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A New Generation

The inter-war years were marred by economic woes and the disastrous general strike of 1926. Nevertheless they witnessed a growth in the number of hospitals that supported skin clinics and more doctors, mostly general practitioners, showed an interest in skin patients. Such clinics thrived, or simply survived, depending on the energy, industry and enthusiasm of the physician-in-charge and the support provided by the hospital authorities. Self-contained departments as in Edinburgh, were unknown in England, with the exception of Sheffield where Rupert Hallam, taking over the care of skin patients earlier than expected, showed remarkable foresight. Many cities could provide ample clinical material to justify such an enterprise but there was no money, no university funding and little general interest. Dermatology was not even in the doldrums, it had yet to put to sea. However the firmament was to be brightened by several individual stars.

Harold Wordsworth Barber49 (1886-1955) was in 1919 the first Dermatologist to be appointed to the staff of Guy's, one of the last of the London teaching hospitals to take this step. He had been preceded by a distinguished series of physicians. Thomas Addison, had been appointed, after no little argument, Assistant Physician in 1824: an Edinburgh graduate he had been a pupil of Bateman and of Willan, and indeed had worked for a while at the Carey Street Dispensary. There followed Gull, Wilkes, Hilton Fagge and Pye-Smith, all physicians interested in and making useful contributions to the study of skin disease17.

Barber, the son of a Nottingham solicitor, arrived at Guy's from Cambridge; unusually bright, charming and cultured, he was clearly marked for advancement. In 1913 he won the Arthur Durham Travelling Scholarship which took him to Paris where he came under the spell of Ferdinand Darier, the incomparable morphologist, with whom he developed an enduring friendship; then on to Unna's clinic at Hamburg where he savoured his quite different, pathological approach. Returning to Guy's he amply confirmed the qualities he had displayed earlier as a Medical Registrar but an inevitable five years in the RAMC delayed his return. In 1923 he was appointed Physician-in-Charge of a Department for Diseases of the Skin - Guy's had schemed well.

He was to become the pre-eminent clinician in London. His knowledge of general medicine, his reverence for French morphological precision, his retentive visual memory, but above all his charisma, ensured a busy life in his clinical work at Guy's and private practice. He produced papers of unusual interest for his ideas were often novel. He attracted a retinue of devoted acolytes who became enthralled by his teaching and charm, while at meetings or lectures he would always command rapt attention. As a therapist he was incomparable, due in part no doubt to his personal brand of "magic". He remained a sincere advocate of the "art" of medicine, encouraging his pupils to appreciate an attitude he felt was in danger of being lost in the modern scientific revolution.

Barber was totally at ease in the drawing rooms of London society. His handsome appearance, his courteous if somewhat aloof bearing, and his wide and cultured interests ensured respectful attention. With a French wife it was hardly surprising that he displayed an expertise in gastronomy and a critical appreciation of fine wine, but his fascinations for cricket, horse racing and steam trains were unexpected; latterly he became an ardent bird-watcher.

His contribution to dermatology, even with hindsight, is less easy to assess. He delved deeply into the pathogenesis and aetiology of skin disease but developed enthusiasms for concepts which now seem a little facile. With Arthur Hurst, the distinguished gastro-enterologist, he explored the relationship between the gut and the skin. Metabolic faults, detectable by esoteric urinary abnormalities, were also investigated but above all his ideas about "focal sepsis" as an explanation of a diversity of disease occupied much of his thinking. Patients with lupus erythematosus, urticaria and indeed most of the commoner problems, were explored to discover some cryptic infection. Teeth, tonsils and appendices were ablated with abandon.

He served twice as President of the Section at the Royal Society of Medicine and twice as President of the BAD. He gave the 1929 Lettsomian Lectures and the 1952 Prosser White Oration. His memorial service was held in the Chapel at Guy's and the packed congregation gave his family some idea of the intensity of esteem and affection his colleagues, pupils and patients wished to express. The likes of Harold Barber are seen but once in a life-time.

Hard on the heels of Harold Barber, came his ex-pupil and colleague, Geoffrey Dowling, whom he had stimulated to consider dermatology as an alternative to pathology. In later years the protégé might be seen to smile wryly at his master's incurable romanticism and his attachment to French foibles and diathetic notions.

Geoffrey Barrow Dowling (1892-1976) stands high in the opinions of the post-war generation for the quiet and unobtrusive stimulus he was to give to British dermatology; it led to a resurgence and modest restoration of national pride. He had been Secretary of our Association, President in 1956 and his thoughts were never far from our affairs.

He was the son of the organist of Cape Town cathedral and his family was closely involved with all aspects of musical life50. For his education, he came to England where after three miserable years at the Exeter Choir School he moved on to Dulwich College. His sights had first been set on the Navy, but he was not accepted for Dartmouth so it was decided that he should instead go to Guy's to study medicine. His training was inevitably interrupted by two years in France as a cavalry trooper, which though uncomfortable did not prove dangerous; furthermore he claimed that he had been able to develop some useful culinary skills.

He graduated in 1920, gaining the MRCP that year and an MD the next, a feat now impossible but providing a clue to his ability. He was appointed to St John's in 1926, after, he claimed, a remarkably relaxed interview. J M H MacLeod was in charge of pathology and Dowling, whose laboratory skills were to prove more than useful, joined him to study the role of pityrosporon ovale in the genesis of seborrhoeic dermatitis.

His next appointment was to Goldie Leigh, a long-term residential Hospital for Children providing treatment for scalp ringworm, then endemic in London. In 1927 Dowling was appointed Assistant Physician to the Skin Department at Guy's where he stayed until 1933 before moving across to St Thomas'. Facilities there were limited and venereology claimed more space, more "student-appeal" and more patients. Two beds were allocated for skin patients, one for each sex; the standing of dermatology was not high.

It was not until after the second German war, largely through the inspirational touch of his new junior colleague, Hugh Wallace, that Dowling's influence became manifest, his erudition, medical knowledge and kindly wisdom having lain hidden under a shy and modest exterior. More about this exceptional man will appear later.

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Another who served the BAD in three roles, Editor of the Journal from 1930-38, Secretary for two years in the war and President in 1946, was Archibald Roxburgh, a quintessential London consultant.

Archibald Cathcart Roxburgh (1886-1954), born in Chile, was educated at Charterhouse, Trinity College, Cambridge, where he obtained a First, and then St Batholomew's where he gained the top entrance scholarship. All three of his sons became doctors following their father's Cambridge and St Bartholomew's path. His brother was the famous Headmaster at Stowe, the newly founded public school.

He qualified in 1913 and after a number of house posts served in the RNVR throughout the first world war. He came back to work as Adamson's Chief Assistant from 1919 before being appointed to the consultant staff working in both the skin and venereal disease departments and proved to be a brilliant teacher of medical students. He arrived at St John's in 1924, at a time when teaching hospital consultants were being invited to join the staff there; in fact he later became Dean of the London School of Dermatology from 1924-30. He also joined the staff of other Hospitals - the Masonic, Wembley and Hampstead Children's, a peripatetic life was then the norm.

Roxburgh was a practical man with a ready sense of humour. He did not relish the highfalutin theories emanating from some of the academic centres and he had not studied abroad. Photography became more than a fascinating hobby to him and he used it extensively in his clinical practice. His successful textbook "Common Skin Diseases" first appeared in 1932 and ran to many editions, later being re-edited by his successors at Bart's. The illustrations were from his own collection and a common sense approach ensured that "Roxburgh" remained a favourite for generations.

He introduced Wood's Light, a fluorescent lamp, from France (Adamson, his senior, was an enthusiastic mycologist) and Thorium-X, a radio-active alpha emitter used as a topical paint which became a popular application for treating capillary haemangiomata, lichen simplex and psoriatic plaques; the long-term results were unconvincing.

Devoted to the BAD and the Section at the Royal Society of Medicine, Roxburgh clearly loved his work. His obituarist considered the words of Cassius - "a plain, blunt man, that love my friend".

* * *

It was not until 1927 that Leeds Royal Infirmary saw fit to appoint its first consultant dermatologist.

John Thornton Ingram (1890-1972) proved to be a mainspring in the Association; as Treasurer he guarded its finances for 20 years, and in 1947 he was President.

From University College he had gone to the London Hospital for his medical training which was interrupted by war service, at first with the Artists' Rifles. Under the spell of his great hero, Jonathan Hutchinson, Ingram, having qualified in 1924, worked with Sequeira in the Skin Department. Later when he became First Assistant he revealed his ability, enthusiasm and considerable ambition.

Though small in stature, and shy by nature, John Ingram had charisma; from the outset he believed and taught that dermatology and general medicine were inseparable. A thorough history and full physical examination were demanded and he was ever ready to consider psychological factors. Leeds students were easily recognized, so well had they been drilled in dermatology; he even persuaded the University to include the subject in the final MB examination and to introduce an external specialist examiner. His dynamic energy enabled him to achieve his aim within 12 years - a fine clinic, plenty of departmental space and facilities which seemed extraordinary by the standards then current. He was first joined by Frank Hellier and after the war by Stephen Anning.

As a result of his personal reputation, overseas visitors and postgraduate students, especially from Australia, visited his clinic. Apart from his teaching, and his insistence on a meticulous examination and the accurate recording of data, his fame rests on the "Ingram Regime", a treatment technique for chronic psoriasis. This consists of daily tar baths, irradiation with ultra-violet light and application of dithranol paste, in various concentrations, under a stockinette dressing. It has stood the test of time.

In 1939, as a full Colonel in France with the BEF, he strove to separate the care of skin patients from those with venereal disease; furthermore he pressed that female nurses should tend skin patients in hospital; both ideas were to be implemented. In the Autumn of his professional life he held the Professorial "fort" in Newcastle for five years, paving the way and keeping the Chair warm for Sam Shuster.

Ingram did not claim to be a scientist but was a careful observer, a brilliant teacher and a forceful personality. He wrote many articles especially onpsoriasis and scleroderma, and was joint author of the later editions of Sequeira's "Diseases of the Skin". It was he who persuaded Leeds University to pass Hutchinson's "Archives of Surgery" for safe keeping to the Willan Library.

John Ingram, like Archibald Gray, was of small stature and with abounding energy; both showed extraordinary organizational skills, invaluable in the early days of the Association; both stressed the importance of a close relationship with general medicine and with the Royal College of Physicians. Many of his admiring pupils became "infected" with his remarkable enthusiasm.

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In Edinburgh, the Skin Department for a time seemed to lose its way after Norman Walker found himself sharing authority with a general practitioner-cum-dermatologist - Dr Frederick Gardiner. However its fortunes were to be restored by G H Percival, an unusual man, a product of George Watson's College and Edinburgh University. The way he hit on dermatology as a career was remarkable.

George Hector Percival (1902-1983) joined the Skin Department in 1923. He had been looking for a clinical post after a spell of research with Professor Cushny in pharmacology and one in ENT was advertised. On his way to enquire about it he saw that Dermatology needed a locum House Physician, he was accepted on the spot. Four years later he was Assistant Physician to the Department44,45.

In 1936 Percival was appointed Consultant-in-Charge of a newly built block in Edinburgh Royal Infirmary, where dermatology had a self-contained unit that included beds, out-patients and laboratories. In fact he made his main mark on British dermatology in the years before the war while many of his contemporaries remained either unaware of his great abilities or vaguely disturbed by them. He possessed considerable charm and great intelligence, but could be contemptuous of colleagues and was convinced that London was behind Edinburgh, particularly in the realm of skin therapy. Perhaps it was, for his team had made a special study of local treatment, and the redoubtable Sister Elizabeth Toddie had written a book on the subject.

This brilliant man could have made a much greater mark on dermatology had his attention not wandered, for example into the realms of Chinese jade or the ageing of salmon as detected by a microscopic examination of their scales. Nevertheless what he built up has developed into the present flourishing department at Edinburgh. As for his contemptuous mien, while he was certainly no respecter of persons, nevertheless he welcomed spirited opposition and was always exceptionally loyal to his own staff.

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