General Practice in East Lothian, 1946-1966
Dr J S Milne
The practice in which I worked was centred on Ormiston and extended from Haddington in the east to near Dalkeith in the west and southwards up to and into the Lammermuir hills. In 1946 many doctors were single-handed and most, including me, had surgeries in their houses. I had a partner, but we ran separate practices, apart from standing in for each other for one half-day and half of every other Sunday. The help in the practice was given by my wife who answered the door and the telephone and dealt with emergencies. I was able to call on the District Nurse and the Health Visitor who were employed by the local authority. After five years of virtually single-handed practice, my partner and I took on two others, after which I had someone with me all the time. My new partner and I built a surgery outside my house. It had a consulting room, a waiting room and a room serving as laboratory, spare consulting room and eventually an office for a secretary. In 30 years this building became obsolete, mainly because of the expansion of the general practice team, which we did not foresee in 1951.
In 1946 people who worked obtained doctor and medicine under the old (1911) NHI Act. Others, mostly wives and families, were private patients and were charged five shillings (25 pence) or so per visit. Most doctors had flexible fees which varied from nothing for the very poor to more than five shillings for the better off. Ormiston was a coalmining village and all colliers, whether married or not, paid sixpence (2.5p) a week to the doctor of their choice for medical attendance and medicine for their families. We also allowed anyone who wished to join a club on the same terms as miners’ families. Hence most of our income came from capitation payments and only about an eighth of our income came from sending out bills. When the NHS started in 1948 the annual payment per patient was 26 shillings (£1.30), instead of the same amount previously for a whole family. Being sixpenny doctors led to our dispensing most medicines ourselves to those not entitled to NHI prescriptions. In those days before the subsequent therapeutic explosion the range of medicines was simple. This dispensing ceased in 1948 because if there was a pharmacist in the village, which there was, dispensing by doctors (except in emergency) was prohibited.
For 6 or 7 years after 1946, wartime petrol rationing continued. This meant there were very few motor cars (four in Ormiston) and all patients had to be visited who could not walk or cycle to the surgery. Services buses were too infrequent to suit. As cars increased in number more people could come to the surgery, until in modern times far fewer visits are needed.
The number of patients in the Ormiston practice was just under 4000 and in 1946 one doctor could cope with that number. After the NHS started the demand increased gradually until in 1951, just before I got a partner, I was hardly able to manage. Elsewhere when this happened the absence of payment in the NHS was blamed for increased demand. This could hardly be true of Ormiston because patients there mostly did not pay per item of service before the NHS. We used to consult morning and evening, seeing about 15 patients each time. There were no appointments, which had the advantage that if you waited, you could see the doctor that day. If the waiting room was very full and someone came in who needed a full examination, I used to take a history only, examine the patient at home next morning and see him again in the surgery to take blood etc. Between surgeries we did visits, averaging 20 or less in a day. At all times we were liable to be called to pit accidents, mostly fortunately not desperate. The changing culture over half a century is shown by the waiting room being full on Christmas morning in 1946 (the Scots not having heard of Xmas) while on New Year’s Day no one came and only severe hangovers merited a call. We each had four weeks holiday yearly and when there were only 2 partners, we employed a locum for 8 weeks. Once there were 4 partners we could do it ourselves.
The surgery had instruments for diagnosis, minor surgery, examination couch, screen, weighing machine, height measure, steriliser, clinical records and drugs for emergency use. Not all doctors had good premises. I remember one with 4 dining room chairs for an examination couch and no washbasin. We carried in the car a bag with diagnostic equipment, a bag for minor surgery, splints, a bag for midwifery and an emergency bag with things like lumbar puncture needles, tubes for lavage etc. Oxygen was kept in the garage because the British Oxygen supply depot was 12 miles away.
The laboratory was equipped for haematology including blood films, staining of films for bacteria and urine testing. We had a good microscope, needed because although we had access to a good bacteriology laboratory in the university, any other examinations had to be done by ourselves. We could even cope with estimating vitamin C in the urine in scurvy. I once diagnosed malaria in a soldier on leave. It was satisfying in my early days to suspect say pernicious anaemia, do the lab work, give the treatment and monitor return to health without involving a hospital. When necessary we did investigations in the patient’s home such as lumbar puncture or chest aspiration.
A dentist visited our surgery from 1946 to 1951. He could only do examinations and extractions there, with his surgery elsewhere for other dentistry. After 1951 there was a dentist nearby. A chiropodist also came weekly, but the patients had to pay him. We had a good relationship with Dr H D Wilson, the Medical Officer of Health. If we failed to immunise a baby his staff would do it and vice versa.
Work in the practice in 1946 was largely concerned with infections, interspersed with serious illness such as congestive heart failure, myocardial infarction, malignancy, stroke and anaemias, plus the run of minor ailments still common in practice today. It is difficult to believe that in 1946 patients with myocardial infarcts were kept in bed for 4 weeks, not allowed to do anything and even fed. The addictions were to alcohol and tobacco only.
The serious infection was tuberculosis. My generation of students were taught to be diligent in searching for it, but early diagnosis resulted in a two-year wait for a bed, which allowed the patient to have a good chance of dying in hospital some time later. A most dreaded form of tuberculosis was tuberculous meningitis, which until anti-tuberculous chemotherapy appeared, was invariably fatal. I saw four after 1946 of whom three died, but the fourth survived.
This was because effective treatment was available by then and because Dr Murray at East Fortune offered an emergency lumbar puncture service, which made early diagnosis easier. This patient was left deaf by the treatment but learned to cope with the deafness in Donaldson’s Hospital. In Ormiston pneumoconiosis with superadded tubercle was an additional hazard.
The only treatment for infections was sulphonamide, which dealt with streptococci and some pneumonias leaving staphylococci and other organisms as dangers. Otitis media was widespread and apart from generating mastoidectomies, led to chronic running ears being common, so common that mothers usually did not mention the discharge. The arrival of penicillin in civil life in 1947 produced a revolution in treating otitis media and eventually to the disappearance of running ears. In those days measles was common, in epidemics, as were whooping cough, rubella, varicella (chickenpox) and mumps. Deaths were rare from these. In 20 years I saw one death from measles encephalitis and two from whooping cough. In the same period one mumps meningitis survived, as did 2 people with poliomyelitis and one with paratyphoid. Streptococcal infections were common and I saw 2 people with acute nephritis and a number with rheumatic fever as sequelae.
Urinary infections were common as always. In the absence of urine culture (too far from the lab) we used history, pH of urine, microscopy of urine for pus cells to diagnose infections. Sulphonamide was the only real therapy and in those days usually worked. Success meant symptoms and pus cells disappearing. During my 20 years new antibiotics improved the treatment of urinary infections.
Immunisation at first was for diphtheria only. Having seen diphtheria commonly as an assistant in 1944-5, I saw one case in 1946 and none thereafter, although I carried prophylactic antitoxin for some years. After 1951 pertussis immunisation led to the relative disappearance of this distressing illness in children. Later the Salk (‘dead’ vaccine) and then live vaccine for poliomyelitis came in. We saw no difference with this, the illness being rare in East Lothian. Immunisation was such an important part of our work that by 1955 we ran a special clinic for it. One good change as the years passed was immunising all patients given anti-tetanic serum with tetanus toxoid.
Childhood illnesses were mainly not serious. We saw many throat, ear and chest infections. Wheezy bronchitis was common in small children. As did most young doctors I thought I had found a new disease when outbreaks of acute anterior ulcerative stomatitis occurred. There were of course some serious ailments – pyloric stenosis, rheumatic fever, leukaemia, and congenital conditions. Many asthmatic children seemed to be free of wheeze on reaching their teens.
Pregnancy showed a post-war boom; this meant hospital delivery was hard to arrange. Hence at first home delivery by the doctor and the district nurse was common with forceps if necessary. Diagnosis of pregnancy was by vaginal examination but tests with the Xenopus toad were available if needed. Antenatal and postnatal care were standard as in hospital, although small rises of BP were less regarded than they were later. Hospital delivery by the GP was available in the Vert Hospital in Haddington. In 1946 this was too expensive for many women, but after the NHS started more and more were delivered there. As time went by more and more women were delivered in hospital in Edinburgh and by 1966 GP deliveries had nearly stopped. A midwifery ward opened in Roodlands was never used. By 1966 GPs were giving antenatal and postnatal care instead of a full midwifery service. Aftercare for the infant was done by health visitors. Fathers did not attend confinements in my day. In 1947 a fright with a postpartum haemorrhage caused me to carry dried plasma (and later dextran) to be given intravenously until the flying squad arrived from Edinburgh with blood.
There were fewer old people in 1946 than now. They were usually looked after by the family. In 1946 housing was scarce and many young married couples lived in ‘my mother’s room’. In this extended family, the grandmother, often a widow, helped a great deal and sometimes the mother could have a job. There was no geriatric service. We had a rudimentary surveillance in that once an old person was on the visiting book we kept calling once a month. There was not much examination unless for a specific complaint, but there was the opportunity to tell us their troubles. The modern silent epidemic of dementia had not started, although there were a few affected patients. It was difficult to get long-term care for them.
Eye problems were dealt with in RIE and in 1946-66 patients were seen quickly. The NHS started out with free glasses. A certificate from the doctor was needed for the optician, which kept the doctor busy and filled drawers with unused glasses, but at least the patient’s sight was reviewed. Disabled people were not greatly helped.
The NHS provided free small motorcars, which was a great boon for a few. The Medical Officer of Health would supply aids if asked but on the whole this was a small service. There were no occupational therapists in 1946. Hearing aids in 1948 were the first free ones available. These were clumsy with a headphone like a wireless operator, a large microphone and batteries carried in a sort of bus conductor’s shoulder bag. Time passing led to increasing miniaturisation and eventually to the inconspicuous aids used today. Congenitally deaf children were very well served by Donaldson’s Hospital.
Mentally ill patients, if necessary, could go to the mental hospital in Haddington. In 1946 this was run by a GP but from 1948 psychiatrists appeared. Outpatient clinics at Jordanburn Hospital were invaluable, mainly for severe anxiety. Most people with anxiety states were treated by us, mainly sympathetic listening and ‘come and see me again any time’. In 20 years I remember 3 patients with schizophrenia and 2 with mania. Depressed people were usually treated by us once antidepressants became available. There was a stigma resulting from admission to a mental hospital and the idea was often resisted. Mentally subnormal people usually lived at home. Even children with very severe mental handicap would be looked after by their parents, but were sometimes invisible in a back room The commonest problem was Down’s syndrome. I remember 2 others with hydrocephalus.
Arranging hospital admissions as emergencies in 1946 was very frustrating. There was no emergency bed bureau and no pagers. Hence one had to wait until a houseman could be found (sometimes a long time) and might then be told there was no bed. It was a great relief when the NHS introduced the Emergency Bed Bureau for Lothian hospitals.
In the 20 years from 1946 to 1966, general practice changed a great deal. The demand for service in the NHS rose and continued to do so. In my time the demand was not unsatisfiable, but in subsequent years increasing out-of-hours demand led to the creation of large rosters in which the doctor on call was up all night. In the nineteen fifties sharing night duty with one partner, I have gone as long as three months without a night call. The extra demand has also led to more partners in practices. As an assistant in 1944 the doctor and I looked after 8000 patients without too much effort. That practice now has 6 partners.
The therapeutic explosion caused great change. The increased number of antibiotics improved the treatment of infections. Greatest of all was anti-tuberculous chemotherapy, which rapidly led to empty sanatorium beds and tubercle doctors turning to geriatrics. We were able to treat successfully such ailments as Weil’s disease and abortus fever. Infants with pertussis were kept out of danger with chloramphenicol and so on. A range of new diuretics, hypotensive drugs, anti-coagulants and beta-blockers improved our treatment of cardiovascular disease. The appearance of steroid drugs was one of the most important therapeutic advances in my time in practice with changes in the treatment of asthma, rheumatic diseases, various inflammatory and allergic disorders etc. Hayfever and allergies were controlled by anti-histamines. Vitamin B12 was a splendid substitute for liver extract. One illness which appeared in the surgery in 1946 was neurosyphilis but this was not so in 1966. Patients with tertiary syphilis were treated by us at home under the supervision of the Royal Infirmary. Occasionally a man would appear with roaring aortic incompetence, a legacy from World War 1.
Sterilisation of syringes was by boiling in 1946, although that was then known to be inadequate. One of my partners found a hot air method, which worked perfectly only to be superseded in a couple of years by syringes sterilised by gamma rays, which were supplied free by government.
Investigation became easier with GP access to haematology and by private arrangement we also had access to X-rays and biochemistry. Contrast this with making my own Wintrobe tubes in 1946, cooking them in the kitchen oven.
Anaesthesia in 1946 was ethyl chloride from a Clover’s inhaler with me as anaesthetist and abscess opener in the surgery and chloroform for midwifery and for dental clearances. This had improved by 1966 to Boyle’s apparatus for midwifery in the Vert Hospital and no anaesthetics in the surgery.
Pit accidents continued to occur. Many were not serious, e.g. burst finger, but there were some with fractures or even once loss of both hands, once paraplegia and twice loss of life. Before the Coal Board appointed a medical officer I used to teach first aid to pit deputies and also instruct them in the use of morphine (which in my time they did not use once).
We kept full clinical records so that if one partner saw a patient previously seen by the other he did not have to ask questions displaying total ignorance. Unfortunately in my time the records were the old NHI ones and the switch to hospital folders had not occurred.
In summary, the main improvements in general practice 1946 – 1966 were purpose built premises, improved diagnostic facilities and the benefits from the increase in useful drugs.