Interviewed by Dr Victor Witten May 23 1967 in Dr Witten's home.
Dr Witten: Let us begin by saying first Dr. Wallace, Dr. Hugh Wallace from London. I'm doing that in order to have it on the record and then I'll revert to Hugh if I may. Please. Hugh it's very nice to have you here with me at home, here in Miami. That you can be with us. I want to tell you now how much we enjoyed your talk yesterday at the Medical School and what a pleasure its been having you here and I think I really reflect the comments of all those in the Department. It's been our pleasure. I'm going to take advantage of you while you're here and during this time that we may sit and talk I want to ask you about yourself. I'd like you to tell me something about well, why don't you first tell me what your position is in Dermatology and in Medicine in London, and then we'll go back.
Dr Wallace: Well. My correct title is Physician in Charge of the Skin Department at St. Thomas' Hospital which is we think is the oldest Hospital in London bar one and possibly the oldest, but the historical records get a bit sketchy after 800 years and so we can't be quite sure about that and like many of my colleagues on at other London teaching hospitals, I am also on the Staff at St. John's Hospital for Diseases of the Skin which is based in Lisle Street, which also has an Inpatient Department rather unfortunately, a long way away about 8 miles outside London (outside central London) and that I think, would be my official titles at the moment.
I am also a Governor of St. Thomas' but this is one of those things that happens with the passing of the years, I think, more than anything else. I think I was the first permanent Secretary of the British Association of Dermatologists, no, not the first. The Founder, Sir Archibald Gray, was perhaps the first Secretary and then after that they had a long period in which we had a Secretary for a year at a time and some perhaps twelve years ago now they decided they would have a Secretary for a longer period. This was a rather interesting phase because, like all Dermatological Associations, it was evolving at that time, and I think, like all Associations, one stays in the thing too long. One tends to mould it subconsciously. I think Victor, you and I know, Presidents really come and go and the person who really runs the situation of this kind is usually the Secretary. And so I felt that at the end of five years, although we had no constitution to say, to this effect, I thought it was time that somebody else took over. This has now been written into the Rules, because I think in a Society of this kind you've given all you're likely to be able to give it in five years and thereafter it just becomes a one man show.
Dr Witten: This was until what period, when was this?
Dr Wallace: Twelve years ago that would be about 1955 - 1960. I wouldn't like to be exactly sure of dates of this period, I'd already been on the Council I think for about ten years before this and so I'd really done, I thought, rather a long stint and I don't believe Societies flourish on that basis.
Dr Witten: No. I know what you mean about that. The Secretary runs the Society and how often the President stands and waits for the nod of the head from the Secretary ..
I really think that I would have to know something about the structure of Medicine and Dermatology in England but before coming to that, tell me something about yourself, where you were born, something about your childhood, the influences that you feel may have brought you into Medicine, your parents, friends and so on.
Dr Wallace: Well, I was born in quite a well known town in England about fifty miles north of London, a place called Bedford, and my mother was English, deriving from the countryside just outside Bedford. She came of a farming family,and my father was a Scot who'd come South fcr health reasons, but he found even the South of England a bit too severe and with the characteristics of so many Scots, took off after a year or two and went out to Kenya where he was one of the early settlers. So I went out to Kenya when I was about two or three years old and was there for just a very short time and my mother came back because she couldn't stand the Kenya climate.
And then came the First World War, and I went to School in Bedford which is a very good educational centre, one of these curious historical situations. I went to the local Council School, I don't quite know what the appropriate phrase is, I suppose State School, in the States (I don't quite know the nomenclature) and I thought at this Council School I had some of the best teaching I ever had. But, for this historical reason, that one of the previous inhabitants of Bedford about 1500, had become the Lord Mayor of London and he was rather grateful to Bedford and he left a large sum of money or it became a large sum of money, and as a result this foundation in Bedford owns one of the most expensive parts of London and has an enormous income from it. And from this they give lots of charities to old people, but particularly to educational foundations. It went a little bit, not quite I think in the terms he intended it to do, because it was really originally intended for the poor boys of Bedford, but the way that things evolve historically are not according to sometimes what the Founder intends. One of the ways in which this money was used was to improve or largely found, in about 1552, a School for what were called, I can't just remember the wording, but to the effect of the poor boys of Bedford and this ultimately, over the years, had its ups and downs, but was in existence all the time until about 1830 or,no,about 1850 and thereabouts, when it was known as the Bedford Grammar School. And then there came the phase in which English so-called Public Schools became into being and the difference being that they were no longer Public, they were in a sense very Private. One was there for the most part by virtue of one's parents income, but at Bedford they had always had this policy for many many years: this was part of the Statute, they would always be accepted by competitive examination. Perhaps about l0 boys a year from the local Council School, of whom I was fortunate enough to be one.
So that's how I went to this really quite famous Public School for which I have always been extremely grateful. This obviously, of course, does mould one's career fantastically, particularly in a society like England which is still perhaps somewhat class-ridden. Class-ridden rather in mode of speech, more than anything else. It doesn't matter when you get to University. Everything sort of flattens out, but if you don't happen to be in say the academic strata of society it's a big differential. It's very difficult to understand, but one can meet someone at another end of the World and you can detect by accent vaguely perhaps 20-30 miles outside London or somewhere like this, and, however hard you try not to be prejudiced, you somehow find that your interests aren't the same. It's very difficult to know how this evolves. Yet you see one can go to Australia, New Zealand, and they speak quite differently and there is no bar at all. Its something very difficult to explain, and this is really one of the reasons that I think that a lot of us feel that Public Schools in England still give by far the best education because their classes are small and they attract the best teachers. They might well nbe modified by profit but not, I hope, scaled down because I think this would be a mistake. You can level things down more easily than you can bring things up, and, of course, this at the moment is the mistake of evolution.....
Dr Witten: The School system here too, I don't want to get in a discussion about your educational system now. You say you went to School in Bedford, that was during what years?
Dr Wallace: 1919 till 1928.
Dr W: Till 28. That then was your early schooling. And then what happened after that
Dr W: Then I went to Cambridge. I hadn't any particular ideas of doing medicine at this time because the economic situation was really rather tedious and so I thought I was going to teach. I'd al-ways been interested in teaching and then I thought I'll see what's going to happen and so I was lucky enough to get an Exhibition at Cambridge, and so therefore the economic situation was dealt with. Here, I think, perhaps there's one thing one should say about - I think there are a lot of misconceptions about the British system of education. In past years it was by no means perfect. There is no doubt, of course, that if one had economic backing,life was very much easier educationally but it was certainly by no means the case that if you had no economic background or you had no family background you couldn't get along the road because when I was at School there was one of my contemporaries,his father was the person who swept the chimneys. This boy, a very nice boy indeed, he became the Governor of what used to be called one of the British Colonies. Another became a Commissioner of Police, the Metropolitan Police in London, and another got the Victoria Cross, and so it wasn't really quite the system that was as class-ridden....
Dr Witten: You're more democratic than I thought.
Dr Wallace: Well, in some ways I think this is right. I don't think it did quite come out as people thought it would. Even this was carried on still further when I went to St. Thomas' many years afterwards. There were three people on the Staff and this is a very reactionary Hospital I suppose if I looked at it in political terms, you know, of its 800 years history. There were three members of staff who had obviously come right from the bottom.
This is only just a side effect but it was never quite this difficulty that people pretend. I think if you are determined enough to do it, I would think it's probably more difficult in England than it would be in a progressive place like the States, or for that matter of course in places like Australia. But this is perhaps a sequence of any long and historical situation except the French, of course, who have a .. and the Scots: they dont have this. They put a much higher value on education than the English do. The English until quite recentIy really rather scorned this and went along on a pragmatic line.
Dr Witten: I always thought that you're educational system was so very good there. Coming back to you. You were in Cambridge how long then.
Dr Wallace: Four years.
Dr Witten: This is four years ln what we would call our academic years of College?
Dr Wallace: That's right. I read Natural Science Tripos and my career did undergo a very smart influence about this time because I then went out to Kenya with a friend to see my father who I hadn't seen for many years, and I thought then I would go into what was called the Colonial Agricultural Service . Both sides of my family came from farming stock and therefore I thought perhaps I ought to go into something on the academic side of farming, which I did. One Term at Cambridge, studying for an Agricultural Diploma, against, I might tell you, the advice of my Tutor, and I realised at the end of about 3 or 4 weeks that wasn't really quite my line really and I had some, what to me were rather traumatizing experiences: like having to judge an Aberdeen Angus animal and I didn' t find that at all tranquillizing. Then we went to things like the Fat Stock Show which was all very interesting but I didn't quite find myself on that wavelength,so I then decided I would do medicine but I hadn't got any money at that time.
Dr Witten: It was at that time you decided on....
Dr Wallace: Well. I thought I would take a gamble.
Dr Witten: What made you gamble? What made you think of medicine in the middle of the agricultural ....
Dr Wallace: Well. I'd been thinking of medicine all along, when I was at Cambridge. Because a lot of my friends were doing medicine. But this did seem a little bit unrealistic, in terms of economics, because it really is a long expensive course. And certainly at the time it was really quite difficult to get along, but I did this and I had enough morey at that time to do one year and so I did the year and I thought I'd retire from medicine for a year and go and earn some more money and do the next year. It didn't, in point of fact, pan out this way because I was very fortunate again and was looked after by some very nice friends whose children had been at Cambridge with me. The man of the house had been a Civil Servant who was a manic depressive and so really my job was to look after him actually and they gave me a home for doing this, to cheer him up from time to time. So I learnt a lot about the manic depressive state and did my medicine at the same time.
Dr Witten: How fortunate you were.
Dr Wallace: OK. I was indeed. Very fortunate.
Dr Witten: Well then, if I understand correctly: you spent four years in your academic period at Cambridge during which time you decided that you would go into medicine and then you continued medicine at Cambridge. Is that correct?
Dr Wallace: Yes. I hadn't done anatomy. I'd done the physiology and so I had to do the anatomy.
Dr Witten: Now how much time did you spend in medicine at Cambridge. How many years were you there.
Dr Wallace: Well, I suppose, three years in all in the sense of taking anatomy, pathology, physiology and pharmacology was three years, and then the other year was done in the sense of doing zoology.
Dr Witten: Well. These really are your basic sciences.
Dr Wallace: These are the basic sciences.
Dr Witten: Your basic sciences of medicine. Now that constituted three years of your training. Then you went into the clinical years in which you were .. and then you went to St. Thomas'.
Dr Wallace: Well, even now they haven't got an Undergraduate School at Cambridge. They've got an undergraduate Clinical School. They've got all the basic stuff of course but not the clinical work. There is a Hospital there just is not enough to support a Clinical School.
Dr Witten: No. But how many years did you spend in your training in order to get what is equivalent to the MD. You had three years of basic and then how many years at St. Thomas'.
Dr Wallace: Three years at Thomas'.
Dr Witten: In other words six years is what's required?
Dr Wallace: You can do it: supposing I'd gone to St. Thomas' direct when I left School, I could have done it in four and a half years, or 5. But going to Cambridge is a very expensive, rather elegant way of doing it. In the broader context.
Dr Witten: I'm a bit confused. Do I understand that you spent 4 years, then 3 and then 3.
Dr Wallace: No. Sorry. I did 4 years at Cambridge but could have done it in 3.
Dr Witten: So those 4 years then, 3 of which you were getting your basic science. So that constituted those total 4 and then 3 years at St. Thomas' so 7 years you got your training. On completion, what is the Degree. Its not referred to as MD there, is it?
Dr Wallace: No. This is there are two Degrees. One is the MB, a Bachelor of Medicine and MB. RChir. And the other way in which you can Qualify' they have an independent Board, or several independent Boards, which have powers to license people as qualified to practise. There are 3 or 4 dotted through the country and each University has its own Qualifying Degree.
Dr Witten: Which one did you obtain.
Dr Wallace: I did both.
Dr Witten: You did both.
Dr Wallace: Yes. The University Degree of course is a little bit harder than the Conjoint Board.
Dr Witten: Well. On completion of this,are you then allowed to practice or must you do what we call an Internship. It's a Registrar is it?
Dr Wallace: No. At that time, if I'd felt so moved, I was qualified to let loose on anyone. And indeed .. maybe it's what you call an Intern. I'm getting my terms confused but what we would call a House Physician at a Teaching Hospital, we had to wait usually six months at least and it's a highly competitive situation, and so during that six months I had to go and earn some money helping some local Doctors and this sort of thing, you know.
Dr Witten: In London?
Dr Wallace: In London. Yes.
Dr Witten: Did you have any desire at that time for a Specialty or were you still thinking purely in terms of general medicine.
Dr Wallace: None whatsoever.
Dr Witten: Up until this point Hugh, had you come in contact with men, whether in medicine or out, whom you felt uere influencing factors in your life?
Dr Wallace: They were influencing in the sense that I reaIised, perhaps I didn't realise quite so much at that time, but I got interested in a subject in which I really wasn't interested.
Dr Witten: Because of the man?
Dr Wallace: Because of the man. I got interested, for example, in orthopaedics in which I had no interest of aptitude whatsoever. But this man taught orthopaedics so well. You couldn't fail to be interested.
Dr Witten: What did he have that others didn't?
Dr Wallace: I think like all teachers, and it happens to be really one of my hobbies and so this may be a retrospective assessment, but I think correct, he had the power to teach. He had personality. And he got you interested. There were about three or four like this. One or two who weren't terribly good at their job. But even so, they were very interesting They got people interested.
Dr Witten: Were you exposed to Dermatology durirg that time?
Dr Wallace: Yes.
Dr Witten: Well. During that time, as with many other Courses, you didn't take Dermatology seriously?
Dr Wallace: No.
Dr Witten: That's not unlike my training.
Dr Wallace: We weren't going to get an obIigatory question in the Examination, and this is really all students concern themselves with, isn't it. Anybody who thinks differently, they've really got a strange idea about students, I think.
Dr Witten: After your six months in practise did you then become a House Physician?
Dr Wallace: Yes.
Dr Witten: And where was that.
Dr Wallace: This was at St. Thomas'. Well do you want to develop for me then the events that followed?
Dr Witten: Yes.
Dr Wallace: It wasn't what I really wanted to do. I think some of itwas governed by economics again and thoughts were perhaps governed by economics to some extent that not only were we not paid for our year as House Physician, which I must say I've never worked as hard before, or since, except it was a very good appointment because you did Casualty and everything. But not only did they not pay you, they didn't even do your washing and the food was bad. And at the end of a year, a very happy year, again the economic thing began to show itself again very much, and I did a job temporarily, well not temporarily, I did Paediatrics for a year. Well I wanted to get some Paediatric experience but the job was paid which was very important and what I really wanted to do at that time was to do General Medicine. And so I went on with General Medicine, and about then there wasn't what we would call a Medical Registrar job going at that particular moment: so I went and did a job coaching and teaching undergraduates and going round giving lots of lectures on paramedical subjects just, you know, to make enough money until the job came up. Then of course, the whole scene was changed because we were then coming up to 1938 and the whole thing was becoming highly unstable, so about that time there was a very useful post going as civilian practitioner attached to the Army, as a Physician. So I became the Consulting Physician ,I think, to the Southern Command in England which was only half-time, very well paid, and the rest of the time I could devote to do what I wanted. But, just before this time, as you know, in England ,even if you are going into any Specialty or anything up till now, we had to do this very tiresome medical Examination called the Membership, where they have a 10% pass rate and so this is the stumbling block for good or ill. So about 1937 I did this and about this time I met Geoffrey Dowling in the corridor, whom I knew quite well socially and by this time had come to realise was the most distinguished member of the staff, by a very long margin. And he said would I like to take up Skins which real y wasn' t at least in my mind. So I thought about it for quite a time and then I became, I think in about 1939, became an unpaid Registrar in the Skin Department of St. Thomas', with Dr. Prossor Thomas. About six months after this, came the War, and I was then full-time in the Army Medical Service as a Consultant Physician and for medical reasons they wouldn't take me into the Army. They kept me on very nicely for about 10 months and all the Generals they wanted to board out they sent to me because there was no come-back. I was in civilian clothes and so it was quite an amusing experience and sad sometimes. And then, of course, ultimately they had to have a Consultant Physician in uniform. Then I really wasn't very clear what I was going to do but then St. Thomas' Medical School, which by this time had had to leave London, and go about 30 miles south, asked me if I would like go and help run their Medical School. I remained a Physician, I did a little bit of Skins, but very little, and so it continued until the War was over. By the time the War was over I was still uncertain what I was going to do and I really didn't know any Skins, but then I made up my mind this was what I was going to do, by which time of course I'd done a lot of Medicine and very, very little Skins. Somewhere about this time about 1946 I think it was, I got on the Staff of St Thomas' as a Dermatologist or Physician to the Skin Department, Assistant to Dr. Dowling,.. . .
Dr Witten: You'd made up your mind then. What made you make up your mind to go into Dermatology?
Dr Wallace: I 'm quite sure, without any question at all, the influence of Geoffrey Dowling, because he was a man who was so respected by all his colleagues who realised .. he was the most remarkable man I think I have ever met, anywhere, a man of infinite clarity of mind and a marvellous Post-graduate Teacher with tremendous influence on the young. A most remarkable man with a highly developed critical faculty and really one who didn't tolerate fools gladly, but the kindest of people, one of the kindest people ever. And this was unquestionably the influence.
Dr Witten: I'm fascinated that here you are, characterizing a man who you feel had such a tremendous influence. What were some of his other faculties that made him such a tremendous influence?
Dr Wallace: He's very modest, the most modest of people. Quite a strong personality but a most modest and humble person, not falsely modest but genuinely a humble person and I think it was his clarity of thought that appealed to me enormously. He didn't mind saying that he didn't know, but he saw where the problems were and these things are very difficult to define, aren't they?
Dr Witten: Of course they are.
Dr Wallace: But I think rost of the, well certainly for the first ten years, unquestionably after the War, there's no question of course, Geoffrey Dowling made British Dermatology and gave it this status. Of course, it hasn't got all that status it ought to have. Of course there was just one other factor I think perhaps not quite related to Geoffrey Dowling in this sense, that we were all made to do this Examination ..
Dr Witten: This was the position of Dermatology.
Dr Wallace: That's right. But this of course wasn't related to Geoffrey Dowling.
Dr Witten: No. Now you then went into St. Thomas' as a Medical Registrar in DermatoIogy.
Dr Wallace: Yes.
Dr Witten: And then you spent how much time in training in Dermatology.
Dr Wallace: Before I got on the staff. You mean as a full-time.....
Dr Witten: Whatever is considered your Specialty training in Dermatology until they consider you're qualified.
Dr Wallace: I think the training I did in Dermatology- I'd be ashamed to tell anyone. But I did about six months possibly. In toto - well, maybe a year in all. But not more.
Dr Witten: That's not altogether. You mean of concerted effort.
Dr Wallace: Well. It was about, you see it wasn't much more than a year. And in fact I had the experience when I got on the staff, one of my colleagues who was a physician on the staff, went ill got tubercule and he was off for about a couple of years and so I was doubled up as a physician to the Skin Department and as a Physician to the Outpatients .. and I didn't know much about ..I knew a bit about the medicine and I learnt the skins en route.
Dr Witten: Well. Follow through with me if you will. Carry me through, this period of training in Dermatology and where you went in Dermatology specifically.
Dr Wallace: All the time was spent with Geoffrey Dowling and in terms of say, doing .. I did a bit of histopathology with Freudenthal who I realised was a very great man. I found it quite impossible to, no doubt in the Dowling class, but not the form of teaching that appeals to an Englishman,this rather didactic minutiae. . that I think this was perhaps a clash of temperament. A person who I thought,a very good teacher in histology was Muende who has now retired but he was a very good teacher. And the rest of it I learnt or didn't learn as I went along. No doubt it was a very bad system. I'm sure one really ought to have formal training,it was just a slightly historical accident.
Dr Witten: Well that was at that particular time. The training has changed, hasn't it. Who were the others to whom you were exposed during this period.
Dr Wallace: Dr. Barber. There were about 3 or 4 who I thought were really quite outstanding people in any company and quite different all of them. Dr. Barber (Thommy's), Dr. McCormack at the Middlesex, and Dr. Roxborough at Bart's. These were the people one met if one went to Meetings. We were very fortunate in this respect there were lots of Meetings and these people had quite an influence. Sometimes one has oblique influence by comparing the one with the other and you could see their strengths and weaknesses, in comparing them for example with Dr. Dowling or somebody else. But they were all people of strong personality, of first class brain and they had a very, very big impact on me when I think of my generation.
Dr Witten: And you remained in Dermatology doing practice at St. Thomas'. Tell me something about your academic progress as you went along.
Dr Wallace: I became interested, perhaps I should say, to some extent, academic work at that time had to he circumscribed by the facilities in terms of building and money and things that we could lay our hands on and although I had had quite a bit of I suppose what we'd call basic research training when I was at Cambridge, because I worked with people like Bareroft and Adrian, by the time one became a medical studert or by the time I got on the staff, the facilities in terms of money and everything were not good. Indeed ,I'm not at all sure that I'd had the aptitude in any event. But I was rather interested in sorting out areas in textbooks which I thought could be sorted out without necessarily too much in the way of techniques. Thi.s is really how I became interested in lichen sclerosis and ....
Dr Witten: Well. I'm going to bring you back to clinical Dermatology after you tell me more about your career academically and how you got to be where you are.
Dr Wallace: On the academic side I've always been most interested in medical education. One includes this under the term academic and I've always thought that it was very important that if you put people on the staff of a Teaching Hospital one of their assets should be, other things being equal, they could teach, by definition. This is a thing that is frequently over1ooked. And of course one must strike an equilibrium because if you have someone of outstanding origi.nality of mind who's going tc do some marvellous research then they must be taken of course, but the combination of someone with that type of originality of research in a laboratory and T'm now thinking in terms of undergraduate education for the moment. Let us say pre-qualification, I'm not quite sure what the word should be here, in other words by the time you can get your MB or whatever it may be, I think that people should address themselves more to asking whether the man can teach and I think one can usually find this out without too much difficulty, I think you can usually get it right at an interview but you could certainly get it right by lines of communication with one's colleagues.
Dr Witten: Hugh, do you think that at this particular time that when you begin to see, almost a division between what is research and what is clinical, that those who consider themselves researchers are teachers?
Dr Wallace: Of course, they are teachers and a very important part of teaching, but I wouldn't call it exclusive. I would say that these were necessarily the people who were the best teachers but I don't think this is a sort of a mutually exclusive proposition. I think you should have, if one's talking about teaching I think one's got two things to have in one's mind. One's got to have the teachers perhaps who influence undergraduates and recently qualified people. Then you have someone like Dr. Dowling who influences recently qualified people and people who have been quali fled two or three years and wonder what specialty they are going to enter. And then of course, you also have the people whose research is so outstanding; these are for the very bright students.
Dr Witten: That becomes then the end result of his capability but not necessarily his ability to give it to another person. In other words, he is judged by his accomplishments. I assume that Dowling was an excellent teacher. He was able to corvey information. This is what I assume that you referred to when you speak of someone as being a teacher.
Dr Wallace: Yes. But of course, there are so many ways of conveying information,are there not. You can either tell somebody or ask them a question, or like Dowling do it by example. And I think that Dowling did this mainly by example. You would listen to him talking and he would give the reasons why he thought this was the situation. But you had to ask him, certainly when I first knew him, and then you get the answer.
Dr Witten: Well. Now. You keep getting away. Apparently I can't get you to talk about yourself and I'm going to make you, for the moment. When did you become then in charge of Dermatology at St. Thomas'.
Dr Wallace: 1955. I should say we had a slightly different system in a way in England that once we're elected to the staff we are all equal. There is someone nominally in charge of a Department but if for example the staff meet, we all have an equal vote and we have an equal right to be heard and we don't have to have it referred to the Head of the Department. We can say that ... If George Wells who is with me now, for example, disagreed with me, he'd have every right to be heard you know. Happily, the situation doesn't arise but i f it did arise he'd have every right to be heard and he would have an equal voting power, as myself.
Dr Witten: But there's still a nominal Head.
Dr Wallace: Ch. There's still a nominal Head. Well I became the Head when Dr. Dowling retired.
Dr Witten: Then you did follow him. And that was in '56 approximately.
Dr Wallace: True. True. '55.
Dr Witten: And you've held that position ever since that time. In your talk yesterday, you indicated that you did not consider yourself a researcher. Judging from your presentation I consider you a clinician. I'd like you to tell me more about your feelings with regard to research from the kasic point of view, from the clinical point of view, as related to clinical teaching today, and whether you think that the trend is a healthy one. Of course you're speaking about England now, as compared to the United States.
Dr Wallace: I'm sure the trend's a healthy one, I think it was really rather sterilizing,the sort of thing to which I was subjected when I first started and this, I'm sure, put a large number of high-class students off Dermatology. Because they say , 'here's somebody who just looks at papules and things, and that's about the beginning and the end of it'. Well, you and I know, that ever if it was quite as simple as that, that you've got to look at people and how they react. Even in those days I didn't think that, shall we say, the prognosis of skin disorders was any worse than other forms of generaI medicine. I never thought this. Our failures were rather more overt because you can't pat somebody on the back if they've got about a square meter of psoriasis and say they haven't got it, -whereas some of our other colleagues can say this.
Equally it was quite clear that until one got in a few good original brains into Dermatology (it would not change), but I would think possibly that this has rather been more the advent of techniques than of brains that has determined this. The number of really original workers in any branch of any science is so small that one perhaps could put them on the fingers of one hand and a lot of other people naturally do the research projects, set pieces and all very valuable. It is very difficult, isn't it, to know where, if you're training people, how much of their time should be occupied in so called research (which I would put with a small 'r') and how much of it devoted to clinical training. The pendulum, I suspect, has swung perhaps a little too much the other way now. I feel bound to say that unless you do see a lot of patients and get a certain clinical feeling about things: I think I've seen this very often, not in the States, but people investigating obviously the many problems, but they haven't asked themselves the right question. This is rather paining where sometimes even in the States, reading a Journal you think ' this chap really can't have seen you know this sort of situation at all, and he's probably seen one case in his life' and, you know, by the time you' ve seen about twenty you. begin to know it just doesn't work that way. This would be my misgiving that I think people should do some basic research, or some research, but whether it should occupy so much of their time I'm not absolutely quite certain. I think in England, whether we've got the proportion right I don't know, but I think interns spend about a quarter of their time doing what might be called basic research. Perhaps not all of them would spend a quarter of their time but I suppose overall this would be about the proportion. And I would think that was somewhere about right. Except for the geniuses who may declare themselves irrespective of what standard you lay down or system of training you lay down
Dr Witten: You feel that this also varies with the particular institution? At St. John's one would probably do more basic research than perhaps some of the other institutions?
Dr Wallace: Yes.
Dr Witten: In your talk yesterday, you touched on your areas of interest in clinical dermatology and in your forthrightness and indicating that you didn't consider yourself a researcher, you still apparently keep your finger in what 's going on and you have on your staff men who are truly bright in the field of research. I'd like to know your thinking regarding this combination and how you balance it, how you permit it.
Dr Wallace: It's a very difficult question to answer, isn't it?
Dr Witten: Well I'm asking you difficult.... I'm challenging you really on the questions, I know.
Dr Wallace: I think the first essential is obviously that you have a happy department and after that nothing else matters terribly much. I think you must have a happy department and I'm very fortunate in this way, really. I couldn't have nicer people to work with. It so happens that Dr. Wells was once my House Physician and he was at school with me and so therefore all the others have been students of mine in the past and so I know them very well. We are very fortunate in being able to attract people from all over England and indeed the States to work with us and so we are very fortunate in this way. And perhaps I hope having had a scientific education somewhere along the line at least I may not be able to do anything myself but I think I can tell the sort of people who have the talent.
Dr Witten: That is important. That you have had a scientific background and therefore you are able to discriminate to have on your staff the type of men who are capable. I think this is a very important point, isn't it?
Dr Wallace: I think so. And of course in this I was also influenced very much by Geoffrey Dowling who had this highly critical faculty. He had this flare of knowing although he hadn't perhaps had the same scientific education. His thoughts went along those lines and he could see through anything that was bogus immediately. And so I think perhaps the combination of these two things does play a big part and I think the thing is really not to start doing things that you can't do. I think a lot of people spend a lot of time doing things for which they're not.....it's a perversity of human nature isn't it, to want to do something for which you're not really equipped.
Dr Witten: Isn't it a remarkable art to be able to recognize what one's incapable of doing. I compliment you.
Dr Wallace: Oh. I'm sure I fall down many times as well.
Dr Witten: Tell me how you bring together then the disciplines of the research and the clinical? In your own interests. And where does the researcher fit in?
Dr Wallace: Well obviously my interests, if one uses this word clinical research they are to some extent geared and are very much influenced by my ten year background in General Medicine and this is for example how I got interested in this angiokeratoma corporis diffusum which, from a parochial interest should be called Anderson's disease. It was first described by a surgeon at St. Thomas' Hospital. This disease,you see, has large medical connotations and it all seemed to me that if one wished to investigate a problem either you could see lots of patients if you like with similar symptoms or alternatively you could have something like this particular disorder which poses so many problems in physiology .and pathology. Shall we say for example no one knows the nature of the pain in this disorder. We've done a lot of experiments about what are the causes of this pain and no one has any idea. At the moment we're concerned also to find out what is the morbid anatomy of the neurological changes they have, and I'm fortunate in being able to call upon the services of a neuropathologist at the National Hospital for Nervous Di seases who uses all the techniques at his disposal and happily all the brain power at his disposal to help me in all this work. And in the past I've had David Wise, who was also one of my Registrars, to help me in the genetics of it. That was the situati on and so it's this sort of problem that really I could see would keep me busy for the rest of my days at St. Thomas'.
Dr Witten: Well. I can see that you do enlist the help of every discipline. Hugh, there are those who feel that with the advances in the laboratory techniques in diagnosis, the advances in the therapeutic procedures which have come in the medicine and dermatology, that the role of the dermatologist is going to eGme less and less as is the need for the Specialty. Do you share this at all?
Dr Wallace: It's so much point a point of flux that anything one says you're only going to guess. I cannot quite see the situation in which you're going to be able to computerize this, shall we say, to a degree in which you can just make a diagnosis in this sense: you can make a diagnosis and say that this patient's got lichen planus by feeding a computer. I would think that there will always be a place for a Dermatologist, if you're talking about clinical Dermatologists,and if only because it takes so long to be able to recognise, if you like, different sorts of eczema and how you would treat them. I cant see quite how one could programme a computer that would give all these variables. Though this of course may prove to be so. And whether in point of fact the patient would derive the same sort of solace from a computerized answer which is, I think, perhaps, something to which people haven't given enough attention. I think patients obviously, in any branch of medicine, get as much comfort from the physician as they do from the medicaments. And I think here, this may be an area where there is going to be the difficulties which may have been underestimated: that you can give an answer and say this is zinc oxide paste here .. but this does not really necessarily satisfy a patient. I could see a situation where, if you're got a limitation of skilled labour, this is obviously what you've got to do, but I could see one possibility of this is the flourishing of quack doctors ,who at any rate pay some attention to their patients ..
Dr Witten: Of course, that 's when you speak of the computer. Let's take for example lupus erythematosus which is more and more turned to the hand of the internist with his interest in the systemic manifestations and the management of the disease. We could look at what had happened ... syphilis is coming back to the Dermatologist now. The atopic dermatitis seems to fall perhaps into the hands of the allergist. Our new methods of therapy have taken things away from us. You've indicated then that you feel that there is something the Dermatologist has that no one can take away. Is that correct?
Dr Wallace: I think this would depend upon the sort of people you attract into Dermatology. I think this may be wrong but I get the feeling that somehow in the States the Dermatologists have let things slip through their fingers and this I think is the one advantage of the British system of education. We don't get in a panic. We look after our own systemic lupus erythematosus. We may share them with our colleagues but we all share one another's patients and so they are not lost to us. The only things we lose are the things we want to get rid of. And are not particularly interested. For instance, I am doing some lymphatics and am fortunate in also having a colleague who is also very interested in, who knows very much more about it than I do, but I don't regard this as lost but I think this is one of the virtues of our higher medical examination or higher qualification: so you don't feel you're being put in a position of inferiority. In fact, I think sometimes we're told that sometimes we're not asked to see patients because we're so scathing about what's gone on before. But I think this idea that the dermatologist would be on the defensive is a most extraordinary view which has never committed itself to me.
Dr Witten: Do you think that has occurred in England, this defensiveness.
Dr Wallace: Not very much. But this is because you see I think they've had people of strong character, like Dowling and like Roxborough and Barber, all people of outstanding intellect and outstanding character, and no one could really take them for a ride very easily.
Dr Witten: In what other ways do you feel that there's a real difference between English and American dermatology?
Dr Wallace: I think we have a very much wider outlook on general medicine,but one can't generalise.
Dr Witten: I understand.
Dr Wallace: But I think many of the American Dermatologists I have seen over the years, I get the feeling that they really are attracted to the Continental, the European system, somewhat authoritarian teaching, but more particularly this morphological outlook on what makes a papule and how many there are and how they're disposed and this has enormous virtues of course, but I'm always a little bit shocked when one asks the question: 'Is it possible they've got meningococcal septicaemia' and that somebody looks at you with a blank look. This to me would be rather, this is rather taking an extreme example, but I've seen this happen in France,and in some of the very best Clinics, I have seen it happen here that somebody said we must eall up an internist. Well to me this is rather an abrogation of one's responsibilities and therefore of one's thoughts.
Dr Witten: That raises the question we entering into, we're in a period of specialization almost a period of subspecialization. Is it possible for the physician today to have the superior knowledge in dermatology and internal medicine, how can he keep up with both adequately?
Dr Wallace: Of course he can't. But then this is no reason why one should suddenly I think abrogate one's responsibilities. I've always thought dermatology was the broadest of all the Specialties by a very long margin. Broader than any branch of general medicine. Because there aren't any general physicians left for all practical purposes perhaps more's the pity, but no one, they either
do the chest or they do the heart or they do the gastrointestinal tract or they do the renal tract, but at least you should be able to talk their language. You know obviously won't know as much about all those specialties but at least you shoul d he able to talk their language, And so you know what they are talking about anyhow. And then I don't think a problem then necessarily arises as to whether dermatology is going to disappear, because if you follow this argument to its logical conclusion everybody else would have to disappear. That renal doctors will only see patients with renal disease.....
Dr Witten: Do you think there is as much need for the Dermatologist now as there was.
Dr Wallace: I think it depends what sort of form the Dermatologist takes in another generation
Dr Witten: Tell me what you would like to see then in the form of the Dermatologist in the coming generation.
Dr Wallace: I would like him tc be much more integrated with his colleagues. I'm now thinking in terms of clinical work. I'm fortunate that I enjoy this position. We live in, I must say, in conditions of great squalor in terms of huildings and things, but we're all thrown together, we all go on one another's Wards.. I suppose we get about two thirds of our work as requests from our colleagues in the Hospital in all branches of medicine, and this to me is the great satisfaction of it. If I just sat around looking at acne, I think I'd get a hit bored with that after a time.
Dr Witten: You think then that the Dermatologist must be a part of medicine.
Dr Wallace: A part of, but not a division of.
Dr Witten: A part of. What else would you look for in this new generation?
Dr Wallace: I find this very difficult to answer because a few years ago I would have said that I would expect them to have something like the Membership that I felt that this was really a sine qua non, for acquiring that status that you could see your colleagues on level terms.
Dr Witten: That he should be .....
Dr Wallace: That you'd have a higher examination in medicine and that, shall we say the Board's dermatology in this country may be of exceedingly high standard, I just don't know,you see,and whether they have the same intellectual standards as the Board's who are
going to do neurology, I don't know. Maybe they have different ..
Dr Witten: I think they do at the specialistic level.
Dr Wallace: Yes. Well you see, I would perhaps put this one back a little bit and have a fairly high qualifying Exam to sort out a lot of people before they even got to the specialist level. I used to hold this view very strongly. I don't think I hold it quite as strongly now. Because this was thanks to an American Registrar I had, who had an entirely different education and as a clinician was one of the best I've ever had and really didn't know an awful lot about medicine in terms of, judged by our standards, but had this sort of clinical sense and, you know, there was not a lot he did not know. So although I would still maintain that this was a highly desirable situation of having a very high standard to start off with irrespective of what happened to you after your specialist work, I think if you had people with a research talent I don't think they should necessarily be subjected to this: I think this can be a very sterilising influence and has been very sterilising on two or three people I know very well. They spent say four years learning about the various epidemics which they were never going to see and it was the formative years and after a time this very tiresome examination. Really they got an anxiety state about it and well, two of them, never did get it.
Dr Witten: Well, do you feel that with this changing trend that the physicians today who are being trained in Dermatology in England are better practitioners of Dermatology because of it.
Dr Wallace: Oh. I'm sure of this.
Dr Witten: You think they're more highly respected, within the....
Dr Wallace: Oh. Yes. Certainly. There's no question about this at all.
Dr Witten: What do you say accounts for this then?
Dr Wallace: I would think primarily the influence of someone like Geoffrey Dowling
Dr Witten: The man?
Dr Wallace: The man.
Dr Witten: What about his training? Not Dowling's training but the training of the young student.
Dr Wallace: The training of the young man is incomparably better than anything that any of my generation had. In fact ours was virtually non existent and so I'm quite sure the training of these boys have, that this generation has is incomparably ..
Dr Witten: You're satisfied with the direction of the training now. You would not wish to say well I think it might go another .. a little bit different..
Dr Wallace: I'd have thought probably we got to a fairly reasonable equilibrium...you can only speak for one's own School perhaps where we do train more than most, but I'd have thought we'd have got somewhere near an equilibrium. I think this may have to .. one really can't quite forecast. Of course there may be some revolutionary discovery that you and I can't visualise ..
Dr Witten: No.
Dr Wallace: .....in molecular biology or something that if one takes the situation as one's seen it evolve over the last twenty years I would have thought, particularly for people who haven't had a research training they should have this basic research training,but I think it's important they should write one or two papers but I've got no brief for this idea that virtue rests in having a bibliography that goes in for about five or six pages. In fact if I see a candidate who comes up they are automatically suspect as far as I'm concerned ..
Dr Witten: Suspect of what?
Dr Wallace: Well. They can't possibly have done any work because if you wrote all those papers you certainly- won't have thought deeply about any problems.. There'll be two things in a lifetime and I think that's not bad.
Dr Witten: I want to ask you a question now about, the time is going to be our limiter today, because you have other plans and we have just a few minutes. What are you gaining from your trip, within your visits of dermatology in the States?
Dr Wallace: Oh. The thing I'm sure I'm most impressed by the facilities that you have here, for the research for your residents. This is really something in quantity we couldn't begin to achieve even in a place where I am and where I am very fortunate, we couldn't begin to achieve this degree. Not at all. And I think this is a marvellous situation for anyone to be exposed to.
Dr Witten: Have you seen anything else here that .....
Dr Wallace: I haven't really seen enough people working in clinics to know, but the one thing that has impressed me very much is how kind people are to their patients. This has impressed me.
Dr Witten: That's good to hear.
Dr Wallace: This is the one thing that worries me in some parts of Great Britain and other countries, that the patients really seem to.... and this is obviously one of the dangers if people get orientated in their careers depending upon basic research, its a very difficult situation.
Dr Witten: I think that's very good to hear 'cos its always been a concern..
Dr Wallace: But certainly, I have been most impressed and you can see this reflected in the patients, the way the pati ents speak to their doctors.
Dr Witten: Do you feel there is any difference in the calibre of the young men who go into Dermatology here as compared to England. This is just an impression, of course.
Dr Wallace: I would think the best here were about as good as the best in Britain, and about the same.. I was going to say I wonder if you perhaps, I couldn't quite see, you see I've just been in specialised clinics you know like Harvey's. I don't know how many residents other clinics have but we couldn't in point of fact in England leave aside economics. We couldn't get enough people really what we would regard as adequate caliber , we could get a lot of people somewhere down the line but we wouldn't want them terribly much.
Dr Witten: You have so many fewer there, when I think of your total number of Dermatologists compared to here .. here we're at the end of the tape and it's been a pleasure and also to have your wife sitting here with us through this.
Dr Wallace: Thank you very much.
Dr Witten: I want to thank you. I think I've challenged you perhaps unduly at times and didn't give you time to think but I think that you have given me an honest expression of what you believe and this is what I wanted.
Dr Wallace: Thank you very much Victor. Kind of you.