The Naturalist Tradition in General Practice I, r, McWhinney, MD London, Ontario For me there have been two great satisfactions of medical practice. One has been the depth of human experience which, as physicians, 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 natural history of disease is the Suppose, for example, people with common with the naturalist. “Natu­ basic science of medicine. 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 sciences. 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 anthropology. 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 physician 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 Family Medicine 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. nature. 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 diseases. 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 bird’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 surgeon 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 birds 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 Joseph Banks 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 epidemic. 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.