BY SOMERVILLE HASTINGS, M.S. LOND., F.R.C.S. ENG.,

SURGEON IN CHARGE OF THE EAR AND THROAT DEPARTMENT, MIDDLESEX HOSPITAL.

Reprinted from THE LANCET, Jan. 14th, 1928, p. 67.

I THINK it will be generally admitted that no profession has seen greater changes during the last half century than our own. During this period the science of medicine has rapidly advanced, and changes in the organisation of the profession have naturally followed. The general practitioner of the past was not only physician, surgeon, apothecary, and accoucher, but also sanitary and public health adviser as well.

But during the last 50 years, at a rapidly increasing rate, one branch of medicine after another has been partially or completely withdrawn from the ken of the general practitioner. Sanitation and public health are now dealt with exclusively by the medical officer of health; indeed, so little is the average practitioner concerned with preventive medicine that he is almost liable to forget the existence of this most important branch of his science. The diagnosis of notifiable infectious disease is still the business of the general practitioner, but directly removal to the isolation hospital is decided upon, he sees and hears no more of his patient. In some degree the same is true of tuberculosis, excepting that even the diagnosis of this disease takes place to an ever-increasing extent in the tuberculosis dispensaries. Both the diagnosis and treatment of venereal disease are now largely carried out at clinics especially instituted for this purpose, and I have been told by practitioners that they now rarely see a case of venereal disease in its early stages, although, of course syphilis in its tertiary form is still cropping up fairly frequently. School clinics are now treating a good many of the chronic affections of childhood, previously dealt with by the practitioner or hospital or not at all, and the maternity and child welfare centres, although not originally intended for the treatment of diseased conditions, do in actual practice give treatment to many cases that would otherwise come to the general practitioner. In some districts a very large percentage of children are born within the walls of the municipal maternity hospital. “There are no fewer than 17 departments, spheres, or directions of clinical activity for which provision is made in this sectional way under the auspices of local authorities. Some of these cover an extensive field of medicine.” (Leading article in Brit. Med. Jour., June 11th, 1927). The treatment of the more serious mental diseases has been lost to the practitioner for many years, but few will, I think, regret this loss.

The appalling housing conditions, not only in towns but in many country districts as well, and the increasing complexity of modern methods, make the need for institutional treatment of the sick much greater than previously. Hospital beds are therefore rarely empty, and the poor-law infirmaries are taking more acute and subacute cases, while not a few of them have become staffed and equipped like the large general hospitals. But in very few hospitals or infirmaries does the practitioner retain any contact with his patient when once he has passed within their doors, nor is his doctor informed of the diagnosis made or treatment received when he passes out again.

A CONTINUING PROCESS

In these and other ways, then, during the last 40 or 50 years, the scope of the general practitioner has been continually narrowed and confined by public or semi-public provision for the treatment of an increasing number of diseases without his aid. Now this process is bound to continue for two reasons: first, because it is part of the spirit of the age to provide for its needs by collective action; and secondly, because, in spite of some defects with which I will deal later, the public provision for sickness already instituted has undoubtedly made for the general good.

Thirty-five years ago 1 person in 7 died of tuberculosis in England and Wales; to-day only 1 in 14 so dies. During the last 20 years (1905-1925) the infantile mortality-rate has fallen from 128 to 75 for 1000 births. Few people will deny that the public provision made has had a good deal to do with these beneficial results. In connexion with venereal disease the effects of State interference have been even more striking. Between 1920 and 1926 the number of new cases reporting at the clinics fell from 42,805 to 22,550 in the case of syphilis, and from 40,284 to 35,052 in the case of gonorrhoea. These, like many other figures, may possibly be misleading, but no one in active practice can, I think, doubt that syphilis is decreasing. But perhaps the best results of all are to be seen in connexion with the treatment of school-children. To take one disease only, Sir George Newman, as Chief Medical Officer of the Board of Education, in his annual report of 1923, tells us that, as the result of preventive and curative treatment, the percentage of children found on routine inspection in London with defective hearing has, during the last ten years been halved, and that in Cambridge and Exeter the results have been even more striking.

As I said before, I maintain that this process of robbing the general practitioner of clinical material is bound to continue and increase. The hospitals are constantly appealing for further extension of bed capacity, and not only do their long and increasing waiting lists support this appeal, but the Voluntary Hospitals Commission recently recommended that another two million pounds of public money should be given to the voluntary hospitals to equip more beds. The improved facilities for treatment in many poor-law infirmaries are enabling them to take many more acute cases which were previously treated at home, and now the Ministry of Health is inviting representatives of the poor-law and general hospitals to come together to discuss, among other things, whether the medical and surgical staffs of the hospitals cannot undertake the charge of cases in the poor-law infirmaries. This is undoubtedly all to the good from some points of view, but it will, nevertheless, tend to rob the general practitioner of a considerable amount of important and interesting clinical material. And now demands are being made for still further provision for certain classes of persons and certain types of disease. A very strong case can be made for the provision of similar inspection and treatment for the pre-school child to that accorded to the child of school age. It is truly pointed out that when children arrive at school for the first time the mischief is often already done and cannot be undone, and their efficiency for the rest of their life is impaired in consequence, and legislation cannot be long delayed in connexion with these young children. On the other hand, an equally strong case can be made for the adolescents between 14 and 16, for whom no public medical provision now exists. These children are, as a rule, earning little, and cannot pay for medical attention privately, and thus the good work done in the schools may readily be made of no account. The maternal mortality at childbirth, amounting to nearly 3000 annually, which has not markedly changed for some 25 years, is causing much public anxiety. What amelioratory measures will ultimately be adopted is not yet clear, but it seems not improbable that the public may demand a vast increase in maternity homes to be staffed exclusively by practitioners of special experience. There is also a demand in some quarters for a national campaign against cancer. Public cancer clinics have been fairly successful abroad, and may at any time be introduced into this country. There is a strong feeling also in some quarters that efficient treatment should be provided for orthopaedic cases and for heart disease in children. Further public provision for the prevention and treatment of disease is inevitable, and if carried out in the same way in the future as in the past, is bound to still further rob the general practitioner of much of the variety and interest of his work.

INCOORDINATION OF PUBLIC INSTITUTIONS

Our public provision for the sick may be looked upon as a series of watertight compartments having no communication with each other. If the right sort of person with the right sort of disease happens to fall into the right compartment the treatment obtained is generally good, but there is little to guide him into the right compartment, and nothing to do for him if he happens to fall into the wrong. A good example of the complete lack of coordination between the different schemes for provision for the sick came before my notice recently. Eighty-three of the patients in a large county sanatorium for tuberculosis are children. Of these only three showed definite signs and symptoms of tuberculosis after careful observation lasting over many weeks. Most of the others were classified as “indefinite for observation.” But 58 per cent. of these children were found to be suffering from septic tonsils and adenoids. Unfortunately, however, in all but one case all attempts to get these tonsils and adenoids removed have so far failed. “Tuberculosis” these children have been diagnosed, and tuberculosis they must remain for the rest of the chapter, and so they will have to stay at the sanatorium for anything up to 18 months at the cost of the ratepayers.

When the Ministry of Health was created, it was hoped that it would serve to coordinate all the various services dealing with public health. Unfortunately, however, we have had, so far, but one Minister of Health (the first) who could be expected to have any knowledge or experience in health matters, the other Ministers of Health being clearly appointed for their skill in getting houses built or preventing their being built, according to the desire at the moment of the Government in power. Moreover, at best the Ministry of Health can only act as a coordinating agency at the centre, and what is needed is coordination at the periphery as well, and no one can do this effectually but the general practitioner. It. seems to me that without him increasing incoordination is bound to occur, as more and more of his patients are taken from him and brought under the care of the State. I look upon the general practitioner as an essential part of the equipment of every family, whether rich or poor, not only to serve as guide, philosopher, and friend, but as registrar of events of medical importance as well. Now if the practitioner is excluded from, and knows nothing of, some of the most important phases in the medical history of his patients, it will be impossible for him to take his part as he should, and I have no doubt that the absence of the natural liaison officer is the main cause of the imperfect success of some of our public health schemes.

Beyond question, such is the increasing complexity of medical science, an even larger amount of treatment will have to be undertaken by specialists, and a good deal of it within the walls of hospitals or similar institutions; but unless the general practitioner’s business takes him to these institutions to cooperate with the specialists in the treatment of his patients, he cannot possibly keep his medicine up to date and know what to expect from each specialist line of treatment. From the specialist’s point of view also it must be admitted that intimate contact with the man who sees all sides of medical practice is going to lessen that narrowness of outlook which is inseparable from specialisation. In my own experience, at any rate, it is often a much more difficult problem to make a diagnosis and decide on the best line of treatment for a given patient than to actually carry it out. The general practitioner, to whose province this must mainly fall, must, therefore, always be the most important person in the medical hegemony, and any scheme of medical service that fails to take this into account is of necessity foredoomed to failure.

Equally, then, from the point of view of the faculty and the public it is essential that the general practitioner should take his proper place in the public medical service of the future.

A PUBLIC MEDICAL SERVICE

The provision by the State of some form of public medical service within the next few years seems to me inevitable. “Whenever I have had occasion to speak of it to a lay audience the proposal has been universal1y applauded, and other people with much greater experience as political speakers have told me the same. We may look upon some form of State medical service, then, as certain within the next few years. Two courses are open to our profession. It may resist the inevitable till the last moment, have some ill-digested and imperfect scheme thrust upon it, like the National Health Insurance Act, or it may profit by the experience of the past and seek to mould public opinion so that. when the new order comes the general practitioner may have an honoured place in it as the natural centre around which the whole scheme revolves.

The Lancet Office, 1, Bedford Street, Strand, WC 2

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