to engage the services of a
young priest as instructor in Siamese, the prince proposed that the
Doctor should come over to the watt and make use of the room
which Mr. Caswell occupied for his class in English, and “there
distribute medicines and teach the young men of the watt how to be
doctors.” Among the papers of Dr. House was found an autograph
letter in English written by Chao Fah Yai about this time inviting him
and the other missionaries to attend a cremation ceremony at watt
Thong Bangkoknoi; and offering him the privilege of distributing
religious books among the head priests assembled there from
several watts and to preach to them on the new religion. On other
visits he inquired about the new instrument that “would send
intelligence quickly” (the telegraph), asked why American vessels so
seldom came to Bangkok, and discussed the difference between the
Latin and English Bibles.
In proper sequence of courtesy the new missionaries were taken
to call upon the other prince, Chao Fah Noi. For some reason this
prince had withdrawn from his former intercourse with foreigners, but
he very courteously received the callers and was manifestly pleased
with the attention. He, too, was interested in Western learning and
especially inclined towards the physical sciences. On the palace
grounds he had several shops, one for a forge, one for iron lathes,
one for wood-working. Power for all this machinery was developed
by slave-muscle. In one room was a working model of a steam
engine, two and a half feet long, made entirely by the prince’s own
hands. Being somewhat unwell he consulted Dr. House, but
explained that he was under the King’s physician and to refuse to
take his medicine would be an act of disrespect to His Majesty, and
for that reason would not ask Dr. House to prescribe for him.
The acquaintance thus formed was used, at first, by the prince
more as a means of securing personal instruction on physical
sciences. Frequently servants were sent to Dr. House to borrow
books or to ask for advice on chemistry, electricity, photography,
lithography and kindred subjects; and on various occasions the
doctor was summoned to the prince’s palace only to find that his
assistance or instruction was desired in some experiment. In after
years, however, when Chao Fah Noi had become Vice-King upon
the accession of Mongkut, his intercourse with Dr. House rested
more upon the basis of friendship.
SCIENCE AND RELIGION

The acquaintance thus conventionally begun was quickened in
mutual interest in an unexpected manner. When Dr. House reached
Siam he found that the Baptist Mission press had for some time
been publishing an annual almanac. He perceived that these
almanacs were not only accepted by the ordinary people as they
would accept Scripture tracts, but that they were eagerly sought after
by a small number of nobles who were interested in Western
science. These men were surprised to find that the eclipse for 1847
was much more accurately forecasted in this almanac than by their
own astrologers, and they were eager to discuss the subject of
astronomy.
This observation together with his own interest in science led him,
in September of his first year, to institute a series of lectures for the
benefit of the servants and employes of the mission compound “in
hopes of waking up their dormant minds and accustom them to think,
and so be a little benefitted by the preaching on the Sabbaths; as
well as to impart useful information and to set before them the great
proof of the existence and wisdom of the Creator, a fundamental
truth all Buddhists deny.” The doctor was to furnish the outlines and
perform the experiments while Mr. Caswell, experienced in the
language, was to do the talking. There was a fair equipment at hand:
chemicals, a magnetic machine, a globe, a set of physiological and
hygienic charts and a skeleton.
The first lecture was on the digestion of food and the effects of
alcohol on the stomach. The audience showed their attention and
interest by responding with questions. After the lectures on
physiology came several on astronomical topics such as the eclipse
of the moon, phases of the moon and relation to the tides; then
followed several on the gases. On the occasion of the first lecture on
the gases, it so happened that Godata, a priest from Chao Fah Yai’s
watt, happened to call on Mr. Caswell and was invited to witness the
experiment. The demonstration opened a new world for him. What
he saw was too wonderful to keep to himself; he spread abroad his
report and the effect was immediate.
The first to respond was Prince Ammaruk, the favourite son of the
king, who requested the privilege of watching the doctor create the
wonderful “winds.” On the day appointed for the special experiment,
Chao Fah Yai sent a request for Dr. House to accompany him that
evening to call upon a brother prince who was quite ill. In reply the
doctor explained his engagement for the evening, but offered to
make the call after the demonstration, and suggested that the Priest-
Prince might himself like to witness the experiment. To the doctor’s
surprise, the Priest-Prince came early in the afternoon to take the
doctor to see the patient, so that they might have the whole evening
free for the experiments. At the palace, Chao Fah Yai explained the
evening’s entertainment to the royal physician (a brother of the king)
who promptly invited himself. By arrangement with Prince Ammaruk
several others were to come, so that at the appointed time the small
house was filled with nobles and princes, and the verandah with their
servants. Fortunately the experiments went off successfully; oxygen
was generated and iron was burned in the oxygen; hydrogen was
generated from water and exploded in combination with oxygen.
Chao Fah Yai was particularly enthusiastic, and called in from the
verandah some of his men to see the wonders, and himself
volunteered to explain the facts to them.
The series of lectures awakened widespread interest among the
progressive nobles. Dr. House became a notable in their esteem.
Nearly all of the group who were present on that evening were
amateur scientists; they had the air pump, the electric machine and
other physical apparatus, but of chemistry they had no idea. Shortly
after this Chao Fah Noi, who had been keeping aloof from
foreigners, sent a request for Dr. House to spend the evening at his
palace and instruct him in the making of gases. How long the series
of lectures continued is not apparent; the journal continues reference
to them while they are novel, but they apparently continued
throughout that winter. Other subjects named were “The Weight of
the Atmosphere,” “The Barometer,” “Heat,” “The Oxyhydrogen Blow
Pipe,” “Carbon and Carbonic Gas,” “Electro-magnetic Telegraph,”
and “Electricity.” The original purpose of instruction for the servants
was outgrown, and week after week one or more of the nobles who
were dabbling in science were present with their ubiquitous train of
servants. From this time on the journal indicates that the doctor’s
instruction in the Bible classes took the form of “Evidences of Natural
and Revealed Religion.”
The popular interest, however, was directed towards a particular
subject, the skeleton. Very quickly news of this strange possession
spread abroad, and every few days in season and out of season
visitors would call and, scarcely able to restrain their inquisitiveness
during the preliminary courtesies, hasten to request a sight of the
skeleton. Even some of the ladies became interested in this
curiosity; and one day a woman of rank, with half a dozen attendants
and a train of servants, came with a request to see the skeleton.
Long after local curiosity had subsided, chance callers from distant
provinces would come to see this object of nation wide gossip.
Very remarkable, the skeleton itself did not seem to make so
profound an impression upon these minds as the “argument from
design” which their instructor deduced from the human anatomy to
prove the existence of a Creator. Female curiosity also called for
demonstrations with the electrical machine. During the reign of the
old king some of the ladies of the palace had a prince arrange for Dr.
House to bring to the prince’s palace the machine which could make
“fi fah” (fire from the sky), that they might see the marvel. The doctor,
of course, was not permitted to enter the presence of the king’s
women, so he had to instruct the prince in the method of operation.
BOND OF INTEREST
An unexpected result of these lectures was that a bond of mutual
interest was established between Dr. House and this group of
progressive nobles, the very party which in a few years dominated
the new government of Siam. It would be interesting for one who
knew the official entourage of King Mongkut to note how many of his
supporters were included in this number who made Dr. House their
friend because of his interest in science. Since Siamese noblemen
were known by titles rather than by family names and since these
titles change through elevation to higher rank only one acquainted
with a person at a particular rank could identify these men with
accuracy.
However the following are frequently mentioned in Dr. House’s
journal as showing a friendly attitude to him, and most of them
interested in Western science. In the régime which began in 1851 his
friends were: the king, the vice-king, the prime minister, the
commander-in-chief, the minister of foreign affairs, the minister of
home affairs, the treasurer of the kingdom. In the régime of
Chulalongkorn, which began 1868, his special friends were: The
second king, the regent, the minister of foreign affairs, the master of
the mint, the commander-in-chief, and the court chaplain. Besides
these were several princes and nobles who did not occupy particular
offices. Several of these men had primitive laboratories or
workshops for experiments.
The series of lectures started such a revival of interest in scientific
matters among them that Dr. House soon found himself the frequent
host of several princes and nobles, seeking instruction in all sorts of
subjects; and he was on various occasions invited to their shops to
inspect their work or elucidate some obscure difficulty, as though he
were a peripatetic professor. He was even seriously troubled by the
borrowing of books and instruments which they were not all
punctilious to return. Moreover, he found himself an agent of some of
these men, ordering machinery and supplies and tools from America
for their use.
Chao Fah Noi said to him confidentially that any one who wanted
to do something new in those days must do it in secret, for if the king
learned of their activities he would call upon them to work for him so
as to keep them from pursuing investigations. This prince, however,
was not altogether secret in his experiments, for under date of July
4, 1848, Dr. House writes:
“This a. m., we saw something new on the river—a little
model steamboat, not twenty feet long, with smoke-pipe,
paddle wheel, all complete, steaming bravely against the
tide, with H. R. H. Chao Fah Noi sitting at the helm. It was
the first native steamer on the Meinam, entirely his own
construction.”
But not for one moment did Dr. House lose sight of his prime
objective. The favour of princes was no reward in itself; he was
always concerned for the influence he might exercise through his
contact with men of power:
“How taken with the new science is the Prince (Chao
Fah Noi). Oh, that acquaintance and opportunity given me
with him may be improved to win and turn him from his
trust in false gods and rites! He has a good mind.”
Not a lecture, scarcely a conversation, on science but Dr. House
sought to point out the unanswerable argument from “design in
nature” as a proof of a Creator and of the truth of Christianity. To
some, the revelations of nature through science became also the
revelations of a Divinity.
“Brother Chandler spoke of a person (Godata) who after
attending the chemical lectures last year, seeing evidence
of wisdom and goodness in the composition of air and
water, said ‘There must be a God—there must be.’”
This same Godata it was who became chaplain to the army under
King Chulalongkorn.
A study of Dr. House’s journal seems to justify the assertion that
his most far-reaching influence upon the mission work was through
his relations with these progressive members of the nobility. It is
even within a margin of safety to affirm that his influence was not
exceeded by that of any other man up to the time of his retirement.
This opinion does not underestimate such men as Rev. Jesse
Caswell, Rev. Daniel B. Bradley, M.D., and Rev. Stephen Mattoon,
whose labours also were pivotal in the development of missions in
Siam. It only so happened that the association of Dr. House with the
officials of the new government was more continuous in its bearing
upon the work. Having gained their sympathy through his practise of
medicine, and enlarged their interest through his knowledge of
science, he won their complete confidence by his sterling character.
When later these men, having obtained chief power in the
government, turned to him for counsel in international affairs or when
he went to them in behalf of the mission they knew that his judgment
was fair and free from ulterior motive. During nearly the entire period
of his service he was a valuable friend of the Siamese government
and a wise advocate of the mission at court.
V
LENGTHENING CORDS AND
STRENGTHENING STAKES
A direct effect of this growing interest in science was to show the
value of Western education in such a way as to create a demand for
the educational work of the mission. Not satisfied with their own
enlightenment several of these progressive nobles requested Dr.
House to tutor their sons in English with a view to instruction in
science. As early as 1847, before the doctor himself could devote
time to such work, Mrs. Mattoon had undertaken to tutor Kuhn Gnu,
the son of the Praklang.
While at the tract house one day the doctor caught a glimpse of
the desire and capacity of the common people for learning. A boy
applied for a book. Knowing that the lad had received one the
previous day, the doctor began to catechise him on that volume
before giving him another. He was surprised to find that in a day’s
time the boy had mastered the details of the story of Elijah. Upon this
the doctor observes: “Now this is in effect, as far as it goes, a school
and a Christian school, where more knowledge is imparted perhaps
than would be in a regular school.”
Under the régime of the old king no regular school was possible,
not only because the monarch was antipathetic to western ideas but
because the Siamese had no common desire for education.
“It is next to impossible to interest the native Siamese in
education, because it is the custom for all boys to enter a
watt as novitiates for the priesthood, and as such are
taught to read; but to read is the limit of their ambition.”
The quickening of an interest in science among the upper classes
proved to be the awakening of some of the younger generation to
the desirableness of a broader education than the priests ever
thought of giving.
The first mention of a school as a proposed department of the
mission occurs as an entry in the journal on the first anniversary of
the arrival in Siam, when the doctor records briefly: “Plans for
interesting and instructing the young Siamese were discussed.”
Looking back over the course of affairs it is apparent that the
embryo of the mission school was the receiving of some children into
the homes of the missionaries to be taught, while assisting in house
work. As early as 1848 Mrs. Mattoon, with an eagerness to do
something to elevate the condition of child-life, succeeded in
obtaining two girls for this purpose, one of whom she named Nancy,
after her own mother, and one Abby, after the mother of Dr. House.
Later another was added, whom she named Esther.
In the next year Dr. House had apprenticed to him a Chinese lad
of thirteen named Ati, the nephew of his Hainanese laundryman. The
boy was bound for a period of three years, during which he was to
act as a house servant in return for instruction in English. As a matter
of fact this boy remained in connection with the mission for a much
longer period. The part played by these children was not simply a
demonstration of their capacity for a Western education but, even
more importantly, they formed a nucleus around which to organise a
formal school later. Until time was ripe for such an undertaking the
missionaries could only try in the most experimental way to develop
interest in education among the common people with whom they
came into more intimate contact.
Although Dr. House fitted himself for the medical profession, he
found that by taste and aptitude he was essentially a teacher. His
fixed purpose was to impart to the Siamese the Christian truth about
God and about salvation, confident that this truth would awaken the
sleeping conscience. His discontent with his profession was to a
large extent because it hindered him from the more direct
propagation of the Gospel. Observation early disclosed to him, what
other educators had discerned elsewhere, that the chief obstacle to
the consideration of the spiritual message of Christianity was the
false cosmogony as held by the people.
Their idea of the universe was based upon a total ignorance of
many common facts of nature, an ignorance which completely
excluded from their minds the idea of a spiritual God. They were so
obsessed with fallacies about natural phenomena that there was but
small common basis of physical knowledge upon which the
missionaries could build an argument to dispose of these grotesque
ideas. For instance, the popular explanation of a lunar eclipse was
that a great dragon was trying to swallow the moon. When an eclipse
occurred, the people would set up a din of kettles and drums to
scare away the dragon. Since the moon always escaped, the people
were the more confirmed in their belief. Then there was the old
notion of the earth being flat. In the midst of the earth was a great
central mountain, whence Buddha had come, surrounded by a vast
plain; and inasmuch as Siam occupied the middle of this plain,
obviously there could be no other greater country. Before truth could
penetrate such an armour of ignorance, it was necessary that nature
be stripped of these false ascriptions in order that there might be a
common ground upon which to consider the arguments for the
Christian faith.
In the presentation of Dr. House’s message there can be traced an
orderly philosophy which reflects this situation. First he sought to
remove some of these false ideas by pointing out common facts of
nature which the natives had never observed. Next he sought to
explain the conception of God as Creator. From this he led on to the
love and mercy of God as revealed by Jesus. As a practical
sequence he aimed to give an elementary education to the few who
would receive it so as to demonstrate the Christian way of life. This
meant in the course of time the development of a system of
education.
SCIENTIFIC INTERESTS

Etextbook 978-0849374968 Photodermatology (Basic and Clinical Dermatology)

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eTextbook 978-0849374968

Photodermatology (Basic and Clinical

978-0323261838 Clinical Dermatology

eTextbook 978-0323319676 Andrews’ Diseases of the Skin:

eTextbook 978-0824758332 Principles and Practices in

eTextbook Clinical Dermatology E-Book 6th Edition

eTextbook 978-1627034890 Pediatric Hypertension

eTextbook 978-0323321976 Body Shaping, Skin Fat and

eTextbook 978-1608318056 VisualDx: Essential Adult

eTextbook 978-1285424637 Veterinary Clinical Procedures

Series Introduction Alan R. Shalita, MD iii

Section I: History and Basic Principles

2. Basic Principles of Photobiology 15

3. Radiation Sources and Interaction with Skin 29

Section II: Effects of Ultraviolet Radiation on Normal Skin

6. The Acute Effects of Ultraviolet Radiation on the Skin 75

7. The Chronic Effects of Ultraviolet Radiation on the Skin: Photoaging 91

8. The Chronic Effects of Ultraviolet Radiation on

9. The Epidemiology of Skin Cancer 119

Section III: Photodermatoses

Part B: Immunologically-Mediated Photodermatoses

12. Chronic Actinic Dermatitis 169

13. Solar Urticaria 185

Part C: Drug and Chemical-Induced Photosensitivity

15. Cutaneous Porphyrias 219

Part D: DNA Repair-Deﬁcient Photodermatoses

Part E: Photoaggravated Dermatoses

Section IV: Photoprotection

19. Novel Developments in Photoprotection: Part I 279

20. Novel Developments in Photoprotection: Part II 297

21. Public Education in Photoprotection 311

Section V: Ultraviolet and Visible Radiation Therapy

23. Ultraviolet-A1 and Visible Light Therapy 335

24. Psoralen Photochemotherapy 347

25. Extracorporeal Photochemotherapy (Photopheresis) 359

26. Photodynamic Therapy 369

29. Laser Treatment on Ethnic Skin 417

Section VI: Appendices

Appendix B. Photopatch Testing 441

Appendix C. Guidelines for Setting Up a Phototherapy Referral Center or an

Appendix D. Guidelines for Setting Up a Laser Center 457

Macrene R. Alexiades-Armenakas Department of Dermatology, Yale University School of

Karl E. Anderson Department of Internal Medicine, Division of Gastroenterology and

Mark Berneburg Department of Dermatology, Eberhard Karls University, Tuebingen, Germany

Henry Hin Lee Chan Division of Dermatology, Department of Medicine, University of

David E. Cohen Ronald O. Perelman Department of Dermatology, New York University

Robert S. Dawe Department of Dermatology, Ninewells Hospital and Medical School,

Thomas Diepgen Department of Clinical Social Medicine, Occupational and Environmental

Brian L. Diffey Department of Regional Medical Physics, Newcastle General Hospital,

James Ferguson Photobiology Unit, Ninewells Hospital, Dundee, Scotland, U.K.

Marjan Garmyn Department of Dermatology, University of Leuven, Leuven, Belgium

Erhard Hölzle Department of Dermatology and Allergology, Klinikum Oldenburg, Oldenburg,

Herbert Hönigsmann Department of Dermatology, Medical University of Vienna, Vienna, Austria

Takeshi Horio Department of Dermatology, Kansai Medical University, Osaka, Japan

Sally H. Ibbotson Department of Dermatology, Ninewells Hospital and Medical School,

Robert Knobler Division of Special and Environmental Dermatology, Department of Dermatology,

Irene E. Kochevar Wellman Center for Photomedicine, Massachusetts General Hospital,

Jean Krutmann Department of Dermatology and Environmental Medicine, Institut für

Michael Landthaler Department of Dermatology, University Clinic Regensburg, Regensburg,