HISTORY OF GENERAL PRACTICE The rise of the general practitioner in the nineteenth century D. U. BLOOR, MRCGP, DCH General Practitioner, Stourbridge; Course Organizer for Vocational Training, Dudley SUMMARY. It was the Apothecaries Act of 1815 of war. They parted company in 1745 when the which Ied to the emergence of general practice hospitals began to flourish and surgery was making as we know it today and it was this one Act which significant advances. The Royal College of Surgeons produced a flood of changes on the medical was founded in 1800. scene that are without parallel in our history. Students were soon to undergo new forms of The Worshipful Society of Apothecaries of training in new medical schools and hospitals, London and medical associations and many journals The apothecaries were tradesmen and belonged to the were founded. The term 'general practitioner' of Grocers. The of the was soon in use. The force behind all Company majority Company driving were concerned with the retailing of groceries and these was the of changes Society Apothecaries culinary spices and their importation. It is not and the new general practitioners, and all too therefore, that in 1525 the often were the two surprising, apothecaries they opposed by Royal to feel the need of a of their own It was at the of the began corporation Colleges. only beginning After this date were twentieth that these new (Cartwright, 1977). they officially century practitioners referred to as a and certain were allowed to call themselves 'doctors'. separate body granted privileges. The Charter of the Grocers' Company was amended in 1607 to recognize this established fact. De Laune petitioned King James in 1614 for a separate Charter and this was granted in 1617 to give Introduction birth to the Society of Apothecaries. The apothecaries T^HE medical from the sixteenth became firmly established on the medical scene after the profession early struck in 1666 remained -*- century had a hierarchical structure which plague (Copeman, 1968); they rigid in the while the ran Not were lasted about 300 years until the nineteenth century. The city physicians away. only three orders of the medical they dispensing drugs but they were increasingly profession.-physicians, them to the lower social classes. This Ied to surgeons, and apothecaries.were complete in them¬ prescribing selves, and and their rules of conflict with the Royal College of Physicians, which rigid sharply delineated, claimed that alone had the to demarcation would be the envy of any modern trade physicians right prescribe union. and that apothecaries should only dispense drugs. The conflict Ied to a lawsuit in 1703 and called At the pinnacle of the profession were the physicians; finally 1704, the Rose case, when the House of Lords decided that were few in number, well versed in Latin and Greek they the had the to as well as to and their were limited to the classes. apothecaries right prescribe patients upper At Their was founded Linacre in 1518 dispense drugs (Roberts, 1962; Copeman, 1968). College by during last a crack had in the hierarchical the reign of Henry VIII and they were granted many appeared rigid privileges. system, a legal sanction had been lifted, and soon a new term, came to be used The surgeons and barbers came together under the 'general practitioner', (Bellers, Medical Act of 1540 to form a company but their 1714). various functions were kept quite separate. They were The causes of unrest at the beginning of the regarded as craftsmen and were more numerous than nineteenth the physicians and were in heavy demand during periods century © Journal oftheRoyal College ofGeneralPractitioners, 1978,28, The rigid hierarchical structure of the profession and its 288-291. three orders was still firmly present at the beginning of 288 Journal ofthe Royal College ofGeneralPractitioners, May 1978 History ofGeneral Practice the nineteenth century but there was now some evidence 'quacks' to every one doctor belonging to a recognized of interchanging roles; some surgeons were also acting body. It was not only the standards of these people that as apothecaries and vice versa. There was, however, were causing anxiety but also those of the people who general dissatisfaction and unrest among the physicians, were recognized by the medical corporations. Surgeons, surgeons, and apothecaries; pamphlets were being for example, discharged from the Armed Services could written, questionnaires sent out, and various associ¬ act as surgeon-apothecaries without any formal training ations were forming (Harrison, 1806). The causes of in pharmacy, since the Acts of 1749 and 1763 exempted this discontent were to affect medicine and its all officers from any form of apprenticeship (Hamilton, practitioners until the second half of the century when 1951). the structure and unity of the profession as we know it today began to take shape. Apothecaries Act 1815 There were three main causes of unrest: the French Revolution, the Industrial Revolution, and the increas¬ It was the influence, therefore, of the French and ing numbers of untrained people practising medicine. Industrial Revolutions and the growing number of untrained people which Ied to the unrest and the French Revolution forming of the Associated Apothecaries (Horner, The French Revolution had swept away the old 1922). They formed to promote a Bill to regulate the institutions of France; new corporate bodies were apothecaries and after much opposition from the formed and democratic principles proclaimed on every Colleges, the Apothecaries Act of 1815 was finally occasion. The long war with France had made the passed. British much more aware of these principles and people A crack had appeared between the three orders of the wanted them put into practice in England and applied to profession after the Rose Case; the Apothecaries Act the medical corporations. produced a real breach and it was this Act more than The Revolution in France had also Ied to a big any other in our history which set the scene for the breakthrough in medical science (Holloway, 1962). This beginning of general practice and the general prac¬ applied principally to pathology, where interest was titioner of today. now focused more on individual organs, and attempts From this one Act flowed many educational develop¬ were made to correlate this with clinical signs. Clinical ments which we recognize today. Wakley started the procedures became all important and efforts were made Lancet in 1823 to report hospital lectures; private to extend their range. Thus we had the invention of the medical schools flourished for a short time and were stethoscope by Laennec in 1819, the clinical ther- quickly replaced by schools attached to hospitals. mometer by Becquerel in 1835, and in the 1850s the University College Medical School was the first to cater ophthalmoscope, otoscope, and laryngoscope. for the new aspirants to general practice in 1826 and, following the Report of the Select Committee on Industrial Revolution Medical Education in 1834, nine provincial schools were The Industrial Revolution during the first half of the inuseby 1858. nineteenth century was gathering momentum. People Many medical associations were also formed at this were leaving the countryside and massing in various time. The National Association of General Practitioners parts of the country to form new towns and cities. This and its allied body, the National Institute of General immediately highlighted the big public health problems Practitioners in Medicine, Surgery, and Midwifery (Flinn, 1968) of housing, sanitation, and water supply made strenuous efforts in the 1840s to form a Royal and their relationship to disease. As soon as these College of General Practitioners. But by 1850 the fire of problems were tackled the diseases caused by occu¬ their enthusiasm had died out (McConaghey, 1972) and pation (Greenhow, 1861) were thrown into sharp relief, another hundred years had to pass before the College particularly in the second half of the century. More became a reality. Another prominent association, the doctors were therefore required and the new middle Provincial Medical and Surgical Association, founded class created by industrialization was demanding more in 1832 by Charles Hastings, had more success and medical care. This class also had the education and the became the British Medical Association in 1856. money to supply the recruits to the profession (Poynter, The Act required all apothecaries to be licensed, to be 1961). 21 years of age, to serve an apprenticeship of five years, and to pass an examination at the end of this time. The Unqualified practitioners Society had the right to prosecute offenders and they Most of the Medical Acts, and indeed the first one of did so particularly against Scottish graduates who were 1540, were concerned with distinguishing between the commonly practising in Northern England without the orthodox and the unorthodox practitioner; between a Apothecaries' licence. person who has had some training and someone who The standard required for the licence was gradually has not. This was particularly so at the beginning of the raised over the years. In 1827 midwifery and diseases of nineteenth century when Dr Harrison (1806) carried out women and children were added to medicine and a survey in Lincolnshire and found that there were nine pharmacy in the examination and in 1839 a written Journal oftheRoyal College ofGeneral Practitioners, May 1978 289 History ofGeneral Practice paper was introduced for the