Howard Nicholson, a chest physician who pioneered multidisciplinary care-planning, was renowned for his meticulous, logical and analytical approach, which made him an outstanding diagnostician and inspirational teacher.
He was born in Houghton-le-Spring, Sunderland, Tyne and Wear. His father, Frederick, was a mining engineer, but was killed in the First World War. Howard was brought up by his mother, Sarah Harrison, who was a teacher, and his grandmother. He came to London to study medicine at University College Hospital (UCH) in 1929, qualifying in 1935. He held training posts there, including the registrar post in radiology. It was typical of his approach that he regarded a thorough knowledge of radiology to be essential to furthering his early interest in chest medicine.
While continuing his training at the King Edward VII Sanatorium, Midhurst, he met Winsome Piercy, who was secretary to the director. Soon after they married in 1941 Howard was sent on active service. He served in the RAMC, mostly in the Middle East as the officer in charge of the medical division and physician to the No 1 Chest Surgical Team, headed by the Scottish surgeon Andrew Logan. He rose to the rank of lieutenant colonel.
During those war years he acquired an immense knowledge of medical and surgical diseases of the chest. Some insight into the work he and Andrew Logan did together can be gained from two papers in Thorax in 1948 and 1949 (‘Hydatid disease of the lung.’ Thorax. 1948 Mar;3[1]:1-14 and ‘Non-specific suppurative pneumonia.’ Thorax. 1949 Sep;4[3]:125-33). The meticulous documentation of the cases described, and the clarity of the writing, attests to the nature of their thinking. Suppurative pneumonia was also the title of the Goulstonian lecture that he was invited to give at the Royal College of Physicians in 1950, and which was subsequently published in the Lancet the same year (Lancet. 1950 Nov 18;2[6638]:549-54 and 1950 Nov 25;2[6639]:605-11).
After being demobilised, he became a registrar and then a chief assistant at the Brompton Hospital. Against huge competition, due to the large number of experienced medical ex-servicemen seeking jobs, he was appointed as a consultant physician at UCH in 1948. He was additionally appointed to the Brompton in 1952, where he continued his close collaboration with surgeons through a weekly meeting with Sir Clement Price Thomas [Munk’s Roll, Vol.VI, p.382]. At the Brompton and UCH, the chest meetings were run on what would now be described as multidisciplinary lines. The meetings were attended by thoracic surgeons and physicians. All cases presenting diagnostic difficulties, and all those who were being considered for surgery, were discussed jointly. Latterly at UCH, other disciplines, including radiologists, also attended, with physiotherapists and social workers, all this having been initiated 50 years before it became standard practice, as it is now, throughout the NHS. Andrew Logan’s obituary paints a strikingly similar picture of the way he ran medical-surgical conferences in Edinburgh, where he had been appointed in 1948 to set up the unit for thoracic and cardiac surgery. In later years Howard often spoke of his time in Egypt with Andrew Logan in a way that made clear the great influence they had over one another’s practice. Logan was one of a number of people who tried to attract Howard to a senior academic post to no avail.
Howard was also an extremely kind man. He demonstrated with superb skill how to deal with difficult colleagues, but woe betide the surgeon or other member of the surgical team who deviated from a jointly made decision without very good reason. As a student on his firm you were accepted as a member of the profession, though again the truculent were skilfully dealt with.
However, his over-riding motivation was his dedication to his patients. In some ways he was again ahead of his time, for example, his personal supervision of his team at the artificial pneumothorax clinic. This clinic was set up in the evening for the convenience of patients who were working during the day, now hailed as a recent innovation. His care and compassion did not preclude a realistic acceptance of the prognosis. This was exemplified when Eric Blair (George Orwell) was transferred to UCH in 1949; Andrew Morland [Munk’s Roll, Vol.V, p.294], the more senior consultant, is said to have professed the vague optimism that would perhaps have been generally expected at the time, but Howard said later that ‘When I first saw him, I had no serious doubt that he was dying’.
In one respect his practice differed considerably from the mores of hospital consultants’ care today in that he emphasised the importance of the longer-term care of patients. One way in which he did this was by making regular visits to both Frimley and Midhurst sanatoria on a Saturday morning, when his patients with tuberculosis were transferred there for long-term continuation of their treatment. Moreover, he invited his registrar to join him to widen their experience and to teach them the importance of continuity of patient care. Such practice would now seem just old-fashioned to some and would certainly fall foul of deanery inspectors.
He was in the forefront of evaluating the evolving treatment of tuberculosis when anti-bacterial therapy was becoming available. With Clifford Hoyle [Munk’s Roll, Vol.VII, p.279] and other colleagues he published two of the first papers detailing their pooled results of long-term combination anti-bacterial therapy for tuberculosis to reduce the relapse rate following conventional short courses. At the time using anti-bacterial drugs for prolonged periods was an untried approach, so it was vital to verify its effectiveness. However, the controlled trial was yet to become the accepted method of proving the effectiveness of a treatment, so the data were uncontrolled. The first paper was published in the Lancet in 1955 (‘Prolonged chemotherapy in pulmonary tuberculosis.’ Lancet. 1955 Dec 24;269[6904]:1310-4) and the second in 1960, but not before resolving resistance from editors to publishing further uncontrolled data: by that time the Medical Research Council was undertaking long-term controlled trials. A debate ensued as Hoyle in particular felt that it was unethical to undertake a controlled trial in this circumstance. The ethical problem was overcome by comparing different unproven drug regimens (‘Prolonged drug treatment for pulmonary tuberculosis.’ Lancet. 1960 Feb 20;1[7121]:409-12).
Howard was made an honorary fellow of University College London in 1959. He was a Murchison examiner 1965 and examined for the MRCP from 1966 to 1968.
Even after he retired Howard kept up to date with the medical literature, continuing to read the British Medical Journal every week even when he was over 100. He had an extensive library and also regularly took The Times Literary Supplement. His broad interests were doubtless in large part due to his family background: his great-grandfather was Joseph Skipsey, ‘the Pitman Poet’. The intellectual milieu at UCH in the late 1920s and early 30s must also have contributed. Sir Thomas Lewis [Munk’s Roll, Vol.IV, p.531] was still active, as was Wilfred Trotter, who Howard often mentioned as a particular inspiration. Trotter was not only a great and pioneering surgeon, but also a man of wide interests. He wrote authoritatively on social psychology and took an early interest in psychoanalysis. The intellectual mix was also greatly enhanced by the arrival of people fleeing Nazi Germany. One of these, who Howard mentioned as a particular friend at that time, was the biochemist Albert Neuberger [Munk’s Roll, Vol.X, p.362] who came to Sir Charles Harington’s [Munk’s Roll, Vol.VI, p.222] laboratory at UCH in 1932 for his PhD. Neuberger was also widely educated, having studied classics prior to his medical degree in Würzburg, which he regarded as an excellent grounding for any academic study. Howard had a great love and knowledge of literature, particularly Jane Austen and Henry James. Opera was another passion. When he retired in 1977 he and Winsome moved to Laughton in East Sussex, close to Glyndebourne, whose festival he had attended regularly since its inception in the mid-1930s.
Winsome died in 2001. They had no children, but Howard was able to live independently in their cottage to the last with the help of members of Winsome’s family and a devoted companion.
Dame Margaret Turner-Warwick
Stuart Bruce
[Turner-Warwick, M. Living medicine: recollections and reflections London, Royal College of Physicians, 2005; The Telegraph 6 May 2014 www.telegraph.co.uk/news/obituaries/medicine-obituaries/10808933/Howard-Nicholson-obituary.html – accessed 7 June 2014; Merrington, WR. University College Hospital and its medical school: a history. London, Heinemann, 1976; Kitchen, A. The Royal College of Physicians of Edinburgh, Mr Andrew Logan obituary www.rcpe.ac.uk/obituary/mr-andrew-logan-frcp-edin – accessed 7 June 2014; Ross JJ. ‘Tuberculosis, bronchiectasis, and infertility: what ailed George Orwell?’ Clin Infect Dis. 2005 Dec 1;41(11):1599-603; Allen AK, Muir HM. ‘Albert Neuberger’. 15 April 1908-14 August 1996 Biogr Mem Fellows R Soc. 2001;47:369-82; Elliott TR. ‘Wilfred Batten Lewis Trotter’. Obit Not Fell R Soc 1 January 1941 vol 3 no 9 325-344]