The Naturalist Tradition in General Practice

I, r, McWhinney, MD , Ontario

For me there have been two great satisfactions of medical practice. One has been the depth of human experience which, as , we are privileged to have. The other has been the satisfaction of observing patients with illnesses of all kinds, in their own habitat, and over long periods of time. This is the kind of satisfaction experienced by all naturalists.

I would claim that observation of prognosis and to rational therapeutics. The clinician, then, has much in the of is the Suppose, for example, people with common with the naturalist. “Natu­ basic of . Nowadays schizophrenia were found to have a ralists,” wrote John Ryle,1 “hold cer­ we use the term “basic science” for biochemical abnormality. This dis­ tain attributes in common, notably the what Abraham Flexner called the la­ covery would have no significance desire to establish the truth of things boratory . There is no harm in without the clinical description of a by observing and recording, by classifi­ this as long as we do not mean that the category called schizophrenia, and a cation and analysis.” Like the natural­ laboratory sciences are more funda­ knowledge of its natural course and ist, the clinician makes careful observa­ mental and more scientific than the outcome. tions of his/her patients, classifies their science of clinical observation. Chemis­ Medicine, like other branches of illnesses into categories, then follows try and physics can explain ill health biology, is predominantly an observa­ them to their conclusion. and abnormality in living organisms. tional science. The observations are To this science of medicine, general Abnormality, however, has first to be made by clinicians, who are the field practice has made, and continues to defined and described — and this Can workers of medical science, just as the make, a distinguished contribution. only be done by clinical observation. field naturalist and field anthro­ The general practitioner has advan­ Knowledge of the natural history of pologist are the field workers of biol­ tages as an observer which are shared disease is fundamental to accurate ogy and . To say this is by few other physicians. The general not to deny the importance of experi­ practitioner can follow illnesses from ment in biology or medicine. In these their beginning to their termination, sciences, however, an experiment us­ even if the course is of many years ually follows and derives from a long duration; all variants of illness, from period of observation. The distinction the mildest to the most severe, can be Thls Paper is adapted from an address given observed; and the can, if ?!. *tlei Annual Awards Day, University of between observation and experiment is Mississippi Medical Center, Jackson, Missis- in any case artificial. The laboratory he/she chooses, observe patients in S'PPi, May 13 and 14, 1976. D r. M cW h inn e y 'S Professor and Chairman of the Depart- scientist and the naturalist both use their own natural habitat. I would like, m.er,t at the University experiments: one creates his own ex­ therefore, to illustrate my theme by ot Western Ontario, London, Ontario. Re­ quests 1°r reprints should be addressed to perimental conditions; the other uses describing the work of three general r' I. R. McWhinney, Department of Family practitioners, all notable contributors euicine, University of Western Ontario, the slow and massive experiments of Condon, Ontario. . to medical science, who made their

THE JOURNAL OF FAMILY PRACTICE, VOL. 5, NO. 3, 1977 3 7 5 observations while practicing for most depth of their interest in nature. “I reported in people who had had cow- of their lives in one community. shall be glad of your observations on pox. Although his colleagues were the cuckoo,” writes Hunter in one skeptical, Jenner did not abandon his letter, “and upon the breeding of hypothesis. Perhaps, he reasoned, the toads: be as particular as you possibly term “cowpox” was being used for can. If you can pick me up anything several different . He began that is curious and prepare it for me, therefore, to make systematic observa­ do it, either in the flesh or fish way.” tions of the lesions on cows’ udders And in another: “I received yours, as and differentiated those of cowpox Edward Jenner2 also the cuckoo’s stomach. I should from those of other diseases. He made Jenner was born in 1749, the son of like to have a few more of them for I similar observations on the lesions in a country parson in the Vale of Berke­ find they do not all show the same man, using an artist to make accurate ley, a beautiful part of southwest thing. If possible, I wish you could drawings. England between the Cotswold Hills remove the cuckoo’s egg into another After many years of observation he and the River Severn. Apart from ’s nest and tame the young one to was ready to make his crucial series of short and temporary absences, Jenner see what note it has.” experiments which lent further sup­ spent his whole life here among the Jenner had a particular interest in port to his hypothesis. The rest of the people and places he loved, rejecting the cuckoo. It was known that the story is well known. Vaccination soon all invitations to come to London, cuckoo laid her egg in another bird’s became accepted throughout the where a lucrative and successful prac­ nest and that the young cuckoo was world, but not before it had been the tice would have awaited him. raised by the foster mother after her subject of many doubts, attacks, and On leaving school at 12 he was own offspring had been thrown from misuses by people who did not really apprenticed to a in the market the nest. It was widely believed that understand it. These were people who town of Chipping Sodbury. Strictly the foster mother herself threw out were using vaccination without the speaking, we cannot call Jenner a her own offspring. After years of background of patient observation general practitioner because the term painstaking observations, Jenner was which formed the basis of Jenner’s did not come into use until the 19th able to refute this theory by wit­ experiments. Jenner was able to refute century. However, the precursors of nessing the process himself. The young the arguments of his critics by refer­ the general practitioner were already cuckoo, soon after hatching, dis­ ence to the hard facts gathered from in existence in the persons of the patched the other eggs and fledgelings his own observations. Misunder­ country surgeon and apothecary. Both from the nest by placing them on its standing about vaccination, and failure of these terms described a social role own back and lifting them up to of inoculation to protect against small­ rather than a particular function. The the edge of the nest. The observation pox, arose from three circumstances surgeon and apothecary both served as was supplemented by experiments in which were well understood by Jen­ general medical practitioners and in which he placed in the nest, with the ner. First, not all lesions on cows’ due course they merged to form what young cuckoo, eggs and of vari­ udders were due to cowpox. “There the Lancet, in the early 1800s, called ous sizes. will be no end to cavil and contro­ the “general practitioner.” The paper which Jenner submitted versy,” he wrote, “until it be defined After a seven-year apprenticeship, on the cuckoo earned him his Fellow­ with precision what is and what is not Jenner spent two years in London as ship of the Royal Society. cowpox.” Second, the cowpox pustule the first pupil of John Hunter, the During all this time Jenner was provided effective virus only for a great comparative anatomist, who had reflecting on a remark made to him by certain period during its evolution, recently settled there and had begun a milkmaid in Chipping Sodbury, who Third, some individuals had more than to build his famous collection. As a told him that she could not get the one attack of smallpox. boy, Jenner had already shown the smallpox because she had had the Another episode from Jenner’s life interest in nature which was to be the cowpox. Smallpox was one of the is worth noting for it gives us a glimpse foundation of his great discoveries. In great scourges of the 18th century. of Jenner as a man and as a naturalist, Hunter he found a kindred spirit, and Between a tenth and a fourteenth of While doing a necropsy of a man who this period was the beginning of a the population died of the disease, and had died from angina, Jenner’s knife lifelong friendship and collaboration in it became customary to inoculate happened to go through one of the the study of nature. While in London, healthy people with smallpox as a coronary arteries which was so hard Jenner also worked for the botanist preventive measure. The disease trans­ that he thought some plaster must sorting, mounting, and m itted by inoculation, although have fallen from the ceiling. Finding classifying material collected by Banks severe, had a lower mortality than that the whole artery calcified, he made, on the voyage of Captain Cook’s En­ contracted during an . Even for the first time, the connection ; deavour. So well did he do this that so, it was an extreme measure, and between the clinical syndrome of an­ Banks offered him a position on the Jenner was attracted to the idea that gina and disease of the coronary arte­ proposed voyage of the Resolution: an the much milder cowpox could confer ries. This caused him much distress, offer which Jenner turned down in immunity. for his great friend John Hunter suf­ order to return to practice in his native He began to gather observations, fered severely from angina, and Jenner Berkeley. both his own and those of his col­ knew that this information would de­ The correspondence between Jen­ leagues. Unfortunately, there were in­ prive him of all hope of recover), ner and Hunter shows the breadth and consistencies. Cases of smallpox were Jenner decided, therefore, not to pul-

3 7 6 THE JOURNAL OF FAMILY PRACTICE, VOL. 5, NO. 3, 19” lish his discovery and wrote about it he invented an instrument — the poly­ patients from the onset of illness to its instead to Heberden, who had written graph — for recording simultaneously end. At the height of his fame in the classical description of angina in the radial arterial and the jugular London he returned to general prac­ 1772. venous pulses. His observations often tice, this time to St. Andrews in extended over many years. Of sinus Scotland. There he established the St. arrhythmia he wrote: “It took me 15 Andrews Institute for Clinical Re­ to 20 years of patient observation, as search; its purpose was to study the it required the collection of an enor­ symptoms of illness in general prac­ mous number of records before I felt tice. Unfortunately, he was already confident in the soundness of this experiencing the symptoms of is­ prognosis . . . I watched children chemic disease, from which he grow up . . . and observed how they died eight years after he moved to St. bore themselves during periods of Andrews. stress in playing games and under­ taking hard work. The symptoms ob­ served had to be compared with those in people with failing and after many years of patient labour, this prognosis was established.” By this method, he was able to James M a c k e n z ie 3 ’4 elucidate the mechanism of extra Mackenzie was born in Scotland in systoles and to determine their prog­ 1853, graduated from Edinburgh in nosis, to describe “paralysis of the 1878, and soon afterwards entered auricles” (later to be called auricular general practice in Burnley, a cotton fibrillation), to classify presystolic manufacturing town in Lancashire. It murmurs according to prognosis, and was there, during the following 20 to elucidate the significance of years, that he carried out the studies dyspnea as a symptom of cardiac which were to lay the foundations of failure. modern . It is ironic that Mackenzie became Like so many before and after him, famous for something which he re­ William Pickles6 Mackenzie was mystified by his in­ garded as an incidental aspect of his Between Mackenzie and William ability to diagnose so many of the work: his invention of the polygraph. Pickles there is a direct connection. In illnesses he encountered in general Then, as now, both public and pro­ 1926, when he was 40 and had already practice. His had fession were more impressed by gad­ been in practice 15 years, Pickles read not prepared him to deal with the gets than by the clinical observations Mackenzie’s “Principles of Diagnosis illnesses of general practice. Blaming without which they would have been and Treatment in Heart Affections.” himself for his lack of knowledge, he useless. His disciples, the new genera­ The book made a deep impression on searched the text books for answers — tion of cardiologists, embraced the him. He resolved to begin making but in vain. The knowledge he sought new technology but, to Mackenzie’s systematic observations in his rural did not exist. disappointment, failed to appreciate practice in the Yorkshire Dales. In In search of answers, Mackenzie the importance of prolonged clinical 1928 there was an epidemic of infec­ began to make careful observations on observation to discover the natural tive hepatitis (then called catarrhal all his patients. Overwhelmed by the history of disease. Mackenzie was by jaundice) in the Dales. Because of their volume of data, he decided to concen­ no means opposed to investigative intimate knowledge of the whole pop­ trate oh the study of and the medicine or the use of the laboratory; ulation, Pickles and his partner were symptoms of heart disease. At this on the contrary, he made frequent use able to trace the spread of the epi­ time there was much dogma, but very of both. But he never wavered in his demic in the greatest detail. Time and little knowledge, of the natural history belief that the basic science of medi­ again they were able to trace the of heart disease. Young people were cine is clinical observation, and that contact through whom each patient kept in bed for months with sinus general practice is the best place to had contracted the infection. This led arrhythmia. The mechanisms of extra learn the natural history of disease. to the discovery that the incubation systoles and of auricular fibrillation After 18 years, Mackenzie moved period was 26 to 35 days. were unknown. There was no way of to London to advance his ideas and to In 1933 Pickles wrote one of the determining the prognosis in patients set up a consulting practice. In this he earliest descriptions of an outbreak of with mitral stenosis. The significance was successful, although he en­ epidemic myalgia, or Bornholm dis­ of dyspnea as a symptom of heart countered much opposition from ease, first identified only a year previ­ failure was not understood. those who could not believe that they ously by another general practitioner, Mackenzie’s method was very sim­ had anything to learn from a general Dr. Sylvest, on the Danish island of ple. He made meticulous clinical obser­ practitioner. After ten years, however, Bornholm. In the ensuing years, vations on his patients. Then he fol­ he realized that he was straying far Pickles extended his observations to lowed their progress to see what be­ from the principles on which all his many other infectious diseases and in came of them. In the case of the pulse, work had been based:5 the study of 1939 published his little classic “Epi-

THE JOURNAL OF FAMILY PRACTICE, VOL. 5, NO. 3, 1977 377 demiology in Country Practice.”7 Like ment? The feeling I am speaking of is like Jenner, he never felt either the desire I suspect, however, that we should the joy of the naturalist when he/she or the need to be other than a family look for deeper reasons for the neglect sees a rare species, or an unusual . He worked in Wensleydale of this aspect of medical science in our variant, or a common species in all until his retirement in 1964 at the age own time. We cannot put all the blame unusual place, or an interesting inter­ of 79. He died in 1969. on the conditions of modern life. It is play between organism and environ­ open to any of us, if we so desire, to ment. It is like the pleasure which is practice among a stable population derived from observing and recording and to stay there long enough for our the common events in one’s own observations to bear fruit. The reasons, habitat - like the yearly unfolding of I believe, lie in a basic misconception spring. about medical knowledge: the belief The beauty of studying natural that little remains to be discovered by history is that it needs so few instru­ clinical observation, and that the la­ ments: the ordinary tools of our pro­ boratory alone holds the key to medi­ fession plus a notebook, a pen, and an cal progress. To correct this fallacy it indexing system for organizing our should only be necessary to reflect on collection. We need no laboratory, for the number of common diseases of the practice and the community are whose natural history we are still our laboratory. And, as Pickles showed ignorant. Ryle’s words are as true us, it is never too late to begin. today as when he spoke them: “There is no disease of which a fuller or additional description does not remain to be written: there is no symptom as yet adequately explored.” 1 However, I do not recommend the study of the natural history of disease because it may lead to great dis­ Our Own Times coveries. Admittedly, I chose as my My three examples represent a tra­ examples men whose work led either dition which runs from the 18th cen­ to great, or at least to significant, tury to our own times. Does the progress in medicine. It is important to tradition continue? Assuredly it does. understand, however, that none of In men like Fry in Britain, Bentsen in them worked on their observations Norway, Braun in Austria, and Hames with this end in view. Their original in the United States, we see the samd motive was the enrichment of their principles exemplified: long-term ob­ own life and work. It is for the servations carried out by individual personal satisfaction that it brings, physicians who share the same habitat rather than any contribution one may as their patients. And for each one make to medical science, that I recom­ who can be named, there must be mend the study of the natural history many we will never know, whose of disease. There may be only one observations enrich their own lives, Mackenzie in every generation, but but never come to publication. In there is not a single physician who recent years, also, the work of these cannot enrich his or her experience in individuals has been supplemented by this way. collaborative studies in which many However good our medical educa­ physicians pool their observations. tion may be, we all fenter practice with It must be confessed, however, that an awareness of how much we still the tradition is tenuous. Many of the have to learn. No body of generalized conditions of modern life do not lend knowledge, or textbook, can ever do References 1. Ryle J: The Natural History of Dis­ themselves to prolonged observation. justice to the infinite individual and ease, ed 2. London, O xford University Press, Patients and physicians are more mo­ local variations which we encounter in 1948 2. Fisk D: Doctor Jenner of Berkeley, bile than they used to be. And we are practice. Medicine always has to be London, Heineman, 1959 learned from experience, and our 3. Wilson RM: The Beloved Physician: so impatient for results. How many Sir James Mackenzie. London, John Murray, research workers today would wish to learning is proportionate to the use we 1926 4. Mair A: Sir James Mackenzie, MD, embark, as Mackenzie did, on obser­ make of that experience. Although General Practitioner 1853-1925. Edinburg vations which might bear no fruit for he/she may make no great original and London, Churchill Livingstone, 19/3 5. M ackenzie J: S y m p to m s and The1 10 or 15 years? How many would be contribution to medical knowledge, I In te rp re ta tio n : ed 4. L on d o n, Shaw an content, like Jenner, to ruminate on a am convinced that no practitioner who Sons, 1 920 6. Pemberton J: W ill Pickles of Wensley­ hypothesis for 20 years, slowly build­ makes systematic observations of his/ dale. London, Geoffrey Bles, 1970 ing up a body of observations until her practice will fail to experience the 7. Pickles WN: Epidemiology in Coun­ try Practice. Torquay, Devonshire Press, ready to perform the crucial experi­ joy of discovery. 1972

378 THE JOURNAL OF FAMILY PRACTICE, VOL. 5, NO. 3, 197