The Evolution of British General Practice, 1850-1948 (review)

Anne Digby. The Evolution of British General Practice, 1850-1948. Oxford: Oxford University Press, 1999. xiv + 376 pp. Ill. $80.00.

Anne Digby's labors at the coal face of medical practice in her previous book, Making a Medical Living (1994), and now in this one, amount to a major contribution to our understanding of the details of medical life over nearly 250 years. The present work is an extremely welcome contribution to an area that seems intuitively familiar but about which, in fact, we know very little: British general practice. The current volume is based on a huge archival survey as well as a massive trawl through printed resources such as the General Practitioner (GP) obituaries published in the British Medical Journal. Digby describes the creation and use of her database in the first chapter. Her research is then presented in narrative form in obvious and extremely useful chapters such as "Recruitment, Education and Training," "Organising a Practice," "Women Practitioners," "Medical Investigation and Treatment," and "Public Duties and Private Lives."

The feeling that one has some sort of intuitive knowledge of general practice in the period covered by this book is, in a curious way, confirmed by it. Nothing in here really surprised me: general practice turns out to be very much the way I thought it might have been. This is not for one second to detract from Digby's tremendous achievement, however. There is wonderful flesh for the intuitive bones here, both in terms of statistics and also in the rich social historical detail of individual practitioners' lives. The book is full of sad, funny, alarming, and revealing stories. As might be expected, variety is more obvious than uniformity. Practices varied enormously in, for example, numbers of patients and economic rewards. GPs varied too in what they were prepared to do. Some would conduct quite major surgery such as appendectomy; others would limit themselves to minor operations. There seem to be no references to anesthesia, yet this must have played quite a large part in the lives of many GPs since they were employed to do a great deal of part-time work in hospitals.

Digby confirms one's sense that there were, in many cases, major gaps between the ideal of general practice, as it appeared in prescriptive literature, and its realities. This was true in many areas. Take, for instance, instrumental examination. Twentieth-century texts written for beginners in general practice would recommend that, in addition to basics such as a stethoscope, practitioners should acquire a microscope, a sphygmomanometer, and a hemoglobinometer. But Digby has discovered that, for example, a Derbyshire practice in the 1920s had nothing more than a stethoscope and a thermometer. Some surgeries, apparently, even after the National Health Service (NHS) had been established, lacked an examination couch and a wash basin. A survey of 1951-52 found one in eleven practices without the very basic technology for urine testing--a state of affairs that conjures up the most dreadful images of the diagnosis and management of diabetes. Digby is extremely good on the economics of general practice and equally interesting on the social relations of these economics. For example, after the NHS was initiated, one GP "told his patients that if they wished to be visited when they weren't very ill they had better stay as private patients, because in these circumstances NHS patients would be expected to come to the surgery" (p. 334).

When I first picked up this book, I took the word Evolution in the title to be a rather casual synonym for "growth" or some such--but after just a few pages I was disabused of this assumption quite sharply by the statement that "evolutionary theory provides a useful approach with which to try to explain some of the many changes in medical practice" (p. 8), followed by a long discussion of perceived analogies between historical change and biological...