During an education session on dermatology the other day, I found myself wondering why I find diseases of the skin so difficult to master. Determined to think positively I tried to recall some of my rare successes in dermatology diagnosis. And then I had an epiphany, a sudden insight. The only skin conditions I can really be trusted to get right nearly every time are the ones I have had myself. These are pityriasis rosea, chickenpox and bed bug bites, all of which occurred in adult life and during my career as a doctor. In each case I seemed to have learned that particular dermatology lesson because it was written on my own skin.
KAFKA'S MACHINE
This thought led, by a process of free association, to a remarkable short story by Kafka called In the Penal Colony. It's a very gruesome tale so I wouldn't advise reading it late at night or when you are feeling depressed. The setting is an unnamed island under colonial rule. A distinguished visitor has been invited to witness the unusual form of execution used in the colony. The execution machine is explained to the visitor by the officer in charge who is extremely proud to be associated with it. The machine is a kind of horror comic version of a modern computer and printer. The prisoner is strapped into the machine, his ‘sentence’ is fed in at the top and the machine then writes it on his naked body. The ‘writing’ is done with a bank of needles, which pierce his skin and gradually inscribe the message deeper and deeper into his flesh (accompanied by many decorative flourishes) until he eventually dies, which takes about 12 hours. (I did warn you.) Around the 6-hour mark, the victim's face starts to show remarkable signs of enlightenment. He seems to be listening intently. He is finally able to understand the message that is being inscribed in depth on his body. The loving way in which the officer describes the process suggests that it might even be worth while being tortured to death in this way in order to have such a great learning experience.
Critical discussions of the story tend to focus on whether Kafka is foreseeing the murderous regimes of Hitler and Stalin (or even the tortures practiced in our own day). Is the apparently liberal and humanitarian visitor too cautious in declaring his opposition to this brutal method of execution, which is in any case on the verge of obsolescence? Is Kafka saying that life is bound to involve suffering? These are all intriguing questions and one can speculate endlessly on what the sage of Prague is really on about. But I would like to draw your attention to a more specific point in the story. The ‘sentence’ that is written on the condemned man's body is not what is to be done to him but the lesson that the authorities say he needs to learn. In the case of the prisoner in the story it's ‘honour thy superiors’ and in the case of the officer, who eventually decides to feed himself to the machine, it is ‘be just’.
Now let's go back to me and my skin disorders. I had the rashes ‘written’ on my skin and as a result I learned the lesson that each rash had to teach me. Now, obviously, Kafka's version is too extreme and I certainly wouldn't get into that machine of his, however interesting the insights promised to be. But he has a point (you should excuse the expression) and it's this. Lessons written on the body are really well absorbed: and you may learn something about your soul as well.
THE CASE HISTORIES
Now I'll tell you about my rashes, starting with the most benign. One day when I was a GP trainee, I noticed some bizarre pink patches all over my body. In those days I knew even less about dermatology than I do now and I was quite scared. I showed the rash to my trainer who knew at once what it was. He looked for and found the Herald Patch; he showed me that the patches had a delicate collarette of scales and that they were arranged symmetrically following my body's skin creases. He told me it wasn't infectious, it didn't need treatment and that it would fade away in 6 weeks. Then he told me to go and look it up in the books (no internet in those days). It was, of course pityriasis rosea. It didn't hurt, it didn't itch, and I didn't need to feel guilty about having acquired it. It was even quite pretty once you got used to it. And I felt good because now that the flowery patterns of pityriasis rosea had been inscribed on my body, I owned it and could diagnose and manage it in other people too.
My second story started on a Friday afternoon back in 1972. On the previous day some smallpox virus had escaped from a lab at St Mary's Hospital in London. I am a bit vague about how it got out but I remember that it did infect a few people and there was a nationwide scare. Panic-stricken people were queuing at GPs' surgeries to get vaccinated. I know, I know, it sounds like the Middle Ages but smallpox had only recently been eliminated as a human disease and it was still greatly feared. On that Friday afternoon I vaccinated about 30 people. Then, my wife and I and our baby son drove up to Leeds to stay with my parents. About 6.30 pm my parents went out (thank heaven) to a concert. At 7 pm we put the baby to bed. At about 7.30 pm I started feeling itchy, and looking under my shirt I was horrified to see … vesicles. It was an unreal feeling. The vesicles were shallow and superficial like tiny drops of water. Commonsense told me it was chickenpox. The distribution was central rather than peripheral (hands and feet included) which would have been more typical of smallpox. Then I thought of all those anxious people I had vaccinated. Could one of them have actually had smallpox? Could I be about to die at the age of 30 from an almost extinct but horribly painful and disfiguring disease? And be the cause of a terrible epidemic? Commonsense flew out of the window and a nightmare scenario replaced it. I decided that the responsible thing to do was to ring the local public Health doctor, in those days called the Medical Officer of Health (MOH). I told him I was pretty sure it was chickenpox but in the circumstances I thought I should notify him and perhaps come and have my rash inspected? The MOH said: ‘Stay right where you are. We'll come to you’. Two of them arrived 5 minutes later in a sort of military looking ambulance clearly designed to take me away to some ghastly quarantine should it prove necessary. There were two of them, both Scots. The senior man inspected my vesicles and said: ‘I agree with your diagnosis. It's chickenpox’
I said: ‘Oh good. Now I can sleep easy in my bed tonight.’ The senior man exchanged a glance with his colleague and said: ‘So can we, laddie, so can we’. The vesicles multiplied, itched like hell, scabbed and eventually went away. I survived. But I felt as if one of the wings of the angel of death had casually brushed over my face. We never told my parents.
Now for the third and final episode, which was chronologically a few years earlier. I was a medical registrar at the Royal Free and we had just moved into a new flat. One day I started itching and discovered a number of horrid looking papules each surrounded by an angry red flare. On the same day we heard that the Apollo 13 astronauts had developed a fault in one of their fuel cells and might not be able to get back to earth. The world held its breath and everyone followed the evolving drama in the media. But I had troubles of my own. The next day there were more itchy bumps and on the third day more still. I medicated myself with antihistamines and steroid creams all to no avail. The spots continued to multiply. Sometimes there would be a respite for a few days and then I would wake up with a fresh crop. I began to panic. Soon my skin would be completely covered and I would disappear beneath a coating of fiery lumps, yellow scabs and scarlet patches. I decided I had better see a doctor. Of course I didn't have a GP so I sought out the hospital's consultant dermatologist in his clinic. He made me take all my clothes off (the way they do) and told me I was being bitten by bed bugs. But I had never seen a bug, I protested and our flat if not spotless was reasonably clean. Was there any old furniture at home? Yes there was. That's where they lived, the dermatologist told me. They came out to feed on me at night and retired discreetly to their burrows before first light. So why wasn't my wife bitten too? She probably was, came the bland reply, but she was not allergic to their saliva like I was. All this may be very well known to my readers who are yawning and going yes, of course, obviously bed bugs, any fool could tell you that. But it was all very new to me in 1970. My dermatologist advised me to phone a pest control agency. I did. They came in a van and inspected my spots with a seasoned professional scrutiny. A bad case, one of them opined, sympathetically. Then they set to work with powerful sprays all over the flat, eradicating my enemies. After that I had no new spots and the old ones gradually disappeared. Oh and the Apollo crew got back to earth safely with the help of some ingenious improvisation.
Now when I see patients with that random pattern of urticarial papules distributed in haphazard little groups, I know exactly what is wrong. I tell them they have bed bugs. Most are inclined to think I am crazy or being offensive, but I persevere. It's not usually necessary to send for pest control: a good blast all round the home with a Crawling Insect Spray from the chemist will generally do the business.
Those who follow my advice don't come back (at least not with itchy spots).
CONCLUSION
Is this the best way, the only way, for GPs to learn dermatology? Could Kafka's machine be modified? I have sketched a few plans for a non-lethal version which might be programmed to write on the body of a willing practitioner any skin disorder he wished to include in his personal development plan. Of course I shall need some help with the software but the idea is the important thing. I think I'll stop there because I've developed an annoying itch and, pulling up my shirt I can see there are some weird looking macules, or are they papules spreading across my abdomen. What the hell can it be?
- © British Journal of General Practice, 2006.
