ever established without including one or more physicians in its membership, and in very many instances the entire board consists of medical men.

It is therefore important, not only that educational facilities should be afforded for this branch of official work, but that they should be of the highest character. It is also important that such men should receive special training in the recognition of the principal infectious diseases, by means of clinical instruction. It is on account of the lack of this education that errors in the diagnosis of small-pox are of very frequent occurrence among those who are called on to fill the position of health officers of cities. A recent writer1 states that in 2 different towns of about 10,000 inhabitants, every physician except I failed to recognize small-pox. In another town of 4000 inhabitants all but I physician failed to recognize the disease. In another town with an outbreak of 30 to 40 cases the disease was called a "continued eruptive fever", no one recognizing it, and this mistake has occasionally accounted for the rapid spread of the disease.

The development of the laboratory as a useful adjunct, not only of medical education, but also of state and municipal sanitary work, has contributed vastly to the successful operation of boards of health and the prevention of the spread of disease and the consequent lowering of the death-rate.

There can be no doubt that the recent general inauguration of a system of state examinations of applicants for license to practise medicine has had a good effect in raising the standard of medical education throughout the country, in suppressing quackery and diminishing the number of ignorant pretenders and consequently of producing better material from which competent health officers may be selected.

The old time practitioner, the country doctor, an all-round physician who was accustomed to rely on his own resources, and to accept all emergencies which came to his door, even to

1) Article on medical education by Dr Geo. G. Groff, American academy of medicine. Bulletin. February 1898. p. 248.

the extraction of teeth, the occasional performance of a capital operation, or relieving the distress of a sick or injured domestic animal, is becoming less and less numerous, while every branch of specialism is full to overflowing. One great reason for this changed condition is the tendency to urban aggregation in all parts of the country. It was quite a common saying at an earlier period that 1000 people were sufficient to support a physician, as an average throughout the community, and that was about the usual proportion. Possibly, the former part of this statement is true to-day as an average, since a very considerable portion of the whole number of medical men is in the position of waiting for support.

The actual number of registered physicians in the United States, according to the most recent count, shows an average for the whole of about 1 to 647 inhabitants, but the proportion in the different states varies greatly. California appears to be the state which is most liberally supplied, the proportion there being physician to 420 inhabitants, while in Iowa nearly the same conditions prevail. On the other hand, in North and South Dakota and New Mexico, the proportion was respectively 1 to 1285, 1296 and 1391 inhabitants.

The following table presents the figures for each state. For some of the states the figures will probably require revision at the next census but may be regarded as approximately correct. The relative conditions in each state are also graphically shown on chart No. 5.

REGISTRATION OF MEDICAL PRACTITIONERS

The first general movement in the direction of establishing general or state boards of health began about the middle of the century, and resulted in the establishment of the Louisiana, Massachusetts and California boards before the close of 1870.2 No recent or successful movement, however, was organized in the direction of limiting and restricting medical practitioners, till a law was enacted in Illinois, in 1877, for the regulation of medical practice and conferring authority for its

1) In the chart facing this page, the space assigned to Oklahoma is blank, in consequence of uncertainty as to the population at the time of preparing the chart, but information received later affords an opportunity to state the population for 1898 with reasonable accuracy, and hence, to present the figures given above (see appendix 1, p. 87).

2) See notes on these boards in appendix 3.