May I95I WELLS: The Riddle of General Practice 237

casionally for crystals. If no crystals are found inan acid specimen of urine of an average specificgravity then the abnormality may be neglected.

(z) Cystinurics who habitually pass crystalsshould be advised to keep the urine dilute by largefluid intake, and to live on a vegetarian or a low-protein diet. The crystals can generally be madeto disappear from the urine if sufficient alkali isgiven by the mouth, but the amount required islikely to be greater than a patient could tolerate formore than a short spell. Anyhow, prolongedalkalinization is not necessary because mostcystinurics who are careful about their diet andfluid intake succeed in avoiding calculous disease.

(3) Once renal calculi have formed surgicaltreatment is necessary. Fortunately the disease isoften unilateral and the patients are in good con-dition for operation. After surgical removal of acystine calculus another may form later in thekidney, so the patient needs to be kept under

supervision. Cawker (I946) advises that after re-moval of cystine calculi from the kidney re-currence may be avoided by adopting, for one weekin each month, a low protein diet with sufficientalkali by mouth to keep the urine alkaline. Hesays that this not only prevents crystallization ofcystine but will actually dissolve a small cystinecalculus. This is worth trying, but there is littleevidence that cystine calculi can be dissolved bykeeping the urine alkaline. Alkalinization of theurine merely prevents the deposition of crystals;,it does not diminish the excretion of cystine nordissolve stones which have already formed.

BIBLIOGRAPHY

BRAND, E., BLOCK, R. J., and CAHILL, G. F. (1937), J. Biol.Chem., 1II9, 685i.

CAWKER, C. A. (1946), Canad. M. A. J., 55, I9.DUKES, C. E. (IgsI), 'Brit. Encyclop. Med. Pract,' 2nd Ed-

(Butterworth), in the press.LEWIS, H. B. (1932.), Ann. Int. Med., 6, 183.MELVIN, P. D., and ANDREWS, J. C. (1937), 7. Urol., 37, 655.REMANDER, A. (1937), Acta Radiol., i8, 807.

THE RIDDLE OF (GENERAL PRACTICEBy C. J. L. WELLS, M.A., M.B., B.Ch. Oxon.

General practice has been brought into the fore-front of medical politics (and I am extremely gladthat this has happened) by, without question, thepublication of the Collins' Report and two B.M.A.Reports, the one on the training of the generalpractitioner and the other on health centres.Collins, as you know, was an individual from thecolonies investigating alone and at the request ofthe Nuffield Foundation. 'He describes in a longreport of 40,000 words his surprise and distress atwhat he saw, wondering in his more pessimisticmoments whether the sinking ship which wasgeneral practice was capable or even worthy ofsalvation, and finally concluding that it was andthat it must be saved. The B.M.A. Committee ongeneral practice and the training of general prac-titioners consisted of 32 members of which, asfar as I could make out, not more than one-thirdwere general practitioners. It sought to plot thepath from the ' Slough of Despond' in which itfound general practice forward to the ' DelectableMountains.'The Collins' Report filled me with the utmost

gloom partly because of its conclusions, and partlybecause those conclusions were so sincerely held.My mind went back to Brett Young's descriptions

of industrial practice before the I913 Act, in suchbooks as ' Dr. Bradley Remembers' or ' BrotherJonathan,' and it appeared from the conclusionsof the report that what was true then remains trueto this day and with even heavier emphasis. Thathis standard of what is good practice and what isbad was not my own had nothing to do withmy gloom; it was the widespread degredation ofmedicine that he depicted which was as shockingas it was incredible. The report is not true ofinnumerable general practices any more thanCronin's ' The Citadel' depicts accurately theaverage inhabitants of Harley Street.The B.M.A. Committee's Report on general

practice and the training of the general practitionerproduced an entirely different impact. I was re--minded of the Pilgrim's progress as he journeyed tothe Celestial City and of all the trials and tribula--tions through which he had to pass before hearrived at that desired haven. Much of it I felt-to be unpractical and idealistic in a severely prac-tical and far from ideal world. I wondered muchif the gentlemen of the B.M.A. could not haveplotted a simpler path and envisaged a simpler-traveller.The report on health centres was to me infinitely-

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the best balanced of the three and I felt at homeand, to a large extent, in agreement with nearlyeverything that was written in it, largely, no doubt,because the majority of the members of thatCommittee were clean-bred general practitionersof good standing..These reports, especially the Collins' Report,

produced an immediate response in the medicaland lay press. A leading article in The Timesstated that ' If general practice is not raised to anew level of competence, some would say restoredto its rightful place, the whole of medicine willsuffer,' and again from another source, ' Of allthe problems besetting the medical professiontoday in its desire to provide the population withthe best medical care, that of restoring the familyphysician to a position commensurate with hiscontribution to society by improving the standardsof general practice appears to be the most pressing.'Both these passages suggested that all was not wellwith general practice, that a deterioration of thepractitioners' work and prestige had taken placeand that what Osler described as ' That flower of-our profession, the cultivated general practitioner,'was in grave danger of fading. This is certainlysuggested in individual letters in the medical-press, certain writers going so far as to deplore thedeterioration of their own services. There arefurther signs, fathers are advising against theirsons entering general practice because they, findpresent conditions in practice humiliating if notintolerable, and the newly-qualified are foundsearching anxiously for openings in other fields ofwork.

This position has been greatly accelerated bythe coming of the new Act although certain aspectsof general practice had been felt to be unsatis-factory prior to this time. As I rememberit, the most popular cry against general practice'before the coming of the Act was the exactingnature of the work, the strain of being on constantcall, the increase in the amount of non-medical and-paper work, the encroachment and unsatisfactorynature of outside clinics, and the peculiar antics ofthe examining medical officers. If these werelegitimate grumbles under the old Act, what ofthe new-' Whereas your yoke was heavy I willadd to your yoke and whereas your fathersscourged you with whips I will chastise you withscorpions.' How true! The heavy increase innon-medical and paper work, the increase intrivialities, and a deep distaste of the bands ofministerial control have caused work which wasalways exacting -to become irksome if not in-tolerable. But there is another and, I believe, afar more important side of the question which mustnot be overlooked and that is the fragmentation ofthe responsibility previously exercised solely by

the family doctor for the welfare of his patients.Immediately this fragmentary process takes placeand responsibility is divided between the clinic,the hospital, the health visitor, the almoner, thepaediatrician, the midwife and the specialist, thenheaven help the patient and heaven guide thestumbling footsteps of the poor general prac-titioner. Whenever division of responsibilityoccurs in this way interest in the personal aspectand even in the clinical condition of the patient islargely extinguished and service of necessitydeteriorates. I do not for a moment believe thatthe restlessness of the'general practitioner underthe Act, blindly stupid as much of it is, is funda-mentally a financial one. The question of adequatepay, that most indefinable of terms, comes in-creasingly to the fore as interest in work recedesinto the distance; that unhappy and needless stateof affairs is what has now overtaken us.

I think I am correct in saying that in this citythere are at least eight Medical or AssistantMedical Officers of Health who control I5 childwelfare clinics weekly, five antenatal clinics weeklyand five postnatal clinics monthly, not to mentionimmunization and vaccination clinics. Thisstructure is further supported by i8 healthvisitors as well as almoners and welfare officers.All these excellent busybodies are, in fact,carrying out and even interfering with what shouldbe the normal duties of the general practitioner,and none of it is work that could conceivably beconsidered to require training at specialist level. Itis no answer to say that some of these clinics aremanned by general practitioners especially in therural areas. What right has any doctor, generalpractitioner or otherwise, to interfere with thepatients of another doctor unless he is specificallyrequested to do so? If a doctor is not willing orcapable of looking after his patients then he shouldlose them to someone who is, and not be temptedto shelter under the protective umbrella of aclinic. Is it not obvious that this whole systemundermines the doctor-patient relationship whichis the foundation of family practice? What is theresult when the advice of the clinic runs counter tothat of the family doctor and the patients' loyaltyto the one is pitted against their loyalty to theother? What indeed?

I

I have heard the term doctor-patient relation-ship scoffed at and I have been asked' What doesthis vague expression embrace? What valuableintimacies are so mysteriously vouchsafed to thefamily doctor and hidden from the world at largeand in any case of what are their medical value? 'Only these. The general practitioner lives

among his people, he knows their habits of life,he knows their families, the inside of their homes,their virtues and their shortcomings, their hopes

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and their fears. He sees them unmasked in illnessand masked in health, he knows the cowards andhe knows the heroes. I am not talking sentiment,I am merely stating hard and often extremelyunpleasant fact. I will go further. The diagnosisof nine-tenths of his patients' functional disordersis presented to him on a plate and often enoughthe causes of their organic disease. To quote Ryle,' There are eyes without a microscope, ears with-out a stethoscope, and wits without chemistry andradiology.' These are his and no clinic systemor specialist service can adequately replace them.The doctor-patient relationship should not bepreserved as a perquisite of the well to do anddenied to the poorer classes, but this is rapidlybecoming the case.What has impressed me of late, much more

deeply than previously, is the fact that generalpractitioners are the only section of the professionwho practice the art of medicine in anything likethe full'sense of that word. There is a great ten-dency at the present time in this country to in-crease both the number of specialists and thenumber of specialities. The body is divided andsubdivided and each subdivision claims its bandof specialists which, I understand, is described asknowing more and more about less and less, butI believe that the increase in real knowledge gainedby such methods is small when compared with theloss of a wide and sound judgment which it sooften entails.

If in cricket you had a man with only onestroke that he could play, possibly with masterlyskill, who 'Was nearly useless in all other depart-ments of the game, which did not even particularlyinterest him, it is doubtful if in any true sense hecould be called a cricketer. He would be aneven more difficult person to place if he insistedthat he was the only person qualified to score offthat particular stroke, as he played it all day longwhereas other people were only playing it as partof a number of other strokes and therefore couldnot in his opinion be considered to play itefficiently. He might go even further and evolve anumber of complicated techniques which wouldconvert what was always considered a compara-tively simple proceeding and within the com-petence of any reasonably good cricketer into amanceuvre that he alone could attempt.' Such aperson would be unbalanced in his judgmentwhich, if followed, would go a long way towardsdestroying the essentials of the game. And so it iswith medicine.The Americans, having discovered the error into

which general medicine can fall through over-specialization and the lack of a balanced outlookit can produce are, at the moment, attempting toreclaim from us the vision of general practice and

the doctor-patient relationship which they havelost. We, with perplexing perversity, are strivingto follow in the footsteps they are now seeking toretrace.

Theoretically, to plan medicine so that allgroups of disease are treated by specialists in thatparticular group, might appear desirable. Inpractice this is not borne out, since all specialists,and this is in no way confined to medicine, tend toget their own speciality out of its true proportion.Surgeons become too prone to interfere, physicianstoo apt to see lions where only lambs exist, and allunconsciously twist pathology into their ownspecial study. That is the result which manifestsitself through the fragmentation of medicine but' the body is not one member but many and if onemember suffers then all the members suffer withit.' That is as true as it was 2,000 years ago and forgood or for ill the general practitioner is the onlyperson who sees the body as a whole. The verybest men are wanted and are not too good for thisentirely essential work, if the standard of medicineis to be maintained and enhanced. If you agree,and I feel that you must do so, how are the bestmen to be attracted? Before I speak on that, mayI point out quite clearly how you will not do this.You will not do it attempting to extract the creamand interest from general practice by multiplyingclinics run by health departments, the verycreation of which suggests to the public the in-competence of general practitioners. You will notdo it by removing. hospital beds from their careand handing their patients over to wandering con-sultants and specialists whose personal interestmust of necessity be small as compared with theirown, and you will not do it by converting thegeneral practitioner into a finger post pointingfeebly in every direction other than his own. Whatis the value of a six years' intensive training if atthe end of it he is to undertake work deprived of allits solid medical interests and supercharged withdrudgery? Not until the full weight of the re-sponsibility for the care of his patients is squarelyplaced on his shoulders will you again attract thebest men into general practice.As a justification of these trends two lines of

argument have been elaborated, which are to meunsound. The medical planners express deepconcern that the general practitioner should betempted to tackle work ' outside his competence,'a loose phrase typical ofmany in common use today.In this connection it can at once be pointedout that errors ofjudgment and technique cling toa general practitioner, who lives amongst hispatients, far more tenaciously than to a consultantprotected as he is by his status and grading; thefear of bad results makes it extremely unattractivefor the general practitioner to attempt things out-

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side and, often enough, well within his competence.I wonder if the specialist is not more likely toattempt things outside his competence than thegeneral practitioner is to attempt things outsidehis.The second argument is that medicine and

surgery have become, with the advance of science,so much more complicated that a wide increase inspecialization has become necessary. Again Iwonder if the exact opposite is not the truth. Ifyou will grant that the complication of techniquesdoes not necessarily denote spectacular advance,then the discovery of the antibiotics and the sul-phonamides, blood transfusion, improvements inradiography and many other advances havesimplified and not complicated many problems.Do not think for a moment that I disbelieve inthe value of specialists; that would be entirelyerroneous. I believe them to be an invaluablegroup, but I am deeply convinced that a highstandard of general practice is more important tothe public weal.There is just one more thing on quite another

subject to which I must allude. In my opinionthere is no single measure in the new Health Act,riddled as it is with miscalculation, built as it is onfalse foundations, and directed as it is by cleverand ignorant men, no measure more calculated tolower the standard of medicine than the abolitionof the sale of practices. Gone to a large extent isthe financial stimulus to group practice and thedetermination to plough back jnoney into the in-crease of apparatus and the improvement ofpremises and amenities, in order to raise the stan-dards of work and service. The satisfaction ofdoing better work must come first, but the resultof better work must be reinforced by the financialrewards that better work should bring. Otherwiseyou are courting indifferent service, you are penal-izing success and condoning failure, which is, tome, one of the -most glaring and fundamentalerrors of the so-called security state. Let me re-mind you of the words of the first Lord Brougham:

' It behoves us to think well and long andanxiously and with all circumspection and with allforesight, before we thrust our hands into amachinery which is in such constant and rapidaction. For if we do so in any way incautiously weshall occasion ourselves no little mischief and maystop that movement which it is our wish toaccelerate.'What beautiful dignity of expression ! If the

planners of the Health Act had been made torepeat these words every night on going to bedand again when shaving in the morning, halfthe blunders of the Act would never have beencommitted.

*

All riddles are said to have answers, though notnecessarily simple and not always complete as werethe answers to the riddles of our childhood. Theriddle of general practice will not begin to besolved until the following steps have been taken:(i) The wide establishment of group practice withfully-equipped central surgeries; (2) The returnand extension of general practitioner hospitals andgeneral practitioner beds; (3) the abolition ofclinics not requiring specialized knowledge; and(4) The freedom to buy and sell practices.Group practice holds many benefits and ad-

vantages, both for the patient and the practitioner.From the patient's point of view there is a widerchoice of doctor within a firm, and there is alwaysthe opportunity for them of obtaining a secondopinion without delay from another member of thefirm who they probably already know and bywhom they are known. Further, it is possible andindeed convenient for each partner to work up aspecial line of medicine or surgery in which he ishimself specially interested as a strong point, andin this way again the confidence of patients isgreatly increased. From the existing practitioners'point of view, the periodic entrance of new bloodhelps to disseminate new medical and scientificknowledge, while in return the newcomer isguided by experienced hands along the highwaysand byways of general practice. A second ad-vantage is an economic one. It is far moreeconomical for three or four doctors in partner-ship to have a common central surgery than thesame number not in partnership to have separatesurgeries. Clerical staff, nursing, receptionistfacilities and apparatus can in this way be indulgedin, the expense of which could not be borne byany single member. Such central surgeries, manyof which of course exist already, are the prototypeof the health centres envisaged in the Act. Herethe poor planners, suffering from a smartish attackof the ' delusions of grandeur,' have only approvedplans for centres the cost of which lies betweenL150,000 to o200,000, with the natural result thatthis promised step has now been indefinitely post-poned. The iniquity of the political jobbery towhich the profession has fallen a prey is that, builtat reasonable cost, such premises especially in thepoorer areas would have raised the standard ofmedical practice more than any other single thing.A third advantage of group practice is that leaveof absence for study or holidays, both of which areessential, can be more adequately and easilyarranged.There will always be doctors who prefer, and

are more suited, to work alone, as there will alwaysbe patients who prefer to know one doctor andnone other. There will always be a place for himbut it may be difficult to attain to the full

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standard of the all-round efficiency of the partner-ships, especially if he be placed in the isolation ofthe country. I would encourage group practiceeven if it extended no further than a workingunderstanding between practitioners workingsingly, more especially in the rural areas, but alsoin the county town and even in the city itself.The next point is the return of all hospitals pre-

viously staffed by general practitioners. It is onlyin this way that practitioners, with the facilitiesavailable only in a hospital, can assume the fullresponsibility for their patients and obtain thefullest satisfaction of medical work. It is only inthis way that you will attract into general practicethe highly-qualified graduate now battering, sooften in vain, at the gates of consultant practice.In these hospitals such men should be given a keyposition on the staff suitable to their specialqualifications, an appointment which will be mademore balanced, more human and of greater valueto the community as it rests on the broad founda-tions of general practice. This is a matter ofinfinite importance because at its foundation lies,in reality, a cleavage of view within the professionitself and on its decision depends the rise or fall ofthe standard of general practice.

I am not, hor would any thoughtful person be,hostile to a sort of medical hierarchy who woulddeal with and seek to unravel for us the deepermysteries of medicine and surgery. Such is andmust always be entirely desirable and necessary,but when one sees an attempt by specialists toelevate specialifiition far above its true positionand to debase general practice, when attempts aremade to prove the part greater than the whole,then one cries with Israel of old, ' You take toomuch upon you, ye sons of Levi.'Now I will refer to clinics. I believe that

theoretically no clinic should be established unlessits object is the carrying out of work of a specialistnature, and work outside the competence of thegeneral practitioner. What clinic does this? Iknow of none. What reasonably well-educatedgeneral practitioner is not capable of carrying outhis own antenatal, natal and postnatal work, guid-ing the welfare of children, carrying out suchthings as immunization with skill equal to thatemanating from the local Medical Officer ofHealth's departments? As I have pointed out,what can be more unsatisfactory than splittingresponsibility in this way? Not infrequently thepatient falls between two stools, and it is then forthe general practitioner to redeem the position.If these individuals wish to enter front-line worklet them enter into it properly and not dally roundthe edge interfering with those who must bear theheat of the day. These well-meaning organiza-tions do an'incredible amount of harm to general

practice and too often impede those movementswhich it is their wish to accelerate. Are these hardwords? They cannot be to those who realize thevital necessity of a first-class practitioner service,and believe me that, when I say that, I am. notputting up a defence for a class to which I havethe honour to belong but because, as I view thewide field of nmedicine, I can come to no otherdecision and can with honesty form no other con-clusions.

I have already stated my opinion of the seriouseffect of the veto on the sale of practices and Ineed add no more other than to quote Alfred Cox,who was for so many years secretary of the B.M.A.' 1 believe our Citadel as a " free profession " was.surrendered when it was accepted that everygeneral practitioner entering the Service must sellhis practice to the State.' This was an absolutetragedy which has had its repercussions, throughour action, on so many other free societies of menand has placed liberty itself in jeopardy. What ofthe future?One day, perhaps quite soon, a Government

driven mad by the vast, mounting and wastefulexpenditure which has resulted from forcingpolitical views for political ends and against all the-advice of a society of men and women bred to ahigh degree of disinterested service, will come hatin hand to the profession and ask what it must doto be saved. Then we must be prepared to meet it,not with a body of pseudo-political, pseudo-medical bargaining negotiators, but with mendetermined to know nothing save of the higheststandards of medicine and of service to mankind.Take heart.One more thing and I have done. People are at

this time commemorating the centenary of RobertLouis Stevenson's birth, and this has reminded me-of his beautifully worded ' Dedication.' ' Thereare men and classes of men that stand above thecommon herd. The soldier, the sailor and theshepherd not infrequently, the artist rarely, thephysician almost as a rule. He is the flower (suchas it is) of our civilization, and when that stage of'man is done with and only remembered to bemarvelled at in history, he will have been thoughtto have shared as little as any in the defects of theperiod and most notably exhibited the virtues of-the race. Generosity he has, such as is possibleto those who practice an art, never to those'whodrive a trade; discretion, tested by a hundredsecrets, tact, tried in a thousand embarrassmentsand, what are more important, Herculean cheer--fulness and courage. So it is that he brings air andcheer into the sickroom and often enough, thoughnot so often as he wishes, brings healing.'

If anyone had a right to describe the merits or-

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otherwise of the profession I suppose it was poorStephenson with his lifetime of ill health, butwhen I first read it, it struck me as so adulatorythat, to say the least of it, it would be a littledifficult for the average doctor to hang it on his

own wall. As the years rolled on I began torealize that Stevenson was only expressing whatwere the sentiments of a large section of the com-munity towards their own doctors, and it was anintensely sobering thought.

PAIN IN MALIGNANT DISEASE OF THE UTERUSBy STANLEY WAY, M.R.C.O.G.

,Gynaecologist, Newcastle Regional Cancer Organization; Associate Suirgeon, Gynaecological Department, RoyalVictoria Infirmary, Newcastle-on-Tyne

Pain is seldom encountered as an early symptomof carcinoma of the uterus, but in advanced andrecurrent cases, especially in carcinoma of thecervix, it is an extremely common symptom andtone which frequently calls for treatment in thelater stages of the disease.

Types of PainIt is usual to differentiate between the two main

types of pain in carcinoma of the uterus (a) visceraland (b) somatic. These types of pain have adifferent aetiology and call for very different types*of treatment.

Visceral PainVisceral pain is so called because it is referred to

the pelvic viscera and is chiefly referred to thebladder and the rectum. It is experienced when*either of these organs is involved by direct ex-tension of the tumour, or it may be due to radiumnecrosis if radium has been employed in the-treatment of such a case. It is frequently difficultto distinguish between radium necrosis and re--current tumour, but obviously from a prognostic-viewpoint it is essential to do so.

-Rectal PainThe complaint of rectal pain in a patient who

-has been treated for a carcinoma of the cervix byradiotherapeutic measures should immediatelyarouse the suspicion of radium necrosis. Involve-ment of the rectum with tumour, even in latestages of the disease, is not common, but irradia-tion injury to the rectal mucosa is the mostcommon manifestation of radium necrosis and-some form of rectal disturbance occurs in prob-.ably as many as 8 per cent. of cases of carcinoma ofthe cervix treated with radium. Todd, in 1938,drew attention to this disorder, which he called*' pseudocarcinoma of the rectum,' and he believed

that it was due to over irradiation of the parametrialtriangle. In some cases he believed it was due toslipped vaginal applicators or to retroversion, forin this latter case the uterine tube is broughtclose to the rectum and may increase the dose ofirradiation by as much as zo per cent. The onsetof the disease may be noticed a few days or weeksafter the completion of radium treatment, when thepatient suffers from a mild proctitis with diarrhoeaand tenesmus. If. the necrosis progresses de-faecation becomes exceedingly painful,, there isconstant tenesmus and these patients are unable tosit with comfort and frequently have localized painin the perineum and anal region, accompanied bythe passage of mucus and slime. Vaginal examina-tion reveals a typical area of rubbery thickening inthe posterior fornix, and rectal examination showsan ulcer on the anterior rectal wall behind thecervix. Bleeding is always present but is usuallyslight; occasionally very severe haemorrhagefrom the rectum takes place.

Treatment. If the necrosis is mild and the painnot too severe, astringent enemata such as tannicacid may considerably relieve the discomfort, butif it progresses it is a clear indication for presacralneurectomy. Colostomy is not indicated for therelief of pain and is only necessary if a very largerecto-vaginal fistula occurs, or if a rectal stricturecompletely occludes the bowel.

Bladder PainThe mucosa of the bladder is more resistant to

the effects of irradiation than that of the rectum,and furthermore the bladder is much more fre-quently involved by local spread of the carcinomaof the cervix than is the rectum. Pain referred tothe bladder is, therefore, often of more serious im-port than pain referred to the rectum. Somedegree of cystitis is extremely common afterradium treatment of carcinoma of the cervix, and

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