The M.D. from Brussels University (M.D.Brux).

In the late Victorian and early Edwardian times, a curious set of letters was often appended to the list of qualifications of medical doctors – the M.D.Brux. This signified that the clinician had obtained the degree – Doctor of Medicine from Brussels University. Dr Montagu Lomax  was thought to have achieved an M.D.Brux 1. This was not in fact true, as he pointed out in 1924 that he had never obtained more than his basic medical qualifications 1b. However, the M.D.Brux is interesting in itself, and worth reviewing as it sheds light on medical status in the late 19th and early 20th centuries.

Studying outside of the UK was relatively common in the years prior to the First World War (WW1), particularly amongst those elite doctors seeking specialist experience in the great medical centres of Paris, Berlin and Vienna. However, to travel abroad in order to obtain a higher degree seems odd, particularly when the qualification of M.D. was available in the British Isles.

In the first place it is necessary to understand a little about medical qualifications. In the early part of the 19th century, anyone could set themselves up as a medical man. Most were trained by apprenticeship to a practicing physician or surgeon, but there were charlatans who had little or no formal training. Clinicians tried for many years to weed out these ‘quacks’ and to professionalise the business of medicine. Eventually the first Medical Act of 1858 decreed that nobody could practice medicine without being placed on the Medical Register. The necessary registrable qualifications could be obtained from one of 22 British licensing bodies including the Society of Apothecaries whose registrable qualification was Licentiate of the Society of Apothecaries (LSA). Most primary medical qualifications were licences to practice or diplomas, not degrees. In 1884, the Royal colleges introduced the first conjoint diploma in surgery and medicine  MRCS/LRCP and this became the standard first qualification for generations of doctors 2.

Lomax was typical of his generation, obtaining diplomas and licences in medicine, surgery and midwifery. His application for entry to the New Zealand Medical Register read as follows:

I, Montagu Lomax-Smith, of Christchurch, Member Royal College of Surgeons England, Licentiate in Medicine and  Midwifery Royal College of Physicians Edinburgh registered 1883, Fellow Medical Society London, and Member of the British Medical Association, hereby give notice that I have, this 2nd day of April, 1890, deposited my diplomas, in evidence of the above qualifications, with the Registrar of Christchurch District, and that I shall apply to be registered under the New Zealand Medical Act on the 2nd day of May, 1890.3

The issue of a degree in medicine was debated from time to time in the medical press. The BMJ noted that ‘most medical students in London did not seek a university degree, so that a large proportion of medical men in England possess diplomas to practice but not degrees in medicine . This is a fact which they sometimes find reason to regret’ 4. Without a degree in medicine, a medical man was not strictly speaking, able to use the title of ‘doctor’ before his name, although his patients would style him ‘doctor’ 5.  The growing middle classes in late Victorian Britain were educated and discerning, so that the magic letters ‘M.D.’ became a significant indicator of professional status for the British public 6. The BMJ noted that ‘the possession of an M.D. degree gives a practitioner a decided advantage in the eyes of the public, and on this account, the desirability of obtaining one must be urged on every student’.7.

However, one cynic noted that ‘the attraction of a university degree lay too often in its marketability than its mental cultivation’ 8. Certainly, 90% of the elite physicians working in the lucrative medical businesses based around Harley Street held a higher medical degree such as M.D. compared with  only 13% of GPs 9. Even outside of Harley Street, an M.D. made a material difference to salary, attracting a bonus of £50 per annum for an ungraded medical officer 10.

How an M.D. could be obtained:

Having established that the possession of and M.D. or equivalent university degree was a prerequisite for a financially successful medical career, the problem was how to obtain such a qualification. The different licensing bodies which included the medical schools, did not all issue M.D.s, and those that did had vastly different rules and requirements. In Scotland, St Andrews gave all its graduates an MD once they reached 40 years of age and it wasn’t until 1907 that the MD was granted on the basis of a written examination. Aberdeen University’s M.D.  required written testimonials and several years of practice 11. Durham required practitioners to be at least 40 years of age with a minimum of  fifteen years in practice. If a Durham candidate didn’t have an arts degree, he had to translate latin passages from the classic texts into English as well as sit written examinations in medical subjects in exchange for an enormous fee of 50 guineas. The London universities required three years clinical experience after matriculation,  knowledge of organic chemistry12,  and an M.D. was only granted after attending a course of prescribed study followed by written examinations. The London M.D. was recognised as being difficult with a high failure rate and consequently it was  accorded high prestige 13.

Effectively then, to gain an M.D., one had to wait until one was well into middle age for the Scottish universities, and Durham. Durham was enormously expensive and required evidence of education in the classics and the Arts, The  London M.D. was prestigious precisely because it was notoriously difficult to pass the examinations. A doctor  writing in the Lancet noted that ‘One reads in almost every issue of the medical press complaints against the English Royal Colleges and other licensing bodies that their members and licentiates are prevented from obtaining the coveted title of M.D.’ 14 .

 However, there was another option open to clinicians hoping to improve their prospects. The Brussels M.D. had been available  to British graduates since the 1870s, and a steady stream of hopeful candidates crossed the channel every year to take its examinations. Even accounting for  travel, living expenses for a week  and exam fees, the whole venture cost less than two thirds of the examination fee for the  Durham M.D. 15 . Prior to WW1, there was no requirement to have studied at the University of Brussels, no additional courses to take,  no written papers, and candidates were examined in English through an interpreter. The standard was considered to be  lower than the English Royal Colleges although the failure rate was still 50-60% 16. The Lancet felt confident that the possession of the degree would amply repay the candidate in social status and it was ‘well worth the time and trouble’ 16. The attractions of the Brussels M.D. were clear, and it became a popular option. In 1914, the BMJ reported that there were 600 Brussels graduates known to be in practice in England and the colonies 17.

Correspondents to the Lancet in 1903 noted that the exam taken by British candidates was exactly the same as that sat by Belgium doctors who were awarded a legal M.D with licence to practice. The British candidates were awarded a scientific M.D., with no automatic right to practice in Belgium. However,  if the a successful candidate decided to live in Belgium, it was thought  that he would have no difficulty in obtaining a State permit to practice without the need for further examinations 18.

Looking through the medical press around the turn of the century, there was a good deal of publicity about the M.D. Brux from the British side of the channel. Letters appeared frequently in the British Medical Journal and the Lancet offering to clarify the terms and conditions of the examination 19 . A small pamphlet  published in 1903 by Dr Albert Henchley, provided  hints and tips on passing the examination and even recommended the best rail route and hotels in Brussels for aspiring candidates 15. There was an active association for the alumni of the Brussels M.D. in the UK – The Brussels Medical Graduates Association. The association provided a link between  existing and aspiring British graduates and the Free University of Brussels. It also lobbied hard for the claim of its members to register their degrees as an additional medical qualification in the UK.

The main drawback of the M.D. Brux. was that it was not ‘registrable’, namely it could not be inscribed as a qualification in the British Medical Register. There was much debate in the medical press as to whether practitioners were breaking the law by putting ‘M.D. Brux’ after their names. There had been a court case but no action was taken against the offending doctor 20. The general feeling seemed to be that if doctors wished to add their degree to their name plate, they should do so 21. Many were proud to place ‘M.D.Brux’ on their list of qualifications. Helen Boyle’s entry in the 1895 Medical Directory is a typical example where the degree of M.D.Brux takes precedence over her basic qualifications of licentiate in surgery and medicine: 

For obvious reasons, the granting of the Brussels  M.D. was suspended during WW1, and was formerly discontinued after the armistice. In 1921 the university announced that the examinations would no longer be open to British doctors and nor would the M.D.Brux be granted to foreign medical practitioners ad eundem 22.The Secretary of the Brussels Medical Graduates Association prepared a petition to the University of Brussels 23. The petition had little effect and letter to the BMJ from the Secretary of Brussels University explained that university regulations meant that it was no longer possible to grant an M.D. without at least one year’s attendance in Brussels on  relevant courses 22. Furthermore, the exams had to be taken in French with no interpreter available 24. It was claimed that the change in university regulations was brought about in order to standardise degrees with other foreign universities so that British medical graduates should no longer be granted special status. However, the Lancet noted that the special reciprocity between Belgium and British doctors set up after the armistice whereby there was a free movement of medics between the two countries, was formerly ended by the British government  in December 1920 25. Perhaps some tit-for-tat was at play, but whatever the reason,  the new regulations  effectively saw the end of the M.D. Brux for British graduates. However, the degree was already becoming an irrelevance as the drive for post graduate medical education grew stronger in  1920s  Britain. 

(References available on request)

Shell Shock And Lunacy Reform

Wilfred Owen (1883-1918), Treated for shell shock Craiglockhart hospital.

By the time Dr Montagu  Lomax wrote The Experiences of An Asylum Doctor (1) in 1921, the campaign for lunacy reform had been ongoing for over half a century. There had been some successes such as the 1890 Lunacy Act, designed to reduce the number of unregulated madhouses.  However, little had been achieved to improve living conditions for pauper lunatics in the asylums. This was partly because the campaigners were often ex-patients as in the Alleged Lunatics Friend Society, so had little status, and partly because  psychiatrists were resistant to change. Dr Lionel Weatherly published his ‘Plea for The Insane’ in 1918. This book was aimed at the medical profession and was largely ignored. Lomax’s book was written for the public. His writing style was clear, and direct, perhaps with an overtone of sensationalism. However, it could be understood by any lay person and more importantly, by members of the Press. The book set in motion a wave of public outrage. 

Cleverly, Lomax keyed into public concern over the treatment of shell shocked soldiers. He wrote about the plight of these young men who had been sent back from the trenches with shattered minds only to find themselves incarcerated within the lunatic asylums. Lomax allied himself with the Ex-Services Welfare Society (ESWS), and was a guest speaker at a number of the Society’s public meetings. The aim of the ESWS was to raise public awareness and funds to help these veterans, some 5000 of whom were still in the asylums five years after the end of the war. Lomax was a good public orator and the national press reported his speeches. The wave of public outrage became a tsunami.

It is worth considering what a diagnosis of ‘shell shock’ meant. On 12 December 1914, the British Medical Journal published an article on functional paralysis following shell explosions (2). The author noted that although there was no obvious physical injury, the proximity to explosions was seen as a causative factor and from the winter of 1914/15 ‘Shell Shock’ became a valid medical diagnosis (2). 

There was a running debate between the top psychiatrists of the day as to whether the diverse collection of signs and symptoms which contributed to the diagnosis of shell shock were functional (psychological) or had an organic (physical) origin. The psychiatrist, Dr Frederick Mott noted the presence of microscopic brain hemorrhages in post mortems of men with shell shock, and hypothesised that the condition was due to blast trauma. This lead him to believe that shell shock had an organic cause (3). The Maudsley psychiatrists believed that shell shock was due to a breakdown of psychological mechanisms. Doctors could find no identifiable organic pathology in 38% of admissions for shell shock (2). This dichotomy between psychodynamic and physiological explanations for shell shock was never resolved (3). There was however a military classification which attempted to distinguish between men who were physically damaged, categorised as ‘Shell Shock (Wounded)’ and a second category of ‘Shell Shock (Sick)’ (4). The Shell shock (W) cases were entitled to a wound stripe and a pension. If a soldier’s neurosis did not follow a shell explosion, he was to be labelled Shell shock (S) and was not entitled to a wound strip or pension. Many of the 306 British soldiers shot for cowardice would probably have fallen into this latter category, now recognised as Post Traumatic Stress Disorder (PTSD).

At the start of the Great War, the military hospitals absorbed psychologically damaged men, who could be treated by specialist doctors without the stigma of certification. As the war progressed, casualty number rose and young soldiers with shell shock were increasingly shunted into the County Asylums (4). Estimates vary, but one study found 63% of shell shock cases in 1916 were placed within the asylum system (3). These men were officially classified as private patients, so that their fees were paid by the government, but their private status was effectively meaningless in times of war and carried no special privileges  for the soldiers. The asylums were understaffed, and overcrowded with patient food reported as ‘starvation rations’ (5). The asylum medical staff were overworked, and had no facilities or specialist skills to treat broken soldiers. For those young men who weren’t insane, there was a significant risk that they would be made insane by their surroundings.

For relatives, there was a very real stigma to having a soldier son in a County Asylum. The asylums were viewed as the domain of the pauper lunatic. Admission was by ‘certification’ under the 1890 Lunacy Act, and a certified pauper lunatic in the family carried with it great shame. This was partly because poverty was a frightening spectre for the working class, but also because of the  strongly hereditarian discourse of mental health which dominated through the 1920s (4). 

Towards the end of the war, the British public were growing increasingly uneasy that ex-soldiers were being treated as ‘ordinary lunatics’ (4). The Ex-Services Welfare Society (ESWS) was founded in 1919 to support the ex-servicemen who were effectively trapped within the County Asylum system. The aim of the Society was to set up residential homes for traumatised veterans so that they could be released from the totally unsuitable environs of the lunatic asylums. It was an ambitious project which required enormous financial input. Fundraising and a prominent public profile was therefore crucial to the success of the ESWS. The Society appointed Captain Charles Loseby, to speak on its behalf. He was a lawyer by training and had a distinguished military service record. As an MP between 1918 to 1922, he concentrated on veteran welfare, eventually taking a keen interest in the plight of shell shocked veterans detained within the lunatic asylums. He took the ESWS under his wing, organising and speaking at a number of public meetings on their behalf. Dr Montagu Lomax used the ESWS public platforms as an opportunity to drive forward his case for lunacy reform. Unfortunately, the ESWS’s association with the  campaign for lunacy reform was subsequently viewed as controversial, and after a series of financial scandals, the Society’s supporters quietly distanced themselves. By the mid 1920s, the British Legion had assumed responsibility for much of the practical support required by veterans including liaison with the Ministry of Pensions, and the ESWS was sidelined. 

It is heartbreaking to read Lomax’s account of the shell shocked soldiers in his book The Experiences of An Asylum Doctor. Men such as these were usually ‘other ranks’, whilst the officer class with shell shock were sent to exclusive military hospitals such as Craiglockhart. For the interested reader, Pat Barker’s Regeneration trilogy portrays shell shock amongst the officer class at Craiglockhart.

Bibliography

1. Lomax M. The experiences of an asylum doctor : with suggestions for asylum and lunacy law reform. [S.l.]: Allen and Unwin; 1921.

2. Linden SC, Jones E. ‘Shell shock’ revisited: an examination of the case records of the National Hospital in London. Med Hist. 2014;58(4):519-45.

3. Jones E. Shell shock at Maghull and the Maudsley: models of psychological medicine in the UK. J Hist Med Allied Sci. 2010;65(3):368-95.

4. Reid F. Broken Men: Shell Shock, Treatment And Recovery In Britain 1914-30: Bloomsbury Publishing; 2011.

5. Crammer JL. Extraordinary deaths of asylum inpatients during the 1914-1918 war. Med Hist. 1992;36(4):430-41.

Hospital Scandal

JH Murray-Aynsley

In the spring of 1895 The Christchurch Hospital was in trouble. A series of complaints about the standards of care at the hospital had resulted in an inquiry which dragged on for several long months. It was covered in excruciating detail in the local press, and syndicated across New Zealand. Amongst the many complaints from the citizens of Christchurch was the callous attitude and rudeness of the house surgeon, a certain Dr J.H. Murray-Aynsley. It was alleged that he had often arrived on the wards drunk, sometimes in his slippers and dressing gown if he was called at night. He  smoked during his ward rounds. He was accused of insisting that  the prettiest probationer nurses assist him in theatre and was prone to peculiar behaviour such as placing patients on a bread and water diet, and squirting water in the face of an injured  child to stop it screaming. The inquiry drew to a close  in August 1895, and for lack of convincing evidence, Dr Murray-Aynsley was cleared of all charges.

However, that was not the end of the story.

John Henry Murray-Aynsley was born in Lyttleton, New Zealand but studied at Christ’s College Cambridge , and St Georges Hospital, London before returning to Christchurch, to work as the house surgeon at the hospital. His job was to look after patients who had been operated on by the honorary  surgeons including those of Dr Montagu Lomax-Smith (later Montagu Lomax).

The two doctors shared the same year of birth – 1860 – but they had little else in common. Lomax-Smith came from three generations of tanners, Murray-Aynsley  had an English aristocratic background, his great, great grandfather was the third duke of Athol. Lomax-Smith’s father was a Church of England Vicar. Murray-Aynsley’s father was a wealthy business man who kept a string of race horses and was a member of the New Zealand Parliament. Lomax-Smith was raised to service and duty, Murray-Aynsley had little sense of the professionalism that his role required. It is not difficult to imagine that Murray-Aynsley would have rubbed Lomax-Smith up the wrong way.

Lomax-Smith must have been appalled that Murray-Aynsley was vindicated by the hospital Inquiry in August 1895. Less than two months later, Lomax-Smith brought further charges against Murray-Aynsley, alleging that he was drunk on duty and neglected the care of his patients. The Hospital Board was reluctant to get involved in another inquiry. Lomax-Smith resigned as honorary surgeon, claiming that Murray-Aynsley had systematically neglected his surgical cases. A series of vicious letters were published in the local and national press with both sides making claims about the other which would be considered libellous today. Lomax-Smith was accused of unethical behaviour for complaining about a brother doctor. Two doctors resigned in support of Murray-Aynsley. Eventually, the Hospital Board agreed to another investigation.

In April 1896, The Hospital Board found Murray-Aynsley guilty as charged and asked for his resignation. Lomax-Smith subsequently withdrew his own resignation. 

The outcome of this poisonous dispute was poor for both men. Murray-Aynsley left Christchurch for a small bush town where he worked for a short time as a GP. He tried to work in the UK, but never really established himself and returned  to New Zealand where he died aged 57. Lomax-Smith left New Zealand in the summer of 1896 to return to the UK. He left behind a prosperous, comfortable existence, and never really recovered the standard of life he had had in New Zealand. However, Lomax-Smith did learn about the personal difficulties faced by whistle-blowers.  He learned that attacking a person rather than ‘the system’ which allowed an incompetent to work within it, was  was personally devastating. Finally, he learned how to harness the power of the Press. These tribulations were  to stand him in good stead some thirty years later when he wrote his book: The Experiences of an Asylum Doctor, with suggestions for asylum and lunacy law reform in 1921.

More at: 

  1. https://en.wikipedia.org/wiki/The_Experiences_of_an_Asylum_Doctor
  2. The New Zealand years.
  3. Montagu Lomax – montagulomax.org 

Since posting this blog, Professor Geoff Rice (University of Canterbury, New Zealand) has written a comprehensive account of the hospital scandal with a very different take on Lomax’s role in the proceedings. ‘When Doctors Differ – The 1895 Christchurch Hospital Inquiry and the 1896 Ousting of John Murray-Aynsley (1860-1917) by Geoffrey W. Rice; Hawthorne Press, Christchurch February 2022.

Why Montagu Lomax matters.

Montagu Lomax (1860-1833) was a British general practitioner  who wrote The Experiences of an Asylum Doctor, with suggestions for asylum and lunacy law reform in 1921[1]. The book was an exposé of conditions within two English lunatic asylums based on Lomax’s experiences as an asylum medical officer between 1917 and 1919. 

The book became a cause célèbre [2]. The national press was outraged by Lomax’s revelations, with The Times publishing an article entitled “Asylum Horrors – A Doctors Indictment’ [3]. Within ten days of the book’s publication, questions were being asked in Parliament [4]. Whilst many attempts at asylum reform had been made previously, it was Lomax’s book and the associated newspaper articles that alerted public opinion on a wide scale [2]. The Ministry of Health decided to use Lomax’s book to start the process of lunacy reform, and to subsume the mental health services, previously managed by the Board of Control [2]. The Lomax affair was a significant prelude to the 1926 Royal Commission on Lunacy and Mental Disorder [5]. The recommendations of the Royal Commission were incorporated into the Mental Treatment Act of 1930 which opened the way to many developments in mental health services over the next thirty years [2].

Lomax had a successful publication which ensured him a place in the tradition of British social reportage [5]. It was an important book because it directed public attention to the defects of the asylum system which had hitherto been taken on trust [2]. Lomax’s vivid descriptions of patients’ behaviour and mental state in asylums and of the institutional process produced insights which were to be rediscovered 30 years later by researchers who themselves went on to influence mental health care from 1959 onwards [2]. However, Lomax did more than contribute to a process of mental health reform. His willingness to write frankly and to criticise provide an example to all mental health professionals who find themselves in settings where abuses occur [2].

More information at montagulomax.org

Bibliography

1. Lomax, M., The experiences of an asylum doctor : with suggestions for asylum and lunacy law reform. 1921, [S.l.]: Allen and Unwin.

2. Harding, T.W., “Not worth powder and shot”. A reappraisal of Montagu Lomax’s contribution to mental health reform. The British Journal of Psychiatry, 1990. 156(2): p. 180-187.

3. Asylum Horrors, in The Times. July 23rd, 1921.

4. Soanes, S., REFORMING ASYLUMS, REFORMING PUBLIC ATTITUDES: J. R. LORD AND MONTAGU LOMAX’S REPRESENTATIONS OF MENTAL HOSPITALS AND THE COMMUNITY, 1921-1931. Family & Community History, 2009. 12(2): p. 117-129.

5. Towers, B.A., The management and politics of a public expose: the Prestwich Inquiry 1922. J Soc Policy, 1984. 13(1): p. 41-61.

Learning disability and public policy.

The previous blog outlined how mentally handicapped children in the Victorian era were removed from their families and placed within the confines of lunacy asylums, private madhouses or if they were lucky, in dedicated colonies. By the mid to late nineteenth century, the medical profession had appropriated the care of the feebleminded, possibly for research purpose, perhaps for financial gain. In doing so they created a problem for society as the numbers of children, and adults deemed to have mental impairment rose rapidly. The increase in numbers paralleled the rapid rise in British population growth, but it began to cause severe problems for the Exchequer, and for policy makers who were required to build appropriate accommodation to house these cases.

Two influential concepts ran through British culture from the mid to late nineteenth century – the ‘Degeneration Theory’ and Eugenics. 

The ‘Degeneration Theory’  was proposed by French doctor, Benedict Morel in the 1850s and  suggested that certain constitutional disorders ran through families. This lead to the belief in ‘hereditary taint’, which proposed that a mentally handicapped child resulted from impurity in the parent. Scientific papers outlining the transmission of a degenerative taint through families were printed in respectable medical journals [1]. Prominent psychiatrists such as Dr Henry Maudsley and Dr Fletcher Beach supported the theory of  degeneration which began to trickle in to popular culture [2]. The ‘hereditary taint’ of a handicapped child thus became a social  embarrassment, and great efforts were made to hide such children from polite society. The Queen’s cousins were placed in the Earlswood Asylum for idiots, a fact only recently uncovered by journalists. It is not surprising that Dr Montagu Lomax gave his son, Armine into the care of Dr Fletcher Beach at age seven, and Lomax never once referred to the boy in any of his prolific writings.

Eugenics, or the concept of pure breeding to improve a population, (and conversely, preventing unsuitable people from breeding) was popularised in late Victorian times by Francis Galton, a distant relative of Darwin. Galton used Darwin’s theories of natural selection and ‘survival of the fittest’ as the basis for his eugenic movement. Eugenics was hugely influential in social policy around the turn of the 20th century, particularly in the USA where the eugenics movement was funded by the Carnegie, Ford and Kellogg foundations.

In the UK, ‘Hereditarism’  formed from the theory of degeneration and the eugenics movements had also begun to inform public policy.   Dr Fletcher Beach suggested segregation of idiots and imbeciles on the grounds that if breeding were prevented it would reduce the numbers of such ‘incurables’ in future generations [1]. Ellen Pinsent* who founded the National Association for the Care of the Feebleminded in 1896, believed that lifelong segregation was the kindest option for the feebleminded. She was an influential eugenicist, serving on the Royal Commission on the Care and Control of the feebleminded of 1908. This lead to the Mental Deficiency Act of 1913 which proposed that mental defectives should be removed from prisons and Poor Law institutions and segregated by sex within  newly established colonies

 Custodial policies resulted in severe overcrowding of the imbecile asylums and colonies. Concerns were also raised over the drain on the public purse as Britain teetered on the brink of  the Depression between the two World Wars.  Compulsory sterilisation of imbeciles was suggested on purely economic grounds by the Eugenics Society in their 1926 Manifesto [3]. Debate raged in the medical journals of the time over custodial segregation vs sterilisation[3].  In 1926, the argument spilled over into the popular press when eugenicist, Harold Cox wrote an article in the Spectator suggesting that lifelong segregation of mental defectives was  an act of ‘callous cruelty’. Cox believed that mental defectives should be released from captivity but only after sterilisation to prevent their ‘terrible taint’ from being passed on [3]. The USA followed this course of action, offering those with intellectual disability the stark choice between sterilisation or lifelong segregation in single-sex colonies. Cox’s controversial beliefs engendered a six month public debate through the correspondence columns of the Spectator. However, at the end of the day, Britain was not ready for such drastic measures, perhaps because of religious opposition. 

The 1913 Mental Deficiency Act with single sex segregation of people with learning disabilities remained in place until it was repealed by the 1959 Mental Health Act. The eugenics movement never fully recovered from its association with the Nazis whose selected breeding to perpetuate the Aryan race and murder of those with learning difficulties took social Darwinism to extremes. 

Post script:

*Ellen Pinsent (1866-1949) was married to Hume Pinsent, a prominent Birmingham solicitor. Ellen was made a dame in 1938 for her work in the care of mentally impaired children. Prior to the First World War, the Pinsent family lived at Lordswood House, in the Birmingham suburb of Harbourne. By strange coincidence, Lordswood House was built by Montagu Lomax’s father, the reverend Thomas Smith, and Lomax lived here until he was 9 years old.

Sale of Lordswood House. Birmingham Daily Post. 18/12/1869

Bibliography

1. Wright, D., Mental disability in Victorian England : the Earlswood Asylum, 1847-1901. Oxford historical monographs. 2001, Oxford ; New York: Clarendon Press. vii, 244 p.

2. Beach, F., A Lecture on the Influence of Hereditary Predisposition in the Production of Imbecility. Br Med J, 1887. 1(1378): p. 1147-8.

3. Crook, P., Darwin’s Coat Tails: Essays on Social Darwinism. 2007: Peter Lang.

Learning Disability in Victorian England

The care of a child with learning difficulties has posed a problem to society for centuries. Prior to the 18th century, many of these children would have been looked after at home, perhaps by an older sibling. The more affluent might have employed a maid servant whose duties would have included care of a handicapped child. When the Industrial Revolution in Britain resulted in migration to the cities for work, a non-productive child became a drain on the families resources. Whilst there was a system of ‘boarding out’ where some parishes paid families to look after ‘idiot children’, this all but vanished with the introduction of the new Poor Laws of 1834. Idiot children who could not be cared for by their families were then required to be admitted to the workhouses as ‘pauper lunatics’. Workhouses soon began to fill up with the elderly, the chronic sick and the mentally disabled such that parishes had difficulty in obtaining places for their temporary paupers. The solution provided by the 1845 Lunatics Act was harsh – the Act decreed that all insane persons should be admitted to the County Asylums, and idiots were defined as a subgroup of the insane. Unfortunately, this just shifted the problem to the Asylums and they too began to fill up with ‘harmless and incurable idiots’ [1]. Families became reluctant to send their idiot children away from their own parish to a County Asylum, and kept them at home often resulting in significant hardship for the family. Some idiot children were retained in the parish workhouse, some from wealthier families were sent to private madhouses. By 1850, it was evident that there were more handicapped children in the community and the workhouses than in the County Asylums [1].

The plight of the intellectually handicapped child captured the attention of the Victorian philanthropists in the 1840s. Some attempt had been made to set up training schemes for the ‘educable idiot’ in France, and Dr John Connolly had also experimented with similar training schemes at the Hanwell Asylum. The philanthropist movement picked up and ran with the idea of schools for the mentally handicapped, setting up Asylums as ‘training establishments’. The ‘Earlswood Asylum For Idiots’ in Surrey came about through the efforts of Dr Connolly and the reverend Andrew Reid. It opened in 1847 and accepted private cases from wealthy families which helped to finance the care and education of pauper children. There was a general feeling that intellectually handicapped children would benefit from being with their own kind and that they would not have to endure mockery and bullying common in the wider community. Some of the milder cases of idiocy  were trained for domestic service or manual trades such as gardening. 

With the rise of the therapeutic Asylums in the mid to late nineteenth century, a small group of doctors began to specialise in idiocy. Dr Fletcher Beach was one of the early pioneers and highly influential in the field of idiocy. He believed that idiot children fared much better within training establishments away from their families, and should be admitted at the youngest age possible [2]. He may have had his own agenda, since it is clear from the records that he was a talented business man who wasn’t averse to bending the rules on advertising his own private establishment for the feeble minded. However there is no doubt that he and his colleagues made great strides in the classification and treatment of the idiot child. 

Bibliography

1. Wright, D., Mental disability in Victorian England : the Earlswood Asylum, 1847-1901. Oxford historical monographs. 2001, Oxford ; New York: Clarendon Press. vii, 244 p.

2. Beach, F., The Treatment And Education Of Mentally Feeble Children. 1895, London: J.A.Churchill.

A Doctor in Victorian Britain.

P1000545
1891 medical directory

The medical profession at the beginning of the 19th century was in disarray. Most doctors were trained through apprenticeship, often within their own families which saved money in tuition fees. The  medical schools, particularly in Edinburgh, and London offered lectures in a wide range of subjects  as well as practical training in anatomy but attendance was by no means compulsory for aspiring doctors. The need to standardise training and exclude quacks was seen as imperative. The 1815 Apothecaries Act and The 1858 Medical Act defined curriculum content and prescribed the routes to medical qualification. The medical apprenticeship was taken away from the family setting and transplanted into the hospital system where established physicians and surgeons headed ‘firms’ of doctors in training. Examinations became the only method to obtain a license to practice. By the mid 19th century, medicine had become a true profession and its practitioners were an intelligent elite who had earned their position in society on merit not through accident of birth. 

The rise of the medical profession during the Victorian era paralleled the rise of the middle classes whose new money came from the industrial revolution. Montagu Lomax was a perfect example of this new professional class whose training was paid for from profits his father’s family had made through the leather industry. 

Unfortunately, by the time Lomax qualified in 1883, the profession was overcrowded. The vast majority of medical graduates followed the path of general practice at this time. It was possible with enough money to buy into an existing general practice, but most new doctors ‘set up their plates’ on their own. Some newly qualified men took on salaried appointments with local dispensaries, occupational schemes or within the poor law hospitals and asylums. This ‘club practice’ provided an income as they began to build their own lists of paying  patients. However, club practice was perceived as low status work, poorly paid and  with the added disadvantage that doctors were supervised by laymen (Peterson 1978).

There is no doubt that some doctors found it hard to make a decent living and were forced to look for other options. Some joined the military where they signed on for a set period and were able to accumulate funds to buy a practice at the end of their service. The pay was reasonable, there was usually travel and sport in every posting and much less drudgery than general practice at home. Astonishing numbers of young Irish graduates (around 20%) signed up for the Indian Medical Service between 1860 and 1905 (Jones 2010). This allowed retirement on half pay after 20 year’s service, and a severance honorarium which would pay for the purchase of a practice. Others went to the colonies, often to Australia where prospects were considered to be better than Britain, and  society to be less hierarchical (Peterson 1978).

It is a fascinating exercise to browse through medical directories of the late 19th century – doctors are listed under ‘London’; ‘Provincial’, ‘Hospitals, Dispensaries and Lunatic Asylums’,‘Local Government Medical Services’, ‘Scotland’, ‘Ireland’, Practitioners Resident Abroad’, and ‘Services and Mercantile Marine’. Of the many practitioners registered abroad in the 1891 edition, British doctors were working all over the world including Uruguay, China and Tasmania. The majority of Irish doctors who went abroad settled for good  in their adopted country, but around 40% returned to set up practice at home after ten years (Jones 2010). This was certainly the case for Dr Montagu Lomax whose six years spent as a GP in New Zealand were both lucrative and personally challenging. (see New Zealand 1890-1896).

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The Medical Directory 1891

Bibliography

Jones, G. (2010). “”Strike out boldly for the prizes that are available to you”: medical emigration from Ireland 1860-1905.” Med Hist 54(1): 55-74.

Peterson, M. J. (1978). the Medical Profession in Mid-Victorian London. Berkley, Los Angeles California, University of California Press.

Exciting Times – Becoming A Doctor in 1883

Montagu Lomax went to Trinity College, Cambridge to start his medical studies  in 1878. He qualified in 1883, having completed his clinical training at St Bartholomew’s hospital in London. It was arguably one of the most exciting times to be a medical student with rapid innovations in medicine and surgery. Anaesthesia had been in routine use for only a decade, asepsis, pasteurisation and bacteriology was just around the corner, and X-rays were just on the horizon. 

At the turn of the 19th century, British doctors were divided those who had been to university –  an intellectual elite known as physicians, and those who had learned by apprenticeships – the surgeons and the apothecaries.  The university-educated physicians took medical degrees, whilst the surgeons and apothecaries took licensing exams. There were no nationally organised curricula and standards were set by colleges of physicians and surgeons and the London Society of Apothecaries, with no Government input. This contrasted with the continent, where governments were predominantly concerned with having high quality doctors to service their armies. In France, some Parisian hospitals  treated the poor for free simply to provide case material for doctors in training. The British Government had no control over numbers entering the profession, and consequently by the 1830s, medicine was overcrowded and medical incomes were falling. After a prolonged campaign by the doctors, the 1858 Medical Act was passed with the avowed aim of protecting the public from quacks and standardising the medical curriculum so that there was a legally enforceable guarantee of a minimum standard of competence. The General Medical Council was established to police standards. Doctors were divided by the Act into hospital-based consultants and community based GPs, although some GPs also held part time surgical posts in their local hospitals. The apothecaries were given some years to transition into the  medical profession, but some split off and became  chemists and druggists. Doctors could then view themselves as part of a single profession with a collective identity. 

So when Montagu Lomax qualified in 1883, he became a member of a fairly new and rapidly evolving profession. His clinical studies would have taken part within small cohorts of young men, who trained and played sport within their ‘cliniques’, forming lifelong allegiances. His studies would have been conducted in English, a complete contrast from the latin and greek used at Cambridge University for the old Physicians in training. The Anatomy Act of 1832 guaranteed that the bodies need for anatomical studies were legally acquired. Knowledge was being shared widely through a plethora of local and national medical societies, and through medical journals, the first of which  was the Lancet founded in 1823. Great strides were being made in surgery, facilitated by the relatively new use of anaesthetics, and asepsis.  

Anaesthesia was initially used in dentistry, but had been adopted by American surgeons, and popularised in the UK by its use in childbirth by Queen Victoria in 1853. Speed was no longer of the essence so that surgeons were able to experiment with new techniques, some of which are still in use today. In 1853, Pasteur showed that wine was soured by the presence of microorganisms, confirming the germ theory of disease and decay. Pasteur’s germ theories were picked up by Lister, professor of surgery at Glasgow. He was actively seeking for a way to reduce post operative mortality rates, and thought that cleanliness might improve on the filthy hands and operating coats of his colleagues. He introduced antisepsis into his theatre using carbolic acid for hand washing and a spray for the surgical field, first described in the Lancet in 1867. His death rates fell dramatically and gangrene disappeared from his wards. This was nothing short of miraculous at the time, and the technique was disseminated widely by Lister’s students who dubbed him ‘the father of surgery’.

The technique of roentgenography (X-Rays) was discovered in 1895,  and for the first time doctors could observe the bones of a living person. 

The sanitary reform movement which set out to provide clean water and living conditions had already resulted in a decline in deaths from communicable diseases by 1880. The germ theory of disease established by Pasteur in 1853, and confirmed by Koch’s work with the microscope formed the basis of the new science of bacteriology. For the first time, the causes of diseases were being discovered, and very rapidly. Koch determined that  consumption was caused by  the tuberculosis bacillus in 1882, Mott found the syphilis spirochete in the brains of patients with General Paralysis of the Insane in the 1890s. Syphilis and TB caused much of the mortality and morbidity in society at the end of the 19th century. Work by Koch, Mott and fellow bacteriologists laid the foundations for cures which transformed society in the 20th century.

These were indeed exciting times to be a medical practitioner. 

Montagu Lomax – a detective story

Welcome to ‘Who was Dr Montagu Lomax’, and to my very first blog page.

I suppose I should explain why anyone should be interested in a man who died nearly a hundred years ago. 

If you put ‘Montagu Lomax’ into Google it will churn up plenty of references to his 1921 book – The Experiences of an Asylum Doctor’ (1), and you will learn that the book shocked the British public to the core by telling them how their relatives were being cared for in the lunatic asylums throughout the country. The ensuing scandal eventually resulted in a change to the law with the 1930 Mental Treatment Act, and the beginnings of the modernisation of our mental health services. That, although interesting in itself, is not the reason for my homage to the man.

Having read his book, it became apparent that there was a missing backstory. How did an obscure, retired GP manage to write a book which had such a profound effect, so that within weeks of publication, questions were being asked in Parliament? The conundrum had also occurred to a certain T.W. Harding  who wrote an appraisal of the  ‘Lomax Affair’ in in his 1990 paper (2). Harding commented that he had very little biographical information on Lomax, and he hoped that he might be able to trace Lomax’s family to ‘allow a more complete account of a remarkable man to be written’. I read this paper in 2010, and as far as I could ascertain, nobody had taken up Harding’s challenge in the interim. 

It has been a detective story – my entertainment through long winter evenings on and off for the past decade. I learned a great deal about Lomax’s background digging through ancestry.com. I was able to read contemporary accounts of his activities through the online newspaper archives, I visited the Public Record Office at Kew, the Bodleian Library in Oxford, the Warwick archives, and corresponded with the Alexander Turnbull Library in New Zealand, the Surrey Archives, and the archivists at Marborough and Gresham’s School. I read history books, medical papers, history papers and began to accumulate an enormous, disorganised collection of facts and ‘interesting snippets’ spread across three computers and spilling out of several drawers. I have always meant to ‘do something with it’ when I had the time. Then in March 2020, COVID-19 arrived and suddenly, I had plenty of time.

The story of Dr Montagu Lomax is laid out in chapters which are arranged in date order through the Home page. The Introduction page explains the background to the story. There are still some gaps in the narrative, so if you are able to help fill them in, dear reader, please contact me. 

 

1. Lomax M. The experiences of an asylum doctor : with suggestions for asylum and lunacy law reform.: Allen and Unwin; 1921.

2. Harding TW. “Not worth powder and shot”. A reappraisal of Montagu Lomax’s contribution to mental health reform. The British Journal of Psychiatry. 1990;156(2):180-7.