of the institutions which constituted departments in heavily endowed universities became less dependent upon tuition fees, they were able to adopt longer courses without considering its effect upon attendance. Besides, about this time the number of medical students was becoming unusually large, so that some schools did not really desire an attendance larger than they could well accommodate. By adopting a longer course they would still have as many students as desired, and they would send out graduates better prepared to gain credit for themselves and for the institution.

Many of the State boards of health now announce that they will not recognize any institution unless it exacts a full three years' course of study and complies with all other standard requirements of education. One of the results likely to follow from this elevation of the course is that there will be fewer new colleges coming into existence, for unless an institution has a good standing with the State boards of health or examining bodies, it can not reasonably expect to meet with much success. But as the present number of medical colleges will be ample for many years to come, no complaint will be made because others can not come into existence. In fact, medical education would be advanced if some institutions already existing were consolidated with others in the same locality.

"The chief difficulty in making a high standard universal lies in the number of the medical colleges. It is, indeed, a sorry admission that the medical schools in this country are the greatest enemy to medical progress, not in themselves but in their number. The remedy lies in their amalgamation. Let the absurdity cease of small towns having three, four, or six of these struggling institutions, no one of which can have a vigorous life.

"There is now all over the country a growing disposition for the universities to take charge of medical teaching and to develop their medical departments with all the zeal they give to the others. We see it in Michigan; we see it in California and Colorado; we see it in Louisiana and Texas as strikingly as in our Eastern States. There is nothing but good in this. The power, the means, the spirit of the university go out to its branch; the university in turn gains by the reputation of its medical faculty, and by the recognition that medicine is an essential part of the new learning which leads on to the highest attainable civilization." 2

EFFECT ON ATTENDANCE OF LENGTHENING THE COURSE.

The question may be asked, How has the attendance of students been affected by the requirement of another year of study? Adding one year to the course means not only increasing the amount of time required, but also an increase in the financial outlay. It would therefore naturally be expected that many young men would be led to seek other lines of employment. In order to determine this question somewhat definitely the statistics for the last five years have been collected of medical, dental, pharmaceutical, and law students, as all of these have had lengthened courses. Instead of any decrease, however, we find the number of students to have grown steadily larger. In 1888-89 the number of medical students was 15,029; since that time the number has gone steadily forward to 19,752 in 1892-93. As yet even the number of graduates has suffered no special loss, except in the dental schools, where the number of graduates in 1891-92 was 1,282 and fell to 507 in 1892-93, when the graduating class first encountered the three-year regulation.

Athough the actual number of students in attendance during the last five years has regularly increased, it is still very probable that many have been kept out by

Since the above was written the regulations have been made still more stringent. In Oregon, Montana, and Minnesota after 1898 an attendance upon four courses of lectures will be required. "The Regents of the State University [of New York] have voted to confer the university degree M. D. only after one year's postgraduate study subsequent to receiving the degree of bachelor or doctor of medicine from some registered medical school, and only on candidates who have spent not less than four years total study in accredited medical schools."-N. Y. Med. Record, July 20, 1895. 2 Dr. J. M. Da Costa, of Philadelphia.

the lengthened course. It should be borne in mind that the same students are now kept in attendance a longer time, and therefore help to swell the enrollment for another year.

a Decrease due in part to failure of one important school to report. b Decrease due to its being the first graduating class affected by the change to a three years' course.

LEGAL CONTROL OF THE PRACTICE OF MEDICINE.

Unless it be the American Medical College Association, probably nothing has contributed so much to the advancement of medical education in the United States as the establishment of State licensing boards, frequently called boards of health on account of a union of their functions. Here we see how far-reaching and important a little clause sometimes becomes, in a law which directs the licensing boards to register all graduates "of colleges in good standing." Probably no one of the legislators who first voted for the bill containing these words, now found in the law of several States, had any idea of what a powerful leverage they would become in the hands of State licensing boards for stimulating medical colleges to lengthen their course of study and raise the requirements for entrance and graduation. But when the Illinois State board announced that no medical school would be regarded in good standing which did not require three courses of lectures, the institutions immediately began to fall into line in lengthening their courses, for in truth many schools had favored such an extension before, but were deterred from taking the step because their competitors did not adopt it. Now, however, they recognized the fact that all schools would soon be compelled to advance their standards. This valuable work of State licensing boards was soon recognized in other States, and now we find such boards in thirty-five States and Territories, all of them contributing to a large extent in placing medical education upon a plane where it will reflect honor upon its followers.

It was not many years ago when, in almost any State in the Union, anyone could hang out his sign as a medical practitioner and charge as high fees as the best quali fied physician in the town. Why, then, should one spend several years in preparing for his work and deplete his purse with the hope of being able to refill it again? It might be said that the meritorious physician would be able eventually to show beyond doubt his qualifications, while the half-educated doctor would be unable to hide his mistakes. That is true to some extent, but the latter generally i

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 meritorions doctor then sees that what he expected has taken place, but as a vacancy has occurred, another one soon moves in who has possibly bought 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 help 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 able physician, and if united with a good degree of dependence on vis medicatrix naturæ 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 time, as individuals, to examine into the qualifications of physicians, to say nothing of the opportunities and knowledge necessary to properly determine such a question. Frequently it is not until soine 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 annual 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, at 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 wish 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

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 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 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 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 authorized to confer the same, or that during or prior to the first year of his medical study within this State he 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 date, showing that the trend of legislation is strongly toward safeguards 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 24, 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.

Reginald H. Fitz, M. D., Boston.

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

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 examiners.

Examination by State board after showing diploma of a college requiring three years of six months.

Diploma.

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 State board after presentation of diploma.

Examination by State board 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.

Do.

Diploma "of a reputable college."

Diploma.

Do.

The words "in good standing," as interpreted 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.

FRAUDULENT 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 the 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 valuable 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 one possessed the diploma it was to be inferred that he also had the required skill and training. Hence a diploma not only gave one the right to practice, but also furnished presumptive evidence of his qualifications. A demand for