There is much misunderstanding in this country regarding the duty of the state in relation to the health of the people. It does not consist in discriminating between schools or systems of medicine, but in requiring without prejudice or partiality of all who seek a license to practise for gain on the lives of fellow beings a minimum preliminary and professional training.'

Midwifery Special tests for certificates of registration as midwives are required in:

In the following political divisions the provisions of the medical practice acts do not apply to women engaged in the practice of midwifery:

In other political divisions, though there are some special provisions for certain localities, the general acts regulating the practice of medicine make no reference whatever to the practice of midwifery by women. It would seem, therefore, that these laws restrict the practice of midwifery to

In the November 1898 Medical record, W. A. Purrington of New York asks if we are to punish the physician who fails to report contagious diseases and allow a person who boasts his ignorance of medical and sanitary science to treat and conceal such cases. Medical laws provide only, at most, that no person shall practise medicine who has not studied medicine; a licentiate may practise as he pleases. But there is no reason why unqualified persons should be allowed to pretend to cure disease, by their pretenses deprive the sick of the benefits of science, and yet escape the just consequences of their imposture.

Either examination or approval of diploma.

3 Those practising midwifery without a certificate can not enforce collection of fee, but this does not apply to the practice of midwifery by women in the town or locality in which they reside.

In Nebraska, North and South Dakota the practice of "medicine, surgery or obstetrics" without a license is prohibited.

licensed physicians. Nevertheless a large proportion of the children in these political divisions are brought into the world by ignorant midwives, and as stated by Dr M. J. Lewi of New York, many women are physical wrecks through their incompetence. Practically the conditions in political divisions where the laws seem to restrict the practice of midwifery to licensed physicians are little better than in political divisions where the practice of midwifery by women without a license is authorized by statute. There will probably be little change for the better till the midwife receives legal recognition and the practice of midwifery is regulated by definite statutory provisions.1

Graded system of instruction - In 1859 the Chicago medical college, now the medical department of Northwestern university, was established to test the practicability of a thoroughly graded system of instruction. Students were divided into three classes, and each class was examined at the close of the year. Each of the three courses was six months in duration. Attendance on hospital clinical instruction and practical work in the chemical, anatomic and microscopic or histologic laboratories were required for graduation. In 1871 the Harvard medical school adopted a similar plan. The Syracuse medical school followed and today the graded system of consecutive lectures is the rule.

In 1896 Pres. Eliot wrote substantially as follows: Within 25 years the whole method of teaching medicine has been. revolutionized throughout the United States. The old medical teaching was largely exposition; it gave information at long range about things and processes which were not within reach or sight at the moment. The main means of instruction were lectures, surgical exhibitions in large rooms appropriately called theaters, rude dissecting rooms with scanty supervision, and clinical visits in large groups. The lectures were repeated year after year with little change, and

1 In New York no agreement has yet been reached regarding a midwifery statute. At the November 1899 meeting of the Federation of women's clubs a resolution favoring the licensing of trained nurses by the University of the State of New York was adopted.

no graded course was laid down. There was little opportunity for laboratory work. The new medical education aims at imparting manual and ocular skill, and cultivating the mental powers of close attention through prolonged investigations at close quarters with the facts, and of just reasoning on the evidence. The subjects of instruction are arranged, as at the Harvard medical school, in a carefully graded course, which carries the student forward in an orderly and logical way from year to year. Laboratory work in anatomy, medical chemistry, physiology, histology, embryology, pathology and bacteriology demands a large part of the student's attention. In clinical teaching, also, the change is great. Formerly a large group of students accompanied a visiting physician on his rounds, and saw what they could under very disadvantageous conditions. Now instruction has become, in many clinical departments, absolutely individual, the instructor dealing with one student at a time, and personally showing him how to see, hear, and touch for himself in all sorts of difficult observation and manipulation. Much instruction is given to small groups of students, three or four at a time-no more than can actually see and touch for themselves.

Medical schools and medical students in 1899 — In 1899 there were excluding graduate schools 156 medical schools in the United States with 24,119 students. The growth in medical students in 21 years has been 142 per cent. Of the 156 schools 125 are regular1 (21,619 students), 21 homeopathic (1833 students), 7 eclectic (582 students), and 3 physiomedical (85 students).

Of the 156 medical schools, 135 hold day sessions, 5 have evening sessions, 9 have both and 7 do not report this item. 74 are departments of colleges or universities, 82 are separate institutions. 152 grant degrees.

In addition to the undergraduate schools there are 8 graduate medical schools which had in 1898, 624 instructors

1 The name commonly applied to the traditional school of medicine. Other designations are the " old," "allopathic" or "heteropathic" school.

and 1813 students of whom 59 were women. In 1899 these schools had 1916 students of whom 73 were women. Nearly half of the students were in the New York schools.

The ratio of physicians to population is 1 to less than 600 in the United States while in foreign countries it varies from I to about 1100 in the British isles to 1 to about 8500 in Russia. We are said to have in proportion to our population four times as many physicians as France, five times as many as Germany, six times as many as Italy.

There are more medical schools in the United States alone than in countries whose total population is six times as great, and yet few of these medical schools in the United States have endowments corresponding to those so lavishly made to other educational institutions or in any way proportioned to their needs. Fortunately the closing years of this century seem to indicate a change in the attitude of philanthropists toward medical schools. In 1897, 14 medical schools reported endowments of $648,262. In 1898, 19 medical schools reported endowments of $1,906,072.1 In New York the advanced requirements for license have been accompanied by extraordinary growth in the property of medical schools, specially in greater New York. A fine building was erected in 1897 by the faculty of the Bellevue hospital medical college. The College of physicians and surgeons, with the Vanderbilt clinic, doubled in size by the additional gift in 1895 of $350,000, and the Sloane maternity hospital, greatly enlarged in 1897, now make the most complete plant in existence for scientific medical education. The Polhemus memorial clinic has been completed and thoroughly equipped, providing accommodations for the outpatient and medical school departments of the Long Island college hospital. In the medical division of the Flower hospital, opened in 1896, the New York homeopathic medical college now gives excellent opportunity for the study of practical medicine. The New York medical college and

1 From 1894 to 1898 the most notable gifts and bequests amounted to $2,631,000 for medical schools and $16,593,701 for hospitals.

hospital for women opened in 1898 its handsome building in West 101st street. An amount reported at $1,500,000 was given in 1898 to build, equip and endow the new medical department of Cornell university in New York city.'

Hygiene and state medicine - More attention should be paid in the United States to instruction in hygiene and state medicine. In Great Britain no one can be appointed a medical officer unless he has a special diploma in public health. In this country little opportunity is afforded for general or special sanitary work on broad lines. This subject is now under discussion and doubtless progressive states will soon provide places where medical officers of health or other persons engaged in sanitary work can obtain practical and scientific training. The scientific investigations which would be made in the laboratories of such schools would be of great value to the public.

In Medical education of the future, an essay in Educational reform which every thoughtful man should read, Pres. Eliot writes: "State medicine has many objects in view. It aims not only to protect the public health, but also to increase it. In state medicine individualism is impracticable for it is impossible for the individual to protect himself. The social cooperation, which in our days the state alone can enforce, is needed to promote security against disease and progress toward better average health and longer life. To take all possible precautions against the spread of infectious diseases is simply an act of good citizenship. Nothing but medical supervision will accomplish the objects of state medicine; and there are no agents so effective as physicians to spread through all classes of the community an educated sense of sanitary decency. Only the state can guard against dirty milk, corrupted water-supplies, impure ice, adulterated drugs, spoilt meat and fruit, and filthy and over-crowded tenements. Only the state can enforce the isolation of cases of contagious disease, the suppression of epidemics, and the

1 Our medical school will be splendidly housed and endowed. Any statement beyond this is purely unofficial.- Pres. Schurman, Sep. 27, 1899.