665

fsc’; that in a tube containing gelatin, protected(uly by a thin layer of cotton wadding, there can

? no development of organic life so long as this

:ug remains in situ, but that when a similar tube is

inoculated with any single kind of organism, he is able,

having seen the seed-tube, to prognosticate with the. utmostcertainty what will be the nature of the growth and of the

changes that will take place in the gelatin as soon as theinoculation has been made and the cotton-wadding plugreinserted. The student has before him a concrete fact.

He knows that if the anthrax bacillus is sown the anthrax

culture will make its appearance in the gelatin-there is

the characteristic naked-eye growth, there are the character-istic changes in the gelatin, whilst the microscopic appear-ances are also readily recognisable. From this it is but a

step to the comprehension of the fact that in order that theanthrax bacillus may appear in the blood of an animal the

?erm of the anthrax bacillus must be introduced from with-

out. When this is associated in his mind with the definite

symptoms that characterise the disease, the student has laidthe foundation of a knowledge of antiseptic surgery whichconsists in keeping out specific organisms from the culti-vation grounds that are offered by open wounds ; and hehas also grasped the principles that underlie the study ofinfective diseases, their causation and their prevention. It

should now be essential that every student should receive a

t5ort course of instruction in practical bacteriology ; and

although this would naturally fall under the head of

practical pathology, the subject has such wide and intimateconnexions with, and bearings on, other parts of the curri-culum that it might with almost equal propriety be claimedby the chemist, the biologist, the physiologist, the hygienist,the surgeon, and the physician.The medical practitioner of to-day is confronted at every

turn by problems to which, without some knowledge of i

bacteria, of their life-history, and of their effects on the

human organism, he is unable to obtain any satisfactoryolution; and nothing has been more striking in the evolutionof modern medicine and surgery than the intimate relation

that is daily being made more and more evident between

specific bacteria and specific forms of disease. Although,as we have already said, it may be impossible for the

indent to devote any lengthened period to the study of

bacteriology, he should at any rate give to it sufficient

attention to enable him to have at command certain details

of technique for instant application. No practitioner canoe said to be even fairly well educated in the practiceuf his profession who is unable to stain tubercle bacilli,! like cultivations from the throats of diphtheria patients,aid recognise the various micro-organisms that may be

found in a swab taken from such a case or in the pus from

a surgical wound or an abscess. Indeed, the bacteriologicalwork of the 14 side room is developing with such rapiditythat "clerks" are now, in many of the well-equippedmedical schools, expected to be able to prepare and

recognise the organisms that are found associated with allthe more common of the specific infectious diseases ; and-0-igh the preparation of nutrient media in flasks and test-tapes cannot there be carried on, an acquaintance withthe methods of inoculation of these tubes and flasks

and the principles that underlie such inoculation is,

under certain of the more thorough of our clinical

teachers, most carefully insisted upon. To meet the

demand thus created we find that in London alone

there are now several well-equipped bacteriological labora-tories where a thorough course of instruction can

be obtained by the medical student. Guy’s Hospital,University College Hospital, and St. Bartholomew’s Hos-

pital, for example, have all acquired special facilities forcarrying on this work ; but there is still much room for the

more general teaching of the subject. In the large universitymedical schools, especially those of Oxford, Cambridge, Vic-toria, Durham, Edinburgh, Aberdeen, and Glasgow, the sub-ject is more or less thoroughly taught, but not in all casesin so practical a fashion as is desirable. Bacteriology, how-ever, is a subject of comparatively recent growth, and manymen who have left their student days behind but a yearor two had no opportunity of acquiring even the most

elementary knowledge of the subject; they now feel thatit is necessary to make good this deficiency. Preventive

medicine may be said to have become truly objective whenbacteria were recognised as the cause of disease ; and therecan be little doubt that the great success that has beenattained in this country in connexion with our sanitation

departments has been largely due to the fact that-some-

times unwittingly, but always very surely -our medicalofficers of health have aimed at bringing under control allthose conditions that are favourable to the growth ofmicro-organisms. Dirt being matter in the wrong place,sanitary dirt may be looked upon as bacteria in the wrongplace ; and it is now the object of every sanitarian to bringthese bacteria into their right position, receiving their aidin the disintegration of dead organic matter, but preventingthem from developing in any place where their presencemight be harmful. As a result of all this, post-graduation courses in bacteriology have now been in greatdemand for some years. They have always been suc-

cessful wherever well conducted, and the demand for theinstruction given in these classes is still increasing. In

Berlin, Paris, and Vienna admirably conducted courses are

always being carried on, but the demand for places in themhas become so great that graduates and students have towait sometimes for months and even for years before theycan be admitted. In London there are facilities for such

study at the British Institute of Preventive Medicine, at

King’s College, and in the other medical schools mentioned,where there is a regular class of instruction ; whilst facilities ..

for original investigation are offered at the laboratories ofthe Conjoint Board of the Royal Colleges of Physicians of £

London and Surgeons of England and in several of the

above-mentioned laboratories. Bacteriology, though up tothe present somewhat neglected in this country, is graduallycoming to take its proper position.

THE LEGALITY OF BRITISH QUALIFICATIONSABROAD.

FOR one reason or another a considerable number of

medical men decide to leave the British Isles and to settle in

practice abroad, either in the British colonies or the countries

belonging to other nations. This being so, a few remarksas to the conditions of practice in the various countries

cannot fail to, be of &bgr;e to readers of THE LANCET.

666

As regards the British colonies there are not many

openings for practice except for those who are willing to"rough" it and work hard. In Canada there are some

outlying districts of British Columbia where a good start

might, perhaps, be obtained, but in Australia the prospectfor the British practitioner is not greater than that whichfaces him in Great Britain. The profession is everywhereovercrowded, and owing to the great depression many prac-titioners have had to leave the Colonies, others have left t

metropolitan centres, and many are very hard pushed tomake both ends meet. The graduates of the Colonial Uni-versities every year more than meet the usual vacancies, andthe local men as a rule get on better than strangers, havingfriends to talk of them and help them to official positions.As to the prospects of British practitioners going to the

United States we may say that there is always an oppor-tunity for a well-qualified man in a large community, butcertainly there is no dearth of medical practitioners in themore thickly populated portions of the States, the averagebeing not less than 1 to 500 of the population.

It may be well to state that difficulties as to identification

may often be obviated if the intending emigrant has hisdiplomas and certificates endorsed by the Consul in Englandbefore sailing.

In regard to Italy the English-speaking practitioner is

practically free to exercise his calling without let or

hindrance. We hope to deal with his prospects in a futureissue

CANADA.

As a rule the possession of British diplomas and degreesentitles the holders to practise in Canada after havingobtained a licence from the Provincial Medical Boards,

paid certain fees, and registered their qualifications.Ontario.-Practitioners must be registered by the Council

of the College of Physicians and Surgeons of Ontario. In

certain cases registration is optional on the part of the

Council.

Qltebec.-A licence to practise without passing an examina-tion may be granted by the Provincial Board to holders ofBritish or Colonial diplomas.New -Bruns,7vick.-The registration fee is$10. There

appears to be an annual payment of from$1 to$2.

Nova Scotia.-The registration fee is$20.Manitoba.-Practitioners must be registered by the

Council of the College of Physicians and Surgeons of

Manitoba.

British Columbia.-A fee not exceeding$100 is chargedfor registration.Prince Edward Island.-A fee not exceeding$20 is

charged for registration.-North West lerritories.-The registration fee is$50 and

there is an annual payment of from$1 to$2.

AUSTRALIA.

There are no examinations. Registration is compulsory inVictoria, Queensland, and Western Australia at least.

TASMANIA.

A certificate entitling to practise may, without examina-tion, be obtained from the Court of Medical Examiners.

NEW ZEALAND.

CAPE COLONY.

It is necessary to obtain a licence signed by the Colonial

Secretary on the recommendation of the Colonial Medical

Council. The fee is 5.

NATAL.

It is necessary to obtain a licence from the Natal Medical

Board. The fees vary from 1 to 3 guineas.UNITED STATES OF AMERICA.

The requirements for the practice of medicine in the

United States are now undergoing rapid changes. A short

time ago there were no Government requirements in the

States, and there are a few States, perhaps half-a-dozen, inwhich that is now the case, but all the others have some

sort of legal requirement varying from registration to a.

State examination. This variation in the requirements inthe different States is probably only temporary, and will bereplaced in a few years by a uniform standard in all theStates, or at least in different sections of the country, It

would be wise for anyone going to America to go with

the expectation of having to pass an examination.1

SOUTH AFRICAN REPUBLIC (TRARSVAAL,’ In 1894 the Volksraad passed a law that no one shall be" advertised" as a medical practitioner, dentist, or drugoistunless his name appears in the Register of the Medical

Board, the penalty for contravention thereof being fine or

imprisonment. Another regulation provides that medical

men and dentists practising within the Republic shall takeout a licence, the cost of which is : for one year, 25; fornine months, P-20 for six months, .B15; and for three

months, E10.FRANCE.

The diploma of Officier de Sante, which is that which

has been commonly taken by English practitioners, is now

abolished, and all foreigners, whatever may be th?ir

diplomas, are obliged to pass at least the two final examina-tions required for the M.D. degree.2

’

GERMANY.

Foreign diplomas are not legally recognised in Germanyas entitling their holders to practice medicine, so that

English medical men desiring to settle in that country hato attend all the classes and pass all the examinations. A

young German before commencing the study of medicine

must pass the Abititrienten-Examen of a gymnasium: it

requires a knowledge of French, Latin, Greek, mathematics,

history, and theology. Foreigners have, as a rule, to pa:4this examination, but if they have already passed a similarone in their own country, they may be exempted from it bya special order to be obtained from the Minister of PublicInstruction for each individual case. Medicine can only bestudied at a university ; the curriculum lasts five yearsafter the second of which the examination called the

Tentamen Physicum must be passed; it includes anatomy.physiology, chemistry, physics, and natural histonAfter the end of the fifth year the student pressshimself for " State Examination," which is practirias well as theoretical, and includes medicine, smge?.

1 We shall shortly publish an article dealing more exhaustively withthe position of the British practitioner in the United States.

667

obstetrics, gynaecology, pathology, materia medica, and

hygiene. If the medical man wishes to have the title of

"doctor" he has to pass another examination, which is little

more than a formality, but the degree of Doctor without theState examination does not confer the right to practise. The

law does not allow qualified British practitioners any excep-tional facilities in passing the examinations ; the time of

seudy may possibly be made a little less than five years for

those who have already studied abroad, but a special order,very difficult to obtain, is always required for this purpose.A thorough knowledge of German is essential. The fees for

lectures are at least .6150, and the examination fees

about 912. The fees for the degree of M.D. vary from

£ 10 to 20, being highest at Berlin University. There is,however, no prohibition against holders of British diplomaspractising in Germany, provided they do not make use of

any professional titles resembling those of qualified Germanmedical men. For instance, a doctor of medicine of a

foreign university would he liable to punishment if he prac-tised by virtue of his M.D. degree, because it is also a

- recognised German degree, but no such cognisance would betaken of the titles L.R.C.P. or M.R.C.S., because they haveno resemblance to any of the titles or degrees used in

Germany. Medical men practising in this way must,however, understand that the law regards them as

snqualified, and that they have none of the rights of

pivileges of the medical profession.AUSTRIA.

In order to practise medicine in Austria it is essential

to have attended the ordinary five years’ course of studyin an Austrian university. British qualifications are not

recognised either as a license to practise or as a groundof exemption from the examinations, of which there are

four-the B6ifeppilluity, or preliminary examination in

general education, and three medical examinations.

Naturalisation as an Austrian subject is also necessaryand is granted only after ten years’ residence in the country.

RUSSIA.

The law relating to foreign medical practitioners desirousto practise in Russia is contained in the two following para-graphs of the Fratchebny fhtav or medical statute :-

Section 93 (a) : No one, whether a Russian subject or a

foreigner, who has not a diploma or certificate from a uni-

versity or from the Army Medical Academy, has the right tofollow any branch of medical or veterinary practice inRussia; (b) foreign medical practitioners who wish to

practise medicine in Russia must, without exception, knowthe Russian language.3 Section 94 : Of foreign practitionerswho shall be invited or who may come to Russia, the rightto decide which of them shall be permitted to free practicehere and under what conditions is in the hands of the

Medical Council of the Ministry of the Inteiior ;some shall be permittted only after the usual ex-

azninations and consequent granting to them of a learned

degree : others more distinguished after an oral examinationicti_iulaa) in the Medical Council; lastly, others who haveT14tdi: a name in the scientific world by their writings orc!-Ma!Iy successful practice, or who have occupied pro-bsorial chairs or other important medical appointments in

3 (a) Dates from 1729; (b) from 1857.

other countries, may be permitted to practise without anyexamination, solely on the decision of the Medical Council,confirmed by the Minister of the Interior, as to the worthi-ness of such practitioners.4 Previous residence in the

country before practice would not be necessary except inthe case of the first group mentioned, who would have to

pass through the usual five years’ course of a Russian medicalcurriculum. As to the prospects of a British practitioner inRussia the country and the smaller towns can present noattraction to an English medical man, even if the fees

obtainable could support him, which they could not. In the

two capitals, Moscow and St. Petersburg, the field is wider.

Competition is, however, great, fees are as a rule small,and bad debts many. The frequency of bad debts resultsfrom the unwritten law by which medical men do not sendin accounts, but leave the patient to pay what he considersa suitable amount.

TURKEY.

Practitioners already qualified have to pass a vivi-voce

examination in physiology, anatomy, medicine, surgery, andmidwifery. The questions are, as a rule, quite fair, the

object of the examiners being to ascertain whether the

diploma which is presented really belongs to the holder ofit. The examinations are either in Turkish or French;foreigners, however, are allowed to take an interpreter withthem from their Consulates. The candidate submits his

name to the Medical Council at the Imperial School of

Medicine, Stamboul, and the day he is to appear for exami-nation is then announced to him. The Medical Council

appoints a committee of examiners, who decide his fate.

The entrance fee is ToB2 (= .61 16s. sterling). Successful

candidates have to pay a further amount of T.E5 (= oB4 10s.

sterling) and receive certificates authorising them to

practise medicine and surgery throughout the Turkish

empire. There are no Government forms to comply with,and residence in the country before commencing practice isnot compulsory. Our information is to the effect that British

practitioners have always been successful in Turkey.

EGYPT.

Duly qualified British practitioners have no examinationsto pass and no fees to pay except a nominal sum for

registration. They must, however, exhibit their various

diplomas and obtain a certificate of good character from theBritish consul. A knowledge of French or Italian and

Arabic would be essential to any newcomer, as the tourist

season only lasts from November to April. Our information

is to the effect that there are no vacancies for additional

English practitioners in Cairo, and that the field is at presentalready well occupied at Alexandria, Port Said, Suez,Assiout, Luxor, As&oaan, Helwûn, and the Pyramids.

PORTUGAL.

It was enacted in 1861 that holders of foreign diplomasshall not be allowed to practise in Portugal without havingpreviously passed all the examinations in the various sub-jects of study at the school where they may desire to

qualify; they will not, however, be required to attend thecourse of study at the school. Applications for examina-tions should be made to the University of Coimbra or to the

4 This Section dates from 1836; it was amended in 1842,1845, and 1867.

668

medical schools at Lisbon or Oporto and should be accom-panied by the candidate’s diplomas. The School Council

will then appoint days for the examinations in all the

subjects. The fees are about .f.40. These are the legalrequisites for practising medicine, but it is understood

that the authorities are very tolerant in enforcing them.Previous residence in the country is not compulsory.

JAPAN.

There will hardly be any opening for British practitionersin Japan until the new treaty between Great Britain andthat country comes into operation. No foreign medicalmen are at present allowed to practise outside the foreignsettlements.

THE COST OF MEDICAL EDUCATION.

WE have for several years been in the habit of placingbefore our readers an estimate of the cost of medical educa-

tion in order that those interested in arriving at the wholeamount of this expense-which is by no means limited tosuch obviously necessary payments as fees, board, and lodg-ingmay have some trust-worthy materials before them onwhich to found a decision about joining a medical school.We obtained our original information from personal com-munications as answers to a schedule of questions placedby the aid of the deans and registrars of the various

medical schools in the hands of a certain number of

selected students, who were requested to furnish in the

form of replies the data from which a general statementcould be prepared for the guidance of others. Althoughthe habits of the individual students necessarily had

a great, even a preponderating, effect upon the replies,the returns were sufficiently numerous to yield averages,and it was easy to see that the average man spentmore money in the metropolitan centres than in the

provinces, and that the standard of living and the cost of

maintaining a given standard varied from place to place.The most complete statement that we received came froma provincial student whose great economy in the matter

of personal expenses could only be looked upon as an

example to distinctly follow..It would have been unfairto expect that every student could live so frugally as to

support himself and pay for rent and food (ten months),clothes, washing, recreation, fees, and even incidental" "

and "unaccounted" expenses out of the small annual sumof .g65. But these headings will serve as a plan uponwhich we can discuss the subject generally-premisingthat only general information can be given that is

worth anything, as a medical student as much as anyother young man can make his expenses as large as he

wishes, while he can only reduce them to the point thatis permitted by the circumstances under which he is

studying.The cost of rent is the first item to be considered, and

naturally enough is a charge which varies greatly with the

locality. A student who occupies rooms in desirable

quarters of London will pay from £2 to E3 a week on this

account alone, whilst in many large provincial centres

lodgings are almost as expensive as they are in London. We

may take it that a student’s rent for furnished apartments

that he can fairly count upon receiving as income, If hi:

parents can allow him Z150 per annum (a large sum and ocethat is beyond the power of the parents of many medicalstudents to set aside for one child) his rent should r.,t

be more than £1 a week. We are calculating that Le

will reside at the particular centre of education for aboc:.ten months during the year. In London it is not alway,easy to live near the hospital and obtain lodgings for muchless than ;S1 a week, so that if a student can only expectZ2 a week or Z6 a month from his parents he is absolutelycompelled to spend an imprudent proportion of his incollein rent. Clearly none of this applies either to the student,who live with their parents, or those who are studying at university for an arts degree concurrently. Nothing moredefinite on this subject can be said than that a careful mancan live as a medical student on Z80 per annum if he doesnot spend more than 10s. a week on his lodgings; but he will,not always find it easy to obtain the lodgings, and everyshilling above this weekly sum will make it very hard

indeed for him to make both ends meet.Referring to other centres, the rent of lodgings in Edin.

burgh is considerably less than in London, but in Dublin itis abou the same as in the English metropolis. In Edinburghthere is a sort of residential club known as University Hall,which affords facilities of social intercourse and mutmi

aid, as, for example, in the lending of books, which i:

practised systematically among the resident students, h

addition to these amenities, the institution secures them

lodgings at a very moderate monthly rent. Glasgow lodgingagain run at about the same level, whilst in Birminghamrent is cheaper still. The cheapest district of which we

have any full information is Aberdeen, where both in thmatter of rent and of food we have heard of an economythat is altogether exceptional, 3s. 6d. a week in summer and4s. 6d. in winter, the additional shilling representing the costof fuel to cope with the Scottish winter. In towns like Cork’s

and Leeds the average rises above this limit, but 15s, a weekis a somewhat high charge. In the Irish provincial towns the rent of rooms is very low, 5s. and 6s. being by no means below the average. A somewhat higher rent is asked, M:still ranging about 10s. a week, in English provincial towns,such as Stockton, or Rugby, or Devonport; but residence in

these involves constant railway travelling, and would harLIlybe adapted for the purposes of a student’s career, unless somespecial considerations influenced the decision with which

fine questions of comparative expense would not come iutc

competition. The lodging accommodation afforded by ie.sidential colleges, hospitals, and the like institutions shouldbe mentioned. But concerning these a word may suffice The advantages of residence in a college are manifold. butthey are chiefly of the intellectual and social kind. Tt-

cost is not less than that of private lodgings thriftilyselected. There may also be in some instances impatienceon the part of the student of the control imposed by r:’regulations, which are necessarily devised for the order::conduct of such institutions. Nevertheless, the

society, and even the inevitable restraint, of such inst::

tions are of great service, especially to young students,’. -’-

have reason to dread nothing more than solitude and an insponsible control of any considerable proportion of their