Commonwealth of Massachusetts.

BOARD OF REGISTRATION IN MEDICINE,

STATE HOUSE, January, 1897.

To His Excellency ROGER WOLCOTT, Governor.

SIR-In compliance with the requirements of chapter 458 of the Acts of the year 1894, the Board of Registration in Medicine submits its annual report for the year ending Dec. 31, 1896.

The number of applications received during the year is 508; the number of applicants registered is 452; rejected, 56; making a per centum of 89 registered and 11 rejected.

The regular meetings of the Board as required by law are held on the second Tuesday in March, July and November. No dates, other than the regular meetings, are especially assigned for the examination of applicants. During the past year three special meetings have been held.

Except in certain cases owing to physical inability to write, or for some other substantial reason, the examinations are conducted wholly in writing. It is the intention of the Board to make its examinations as practical as possible, free from technicalities and catch-questions, the object being to "test the qualifications of the candidate as a practitioner of medicine." The questions given to the different members in a class are the same; the answers are marked on a scale of 1 to 10, and the rating is obtained by making an average of the footings in the different subjects. Registration is refused when the average thus obtained is less than 70 per centum.

At the November examination 70 applicants were present, 24 of whom were unsuccessful. Of the unsuccessful, 20 had been examined previously, 19 of whom again failed. The questions were the following:

PATHOLOGY.

1. Given the body of an infant, how would you determine the fact that death occurred after birth?

2.

Give the various lesions found in a fatal case of septicemia. 3. What post-mortem changes may take place in the stomach? How explained, and how would you differentiate from ante-mortem conditions?

4. What is meant by arterio-sclerosis? What organs other than the blood vessels show coexistent changes?

5.

. 1.

Describe the nutmeg liver.

PHYSIOLOGY.

What results from the use of an excessive amount of albuminous food?

2. Explain the action of the vaso-motor nerves.

3.

4.

5.

tem?

What are the functions of the mitral and the tricuspid valves?
What part does bile take in the digestive process?

What nerves connect the heart with the central nervous sys

OBSTETRICS.

1. Called in consultation after several hours of second stage of labor, you find the brow presenting and the funis prolapsed and pulseless. Give treatment.

Give three positive signs of pregnancy, and the period at which each may be recognized.

3. What influence do the examthematous diseases (variola, measles, scarletina, erysipelas) exert upon pregnancy and the fœtus in utero?

4. After six months of pregnancy, your patient has more or less constant but increasing bloody vaginal discharge, no pain nor any history of accident. Give diagnosis and treatment.

5. Give in detail the method of using antiseptics in obstetric practice.

PRACTICE OF MEDICINE.

1. What are the indications in acute diseases of the larynx which necessitate tracheotomy.

2. Differentiate by physical signs pericarditis from pleuritis in first and second stages.

3. How by physical signs can you distinguish a murmur caused by anæmia from that caused by an organic lesion of the heart? Give in brief the indications for treatment in each case.

4. Describe chorea, also epilepsy and catalepsy. Give treatment in each case.

5. Is prophylaxis important in phthisically inclined patients? If so, why, and what would be your method or advice?

SURGERY.

1. State the symptoms of acute intestinal obstruction and how you would treat a case.

2. Diagnose ovarian tumor and fibroid growths of the uterus. 3. Give etiology and diagnosis of pyelitis, and treatment.

4. Describe Scarpa's triangle. Name the muscles forming it, and give the relation of the vessels and nerves within the triangle. 5. In an old rupture, describe in detail the operation for restoring the perineum.

The registration act, as amended by the last Legislature, is mandatory that all applicants must be examined as to their qualifications for practice. Certificates of registration in other States, or diplomas of graduation from medical colleges, therefore, are not received in any case in lieu of an examination. This is as it should be. Any system of registration not conditioned on a reasonably rigid examination into the qualifications for practice of every applicant will, we believe, prove unsatisfactory and unproductive of lasting benefit.

It is well known that the numerous medical institutions in this country differ from one another widely as to their requirements for graduation, or for conferring the degree of "Doctor of Medicine." This fact alone is conclusive as to the necessity of an examination by examining boards. Indeed, some of the so-called medical colleges make little or no requirement except the payment of certain fees. In other words, they are "diploma mills," organized and operated for the sole purpose of selling certificates of graduation. Nothing can be more clear than that this sort of business unfortunately receives direct encouragement, from the fact that the laws in several of the States regulating the practice of medicine provide for the registration of persons holding certificates of graduation from any medical institution chartered and empowered to confer degrees in medicine, without requiring any examination whatever as to acquired qualifica

tions for practice. The mere possession of a diploma, no matter from what source received, if from a chartered institution, is held as prima facie evidence of fitness for professional work. A registration based upon such requirements only is sure ultimately to result in more harm than good. It encourages not only the establishment of fraudulent institutions, but becomes an incentive to the average young man seeking a medical education to patronize a low-grade school. It therefore indirectly tends to lower the standard of medical education, and open the way to practice for a larger per centum of poorly trained professional men. In view of such facts and tendencies, the recent discussions in medical journals and by medical men and societies in several of the States, in favor of a national registration law, or of requirements for registration that shall be uniform in all of the States, are most timely and important and are entered into most heartily by this Board.

The promoters of the registration act designed that the Board should be self-supporting, that the Commonwealth should not pay out of its treasury for the administration of the law more than the amount received in fees by the Board and paid into the treasury. But, in order to meet the expenses of the Board in its endeavor to secure a thorough enforcement of the law against illegal practitioners, the fee required from applicants for registration must be largely increased. In the last annual report, in discussing that section in the law which provides that it shall be the duty of the Board to investigate all complaints of disregard, noncompliance or violation of the provisions of this act, and to bring all such cases to the notice of the proper prosecuting officers," the Board stated that its experience in this respect had not been satisfactory; that in many instances where such notice had been given no prosecution had followed, and the violators of the law had been permitted to continue in their illegal work indefinitely. The experiences of another year add new force to this criticism. The Board has found it necessary, in most instances, in order to secure prompt action, or indeed any action at all, not only to notify the prosecuting officer of violations of the law, but personally

to look after all the details of evidence necessary to secure conviction in the courts, and even to employ counsel to conduct the prosecutions. Such demands on the Board will add largely in the future to its expenses, in a way not contemplated when the law was enacted.

The Board therefore recommends that the law be amended, so that all applicants for registration shall be required to pay a fee of twenty dollars. When it is considered that there is no other expense attending registration, and that when once secured it becomes continuous and in force in all parts of the Commonwealth, this amount cannot be considered exorbitant. Were a renewal of registration required each year, or on completion of a term of three or even five years, the case would be very different. In nearly all of the other States in which registration is effected through examining boards the fee is not less than the amount here recommended, while in New York, New Jersey, Pennsylvania and in several other States the amount required is still larger.

It is to be regretted that more stringent provisions were not made in the law, as originally enacted, in regard to registration before the Board was charged with the duty of conducting examinations. Not only were graduates of medical colleges resident in the Commonwealth admitted to registration, but also persons of little or no professional training who had carried on some sort of medical practice in the State continuously, for a period of three years next prior to the passage of the law. No other required qualifications were set forth in the law, not even a certificate of good moral character. The result was, that during the allotted period of six months nearly all the persons practising medicine in the Commonwealth, the educated and the uneducated, the graduate and the non-graduate who could substantiate his claim to three years of continuous practice, improved the opportunity to secure registration on such easy terms. On the first of January, 1895, therefore, when those provisions of the law became operative which require applicants to submit to an examination as to their qualifications for practice, the registration list contained the names of nearly four thousand practitioners. If it should be said that this list contains the