412

THE LANCET.

LONDON: SATURDAY, AUGUST 17, 1895.

THE TITLE OF DOCTOR.

OUR columns have again been opened to the discussion ofthe several questions which arise out of the fact that the

prefix of Doctor is both a correct academic appellative and acolloquial method of address. The ambiguous position ofthe title has bred, as was natural, many ambiguities, so thatthere are points and half-points without number over whichdifferences of opinion will prevail, and consequent disputecan take place. This is well illustrated by the letters received

by us, a typical selection of which have been printed, andwe may say at once that we do not intend to deal seriatim

with the issues therein raised. We intend to use them as a

text for an exposition of our views on the question, premisingthat these views have been adopted by us more with an eyeto courtesy and practical expediency than to cold logic,which can have little part in anything which starts with a

flaring ambiguity.Firstly, there can be no doubt that in all circumstances

where medical status has a claim on professional or publicattention, in all official connexions-whether exclusivelymedical or no, and in the social relations of strictly medicalcircles, only one class of practitioner has a clear and incon-trovertible right to the title of Doctor-viz., the Doctors ofMedicine of those universities whose doctorates are regis-trable degrees. It would be strictly logical counsel to advisethat only the persons possessing this clear and incontro-

vertible right should be addressed as Doctor, but as we

ourselves, in a medical journal, have decided that such a

counsel is too much one of perfection in a world of neces-

sary compromise for us to rigidly follow, we cannot

consistently urge the necessity of the strict limita-

tion upon our readers and upon the numerous

correspondents who have asked us for a pronouncement. There are undoubtedly cases where the withholding of thetitle, while strictly correct, constitutes an ungracious act ofomission. In the case, for instance, of a man who is

registered by the General Medical Council as holding the

diplomas of recognised licensing bodies, and who adds

to these the doctorate of a university of whose status as a

degree-granting institution there can be no doubt, althoughnot registrable-in such a case we consider the frailty of

addressing the practitioner as Doctor so venial that we lapseinto it as a habit. It will be noticed that the error, thoughwe hope pardonable, brings with it its own risk of punish-ment, for it might entail at any moment the invidious taskof defining the status of a given university. This in some

cases would be easy, but in some might require an amountof discrimination that could not be provided for byrules ; and then the situation would have to be dealt

with by every man according to his private taste.

Again, to give a second very obvious example where the with-holding of the title of Doctor causes the precisian so doingto assume a somewhat awkwardly exclusive attitude, there

is the case of Bachelors of Medicine, whose baccalaureatesare held from universities granting a duly registrabledoctorate. Should these gentlemen be addressed as Doctor?We ourselves give them the title, knowing that to do so isindefensible logically, but finding that not to do so to somawould entail serious confusion, and that, as a consequence,not to do so to all would have the appearance of a

no less serious lack of courtesy. There have been

Bachelors of Medicine who have held the highest posts at

general hospitals or in the great medical corporations without.proceeding to the doctorate. Such Bachelors of Medicine

have been, and are still, considered eligible to apply for the.

staff appointments at public institutions, whose honoraryphysicians are so universally styled Doctors, and have been

styled Doctors for so long a period, that to do otherwise.would require, in our eyes, a more practical justificationthan an attempt, however laudable, after accuracy in

terminology. We cannot admit that the question of’

the comparative difficulty of the examinations of certain

of the universities and certain of the corporations.affects the procedure. While the period between the,

securing of the baccalaureate and the advance to the

doctorate is unlimited in length by the universities, andwhile strictly medical circles recognise the Bachelor of

Medicine of all the degree-granting universities as a propercompetitor against the Doctor of Medicine for medical

appointments and awards, so long will it be a task too hard:

for us to abstain from illogically conferring the title of

Doctor upon the Bachelor of Medicine; and we cannot

attempt to separate the Bachelors of different universities

into groups requiring different treatment, although the gulfplaced by some-London University, for instance-between

the baccalaureate and the doctorate is a sensible obstacle,.while that in others forms no practical impediment.The position of the diplomates of the several Royal

colleges and corporations is so universally recognised(and also, we are pleased to say, so universallyacquiesced in by themselves) that it may seem over-

explanation of the obvious to refer to it ; but there are one’or two little points even here that, from the frequency withwhich they are referred to us for our opinion, would seem to’require elucidation. Firstly, such diplomates are not entitledto the style of Doctor however well known to their patients-they may be under that style. The diplomate must not

arrogate to himself a title conferred upon him colloquiallyand not gained academically. The profession, knowing wellthat degrees do not make a man, and the public knowing italmost as well and daily learning to know it better, he willsuffer nothing by his abstention ; and this we are glad toremember, as undoubtedly there are degrees obtained

by many university graduates whose professional attain-

ments are in no way superior to those of the diplomatesof the Conjoint Board, and whose preliminary testing has.neither been so severe or so thorough as many of their fellow-students to whom circumstances have made the rightfulpossession of the title of Doctor almost an impossibility.Secondly, the holder of the Licence of the Society of

Apothecaries of London is not entitled to be called

Doctor ; the fact that the Licence constitutes im

itself a double qualification not being relevant to the

question. Thirdly, the holder of diplomas from any

413THE TRUE HOLIDAY.

corporation who happens to be a Doctor of some other

faculty than medicine in any university-it makes no t

difference whether the medical doctorate of the university is r

recognised by the General Medical Council or not-is not r

entitled to be addressed as Doctor in medical circles.

We cannot, while treating the subject in a general manner, r

take up all the special points that have been laid before our readers in the recent correspondence. Nor can we furnish a i

ready-made opinion to fit the many cases that will assuredlybe submitted to us in the future as they have been in the

past. We have only taken advantage of the fact that as

many communications on this ever-green topic have lately (

been before our readers the subject must be in their minds, and the opportunity for explaining our procedure is therefore

advantageous. We do not claim to be, or to have been,

strictly logical in this procedure, but we consider that

circumstances prevent the strictly logical method of .

limiting the use of the title from being quite fair or quite 1

convenient. -------- ------- ---------

THE complex conditions of modern working life make theabsolute need of a holiday more apparent every year. In all

classes of life, from Emperors down to the humblest workers,we do as much in a week as our forefathers were accustomed

to do in six months, and the need for recuperation is, there-fore, so much the greater, and fortunately the means forsupplying this need have grown coincidently with it.

The enormous increase in facilities of locomotion which

is a notable characteristic of the present day enables

even those of moderate means to go far afield ; neither

can there be any doubt that a complete change of air,scenery, and surroundings is a very powerful factor for goodin the treatment of those wearied with work of whatsoever

kind. The days are gone when Islington was really merry" "

and had fields, when the fisherman could walk to Tottenhamand find a clear Lea to exercise his craft upon. There are still

left a few places within twenty miles of London which are

really country, and not given up to the builder, jerry or

otherwise; but the majority of holiday makers go eitherto the seaside or on the Continent, and it is this kind of

holiday that we propose more particularly to consider now.It may be well asked, "Do those who go for a holiday

set about it in the majority of cases in the right way?" and the answer in general is "No." First of all comes

the family conclave assembled to decide upon the importantquestion of where to go, which generally ends in the

selection of some place favoured by the younger male

members of the family. And here we may pointout that when people live together all the year round it

is the greatest mistake for them to attempt to take a holidaytogether. The true holiday implies much more than goingaway from home; it means rest, change of company, beingtaken out of oneself-this last item is perhaps the mostvaluable of all. We will suppose, then, that the holiday makerhas settled the matter to his or her satisfaction and has

started with a friend. Let him beware of the other great mis-take so constantly committed-that of trying to do too much.To rush from one town to another; to "do" the Ardennes,

Cologne, the Rhine, Nuremburg, perhaps Bayreuth, Styria,and more or less of Italy in six weeks is not a holiday but

a penance, and yet there are those who do this and thinkthat thereby they are laying up a store of health for theirreturn to work. The true holiday consists, not in doingnothing, but in having nothing to do-it is the sense of

freedom, the feeling that one can go on or stop, whichever ismost convenient. Trains and the catching of them, the bale-ful superstition that " objects of interest " must be visited andinspected, the hurrying from one hotel to another, all thesemar the rest which is sought. Then, too, there is the questionof climate. We are convinced that the general rule which isfollowed of going south for the winter-unless, indeed, Egyptor some similar place be selected-is wrong. The countries to

go to in winter are those where winter is a reality, and wheremeans are and can be taken to meet it. Russia, Norway, andSweden are seen at their best in winter, and the beauty of anorthern winter night is inconceivable to those who have notseen it, while the dry, windless, cold atmosphere braces everytissue of the body, and if the cold begins to be felt toomuch the houses are really warm, and warm throughout.Compare this with a shivering day on the Riviera where the

art of keeping houses warm is unknown. The same

argument will apply to summer. If a warm country is

selected the house, the food, and the style of clothingwill be found in keeping. In the variable climate with

which we are favoured we can neither prepare for winters

like the last nor summers like that of 1893; but at least,when we can go to a country blessed with climatic regularity let us visit it at the most favourable time.The true holiday, then, is not such an easy matter to

obtain as it seems at first sight. A congenial companion,a determination not to try to crowd too much into a short

space of time, a discriminating selection in the matter ofplace and distance, and for most places some knowledge oftheir history, whether political or natural, will go far to

make a holiday what it really should be-a complete restnot only for the body, but, what is perhaps more im-

portant, for the mind also; and if certain discomforts

are met with-and they very generally are-we mayremember the words of an old writer: "Nothing wouldbe more tedious than to be glutted with perpetualjollities ; were the body tied to one dish always, thoughof the most exquisite delicacy that it could make

choice of, yet after a time it would complain of loathingand satiety. Discontents are sometimes the better part ofour life. I know not well which is the more useful ; joyI may chuse for pleasure, but adversities are the best for

profit. And sometimes these do so far help me as I shouldwithout them want much of the joy I have."

THOSE who desire that due instruction in the rules of pro-fessional conduct should not be omitted in medical schools

will be pleased to read the admirable address on Medical

Ethics by Professor GREENFIELD, delivered to the new

graduates of the Edinburgh University and published in ourpresent issue. It will well repay perusal by all who wish toguide their conduct on principle and to uphold the reputationof the profession. He makes a point of assuring the younggraduates that they are not " mere licentiates of a medicalcorporation," but members of a university which in the

past has been, as he trusts it will be in the future,

414 AN EDINBURGH PROFESSOR ON MEDICAL ETHICS.

distinguished in all branches of learning. The distinction

drawn by Professor GREENFIELD is perhaps capable of beingconsidered somewhat invidious, and we have no intention of

endeavouring to appraise the relative merits of universitiesand corporations. There is, however, one point in whichthe corporations undoubtedly show to advantage in com-parison with the universities, and that is in respect of

the question of medical conduct. The corporations some-times administer discipline to their members, even to

the measure of excommunication. If the members

violate the regulations of a corporation in the matter

of professional ethics they are rebuked, and if theydo not repent they are deprived of their diplomas andremoved from the roll of membership. Most of the

universities have no such powers over their graduates,and some of them do not seem to wish to have them.

"Once a graduate always a graduate" is their doctrine.

Graduates are, according to this view, the only class to

whom the punishment of degradation must not be appliedFortunately, the doctrine is breaking down, and some ofthe universities are, in fact, seeking the powers wherewithto rid themselves of those graduates who act unworthilyof their gowns, and to place themselves in this regard ona level with the corporations. We would remind those

universities which do not seem too keen to acquire such

powers that if they wish the profession and the public toregard their graduates as " more than mere licentiates of

corporations " they must act accordingly and be prepared,if necessary, to degrade those whom they have graduated.We must pass hastily over Professor GREENFlELD’S inter-

esting and just remarks on the happy relations which subsistbetween the town and University of Edinburgh. It was not

perhaps, always so. There was a time when the town council

had too much patronage in its hands, though to its honourthe professors it chose were often men of the widest renown ;but now nothing can be more satisfa ctory than the pride ofthe Fathers of the city in the university, and their

cooperation with its authorities in maintaining its highprestige. Coming to the main points in the address,we may enumerate them broadly in the following way.Cultivate a high ideal of professional life and its

objects ; respect the confidences of the profession ; con-

sider how to convey truth to patients and their friends ;remember that sickness makes a man not himself—’’ the

higher his intelligence the greater his activity, the widerhis responsibilities the more intolerable to him is sick-

ness," as involving not so much physical pain as

mental, and the suffering of others dependent on him ;have patience under such circumstances with peevishnessand cultivate calmness, cheerfulness, and sympathy in

connexion with clearness, decision, and thoroughnessin directions and candour in speech. Like all goodmoralists, Professor GREENFIELD had to fall back on

the Scripture and say, "We that are strong ought to

bear the infirmities of the weak," and to quoteseveral other texts from the same indispensable source.

While vindicating the perfect freedom of patients to

choose their own medical man, he was emphatic inreminding his hearers that "one of the most stringentand primary rules is that no medical man should

under any guise, directly or indirectly, interfere with

the conduct of a case which is under the care of

another unless consulted by him." He denounced all

tendency to comment on the treatment and diagnosis of

others, insisting that no man can judge of a case he hasnot seen. At the same time he discouraged all local

jealousies and distrusts of professional neighbours. He

remarked that he had often been astonished that patientshad not enjoyed the advantage of consultation with medicalmen in their own neighbourhood, and found the explanationin mutual distrust. He enjoined on his hearers the duty of

thoroughness in investigating cases, observing most trulythat more mistakes are made by want of thoroughness than

by ignorance. Finally, he ended with a word of cheer tothose who had been backward in class and college distinc-tion, reminding his hearers that it is not ahvays the brilliantstudents who become distinguished in after-life.These are thoughtful words and cover more than may

appear at first glance. There is a disposition at present tocorrect the evils of the profession by legislation and by thedisciplinary action of the medical authorities. There is need

of these ; but, after all, the strength of the profession andits place in public estimation will depend on faithfulness toits own traditions, to its great unwritten laws, to its highestmorals. Reverence for patients, respect for their feelingsas well as for their health, will make us adepts in theinvestigation and treatment of their cases and in the

art of telling them all the truth that can do them

good or is consistent with our main duty-that of pro-

longing their lives. It will make us honourably reticent ofall family and personal facts which we come to know

professionally. Reverence for professional neighbours willmake us charitable in our judgments of them and quickto see in each of them a brother rather than a rival.

Reverence for ourselves will make us less discouragedby the vicissitudes of practice and more incapable of all

mean methods towards success.

Annotations.

SMALL-POX AND THE ROYAL ;COMMISSION ONVACCINATION.

- "Ne quid nimis."

THE existing prevalence of small-pox in the metropolisacquires additional importance, not only because it has

appeared at a time of the year when small-pox is, as a rule,least likely to become epidemic, but because at no timewithin the present generation has there been so much

tendency to disregard the law as to vaccination. This lattercondition of affairs has been brought about by the extra-ordinary delay in the issue of the report of the Royal Com-mission on Vaccination which was appointed in August,1889. We do not doubt that the preparation of all theevidence which has been brought before the Commission, bothby witnesses and by subcommissioners of their own appoint-ing, must take a considerable time, but it is absolutely im-possible that the minds of the Commissioners should not bemade up as to the various points which were submitted tothem when they were appointed ; and we see no reason whyParliament should not request the report forthwith; leavingthe question of evidence to stand over, as was done in thecase of the Royal Commission on Tuberculosis. In one