The account that follows was based on a contribution to the collection of published recollections by surviving members of the Leeds Medical School of the year 1956 for our annual reunion in May 2015. We all trained as students at the Leeds General Infirmary (photo).
What was the National Health Service like in those distant days? Well, prior to the start of the National Health Service (NHS) in 1948 there were many family doctors and few consultants. The latter were appointed to the hospitals as so-called “Honoraries” receiving little or no remuneration from that source for their advice. However, such honorary appointments were much sought after and obtained by the relatively few very distinguished doctors, usually outstanding students of their training years, who aspired to be medical and surgical specialists. The opportunities were few in number when compared to the numerous consultant appointments in to-day’s hospital service.
Before the NHS most of a consultant’s income came from private practice. Everyone seems to be a ‘consultant’ these days (those who are not Professors!!) and perhaps the term “specialist” would more accurately describe their role, but in the 1950s these people really were ‘consultants’ in the true sense of the word. They were few in number and usually they had been the ‘academic stars’ of their years as medical students. They were literally “consulted” by the hospital resident hospital doctors, the Resident Medical Officer and Resident Surgical Officer (the RMO and RSO) the registrars and by the family doctors on difficult or unusual problems. As they were constantly seeing difficult and demanding problems they gained a vast amount of experience.
In contrast to the surgeons, the physicians were more advisors than ‘doers’ in the majority of cases. The most respected consultants were the surgeons who did operations and cured people. Although, in fairness to consultant physicians, when my grandmother Fanny Walker was unable to breath and dying at home with a pleural effusion (collection of infected pus in the chest following pneumonia), a consultant physician, the Professor of Medicine no less, came to her house, inserted a large needle into her chest and drained her pleural effusion – after which she recovered and lived for many years! This was in the Thirties before penicillin.
In some specialties, such as general surgery or cardiology, the consultants were very wealthy. In other specialties, where there was less private practice, the consultants were less well off. For example, there were few consultant paediatricians before 1948, after which the NHS provided consultant paediatricians with a steady if modest income.
The quite staggering progress of medicine and surgery over the past almost 65 years, since we qualified as doctors in 1956, prompted me to try and document the practical implications of many of these advances from the point of view of one who has been intimately involved as a practising paediatrician throughout this period
Medicine was “a way of life rather than a job”
In the Fifties both as a junior doctor and later as a young consultant, it seemed to me that success was more likely if one became totally involved in one’s job and accepted that was to be one’s way of life. Medicine was a very interesting and rewarding career – providing, of course, one had a supportive and understanding wife and family. As one senior medical writer observed it was “a way of life rather than a job”.
Apart from annual holidays or at times of personal illness, a consultant would always be available to visit patients on a domiciliary visit or give advice on the telephone when requested by the general practitioner. There was no such thing as “off-duty” for consultants. Also general practitioners provided their own 24 hour cover or emergency call service.
Of necessity, this degree of commitment involved the doctor’s whole family to a degree that I now wonder whether it was really fair to them. The family’s understanding and tolerance were essential. However, many doctors at that time had the consolation that medicine is vastly more interesting than most other occupations or hobbies and certainly more emotionally rewarding. We considered ourselves fortunate to have such an interesting and emotionally rewarding job even if the financial rewards were modest! It must be said that the patients and parents were more considerate and grateful in those days and the whole system was far less litigious.
There were fewer “sub-specialists”
Conditions that the consultant saw frequently were as a rule well-treated if indeed there was any treatment. However, although treatment of many conditions was limited by today’s standards, standards of history taking, physical examination of patients and note-keeping were much higher than is the case today; but there was less to do for the patients and fewer complicated diagnostic and treatment procedures. Rarer conditions, which would now be treated by a sub-specialist such as leukaemia, rheumatoid arthritis, cystic fibrosis, renal failure to mention only a few, with hindsight did not always receive even the best treatment available at the time. Subsequent steady improvement in outlook for many of these conditions confirms the value of specialist care for many of these disorders.
Sub-specialists usually developed a special skill
For example paediatricians have tended to flourish as specialists if they develop or acquire the special skills to perform a particular test or investigation – their particular “trick” so to speak useful to colleagues! Other paediatric colleagues would avail themselves of this skill and refer patients for the particular test – for example bronchoscopy, jejunal biopsy, liver biopsy, upper gastrointestinal endoscopy and colonoscopy. The paediatric cardiologists led the way with their specialist investigations of cardiac catheterisation and cardiac angiography. Sometimes the patient was referred just for the test, at other times the referring consultant would hand over the care of the patient to the consultant with the particular interest. Hence he/she would also gain more experience in management of the disease in question.
“Intelligence is learning from experience”
To digress for a moment, the only justification for recording one’s previous experience is the hope that some of the lessons learned over the years may help others to avoid making the same mistakes. The more I considered the changes in management of cystic fibrosis, the more it became apparent that this really has been a quite astonishing 40 years of progress, not only for people with cystic fibrosis but for medicine generally. Many doctors say that of their professional lifetime I hear you say – Sorry, but this really has been an astonishing period of progress by any standards in any age. So rapid has been the progress in developments of investigations and treatments that it is no surprise that the NHS facilities and funding have failed to keep pace in so many areas.
I have endeavoured to document the history of cystic fibrosis in considerable detail elsewhere (www.cysticfibrosis.online/history).
Perhaps unwisely, in this present section I have attempted to produce an account, which will be intelligible to both medical professionals and lay readers. The habit of writing documents useful for both doctors, professionals and patients has been the practice in our Regional Paediatric CF Unit at St James’s in Leeds for many years. Rarely did parents or patients complain of being given too much information. Patients and relatives usually complain of a lack of information.
Some of the major advances over the last 40 years
So what have been the major advances over the last 40 years as seen by a general paediatrician? Well, if we look back to 1956, when we qualified as doctors, medical practice and knowledge were very different from the Thirties when incidentally many of our medical teachers in the Fifties were trained; they were also very different from today.
Medicine in the Fifties
Consider the situation in 1956. The NHS was less than 10 years old, coming into existence in 1948 under the guidance of the Minister for Health in the Attlee Government, Aneurin Bevan (photo). Although now salaried, most of the senior consultants still regarded themselves as “Honoraries” who earned most of their income from private practice and some almost considered that they did the hospital a favour by seeing some of the more difficult patients there! Many consultants and family doctors had been reluctant to join the NHS at its inception in 1948. Bevan, when asked how he obtained their agreement eventually, said, “I stuffed their mouths with gold!”
Even in 1956 when I qualified, some (I stress not all) of the Leeds General Infirmary consultants would spend much of their time attending to their private patients in their consulting rooms in Park Square or operating in nursing homes in the nearby Clarendon Road, a short distance from the hospital. A few would pay only short visits to the hospital to see all was well with the NHS patients, who were mostly looked after by the senior resident doctors – the Resident Medical Officer (RMO) and the Resident Surgical Officer (RSO) and the various house officers. However, a number of specialities, including paediatrics, did flourish as a direct result of the NHS and the two paediatricians for whom I worked (Professor Stuart Craig and Dr Eric Allibone) were very busy with NHS work. As mentioned above, there were specialities where there was relatively little private practice such as paediatrics, geriatrics, mental subnormality and psychiatry.
In 1956 in Leeds, consultants were few and far between. For example, in a major northern city with a population of half a million, their were only 3 consultant paediatricians and two were employed by Leeds University , Professor Stuart Craig, his Senior Lecturer, Dr. Michael Buchanan and the one National Health Service consultant, Dr. Eric Allibone. They all worked at the three main hospitals, the major paediatric unit being at the Leeds General Infirmary, the others being at St James’s and Seacroft. Also they shared the care of approximately 10,000 newborns born in city’s three maternity units at Hyde Terrace, St James’s and St Mary’s, Bramley. Today there are at least 20 consultant paediatricians in the city in addition to a vast increase in non-consultant medical staff!
Junior doctors in the Fifties
In the 1950’s we junior resident hospital doctors worked longer hours – hours which are hard for young the doctors of today to comprehend. However, expectations were different. The new resident doctor in 1956 expected to be totally committed. He/she lived permanently in the hospital as an animal would live in a zoo; work (and plenty of play it must be admitted!) would occur there with little thought of the world outside.
In 1956, when starting my second house job with Mr Geoffrey Wooler and Mr John Alwyn, the thoracic surgical firm at the LGI, the Registrar of the firm at the time (John Shoesmith, a very pleasant man and skilful surgeon who subsequently became a leading consultant at the Leeds General Infirmary) asked me when I would prefer my half-day. I opted for Tuesdays. “No, No” he said kindly, “I mean, which half day in the 6 months? You didn’t expect one every week did you?” Most of the junior doctors did have a half day each week but returned by midnight, perhaps not having started their half day until late in the afternoon. But as the junior doctors were on duty all the time, one mostly looked after one’s own patients usually on one or at the most two wards. Nowadays though the off duty is more generous, when the junior doctors are on duty they seem to work all the time, covering numerous wards full of patients of whom they have little or no previous knowledge.
But why did the junior doctors of 1956 not revolt at the terrible conditions? The answer is clear – most of us really enjoyed our work, which we were very grateful to have almost as reward for completing 6 years hard training. Most regarded the work as a valuable sought-after learning experience, and this phase would not last indefinitely. The pay was terrible even for those days – £450 for the first year as I recall although accommodation and food were provided. Indeed, in some of the major London teaching hospitals there was no pay at all – the doctors did the job for the experience of working with leading consultants. Also virtually all the house doctors at the LGI in 1956 were single; it was very unusual for junior doctors to be married. I recall only two who were married in 1956 and they were both ex-army service men. Most of the resident doctors’ working and social lives centred totally on the hospital, a hectic life of work all day and then play, if not all night, often until far too late!
The junior doctors’ behaviour “after hours” would now be regarded as anti-social, irresponsible and unacceptable but in those days it was considered the norm for these overworked disciples of Aesculapius! Mess parties were held frequently and nurses were the usual guests, and heavy drinking was considered normal, however, alcohol and tobacco were the only drugs used in those days. There is no doubt that such behaviour acted as a release from the quite severe and unaccustomed stresses encountered during the day for many of these young doctors.
But, without appearing too pious, work was our ‘raison d’être’ and did always come first – even if some mornings we were a little under the weather! Overtime was never considered as it was accepted that we were on duty all the time; furthermore, we were grateful and yes, admit it, proud to have a house officer job in our teaching hospital.
However, although the work of we junior doctors was hard, sometimes cruelly so, it would improve with time and we dreamed of the day when we too would be consultants or respected general practitioners. We knew this strange existence would not go on forever.
Medicine was less complicated
Undoubtedly medicine in those days was less complicated. There were fewer time-consuming complex investigations and treatment procedures. Certainly we when I was the Paediatric House Physician in 1956 we seemed to see more children in the casualty department each day – I remember in one day seeing 30 children with acute medical problems in the casualty department in addition to my work on the ward. Although I could consult the paediatric registrar, it was often my decision as to whether the child was admitted or sent home with treatment – some of the latter were brought back the next morning to be checked over.
Many of the wards were still typical off the old LGI children’s ward. There were long ward rounds with the paediatric consultants almost every day and often on Sundays with Professor Craig, but the turnover of patients was slow. Some children would be in the ward for many weeks e.g. those with tuberculosis, rheumatic fever, acute nephritis, Perthe’s disease, cystic fibrosis and coeliac disease. Over the next few years many of these conditions gradually disappeared or succumbed to effective treatment. That old paediatric favourite the infant with “failure to thrive” was a relatively frequent reason for admission. Although the NSPCC had been formed in the late nineteenth century, the relatively frequent occurrence of serious occurrence of child abuse recognised today had not been appreciated in the Fifties. Undoubtedly some of the children with unexplained failure to thrive we saw then certainly fell into that category. One particular condition, not recognised at the time as due to trauma, was subdural haematoma in the infant. In such infants we used to aspirate blood from the subdural space regularly through the lateral angles of the anterior fontanel until the collection was cleared but surprisingly the condition was not linked with parentally inflicted trauma.
More on consultants in the Fifties
Many of the consultants in 1956 were very demanding of their junior staff. Believe me, the bombastic behaviour of Sir Lancelot Spratt of Doctor in the House fame, was no exaggeration as far as some were concerned. “Proper” consultants in those days were expected to be arrogant, rich and much in demand by general practitioners for consultations. It was good to be busy and in demand for the successful consultant “needed to be needed”. Ideally they should wear a morning suit with a black jacket and striped trousers and have a fresh rose in their buttonhole. In Leeds they would arrive for work at the hospital in a Rolls Royce or failing this a Bentley or Daimler, where their team would be waiting in the front hall of the Leeds General Infirmary to greet them. Obviously, not all consultants came up to these demanding standards but surprisingly many did. Sir Lancelot Spratt in Doctor in the House (1955) was fairly typical of many!
The consultants, particularly Professor Craig, expected us to know every detail of each child in the ward, including the results of any investigations, without referring to the records. How different from today when the consultant is the most likely person to know the patient’s details – the resident doctor of the previous day who admitted the child having gone off duty!
Other features of the Fifties
Leukaemia, even acute lymphatic leukaemia in children was usually treated by general paediatricians such as myself in my early days as a consultant in the late Sixties – we did not have a paedaitric oncologist until the early Seventies when Dr Cliff Bailey was appointed. Sadly leukaemia was invariably fatal within a few months – today the majority are cured. The reason the majority of children with leukaemia are cured nowadays is because they are treated by specialist paediatric oncologists and their teams often using the same or similar drugs that failed in our hands.
Older people in the 1950’s accepted that a proportion of infants and children would not survive. Those from large families, such as my own mother’s, would have accepted that only six of her seven siblings had survived. Both the infant death rate (deaths per 1000 infants in the first year) and the infant mortality rate (death per 1000 births) were much higher than they are today. In particular, the death rate of small premature infants was very high.
Newborn care in the Fifties
In the 1950s the treatment of premature infants after birth was relatively ineffective and they were often starved of fluid and nourishment to avoid the serious and often fatal complication of inhalation of fluid into the lungs. Inhalation was very serious as tracheal intubation and ventilation (inserting a small tube directly into the infant’s windpipe) was not generally available for very small babies until the mid to early 1960s. In fact, in the 1960’s long term ventilation of premature infant’s lungs, now a routine neonatal procedure was regarded as impossible due to immaturity of their lung tissue. Although endotracheal intubation of the newborn infant who was asphyxiated and slow to breath had become routine during the 1960’s, even then older methods of resuscitation such as rocking to encourage diaphragmatic movement were still appearing in paediatric respected paediatric textbooks.
A classic paper on neonatal resuscitation by Dr Osmund Reynolds from St Thomas’s, detailing the equipment required and methods to be employed for neonatal resuscitation appeared in 1960 and caused a great deal of interest. Following this publication, intubation of newborn infants, previously considered impossible, gradually became routine in most neonatal units. This was quite a stressful time for we paediatric staff who until that time had been observers and advisers – now we had to be ‘doers’ and no mistakes! The paediatrician became a recognised part of the obstetric team, albeit regarded with some suspicion by the more senior obstetric consultants. “Ask our friend in the RAMC tie (yours truly!) if the infant’s all right Sister!” said one obstetric Knight when I was attending “his” Caesarean section to resuscitate the infant.
Although effective resuscitation of newborns became routine practice in the early 1960s, it was well into the 1970’s before more prolonged ventilation became a successful procedure and then only after a very traumatic learning curve for all concerned. In the late 1960’s and early 70’s many of the ventilated premature infants died.
Thus, from the early 1970’s the way was clear for the impressive advances in neonatal care and in particular the care and survival of small premature infants. Undoubtedly the management of the newborn, in particular the premature infants, has been one of the most impressive advances in the last 30 years. Dr Osmond Reynolds was one of the leaders in developing neonatal services and establishing the speciality of neonatology – now a highly technical specialised branch of paediatrics quite beyond the scope of the general paediatrician.
It is worth emphasising again that sub-specialisation has been the major factor in improving care and survival of children.
Undoubtedly sub-specialisation has been a major factor responsible for the improvement in treatment and outlook in so many areas of children’s medicine; but sub-specialisation was opposed by many of the older paediatricians and the introduction of sub/super specialists has not been without problems. For example, when the British Paediatric Association’s (BPA) Working Party on Cystic Fibrosis suggested in the early 1980s that all children with CF should have some contact with a Specialist CF centre, their advice was rejected by the Council of the BPA, largely on the grounds that it would “undermine the role of the general paediatrician”. Yet subsequently the care developed at Specialist CF Centres has been the main reason for the improved treatment resulting in better survival of children with cystic fibrosis in the UK. In the Sixties few children with CF reached teenage and very rarely adulthood – now there are more adults with CF than children.
Progress in the treatment of many children’s disorders over the past 30 years has been, quite frankly, awesome. Virtually all progress has been made at specialised units and I will deal with some of these advances in more detail in future articles.
I qualified as a doctor in 1956 and was appointed Paediatric House Physician for 6 months at the Leeds General Infirmary with Professor Craig and Dr Allibone and for the next 6 months as House Surgeon in Thoracic Surgery with Mr Geoffrey Wooler and Mr John Alwyn.
Geoffrey Wooler was an outstanding thoracic surgeon and a pioneer in the use of the Melrose Heart Lung machine. He writes about his very varied and outstanding career in an autobiography “Pig in a Suitcase” It’s a very good read.
At the end of the six months with Geoffrey Wooler, I harboured thoughts about going into surgery. I discussed with Mr Wooler and he said he would ask an excellent general surgeon in York, Mr. Jock Hall to have me as his house surgeon for six months to gain some experience in general surgery. I was duly interviewed by Mr Hall and offered the job but unfortunately could not gain another 6 months exemption from National Service in the RAMC.
So after a year and two house jobs at the LGI I was called up into the Royal Army Medical Corps and served for the next 2 years in Malta as a families’ medical officer. I enjoyed all these appointments, even the army, but realise it was a very different world in those days. I will deal with further aspects of life and work as a consultant paediatrician in subsequent sections.