Facts and Fallacies Concerning In- 
terstate Reciprocity in Medical 
Licenses. 
A Paper Read, by Invitation, Before the Illinois 
State Medical Society at Springfield, 
May 17, 1906. 
JAMES A. EGAN, M. D„ 
Secretary Illinois State Board of Health. FACTS AND FALLACIES CONCERNING INTERSTATE 
RECIPROCITY IN MEDICAL LICENSES. 
JAMES A. EGAN, M. D. 
SECRETARY ILLINOIS STATE BOARD OF HEALTH. 
The fallacies concerning interstate reciprocity in med- 
ical licenses arise from the very general misconception or 
lack of understanding of the facts and conditions governing 
medical licensure. The forms of reciprocity advocated by 
many physicians would, if enforced, result in the nullifica- 
tion of the provisions of the medical practice acts of many 
states. These laws have been secured, in the majority of in- 
stances, through the efforts of the physicians of the several 
states, who would naturally be loath to see their labors set 
at naught. 
The chief fallacy in interstate reciprocity, however-and 
one can hardly read a medical journal of the present day 
without being impressed how general this misconception is 
among medical men-is due to a lack of knowledge of the 
powers conferred upon the states-or rather, retained by the 
states-and amply recognized by the preamble to the con- 
stitution of the United States. 
That each state has power to regulate, by general laws, 
the practice of medicine within its jurisdiction, has frequent- 
ly been affirmed by the court of last resort-the Supreme 
Court of the United States-which in unequivocal terms has 
declared that the right to practice medicine is not a privi- 
lege or immunity guaranteed to citizens of the United States 
under the Fourteenth Amendment to the Constitution. Yet, 
notwithstanding this-notwithstanding the positive declara- 
tion of Mr. Justice Field in the case of Bartmeyer vs Iowa 2 
(18 Wall, 129), that no one, to his knowledge, pretends that 
the Fourteenth Amendment to the Constitution interfered in 
any respect with the police power of a state,-we have pre- 
sented to us, almost daily, by physicians who are presumed 
to have given the matter much thought and study, proposed 
legislation, which, if enacted, would abrogate the police 
power of the state, and which could not be enacted without 
material amendment to the Federal Constitution. 
Why this should be it is difficult to say. No one ex- 
pects the busy practitioner, whose time and attention are ab- 
sorbed by the professional exactions upon him, to be con- 
versant with the intricate problems affecting interstate re- 
ciprocity. He naturally looks to the board of registration 
or examination of his state whenever he desires information 
on the subject-which is seldom. 
We do, however, look to those who attempt to speak, ex 
cathedra, in the matter, to possess at least a fair knowledge 
of the fundamental principles of the Constitution of the 
United States and the incontestable powers of the state. 
I have referred to the police powers of the state-the 
power under which a state regulates the practice of medicine. 
In the language of the Supreme Court of the United States, 
in the case of Dent vs West Virginia, (129 U. S., 114), "it is 
the power of a state to provide for the general welfare of its 
people, and authorizes it to prescribe all such regulations as 
in its judgment will secure or tend to secure them against 
the consequences of ignorance and incapacity, as well as de- 
ception and fraud." 
In regard to this same power, Mr. Justice Brown, in the 
case of Lawton vs. Steele (152 U. S., 136), says: "The ex- 
tent and limits of what is known as the police power have 
been fruitful subject of discussion in the Appellate Courts 
of nearly every state in the Union. It is universally con- 
ceded to include everything essential to the public safety, 
health and morals." 
Mr. Justice Harlan, in a more recent case-Jacobsen vs 
Massachusetts, (25 S. C. R., 358), speaks still more decided- 
ly concerning the police power of' a state, which he terms: 3 
a power which the state did not surrender when becoming 
a member of the Union under the Constitution." He says 
further: "Although this Court has refrained from any at- 
tempt to define the limits of that power, yet it has distinctly 
recognized the authority of a state to enact health laws of 
every description; indeed all laws that relate to matters com- 
pletely within its territory, and which do not by their neces- 
sary operation affect the people of other states. According 
to settled principles, the police power of the state must be 
held to embrace, at least, such reasonable regulations estab- 
lished directly by legislative enactment as will protect the 
public health and the public safety." 
The Supreme Court of Illinois has had much to say con- 
cerning the extent of the police power of the state. In the 
case of Lakeview vs Rosehill Cemetery, (70 Ill., 191), the 
Court held that the "police power of the state is co-exten- 
sive with self-protection, and is not inaptly termed 'the law 
of overruling necessity." Speaking further of this power 
the court said: "It is the inherent and plenary power in the 
state which enables it to prohibit all things hurtful to the 
comfort, safety and welfare of society. It may be exercised 
to control the use of property or corporations as well as of 
private individuals." The State Supreme Court has also 
held at different times that "all rights, whether to things 
tangible or intangible, are subject to the general police power 
of the state." 
Further upholding the police powers of the state, the 
Illinois Supreme Court said, in the case of Booth vs People, 
(186 Ill. 48), "the law of the land may expressly prohibit and 
make criminal the doing of an act which, in the absence 
of such law of the land, would constitute a liberty or prop- 
erty right within the meaning of the constitution, even 
though such act be not within itself immoral." In the case 
of Williams vs People, (121 Ill. 84), the Supreme Court said 
regarding the police power: "It is the common exercise of 
legislative power to prescribe regulations for securing the 
admission of qualified persons to professions and callings de- 
manding special skill; and nowhere is this undoubtedly valid 4 
exercise of the police power of the State more wise and sal- 
utary, nor more imperiously called for than in the case of 
the practice of medicine. It concerns the preservation of 
the lives and health of the people." 
To return to interstate reciprocity,-although we have 
not yet departed from this subject, for all laws providing 
for reciprocity must be based on the acts to regulate the 
practice of medicine in the state, and these acts are 
directly dependant upon the police power of the state,-it 
may be well to devote a little attention to the proposed 
legislation referred to in a previous paragraph. 
In January, 1906, the New York Medical Journal offered 
a prize for the best essay on Interstate Reciprocity in Licen- 
ses. Several physicians entered the contest; and among 
them may be especially noted Dr. S. A. Knopf, of New York 
a world-renowned authority on the treatment of tuberculosis. 
Dr. Knopf, however, did not compete for the prize. Of the 
several essayists, ten offered the following propositions in 
the order named. To these I wish to call particular atten- 
tion. They were as follows: 
(1) The creation of a National Board of Examiners, 
acting under laws passed by Congress; 
(2) The creation, by the Federal government, of a de- 
partment of Medical Affairs, the passing of whose examin- 
ation would entitle the physician to practice anywhere in 
the United States; 
(3) A comprehensive set of national government ex- 
aminations; 
(4) A voluntary Board of National Examiners, the li- 
censes of which would be accepted in the several states; 
(5) The appointment, by the President of the United 
States, of Examiners at large, who would hold examinations 
in the Capitol of each state or territory; 
(6) The National control of all questions pertaining to 
the examining and licensing of all physicians; 
(7) A National Board of Examiners under the Federal 
law; 
(8) A central board at Washington, which would pre- 5 
pare examination questions for the several state boards and 
afterwards grade the answers; 
(9) A Board of Medical Examiners created by acts of 
Congress; 
(10) And last, the creation of a National Examining 
Commission, to be appointed by the American Medical As- 
sociation,-this Board to prepare the questions for examin- 
ation and send them to each state board, which would have 
the power to grade them, the Commission, however, to be 
empowered to appoint one or other members in each state 
to see that the examinations were properly conducted. 
Assuming that it was the intention of the essayists to 
offer a practical solution of the reciprocity problem, I leave 
it to your judgment to determine whether any one of the 
physicians above quoted has progressed far toward the ac- 
complishment of his purpose. 
The regulation of the practice of medicine comes within 
the police power of a state, a power of which sufficient has 
been said in previous paragraphs, and is in no wise subject 
to Federal control. To put it more plainly, the United 
States Government has no more to do with the regulation 
of the practice of medicine in a state of the Union-a regu- 
lation which leaves the field open to all who possess the 
prescribed qualifications-than it has to do with the regula- 
tion of the form of services in the church in which the 
Illinois State Medical Society is now holding its meeting. 
I have nowhere seen the actual conditions existing 
summed up more clearly, more concisely or more fairly, than, 
in an editorial in the New York Medical Record of March 
31, 1900, reading as follows: 
''It is natural for a physician duly licensed in another 
state to ask why the assumed privileges and immunities 
as a physician of that state do not protect him from the 
necessity of passing a further examination when he comes 
to New York to practice. A full comprehension of this 
question in all its bearings depends upon a proper under- 
standing of the history of the United States. Before the 
several states adopted the Constitution of the United States 
in 1789, each of these several states was a complete inde- 6 
pendent sovereign. When the Constitution was adopted, the 
national government was thereby created with certain 
powers; and those power resulted from the surrender by the 
individual states of certain features of their own sovereignty. 
In order that the sovereignty of the different states should 
not be altogether merged in that of the central government, 
the following amendment was added to the Constitution: 
'The powers not delegated to the United States by the Con- 
stitution, nor prohibited by it to the states are reserved to 
the states respectively or to the people'. 
"It has thus resulted that the individual states were in 
no wise divested of their sovereignty by the adoption of the 
United States Constitution except, so far as that instrument 
shows an express surrender of their sovereignty. In all 
other respects they have retained it. Every state, for ex- 
ample, has retained unimpaired its original power to make 
police regulations, included among which is the right to 
make laws concerning the regulation of the practice of med- 
icine. This proposition has been fully determined by the 
supreme court of the United States, and the courts of the 
individual states have uniformly sustained the power of 
their states to pass legislation of this character." 
And now let us consider for a moment something of the 
character of the solution of the problems of interstate recip- 
rocity offered in this competition to which I have referred- 
offered in the face of the legal limitations which surround us 
in the selection of our remedies. It is of interest to state 
that the prize was awarded to one-Dr. William Warren 
Potter-who, in his solution, suggested no attempt to lodge 
the power of controlling medical practice or reciprocity in 
other hands than those of the state government-a fact which 
is significant of the solidness of his argument, and incident- 
ally, indicative of his familiarity with the law. The members 
and officers of State Boards competing in this contest in no 
instance recommended Federal control. They were appar- 
ently heartily in accord with the principles set forth by Judge 
Cooley in his work on Torts, as follows: 
"No one has any right to practice law or medicine except 
under the regulations the state may prescribe. To practice 
in the courts or to practice medicine is not a privilege of cit- 
izenship, and is, therefore, neither given or protected by or 7 
under the Civil Rights Act of Congress; or the new amend- 
ments to the Constitution. The privilege may be given to 
one citizen and denied to the other, and other discriminations 
equally as arbitrary may doubtless be established. " 
But even Dr. Potter, as clearly as he seems to have 
grasped the legal aspect of interstate reciprocity, fails to go 
so far as the facts would warrant. He is found to say: "One 
of the early suggestions was a national examining board, but 
this was abandoned very soon by the most careful observers, 
because it was apparent that the general government would 
not usurp the police power of the states for the purpose 
named." It would have been more in accordance with facts 
had Dr. Potter, said that "the general government could not 
usurp the police powers of the state, and parenthetically, 
would not if it could." 
The solution suggested by Dr. S. A. Knopf, deserves 
special consideration, coming as it does from one of such rec- 
ognized authority on hygiene and preventive medicine. 
Dr. Knopf advocates the creation of a national organ- 
ization-a Federal Department of Public Affairs-which 
should be empowered as an examining and licensing body, 
and whose certificate should be accepted as authority to 
practice medicine and surgery in any state or territory of 
the Union. He admits that such an organization could not 
be created at once, and recommends, in the meantime, a tem- 
porary medical board, voluntary of course, which shall per- 
form the functions of a United States examining commission. 
For reasons which have been set forth in detail, this 
scheme is entirely impracticable and impossible of execution 
at the present time. We are seeking the possible-not the 
impossible. No plan which contemplates the assumption of 
the control and regulation of medical practice by the Federal 
Government could become operative without amendment of 
the Constitution of the United States, and such an amendment 
could only be obtained by recommendation of two-thirds of 
the members of both houses of Congress or of the legisla- 
tures of two-thirds of the states of the Union and upon 
such recommendation receiving the sanction and approval 8 
of the legislatures of three-fourths of all of the states. 
It is beyond the realm of possibility that the Federal Consti- 
tution which has remained unchanged, even in the face of 
grave national problems, practically since the close of the 
Civil War, would be amended by the people so as to permit 
a physician licensed in one state to practice in another with- 
out a further examination; would be amended so as to deprive 
the several states of their police power-a power which the 
states would not surrender in 1789. We are not living in 
Utopia, and the millenium is not at hand. 
Dr. Knopf states with approval the fact that in all Euro- 
pean countries the medical examination entitles the success- 
ful candidate to practice throughout the entire nation and all 
provinces; that in Germany the man who has passed his ex- 
amination before the Government Board has a right to prac- 
tice in any of the several kingdoms or,minor states. Nota 
great while ago I was favored with an expression of opinion of 
an eminent German physician who had been licensed to prac- 
tice in the German Empire, that it might be better if these 
conditions did not exist in the Fatherland. He seemed con- 
vinced that if every minor kingdom, state or province had 
the power to say who should or should not practice within its 
confines, the Empire would be far freer from charlatanry and 
quackery. Fortunately for the physician, his opinions were 
expressed on this subject on this side of the Atlantic. Had 
they found utterance within the realms of the Kaiser, the 
physician might now be serving a sentence of ten or more 
years for lese-majeste. 
But it is hardly necessary that we should pattern our insti- 
tutions or our practices after those of foreign nations, especi- 
ally those in which a whispered criticism of the regulation of 
public affairs may subject the offender to imprisonment 
"which may be for years and may be forever." 
However, if it may seem advisable for us to determine the 
value of our standards by those of foreign countries, it is not 
necessary that we cross the seas to obtain our statistics. We 
can procure information from countries which are nearer at 9 
home, and concerning which our information is more exten- 
sive and more reliable. 
On our northern borders we find British dominions, con- 
sisting of the Dominion of Canada and the Island of New- 
foundland. Each of the several provinces in this vast terri- 
tory enacts its own medical laws: A license issued in one 
province does not entitle the holder to practice in another. 
A license issued in Great Britain is recognized in but a few 
of the provinces, and then only under special conditions. 
The Federal Government exercises no control over the prov- 
inces in the matter of medical legislation. While two or 
three of the provinceshave entered into reciprocal relations, 
there is no general reciprocity between the provinces. 
The proposition to create a National Examining Com- 
mission, to be appointed by the American Medical Association 
and to perform the duties described by one of the essayists, 
is so obviously absurd that consideration here would seem an 
unneccessary imposition upon your time and patience. How- 
ever, it may be well to touch upon this subject for a moment, 
lest silence concerning it be misconstrued. 
This proposed National Examining Commission bears a 
very close relationship to the voluntary Board of Medical 
Examiners advocated with such enthusiasm but a few years 
ago, after it was realized-by some-that the attainment of 
the much discussed National Board of Medical Examiners 
was beyond the bounds of possibility. 
It may be accepted without question that, if the various 
State Boards of Medical Examiners would delegate the pow- 
ers conferred upon them, by state law to any voluntary or- 
ganization, that organization would be the American Medical 
Association, but it is exceedingly doubtful if there is a board 
that could, if it would, delegate its powers to any body which 
had not legal authority to perform its functions. 
In this connection it may be noted that, in 1893, an effort 
was made to give to the Association of American Medical 
Colleges the right to determine those colleges which should 
be accepted as in good standing with the Illinois State Board 
of Health. This effort brought forth a vigorous remonstrance 10 
from the late Dr. Nathan Smith Davis, a man who certainly 
would not be accused of disloyalty to the Association of 
American Medical Colleges. This remonstrance, which was 
addressed to a member of the Illinois State Board of Health 
read as follows: 
'Chicago, August 23, 1893. 
Dear Sir:- 
Your letter relating to the Association of American Me- 
dical Colleges is at hand. The Association named is a volun- 
tary organization of such medical colleges as chose to appoint 
delegates and comply with its Constitution and By-Laws. It 
has no legal status or authority to fix a standard for any col- 
lege not belonging to it. Consequently it is absurd for the 
Illinois State Board, legally charged with the duty of deter- 
mining what standard of requirements a medical college must 
have to entitle its diplomas to recognition, to attempt to del- 
egate that duty to a number of voluntary college associations 
or societies, any one of which may change its rules every 
year. The action of the Illinois State Board, in adopting the 
rule you mention, was a ridiculous abandonment of the claim 
to regulate the education and practice of medicine in this 
State, persistently exercised during all its previous history. 
Yours truly, 
N. S. Davis." 
Due consideration must certainly be given to the views 
expressed by the man who was aptly termed the Nestor of the 
medical profession, of the United States, Dr. N. S. Davis, 
the "Father of the American Medical Association," even 
by the most ardent advocate of National or Voluntary or- 
ganization control of state medical affairs. 
So much for the common fallacies concerning interstate 
reciprocity-the fallacies in the midst of which we find many 
of the pertinent facts upon which a satisfactory adjustment 
of this subject must eventually be based. 
To-day we hear much of reciprocity. A few years ago 
we heard little or nothing. In 1898 when a bill of which the 
present medical law of Illinois was the outcome, was under 
consideration by the Illinois State Medical Society, reciproc- 
ity was not even suggested. A physician to whom I men- 11 
tioned this fact recently, stated that the omission of reciproc- 
ity from the discussion was due to the fact that at that time a 
diploma admitted to practice in the majority of states in the 
Union. As a matter of fact, over one-half of the states and 
territories even then required an examination for admission 
to practice. 
But while, as I have said, we now hear much of the ad- 
vantages of a reciprocal relation with our sister states, the 
reciprocity discussed and advocated, at least in Illinois, is 
fliat applying to certificates issued after examination. No 
other form of reciprocity seems to possess much interest for 
the physicians of the State. This opinion is forced upon me 
after a perusal of voluminous correspondence on the subject 
in the offices of the State Board of Health. In fact practi- 
cally every communication received at the office of the Board 
on the subject of reciprocity in the case of old practitioners, 
comes from licentiates in other states or those who desire to 
remove to other states. 
It was but a short time ago that I received a vigorous 
protest from a physician in central Illinois, against the action 
of the State Board of Health in declining to license without 
examination, a licentiate of an adjoining state who was 
licensed ten years ago upon presentation of his diploma. I 
have just ascertained that my correspondent desires to 
remove to the state in question. His protest was born entire- 
ly of his personal desires and his self-interest, and not of any 
sentiment for the elevation of the standards of medical prac- 
tice or the betterment of the conditions of practice within 
the State. 
The Illinois State Board of Health reciprocates, not 
under any specific authority of law, but under its general 
powers. Reciprocity, however, is impossible on any other 
basis than after examination, for the medical law of Illinois 
requires an examination. 
Provision for obligatory examination has been sought 
for by the medical profession of Illinois for many years, in 
order that there might be brought about "the separation of 12 
the license from the degree," to use the apt expression of 
the Chairman of the Committee on Legislation of the State 
Medical Society in 1899. 
The medical law on the Statutes from 1887 to 1899 had 
no peer in the United States, as far as it went,-but it did 
not go far enough, according to the view unanimously ex- 
pressed by the Illinois State Medical Society at different 
times. 
An examination was called for by the several thousand 
physicians of the State, who endorsed the medical bills of 
1899 and 1903-which bills were also endorsed by the State 
Medical Society at the Galesburg (1898) and the Quincy (1902) 
meetings. 
The present Medical Practice Act is, in fact, the result 
of the efforts of as large a representation of the medical pro- 
fession of the state as can be aroused to activity for any work 
of advancement of medical education. 
It owes its being primarily to the efforts made by the 
Illinois State Medical Society to elevate the standards in 
Illinois between 1897 and 1899. A bill introduced in 1897 
received but little consideration in the Legislature. At the 
1898 meeting, the State Society, by unanimous vote, unqual- 
ifiedly endorsed the bill presented. The chairman reported 
that he had found the profession almost unanimously in favor 
of its legislative enactment. This bill so favorably and gen- 
erally accepted, provided for the examination of all persons 
desiring to commence the practice of medicine in the state, 
but as stated, contained no provisions for either immediate 
or ultimate reciprocity. 
This bill was submitted by physicians who had given the 
matter exhaustive study and consideration-such men as 
Pettit, Brower, Graham, Hamilton, Moyer, J. B. Maxwell, 
and others whom I might name. At the meeting at which 
this bill was presented for ratification by the State Society 
(1898), Dr. Harold N. Moyer read a paper on Needed Medical 
Legislation in Illinois, which seemed to represent the senti- 
ment of the Society's members. He made a strong plea for 13 
the enactment of a bill along the lines suggested by the 
Committee. He referred to the defects in the existing law, 
and stated that the most serious errors in the control of me- 
dical practice were due to the recognition of diplomas, and 
said that "Legislation was called for which should at once 
eliminate the diploma as a basis of qualification and substi- 
tute a state examination." 
It is to be assumed that Dr. Moyer advocated an exam- 
ination which should apply to all practitioners. If he con- 
templated the exemption of any physicians from such exam- 
inations, he failed to say so. In fact, he stated that the rai- 
son d'etre of many schools was found in the fact that the di- 
ploma was equivalent to a license to practice. These senti- 
ments, as I have said, seemed to bear the approval of the 
members of the State Society and of the medical profession 
in general, and were the provisions which seemed to be re- 
garded essential to a satisfactory medical practice act. 
At the Quincy meeting of the State Medical Society in 
1902-at a time when interstate reciprocity in medical licen- 
ses had become a much more common topic for agitation, the 
bill presented as improving the conditions of medical prac- 
tice in the state, made provision for reciprocity, but only in 
case of certificates issued by other boards after examination. 
This bill also was unanimously endorsed by the Illinois State 
Medical Society. 
Reciprocity was also provided for in the medical practice 
bill introduced in the General Assembly of 1903, at the in- 
stance of the Committee on Medical Legislation of the Illinois 
State Medical Society, but in a further section the proposed 
State Board of Medical Examiners was authorized to accept 
as equivalent of an examination in part of the subjects re- 
quired, satisfactory evidence of one or more years of repu- 
table practice of medicine since graduation. It is evident 
that those who framed this bill intended that the so-called 
"old practitioner," he who was licensed in other states merely 
on the presentations of a diploma, should qualify in Illinois, 
if he intended to practice therein, solely through the medium 
of an examination. 14 
From the attitude which the Illinois State Medical So- 
ciety and the medical profession of the state have taken to- 
ward the enactment of laws to regulate the practice of medi- 
cine in Illinois, it is to be fairly assumed that the sentiment 
is almost unanimous that no one shall be admitted to practice 
until he has demonstrated, by examination his educational 
qualifications and attainments, and it is but fair to presume 
that no form of reciprocity contemplated in later years 
should be based upon other than this general principle, and 
that its privileges should be extended only to those who 
had passed examinations, and had met educational require- 
ments practically equivalent to those exacted in our own 
state, under the law in force. 
The only protest against such a form of interstate re- 
ciprocity which deserved serious consideration was the pro- 
test from the older practitioners of medicine in other states, 
who while in many instances unqualified to pass satisfactory 
examinations in the little-used elementary branches of med- 
icine, are unquestionably thoroughly qualified for the practice 
of the profession. But protests of these older members of 
the profession have been considered and have been acted 
upon by the Illinois State Board of Health in a way which 
does not alter the general requirements, which does not 
violate the specific requirements of the statutes, and which has 
proven equally satisfactory to the state and to the old prac- 
titioner. By a resolution passed by the Illinois State Board 
of Health at its meeting in October, 1904, the old practi- 
tioners of other states are allowed a credit of five per cent, 
on the required seventy-five per cent. of. successful answers 
for each five years they have been in active practice. 
The New York Medical Journal in commenting upon 
this action by the Illinois State Board of Health voices the 
general approval with which the resolution has been re- 
ceived, saying editorially:- 
"The Illinois State Board of Health, one of our most 
progressive sanitary bodies, has lately adopted a resolution 
that will materially aid the established practitioner, rusty 
though he may be as to his elementaries, to pass its examina- 15 
tion for the license to practice. By the terms of the resolu- 
tion, on and after January 1, 1905, the Board will accept as 
an equivalent of a part of the examination required 'satisfac- 
tory evidence of live or more years of reputable practice of 
medicine and surgery since graduation, and will allow a 
credit of five per cent, upon the required average of seventy- 
five per cent, for each period of five years of such practice 
on the part of a candidate for a certificate.' We hope that 
this move in the direction of justice will be followed by other 
state examining bodies." 
The trend of opinion expressed by medical editors, on 
what I may term the "Illinois method of dealing with the old 
practitioner" indicates that its adoption has contributed ma- 
terially to the right of the Illinois State Board of Health to 
the title so graciously conferred upon it by the editor of 
American Medicine-"the leader in practical reciprocity". 
By the establishment of reciprocal relations with various 
states having practically equivalent requirements of prelim- 
inary education and examination, and by providing equitably 
for the older practitioners upon a sliding scale in constant 
relation to the years which have elapsed since medical college 
study, the State Board of Health seems to be carrying out 
what were certainly the wishes of the medical profession 
when our present laws were agitated-and that without work- 
ing hardship upon the only class which seems to have legiti- 
mate grounds for a plea for special consideration. 
But it is frequently said that the methods of examination 
in Illinois now in operation do not meet with the approval of 
a large per cent, of the members of the medical profession 
of our state. To be sure, the statements to this effect are 
made almost solely by physicians of other states, and by 
members of State Boards who advocate reciprocity on the 
basis of diploma licensure; still as they have been, and are 
still being made, they call for attention and consideration. 
If the law is unsatisfactory then the law should be amend- 
ed, and amended it can easily be if the medical profession 
of the state so will. 
I cannot believe that there is any considerable number 
who would advocate any deviation from the policy of exam- 16 
ination of applicants. But accepting examination as desir- 
able for recent graduates, is it, as believed, the desire of the 
profession that we enforce the rule in the case of the older 
practitioners also? 
Is it wiser that we should continue the examination of 
old practitioners from other states who desire to enter upon 
practice in Illinois, making ample allowance fortheir years of 
practice, as is done under the provision of the present law, 
or to secure an amendment to the law, which will permit the 
State Board of Health to license, without examination, grad- 
uates of reputable institutions, who possess the licenses of 
other states issued seven or more years ago? 
As you are doubtless aware, a number of western states 
have adopted a qualification for reciprocity which provides 
that a certificate of registration issued by the proper board 
of any state, may be accepted as evidence of qualification for 
reciprocal registration in any other state, provided the hold- 
er of such certificate has been engaged in the reputable 
practice of medicine in such state at least one year, that he 
was the possessor of a diploma issued by a medical college in 
good standing, and that the date of his diploma was prior to 
the legal requirement of the examination test in such state. 
The Illinois State Board of Health has been urged to 
adopt this qualification, but has constantly declined to do 
so-first, because the law does not permit the licensing of 
physicians except after examination; and second, because 
the members do not believe in the practicability of this form 
of reciprocity. The adoption of such a qualification would 
mean that the Illinois State Board of Health would be com- 
pelled to license, without an examination, the holder of a 
diploma from a seemingly reputable medical college who ob- 
tained a license in any other state previous to 1899, on the 
presentation of a diploma, when the license was his for the 
asking. 
It is significant that this provision has been urged upon 
the Illinois State Board of Health principally by physicians 
residing outside of the State, and would not be expected, if 
entirely free from selfish motives, to be so markedly solicitous 17 
regarding the welfare of Illinois physicians. During the past 
five years, in which time this matter has been frequently 
agitated, the State Board of Health has not been asked to 
adopt this qualification by a dozen Illinois physicians. Those 
who urged this form of reciprocity in Illinois either had re- 
moved or were desirous of removing to other states. I have 
never heard a prominent practitioner of Illinois raise his voice 
in support of the qualification, although this form of recip- 
rocity has been advocated constantly for five or more years 
past by the boards which have adopted it, and has been given 
wide publicity in the Journal of the American Medical As- 
sociation and other periodicals. 
If the members of the Illinois State Medical Society 
favor this form of reciprocity, the members of the Illinois 
State Board of Health wish to be advised of the fact in order 
that they may properly govern themselves. The reciprocity 
desired by the members of the medical profession of Illinois 
is the form of reciprocity which will be advocated and en- 
forced, when possible, by the State Board of Health. 
Intimately associated as I have been with physicians of 
the State of Illinois in their efforts to secure higher stand- 
ards of medical education, I cannot resist the conclusion that 
the vast majority do not desire any measure which will re- 
duce or lower the Illinois requirements of medical practice. 
As regards general interstate reciprocity, I am impressed 
that it may be obtained with an elevation rather than a low- 
ering of standards and requirements, without the intervention 
of the Federal government; without revision of the Constitu- 
tion of the United States; and without very radical changes 
in the laws of the various states. In fact it is my impression 
from the progress already made in this direction, that the 
several states will sooner or later adjust themselves to the 
conditions necessary for the establishment of proper recipro- 
cal relations without any material statutory changes. Those 
states which will require further legislation to permit inter- 
state reciprocity in medical licenses are in the minority. 
But when further legislation is called for the most im- 
portant point is to secure practically uniform medical laws- 18 
laws which will give to the boards of the various states prac- 
tically the same powers and practically the same limitations, 
and which will establish practically the same requirements 
of medical education, or authorize their several boards do to 
so. Absolute uniformity of medical practice laws is hardly 
within the range of possibility, nor is absolute uniformity in 
any way essential. With laws practically the same, there 
should be a provision in the statutes making it obligatory 
upon boards to extend reciprocity to states which maintain 
the same standards for medical licensure. There are a few 
states in the east and west, whose laws are such that recip- 
rocity could be established by the action of their examining 
and licensing boards, and yet these boards arbitrarily refuse 
to consider reciprocity under any circumstances, even with 
those states having requirements superior to their own. In- 
cidentally, it is the arbitrary attitude of these few states 
which interferes more than any other factor with the attain- 
ment of the desired end, and the passage of reasonable rules 
by these states must be the first step towards the establish- 
ment of general interstate reciprocal relations. We may 
overlook the failure of a board to embrace so popular a mea- 
sure as interstate reciprocity if the state laws prevent such 
action; but it is exceedingly difficult to palliate the attitude 
of the board empowered to act and yet which persistently 
refuses to take advantage of its power. 
Each state could and should retain the right to accept 
or reject any individual applicant, as might be determined 
by moral character and the board's individual estimate of 
the good standing of the college from which he is graduated. 
Ample and fair provision should be made for the old practi- 
tioner, as is done in Illinois, and thus, in my belief, proper 
reciprocity can be secured without an entire re-organization 
and revolution of the medical practice laws of the states of 
the Nation. ADDENDA TO PAPER. 
Attention has been directed in the foregoing paper to 
solutions of the problems of interstate medical reciprocity, 
which have been suggested recently. It will not be out of 
place to discuss here the following recently published opin- 
ions on the subject of medical laws, especially as these come 
from such an eminent authority as the President of the 
American Medical Association. 
In his presidential address delivered at Boston on June 
5th, 1906, at the annual meeting of the American Medical 
Association, the President, Dr. William J. Mayo, said: 
"Another question of great importance is 
that of reciprocity in medical license. The con- 
ditions are now well-nigh intolerable and restrain 
the individual freedom guaranteed by the Constitut- 
ion. The boundaries between the states are imagin- 
ary lines; yet a physician on one side of the border 
cannot relieve human suffering on the opposite side 
without becoming amenable to the law or subject- 
ing himself to vexatious examinations which he has 
already successfully passed in his oion state. This 
must be met and speedily by agreement between 
examining boards as to the minimum of require- 
ments." 
In connection with Dr. Mayo's remarks the editor of the 
Journal of the Association, in the issue of June 9th, says: 
"there are few who will not agree with him in what he says 
in regard to state licensure and reciprocity. " 
It may be that there are many who will agree with Dr. 
Mayo that the conditions now existing "are well nigh intoler- 
able," but with all respect to President Mayo and the editor 
19 20 
of the Journal of the Association, there are but few who 
have given the question of National and state control of the 
regulation of the practice of medicine proper consideration 
who can agree that the conditions set forth by Dr. Mayo 
actually exist. 
In the logical consideration of a problem, we must deal 
with facts, not with fancies. In an attempt to solve a prob- 
lem we must, if we are to attain success, deal with the finite, 
not the infinite; the possible, not the impossible; with prac- 
tice, not with theory. 
The right to practice medicine is not a part of the in- 
dividual freedom guaranteed by the Constitution. As has 
been aptly stated "the individual states were in no way di- 
vested of their sovereignty by the adoption of the United 
States Constitution, except so far as that instrument shows 
an express surrender ot their sovereignty. " The regulation 
of the practice of medicine comes within the police power of a 
state, a power which the states have retained unimpaired 
since 1789. 
"The boundaries between tlie states are imaginary lines," 
in but imagination. In reality the state's boundary lines are 
as stable and definite as the National boundary lines. State 
lines existed prior to the National lines. In the original 
establishment of the United States, the state lines were the 
definite and well defined lines, while the Federal lines have 
remained expansive to be adapted to the extension of the 
states constituting the Union. The line between Illinois and 
Indiana, where no geographical line of demarcation is to be 
found, is quite as definite and exact as the line between the 
United States and Canada, or that between Austria-Hungary 
and the Russian Empire. 
The necessity for a physician on one side of the border 
of a state relieving human suffering on the opposite side, is 
not obvious except in case of dire distress, where an emer- 
gency exists. Under these circumstances a border line physi- 
cian can practice without let or hindrance, and no state board 
will interfere with him. But there is seldom an emergency, 
seldom a case of dire distress, which cannot be given attention 21 
by the physicians of the state in which it occurs. Nearly 
every state has its quota of capable and qualified physicians. 
But it has been said that a citizen of one state taking ill 
in another state cannot be attended by his family physician 
unless the latter be licensed in the state in which the patient 
lies. I deem it sufficient to call for statistics of prosecutions 
instituted in the various states on account of practice of this 
character. I refer now to practice in an individual case, by 
the bona file family physician. I do not refer to the practice 
of the itinerant. I do not refer to the practice of the tour- 
ist who is often too prone to consider himself the family 
physician of all persons-and their friends, relatives and ac- 
quaintances-coming from his native state. I do not refer 
to the practice of the physician who, when summoned to an- 
other state to treat his patient, treats all who apply to him. 
But even now the laws of nearly forty states permit the 
practice of physicians from other states in consultation. 
It would be exceedingly difficult for any state, which 
must remain the controlling power in medical licensure until 
the Constitution of the United States is radically changed, 
to draw a line which would limit the invasion of physicians 
from other states if the natural state boundary lines were 
ignored. The state line must be the logical and only prac- 
tical limitation for the practice of the physicians of each in- 
dividual state. 
As to the limitations placed upon practioners of the 
various states, the statements of Dr. Mayo are misleading. 
The restrictions upon those who have already successfully 
passed examinations in their own states are gradually dis- 
appearing under the present systems of reciprocity. Few 
physicians who have successfully passed examinations in 
their own states are required to pass examinations in other 
states. Thirty-seven states are now empowered to recipro- 
cate, of these twenty-six do reciprocate. But it must be borne 
in mind that the per-centage of physicians who have passed 
examinations of any kind in their own states is small. 
It may be added further, in commenting upon the brief 
extracts quoted from Dr. Mayo's presidential address, that, 22 
among the majority of boards which have found reciprocal 
relations consistent with the laws under which they operate, 
a definite understanding has been reached in regard to the 
minimum requirements of medical education. 
June 9, 1906. 
James A. Egan.