Lives of the fellows

Theodore Fortescue (Sir) Fox

b.26 November 1899 d.19 June 1989
Kt(1962) BChir Cantab(1926) MB(1937) MA MD(1938) *FRCP(1946) LLD Glasg(1958) D Litt Birm(1966)

Sir Theodore Fox, a medical editor who exerted a profoundly beneficial influence on the practice of medicine in his time, began his work on the staff of The Lancet in 1925 and he retired in 1964, after 20 years as its editor. He came from a long family line of Quaker doctors and his mother was the daughter of a Presbyterian minister in the Scottish Highlands - an ancestry that hardly gave him a taste for relaxation or merriment but imbued him with a dedication and a resolve to see right prevail, which infused all he did. From Leighton Park School he won a scholarship to Pembroke College, Cambridge. In 1917 he wanted to join the Army but his family persuaded him to enter the Friends Ambulance Unit and he became an orderly on an ambulance train in France.

When the war was over he went up to Cambridge and subsequently became house physician to Sir Robert Hutchison [Munk’s Roll, Vol.V, p.208] at the London Hospital. Later, after an expedition to India as a ship’s surgeon, he accepted an offer of locum work from the editor of The Lancet - a post which became more than temporary.

With the advent of the 1939-45 war, Fox spent three years in the RAMC including a year as a regimental medical officer, some of the time in France. Later he worked in the Army blood transfusion service and edited the Army Medical Department Bulletin at the War Office. The Lancets request for his return was eventually granted and he rejoined the journal’s staff at its wartime office in Aylesbury, before its return to London with Fox as editor. He was soon deep in the often turbulent discussion about the coming National Health Service in Britain.

The Lancet set out to argue the case for freeing medicine from the ‘marketplace’ and for eschewing the fee-for-service which many doctors wanted. Though Fox wished to see the establishment of an organized State service he never missed an opportunity to remind the profession that its prime duty would still be to patients and that doctors should never regard themselves as mere technical workers in a State-run and State-financed service. When a niggling editorial in the British Medical Journal suggested that the BMA’s attitude should be to cooperate with the NHS while acting as a watchdog for the profession, The Lancet retaliated: ‘Since when has cooperation become an attribute of watchdogs?’.

His journal’s influence at this time was considerable perhaps even crucial to the outcome, for if the NHS had not begun in 1948 more or less under the terms that Fox supported in face of much professional opposition then it is unlikely that subsequent efforts to establish a non-fee-for-service system would have prevailed. He would probably have looked with misgiving on some moves begun in the late 80s to reintroduce another kind of ‘marketplace’ into a service which he always hoped would remove all financial impediments to satisfactory care - on the frail assumption that the Exchequer could invariably be persuaded to provide enough money.

A landmark in Fox’s early years as editor was the publication of the Collings Report (The Lancet 1950;i:555-85) which illustrated, through the eyes of an Australian visitor, the imperfections of general practice in Britain. Hopes that the NHS would speedily improve matters proved vain, but the coming of the College of General Practitioners - in which Fox had a hand - and the growing appreciation of the importance of primary care fostered by his journal, eventually raised the standards and status of general practice from the level of a retreat for the unambitious graduate or the failed specialist.

In 1961 he recognized the significance of the Christ Church conference on postgraduate medical education and he published George Pickering’s commentary [Munk's Roll, Vol.VII, p.464] on its conclusions, thereby hastening the emergence of a more active on-going medical education. Fox had a talent for grasping the essential achievements and failures of health care in other lands. Short visits to the Soviet Union (1954), China (1957), the United States (1960) and Australia and New Zealand (1963) were cues for penetrating articles on what had been achieved and what was lacking in the health systems of these countries. Despite the mass of fact and observation with which he had to grapple, he made these commentaries illuminating and entertaining.

Outstanding among his other signed contributions to the journal was his 1965 Harveian Oration entitled ‘Purposes of Medicine’. Here he declared again that the primary role of doctors was to help people rather than to advance science, and he maintained that they should not prolong life against the patient’s interest: ‘I do not believe that confidence in our profession depends on following rules at the expense of people.’ Another passage reads poignantly today in the shadow of events in many tormented parts of the world where doctors have been victimized because their actions were seen as contrary to the will of those in power: ‘In principle ... nations allow that Medicine has a more advanced code than their own - that the doctor is right to put his duty to the human race before his duty to any of its component groups ... However uncertain and tentative, he is a prototype of supranational man.’ One of his earlier pieces, ‘The Greater Medical Profession’ (The Lancet 1956;ii:779-80) has also been much quoted.

He wrote of the medical empire transforming itself into a commonwealth with more and more of its colonies and dominions becoming wholly or partly independent. He helped many readers to recognize that medicine should be seen as only one member in a family of professions, among whom cooperation rather than financial competition was vital to the success of any health service. With all these thoughtful and elegant texts, and with many more, Fox enlivened the pages of his journal and compelled his readers to think about what they and their colleagues were doing both individually and in their corporate actions.

At the same time, over the years, he encompassed the daily tasks of an editor upon whose desk papers and letters fell in mounting numbers as medicine became ever more scientific in the surge of genetics, immunology, and molecular biology clamouring for places in a general journal. In his time The Lancet sought advice from outside advisers on submitted papers much less often than it came to do in later years. Fox’s Heath Clark lectures of 1963 - published as a book, Crisis in Communication, London, The Athlone Press, 1965 - had this to say about the refereeing of papers: ‘By enlarging the editorial group, so as to dilute the influence of personal prejudice, one inevitably reduces the chances of the unorthodox. Referees are on the whole conservative and the more referees look at the paper the less the journal is likely to take a risk. An independent editor may often have golden dreams that a horse he has backed will come romping home at 45 to 1; but an editorial committee seldom sees its duties in a sporting light.’ Those editors with sporting instincts were warned, however, by his next remark: ‘... my impression is that, in the journal I work for, the worse mistakes of the past four decades have been errors of acceptance rather than rejection.’

One of his successors as editor has agreed with this view although he pointed out that mistakes of commission were almost always rapidly exposed while those of omission could remain hidden for a long time. When Fox retired from the editorship he became director of the Family Planning Association. This work strengthened his views on population control and stimulated another vivid lecture, ‘Noah’s New Flood’ (The Lancet 1966;ii:1238), in which he argued that Britain, like any other country, should have a population policy. After he left the FPA in 1967 he seldom wrote again for publication, though he did emerge to reiterate his opinion that industrial action by doctors was a mistake (The Lancet 1976;ii:892). He kept in touch with a mass of friends by letter and by his famous hand-painted Christmas cards.

He became a knight in 1962, having declined the honour earlier because he feared his acceptance might be thought to prejudice the independence of the journal. The universities of Glasgow and Birmingham gave him honorary doctorates and he was an honorary fellow of the Royal Australasian College of General Practitioners and the New York Academy of Medicine. In 1962 he was a close contender for presidency of the Royal College of Physicians.

He married Margaret McDougall in 1930 and they had four sons. Robin, their youngest son, became editor of The Lancet in 1990.

I Munro

* Elected under the special bye-law which provides for the election to the fellowship of "Persons holding a medical qualification, but not Members of the College, who have distinguished themselves in the practice of medicine, or in the pursuit of Medical or General Science or Literature.."

[Brit.med.J. ,1969,299,47-49,1518-84; The Times, 23 June 1969; The Independent, 22 June 1989; The Daily Telegraph, June 1969; FPA Annual Report 1968/89,28; NY Acad.of Med.,Bulletin,61,No 5,June 1985;The Independent, 5 July 1985; Belfast Telegraph, 3 Nov 1965; The Lancet, 1965,2 Jan; Medical News, 1 Jan 1965;Family Planning, 1964,13,No 2,38;1968,16,No 4,104-5]

(Volume IX, page 178)

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