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increased demand for a preliminary education, the 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.” 1

In twelve States and Territories it is required only that the candidates for licensure sball 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 information as to the medical schools of the 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 examination elsewliere 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 coufer the same, or that during or prior to the first year of his medical study within this State ho passed an examination conducted under the authority 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, orthography, American history, English composition, and the elements 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-named 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 dato, showing that the trend of legislation is strongly toward safeguarıls 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 medicine only went into effect October 1, 1893, and in Nebraska it was enacted 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 effect 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., Boston.

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

States and Territories.

Requirements.

Alabama
Arizont Territory
Arkansas.
California
Colorado.
Connecticut

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Delaware
District of Columbia..
Florida
Georgia.

Idaho...
Illinois
Indiana
Iowa..
Kansas
Kentucky
Louisiana.
Maino
Maryland.
Massachusetts.
Michigan.
Minnesota
Mississippi
Missouri
Montana.
Nebraska.
Nevada.
New Hampshire.
New Jersey
New Mexico Territory
New York.
North Carolina
North Dakota
Ohio
Oklahoma.
Oregon
Pennsylvania.
Rhode Island.

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

Do.
Diploma of a college "recognized as reputable by one of the chartered

medical societies of the State.
Diploma of "a respectable medical college."
Diploma; but practically no requirements.
Examination by State or district board of medical examiner.3.
Examination by State board after showing diploma of a college riquir-

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

Do.
Examnation by State board of examiners.
Examination by State board of health.
Diploma of coliege "in good standing."

Do.

Do.
Diploma.
No legal requirement.
Examination by State board of examiners.
Diploma of college “in good standing."
Examination by Slato board of examiners

Do.

Do.
Diploma.
Diploma of collogo "in good standing."

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

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

D.
Diploma “of a reputablo college."
Dilema.

Do.

South Carolina.
South Dakota.
Tennessee
Texas.
Utah Territory
Vermont
Virginia
Washington
West Virginia
Wisconsin.
Wyoming

The words "in good standing," as interpreted by the State boards of health and boards of exam. inere, refer only to those colleges whose regulations comply with the conditions established by theso boards.

FRAUDI'LEST MEDICAL SCHOOLS,

In the report on education for 1894 of the 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; any. one 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 valuable article, because it answered the purpose of securing a license. It oven did more than this; inasmuch as the law required a diploma as evidence of special skill and training before one could practice, thereforo when ono possessed the diploma it was to be inferred that he also had the required skill and training. IIence a diploma not only gave one the right to practice, but also furnished presumptive evidence of his qualifications. A demand for

diplomas therefore immediately arosc, and the supply was soon fully equal to the demand. Had it not been for the energetic efforts of tho Illinois Stato bourd 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 notwithstandling the efforts to weed out all diplomas of fraudulent schools they still find a ready market, for although it has been repeatedly shown 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 bronght against them. Even when the venders of bogus diplomas are brought into the courts and fined they only engage in tho business more assiduously than ever in oriler to recover the amounts they have 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 aro practicing thereon."! A hardware dealer in Buffalo, who had never spent an hour in the study of medicine, received by express his medical diploma, dlated May 27, 1889, paying for it $60 on delivery. These bogus diplomas are found in all the States allowing practice on a diploma from a legally chartered medical school, and they aro 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 chartered medical schools."

SPRING COURSES OF LECTURES.

A few years ago the catalogues of nearly all medical schools spoke particularly of spring courses of loctures, 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 even 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 effective 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 the 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, while only twenty-two answer affirmatively; the remaining schools do not answer at all, but very probably have no spring course.

STUDY UNDER A PRECEPTOR.

A few years ago, when nearly all medical colleges had a course of oniy 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 physicians who were most competent to

Rep. III. Board of Ilealth, 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 the course in a brief period, registered his name, age, and residence, and the name of his preceptor, paid his matriculation fee, and began to attend the samo 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, colporraphy, 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 the same thing the next year and would then understand it.

Now that the medical schools have adopted gradeil courses of three and four years, and the student is led along in his work in an orderly and systematic manner, he is no longer required to spend 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 ho expecteil to graduate.”

CLINICAL INSTRUCTION.

Although the State governments and municipalities render very little assistanco directly to medical education, yet indirectly very much is done by city governments and charitable citizens, an aiil 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 difficult would it be to give instruction 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 baving 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, frequently as memorials of relatives or friends. Municipalities often establish them, and when their great usefulness is madlo apparent to the public, friends spring up to make known their claims, and they meet with the success so evidently merited. Every largo 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 in 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 curo 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 medical student can properly enter upon the practice of his profession until he has had this clinical teaching, for it is a knowledge which can uot be obtained from books and lectures. All medical colleges make special efforts to provide for their students full instruction of this kind.

But since the courses in medical colleges have been raised to three and four years and the sessions lengthened to eight and nine months the schools need other assistance than that derived from clinical instruction in the hospitals; for, notwithstanding the great value of this instruction, it is not a source of revenue at all. The schools shonld not be left to depend upon tnition fees for support. This fact is becoming known to men of wealth, and some institutions are receiving substantial assistance from them.

Mr. William Deering, a wealthy Chicago, manufacturer, has given $50,000 to the trustees of the Northwestern University, to endow a chair in honor of Dr. N. S. Davis, in the medical department of the university-the old Chicago Medical College, of which Dr. Davis was the founder.

The Harvard medical school received a bequest in 1891 valued at $50,000, under the will of the late Rev. W. C. Moseley, of Newburyport.

The New York Homeopathic Medical College received from the estate of Mr. William Ogden $50,000.

The medical department of the University of Pennsylvania received $50,000 from Dr. William Pepper when resigning his position as provost of the university.

STUDENTS HAVING DEGREES.

It would be of interest to know how the percentage of medical students having degrees in arts or science at the present time compares with the number of such students some years ago, especially since we find the secondary schools constantly increasing the amount of work required of their students and consequently raising the age at which it can be completed; while, on the other hand, the medical schools are all adopting courses of three or four years and at the same time becoming much more rigid in the requirements for matriculation. To determine with any accuracy the number of medical students having degrees in arts or sciences is a difticult matter, for only a few medical schools keep an accurate record of this item. Harvard Medical College is one of the few institutions which keep this record. In it the decrease in the number of graduate students since 1881 has been remarkable. The figures are as follows:

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Here we find that since the year 1884, with one exception, there has been a uniform decrease. The per cent of students holding degrees in Harvard medical school would no doubt compare quite favorably with the number in any other school, and since it is about to add a fourth year to its course the proportion of graduate students will probably be diminished still further.

Medical graduates would doubtless be well qualified for their work if they first completed the entire secondary school course, which President Eliot places at about the eighteenth or nineteenth year; then a college course at 23 and the medical at 26 years of age, or at 27 in those schools which require four years; and allowing them only three years for hospital experience and in which to get located and a practice started, such students might be expected to become self-supporting at 30 years of age. No allowance is made here for the loss of a year or two by failure to reach the required standard at any time, or on account of sickness, or other reason, but it is a steady, nonintermittent course, and one which needs to be sustained by a well-filled purse. At a recent congress of American physicians and surgeons a member claimed that the medical student should have tho A. B. degree, requiring four years; then he

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