Some Remarkable Clinicians
On the whole little interest was taken in promoting dermatological knowledge at this time, nevertheless a few outstanding individuals were to make lasting impressions.
In Manchester, Louis Savatard, Brooke's pupil, was meticulously analysing all the various cutaneous malignancies.
Louis Savatard (1874-1942) was a pioneer of radiotherapy but it must have been Brooke's interest in pathology that set him on his way; he was to become an acknowledged expert, spending endless hours at his microscope. From 1920 to 1940 he published many papers on superficial and pre-malignant skin changes and his interest in "mulespinner's cancer", led to his appointment to the special Home Office Committee. He virtually founded both the North of England and the Manchester Dermatological Societies and was President of the BAD in 1940. Savatard worked in isolation, but he made Manchester aware of the subject at what was surely a barren period.
In London one or two others were now to make a name for themselves and for dermatology.
Arthur Whitfield (1868-1947) entered King's with a scholarship in 1887 and remained a devoted King's man throughout his life; he is remembered proudly, even revered, by generations of his successors. During his several house appointments he was happiest in the medical wards, he gained the MRCP in 1893 and was awarded the Sambrooke Medical Registrarship, a prestigious prize at King's after completing his house jobs. Like many of his most outstanding forbears in dermatology, he based his thinking on a strong foundation of general medicine.
After three years in Vienna and Berlin he returned home, but purely dermatological appointments in the London Hospitals, with few exceptions (UCH, Charing Cross and Middlesex), were non-existent. The staff of the Blackfriars Skin Hospital consisted of surgeons - Hutchinson, Anderson and Waren Tay, with Payne and Stowers as the senior physicians.
Whitfield was appointed Assistant Physician first at the West London Hospital and then at the Royal Northern. Finally, in 1899, King's gave him his own "department", even providing a modicum of space, and that was always at a premium; only two beds were forthcoming, dermatology made but little impact. However, having achieved this breakthrough, he decided to devote his energies wholeheartedly to the affairs of King's, eventually becoming Dean of the Medical School. In 1906, having been elected FRCP, he was appointed to the staff as full physician and given the title of Professor, a sure indication of his colleagues' esteem. Then, accepted on equal terms, he could widen his sphere of activity and devote his energies to the Chairmanship of the Medical Committee. In fact he helped in the establishment of other special departments at King's, those which had been struggling for recognition as he had done. During the 1914-18 war he acted as the physician in outpatients.
He differentiated nodular vasculitis of the hypoderm from Bazin's tuberculous type at a time when tuberculosis was common and warm homes certainly were not. He was also a pioneer in the use of vaccine therapy, a technique popular only briefly, but it is in the field of mycology that he is best remembered, and that will be considered later. His "Handbook of Skin Diseases and their Treatment" ran to two editions; a third was completed by E H Molesworth, his Australian ex-pupil. In the Lumleian Lectures he reported generalised eruptions that had been stimulated by traumatic bruising, and defined "Secondary spread" of eczema stemming from an irritated primary focus, (auto-sensitization). These concepts were developed at the 1935 Congress where he described a similar event following a tendinous sprain, this he designated as "autophytic eczema".
Whitfield did not write articles without good reason - "I write with my blood", he claimed. A study on the origin of naevus cells, for he was an enthusiast of microscopy, was an early venture: it appeared in the BJD. His professional success was attributable to his knowledge and experience of general medicine, his careful attention to any item which could possibly relate to the problem in hand, a meticulous examination of the patient, and finally a willingness to consider any other sensible approach if it could possibly throw any light onto the final diagnosis.
He was the first Secretary of our Association and then President in 1927. He wrote an account of "British Dermatology in the early eighties"37 which provided a fund of information for this report. Over the years many accolades were to come his way. Though he did not suffer fools gladly, he was an outstanding teacher and attracted postgraduates, especially welcoming those from overseas. He idolized Colcott Fox for his infinite care, an influence that seemed to permeate his own life, and one which he passed on to his own pupils. In treatment he was an optimist, he was also unselfish to his colleagues and always scrupulous in giving credit to others. In retirement, in spite of infirmity, his energy, alertness and even his dogmatic manner never seemed to flag.
Frederick Parkes-Weber (1863-1962)41, German by birth, was the eldest son of a distinguished Victorian physician, Sir Hermann Weber, who had been on the staff of the German Hospital specializing in diseases of the chest. He had attended the Queen and looked after no less than five Prime Ministers. He had also been an ardent collector, specializing in coins, an interest he passed on to Frederick. The name Parkes was added to Weber in deference to E A Parkes, the Physician at University College Hospital, and nephew, pupil and successor to Anthony Todd Thompson; he was a particular friend of Sir Hermann.
After Charterhouse he went on to Trinity College, Cambridge, where, rather surprisingly, he made no particular mark other than becoming, like his father, an enthusiastic collector. At first it was coins but then other diverse objects took his fancy such as postage stamps, moths, fossils and also rare diseases, especially those involving the skin. The coin collection of father and son was broken up in 1906 most of it going to the Boston Medical Library, some to the British Museum, and some to both the Bodleian at Oxford and the Fitzwilliam at Cambridge.
Frederick's initial clinical work was at St Bartholomew's as House Physician to Dyce Duckworth, himself no mean dermatologist. He was destined to be a general physician with a particular interest in diseases of the chest, just like his father, indeed in his early days he worked at the Brompton and later was on the staff of the Mount Vernon Hospital in this capacity. However most of his clinical work was, again like his father, carried out at the German Hospital. His knowledge of pathology was profound and throughout his life he contributed to many a pathological meeting. With diseases of the skin he focused on the rare and the obscure. He had no pretensions to be a practising dermatologist, but over the years attended most of the clinical meetings where his opinion was often sought as the final arbiter of a debatable diagnosis. His tall, stooping figure came to be recognized in the medical wards of most of the large London hospitals. His comments were learned and often discursive. Indeed, at meetings he had been known to disregard the Chairman's strictures when he had overrun his time, even obscuring the red warning light designed to arrest the verbose; once he even tried to wrench it away from its stand.
This erudite and remarkable man lived to a great age, narrowly missing his century. He continued to attend the Section meetings at the Royal Society of Medicine into his ninetieth year - this in spite of deafness, failing vision and unsteadiness of gait. He was ably supported by his devoted wife who acted as nurse, secretary, stabilizer and general factotum. He would often contribute to the discussions, quietly yet revealing in a modest way his astonishing erudition. He had the kindliest disposition and when giving a second opinion would never let the referring physician lose face over a faulty diagnosis, so subtle would be his remarks and so gentle his correction. Mention of a relevant reference would cunningly give the game away.
He is credited with having written 23 books and over 1,000 articles scattered in various journals. His perceptive anthology "Aspects of death and correlated aspects of life" was a remarkable achievement - it was written with his wife and ran to four editions, the last, considerably enlarged, being published in 1922. The College of Physicians awarded him the Mitchell Lectureship in 1921 and the Moxon medal in 1930. In 1959 he founded his own triennial prize and medal to promote advances in dermatology.
Geoffrey Dowling in 1962 wrote41 - "For about as long as any living physician is able to remember, it was customary to consult Parkes-Weber on any case of exceptional rarity or obscurity. He was the kindest consultant imaginable but had sometimes the fault of crediting his colleagues with more knowledge than they possessed".
On his 80th birthday his friends at the German Hospital presented him with a handsomely bound volume containing a summary of his life and a bibliography of his publications. Rare diseases and syndromes which are rightly associated with his name include - Sturge-Kalischer-Weber (encephalofacial angiomatosis): Weber-Christian (nodular non-suppurative panniculitis); Klippel-Trenaunay-Weber (haemangiectatic hemihypertrophy): Rendu-Osler-Weber (familial haemorrhagic telangiectasia); telangiectasia macularis eruptiva perstans; recurrent bullous eruption of the feet in children, this some years before Cockayne's 1938 paper.
He was one of the greatest contributors to the world literature, surely ranking with Professor Albert Touraine in Paris. All his papers, bound in separate volumes, are to be found in the Willan library.
Horatio George Adamson43 (1860-1955), after various house appointments, spent some years in a Surrey general practice before returning to hospital medicine. He had qualified at Bart's but learnt his dermatology with Pringle at the Middlesex. Back in London, his appointments, such as physician to the North Eastern Hospital for Children, were all maintained until 1909 when he returned to St Bartholomew's to be in charge of the Department as a full-time specialist.
His paediatric experience was by then considerable and led to the publication in 1907 of Skin Affections of Children; many other papers followed. He developed a lifelong interest in mycology which was fostered by his work with Colcott Fox at the Downs Ringworm School in Sutton. There Adamson modified the Keinbock technique for X-ray epilation for scalp ringworm, a method maintained by Cochrane Shanks40 until 1947. Grisefulvin had yet to appear.
An active member of the Dermatological Society of London, he was later President of the Section at the Royal Society of Medicine. He attended and contributed to the Third International Congress (1896); was a Vice-President, opening the discussion on Tuberculides at the Eighth (1930) in Copenhagen; he was happily able to welcome old friends and pupils in London at the 10th (1952).
He was Goulstonian Lecturer at the College in 1912, the first dermatologist since Robert Liveing 40 years earlier to be so honoured. He had been Treasurer of our Association for many years and was President in 1924. This distinguished man did not court publicity. He wrote two books - "Some thoughts of a doctor" in 1936 and "More thoughts of a doctor" two years later. He was a keen antiquarian and an enthusiastic amateur artist, producing water colours in various shades of grey as he was green/red colour-blind43. An inspiring teacher he was beloved by his colleagues, by postgraduates, and by generations of students at St Bartholomew's Hospital and Medical School.
Ernest Graham Little (1867-1950), an indefatigable worker and keen student of pathology, followed Malcolm Morris at St Mary's Hospital, contributing much to the London scene.
After qualifying from St George's, he had carefully planned his career in dermatology and studied with Besnier, Brocq and others in Paris. He wrote a number of papers on a variety of subjects but is remembered especially for his work on lichen planus and for the recognition of a follicular pattern in the scalp leading to atrophic bald patches. He was held in considerable esteem, being President of the RSM Section, leader of the British Delegates to the Ninth Budapest Congress and President of the BAD in 1936.
He was elected to the Senate of London University and did much to secure the admission of women as external students. From 1924 as Member of Parliament for London University he retained the seat until university franchise was abolished. He was a strong opponent of socialism and the National Health Service, but a supporter of the Footpaths Association, an upholder of the Empire and an advocate of wholemeal bread. It is hardly surprising to learn he was a keen member of the Society for Individualists. He was knighted in 1931 and assumed his double-barrelled name.
James Henry Sequeira (1865-1948) edited the Journal from 1911-1915. He had been a student at the London Hospital where his early interests were surgical; he won the Hutchinson Prize and became House Surgeon to Waren Tay. After obtaining the FRCS he taught anatomy before turning to medicine, and was then to work with Stephen Mackenzie, the general physician who had charge of skin patients, with whom, for a while, Galloway was the assistant. With Jonathan Hutchinson and Waren Tay around, Sequeira must have found himself surrounded by an array of wisdom and experience.
With such illustrious mentors his knowledge both of dermatology and syphilology burgeoned so that when he was appointed to take charge in 1902, as the first full- time dermatologist at the London Hospital, he had become a formidable clinician. In his turn he was to train men who were to become distinguished such as his successor, W O'Donovan; John Ingram who went to Leeds; R T Brain, Royal Free; and J E M Wigley, of Charing Cross and long-term Dean of the embryonic Institute of Dermatology.
Sequeira had been to Kaposi's clinic in Vienna and wondered, wide eyed, at his huge department; but a more fruitful experience was a visit to Finsen in Copenhagen to see the actinotherapy technique for the treatment of lupus vulgaris, a disease then endemic in the East End of London. He translated Finsen's Phototherapy into English and, once back home, he acquired Finsen lamps to be formally presented by our Danish Queen Alexandra; her statue in the Hospital garden records the event. This busy UV department flourished for many years, until modern chemotherapy surpassed its effectiveness.
Photography and radiotherapy were studied; radium plaques were used to treat rodent ulcers and in these early days several pioneering colleagues were to suffer radiation damage. He was always busy; an unending stream of patients waited to be seen, students to be taught, secretarial and presidential posts to fulfill. All were taken in his stride.
After retiring to Kenya, Sequeira worked on a leprosy project sponsored by the BMA and for 10 years edited the East African Medical Journal. In 1932 he was back in London to give the Chadwick Lecture. Glaucoma was to prove a tiresome trial and, after months of angina, he died on 25th November 1948.
Henry MacCormac (1879-1950) followed his teacher J J Pringle at the Middlesex. His grandfather had practised in Belfast, and his uncle William had been President of the Royal College of Surgeons of Edinburgh.
After qualifying in Edinburgh he moved south for his house and more senior appointments to the Middlesex and the Westminster Hospitals. In addition he read for the Bar, and even ate his dinners though he was never "called". His lectures on forensic medicine, the responsibility of the Assistant Bacteriologist, were ever popular. Obtaining the MRCP in 1909, he was clearly earmarked by his seniors as a potential staff member at a time when the fact of obtaining an appointment to the Honorary staff of a teaching hospital was more important than the actual speciality to be practised. He was elected Assistant Physician to outpatients in 1912 and soon joined Pringle in dermatology. The die was now cast. The Middlesex staff having picked their man, sent him off to Paris to learn his trade at the feet of Darier and Sabouraud. Back in London he worked with Pringle until his retirement in 1920; MacCormac then assumed full control.
During the 1914-18 war he was in charge of the 25th General Hospital at Hardelot, and he wrote with authority on current military skin problems, indicating how they contributed to unnecessary wastage of manpower; for this he was twice mentioned in despatches and awarded the CBE.
Harry MacCormac was a personable fellow and soon became accepted as one of the leaders in London, building a busy private practice. For a time (1938-1941) he was Secretary of the BAD. He became an experienced syphilologist and an expert in the use of the newly introduced arsenical drugs, this was to provide the substance of his Lumleian Lectures given at the College of Physicians in 1945. With Robert W Scarff, a pathologist at the Middlesex, he studied the various patterns of skin cancer and together they first described molluscum sebaceum later to be renamed keratoacanthoma, recognizing its distinctive morphology, predictable evolution and usually benign behaviour.
One of his major undertakings was editing and revising Jacobi's Portfolio of Dermochromes; this was immensely popular and had world-wide appeal. He wrote no textbook but many papers; latterly industrial dermatitis took pride of place, he made a particular study of these patients and was the first Medical Referee to adjudicate. As a teacher at the Middlesex and at St John's he was always popular; as President of the Section at the RSM and of the BAD in 1942 he was excellent, a witty speaker with a delicate touch. He was awarded Honorary and Corresponding Membership of many foreign societies and in 1941 was elected to the Council of the College of Physicians.
He continued practice to within a year of his death. Supported by his wife as secretary he had given up all leisure pursuits like his garden, even his golf; work took over. Harry "Mac" was universally regarded with great affection.
Towards the end of the 19th century, enterprising men with an eye to studying skin disease had to travel to one of the European academic centres for enlightenment. The Paris School at the St Louis was pre-eminent in France; Kaposi and Ehrmann along with Ferdinand Hebra, wielding his strong pathological hand, provided a masterly triumvirate in Vienna. In Hamburg, P G Unna developed his own personal Clinic, at first in a modest town house which served both as a dispensary for the sick poor and as his clinical laboratory for the study and teaching of dermatology. He was the pioneer of skin histopathology and with his obsessive zeal and industry achieved enduring fame.
Pure dermatological appointments were virtually unknown here at this time and the care of patients with skin diseases remained largely in the hands of physicians and surgeons who may or may not have had any particular interest in the subject. So it was natural that a group of aspiring dermatologists, many of whom had by now studied abroad, were emerging and determined that this branch of medicine should be properly recognized. Furthermore ancillary skills were developing. The microscope and the concept of cutaneous histopathology had intrigued Tilbury Fox for Neumann's Treatise, already translated from German, had provided him with a hint of what jewels lay in store; Radcliffe Crocker had also admitted his considerable fascination.
H G Brooke stayed two years in Germany and was an early visitor to Unna's clinic. His skill at identifying trichoepithelioma, supported by such distinctive pathological features, must have been in part due to the experience he had assimilated in Hamburg.
Alfred Eddowes, from St Bartholomew's, had also studied in Hamburg, and on his return to London joined the staffs of St John's and the West London Hospital for Nervous Diseases. He maintained a lifelong interest in skin histopathology, publishing a paper "The nature of Herxheimer's spirals" in the British Journal of Dermatology. A modest physician, he was a regular attender at both national and international meetings; he died in 1946 aged 95.
J M H MacLeod visited Hamburg especially to be with Unna; in London he continued his histological work and became something of an evangelist. Once appointed assistant to James Galloway at Charing Cross Hospital, MacLeod was generously loaned laboratory space by William Hunter, the pathologist. He also created a workshop at his home and there he taught dermatopathology to selected postgraduates, one being the distinguished American, Oliver Ormsby. At St John's he was given greater scope for his laboratory work and his dynamism quickly became obvious. Geoffrey Dowling, on joining him, set about to explore the importance of skin commensal yeasts and their relationship with the so-called seborrhoeic eruptions. Later Isaac Muende studied histopathology with MacLeod, co-operated on a new edition of his textbook and ultimately took over the routine histopathology reporting at St John's Hospital.
In Edinburgh the interest of Professor J H Bennet in the field of mycology had long been recognized. A pioneer microscopist, he taught his pupils the necessary skills. He had worked with favus, then endemic in Scotland and Ireland, and transmitted it experimentally, confirming Gruby's findings. According to Mapother20 the physician to the Adelaide Hospital in Dublin, W G Smith, had also worked with favus and transmitted it successfully.
At the Westminster Hospital Thomas Colcott Fox showed great interest in children and their skin diseases, this prompted his special and unwavering interest in the fungal infections ever present in London. He spent most of his evenings studying the specimens he had acquired during that day. His knowledge of the subject was unmatched and he became the undisputed authority on ringworm infections at a time when tinea capitis was the scourge of the city's schools. He gave many demonstrations and was responsible for a number of useful and informative papers.
H G Adamson, an ex-pupil of Colcott Fox, had developed an expertise in paediatric dermatology as, before returning to St Bartholomew's, all his early appointments had been to children's hospitals. With his lifelong interest in mycology he was able to demonstrate the route taken by fungus as it penetrated the hair shaft (Adamson's fringe) countering the views of Sabouraud. He explained that the Professor had been pressing his specimens with solutions of potassium hydroxide which were both too hot and too strong.
The name of Arthur Whitfield, who was appointed to his parent Hospital, Kings, in 1899, has always been associated with fungal diseases: his ointment, lotion and forceps are, even now, occasionally in use. A pioneer of dermatological mycology he was able to demonstrate, in 1908, fungal mycelia in specimens from a patient with interdigital tinea. This fundamental connection had even then not been made by Professor Sabouraud. It was with some dismay therefore that Whitfield subsequently learnt of an obscure publication by one Djelalludin Muktar in an Egyptian journal, making identical claims. Thenceforward he invariably gave credit to Djelalludin Muktar as first in the field. In 1911 he was able to demonstrate, at the Royal Society of Medicine, a patient with "eczematoid ringworm of the groins" along with supportive mycological specimens. This prompted a special visit from Paris by Professor Sabouraud.
Others to show interest in fungal infections were Alfred Eddowes in London and Leslie Roberts in Liverpool. The latter, appointed in 1893 to the Royal Infirmary, was an enthusiastic clinician but also an ardent part-time mycologist who produced a number of competent papers.
However only two investigators, Robert Cranston Low and George Percival, undertook any really fundamental work in those early days; both were Scots, a reflection no doubt on the medical education and training they had received in Edinburgh. Low's work on anaphylaxis and allergic sensitivity to Primula obconica is referred to later. On retirement he happily returned to full-time laboratory work and for three years was Curator of the Laboratories at Edinburgh's Royal College of Physicians. George Percival had his eyes opened during a prolonged period of study on the Continent, not only by the clinical feast provided at l'Hôpital St Louis but also by the scientific enthusiasm of Bruno Bloch in Zürich. On returning home he worked with C P Stewart, correlating calcium and parathormone metabolism with skin disease; he produced several papers on that subject, also on chemical mediators and the response of blood vessels in cutaneous inflammation. In fact he had a contretemps with Sir Thomas Lewis over a paper in which he stated that mediators other than histamine could be inferred in some inflammatory reactions. Percival was not to be deterred by Lewis and his contrary views, so continued undaunted on his way. Bloch, when he heard of these events, referred to Percival as the Feu sacré of dermatological research in Britain.
These then, were some of the first in Britain to show any glimmerings of interest in the scientific basis of skin disease. The second World War was to create a gap before the Medical Research Council decided to establish its own special unit in Birmingham