The Longest Art

Text © 1969 Kenneth Lane





Chapter 1: Family Doctor

Chapter 2: Early Problems

Chapter 3: The Significance of Trivial Ailments

Chapter 4: The Piers Family

Chapter 5: Practice Planning

Chapter 6: The Unpredictable Emergency

Chapter 7: General Practitioner and Hospital Beds

Chapter 8: Doctor and Patient

Chapter 9: Doctor and Family

Chapter 10: Responsibilities: Drugs

Chapter 11: Responsibilities: Certificates

Chapter 12: Abortion and Contraception

Chapter 13: Negligence

Chapter 14: Screening and Research

Chapter 15: Education

Chapter 16: Emigration

Chapter 17: The Faith of a Doctor

Chapter 18: The Continuity of Family Practice



8: To the Royal College of General Practitioners, whose constant aim is to raise the standard of general practice in the United Kingdom and to reveal its true value


9: To Dr. Sydney Abrahams — a Fellow and Founder Member of the Royal College of General Practitioners — whose regular visits to our partnership over several years did much to open our eyes to the significance of the relationships between doctors and their patients and between patients and their families.


10: After more than twenty years in a busy general practice Dr Kenneth Lane has a right to claim, from personal experience, that the life of a family doctor can be challenging and highly rewarding in a great many ways. In this well written book he illustrates how a general practitioner has to switch constantly from trivial complaints to serious and dramatic illness and emergencies; and how many events in the life of his patients tend to become his own personal concern. Every doctor is sometimes unfairly blamed and sometimes unduly praised — "on balance we strike about even".

11: When discussing modern developments in National-Health-Service general practice in Britain he says that the introduction of appointment systems was, in his opinion, the turning point for improvement. He agrees with many others about the importance of general-practitioner hospital beds, although he offers no solution to the problem of how to provide enough of these in the winter months, when upper-respiratory infections are common, without having them empty in the summer when far fewer are needed. Many people will not agree with the author when he deplores the modern tendency for some keen family doctors in group practices to develop special clinical interests. Throughout the book his own particular interests and antipathies are clearly portrayed.

12: Like others before him, Dr Kenneth Lane recognises how a doctor's character and attributes become manifest when he treats a seriously ill or dying patient. "The presence of a good man or woman of serene temperament is of more value than a syringe full of morphia… Usually the doctor's influence on the nearest relative is what matters most… helped more by what we are than what we say… If I should suffer from an illness like cancer, may I be attended by a doctor who feels with me and yet is not emotionally involved, who will help all he can yet will be willing to admit when he can do no more, who regards his help to me as a willing duty and not as a favour, who is a man of courage and compassion himself, yet possesses the quality of humility — having self respect but no conceit". This is the kind of general practitioner which every country still badly needs and which this excellent and humane book will help to produce.


Chapter 1: Family Doctor

14: The general practitioner today is an anachronism. If one suffers from heart failure, one needs to consult a cardiologist; if one suffers from endogenous depression one needs to consult a psychiatrist. In any specific illness requiring specific treatment, there is therefore no place for a general practitioner.

15: This remarkable statement was made not long ago by a consultant on the staff of a great London hospital. Partly as a result of teaching of this sort, less than 30 per cent of newly qualified doctors choose general practice as a career.

16: I hope to show that the art of healing survives in the scientific age. As long as healing depends on understanding the emotions and relationships of men and women, it will remain an art. The disorders of cells, tissues and organs may be successfully treated by the skilled mechanic or even the computer, but the roots of illness often lie elsewhere. Not only are mother and child one flesh, but all the members of a family are parts of a complex unit. This is often torn by tensions, and sometimes separated by great distances into its component parts, but it is still held together by deep-seated emotions, as often of hatred as of love. Unless this background to illness is borne constantly in mind, treatment will only be symptomatic. Without some understanding of it, doctors will meddle blindly with their patients' health.

17: The future success of the Health Service depends on first-class general practice and this depends on the number and quality of the young doctors who make it their career. It seems therefore of great importance that the life and work of the general practitioner should be seen as it really is — as the most demanding and the most rewarding career in medicine.

18: My own practice has been for many years in an industrial area. Coal-mining with widespread unemployment associated with it in the early 1930s has been gradually replaced by other industries. Printing and shoe-manufacturing are now the main occupations. This has entailed a considerable change in population as skilled workmen have been brought into the district from various other industrial areas. Outside the town are villages and farms in which rural practice has changed little since the partnership was first formed over a hundred years ago. Experience of industrial as well as rural practice, the drama of mining accidents, and the great variety of the patients in the practice is the basis of my claim to write about general practice in this country. I mention these credentials in case it should be thought that my optimistic view of general practice is based on a limited knowledge of the work or on experience confined to quiet rural England. The worst conditions of the hungry thirties are more familiar to me than the placid content of the successful farmer. The simple fact is that human beings are much the same under all conditions. It is remarkable how small is the effect of environment on happiness provided one has the comradeship of one's own kind. The conflicts and the pain are the same everywhere.

19: To give a true picture of the doctor's life, it will be necessary to describe the daily work, the planning and the responsibilities, but above all the relationships between doctor and families. My own experiences inevitably form the basis of my description. These will be altered and stories inter-mingled in a way that makes them true in principle but not in fact. Obviously no family can be photographically revealed to the reader. My hope is that these impressions will draw aside a veil and allow the life of the family doctor to be seen clearly. His value to the community can then be fairly judged.

20: For certain aspects of the relationship between doctor and patient, I will describe from time to time episodes in the life of one particular family. In the first of these I shall try to show how life in general practice came to appeal to me by its close involvement with men and women.

21: I first met the Piers family one spring when the threat of the Second World War had reached menacing proportions. The call came by telephone during the afternoon. It was noticeable for its careful instructions about how I should reach the farm. If I could say what time I should call, I could leave the car at the gates and someone would be there to meet me. The track up to the farm would be too rough for my car, but there was a short cut up a steep path — called I later discovered 'the slip' — which would save me a quarter of a mile walk.

22: As I approached the farm gates in the early evening, my guide was there waiting for me. She was a long-legged girl of twelve or thirteen. She opened the gate just wide enough to let me through, and looked at me appraisingly.

23: 'Do you think you'll be able to cure him?' She seemed to be thinking aloud.

24: 'I'll tell you better when I've seen him.' We walked in silence. 'How far is it?'

25: 'Not far.'

26: We climbed and the track was rough and muddy. The red brown of the winter fields gave way here and there to a faint flush of green on the hedgerows. The March wind had suddenly blown soft, carrying with it the whiff of cows and the sharp dank smell of the woods. My guide walked a pace ahead of me, taking short steps because of the slope. Her skirt was short — for economy in those days, not for fashion. Her young legs were perfect and I watched the rhythmic movement of her gastroc-nemii. Suddenly she turned and looked right through me into the distance. The classic features made me wonder — some Norman ancestor perhaps, or a wayward aristocratic Squire a few generations back.

27: 'How long have you been in Westover?' she asked.

28: 'Several years.'

29: 'Are you married?'

30: As soon as I said yes she went on, 'Do you want a nurse-maid?'

31: 'Well, not yet. But perhaps we might soon. My wife is expecting another baby in June.'

32: 'Well then?'

33: 'We'll have to see about that later.'

34: Presently she pounced on a spot in the bank and came up triumphant, holding a small yellow flower.

35: 'The first,' she said. 'Maybe it will bring him luck.'

36: 'How nice. Let me see, what is it called?'

37: 'Celandine.'

38: 'Of course.'

39: 'We found one on the third of February last year.'

40: 'What is the matter with your father?'

41: 'It's one of his attacks. He'll get better.'

42: 'Then why did you say could I cure him?'

43: 'Stop them, I meant. Not let them happen. Every spring and Michaelmas he gets them.'

44: It did not sound too bad. And the day was warm and it was spring, with new life under every blade of grass. Young Catherine was the embodiment of it all. The daughter and mother of men, the pride of creation. Yet there was a touch of sadness in the air. Perhaps it was something perverse in me, or perhaps it was because the year was 1938.

45: There was no melancholy in my guide. 'Quiet here,' she said. 'Blackbirds' nests on each side.'

46: We arrived at the smallest farmhouse I had ever seen. Neat rows of wallflowers grew on each side of the front door. They were exactly nine inches apart, bushy plants, full of the promise of scented bloom in a few weeks' time. A winter jasmine was still in flower, carefully tied to the wall.

47: 'Good afternoon, Mrs Piers. I'm sorry your husband is ill.'

48: She was an exact, older replica of the daughter — an interesting face, with clear-cut features and quiet, brooding enigmatic eyes. The black hair was brushed back from her forehead.

49: 'This is three times he has been ill in two years, and he never had anything wrong with him before.' She looked puzzled and anxious.

50: 'Tell me about him.'

51: 'He is giddy when he moves and he says he is seeing everything double.'

52: 'When did it happen?'

53: 'He came in last night and said he felt queer. Thought he had eaten something and went early to bed. Then this morning he couldn't get up.'

54: 'What were the other attacks? The same?'

55: 'No, the first attack was his sight. He went almost blind in one eye. It got better in a week or two and we thought no more of it. Then last Michaelmas he lost the use of his hand. It got better, but it was never as strong as it was before.'

56: 'Didn't he see a doctor?'

57: 'Not since we were married, and that's fourteen years.'

58: 'He's upstairs?'

59: 'This way.'

60: Fanner Piers lay in bed in an icy bedroom, his head half covered by the bedclothes. When these thick stone walls are chilled by winter frosts they keep out the spring warmth for weeks, just as, against the autumn north-easters, they keep their summer warmth. He appeared to be asleep.

61: 'Wake up Arnold. It's the doctor.'

62: He was a magnificent specimen — six feet four in height and perfectly developed in proportion. A fair-haired, blue-eyed giant. His great height was obvious, even in bed. He held a hand over one eye. 'Excuse this,' he said. 'It's the only way I can reduce you from two doctors to one.'

63: I took a careful history and examined him. An old medical chief used to say that if you found anything you did not expect when you examined a neurological case, you had not taken a good enough history. The diagnosis was unpleasantly obvious. He had disseminated sclerosis.

64: What now? What must I tell him?

65: 'I'm all right as far as the sight goes when I cover up one eye, but it's this giddiness,' he said.

66: 'I'm afraid you will have to rest until that passes.'

67: 'Can you give me something for it?'

68: 'I will give you some tablets. They will help. It may take a week or two before it steadies down though.'

69: 'And what's going to happen to the farm in a week in March with everything to be done?'

70: 'Can you get help?'

71: 'I don't reckon on much help and everyone's busy in farming just now.'

72: 'Your family?'

73: 'The boy is only eleven, and is more of a scholar than a farmer. The women are no good.'

74: 'Things will have to wait a week or so, I'm afraid. There's no escape from that.'

75: 'A week or so? That could cost me dear.'

76: 'Why didn't you see a doctor when you were ill before?'

77: 'I wasn't what you'd call ill. Like a touch of 'flu perhaps. Then this eye. But it didn't signify much — it was my weak eye, one I injured as a boy.'

78: 'And the weakness of your hand?'

79: 'That was my left hand. If it had been my right I should have had to go.'

80: I marvelled. The average Briton is supposed to run for a doctor with the slightest provocation, and here was this man in his third lesion of disseminated sclerosis, and he had never seen a doctor. God help him, it would have made no difference if he had seen a dozen of them.

81: 'You are not very fond of doctors?'

82: 'It's not that exactly. But I don't like to feel dependent on anybody. What's going to happen to the farm now though?' It seemed as though he thought sending for me had been the real folly.

84: Downstairs I was even more on the defensive. Mother and daughter seemed to be attacking me with quiet ferocity. What was it? What would happen? What could be done? Was it creeping paralysis? Something must be done.

85: Something must be done. I reassured them that the giddiness would pass and probably the double vision too, but I dared not discuss the future. I would get him seen by a specialist at the hospital, and we would talk about it again. In those days, it was difficult to ask a consultant to come into the country without a fee. In theory they would always come for nothing but one hesitated to ask for their charity. The fee would be ten guineas and I guessed this was more than they could afford. Things were difficult enough already. Nowadays, it would be a simple matter because the consultant's fee would be paid through the Health Service.

86: I sat down in the small farm kitchen where I have sat a hundred times since. We talked about the illness and the farm. They had about eighty acres — a small herd of red poll cows which was their pride and joy — and some arable land. I was ill at ease because flashes of their future kept passing through my mind. I saw Arnold Piers bedridden, perhaps incontinent, with bedsores, his beautiful wife strained to breaking point by nursing him. Their livelihood would go, and poverty would be added to chronic sickness. Even then I did not foresee half of what awaited them.

87: As I walked down the track towards the car, the March light was fading. Thrushes were singing their exquisite early spring songs, different I think from those of May. In March they talk together in short lively bursts. In May they seem more conscious of their fine voices and sing for joy.

88: I drove towards home. Crushed flat on the highway was a dead hedgehog. I had always wanted to work in general practice but this was the occasion when it was first deeply impressed on me that I should never want to do anything else. Life and death are inseparable. I wanted life and always found it more abundantly where there was death too.

Chapter 2: Early Problems

89: The early trials of life in general practice have not changed much in thirty years. In one important way, the burden is lighter now because the young general practitioner has not been obliged to pay a large sum for his practice. This usually entailed borrowing and mortgaging his future. In my own case, I borrowed to pay for my education, borrowed to pay for my practice, borrowed to pay for my car and borrowed to pay for my one respectable suit. Apart from the fact that the modern young doctor is better off financially than his predecessors, he faces the same doubts and suspicions from his patients as I did myself. I well remember one January afternoon in the 1930s.

90: I had sat day after day in the consulting room I inherited from my predecessor, listening to the hum of conversation from patients waiting to see my partner. This is one of those slow tortures that increases its torments gradually. At first you take little notice. You nonchalantly write a letter or two as you wait for patients. Then you begin to feel sorry for the fools who have no idea how much they are missing by not consulting you rather than anyone else. Then you become downright angry at the waste of their time and your own. The anger finds no outlet, and begins to feed on your confidence and self-esteem. Slowly your spirits sink.

91: I had reached this stage when Robert Dando came into my consulting room. Scarcely believing he was real, I got up and grasped him firmly by the hand. 'Good evening,' I said. 'Your name is … ?'

92: 'Dando, sir.'

93: 'Sit down, Mr Dando. Sit down.'

94: He sat, with head bent forward, an unhappy expression on his face.

95: 'It's my head,' he said quietly. 'My head.'

96: 'You've got a bad headache. Tell me about it.'

97: 'It's right inside like something trying to burst out.'

98: 'How long have you had it?'

99: 'It came on yesterday when I came home from work.'

100: 'Did it keep you awake during the night?'

101: 'I never shut my eyes. And then in the early hours, the sickness began.'

102: 'Do you still feel sick?'

103: 'Yes.'

104: 'When were you sick last?'

105: 'Just before I came to see you doctor. And now it's in my neck — all up the back. If I straighten my head —.' He tried to raise his head and the pain distorted his features.

106: 'Meningitis,' I thought. Here was my chance. Cerebro-spinal meningitis would respond to the new sulphonamide drugs.

107: 'Get on the couch, will you please. That's right. Easy does it.'

108: I examined him from head to foot. The only concrete signs were the neck rigidity and some pain produced in the legs and back by raising the straight leg from the horizontal. His mental activity was slow and his temperature 99 degrees. This was a cast-iron case of early meningitis.

109: I wondered whether I should ask my partner to see him there and then — not because I doubted my own opinion, but because it was pleasant to be able to show him my ready skill in diagnosis. Perhaps as he was busy, it was better not to trouble him. I would admit Dando to the Cottage Hospital, put him in a room by himself, and do a lumbar puncture. If the cerebro-spinal fluid was cloudy, I would start him on treatment at once, while the laboratory was isolating the organism that had caused his condition.

110: I explained to him that I thought it was necessary to admit him to hospital to do another test. Optimistically, I added that I thought we should soon have him fit again. It was near the end of the official surgery hour, and I went out to tell the dispenser that I was leaving for the hospital, taking my patient with me. Robert Dando was looking a good deal worse already, and I led him by the arm through the crowded waiting-room. There was sudden silence as all eyes were upon us. I was not in the least embarrassed now. After all, I was a quite good doctor.

111: I put him in my car, and then remembered to telephone the hospital to tell them to get the bed ready, and the instruments for lumbar puncture. I drove slowly, thinking of the poor fellow's bursting headache. He threatened to be sick once or twice, but the journey only took a few minutes.

112: The ward sister was a splendid woman and seemed delighted to have a real case admitted. I rather prided myself on my skill in doing lumbar punctures and all went well. I 'got in' first time and took off a few cubic centimetres of cerebro-spinal fluid. It was crystal clear under the right pressure, showing no sign of meningitis.

113: Hiding my embarrassment, I behaved as though this was just what I had expected. As we cleared away the instruments and got the patient comfortable, a junior nurse came in to say that Mrs Dando was here and insisted on coming in to see her husband at once. 'All right,' I said. 'She can come in now.'

114: A young woman in her twenties came in and, ignoring me, went straight to the bed.

115: 'Bob, I'm sorry. I didn't know your neck was so bad. I thought it was like the ones you always get. And I didn't mean all those things I said. I know I upset you, and it was all my fault.'

116: We left them together, locked in each other's arms, as far as this was possible with one in and one out of a hospital bed. Presently I went back and examined him again. His neck was still stiff but already better. His leg signs had disappeared.

117: 'Will you want the cerebro-spinal fluid sent to the laboratory, doctor?' The sister's manner was impeccable, but I knew that she knew. I had mistaken an emotional upset for meningitis.

119: 'When can I go home, doctor?' said Dando.

120: 'In the morning,' I said. 'I'm afraid you will have to stay tonight.' This was because of the lumbar puncture.

121: So the romantic reunion had to wait a few hours. No other harm was done except to my self-confidence. This was my first crude lesson in the effects of emotion on health.

122: The early struggles of every young doctor are mainly concerned with establishing his reputation. In the past this was his ultimate and most powerful therapeutic weapon. Its greatest value was in treatment by suggestion, and in older days most treatment was by suggestion. Every box of tablets and every bottle of medicine was endowed with magic properties. A generation or two ago the doctor replaced the priest as the dispenser of strange healing powers. Today a goocLreputation is less essential but it is still of value. By its means, it is still possible to save precious time by a firm assertion without explanation. It is still possible to reassure the anxious in a matter of seconds. Small wonder that in the past members of our profession have tended to stick together in mutual support rather than let one of the group lose prestige.

123: The young doctor has always begun with two advantages. He is fresh from the glamorous world of the teaching hospital and is therefore automatically regarded as up-to-date. There is furthermore a strong tendency to dub him as 'brilliant'. Why this should be I am not sure. I think it is wishful thinking; those who are ill seek to re-assure themselves that they are in the best possible hands. The other asset of the new general practitioner is his own confidence in himself. We are often taught in our teaching hospitals that the average general practitioner is a poor specimen, out-of-date and out of touch. The young man himself, fresh from house jobs at a big hospital, naturally regards himself as the superior of those who appear to have learnt their medicine under Addison or Bright in the dim recesses of prehistoric times. I well remember in my own early days in general practice, flatly

124: contradicting the opinion of an excellent provincial radiologist, because I thought my London training superior to his-in his own speciality! I hope he has long since forgiven me.

125: Another factor which favours the early attainment of a good reputation is the recent advancement of knowledge. Successful treatment depends far more nowadays on exact knowledge and understanding than on the power of suggestion. The good young doctor soon gets a good name by the careful use of routine methods of treatment. He will accurately assess the degree of cardiac failure in the wheezing elderly bronchitic. He will be familiar with the armamentarium of modern drugs which can support a failing circulation. He will treat the child's earache with enough antibiotics to assure a return to normal hearing. He will treat the woman with bladder infections long and accurately enough to reduce the risk of relapses. He will have at his fingertips die benefits and risks of some of the drugs used in the treatment of psychiatric illness. The weapons at his disposal are so vast that their careful use is enough to guarantee his recognition as a good doctor.

126: What then does he lack? Two things, I suggest. The understanding of the people who bring him their symptoms, and an awareness of the significance of trivial complaints. One man's 'bit of discomfort' is another's 'agony'. Some, but not many, will present their troubles clearly and openly; others are only conscious that all is not well and will withhold important information. Some people need the support they receive when they are ill in order to face life at all; ill-health becomes their prop. The only satisfactory doctor is the one who admits he cannot cure them. Sometimes a marriage under strain will produce illness in both partners. Both may be quite unconscious of the way they are vying with each other for the reputation of being the greater sufferer. The complexities of human behaviour are a life-long study.

Chapter 3: The Significance of Trivial Ailments

127: When I started work in general practice I treated illness as I had been trained to treat it. Disturbances of normal health were mechanical. I had spent six years learning about the workings of the body, the effects of mechanical breakdowns, the ravages of infection and the biochemical disturbances which led to failure of physical function. The human body was a wonderful piece of machinery, relying on the exact balance of hormones and the rhythmic functioning of heart, kidneys and blood vessels to keep it in perfect order. Every disorder produced certain clear-cut symptoms and signs. These, properly investigated and considered, led to a diagnosis and this to the appropriate treatment. If you had been a good student, all was plain sailing.

128: It follows that in my early days I examined each patient carefully and treated the catarrhal infections, the rheumatic pains and the dyspepsias as mechanical disturbances. Those who came repeatedly, with one group of symptoms after another, I regarded as neurotics. On the whole, I was patient with them and, after a time, they would stop coming for trivialities. The real reason behind this common pattern did not enter my head for years. I was quite ignorant of the fact that the majority of major illnesses and many accidents have an emotional component which needs treatment if the malady is to be dealt with properly. I was equally ignorant of the fact that the majority of minor illnesses are entirely due to emotional stresses and can only be relieved by dealing with the emotional problem.

129: It took a long time to realize that, well-trained as I was in the mechanics of the body, there was much I did not know about illness and about people. The declarations of many of my seniors that they were not going to waste time on neurotics but would move heaven and earth to help those who were really ill had its inevitable influence. Their theory was that there are two classes of people — the decent honest ones who developed real physical illnesses, and who were to be treated with all care and skill — and the weaklings and neurotics who make a fuss over nothing. The doctor's duty was to be firm with these drags on the community and keep them at work. Any case you did not understand rapidly joined the ranks of 'neurotics'. This theory had one enormous benefit. It kept up your self-esteem.

130: I soon found myself out of sympathy with the mechanistic school of thought, and met many a baffling problem. Even now after the pioneer work of Dr Balint and others, our ignorance of the 'normal' human mind is profound. Before, we were barely conscious of our ignorance. We fitted our patients into categories to suit our knowledge.

131: The theory of the humours held by the medical profession centuries ago fitted every illness. No sick person was then accused of being a fake or a neurotic. Not until the early twentieth century was it found necessary to banish what could not be explained as non-existent — a highly unscientific attitude for a scientific era.

132: As soon as you abandon the mechanistic theory, you add vastly to your problems. About two-thirds of all your cases are problems of organic disease, with an emotional component which may or may not be of importance. The other third consists of a tangled mixture of fussers (who complain excessively over small disabilities) malingerers (including a few who seek an opportunity of drawing sick benefit when a period at home is a convenience for some domestic reason) and those who present themselves with minor ailments but who are genuinely ill with an underlying emotional conflict. Members of this last group are often much more deeply distressed, and in greater need of help than those who are organically ill. The dramatic improvement in mood and serenity that occurs in a member of this group if he becomes organically ill is evidence of this. His problems are temporarily resolved.

133: The diagnosis, however, is often difficult and always important. It is foolish for the doctor to allow people to make unnecessary claims on his time; it is culpable to allow malingerers to batten on state funds, but it is shameful to accuse someone in deep distress of wasting your time. The differential diagnosis may be more important, shall we say, than that of a neurological case, when the main importance of the diagnosis is to enable a forecast to be made of its future development. In those cases there is often no treatment anyway. In the cases I am referring to, the treatment is entirely different in the three groups and is usually successful if the diagnosis is correct.

134: In more recent years, a young man consulted me twenty-seven times in the course of a year — always with minor ailments. First he came complaining of headaches and giddy attacks. A few weeks later the trouble was diarrhoea and perineal irritation. Later he complained of persistent indigestion both day and night and later still of palpitations and giddiness again. The variety of symptoms and his obvious distress indicated clearly that he was a case of emotional illness. He was not a malingerer or a fusser. It may save time in these cases to spend an hour rinding out the cause of the emotional distress because further attendances may become unnecessary. The object of the interview is to give the patient some little understanding of the workings of his own mind.

135: He was a pleasant quiet man of thirty-five, with thinning hair — a motor mechanic earning good pay and well thought of by his employer. He had an attractive wife and two children. He had no worries, he said, and there appeared no cloud on the family horizon. His parents were good working-class people who had brought him up strictly to conform to their own high standards of correct behaviour. He had been engaged ten years before to a girl he had been deeply in love with. Things had gone wrong between them but he could not tell why. He thought she had flirted with other men. They drifted apart because 'something always got between them'. Eventually they decided to part company, but it took him five very unhappy years to get over the affair. Once they had tried to start again but it was no good. The strange thing was that they never really quarrelled. Although she became furious with him, he never lost his temper with her. He always became silent and unhappy, and could never understand her tantrums.

136: 'Did you never tell her you didn't like her flirting with other men?'

137: 'No. It wouldn't have been fair. And I wasn't sure she had anyway.'

138: 'Wouldn't it have been better to tell her than to bottle up your resentment?'

139: 'Perhaps it would.'

140: 'If she had such tantrums why were you so upset about breaking it off?'

141: 'I was mad about her. She never lost her temper with anyone except me though.'

142: 'Did you find another girl quickly?'

143: 'Not for five years. Then I met my wife and we were married within the year.'

144: 'Do you ever quarrel with her?'

145: 'No. She is quiet and a very good sort. Never loses her temper.'

146: 'You are always kind to everyone aren't you? Do you ever get angry with other people?'

147: 'Yes, I do at work sometimes, but I never show it.'

148: 'Why not?'

149: 'It doesn't help, does it?'

150: I told him that I thought his trouble was that he never let himself get angry with people. If he bottled up his anger, it could upset his nervous system and produce a variety of symptoms. It seemed likely that this was the trouble with his first engagement. It is natural for lovers to quarrel and his girl friend might have felt happier and more satisfied if he had occasionally lost his temper. I told him that an outburst of temper is sometimes a necessary purge to our feelings. We are all born with the same essential ingredients of good and bad, and there is no harm in behaving naturally when this is socially possible.

154: When I saw him a few weeks later, he had just had a fairly sharp quarrel with a workmate who had been dealing unfairly with him for years. He had no further symptoms and felt better. Much that he said made me wonder whether he regretted parting with his first girl friend. However she was married now and he was on the whole happy in his family life. So I did not pursue the argument further to point out that he probably resented his wife for having replaced his earlier love, but could not express his anger with her-though this was possible. He learned to express his aggressions naturally at work and his symptoms disappeared.

155: The distinction between fussers, malingerers and the emotionally ill is not always as easy as this. Some cases belong to all three categories. A woman came to me complaining that her feet were painful and she suffered from persistent indigestion. She was aged about fifty, considerably overweight, and rather deaf. Examination revealed nothing much wrong except some corns on her toes and a distended obese abdomen. We talked about diet and weight reduction, and before she left she asked for a certificate of unfitness for work. If I gave her this, she could claim three pounds a week from a sick benefit scheme at work. I refused it with some little indignation. Was she a fusser? Yes. Was she trying to get sick benefit under false pretences? Yes. On the other hand, why was she overweight? A few questions revealed that her husband was out nearly every evening; her deafness interfered with all social activities; her only son was married and had left the district; and she spent hours each evening alone. Food — biscuits, sweets, cakes — were a low-grade compensation in an unhappy life. To this extent, she was emotionally ill too.

156: The young doctor who is not interested in this unhappy, unattractive woman should not enter general practice, for much of sad, bewildered humanity is of such stuff as this.

157: Whenever someone complains of a trivial symptom, one has to restrain the surge of impatience and ask oneself what may lie behind this consultation — for consultation it is. An adolescent complains of pain in an obviously normal wrist or elbow because he is having bad dreams which frighten him. Another complains of pain in the shoulders after a game of cricket when what is really worrying him is an enlargement of the rudimentary male breast -a developmental mastitis — which he is convinced has some terrible significance, though he is shy of speaking of it. If one's irritation — when tired perhaps — overcomes better judgment, these youngsters will go away troubled, to find relief from their anxieties somewhere else.

158: The presentation of emotional disturbances in the guise of physical symptoms depends on the present-day climate of materialism. And we are as much to blame for this as anyone. Doctors are people who treat mechanical breakdowns of the body; therefore they will listen to you only if you have some physical symptom. At the same time the patient wants help, and does not know where to turn for it. Physical symptoms will gain respectable access to the doctor, and then perhaps he will help.

159: One well-known example of this process of thought is referred to as 'the child as the presenting symptom of the mother's illness'. Sometimes the mother's approach is consciously experimental. She suffers from headaches, or anxiety or sexual frigidity and is not sure whether it is right to consult the doctor over her vague symptoms. When her child has some minor complaint, she brings it to the surgery, as it were to spy out the land, to see what your mood is. People sometimes have a strange conviction that if the doctor meets them socially or in the street, he will know if there is anything really wrong. The mother hopes that a chance question 'How are you, Mrs So and So?' will give her the opportunity to consult you. Her conscience is then clear and she can feel she is not wasting your time. Sometimes the mother's appeal is unconscious. She is in distress and does not know whether she can get help from the doctor. Her tension induces a reaction in the child — sleeplessness or perhaps recurrent catarrhal infections. At the second or third consultation, the doctor probably realizes that it is the mother who is ill and not the child. He gives her a chance to consult him and her problems may be aired.

160: An anxious young mother came to see me, complaining that her six-month-old child never slept more than an hour or two every night. Her own, and her husband's nerves were being strained to breaking point. She could not carry on, and the marriage itself was likely to break up. It is fairly certain that any infant who regularly fails to sleep is reflecting its mother's tension. I told her this and presently had her story. She had been unhappy in her own childhood with a stepmother who was unsympathetic. She felt no love for her own baby and this made her feel intensely guilty. She felt unloved and unloving and frigid towards her husband. The problem was a difficult one but at least I could start in the right place instead of trying one sleeping draft after another for the child — or dismissing the case as futile.

161: It is possible to argue that people who refuse to consult you sensibly don't deserve to be helped. On the other hand they often need help far more than the bolder ones who stride into your consulting room, breezily ask you how you are and then proceed to outline their troubles at length, calling you 'Doc' as they do so. I suppose we are all irritated by some patients and this is a dangerous reaction. Nothing upsets judgment more completely than simple dislike for a patient or a reaction of annoyance to a particular manner.

162: I have known a man of solid character consult a first-rate general practitioner — who was well aware of all I have been writing about — over a period of two years. Always there was a fresh group of minor symptoms and always a refusal to discuss any anxiety or emotional disturbance. At last he wrote a letter to the doctor saying that he had been worrying for years over the possibility of having contracted V.D. while abroad. He had had a blood test but wanted reassurance that this excluded the possibility of brain disease at a later date. Poor man. How can one get angry over these cases?

163: There is one essential question that the doctor must ask himself at any consultation over a trivial complaint. Does this patient really need my help — consciously or unconsciously? If the doctor fails to look beneath the surface, he will become a very poor general practitioner. This is a counsel of perfection and stresses the need to take time over one's work. My earnest hope is that if and when the newly qualified doctors realize the full life that can lie ahead of them in general practice, there will be more and better family doctors, and the standard of our health service will rise.

164: I have written first about the problem of trivial complaints because young doctors appear to be terrified that they will spend their lives dealing with petty illnesses. They need have no fear. The occasional adolescent who consults you over nothing more than a blister on the foot is so rare as to give a welcome excuse for an outburst to a colleague about this generation of long-haired moderns. Our aggressions must come out somewhere — and better in the national pastime of grumbling than on a sensitive youngster who is at our mercy.

165: As I wrote these last words, the telephone called me to a seventy-year-old woman in acute heart failure. A raised blood pressure had caused sudden failure of the left ventricle with resultant dropsy of the lungs. She was blue-grey and sweating and her breathing was asthmatic. From behind the anxious eyes, the world must have looked a red haze with dark figures moving here and there. The pricks of hypodermic injections would be painless in the presence of the all-pervading struggle to breathe — a struggle that would go on like the efforts of Tantalus into a seemingly endless future. In a few hours she recovered. The contrast between dramatic illness and triviality is intense, but if the eyes are open, the cases can be equally absorbing.

Chapter 4: The Piers Family

166: It is not easy to describe the extraordinary variety of a family doctor's work. Not only does he move constantly from triviality to dramatic emergency, but there are events in the life of every family which become his close personal concern. Whether he likes it or not, he becomes involved as friend and counsellor.

167: Catherine Piers grew during the war years into a beautiful young woman. She came into my consulting room one May evening wearing a look of defiance that contrasted oddly with her usual serenity. Perhaps lack of involvement rather than indifference would describe her customary manner. She sat before me like a young animal at bay.

168: 'I'm going to have a baby,' she said. Time had already taught me to hide my personal feelings and I hoped my mask did not slip from its place. 'Tell me about it,' I said.

169: 'I'm never late. Four weeks to the day — to the hour almost. And now I'm two weeks over.'

170: 'Have you got a regular boy friend?'

171: 'Well, sort of.'

172: 'Have you taken any risks?'

173: 'Yes, a month ago, twice.'

174: 'How can I help you, Catherine?'

175: 'I want to know first of all whether I am or not.'

176: 'It's difficult to tell for certain at this stage, but I'll have a look at you if you like and tell you what I think.' There were no easy chemical tests for pregnancy in those days, and the biological tests took time. Her breasts were well developed and slight enlargement was difficult to assess. The nipples were perhaps a shade darker than virgin pink, but she was a brunette anyway. Her uterus seemed a little enlarged but I could not really be sure of this. When she had dressed I said, 'I honestly don't know, Catherine. In spite of what evidence there is, you mustn't take any action at present based on the belief that you are pregnant.'

177: 'Oh.' The sigh was short and rather desperate.

178: 'You will have to wait a fortnight at least and see me again, I'm afraid.'

179: 'I can't do anything about it, I suppose?'

180: 'Nothing at all if you are pregnant. If you are not, there is nothing to do anyway.'

181: She seemed reluctant to go, and evidently wanted to talk. 'Have you told your boy friend?'

182: 'No. Not yet.'

183: 'Your mother?'

184: 'No.'

185: 'Had you intended to get married?'

186: 'Not really.'

187: 'Have you known him long?'

188: 'Two years at College.'

189: 'Can I help you anyhow?'

190: 'It doesn't look like it. But I thought perhaps there was something I could do.'

191: I shook my head. 'I'm afraid not. But it may well be nothing at all. Worry can put off a period quite easily.'

192: 'Not with me I don't think. Can't you tell by examining me?'

193: 'Not for sure.'

194: 'Do you think I am?'

195: 'I don't know. I told you.'

196: 'That means you think I am.'

197: Later, as I looked back on the day I realized that this one event dominated it. She was a splendid young person, full of character and the promise of life, and now she was in the old, old trouble. She might easily be persuaded to marry the wrong man, or alternatively go through the heartbreak of having a baby adopted. No woman in early pregnancy is in a fit state to make decisions as important as this. Her parents too had suffered a great deal because of her father's illness. He had fared better, so far, than many with the same disease and suffered only from some weakness of the legs and difficulty of speech. He had kept the farm going, with a lot of help from his wife, and had insisted on Catherine taking advantage of a university scholarship. And now this. Unreasonably I cursed the young man who had caused the trouble. After all it was an affair of two. But I knew Catherine and I did not know the young man.

198: It always seems to me that to know and to understand are to love, or perhaps 'like' is a better word. If one can really understand the behaviour of any human being a feeling of warmth soon follows. Dislike, in my own case, arises unreasoningly from some irritating quirk of manner and then from failure to understand. I have been blessed so far in life by never having experienced the hatred that is induced by fear. I thought I understood Catherine. I disliked the young man without reason.

199: It was a few days later that he came to see me. He was good-looking, well spoken and seemed intelligent. 'I'm not a patient of yours, doctor,' he said. 'It's about a young woman whom I seem to have got into trouble — Catherine Piers. I believe you saw her the other day.'

200: 'Yes,' I said.

201: 'Of course I'm quite willing to marry her if necessary, but it will be pretty difficult. I've got no money and my father is not well off. Naturally too I would prefer to marry for love. You understand what I mean?'

202: 'I think so.' The professional mask was never harder to keep on than at that moment.

203: 'I have heard that it is not difficult to bring on a miscarriage in these cases. You could hardly call it a miscarriage as early as this.'

204: 'I'm afraid you can't call it anything else except by its proper name — abortion.' I knew I was being unsympathetic.

205: 'Couldn't you help us, doctor?'

206: 'I'm afraid not.'

207: 'I'm going to be quite frank with you doctor. I accept full responsibility, with Catherine, for this baby — if you can call it a baby at this stage. Anyway if we leave things alone a baby will develop — one that is not intended and not wanted. It would be worse than folly to let this happen. The right thing to do is to prevent it, for everyone's sake.'

208: 'It's too late for that.'

209: 'What is the difference between preventing a baby by contraception and preventing it by — bringing on a very early miscarriage?'

210: 'I'm not going to argue with you.'

211: The young man's expression changed. 'This is what you call good morals, is it? To refuse to help two people like Catherine and me. Because we haven't much money, is it? To allow our lives to be more or less ruined just because you stick out for what used to be called high principles. If one of us had a growth you'd presumably be willing to cut it out?'

212: 'That is a pointless comparison. I'm not responsible for the laws of England. I am not willing to help to obtain an illegal abortion. Do you realize that — apart from anything else — if I did I could be really and truly ruined?'

213: 'You are saying that you have never helped a girl in this sort of trouble to get rid of it?'

214: 'No. Never.'

215: 'I didn't mean to bring this up, but you force me to.' He mentioned the name of another patient of mine. 'I happen to know that you treated this particular person more kindly.'

216: 'I don't know what you are talking about.'

217: 'Don't you doctor? The lady I am referring to came to see you some months ago in the same trouble as Catherine. You gave her some tablets and in a few days all was well.'

218: The truth came to me suddenly. One is so vulnerable that accusations of all sorts can be made when one least expects them. He referred to my having given this patient some sedative tablets. If the delay is due to anxiety, sometimes a period follows. I explained this.

219: He got up to go. 'You haven't heard the last of that little episode, doctor,' he said. 'Not by any means.' He left me with the threat drumming through my head. It was the end of my surgery and I sat still, thinking back. There was only my word for it that the tablets I had given were sedatives. There was no real worry, I supposed, because as far as I knew there was no effective abortifacient in tablet form. Nevertheless it would have been wiser to have given her a prescription so that the nature of the tablets could be proved by the chemist. From that day onwards I always took this precaution. It became more important with the introduction in later years of the hormone pregnancy test. I disliked this young man. Poor Catherine.

220: A week later, I was asked to call at the farm. In spite of the family's troubles, Mrs Piers still looked in the prime of life. Arnold Piers had changed a great deal since I first called on him some years before. He was cheerful, but with a cheerfulness that was disturbing. It seemed as though he was not fully aware of his own disability. Things were apt to pass over his head, and obviously his wife supplied the energy needed to run the farm as a business. Today Mrs Piers was in deep distress.

221: 'Catherine has told you of our latest trouble doctor?' She spoke with a trace of bitterness.

222: 'Yes. Things are the same I take it?' I glanced at Catherine and she nodded.

223: 'Catherine wants to marry this boy from town and I won't hear of it. She may listen to you. Will you tell her what you think?'

224: The sudden request to give non-medical advice is a commonplace in general practice, and did not surprise me. What puzzled me was that Mrs Piers was evidently confident that I should be against the marriage and therefore on her side. She had never heard my views on these matters as far as I knew. Here I was wrong. One's views, if they are constant, soon become known to most of one's patients.

225: 'Marriage is too serious a business to be undertaken merely because a girl is going to have a baby,' I said. 'Of course if she intends to marry anyway and it is only a matter of timing, she could well marry now. Otherwise no.'

226: Catherine was looking defiant, almost surly. I recognized that look on the face of youth that warns you that whatever you say will have a cold reception.

227: 'What do you think I can do to help?' I asked.

228: 'I don't know, doctor. I don't know. I am clutching at straws. The truth is I am at my wits' end.'

229: Tears would have helped both mother and daughter, but nothing was farther away at that moment.

230: 'I've made up my mind,' said Catherine. 'I am going to marry him. I love him and we are going to have a baby. I should have thought that was reason enough.'

231: 'The other reason would be his being in love with you,' I said.

232: 'He is. He wants to be married.'

233: 'Did you know he came to see me?'

234: 'Yes. Of course.'

235: 'Then you know what he came for?'

236: 'Yes.'

237: 'If I had been able to do what he asked, would you still have wanted to marry him?'

238: 'Yes.'

239: 'Would he have wanted it?'

240: 'I think so.'

241: Mrs Piers spoke again. 'Doctor, we are not rich, but we would spend all we have to help Cathy. Isn't it true that we could have an operation done somewhere — nothing to do with you I mean — by paying for it?'

242: 'There I can't help you, I'm afraid. To begin with, I don't know where these things are done any more than you do. I know they are done and I know there is a risk about them. If I did know, I couldn't send Catherine there.'

243: 'I'm sorry I troubled you then, doctor.' Her expression was flat and hopeless.

244: 'I wish I could help you, but I suppose this is Catherine's decision. If she decides not to marry, perhaps the baby could be adopted.'

245: Catherine noisily piled some books together and moved to the door. 'Thank you very much. If you have all finished planning my life, I'll go and do some packing.'

246: Mrs Piers slumped into a chair. 'We've never even met him,' she moaned.

247: 'Catherine is coming to see me next week. I'll have another talk to her.'

248: Arnold Piers stood leaning against the mantelpiece throughout the interview. I was shocked at how small a part he took in the exchanges. 'Thank you, doctor, thank you,' he said, as though I had just dropped in to prescribe him a tonic.

249: Catherine came to see me a week later. She sat before me without a word.

250: 'The same?'

251: She nodded.

252: A further examination seemed out of place in her resentful mood so I talked to her.

253: 'You know, Catherine, when I saw you the other day, I didn't want to interfere with your personal decisions. The fact is I was saying what I think your father would say if he were really well. He's not well, you know.'

254: 'In what way do you mean? He's over his attacks — almost.'

255: 'You know what his illness is. He has to fight to keep the farm going. And he is not really indifferent to what happens to you, you know.'

256: Her manner told me I had hit on the right line of approach. 'What is going to happen to him?'

257: 'No one knows. It is fairly certain he will have more and more disability. It is possible he will become paralysed and bedridden. That is why I don't think you should let your mother shoulder any more responsibility.'

258: 'I'm not going to. I shall marry and carry my own burdens.'

259: 'I know you will carry your own burdens as far as you can. But you have to understand that a decision like this does affect your parents as well. It's fashionable nowadays to say that it is your life and you must do what you think best, but none of us are completely free.'

260: 'I'm free to marry whom I like, surely?'

261: 'Yes, of course. How well do you know the young man?'

262: 'I told you. I knew him quite well at College.'

263: 'Has he had any other affairs?'

264: 'Possibly.'

265: 'I'll be frank with you. I don't think I'm bound to secrecy over my interview with him. He didn't come as a patient. He seemed to know a good deal about another young woman who thought she was pregnant some time ago. He thought I had got rid of her pregnancy — which of course I hadn't — and as good as threatened me that he would expose me if I didn't get rid of yours.'

266: She was silent. Then, 'I know everyone's against him, but I love him, don't you understand? I love him.'

267: 'All right, let's say no more. I'd better have another look at you.'

268: When I examined her, I found her uterus no more enlarged than it was two weeks before. I couldn't be sure, but it seemed possible that she was not pregnant after all. I told her what I thought. Her reaction, or lack of it, surprised me until I realized that she was obviously infatuated with the young man and wanted to marry him, pregnant or not. It is odd how we use the word 'infatuated' for an undesirable attachment, while for a desirable one we talk about being in love.

269: 'Don't decide anything. See me again in two weeks. And make no definite plans. Agreed?'

270: 'All right.'

271: She did not come to see me a fortnight later, but wrote me a letter to say she was 'all right'. Somehow the affair petered out. I guessed that she had got over her infatuation. Perhaps my slightly unethical revelation to her had had its effect. I did not know. I was relieved all the same.

272: When I was a medical student, an eminent teacher warned us that many of us would be sorely tried when, one day, our best friend's daughter would become pregnant out of wedlock. We were told it would be painful to resist his anguished requests for help, but we should have to harden our hearts. I thought he was exaggerating, but time proved him a wise counsellor.

273: A generation ago, there was no great battle of conscience over the refusal to have anything to do with a requested abortion. You were sorry for the families in distress, but it had been firmly drilled into you that abortion was something you had no part in. Today, with the new abortion laws, the problem is far less simple. This will be discussed in a later chapter.

Chapter 5: Practice Planning

274: Life as a general medical practitioner offers challenges, rewards, and to some a deep sense of satisfaction. Whether or not it will prove satisfying depends on what is expected of life in the first place. If a man is interested in the complex of vigour and sadness, hope and frustration, and all the paradoxes that fill human life, he will find that in general practice he is living near to the heart of affairs. The mainsprings of life are not in Westminster or the White House, nor on the factory floor, but in the family. If he is enthusiastic about the mechanisms of mental and physical health which so profoundly affect human happiness, he will be able to exercise his skill and ingenuity to his heart's content. If, as well as this, he begins his adult life with the conviction that he has received so many blessings that he has a great deal to repay, he will have unlimited opportunities to serve.

275: It is well to remind oneself constantly of these things, because the day-to-day work needs as much hard-headed planning and as much careful organization as any process on a factory floor. It is all too easy to become absorbed into the machinery of medical practice and to forget the human element. But without good organization, the work could not be done at all.


277: The root of the trouble in general practice in the United Kingdom is the difficulty in obtaining adequate working premises in the great towns and cities. Had the promised health centres been provided,this difficulty would not have arisen. It is impossible to work properly in dingy and outdated buildings. It is as reasonable to expect the work of a modern post office to be done efficiently in a village store as to ask a modern doctor to work in a surgery built in 1930.

278: The design of the new buildings has been decided by social change. Family doctors between the wars did most of their work in the patients' homes. They opened their surgery doors for an hour morning and evening to see those who preferred to pay a smaller fee for their advice, together with some of their 'panel' patients with minor ailments. The fee for a private consultation in the surgery in the 1930s was usually about half a crown. Cough medicines and ear drops were dispensed. Bismuth mixtures were given for dyspepsia, and a bromide and mix vomica mixture seemed an accepted panacea for most nervous disorders. When patients became dependent on the medicine they came back time and again with their half crowns for more. The surgery was little more than a dispensary with limited drugs in its store.

279: After the Second World War, the pattern of work began to change. The doctor had more to offer as the new drugs came into his hands, and surgeries became longer. The motor-car brought people to the consulting room who would previously have asked for a visit. With the beginning of the Health Service in 1948, the prospect of 'something for nothing' began to increase the patients' demands. In our practice surgeries became affairs of two to three hours, twice a day, and the patients endured long periods of waiting in rooms built for half the numbers, ill ventilated, and filled with heavily infected air. If you had nothing much wrong before you came to the doctor, you had a good chance of having something when you left him.

280: It is surprising that we allowed this state of affairs to go on for so long. In some industrial areas things are still unchanged today. The weight of tradition was heavy on us of course, and there was no financial incentive to improve conditions. The reverse was the case. Adequate surgeries had to be built and secretaries paid out of the doctor's own pocket. His income depended on how many patients he had on his list, and this was intended to be adequate to cover his expenses. Running his practice properly from a well-equipped building became a difficult matter for men with families to educate. Little wonder many of them were slow to spend the thousands of pounds necessary to bring their premises up to date. The Ministry of Health did make one concession. They made an interest-free loan for the building of practice premises which satisfied their standards. In my own practice, we took advantage of this and built a new surgery in 1958. It had three consulting rooms, each with direct access to a central secretarial room where the records were kept, a large waiting room, well heated and lit, and all the necessary conveniences for patients. It was, however, planned on the assumption that the old system of patients waiting their turn to see the doctor would continue. The next step in progress towards better practice, and the most far-reaching in its effect, was the introduction of a system of appointments for all patients.

281: The cost of this advance, with all the extra secretarial help it involved, had again to be borne by the doctor. The main benefits were for the patients. Looking back it is surprising and reassuring that so many doctors began an appointment system in spite of the extra work it involved. It had no competitive advantage because most doctors had, in any case, more patients than they wanted. In my own partnership, we began an appointment system on April i, 1961, as a bold experiment. Some people warned us that we should be overwhelmed with work, but this did not happen. It had some advantages for us too. We knew at the beginning of each surgery how many patients we had to see and case records were put out for us beforehand. A minor advantage to the doctor was that there was no danger of his forgetting the patient's name! The record card reminded him of all he ought to know. Most of the patients were pleased, though some were puzzled. One old man said to me 'We have to come to the surgery twice now for every once we see you.' He meant that, not being good on the telephone, he had to call first to make an appointment.

282: The appointment system was the turning point into a new era. It led to a complete change in the whole system of practice. To begin with, much more secretarial help was needed. Previously we had one secretary-dispenser between three of us. Now we needed three extra part-time secretaries, the four girls doing a total of over a hundred hours a week. The second effect was that house visiting has been steadily reduced over the years. Most patients have cars, or can ask a friend to drive them and we are able to ask them to come to see us by appointment, even though they feel quite unwell. Even patients with temperatures can be brought to see us. They often prefer this because they can be seen early and start treatment at once, instead of waiting for a visit at some uncertain time later in the day.

283: Another system is being tried in some areas. The doctor sends a car to bring sick patients to the surgery on certain days of the week. Those most suited to this method are the elderly and chronic sick. They are asked first whether they will be willing to come in by car. If they agree, a trial is made. Almost invariably they are pleased with the change. A recent report in the British Medical Journal related how a number of elderly patients, previously house-bound, had found new confidence in themselves and had even started to go out shopping again. It is of the utmost importance that in these days of lengthy old age the elderly should remain as active as possible. The car transport system is an excellent innovation.

284: With the work concentrated in one place, the next step was for nursing help to reduce the load of minor affairs. The new system certainly increased the number of consultations for insignificant ailments. None could be hurried in case the triviality was only an excuse for consulting you on something quite different. The nurse's help became essential. She could syringe the wax from obstructed ears and do dressings. She could give routine injections, and explain the taking of urine specimens for laboratory

285: lysis — a process that takes two to four minutes, according to the intelligence of the patient. She could do haemoglobin estimates and take blood from a vein for laboratory investigation. She could take cervical smears from women patients, and attend ante-natal clinics, where she would measure blood pressure, test urine, and weigh patients. She could fill in forms and give instruction to the uninitiated about claiming maternity benefits, and talk to expectant mothers, giving them advice about exercises, diet and breast preparation.

286: All this saved a great deal of time, but in due course our nine-year-old surgery became completely out of date. We needed a room for the nurses. At first they had used one of our consulting rooms if it happened to be free, carrying their equipment from place to place on a tray or trolley. As they took on more work they needed their own consulting room with examination couch, desk, chairs and cupboards. As we became more free from time-consuming minor activities, we had more time to examine the patients. We needed examination rooms in addition to our consulting rooms, so that we should not have to wait while patients dressed and undressed. Examination rooms remove one of the mental dampers which cause the doctor to hesitate between a full and an inadequate examination. Another equally important need was a better reception area. Patients coming in must have quick access to a secretary who can give them an appointment, take a message, or receive their name if they already have an appointment. The reception counter has to accommodate two secretaries, one of whom receives patients and tells them when their doctor is ready. She must have a good view of the whole waiting room, and be easily accessible to patients coming in. The other answers the telephone and makes new appointments. She must have reasonable privacy, because some of her conversations would be highly embarrassing if widely broadcast. At the same time she too must be easily accessible to patients coming m. Finally we needed more room for our secretaries. It was evident that large and expensive additions to our surgery building had become necessary.

287: Now we have a surgery building which consists of four consulting rooms, two examination rooms, a nurses' room, a secretaries' room, a waiting room and adjoining this a large reception area enclosing a records room. There are two entrances and washrooms for staff and patients.

288: At the end of each consultation, the doctor presses a button which sounds a buzzer in the waiting room and lights up his name. With a little help from a receptionist, the next patient finds his way to his doctor's room. Some doctors claim that they like the exercise of fetching each patient in themselves, we prefer to take our exercise in other ways.

289: The additions to our building cost about £4,500, one-third of which was paid by the Ministry of Health. The total cost of about £10,000 if raised on an interest-free loan would have cost each of four partners a little under £400 a year for seven years. If each one had three thousand patients, no seniority award, and did forty maternity cases a year, he would earn about £4,500 per annum net. The £400 a year could easily be met out of this. It is, moreover, a saving which keeps its real value.

290: The situation in larger towns is more difficult. In the centre of Birmingham or London, a site such as ours might cost a very large sum indeed. In these areas a health centre or extensive help in building a surgery is essential.

291: In most areas, improved premises and more ancilliary help have been made possible by the so-called 'Charter of General Practice' of 1966. Our remuneration was increased and 70 per cent of the cost of our ancilliary help is now paid for us. More recently we have had valuable co-operation from the local authority. By arrangement with the medical officer of health, we have been provided with half our nursing help free of charge. In return, the nurses and health visitors use our accommodation for some of the work they would otherwise have done in patients' homes. One can see the ancient British genius for slowly making headway towards the integration of an effective system.

292: Finally the appointments system allows a far greater elasticity in our surgery hours. It is possible to stagger these in such a way that there is a doctor in the surgery almost all day. In the case of emergencies, this is an obvious advantage. The occasional anguished relative need no longer be distressed by the unhelpful answer that 'the doctor is on his rounds'.

293: Work in the surgery is extremely concentrated. We see about eight patients an hour and this means that the mind is working to the limit of its capacity. A two-and-a-half-hour session is the longest we can do without undue fatigue and loss of efficiency. The best plan is to break away after this to some of the other activities and return later.


295: The most important line of communication from the surgery is that with the laboratory. Access to full laboratory help came at varying speeds in different parts of the country. It appears to be good now all over England, though the quality of help given varies to some extent. Without laboratory help, practice would be impossible.

296: In the 1930s we used to do a few laborious investigations ourselves. These were usually so inexpertly done as to be of value only to our self-esteem. Today our efforts would be completely valueless. Each doctor sends several urine and blood samples to the laboratory every week. All maternity cases have blood tested during pregnancy to exclude syphilis, and to record the blood group and rhesus factor. Blood examination for primary anaemia is occasionally necessary, and white cell counts more often. Blood sugar estimates are routine in diabetics and in suspected diabetes, and blood urea estimates are sometimes needed in elderly people. A specific test for rheumatoid arthritis is needed every few weeks, and a blood test for serum changes in doubtful cases of coronary thrombosis every month or two. A blood uric acid test is needed about equally frequently.

297: The only tests we do ourselves are simple urine examinations for albumin and sugar, and blood tests for haemoglobin estimation and sedimentation rate. These can easily be done by the nurse.

298: There is one comparatively new development in the realm of cytology. The same laboratory technicians who are skilled in reading cervical smears are able to give valuable information on the hormonal state of expectant mothers. By examining a vaginal smear in early pregnancy, they are able to indicate those who need special treatment to avoid a miscarriage.

299: It is worth remarking here on the personal appreciation felt by most family doctors for such service as this. One who has felt the anguish that a miscarriage means to a young woman whose whole body and mind had become keyed up to the task of producing her own baby, would do all in his power to help her to avoid a recurrence of the disaster. Significantly, these young women are heard to say, not 'I had a miscarriage,' but 'I lost my baby.' They come back in due course, saying 'I think I am expecting a baby. Do you think I shall be all right this time?' Until a year or two ago, we could only point out that many women have one miscarriage, and that this time probably all would be well. We could only cross our fingers and hope. Now we can, in a matter of minutes, send off a vaginal smear to the laboratory. If the report comes back 'progesterone deficiency' we can give her a series of injections which will reduce the risk of a second miscarriage. The technician in the background misses the relief that his services bring to the worried young couples. We, the dispensers of the results of his skill, reap the harvest.


301: The next essential line of communication is with the consultants. No human being can carry in his mind up-to-date knowledge of every branch of medicine. In my own opinion, some of the best brains should be in general practice because, of all the branches of medicine, this is the most difficult to do well. At present, however most of the best brains are those of the consultants. Fortunately they are close at hand, day and night, to give help and advice. Specialist help can be called on in two ways — by sending cases to hospital out-patient departments, and by calling in the specialist to visit the patient's home. In those areas where there is a cottage hospital the general practitioner and the consultant meet regularly and work together. One has only to go with the patient to the hospital, to be able to discuss his case, with a visiting consultant. Easier still, one can meet the consultant there to ask advice. When the general practitioner knows the consultants well, he can, and frequently does, telephone to ask about any problem in their special sphere.

302: Consultants are paid a fee by the Ministry of Health for domiciliary visits when a patient is unable to attend hospital outpatients. With a cottage hospital close at hand, where patients can be seen without much effort on their part, these visits are not needed very often. Those from a psychiatrist are wanted most frequently. Occasionally a physician's opinion is asked for. I have had three domiciliary visits to my patients in the last year: one was from a psychiatrist to an elderly patient who was depressed and agitated, two were from physicians. One case was of persistent asthma, and the other an octogenarian with a problem involving an enlarged liver. Similar visits are sometimes valuable in pediatric cases, when one is anxious to avoid sending a small child to hospital — often a traumatic affair — and the diagnosis is difficult. These occasions are, of course, time consuming, and the general practitioner is, quite reasonably, paid no fee for his attendance; but they are usually relaxed, pleasant and informative affairs.


304: Four general practitioners out of every five in the United Kingdom are in partnership. This has become essential if adequate free time is to be arranged. Not many people can remain on duty for twenty-four hours a day, and seven days a week, without suffering in health. If the number of doctors in a partnership is too large, there is loss of the personal relationship between doctor and patient; if it is too small, there are not enough to arrange a reasonable rota system. I think the ideal number is four. Good personal relationships between the doctors in a partnership is, of course, important. We used to be told that a good partner is as important as a good wife. The larger the group, the greater the chance of clashes of personality. If possible, the wives should get on equally well. It is well known to every wife that her own husband works harder than any other doctor in the partnership. This puts an initial strain on the relationship, but with good will and tolerance this built-in drawback can be overcome.

305: In a partnership of four, it is possible for one to be on duty for all at the weekend. Each one can then be free for three weekends out of four. A weekend in our case lasts from noon on Saturday until 8 a.m. on Monday. In addition to this, a free half-day can be arranged for each partner during the week.

306: It is necessary to decide whether maternity cases will be attended during times off duty. As far as possible, it is our practice to attend our own cases, whether we are on call or not. It seems churlish behaviour to a young woman who has put her faith in a doctor, to say, at her moment of greatest need, 'I am off now. Doctor so-and-so will look after you.' If one is away from home or on holiday there is no alternative, a partner takes over.

307: It is worth recording that the personal attendance of a trusted individual can have a remarkable effect on the progress of labour. Most of us have from time to time been called in to see a frightened young woman having her first baby. The nurse has sent an apologetic message, saying that the patient was nothing like 'ready' but has been having strong pains for several hours and is getting nowhere. After examination, you sit quietly by, giving reassurance and in a short while the pains become less fierce, and the progress rapidly increases. The drug 'doctor' is safe and powerful.

308: There are several methods of transferring telephone calls while off duty. They can be transferred by a surgery telephone exchange, or by a recording device which tells the patient who is on call if their own doctor is not. The ideal is still the manually operated local exchange. This, alas, is in most areas a thing of the past. It was an efficient and friendly affair. I remember a patient telling me that when he rang me one night, the voice of the operator said 'You won't get him. He's gone to so-and-so over at Farrington.' The patient lived nearby and fetched me from the house in question, so my wife was saved a second wakening.

309: It is frequently argued that much larger group practices working in much larger centres will be needed in future. From the point of view of economy, premises must be built in large enough units to accommodate the work of an area included within a radius of two or three miles. This in the larger towns would certainly have to be big enough to accommodate a large number of doctors. They could still however work in small, well-integrated groups.

310: The suggestion of larger working groups is associated with the far less desirable idea that each doctor should develop a special interest in one subject — pediatrics, dermatology, maternity and so on; in other words, he is to become a second or third-class specialist. To my mind, the general practitioner has plenty to do to maintain his efficiency in his own work. Nothing detracts more from an understanding of his real function than the suggestion that he ought to try to do something else as well. It is never suggested that a radiologist or a dermatologist should take on work as a part-time surgeon. A general practitioner's special interest is obviously his personal concern, but I do not think that this should be put forward as the main reason for giving him access to hospital beds. Hospitals, it is argued, are specialist territory. Therefore to obtain access to them the general practitioner must be a part-time or pseudo specialist.

311: There is no doubt that the general practitioner must obtain full access to hospital beds — but this must be to treat his own cases — cases that do not normally need specialist care. The case for general practitioner hospital beds is so important that it will be considered in a separate chapter.


313: This may seem a dull subject but to those who have watched the virtual disappearance of diphtheria, tetanus and whooping-cough, and the enormous reduction in poliomyelitis, and who now anticipate the disappearance of measles, it has some fascination. Inoculations have in the past been partly done at local authority welfare clinics and partly by the general practitioner. When the general practitioner has adequate premises and full ancillary help, he can quite easily undertake responsibility for this department of preventive, medicine in co-operation with the Medical Officer of Health.

314: The system now working in our district promises well. Lists of all our patients under the age of ten were sent to the County Health Department. When an infant is added to our lists we hand on to the same department the necessary details. With the help of a computer the county then inform every parent when a child is due to receive one of the preventive inoculations on an agreed schedule. This begins at the age of four to six months, with the first triple inoculation against diphtheria, whooping cough and tetanus and the first oral dose of poliomyelitis vaccine. Periodic doses of these, as well as measles vaccine and smallpox vaccination are offered as well.

315: Every month our secretary receives a list of children for inoculation on a simple form on which the ringing of a letter in an appropriate column indicates that the injection has been done, deferred or that the patient failed to attend. We take it in turn to attend these preventive inoculation clinics and one doctor is assisted by two nurses and two secretaries. Fifty or sixty children are dealt with in about an hour. When the scheme has been longer in operation, an hour or so's work by one doctor every onth will be all the time needed. Payment for this service is automatically by the local authority after analysis of the forms.

316: The whole of the routine inoculation of children is in this way cared for with the minimum expenditure of time on our part. Again everything depends on suitable premises and ancillary help.


318: I refer of course to the doctor's wife. Her part in practice planning is more historical than actual in most practices. She has been described both as something approaching the ideal of womanhood and as the embittered dragon who is the patients' natural enemy. In truth of course she is like any other woman. She shares the funny little stories and the occasional heartbreak of the practice, watches her husband's absorption in his work, and from time to time sees him drained of energy because of it.

319: In the past she was the cornerstone of the practice organization — secretary, assistant, treasurer and accountant combined. Even now with full secretarial help in the practice she still has a good deal of telephone work to do. She acts as telephonist on the evenings and nights when her husband is on duty, and in some practices this is still seven nights a week. Furthermore, patients are apt to consult her when the doctor is out. It is fatally easy to take too much responsibility.

320: Recently, a young wife with two small sons was bathing the younger, aged six months, while the elder, aged two, was balancing on a chair reaching for a toy on the bathroom shelf. The telephone rang, so she was obliged to take the baby out of the bath, wrap him in a towel, and hold him, strongly objecting, in her arms. She tried to keep an eye on the older boy at the same time. A voice on the telephone gave a name and address and went on, 'Is the doctor at home?'

321: 'No, I am afraid not. He'll be in at seven o'clock.'

322: 'Well, you see, it's my little girl. She's been crying all day with pains in the stomach.'

323: 'Did you ring the surgery?'

324: 'Yes, but the doctor is not there.'

325: 'Will you ring them again, please. They will tell you what to do.'

326: 'I've done that Miss and I haven't got another four pennies.'

327: At this point the elder child reached his boat and threw it into the bath. It fell on its side, so he learned precariously over to right it. The young wife watched him anxiously.

328: 'If you could just tell me what I ought to do. The wife's a bit afraid of appendicitis.'

329: 'How long has she had the pain?'

330: 'Since this morning.'

331: 'That's less than twelve hours. I think it can wait an hour till my husband comes in.'

332: 'Would aspirin be safe, do you think?'

333: At this point the baby in her arms began to cry vigorously. 'Yes. Yes, that would be all right. Will you ring again after seven?'

334: 'All right.'

335: As she regained control of the children, she wondered whether it had been wise to say that aspirin would be suitable treatment for abdominal pain.

336: The general practitioner's work outside his surgery — and this is still nearly half of it — is unplannable. Even that in the surgery is subject to dislocation by the unpredictable emergency.

Chapter 6: The Unpredictable Emergency

337: 'Art is long, life is short, the occasion sudden…'

338: The sudden occasion, the unpredictable emergency, plays havoc with the best of plans, and makes chaos of the most orderly of days. Planning in general practice has to be elastic enough to accommodate the day's affairs to sudden dislocation with as little inconvenience to patients as possible. At times — and it is usually like a thunderbolt out of a clear blue sky — a pleasant orderly day can be turned into a nightmare.

339: One sunny May morning — it was a few days before we were to set out on holiday — we were up early. There was a lot to be done in the garden before we went away, but the May chorus of birds was so delightful that I spent much of my time recording it on our new tape recorder. We have a number of trees around us in spite of being in a built-up area and on a main road, and the sounds were fascinating. At about 6 a.m., as the traffic began to increase, I turned off the recorder and played, I remember, a record of Mendelssohn's Violin Concerto. The windows were open and the sounds flooded the garden. A glorious morning, one to be remembered. I was reluctantly thinking of coming indoors when the telephone rang. My wife answered it and her expression warned me that trouble was near.

340: 'There's been an accident underground,' she said. 'A man is trapped and they can't move him.'

341: The grim situation was clear to both of us. 'Have you kept them on the phone?'

342: 'Yes.'

343: A few questions confirmed my fears. A man was trapped by fallen roof which had crushed and pinned his leg. It would probably need an emergency amputation. I do no surgery normally except minor affairs. The last time I had done a major operation was during the war. My partner, who had his fellowship in surgery, was on holiday, and there was no surgeon in the town, the nearest being ten miles away. I sent a message to a fellow general practitioner, asking him to join me as soon as possible underground, then drove to the surgery and picked up some extra instruments and the midder bag. This contained chloroform and a mask which was seldom used even in those days. The instruments were clean but not sterile. Any hope of a sterile operation was in any case out of the question. I had a scalpel, a number of artery forceps, some catgut, and plenty of dressings. I had no saw if a bone was to be divided. The prospect was appalling. If the man was bleeding or in a serious condition, it might be necessary to disarticulate the hip joint and remove the whole leg. With luck the bone might be already broken proximal to the point where it was pinned to the ground. Possibly only the lower leg was pinned. This would simplify matters. I arrived at the pithead less than a mile from our surgery and was met by willing helpers. My heavy cases were seized and one of the men handed me a safety helmet. Judging by their respectful attitude, they had no idea how I was feeling. The task before me was in all probability far beyond my capabilities. The man would die under my hand as that gypsy child had died under my tracheotomy knife years ago when the parents had treated his diphtheria for eight days in a caravan without advice.

344: I was led by the under-manager to the cage. Two black-faced men followed with my cases. Sometimes on these occasions thoughts seem to come into the mind from somewhere outside oneself. 'Plasma,' I thought, and spoke to the under-manager. 'Send to the hospital will you, and ask them to send two bottles of blood plasma and some transfusion sets to the top here. I'll need it when we get him up.' If we get him up, I thought. Tell Matron what's happened. She'll send whatever she thinks we

345: might want.'

346: A moment later we were in the cage, moving smoothly and dripping with water. Some shouts and a clanging of metal from somewhere and we were on our way down. I always feel a profound respect for the men who care for machines with a skill I could never match. Our journey was controlled with perfect efficiency. The cage rushed downwards past the dripping walls of the shaft as though airborne. Six hundred feet it dropped and then seemed to lift us effortlessly upwards as it came to a halt. The small procession passed across an underground hall to a roadway with narrow-gauge rails.

347: 'We shall have to walk, doctor. It's about half-a-mile and not too rough.' I can still hear the confident West Country speech. It seemed at that moment that I had to carry a great weight of responsibility on my shoulders. We walked on past the lights and into a darkness pierced only by our torches. The anaesthetic, I thought, very light chloroform. He would be badly shocked and would have had morphia. I would get him under, and then get someone to hold the mask. After that, it all depended on what I found. If the knee were free I could disarticulate the joint easily.

348: 'They will have put on a tourniquet?' I asked.

349: 'Yes. Blacker's there sir. He'll have done that and given him morphia.'

350: I blessed the wise provision of morphia and men trained to give it at these first-aid posts. Perhaps everything would be all right. However rough the surgery, if we could anaesthetize the man and get him free with a good tourniquet round the thigh, it would be easy to put things right once we were on top ground again. If the thigh were crushed too high up for a tourniquet, heroic surgery might be useless. I must wait. It wouldn't be long now. A little confidence came slowly back, relieving the blackest fear I had ever known. I walked on, thinking vaguely, for an unguessable distance. I remembered Cronin's character who had successfully amputated an arm underground and much enhanced his reputation. That was in a book, though, and an arm was a much simpler affair anyway.

351: Somewhere at the back of my mind there was the distant high-pitched sound of metals banging together, then the sound of wheels on the track. There were lights approaching.

352: 'Wait a minute, sir. They must have got him out. That's a stretcher on the truck.'

353: The other party drew nearer and in a moment we met. They had the man on a stretcher covered by grey blankets. Somehow they had managed to lever up a great weight of rock and drag him free. I felt his pulse which was not too bad, exposed the leg which was hopelessly crushed from lower thigh downwards. The tourniquet had controlled the bleeding. All was well — or nearly well.

354: I walked back alongside the stretcher. The relief was enormous. A quarter of an hour later we had him in the casualty room under a good light. The plasma had not arrived. He was given a cup of tea and a cigarette. Presently I fixed up the intravenous drip and with the fluid running in fairly briskly we loaded him on to the ambulance. He went off to Bath where they cleaned him up and did a planned amputation later in the day.

355: I see the man still from time to time. His artificial leg has been troublesome but he is alive and well. He is usually standing at an awkward corner unofficially directing the traffic. We look at each other like men who have shared some great experience although I did nothing whatever to save his life. I had worried and planned and done nothing, but it might have been a different story.

356: It was eleven o'clock before I got to the surgery. The patients had all gone away and would no doubt come back in the evening or next day. On these occasions life seems out of joint, and it takes a day or two to catch up with the routine of work.

Chapter 7: General Practitioner and Hospital Beds

357: There is, I believe, one grave mistake in the planning of the National Health Service, and until it is corrected there is no hope of an entirely satisfactory and efficient service. There has been no provision for general practitioner hospital beds.

358: Attention is first drawn to this anomaly by the most casual observation of the health services of other advanced democratic countries. In America, Canada, Australia and New Zealand, the countries which claim the majority of our young doctors who emigrate, all general practitioners have free access to hospital beds.

359: The complaints levelled at our own service, all relate to this problem. Why are general practitioners forced to send so many of their cases — cases they could easily treat themselves — to be treated by others? Why do general practitioners so quickly become isolated from contact with hospitals? Why do they not have daily contact with consultants? Why do they become so quickly out-of-date in a rapidly changing world? Why do they lose prestige? Why do some consultants, like the one quoted in my first chapter, claim that the work of general practitioners could be done by men with one or two years' training? Why is seven or eight years' hospital training wasted in the case of so many doctors in the United Kingdom?

360: The answer is the same in each case.

361: As I remarked previously, the need to keep the general practitioner in touch with hospitals is accepted. But the solution proposed — that by reason of a special interest he should work in a hospital as a part-time specialist — is the wrong one. This proposal can only apply to a minority of general practitioners and will leave out many of the best and most dedicated family doctors. The true place for general practitioners in hospital is in the care of those of their own patients who cannot be nursed at home and yet who do not need specialist treatment.

362: The first point that must be recognized is that social changes now demand that nearly everyone who becomes seriously ill must be nursed in hospital. Few families are prepared to undertake the toil and trouble of nursing their incapacitated relatives for more than a short period. There are, it is true, certain advantages to the patient in being in hospital. Nurses work fixed hours and do not usually become excessively tired. Night nurses are available who can sleep by day. Medical investigations are more easily done. Treatment by regular injections becomes a practical possibility. Records of temperature and fluid intake and output are kept without difficulty.

363: In a rich materialistic society, sick people will in future be largely treated in hospitals. Most of these same sick people have in the past been treated by their general practitioners. They are not problems for consultants. They can be adequately cared for now, as they have always been, by their own doctors. Yet under present conditions these cases are being sent either to a major hospital where they occupy specialists' beds or to a chronic sick hospital where they will receive virtually no treatment at all beyond the simplest nursing care.

364: To make the argument more explicit, here are some of the cases I am referring to:

365: Most cases of acute cardiac failure can be properly investigated and treated in general practitioner beds. After clinical examination, chest X-ray and electro-cardiogram they can be adequately assessed. Treatment by rest and diuretic and cardiac drugs will bring most of them under control. They can then be rehabilitated to moderate activity under the eye of their own doctor. Acute chest infections, bronchitis and pneumonitis, especially if there is some cardiac weakness, can be best treated in the same type of hospital.

366: Old people whose health is threatening to break down can be admitted while an attempt is made to rehabilitate them. Physiotherapy, treatment of infections, adequate diet, and assessment of cardiac defects may be of great help. If this fails they may be regretfully sent to chronic sick beds elsewhere, unless their families can cope with them.

367: Cases of terminal cancer can be better relieved in these beds than anywhere. All necessary nursing help, analgesics, and sedatives are available, and the relatives and family doctor can visit them daily. The essential need in these cases is that the patient should know that he has an ally who will not desert him from the beginning to the end of his illness. The same doctor should remain in attendance. Let anyone consider how he himself would feel, at the time when he needed more nursing help, if he were suddenly transferred into the hands of strangers, knowing he was sent to them to die, and fearing what the end might be. Perhaps too little is thought about this problem because those who suffer that particular anguish never come back to tell the tale. There is for them no humane alternative to the general practitioner hospital bed.

368: In the opinion of many physicians, coronary thrombosis can be adequately treated in a general practitioner hospital bed. This may shock some people but I have high authority for this statement. It is not yet clear how much extra benefit can be guaranteed for these cases in an intensive care unit, even if these were always available. The majority of cases can be accurately diagnosed and treated in a general practitioner hospital. If it is eventually decided that all coronary cases would benefit from special care units and if these become available we should be relieved of the care of these cases.

369: Strokes are ideally treated in this type of hospital. Bladder control can be assisted in the early stages, and active movements and physiotherapy given later. These cases are among the saddest, as well as the commonest sights in our society. A man of vigour and intelligence can suddenly become a pathetic and useless thing, incontinent, with mumbling speech and flail useless limbs. In the past he was usually regarded as a 'write-off and left to his family to make the best of. There but for the grace of God goes any one of us. It behoves us to give him all the care in our power. The outlook is grim, but not so grim with a cheerful and encouraging physiotherapist to help him back on to his legs, and with a daily visit from his family doctor to make him feel that something is going to be done to help him. There is often a 60 or 70 per cent recovery, and limbs that might have been useless can in a few months be made to work again. One day, perhaps in half a century, there may be intensive care units for these cases too. Until that bright day dawns — if it ever does — the patient is best in a cottage hospital or equivalent general practitioner bed.

370: Convalescent cases after abdominal surgery are often transferred from the major hospital to the general practitioner bed at an early stage, saving valuable bed space in the main hospital.

371: Almost the only general practitioner beds in existence at the present time are those in the cottage hospitals which are occasionally to be found in the older and smaller towns. Those general practitioners fortunate enough to have access to them find that much of their work soon centres around these hospitals. In our own cottage hospital a visit is usually made to our patients there each day and at the same time any minor surgical procedure is done in the casualty department. Abscesses are opened when necessary — a less common affair in these days of antibiotics. Haemorrhoids are injected, hydrocoeles 'tapped', and such small but useful jobs done as the injection of 'tennis elbow' with cortisone and local anaesthetic. We then visit the X-ray department where our patients' X-ray films are left in our lockers. X-rays of chests, joints and bone injuries are the routine ones. X-rays of kidneys by intravenous pyelogram and of gall-bladders are done when necessary. Help in interpreting the X-rays is given by a radiologist

372: ys weekly visit. Barium meals are done by him alone.

373: The hospital round includes a visit to the maternity unit which is done first, and a visit to the physiotherapy department, when necessary, which is done last. In our case there are twelve visiting general practitioners. It is a good meeting place. There is always someone to give a 'gas' for you, and always someone to talk 'shop' to. Consultants visit regularly to do out-patients' sessions. They are then available for discussion and questioning.

374: The value of these general practitioner hospitals to the patients is very great. They have the advantage of unbroken care from their family doctor with consultant advice when necessary. Beds for geriatric cases and cardiac emergencies, terminal cancer and the cases I have already mentioned are far more easily available here than in a major hospital. There is a national shortage of chronic sick beds — if these are regarded as an alternative -and precious time is often lost while waiting for them when real help could be given. The value to the family doctor is incalculable.

375: In spite of their immense value, the cottage hospitals are being gradually closed down. This is partly on grounds of economy. They are small and comparatively expensive to run. Another reason is, I believe, that they have not in the past been used entirely as general practitioner beds in the sense that I mean. They have been largely used as surgical beds by general practitioner surgeons. It is now seen that surgery is best done by full-time surgeons in larger hospitals, so that the original reason for cottage hospital beds has disappeared. If they had been used as real general practitioner beds their great value would have been more obvious.

376: In making the claim that general practitioner beds are a necessity throughout the country, I must make it clear that I do not ask for a larger total of hospital beds. My plea is that some of the available beds in the major hospitals should be handed over to the general practitioners. By rearrangement, certain cases at present occupying specialist beds could be transferred to a department where their own doctors would treat them. Any consultant who is more interested in empire building than in the success of the Health Service will probably object to this proposal. In this as in many other ways we may have to follow the example of Canada and Australia, who are ahead of us.

377: In Adelaide, the Queen Elizabeth Hospital has already set aside a whole floor of wards for use by general practitioners, and teaching takes place there. The University of British Columbia is planning a similar large unit in their new hospital.

378: If this one great deficiency as well as the problem of working premises could be overcome we should have I believe, in due course, the best Health Service in the world. The general practitioner bed problem is the bigger of the two. Enormous resistance to its solution must be expected. The first thing is to convince the profession and the Ministry of Health that the only way to keep general practitioners in full contact with hospitals and therefore up-to-date in a changing world, as well as to use their skill and training fully in treating the cases they have always treated in the past, is to give them access to hospital beds.

379: The number needed would be very approximately one bed for each thousand patients on a doctor's list. In a town of 50,000 people, fifty general practitioner beds would be needed. To begin with half that number could be allotted from major hospitals and administered like all the other wards. Numbers could be adjusted to needs in due course.

380: Are there any young men who possess not only vision but the ability to get things done?

Chapter 8: Doctor and Patient

381: Every human relationship is a two-way affair. It helps, in analysing the doctor-patient relationship, to distinguish the two extreme types of family doctor — the authoritarian and the fraternal. The authoritarian is usually a more rigid character -1 hesitate to say stronger, because I am not sure what this means if it is not merely more rigid — and the fraternal type is more flexible.

382: The authoritarian feels that he is very much in charge of the interview. He usually places his patient opposite to him on the other side of his desk or table, as much as to say, 'I am here to instruct and you to obey; this chair and this table are symbolic of my priesthood; you are the suppliant to whom I will, of my skill and charity, give of my best. But don't argue with me; you may not understand what I tell you but I know best. Don't expect help from me unless you obey strictly. But if you do obey all will be well with you, you have nothing to fear.'

383: There are many patients who like this relationship, who prefer a father figure as their guide and instructor. They feel in the situation something of the relief that many people experience when they accept a dogmatic religious teaching. Let us hand ourselves over to authority, they say, it is strong and charitable; we are in no position to be proud; let a greater, wiser power take over our frailties and all will be well; there will be no need to think and think, and to wonder for months and years what is right and what is wrong; we accept and we relax; we become as children again, and a wise father will take care of us. This is a human and for many people a wise attitude. I do not for a moment decry it, but not everyone can adopt it. One thing, however, is certain, and this is that authority — the father figure, the wise doctor — must never let you down. If at times he seems less than perfect, it is because he is busy with weightier matters. If he seems to have made a mistake, there is some other explanation and it is you who are wrong. Although doctors as a class are human and fallible 'my doctor' is unusual. He is brilliant. He is good. Only so can the full benefit of the relationship be maintained. It is for this reason that this type of doctor has some special problems in his social life. The wise father figure may seem different at a cocktail party. His prestige must somehow be maintained, or the mystique of the consulting room may fail next time it is needed.

384: This is the extreme of one type of family doctor. I, for one, still like him and hope he will not disappear from society. What is more, he is often a very good doctor.

385: At the other extreme is the fraternal type. He does not dominate the interview. He is more sensitive. He feels his way, and the patient finds him easier to talk to. He never condemns, and more important, he never seems to condemn, as the authoritarian sometimes does. The chair for his patient is usually placed at the side of his desk, so that the patient does not need to face the doctor. Either can face the other by turning a little. On the other hand, by looking straight ahead they can break the tension between them. He has a willing ear, and will listen as long as the patient wants to talk. His theory is that if you ask the patient questions you will get answers, but you may not learn what you ought to know. If you listen long enough you will hear what really matters. There is an ease and equality about the interview which is reassuring. The doctor is a brother. He has studied one particular subject that the patient has not-that is the only difference. Doctor and patient approach the problem hand in hand, as it were, and find a solution.

386: There are many people who can talk much more easily to this type of doctor. They feel he will understand and not criticize. The nervous introspective patient, in particular, finds him easier to talk to. He too can be a first-class family doctor; he can probably share the family life, taste the home-made wine, and joke over the cup of tea better than the authoritarian. Most patients can adjust themselves quite well to either type, and of course most doctors are a blend of both.

387: It is worth looking closely at the doctor in his consulting room. The relationship with the patient is something very much alive. The most important therapeutic agent the doctor has is himself, and if he can give himself in large enough doses he will cure many a sickness — often those he only half understands.

388: A patient came to see me one day, asking for a nerve tonic.

389: 'It's not like you to need a nerve tonic,' I said. 'What is the trouble?' She was a young woman, married three or four years, with no children. She worked as a typist, and her husband was a skilled workman.

390: 'I have a tightness in my head with a sort of pressure, as though I have a hat on that is too tight.'

391: 'Anything else?'

392: 'Well yes. My breasts feel heavy and tingle in a peculiar way.'

393: 'You are not worried ?'

394: 'No. I don't think so.'

395: 'Not thinking about growths and that sort of thing?'

396: 'No. Not a bit.'

397: 'Doesn't your husband's mother live with you?'

398: 'Yes. She runs the house now, while my husband and I are away all day. It all seems to work very well.'

399: 'You and your husband are quite happy?'

400: 'Perfectly.'

401: 'Do you ever think about having a family?'

402: 'Yes, we do, but — well nothing has happened so far.'

403: 'How long have you been trying?'

404: 'Over a year now.'

405: 'There's plenty of time.'

406: I watched her as I said this. The effect of facile reassurance is interesting. If this is the real cause of worry, there will be some reaction — perhaps a slight annoyance — something which seems to say 'you are are not going to help me'. I interpreted her facial expression as just this.

410: 'Or is there?' I asked.

411: 'We'd like a baby very much. And yet in some ways things are very well as they are.'

412: 'Do you know what I think? I think this tingling in your breasts is something inside you, telling you that it is about time you had a baby.'

413: She looked at me a little incredulously. 'Really?' she said.

414: 'I think your body wants a baby, without a doubt. We are not made as simply as many people imagine, you know. Tell me a bit more about your husband's mother.'

415: 'Oh, she is a marvellous person. She is a good cook, and keeps everything spotless.'

416: 'It wouldn't be so spotless if you had a baby.'

417: 'No, but … '

418: 'I'll give you a nerve tonic and you come and see me when you have taken it. Talk babies to your husband in the meantime.'

419: If I had been on the wrong track she might not have come back, but she did come back the next week.

420: 'I feel a bit better,' she said.

421: 'Yes?'I waited.

422: 'I talked to my husband and he's not too keen on having a baby.'

423: 'You knew this before though.'

424: 'We hadn't talked about it much.'

425: 'He must have agreed to your having one or you would have used a contraceptive.'

426: 'Well we did, and we didn't.'

427: 'You mean he withdraws.'

428: 'Yes, nearly always.'

429: 'So what you really have to do is to decide, between you and your husband, whether you want a baby or not.'

430: 'I suppose so.'

431: 'What does his mother think?'

432: 'Oh I don't know — we never discuss it.'

433: 'Doesn't she ever say it would be nice to have a baby running around?'

434: 'No.'

435: 'Your husband is her only son, isn't he?'

436: 'Yes.'

437: 'Talk to her about it. Perhaps she is at the centre of the home as she does the housekeeping. Find out what she would like to happen.' I gave her no medicine this time, but she agreed to come back in a few days, which she did.

438: This typical interview is dominated by the doctor who relies on his own instincts to feel his way, and as far as I can see myself, I am inclined more towards this authoritarian approach than the fraternal. The more fraternal doctor would probably have got the same result by making the patient do the talking, but this takes longer of course. In my method you must be very careful not to lead the interview astray. In this particular case, it took several months before the young woman got her own way and became pregnant. She worked on her husband and mother-in-law quietly and persistently, with a little persuasion from me, until all were agreed. An occasional bottle of nerve tonic was needed to camouflage the affair, so that mother-in-law did not feel a sinister influence from outside, interfering with family life.

439: Remembering that every relationship works both ways, one has to consider the effect of the patient on the doctor. The first and obvious effect is that when a human being comes and asks for your help, your morale is boosted. I noted earlier in this book my sudden flood of gratitude to the first patients who consulted me. To some extent this gratitude continues. The more you like your patients, the more grateful you are when they ask your help. They give you a sense of value and make you feel that your life has purpose. Of course there are times when the telephone goes and you groan and say, 'Please, no more now.' But take a holiday, or have a quiet spell in the practice, and you will be pleased to see your patients again. You will always give your best to those you like. Nothing can more interfere with diagnosis and treatment than a simple dislike for a patient. Fortunately this is unusual because it is hard to dislike someone who needs your help. Compassion towards those who ask comes easily, less easily to the aggressive, and less still to the hysteric. A patient whom you dislike, moreover, will soon leave you-unless he has already tried all the other doctors in the district!

440: The reaction of the doctor to a consultation with an hysteric is well known. I use the word hysteric in the strict medical sense of a patient who is facing an intolerable situation in his life or affairs, and escapes from his difficulties by developing what appears to be a physical disability such as a paralysed limb, loss of sensation in hands and feet, or perhaps loss of memory. Sometimes this kind of disability is super-imposed on an injury for which compensation is being claimed from an employer or an insurance company. An arm may lose all power for months or years after a minor injury, or a back may cause prolonged pain long after all physical disability has disappeared. A characteristic attitude of the hysteric is the bel indifference described by physicians long ago. He says, 'Here I am, a brave fellow, suffering badly but quite cheerful.' He smiles defiantly at you, knowing you are unlikely to cure him, and his illness suits his situation very well. As time goes on the persisting disability may no longer be necessary but he is unable to get rid of it. Then he is less happy. It is difficult to meet such a case without an initial reaction of annoyance. He is a genuine case, but he is deceiving himself and everyone else. Deceit is at the centre of his being. It is not easy to be generous and to say with true humility, 'We are all sinners, we might all be like this if we were born with exactly this intelligence and were faced by exactly the same problems.' This is true, but such detachment is beyond most of us. It may be a rational response, but it is not the usual emotional one: the emotional response is often exasperation.

441: Many doctors, feeling this irrational sensation early in an interview, realize at once that they are dealing with an hysteric. Their emotional response makes the diagnosis for them.

442: The personal response to a patient must be spontaneous, it cannot be forced. One can force oneself to be courteous, but not to be amiable. The result of forced amiability is insincerity which is obvious to the patient. The only way to be amiable is to understand, because understanding breeds compassion and friendliness. But to understand is the great problem, not only of doctors but of everyone.

443: Sometimes one has to make a conscious effort with children. They can be charming and evoke the friendliest possible response; they can also be very difficult. The child who comes in to the surgery full of aggressiveness, determined to sulk and not to be examined, needs a lot of patience. The other who romps round the room, picks up your telephone and then rushes to the cupboards and pulls everything out before its mother can stop it, is a slightly easier problem of diagnosis but still needs patience. The older child, who knows everything, diagnoses himself as a gastric ulcer and says he needs an X-ray, is another mild irritant. All these are fairly easy to understand however. They are all reflections of their parents, products of their environment, and are all in trouble. One can soon like them. It may even, at times, be salutary to imagine the relationship between you and them in twenty or thirty years' time, when you yourself might be senile and pathetic — begging their help. The key I think to a successful relationship with children is to regard them — as Dr John Apley expresses it-as 'equals of lesser experience'. I would add of lesser experience 'for the moment'.

444: The strong emotional response of the doctor to the patient is revealed most vividly when a patient changes his doctor. The anger sometimes caused by this event is obviously not due to loss of income. Why should a doctor of solid character become furiously angry when one of his patients leaves him?

445: Many years ago an anxious father — a working man earning at that time about £2 a week — called on me and begged me to see his son, who was a patient of another and older doctor. I told him I should have to ask the permission of his present doctor first. The man remonstrated that the matter was urgent, that his present doctor was no longer in attendance, and what was more he had given him a note saying he was willing for him to consult anyone he pleased. He showed me a letter saying 'To whom it may concern, so-and-so is suffering from a cerebral tumour and his father is free to consult any doctor he wishes.'

446: This seemed to clear the matter and as the father was so distressed I visited the boy. A cerebral tumour seemed a likely diagnosis, and I offered to send him to Guy's Hospital for opinion and possible treatment. I knew the neurosurgeon at Guys and felt sure the boy would have the best available treatment there. I rang up the other doctor, intending to offer this help. They were poor people and money did not come into the matter. I said on the telephone 'I had your note about so-and-so, and I have just seen him.' This was as far as I got. There was a roar at the other end. 'You've seen my patient?' He would report me to the Ethical Committee — and so on, and so on. Eventually he was so rude that I said I should now take over the patient in any case and send him up to London. This I did, but he died a few months later.

447: The reason for the outburst of anger was presumably the hurt pride of the older doctor. He felt that his decision should have been final. The boy had a tumour on the brain and the boy would die. Nothing could be done for him — it was useless to refer him to a specialist. But because the father insisted, he was given the brief note intended to allow him to consult a physician, and not understanding this, the man had consulted me, another general practitioner. Here was the authoritarian doctor at work. He was clinically absolutely right but his patient's father, in desperation, looked round for any straw to clutch. I was the straw he found.

448: When a plumber or a grocer loses a client, presumably it is his financial loss that distresses him most, though pride may be a minor factor. In the case of the doctor, pride is the main cause of the resentment. It seems that we, as doctors, have a very high opinion of ourselves. If anyone doubts us, we are angry. Our pride and importance are fed by our patients' admiration. We are evidently plagued by underlying doubts about our infallibility, and our morale has to be continually supported by the good opinion of our patients. If a small part of this support is taken from us something vital is threatened. We are in fact as insecure as anyone else, and like everyone else we depend on our neighbours to carry us along. But unlike most other people, we are carried by our neighbours shoulder high. They must not let us fall; it would hurt too much.

449: As one gets older one usually develops moderate insight into one's real ability and real failings. It is very certain that we are praised far too much for some small services, and far too little for others that have cost us dear. We are sometimes unfairly blamed and sometimes unduly praised. On balance we break about even.

450: I once treated a retired coal miner for many years. He suffered from pneumoconiosis and I did more night visits to relieve his distress than for any other score of patients. This went on for month after month. When eventually he died, the whole family transferred to another doctor. I never really knew why. It may be that the automatic resentment against night calls showed itself on some occasions in spite of my sympathy with the man. Possibly, however, there was another cause. When I first treated the patient I was new to the district and unfamiliar with the symptoms and signs of pneumoconiosis, which is a rare disease except in a mining community. The man was sent by bis union to be X-rayed and I had no part in making the diagnosis. The patient eventually told me the facts about his condition. This for a young doctor must have been hard to swallow. Perhaps resentment began then. I may have had an unconscious desire to prove my value, and have done some unnecessary night visits with a martyred air. This to a breathless patient might have been almost intolerable.

451: Sometimes a patient changes his doctor because they have shared together some traumatic experience which the patient needs to forget. Quite early one morning I was called in great urgency to a household where a mother had become violently insane and had attacked her twelve-year-old daughter with a carving knife. She had made a nine-inch gash in the girl's throat, fortunately not deep enough to cut any vital structure. The police were informed and took the woman into custody. The husband, a sturdy coal-miner, was a tower of strength but the child of course was terrified. I gave her strong sedatives and then took her to the Cottage Hospital where I spent an hour or more suturing the laceration under local anaesthesia. I thought I made a good job of this and was pleased with my work. Afterwards I attended the child with all the care and kindness that this tragic affair provoked. Sometimes when I saw her in after years, 1 glanced with some pride at the fine white scar which had become hardly noticeable. The scar on her mind must have been infinitely greater. The mother spent many years in Broadmoor but was eventually discharged and returned home. The last time I saw the daughter was just before her marriage. Immediately after this she changed from my list to that of my junior partner who had not taken part in the terrifying events of that morning. I still attend the rest of the family and I believe she had needed to change because I was too deeply associated in her mind with a dreadful experience. Quite often of course people change doctors for the very simple reason that they like one better than another, but it is not always so.

452: It is clear that the emotional relationship between doctor and patient is complex. It would seem very important, therefore, for the patient to retain the freedom to change his doctor at will.

453: Undeserved praise is as difficult to explain as undeserved blame, but the ego cares little for explanations of praise for itself. Perhaps after all, it says, I deserved it? An old patient said to me the other day, 'You saved my daughter's Hfe, you know, twenty-five years ago.'

454: 'How did I do that?' I asked.

455: 'She was wasting away because we were feeding her with too much fat. She was being poisoned by acidosis. You told us to stop the fats and give her glucose, and she never looked back.'

456: 'Well, well.'

457: The age-old problem of 'telling the patient' grows yearly in complexity for two reasons. First because the information we have to give is becoming more accurate, and secondly because our patients are part of a more materialistic society which stresses the over-riding importance of the body. How good is our understanding? Does it entail absolute frankness or occasional deception? What is the effect of mistrust or doubt? Under what circumstances, if any, is the doctor justified in deceiving the patient?

458: When a solicitor or a priest are consulted, it is taken for granted that they will reply by telling the truth as far as they see it. When a doctor is consulted, the patient is never quite sure whether he is being told the truth. So frequently are patients told direct lies that under certain circumstances their suspicions are automatically aroused.

459: 'Is this a growth, doctor?'

460: 'No, it is an ulcer.'

461: 'Can it be cured by operation?'

462: 'Yes.'

463: 'Shall I be fit for work in three months?'

464: 'Probably, yes.'

465: The patient knows that the doctor is unlikely to tell him if he has a cancer, so he is still worried. The results of our evasions of truth boomerang upon us. It is impossible to reassure patients who have only a simple ulcer. This is a deplorable situation.

466: Then must we always tell the truth? When we are certain that a patient has an inoperable cancer, must we say 'You have a cancer, you will only live a few months; we can relieve your pain but we can't save your life'? If we do this, the patient will be deprived of hope, and the family may find life with an anguished frightened relative a far greater burden than it need be.

467: Is truth always better than non-truth, or is non-truth justified to make life easier for those in distress? Is it our duty to comfort always, and if so, does this include lying to the patient?

468: It is easy to marshall arguments on either side of the controversy. A doctor friend told me of a man who suffered from cancer of the lung. He had married a second time and had a daughter by his first wife. His will had been made several years before and left everything to the second wife. At the time of making the will, his daughter was well married and in good health. She was later widowed and developed rheumatoid arthritis, and when the father's cancer was discovered, she was largely dependent on him for support.

469: The second wife refused to allow her husband to be told the truth about his cancer. She said he would not be able to face it. The doctor knew nothing of the circumstances of the will, and agreed with the wife to keep up a charitable deception. When the man died, his wife inherited a large sum and his daughter nothing. The younger woman was forced to live on the charity of her step-mother who eventually left the money to relatives of her own. It was certain, said my friend, that had the man known the true state of his health he would have changed his will. He himself felt deeply guilty.

470: Another reason against the policy of deception is that the doctor assumes too much responsibility. If he can offer no hope to a patient, he could say, 'My colleagues and I can offer you no help. As far as we know, your condition is incurable. We may be wrong. We are not infallible, and we are not the only sources of healing. This is the truth as we see it.' If the patient then wanted to resort to some other form of treatment, such as spiritual healing, he could do so. There are some patients for whom this attitude would be the right one, and any deception by the doctor not only wrong but arrogant. Many religious people prefer to know the truth and often their priests will help the doctor in breaking the news. Many of us, religious or not, would rather know the truth, however grisly, than be the victims of soft deception.

471: There are of course many people who prefer not to know the truth. Some even pretend not to know it after they have been told. It is gross unkindness to force them to face the facts, if they shrink from them. With such people, an understanding usually arises without a word being spoken about the future. It is enough to live from day to day.

472: My own belief is that one should never tell a lie to a patient. If I am asked directly 'Is this a growth?' I answer the truth as far as I know it. Having made this one rule — a far more difficult one to keep than it sounds -1 can say to my patients, 'If you insist on knowing, I will not deceive you. Therefore if I tell you all is well, I mean it.' When in difficulties, we are sometimes helped by our ignorance. It is at times impossible to say how malignant a tumour is, or how long life will last. Usually there is no direct confrontation with the bare truth. People usually know and do not talk about it. Most have far more courage than they are credited with.

473: I once treated a charming and devoted old couple, both well into their seventies. The old man developed a cancer of the bronchus and he found out the truth while he was in hospital. He would not hear of his wife's being told, because he would not have her worried. I pleaded with him that she would be far more deeply shocked in a few months time than if she had had a fair warning, but he was adamant. Time went on and he showed amazing courage in keeping active. He got in the coal and did his share of the housework as he had always done since his retirement. At last his end came quickly and mercifully by a haemorrhage.

474: When I was trying to console the old lady, something strange in her manner made me wonder how much she had known or guessed. 'I knew it wouldn't be long doctor,' she said. 'That was why I didn't tell you about myself. I have a little trouble too.' She indicated her abdomen.

475: I must have been blind or I should have realized it sooner. She herself was cachetic. I examined her and found she had a huge cancer of the womb. She had felt it grow, and taken nothing for her pain in case he should discover her secret.

476: 'It's best this way,' she said. 'We shan't be apart for long.'

477: The doctor-patient relationship has an important bearing on night visits. These are a very special part of the life of a family doctor. I know of no parallel in any other profession. They are a part of, and yet apart from, routine life in general practice.

478: My own habit is to sleep deeper for the first part of the night. A night call at 4 a.m. is no great hardship, but one in my first sleep is a physical burden which becomes no easier with the years. People often say 'Oh well, I suppose you are used to it.' I am not used to it, and never shall be.

479: Apart from maternity work, I do about one real night visit between midnight and 6 a.m. every five or six weeks. Sometimes of course there are three nights out in succession but over long periods the number is about nine or ten a year. Maternity — and I do about forty cases a year now — gives me another eight or nine night calls a year, making a total, on average, of one night call every three weeks. This does not sound much, but the knowledge that you may be called out accounts for much of the wear and tear of life. Years ago, before the days of antibiotics, when pneumonia and mastoids were common illnesses, night visits were much more common.

480: Some doctors in towns pay a deputy to do their night calls. Anyone would gladly pay several guineas to avoid a night visit, but the basic cost of paying a deputy to be on night call every night can only be borne if it is shared between fifteen or twenty doctors. Not all doctors believe this arrangement to be entirely satisfactory, however; there are some strong arguments against it from the patients' point of view.

481: If one analyses the cases which need a night visit, about 80 per cent of them are physical emergencies. Three conditions are about equally common: acute cardiac failure; the major colics, renal and biliary; and haemorrhage due to a miscarriage. The usual cardiac trouble is acute left ventricular failure causing severe breathlessness, the failure of the ventricle causing the lungs to become congested. This is an intensely distressing condition, causing restlessness and agitation which induce, by a vicious circle, further cardiac failure; the patient knows that he may die unless quickly relieved. These cases usually respond dramatically to oxygen and morphia. The major colics are true emergencies because the pain is agonizing — as intense asj or worse than, the final stages of labour. And severe haemorrhage is always alarming.

482: All these cases can be treated as well by one doctor as another. There is no special need for the family doctor, but most people in great distress prefer to be treated by someone they know. Even with renal colic, it is surprising how much difference the presence of a familiar doctor can make. The pain is partly due to the violent contraction of abdominal muscles which increases with agitation and fear of fresh spasms. This can be felt to relax soon after morphia is given and I have known a warm, reassuring hand on the abdomen bring a cry of gratitude long before the morphia could take effect. Nevertheless, it is fair to say that any competent doctor would be able to deal with it.

483: In my own practice there are four partners, and we have Saturday and Sunday nights off duty for three weekends out of four -six free nights in twenty-eight. The patients always have a doctor they know in a night emergency though not necessarily their own doctor.

484: In about 20 per cent of all night visits the illness has an emotional component. There is always a sense of urgency and anxiety, but in some cases emotional distress is the cause of the emergency. In these situations, there is sometimes a brief period in which pent-up stresses come suddenly to the surface. They are for a short time amenable to treatment. Occasionally the night call is an anguished, almost inarticulate cry for help. A strange doctor is at a disadvantage and may be unable to help.

485: A woman in her forties came to see me several times in a state of stress, anxiety and sleeplessness. I did my best to find the cause of her trouble but failed. Everything at home was as it should be. She was happily married and there was no family trouble. She had no worries, she said, but could not sleep, and this made her tense and irritable. Twice I gave her tranquilizing drugs. Then one night at 1.30 a.m. I was sent for urgently by her husband.

486: The patient was lying in her night clothes on the floor in the living room. She was apparently stuporous and beside her was the empty box which had contained her sedatives. If she had taken them all, the dose could easily be fatal. I managed to make her vomit a little, and then called an ambulance and had her taken to the Cottage Hospital. We washed out her stomach and her condition improved. Leaving the night sister to keep a close watch on her pulse and respiration, I went back to talk to the husband. He was a slow, quiet man and seemed completely taken by surprise by the affair. All he could tell me was that she was worried about her daughter. The girl, who was eighteen, was going out regularly with a very nice young man in his early twenties. There seemed no cause for anxiety, and I was as puzzled as the husband. I determined to have things out with the patient as soon as she was wide enough awake. I doubted whether she had taken all the capsules, and it seemed likely that this was a call for help rather than an attempt at suicide. If I had left her until late the following day, she might have been just as rigidly defensive as before, and we should have got nowhere. So I went to the hospital again before eight o'clock, having slept for several hours in the meantime.

487: 'You really need help, don't you?' I said. 'You will have to tell me what is the matter. It's something to do with your daughter's affair with the young man, isn't it?'

488: 'He's such a nice boy,' she moaned.

489: 'I know. So why are you so worried?'

490: She began to cry and I waited.

491: 'I've never told her,' she said, at last.

492: 'Told her what?'

493: 'That my husband is not her real father.'

494: Suddenly I remembered. Soon after the war she had become pregnant on holiday. The young man concerned was more or less a stranger, and marriage was not thought of. Adoption was to have been arranged, when suddenly she changed her plans, and decided to marry an old sweetheart. This young man, her present husband, had been willing to marry her and bring up the child as his own. I had forgotten that he was not the father of the child, and as far as I knew, this matter was a secret.

495: 'Why do you think you ought to have told her?' I asked.

496: 'There are one or two who know, and I couldn't bear her to find out from them. I must tell her, but it might spoil her life.'

497: We talked for a long time, and she told me that she had always been half in love with the girl's real father. Her husband had been a disappointing second best, and now she was afraid history might repeat itself. Her innocent daughter might lose her attractive young man as she herself had done. She felt responsible and guilty.

498: At last I managed to convince her that the news would have no ill effect on the young couple — certainly not on the young man's feelings. As I drove home, I pondered on the fact that the daughter was a beautiful girl, and quite unlike her plain and prosaic father. Her young man might even be grateful for the knowledge.

499: The episode ended happily. The young couple married in due course, and now have a child of their own. It took this shock of a self-inflicted emergency to bring matters to a head, and the night visit was therapeutically a success. Had a strange doctor answered the call, the result might have been different. An attempted suicide is usually referred to a psychiatrist. Had he failed to discover the cause of the anxiety and the reason for the call for help, she might well have been given electrical convulsive therapy, and many months of drugs. Or am I being unfair to the psychiatrist?

500: On the whole, I think the family doctor should do his own night calls, except when a partner takes over from him.

501: There are, to my mind, two very special relationships experienced by the family doctor. One is the sharing of the discomforts of pregnancy and the pain and anxiety of labour with a young mother. The other is the sharing of the last months of life with a patient dying of cancer. To write of sharing these experiences with the patient may seem an exaggeration. The share of distress taken by the doctor may be a very small one, but it is a share, and I believe it is a real help. If I should suffer from an illness like cancer, may I be attended by a doctor who feels with me and yet is not emotionally involved, who will help all he can yet will be willing to admit when he can do no more, who regards his help to me as a willing duty and not as a favour, who is a man of courage and compassion himself, yet possesses the quality of humility — having self-respect but no conceit. Is there any such? If so, he would be a good family doctor.

502: - When patients with inoperable cancer are discharged from hospital, they have usually been totally misled about their condition. Some have been told emphatically that they are not suffering from cancer. The general practitioner is then in difficulty because he cannot flatly contradict the hospital and he has to deal with a patient who is increasingly puzzled at his deteriorating condition. More often patients have been left in a state of anxious doubt; no one has told them anything.

503: I can never get over my conviction that this is an affront to human dignity. To have a cancer is bad enough. To be treated like a child or some feeble spineless creature is worse. I have already indicated my own attitude over this problem and usually after a visit or two an understanding between doctor and patient has been reached. It is seldom necessary to dwell on the future and before long an atmosphere of living in the present is established.

504: The relationship between doctor and cancer patient must be established first by regular visits — about once a week while the patient is able to get about. The separation of these patients into a special group who need not attend the surgery is the first move. Visiting the patient in his home is the first step towards a sort of comradeship. The doctor learns a good deal about the patient, his family, his interests and his way of life. He talks a good deal of his own affairs too — the illness is the main topic of conversation in some cases but not in others; some patients much prefer to talk of other things. I have one patient who fights a constant battle to prevent me from mentioning her body.

505: In the realm of physical treatment, mild sedation and analgesics are usually necessary in the early stages. Morphine with cocaine and small amounts of alcohol will overcome most of the later distresses. Powerful drugs are usually only needed in the terminal stages and in the most distressing cases. Small doses often give great relief. The most important principle of treatment is never to let the pain become severe. Once it has done so, the patient becomes fearful and loses confidence. He then needs heavy doses of analgesics before the situation is restored. The medical resources available are enormous and put the doctor in a position of confidence from the start.

506: Our help to the dying patient depends as much on what we are as on what we do. The presence of a good man or woman of serene temperament is of more value than the syringe full of morphia. Such help may be present in the person of a clergyman or a relative of possibly even the doctor himself. He can be ready to give comfort and support if it appears that the patient wants it. Usually the doctor's influence on the nearest relative is what matters most. Here again he or she will be helped more by what we are than by what we say. The relationship between doctor and patient is a close one, but the question is whether or not this personal relationship has any therapeutic value. I think its value is twofold.

507: In the first place, every illness has an emotional component which needs treatment in varying degrees. The doctor who has an established relationship with the patient can be unobtrusively aware of any need for help of this sort. Alternatively every patient would need to be seen by a psychiatrist or psychiatric social worker — a consultation which most people would resent. In the case of illness which is primarily emotional in origin, treatment is entirely dependent on the establishment of a personal relationship with the therapist. Here again, an existing relationship is an advantage.

508: Secondly it helps the patient by making use of the confidence that he feels in one particular doctor. Men and women of strong personality may not appreciate what it means to their weaker brethren to have easy access to help and explanation over matters of health. The independent-minded will obtain help from any efficient stranger, the more dependent personalities would often rather stay away from medical help than consult someone unknown. An easy relationship opens the way to help, and confidence is halfway to a cure.

Chapter 9: Doctor and Family

509: The relationship between the doctor and the family is in theory only an extension of that between doctor and patient. The interrelationships inside the family however add another dimension of complexity. Rather than discuss its importance theoretically I can best illustrate the great part it plays in general practice by relating a further episode in the life of the family that I have mentioned previously.

510: One night in late summer Arnold Piers tried to end his life. I was called at about one in the morning and drove to the farm with my mind in a turmoil. He had been fairly active until a week previously, when the latest blow had fallen. He developed a lesion of disseminated sclerosis somewhere in his spine which affected his legs and bladder control. This was the development I had dreaded most. To him, it came as an unexpected thunderbolt, causing utter desolation. The degree of recovery to be expected was uncertain, and he faced a probable lifetime of invalidism and complete dependence on his family.

511: My first thought was that perhaps this was a merciful thing. It was no sin to take his own life when his future was as bleak as this. His wife faced an almost intolerable burden, and he would probably be sent eventually into a chronic sick bed in one of our most distressing hospitals. To face this at fifty was beyond most men's courage. Should I then do nothing to revive him? Would efforts at resuscitation be unwarranted interference, 'striving officiously to keep alive'? However logical it might seem to say 'let the poor fellow die if he wants to', inactivity on such occasions is contrary to all tradition, all one's training and all one's instincts.

512: The track up to the farm had now become a roadway fit for a car. As I drove up it, I had no clear idea of what I should do -perhaps it was too late anyway. As this thought went through my mind, the immediate reaction was to hurry and to resolve that it must not be too late.

513: A curious feeling of loneliness and responsibility comes over you when you enter a household which has been struck by a sudden emergency. It is the same when you are called to a serious accident. People who are baffled and have no idea what to do next receive you gratefully. They make way for you, and watch with a new respect almost amounting to awe as you approach the patient. I hope I shall not be accused of delusions of grandeur when I suggest that the feelings of a cricketer walking out to bat in a test match must be somewhat the same, except that he has many more people watching him.

514: My first surprise, and afterwards it seemed curious that it was a surprise, was that Mrs Piers was quite distraught at what had happened. It seemed that she would rather face a lifetime of imprisonment in a sick room than lose her husband in this way. Arnold Piers was breathing quietly as though in a natural sleep, but he was pale, and failed to respond to vigorous stimuli. He had evidently taken an overdose of nembutal about an hour ago. I was not sure how much good I should do by a stomach washout, but clearly it had to be done. The stomach tube passed easily down his gullet and I was relieved to find he had a retching reflex as it passed over his pharynx.

515: Gastric lavage is an unpleasant affair. With Mrs Piers' help, I poured a pint of warm water through a funnel and down the tube into the stomach, syphoned it off again and repeated the procedure several times. I gave him an intravenous injection and then rang for the ambulance. He would need all the help of a major hospital for the next few hours. I telephoned the house physician, who was still up and working at two in the morning. I apologized for loading this fresh burden on him, but it was unavoidable.

516: Some time after we had completed the stomach washout, I stood at the door of the farmhouse waiting for the ambulance. It was late August and still quite dark at 2.30 a.m. The stars were clear, and standing on top of the hill I watched the headlights of the ambulance approaching from Westover. They stopped for a moment by the farm gates and turned slowly up the track.

517: I was uneasy about Arnold. It is one thing to try to revive someone who has attempted suicide during a bout of depression from which he is likely to recover; it is quite another to try to bring a man back to a life of suffering that one can do little to alleviate. In hospital, the struggle to help him would continue. There was little possibility of merciful inactivity there, and rightly so. Young housemen, registrars and nurses could not be expected to shoulder a responsibility that I had shirked. This decision and others like it have to be made before the patient enters hospital. I had another case recently of a mongol baby with congenital heart disease who would die of pneumonia at home, but would probably recover in hospital. The decision must be made at home and is not easy. In that case it was possible to share the responsibility with a consultant colleague visiting the home; in Arnold's case this would have been useless, because by the time a second opinion could be obtained, efforts at resuscitation would have been too late. To act as I had done was to follow tradition and to play safe. It was distressing, but I had decided and nothing could be altered now. It is essential to put doubts behind you as soon as possible on these occasions.

518: The ambulance was backed skilfully between two out-houses and as near the front door as possible. One of the men leapt out and walked briskly to the rear to open its doors. Then the two men together adjusted the sloping framework supporting the stretcher. I have always admired these men. They keep a sense of willingness and cheerfulness on these midnight journeys that many a disgruntled doctor — and I have often been one myself — might try to copy.

522: 'Good morning, doctor. Upstairs is he?'

523: 'You'll need your folding carrier. The stairs are narrow. He's heavy, too.'

524: 'Oh, I've known Arnold for years. Leave it to us, sir.'

525: One of the men was small and wiry, but he seemed immensely strong. The great form of Arnold Piers was transferred to a deck-chair-like conveyer. He was so long that we had trouble in supporting his head. In the hall, he was transferred to the stretcher and carried the few yards out to the ambulance.

526: At that time, Catherine had married and lived twenty miles away from home. She came back every week to see her parents. David, the Piers' son, had after all preferred farm Life to an academic one, and had grown into a useful young farmer. He had married an attractive girl who was not at all like the accepted image of a farmer's wife. She was small and delicate looking, rather pale, but gentle and kind. The young couple lived in some newly built rooms added to the east side of the old farmhouse. They must, I thought, have been a great comfort to the parents.

527: As Arnold was lifted on to the stretcher, Cynthia, David's wife, showed great concern, and stroked the unconscious head. Mrs Piers, who stood on the opposite side, said sharply, 'All right, Cynthia, I can manage.' And she held her husband's head until he was on board the ambulance. It was a discordant note in an already painful situation. She seemed to be saying 'Keep away from him, he's mine.' Strange, I thought, but I soon forgot.

528: Atnold was very ill for twenty-four hours, but made a complete recovery. He was visited by a psychiatrist who, naturally enough, could do nothing to help him face his future. After a few days, like many other big human problems, he was referred back to me as the family doctor.

529: David and Cynthia came together to see me while Arnold was in hospital. Cynthia was expecting her second baby and was feeling very sick. I was surprised to see David until he explained. 'I thought I had better come too,' he said. 'Cynthia is having rather a thin time with our Mother. Maybe we made a mistake sharing the same house. I ought to have insisted on living over at the other end of the farm. But we thought, Father being as he is, we could help best where we are. It was all right at first. Then Mother seemed to change. Whatever we do is not right. She'll go days without speaking, and then she'll get angry about something so trivial that I wonder sometimes if she isn't going out of her mind. She's so different.'

530: 'What sort of things does she complain about?'

531: 'Everything. Well, take last Christmas. The Young Farmers, as you know, have a few parties after Christmas. More than a few! One year there was a party every night till Valentine's Day. Anyway we were out late a few times. Then Mother started sitting up waiting for us. She waited up till two one night, and nearly three another. You're only young once, and we enjoy a bit of a party. When we got in, she would be as frigid as ice. She wouldn't say much except "Now you are in, I'll go to bed!" But it was the way she said it. We begged her not to wait up but she would do it, and it made us feel guilty. The baby is no trouble and she would have soon heard her if she cried.'

532: 'She's had a very trying time with your father, of course.'

533: 'I know she has, and we want to help, but we can't understand why she behaves as she does. Now last Easter, there was a ball on in town. That time we did ask her to sit up for us because the baby was ill. Not too bad, but a bit fretful. She agreed, but just as Cynthia came down, changed and ready to go, she put her coat on and said "Sorry I can't sit up for you tonight after all. I've got a w.i. meeting. You'll have to get someone else!" We were flabbergasted.'

534: 'What had upset her, do you think?'

535: 'I have no idea.'

536: 'Is she pleased about the second baby?'

537: 'I shouldn't think so. Her latest was over something Cynthia cooked for them. She made them a cherry cake that Father likes, and a nice apple pie. She took them in a few days before Father went to the hospital. Then next day she found that Mother had thrown them away just as they were into the dustbin. They'd never touched them! Cynthia didn't know whether to say anything or not, but I went in and had it out with her. All she said was she didn't want other people's cooking. "Other people's" mind you, to my wife! Nor did she want other people's sympathy. Well that sort of thing when you are feeling sick all day takes a bit of swallowing.'

538: How often, I thought, the patient gives you the cause of his symptoms if you let him talk long enough. There was no doubt why Cynthia was suffering from excessive pregnancy sickness when she had been free from it with her first pregnancy. She was in the middle of things she could not swallow.

539: 'Yes, I see,' I said. 'There must be some explanation. Perhaps I can see her some time. Is she any different since your father has been in hospital?'

540: 'No. Worse if anything. She won't even let Cynthia drive her in to the hospital for visiting.'

541: 'I shall be coming to see your father when he comes home. I can probably have a word with her then.'

542: 'Do people get like that in the change of life?'

543: 'No. There's more in it than that.' I gave Cynthia an appointment at my ante-natal clinic the following week, and some tablets to help her sickness.

544: My first visit to Arnold after his discharge from hospital was distressing. His long illness had produced some personality changes, and these to some extent blocked our exchanges. I asked how he was and he replied 'Fairly well.' I examined his legs, and found the degree of stiffness and weakness unchanged. There had been some improvement in his bladder control, but this was still unreliable. The mackintosh under his sheet told its own sad tale. For a time I talked about small improvements and the prospect of considerable recovery, but could get no response from him. When I stopped talking, the most harrowing sight confronted me. His face screwed up and large silent tears fell down his cheeks. A strong man reduced to this state is enough to move the heart of a psychopath.

545: I sat beside him in silence for a few minutes. 'I had to try to revive you Arnold. There was nothing else I could do.'

546: 'I know. I'm not blaming you.'

547: 'Things like this are outside our control. You've got to battle on. I believe you'll improve enough to enjoy life again. There are times when the fittest of us would be willing to contract out of life. I know what it's like for you. All I can say is that everything that mortal man can do, we'll do. I shall be in each day for a bit, and soon we'll be getting you out of bed. There are some wonderful contraptions nowadays for helping you to walk.'

548: Downstairs, I talked platitudes to Mrs Piers. It was strange how she had reacted to her husband's illness. Most women find some satisfaction in the maternal instinct that nursing evokes. She evidently hated her daughter-in-law. Perhaps she had been in love with her son — a not unlikely state of affairs for a woman with an impotent and invalid husband. This would be harmless enough if intelligently faced but people are sometimes so horrified at the thoughts of incest that play in their minds that they cannot face them. Fortunately she herself brought up the subject of Cynthia.

549: 'It seems we are going to have another grandchild.'

550: 'Are you pleased?'

551: 'Not very. I suppose I ought to be.'

552: 'Cynthia is not feeling so well with this pregnancy. Is she accepting it happily?'

553: 'Oh yes, she'd accept a dozen as long as David was prepared to let her have them.'

554: 'This is only the second. Cynthia fits well into the household, doesn't she?'

555: 'Yes, I suppose so.'

556: 'What does that mean?'

557: 'She tries to turn David against me. She can't bear him to be fond of me. She wants everything — everything.'

558: 'Has she done anything special to upset you?'

559: 'Nothing I could put my finger on.'

560: 'Does David talk to you about her?'

561: 'Only to tell me I'm not good enough to her.' Then it all flooded out. She admitted intense dislike for her daughter-in-law. She couldn't stand her 'holy, holy, ways'. She was always turning the other cheek. It was all very well to go to church, but not to drive everyone mad by being such a hypocrite. And so on, and so on. What she meant was that if only Cynthia would quarrel with her, would lose her temper, she could forgive her. Then she would stand equal to her in David's eyes. Her efforts were sometimes unconsciously aimed at provoking her to respond in kind, to hit back, and to reveal that there was a streak of nasti-ness in her that made her no better than her mother-in-law.

562: I let her talk, and now and then tried to provoke her to confess that she wanted Cynthia to reveal a nasty side to David. Her own feelings for David were very strong, but she would never admit to being as emotionally involved with him as she was. Nevertheless I hoped she would obtain enough insight to realize why she was being systematically aggressive to Cynthia. She had to understand that efforts at degrading her in David's eyes were doomed to failure. She was more likely to unite the young couple against her. Eventually, I thought, she realized this, so we talked again about Arnold.

563: 'Your life has been pretty hard for a long time now,' I said, but I couldn't get her to talk about her personal trials. She complained about her frequent hot flushes, and her tight heads with vertical pressure that sometimes lasted for days. I said this was mainly the result of the tension induced by her family life but we could get no farther on that occasion.

564: I visited Arnold frequently, as I had promised. Some days I felt so completely useless that it seemed a waste of time to call. He was listless and despondent, his wife tense and resentful.

565: There followed one of those difficult periods common in every general practice, when the patient cannot be helped, and is not yet resigned to the situation that faces him. Small items of symptomatic treatment are given without much hope of benefit. It is fatally easy to load a sickroom with a multiplicity of boxes of pills — expensive but useless. It is so much easier to cut short a visit by leaving a prescription and saying 'perhaps they will help', than to admit one has little to offer. One has to regard oneself on these occasions as a visiting friend on intimate terms with the illness, not as a dispenser of pills. It is always better to admit one's inability to do much. Many patients find this confession curiously satisfying.

566: A week or two after his return from hospital, he spoke for the first time about his attempted suicide.

567: 'I should have been out of it all by now, if you had left me alone,' he said.

568: 'I couldn't leave you alone, Arnold. You know that.' I remembered how my actions had been dictated by tradition. This meant that I had not given enough thought to this problem beforehand.

569: 'I suppose not. But you must admit I should be better off dead, and so would the wife.'

570: 'And Catherine? And David?'

571: 'The wife's at the end of her tether. I've been no good to her as a man for ten years now. I should like you to promise me something, doctor. If ever I should get near to finishing it all off again, that you'll leave me alone.'

572: 'What really makes it intolerable, Arnold? Is it worrying about your wife?'

573: 'Yes, mostly. She was a lovely woman.'

574: 'You feel all this is too much for her?'

575: 'She's had enough.'

576: He would not utter a word against her, but I felt that it was her attitude that was decisive in making his life unbearable. So it all came back to understanding her.

577: I had tried to hedge, to put Arnold's question aside, but in all fairness I had to answer it. Either I must agree, or give some clear reason why I could not. If I had had a firm belief in Christian orthodoxy, I could have said that our life on earth is a mystery but is a preparation for a life to come. It was therefore our duty to preserve life on all occasions until it was God's will to take it. But my Christianity is far from orthodox. I only know that I have a duty to help to the best of my ability. I have been taught the technique of helping a diabetic, or someone with bronchitis or heart failure. I have not been taught how to help a chronic invalid who wants to die. Once more, my own ignorance came to my rescue.

578: 'Arnold, I can't promise this because I honestly don't know what the future holds for you. It would be arrogance to pretend I do. You may recover the use of your legs. You may play a vital part in the life of your family. There are scores of imponderables. If the time came that I thought- your suffering was too great, that recovery was impossible, of course I wouldn't try to keep you alive. Of course I would give you all the relief I could. And if my efforts at relieving you made you die more quickly, of course I would still continue them. Does that answer your question?'

579: 'I expect it's all the answer I shall get.'

580: I talked to Mrs Piers again a few days later. She still had the tense, brittle voice and the rigid resentful features that I had become accustomed to.

581: 'Life has become very hard for you,' I said. 'Is there anything I can do to help?'

582: 'No one can help me.'

583: 'Things would be better if you felt happier with David and Cynthia, wouldn't they?'

584: 'I suppose so.'

585: 'You have a strong dislike for Cynthia, haven't you?'

586: 'I don't like hypocrites, and I don't like sanctimonious people at any time.'

587: 'David's fond of her, isn't he?'

588: 'Oh yes. He's like a moonstruck boy still.'

589: 'He's a pretty shrewd judge of people. Don't you think you may be misjudging her?'

590: 'He's a good enough judge with anyone else, but love is blind.'

591: 'It seems to me very important that you should have as much harmony in the house as possible. After all, you have enough trouble as it is. I shall have to risk offending you, because I think you are misunderstanding the young couple. I believe you are bitterly jealous of Cynthia. Your own husband is an invalid and you were very fond of David. You had learnt to rely on him. Now you find he belongs body and soul to someone else. Even though Cynthia were an angel, wouldn't it be understandable if you were jealous of her?'

592: 'Body and soul! Jealous of her!' She looked fury at me.

593: 'Yes, jealous.'

594: 'You think I'm a jealous woman as well as a frustrated one! With a great incontinent baby upstairs who hates the sight of me. And now you talk like this!' She lost her temper, and the words she used are of no particular importance. She ended by asking me to leave the house and not to come again. They would be changing their doctor.

595: I was taken sharply aback by her fury, and could do nothing but bend to the storm. She came to the door with me, talking without a pause. Her words became almost incoherent, and at last the door was forcibly shut behind me. My first reaction was anger and resentment. I went home and complained bitterly of the atrocious way I had been treated — and after all I had done for that family! My wife joined my condemnation so roundly that, following the usual pattern, I began to look for excuses for Mrs Piers' aggressive behaviour, and presently to try to understand it. Perhaps I had been foolish to try to give her some insight into her own mind. My words must have conveyed more to her than I had intended — women often seem to have an intuitive knowledge of what I am thinking. I saw her as a healthy, decent woman with powerful emotions, pent up for long periods, frustrated by enforced widowhood, devoting all her love to her son, perhaps secretly seeing him as her lover, and plagued by incestuous thoughts that terrified her. The only outlet to her feelings was aggression towards her daughter-in-law who made her feel worse by perpetually turning the other cheek. And so she came to hate herself. She may even have purposely left Arnold's sleeping pills beside his bed, to give him an opportunity to take an overdose. She might then have felt guilty and worked madly with me to resuscitate him. All this was guess-work.

596: What was I to do next? There seemed nothing for it but to wait. As I had no message from the farm for a week, however, I felt impelled to call again for Arnold's sake if for no other reason. I was very doubtful of my reception, and was surprised to be received as though nothing had happened.

597: 'We need some things for the nurse,' Mrs Piers said, 'and something for the pain in his legs.'

598: I paid a visit to the sickroom, ordered what was needed and sat down.

599: 'I'm afraid you had a bit of an upset with the wife,' Arnold said.

600: 'I think I upset her more than I meant to.'

601: 'It's done no harm.' He wouldn't say any more.

602: Downstairs I had a brief apology from Mrs Piers. 'It's the change of life, I think/ she said. 'I get flustered out of all reason at times.'

603: 'Of course,' I said. 'I understand.'

604: In the next few weeks, Arnold improved a little and we got him into a wheel chair. He was able to stand with help and his bladder control returned. He knew, and we all knew, that it was only a matter of time before the next blow fell. But he grew more contented, and his wife's manner became warmer. Cynthia told me when she came to the ante-natal clinic that things at home were better. For the time being, at any rate, the household was comparatively serene.

605: My attempts at psychotherapy in this case were like many others. You never knew whether you had done any good or not. There was no doubt that Mrs Piers became less tense and her manner to Cynthia less aggressive, but whether any of this was my doing, I didn't know. I hope that one day she will refer to the matter again but I shall not bring it up myself. It is probably too much to hope that her outburst was the result of a sudden insight into her own mind and that my acceptance made her feel less guilty. There are other explanations of the improvement. She might have been going through a climax of emotional turmoil which passed of its own accord. Or the whole family might have become more sympathetic as each understood better the distresses of the others. My own experience of psychotherapy is that there is seldom any dramatic change. People are what they are. One can only help them over a hurdle here and there.

Chapter 10: Responsibilities: Drugs

606: The word 'drug' applied to chemicals used for therapeutic effects is a singularly unsatisfactory one. It has about it a suggestion of sorcery, of something whose benefits, like the gifts of Mephistopheles, have sinister conditions attached to their use. People talk about feeling as though they were drugged. Perhaps one day someone will find a word that means a 'chemical substance having a therapeutic effect'. Meanwhile the word has one advantage. It serves to remind us that powerful medicines are usually not without occasional adverse effects.

607: New drugs-or new medicines — are among the wonders of the century. When the twentieth century becomes history, it may be that nuclear power and space travel will pale into insignificance beside the long-term effect of drugs on the human race. By means of them we are, for better or worse, interfering with the whole balance of power in nature. For millions of years an equilibrium has been maintained between animal life, bacteria, fungi, viruses, and probably other forms of life. When animals are attacked by bacteria, they respond by producing antibodies. Some bacteria merely keep fungi at bay. Others become virulent and decimate large animal populations. Then the survivors respond by developing an increased resistance to the invaders. The bacillus of tuberculosis may cause rapid destruction in a population never before exposed to its attack. Resistance develops slowly and in time the balance of power is restored. It was common experience, in the past, to observe the powerful immunity of the slum child exposed to infection from its infancy, as compared with the country child reared in pure air and clean surroundings. This natural immunity is rapidly becoming a thing of the past. It is true that a valuable artificial immunity is now being induced by inoculation of children. This is biologically sound but the long-term effects of antibiotics are unpredictable. Their use is disturbing the development of natural immunity to infection. Generations are growing up whose bodies have never needed seriously to contend with the common infecting organisms. The moment these organisms threaten sufficiently to produce a raised temperature they are killed, not by naturally developing antibodies but by artificially given antibiotics.

608: This is not to argue against the use of antibiotics. Far from it. It is merely to suggest that these powerful drugs should be used with wide open eyes and that a long view should be taken of their effects. There are obvious occasions on which they are necessary to save life, or to prevent serious damage to health. In pneumonia and meningitis they are life saving, in inflammation of the middle ear they may prevent deafness. On the other hand, it is highly probable that children who are given antibiotics at once for every mild infection are slow to develop natural immunity. They therefore succumb more frequently to simple childish infections. This has yet to be proved by experiment. The total number of days of illness due, say, to respiratory infection must be shown to be more, over a five-year period, if antibiotics are regularly given for each infection than if they are withheld -except when the threat to health becomes serious. The long-term effect of antibiotics used over several generations has still to be determined. It is likely to be of considerable significance.

609: The need for caution in the use of antibiotics is small however, compared with the need for care in the use of drugs affecting the nervous system. I am not so much concerned with the immediate risk to health. This is adequately cared for by the Dunlop Committee on the Safety of Drugs. It is their long-term effect on a community that gives rise to greater concern. Strength and stability of character are developed by learning to resist the wear and tear, the stress and strain of life. What sort of society shall we breed, when everyone who suffers the discomfort of anxiety or tension, or even sorrow, at once has recourse to soothing drugs? Many drugs which act on the nervous system are considered safe for use during pregnancy. They are to my mind used with terrifying freedom. We know little of the long-term effects of such drugs on the foetus. What effect may they have when the unborn infant has become a middle-aged man or woman? The worrying element in this matter is the long delay that can occur before ill-effects show themselves. The tragedy of thalidomide has made the name a household word. More recently we find that, given in infancy or pre-natal life, tetracycline can cause bright yellow discolouration of the teeth in later years. The only case of yellow teeth I have seen was a girl who had admittedly been given tetracycline over long periods of her infancy. We are assured, however, that even a normal course of the drug may cause discolouration of the permanent teeth if given at a critical time in infancy. This discolouration is so disfiguring that the front teeth or possibly all teeth would need to be removed from those affected by it.

610: Naturally we have now, after many years, given up prescribing tetracycline for expectant mothers and infants. But what will come next? The right attitude for everyone concerned seems to me to be this. Here is a drug which, as far as we know, is wholly beneficial. As we do not know its long-term effects we will use it only when its use is justified by absolute necessity. We will run a small premeditated risk. Anyone who scoffs at this cautious view should wait a long time before he laughs.

611: The effect of the frequent use of analgesics on a community is also uncertain. If the sturdiness of the Central African is compared with that of the Western European, it is evident that the pain threshold of the African is far higher than that of the European. In other words the African can bear pain with far greater ease than the European. Is this a racial difference or the result of our use of analgesics? The change in toughness of Europeans in the last century suggests it is the analgesics. My own great-great-grandfather is reported to have helped the surgeon to saw through his own leg because the surgeon was too slow. I must confess that my own reaction would be very different! If the future of the world is to be settled by the old method of struggle between the sturdy and the less sturdy races, the more civilized will be at a great disadvantage.

612: It appears that there is a danger that we are helping to create a society which has a poor natural resistance to disease and which is incapable of bearing strain or pain without artificial help. It could be argued that the last bastions of a strong virile and disciplined society will soon be down! It is against a background of these considerations that one should consider the question of drugs prescribed at the present time.

613: The general practitioner is under constant bombardment from the drug manufacturers on the one hand and the Ministry of Health on the other. Every day the post brings ten or twelve advertisements of drugs, sometimes teasingly disguised. Every week, a pharmaceutical representative calls to give persuasive evidence that his firm has something quite new in the way of relief for patients and in time-saving for the doctor. To some, the representative has quietly taken the place of postgraduate education — the doctor can easily deceive himself that he is being kept up-to-date by the 'rep'. The monthly index of proprietary medicines contains information about more than two thousand preparations from which the doctor can choose. Every two months The Prescribers Journal — an excellent booklet containing reasoned advice about the drug treatment of one or two conditions-is published by an independent body. From time to time a chart revealing the comparative costs of various drugs having the same or nearly the same therapeutic value is sent by the Ministry of Health to every doctor. These charts often startlingly reveal that a proprietary preparation is five or six times the cost of a simple and equivalent drug from the British Pharmacopoea. Finally The Consumers Association publish fortnightly its Drug and Therapeutics Bulletin. This is similar to The Prescribers Journal but has to be paid for. It contains an excellent assessment of the value of new drugs. As these can often be discounted by a glance at the 'conclusion' a great deal of mental effort at keeping up-to-date can be saved!

614: The community has learned to expect free access to the enormous wealth of drug power. The fact that these are virtually free leads the doctor to prescribe them more liberally than he would do if the patient had to pay even a small percentage of their cost. On the other hand, modern drugs are often essential to treatment and are very expensive. Treatment would be impossible if their whole cost had to be borne by the patient. Many appear to have great beneficial effects on the tired, the tense, the anxious, and the depressed. And who of us is not at times tired, tense, anxious or depressed? No less than a hundred drugs are listed which effect the central nervous system. When it is considered that the general practitioner has, on average, seven to eight minutes for each surgery consultation, it is not surprising that he often cuts short the interview with a prescription for tablets or medicine. The alternative is to risk spending twenty minutes explaining to the patient that no medicine is necessary.

615: According to the latest figures available, the average cost of drugs per person in England in the month of April was 55 id. This indicates a drug bill of approximately £12 million. The average cost of each prescription was us 2d. On average therefore nearly one person out of every two covered by the National Health Service, had one prescription during April. This indicates an enormous consumption of medicines. Those of us who are healthy may feel that it is excessive. Perhaps the right conclusion is that we are lucky. It is clear that there are two ways of effecting economy. One is the use of less expensive drugs, and the other is the reduction of the number of prescriptions. I think the second is the more hopeful line of approach.

616: Every doctor has to learn the uses and cost of a selection of the necessary drugs. This probably entails using between 2 and 3 per cent of the drugs and medicines listed in the monthly index. Some expensive drugs are better than the cheaper ones. Whether any drug is worth seven times the cost of another with similar pharmacological action is debatable. One cannot condemn the high cost of drugs out of hand because of the high cost of the research done by the drug firms in introducing them. Without competing drug firms we should at present be lacking a number of drugs of immense value. The fairness of the advertised price is not the concern of the general practitioner, but the choice is his.

617: In making his choice the doctor has a duty to the patient to give the best available treatment. He also has a duty to society not to waste public money. The duty to the patient has always been admitted. It is age old and traditional. The duty to society developed suddenly with the coming of the National Health Service, in 1948, and is being accepted slowly. Many doctors refused to admit a duty to society because they resented the change to a state service which was forced upon them. A calmer consideration of the present situation has led most of us to accept the second duty. Acceptance of the duty to society entails a great deal more work. This is one reason why the reduction of the national drug bill is slower than it might be.

618: There are many drugs of great value. There are many that could well be done without. I will mention some of those that I consider essential to treatment, with their approximate cost. I make no attempt to evaluate these drugs, only to emphasize the enormous difference in their prices. Many of those listed are essential and have to my knowledge no cheaper alternative. Others are to a large extent interchangable and give opportunity for economy. Proprietary names which are more familiar than the chemical equivalent are used in some cases.

[Note: The author gave the price of all the drugs in the original edition, but these have been removed in the interest of accuracy. Six drugs have also been removed which are no longer recommended.]

619: (1) Antibiotics

The last two drugs are necessary occasionally for resistant cases of urinary infection.

623: (2) Analgesics

631: (3) Antidepressants

632: (4)Tranquillizers

633: (5)Hypnotics

634: (6) Drugs Used in Cardiac Failure

All these drugs are essential at times.

640: (7) Steroids (of the Cortisone Group)

643: Economies may often be made, but they cost the doctor time. An example occurs in one of the commonest of women's diseases — cystitis. The majority but not all of these infections respond to sulphonamide treatment costing about 35 a week. If a laboratory report is obtained before any of the more expensive drugs are used, the saving will be enormous. Cure is then certain and as quick and cheap as possible. Without laboratory help, it may be necessary to prescribe two or three courses of expensive drugs before the right one is found. Naturally, if he were guessing the causal organism, the doctor's first choice would be a drug which is likely to succeed in nearly all cases. This would probably be ampicillin at 28s a week.

644: Obtaining accurate laboratory help takes time. While the laboratory report is awaited, a course of sulphonamide treatment is started. This inexpensive treatment cures the majority of cases. When the laboratory report arrives, a change of drug is made to the few cases in which this is necessary. The report indicates which drug is needed.

645: Sometimes great economies can be made by the accurate diagnosis of a family situation of which the children's ailments are the presenting symptom.

646: A woman came to my surgery month after month, with her children aged two and four. There was always something wrong. Colds and coughs and earache predominated. Sleeplessness and behaviour problems punctuated the attendances for acute infections. Each illness was treated on its merits, often by antibiotics. Then the woman came to see me complaining of prolonged heavy menstruation. Examination showed little abnormality. Later she complained of frigidity and at last I realized there was a family emotional problem. At a long talk it transpired that for years she had been at loggerheads with her husband's mother who lived nearby. The mother-in-law would come to her home ostensibly to help out and would stay all day until bedtime. This happened several times a week, and invariably she would take away her son's shirts to wash. The son was never willing to ask his mother to leave them alone. Husband and wife became estranged and when mother-in-law came on holiday with them, this seemed the last straw. The husband had to choose between possessive mother and jealous wife. He would not do so. Hence the tension and family illnesses. After they had talked it all out no dramatic action was taken but both husband and wife gained some insight into what was happening. The total attendance of that family during the next two years was less than it had been for any month previously. One wonders how many courses of antibiotics would have been taken by the children if the presenting symptoms had not changed to something of which I recognized the significance — frigidity.

647: The drugs that I have listed demonstrate the high cost of many essential treatments. Economies can be made, but are by no means easy. Much care will produce only moderate saving. The drugs mentioned fall naturally into groups, but when I analyse the prescriptions I have given, it becomes evident that these comprise less than half of the total that I use. The remainder are so varied that it would be tedious to attempt to mention them all.

648: The great variety of cases which pass continually through the hands of the family doctor make the work difficult to describe. Nevertheless in order to convey as clear an idea as possible of the variety and cost of the drugs used as well as to give some picture of the work of the general practitioner, I will report in the next chapter as accurately and faithfully as I can, two actual surgery sessions — one in summer and one in winter.

649: It becomes clear that the economies that can be achieved in a surgery session are limited. On the other hand, in the sphere of chronic sickness there is a huge problem of wastage. It is here that the greatest opportunity for saving occurs. In the first place, in order to avoid wastage patients must be taught to respect and value the drugs they are given. They would certainly respect them if they had to pay their actual cost. As there is no hard commercial reason to induce respect, other ways must be found. First it is essential to explain what a drug is meant to do. When the patient relates his medicine closely to a certain part of his illness, he values it more. A good example is the addition of one after another drug to the treatment of heart failure. Digitalis is usually accepted as the drug for the heart. It must be explained that diuretics are tablets which get rid of water in the system which would otherwise get into the lungs and embarrass the heart. The addition of inderal can be explained as the drug which quietens and slows the heart and prevents it from wearing itself out by beating too fast. Such explanations seriously given put the drugs on the right footing. From time to time it is good practice to point out that a drug is very expensive and so must be taken with great care exactly as directed. Nothing is worse than a 'take it or leave it' attitude. The doctor must respect and value the drugs himself before he can expect the patient to have the right attitude.

650: The next essential is to prescribe as small a number of tablets as possible. If a patient is given a huge box of tablets they often achieve as little significance as a box of sweets. In the case of a drug like digitalis taken over long periods, it is reasonable to prescribe a hundred at a time. When there is the slightest chance that they will not all be taken, it is far better to prescribe too few than too many.

651: It makes me very angry when patients take these modern blessings for granted. A woman new to this district telephoned me one evening saying she had developed cystitis again and could she have a box of furadantin tablets. She was going away tomorrow. Her previous doctor had been in the habit of dealing out these expensive tablets whenever her symptoms recurred. She had never had a specimen of urine examined by a laboratory. I have no doubt she thought me very fussy or very old-fashioned when I insisted on a specimen being prepared for the laboratory before she was allowed a single tablet of any sort. Her attitude was not her fault, of course, but her doctor's. Sometimes it is very difficult to maintain a proper loyalty to one's colleagues.

652: It is often argued that a prescription charge of half a crown or so makes the patient value his medicine, and makes him less likely to demand treatment for minor ailments. This is quite untrue. A prescription charge may or may not be a reasonable way of taxing members of the community. It has no other purpose. Its effect on the patient's attitude to the value of his medicine is, if anything, adverse. He is inclined to think that 2S 6d pays for it, which of course in most cases is ludicrous. The anomalies of this tax are such as to make it positively harmful. It is to be hoped that sooner or later some semblance of justice will evolve in its application. At present I have many chronically ill patients who have to pay this charge in spite of the fact that their income is the lowest possible without 'supplementary benefit' because they do not come under any of the categories for exemption.

653: Economy in the national drug bill is the concern of all doctors. It is a laborious affair and a matter of constant attention to detail. It is only a small fragment of their responsibility, but it is an astounding fact that if 20,000 general practitioners were able to halve the national drug bill they would save enough to pay their entire combined salaries.

Chapter 11: Responsibilities: Certificates

654: To economize with the prescription of drugs is not the doctor's only duty to society. He must also see that his certificates of incapacity for work are given with due care and attention. When a workman tells a doctor that his back is painful and work impossible, there may be nothing to support his statement. It may or may not be genuine. An office worker may complain that he cannot concentrate and work is impossible. Examination may reveal nothing either to support or refute his complaint. A fair decision is not easy.

655: To a considerable extent, the patient's word has to be relied on. What therefore is to prevent an unscrupulous individual from obtaining sick benefit when he is perfectly well? The doctor has to fall back on his knowledge of the patient and the impression he receives from examination to decide the genuineness of a case. I have no hesitation in saying that after thirty years' experience I am still making mistakes both ways — usually in being deceived by a malingerer but occasionally by unfairly refusing a certificate of incapacity. The idea of being unfair to a sick person is so abhorrent that we usually give the benefit of any doubt to the patient. Some therefore succeed in deceiving us.

656: Malingering is despicable. Unfortunately it was made respectable in two world wars when it was held to be justifiable as a means of getting the better of authority in the only way possible. In a Welfare State it is grubby behaviour. In some ways it is a pity that the malingerer, even when discovered, suffers no penalty. Perhaps I speak with feeling because although the malingerer is my natural enemy, I have in me a streak of laissez-faire which sometimes lets him get away with it. Afterwards I dislike him the more for his suspected victory over me.

657: It is fashionable nowadays to say that most people are kind and good. The speaker feels a glow of warm humanity as he compliments the good folk about him. I think it is better to see people as they are-if possible not blaming but understanding them. It does no good to pretend that all is mercy, light and goodness in the world. An old parson friend of mine said to me very often 'Unredeemed humanity is not good. It is often very bad.'

658: Recently a very pleasant jolly man who would never harm his neighbour, and who happened to be very well insured against sickness, did his utmost to persuade me to give him prolonged certificates of incapacity when he was, to my knowledge, working on his farm. ('After all, doctor, I have paid in for years.') It is so easy to be an easy-going jolly old doctor who receives a couple of geese at Christmas and a bottle of something now and again, and it sounds so unbearably priggish in these days to be strict in one's decisions. On the other hand, one of the blessings of growing older is that people's good opinions do not matter so much. Few things matter quite so much.

659: Our duty as doctors is to be sure that when we sign the certificate which says, 'in my opinion you were incapable of work at the time of examination', that this is an honest opinion, arrived at with all reasonable care. These decisions and a score of others have to be made quickly and frequently at every hour of the day. The variety of the general practitioner's work makes it difficult, yet every challenge makes it more worth while. So much of the work is done in the surgery that the only way that its real nature can be conveyed to those interested is by relating the events exactly as they occur. Much of it is routine and easy, but at any moment problems will arise that tax all the resources he has. This is a report of one surgery session in February 1968:

660: 1. A pale plump woman of middle age, with an obvious goitre. Previously very thin she has been putting on weight for a year or two and now feels very tired. She is a case of Hashimoto's thyroiditis, now becoming deficient in thyroid secretions. She has been taking two grains of dried thyroid a day without benefit. I change her treatment to eltroxin tablets (almost equally inexpensive) and tell her to take three a day. I ask whether the lump in her neck bothers her and she replies that it does not. I explain what has happened to her thryroid gland and that she is likely to need tablets indefinitely. I give her small daily doses of iodine in the hope of improving the activity of her remaining thyroid tissue. The latter is a matter of trial and error. She will see me in one month.

661: 2. A middle-aged factory worker tells me he has 'flu and needs a certificate. I take his temperature which is 100 degrees and look at his throat which is infected. I ask a few questions and give him a certificate of incapacity for five days, when he will see me again if he is unfit for work.

662: 3. A young woman of twenty says she has 'flu. Her temperature is normal and her throat clean. She says she aches all over. I know her and am doubtful whether she is really unfit for work. I give her a note of incapacity for one day only and tell her to come again tomorrow if she is not well enough to work.

663: 4. A man who has nasal polypi and is awaiting operation has a cold and complete nasal obstruction. He is very uncomfortable. I give him ephedrine nasal drops.

664: 5. A woman of fifty (overweight) complains of sternal pain on exertion. She has had it increasingly for five or six weeks. It is true angina pectoris. Her blood pressure is 190/105 and she weighs 11 stone with a height of 5 feet 2 inches. I arrange for her to attend the cottage hospital the next day for electrocardiogram. The sister there will take the tracing and leave it for me in my locker. I give the patient a 1,200 calorie diet sheet and some phenobarbitone tablets. The blood pressure will probably fall with weight reduction and her pain is likely to improve with this too. For the present, I tell her, her pain is a signal of how much she can do. Other relief can be given in due course if necessary. The electrocardiograph tracing, with possibly a second one later, will indicate whether she began her symptoms with a coronary infarct. If the tracing is normal, she will be treated by weight reduction and general advice and trinitrate tablets for the pain when necessary.

665: 6. A young man who has suffered from asthma since childhood has an acute chest infection. Examination indicates some acute bronchitis though his temperature is normal. I give him oxytetracycline and tell him to rest for five days. I give him a cer tificate of incapacity and he will see me again.

666: 7. An anxious-looking woman of middle age complains of per sistent low backache. It has troubled her for months, is getting worse, and is at its worst before her periods. Periods are normal. Her spine and hips more freely and painlessly. A vaginal pelvic examination reveals a normal pelvis but some tenderness of the uterus and the ligaments behind the uterus. This is probably an emotional problem and I ask her about her family life. She has three children, and was well until a year ago. Since then she has been frigid and dreads intercourse. Treatment depends on a detailed history and I make an appointment for a long talk with her later that week. I tell her that there is nothing physically wrong, but the condition is due to emotional stress and so is her frigidity. She is anxious to come for a long talk. No medicines will help.

667: 8. A labourer in his thirties has a throat and chest infection with a temperature of 101 degrees. I give him cough medicine and send him home to bed. He will see me in five days or send for me if he is worse.

668: 9. A child is feverish and crying with earache. Both ear drums are inflamed. His chest is clear. I give him oral penicillin and arrange another appointment in five days. He is to be seen sooner if not rapidly improving.

669: 10. A male factory worker has boils on his buttock and thigh. He has had them before and this time they were preceded by a painful nose. I give him a prescription for sterzac to be used daily in his bath until the boils have been clear for a week. He is also to use soframycin nasal spray for four or five days as the infection is probably being carried in the nose. Sterzac contains 10 per cent hexachlorophene. It costs about one shilling an ounce but it is worth its weight in gold to any sufferer from boils. It is not listed in the monthly index of drugs, I do not know why.

670: 11. A lean man of thirty-five complains of a relapse of his stomach pain. It is clinically typical of a duodenal ulcer, but the result of barium X-ray six months ago was negative. His attacks come on when he has had some family tension. His wife is a large robust woman who sometimes attends the surgery complaining of headaches, which she says are due to her husband's impotence. They have two children but the husband is of recent years be coming overwhelmed by his wife's demands on him. He is not a strong enough personality to discuss matters openly with her and takes refuge unconsciously in impotence. The tension be tween them probably induces the husband's duodenal symptoms. It is a help to know this background because much time can be saved in helping the condition. It is remarkable, furthermore, how easily a question put from time to time at successive inter views to one or other member of such a family can reveal a gradually unfolding pattern and increase the understanding of a family problem. It is in this way that the family doctor with open eyes has an advantage over other observers.

671: 12. A young woman about to be married has discovered a small lump in her breast. Examination reveals slight nodulation in both breasts but nothing that could be malignant. I reassure her clearly and emphatically, and tell her she need not attend again unless she is worried. I explain that the condition is a thickening of the milk ducts and treatment could be given if she were unduly worried by it. In my opinion this is not necessary. She goes away rejoicing. In any case of doubt over a single breast lump the practice is to have this removed and sectioned while the patient is anaesthetized. Fuller operation is done if the pathologist reports malignancy. Once this procedure is decided upon, I feel justified in asking the surgeon to admit the patient as an emergency for his next list. If all is well only a few minutes of his time are wasted. If not, precious time is saved. For the patient the untold anguish of waiting can be reduced to a matter of hours or a day or two.

672: 13, 14, and 15 are all cases of children suffering from upper respiratory infections, earache, pharyngitis or bronchitis. Two of them justify the giving of oral penicillin.

673: 16. An elderly woman, small and pleasant, is worried. She complains of intolerable irritation of the skin of her legs which have been scratched raw. She has had some varicose veins and this is often called varicose eczema. In her case it is a nutritional deficiency of the skin due partly to her age and aggravated by constant scratching. The problem is to stop the scratching. I give her eurax hydrocortisone cream (a 6s tube) and long-acting pheniramine tablets to take one each night. They cost 7d each and are intended to be discontinued when possible. Constant itching is hard to bear. A memory of several days and nights of total itching from head to foot which followed an injection of tetanus serum during the war makes me sympathetic, 7d a night is cheap relief!

674: 17. A woman of forty, kind-faced and red-haired, complains of stiff painful fingers, worse every morning. They have troubled her for several weeks. Her other joints appear normal. She has felt unwell in a vague way for some time. This may be early rheumatoid arthritis. I tell her there is a need for blood tests, scribble 'Rose test and E.S.R.' on a scrap of paper, sign two forms and ask her to take these to the nurse to be filled in. She will see me in a few days and I shall probably be able to help her with tablets or possibly gold injections.

675: 18. A krge, heavy woman has painful knees. I have given up trying to diet her to reduce the strain on her arthritic knees. I give her phenylbutazone tablets for relief of pain. I mention diet again and, as usual, she says, 'I'll try, doctor,' knowing that her sweets are worth the pain.

676: 19. A woman of fifty complains of pain in her shoulders and both arms, worse at night. She is wakened every morning by it at 2 or 3 a.m. It feels like toothache and is driving her mad. She has had it for over a week and is ashamed because there is nothing to show. She has cervical nerve root pain. I give her a form to have her neck X-rayed and a note for the physiotherapist at the cottage hospital who will fit her with a sorbo collar to wear at night. She is to see me for a decision on traction treat ment when I have seen the X-ray. She is also to bring a specimen of urine for nurse to test the next day. Diabetes occasionally produces the same condition but it disappears like magic when the blood sugar is controlled.

677: 20. A boy of seven is brought in with a story of abdominal pain for two days. He vomited yesterday and has eaten nothing today. He walks easily and leaps on to the couch, thus telling me he is not suffering from appendicitis as his mother had feared. He had a sore throat a few days ago, has no signs in his abdomen, but possibly has some inflamed abdominal glands. I reassure the mother and give him some eumydrin drops to relieve the colicky pain.

678: 21. A man of fifty-five, well built, complains of going all to pieces for several months and getting worse. He is constipated and al ways tired, has lost interest in everything, feels 'fed up' all the time. He wakes at 4 a.m. every morning and cannot sleep again. In the morning he does not care whether he lives or dies. I make a brief examination and take his blood pressure. He is suffering from endogenous depression and I prescribe imipramine. I warn him he will not feel any better for two weeks but that he will certainly feel a different man in a month. He leaves, showing his doubt about whether a box of pills can work such a miracle. I feel satisfaction near to smugness in my certainty that he will improve dramatically. For the thousandth time I admit my gratitude for modern drugs.

679: 22, 23, 24, 25, 26. The next five patients are all appointments made late in the day for people suffering from the current brand of upper respiratory infection. They occupy only a few minutes of time each, demand no effort on my part, and receive certificates of incapacity for a few days to a week.

680: 27. A man in his late forties complains of severe back pain. He has been incapacitated for a month, has been X-rayed with negative results, and is a difficult problem. He is one of the much-publicized members of the community who because of the number of their children receive higher pay when they are unemployed or ill than when at work. I do not blame him altogether for his efforts to prove himself unfit for work. It is a battle of wits, and he holds many of the winning cards. Prolonged examination reveals no abnormality except a stiff back. I have him stripped to the waist and get him to pass urine for a test specimen, get on and off the couch, and dress again while I watch his lumbar spine. Finally I am convinced that the stiffness is not genuine and, if so, the pain is probably not genuine either. These cases are notoriously difficult, need infinite patience and when one is busy often receive the benefit of any doubt. There is no complex emotional problem here. He is malingering. Poor chap, with all those children I can hardly blame him. An oral contraceptive for his wife fifteen years ago would have saved him — and me — a lot of trouble! I tell him gently that I think he can manage his work all right and give him a certificate of fitness. He is not upset and we seem to understand each other. He is the last and I am suddenly very tired.

681: August 1968: A very dull afternoon with showers.

682: 1. A smartly dressed woman of sixty, slim but with poor posture, carries a huge black handbag and speaks with difficulty as though with a plum in her mouth. She saw me two weeks ago and a week before that had a slight stroke. It affected her speech and to a slight extent her right hand. Her blood pressure at that time was 240/130. I take her blood pressure which is now 250/135. It is now three weeks since her slight stroke and time to reduce her blood pressure. I prescribe aldomet tablets and explain what they are for. Their cost is about £2 for three weeks' supply. There is no cheaper satisfactory alternative. She asks if her blood pressure is much too high and I tell her that it is too high but this is no great problem. It will come down with the tablets which she will have to continue indefinitely. She asks how long before her speech comes back, and I tell her I am not sure but that it will improve enough in a month or two not to bother her. The important thing is to avoid a recurrence of the trouble and this is what the tablets are meant to do. She will come to see me again in two weeks.

683: 2. A large cheerful but mousy looking woman of about forty-nine beams and whispers that she has lost her voice. It has happened three days ago after a cold. Her throat is infected. She has no family problems and the second commonest cause of loss of voice — a hysterical aphonia — does not apply. I give her some benylin expectorant and tell her to inhale from friar's balsalm in boiling water. No strong medicines are needed.

684: 3. A woman aged thirty-five complains of a 'funny elbow'. A large, boggy, discoloured swelling has appeared suddenly the night before. She watched it swelling up. It is a spontaneous haematoma — a blood vessel that has burst probably after a mild injury. There is no other evidence of an abnomral tendency to bleed. I explain matters and tell her what to do if the same thing happens again. She is to see me if other bruises appear. Before she leaves, she says conspiratorially, 'My husband is coming in next. His mother died of cancer at the age he is now. I don't think there is much the matter with him.'

685: 4. A youthful looking man with regular features and a desire to please. He complains that his old duodenal ulcer pain has re curred with a difference. It is accompanied by frequent small and occasional large vomiting attacks. He has had a duodenal ulcer for ten years or more. I examine him and find nothing. He will only be fully reassured by a barium meal X-ray, and I think this justified. A possibility to be excluded in pyloric stenosis (shrinkage through scarring of the duodenum). I make a note to arrange the X-ray with the radiologist who visits the cottage hospital. Meanwhile I give him a prescription containing belladonna, phenobarbitone and aludrox.

686: 5. A tense, keen looking man of about thirty, says he has felt as though he had 'flu, and after resting a few days is left with a very painful throat and a few glands in his neck. He has no fever. An antibiotic is indicated and I prescribe a five-day course of oxytetracycline.

687: 6. A young woman complains of vaginal soreness and irritation that is maddening her. On examination this appears to be a monilial infection but I am not quite sure. I take a swab which will be despatched in a liquid culture medium to the laboratory. While waiting for the report I give her fungilin pessaries which will work if my judgement is-correct. The cost of fifteen pes saries is 10s 6d. She is to return in forty-eight hours if not improved and in a week in any case. I wonder why this condition has become so much commoner lately. It is usually not a sequel to the taking of antibiotics. I do not know the answer.

688: 7. A dental technician has a small hard wart on his index finger. It interferes with his work and has not been cured by carbon- dioxide snow. I arrange to remove it under local anaesthesia in the cottage hospital the following day.

689: 8. A heavy middle-aged man dislocated his shoulder a month ago. It was reduced in Bath. There is still much pain and stiffness. He is having physiotherapy in the cottage hospital, and needs pain relief. A depronal tablet every twelve hours has given him much relief. These cost 27s 2d. for fifty, and I hesitate to repeat them because of this. I give him a prescription for paracetamol (35 for fifty) and make a mental note that if he persists that depronal is much better, I will repeat them next week. Which should I take myself?

690: 9. A youth of twenty was involved in a car accident six months ago. He fractured a femur and an elbow. He is a decorator and could work for three to four hours a day but his employer cannot afford to employ him half-time because of Selective Employment Tax. Furthermore he would be no better off on the half-pay that was earned than on insurance benefit. I give a further certificate of incapacity.

691: 10. A middle-aged man complains of irritation and tenderness of his ear passage. He has external otitis. I syringe the ear and give drops of Efcortelan N. They cost 9s for a small vial. He is to come to the nurse in five days for further syringing, and to me in ten days.

692: 11. An elderly woman, thin and round-shouldered, complains of pain in the middle of her chest as though her food sticks in her gullet. She can in fact swallow freely but that is how she describes the sensation. She has had it for two weeks, and it started gradually. It is not affected by food but is a little worse after exertion. On examination her heart rate is rapid, but she is not fibrillating. The sensation is probably cardiac in origin, or possibly secondary to her kyphosis (round shoulders). There are no signs of cardiac failure and her blood pressure is normal. I give her digitalis and arrange to see her again in a week. She needs watching.

693: 12. A middle-aged man has severe haemorrhoids. I give him the third of a series of injections into the haemorrhoids.

694: 13. An elderly man has chronic bronchitis, emphysema and asthma, with resulting cardiac weakness. He has not worked for three years and was very depressed when last seen. In addition to digitalis, and ephedrine, I gave him at that time an anti- depressant — imipramine. He reports himself much better. He is breathing and sleeping better, he says. Depression is very com mon at all ages, especially in the elderly. It frequently appears as a worsening of any and every other disease in existence — as in creased arthritis, increased bronchitis, increased pain of any sort. Improvement in the depression reveals itself as improvement in the accompanying disease. People can cope with many illnesses while they are not depressed. When depression sets in they are overwhelmed and cannot carry their previous burden. Anti-depressant drugs are of wide value.

695: 14. A gardener aged sixty has a grossly swollen face and almost closed eyes. It's his own fault, he says. It's these bloody pyrethrums, what should he do? No, he won't touch the bloody things again as long as he lives. I tell him to wash frequently in salt and water and apply i per cent hydrocortisone lotion every four hours with his fingers. He must rest from work and has a certificate.

696: 15. A farmer aged forty is feverish and coughing up blood. He has been haymaking but not in contact with old or mouldy hay such as might cause an attack of farmer's lung. He has had this before but only after moving old dried hay under cover. I am not sure whether this is acute infection or farmer's lung. I give him a sputum pot for a specimen to be sent to the laboratory, then a prescription for oxytetracycline tablets. I hesitate and then add prednisolone tablets. The laboratory will probably isolate the aspergillus responsible for farmer's lung if it is there, but this takes several days. The condition is rapidly suppressed by pred nisolone. Meanwhile if he has infected lungs the antibiotic will probably cure him. This is slightly unscientific but may save time — an important consideration for a farmer in August.

697: 16. A child has conjunctivitis in both eyes. It is probably in fective 'pink eye'. I give him eyedrops — betnesol N costing 55 for a small vial.

698: 17. A woman of about fifty sits before me sadly. She complains of headache. I groan inwardly, but force myself to sit back and let her talk. The headaches come on gradually during the day. They are everywhere in her head and press on the top. She has difficulty in sleeping, and difficulty in getting up in the morning. There are no other symptoms. I know her family. Her mother died in a mental hospital recently. She will have to be watched. This is probably anxiety and fear of mental illness. I take her blood pressure and examine the back of her eyes — more for her reassurance than for my enlightenment. I talk about her mother and reassure her. I give her largactil as a sedative and she promises to see me in a week. She will need help for a time and I have to establish some kind of relationship with her.

699: 18. A young woman bounces in. She thinks she is pregnant. Is she please? Also her friend's little girl had German measles last week. Could she catch it? I examine her and think she is about seven to eight weeks pregnant. I question the history of contact with rubella. She has not had direct contact with the child — only with her friend. She does not know whether she has had rubella. The present evidence is that 90 per cent of women are probably immune to rubella and therefore the need for a gamma-globulin injection is questionable. Nevertheless until further information is available we give the gamma-globulin to those cases who have had direct contact with rubella during the first three months of pregnancy. When this is given, protection should last throughout pregnancy. I reassure her with as full an explanation as I can.

700: 19. A child is brought in with half a dozen spots scattered over her head and body. She has been in contact with chicken-pox. They are going on holiday in three days. Yes this is chicken-pox. I suggest delaying the holiday two or three days and, as it will be in a caravan by the sea, isolating the child from other families there. It is no more difficult than isolating her at home.

701: 20. Another child has slight earache. They too are going on holiday. I confirm that there is definite otitis media and prescribe penicillin with strong pressure to the mother to give the whole of the five-day course.

702: 21. A man of middle age complains of acute back pain which came on at work today. He has a slight scoliosis but there is no reference of the pain to his legs. I put him on the couch and per form the two manipulations that I find useful. On sharp rotation of the spine there is a snick and I repeat it. At first he thinks he is better but when he walks about the room he finds he is just the same. It sometimes works but not this time. I give him paracetamol and tell him to rest by day on the floor and by night on a firm bed. He will see me in three or four days. He is the last. My secretary has written three repeat prescriptions for me to sign. I ask her to write 'See me next time' on one of the patients' record cards. This ends the session.

Chapter 12: Abortion and Contraception

703: Every citizen has his responsibilities to the rest of society, but in the case of the general practitioner these are more than usually great. If he knows that a patient suffers from epilepsy and yet is driving a car, what should he do? He should advise the patient not to drive. If he were met with a flat refusal to take advice, what next? Should he inform the police? This and many other responsibilities crowd upon him every day.

704: The first is the problem of abortion. The new law lays down the principle that if a pregnancy is likely to have an adverse effect on a woman's health or that of her children, it may be terminated. Further, if an expected child is likely to be born seriously handicapped, that pregnancy may also be terminated. In considering the effects on health, it is permissible to take into consideration not only conditions at present but conditions which are likely to arise in the future. This gives discretion to the doctor, usually the general practitioner. If he honestly believes an abortion is advisable and permissible by law, he will have no difficulty in finding a gynaecologist who will agree with him. Gynaecologists, like general practitioners, naturally vary in their opinions. Those I know have given careful thought to the problem, and if they have no religious reason for inaction usually agree to perform an abortion if the general practitioner can present a good case for it.

705: Every case is difficult. How will the health of an unmarried girl be affected by a pregnancy following a casual sexual experience? If she is aged sixteen, it is argued that her future happiness will be profoundly affected by her having had an illegitimate baby at such an early age. If her happiness is affected, how does this affect her health? Take the case of the married woman with three children. She has taken reasonable precautions to prevent the conception of a fourth child but has nevertheless become pregnant. She argues that she and her whole family will be adversely affected by the birth of a fourth child. There is already tension between husband and wife and the extra strain is likely to break down the marriage completely. This would undoubtedly affect the health of all concerned, especially the children. If the doctor disagrees with this argument, the patient can reasonably claim that he is denying her the benefit of the law. He can of course side-step the problem by saying he cannot in conscience recommend abortion but this merely puts the responsibility on to someone else.

706: Where then do we draw the line? Should a young woman of twenty who has been promiscuous in her sex life be aborted because her freedom will be interfered with? It is at this point that one has to face the fact that the patient's morals are not the doctor's concern any more than they are the concern of any other citizen. We have no right to dictate our patients' behaviour, much as we often want to. We have no right whatever to say, 'You have done wrong, you must therefore suffer for it.' The promiscuous girl of twenty may have her baby adopted, or she may be overwhelmed by her maternal instinct and want to keep it. We have to form our judgement on the effect of the birth on the mother's health. It is highly probable that she will have to keep her pregnancy. No one wants to see the birth of an unwanted child but this consideration must not influence the decision.

707: In the case of a young engaged couple, pregnancy in the young woman is unlikely to be prejudicial to health, and the matter is fairly easy to decide. It would be difficult to argue that the inconvenience of having her family earlier than she had intended was bad for her health. In my experience no young couple seriously attracted to each other ever considers having their baby destroyed before its birth. The problem of abortion does not as a rule arise. If it did, a refusal would probably be indicated.

708: In my own opinion it is hard to recommend an abortion on health grounds in the case of the girl of sixteen. The case of an unwanted baby late in a family is debatable, but would be difficult to refuse. On the other hand, I am impressed by the way in which the women in these cases adjust to the situation once the first shock is over. The decision, I think, would depend on the stability of the family concerned and the previous health and personality of the mother.

709: A woman aged thirty-eight had three children. Her blood was rhesus negative and with the second and third children there had been repeated blood transfusions in early infancy. She became unexpectedly pregnant with a fourth child and felt she could not face the blood problem all over again, in addition to her increasing family burden. In the early weeks of pregnancy, she seemed likely to break down completely. This case occurred before the new law was passed. I was in great doubt about the effect of the pregnancy on her health and sought the advice of a consultant. He took the greatest care over his decision. He took blood samples from both parents to see whether there was a possibility of the new foetus being rhesus negative and therefore causing no more trouble than any other infant. It turned out that there was a chance of this being so, though a small one. The effect of the careful investigation of the facts was to pacify the woman to a great extent. She felt that she was having a fair deal. After discussion among us for two or three weeks she accepted the pregnancy. The consultant had explained that he thought there was no adequate reason for aborting her. He was absolutely right but his success with the patient was due to the time and care he took over his decision. (This was by the way a hospital case and not a private on.) The family now consists of four fine boys. Under the looser law today she would have had her pregnancy terminated.

710: The following story is attributed to Maurice Baring. One doctor said to another, 'I want your opinion about the termination of a pregnancy. The father was syphilitic. The mother was tuberculous. Of the four children born, the first was blind, the second died, the third was deaf and dumb, the fourth also tuberculous. The woman was again pregnant. What would you have advised?'

711: 'I would have ended the pregnancy.'

712: 'Then you would have murdered Beethoven.'

713: This story serves to remind one of the responsibility taken whenever a pregnancy is terminated. It is necessary in good faith to be convinced that a woman or her children will suffer in mental or physical health as a result of the pregnancy. It is the determination of how much the mental health will be affected that gives rise to the widest differences of opinion. There are very few pregnancies which will adversely affect the mental health of a family. Even a marriage on the verge of breakdown could be helped rather than hurt by another pregnancy. The new abortion law throws a great responsibility on to the general practitioner who must to a large extent administer it. He must take a great deal of care in forming his opinion. He must discuss the matter with both husband and wife. He must consider the previous health of both and the health prospects of the unborn infant as well as of the other children. When the health of the unborn infant underlies the request for abortion, there must be a risk that the child will be 'seriously handicapped'. In the case of a mother having rubella between the fourth and twelfth weeks of pregnancy, there is about a one in four chance of a serious handicap to the infant. A practical difficulty here is that rubella is not always easy to diagnose. A clear-cut case with typical rash and swollen occipital glands is easy to pinpoint but many cases are difficult. There may be flushed eyes, no inflammation of the occipital glands, and a rash of short duration fading within a day. It is no use asking consultant help in this problem. The general practitioner must study cases of rubella with extreme care in order to be able to recognize the syndrome when he sees a borderline case. (I wonder how the psychiatrist quoted on page 11 would deal with this problem. Would he call in a dermatologist or a physician on an urgent domiciliary visit?)

714: Laws on the statute book are interpreted by the courts. It may be that some of us will have to answer in a court of law for our actions. It seems likely however that no doctor would be prosecuted — still less convicted — if he acts honestly after taking all proper care in making his decision.

715: The prescription of oral contraceptives is a related responsibility. The general practitioner's decision as to whether he will or will not give a certificate for the Pill must depend on whether he thinks it is medically suitable to the patient concerned. If she has extensive varicose veins, a history of thrombosis, diabetes, or a high blood pressure, the risk of taking it will be greater. Should we therefore concern ourselves with the question of whether or not the patient is married? I have no hesitation in giving the Pill to a girl who is engaged to be married. I must confess I have reservations about giving it to those who want to use it for safety in free love. It is not my duty to concern myself with the patient's morals, but it is only by a conscious effort that I can be objective. It is, in fact, more important that the promiscuous young woman should not have an unwanted baby than that the engaged couple should be protected. From society's point of view, the avoidance of unwanted babies is of paramount importance. One should prescribe it whenever it is medically safe. If the general practitioner refuses to prescribe it, he will not improve the morals of the young woman. Fear of pregnancy, in any case, is not a way of raising moral standards, only of forcing people into a pattern of behaviour suitable to a police state. Higher standards will be achieved when a spiritual force raises them. A cloistered virtue is no real virtue. Nevertheless, in making his decisions, the doctor is faced by searching questions of right and wrong.

716: One other responsibility of the general practitioner should be mentioned here, and this relates to the proper use of the hospital service. Many people become hospital addicts. Patients with no need for hospital treatment go from one hospital to another being investigated for imaginary diseases. If they were only accepted in hospital on the recommendation of the general practitioner and if he took adequate care in his assessment before referring them, this would be avoided. It is a well-known fact that many general practitioners — sometimes through overwork and sometimes not — refer patients to hospital without need. Every houseman in every hospital will tell the story of a patient who has arrived with a visiting card from his doctor, on which are written only two words 'Please examine'. There are a few general practitioners near every hospital who give general practice a bad name. I refer to what could and should be.

717: It should be remembered that when a patient arrives at a hospital without a specialist appointment, he is seen by the casualty officer, who may be a foreigner with a limited command of English. He is usually a competent young doctor but naturally he has little experience. Any doctor who has tried to assess the integrity of a patient in a foreign language, or even take an adequate history, will know how unbelievably difficult this is. Suppose that a man bent on getting attention and unknown to the casualty officer arrives complaining that he had a giddy attack and then fell down with a blinding pain in the back of his neck, and that the pain persists. No one could dismiss him without investigation. He might for instance have a subarachnoid haemorrhage which would prove fatal a few hours later. A lumbar puncture will be performed and the registrar and probably a neurologist as well will make a long and careful examination. This is an unavoidable waste of time. Even if the patient is a known malingerer, the examination is necessary. The person most likely to prevent all this is the one doctor who knows the patient personally — his family doctor.

718: Reference is made in The Times of August 30, 1968, to six hospital addicts who were estimated to have cost the National Health Service £100,000. One patient was known to have had 120 chest X-rays.

719: All general practitioners have what are called 'fat envelope cases' — patients whose records show that they have been to every available specialist without help. These are not the specialists' failures but our own. We have never fathomed the underlying emotional disturbance that causes the recurring complaints. If we had the time, and took the care, it is probable that half the hospital out patients could be diagnosed and treated at home. Most of these cases are not difficult for any competent doctor to deal with. What is needed is a sound reputation so that the patient has confidence, enough time, and access to X-rays and other facilities. The facilities are now usually available. The time and the reputation depend on the future development of the Health Service.

720: These responsibilities make it important that the doctor in general practice should be a man of intelligence and vision. His influence on the life of our society can be very considerable-and this at a time when it is threatened by instability and breakdown. It is not, I think, unfair to point to certain similarities between the present time and the fourth century, just before the fall of the Roman Empire.

721: Edward Gibbon gave five reasons for the 'decline and fall':

722: 1. Increase in divorce with the consequent undermining of the sanctitity of the home.

723: 2. Higher and higher taxes; the spending of public money on bread and celebrations.

724: 1. The mad craze for pleasure.

725: 3. The building of gigantic armaments when the real enemy was within — the decadence of the people.

726: 4. Decline in religion, faith fading to mere form, people losing touch with life and becoming impotent to guide it.

727: He could have been describing the late twentieth century. Unfortunately at the present time most of the best brains in medicine are moving towards the scientific centre of the medical service, the research laboratories and teaching hospitals. If the influence of the general practitioner in society is what I believe it is, some of the best doctors should be working among the people.

Chapter 13: Negligence

728: An important reminder of the responsibility carried by the family doctor is that in so much of his work he is exposed to the risk of claims for negligence. This is inevitable and he must learn to accept it in early years as the price of the trust that is put in him. His power is great and power can corrupt. The possibility of facing a legal action for negligence keeps his activities within certain broad bounds for the safety of society. Eventually it benefits the doctor himself as well as his patients.

729: News of an occasional penalty or reprimand to a colleague can be alarming, but on the other hand if the doctor remembers that he is only expected to act with 'reasonable care and skill' his case is not too hard. The difficulties lie in the constant need, day and night, in sickness and in health, when fresh or weary, to exercise this reasonable care. It is no excuse to say that he overlooked a fractured scaphoid when he was tired one morning because he had been out all the previous night.

730: Most doctors hear, from time to time, the voice of an imaginary barrister cross-examining them in the witness box.

731: 'Doctor, when you told this patient he was suffering from a stiff neck, had you considered the possibility of meningitis?'

732: 'Would you say that if this arm had been X-rayed in the first place, this patient's chances of a useful limb would have been much greater? And did you have it X-rayed?'

733: 'When you told this mother that her infant was suffering from gastro-enteritis, did you consider the possibility of pneumonia as the cause of the diarrhoea? And would treatment of the pneumonia have saved the child's life?'

734: 'Doctor did you consider asking for a specialist's opinion about this mother? And if you had induced labour a week earlier, would the child's life have been saved?'

735: The voice of the accusing barrister must be lived with and on the whole this does no harm. If members of the medical profession were entirely free from the ultimate restraint of legal action it is not cynical to say that standards would fall. They depend, of course, mainly on the conscience of the doctors but in times of strain or fatigue, or in those times when vitality is at a low ebb and high purposes lose their clarity, it is good that there is a 'book of rules'. The rules of course are being formulated all the time. It is an unfortunate necessity that they have to be made by penalizing, or even crushing, an individual here and there, who has strayed off the tramlines which must guide his conduct. Sometimes a very human mistake is made and disaster follows. In theory, an error of judgement is not negligence and is not culpable. The distinction however is not a clear one.

736: Great 'harm can be done by an error in administration. A doctor went away on holiday and left his partner in charge of his practice. One of his patients had developed early signs of toxaemia in the eighth month of pregnancy. These signs were slight, but to be cautious in view of his impending absence, he told her that his partner would call on her early the following week. In telling the partner of the case, he remembered the condition was mild and thought he had told the patient to visit the surgery. During the following week, her condition deteriorated. She had increasing headaches but as she was expecting the doctor to call she did not send for him. Five days passed before the husband insisted on .sending for the doctor in temporary charge of the case. This doctor, who was doing double work, received a message that Mrs so-and-so had a headache and would he call? He called late the same evening, by which time she was bordering on a state of eclampsia. She was moved to hospital and her life was saved, but her baby died-a much-wanted child after ten years of marriage. It was heart-breaking for all concerned. On his return the doctor on holiday suffered, almost as much as the patient had done. The husband, after careful thought, sued for damages. He felt to some extent that this was his duty, but as with most actions, his purposes were mixed. He thought that his wife's depression might be relieved by some definite action, and his own aggressions urged him to strike a blow at the agent of fate which had served him so cruelly. This case was eventually dropped after the intervention of the Medical Defence Union, but a great deal of anguish could have been avoided if a tired doctor in need of a holiday had exercised greater care in the details of his handover. He was careless, and a child died — a much-wanted son in a farmhouse which had been in the family for several generations. There but for the grace of God goes any member of this vulnerable profession.

737: Mistakes are not always punished. When I had been in general practice a few months I was left in charge of one of the great ladies in the practice by my senior partner who was on holiday. I had to give her a hypodermic injection in her home for some reason. I remember that she was not in bed but stood up in her bedroom while I gave the injection into her arm-I can still see the fine furniture and large airy bedroom. At the instant of withdrawing the needle it snapped at its 'hilt. I can still hear it. The broken end was just visible, protruding from her arm. My left hand was holding the arm with the skin taut under pressure from my thumb. If I moved my thumb the needle fragment would disappear under the skin, and it was too small to get hold of with the finger and thumb of my right hand. These things can be extremely difficult to find once they disappear, and involve a krge incision under local anaesthesia, and perhaps operation under X-ray screening into the bargain. Perhaps only a second or two passed, but I saw the future of her case in terrible detail. How was I to tell her? Then a voice that I can still hear spoke with charming firmness. 'If we both move together to my dressing-table over there, you will find a pair of tweezers. Would they help?'

738: My relief was intense. We moved with small, careful steps towards the heaven-sent tweezers and in a moment the fragment of needle was out.

739: When a patient decides to lodge a complaint against his doctor, he does so to the Executive Council of the area. The address is on his National Health Service card. If the chairman of the appropriate committee of the Council finds there is a prima facie case for complaint it is investigated. If the patient is not satisfied he may appeal to the Minister of Health. These procedures take time, often many months. Three complaints out of four are found to be groundless. They are sometimes so frivolous as to be almost unbelievable but the doctor must submit to months of unease or anxiety until the case is settled.

740: This case was recorded in the Annual Review for 1965 of the Medical Defence Union. 'A doctor's wife who answered the telephone at lunch-time was informed that the doctor had visited Miss D earlier in the day, that after he had given her an injection she was able to visit the hairdresser, but that she had just had a relapse and the doctor was again wanted at once. The doctor's wife explained that as her husband was on his rounds she might not be able to contact him until he returned in about three-quarters of an hour. When, in an attempt to assess the real urgency, she enquired into the nature of the patient's condition, she was told rather tardy that in three-quarters of an hour it would be too late for a visit from the doctor since Miss D was going to be married in thirty minutes. These events were followed by an unpleasant letter of complaint to the executive council in which the doctor was accused of a failure to visit. Not surprisingly the complaint was dismissed without a hearing.'

741: Another case is reported in the Annual Review for 1967. 'A middle-aged man died after an illness lasting less than twenty-four hours. The cause of death was acute respiratory failure due to the sudden expansion of a cyst of the mid-brain. The widow believed that her husband's death was connected with a severe degree of myopia which had been present for many years and that the general practitioner was in some way responsible. When the widow complained to the Executive Council, the Chairman of the Medical Service Committee did not seek the practitioner's comments. The committee considered the complaint, resolved to dispense with a hearing, and recommended that no further action be taken. The Executive Council accepted the committee's recommendation with the result that the practitioner remained unaware that a complaint against him had been considered by the appropriate committee of the Executive Council.

742: 'A few months later the doctor was informed by the Ministry of Health that the complainant had entered an appeal against the council's decision. The Ministry asked the doctor for his comments on the appeal and, on the advice of the Union, he replied stating that he was unable to offer any useful comment on the complainant's appeal because, as the executive council had not asked him for his observations on the complainant's original letter, he had no knowledge of the complaint. A month later the doctor had a further letter from the Ministry stating that arrangements were being made for the appeal to be heard by a tribunal. It seemed that the administrative steamroller had no brakes. The problem was put to the Union's solicitor, who wrote a letter to the Ministry explaining the plight of this practitioner. The steamroller paused, apology was made; the doctor was allowed to present his comments with the anticipated result that the Minister dismissed the widow's appeal without a hearing.'

743: Another case reported by the Medical Defence Union concerns a patient who had for some months been consulting his family doctor complaining of abdominal pain, usually at the weekend, and the practitioner's prescription for an antacid and a sedative had proved efficacious. 'After a considerable interval the patient had an attack on a Sunday and, finding himself out of tablets, telephoned his general practitioner between 7 and 8 p.m. The practitioner remonstrated with him for telephoning on a Sunday evening for a repeat prescription for a sedative which he had been taking regularly. The conversation became acrimonious and concluded with the practitioner inviting the patient to come and fetch a prescription; he did so and the practitioner told him which chemist would be open.

744: 'The patient complained to the Executive Council, alleging that the practitioner had given treatment in such a way as to aggravate his condition and nullify any relief from the treatment and that he had thus failed to comply with the terms of service and provide all proper and necessary treatment. The complaint was rejected by the Medical Service Committee and the patient appealed to the Minister of Health. After a hearing the Minister found that the patient's argument was one which he could accept in principle; he did not however accept it in this particular case because he was not satisfied that the altercation significantly reduced the benefit of the treatment. He found that the practitioner had not contravened the terms of service and dismissed the appeal.'

745: It is a wise provision that, when a doctor is asked to visit a patient, he must himself decide whether that visit is necessary. This sounds like a concession to the doctor, but in fact it merely places the responsibility fairly and squarely on his shoulders. A doctor may be asked in the late evening to visit a fretful child who is likely to keep the parents awake. Some parents are so anxious to avoid a night's disturbance that they would send for a dozen doctors rather than risk such discomfort. Others will only ask help when it is needed. Aconversation will run something like this:

746: 'The baby is very ill. Will you come and see her?'

747: 'What is the trouble?'

748: 'She is flushed and cries all the time.'

749: 'How long has she been ill?'

750: 'Since suppertime.'

751: 'You mean about an hour?'

752: 'Yes, more than that perhaps.'

753: 'Is the breathing all right?'

754: 'Yes she breathes all right.'

755: 'Any diarrhoea?'

756: 'No.'

757: 'Has she been sick?'

758: 'No.'

759: 'Does she take her food?'

760: 'At tea-time but not now.'

761: 'Are there colds in the house?'

762: 'The wife's got a cold.'

763: The child has probably had a feverish cold for about an hour and does not need an urgent visit. On the other hand, if she develops earache badly in the night the parents may well call the doctor out at 2 a.m. The doctor may justifiably prescribe a sedative without seeing the patient, and suggest a consultation by appointment in the surgery the next day. From the moment, however, that he refuses a visit, the doctor must be very careful. If the parents, in a huff, neglect to bring the child to be seen the next day and there follows some degree of generalized infection, a dangerous condition may follow. If the child has earache, it will sound plenty of alarms. If it has an intestinal infection with diarrhoea or sickness, the parents will give plenty of alarm signals. If the child has a severe chest infection it will be fairly obvious. But septicaemia may cause a quiet lethargic state which may give parents a false sense of security. I have seen an insidious infection in a child of two suddenly become dangerous after three or four days, leading to a series of thromboses and the tragic loss of both feet. The feelings of the parents in a case like this, if a visit had been refused, can be easily imagined.

764: For these reasons some doctors find it easier to accept every call, day and night, as a genuinely urgent one. Sometimes time is wasted on unnecessary visits, but a definite risk is avoided. More often than not when the doctor refuses a visit a mental malaise forces him to change his mind and go after all. I once had a charming elderly Portuguese Indian assistant, who would argue on the telephone for ten minutes over every late evening call. He would come back to his chair grumbling about 'these thoughtless people' and their 'damnable selfishness'. Within a quarter of an hour he would with the utmost regularity get up and say, 'Perhaps I had better go and see those people after all.' And off he would go.

765: There are certain difficult cases which the doctor is on the look-out for — where mistakes have been made before, for which others have had to suffer. The list is far from exhaustive, but it is a help.

766: A fracture of the scaphoid bone in the wrist is one of these. The bone may be fractured but an X-ray taken soon after the injury does not show the fracture. A second X-ray taken a fortnight later will show it. If this is neglected a piece of dead bone may result, giving endless trouble in the wrist. Another fracture easily overlooked is that of the neck of the femur in an old person. The patient may catch a foot in the carpet and fall a little awkwardly and the resulting pain may very easily be attributed to something milder than a fracture. Any injury which is not X-rayed may turn out to be a fracture and the failure to X-ray is regarded as negligence. Naturally .thousands of X-ray pictures are taken each year to save the doctor from remote possibility of reproach.

767: Another well-known source of trouble is the broken hypodermic needle already mentioned. This does not occur so frequently now, because the Ministry of Health provides a new disposable syringe and needle for every injection. These needles are far less likely to break than the old steel ones which, for economy's sake, were washed and sterilized many times. A microscopic area of rust at the hilt could, and did, easily cause a fracture at the critical moment.

768: Another common mistake of recent years is the failure to ask a patient in need of penicillin whether he is known to be sensitive to it. A severe reaction may follow which could be avoided by 'due care'.

769: Failure to detect diabetes or nephritis by urine testing are other mistakes made more easily than sounds possible. These tests are routine on admission to hospital but not on attendance at the surgery. Probably a thousand tests would show normal results for one abnormal one.

770: The main problem is time. If, in general practice, half an hour or more were available for every consultation, a full routine examination could always be made. In most cases this would be sheer waste of time and four times the present number of general practitioners would be needed to run the system. A patient complaining of a tennis elbow does not normally need his urine and rectum examined. The criticism usually made of the National Health Service, however, is that the doctor is always in too much of a hurry to do his job properly. Unless and until more good doctors decide to take up general practice this statement will be to some extent true. Nevertheless if the number of claims for negligence in Britain is compared with that in America the argument falls to the ground. The sum paid by British doctors to insure against all the legal risks they run is £6 per annum. The equivalent American premium is twenty times as large. Even allowing for the fact that damages may involve much larger sums in America, the claims there, where there is no National Health Service, must be much more frequent.

771: The number of cases of alleged professional negligence dealt with in 1967 by the Medical Defence Union — which has nearly 58,000 members-was 165. Of these, 104 were either abandoned or settled without a contribution from the Union. In other words, about one in every thousand doctors suffered in that year from a complaint of negligence, which to some extent went against them. At this rate, in a life-time of 40 years in practice, 4 per cent of doctors would be found negligent at some time or other. If this state of affairs is to be improved, an adequate number of skilled and dedicated family doctors must be made available. The work can be done with very high efficiency but so long as there is loose talk of 'a dying branch of the medical profession' there will be too few new entrants to general practice and the present difficulties will continue.

Chapter 14: Screening and Research

772: Every now and again a middle-aged man asks his general practitioner for a 'check-up'. The only virtue of this unattractive Americanism is that its meaning is clear. I have never known a woman ask for such a thing, and I am not sure why it should be such a predominantly male request. Perhaps it is because middle-aged men begin to realize that their wives will probably outlive them. Or perhaps it is because there are schemes in some parts of industry for the periodic examination of management executives. People argue that if an industrialist is willing to spend money on such a scheme it must be valuable.

773: When a patient asks to be overhauled one is bound to agree with the request. In theory he has only to show some degree of anxiety about his health for the whole examination to be necessary as part of the treatment.

774: The value of this sort of examination is doubtful. I have American friends who claim that they emerge from their 'annual check-up' walking on air, because they have such renewed confidence in their good health. One can only conclude that their periods of exhilaration are preceded by periods of gloomy anxiety which over the years must cancel them out. The value of the examination depends on whether any diseases can be discovered in an early stage before they cause symptoms. If the procedure consists of a full clinical examination followed by analysis of the urine, chest X-ray and electro-cardiogram, there are only two abnormalities which are likely to be discovered in this pre-symptomatic stage. These are the presence of sugar in the urine and a raised blood pressure. Both are useful pieces of information and would indicate the need for certain other investigations and treatment, and both could be done perfectly well by a nurse. There is, I think, a good case for the screening of the whole population over the age of forty for these two conditions. The tests can be done by the nurses attached to the practice and abnormalities reported to the general practitioners. Before adequate treatment of hypertension was possible, it was usual not to tell a patient he had a raised blood pressure. Anxiety over it only made it worse. Now that progressive damage to heart or arteries can be reduced by control of the hypertension, it seems reasonable to look for the condition and to treat it before it gives rise to symptoms. There is certainly a strong case too for regular chest X-rays being done by the Mass Miniature Radiography Service, but none of these examinations need involve a complete clinical overhaul.

775: It is possible to do the complete examination indicated and yet to find no evidence of an already existing cancer of the bronchus, stomach or colon. Furthermore the normal electro-cardiogram may be followed by the death of the patient the next day from a coronary thrombosis. It may be argued that the routine screening examination should include a barium meal and a barium enema for X-ray purposes and bronchoscopy. It is true that these might reveal a very early cancer of the stomach — one of the most fatal forms of cancer. It is doubtful however whether early treatment would much improve the outcome of the disease, and it would certainly prolong the period of fear and anxiety that the diagnosis involves. Cancer of the colon might be discovered occasionally in a very early stage and an operation then would be more likely to cure it than one performed after the first symptoms appeared. Cancer of the bronchus, too, might be discovered in an early stage by bronchoscopy but here again the results of surgery even on early cases are not good. Bronchoscopy furthermore is a very uncomfortable investigation even in skilled hands. For those who live such a miserable life that they are haunted by constant fear of disease, these examinations may sometimes be justified, but as a routine, heaven forbid! In a just society they would have to be offered not merely to the rich but to every middle-aged member of the community. We should spend much of our meagre resources with gross improvidence and breed a nation of hypochondriacs into the bargain.

776: If the simple routine of clinical examination and urine analysis followed by chest X-ray and electro-cardiogram were adopted the benefits would be no greater than the still simpler screening done by nurses. What is more, the examination would have certain harmful effects. In the first place people would become even more health-conscious than they already are. This is an introverted and harmful state of mind. In the second place, patients so strongly reassured about their health would be likely to neglect symptoms which should be reported. A man who developed a slight chest pain on exertion the day after his overhaul would probably take no notice of it. Or he might, in his mood of exuberance, overlook the passage of a little blood and mucus in his motions due to a cancer of the colon. Symptoms are of real importance and the taking of a careful history of the patient's complaints is more important in diagnosis than many special investigations.

777: The choice appears to be between an elaborate and wasteful regular examination of the whole population on the one hand, and a series of simple but valuable screening tests on the other. In addition to urine testing and blood pressure reading by the surgery nurses, and chest X-ray by the Radiography Service, cervical smear tests on all women over the age of thkty are of proved value. These services can only be offered, not enforced, and in general practice all one can do is to encourage patients to accept them. Our policy over cervical screening is to make the test available to all who care to ask for it. It can be done routinely by the nurse, though she may need help in some cases and may want the doctor to inspect others. Provided there is a nurse always in the surgery this works very well. We recommend the test to all women who have for some reason to undergo a pelvic examination. It can then be done without additional discomfort as part of the examination. Routine post-natal and oral contraceptive examinations offer the same opportunity.

778: The extent to which these four screening processes will be used depends on the degree of the general practitioner's conviction that they are of value. In some areas in East London clinics have been closed because there is too little demand for cervical cytology. The general practitioner can easily encourage the procedure if he wants to as part of his work in educating the public in health matters.

779: Mass radiography is used somewhat haphazardly and again its value will be lost without active encouragement from the general practitioner. It is used routinely in some factories but not in others. It seems wise to recommend it for all young people who consult the doctor for any form of general examination whether they are ill or not. Curiously enough people are always willing and anxious to have a chest X-ray once it is suggested. The Radiography Service issues regular information about the positions of its mobile units and by giving the patient a form and an appointment, the doctor can be sure of a report on the X-ray a few days later.

780: The work of routine medical examination with the object of early diagnosis of disease is not fraught with excitement. The prospect of endless physical examination of normal people is frankly a very dull one. If this became the main work of a general practitioner I would not advise any young man to enter this branch of the profession. Fortunately for us the examination of normal people is largely the work of insurance medical officers and those in charge of welfare clinics. The real interest lies in the research work entailed in discovering which, if any, screening processes have value. Much of this must be done by general practitioners.

781: Today the word research has a touch of romance about it. If you ask a student what he is going to do after graduation, he will speak the word reverently. Research is a necessity in every sphere of science. Blind or ignorant power has become a danger to humanity itself, and the only hope for the future lies in increasing enlightenment. No one, however, who has ever been engaged in research could call it romantic. It is arduous, monotonous and often boring. It is therefore something which in general practice one is tempted to leave to others. At the same time, in no sphere of life is it more important.

782: Recently a study was published of a screening process for measurement of ocular tension in a general practice. As glaucoma is one of the major causes of blindness in older people, the discovery of those likely to suffer in this way in the future is of obvious value. Other screening studies of this condition have been done but this was the first in a general practice. The advantage of the present study was that the general practitioner would be able to follow up the cases needing special attention in his own practice. Screening studies for anaemia have been done and a world-wide reduction in haemoglobin values found at certain ages and places. In July 1968 a study of a hundred 'well' women was made and a surprising number of abnormalities needing treatment were discovered. It will of course be argued by some that if people do not complain they are best left alone. If it is discovered, however, that an improvement in positive health can be obtained in a considerable number of people, this study is worth while. It seems on present evidence that routine pelvic examination of women may give greater opportunities for preventive treatment than routine examination of men. Women are beginning to accept the value of cervical cytological examination and it may be that a fuller examination at the same time would be a justifiable procedure.

783: Investigation of all these matters is continuing. Whatever may be the arguments for and against screening processes, more knowledge is needed about their value. Knowledge and truth are always better than ignorance and untruth. The wisdom to use properly the knowledge gained is another matter, and this is where the best minds are needed.

784: Some time ago I took part in an investigation into practice administration. It entailed the filling in of a separate card for every patient I saw for four chosen weeks in a year, together with the completion of various forms summarizing certain pieces of information. I found it troublesome work and my patients kept dragging my attention away to their affairs instead of letting me get on with my research. A great deal of hard work was done by sixty or seventy doctors and even more by those who analysed our results. Unfortunately, nine-tenths of all honest laborious research will give negative results. We cannot all have the good fortune as well as the skill to be Jenners or Flemmings. This being so, it is an admirable thing that so many young men and women set out on the thorny paths of enquiry. The spirit of investigation is essential in modern medicine and we can be proud of the number of general practitioners who spend hours of their limited spare time on work which gives them little personal satisfaction.

785: My own interest urges me to find out more about human beings. Enquiries that attempt to elucidate the relationships between people — members of a family, doctors and patients, employers and employed — hold a fascination for me. Unfortunately they are difficult. An interesting study was published in the August 1968 number of the Journal of the Royal College of General Practitioners. Its aim was to study the effects of having a still-born child on a series of one hundred women. The results however forced attention on the doctor-patient relationship in these cases. It was remarkably and frequently disturbed.

786: Since the days of Dr Balint, whose book The Doctor, His Patient, and the Illness was published in 1957, the whole face of general practice has changed. We have in our own practice the benefit of a retired doctor who worked with Dr Balint at the Tavistock Clinic for many years. One of the results of his presence has been to show us our own mental reactions and the effects of these reactions on our patients. There is a dynamic ebb and flow which has far-reaching results on our personal relationship with patients and on their response to treatment. There has been for us a gradual opening of the eyes, though in my own case the light is still dim. Our visiting doctor interviews patients with difficult emotional problems whom we ourselves find we are unable to help. He is temperamentally able to make them talk freely and permissive enough to convince them that he will never condemn them. Frequently he establishes a relationship with patients in great emotional trouble which reveals to them the workings of their own minds. Insight and awareness give them relief from inner conflict. Sometimes the emotional problems of a family which have led to frequent surgery consultations are solved and the health of the whole family improves. I hope that in due course he will publish his results — successes and failures — with his own conclusions. This is research of great value. If only a flicker of light appears, it is light where it is most needed.

787: Research in general practice is one of the primary objects of the Royal College of General Practitioners. Since the register of research projects was begun in 1960, seven hundred entries have been made. Individual studies are published in the Journal each month. Doctors interested in any of the countless subjects for investigation are put in touch with each other. Enthusiasts who set out to prove or disprove the value of specific remedies are sometimes brought kindly to earth by warnings of the necessary techniques for such enquiries. The choice of designs, 'controlled or uncontrolled, open, single blind, double blind, comparative groups or crossover, matched pairs or matched groups, open ended, or close ended sequential' depends on the aims of the study. The College gives advice on these matters, and most of us certainly need it.

788: It is in the widely based comprehensive investigations, however, that the College is of paramount importance. I think the scope of some of these researches is unique and of world-wide significance. The first major piece of research undertaken was the study of the value or otherwise of drugs in the prevention of the complications of measles. Briefly it was found that drugs given prophylactically do not help to prevent these complications. The saving in drugs resulting from this conclusion must have been enormous. The most recent study is of still greater and wider importance. This is an investigation into the effects of the oral contraceptive pill on the health of women who take it over long periods, a major study in which 2,000 doctors have been asked to take part. Its results will be awaited with great interest.

789: The work of those who take part in studies of this kind is arduous and not in itself satisfying. I do not know of any major research work which is other than arduous, and as it is usually a matter of team work, individuals must often feel that their personal contribution is small. Part of the value of the work is the stimulus given to the doctors who undertake it. Minds are kept active, eyes are kept open and men with like interests led to communicate with each other. The old cynicism that the purpose of research is the advancement of the research worker has a grain of truth in it. The advancement is not material but a benefit to mental health. In one sense it is better to travel happily than to arrive. The value of individual studies may often be negligible, but in time their sum will be considerable. Far more important, general practitioners begin to think, to talk, and to write. Sparks from one set alight a fire in another. Three or four have only to gather together for new ideas to arise and struggle for expression. Enthusiasm grows when the ideas of hundreds of small groups are finally pooled. The day of the lonely isolated general practitioner is nearly over.

Chapter 15: Education

790: 'Gladly wolde he lerne and gladly teche.' The clerk in Chaucer's Canterbury Tales had the qualities of the best scholars, teachers, doctors through the ages. We all have plenty to learn and each one of us has something to teach.

791: Teaching about general practice is difficult. The early scheme of paying a small salary to young doctors while they did a year's training with selected general practitioners was good in theory. Unfortunately it led all too often to the trainee becoming a free assistant. I myself had a trainee for one year in 1950 but I have not had one since. The young man allotted to me was intelligent and has since become a good doctor, but I found that a year was much too long a period to share every ante-natal examination with a third party, and to take responsibility for all that someone else did. It is a tiring business, and, undertaken in one's busiest years, puts too great a strain on the teacher. Since that time my partners and I have taken on fifth-year medical students from time to time for periods of two weeks. This is valuable to the student and easy for us. I think the ideal would be for those entering general practice to have a month working in each of three or four chosen practices.

792: At the present time, the Royal College of General Practitioners is engaged in exploring ways of training selected general practitioners to become teachers of general practice. It is too early to say how this scheme will work.

793: If medical education for general practice is to be adequate the teaching at medical schools must be orientated for this purpose. Here is a quotation from the teaching of an ear, nose and throat surgeon at a London hospital which illustrates how this is sometimes done:

794: 'It is calculated that 30 per cent of one's time in general practice is spent on ear, nose and throat problems. Consequently, in my many years in ear, nose and throat I have had much contact with general practitioners.

795: 'These years have taught me that the good general practitioner will always fulfil an essential role in medicine. But I emphasize the adjective "good". Let us take the day-to-day problem of recurrent acute tonsillitis — we have seen four children this morning with this condition; we will use two of them as examples:

796: (a) One child aged ten had had recurrent attacks of tonsillitis for the last six years, losing much schooling and causing much distress and worry to the patient and his family. Antibiotics had been successful at first but appeared to have little or no effect for the last four years. Did you notice how fretful the child was and how anxious was his mother? Granted, the indications for tonsillectomy at present are controversial but surely everyone would agree that this child should have a tonsilleetomy. Why, oh why, did the general practitioner wait for so long before referring him for tonsillectomy? And what is the use of a general practitioner's letter which says: "Recurrent tonsillitis — please advise." No details of the length of the history or of the treatment given, etc. — it sometimes makes me despair.

797: (b) A second child aged two years has had recurrent attacks of acute tonsillitis. The general practitioner's letter read as follows:

798: 'Alison has had eight attacks of acute tonsillitis during the last year. Treatment with penicillin has had little effect on the severity of these attacks. During each attack, the child becomes severely pyrexial and is considerably distressed.

799: 'In view of the frequency of these attacks and the almost constant distress they are causing her and her family, I would be grateful of your opinion as to whether tonsillectomy is advisable at present in spite of the fact that Alison is only two years old.'

800: The books would suggest that Alison is too young for tonsillectomy but, in spite of this, the general practitioner has shown good judgement. Some ear, nose and throat surgeons may not be prepared to perform a tonsillectomy until Alison is older but from the point of view of the general practitioner's handling of this situation, this does not matter. He is practising positive thoughtful medicine over a common every-day problem.

801: These two examples illustrate how general practice can do so much good or so much harm. I would say to you that general practice is entirely what you make of it — the scope for practising good medicine is extensive but if you don't use your head even over everyday problems you will not be equipped to take advantage of the opportunities which general practice offers you.'

802: Had a general practitioner teacher been present he would perhaps have pointed out the need to know much more about the home conditions of these children than the letters indicated. The number of older children, and the hygiene of the household are obvious factors to take into account. It is possible that the child of two had several school-age siblings who were constantly bringing infection home. It would be questionable, in that case, whether tonsillectomy would do more than transfer the catarrhal infection from the throat elsewhere. It is equally possible that the emotional tension of the household was a major factor in either case. The fretful older child and the anxious mother suggest this. In this case removal of the mechanically obstructing tonsils would need to be followed by advice to the family as a whole-the emotional background perhaps being more important than the large tonsils.

803: Here is another quotation which shows that some consultants are aware of the priorities in medical education. A thoracic surgeon said:

804: 'I often wish I had more time to use my influence in making undergraduate and postgraduate medical education more realistic and pertinent to the demands of general practice. It is all very well for me to give you my views concerning heart transplantation or mitral valvulotomy but surely, above all else, the years spent as a medical student should be used in developing good medical judgement. I genuinely consider that my most rewarding and instructive years in medicine were during the war when I was a regimental medical officer — in other words, I was in effect a general practitioner. Those years were invaluable — for the first time in my professional career I had to exercise fundamental medical judgement — I had to decide which patients were genuinely ill and which were not. One might consider this to be a simple decision to make but I assure you it is not. Undoubtedly, I feel it is far easier for me to be a competent thoracic surgeon than it is to be a sound general practitioner. General practice demands great personal qualities and it develops sound clinical judgement. Truly, some time spent in general practice should be obligatory in the postgraduate training of all doctors in order to develop these qualities.'

805: This is simply an appreciation of general practice as a career, but the influence of a cardiac surgeon who speaks in this way is obviously considerable.

806: Teaching in every specialist's department with an eye on general practice would have wide ranging benefits for prospective general practitioners. It appears that general practice is now being recognized as a vital part of the health service of the future, and it must follow that every consultant teaches to this end. If each one knew enough about general practice he would teach his own subject in the right way. I have no knowledge of the way in which the subject of general practice is being taught in Edinburgh, where a special general practitioner teaching department exists. I would hope that a general practitioner teacher attends out-patients with the students and joins in discussions in each department.

807: There is another way in which the problems of general practice could be studied which so far as I know has not been extensively tried; this is the study of tape-recorded interviews between general practitioner and patient. There are difficulties involved, because the patient must first be warned that the interview will be recorded. He would be told the purpose of the recording and promised that it would not be used against his wishes. When this is done, both doctor and patient may be a little self-conscious. If however it were done frequently enough, the doctor would behave perfectly naturally in spite of it, and the patient would to a large extent take his mood from the doctor. Chosen tapes could be used for teaching. They could be discussed and criticized and the working of the doctor's mind and his mistakes demonstrated.

808: The postgraduate education of the general practitioner himself is a more straight-forward matter. The difficulty is mainly that of time. If the doctor has 3,000 patients and does his share of maternity work, his time is fully occupied. He will need to take every advantage of ancillary help and good group practice organization to enable him to take time off for study.

809: There are five ways in which he can do his best to keep up-to-date.

810: The first, and I think the most important, is regular contact with consultant colleagues. When consultants visit a cottage hospitals or general practitioner hospital beds, cases can be discussed at an out-patients' session or bed patients can be reviewed together when required. This sort of contact is more difficult in a major hospital because the patients' appointment time is often inaccurate and the general practitioner would have to wait as long as the patient. The time factor is vital. When a doctor is too busy in his practice he will not be willing to spend time looking after patients in hospital. Nevertheless the future service will only be satisfactory if he has access to beds. When he does, more young doctors will be attracted to general practice, and the problem of time shortage will gradually solve itself.

811: Discussion of cases with consultants on domiciliary visits is more useful still. I have one criticism here of the present system. Consultants are paid for only a limited number of domiciliary visits each quarter. Some are therefore done for nothing. I have never known one refused, but it is a lot to ask a consultant to come ten miles into the country to see a case — using perhaps two hours of his time — without being paid for it. It would be embarrassing to ask if he has yet done his quota of domiciliary visits and I suspect he is often being asked for free help. There should be no limit to the number of domiciliary visits for which a consultant may claim a fee.

812: The second channel of learning is of course reading, for which there are, I think, three essential publications. The first is the Practitioner., which deals with every medical subject, with advances in treatment, with new drugs and techniques and all matters pertaining to general practice. The second is the Journal of the Royal College of General Practitioners. This contains articles and studies often by general practitioners, and reports of symposia on various subjects. The third is the Prescribers Journal already referred to. A couple of hours' concentrated reading each week is required to extract what is needed. The B.M.J. and the Lancet are of course excellent journals but only small sections of these apply directly to general practice.*

813: The third method of post-graduate education is the attendance at lectures in the nearest teaching centre. In Bath, regular weekly lunch-time sessions are arranged for three terms in the year. A cold lunch is taken and usually finished while listening to the speaker. Discussion follows. In Bath and in many other centres, a clinical society arranges evening meetings. These are for all doctors in the area and are usually given by distinguished visiting speakers. These lectures entail a certain amount of travelling — up to twenty miles each way — but when one reads of Australian doctors travelling a hundred miles over rough roads for the same purpose, one is less likely to grumble.

814: *A more recent publication called UPDATE is excellent and may become standard readingffor the General Practitioner.

815: Fourthly, postgraduate courses of a few days to two weeks are run at all the teaching centres. These are of particular value to doctors working away from hospital and in some degree of isolation. They afford an opportunity to talk to colleagues from widely different areas and to hear lectures of the highest calibre. They are too a very pleasant rest. It is good sometimes to revert to the ease of student days.

816: Finally, tape-recorded lectures are sent out on loan from the college. These are valuable and on widely different subjects. In my own practice we choose in advance what we want of these and meet every two or three weeks to hear and later to discuss them.

817: Ample facilities for keeping abreast of the times are available. The factor determining how much you learn is the amount of energy left after doing a tiring job of work. But then no one would suggest that general practice is a career for the tired, the un-enthusiastic or the playboy.

Chapter 16: Emigration

818: The success or failure of the British Health Service is a matter of interest to many people inside and outside the United Kingdom. Emigration of many young doctors has been taken as evidence of the failure of the system, but this conclusion needs careful scrutiny.

819: There are, of course, many reasons for emigration. It is difficult to know how many of our young people emigrated to the American continent and Australia between 1850 and 1950. The numbers were certainly large. Nowadays communication is so much better, we know so much more about these countries, and it is so much easier to go there and see whether we like them or not, that emigration has naturally increased. Britons have always been travellers from the time of the first Elizabethans and we have not changed. There is a natural outward pressure from a densely populated island. One visit to America is enough to attract many people to the wonderful open spaces. The weather and countryside of the New England States is a great attraction to the middle-aged, and even more so to youth.

820: There is another factor tending to encourage emigration which is common to most English-speaking nations. There is inevitably in every country a minority who are dissatisfied with the environment and institutions in which they grew up. In our form of democracy it is not easy for small minorities to effect changes. We are not revolutionaries by nature and the tendency for the dissatisfied groups has always been to emigrate. The same thing happened in America when the dissatisfied could always move West. Now that the West is fuller, some are going to Australia, others with nowhere else to go are beginning to express their resentments in the violent outbursts we see in America from time to time. Some degree of emigration is inevitable and we need not be distressed because some of our best as well as our most resentful young people are spreading their influence in new worlds. If we are to become citizens of the world and the old isolation of nationalism is to disappear, we must not regret some losses. As to letting our morale at home become depressed, this would be ridiculous. We have much still to give the world and much still to attract the rest of the world here. In London and Cambridge I have been impressed by the way in which first-class Australian brains have been drawn here and occupy by right some of our best medical appointments. The brain drain is not all one way. It goes round.

821: The majority of young doctors who emigrate go to Canada, America and Australia. It is well to compare the medical services in these countries with our own.

822: There are two important differences between the systems of general practice in the United Kingdom and that in the other countries. The first is that payment in all the others is made by fees for each item of service, the second is that in all the others the general practitioners have free access to hospital beds. There is one important common factor in all the countries mentioned and this is the concern felt over the preference of young doctors for specialist work instead of general practice.

823: In Australia fees and conditions of service vary in the different states, but the usual fee for a surgery consultation is 255 and for a house visit about £2. Surgery appointments are made at ten-to fifteen-minute intervals but sometimes have to be double-booked for lack of time. None of the patients so booked are attending merely for a continuation certificate of incapacity. This partly accounts for the shorter average time of British surgery appointments. The general practitioners in Australia, as in the other countries, see an average of fifty patients a day. The patient has an itemized bill which he pays and then he claims back about 70 per cent of it from his insurance company. Fees are payable to doctors for attendance on patients in hospital, and the full use of hospital beds by general practitioners is thereby encouraged. A separate insurance costing 35 to 8s a week for a family covers the cost of a hospital bed in a public ward. There is no doubt that the system of payment by item of service is popular with both doctors and patients. Essential drugs are paid for by the state provided these are included in a list of over two hundred considered to be essential or life-saving drugs. The patient may have to pay the extra cost of a proprietary brand if a standard drug has the same action.

824: Australian doctors have free access to hospital beds in smaller and private hospitals. In some of the large cities they are excluded from the major hospitals. It is regarded as their fundamental right to treat their patients in hospital. There is also easy access to laboratory and X-ray facilities, most of which are paid for by the patients' insurance. About 75 per cent of the population are covered by private insurance and special arrangements are made for the treatment of pensioners and war casualties and certain other groups. These also have treatment paid for per item of service, but they do not contribute to the insurance cover.

825: In Canada hospital and laboratory services attached to them are provided free, the cost being covered partly by the state and partly by the federal government. Drugs are paid for entirely by the patient. Doctors and specialists are paid in a similar manner by an insurance cover and by item of service. The general practitioners have access to hospitals in every town. Their activities are however subject to considerable control which is exercised by their own organizations. A general practitioner may only do a major operation if he has had adequate training and proved himself capable. 'Tissue examinations' are done on a large scale and if many normal organs, such as appendices and gall bladders, are found to have been removed, investigation is demanded, and the doctor may have his right to use the hospital beds temporarily suspended. This measure of self-discipline by the profession works well. Nearly all maternity work is done in hospital in both Canada and Australia.

826: Canadian general practitioners are highly paid. Their net earnings amount to £8,000 to £10,000 a year. In Australia the figures are less but sometimes amount to £8,000 a year. In view of all these favourable circumstances it is a surprising fact that there exists the same flight from general practice in each country. In America the situation is harder to assess because of a difference of terminology. There are fewer and fewer 'generalists' and yet many doctors do the work which general practitioners do in this country and in other countries. In Australia and Canada as well as in the United Kingdom, great concern is being caused by the increasing tendency for newly qualified doctors to specialize. Various reasons are given, and these are probably common to all the countries under review. First there is a higher prestige about the work of specialists; secondly the general practitioner has to work longer hours; thirdly the fact that teaching is done almost entirely by specialists means that the influence of their own work is strongest in the most formative years of a young doctor's education.

827: The incentive to specialize is not financial in any of the countries. In Australia the young consultants have a hard time financially. In most states an honorary system exists by which much consultant time is given free. Furthermore many operations are done by general practitioners and if they have free access to laboratory investigations much of the work of physicians as well. The prestige of specialization is undoubtedly the main reason for the preference.

828: Part of the reason for the higher prestige of specialization can be found in history. A hundred years ago all doctors were either surgeons or physicians. All were in a sense general practitioners. As medicine advanced the best of these general practitioners became consultants. Early this century the pick of the young doctors became consultants, and those who failed in the race became general practitioners. As specialization became narrower, the work of the general practitioner became more demanding, making the idea that the best doctors become specialists and the also-rans general practitioners no longer rational. Some of the best all-round brains should therefore go into general practice.

829: Apart from access to hospitals the main difference between general practices in Britain and those in the other countries is the method of payment. In each of the other countries, the principle that people should make an effort to help themselves towards security has been regarded as of paramount importance. There is little doubt that the principle is a sound one, but the resulting health services are far from ideal.

830: The effect of payment per item of service on the standard of medical practice is arguable. In some ways from the patients' point of view it produces a more comfortable relationship. There is no need to feel apologetic about calling on the doctor for help. I often think, when I visit the dentist, that I should feel less of a suppliant if I paid him a fee. On the other hand in my experience the British system provides, so far as the method of payment goes, an ideal medium for the practice of good medicine. The old system of private practice encouraged competition for popularity which was certainly not conducive to good medicine. The present system leaves the doctor free to practise the best medicine he is capable of, with no thought or disturbance from the commercial side of the work. Teachers, professors, judges do excellent work without the incentive of payment per item of service. Medicine falls naturally into the same category. The service is sometimes too important to be assessable in terms of money. Furthermore, more people are realizing that the work of general practice entails investigation and understanding of family problems. Fees per item of service are difficult to fit into this part of the work. The absence of financial factors leaves the doctor free to give an honest opinion to the patient. He need not pat him on the back and say 'You poor man. Come and see me again soon' unless this is really necessary. He need not fear, when a patient needs careful watching, that the family will think he is seeing them frequently because of the fees. The only controlling influence is his own conscience. On the whole the separation of payment from the services given by the doctor is an advantage.


832: It is clear that general practitioners in Australia, America and Canada have the advantage of higher incomes — about double that in the United Kingdom. They also have the inestimable advantage of free access to hospital beds with its associated contact with consultant colleagues. These two factors certainly account for some of the emigration.

833: Another influential factor of great importance is the bad reputation that general practice has earned in many of the great towns of the United Kingdom. This reached its lowest level some years ago with the publication of the Collins Report. Practices were described in which premises were grossly inadequate and in which examination couches had not been used for years. It is an unfortunate fact that in the neighbourhood of some of the great teaching hospitals there are a few practices of the worst type, where patients are constantly referred to hospital for conditions which the general practitioner could easily treat himself. This is the result of many deficiencies — shortage of doctors, bad traditions, bad habits and bad premises, and the doctors' despairing conviction that nearby is an institution which could easily take a few more cases within its ample embrace, and treat them more efficiently than he could himself.

834: The discontent among general practitioners in large towns is still great. Apart from the difficulty and expense of obtaining good premises, the main trouble is that the general shortage of general practitioners is felt most acutely in these areas. Not unnaturally most doctors prefer to live in more attractive places and take advantage of the opportunity to do so. The result is that many general practitioners in industrial areas have an impossible load of work. Four thousand or more patients on one man's list can be heartbreaking. Under conditions of strain the quality of work suffers and then morale falls. If one man in such an overcrowded area moves away, his colleagues are left even worse off. I have had the experience of looking after over 8,000 patients for a year with one assistant who was over seventy. This work is killing.

835: Today more and better practice premises are becoming available everywhere. Provided that full use is made of nursing and ancillary help, and the practice is carefully organized, even very large practices can be run efficiently. But the work still remains very hard; it is not surprising that there is a constant stream of emigration from the industrial areas and the difficulties increase. I can only repeat that if more doctors can be shown the attractions of good general practice the problem would be eased.

836: There are in every practice, urban or rural, a few disgruntled patients who are out to get their 'rights' at all costs. This problem has been exaggerated out of all proportion because it makes a better story than the truth. Nevertheless it has an adverse influence on the reputation of general practice as a career. These cases are not difficult to deal with because the doctor has all the necessary power in his hands. His main concern is not to use this ultimate sanction too freely.

837: Not long ago, I was asked during evening surgery hours to visit a child with a stiff neck. After some questions I suggested that the mother should bring the child to see me. They had a car and the husband was at home. Half an hour later there was another call from the child's father. He was abusive and demanded an evening visit because of the stiff neck. I stifled my rising anger and asked more questions. Then I asked him to bring the child to see me and gave him an appointment.

838: 'This boy is in great pain,' he said. 'I insist on your coming to see him and pretty soon too. If you don't, you will be for it. I shall see to that.' With this he rang off abruptly.

839: I was not sure at first what to do. After some hesitation, I decided to visit the child, give any treatment that was needed, and then have the family removed from my list. When I called at the house, I asked to see the father but was told he was in his bath and could not see me. I made sure the child had nothing more than a stiff neck and advised some aspirin. Then I explained to the mother that I could not go on treating the family because the aggressive behaviour of her husband made a normal relationship with them impossible. I felt very sorry for the woman who had evidently suffered often from her husband's ill temper.

840: The family were in due course removed from my list and told to register with another doctor. I met them by chance in the hospital a few weeks later. The husband apologized for his rudeness and asked if I would accept them again. I agreed and he promised to be reasonable in future. Many aggressive patients would not have apologized and they are best removed from one's list. If other doctors refuse them, they are allocated for a minimum of six months to the list of a doctor selected by the Executive Council. My own experience is that if patients are once removed from a doctor's list, they show more consideration to the next doctor. Rude and aggressive behaviour of a minority is common to all practices and is not confined to this country. It need not make general practice difficult. We treat only those whom we accept and are not obliged to accept anyone other than the very occasional allocated case.

841: Before the young doctor emigrates he should investigate for himself what opportunities there are to do really good general practice in the United Kingdom. Wherever he goes he will have to work hard. Having experienced both types of practice, I personally prefer the present British system to the old, in which payment was made for each item of service. There were far more abuses in the past but they were not so much publicized. Whatever his decision, let him not be influenced by the absurd idea that doctors in urban practice are on the whole less conscientious and less efficient than those in the country. There are good ones and bad ones everywhere. There is nothing wrong with the opportunities for good work offered by the National Health Service. All that is needed is good men.

Chapter 17: The Faith of a Doctor

842: If medicine is an art and not a series of techniques, it depends on the talent of its exponents. Many of the problems of the doctor in general practice revolve round the sudden episodes of anguish in the lives of his patients. The help he can give depends partly on his own personality but partly also on his philosophy of life. The natural man, with his lusts and aggressions, must find somewhere a spirit of dedication.

843: It is true that practical considerations often dominate our theories of right and wrong. When I thought it would have been right to let Arnold Piers die after his attempt at suicide, the weight of tradition and his wife's distress led me to take vigorous steps to revive him. This is common experience. We are constantly influenced by the climate of opinion of our times. Nevertheless there is no doubt that a view of life which may be called, in the broadest sense, religious, has a profound effect on the conscience and therefore on the day-to-day work. The simple daily decision on a patient's fitness for work can be taken light-heartedly — often at the country's expense — or with great pains and labour. The degree of care of a patient in whom the diagnosis is in doubt can vary enormously, from the 'he will probably be all right' attitude to the persistent attention and frequent visits that his case may need.

844: There are many problems which have something of a moral flavour. For instance, an unattached young woman who is going on holiday asks for a prescription for an oral contraceptive. Should we express an opinion as to whether her promiscuity is right or wrong or is it none of our business? A young man comes to the doctor saying that his wife wants to leave him, taking their two children with her. Will the doctor talk to her and try to persuade her that the children's welfare is more important than her immediate happiness? If the doctor agrees to talk to her, what would be the basis of his advice about right and wrong? A woman is obsessed by feelings of guilt; do we try to persuade her that she has done no wrong or do we tell her that we are all sinners and that she is not alone? Is guilt always a pathological symptom or is it evidence of disharmony with something in nature? If the disharmony is sinful, can the woman find peace and a sense of forgiveness? The usually accepted opinion is that guilt is a pathological symptom, but how presumptuous is this assertion?

845: Recently a happy and attractive young couple — married only a few months — had their happiness shattered by an event so dramatic and so personal that I am unable to relate it. They were temporarily separated and the girl begged me to intervene in order to save the marriage. No other living soul knew of their trouble. They had no idea how to seek help from a marriage guidance counsellor nor would they have gone to a stranger if they had known where to go. There are countless examples in the family doctor's daily work of traumatic events that threaten to destroy homes, lives and marriages. He may succeed in helping because of what he is as a person, but success often depends very much on what he believes.

846: Many of us are convinced materialists. We are guided by a traditional code of behaviour which has survived the decline of religious beliefs and which is both practical and kindly. But materialists are seldom artists and those who claim that medicine is an art must look below the surface of material things. Convictions of conscience may derive from ancient cultures, from education, from the influence of books and of great men. They will not come from the study of anatomy and physiology — necessary as this is for the understanding of our trade. The education of a doctor needs to cover a wider field than that of pharmacology and physics. Home, school, university, medical school, all have a part to play. In my view a study of literature is not the least important part of the preparation for general practice, but this is another and wider subject.

847: I do not suggest that the good doctor must hold any orthodox religious views, but he must have a certain attitude of mind which is, in the widest sense, religious. To the materialist, the pursuit of pleasure is the main purpose of life. In days when life was short and uncertain, and pain and distress a certainly, men delved into the mysteries because it was the only way of making life tolerable. Now there is constant opportunity for pleasure and a good measure of freedom from physical pain. The pursuit of pleasure has therefore become a rational way of life. There is always or nearly always, except for the impotent, sexual pleasure. There is the pleasure of company and talk, except for the shy. There is the pleasure of wine and food, except for the dyspeptic. But there is, too, the prospect of old age and progressive weakness. The principle of 'do as you would be done by', if generally adhered to, would lead to a successful antlike society — a society in which pleasure would be the object of life. It is an easily accepted but sterile rule for human conduct. If we believe that human society must attain to something better than this we have to look further.

848: When Thomas Hardy asked himself whether any supernatural power existed, he expressed the question in poetry:

849: 'Has some vast imbecility

850: Mighty to build and blend

851: But impotent to tend

852: Framed us in jest

853: And left us now to hazardry?

854: …like a knitter drowsed

855: Whose fingers play in skilled unmindfulness

856: The will has woven with an absent heed

857: Since life first was and ever will so weave.'

858: This is a very beautiful expression of a very pessimistic view of life. If one examines the dazzling record of evolution, one is forced to two conclusions. The first is that it would be amazing if a process so remarkable and so complex should suddenly stop its movement towards increasing complexity and awareness. The second is that this is a success story, far beyond the imagination of the greatest man alive. To hold that all this happened for no reason — that it just happened — does not give a basis for rational thought. If evolution is still proceeding, men should try to find out all they can about it and about the power behind it, if such there be.

859: Not long ago I visited a ninety-three year old patient in her home. She has had a hard life, without children, and has been widowed for many years. She now lives in a bed-sitting room about fifteen feet by ten feet. She is very active, walks every day; I have never heard her grumble. She is the life and soul of every group of people she joins. When the family in whose house she lives go on their summer holiday, she comes to the cottage hospital for two weeks to be looked after. In a day or two she transforms the ward and the old people there begin to laugh and chatter like youngsters. She is a Roman Catholic by religion and strict in her beliefs. On the day I visited her, she was walking in the garden. I was asked to sit in her room and she would be fetched. I sat in an armchair and waited. I was on my way from the hospital and hoped to get four visits done before lunchtime. It was a nuisance to be kept waiting. Then as I sat I relaxed and felt an extraordinary atmosphere of peace. It was not the peace of a quiet afternoon's nap but something more alive and yet completely serene. I am not an imaginative individual and this delightful sensation was new to me. It changed my mood of hurry and affected me for several hours afterwards. There was no doubt that the atmosphere emanated from the serene old lady who lived in that room. She was something quite saintly. I believe there are some people who do find a way of communicating with the power behind evolution.

860: Whatever one's personal views, one remarkable fact stands out. The attitude of mind of the true scientist, whether or not he is an atheist, is remarkably close to that of the true religious. Both maintain an attitude of humility in the search for truth.

861: The present generation is in some ways the most unscientific since the Middle Ages. The materialist blindfolds himself to all but the techniques of life. He can never hope to see the power and the glory which may occasionally be glimpsed when the eyes begin to open.

862: These then are the two rules on which I think the doctors' creed should be based: first he must maintain an open mind -an attitude of humility in the search for truth, and secondly he must try to keep in mind, through all his successes and failures, in times of rejection and of gratitude, the motto of Thomas Guy's Hospital: 'Dare quam accipere'. Our grandfathers might have expressed these two rules in different terms but they meant the same thing. Both are extremely difficult to obey.

863: How far do these views help in deciding the various moral problems of general practice? In the details of day-to-day work and when one's advice is asked over matters of behaviour and of personal relationships, belief and attitude to life make a difference. There remain however many difficult problems and every man must solve them as best he can. Medical knowledge is reaching a stage when almost any living being can be kept alive for a long period. At some point the effort to keep people alive must be stopped. Someone must switch off the iron lung and the dialysing machine. Each of us can only act in his own sphere, according to his own degree of understanding.

Chapter 18: The Continuity of Family Practice

864: I set out in this book to show that the life of a general practitioner can be both challenging and highly rewarding. The success of the National Health Service depends on the quality of the young men who enter general practice. High rates of pay alone would not attract the right type; the need is for good working conditions.

865: The two main defects of the present time are the lack of good premises, especially in some of the large cities, and the lack of access to hospital beds. There can be little doubt that in the next decade good premises will become generally available. It is official policy to provide them. It is not likely, however, that the equally vital need of general practitioner hospital beds will be met for a long time to come.

866: If I were a young man now, I ask myself, and knew I should never have access to hospital beds, should I still become a general practitioner? The answer is yes. I should, however, move heaven and earth to get them. If on the other hand I thought the future would deprive the general practitioner of his essential role as a family doctor, I should not enter general practice. The essence of the work is family doctoring. Without this, it would be robbed of much of its interest and much of its demand for skill. I for one should be off to another country where politicians had more vision.

867: It is not easy to be sure of the future. The Royal Commission on Medical Education recommends that three years of postgraduate training should be undertaken before a doctor becomes either a junior consultant or an assistant in general practice. This recognizes the difficulty of being a good general practitioner. Another suggestion however is a salaried service for general practitioners. I have no objection whatever to being salaried, but I fail to understand how this method of remuneration can be consistent with service as a family doctor. If a salaried service means fixed hours, this would be the end of family doctoring. For the benefit of all concerned, this characteristic of general practice should be preserved.

868: The importance of family practice, if possible with continuity, is paramount. From the doctor's point of view, it means involvement in a hundred family sagas less notable than that of the Forsytes but equally absorbing. From the patients' point of view, it means the availability of an experienced adviser. No amount of description can convey the value of family doctoring either to the doctor or to the patient. In the hope — and it is my only hope — of conveying something of what it means, I will relate a final episode of the life of the family to whose story I have referred before.

869: Arnold Piers died soon after his sixtieth birthday. I visited the farm so often that it seemed as though my car would find its way there by itself. Once when I was not concentrating, I found myself approaching the farm gates when I was intending to go somewhere else. Treatment was mostly practical and we did not talk much. Mrs Piers had insisted on keeping him at home and doing most of the nursing herself, but the district nurses went in every day for months. My own visits had to do with changing his indwelling catheter, advising in the constant battle against bedsores, and giving what little pain relief was needed. His mental condition was interesting. He was fully conscious of the present but hardly aware of the past or the possibilities of the future. He read one book over and over again. By the time he had finished it he had forgotten its beginning, and started it again. He was curiously indifferent to his physical state, and often surprisingly cheerful. As his kidneys gave increasing trouble, he had headaches and dozed a good deal. He was quite bedridden for three whole years before his death. I gradually lost most of my emotional involvement in his illness and it became at times an effort to appear sympathetic. This often happens in chronic cases because the feeling of sympathy fatigues in the same way as the senses do. It is just as well that one cannot go on all the time feeling sorry for people. They do not want it anyway, they want practical help.

870: He was comatose for twenty-four hours or so and I was there at the end. He died on a cold December night. Mrs Piers had aged a great deal; the lines in her face were deep round the mouth and her hair was almost white. There was the inevitable cup of tea, and then before I left she wept uncontrollably. The years had been incredibly hard for her and the constant demands of practical nursing had kept her occupied at full stretch. She was like someone who had been on a very long walk that leaves the senses numbed with fatigue before the end. I had thought she would be too exhausted to cry, but evidently there was still pent-up energy which had to be released. I suggested a sleeping pill but she refused.

871: I gradually realized that she had been in love with Arnold to the end. This must have been partly because his regression to childhood satisfied the maternal instinct in her, but it was more than this. In spite of his condition he had enough of his masculine characteristics left to satisfy something feminine in her. One sees this in many marriages among older people whether the sex-life continues or not. The outbursts of aggression on each side are understood instinctively and accepted. The more I see of marriage the more I am impressed at the adaptability of people to each other. The generation I am referring to were of course brought up, not in a permissive society, but in one which demanded adaptation from an early age. It would be interesting to know how children with today's permissive upbringing will manage to adapt when their environment becomes unyielding.

872: At the time when Arnold took the overdose of sleeping pills, I thought his wife almost hated him. She had in fact hated the disease that kept them apart but somehow managed to love the man. They had got through the years together and afterwards she told me that at times they had been very happy. There had been a day that Summer when he had been carried to the window and laughed at the antics of the grandchildren in the garden. There was seemingly nothing to make them rejoice and yet their relationship had produced joy from somewhere. Happiness is remarkably independent of external circumstances. It is possible to reach a degree of happiness in adversity which eludes the same person under almost idyllic conditions. I once thought she might have left his sleeping pills by the bedside on purpose. She had not, and had felt guilty for months afterwards because of her carelessness. She had never thought it possible that he would attempt to end his life, but at that time they had been far apart mentally as well as physically.

873: After his death she felt her life had suddenly stopped. I went to see her the next day and took the death certificate. David would attend to all that. Catherine was there and intended to stay for a few days. David's wife, Cynthia, was expecting her fourth baby in a week or so and was out of action. Catherine had been married for fourteen or fifteen years and had no children. Her beautiful figure was a little fuller and it seemed unnatural that she had never achieved motherhood. She had come home to consult me about all that years before and we had found that pregnancy was unlikely because of the low fertility of her husband. The question of adoption had been discussed and finally decided against. I had tentatively brought up the subject of artificial insemination but this revolted her.

874: Catherine's marriage was a happy one in spite of its barrenness. It often happens in my experience that a childless marriage is a close and satisfying one. The couple seem to rely more on each other than they do if there are children. They have the lack of children in common, and their sex life is often uninterrupted and happy. Children are indeed a blessing but they are a strain too at times.

875: 'I think your mother will take longer to get over this than I had thought,' I said.

876: 'They were very happy the last few years, in spite of everything.'

877: 'Will you take her away?'

878: 'She won't come. She wants to stay at home for Cynthia's baby and Christmas.'

879: 'It's coming back to the empty house that is the trouble of course, but the other family are very near. They all get on well now don't they?'

880: 'Mother and Cynthia do. David is a bit strained with Mother at times. He's never quite forgiven her.'

881: 'For what?'

882: 'For her treatment of Cynthia when they were first married.'

883: 'She'll need his help now.'

884: 'Could you talk to him? He's very stubborn. Once he has an idea in his head it takes a national crisis to move it.'

885: Til try.' I went to see Cynthia before I left. Her older children were aged nine and ten and the third was three. They were all girls and delightful children. She had had all three in the cottage hospital maternity unit without any trouble. She had tried to persuade me to let her have this one at home because the third child was still very mother-dependent. I respected her instinct about not leaving the youngest but as the farm was very out of the way I thought she had better come in to hospital. If there were any trouble it would be so much easier to deal with there. Furthermore she would have a better rest. I examined her and all was well. The baby's head was well down in the pelvis and there was no likelihood of trouble. I arranged to visit the house a week later if I were not needed before and went downstairs to see David.

886: He had grown large and very hearty. He spoke loudly and always called me 'Doc'.

887: 'Going to bring us a boy this time?' he said. 'You can take it away again otherwise you know.'

888: 'Another one of the same pattern won't hurt you.'

889: 'Girls are all right, but we need a boy round here.'

890: 'What do you think of your mother?'

891: 'She's pretty marvellous, don't you think?'

892: 'I do.' But I knew that if David thought her marvellous, it meant she had not revealed her feelings to him. 'She won't let me help her even by a sleeping pill. She's going to need a lot of support for a week or two.'

893: 'Don't you worry, Doc. We shall take care of her. She'll have a bit more freedom now. Take one of these Continental trips next year I shouldn't wonder.'

894: 'I am not very happy about her. She never complains. She hasn't complained for years. Last night she broke down completely — afterwards. But of course, she'll have you nearby. She's very fond of you, David.'

895: 'Is she? Well, perhaps she is a bit nowadays. There was a time when she wasn't though, you remember?'

896: 'I think she was always very fond of you.'

897: 'What you are trying to say, Doc, is that it's up to me to keep a good look-out after her.'

898: 'Exactly right.'

899: 'Then, as I said, don't you worry.'

900: I hoped all the next week that I should have news that Cynthia was in labour and had been admitted to the maternity unit. I saw her on the day she was actually due, a week later. All was well but there was no sign of labour. I hoped she would not be too much delayed. She was sublimely confident herself and this always reassures the doctor if he is suspecting trouble for no reason. She was a small neatly shaped woman with a good pelvis, a little pale and delicate-looking, but this is nothing to go by.

901: 'You've got a nice sturdy baby there,' I said. 'The heart is as steady as a rock and the head is well down. You haven't set your heart on having a boy, have you?'

902: 'Not really. David wants a boy. And-well I might as well admit I do want a boy.'

903: 'I hope we shall soon know anyway.'

904: The days passed and when she was a week late, I became uneasy as I always do. The fact that I had attended over a thousand births did not let me forget that there are always risks. The foetal death rate rises rapidly after ten days post-maturity. I should have to get her seen by an obstetrician for him to approve my inducing labour. This is advisable because if surgical induction fails the case has to be taken into a major unit for further measures to stimulate labour. It is only fair that the obstetrician who might have to deal with the case later should see it before we interfere. Indications of the need for surgical induction of labour are still a matter of opinion. If there is no toxaemia and no disproportion it is safe to wait up to ten days. Interference has its own risks and is only done when there are no specific centra-indications.

905: I made plans to send Cynthia to be seen by an obstetrician on the Monday morning if she failed to go into labour over the weekend. In fact she started labour during the Sunday night.

906: I was called by telephone at about five o'clock on the Monday morning. David was speaking. Tm not sure what we ought to do,' he said. 'She's flooded the bed with water and there's quite a bit of blood. Shall I take her to the hospital? It's a proper nasty morning.'

907: 'Any pains?'

908: 'Well, sort of niggling.'

909: 'All right. Leave her alone. I'll come along and see her.'

910: If the bleeding were significant, she would have to go straight to Bath. On the other hand a little blood looks a lot under these circumstances. I dressed quickly and got the car out. I was concerned about Cynthia. It happens sometimes that you sense trouble beforehand. In my own case the suspicion is often not justified at all and everything goes perfectly well. She was only eight days late and would certainly start labour now that the waters had broken. It should be all right

911: Then I looked out of the door and saw what David meant by a proper nasty morning. It was snowing hard. I had had a case similar to this in a snow storm only a year before. It was an ante-partum haemorrhage and I had sent the woman by ambulance to Bath that night. The journey had been difficult and then the delays at the other end in getting an anaesthetist over impassable roads had eventually led to a still birth. I would have to manage Cynthia myself if possible. The roads were not bad yet and I made the journey quite easily except for the road up to the farm, where I skidded.

912: Cynthia was looking well and quite cheerful. Pains had started in earnest in the last twenty minutes or so. It looked as though she would have a fairly quick labour. The bleeding was negligible and amounted only to a good 'show'. The only problem was whether to move her to the cottage hospital or not. I watched her for a few minutes. She was getting very strong pains and I decided to wait and deliver her at home. We sent for the nurse and I had my things brought in from the car. David and I made what preparations we could, brown paper on the floor and a mackintosh on the bed. I got my portable sterilizer going on the electric stove and put all the instruments I could possibly need into it. Then I sat on the bed in mask and mackintosh-apron and waited. I wondered how the nurse would make the journey and asked David about the weather.

913: 'Still snowing,' he said. 'Pretty thick too. Shall I get the Land-Rover out and go and fetch her, do you think?'

914: This would leave me alone with only Mrs Piers in the house to help, and she would soon be fully occupied with the children. 'I think you'd better stay David. We can manage between us if the worst comes to the worst.'

915: Everything seemed to be going well until I listened to the foetal heart during a pain. It slowed ominously. There was nothing else to be done and I waited. Pains were getting stronger and I listened each time. There was no doubt at all that the foetal heart slowed badly at each pain and was taking longer to recover when the pain stopped. I had some oxygen in my car and asked David to get it. I did not tell him what it was. A gas cylinder would look much the same to him. I got Cynthia to breathe intermittently through the mask in the hope of improving the baby's oxygen supply. She would not, I thought, know what was in my mind, but of course she did.

916: 'Is baby all right?' she asked.

917: 'Yes, fine. We want to get him here as soon as we can, that's all.' It does not matter what you say to women in these conditions. They know exactly what is happening.

918: 'How long will it be?'

919: 'I'm going to examine you and see.' She was already almost fully dilated and the head low. 'Doing splendidly. We shan't be long. I shall get some things ready to help in case we need them.'

920: The worst stage of any labour is just before full dilation. Pains are distressing and the mother feels as though she is making no progress. It is very hard for her to relax. Once she begins to push she knows the end is in sight. I sat beside her with a hand on her abdomen and talked as soothingly as I could. 'This is the worst part,' I said. 'You'll soon be pushing. There's nothing for you to worry about. The oxygen is only a precaution. We do a lot of this sort of fussing nowadays.'

921: For half an hour pains came every minute. Perhaps this was going to be a really quick labour. That would solve its own problem. At last she began to push and then the pains had longer intervals. This was all very good except that the foetal heart was getting weaker. It varied from very slow during the pains to 180 or more between them. I groaned inwardly. I should have to deliver the baby by forceps and that as soon as possible. In the old days this would have meant a general anaesthetic. Thank heaven for local anaesthesia. It is infinitely safer anywhere, particularly in a house in the country. I had not had to apply forceps in a house for years. We always admit patients to hospital for even this simple procedure but it would be madness to move her in this condition on a night like this.

922: There was still no sign of the nurse and with the preparation of instruments and listening to the foetal heart I was pretty busy for the next twenty minutes. The infant seemed no worse but was still obviously distressed. It was impossible to know how much strain it could stand or why it was distressed. Labour was rapid and the child a little post mature; presumably that was the trouble. I gave Cynthia an injection of promazine and set about the task of putting in the local anaesthetic. I was anxious for David not to have to watch me put on forceps or even insert the ten-centimetre needle for the nerve block. It looks so much worse to the onlooker than it is for the patient. I explained to them both briefly that the baby was under strain and we had no alternative but to hurry the delivery a little. I did my best to seem composed and unhurried but there was a lot to think about. Practical preparations always worry me. I am apt to forget things and rely very much on the nurses who help me.

923: We were just preparing to put Cynthia in position for the local anaesthetic when we heard the nurse arrive. I breathed a sigh of relief. She was evidently proud of herself for getting through the journey and was talking cheerfully downstairs. 'Tell her to come along up David, we can't hang about.' I spoke with the irritability of tension. As soon as the nurse entered the room she took in the situation at a glance. 'A little foetal distress,' I told her. 'When you have scrubbed up have a look at the instruments under that sterile towel and make sure I haven't forgotten anything. Then come and support her legs for me. Do you want to stay, David, or not? We can manage now.'

924: 'Then I think I'll wait outside. Give me a call if you want anything.' He seemed relieved to get away.

925: I put in the pudendal nerve block and waited a few minutes.

926: Nurse listened to the foetal heart. 'Sixty,' she whispered. The minutes of waiting for the local anaesthetic to work seemed long ones. She was fully dilated and pushing hard. It looked as though she might deliver the baby spontaneously after all. I waited a little longer. 'Still only sixty, not too good,' the nurse said. So I made an incision and then delivered the baby by forceps. The umbilical cord was twice tightly round the baby's neck and this probably accounted for the distress. I think it was delivered only just in time, although it is never possible to be sure. It might have been all right if left to nature. One thing is sure, the relatives and nurses always give the doctor the benefit of any doubt and praise him unstintingly. It makes a more dramatic occasion perhaps, or maybe they are just being kind. A small amount of resuscitation was needed. Those early gasps, so like the last that are made in life, increasing to a breath as the colour improves, and followed by a lusty cry, are among the finest sounds I know.

927: David put his head round the door.

928: 'All right, I gather,' he grinned. 'What have we got?'

929: 'A boy,' nurse said as triumphantly as if she had had the baby herself.

930: David looked at the baby.

931: 'There you are then, young Arnold,' he shouted. 'We've been waiting for you a long time.'

932: The job was over as far as I was concerned. A little stitching and care of the placenta and I relaxed. When we had told Cynthia five times that it was a boy she began to believe us-which seemed to show the intensity of the anxiety she had felt for months past over the sex of the child. We drank tea downstairs. It was eight o'clock and just getting light as I left the house. I was tired but it was pleasant to be lionized because all had gone well. I was even credited with the responsibility for it being a boy.

933: The older children were already out playing in the snow. They usually rode in the car as far as the gate, and insisted on doing it today in spite of the snow. We parted at the farm-gates and their shouts of goodbye rang in my ears as I drove away.

934: It was Monday morning and there was a fairly heavy day ahead. But there was another Arnold Piers in the world vigorous and healthy. There was a lot to be thankful for.


935: Abortion, 123

936: Analgesics, 104

937: Antibiotics, 98, 104

938: Antidepressants, 104

939: Apley, Dr John, 71

940: Appointment System, 43, 47

941: Australian Medical Service, 156

942: Balint, Dr Michael, 145

943: Baring, Maurice, 125

944: Brain Drain, 156

B.M.J., 153

945: Canadian Medical Service, 157

946: Cardiac drugs, 105

947: Cases in surgery, 110-122

948: Certification of incapacity, 109

949: Change of doctor, 71

950: Chaucer, Geoffrey, 148

951: 'Check-up', 140

952: Collins Report, 160

953: Consultants, contact with, 48

954: Contraception, 127

955: Cost of drugs, 104

956: Cottage Hospitals, 62

957: Doctor's wife, 53

958: Domiciliary Consultations, 49, 152

959: Drugs, national bill, 102, 108

960: Drug and Therapeutics Bulletin 102

961: Dying, care of, 82

962: Emotional illness, 22, 26, 30,67, 80

963: Examination rooms, 45

964: Gibbons, Edward, 129

965: Hardy, Thomas, 166

966: Hospitals, Abuse of, 128

967: Hospitals, General Practitioner, 62

968: Hospitals, Reference to, 128

969: Hypnotics, 105

970: Hysterics, 128

971: Journal of the Royal College of G.P.S, 145,148,153

972: Laboratory Service, 47

973: Lancet, 153

974: Malingering, 109

975: Mass Radiography, 141, 143

976: Medical Defence Union, 134, 139

977: Night visits, 78

978: Nurses in surgery, 44

979: Partnership, 49

980: Practitioner, 153

981: Prescribers Journal, 101

982: Prescription charges, 108

983: Preventive innoculation, 52

984: Queen Elizabeth Hospital, Adelaide, 64

985: Radiography-mass miniature, 141, 143

986: Receptionists, 45

987: Royal College of G.P.s, 146, 148

988: Royal Commission on medical education, 169

989: Salaried service, 170

990: Special relationships, 82

991: Steroids, 105

992: Surgery, buildings, 41

993: Surgery, cases in, 110-122

994: Surgery, cost of, 46

995: 'Telling the patient', 75

996: Tranquillisers, 104

997: University of British Columbia, 64

Kenneth Lane, Photograph

Dr. Kenneth Lane in the 1940s