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A short history of general practice: Professional roots

Stephen Gillam is a semi-retired GP and public health specialist who has written extensively in both fields. He is the author of ‘Of Patient Bearing – A History of General Practice in Eight Generations.’

Introduction

I was 47 years old when I discovered, almost by accident, that I was eighth in a line of generalist doctors dating back to 1770. It was something of a shock. Most of us like to believe we exercise free will and discretion over our life choices. Mine it seemed had been determined two centuries earlier. Doctors are inclined to be fatalistic for we witness every day the impact of genes and inheritance on our patients’ lives. However, I was left pondering my ancestors: their lives and livelihoods, their foibles, strengths and flaws – and their influence on mine.

My book tells the story of general practice down those eight generations.1 It describes the evolution of the discipline from its apothecary roots, focusing on themes such as the burden of disease, developments in policy, practice, training, pay and conditions.

Talking to medical students, registrars and even peers, I am forcibly struck by how little they know of our history. The commonest misconception is that general practice, the ‘jewel in its crown’, is largely a product of the NHS. This short series of articles hopes to inform, stimulate and provoke.

From Apothecary…

My family’s origins were humble. The surgeon-apothecary William Skrimshire (the Older) (1739-1814) practised in the marshy hamlets and villages around Wisbech. In those days, malaria and other marsh fevers were still a scourge. A plurality of practitioners offered their services2 in the 18th century medical marketplace. The profession of apothecary can be dated back to Babylonian times.  GPs today may offer many of his services but the modern pharmacist is the apothecary’s more obvious descendent. The Worshipful Society of Apothecaries, founded in 1617 admits members by examination to this day.

The period from around 1790 to 1860 yielded major medical reforms in Britain.3 In William’s time there was not one medical profession but three. The physicians, members of a learned profession, dealt with internal disorders. Surgeons were craftsmen whose sphere was still largely external. Apothecaries compounded and dispensed physicians’ prescriptions until they won the right to visit, advise and prescribe (see below). This well-known division conceals the extent to which their respective practices overlapped with one another – and those of many untrained, less costly ‘irregulars’ (travelling quacks and charlatans).

The traditional view of rank-and-file practitioners such as William characterizes them as ill-educated and near-illiterate tradesmen who kept shops selling medicines and groceries to supplement earnings from their primitive practice. This caricature is harsh. In addition to dispensing medicines directly to patients, the apothecary offered general medical advice and a range of services that are now performed by other specialist practitioners, such as surgeons and obstetricians. Apothecaries often operated through a retail shop which, in addition to ingredients for medicines, sold tobacco and patent medicines. They were, in other words, frequently the sick person’s point of first contact.

…apothecaries were free to practice physic and become the doctors of the poorer classes.

Much had changed on 15th March, 1704 when William Rose was prosecuted for treating William Seale, a butcher at Hungerford Market. Annoyed at his £50 bill, Seale had sought redress through the College of Physicians. Lord Chief Justice Holt reluctantly found in favour of the College on a point of law but the House of Lords sensibly reversed the judgement in the light of customary practice.4 Much has been attributed to this infamous case including our present-day tendency to over-prescribe. Its impact on the status of apothecaries was ambiguous. On the one hand, the decision perpetuated their inferior status as financially dependent on sales of goods rather than expert knowledge. On the other hand, apothecaries were free to practice physic and become the doctors of the poorer classes. It gave legal confirmation for the first time to their role as medical practitioners rather than tradesmen.

The rise of the surgeon-apothecary in the eighteenth century was in large measure driven by economic expediency. Most surgeons practiced physic and pharmacy in order to survive while apothecaries frequently undertook simple surgical procedures. Across the country in small towns and villages, most medical men – however they styled themselves – were undertaking much the same kind of general practice, involving all branches of medicine.

…to General Practitioner

William’s son, another William (1766-1829), was the first to qualify as a doctor but his passion was entomology. He bequeathed an extensive herbarium to the Wisbech museum. He was the first to write of using roasted iris seeds as a coffee substitute5 and was entrepreneurial too. He concocted a product called ‘British Salop…as a substitute for cocoa, chocolate, tea and coffee…one of the most nutritious preparations ever offered to the public…as useful in the sick chamber as at the breakfast table.’  This, after all, was the ‘Golden Age of Physic’.6 To this day, a taint of trade lingers about our branch of the profession.

Medical education then was a thriving industry but chaotic. Organised training and qualifications did not distinguish regulars from irregulars. Aspiring doctors’ increased financial expectations were some compensation for the initial outlay but their livelihoods were threatened still. Pressure for reform was growing up from below.

A major driver for change was thus the rise of dispensing druggists. Like many apothecaries before them, they served their apprenticeships as grocers or tea dealers but observed the profits to be made from pharmacy.  A striking feature of proto-GPs’ surviving accounts and workbooks is the vast quantities of medicines dispensed and their financial dependence on prescribing.7 By 1794, surgeon-apothecaries were each now losing £200/year to druggists.

Dr Edward Barlow was foremost among those with proposals to transform ‘that excellent species of practitioner, the surgeon-apothecary’ into an educated generalist. ‘On the competency of this class must the great mass of the population rely for the preservation of health and removal of disease. To by far the greatest portion of society they are the sole physicians, and even the highest ranks are known to depend with fullest confidence on their skills and ability.’8 Barlow’s particular concern was the chaotic state of medical education. He believed the College of Surgeons was the most appropriate institution to take on responsibility for training and oversight.

The first association properly to address the needs of general practitioners was founded – in the best professional traditions – at a meeting in the Crown and Anchor in the Strand on 3rd July, 1812. A protest had been called in response to a rise in tax on glass by which apothecaries had been hard hit. A new Association of Apothecaries and Surgeon-Apothecaries of England and Wales was proposed. Its object was to improve the education and status of the profession. Its indefatigable chairman, George Man Burrows (1771-1847), has been called the ‘father of general practice’.9

With great perseverance Burrows led the production of a Bill that combined idealism and self-interest. The Association’s aims were, firstly, improved training and examination based on a broad curriculum and, secondly, a licensing process that clearly distinguished irregular practitioners from the formally educated. It proposed that future general practitioners be examined and licensed by a ‘fourth body’, that they be required to hold a diploma from the Royal College of Surgeons and that a new London-based school of medicine be founded for their training. In this manner, the surgeon-apothecary would gain legal status as a generalist licensed in medicine, surgery and midwifery while unlicensed practitioners would be liable to prosecution. The idea of a fourth body (or College of General Practitioners) was, of course, anathema to the other Colleges and duly suppressed.

The Society of Apothecaries was to be responsible for the examination and licensing of future general practitioners and for prosecuting the unlicensed.

The Apothecaries Act had received its first reading on January and was eventually passed by the House on 11 July, 1815. The Society of Apothecaries was to be responsible for the examination and licensing of future general practitioners and for prosecuting the unlicensed. Candidates for the Licentiate of the Society of Apothecaries (LSA) were required to have spent six months at a recognized hospital or dispensary. The penalty for practising without a licence was £20 but ‘Pre-1815’ medical men were exempted. Membership of the Royal Society of Surgeons (MRCS) was not compulsory but the diploma was so frequently taken that the dual qualification MRCS LSA (colloquially known as ‘College and Hall’) became our hallmark.

On the one hand, the Act added compulsion and examination to the pre-existing educational framework and was a step forward towards full professionalization. The term ‘medically qualified’ at last had a clear meaning.  On the other hand, the Act was undoubtedly muddled with no clear definition of an apothecary or what constituted illegal practice. It failed to outlaw irregulars.

Conclusion

Was the Apothecaries Act among the great reforms of the nineteenth century or a degrading compromise in the face of reactionary opposition from the Colleges of Physicians and Surgeons?  Medical historians are divided. Few general practitioners were satisfied with the outcome but GP numbers nevertheless grew rapidly over the first decades of the nineteenth century.

The GP was thus not a sudden creation but evolved from the surgeon-apothecary and man-midwife in the first half of the eighteenth century. This evolution was as much a product of political struggle as of planned progress in medical education and practice. No history can ignore the dubious consequences of GP exceptionalism which surely dates back to these early struggles. Down the decades, GPs have generally never had it so bad: battling threats real or imagined from less qualified competitors, countering the condescension of Royal Colleges, or fighting off managerial incursions. Shroud waving is a tribal pastime. Bouts of professional militancy went on to feature in the early days of national health insurance and the NHS. They continue to shape the profession’s self-image to this day. A necessary part of the practitioner’s armamentarium has always been the ability to subvert official controls.

The term ‘general practitioner’ was slow to catch on with the general public but by the middle of the nineteenth century, it was in common use among a confident new medical cadre with a growing sense of corporate identity.10 William Skrimshire (the Younger) ended his working days as one-such doctor.

This article is one in a five-part series: A short history of general practice:

References

  1. Gillam S. Of Patient Bearing – A History of General Practice in Eight Generations. Holt: Hill House Publishing, 2021.
  2. De Renzi S. The Sick and their Healers. Chapter 2 in Elmer P ed. The Healing Arts. Health, Disease and Society in Europe. Manchester: Manchester University Press, 2004, pp 136-165.
  3. Loudon I. Medical Care and the General Practitioner, 1750-1850. Oxford: Clarendon Press, 1986.
  4. Clark G. A History of the Royal College of Physicians of London. London: RCP, 1966, pp 476-9.
  5. Skrimshire W. Account of a British vegetable product [Iris pseudacorus], that may be substituted for coffee. Nicholson’s J Natural Philosophy 1809; 22: 70-73.
  6. Eyre-Brooke AL. Richard Smith junior and his Life and Times. Bristol Medical Chirurgical Journal 1969; 84, 1.
  7. Baine B. Bill from Mr Bernard Baine, surgeon apothecary to Thomas Carew. Somerset CRO, Taunton, DD/TB box 14/20, 1755.
  8. Barlow E. A Disinterested Physician. MPJ 1813, 30, 265-296.
  9. Bettany GT. Burrows, George Man. In Stephen, Leslie. Dictionary of National Biography. London: Smith, Elder & Co, 1886.
  10. Bloor DU. The Rise of the General Practitioner in the Nineteenth Century. J Roy Coll Gen Pract 1978; 28: 288-91.

Featured image: The dance of death: the apothecary. Coloured aquatint after T. Rowlandson, 1816.. Credit: Wellcome Collection. Public Domain Mark

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