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A century of doctor-patient relationships

Some 30 years ago I received a book from my uncle. He had bought it from an antiquarian book shop in Liverpool for £1. The only identification was the title ‘Tactics' – there was no other indication as to author, publisher or year of writing. The theme was one of doctor-patient relationships, and the book also advised on how to retain and increase the size of one's practice – rather like the Practice Business section of Pulse magazine now.

Advice from the Wellcome Library suggested that this was a series of articles, bound together with a view to publication. Based on a number of comments within the text - such as a reference to Digalen, which wasn't available until 1904 – I guess that the book was produced in the early 20th century. I tried to find out who had written the book using internet searches but have so far failed to identify my co-author – although I'm sure that he was male and probably worked in London. He makes several references to London businesses such as Lyons teashops, the department store Gamages, a publishing company named Partridge, Allen & Hanbury's, and a medicine bottle labelling company named Suttley and Silverlock. But until I know the author's name, I'm calling him ‘Our Practitioner'.

His approach to the practice of medicine provides an insight into some the challenges that faced the Edwardian equivalent of today's GP. He refers to the treatments on offer, equipment used, historical figures and the prevalent diseases of the day. There are many areas in which we see his compassion for patients – although some of his advice arguably seems biased towards making a good impression on them, and thus a good living for himself

In some ways, the way the doctor used to work varies significantly from modern practice. He emphasises the importance of creating a good impression onwomen patients, as it is their word of mouth that will enhance his reputation. However, he perceives them as being ‘much more impressionable through the emotional and aesthetic faculties'! I got the impression that he is much more on his guard when dealing with female patients, and he takes pains to avoid asking them indelicate questions. He would even skip certain parts of the consultation in order to avoid any embarrassment. For example, he writes: ‘Abdominal examinations should not be made in women, unless the symptoms require it.' He appears to be influenced by Dr Silas Weir Mitchell, an American doctor from the 19th century, who wrote that, ‘the woman's desire to be on a level of competition with man and to assume his duties is, I am sure, making mischief'.

His approach to patients is often paternalistic. There seems to be a tendency to avoid, where possible, breaking bad news, and discussion of the way in which the limited available therapies of the time actually worked.

The book also gives us an insight in to the class system he lived under. "With working people, a greater heartiness in the tone of voice is desirable, while avoiding any undignified familiarity," the author writes. "Such patients are often embarrassed at meeting their ‘betters', afraid that they are giving trouble or intruding." Later on, there is a reference to therapeutic restriction, when he notes that Digalen might be appropriate for the patients who can afford it.

Patients and doctors alike were hypervigilant about tuberculosis and syphilis, as both diseases were common at the turn of the century, and it is a sobering thought to consider how TB persists in London a century later. Conditions such as scarlatina, whooping cough, measles, chorea, scurvy, rickets, lead and arsenic poisoning, were all much more prevalent then.

But for all its differences, the book also has some parallels with contemporary practice. Present day private practice, and generic issues such as governance, use of placebo, care of the dying, patient choice, differentiating between disease and neurosis, socio-economic pressures and even ‘alternative' therapies all appear in the book as often as they do in the modern trade press. I would leave any judgment with my GP colleagues as to how being part of the NHS would have changed ‘Our Practitioners' life and work.

Dr Stephen Connellan is a retired Consultant Respiratory Physician who worked in Wolverhampton. The Medical Tactician is available as a print and e-book from Amazon, and we also have a copy available for review – contact for more details.