Dermatology in Edinburgh - The First 100 Years
Dr John Savin
The following account is reproduced, with permission, from the British Medical Journal of Christmas 1984 (BMJ 1984;289:1762-4).
Here we sit, smug and snug in our glistening new seminar room. One hundred people, all working in dermatology, 15 of them from our own department, are soaking up the massed wisdom of the country's seven professors of dermatology - all this to celebrate the 100th anniversary of the skin department at the Royal Infirmary of Edinburgh. The professors sparkle brightly, but after a few hours images from the past begin to drift across my mind ...
In the foreground I see another professor, the late G H Percival (left), proud to have been the first holder of the first established university chair of dermatology in Britain. Pen in hand, he is fully able in his 80s to dash off the 357 pages of his pungent and scholarly treatise on "The History of Dermatology in Edinburgh" (unpublished observations), so inadequately condensed to a few sentences here.
Behind him stands the bristling Dr Allan Jamieson (right), triumphant at last in his "small dark room" at the infirmary. Beyond Jamieson the line of dermatology stretches back to Robert Willan, graduating from Edinburgh University in 1780. Further away still the early infirmary, founded in 1729 and royal since 1736, is shrouded in mist. It seems incredible that such a hospital could have limped on for a century and a half without a skin department.
But in those days the general physicians and surgeons here were keen on dermatology. How they squealed when Dr Jamieson, fresh from Hebra's clinic in Vienna, kept pressing for a room in which to see skin patients. Skin cases were not numerous, they said, and the existing consultants were well able to deal with them. And perhaps they had a case.
Joys of lumping and splitting
Who can fault a system that delivered such a fine series of doctors, many interested in dermatology, into key positions in London? Edinburgh had perfected the methods of clinical training started in Leiden, and its teaching during the second half of the eighteenth century was among the best in Britain. Richard Bright and Thomas Addison, both Edinburgh graduates, had flirted with dermatology but their main achievements were to lie in other fields. Robert Willan and Thomas Bateman, however, went on to become the two most important dermatologists of their time Robert Willan, one of the first to bring order to the chaos of skin diseases, had learnt the joys of lumping and splitting from William Cullen, professor of the institutes of medicine, master nosologist and follower of Linnaeus, whose writings were also much admired by the French dermatologist Alibert (1). Indeed, that "cradle of British dermatology," the Carey Street dispensary in London, was between 1783 and 1791 staffed largely by graduates from the Edinburgh medical school.
In Edinburgh the torch of dermatology was carried onward through the nineteenth century by a group of interested general physicians and surgeons led by John Hughes Bennet, a professor in the faculty of medicine. In the 1840s he was hot on the trail of Schonlein and Gruby in pursuit of the recently discovered "parasitic vegetable structures," which cause favus and ringworm, beating both to become the first to reproduce favus experimentally in man (2). He wrote widely on dermatology and in 1850 was given two wards in the infirmary solely for the care of skin conditions. Thomas Laycock, professor of the practice of physic, also wrote a pamphlet on skin diseases and studied the contagiousness of boils. The two of them shared, rather uneasily, the running of the skin wards and were later joined by Sir Douglas McLagan. Edinburgh surgeons were also interested in dermatology, notably Joseph Bell, whose inspired guesses from the state of the skin and nails - "You know my methods, Watson" - made Conan Doyle turn him into Sherlock Holmes.
Against this background it is easy to see why dermatology was hard to establish as a separate discipline in Edinburgh. Professor Percival lingers lovingly over the paranoid scufflings that scotched the first attempt to establish a dispensary for diseases of the skin by Dr Edward Duffin in 1824. Duffin backed off to London and ophthalmology. A second attempt in 1838 foundered after a few years, as did a third in 1869. Later a fourth Edinburgh dispensary for skin diseases did useful work between 1890 and 1966.
Life was no easier at the infirmary itself. Dr Allan Jamieson had both drive and ability and later was to become president of the Royal College of Physicians of Edinburgh, but he needed luck as well to force his way in - and here leg, eczema enters the story for the first time. He did well with the eczema of one of the hospital managers, Daniel Rutherford Haldane, who was able to jockey Jamieson's request for outpatient facilities through a split board of management. In 1881 Jamieson's reward was a share in a small dark room that he could use on Saturday mornings. Seven years later, after a titanic struggle with the clinical professors, he added a few beds to his empire. In 1892 he was joined by the influential Dr Norman Walker (later to be Sir Norman and president of the General Medical Council), who had studied under Kaposi and Unna.
These two master tacticians more than held their own in the jostling throng of new specialists in other disciplines, and together built up "the most fully equipped skin department in a general hospital in Great Britain" (3). Soon the Saturday morning clinics were teaching "the greatest number of English speaking students that have anywhere assembled to learn dermatology." Many came from abroad, and Edinburgh skin textbooks went round the world, Walker's running to 13 editions. In 1899 dermatology became compulsory for the medical students, who had to spend more time on it then than they do now.
Need for a new department
Jamieson and Walker were followed by Frederick Gardiner (appointed physician in 1912), an expert radiologist as well as a dermatologist, Robert Cranston Low (1924), one of the first to look into the immunology of contact dermatitis, and Robert Aitken (1933). Their clinics grew remorselessly; patients spilled over into the corridors; and at last the rest of the medical staff had to admit that the hospital's most pressing need was for a new skin department. A five storey ferroconcrete pavilion shot up, combining the 1930s' look with a faint hint of the Scottish country house. But the venereologists took the lion's share of it, aggravating their offence by sending a stream of arsenical eruptions up to the dermatologists packed into the top two floors.
Dr George Percival joined the consultant staff when the new building was opened in 1936. Trained in Paris, Lausanne, and Zurich, he knew as well as Dr Jamieson how to deal with leg eczema. Sir Robert Grant, the head of a family already lavishly generous to the University of Edinburgh, was aware of the damage that skin disease could do to his employees, and was unhappy when he developed eczema of his legs after several days of strenuous shooting in wet weather. Pleased with Percival's cure he gave £80,000 to found a chair of dermatology in Edinburgh, and in 1946 Dr Percival became its first holder. New staff brought new strength to the department.
Dr G A Grant Peterkin, whose first description in 1937 of orf in man has become a modern classic (4) and Dr Patrick Hannay, became consultants. A whole floor was reclaimed from the venereologists. Professor P J Hare succeeded Professor Percival in 1966. All helped to build up a modern department and to man peripheral clinics covering Fife and the Borders. In 1982 we moved to our new outpatient department, its many light rooms in striking contrast to Dr Jamieson's small dark one.
But enough of the past: dermatology is still a young subject. One half of all the consultant dermatologists ever appointed to the Royal Infirmary are here today in the seminar room. The professorial fireworks are spluttering to an end and soon we will be joining those who trained here, but who now work elsewhere, in a feast to celebrate their return to Edinburgh and to fill us with energy for the future. With things as they are now we need another slice of luck: even the fatted calf will be searched for traces of eczema.
Hare PJ A note on Robert Willan's Edinburgh days. Br J Dermatol 1973;88;615-7.
Shelley WE. Experimental disease in the skin of man. Acta Derm Venereol (Stockh) 1982; suppl 108:1-38.
Graham-Little E. Celebrated British dermatologists of the last 50 years. Br J Dermatol 1938;M:503-8.
Peterkin GAG. The occurrence in humans of contagious pustular dermatitis of sheep (orf). In: Shelley WE, Crissey JT, eds. Classics in Clinical Dermatology Springfield: C C Thomas, 1953:437-8.