Dr Trevor Howell 1909-1988 (Post 1)

Trevor Howell (1909-1988): pioneer, prolific author, researcher, philosopher and indefatigable supporter of geriatric medicine. 

Dr. Trevor Henry Howell, FRCP. Ed., was shy, courteous, kind, patient, well read and reserved but with a dry sense of humour and a great concern for others.  He had an enormous appetite for learning: not just medicine but also philosophy, management, journalism, public speaking and administration.  He left a copy of his candid unpublished autobiography to the British Geriatrics Society, on which this account is largely based.   

He was born in Barnsley, Yorkshire on 6th October 1908 with a strong medical background: his father was a doctor and his mother a nurse.  On the whole he did not have a happy family life.  While he had great affection for his father, who unfortunately died at the early age of 50, his mother totally lacked a sense of humour and was a strict disciplinarian.  She made him have music lessons and when he played truant she locked him up trying unsuccessfully to beat him into submission.  When he went to boarding schools he experienced fagging and being bullied.  By and large, he admitted, his school years were miserable, unsuccessful, depressing and disappointing. 

He was much happier in his graduate education although he had persistent problems in passing examinations.  He was educated at St. Johns College, Cambridge, and at St. Bartholomew’s Hospital.  He qualified in 1934 and decided on a career in medicine.  To improve his chances of passing the MRCP examination he took a post graduate course at the newly opened Royal British Postgraduate Medical School at Hammersmith (RBPMS) and was appointed medical tutor at several London hospitals including the RBPMS in 1936.  Unfortunately he failed the London MRCP exam three times but was successful first time in the Edinburgh examination in 1937.  That same year he married Margaret Bannochie, by whom he had two daughters and two sons.  Financial problems prompted him to enter general practice in Worthing, where many of his patients were elderly. 

War time experiences (a) The Royal Hospital for Chelsea Pensioners

At the outbreak of war he joined the RAMC, was posted to the Royal Hospital Chelsea where his interest in old age was ignited.  He examined each pensioner and was surprised to find many abnormalities, which puzzled him: were these signs of old age or disease?  

Air raid shelters were dug in the grounds of the Royal Hospital where a kind of social life developed at night.  The Ministry of Works installed air conditioning to improve the atmosphere.  This irritated the pensioners who preferred the usual ‘fug’ and responded by plugging up the vents.  Unhappily Howell learnt that his house in Worthing had been bombed and, worse still, looted.  

The Royal Hospital was damaged in several air raids in 1941 and a searchlight detachment, based in the hospital grounds, was destroyed.  The pensioners were transferred to St. Luke’s Hospital nearby, but when this was bombed a few days later they were moved to Ascott House, Wing, near Leighton Buzzard, the residence of Mr Anthony Rothschild.  The latter allowed Howell to use his library where he found an enormous range of books on literature.  He read voraciously: biographies, translations of the classics including Plato, Aristotle, Descartes and Spinoza, fiction, travel books and essays.  This zeal was assisted by his phenomenal ability to speed-read at over 250 pages per hour.

Howell’s New Year’s resolution was to research the problems of old age and in 1944 he published his first book.   He made contact with Marjory Warren and the Nuffield Foundation.  He told them of his research and was assured by the Foundation that funds might be available for him in the future.  However his enthusiasm was severly dented when he met Sir Thomas Lewis, the acknowledge expert on medical research, who said he was too old and lacked the necessary education to research.  

War time experiences (b) India and Burma   

In autumn 1944 he was promoted to major, left Ascott House and was posted to Poona in India.  He now saw cases of poliomyelitis, infective hepatitis, dysentery, malaria, parasitic infestations and the plague.  Later he was posted to a hospital in Burma, where he was senior major and held post mortems on those patients whose death was not clear.   He returned to the UK in September 1945 and found that his young son took time to realise that the strange man in the house was his father. 

Post war 

Not surprising, after his wartime experiences, Howell realised that general practice did not satisfy him.  He sold his practice in Worthing, moved to Croydon and renewed his interest in geriatric medicine.  The Nuffield Foundation funded his research and he met Marjory Warren for the first time.  He started work in LCC hospitals in south London, eventually settling on St. John’s Hospital in Battersea, where he opened a research unit, an outpatient clinic, and re-established contact with the Royal Hospital.  He researched chronic bronchitis, urinary incontinence, methods for improving mobility and made much use of morbid anatomy studies.  He was particularly interested in pathology of old age and worked with Dr. Piggott, a pathologist at St. James Hospital, who had extensive records of over 10,000 post mortems of which more than one in five were over 65 years.  He was joined at St. John’s Hospital by Dr. Tom Wilson, an ex RAF medical officer, who became a strong supporter of geriatric medicine in Cornwall.  

At St. John’s Hospital he examined all the inpatients and got the waiting list under control, which bore little relation to the true situation because some patients had died, while others could be managed as an outpatient.  He discovered that his inpatients considered they had been admitted ‘for life’.  Many had become so institutionalised that they did not want to leave hospital and he therefore suggested the concept of a ‘Halfway house’, which was supported by the Kings Fund.  

His workload became very heavy: and he calculated he saw about 600 patients a week.  In the pre NHS era he had no junior staff to assist him and it was not until the advent of the NHS that he acquired a house physician.  He thought that his achievements were compatible with Marjory Warren, and demonstrated a considerable increase in admissions to his hospitals.  Like others he emphasised the need for adequate staffing with doctors, nurses, physiotherapists, occupational therapists and social workers backed up by adequate community support services.  

Genesis of the Medical Society for the Care of the Elderly

Howell met Dr. Banks, Dr Sturdee and Lord Amulree of the Ministry of Health, who knew about Marjory Warren and were searching the country for like-minded doctors.  They discovered Lionel Cosin and Eric Brooke working in isolated areas.  Howell was asked to visit them and to assess the ‘workhouse’ hospitals in south London, which he found to be grim, stark places with few facilities. 

In November 1946 he invited Marjory Warren to his house to consider the formation of a medical society.  Although she was not enthusiastic he continued to foster the idea.  He contrasted the situation in the United Kingdom with the United States of America, where there were two societies concerned with the elderly (The Gerontological Society of America and The American Geriatrics Society), each with its own journal.  The United Kingdom had neither.  

In September 1947 he organised another meeting of leading geriatricians and medical officers from the Ministry of Health to create a specialist society.  Those attending included: Lord Amulree (elected as President), Drs. Wilson, Sturdee (who chaired the meeting), Warren, Brooke and Alfred Mitchell (the Superintendent of the St. John’s hospital).  Howell was elected as Secretary.   It was agreed to form a purely medical society: the Medical Society for the Care of the Elderly.   Unfortunately Howell’s relationships with Dr. Mitchell were not always amicable and worsened steadily until Mitchell retired.  Consequently Howell reduced his sessions at St. John’s and took on a similar role of physician at Queen’s hospital in Croydon in 1951.  

His professional activities

Howell wrote, lectured and studied enthusiastically.  He kept meticulous records of his patients, which formed the basis of a prodigious output of over 300 papers and four books.  He kept a hand written record of every book he read, every patient he saw, and every post-mortem held on his patients carried out by Dr. Piggott.  He read papers at many international conferences. He studied philosophy, took courses in management, administration, public speaking and became an associate of the Institute of Management.  

His philosophy was firmly based on clinical practice, research and teaching.  He considered geriatric medicine was an art based on early admission with prompt, active treatment, and was not merely just another branch of medical knowledge.  His enthusiasm and teaching resulted in many consultants developing their interest in geriatric medicine.  He echoed the cry of the surgeons; ‘Why didn’t we get these [patients] sooner?’  He attacked the problem of bed blocking by elderly patients, quoting an unnamed hospital where eight old men were found unfit for prostatectomy.  They remained as inpatients for 2 years before transfer elsewhere.  

He championed research.  As he put it ‘the harvest truly is plenteous but the labourers are few’.   A great gulf ‘existed between those who research into the problems of senescence and those who look after the aged…research is rarely carried out in hospitals for [the] chronic sick’.    He advocated an Institute of Gerontology, which would research, teach and publish.  

He firmly supported teaching since many doctors got the impression that diseases, which they did not see in their training schools, were untreatable, incurable and uninteresting.   He taught medical students from Bart’s, Charing Cross, Westminster and St. George’s hospitals.  

Recognition

His expertise was nationally and internationally recognised.  In the early 1960s he was visiting professor in geriatric medicine at the Alexandria University in Cairo.  In the United States he was the first Englishman to be awarded the American Geriatrics Society’s Willard Owen Thompson Gold Medal.  The Royal College of Physicians awarded him the prestigious F.E. Williams medal.  The British Geriatrics Society gave him its first Founders medal, made him its vice president and later set up a memorial lecture in his name

Coda

Retirement was not an entirely happy time clouded as it was with ill health due to cancer and a stroke.  He regretted that he never became President of the BGS or being appointed a Professor of Geriatric Medicine.  He was saddened that the benefits that he had brought of the care of older people at St. John’s were forgotten as his influence declined, by the closure of Queen’s and St. John’s Hospitals and the halfway house he had pioneered.  

On the other hand he continued his studies in philosophy and his love of clinical geriatrics, working as locum tenens at Charing Cross hospital while the incumbent, Peter Helps, was recovering from a serious assault by a psychiatric patient.  He was delighted to be appointed an honorary research fellow at St. George’s hospital and to be president of the Streatham swimming club.  

He was survived by his wife Margaret, two daughters (one a consultant rheumatologist) and two sons (both dental surgeons)