Irvine Loudon

Book Review from The New England Journal of Medicine — Book Review

FRCS: hallmark of the pure surgeon After 1815, however, when for the first time it had become customary for all orthodox medical practitioners to have a formal qualification and letters after their name, it was galling for the elite hospital surgeons to have the same qualification (MRCS) as the general practitioners who, to make matters worse, often called themselves surgeons. The elite's reaction was to create a new, unofficial category of “pure surgeons” who differed from the general practitioner with an MRCS not only by possessing greater surgical skill and an appointment at a hospital but also on the negative grounds that under no circumstances would a pure surgeon dispense drugs or practise midwifery. Out of 8000 practitioners who held the MRCS in 1834 there were just 200 “pure surgeons,” almost all in London.8 Only the latter were eligible for election to council and allowed to use the front door of their college: the general practitioners with an MRCS had to go round to the back. When a new charter in 1843 changed the Royal College of Surgeons of London into the Royal College of Surgeons of England, the opportunity was taken to introduce the rank of fellow (FRCS), which became the hallmark of the pure surgeon and was firmly linked to the convention of addressing surgeons as Mr.2 The other problem with Mr and Dr was midwifery, which was outlawed by members of the Council of the Royal College of Surgeons. Thus, from the late 18th century to the late 19th century almost all of the growing number of obstetricians appointed to teaching hospitals were physicians. Indeed, most were Fellows of the Royal College of Physicians, called themselves “physician-accoucheurs,” and were addressed as Dr.9 Conflict arose at the end of the 19th century, however, with the growth of operative gynaecology. This is a complex story, but the root of it is the argument made by surgeons that gynaecology belonged to them because it was operative; the physician-accoucheurs claimed that obstetrics and gynaecology belonged together. As we know, the surgeons won the argument. By the 20th century the obstetrician-gynaecologist (who often, but not necessarily, possessed the FRCS) became another kind of doctor who was always addressed as Mr. And this is more or less the position today; but is the persistence of this tradition sensible? Fifty years ago it was relatively simple. Physicians treated medical diseases and surgeons operated. Today, the treatment of surgical disorders is often undertaken by teams of doctors any of whom may “intervene” in a technical or surgical manner (the interventional radiologists are an example), whether they are titled Dr or Mr, Miss, Mrs, or Ms. Thus patients with cancer who happen to be sticklers for addressing people correctly may well be puzzled when they are referred by Dr A, their general practitioner, to Dr B, an oncologist, and Dr C, a radiologist, before seeing Mr or Ms D, a surgeon. An operation is performed under an anaesthetic administered by Dr E after which the patient is referred to Dr F for radiotherapy and back to Dr B for chemotherapy depending, perhaps, on the findings of a pathologist, Dr G. Further, the patient may enter a controlled trial run by a medical statistician, Dr H, who is not medically qualified but has a PhD. That is eight “Drs” to one “Mr (or Miss or Mrs or Ms).” Note that any of these doctors, including Mr B, might possess an MD or a DM, which often puzzles American doctors who are not always aware that in the United Kingdom these are postgraduate degrees. But whether or not they have been awarded a university doctorate (an MD, DM, DPhil, or PhD) is irrelevant to how they are addressed. Only the surgeon is addressed as Mr (or Miss or Mrs or Ms), together with his or her registrar; but the house surgeon is not, for it is (or used to be) considered bad form if Dr John Jones who was a house physician yesterday insists on being called Mr Jones when taking up the house surgeon post tomorrow. Medical qualifications in the United Kingdom have been in an unholy muddle ever since the Medical Act of 1858 when no less than 18 independent medical institutions offered a range of bachelorships, licences, diplomas, memberships, fellowships, and doctorates all officially recognised by the General Medical Council. This cannot be altered. Now, however, so much of surgery is teamwork that it seems to me that the original and rather trivial reasons for “mistering” surgeons have disappeared. Would surgeons be willing to abandon this pretentious anachronism so that all who possess a medical qualification that is recognised by the General Medical Council, regardless of the specialty and the letters after their name, are simply addressed as Dr? It is at least worth considering.

High maternal mortality was a feature of the Western world from the mid-19th century, when reliable record keeping commenced, to the mid-1930s. During this time, maternal mortality rates tended to remain on a high plateau, although there was wide disparity between countries in the height of the plateau. From ≈1937, maternal mortality rates began to decline everywhere, and within 20 y, the intercountry differences had almost disappeared. The decline in maternal mortality rates was so dramatic that current rates for developed countries are between one-fortieth and one-fiftieth of the rates that prevailed 60 y ago. In this paper, the reasons for the high mortality before 1937 and its decline since that date are discussed. It is suggested that the main determinant of maternal mortality was the overall standard of maternal care provided by birth attendants. Poverty and associated malnutrition played little part in determining the rate of maternal mortality. This view is supported by much evidence, including the fact that, unlike for infant mortality rates, maternal mortality rates tended to be higher in the upper than in the lower social classes. The potential relevance of these findings to developing countries is discussed.