August 13, 1886.] 



SCIUJ^CU. 



149 



judges would consider so low a standard as to be 

 ridiculous and useless. The demands are widely 

 different, and con-esponding differences exist in the 

 soui-ces of supply, that is, in the medical schools. 



There is a class of medical schools in the United 

 States whose object is to give the minimum 

 amount of instruction which will enable a man 

 to commence the practice of medicine without 

 much danger of making such serious and glaring 

 blunders as will be readily detected by the public. 

 There are other schools whose aim- and object is 

 to make faiiiy well trained practitioners : the gen- 

 eral character of the instruction given in these 

 being substantially the same as that given in your 

 English hospital schools. The results of such a three- 

 years' graded course of instruction in medicine as 

 these schools furnish, depend upon the character 

 of the material upon which they work ; that is to 

 say, upon the general preliminary education pos- 

 sessed by the student at the time of his matricula- 

 tion. This is evidently too often defective, and 

 only a few schools have thus far ventured to 

 establish any standard of preliminary examina- 

 tion which at all approaches in its demands that 

 which is required in England. 



As a rule, the efforts which have been made to 

 secure legislation upon medical matters in Amer- 

 ica have come from the profession itself and have 

 been chiefly urged and recommended by physicians. 

 The general public, and even the educated pubhc, 

 has shown very little interest in the matter. It 

 dees not demand protection against ignorance, 

 but entrusts the care of its health and the lives of 

 those who are nearest and dearest to it to almost 

 any one who announces himself as prepared to 

 take charge of them. The number of those who 

 profess to practise medicine in the United States 

 and ai'e not qualified to do so is undoubtedly large, 

 though by no means so large as one might sup- 

 pose after listening to the impassioned eloquence 

 which is duly aired every year upon the subject. 

 There are some advertising charlatans, and travel- 

 ling quacks are occasionally to be met with, but 

 they are rare. 



But what evidence have we as to the results upon 

 the health and life of the people? What shall 

 we take as the measure of the difference of skill 

 in physicians ? The death-rate? If we compare 

 the death-rate of the United States with those of 

 other civilized countries, we find that it is as low 

 as any with the exception of Sweden. Does a 

 low death-rate mean better sanitary condition, or 

 more skill among the doctors ? For the last 

 twenty years the death-rate has been diminishing 

 in England ; the average amount of life for each 

 person here has been increased, but I observe 

 that the sanitarians claim this as proof of the 



value and importance of their efforts, and that 

 nothing is said about its being in any way due to 

 increase in medical skill or to improvements in 

 medical science. Evidently this test is not a 

 convincing one. Almost the only matter in which 

 figures seem to demonstrate the importance of 

 superior medical education and skill is in the 

 statistics of deaths due to childbirth and of the 

 results of surgical operations. 



The proportion of deaths from childbirth to the 

 number of births is decidedly greater in the rural 

 districts than in large cities, and among the colored 

 than among the white population. Similar dif- 

 ferences are found in England, and are undoubted- 

 ly due to the better treatment afforded in the cities 

 by the surgeons and hospitals. 



Now, seeing that really efficacious legislation 

 with regard to medical education or to the prac- 

 tice of medicine must, like all efficacious legisla- 

 tion, be substantially in accord with public opinion, 

 since it is impossible to continue to punish for any 

 length of time that which public opinion does not 

 condemn ; and as the great mass of the people of 

 the United States have not as yet had such evi- 

 dence as they can understand, and which would 

 thoroughly convince them that it is to their in- 

 terest to suppress quackery, it follows that it is 

 necessary to go slowly and to allow such evidence 

 to accumulate. 



To me it seems that the most important of the 

 first steps to be taken in this direction is one 

 which has aheady been taken in Great Britain — 

 namely, the requirement that every death in the 

 community shall be registered, and that in such 

 registration satisfactory evidence shall be given as 

 to the cause of death, sufficient at least to prove 

 that such cause is what is known as a natural 

 cause, that is, that it is not due to crime. When 

 it is admitted that one of the duties of gov- 

 ernment is to provide for such registration, it fol- 

 lows, necessarily, that those persons whose certifi- 

 cates as to the cause of death are to be accepted 

 must present evidence that they are properly 

 qualified to make such certificates. 



So far as the art of medicine is concerned, the 

 demand has much, though by no means all, to do 

 with regulating the quantity and quality of the sup- 

 ply ; and there are few localities in the United 

 States where the quaUfications of the medical man 

 are not fully up to the standard which the commu- 

 nity is able to appreciate and is walling to pay for. 

 The laws regulating the practice of medicine in the 

 United States are all state laws. Of the various 

 methods which have been tried in different states 

 to insure by law that physicians shall be properly 

 qualified, I will call your attention to two which 

 are of special interest. 



