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 a degree, Doctor of Medicine from Brussels University. Dr Montagu Lomax possessed an M.D.Brux 1 , although he never declared it in the medical directories. Travelling abroad to study 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 degree seems odd, particularly when the qualification of M.D. was available in the British Isles. Moreover, why did Lomax go to the trouble and expense of obtaining a foreign degree, and then not advertise it in the medical directories? This short essay will attempt to answer both of these questions.
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. This was almost certainly the route Lomax took since he worked in Brussels between 1907 and 1914.
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 education grew stronger in 1920s Britain.
(References available on request)