General Practice in East Lothian 1946-1966
by John S. Milne DSc, MD, FRCPE
When I graduated in medicine in January 1944 from the University of Edinburgh I knew nothing about general practice and there was no official training scheme. Indeed one could graduate on Monday and become a principal on Tuesday. A friend who was a general practitioner had shown myself and some fellow students many patients in our student days but he was showing us ill people, not teaching about general practice.
My own preparation for general practice was a job as a house physician (Professor LSP Davidson, Western General Hospital, Edinburgh) and then just over a year with a very good general practitioner (Dr Angus Walker, 7 Wellington Place, Leith) who was notable for having had as assistants men who subsequently became a Professor of Cardiology, a Professor of Biochemistry, a Consultant Thoracic Surgeon, a Consultant Anaesthetist and a Consultant Geriatrician. His methods of training were always being ready to answer questions, some didactic activity and, once I had learned a bit, to give me a carefully chosen list of visits to do. On my return I would be questioned about what I had done and would be expected to justify my diagnoses and decisions. I was also given time to attend an Ear Nose and Throat Clinic, a clinic for Diseases of the Skin, a session where the Professor of Pathology reviewed the week's post- mortems and to follow emergencies into hospital and watch the operations. He and I also went together to various lectures available to us in the Edinburgh Medical School. Dr Walker taught me nothing about midwifery, so on leaving him I did a house job in Obstetrics and Gynaecology (Professor RW Johnstone, Western General Hospital, Edinburgh). Following that I spent six months doing locum tenens jobs in a variety of general practices.
After that preparation, in August 1946 I became a partner in a practice in Ormiston, East Lothian. Ormiston is thought to have begun as a mill-toun in mediaeval times and a village community had gradually grown up around it. From the point of view of Scottish social history the most interesting thing about it is the improving activity of an eighteenth century laird, John Cockburn (1679 - 1758). Cockburn is well known among the improvers of the day and introduced innovations in farming techniques, farm leases and cottage industries. He improved the appearance of the buildings of the village and planted the double row of trees which line the broad main street today.
Ormiston lies within the Lothian coalfield and coal has been extracted from the ground there since the 13th Century. The pits were shallow, about 30 fathoms, and there was no inflammable gas. At work the men wore soft hats with a metal plate on the front to hold an acetylene lamp. At night one sometimes met two lights on the road coming towards one. This was a miner cycling home with his bicycle lamp and working lamp both lit. In 1946 the mines belonged to the Ormiston Coal Company. After the National Coal Board (NCB) took over in 1947, electric lights and hard hats became general. The shallow pits meant surface water often came through to the workings and men had then to work in oilskins. This, added to low seams sometimes only eighteen inches high, made the work very hard. Early accommodation to these conditions was necessary and it was difficult to start work in the pit later than the early teens. Some men wore a broad blue cloth band to protect their backs!
Housing in Ormiston was mainly good, being mostly between-the-wars council housing, and many miners lived there. Some miners lived in company property. The best of it had been partly brought up to date but might have anomalies like the bath in the kitchen or a long straight stair. The worst had two rooms, one opening from the other, one cold tap inside, a lavatory serving three houses outside, a kitchen range and no hard surface round the houses. There were no pit-head baths and washing in the worst houses was in a tin bath with water heated on the range. The NCB gradually introduced pit-head baths and athlete's foot, which had been virtually unknown in Ormiston, became common.
My partner was in Tranent, one and a half miles due north of Ormiston and we worked on either side of a line drawn east and west between Tranent and Ormiston. My part of the practice extended from Haddington in the east nearly to Dalkeith in the west and south into the Lammermuirs. We ran single-handed practices, apart from standing in for each-other on half-days. I had between 3000 and 4000 patients; in 1946 one doctor could look after such a number, the demand being much less then. In 1946 practices were bought and sold and the price was standard, one and a half years’ gross income. One could buy from a retiring doctor or from a widow selling a death vacancy or one could choose a partnership. Many doctors were then single-handed and consulted in their houses. This meant the new doctor was wise to buy the doctor's house to which the patients were used to coming. Indeed it was often obligatory; the house [Figure 1] that I had to buy had eleven rooms, including the surgery and waiting room, rather large for a young doctor with a wife and one baby. At this time I was only twenty-five and had some trouble with ‘you're awful young to be a doctor.’
My principal helper was my wife who answered the door and the telephone and, being a State Registered Nurse, dealt with emergencies in my absence. We also had help from District Nurses, usually one to a village, and a Health Visitor. There was a progressive county councillor in Ormiston who in 1946 started a home-help service run by the Relieving Officer. He supplied home-helps at my request and if he had no one available would ask me if I knew anyone who would do. I usually did and he said ‘you send her and I'll pay her’ - an effective system compared with modern times.
Petrol was rationed (a little less severely than in wartime) for six or seven years after 1946 and public transport in our area was poor from the practice point of view. So we did many more home visits than a GP would do now, up to twenty per day taking five or six hours with ten miles the greatest distance from base. This could double in an epidemic. Two surgeries per day would have fifteen patients or so at each but there could be many more and there were no appointments. If the waiting room was full and someone came in with a serious problem, I used to take the history only, examine the patient at home next morning and see them again in the surgery to take blood etc. This split a lengthy consultation into three. At least in 1946 if you arrived in the waiting room you would see the doctor. In a culture in 1946 different from that today, on Christmas morning 1946 the waiting room was full and on New Year's Day 1947 it was empty.
A practice like this was a pleasant place to work. I knew nearly everyone I saw as I moved round the practice, whether they were my patients or not, and sometimes made diagnoses from the car. I remember one with thyrotoxicosis, one with severe anaemia and one fractured neck of femur using a broom as a crutch. Our work was in villages and in the rural areas between. I never refused a request for a visit. One example will show why. A teenager asked at 1 a.m. for a visit to his sister. ‘Why?’ ‘She has a sore back.’ When I got to the house, I found a fifteen year old girl in labour, the pregnancy being previously unknown to me. The mother had vainly hoped to keep the matter secret, hence the misleading message.
The consulting room and waiting room, were in my house, approached by a side door. The surgery was about ten feet by six with a small roll-top desk, chairs, examination couch and wash basin. Not all doctors had as much. I knew one who had four dining room chairs as a couch and one who had no wash basin. Figures 2 and 3 show this room which, as well as the furniture mentioned, had a weighing machine, a height measure, a steriliser using boiling water, microscope and a cupboard with instruments, liquids, dressings and drugs. The lamp, seen on the right, was made from an old car headlight and used with a forehead mirror. Later, before free syringes came in, there was a hot air steriliser which heated up to 180 degrees C. I, and later my partner, always kept detailed records. When there were two of us this saved asking questions already answered by the patient. When I started in 1946 there had been no records apart from letters from hospital.
Before there were antibiotics, abscesses and pulp infections needing incision were common. General anaesthesia was given by me using a Clover's inhaler. This lasted just long enough for me to open an abscess and insert a drain. Other minor surgery was wound suture and removal of sebaceous cysts and skin papillomata.
In the car I carried a bag with diagnostic equipment and emergency drugs, a midwifery bag with forceps and chloroform (well enough equipped to do a delivery literally anywhere), a bag for minor surgery, long Liston's splints of various sizes and plaster of Paris bandages. There was a little used but essential emergency bag with a giving set for oxygen, dried plasma (later Dextran) and giving set, lumbar puncture needles, aspiration syringe, tracheotomy tube, catheters and material for gastric lavage. Oxygen was kept at home being too clumsy to carry in the car all the time.
How did we get paid? For workers who had insurance cover under the 1911 National Health Insurance Scheme we were paid 9/6 yearly (less than 50 pence) which rose to 15/- (75 pence) in 1947. This included the miners who also each paid 6d (21/2 pence) weekly at the colliery for the doctor of their choice; for this the doctor had to supply his services and medicine for all members of the miner’s family. Miners paid this even when single. The money was paid to the doctor by the coalmaster and we allowed any non-mining family to pay in the same way. So I was truly a sixpenny doctor. Private practice was perhaps an eighth of our income. The charge for a visit varied from nothing to 10/- (50 pence) according to how poor or well off the patient was. When the National Health Service (NHS) came in 1948, the payment was 26/- (£1. 30) per person per year which was a pay rise for our kind of doctor. We dispensed medicines ourselves to the sixpenny patients but that ceased with the start of the NHS.
Available investigations were limited. During the war East Fortune Hospital (a tuberculosis sanatorium) had moved to West Lothian and no X-rays were available in East Lothian in 1946; the local authority paid for chest X-rays at the private clinic of Drs King and Allan in Edinburgh. After 1947, when East Fortune returned to East Lothian, Dr Wm Murray supplied chest X-rays. Professor LSP Davidson (Professor of Medicine in Edinburgh University) had made sure all students could carry out simple haematological tests and I did my own in Ormiston until eventually there was an NHS Haematology Service for GPs. The tests were red cell count, white cell count, haemoglobin, reticulocyte count, differential white cell count, blood film and erythrocyte sedimentation rate. I could check for achlorhydria if necessary. Hence I could treat pernicious and iron deficiency anaemias in Ormiston and check the reticulocyte response in pernicious anaemia. Wintrobe tubes were made up by me and dried in the kitchen oven. Diseases diagnosed in this way included iron deficiency anaemia (many) pernicious anaemia (not uncommon) haemolytic anaemia (2) various leukaemias (6) glandular fever (many) and malaria (1).
Edinburgh University supplied a good bacteriology service used mainly for examining sputa and throat or rectal swabs. Antibody tests were also available. Dr Wright of the department would always help in interpreting results. Urine culture was not possible because of distance from the laboratory. So we looked for pus cells, checked pH and sometimes made a Gram film in diagnosing urinary tract infection. In the 1960s urine culture with an estimation of number of organisms per ml became possible by refrigerating specimens on the way to the bacteriology laboratory. Urine microscopy was also used for red cells, casts and crystals. Lumbar punctures and chest aspirations were done at the patient's home for meningitis, subarachnoid haemorrhage and pleural effusions. I had worked in the clinical laboratory of Edinburgh Royal Infirmary as a student and a friend there would process specimens for me (unofficially). A friendly radiologist said I was entitled to consult him directly which meant I could get barium X-rays done.
By 1951 the work had increased so much that I could barely cope and my partner and I took in two extra partners, one for each of us. This increase in demand was general in the NHS. But it was surprising in Ormiston since our patients had experienced no relief from paying doctors’fees as most of our pay was by capitation fee before the NHS began.
My new partner and I built a mini health centre There was quite a large waiting room since there were no appointments in those days. The consulting room was larger than the one in the house. It had a five gallon water heater over a steel sink intended for washing glasses in a public house but ideal for a surgery. A custom-made cupboard held all our equipment; three quarters of it were cupboards and drawers and the remaining quarter had a tambour. This part was used in daily work and the absence of doors was an advantage. A room between the waiting room and the consulting room was a hybrid with a laboratory bench, a couch to allow it to be used as a spare consulting room and a window with a built-in desk which, after I had given up general practice, was used by a receptionist. This building was satisfactory for twenty years or so but became obsolete when teamwork arrived in general practice and the building was then too small.
When I was an assistant, the doctor's wife told me ‘just now you are the young doctor. When you get a practice you will be the doctor. If you take a partner, whatever age you are, you will be the old doctor.’ My new partner was my own age to within 6 months and one night a man came into the waiting room and said "is it the auld yin the night?". Confirmation?
What sort of problems did we see? Work in 1946 was largely concerned with infections and the vague self-limiting ailments common in general practice interspersed with serious illness - cardiovascular, malignancy etc - much as GPs see today - although it is difficult nowadays to think of keeping a patient with a myocardial infarct in bed for 4 weeks. Acute left ventricular failure was a recurring problem, although my own GP says it is rare now. In 1946 there was no treatment for hypertension and we had none of the preventive therapy for cardiac disease which is used today, which no doubt explains the change in incidence. I only saw one patient with left ventricular failure who died during the attack. Chronic obstructive airways disorder was common as was asthma and cigarette smoking. Peptic ulcer was also common and difficult to treat.
However there were some problems common then but rare today. First was tuberculosis which was still common then and virtually untreatable. I have no records now, but can remember four people with chronic fibroid phthisis when I joined the practice. In the next few years I remember six new cases of pulmonary tuberculosis, several with pleural effusion, two with spinal tuberculosis and four with tuberculous meningitis. Three of the latter died, but when the fourth appeared streptomycin had become available and she survived. This is partly ascribable to the emergency lumbar puncture service started by Dr Murray at East Fortune from which he admitted any patient with positive results. Unfortunately my patient was given intra-thecal dihydrostreptomycin and was left totally and permanently deaf. Since she was less than two years old Donaldson's Hospital in Edinburgh was able to teach her to lip-read and she came to have a good speaking voice. There were also patients with glandular tuberculosis. Patients waited one or even two years for a bed after diagnosis (usually made early because of the way we had been taught as students) and could not look to a very rosy future in hospital. So there was rejoicing when Ian Grant, Norman Horne, Ian Ross and Professor John Crofton worked out how to use anti-tuberculous chemotherapy. Beds then became empty and tubercle doctors became geriatricians.
There are no longer any coal-miners in Ormiston but in 1946 there were many and there were always victims of pit accidents. Fortunately, these were mainly not dangerous - burst fingers, bruises, minor fractures, back injuries - although unpleasant for the man concerned. Some others were very much worse. I remember two men killed, one paraplegic after being hit by runaway hutches, one who lost both hands in an explosion and several with severe fractures of both bones of the lower leg. There were men with industrial diseases - beat knee, beat elbow, industrial dermatitis and leptospirosis. Always we had coalminer's pneumoconiosis in mind and chest X-rays were frequent in search of it. Many older men had progressive massive fibrosis with constant black sputum and superadded tuberculosis. Before the National Coal Board appointed a medical officer I lectured to the deputies on first aid and this included teaching them to use morphine as Omnopon. The Omnopon was stored in special locked containers below ground along with stretchers and blankets. In my time the Omnopon was never used; the deputies may have been put off by the contra-indications.
Congestive heart failure was our commonest severe illness. Some were the result of rheumatic heart disease. Rheumatic fever was common in those days and chorea less so. Some of these children developed carditis and valvular disease. During my time in practice rheumatic fever seemed to disappear and some housemen I met later in my life had never heard the murmurs of rheumatic heart disease. It was a great day when the first mitral valve was split with all the later valve surgery still to come.
In 1946 the welfare state was in embryo and it was still possible to starve. In my early days I saw four people with scurvy, one of whom died. One old woman lived in a hayloft and was diagnosed by candlelight. Another man, not known to any local doctor, was seen on a freezing January day with no food and no fuel in the house and his only bed clothes some old coats. He died in hospital next day.
Ormiston was not exactly a hot bed of venereal disease. I saw only one primary chancre in twenty years. However in my early days I saw three people with tabes dorsalis, one with cyclitis and one roaring aortic incompetence in an oldish man which I thought dated from the First World War. These patients were assessed in Edinburgh Royal Infirmary and were thereafter treated at home by us with hospital follow-up. This saved them many weary journeys to town. One of my younger partners had not seen anyone with tabes, even as a student.
Another disorder that disappeared, once its cause was found, was Pink Disease in small children. The only addicts I saw were to alcohol and tobacco and one woman who came to me as a heroin addict had been started on heroin elsewhere because of a mistaken diagnosis of malignant disease; it did not seem to cause her any difficulty.
Infections were a large part of our work. The common ones, other than respiratory, were measles and whooping cough which used to sweep through a village and not reappear until another susceptible group had grown up. In twenty years, I saw one death from measles and two from whooping cough; all three died from some form of encephalopathy. Diphtheria had been common in Leith in 1944-5 but I only saw one case in Ormiston in 1946, although I carried prophylactic antitoxin for some years after that. In twenty years I saw one case each of paratyphoid, proven staphylococcal endotoxin food poisoning, tetanus, rat bite fever, and meningococcal meningitis. There were several cases of viral meningitis and two each of brucellosis and leptospirosis. The organism was not isolated in the latter but both had high and rising titres of antibody. One patient did not send for me until he was recovering but still looked extremely ill; the other was treated at home with penicillin and recovered quickly. There were many rats in the pit at the time of these illnesses, but immediate action was taken to kill the rats once the chief inspector of factories had been notified by me. The young man with meningococcal meningitis illustrates changed days. After I saw him I rang the Medical Officer of Health for a bed in the fever hospital. He asked if I had done a lumbar puncture and suggested I should. So I went back, did the lumbar puncture, did a cell count and a Gram film at the surgery and returned to give intra-venous sulphonamide (all that was available in 1946) and sent him in next day. Difficult to imagine in 2004.
Children with running ears from chronic suppurative otitis media were so common that mothers did not even mention the discharge. Once penicillin became available in 1947 it was not long before the word went round and we saw many children with acute otitis media which resolved well. Most problems that I saw in children were infections. In common with other young doctors I thought little outbreaks of acute anterior ulcerative stomatitis were due to a new disease discovered by me. There were of course serious but rarer problems. I remember pyloric stenosis, leukaemia, intussusception, coarctation of the aorta and hypertelorism.
Immunisation was important enough for a special clinic. Beginning with smallpox and diphtheria toxoid, I added pertussus vaccine in 1951 and later tetanus toxoid and then polio vaccine. When possible we used gamma globulin to abort measles in pre-school children. A good move was the introduction of tetanus toxoid to immunise any person who had had antitetanic serum. Eventually 95% of our children were immunised as described.
The post-war rise in the birth rate led to difficulty in getting babies delivered in hospital, so most babies were delivered at home by the district nurse or myself. She also gave chloroform for my forceps deliveries. Diagnosis of pregnancy was by vaginal examination sometimes with confirmation by the Xenopus toad test, a biological test in which the injection of urine from a pregnant woman made the toad lay eggs. Antenatal and postnatal care were as in hospital with less worry about slight rises of blood pressure than later. The Vert Hospital in Haddington had GP midwifery beds but charged £3, too much for many until the NHS started when the hospital was free, popular and efficient. GP midwifery diminished gradually over my twenty years, possibly because more beds became available in Edinburgh and the Vert Hospital eventually closed. I had a fright with a post-partum. haemorrhage in 1947 - deep snow, miles up country and a big haemorrhage controlled with difficulty. Next day I asked Dr CP Stewart of the Blood Transfusion Service about dried plasma and he gave me enough, with giving sets, for doctors round about as well as myself. This was a big help since the Flying Squad, once it started only needed to change the bottle to blood.
There were fewer older people in 1946, many living in an extended family. With the housing shortage many couples lived in ‘my mother's room’ which meant that the grandmother helped with the children and the mother could work, usually in the fields. There was no geriatric service and the silent epidemic of dementia had barely started, which was just as well because placements were very difficult. My partner persuaded me to let any old person who got on to the visiting book stay there; thereafter a monthly visit provided rudimentary surveillance. There was not much examination but we saw them and heard about any problems
The NHS produced many free pairs of glasses. I used to wonder how necessary they all were but at least the patient's eyesight was examined. Early hearing aids made the person look like a bus conductor doubling as a wireless operator, with a large headphone, a large microphone and large batteries in a shoulder bag. Fortunately miniaturisation proved to be possible. Disability aids were few. We had two people with single-seater motor cars because of spastic diplegia. The medical officer of health had catalogues of aids and would obtain them if asked but the service was used seldom.
Mental illness was treated in a hospital run by a GP until the start of the NHS supplied a psychiatrist. I saw five patients with schizophrenia and two with mania in twenty years. Depression was commoner and usually treated by us once suitable drugs appeared. Many people with anxiety states were supported by us. This amounted to listening and offering to listen again anytime. Dr Betty Magill in Jordanburn Hospital was very helpful with severe anxiety. Mentally subnormal patients were mainly Down's syndrome. We had two people with hydrocephalus. Some other severe varieties of mental deficiency were invisible in back rooms.
It was always easy before the NHS to get patients into Edinburgh Royal Infirmary by writing ‘please admit’ at the bottom of the letter. Other hospitals were more difficult and much time could be wasted while a houseman was found in an era of no pagers. Once the Emergency Bed Bureau was set up life was easier but rising demand eventually made life harder for the bed bureau.
From what has been said so far, it seems that there has been no fundamental change in general practice in the last fifty or sixty years. Doctors have better premises. They have receptionists, appointments, ancillary workers, rotas for out of hours work and access to investigations formerly needing hospital referral. Nevertheless, the job the GP does is to be the first contact the patient has with the NHS and he or she deals personally with most of the problems so encountered without seeking hospital help. This is what general practitioners did half a century ago and many of the problems are the same. There is no general practice equivalent of advances such as magnetic resonance imaging or bypass surgery. What has changed fundamentally is treatment. When I was a student, Dr Alexander Brown, sub-chief to Professor Derrick Dunlop, came once a week to the practical pharmacology class and spent a few minutes telling us about one prescription. So in a three-term session we learned about thirty prescriptions used by physicians. I remember him suggesting that these would see us through our careers. The therapeutic explosion was then still hidden in the future. So in 1946 my armamentarium was Dr Brown's thirty prescriptions. I would like to end by giving some examples to show the difference between then and later.
In treating infections in 1946 we had only sulphonamides. (table 1)
Table 1. Drugs used to treat infection
They were useful against streptococci, some pneumococci, meningococci etc, but not against staphylococci, an important gap. They needed a big fluid intake - not easy in general practice - and did not do well in the common acute otitis media. Some exudate often remained in the middle ear. I have already mentioned the excellent effect penicillin had on acute otitis media. Table 1 shows the vast choice in anti-bacterial drugs later than 1946 and is not exhaustive.
Congestive heart failure was our commonest severe illness and our only diuretic was intramuscular Mersalyl, once a week or sometimes twice. I well remember the improvement when the more powerful thiazide diuretics and later others (Table 2) appeared with daily instead of intermittent treatment.
Table 2. Diuretics
It is impossible to work through all the pharmacopoeia but I can give some examples. For epilepsy in 1946 we had phenobarbitone, phenytoin and paraldehyde (for status epilepticus) with a much better choice later and some drugs for petit mal (Table 3).
Table 3. Anti-Convulsants
Parkinsonism was treated in 1946 with tincture of stramonium with much better therapy now but still not ideal (Table 4).
Table 4. Drugs for Parkinsonism
The only anti-thyroid drug in 1946 was potassium iodide given for a few weeks before thyroidectomy and now oral therapy has replaced operation (Table 5).
Table 5. Anti-Thyroid Drugs
We treated diabetes in 1946 with ladder diets and if these failed with soluble or protamine-zinc insulin. Now there is a range of insulins and oral drugs for type 2 diabetes (Table 6).
6. Treatment of Diabetes
There was no treatment in 1946 for hypertension except sympathectomy which wore off anyway and now (Table 7)
7. Drugs for Hypertension
there is a large range of drugs. Side effects have become less troublesome than they were at first. For asthma in 1946 we used ephedrine by mouth and adrenaline subcutaneously, sometimes a minim a minute until the attack subsided. I cannot remember if we had intravenous aminophylline then but now there is a range of effective therapy (Table 8).
8. Drugs for Asthma
Later there were drugs not dreamt of in 1946, for example steroids, beta blockers, antihistamines, cytotoxic drugs etc. Vitamin B12 was a great improvement on liver extract, being a pure substance instead of a mixture needing biological assay. So was thyroxin compared with tablets made from the gland and digoxin instead of digitalis leaf products.
Enough has been said to show that to a GP of nearly sixty years ago the striking change for the better in general practice is in treatment. This paper describes work in what was still a mining practice when I left it in 1966. So to finish here is a story about miners.
In the early 1970s the miners were on strike and I was living in the New Town of Edinburgh. One day I went into the newsagent to get my paper and the newsagent lady said ‘Isn’t it terrible these miners being on strike?’ To this I replied, ‘If they'd give them the money they wouldn’t be on strike.’ Next day my wife went for the paper and the newsagent lady said ‘Your husband is the only man about here who has a good word for the miners.’ To this my wife replied, ‘My husband is the only man about here who has ever seen a miner.’