Recollections of Dermatology and Some Dermatologists
The first dermatologist I ever saw, at the age of 14 or so, was Dr JMH MACLEOD, in his London consulting room, on account of acne. I think the consultation had really been arranged for the benefit of my father, because I had seen the spots on the faces of my contemporaries, and had already decided that mine were a minor problem. The great man, having examined my face, had scribbled away, and in due course I received a large bottle of white medicine to take, which roused my bowels, and a lotion that dried on the skin to leave a little white powder. I don't think the treatment was persevered with for long; and the acne pursued its usual up and down course for some years, without further interference. Dr MACLEOD made no clear impression on me, contrary to the subject of my next encounter, Dr GB Dowling.
By this time I had become a medical student at St Thomas's Hopital in wartime London. Dermatology was not a popular subject with the students. This now amazes me because in reality it is most interesting and, contrary to common belief, demands a great breadth of knowledge. The clinics were so sparsely attended thaht there was no difficulty in examining the patients thoroughly in a good light, unobstructed by the competition of other students pushing and jostling to get a good view, as they did in the Eye Department, for example. Consequently my knowledge of eye diseases remains rudimentary.
Perhaps my interest in dermatology had been aroused early, because my father and his sister had psoriasis, which causd them embarassment in various ways; his because of the staining produced by chrysarobin ointment; hers because of the unsightliness and disability consequent on hyperkeratosis and fissuring of the palms; and in both because of the feeling of 'infection' and uncleanness that the disease produced in their minds. But I would have become a dermatologist eventually without any such prompting simply because of Dr DOWLING.
It was not that he indulged in histrionics of any kind -- far from it -- but that he radiated an air of knowing what he was doing. He would peer at the skin through his binocular loupe, utter to himself, rub the skin, rub his chin, write the diagnosis on the case sheet, cast it in the 'out' tray, and mumble "next sister".
If you asked him why he had written "lichen planus", or whatever, the result was disappointing. "Because it looks like it" was all that he would say, and return at once to the next case sheet, with the slightest air of irritation that his thoughts had been interrupted. In fact this reply was ideal because you would look the disease up, read aabout it, and with luck you might recognise it for yourself the next time. But that did not suit students who liked knowledge presented to them on a plate. It was a method of teaching that contrasted sharply and favourably with that of a certain physician, for whom you had listened to a patient's heart. "Well, what do you hear, boy?". Your unsatisfactory answer was greeted with "Go and listen again" -- an admonition repeated perhaps several times , until you gave up in frustration, still unenlightened. DOWLING's method might have been enigmatic -- that was part of its appeal -- but at least you were being educated, i.e. led out of ignorance.
The enigma presented by Dr DOWLING's obviously great knowledge , and his inability (or unwillingness) to explain how he reached the diagnosis was provoking, and stimulated you to greater effort.
The way that Dr DOWLING treated everyone was notable. Students in many clinics found themselves the 'doormat' in the pecking order, but DOWLING regarded them as both human and intelligent until proved otherwise. You never had the feeling of being talked down to or patronised. You felt his equal not in knowldege but before God.
An episode demonstrated his humility and sense of duty. I was at Botley's Park Hospital (St Peter's) Chertsey in 1941 as a student doing a medical clerkship. Because of war-time difficulties both students and consultants had to travel from hospital to hospital in the sector -- i.e. the area to the south-west of London that had been allocated to St Thomas's. It was late; all of a sudden Dr DOWLING appeared out of the darkness wearing his crash helmet and riding the motor scooter on which he used to phut-phut about the countryside, trying to keep up to date with the large load of work occasioned by the war-time shortage of consultants. He was taken to see his patient, whom he examined in the way already described . "What is it?" he was asked. "I don't know,' he replied , " but it doesn't look good.' Soon after that the patient died. The story may sound unimpressive but in my view what he said was masterly. The erudite dermatologist, erudite beyond most of his peers, comes on a dark night not driving a Bentley but on a motor scooter, to see a patient in a peripheral hospital, and says he doesn't know what the diagnosis is, but fears the worst. Not many consultants would have been so honest or so humble. That was typical of Dr DOWLING. Dermatology always came first, and his own 'image' didn't figure at all.
At about this time I was working as a student in the Royal Surrey County Hospital at Guildford, and attended a dermatology clinic conducted by Dr GW BAMBER. The only memorable incident was of him injecting boiling water into a cavernous haemangioma; a treatment comparable in its heroics perhaps to dosing with thallium acetate for epilating scalp ringworm, that I would encounter later in Edinburgh. But Dr JO'D ALEXANDER tells me that carefully controlled (as it was at Edinburgh) thallium treatment used also to be the routine at the Glasgow Royal Infirmary, and was preferred to X-ray epilation. This reminds me that at the start of the NHS we were inundated wih requests for wigs for patients who had been treated with X-rays, and that one of them reported a sharp decline in school performance afterwards.
Dr HUGH J WALLACE was a general physician with a special interest in dermatology. I went as his house physician at the Woking War Hospital (the old Southern Railway Orphanage) in 1942. The striking thing about him physically was his hunchback (due to a congenital deformity of the vertebrae) which had the effect of making his head appear to be sunk between his shoulders. This abnormality barely constituted a disability because he took so little notice of it: in fact he was immensely strong as I discovered when wrestling with him, probably over some disagreement on the putting green in the hospital grounds.
Some routine hospital procedures at that time would be thought unacceptable nowadays. For example I remember aspirating an empyema using a 20ml glass syringe -- part of the ward stock of re-usable glass syringes -- and then cleaning it by washing it under the tap and then boiling it up in the little ward sterilizer, ready for subsequent use on another patient, which could well have been for giving an intravenous injection. That would not have been by any means unusual. Disposable syringes were not in general use at that time.
HUGH WALLACE was a perceptive physician, and he taught me a lot on the general subject of Medicine.
He was in the learning phase in dermatology himself at that time , so I was dragged along as you might say in his slipstream, and learnt a great deal. He introduced me to the meetings of the Section of Dermatology at the Royal Society of Medicine in London. At one meeting we noticed that a patient presented by an eminent dermatologist as a 'Case for Diagnosis' had a scabies burrow on his finger. "Do you think, Alan" said Hugh, "that we dare mention this in the discussion?" We looked at each other silently and decided that, being 'new boys' discretion was the better part of valour.
Hugh's analytical physicianly mind and his friendship with Dr Dowling, enabled him to discover the logic of Dowling's diagnoses, so that others could follow the same steps themselves. Hugh's mind was habitually alert; on a ward round he would suggest, for example, that one leg should be treated with coal tar ointment , and the other with zinc and castor oil cream, in order to compare the two. In this, I was to discover later, he was unconsciously following in the footsteps of Daniel Turner, who gave the apothecary one of the patient's legs to treat , and took the other himself on which to use his famous cerate.
These were the days before corticosteroids and antibiotics. Sulphonamides had arrived , and were used locally for treating impetigo, with great success. The first skin reactions were occurring, but were regarded at that time as unusual, and an insufficient reason for abandoning this useful treatment: in fact we felt rather irritated at the official advice not to use them topically. It is probable that our mild reactions were due to the comparative sunlessness of Surrey as compared with the sun-drenched Mediterranean.
Hugh was interested to know the precise cause of his patients' deaths, and since, under wartime conditions, there was no pathologist in the hospital, it was sometimes my duty to do post-mortems on our patients. This entailed visiting at night a little hut in the grounds that had a corrugated iron roof that rattled in the wind, and doing the post mortem entirely by myself -- an eerie experience. I founded my scanty knowledge of post-mortem work on seeing Professor WG BARNARD working both at Kingston Hospital and at St Thomas's. He was an impressive performer, and a good teacher; I used to be anxious seeing him clasping a kidney in one hand and slicing into it with a sharp knife held in the other hand, the blade directed towards his own palm. I was to find, in doing my own post-mortems, and contrary to the facility demonstrated by Professor BARNARD, that it was not always easy to make a pathological diagnosis: and then you would be faced with the need to write a cause of death such as 'debility' which (rightly) roused the wrath of the Registrar General, who would return the death certificate demanding a proper diagnosis. On one occasion my recently espoused wife was persuaded to come and see me doing a post-mortem. I don't remember the roof rattling on that occasion, but at one point the calvarium, which I had just sawn off, slipped through my fingers and lolloped off across the floor.
Importunate and difficult patients seemed to get under Hugh's skin in a way that troubled him excessively. He felt unable to avoid their importunity except by running away when he saw them coming; and I saw him do that several times in the long corridor at st Thomas's, or in the long tunnel in the basement, to which we had to retire because of the bombing.
Both HUGH WALLACE and Dr DOWLING were approachable, a feature that appealed to juniors, who were not always listened to seriously by their seniors, as though they were intelligent human beings. This perhaps contributed to the popularity of the Department of Dermatology at St Thomas's Hospital at the end of the war when many young doctors were looking for training.
After being HUGH WALLACE'S house physician I was called into the RAMC and after service in a Field Ambulance, landed up just before the Normandy invasion as Regimental Medical Officer to the 11th Battalion, the Durham Light Infantry. I was wounded at Mezidon (on my second wedding anniversary) in August 1944, and was evacuated first to a Canadian Field Hospital at Bayeux and treated by injections of the newly introduced antibiotic penicillin. The injections were painful -- a wasp sting at that time was absolutely trivial -- so that the patients receiving penicillin would try and disappear under the sheets when they saw the penicillin trolley coming. Then I was evacuated by sea to Portsmouth, and arrived at least at the familiar Botley's Park Hospital, to be welcomed with the remark "Oh, it's you." This period of my life had been short of dermatological experience, but was by no means devoid of interest, excitement and fear.
I started training in dermatology in 1946 after being demobilised, and getting a temporary post-war registrar appointment at St Thomas's. By this time there was a scramble to get out of the forces and on to the 'ladder' and I joined such hopefuls as JOHN SIMPSON ( later of Exeter), BOB BOWERS (Gloucester) and HUGH CALVERT (Reading), picking up the crumbs of knowledge that fell from Dr DOWLING'S table. This was the time when the George Club was foundeda Journal Club that met every month at the old George Inn, Southwark. From it developed the Dowling Club. But it arrived too late for me as I had just landed a job at Addenbrooke's Hospital, Cambridge, as post-war registrar to Dr CH WHITTLE. Dr DOWLING had advised me to take it, as he said they would take me on there eventually, if I didn't blot my copy-book. As it turned out I didn't; and nor did they, but that is another story.
CLAUDE HOWARD WHITTLE was a general physician who had taken to dermatology, apparently at the behest of Addenbrooke's Hospital. This was the old Addenbrooke's opposite the Fitzwilliam Museum. Dr WHITTLE was well suited to dermatology, having the eye of an artist, the mind of a physician/pathologist, and a personality that was friendly, adaptable and not easily discouraged. Perhaps he was a little too adaptable for my somewhat severe Scottish genes --- or so I thought at the time --- but it was from him that I learnt that between black and white came various shades of grey. I learnt also the advantage of compromise, and of bending before the wind. It may have been signficant that he liked particularly to paint willow trees in water-colour, with their flexible branches, after the style of Corot.
The training and experience at Cambridge were marvellous because Dr WHITTLE had dermatological oversight of a large area of East Anglia, with two registrars to help him. The other was Dr RONALD E CHURCH, later of Sheffield. RONALD CHURCH had just ended his RAMC service in Palestine. RONALD and I called Dr WHITTLE 'Charlie' after his initials CH --- and 'Charlie' he remained to us. It was a nickname born to some extent of frustration , because he always referred to us as 'his boys', but it was also of affection.
Because there was such a huge and scattered workload RONALD and I had a deal of responsiblility, and sometimes did clinics entirely on our own. On one such occasion, at Peterborough Memorial Hospital, I was on my own when a man came to the clinic from the local leather works, to say that he knew he had anthrax because it was just like the picture in the factory". So it was; it was firmly indurated , and there was a black eschar. The unusual thing was that he didn't seem very ill. So I appealed to the bacteriologist in the little lab upstairs a canny Scot. "If it's anthrax, laddie, a swab will be full of the organisms." It wasn't: and the lesion proved to be streptococcal.
There were regular clinics not only at Addenbrooke's Hospital, but also in the periphery at Newmarket, Bury St Edmunds, Wisbech, Peterborough and Bedford. We had a constant supply of patients , many of them interesting, and 'Charlie' encouraged us to demonstrate the most interesting on his behalf at the RSM in London: which was the very best way of learning, and also of getting to know the other dermatologists. BARBER impressed me; and so did PARKES WEBER, with his encyclopedic knowledge of rarities. The meetings were popular and well attended; and at one time a sort of traffic light was installed on the rostrum to warn speakers that their time was up. PARKES WEBER had progressed from the green phase to the amber and then to the red and the flashing red, without taking the slightest notice. Then he brushed aside these warnings with an impatient sweep of his hand; and then tried to unsuccessfully to wrench the contraption off the desk.
A feature of the case presentations at the RSM was the histopathology, the slides being on view at a table loaded with microscopes. You learnt not only to recognise the histological picture associated with the disease in question, but also, more importantly, to understand the difficulties and limitations of taking biopsy specimens. I had learnt the basics of histopathology from the textbook of MACLEOD and MUENDE. All our biopsy material at Cambridge was sent to MAX BARRETT , a University pathologist, and we discussed the slides wtih him at weekly meetings held in the University Pathology Department. Dr DOWLING used to ask the opinion of WALTER FREUDENTHAL at UCH: I remember going with Dr WHITTLE at short notice to London to join a number of junior dermatologists in order to meet Dr FREUDENTHAL, who impressed us with the importance of histopathology; but he was really preaching to the converted. He also said that the juniors present would be the future leaders of dermatology --- which may have been true, but I thought rather premature. The impression he gave was that histopathology was something rather new in the UK; but I discovered that was not true. For I learnt later that NORMAN WALKER had translated UNNA'S Textbook of the Histopathology of the Skin into English in 1896, and that MACLEOD, who had also worked with UNNA at Hamburg, had written his own book on the subject, the second edition of which had become the MACLEOD and MUENDE already mentioned. NORMAN WALKER'S industry had not proved fruitful in Edinburgh until the advent of GEORGE HECTOR PERCIVAL in 1936, who maded a special study of cutaneous histopathology. It was HENRY HABER whose opinion was most frequently heard at the RSM; he was a clinician as well as pathologist. Like many refugees from Europe who came to the UK he encountered difficulties in becoming established, and I believe that he was much more able than was generally recognised. He maintained that the disease later known as the Staphylcoccal scalded skin syndrome was a form of pemphigus, and he used to ask whether my patient hadn't developed pemphigus yet. Our last conversation was held in the Surgeons' Hall in Edinburgh at the time of the 1962 BAD Meeting, on the night that he died, and I hope that my refusal to agree with him played no part in his suicide. Henry used often to be seen at meetings with his cine-camera photographing the participants; I have often wondered whether these pictures still exist, because they would form a most interesting record. By the time I reached Edinburgh myself I knew enough about histopathology to appreciate the high standard of that subject in PERCIVAL'S Department. It was here that I first appreciated the value of serial sections for following lesions in three dimensions; and I also found a system in operation for filing biopsy slides under diagnosis, which facilitated learning the subject.
Dr WHITTLE was a great practical man: he always believed in trying things out. For example he used to try and grow pathogenic fungi in culture bottles of Sabouraud's medium, which were kept in a huge enamel tray in a cupboard in the out-patients department: and we would mount material from the cultures in lactophenol cotton blue to try and identify them. To improve our knowledge of mycology he took us to visit Dr WALKER in his laboratory in London. Our Wood's light in the Department comprised a Wood's filter mounted on an ultraviolet machine. This apparatus was rather old and decrepit, and water used to leak out of the cooling system on to the floor. You sometimes found yourself standing in a pool of water when examining a scalp, in imminent danger of being electrocuted by handling the imperfectly earthed lamp. Perhaps I was saved by my rubber soles, but we certainly had some electric shocks. In the same side room was kept a huge carbon dioxide (CO2) cylinder, upside down in a stand. CO2 snow was produced by blowing off the gas into a chamois leather bag, where it collected --- an improvement on the old habit of using a top hat for the purpose. From time to time the valve on the cylinder would jam open, and then the registrar would erupt into the clinic bearing his little chamois leather bag, to the horrendous noise of escaping gas, and the consternation of the waiting patients, who would suddenly see this strange figure materializing out of the 'smoke'. Every patient with a possible fungus infection had scrapings mounted in potash solution, which were examined on the long-suffering microscope in the clinic; which was soon scarred by the potash solution that leaked onto the stage. Equally every patient who might be infested had scrapings examined; in the case of scabies that patient would be shown their own Acarus crawling on the glass slide, and attempting to burrow into it: it gave the patient a great incentive to carry out the treatment thoroughly. Everywhere I worked subsequently I have been amazed at the comparative neglect of the microscope in the clinic for such practical investigations. Dispatching specimens to the laboratory is a weak substitute for examining them on the spot for yourself. How many laboratory results of positive scrapings have really identified 'mosaic' fungus?
I have forgotten so far to mention our own superficial therapy X-ray machine in the OPD. Radiotherapists in my experience don't believe radiotherapy works in diseases such as lichen simplex , and for that reason think that patients should not have it; we believed that the results of superficial therapy when we did it was better than later when it was entirely in the hands of radiotherapists, doing it under sufferance. Perhaps this had been due to positive suggestion in our department and negative suggestion in radiotherapy. In this connection I did notice that the therapeutic results in non-malignant skin diease tended to be best in the patients who had furthest to travel. The ultimate physical dangers of irradiation were impressed on us by seeing one of the X-ray pioneers who attended the clinic with his atrophic and cancerous digits.
I do not suppose that such training as we had could be obtained anywhere in Britain today, both for its range and for the amount of personal responsibility entailed. Dr WHITTLE taught me most of what I know once the germ of interest had been activated by DOWLING and WALLACE. Dr WHITTLE bore his didactic skill so lightly, almost as though it surprised him, and he couldn't imagine how it had happened. It was a wonderful period of my life, of a kind never to be recaptured later except for once when we had Professor HERMANN PINKUS as visiting professor for a year in the Department at the Glasgow Royal Infirmary. His visit galvanised not only our Department , but also pathologists and clinicians in Glasgow generally. But it was a period lived under the shadow of the MRCP exam.
It was a reasonable idea (with which Dr DOWLING had a lot to do) that dermatologists should be properly trained in Medicine, and one with which I agree fully . The snag for me was that at Cambridge it was possible to learn a great deal about Medicine, but little about examination technique. The result was that I failed the London MRCP eight times in all; I went and passed the Edinburgh MRCP on the first occasion. The difference between the Edinburgh and London exams seemed to be that in London there could be only one mistake and you were out; but in Edinburgh you had a thorough vetting , and could survive a venial sin or two. The practical result of having the Edinburgh rather than the London MRCP at the time meant that my future prospects were confined to the north of that magic line that stretched from the Severn estuary to the Wash. Consequently my next port of call was Edinburgh, where I encountered a different climate both geographically and culturally.
It was not only the Edinburgh weather , which was much cooler in the summer than Cambridge, but also the sense of restriction and authoritarianism that existed. In Cambridge it had not only been possible to have your say on anything, but you were expected to do so. In Edinburgh you had to be careful what you said in case you were thought to be presumptuous. It was really a case of 'little boys should be seen and not heard'. Soon after I arrived I witnessed a scene that I could hardly believe. A senior physician was leaving the Edinburgh Royal Infirmary. He emerged , preceded by a junior, and was followed by the rest of the medical staff. The junior opened the door of the chief's car, while the others formed a respectful semi-circle as the chief got in. He then drove off in a puff of smoke, while the farewell party dispersed. What a contrast to Dr DOWLING arriving on a dark night on his motor scooter wearing a crash helmet; arriving and departing unheralded and unannounced. I do not wish to suggest that there was anything wrong with the way they did things in Edinburgh; it was just that they did things differently.
My boss at Edinburgh as far as the University was concerned was Professor GH PERCIVAL; but I was also responsible in the NHS to Dr GRANT PETERKIN and Dr ROBERT AITKEN: a source of possible confusion as well as embarassment.
Professor PERCIVAL was a fascinating and in some ways infuriating character for he was extremely able, had contrived to have a new self-contained skin department built with the financial help of a grateful patient, but had then virtually lost interest in dermatology, and so his new Department had failed to achieve that degree of excellence that the facilities had made feasible. For the Department possessed out-patient facilities, wards with their own nursing staff, and laboratory space, and was an integral part of the Edinburgh Royal Infirmary, an important Teaching Hospital -- all the things that PERCIVAL'S predecessors had hoped for, and that should have made for an excellent academic department, the like of which existed nowhere in London, and in Britain at that time only perhaps in some degree at Leeds and Sheffield. Apart from ERASMUS WILSON (1809-1884), who endowed a chair of dermatology at the Royal College of Surgeons of England, and occupied it himself for eight years (after which the College diverted the money to other uses), I do not think that there had been any established chair of dermatology in Britain before Percival's chair at Edinburgh. The donor of the money for the Edinburgh Department had developed what was probably a contact dermatitis from his wet shooting stockings.
PERCIVAL trained in Europe , and as a result he tended to look towards Europe, especially France, rather than London. His two chief interests were the topical treatment of skin disease, and the histopathology of the skin: he was fond of saying that they knew nothing about treatment in London, in which there was indeed a grain of truth. PERCIVAL and Miss ELIZABETH TODDIE, the sister in charge of the skin wards, devised a system for applying bandages to any part of the skin, and they wrote a book on the subject, 'Dermatology for Nurses', published by Livingstone in 1947. Topical treatment was an important consideration in pre-corticosteroid days. The treatment facilities were used not only for all in-patients, but for selected out-patients as well, and often it was possible to keep a patient at work who would otherwise have to be admitted. The method was costly in respect of nurse hours, and of patient hours too, but the results were certainly superior to anything I had seen previouisly. The advantage of having beds in the skin department was tremendous, as it avoided the necessity of a time-wasting trek round the medical wards looking for a patient or two in each, and then having to try and persuade the nursing staff on that ward to do the dressings, a task for which they had not been trained, and towards which they brought little enthusiasm. This had been the staste of affairs at Addenbrooke's, and was also to be found in all the United states hospitals I was to visit later. It distresses me that there is now a suggestion that skin departments do not need beds any longer. It is an idea that may appeal to the administrative mind, which wants to save money, and thinks that dermatology is a trivial subject, or, as some physicians say a 'minor specialty'. Dermatologists know differently from practical experience, and so do their patients who have experienced a well-run Skin Department. An epidemic of generalised pustular psoriasis and pemphigus among administrators might work wonders of comprehension.
PERCIVAL'S coolness about London was matched by London's coolness about him; which is a pity because each camp underappreciated the other. London may have been superior in some aspects , but patients received a much higher standard of tender loving care in Edinburgh.
PERCIVAL had considerable charm, but he could be difficult on occasion though a good point about him was that he didn't harbour grudges. He had produced an Atlas of Regional Dermatology in which one of the pictures was said to illustrate a syphilitic chancre of the lip. We told him it was almost certainly a gumma , but he wouldn't hear of that. Some days later he came in in a good mood, and suddenly said: "You know, Alan, I have been thinking about that chancre in the Atlas; I think it might be a gumma." That was quite characteristic of his ability to let an idea ferment in his mind and then , if necessary, and after a due interval, to announce that he had changed his mind; if possible in away that made it seem as though it was his own idea.
Dermatology was no longer his main interest in life as it was with DOWLING; although DOWLING was certainly not devoid of cultural interests. But PERCIVAL had come into dermatology by accident almost, because there happened to be a vacancy in dermatology at a time when he needed a job. Had he been motivated to concentrate single-mindedly on dermatology he would have made a great name for himself; but as it was he never attained that distinction to which his innate ability ought to have entitled him. But his energies were directed now to such activities as the appreciation of Chinese jade, the vagaries of the Stock Exchange, and the microscopic study of salmon scales to determine the life history of the fish. It was said that when he attended a meeting in Cambridge he lectured the staff of the Fitzwilliam Museum on the proper classification of their collection of jade. Whatever may have been his shortcomings from the dermatological point of view he did inspire loyalty in the junior staff, and supported them in their subsequent careers.
I have written at some length about PERCIVAL because his virtues have never been fully appreciated , even in Scotland, while his defects have been magnified unduly. There would not be a flourishing Chair of Dermatology today at Edinburgh if PERCIVAL had never lived.
Since 1912 there have been two charges in Dermatololgy --- virtually two separate departments --- at the Edinburgh Royal Infirmary. Dr GRANT PETERKIN held thet second non-University one. I had less to do with him than with Professor PERCIVAL, and consequently know less about him. This dichotomy made difficulties for me as Senior Registrar, as I had two masters --or three , if the aged ROBERT AITKEN (author of 'The Problem of Lupus Vulgaris') is included. I'm not quite sure where he fitted in; he seemed a kind of relic , who hovered in the background and did 'ghost clinics' on some afternooons , when there were few, if any, patients. He was displeased because, not knowing of his existence, I hadn't attended these clinics at first. He had been concerned with the Finsen Light Clinic for treating lupus vulgaris, an important therapy in its time, but then being displaced by calciferol, and later by chemotherapy. His bleak existence was soon to be cut short by a ruptured heart valve, but not before he had a disastrous holiday in the Mediterranean, when his luggage had failed to arrive until the very end , and he had had to spend his governmentally rationed spending money on clothes to wear. I feel I didn't get a proper idea of him having witnessed only the closing weeks of his career.
Because Professor PERCIVAL and Dr GRANT PETERKIN held separate charges, it was possible for interesting patients to exist on one side of the house unknown to the other side. I was told that this had actually happened, when PERCIVAL wrote a paper on major blistering eruptions (this was before we knew of Civatte's description of acantholysis in pemphigus) without knowing that PETERKIN had a patient whose blisters showed acantholysis. But the patients that PERCIVAL described all had sub-epidermal blisters, and the chief conclusion of his paper was that a blister that had started out as sub-epidermal would soon appear to be intra-epidermal due to regrowth of epidermis beneath the blister floor.
PERCIVAL delighted in salmon fishing and in his garden, whereeas PETERKIN was addicted to golf, which he enjoyed not only as a game, but also as a social occasion, and for the status that belonging to an exclusive club conferred. PETERKIN knew, or knew of, some United States dermatologists, which was useful to me when I was planning to visit major centres in the USA (after I had left Edinburgh). PERCIVAL on the other hand looked towards Europe. They both taught undergraduates, but it was PERCIVAL who was concerned with academic dermatology, while PETERKIN was a clinician. He was a mine of information on clinical dermatology, mostly of the anecdotal variety. He was particularly interested in drug eruptions, on which he was regarded as an expert. He was also known for having described a case of human Orf, when that infection was not recognised by dermatologists, though it was familiar to farmers , vets and butchers. While helping at his out-patient clinic at Leith Hospital I suggested that liquid nitrogen would be safer than liquid oxygen for treating warts. His response was not to order liquid nitrogen, but to remove the liquid oxygen canister from his room, and to put it in mine.
Edinburgh produced a number of dermatologists such as DUNCAN DUTHIE (an ex-prisoner of war of the Japanese and an ardent rock-gardener) and ERIC DONALDSON, who both worked at Stoke-on-Trent, and Dr GEORGE SENTER at Birmingham, and AITKEN ROSS at Portsmouth; but the one whom I got to know best was Dr IAN MACCALLUM, who went first to Nottingham, and then transferred to Inverness. He had been in the BEF (British Expeditionary Force) at the beginning of the Second World War in 1939, and when the German attack came he had failed to reach Dunkirk, and had travelled laboriously through France, reaching Marseille eventually, after adventures that he described in a fascinating diary that must still be in existence. Perhaps his daughter MARY CARR, who is a dermatologist at Durham, may know where it is. Ian was a strong character, of firm Presbyterian faith, with whom it was not possible to discuss rationally the pros and cons of Mary Queen of Scots. Ian escaped from France with the help of the Reverend Donald Caskie who had himself travelled laboriously from Paris to Marseille, as described in his book 'The Tartan Pimpernel' (Collins, Fontana Books, 1960). Apart from Ian being a credit to the human race (what my mother-in-law would have called 'the salt of the earth') Ian was known for his writing on Crohn's disease of the skin. We never worked together, and I regret that I never took up his invitation to visit him, and to get to know him better, before his longstanding cancer of the tongue ended his life.
Aberdeen was not a happy period. TOM ANDERSON, who had been the sole consultant, was faced with having a second consultant appointed. He, and some of his friends, had hoped to choose a local man, but a majority on the Committee thought otherwise, and he was landed with me. This was a difficult situation, aggravated by the traditional suspicion that Aberdonians direct against any outsider. Lack of granite genes is a great disadvantage in the north-east of Scotland, and my Scottish ones emanated from south of The Mounth, in Angus, and my wife's in Fife. Under the circumstances our relationship was fairly amiable, even though the unsuccessful candidate stayed on for a bit as Senior Registrar. Both he, and TOM himself, were normally perfectly agreeable people, but the situation in which we all found ourselves was not conducive to being a happy family. I felt, my own family felt, that we were unwelcome, and that I was given the least possible amount of help and support by TOM (unlike what I received from many of my other colleagues). For example, it was a major struggle for me to get a bed into which to admit a patient. TOM had said that of course I could admit patients --- and he would look after them! In general TOM resisted the idea tha we were in any sense equals, as I thought we should be, and as I was determined that we would be. This is why, in my paper on Toxic Epidermal Necrolysis, I described myself as assistant Physician rather than as Consultant. TOM'S attitude was that I was a difficult young man (I was nearly 40) and mercenary because I complained, for example, about being given only seven sessions rather than the nine for maximum part-time.
The situation culd have degenerated into open warfare, but somehow it didn't. We muddled along, missing opportunities to set the Department on a better footing because the requisite unity of dermatological opinion was absent. I remained unhappy , and was relieved to be appointed after seven years, to be in charge of the Skin Department at the Glasgow Royal Infirmary. I felt no animus against TOM. We had behaved rather after the fashion of automata, each adopting the part into which the circumstances and our feelings had dictated, avoiding outright confrontation, but failing to make the progress that I had hoped for. It was perhaps the best that could have been done, while avoiding bloodshed: and I like to think that it didn't queer the pitch for my successor.
If Aberdeen had been unhappy, Glasgow was both happy and fulfilling, even though my hopes for it were never fully realised. My object was to promote dermatology as an important speialty -- as important as cardiology or neurology, for example, and at least as demanding. But although this thought may have entered some minds, it did not penetrate the pachyderm of the average general physician, who continued to believe that dermatology was an insignificant specialty, while he or she belonged to the elite: and to contrive to do so even while 'General Medicine' was fragmenting into distinct specialties, none of which were intrinsically more important than dermatology. It was just traditional to assume that dermatology was insignificant.
Although my efforts were not wholly successful, progress was made. Our laboratory facilities proved rather unfruitful because we lacked scientifically trained personnel: on the other hand we now had wards in which , thanks to overhead fluorescent lighting, it was possible to see the patients' skin clearly, even when the curtains were drawn. We also contrived a small lecture room, by bridging over angles on the outside of the building, in which academic functions such as a weekly departmental meeting took place; and in it we founded a basic dermatological library. Dr ALEC IMRIE, a physician, agreed to rotate his junior medical staff through dermatology, to our mutual advantage. The Ayrshire (Dr THOMAS COCHRANE) and Lanarkshire (Dr GEORGE LESLIE) consultants did out-patient clinics at the Royal, and attended our meetings: and we supplied locums for them when necessary, and visited them occasionally to discuss problems. Nevertheless, our efforts were frustrated because the University saw the Western Infirmary as its primary dermatological concern (whatever some of the Professors at the Royal might maintain to the contrary) and we therefore functioned without significant University help. In the circumstances, and considering that I was poor at fund-raising, we did quite well. Another frustration was that our liaison with Ayrshire and Lanarkshire was impeded by administrative re-organisations tha have favoured rigid demarcation , and are inimical to flexibility. Professor MILNE at the Western Infirmary and I had hoped eventually to rationalise academic dermatology in Glasgow by combining the expertise of the Western and Royal Infirmaries, but this idea petered out, not because our enthusiasm failed, but because the traditional rivalry between the Royal and Western Infirmaries made such co-operation difficult. The only practical outcome of this co-operation was that I did a weekly teaching round at the Western Infirmary, and that a Regional Contact Dermatitis Unit was opened at Belvidere Hospital under Dr LATAFAT HUSAIN.
After Professor MILNE had died, and Professor RONA MACKIE succeeded to the chair, the situation changed, and now the Western Infirmary has the monopoly of academic dermatology. Disappointing as this may be for me personally, in the long run it is likely to allow academic dermatology to flourish in the University for many years to come. it might even result in dermatology being accepted as of equal importance with other medical subjects; a process that will be facilitated by the inevitable demise of 'General Medicine' as an elite discipline. But do not suppose that I believe in superspecialism --- knowing more and more about less and less. On the contrary we need to relate our knowledge of the skin ever more widely in the fields of general medical knowledge and general scientific knowledge, and the general understanding of humanity's place inthe world: so that dermatologists, far from retreating into the obscurity of specialised knowledge, of interest only to the initiated, will enter the consciousness of all who take an interest in the mystery of life. We need, in fact, to consciously adopt the broadest possible approach.
Whatever the future may hold for dermatology in the Glasgow Royal Infirmary, I must record what a happy Department I had the good fortune to belong to. We may not have engendered reams of paper, but we did generate a corporate climate of concern for skin patients , and of interest in skin diseases. We learnt a lot together about the art of caring for skin patients, and this knowledge has been disseminated widely by members of staff who have travelled to other places, some of whom have become dermatologists. They include, witin Scotland STEWART DOUGLAS and ALEXANDRA STRONG in Lanarkshire, KAREL KENICER and his wife MARGARET in Dundee, SAM CRAIG in Ayrshire, TOM McFADYEN at Erskine, ALAN MATHIESON in Kirkintilloch, MARGARET ANDERSON in Edinburgh, JEAN McNEILL in Stirling, WERNER SUSSKIND and DAI ROBERTS in Glasgow, LESLIE STANKLER in Aberdeen and GORDON FRASER in Inverness: in England ELSPETH YOUNG at High Wycombe, JANICE DEMPSTER at Southampton, HELEN NELSON in Derby, HELEN COOPER in Newcastle-upon-Tyne, KALMAN KECZKES in Hull, and HAMID HUSAIN at Rotherham: In Ireland RAYMOND FULTON at Limavady: In the USA LATAFAT HUSAIN (now HUSAIN HAMZAVI): in Canada JIM WALKER: In Australia PETER BERGER: and last, but by no means least, Professor TAHIR SAEED HAROON at Lahore, Pakistan. (My apology if my aged memory has forgotten anyone -- please forgive me.) Something of what they picked up with us has been disseminated widely in the world. That may be a solemn thought, but it is also a comforting and humble one.
I have said little about members of the staff who are still alive, but must make an exception in the case of Dr J O'D ALEXANDER, my fellow consultant at the Glasgow Royal Infirmary, who supported me faithfully at all times. It is sad that his greatest achievement, a textbook of dermatological entomology, should have failed to receive the recognition it deserved; only one or two knowledgeable people appreciated it properly. Dr ALEXANDER had been in the Department long before I arrived in 1962, and but for him I should have had a severe uphill struggle. He had kept the flag of academic dermatology flying during the dark ages of the era of the SHMOs, wqhen this grade was used to do consultant work on the cheap. When this situation was being tackled I was the dermatologist member of the committee which considered the grading of individuals. The discussion became heated, and the chairperson, a member of the Regional Hospital Board, said to the medical members "Some of youse doctors needs to take some pills."
Dr JOHN THOMSON was my successor. Because I retired precipitately and prematurely (having fallen out of love with the NHS; and realised that when Dr ALEXANDER had to retire they would expect two consultants to do the work of three) he was left in the lurch; for which I feel guilty and apologise to him.
I would like to leave you with the memory of Dr PASIECZNY, as representing the spirit of our Department. TADEUSZ PASIECZNY was born in Poland, and qualified in Warsaw in 1929. He specialised in dermatology and venereology. His family had given distinguished service to Poland. When the Germans invaded his country, TADEUSZ was arrested by the Gestapo; but he escaped, and after adventures that he never fully revealed, reached Britain. He served in the Polish forces, including in Norway. He was wounded, and decorated by the Poles, the Norwegians, the French and the British. There was a photogtraph of him in battle-dress wearing all his medals, but the picture didn't show that he had no trousers on because they had become too small.
At the end of the War, this much decorated Colonel, who was used to commanding men, became a humble Junior Hospital Medical Officer in the Department of Dermatology at the Glasgow Royal Infrmary, and in the VD clinics of the City of Glasgow. He was known as 'Dr WHITE' because at that time the name PASIECZNY was thought to be too difficult to deal with. His status in the NHS may have been the humblest , but his distinction as a man shone out, and was obvious to everyone he met in the Hospital , patients and staff alike.
Eventually he became a Consultant Dermatologist, and was elected to the British Association of Dermatology (as it then was); but to his great disappointment he had to give up Venereology, which by that time had separated from Dermatology. He also received a PhD degree from the University of Glasgow on Non-specific Urethritis.
He insisted on retaining his Polish nationality; but in a way he saw himself as a native Scot. "Well Tad" he was asked on returning from a holiday at a Highland Hotel, "How did you get on?". There had been many foreign vistors, "I was the only Scotsman there" he said proudly.
These bare facts clothe a life lived with extraordinary consistency and rectitude, often under difficult circumstances. He is remembered with much affection and we were proud to have him in the Department. Let him stand as a symbol of what our Department was like. We were happy, and I felt honoured to belong.
The Art is long, and individual lives endure only briefly. Everyone has their own picture of the times through which they have lived; but dermatology goes on and develops a life of its own; each person contributing their mite of understanding, and knowledge is passed from one person to another, and contributes to the global perception of dermatology ---much more readily in these days than in the past, due to the computer. But is there not a danger that the phenomenal facility of this device culd lead us to a second dark age, the weight and the volume of the accumulated facts blinding us to the truth of life as it actually exists, if we could only bother to look and think? Change has left me behind. Now I can only watch events unfolding that are in the hands of others. But I trust that my antique words will convey a realistic picture of how things were in dermatology between 1940 and 1980, which will be of some interest to our successors.
Other biographical and historical writings by Dr Lyell
Obituary: Dr Tadeusz Pasieczny. Brit J Dermatol (1977) 97, 464-465
Lister and Ogston. Not Published
Daniel Turner. International Journal of Dermatology () 21 (3), 162-170
Alexander Ogston (1844-1929) - Staphylococci. Scottish Medical Journal (1977) 22, 277.
Erasmus Wilson and the Chair of Pathology at Aberdeen. British Journal of Dermatology (1979) 100, 343-346.
John James Pringle (1855-1922) (1985) American Journal of dermatopathology 7 (5), 441-445
Dermatology and Edinburgh (1986) Clinical and Experimental Dermatology 11, 413-421.
John Ferguson Smith (1888-1978)(1986) American Journal of Dermatopathology 8 (6), 525-528.
Hermann Pinkus (1905-1985) Obituary. British Journal of Dermatology 115, 507-509
Memories of working with Howard Whittle (1987) Clinical and Experimental dermatology 12, 29-30.
Alexander Ogston and Joseph Lister. Micrococci. ( ) Journal of the American Academy of Dermatology 20(2) 302-310.
Daniel Turner and the first controlled therapeutic trial. (1986) Clinical and Experimental Dermatology 11, 191-194