The Development of Dermatology in the Oxford
Region
Terence Ryan
Early days
The Oxford Medical School can claim that dermatology was there right from the
start.
St Frideswide in Saxon times cured a student from York of his leprosy by
kissing him. In addition, John of Gaddesdon, Chaucer’s Doctor of Physic in The
Canterbury Tales, had a stall in St Giles market place where he sold his greases and
powders for the skin. His textbook makes good reading for dermatologists.(Rosa
Angelicus).
However no one could claim that there was much interest in the skin before the
19th Century. The Medical School owned little teaching material apart from a piece of
skin from a criminal. Bearing in mind that the clinical school did not begin until
1939, and that previously the hospital in Oxford was an infirmary overseen by general
practitioners, one could not expect much expansion in the nineteenth century. There
was no great regional community, and the 19th Century Oxford Medical Society
attracted its members from no further away than the Cotswolds.
Osler and Mallam
When William Osler arrived in Oxford he gave his name to several skin
conditions (Savin JA. Osler and the Skin. British Journal of Dermatology 2000; 143:
1-8. ), having discovered most of them while he was still in North America. His paper
in the B.M.J., which described patients from the Oxford County attending his clinic
with vasculitis, has been quoted enthusiastically by myself (Ryan 1976). A physician,
Ernest Mallam, looked after skin and venereal diseases for the first three decades of
the 20th Century.
Alice Carleton
Alice Carleton came to Oxford from Dublin in 1921 to teach a few girls, separated
from the boys, about anatomy above the waist, in an attic of the Anatomy School. In
the 1930s she visited Paris and Vienna and acquired the skills of a dermatologist. Her
presence was noted at an early meeting of the British Association of Dermatologists.
Her practice was widespread geographically, including Swindon and Cirencester, but
she was still teaching anatomy as well in 1950, when I first met her. Only a few years
earlier Dr Dowling’s St Thomas’s and Guys’ boys had spread out in the Oxford
Region (see below).
I avoided Alice in the anatomy school because her wit was capable of destroying
me, and I had to struggle to learn the language of anatomy and its long lists of parts.
However by 1954 it was time to do dermatology: my father had met her brother and
she knew of my existence. This made me work a little harder on knowing my spots.
Later I dedicated a book to her, quoting her command “Look boy, look!” She was
pleased, saying she had never claimed to advance the subject but found the dedication
“entirely acceptable”.
The way she practiced dermatology amused her medical students. Every patient
was undressed and taught on, and anyone who called a macule a papule might get hit.
I was there when she swung round to a female assistant who was nodding a clue to a
student from behind her, and punched her firmly in the chest. She had a psychiatrist
(Kenneth Dewhurst, best known as a medical historian) in the clinic waiting in case a
patient needed talking to. An allergist (Morris Owen) was also there in waiting. All
prescriptions were written by the female doctor in attendance who on other days
looked after female V.D. In the next room Mary Assinder and Susanne Alexander saw
the follow-ups. These clinics were held twice a week and there was a weekly ward
round.
The dermatology inpatient department had once been the “septic ward” of the
infirmary, but now comprised 40 beds at the infectious diseases unit. The occasional
lumbar punctures for cerebral syphilis were done there (more whenever the ballet
visited Oxford!), but students visiting this outlying unit were rare and saw only
special cases such as leprosy or anthrax.
I was still a student when Alice Carleton retired, and I helped to drag her car to an
“Alice in Wonderland” farewell at the Infirmary on the occasion of her last clinic. I
had attended her clinics electively, and when I went off to do my National Service as
an E.N.T. surgeon at the Military Hospital in Colchester, I was given the job of being
a dermatologist as well. I also had holidays with Alice in France and was introduced
in the late `50s to the Hopital St Louis.
Alice was correct in saying that she had advanced dermatology very little but
because she was a brilliant raconteur, even in French, she was well-known in Europe.
Tom Fitzpatrick, who studied pigmentation with Blaschko in Oxford for one year,
was also a good friend and Alice was appointed as the Prosser White Lecturer at the
old Royal College of Physicians while he was in Oxford. She was very nervous about
this - feeling that she had little to offer, but knowing that she was expected to be
amusing. She spoke about the history of scabies but it was not a good performance.
Tom and I tried to cheer her up at a small dinner party afterwards.
During the war she wrote papers on British anti-lewisite (BAL) and published a
few significant case histories. She was one of the first to write about hereditary
factors in venous leg disorders. She was the first British dermatologist to visit Japan
and she published a few anecdotes about this. Her photographer, Tugwell, was superb
and the black and white photos in the Oxford Textbook of Dermatology in the 1990s
were from that collection and deemed outstanding by reviewers.
Dr. Dowling’s boys
After the 2nd World War, the following appointments were made: Hugh Calvert
(Reading), Darrell Wilkinson (Aylesbury, High Wycombe and Amersham), Ken
Crowe (Swindon), and Bob Bowers (Cheltenham). In “the North” (everywhere North
of Oxford is Black Country until one arrives in Edinburgh!) Dickie Coles and Ivor
Hodgson Jones were based at Northampton.
Renwick Vickers
Renwick Vickers came to Oxford in 1957. He had learned his dermatology from
Rupert Hallam and was appointed as a very young man to assist him in Sheffield. The
war saw him in the Royal Navy as a dermatologist and after the war he returned to a
busy practice in Sheffield. His philosophy, partly learned from his friend Ingram, was
that dermatologists should first and foremost be physicians and must therefore have
the “Membership”. This view, supported by Charles Calnan, was a major influence on
British dermatology. He also gave a Prosser White lecture, focusing on clinical
dermatology and general medicine. The lecture closed with a reference to myself as a
student opting for dermatology because I saw it as the least specialized of the
specialties (Vickers 1969).
Renwick set out to gain local and then national respect for the subject of
dermatology. He gave time to the Royal College and became the Chairman of
Oxford’s Medicine Board. One of the best gifts I gave him was the opportunity to
follow me at the Royal Postgraduate Medical School when he wanted a retirement
job. Chris Booth was delighted to have such a distinguished “physician” taking part in
the well-known grand rounds. In Oxford, Renwick made special friends with Paul
Beeson, the American Nuffield Professor. Although keen to gain respect for
dermatology world-wide, he published little and had one tour to Australia, but only
after he had retired.
Other dermatologists
As a registrar, and then as a senior registrar, after Renwick had become wellestablished, I had the job of helping to set up regular monthly meetings, which were
attended by regional dermatologists, by American dermatologists from the Upper
Heyford Air Base, and by occasional visitors to the Department of Biochemistry, such
as Lowell Goldsmith who lived with his family in a wing of my country house. Much
earlier, as an unmarried registrar, I had shared my house with R.S. (Charles) Wells
while he worked on families with ichthyosis - at first in the Oxford region, and later
nationally. An easy lodger, he possessed a small table, which I have kept, and a
packet of Kellogg’s cornflakes, which I have not.
In the Region we had considerable expertise and initiatives. Ken Crow made a
name for himself as an advisor on dioxin and the Sevesco disaster. Bob Bowers had
an interest in haemangiomas. Dickie Coles was starting his Group Therapy and used
hypnotism for warts. Hugh Calvert was the most widely read, and he had an interest
in French texts. Darrell Wilkinson, whose clinics I used to attend while I was a
registrar at Stoke Mandeville prior to joining Renwick, had multiple interests and was
the region’s most prolific writer. He started me on the topic of leg ulcers. About twice
a year we would have a Saturday morning visit to one of the outlying consultants.
Records of these meetings are on file.
Patient Associations
Renwick Vickers and I took up Dickie Coles’ interests and we became the first
department to set up a local branch of the Psoriasis Association. We were also much
involved with the founders of the Eczema Society. Renwick had a fatherly regard for
his patients and after a formal ward round would do his own round, socializing with
them. It was natural for Oxford to become the home of the first Camouflage Clinic
run by Mrs. Savage, and later formally to set up a consultancy with the Red Cross.
Letters to consultants about the role of patient associations and the need for
camouflage make diverse reading (I have them on file). Renwick was welcoming to
the representatives of the pharmaceutical industry, and so we had much support from
Dennis Love of Stiefel and from Seton products - with whom we began to create a
new pattern of leg ulcer service based on bandaging. The department had an ex navy
male nurse, Mr. Eric Haines (later M.BE.), in charge of VD, leg ulcers and inpatients.
On the academic side
While I was Renwick’s Senior Registrar, the BAD scheduled him to host the
Annual Meeting with the French as our guests. Ken Crow was the local secretary but
inclined to depression and to be obsessive compulsive. The role of secretary was too
much for him and much fell on my shoulders. It was a chance that Renwick gave me
to put on a demonstration of capillary microscopy and also to have a plenary session
on the growth of cutaneous blood vessels. (Ryan 1967) I mention this because, while
Renwick was single-handedly attempting to give Oxford dermatology its medical
flavour, he was conscious that Cambridge had the academic lead through the courses
on ‘Biology of the Skin’ that Arthur Rook was organizing. My efforts were regarded
as a contribution to science from the department. It resulted in my being promoted to
St. John’s Hospital for Diseases of the Skin, the Mecca of Dermatology, under the
leadership of Charles Calnan, where I was given my own vascular laboratory for five
years.
Renwick’s first Senior Registrar in Oxford was Tony Cowan, who studied the
silver staining of the cutaneous nerves in psoriasis, working with the anatomist
Grahame Weddell. Grahame developed the electron microscope for studying nerve
axons in the skin and this attracted the leprosy field. During my time as registrar it
was realized that electron microscopy needed fresh material, and not material sent
from Nigeria in formalin. Renwick offered two beds for the program, and soon the
department became a centre for leprosy research. First Frank Allenby, and then
myself organized quarterly meetings for experts on leprosy. Attending these were
Robert Cochrane, Paul Brand, Stanley Brown, Michael Walters, Dick Rees, Roy
Vollum and Jamison, as well as Grahame Weddell.
While I was in London for 4 - 5 years at the Institute of Dermatology, Renwick
negotiated with the Nuffield Foundation for an extension to be built onto the in patient
department. It was named after, and opened by Robert Cochrane. Colin MacDougall
had joined Grahame Weddell from the field of leprosy and TB, and supervised
patients admitted to the unit for trials of Chlorfazamine and for rifampicin. The
subsequent history is lodged with the Wellcome History of Medicine project and in
documents held in 13 Norhams Gardens in Oxford.
Later developments
Renwick Vickers was appointed as adviser on dermatology to the government.
The Dermatology Outpatient Department moved to the new John Radcliffe Hospital
and was still separated from its inpatient, administrative and research bases at the
Slade Hospital. From time to time the Health Authority, wishing to reduce its multiple
site occupancy, threatened to close this site without appropriate planning for resiting
the department. Its location, with extensive lawns and mature trees as well as
adequate parking, was popular with patients and staff alike. Indeed as special clinics
(leg ulcer, PUVA, biopsy and minor surgery, patch testing, leprosy, camouflage)
developed, they were based at the Slade. Closure was fought with the help of patient
associations and the press. The Health Authority was displeased and Renwick was
told by one chairman that any proposal for a ‘national honour’ would be blocked.
After his retirement, a second attempt to close the department was fought by me,
helped by the Community Health Council and the Media as well as by patient
associations.
The St. John Ambulance Brigade
I had joined St John Ambulance in my days as a registrar, and progressed from
Divisional Surgeon to County Surgeon, to Commissioner, and to Commander over a
20 year period. Initially St John was nominally in charge of the Ambulance Service
but, by the time I had progressed in authority, a New Health Service authority was
created for Ambulance Services. As someone working closely with the Community, I
took part in Health Authority planning for nuclear Attack. I managed the emergency
services with the Red Cross when the Ambulance Service went on strike or when
extra services were required for pop festivals or for the sudden evacuation of armed
services and their families from Cyprus to Oxfordshire. My first job was to manage
the First Aid requirements for Churchill’s funeral in Oxford. The reason for
emphasizing all this as part of the history of dermatology in Oxford is the belief that
some of the battles fought for dermatology were won because of the strength of our
community/patient organization relationships. Being on the Community Health
Council (and Oxford’s was a powerful prototype) was unusual for a hospital
consultant, and several years later this was not permitted.
The part-time married women’s scheme
One of Oxford’s unique pioneering schemes was the ‘Part-time Married
Woman’s Scheme’ of Rosemary Rue the Regional Medical Officer. Renwick worked
with Rosemary and took full advantage of the popularity of dermatology for the
woman with a family. Consequently this was one of the first ways in which an
increase in staffing was obtained.
Renwick worked hard to get a senior registrar and later to get a second consultant.
Parallel activities were the gradually increasing demand for dermatology services and
the enlargement of the Medical School.
Leg ulcers and lymphatic drainage
On my appointment as the second consultant, there was an unwritten belief that I
would lead the academic development of the department. I had become an
international authority on the blood supply of the skin and maintained that role mostly
by reading the non-dermatology literature in that field and taking the Chair of
Microcirculation Societies, culminating in the presidency of a World Congress on
Microcirculation. I was the first to use the full facilities of the new academic centre
of the John Radcliffe. The management of leg ulcers became central to the
development of the department of dermatology, which had otherwise concentrated on
leprosy.
Leg ulceration in Oxford was managed by divers national experts. Mr. Tibbs
(surgeon) and Dr. Scott (physiotherapist), the geriatricians, the rheumatologists, and
the family practitioners, had a big role to play. In discussions with the Area Health
Authorities Medical Officer we were able to put a case for being a Gate Keeper. I had
brought George Cherry into the department and eventually persuaded Alec Gatherer
to employ him to manage our leg ulcer program. It was a time when many new
dressings were being generated and the industry needed clinical trials. These had to be
backed by animal trials. George used pigs, and we set up a cell culture laboratory to
do basic science work using overseas graduates. Importantly the hands-on
management needed skilled nurses. Expertise gradually enlarged and the research
potential of nurses became evident. I was asked by nurses working in several fields to
help to set up a Nursing Research Group, and facilitate their development through the
university. I got myself onto the Regional Authority’s Nursing Committee. I was also
appointed to the Board of the new Institute of Nursing and from this was able to
appoint more senior nurses to the Department of Dermatology.
As it moved from the study of blood supply into the study of lymphatic drainage
and of wound healing, the department became the centre for a number of new
initiatives. Thus with Peter Mortimer as Senior Registrar we worked with Bob
Twycross in palliative care to meet the cry of help from the Post-mastectomy Society
for the better management of lymphoedema. We therefore set up the British
Lymphology Interest Group and gradually took on leadership in this field - locally,
nationally, and internationally.
Huge developments in the leg ulcer field were led by George Cherry. He
established an annual course on wound healing for young European investigators, and
then we joined in and led the establishment of the European Tissue Repair Society,
which collaborated with the American Wound Healing Society. Dermatologists
played a leading role in both. These contacts enhanced the reputation of the
department, and others in the department creating global leadership too. (See below)
The profile of nurses
George Cherry continued to develop the nursing profile in wound healing up to an
international level. I tried, over a period of seven years, to get Oxford University to
approve the nurse’s intellectual development - partly to keep them in Oxford and in
nursing. I worked with Basil Shepstone and several senior nurses but, partly because
their language was educational and sociological rather than science-based, Oxford
University refused to allow them entry. They therefore quickly went to Oxford
Brookes, where they have flourished. I had attempted to get myself an ‘ad hominem’
chair when the University of Oxford began to open up this possibility to N.H.S.
consultants. The very strong Department of Medicine took the first of these. Oxford
Brookes gave me an ‘ad hominem’ title of Professor; but I was called to the office of
the Regius Professor, Henry Harris, and told not to use it! After a couple of years the
University of Oxford appointed me as Professor, and this was an important step
forward for the academic reputation of the department.
With the nurses in the department, we set up a committee to take their role
forward. When I was President of the British Association of Dermatology, we had a
combined meeting with the Canadian Association of Dermatology, and I seized the
chance to have a plenary session on Community Nursing. By this time I had become
Secretary of the International Foundation of Dermatology, the aim of which was to
take skin care into the developing world. This organization focused on the training of
allied health professionals. Through these activities we set up, in our department of
dermatology, the British Skin Care Nursing Group and the International Skin Care
Nursing Group. The former soon became affiliated to the British Association of
Dermatology and is now its largest branch. The latter is still small but affiliated to the
World Council of Nursing.
George Cherry then brought another new organization to the department - the
European Union Advisory Panel on Pressure Ulcers. These wound-healing initiatives
spread the influence of the department world-wide.
Other staff appointments
When Renwick Vickers retired, Rodney Dawber was persuaded to join us from
his successful post in Stoke. Over the next twenty years he established leadership in
three fields: cryosurgery, hair and nails. Not only was he a national consultant in
these fields, but his many publications and lectures spread his influence world wide.
He was especially successful at exciting the younger members to take up research and
bringing overseas trainees into the department.
When we were able to add a third consultant, Fenella Wojnarowska, further
national and international kudos followed, especially in the fields of bullous and
vulval diseases. Sheila Powell’s appointment to manage the contact dermatitis field
added one more person who was to play a national role.
A new building
All these activities provided the background to persuading a number of donors to
fund a new building. This was helped by the political background of the ‘Thatcher
era’, which encouraged such initiatives. Over a decade, several excellent new
buildings in the Oxford Region have benefited dermatology. Half the money came
from the Dunhill Medical Trust, which had funded my time at the Institute of
Dermatology in London 20 years earlier. A substantial grant also came from the
wound healing industry. A very fine new building was built in time for a
“Celebration of Dermatology” at the 1992 British Association of Dermatology
Meeting in Oxford.
Recent developments
This history goes up to the year 2000. New consultants are expanding our services
in dermatological surgery and there is a fine extension to the building for this. Susan
Burge has forged strong links with the medical school and the Royal College of
Physicians. Several links with leading university laboratories have led to new
discoveries.
Oxford has trained many consultants but Darrell Wilkinson, and later his son
John, have showed huge capacity for enhancement. Not only did Darrell establish the
world’s most successful dermatology textbook (his Cambridge colleague Arthur Rook
being his leading partner) but he set up links with Australia for training registrars, and
a Korean registrar is currently a potential president of dermatology’s leading
congress). Darrell developed contact dermatitis clinics before they existed in Oxford
and generously, in consultation with myself, set up the channels for my own
international reputation and the International Foundation of Dermatology. Unlike the
case in Oxford, he won a battle to keep dermatology beds by agreeing to unisex
wards. Later he negotiated a fine building for his department in Amersham.
Our region continues to demonstrate that dermatologists are friendly and
cooperative. Its regional meetings are well attended and carry out formal
administrative and advisory functions.