NEED OF A STATE BOARD OF MEDICAL EXAMINERS. liY JOHN R. ROBERTS, M. D., PROFESSOR OF SURGERY IN THE WOMAN’S MEDICAL COLLEGE OF PENNA., ETC. FROM THE Medical and Surgical Reporter, March 15, IS9O. [From the Medical and Surgical Reporter, March 15, 1890.] NEED OF A STATE BOARD OF MEDICAL EXAMINERS.1 JOHN B. ROBERTS, M. D., PROFESSOR OF SURGERY IN THE WOMAN’S MEDICAL COLLEGE OF PENNA., ETC. Mr. President and Gentlemen of the Society : I do not propose to read a definite paper to-night, because it seems to me that there is danger, in a subject as long and as im- portant as this, that a paper written might be too long, if I said all that should be said, and might not be as impressive as if spoken off-hand. It may be familiar to some members of the Society—it certainly is in the recollection of a few—that in 1884 I had the honor to read before the Society a short paper enti- tled “ The Legal Control of the Medical Practice by a State Examination.” After the reading of that paper a committee was ap- pointed to prepare a bill to be presented to the State Legislature. This was prepared and presented, but no action was taken on it. It is not worth while going over the various arguments which were used in that paper to show the necessity for a State Board of Medical Examiners, or for some 1 Read before the Medical Jurisprudence Society, of Philadelphia. 4 legal control of medical practice, nor is it necessary to read to you the voluminous documents I hold in my hand. Since 1884 the topic has been discussed in nearly every county medical society in this State, and has been earnestly considered by the Philadelphia County Medical Society, the State Medical .Society and the American Medical Association. It seems to me that the best way to take it up is to say in the first place that this bill was not intended by any of us, who have brought it forward or who speak in favor of it, to protect the medical profession. I would not support any bill designed to pre- vent other physicians practicing in this State who were educated graduates of medi- cine. The only basis upon which such a law can be proposed is that it protects the State ; in other words, it insures to the State the best working capacity of its citizens, it in- sures to the State the longest life of its citi- zens, and the smallest number of paupers, as under its enforcement those that become disabled or sick will be as far as possible more rapidly restored to health than if sub- jected to the dangerous care of uneducated and ignorant doctors. The present need of a State Board of Medical Examiners and Licensers is due in the first place to the present defective con- dition of the existing law. The present registration law, which was enacted in 1881, is defective in a number of ways. It pro- vides that every man practicing medicine in the State of Pennsylvania shall be registered in the Prothonotary’s Office. If he has a diploma from a medical institution situated 5 outside of Pennsylvania, he must present his diploma for indorsement to a faculty giving instruction in medical science in this State. Now the fault in the law is this : It says that a man, coming from ouside this State, that is, from Europe or Australia or South America or from New York, Ohio or any other State, shall present his diploma to the faculty of one of the colleges; and that said faculty being assured of the genuine- ness of the diploma and of his qualifica- tions as a physician shall indorse his di- ploma, which he shall then take to the Prothonotary’s Office and present for regis- tration. After this he shall be a duly registered physician and entitled to prac- tice. The law, you see, therefore, is very indefinite. The indorsing faculty must be assured of the genuineness of his diploma and of his qualifications. Now how can a Dean of the Faculty of one of the colleges in this State be assured of the qualifications of another man who comes into this State to practice, excepting by examining him? How can he be assured of the genuineness of the diploma which is presented to him for indorsement? He can write, it is true, to the distant college which is supposed to have issued the diploma. He may get an answer, he may not get an answer. He may hear from that college that a man with the name corresponding to that on the diploma graduated at such and such a time, but how does he know that the man who presents this diploma is the man who is named ? It is easy enough for one to give the name cor- responding to that on the diploma presented. A man was discovered some time ago, who, 6 it was said, had been practicing on a di- ploma granted to his father. This shows the defect in the law as to the genuineness of the diploma. The defect as to the qualifications of the applicant is far greater; and has been met by some of our medical colleges by their insisting that a man who comes to have his diploma regis- tered shall pass the same examination as their own students do. This puts the faculty to much trouble and necessitates the applicant’s paying a fee of $2O or $3O. He has got to pass the examination in this case and pays a higher fee than if the State Board of Medical Examiners was created by the enactment of the proposed bill. Besides, the examination is likely to vary in each college, and the applicant will probably seek the easiest and cheapest. So much for the defect of the present law in this regard. Again, many diplomas have been accepted by Prothonotaries throughout the State, and particularly in the country towns where the Prothonotary’s clerks knew very little of the appearance of diplomas, which were bogus diplomas; that is, bought outright, or not diplomas at all, but simply certificates. Thus there are many persons registered at the present time who possess no diploma, or merely a diploma for which they have paid. Of course this thing does not affect us so much in the large cities as it does in the country districts. The country has suffered more than the cities in this respect. I am told that in one of the counties the Pro- thonotary’s clerk accepted and filed with great diligence, as a genuine diploma, a 7 letter which set forth that the man presenting it was a hospital steward in the German army. On this document he became a legalized practitioner in Pennsylvania. Another defect in the law is that these diplomas shall be presented to a medical school or college and be indorsed, but does not describe what sort of a medical school. There is one medical school which does not touch undergraduates. I refer to the Poly- clinic, of which I have the honor to be a member. Over and over again we have been asked to examine and indorse diplomas of men who have graduated out- side Pennsylvania, but we have declined to do so. We could do so, because the Poly- clinic is certainly a medical school and the law does not restrict the indorsing school to schools for undergraduates. The view that our faculty has taken is this, that as a post- graduate college cannot grant diplomas and convert citizens of Pennsylvania into physi- cians, it should not make a graduate who comes from a foreign State a legalized Penn- sylvania physician. A second argument in favor of the Medi- cal Examiner’s bill is that there are, as you know, similar laws bearing on pharmacy and dentistry. They do not in all respects cor- respond with the law we propose, because the conditions are quite different, but they have for their object the protection of the public from dangerous ignorance on the part of druggists and dentists. That there is need for some examination of graduates is, I think, very apparent, from what has been said in the various numbers of recent medical journals. 8 For example, we know that the Army and Naval Boards of the United States examine men for admission as Assistant Surgeons in the army and navy. The applicants are graduates of medical colleges, and yet a very large'number of them are found to be totally unable to pass the necessary examination for admission to the medical corps of the navy or army. I believe it is more of an honor to be a member of the medical corps of the army or navy of the United States than to hold the diploma of any college in this con- tinent, none excepted, because I know that men cannot get into the army and navy without passing a very severe examination, which is probably a better test of ability than any examination that is ever passed at any of our colleges of medicine. I have here a paper prepared by Dr. Jack- son showing some of the answers which have been given by graduates when examined by State Medical Examining Boards, or by the Army and Naval Medical Boards; and as I read these questions and answers to you, even those of you who are not medical men can measure the calibre of these graduates. They were graduates and often doubtless of good schools; but there is a temptation, when the professors who teach at the same time give the diploma, to let students slip through the final examination. Especially is this so if they know his father or if they feel he is a poor young man. A professor once said to me, “These men come here and stay two years at study, and it is very hard to reject them when you know their money is all gone and that they perhaps have fami- lies depending on them.” 9 These are some of the answers which have been given : “ The corpus callosum is that part of the dura mater which separates the cerebrum from the cerebellum.” “ The vertebral artery communicates with the cavernous sinus.” “ The aortic artery makes its exit between the first and second ribs.” “The peritoneum is a serious membrane lining the belly and extending into the chest, covering the heart and lungs.” “ The boiling point of Fahrenheit is about 3°°°.” “The normal temperature of the human body is from 1120 to 140°. “ The temperature of the body in African fever is 96°, much above the normal tem- perature of the body, which is 920 F.” “The temperature of the system is vari- ble. In health the cuticle stands at 700.” “ The average respiration are 70° per minute.” “ The symptoms of delirium tremens, of which I have had numerous cases, are dilated pupils, hot, dry skin, slow pulse and glassy eye.” “Galen introduced vaccination or inoc- ulation in the seventeenth century.” “ Acupressure may be pressure by a tourni- quet, by a V-shaped bandage, by a pad, or by the hand.” “Acupressure is made with the finger or any other instrument.” “ The laryngoscope is a short tube, which you put into the throat to look through.” “ The tuberosity of the tibia is the part broken in Pott’s fracture.” “ Ranula is a disease of the eye.” “ Coxalgia is an inflammation of the coc- cyx. ’ ’ “ Scarlatina is an eruption of the head and face.” “What is dengue or break-bone fever?” ‘c A fever that comes on soon after the bones are broken. The patient should be cau- tioned against moving, for fear the bones should break.” “ The best way to facilitate the expulsion of the placenta is to let the woman get up and walk about the room, allowing five min- utes to elapse after delivery before requiring her to get up and walk.” “ Phymosis is the result of old age.” “The difference between galvanism and electricity is that one of them is the sub- stance itself and the other its use.” “ The most simple form of galvanized battery is the Leyden jar.” “Phosphorus burns and makes nitrogen gas.” “ In apothecaries’ weight there are sixteen ounces to the pound.” “The technical name of rhubarb is col- umbo.” The following were given by doctors said by their diplomas to be learned in the science and art of medicine as the proper doses of the respective drugs, for administra- tion by the mouth ; Powdered cantharides, 40 grains; tartar emetic, 10 grains; cor- rosive sublimate, 1 grain ; atropia, 60 grains, or 10 grains hypodermically. One did not know what placenta previa was; another believed pneumonia to be a particular disease of one lung, and pleurisy 11 the name given to it when it affected the other. A third wrote that for orchitis, “ extirpation of one or both testes must be submitted to, being the last and only re- source to be had that can possibly save the patient.” A fourth, having absented himself from an examination, explained that he “had been ill with cholera infantum.” Here is a list from the medical board of Virginia showing the number of rejections of candidates from some of the colleges which have been represented by graduates who were applicants for license to practice in Virginia : The work was done by the Medical Ex- amining Board of Virginia from January 1, 1883, until October 9, 1888. Medical College of Virginia, 57 appli- cants, 8 rejections. University of Virginia, 33 applicants, 1 rejection. College of Physicians and Surgeons, of Baltimore, 34 applicants, 10 rejections. University of Maryland, 34 applicants, 9 rejections. Jefferson Medical College, 12 applicants, 3 rejections, Bellevue Hospital Medical College, 6 ap- plicants, 1 rejection. University of City of New York, 7 ap- plicants, 2 rejections. Louisville Medical College, 2 applicants, 1 rejection. Columbus Medical College, 3 applicants, 2 rejections. There are many other medical colleges mentioned, but this partial list is sufficient to prove the inefficient knowledge of at least some of the graduates of well-known insti- tutions. There have been several objections made to the bill, which I think ought to be an- swered before I sit down. It has been said that if the Governor is given the power to appoint without any supervision he might appoint men who are unacceptable to the profession—men who are not competent to examine. It is said that only teachers know how to examine, and therefore as this bill excludes men hav- ing connection with colleges from serving on the board, it would be impossible to find suitable examiners. To this I would answer that the Examining Boards of the Army and Navy are made up exclusively of physicians from the army and navy who of course are not teachers. Moreover there are many physicians in Pennsylvania now unconnected with medical schools who have at some period been teachers in scientific schools or quiz masters in medical colleges. These would make good examiners. To get over the objection that the Gover- nor would have liberty to appoint whom he chose, the bill reads that the various State Medical Societies shall submit lists of names to the Governor, and that he shall choose from these lists the members of the Board,1 Opposition, it is said, will come from the schools and colleges. I admit that some of the schools may dislike the idea of their diploma losing its power as a license. Schools, I think, are short-sighted who look at it in that way, because if this law is 1 This feature of the bill was subsequently modified. passed it will have a tendency to keep men in the State who desire to study medicine, because they will say, “If we remain in Pennsylvania and study in the State schools, we will be better able to pass the examina- tion of the State Board, and can then prac- tice without going to the trouble of another examination.” I think such a law would have a tendency to add to the classes in the schools. I may state that I looked over the mem- bership list of the Warren County Medical Society the other day and found that only two men in that Society had graduated from colleges in the State of Pennsylvania. They were mostly graduates of colleges in New York, Ohio, or Maryland, who had come into Warren County, finding it a good place to practice. Now if there was a State Examining Board at the time these physi- cians graduated, it seems to me that they would have been more likely to have entered the schools in the State than to have gone outside the State in order to get their medi- cal education. A State Examining Board with power to license has worked well in other States. It gives the State a better class of men to take charge of the health of its citizens, and diminishes the number of sick thrown on the bounty of the State, because of incapacity due to poverty from ill-health. Finally, it is a fact that the profession de- mands such a law. The subject has been discussed at several annual meetings of the State Medical Society, and overwelmingly approved. The bill has been advocated by the Philadelphia County Medical Society, 14 and by very many other societies throughout the State. The medical journals have ap- proved of the principle of the bill. Of course such a board, to be just, should not be expected to recognize any sect of medi- cine ; there should be no mention or allusion in the law to special doctrines or special methods or practice. The present bill is framed with this as its underlying principle; and is equally fair to all forms or systems of practice, all of which have the same right to be represented in its composition.