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recognize this fact himself, and when the truth begins to reveal itself to the people, he quietly moves off, possibly to another section of the same city, and begins to plod his old course in a country new. The meritorious doctor then sees that what he expected has taken place, but as a vacancy has occurred, another one soon moves in who has possibly bonglit out the good will of the departing brother, and then perhaps begins again the identical course of events. Besides, medical knowledge and skill do not alone determine a physician's success; there are other things that lielp to decide it. An air of self confidence, a good personal appearance, a cheerful and sociable disposition, and a happy faculty for making acquaintances go far toward securing a reputation as an ablo physician, and if united with a good degree of dependenco on vis medicatrix natura he may enjoy many happy days of visiting patients, drawing a veil over ill-timed prescriptions, collecting good fees, and receiving high encomiums from warm-hearted friends.

It may be said that the well qualified physician should also endeavor to possess these external requisites, that they are really as essential in restoring health to the invalid as a well selected prescription; but that is no reason why they should constitute the stock in trade; no reason why the confiding patient should be left to chance or to nature when by the administration of the proper medicine, convalescence would at once begin. But, above all, that is no reason why, so far as can be avoided and when perhaps a life is in danger, dependence should be had upon some one supposed to possess both knowledge and skill, when in fact he has neither. This only illustrates the ease with which deception can be practiced in the healing art, and why the governments of Europe and so many States of this country have adopted regulations to secure at least presumptive evidence that medical practitioners are qualified for their responsible duties. The people have not sufficient tine, as individuals, to examine into the qualifications of physicians, to say nothing of the opportunities and knowledge necessary to properly determino such a question. Frequent it is not until some member of the family has been suddenly taken sick that the question arises what physician shall be called, and the query is quite often determined by hurrying to the first drug store and inquiring of the clerk for the nearest physician.

There are eighteen States in which the diploma of no medical college confers the right to practice, but all candidates for this privilege must undergo an examination. These States are Alabama, Arkansas, Florida, Georgia, Maryland, Minnesota, Mississippi, New Jersey, New York, North Carolina, North Dakota, Pennsylvania, South Carolina, South Dakota, Texas, Utah, Virginia, Washington. In seventeen other States the diploma confers this right only when the board of health or other determining body shall have declared the college to be “in good standing,” and this has been interpreted to mean that they are satisfied with the entrance requirements, the length of the term, the number of courses required before graduation, the character of the instruction given, and all other items which aid in fully qualifying the graduate to practice. In some instances State boards have announced in advance that they would recognize no college which did not require so many courses of lectures, or which did not have an animal session of so many months. Medical institutions would then see that they must comply with these requirements or else their graduates from such States would be on unequal footing with those from other schools, and consequently the number of their students would be diminished. In self-defense, therefore, they must comply with all reasonable stipulations.

"A conspicuous effect of these laws has been seen in the improvement of the standard of medical education. To them, more than to any one cause, is due the difference which exists between the condition now and in 1870. In Alabama, Colorado, Connecticut, Illinois, Nebraska, Oregon, South Dakota, and Washington, it least three full courses of five to six months each, no two in the same year, are demanded. The State of Oregon, after 1898, will require four courses of six months each from physicians who wisli to practice in that State. There is not only a prolongation of the period of study as the effect of these laws, but there is also an

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increased demand for a preliminary education, tho establishment of new professorships, and more exacting examinations for the degree. Of all agents distinctly bringing about this change, the Illinois State board of health, and especially its secretary, the late Dr. John H. Rauch, deserve the highest consideration.”ı

In twelve States and Territories it is required only that the candidates for licensure shall present a diploma from some medical school; no question being asked as to the character of the instruction given in the school. This opens a wide door to dishonest evasions of the law, and the traffic in fraudulent diplomas flourishes in consequence. The registrar of medical practitioners frequently has practically no inforination as to the medical schools of tho country, and makes no pretense to examination of the diplomas. But another serious defect in many States is that little or no effort is made to see that unregistered physicians do not practice. The law is left to enforce itself.

An act to regulate the practice of medicine and surgery was lately passed by the legislature of Maine, but its requirements have not yet been ascertained. This leaves New Hampshire as the only State in the Union with no medical-practice law, which it will soon have to enact in self-defense.

in New York the law has probably gone further than in any other State to prevent the licensing of persons not qualified. It is intended, in the first place, to prevent anyone from entering upon the study of medicine who has not the proper preliminary education, and in the second place it prevents anyone from beginning practice without undergoing an examinatiou elsewhere than at the college he attended. Every medical student is required by the law of 1889, as amended in 1890, to file with the regents of the University of the State of New York a certificate “showing either that he possesses the degree of bachelor or master of arts, of bachelor or master of science, or of bachelor or doctor of philosophy, received by him from a college or university duly anthorized to confer the same, or that during or prior to the first year of his medical study within this State lio passed an examination conducted under the anthority of the regents of the University of the State of New York or by the faculty of a medical school or college entitled to confer the degree of doctor of medicine, in accordance with the standard and rules of the said regents in arithmetic, grammar, geography, orthograplıy, American history, English composition, and the eleinents of natural philosophy, or in their substantial equivalents approved by the said regents, or that he possessed qualifications which the regents considered and accepted as fully equivalent to the above-nameıl qualifications."

After he has received his degree, and before he can begin practice, the medical student in New York is required to pass an examination before the State board of examiners, regular, homeopathic, or eclectic. (Law of May, 1893.)

In several other States the laws on this subject are of very recent date, showing that the trend of legislation is strongly toward safegnarıls against incompetent practitioners. In Pennsylvania an act was passed May 18, 1893, to take effect March 1, 1894, requiring an examination before a State board of examiners. In Connecticut the law regulating the practice of medicino only went into effect October 1, 1893, and in Nebraska it was enactel in July, 1891. In South Carolina the law requiring an examination was repealed December 21, 1890, but was reenacted in December, 1893. The laws of Georgia, Rhode Island, and Maine are of still more recent enactment. The medical-practice law of Georgia takes offect January 1, 1895. It provides for three distinct boards of examiners of five members each, regular, homeopathic, eclectic. All applicants for license must undergo an examination before one of the boards, but no one can be examined except graduates of incorporated medical colleges requiring not less than three full courses of six months each.

1 Reginald H. Fitz, M. D., Loston.

Legal requirements for the practice of medicine in the United States.

States and Territories.


Arizona Territory

District of Columbia

New Hampshire
New Jersey.
New Mexico Territory
New York.
North Carolina
North Dakota
Rhode Island.

Examination by State or county board of medical examiners.
Registration of diploma.
Examination by State or county board of medical examiners.
Diploma of college in good standing."

Diploma of a collego" recognized as reputable by one of tho chartered

medical societies of the State."
Diploma of "a respectable medical college."
Diploma; but praetically no requirements.
Examination by State or district board of medical examiners.
Examination by State boarı, after showing diploma of a college requir.

ing three years of six months.
Diploma of college "in good standing."
Diploma of college "in good standing."
Diploma of "a reputable college."
Diploma of a “medical institution of credit and respectability."
Law recently passed; requirements not known.
Examination by State board of examiners.

Examination by State board of examiners.
Examination by State boarıl of health.
Diploma of college " in good standing."


No legal requirement.
Examination by State board of cxaminers.
Diploma of college "in good stauding:
Examination by Siate board of examiners


Diploma of college in good standing."

Examination by State board of examiners.
Diploma " of a reputable and legally chartered medical college, indorsed

as such by the State board ot health.'
Examination by Stato board after presentation of diploma.
Examination by Stato board of health,
Diploma of college “in good standing."
Examination by a district board of medical examiners.
Examination by Territorial board.
Examination by State board of examiners.

Diploma "of a reputablo college."


South Carolina.
South Dakota..
Utali Territory
West Virginia.

The words "in good standing," as interpreter by the State boards of health and boards of examiners, refer only to those colleges whose regulations comply with the conditions established by these boards.


In the report on education for 1894 of tho Illinois State board of health, notice is given of forty-six medical schools which have fraudulently carried on the business of diploma selling, six of which were chartered within the last five years. Before the States had any laws restricting tho practice of medicine, fraudulent schools could not reap a harvest from selling bogus diplomas, because no diploma was needed; anyone could claim to be a doctor. But when the States began to enact laws forbidding anyone to practice medicine who was not a graduate of a "legally chartered medical school,” a diploma became a valuablo article, because it answered the purpose of securing a license. It even did more than this; inasmuch as the law required a diploma as evidence of special skill and training before one could practice, therefore when ono possessed the diploma it was to be inferred that ho also had the required skill and training. Henco a diploma not only gavo one the right to practice, but also furnished presumptivo evidence of liis qualifications. A demand for diplomas therefore immediately aroso, and tho supply as soon fully equal to the demand. Had it not been for the energetic efforts of tho Illinois Stato board of health, to whom great credit shoull be given for exposing at least ten of these bogus colleges, there would no doubt have been many others in existence. But notwithstanding the efforts to weed out all diplomas of frandulent schools they still find a ready market, for although it has been repeatedly słown how easily a diploma can bo obtained from a "legally chartered school,” yet the legislatures are slow to act, and it does not fall within the province of any particular one to have the law changed, and the medical profession especially can not well make the effort lest a charge of selfishness be brought against them. Even when the venders of bogus diplomas are brought into the courts and fined they only engage in the business more assiduously than ever in order to recover the amounts they havo lost. “Carey has been twice arrested, convicted, and fined for practicing medicine illegally, nevertheless his diplomas are recognized in Washington, Idaho, and elsewhere as those of a legally chartered institution, and persons are practicing thereon.”! A hardware dealer in Busfalo, who had never spent an hour in the study of medicine, received by express his medical diploma, dated May 27, 1889, paying for it $60 on delivery. These bogus diplomas aro found in all the States allowing practice on a diploma from a legally chartered medical school, and they are not even confined to this country, but find their way across the Atlantic. Complaint has more than once been made to the National Government by the European authorities of persons seeking practice on the strength of fraudulent American diplomas. It is probable that since the medical colleges are all lengthening their courses and adopting other restrictive measures, there will be a greater demand than ever for diplomas from “ legally chartercd medical schools."


A few years ago the catalogues of nearly all medical schools spoko particularly of spring courses of lectures, and of the advantages students might derive from them. Now there is very little said on the subject. At that time the length of the annual session was only four or five months, and it was a common occurrence oven then for first-year students to leave a month or two before the close of the session. Many institutions recognized the importance of longer sessions, and endeavored to remedy the matter by having a complementary session in the spring or fall, but notwithstanding the efforts made to get students to attend them, the number was always insignificant. A more efi'ective method has therefore been instituted. Quite a number of institutions have lengthened the regular annual course to six or seven months, and some to eight or nine months, and the students not in the graduating class are required to remain till the close of the session before they can receive the certificate of a year's attendance. Consequently these colleges no longer have any complementary course, although tho students have the privilege of remaining during the summer and attending the clinics if they so desire, but this is scarcely advisable after a long medical session. In answer to the question asking the number of weeks in the spring course, fifty-five medical schools state that they have no spring course, whilo only twenty-two answer afirmatively; the remaining schools do not answer at all, but very probably have no spring course.


A few years ago, when nearly all medical colleges bad a course of only two years of four or five months, it was generally stated in the catalogues that the student would be required to spend one year under a preceptor before he could matriculate; and this would have been of much value to him if it was spent under proper direction and attention; but unfortunately those plıysicians who were most competent to

· Rep. Ill. Board of Health, p. 140.

direct his work were generally so engrossed with other duties that they had little time to devote to the medical student. The latter soon recognized the fact that his time was not being well spent, and that he must look after his own interests; consequently he usually spent only a few months, or perhaps weeks, in the study of anatomy, aided only by a few bones which had been hidden away in his preceptor's office. Ho then went to some medical college where he felt confident he could complete tho course in a brief period, registered his name, ago, and residence, and the name of his preceptor, paid his matriculation fee, and began to attend the same lectures as those who were soon to complete the course, He soon recognized, however, that he labored under difficulties, for he was nonplussed at the terms spondylolisthesis, symphyseotomy, colporraplıy, oöphorectomy, sponge tents, etc., but when he spoke of it to his fellow-students they allayed all fears by telling him he would hear exactly tile same thing the next year and would then understand it.

Now that the medical schools have adopted graded courses of three and four years, and the student is led along in his work in an orderly and systematic mauder, he is no longer required to spent any time under a preceptor, for it is well known that his time could be far better employed at the institution; in fact, the time in a preceptor's office is wasted. “According to Dr. N. S. Davis it (reading medicine in a doctor's office) consisted in 1877 in little more than the registry of the student's name in the doctor's office, permission to read the books of his library, or not, as he chose, and the giving of a certificate of time of study for the student to take to the medical college when he expectel to graduate.”


Although the State governments and municipalities render very little assistance directly to medical education, yet indirectly very much is done by city governments and charitable citizens, an aid the lack of which would be serious indeed, but one which is not yet fully utilized. How difficult would be medical instruction without hospitals to furnish illustrations of the various diseases; and especially difficnlt would it be to give instrnction in surgery. It would be the written description of a steamboat to a boy, instead of placing him on the wharf where he might see it with his eyes instead of having to build it up with his brain. The catalogues of medical institutions almost without exception call particular attention to the hospital advantages which they possess, indicating how important it is that the student enjoy full clinical opportunities. These hospitals have sometimes been established by the munificence of wealthy individuals, freqnently as memorials of relatives or friends. Municipalities often establish them, and when their great usefulness is made apparent to the public, friends spring up to make known their claims, and they meet with the success so evidently merited. Every large city now has one or more of these institutions ready to receive and carefully attend the indigent sick and those suffering from accidental injuries. The advantages of treatment in a large hospital possessing all necessary appliances and accommodations arranged for constant use, and in furnishing well-trained nurses, are so great that many persons of ample means prefer to be treated there rather than at home. But to the poor, who can barely provide common food and shelter when it health, and whose domestic environment is frequently such as to induce disease instead of warding it off, the hospital comes as a great blessing, furnishing proper diet, the advice of skillful and experienced physicians, and attendance of trained nurses; and the only compensation asked of them is that young men and women whose work in life will be to ameliorate suffering and cure disease shall be permitted to observe the symptoms characteristic of different diseases, so that they may afterwards be able to recognize them at a glance and institute proper treatment at the outset of disease. No meilical student can properly enter upon the practice of his profession until he has had this clinical teaching, for it is a knowledye which can not be obtained from books and lectures. All inedical colleges make special efforts to provide for their studeuts full instruction of this kind.

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