and to permit every man to use his powers and opportunities in whatever manner he may prefer, with the single condition that, in the exercise of his own individual right, he shall not trespass upon that of another. It is the wise practice of our governments to refrain from doing for the individual anything which he can as well do for himself.

The natural tendency to forget this principle creates the greatest danger which State medicine has to encounter. In our eagerness to do all that lies before us, in our keen appreciation of the great desirability of accomplishing certain ends, we are in danger of losing sight of the distinction between things proper for State medical authority to do, and things which are desirable in themselves but belong properly in the domain of individual effort.

I dwell upon these fundamental principles because the future of State medicine, especially in a country governed, as ours is, by public opinion, will be determined by the degree of conscientious care exercised by its executive agents in confining themselves strictly within the limits of their proper functions.

It is inevitable that the enforcement of public right in these matters shall interfere somewhat with the interests and convenience of certain individuals, and the enmity of men thus interfered with, and that of their friends, must constitute a hostile agency, working constantly upon public opinion, alert to turn to account against the system whatever it can seize upon for such use. If the system is to be maintained, unembarrassed by effective criticism, it must be kept free from liability to just censure. It must look for justification to the public conviction that its work is not only beneficent, but necessary; that the functions conferred upon it are conferred in the public interests for a necessary public purpose, which could not be accomplished by private effort. It is important, therefore, that we shall, in the outset, draw the line very sharply between the respective domains of State and individual action; that we shall keep the distinctions thus made clearly in view, and that we shall, in this inquiry, keep strictly to the broad principle that governs the matter in order that there may be no possibility of stumbling, no occasion for defense.

The broad principle may be formulated thus: State medicine is charged with the protection of the health of the people from dangers which are beyond the control of private effort; its just functions are derived from necessity, and the necessity constitutes their limit; in their exercise, every unnecessary invasion of private right, every unnecessary interference with the perfect freedom of personal action, is a usurpation of power, an unjustifiable trespass upon the liberty of the citizen.

With the limits thus set, there is much for State medical officers to do, and brief as the history of the system has been, it has already accomplished notable results.

Its work relates primarily and directly to three principal subjects. These are first, medical education; second, sanitation; third, quarantine. Incidently and indirectly it has other functions not less important, namely, first, the education of the people in sanitary laws, and, second, the advancement of science. It is to the credit of the medical profession that, in invoking the authority of the

State in behalf of the public health, and in exercising the powers granted the State Board, the first efforts have been directed to reforming the medical corps of the State by seeking to cast out ignorance, pretension, incompetence, and all manner of quackery. Through the work of the Board, the profession has deliberately said to the people: "Your greatest danger is from ignorance and the iniquity of pretending physicians, and we have sought, and are seeking, to protect the people at this point, by subjecting the qualification of all persons desiring to practice medicine to reasonable and satisfactory tests."

The extent to which ignorance, incapacity and fraudulent pretense actually afflict the people is well illustrated by what has happened under the working of the "Act to regulate the practice of medicine. in Illinois."

Briefly stated, its provisions with reference to physicians, required only that every physician should have his qualifications to treat disease subjected to a fair and reasonable scrutiny; that the result of such scrutiny should be officially recorded, and that men who should be insufficiently prepared for the proper discharge of their functions as physicians should fit themselves by further study, or should abandon practice in the State under penalty. In executing this law, the State Board of Health has taken pains to govern itself by the rule of great liberality in its tests. It has set up no arbitrary rule of exclusion. It has fully recognized not only the existence and the authority of what are called different schools of practice, but the right of private judgment and opinion also.

In the examinations held by the Board, respect has been paid to differences of opinion upon therapeutics, and theory and practice of medicine.

Diplomas have received from the Board so much respect as they were entitled to, and no more. That is to say, diplomas of those schools which are known to graduate students only when reasonably well educated, have been accepted as proof of the fitness of their possessors to treat disease; while diplomas which properly create no such presumption, have been held to be insufficient evidence of qualification.

On the other hand, practitioners who have no diplomas at all have not been excluded. All who have not been in practice in the State ten years previous to the act taking effect, have been required simply to submit to a reasonable examination of their acquaintance with the science of medicine. In a few words, the Board of Health in its enforcement of the law, has sought simply to ascertain, in each case, whether or not the person undertaking to treat disease was properly qualified to discharge his functions intelligently and with skill. Nevertheless, even under so liberal a system as this, one thousand seven hundred and fifty men who had been practicing medicine in Illinois, have been compelled, by their discovered ignorance and unfitness, to abandon practice or quit the State.

When the law went into effect, there were about 7,400 persons practicing medicine in the State, of whom 3,800 were non-graduates. There were 423 practicing under the pretended authority of spurious or fraudulent diplomas, and 67 under assumed names. There were

73 itinerants and 23 "cancer doctors."

After the act had been in force three years-that is, in 1880-the number of non-graduates practicing in the State was reduced to about 1,500, the itinerants to 9, and the "cancer doctors" to 4.

The number of graduates from reputable medical schools had increased from about 3,600 to 4,825.

The question arises at this point, how far and in what way State authority may properly provide further against ignorance and incapacity in the practice of medicine. There cannot be two opinions respecting the right and duty of the State to forbid men without medical education to practice medicine; but it is certain that even under the restrictions provided in Illinois, and some other States, there is room and opportunity for incompetence to work ill. It has been found necessary, therefore, to scrutinize very closely the claims of various medical colleges to respect as educational institutions. Graduation from many even of those which cannot properly be called fraudulent schools had been found to be much too easy; it has been found that the diplomas of some of the schools really testify to no adequate preparation. Some of them have so inferior a standing in the profession, and mean so little, that the Board has had to refuse to accept them as proof of their possessor's education in medicine.

In the case of others, the schools have been notified that their diplomas will command respect only after they shall have made certain improvements upon their present methods of teaching and examination, advancing the standard of acquirement necessary to graduation. The effect of these measures, especially when they shall become general in the States, will be to cure a very serious evil which is uncommonly difficult to deal with by other methods. Let me suggest some of the peculiar difficulties that have been encountered by the advocates of higher medical education.

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They make doctors very easily now," said a distinguished physician recently; and the fact is beyond dispute, even if we exclude all the fraudulent "colleges," and many of the less thorough, honest schools from the account. The truth, known to every physician, is, that it is possible and not difficult for men imperfectly fitted for the profession to secure diplomas from reputable medical colleges. There are two desirable standards which are in a few colleges only held high enough to make fitness certain in every case, namely: first, the standard of preparatory education and general intelligence, which ought to be reached before matriculation in a medical college; and, second, the standard of acquirement in medicine, required as the condition of graduation. There are thoughtful men whose opinions are worthy of respect, who regard indifference to the first of these requirements as a more serious evil than neglect of the other. Medicine is not so exact a science, and the practice requires so large and constant an exercise of trained judgment, acute discernment and broad, active intelligence, that the lack of that preliminary cultivation of the faculties upon which the soundness of judgment and alertness of perception depend may fairly be reckoned as even more fatal than insufficiency of technical training. The standard of the colleges is too low, however, in both respects. The most that can be truly said of any medical school in this country is that it affords an intelligent, properly prepared and conscientious

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student all necessary means of acquiring a sound and sufficient medical education. In few of them are the conditions such that the student must actually get such an education; in but few of them is it made impossible for ill-trained men to secure diplomas; yet every diploma is the certificate of the college that its possessor is well and properly trained in his profession.

The desirability of elevating both standards is felt by the authorities of every reputable medical school, but the obstacles which stand in the way of reform are great and peculiar. The difficulty grows out of the unfortunate fact that the medical schools are forced into rivalry with each other, for the patronage of students. Without endowments for their support, the schools must depend upon the fees of students for funds with which to maintain themselves.

In these circumstances, an advance of the standards of admission and graduation in any medical school or increased rigidity in the maintenance of existing standards practically involves the decay of the school itself.

Students insufficiently prepared for the study of medicine, and students in haste to graduate with the smallest possible expenditure of effort in technical study, will naturally shun the school whose requirements are severe, because they may secure their diploma elsewhere more speedily and with smaller effort.

For the practical purposes of the student, the diploma of the easy-going school is as good as that of its stricter and more conscientiously conducted rival. The reforming school, therefore, simply reforms itself out of existence by driving away the students whose fees are necessary for its support.

The right remedy for this evil would be judicious liberality on the part of the public in providing adequate endowments for those schools which are disposed to maintain high standards of qualification. If that was done such schools would lose students, perhaps, for a time, but they could afford to do so, and in time the difficulty of securing graduation at their hands would so enhance the value of their diplomas that a new incentive to attend such schools in preference to laxer ones would operate powerfully in their favor. In the absence of conditions so desirable, however, much good in this direction is sure to be accomplished by State requirements acting directly both on colleges and on students. When the States generally shall adopt a course similar to that taken by Illinois, the hands of the conscientious schools will be upheld by a powerful influence. Students will not attend a medical school whose diploma is denied recognition in any considerable number of the States, and thus the very end sought by the schools in lowering the standards and relaxing their rigidity of requirement, namely, the attracting of students to their lecture rooms, will be attainable only by reversing the rule, advancing the standard, and holding candidates for graduation strictly to their duty.

It is not the function of the State to train and educate physicians, or even to provide facilities for their education; that is a matter belonging strictly within the domain of individual effort. But in the way just pointed out, what we call State medicine can and must operate to advance the standards of the colleges and cure the defects of the existing system of medical education. If this is an in

direct result, it is one far reaching and beneficent, and it should be counted not the least among the good fruits of the system.

With respect to the two remaining points in which State medicine is a directly acting force, namely, quarantine and the enforcement of public sanitary regulations, the necessity for governmental interference is obvious. The dangers which are to be guarded against by quarantine and sanitary regulations uniformly have the test characteristics of things proper to be dealt with by public authority. There are grave dangers to the whole community which are wholly beyond the control of individual care. As an individual, I cannot protect myself against the danger of the yellow-fever infection which the reckless selfishness of a fugitive from some fever-stricken city prompts him to bring to my door in his baggage.

As an individual, I am powerless to compel my neighbor to keep his drains in proper condition; and the dangers from these sources which assail me equally threaten every individual in the community in which I reside.

If the neglected drain of my neighbor endangered only himself, there would be neither occasion nor, strictly speaking, right for the interference of a health board. If the luggage of the fever fugitive contained disease-germs dangerous to himself alone, the State could not take possession of his goods without violating his private right. But these things, and things like them, threaten the health, the lives and the prosperty of whole communities, and are therefore distinct violations of public right, and it is with violations of public right that the State, through the law, deals.

The duty of government to establish and maintain quarantine and sanitary restraints is therefore obvious and undisputed.

The only points that are open to discussion with respect to this branch of the subject are those which relate to conflicts of authority on the one hand, and those which concern methods on the other. Our peculiarly complex system of government and the utter failure of anything like coincidence between State lines of business and social communication, give rise to some vexing problems with respect to local, State and national health jurisdiction. How shall quarantines be maintained? By whose authority, and under what restraints? These are grave and perplexing questions sometimes, and they are made the more difficult of correct answer by two facts: First, that local jealousy and business greed frequently seek to turn the public anxiety to wrongful account; and, second, that the territorial limits of State or municipal jurisdiction sometimes forbid the efficient performance of the necessary duty.

It is frequently found that the gate which must be shut against infection lies beyond the territorial jurisdiction of the threatened community, or of the State of which it is a part. In like manner

the inhabitants along a State's border are powerless to protect themselves, even with the aid of the law, against unsanitary conditions existing on the other side of the imaginary line that bounds the jurisdiction of the State in which they live. On the other hand, local health boards have been known to use their power of quarantine for the unjust injury of rival cities and towns in business, a form of abuse which needs to be guarded against with the utmost vigilance.