Horace Joules graduated in 1925 from Middlesex Hospital, proceeding to his London MD with gold medal in 1928. After an appointment at Selly Oak Hospital in 1929, he came to the Central Middlesex in 1935 and for many years was its medical director.
The Times described him as one of the stormy petrels of the early days of the National Health Service. ‘His pen and his voice, both of which he could use with facility and abrasiveness all too often did him and his cause a disservice.’ Those who knew him better and worked with him were more generous in their appreciation. There was no doubt that he was a fighter. If he saw anything he considered wrong, either in the abuse of power or of vested interests he considered it a personal challenge. Frustration often made him angry but never led to despair. But fierce battle in committee never led to personal antagonism or rancour; many who disagreed with him publicly came to appreciate his warmth and friendship in private.
Horace was in every way a big man. By 1948 he had helped to raise the Central to a dominant place among the non-teaching hospitals of the country. Many will remember him striding down the main corridor at 9.00 a.m., pausing for a friendly word with painter or porter, houseman or cleaner. He took a personal interest in everyone who worked at the hospital. In his 1955 medical director’s report he wrote ‘Once again the staff, medical, nursing and lay have responded excellently despite inadequate salaries in many grades. Our thanks are due to domestic workers, porters, catering staff and other ancillary workers who do so much of the heavier work of the hospital’.
He will best be remembered as a physician with a passion for preventive medicine resulting from experience with his own patients: young women with tuberculosis, older men with chronic bronchitis or lung cancer, or miners crippled with dust disease. He was indignant when he saw his patients suffering needlessly from their environment or their own habits.
At the end of the war tuberculosis was a serious problem and 11,000 patients were awaiting admission to hospital. The high incidence of tuberculosis in nurses caused many general hospitals to refuse admission to these patients. In 1945 Joules opened two wards for tuberculosis at the Central, and took the greatest care to protect nurses from infection. As a result hardly a single nurse became infected, and their Mantoux conversion rate was much lower than nurses working in the old LCC or London teaching hospitals.
He had always been concerned about the tragedy of chronic bronchitis. The black smog of December 1952, when over 4,000 additional deaths occurred in London, resulted in his outspoken attacks on government and on medical inertia. As a member of the Central Health Services Council, he urged political action to control air pollution. The Beaver Committee was set up and later the Clean Air Act came into being. As a result the air of our major cities is much cleaner, and London smogs no longer occur. To the BMJ he wrote, ‘I believe we shall not progress in the prevention of this and other chest diseases until we regard a persistent cough as seriously as persistent vomiting. The air we breathe is as important as the water we drink. It must be uninfected and unpolluted.’
He was particularly concerned with dust disease in miners, especially those who developed chronic bronchitis with no radiological evidence of pneumoconiosis. As a result they receive no compensation, an injustice which he fought hard to put right.
Following Doll and Hill’s work in 1952 he campaigned strongly against cigarette smoking. He had been a heavy smoker for 30 years but managed to break his addiction. In the Lancet he wrote, ‘Cancer of the lung continues to cause more and more deaths. It is in the approach to this grave national problem that the Ministry of Health has manifested its weakest aspect. We are witnessing an epidemic form of cancer which has been unknown in human society before. Unless trends are modified a million people in England and Wales will die of this cancer before the end of the century.’ His prediction was more than justified, and at present rates the one million deaths he forecast will be reached well before the year 2000. He wrote, ‘The Royal College of Physicians can re-enact history and help to revivify itself by giving advice comparable to that given in respect of alcohol 200 years ago.’ Fortunately the College did take his advice, and six years later published its historical report on Smoking and Health.
Perhaps he will best be remembered for his Friday afternoon teaching rounds. He towered above all others in a characteristic pose, wagging his finger for emphasis. These occasions were immensely popular and 40 or 50 students would crowd round the beds. They were impressed by his gentleness, kindness to patients, his diagnostic skill, his fund of knowledge and his practical common sense. He thoroughly enjoyed the cut and thrust of teaching, and the students responded with fascination and delight.
Since he was always interested in the social conditions of his patients, his teaching did not end in the wards. Once the round took place in the old Acton Power Station. After an hour at the furnaces, toasted in front and frozen from the wintery blast behind, and with soot dripping from their eyelashes, the students knew more about the causes of chronic bronchitis than they could ever have found out from a lecture.
In private life he was a keen gardener and took much interest in farming. He often enjoyed a few days on the Essex marshes bird watching, accompanied by a volume of John Clare, his favourite poet and natural philosopher. In 1962 the illness which had first shown itself during the war returned and forced an early retirement. Perhaps he had to pay for the constructive years and dynamic activity which had done so much for the Central, the profession and the Health Service. When manic depression was at last controlled he lived quietly at home in Colchester, cared for by his wife Mary, who survived him with one son and a daughter.
KP Ball
[Brit.med.J., 1977, 1, 449; Lancet, 1977, 1, 317; Times, 28 Jan 1977]