LECTURES AND ADDRESSES

LANDMARKS IN THE EVOLUTION OF THE GENERAL PRACTITIONER* E. W. GOODWIN, M.B., CH.B. Leicester I wish to present a fairly factual and objective account of the development of the general practitioner, for "'tis opportune to look back upon old times and contemplate our forefathers ", so let us start at the beginning of the nineteenth century when there were only three recognized classes of medical practitioners, namely, physicians, surgeons and apothecaries, with their respective govern- ing bodies having the legal right to confer licences to practise in England and Wales. Oxford and Cambridge Universities held similar rights, but there was no real statutory restriction on practice. Unqualified practice had flourished from time immemorial, for even in those days it was an established principle that every man had a right to choose his own doctor-qualified or unqualified- although I daresay that expediency and the financial situation were often the determining factors. Let us look at the position of the qualified practitioners. The physicians, who received their charter of incorporation in 1518 from Henry VIII, 440 years ago, were allowed theoretically, to practise physic in all its branches, but in actual fact, were confined to the prescribing ofmedicines to be compounded by the apothecaries and " in so far superintending the proceedings of the surgeons as to aid his operations by prescribing what was necessary for the general health of the patient and for the purpose of counteracting any intemal disease ". Fellowship of the College of Physicians was confined to graduates of Oxford and Cambridge and was a greatly coveted honour, conferring a high social status and many privileges. The " Barbers Company" and the " Surgeons Guild" had existed in uneasy rivalry since the 14th century. In 1462, Edward IV granted Letters Patent to the Barbers Company establishing the right of its members to practise surgery. In 1493, the Guild of Surgeons entered into an alliance with the Barbers Company, and in 1540, the two were formally united by Act of Parliament. This union was dissolved about 200 years later (1745) and the two companies again took their separate ways. In 1800, the Company of Surgeons was refounded as the Royal College of Surgeons of *Presidential address delivered to the Leicester Medical Society, 22 October, 1958, abridged J. COLL. GEN. PRACr., 1959,2, 221 222 E. W. GOODWIN London. Finally, in 1843, a new charter was obtained and the College became the Royal College of Surgeons of England. Outside London, there were very few pure surgeons. The provincial surgeons combined midwifery with their surgery or acted as family doctors. The right of ordering medicines for patients under their care was only acquired by the surgeons after strenuous opposition by the physicians. The surgeon had not the right to practise medicine. The Rise of the Apothecary We now come to the third and most interesting class, the apothe- caries, who began in mediaeval times as itinerant sellers of medicines and nostrums, and later settled in shops. In 1606, the apothecaries and grocers formed a common guild and all members kept shop, but in 1617, the apothecaries obtained a new charter making it unlawful for " grocers or any person to supply or administer medicines, or by any other way to use or exercise the art, faculty or mystery of an apothecary within the City of London and the suburbs, or within seven miles of the City ". The physicians had always been jealous of the apothecaries, whom they regarded as a much inferior class. In 1632, the College of Physicians obtained an order forbidding apothecaries prescribing medicines, and, until the time of the Great Plague, the physicians succeeded in exercising more or less a monopoly over the treatment of the sick. The physician prescribed, the apothecary dispensed. During the Great Plague, the apothecaries remained at their shops, and also visited the plague victims in their own homes, when most of the physicians had departed for a more salubrious atmosphere! The right to treat the sick was thus established in the minds of the public, and in 1703, the judgment ofthe High Court in the celebrated Rose case, ruled that " the wants ofsociety, ifnot the law, sanctioned the existence ofthe practising apothecary ". The office of an apothe- cary was defined at this time, as being " to ascertain the nature of disease and to treat that disease". He was only allowed to charge for medicines supplied and not for advice. -In 1829, it was at last held that an apothecary might claim remuneration either for his medicines or for his skill and attention, but he must not charge for both. In the following year, Lord Tenterden allowed an apothecary to charge 2/6 for each attendance, in addition to his charge for medicine. In giving evidence before the Select Committee on Medical Education in 1832, John Nussey, Master of the Apothe- caries Society, stated that apothecary was " a person who attended an individual suffering from some internal disease, not requiring external or manual aid; who prescribed for the cure of such com- plaint and supplied the medicine". In 1838, the right of the apothecary to claim payment for both medicine and advice, was THi EVOLuTiON OF THE GENERALtRACrITONtER AIA-ili)'.A confirmed by Mr Justice Littledale, who laid down that "an apothecary may certainly charge for medicine and attendance". In addition to the three recognized grades of practitioners, there were also the druggists, who were supposed only to supply medicines on prescriptions. This rule was not rigidly enforced in practice, the druggists often prescribing over the counter simple remedies, as do their descendants, the pharmaceutical chemists of today. But, unlike the apothecaries, the druggists did not visit patients in their own homes. Up to the year 1815, there was little actual control over medical practice, especially in the provinces, where all sorts of unqualified, self-styled practitioners continued to flourish. The striking fact is that there was no class ofmedical men entitled to practise medicine in all its branches, that is to say there were no general practitioners. No doubt the apothecaries, to a very limited extent, occupied a position corresponding somewhat to that of the family doctor. Nevertheless, the general practitioner of today must be regarded as the lineal descendant of the seventeenth century apothecary. The short-sighted and exclusive policy of the two Royal Colleges left the most important part of medical practice to a trading guild. The apothecaries, by devoting more and more attention to the opportunities afforded them of practising medicine and surgery, gradually developed into general practitioners in function, if not in name. A hundred years later, Dr Thomas Percival, in his Medical Ethics, described the apothecary as " the physician of the poor in all cases, and of the rich when the distress or danger is not very great ". The first great landmark in the history of the general practitioner is the Apothecaries Act of 1815, a little less than 150 years ago. This Act made it illegal for anyone, not licensed to do so by the Society of Apothecaries, to call himself an apothecary anywhere in England and Wales. It created a body of qualified practitioners, who were entirely independent of the Royal Colleges of Physicians and Surgeons, and who were entitled to practise medicine not merely by sufferance but by law. Candidates for the licentiate of the Society of Apothecaries had to serve an apprenticeship of not less than five years to an approved apothecary and had to produce certificates of attendance for at least six months on the medical practice of some public hospital or dispensary. They were examined in Latin, pharmaceutical chemistry and materia medica, and in the theory and practice of medicine, but not in surgery nor midwifery. Membership of the Royal College of Surgeons was conferred after an examination in anatomy and surgery, and the standard qualifica- tion of the new class of " general practitioner " became M.R.C.S., L.S.A., although many practised on the strength of a single qualification. '1A S. W .GOODWIN The next landmark in the history of the general practitioner is the case of Handey v. Hensen in 1830, heard in the Court of King's Bench. Mr James Handey, surgeon and apothecary of Waterloo Bridge Road, brought an action against Mr Hensen, an attorney, to recover £7 Os. 6d. for medicine and attendance to the defendant's family. Handey did not send in large quantities ofuseless medicines, but attended when necessary and charged for his professional services and visits. The verdict, which was for the plaintiff, was hailed with delight by every advocate of medical reform. The redoubtable Thomas Wakley, editor of The Lancet, who had supported Handey throughout, printed the following triumphant editorial: The hand of justice by a single effort has raised, what Mr Benjamin Brodie was pleased to term the 'subordinate members' of the profession, that is, the general practitioners, a thousand degrees in the scale of professional usefulness and respectability, and ten thousand degrees in the estimation of society. Rivers of mixtures and draughts, mountains of pills, boluses and plasters, at once vanish before the decree of this acute and venerable judge (Lord Tenterden). General practitioners will no longer be regarded as plunderers, whose interested object is to convert the stomachs of their patients into drug-shops, but they will now be looked upon as men of experience and skill; and their ability to prescribe appropriate remedies for diseases, will be valued rather more highly than the ability to mix those remedies in a bottle, or in a mortar. The designation General Practitioner came into common use about this time, roughly 130 years ago. From the editorial of The Lancet of 23 January 1830, I abstract the following sentences: The strength, the power, the wealth, the respectability and the utility of the general practitioner, will now extend to their legitimate limits. Instead of being tied and oppressed by the law, and degraded in the eyes of society, he is now encouraged and protected by the legal institutions of his country, and he will soon be recognized, as he always ought to have been, in the highest circles of the community, as a man of science, a scholar and a gentleman." There is also a reference to " the solid and well-founded claims to public confidence of general practitioners. On 1 May, 1830, the Metropolitan Society of General Practitioners in Medicine and Surgery was instituted, primarily for the protection of the mutual and individual interests of this class of practitioner throughout England and Wales. Its programme included altera- tions in the laws and customs relating to medical practice; measures to advance medical science; periodical meetings for scientific discussions and social intercourse; the creation of a general fund and of a benevolent fund for the relief of distressed medical men and their families; it was also proposed to secure a house and to form a library, and rooms were engaged at No. 4 Regent Street, but although the Society at first met with strong support, it had many opponents and its existence was very brief. However, the general practitioner slowly established himself during that great era of reform, and in time, he flourished. A correspondent of the London Medical Gazette wrote: " We are a body of men who exist because the wants of society have raised THE EVOLUTION OF THE GENERAL PRAcrITINoNER .225 us up. The pure practitioners of surgery, or of obstetrics can subsist only in a prosperous city. The physician indeed earns his bread, but there is room for one physician only, where there may be twenty general practitioners." In Queen Victoria's reign, medicine began her renaissance, by which it enlarged from an art of observation and empiricism to an applied science founded upon research, and disease came to be more and more studied along the lines pointed out by Harvey, and after him, John Hunter, but medical education lagged behind the advance of science, and the general practitioner learned his medicine by practising it. After several years of apprenticeship, a few months studying at an anatomy school, and a period spent in " walking the hospitals ", as it was called, his medical education was considered completed. The Medical Act of 1858 The next great landmark appeared 100 years ago, on the 4th August, 1858, when the first Medical Act was passed, setting up the Medical Register, which separated the qualified practitioner from the multitudes of quacks. Also, the General Medical Council was inaugurated and was held responsible for advising the licensing bodies as to the character and standard of medical education for admission to the register, and it was invested with the power of erasure from the register ofnames ofdoctors found guilty ofinfamous conduct in a professional respect. In the words of Sir George Newman (1932): It organized medicine to serve the nation, regularizing and defining it as a profession, able to render a greatly needed public service, as well as fulfilling its personal and historic purposes. From that date onwards, the State itself was to receive the immense advantage of organised medicine, and science and healing were to become more available for the benefit of all. The latter half of the 19th century saw the growing power and influence of the British Medical Association, which was founded in 1832 to promote the medical and allied sciences and maintain the honour and interests of the medical profession. Under Sir Charles Hastings, professional organization and the welding together of practitioners was developed into a coherent whole, a valuable part being played by the British Medical Journal. The Lancet, established by the medical reformer, Thomas Wakley in 1823, reached the height of its power in the second half of the century. Thesejournals put fresh currents of scientific thought and discoveries into circulation among the working doctors of the country and brought into focus the force and pressure of professional opinion. Sir Clifford Allbutt, in his presidential address to the British 226 E. W. GOODWIN Medical Association at Cambridge in 1920, said this about the general practitioner of the nineteenth century: His university was nature; in his clinical experience, he enriched the instruc- tion, half empirical, half dogmatic, of his medical school, by the shrewd, observant, self-reliant and resourceful qualities of the naturalist. His science and his practice were of the naturalist, not of the biologist. His rules of thumb were not without their efficacy, and his flair for the issues of disease marvellous. To his patients, this skilled craftsman and wise counsellor seemed to embody the final stage in the evolution of the family doctor, but the unresting march of science began to leave him behind, and a new phase of general practice was at hand. At the opening of the twentieth century, the practice of medicine was becoming more technical and with the linking up of the laboratory and the ward, the methods of diagnosis and treatment became more intricate and the general practitioner found it increasingly difficult to keep pace with the new knowledge and the demands of an educated public for new methods. The growth of specialism and the setting up of special services also affected him. Specialism went on its way from orifice to organ, from sex group to age group, from system to disease, and from diagnostic apparatus to therapeutic appliance. This added greatly to skill and knowledge, but whether it had pro- moted wisdom may be doubted. " Knowledge is proud that he has learned so much; wisdom is humble that he knows no more ". The personal relations between patient and doctor were changing as the State and local authorities intruded further into the sphere of general practice. Hitherto, the general practitioner had confined his work to curative medicine and the individual patient, responsible only to himself and his patients. The idea that a private doctor should be the outpost of preventive medicine was novel and disturbing. There seemed no end to the fresh statutory duties which social legislation would thrust upon the doctors. To turn medicine into a semi-public profession seemed foreign to all its tradition, but that was what was happening under the growing impact of State intervention. Under the expansion of contract medical practice, a pernicious system of so-called " club " doctors, large numbers ofdoctors were committed under stress ofcompetition organized by various working men's clubs and friendly societies. The fees were paltry and conditions of service often degrading, and those practitioners who gave honest and efficient service, usually did so at a loss. Concurrently with these changes, a falling off in the material position of the general practitioner could be observed which lead to a feeling of insecurity. The next great landmark in general practice appeared in 1911, when Lloyd George, amidst a whirlwind of party politics and professional controversy, ultimately successfully produced his National Health Insurance Act. General practice among the THE EVOLUTION OF THE GENERAL PRAcmTiONER 227 wage-earning classes became a form of part-time civil service under the discipline of the insurance commissioners. Within the space of three years, a revolution in general practice had begun, but was as yet incomplete when war was declared. Thousands of general practitioners left their practices to serve at home and abroad, and formed their own opinion of medicine under discipline and regulations. After five years upheaval, habits and ideas had been shaken, and there was already talk, for the first time, in some quarters of a whole-time, salaried state medical service. The exces- sive entry of students, both men and women, during the years immediately following the war, brought with it the likelihood of an overstocked profession, so placing a further weapon in the hands of the insurance administrators of the newly formed Ministry of Health. His training was criticized and defects pointed out, and as a result, the standard ofprofessional examinations in the teaching schools was reviewed and raised, and his training rounded off in resident hospital posts. Thus he became competent to deal with disease in most of its forms, but what was needed was the time and means to apply the methods he had learned. The cottage hospital system was developed in many parts ofthe country and postgraduate courses instituted. The motor car rendered the general practitioner less isolated and enabled him to attend professional meetings, and his social standing became higher. Nevertheless, his position, both within the profession and in relation to the community, was changing, and there was a tendancy to push him and his work into the background, which was a retrograde movement. But the evolution of the family doctor had but paused to adjust itself to the new conditions. The coming of the National Health Service Then in 1939, we were to witness for the second time in our life- time, history repeating itself in the outbreak of the second world war, and my remarks about the general practitioners in relation to the first world war have a strangely familiar ring. But now the nation was to profit by its past experiences, and anticipating the tremendous social and economic upheaval, which the war would inevitably bring in its train, whatever the outcome, the Government appointed Sir William Beveridge to investigate this problem and make recommendations. In 1942 he produced his famous report on social security, recommending a complete medical service for all, as well as other welfare benefits. His Assumption "B" recom- mended " a scheme for comprehensive health and rehabilitation services, for the prevention and cure of diseases and restoration of capacity for work, available to all members of the community ". The British Medical Association had had this problem well in 228 E. W. GooDwiN mind as far back as 1928, when it produced proposals for a General Medical Service for the Nation (Lord Dawson of Penn), but the politicians were not interested. Nothing daunted, these proposals were revised and publicized in 1938, and in 1942, a planning com- mission, set up by the British Medical Association, issued an interim report dealing with hospitals as well as the general practi- tioner services, which doubtless had some influence on the findings of the Beveridge Report. The then Minister of Health, Mr Ernest Brown, followed this up with his ideas of a whole-time salaried service, with doctors to be appointed by the Ministry to areas and blocks of patients, without any option to either doctor or patient. The reaction of the British Medical Association was so sudden and complete, that Mr Brown incontinently withdrew the scheme, and talks began. In 1945, a general election produced a socialist government with Mr Aneurin Bevan as the Minister of Health, and negotiations had to be started all over again with a new government, known to be in favour of a whole-time salaried service. It was only after much diffi- cult, protracted and sometimes acrimonious negotiations, that the Minister agreed that a whole-time salaried service could only be established by Act of Parliament and not by regulations. And so on 5th July, 1948, the National Health Service Act came into force, constituting the most revolutionary and the most important landmark to date, in the evolution of the general practitioner. We have now moved a long way from the apothecary of old to his counterpart of today, but fundamentally, his role is much the same-plus Va change, plus c'est la meme chose-and notwithstanding all the wonderful scientific advances in medicine and surgery, he is still the guide, philosopher and friend of his patient, with a very personal and continuing responsibility. There will always be the need for the art of medicine as long as human sickness continues.