Abstract
This is the fourth instalment of the autobiography of John Horder. He intended it to be read solely by family and friends. However LJPC persuaded him to serialise it for a wider readership. The autobiography as a whole is an important piece of history. It is remarkable for its humanity, perception and humility – much like the man himself.
John is a founding father of modern general practice. He was doing his medical finals when the NHS was founded in 1948 and has been an active advocate of whole person, family and communityoriented general practice ever since. He became active in the College of General Practitioners shortly after its formation in 1952 and before it gained its Royal Charter in 1967. He was one of the two founders of the Leeuwenhorst European Study Group that defined the job description of a general practitioner in 1974. He was President of the RCGP between 1979 and 1982. He assisted the setting up of general practice educational bodies in several Western European countries, especially Yugoslavia and Portugal. He has been a tireless supporter of inter-disciplinary learning and founded the Centre for the Advancement of Inter-professional Education (CAIPE) in 1987. He lives in Primrose Hill with his wife Elizabeth June, who was also his partner in general practice.
Abridged by Layla Stock (Ealing PCT)
The London Hospital Medical School
We left Oxford for London in the Autumn of 1945. The war with Germany had ended in April 1945. My wife passed her final examination in July. We had to find a new house and I had to choose a new medical school for the clinical half of my training.
There was no thought of returning to Ealing as we wanted to be nearer to the centre of London. An estate agent in Camden Town directed us towards Chalcot Crescent, where we were amazed to find a green hill just beyond the end of the road. No 2, the house closest to Primrose Hill Park, cost £2 000. To meet this large sum we needed a mortgage.
I chose the London Hospital Medical School in Whitechapel. My interview with the Dean, Dr Archibald Clark Kennedy, was a foregone conclusion. Students from Oxford or Cambridge were seldom turned down at any of the London teaching hospitals. I worked there for the next five and a half years.
Unlike most of my fellow-students, I remained ill-at-ease in the world of medicine – not fully committed. I started the London Hospital Music Society. The central element in this was a choir which gave an annual concert in the large medical school library. I called on the Matron – then a most important figure – to ask permission to invite nurses to join in rehearsals. This proved to be a radical request, needing much consideration. The reply was eventually: ‘Yes, but my Assistant Matron will always accompany the nurses who join’.
When the Music Society was first proposed, one of the consultant surgeons was heard to say that it would last one year. Fifty seven years later it is still flourishing.
As students we chose (or were encouraged) to see the London Hospital as an island of culture and charity in a desolate part of the city – a place to which most of us travelled daily and seldom remained at night. Some of our most senior role models turned up twice a week in chauffeur driven cars, returning to Harley Street, the real centre of their working lives. This was, after all, three years before the start of the National Health Service. We were not taught to respect those who were providing medical care in the ‘East End’ if they had no connection to the hospital. This applied particularly to the surrounding general practitioners, with a handful of exceptions. The hospital included the largest outpatient department in London and this was judged to be a better alternative for patients than what were believed to be inadequate services all around us.
One of the first consultants for whom I developed high respect was the neurologist, George Riddoch. He exacted demanding standards from all who worked under him, including students. When asked by a chief assistant who had already worked with him for two years to provide a recommendation for a consultant appointment elsewhere, he said: ‘No, Dr X., I do not think I have known you long enough’. An obsessive worker, he demanded the same high standards of himself, and this may have played a part in the fact that he was tortured by a duodenal ulcer for many years. For this he decided, not long after the time when I worked on his ‘firm’, to undergo major surgery. This was carried out by two colleagues, both famous surgeons, but he died of internal haemorrhage within days of operation. David Razzak and I were the only two students attached to his firm, instead of the usual eight, so throughout our three months we always had at least 15 patients each to look after – a learning experience unknown in quantity, duration or personal relationship by students today.
One notable character at that time was Dr Donald Hunter, a flamboyant Australian, whose lectures on anaemia included the emptying of a bucket full of iron tablets by scattering them over the whole audience (to emphasise the need for adequate dosage). He was an expert on industrial diseases. Another notable character was Sir James Walton, surgeon to the royal family, famous not only for his skill, but also for refusing to carry out any operations for private patients without prior payment in gold coin.
Ward sisters were important people. Each worked with only one or two of the consultants whose patients alone occupied their wards (it is no longer like that today). They varied greatly in age, but all were respected and obeyed, even by medical students. Some sisters were spinsters who had devoted themselves to this work for many years. Some were still candidates for marriage to future medics. They wore fine uniforms and elaborate lace head-dresses.
Because I had become a medical student with the ultimate intention of practicing as a psychiatrist, I looked for relevant teachers. I found at the London an exceptional tradition of great names in neurology (Hughlings Jackson, Henry Head, George Riddoch and Russell Brain). They were accustomed to regard psychiatry as part of their own fief. As an extra, students were taken by bus to Claybury Mental Hospital, in order to be entertained by Dr Woods exhibiting the most bizarre inmates that he could muster (causing us, most shamefully, to laugh at his victims). But things were just starting to change. Professor Millais Culpin had started lecturing on psychology and Dr Henry Wilson, a very reliable Quaker, had begun to set up a separate department in a hut on the roof of the outpatient department. He even had four beds to fill.
But the attitude of most teachers towards psychiatrists and their patients was still one of veiled contempt. Psychiatrists were known as trick-cyclists and their patients dismissed as functional, neurotic, hysterical or self-centred. Depressives were expected to pull themselves together. Psychiatric patients were largely neglected or passed to someone else, usually their GP, as quickly as possible. Most doctors felt fear and frustration at their own failure to understand or help, and it was easy for them to relapse into an attitude of rejection that was shared with most of the general public.
I returned to Oxford in the summer of 1948 to take the BM BCh final examination. All I remember of it is the vision of two young midwives whose heads watched me above a screen when I was examining an unusually large pregnant abdomen, adding the V sign with their hands. Whether I would have failed to recognise twins (and failed finals) without their help, I shall never know.
I spent the next 18 months living in an elongated box containing 24 identical compartments. This was the accommodation for London Hospital ‘house-men’, the lowest rank in the hierarchy of doctors. Fortunately one spent little time there except when asleep.
I had applied to work for two physicians for the next six months – Dr Russell Brain (later Sir Russell and later still Lord Brain) and Dr Richard Bomford. My first meeting with Russell Brain (often referred to as ‘God') was memorable. I was one of the first newly qualified doctors to have returned from war service or to be married and have young children. When I asked him whether I could go home for one night in a fortnight, he looked down at me through his monocle and said that he would have to discuss that with the House Governor before he could agree to it. He did so. I had my way, but one night only in a fortnight.
The years that followed were not good for my family. Today young doctors, married or unmarried, no longer tolerate such experience. But the continuity of care experienced by patients and the pattern of subsequent medical behaviour established by this beginning were extremely important, whether we later worked inside or outside hospitals.
After six months with this ‘firm’, I changed to a general surgical firm. Here were now a few junior doctors and students who had had war experience and were therefore older. They made this six months particularly enjoyable.
For my third six months, I chose neurosurgery, always having in mind a future career in psychiatry. The neurosurgeon, Douglas Northfield, had started his career as a dentist and, as a convert to a particularly difficult surgical role, he was devoted, serious and without any sense of humour. But to his house officer he was wonderfully supportive, even if one had to telephone him in the middle of the night. I needed support, because I made some dangerous mistakes.
I now reached the end of incarceration in Whitechapel, of very late night working and the risk of being woken from sleep any night of the week. For the following year I became a ‘junior registrar’, working mainly in out-patients and seeing people referred by their general practitioners who certainly deserved a much more experienced opinion.
During the same year I also worked in the psychiatric outpatient department at the London. Henry Wilson allowed me to see patients in what must have been a clinic for those who were not amenable to active treatment – ‘the chronics’. It was not an exciting or encouraging experience and I remember little, if any, tuition. But I admired Henry's ability to keep patients happy while revealing their very personal problems in the presence of several students. He also taught me much about watercolour painting and introduced me to the Medical Art Society, of which he was Hon. Secretary.
Meanwhile my wife was working as a part-time assistant in the nearby practice of Dr John Wigg. He needed a feminine assistant, because in his absence throughout the war what remained of his practice was looked after by Dr Dorothy Mason, the wife of a neighbouring doctor. On his return, he found that his patients were almost entirely feminine. My wife, who had started to practice in 1946, experienced two years before the beginning of the National Health Service. She discovered what it was like to charge fees to people many of whom were very poor. This created frequent and sometimes painful dilemmas about whether or not to charge at all. It created a pressure to secure at least a few richer patients who could afford higher fees to balance the losses. From all of this the National Health Service proved a welcome release in 1948.
Our eldest child started to go to the nearby primary school when he was five, because we did not believe in private schooling. But we soon had to give up this principle as he was unhappy and it seemed best to move him to an extremely traditional establishment with high standards and an elaborate system of marks and stars for the boys. He was not happy there either, although the reasons were different. He had already proved to have difficulty in reading and writing (the study of what has since been known as dyslexia had scarcely started and his problem was easily misunderstood). He was often difficult with his siblings, particularly to his younger sister, and to both of us. I found it very hard to know whether to react spontaneously or to suppress the aggression which his behaviour stirred in me. A combination of Christian and psychoanalytic ideas made me choose the latter, probably making me seem unreal. I still do not know which is the right way to react to children in this situation.
We eventually sought advice from Robert Moody, the psychiatrist who had looked after me in 1942. He recommended psychotherapy based on Freudian principles. Perhaps it was a mistake that we discussed this advice with our son's headmaster, who strongly advised against any such intervention. In retrospect, I think it is likely that his advice was wrong. We were soon to become wrong again in deciding that our son needed to get away from his family and would be happier at a boarding school.
We were now committed to private schooling. Our daughter was happy at her school in Hampstead; she made good friendships there. Our third child, another boy, was born at the London Hospital in 1950. Like his elder brother, he was a very happy small child.
This story has now reached the year 1951, when my job at the London Hospital ended. I failed to get another hospital appointment at St Stephen's Hospital, Fulham, and decided to fill the gap before applying elsewhere by accepting an invitation from John Wigg to act as a locum-tenens in his practice for two weeks. This proved to be a revelation to me.