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Growth in a Wider Scene

The medical vista for the country as a whole was unclear; the National Health Service was in play and hinted at a new millennium. Post-war trainees, many having been specialists in the services, would soon be ready for consultant posts, and these seemed likely to increase in number; a few that had fallen vacant during the war had thoughtfully been left unfilled. Many areas had been devastated by airraids, hospitals were outdated, even derelict; ward space and serviceable buildings were in short supply, as was equipment.

Dermatology had a low priority. Huge clinics were staffed by few doctors, most of whom had received no formal training, relying on reading books and personal experience gleaned over years of practice. The figure of one consultant post for 200,000 persons, as depressing then as it seems to remain, was regarded appropriate; a number of provincial regions have taken time to meet even that target. Separation from venereology, as in the services, was officially supported though some seniors naturally persisted in their dual roles. Alluring private practice could deflect interest from the hospital scene and the ethos of a National Health Service had, among some seniors, yet to be accepted.

In Scotland, Edinburgh, as ever, was a law unto itself, and in many ways academically advanced. It is true that when Percival first arrived there were no histological slides to be found anywhere in the department in spite of Norman Walker's earlier interest in pathology, but he promptly set about recording and storing material so that in time a fine collection of slides, classified by disease, was created44,45.

Percival was becoming a dominant force on the British scene and his department strove to perfect the technique of local treatment; precise methods for applications to the skin were demanded, dressings, bandaging and support all had to conform to a meticulous standard. This was very different from the state of affairs in many British hospitals where the prescribing of ointments and pastes was crude, simple and haphazard. Often these medicaments were given without advice as to how they should be used. Several large clinics simplified their prescribing by using a limited selection of topical applications which were designated in code; this reduced the time taken to write a prescription and allowed the pharmacy to prepare these concoctions in bulk. Treatment was one of Percival's priorities.

In 1945, Sir Robert Grant, a friend, patient and admirer of Percival, had donated £70,000 to endow a University Chair of Dermatology for him in Edinburgh. It was the first in Britain enabling dermatology to be accepted academically in the University, and was a major academic coup. Percival soon had a popular (1947) textbook to his credit for Histopathology of the Skin had been produced jointly with T C Dodds and A Murray Drennan. After the war he was rejoined by G A Grant Peterkin and the two of them with similar enthusiasms if different styles, ensured that dermatology in Edinburgh remained in the forefront. Numerous postgraduates, from home and abroad perpetuated an eager spirit.

George A Grant Peterkin (1907-1987), a proud Scot from Forfar, was educated in Edinburgh. Having been afflicted by a severe rash provoked by anti-tetanus serum, he saw clearly that skin diseases deserved study; a scholarship enabled him to do this in Copenhagen. He was appointed Assistant Physician to the Edinburgh Department in 1933, and soon acquired other posts in regional hospitals. By 1942 he was in the RAMC in charge of a large skin unit in Penshurst before being posted to North Africa. There he observed the various eruptions resulting from sulphonamide administration, recently introduced and seemingly effective in combatting wound infection; he described lupus-like photosensitivity among other patterns. He also recorded early reactions following the anti-malarial drug, mepacrine. While in North Africa "Pete" formed close friendships with a number of the younger American dermatologists, some of which were to be sustained long after the armistice. Later he travelled to the United States, visiting old friends and meeting their students, reciprocal trips were also arranged. With his students he was the old-fashioned type of teacher, clear and clinical; his papers likewise were factual without airy speculations. As President of the BAD his warm generous personality shone through.

Glasgow, indeed the whole of Western Scotland, owed much to Thomas McCall Anderson, whose ancestry was so elegantly displayed by Alexander33; he laid the foundation of his practice and teaching. The Skin Dispensary had been founded as early as 1861 and while a number of physicians were soon to be found practising dermatology in a profusion of clinics, they were inevitably overshadowed by the giant at the Royal Infirmary. This group included Alex Morton, and George McIntyre, both of whom studied the subject seriously, but it was Ferguson Smith who made the most recognisable academic impact. Allison MacLachlan and Herbert Brown came to be regarded, along with Ferguson Smith, as the Glasgow Triumvirate. Herbert Brown, a tall courtly gentleman, had produced a popular atlas of the cutaneous lesions of syphilis but is especially remembered as an expert clinical photographer. His name is revered by the Glasgow Dermatological Society.

John Ferguson Smith (1888-1978), the son of an Anglican clergyman, was educated in Glasgow. His early clinical experience was one of great variety - general practice, bacteriology and pathology all featured. In the 1914 war he served in France being mentioned in dispatches. From 1919, back in Glasgow, he worked in bacteriology and assisted George McIntyre in the Skin Department of the Glasgow Royal Infirmary, the hospital where Lister had introduced "antiseptic surgery". In 1922 he took charge of affairs there58,59 and over the years wrote a number of clinical papers always displaying an acute awareness of pathological detail. In 1933 he reported on his patient with multiple, primary, self-healing squamous carcinoma, subsequently shown to be a genodermatosis, the autosomal dominant inheritance of which has been studied by his son.

This delightful and truly gentle man was awarded the MD with honours in 1936 and the Bellahouston Gold Medal for his work on the bacteriology ofsycosis barbae, a scourge of the shaving male in those pre-antibiotic days.

At this time in Glasgow a few self-taught and non-academic consultants assisted by Senior Hospital Medical Officers, (SHMO grade is disbanded) held sway and kept the flag flying until Milne arrived on the scene.

John Alexander Milne (1920-1977)60 became the first Professor of Dermatology in Glasgow in 1968, he had been Reader since 1960.

After a firm grounding in pathology, especially microscopy, he gained a scholarship to the Mayo Clinic where he studied with Hamilton Montgomery; he was to become a valued friend, as indeed did Herman Pinkus. Back home he soon established himself as a premier dermato-pathologist, his regular and concentrated courses were highly regarded and more often than not oversubscribed. On appointment to the Glasgow Chair he needed to embrace clinical work once again; this he did readily for he was to inherit a colossal clinical empire that had been amassed by the energetic Walter Sommerville.

In England, London's privileged teaching hospitals were developing their own skin departments though St John's and the Institute provided a central focus for most trainees. The Dermatology Section at the Royal Society of Medicine presented a regular opportunity, not only for seeing the rare and the bizarre, but also for demonstrating patients; the same can be said of the St John's Hospital Dermatological Society whose Thursday meetings were less formal and intimidating for the tyro; both were highly educational and helped presenters to develop confidence in confronting a critical audience.

The Dowling Club had started with the cluster of St Thomas' Registrars foregathering at the Hospital before moving to the Antelope, a popular "watering-hole". At the will of Geoffrey Dowling this group grew into a regular dining club with meetings at the George, a Dickensian inn close to Guy's Hospital and much favoured by tourists. Current journals could be discussed there in a friendly informal way. Dowling's interest and hospitable nature ensured that any keen registrar, and this was primarily a grouping of the young, should be able to join. Later the idea of travelling to a foreign centre was introduced, something which over the war years had been impossible. The first visit was to Paris, the next to Copenhagen, and these were memorable affairs. Since then regular travel has been an essential ingredient in cultivating friendly relations with dermatologists throughout the world, especially the young ones.

In provincial England, centres like Leeds and Sheffield were developing. John Ingram was not appointed to Leeds until 1927, but interest had already been shown there, indeed a special hospital had been established in 185762 . Clifford Allbutt (later to be Regius Professor in Cambridge) held regular demonstrations when Physician to the Infirmary as did John Eddison, and both gave courses of winter lectures on skin diseases. A Finsen lamp was acquired in 1901 to treat the many tuberculous patients and a nurse was sent down to Sequeira's clinic at the London Hospital to learn the necessary skills. Under Ingram, dermatology at Leeds became renowned.

Frank Findlay Hellier (1904-1986), son of a professor and one time Dean of the Leeds Medical School, obtained a double first at Cambridge and narrowly missed a Rugby blue. He seemed destined to be a general physician but in 1927 John Ingram's magnetism was to convince him that dermatology must be a serious option. A new department was being planned and Ingram's thesis, that dermatology was but a part of general medicine, appealed. After six months with Barber, and visiting Freudenthal at UCH in London, he went across to Professor Pautrier's clinic in France. The bait had been taken and Hellier was soon appointed Assistant Physician in the Leeds Department.

In 1940, with Ingram in France, Frank Hellier took charge, but they were to "Box and Cox", for when Ingram was released from the Army, Hellier joined Western Command as a Lieutenant Colonel. He was one of the first to use topical penicillin for pyococcal infections and recorded a miraculous outcome; with Geoffrey Hodgson he puzzled over the troublesome "khaki dermatitis".

The Leeds department thrived, in fact pulsated; it was to attain an enviable reputation for facilities there were outstanding. Hellier became an expert in Industrial Skin Diseases, and in the department he made a point of reviewing all the histopathology, it became a feature of his teaching. It was not possible to "outshine" John Ingram but the two formed an admirable team and, when Ingram left for Newcastle, Hellier, now with Stephen Anning, took charge in Leeds. His Personal Chair, awarded in 1968, was celebrated with great and universal joy. He had joined W N Goldsmith to edit the secondRecent Advances in Dermatology and was a popular President of the BAD in 1964; he gave the Watson Smith Lecture in 1969. Frank Hellier had a bubbling personality and an infectious charm as did his wife, an operatic singer. His interests and approach differed in many ways from those of John Ingram, but they balanced each other and cooperated admirably.

Stephen Towers Anning (1908-1984) joined Ingram and Hellier as third consultant in 1950. Like Hellier, he was from a medical family and he too, after Cambridge, returned to Leeds for his clinical years. While in general practice before the war, he had been a keen territorial and ended his service commanding the 27th General Hospital as a full Colonel. Much of his time had been spent overseas, and while in the Middle East he had studied the tiresome "Desert sores", this provided the data for his MD.

On appointment he took over the daunting Leg Ulcer Clinic, but he made it rewarding and his observations were to lead to a useful textbook (1954). In the introduction he found himself delving into the lore of "festering sores" and this seemed to turn his interest towards a historical perspective of medicine. He embarked, with his colleague W K J Walls, on a two volume History of the Leeds Infirmary which appeared on the occasion of its 150th anniversary. Thus it was that he received from Leeds University an Honorary Mastership of Philosophy; he was also elected by the Society of Apothecaries to their group of Lecturers in the History of Medicine and was appropriately nominated first Willan librarian to catalogue and nurture our own collection.

In Sheffield, dermatology had been encouraged ever since William Dale James had first been granted facilities in the Royal Infirmary in 189363; (as a lifelong sufferer from psoriasis he had made a special visit to see Professor Unna in Hamburg to gain his expert advice). Three beds and two outpatient clinics were allotted, followed by baths and a Finsen light. At the Royal Hospital, Arthur Hall, later Professor of Physiology and then of Pathology, had taken an interest in skin diseases; in fact he reported on the histopathology of some of James' patients. Hall had made a study of xerostomia, analysing 39 cases, these were subsequently included in Sjorgren's original series (1933). Following James, William Cocking took over skin responsibilities but briefly, never physically fit he had to retire early.

Arthur Rupert Hallam (1878-1955), the son of a Sheffield doctor, had spent five adolescent years in Hamburg before studying medicine in Edinburgh. While a Resident at the Sheffield Royal Infirmary, and Houseman to Dale James, he went on to assist Dr Cocking, then in charge of the skin patients, but after Cocking's early death, Hallam found himself in charge much earlier than expected. He was also appointed to the Infirmary's embryo X-ray Department, a useful linkage as he was to become a pioneer of radiotherapy. Though keen to make dermatology his career he had, to his great regret, never been able to study at Hamburg or at other continental clinics. However, while in the RAMC during the 1914-18 war, he made a point of visiting a number of the European centres and on his return was determined to incorporate into his department the features he had seen abroad. In 1930 he established the concept of a full-time clinical assistant, the equivalent of today's senior registrar; this was something entirely novel. H R Vickers was appointed and subsequently became his junior consultant colleague just two years before the second world war. In 1949 the department, by then considerably enlarged, was officially dedicated to Rupert Hallam.

Convinced that a thorough training in general medicine was essential to a dermatologist, Hallam studied common problems like chilblains and psoriasis, and especially papular urticaria, which he was able to relate to insect bites, as Tilbury Fox and Hutchinson had earlier suspected; it was a classic study. He was an inspiring teacher and, conscious of working in isolation, took every opportunity on his holidays to travel and visit various European clinics; he spoke enthusiastically of the Copenhagen and Budapest International Congresses.

A founder member of the BAD he was President in 1936. His was an austere somewhat forbidding presence, tall and dignified; to those who knew him well he was a loyal and entertaining colleague and adviser. He had throughout insisted that dermatology was part of general medicine, but to appoint a full-time Assistant to his clinic at that time was a triumph.

Henry Renwick Vickers (1911-1993) was the able and energetic Sheffield graduate selected, and it was soon arranged that he should spend time in London, visiting the most reputable clinics to see the experts in action. It was then that he became friendly with Dowling. Already in the RNVR he was mobilized in September 1939 and became the first Consultant Dermatologist in the Royal Navy based at Haslar Hospital. He gained an early notoriety by diagnosing leprosy in a serving officer, a diagnosis until then that had not featured in the official naval medical index.

With Hallam's retirement in 1944 a special dispensation enabled Vickers to curtail his naval service and return to take over the Sheffield department where he was joined after the war by Ian Sneddon, another outstanding physician. The two of them, by their industry, ability, common sense and example, made dermatology a star subject. Private practice was heavy, he became medical adviser to the National Coal Board and completed his MD thesis on "Dermatitis in an industrial population" in 1959; that same year he moved to Oxford.

Ian Bruce Sneddon (1915-1987) also followed in the footsteps of Rupert Hallam in Sheffield by retaining an overriding interest in general medicine throughout his dermatological life. He portrayed the very best aspects of the British medical tradition and in 1970 was President at the Association's 50th Anniversary celebrations.

Sneddon produced a number of clinical papers, all of the highest class. A shrewd observer, he established with D S Wilkinson, the entity of "subcorneal pustular dermatosis" in 1956. In 1965 he described cerebro-vascular lesions occurring in patients with livedo reticularis, a neuro-cutaneous entity now recognized as Sneddon's syndrome. Teaching came naturally and was well appreciated in his medical school where he proved a popular and effective Clinical Dean from 1950-1968. Held in the highest respect, he was much sought after as a speaker. He gave several formal lectures such as the 1963 Watson-Smith in London and in 1968 the Thom Bequest in Edinburgh. He travelled widely and was a fine ambassador for British medicine. The University of Texas honoured him with a visiting Professorship in 1974. The reputation of the Sheffield department was maintained, even enhanced, since Hallam's days, by the contributions of this charming, modest man. To the delight of all his friends and colleagues, he was honoured with a CBE.

Bristol and Bath both claimed, early on, physicians who showed an interest in dermatology64, doubtless the affluence of these two cities presented opportunities for lucrative specialism. Henry Waldo was an expert syphilologist, and he must have had plenty of scope with the rare and exotic venereal diseases presented by the seafarers passing through Bristol docks. Alfred Harrison, from Guy's went to the Bristol General Hospital where he introduced electrical and hydropathic treatments and he became a skilled animal anaesthetist at the Bristol Zoo. Kenneth Wills, also from Guy's, was to follow and he developed an enthusiasm for the new Röntgen rays with which he treated rodent ulcers and lupus vulgaris. After the 1939 war Peter Samman was appointed the first full-time registrar in Bristol and it was there that his long-term interest in cutaneous lymphoma started. Clifford Evans followed Wills and was to be joined by Robert Warin and then by Roger Harman.

Robert Phillipson Warin (1915-1992) was President of the BAD in 1977; the Bristol meeting was a splendid affair. He was a graduate of Leeds University and returned there after serving in the RAMC, mostly with 167 Field Ambulance in North Africa and the Middle East. At the Leeds Royal Infirmary he worked with John Ingram as his Registrar until he was appointed consultant to the Bristol Royal Infirmary in 1949.

There is no doubt he was an enthusiast, both as clinician and teacher, reflecting the keen approach of his mentor. He soon set up a mycology laboratory in Bristol, for only Glasgow and Leeds outside London were involved in any serious work in the 1950's. Mary English was the first mycologist to be appointed and together they conducted useful epidemiological studies of human infection; animals at the Bristol Zoo were not excluded from their investigations. However it was the challenge of the urticarial reaction which proved his greatest interest; indeed he made it a lifelong study, continuing well after retirement. This resulted in a flow of publications including a monograph produced jointly with R H Champion.

He had been a first class hockey player and keen cricketer, another interest was his splendid garden. He had an encyclopaedic knowledge of horticulture and of the Bristol Zoo on whose Council he served for 25 years, and on which, with his wife, he had written a best-selling book. Bob Warin and Anne his wife were killed in a road traffic accident en route to Desmond Burrows' 1992 meeting of the BAD in Bournemouth. Inevitably it cast a melancholy pall over the whole event.

Roger Richard Martin Harman (1927-1993) qualified from St Thomas' in 1950. After various training posts and two years in the army he arrived at St John's, finally ending as Senior Registrar. It was at the time when secondment from the Institute of a young dermatologist to the University Hospital in Ibadan, Nigeria for one year was a successful arrangement, Roger was one of the first to go. It gave him a taste for travel and for practising dermatology in a different economic and climatic environment65.

After his appointment to Bristol he was able to make many visits to various underdeveloped countries. Kumassi in Ghana, where the development of the teaching and status of dermatology had been close to his heart, accorded him a visiting Professorship; he has been vigorously involved in fundraising to support this fine enterprise. Other visits to Africa and a spell in Jeddah as visiting Professor were to imbue him with expertise in tropical dermatology. His reports from Africa start in 1968 when, with Shrank, he described the distinctive atrophying pustulosis of the legs, the result of overgreasing the skin. He also contributed sections on leprosy and on parasitic worms to the first editions of Rook's Textbook of Dermatology, and more recently edited with Canizares the second edition of his Textbook of Tropical Dermatology.

It would be wrong to think that his energies were exclusively directed towards the problems of poverty, malnourishment and hostile climates. He was critical of poor standards or lax administration wherever found; the Hospital authorities in Bristol were more than familiar with his views. He took on the Chairmanship of the Special Advisory Committee on Training and also of the Dermatology Committee at the Royal College of Physicians, all added burdens to his busy Bristol life. As President of the BAD in 1989 he was the first to host the meeting on "foreign soil"; Warwick provided admirable facilities but it was not home ground. He more than made up for it by arranging novel and delightful entertainments with an Art and Craft Fair, accompanied by home-made music (how talented are our colleagues and especially their spouses).

His independent spirit and strong Christian convictions were to involve him, with Pamela, his GP-wife, in many activities - pastoral, musical and dramatic in Chew Magna, the village where they lived for many years. That is where he happily took on the role of farming smallholder with tractor and pitchfork66. To die at 66 is too young for such as Roger Harman.

In Cambridge, Howard Whittle had moved from pathology to concentrate on dermatology; his regional commitment was vast and Addenbrooke's Hospital was planning to move from its old buildings to a splendid new hospital complex. Arthur Rook left Cardiff to join him and brought his organizing brilliance and his teaching skills to bear. The regular Cambridge study-courses of postgraduate instruction became immediately successful, attracting high-class contributors and participants. They have become a regular feature of the dermatology calendar.

In Oxford the first clinics had been in the hands of Ernest Mallam, a respected practitioner who had presided over the BAD meeting of 1928. He was joined by the enchanting Alice Carleton from Dublin, who had come over to Oxford ostensibly to "keep an eye" on the first intake of female medical students but officially to work in the anatomy department; she became renowned as an amusing, indeed scintillating teacher. She was soon embroiled in Mallam's skin clinics and after his retirement took charge. She had no formal dermatological training but in those days this was not unusual. With her intellect, learning and Irish wit she achieved peculiar fame, becoming an outstanding President of the BAD's Oxford meeting in 1951.

In 1957 Alice Carleton retired and Renwick Vickers arrived, somewhat surprisingly, to take her place, leaving Ian Sneddon in charge in Sheffield. The energy, experience and personal charm of Vickers ensured that dermatology was to thrive and his interest in leprosy was sustained with the MRC unit already established there. He never lost the chance to stress the interface of dermatology with general medicine and his Watson-Smith lecture of 1959 was entitled "The place of dermatology in a general hospital". He became Chairman of the Medical Staff Council and later Chairman of the Medicine Board at the University. With such personal charm, articulate speech, common sense and industry it was not surprising that the students decided to present him with a "Golden Stethoscope".

Vickers was President of the BAD in 1966 and in the same year took on the new role of Adviser to our young trainees. When Consultant Adviser at the Ministry of Health, he presented in 1970 a joint paper with P D Samman, then Dean of the Institute in London, on Postgraduate Training in Dermatology in England67. Renwick Vickers was a popular recipient of the Gray Medal and on his retirement happily filled a dermatological vacuum at the Postgraduate School at Hammersmith Hospital; there he was able to join in the Grand Rounds with considerable gusto, showing little reticence in the company of such academic profundity.

Newcastle's medical school had, at this time, made no contribution to dermatology though Sir Robert Bolam, medical politician (BMA and GMC) and a close friend of Norman Walker, was ostensibly in charge of a skin department and had presided over the Newcastle BAD meeting of 1934. Following the institution of the Professorial chair in London, an academic department was envisaged for Newcastle but initially no candidate was deemed suitable. It was suggested that Ingram, an outside assessor, should fill the chair as a stop-gap and this he did, being able to develop many of the essential facilities ready for a definitive appointment. Five years later Sam Shuster was installed.

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Throughout the country the development of dermatology, uneven though it may have been, was obvious and not restricted to University centres. These vignettes have included some of the departments that were involved in postgraduate training after the war; it should be realised that the numbers of these demobilized young men enabled the NHS to expand its dermatological services in a way which would not otherwise have been possible. Their youth, energy and enthusiasm made for a lively, healthy scene. Sadly the number of consultant posts coming "on stream" did not match expectations, some were to find themselves "stuck" in training posts for far too long; others were forced to give up the quest.

Another welcome opportunity for the young generation was the chance of unrestricted foreign travel; it had been out of the question during the war. International meetings and famous departments abroad could now be visited; several were fortunate enough to spend months of study and research in such clinics. It is noteworthy that many American university centres had added to their academic lustre by taking in brilliant emigrants from Hitler's Europe, be they physicians, scientists, or musicians. In this country we benefitted similarly from, among others, the experience and wisdom of Walter Freudenthal and Henry Haber.

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