Quote from the Hippocratic oath

I will use my power to help the sick to the best of my ability and judgment; I will abstain from harming or wronging any man by it. I will not give a fatal drought to anyone if I am asked, nor will I suggest any such thing . . . Whenever I go into a house, I will go to help the sick and never with the intention of doing harm or injury. I will not abuse my position to indulge in sexual contacts with the bodies of women or of men . . . Whatever I see or hear, professionally or privately, which ought not to be divulged, I will keep secret and tell no one.^[1]

The Hippocratic Oath quoted above is one of the most well-known attempts to define what it means to be a doctor. A dominant theme in this definition is the physician’s possession of a distinct authority over those he or she treats. The oath emphasizes the importance for the physician to only use his “power” and “position” appropriately; by taking the oath, the doctor promises not to abuse the privileges that accompany his status.
Power in the medical field is of the most personal and critical importance. The physician’s power allows him or her intimate access to many very private aspects of the patient’s life. The concept of medical authority and power, therefore, deserves to be closely studied. How is the medical authority implied in the oath constructed, granted, and maintained – and for what purposes? How does an organized medical profession both create and regulate power and authority among medical practioners?
To answer these questions, I will examine some of the institutions set up to control medical education and regulation. Today the system of medical training is very standardized; an individual must complete a lengthy and tedious process of classes and examinations in order to obtain a degree and begin practice. Institutions, both within the medical field and outside of it, train and manage those involved in medicine. For example, medical practice is closely monitored by supervising physicians, by national organizations, by general laws, and by individual cases or lawsuits. This complex system serves to control the distribution of power and authority among those who provide medical care.
Yet the social institutions that make up this system as we know it today did not always exist. By discussing the context and motives behind their establishment, we can learn more about this abstract concept of medical authority and how its controlled distribution leads to a hierarchy of power within the field of medical care.
In this paper, I will focus on significant developments in the field of medicine in Boston in the late eighteenth century, particularly the founding of two influential institutions: the Massachusetts Medical Society and the Harvard Medical School. Young American physicians, motivated by the chaotic social and political climate of the Revolutionary War and inspired by both Enlightenment ideals and patriotic visions, created two types of social institutions – medical schools and medical societies – and through them introduced their own version of medical authority, changing the standards of medical care.
These new standards, in contrast to earlier colonial regulations, had an exclusive rather than inclusive intent. By becoming the definers of what constituted medical competence, the founders of these institutions established a new professional hierarchy with themselves at the top – and thus gained greater social, economic, and scientific power. By founding medical schools and medical societies, the physicians professionalized medicine and increased their own power.

I will begin by discussing the state of medical care in Massachusetts prior to the founding of these institutions. Who were the early physicians in the Massachusetts area? Historical records indicate that in the early years of settlement there were very few physicians who had received official training in medicine. Deacon Samuel Fuller, who came on the Mayflower in 1620, is reported to be the first practioner of medicine in Plymouth Colony. However, he had no medical degree and had only studied medicine at Leyden while the pilgrims gathered there. By 1628, two surgeons had been sent to the Massachusetts Bay Colony, and later in the colonial period a few other European physicians traveled to the colonies.^[2]
Wide variation existed in the care provided by early medical practioners, who were often not even physicians. In 1760 there was no more than one regular physician for every ten domestic practioners.^[3] Frequently the role of medical care-giver was not the practioner’s only occupation. In 1869, Oliver Wendell Holmes compiled information on all of the medical practioners who came to Massachusetts before 1692. His list contained 134 names, and though incomplete, suggests the lack of distinction between medicine and other fields. Holmes found that at least twelve of the practioners practiced surgery, three were barber-surgeons, six or seven (and probably more) were ministers, one was a schoolmaster and poet, one a tavern keeper, one a butcher, and one a female practioner employed by women.^[4] One reason for this mixture between medicine and other fields is that in order to make a living, another source of income outside of medicine was often necessary. For example, care-givers in rural areas often were unable to support themselves solely through their medical practice. In 1756, two rural Massachusetts physicians reported that they each saw only about ten patients a week; to support themselves, they worked as farmers as well.^[5]
The majority of the early medical care in Massachusetts was provided by either governors or clergymen, who often combined their work with providing medical care to their communities.^[6] The clergy were among the most educated individuals in the colony, and their studies had often included medical authorities such as Hippocrates and Galen.^[7] Medicine provided additional means to support themselves, as Giles Firmin described when he wrote to Massachusetts Governor John Winthrop in 1639, “I am strongly sett upon to studye Divinitie; my studyes else must be lost: for Physick [medicine] is but a meane help.”^[8] Governor Winthrop himself also studied medicine, going so far as to request a list of prescriptions from a doctor in Europe in order to make it easier for him to provide care to the sick.^[9]
This variation that existed among practioners was further extended by the method of training of practioners, which relied mainly on an informal apprenticeship. The first documented example of this apprenticeship system in the colonies took place in 1629, when surgeon Lambert Wilson of Salem agreed to give medical training to one or more young men. This action, according to one historian, “might well be cited as the first effort at medical education, unpretentious though it was, in the English colonies.”^[10]
As years passed, this system of apprenticeship became more and more prevalent; by the eighteenth century, the majority of medical education was conducted this way. A student was apprenticed to an established physician, usually for a period of three or four years. During this time the student often lived with the doctor’s family and participated in many aspects of his life, from helping around the home to accompanying him on patient visits and learning how to make pills and potions.^[11]
Often these apprenticeship systems existed within families, with fathers passing on their trade to their sons. One remarkable example of this trend is the John Clark family of Boston, in which seven generations in a row practiced medicine in Boston, dating from 1651, when the first John Clark came to America, until the last John Clark died, leaving no son, in 1805.^[12] Though this is no doubt an extreme example, the passing down of the medical trade – and thus, of medical authority – through families was quite common. A survey of almost 1,600 Massachusetts physicians from 1630 to 1800 showed that forty-four percent of those that received apprenticeship training were themselves sons of doctors.^[13]
In this system, the apprenticeship concluded whenever the student and the physician agreed that the student was ready to begin practicing on his own. There were no legal guidelines or restrictions for when this time occurred. Medical “diplomas” were sometimes given out when the student was deemed ready and consequently “graduated,” but the certification was at the most informal and was not necessary in order to begin practicing.^[14]
Thus, individual remedies and preferences were passed on to new generations of physicians; as William Rothstein points out, “Consequently, the apprenticeship system contributed to a highly idiosyncratic system of medical practice where each student used the techniques of his preceptor.”^[15] The unique style of care practiced by each physician – whether good or not – was the only method taught to his student, and “Each preceptor, skilled or unskilled, produced after his kind.”^[16] Often, the preceptor had inadequate experience or equipment to educate the student; Charles Caldwell described his own experience with the apprenticeship system:
I . . . placed myself under the tuition of a gentleman of reputation and standing . . . But, in relation to the advantages for improvement which I anticipated, I encountered a sad and mortifying disappointment . . . He had no library, no apparatus, no provision for improvement in practical anatomy, nor any other efficient means of instruction in medicine.^[17]

There existed no universal standards or procedures for medical education through the apprenticeship system to guard against this type of problem.
The apprenticeship system, though by far the dominant method, was not the only system of medical training that existed. Many doctors did not engage even in formal education to this extent; in 1769 a group of practioners argued that “some of the best physicians in this country . . . were never under the care of any particular tutor.”^[18] Other future physicians traveled to Europe to supplement their apprenticeship experience with medical education at a university. However, much fewer were trained this way, as it was only an option for individuals from the wealthiest families.^[19] In total, only several hundred Americans studied in Europe before the Revolutionary War.^[20]
These physicians who had been trained in Europe often returned to America critical of their fellow practioners who had only been educated in the apprenticeship system or through even less formal methods. In 1753, Dr. William Douglass of Boston complained that “Frequently there is more Danger from the Physician than from the Distemper.” Dr. John Morgan, the founder of the College of Philadelphia’s school of medicine in 1765, declared that even in large towns many practioners were “in a pitiful state of ignorance,” and he personally appealed to them to withhold their “exterminating hands.”^[21]
European trained physicians were not the only ones critical of the quality of medical care being provided in Massachusetts. Even some laymen expressed anger and concern about the medical care available to them. Around 1737-8, a statement appeared in the Boston Weekly Newsletter urging regulation of medical care and accusing that “we are infected with . . . an Infatuation in favour of Empiricism or Quackery.” Furthermore, the author – who signed the writing “Philanthropus” – argued that:
Methinks it would be . . . of no great Difficulty to concert some proper measures for regulating the Practice of Physic throughout this Province . . . so that no person shall be allowed to practice Physic within . . . this Province, unless he be first examined by such regular, approved . . . Physicians and Surgeons as the Honourable Court shall see meet to appoint.^[22]

Twenty years later, in 1757, the historian William Smith remarked that “Few physicians among us are eminent for their skill. Quacks abound like locusts in Egypt. . . This is less to be wondered at as the profession is under no kind of Regulation. Any man at his pleasure sets up for Physcian, Apothecary, and Chirurgen.”^[23]
Despite these calls for reform, very few regulations did exist to monitor or control the field of medicine. There was no attempt at standardization of the medical care provided by the early physicians.^[24] Instead, medicine at this time was very individualistic and idiosyncratic:
It was more or less an age of individualism; every physician stood somewhat on his own pedestal and there was little rivalry amonst doctors as we know the word to-day. Physicians had their own patients and family groups and often had their own secret or semi-secret remedies. The leading doctors had pupils resident in their homes, to whom they passed on their knowledge and ideas. These men became particularly loyal to the older physicians, and during the stress of the American Revolution, the pupils usually followed the footsteps of their teacher.^[25]

The apprenticeship system established loyalties between individuals and discouraged the development of wider professional ties.
As a result, though criticism of the medical care being provided existed, throughout the seventeenth and eighteenth centuries little was done about it. The only existing attempt at regulation of physicians during this time was a 1649 Massachusetts law in which the General Court of Boston decreed that:
Forasmuch as the lawe of God (Exod ;20;13) allows no man to touch the life or lime of any pson except in a judicyall way, bee, it hereby ordered and decreed, that no pson or psons whatsoever that are imployed about the bodyes of men, woemen, and children for preservation of life or health, as phisitians, chirurgians, midwives, or others, shall presume to exercise or putt forth any act contrary to the knowne rules of arte, nor exercise any force, violence, or cruelty upon or towards the bodies of any, whether young or old, - no, not in the most difficult and desperate cases – without the advice and consent of such as are skilfull in the same arte, if such may be had, or at least of the wisest and gravest then present, and consent of the patient or patients (if they be mentis compotis), much lesse contrary to such advice and consent, upon such punishment as the nature of the fact may deserve; wch law is not intended to discourage any from a lawfull use of their skill; but rather to encourage and direct them in the right use thereof, and to inhibit and restrayne the presumptious arrogance of such as through praefidience of their owne skill, or any other sinister respects, dare be bould to attempt to exercise any violence upon or towards the bodies of young or old, to the prejudice or hazard of the life or lime of men, women, or children.^[26]

The goal of this act is clearly not to keep individuals from practicing medicine – instead of “discourag[ing] any from a lawfull use of their skill” the legislation aimed to “encourage and direct them in the right use thereof.” Any attempts made at regulation were largely inclusive – meant to monitor medical care being provided but not to restrict who was allowed to provide the care.
Very little differentiation between practioners was emphasized in this inclusive atmosphere. In contrast, in England, institutions such as guilds, societies, and schools allowed discrimination among various types of medical care-givers.^[27] Why didn’t this distinction transfer to the colonies as well?
On a practical level, differentiation was less feasible because there were fewer physicians in the colonies than in England. Boston directory listings identified 14 physicians for 12,000 inhabitants in 1780 and 31 for 25,000 inhabitants in 1798.^[28] This scarcity of qualified physicians limited the standards that could be set because the care – even if it was less that adequate at times – was critical.^[29] In addition, the individualistic nature of the apprenticeship system made group organization – or discrimination – difficult. Another factor was public opinion against this type of hierarchical structure; as Joseph Kett describes, “The tide was running against legislative attempts to establish the principle that some practioners had superior qualifications.”^[30] Thus, from the times of the first European settlers in Massachusetts for well over a century, medicine was characterized largely as individualistic and autonomous, lacking a coherent professional consciousness.^[31]

The first medical schools and societies in Boston

However, the early 1780’s saw many significant developments in the field of medicine in Boston that changed the concepts of power and authority of those who provided medical care. In 1781, the Massachusetts Medical Society was founded, and Harvard Medical School was established soon after. These institutions set up a basis for a complex system of training and regulation of medical care with an exclusive rather than inclusive purpose. Why were they founded? Why was there this shift from an inclusive to an exclusive intent in dealing with medical practioners?
The answers to these questions can be considered by first analyzing why these institutions were established when they were. As discussed above, quackery had long been publicly recognized as a threat to patients. Since the first colonists had settled in America, there had been a need for more and better-trained physicians, as well as stricter regulations on all those who practiced medicine. The call for medical education at Harvard, for example, had existed since 1647.^[32] So why did these developments take place when they did?
The Revolutionary War impacted many aspects of American society, and medicine was not excluded. Military activities forced cooperation and organization among colonial physicians; William Frederick Norwood called it “a potent factor in the broadening of American medicine,”^[33] describing how:
. . . it cannot be denied that the need for more and better trained surgeons was constantly and increasingly manifest as the conflict progressed. Colonial Army surgeons knew what anatomical knowledge meant to the man called upon to deal with every form of injury to every organ of the body . . . All too well were they aware of the imperfect manner in which many doctors to whom the health of the community was intrusted were taught. Recognition of the deficiency was but a step removed from an effort to meet the need.^[34]

Doctors – more than 1400 of whom were suddenly forced to work together in the Continental Armies – saw firsthand the pressing need for universal standards across the field of medicine.^[35],[36]
Facing these chaotic social and political conditions, young American physicians were inspired by a patriotism – based on Enlightenment ideals of order and progress – to better their new nation. They applied the concepts of standardization and rationality to create stricter regulation and control in the field of medicine, with an explicitly patriotic goal. With the exception of Dr. Waterhouse, all of the early faculty members at Harvard Medical School were patriots, and all were quite young – nearly everyone was under the age of thirty.^[37] A youthful confidence characterized their patriotism: “The eager young men responsible for organizing the first three medical schools in the United States were filled with a zeal to improve medical education and medical practice in their native land.”^[38] These idealistic American physicians wanted to prove themselves capable of competing with their European peers.^[39] They wanted to secure their independence from European institutions – for years, the best trained American physicians had to have been educated at European medical schools since there was no American equivalent. By establishing their own competitive medical schools and societies, Americans again asserted their freedom from traditional European institutions.
Linking reform in the medical field to broader sentiments of nationalism benefited the physicians by enhancing popular support for their cause. As Richard Shryock described, the hope that the United States could be an independent and respected nation “enabled doctors to identify professional advances with national progress and so to appeal for what had hitherto been lacking; namely, popular support for medical reform.”^[40] Interestingly, this direct association between the medical school and nationalism continued until 1935 – up to that time, the only oath Harvard Medical School faculty members were required by law to take was in support of the Constitution.^[41]
It was in this unique social and political climate that the charter of the Massachusetts Medical Society was established by the state legislature on November 1, 1781. Its first meeting was held later that month, and it was from the beginning a group project, with fourteen individuals listed as “Founders” and thirty-one as “Incorporators.”^[42] Yet despite being a group movement, membership was by no means open to all. The names of these charter members were among the more illustrious and wealthy individuals of the city – twenty-three of the thirty-one had graduated from Harvard College.^[43] Moreover, the stated goals of the society were explicitly exclusive and elitist in their desire to regulate those who participated in the medical profession; the charter states “And whereas it is clearly of Importance, that a just Discrimination should be made between such as are duly educated and properly qualified for the Duties of their Profession and those who may ignorantly and wickedly administer Medicine.”^[44] The charter limited the number of members to seventy and furthermore gave the society the right to “examine all candidates for the practice of physic and surgery.” If a candidate proved satisfactory, he would receive letters testifying to his approval by the society and signed by the president or other members.^[45]
Thus, the motive behind the establishment of the Massachusetts Medical Society was not simply to promote medical knowledge. Its members desired to be able to personally choose who would be authorized to provide medical care. By calling for this control in regulating all who attempt to practice medicine, it emphasizes the selected distribution of medical authority.
In the same month that the charter of the Massachusetts Medical Society was approved, the establishment of the first medical school in Massachusetts was proposed at a meeting of the Boston Medical Society. Dr. John Warren was asked to repeat a series of lectures on anatomy that were similar to those which he had given at the military hospital the year before. The Corporation of Harvard University, meanwhile, was seriously considering the establishment of a medical institution. In 1770, Dr. Ezekiel Hersey, a physician in Hingham, Massachusetts, had donated 1,000 pounds for a “Professor of Anatomy and Physic” if such a chair was established. A committee appointed by the Corporation on May 16, 1782 described the establishment of professorships in physic, including detailed plans for the selection of professors and the activities of each. The following November Dr. Warren was appointed the first Professor Anatomy and Surgery, and he – along with Dr. Benjamin Waterhouse – were publicly inducted into office on October 7, 1783, the day when the Medical Institution of Harvard University was declared open.^[46]
Upon graduation from Harvard Medical School, the articles of the school stated:
That every student who on examination shall be judged qualified to enter upon the practice of surgery, shall have a certificate under the seal of the University, that he has had a regular medical education, and that on a public examination he has been found qualified for such practice.^[47]

The first medical class graduated on July 16^th, 1788. The records of the Harvard Corporation for that date state:
George Holmes Hall and John Fleet, who passed their examination on the 8^th instant for the degree of Bachelor of Physic, this day produced certificates to the President from the Medical Professors of their being qualified for said degree. These certificates being communicated by the President to the Corporation and Overseers, the degree was voted, and both these young Gentlemen were publicly admitted to it immediately after the Masters had received their degrees.^[48]

Before the end of the eighteenth century a total of 25 students graduated from Harvard Medical School.^[49]

The emergence of a professional group identity among medical care-givers

At a meeting of the Sharon Medical Society in 1780, Dr. James Potter proclaimed confidently that “No demonstration in Euclid is more certain than the rapidity with which our profession hath agreeably increased in a very few years. Every measure has been taken to accelerate our physical knowledge, and form a complete system of medicine.”^[50] In the following years, the standards and policies introduced by the new medical schools and societies contributed to the emergence of this “system of medicine” in Boston. The organization and regulation that they placed on those who practiced medicine resulted in the recognition of a distinct medical profession. This professionalization was accompanied by an increase in group consciousness and unity; during the late eighteenth century and into the nineteenth century, physicians in Massachusetts experienced a substantial increase in professional morale.^[51]
However, one might argue that although professional morale may have increased, an organized medical profession could have existed long before the eighteenth century. Vern Bullough examines what it means to define a profession and argues that by the sixteenth century, medicine was acknowledged as a profession – indeed, it was at this time that the Oxford English Dictionary gave several references to medicine as a profession, putting it on the same level as divinity and law.^[52]
It is tempting – yet I believe misleading – to believe that this means that worldwide, the beginning of a medical profession dates back to the sixteenth century. Even Bullough warns that “medicine has not always shown an upward curve of development.”^[53] In the settlement of the colonies, the concept of medicine was quite different than it was in Europe at this time; Norwood describes how some historical accounts “portray a faculty of physic in colonial New England, heterogeneous in membership, sans professional group consciousness and any organized system of medical instruction, but with a spirit of sacrifice and devotion equal to that of the courageous pioneers who depended upon it for succor in the wilderness.”^[54] The unique conditions under which medicine was practiced in the colonies forces us to consider its development independently of conditions in Europe and elsewhere in the world. Prior to the Revolution, American physicians “had little professional consciousness and held only a very limited concept of professional ethics or responsibility.” In the late eighteenth century in Massachusetts, the establishment of the medical schools and societies illustrated the emergence of a structured, recognized medical profession – as had happened at least several centuries before in Europe.
The resulting rise of a professional group consciousness among physicians introduced a new version of medical authority by refining and narrowing the concept of a professional group of physicians and the role of a physician. Medical training and examination by societies became seen as a way of initiating and selecting individuals for membership into a select professional group. This group mentality was not all-inclusive or egalitarian – rather, a new professional hierarchy was being introduced.
The evolution of this new hierarchy is visible in the distinction of names and terms within the medical community that developed. Doctors, surgeons, and apothecaries – as well as other specialties and divisions – became more distinct roles, each with its own set of duties and skills. This distinction of terms allowed for the emergence of a medical elite and thus established a hierarchy among those who provided medical care.^[55]
But what would be achieved by this increasing professionalization of medicine and the hierarchy that its definers introduced? In what ways would greater power be achieved?

The effect of an organized medical profession on the power of physicians

By creating a system of training and regulation of the medical community, the founders of these institutions set up a new form of medical authority which was limited to only those individuals whom they personally chose and educated. Thus with the establishment of these early social institutions, power within the medical field was, for the first time in the colonies, concentrated within a select group of individuals. The founding of these institutions and the system that they established affected the social, economic, and scientific power of physicians.
Social power for the physician depended on recognition both from the general population as well as within the medical community itself. By granting official diplomas to those who met their standards, the medical schools and societies set up a system that established a concrete form of social authority which could be recognized by both patients and by fellow doctors. The certification granted upon graduation from Harvard Medical School and upon passage of an examination by the Medical Society represented a new form of medical authority. Earlier physicians, in completing apprenticeship training, did not receive this type of official, standardized certification, and it created a new way to regulate the distribution of power in the medical community. The official diplomas were a tangible, recognizable symbol of power that was visible to all.^[56] They were meant to be displayed prominently for all to see; the diploma granted by the Massachusetts Medical Society to an individual upon passage of their examination was very large – 29 inches long and 26 inches wide – with ornate decorations including the seal of the state of Massachusetts and the seal of the society, formed in red wax and placed upon a circular piece of tin which was attached to the parchment.^[57]
The authority that physicians attached to an official diploma can be seen in the case of Dr. Waterhouse, one of the first professors at Harvard Medical School. Waterhouse was likely the best trained physician in his time in all of America; he had studied in Edinburgh, London, and Leyden, and he had trained under his famous uncle, Dr. John Fothergill of London, a recognized authority in medicine. He was one of the few men in Boston with an earned medical degree, and other physicians accused him of acting superior because of his diploma.^[58] Though other physicians may have resented Waterhouse, his official diploma meant that they still recognized him as an authority, and he was offered a prominent position teaching in the medical school.
The institutions established a hierarchy of social power within the medical community by creating prestige and the opportunity for peer approval or critique within the medical community. Unlike the individualistic apprenticeship system, the new institutions set up a system that allowed for judgment and approval within the medical field. For example, when the first graduates of Harvard Medical School, George Holmes Hall and John Fleet, successfully won the approval of the Massachusetts Medical Society, they were not automatically members. Rather, they were simply referred to as Licentiates, meaning that they had been judged fit to practice medicine. An additional set of requirements had to be fulfilled before a candidate could pass up from the Licentiate position to a full Fellowship.^[59] This system was modeled after English institutions, particularly the Royal College of Physicians. The perceived discrimination and hierarchical structure that such a method established within the profession was unpopular and even resented by some practioners. Many respected individuals who practiced medicine in the area refused to undergo an examination by the society because of the apparent professional inequality that they saw as a result.^[60]
In addition to the refined social power that resulted from the establishment of the new institutions, economic benefits also accompanied this professionalization of medicine. An organized professional group meant that its members could benefit more economically. Before these changes occurred, the practice of medicine was “far from lucrative.”^[61] But, with the establishment of medical societies, prices could be set higher, as Boston physician Ephraim Eliot reported:
The first fees established by this medical club were half a dollar for a visit, it in consultation, a dollar; rising and visiting after eleven o’clock and previous to sun-rising, a double fee; cases in midwifery, eight dollars; capital operations in surgery, five pounds lawful money. . . The profession was much benefited by these regulations.^[62]

In 1798, William Manning, a Massachusetts farmer, complained about the effects of these new social institutions on the price of medical care:
The Doctors have established their Meditial Societyes and have their State and County Meetings, by which they have so nearly enietlated [annihilated?] Quacary of all kinds, that a poor man cant git so grate cures of them now for a ginna, as he could 50 years ago of an old Squaw for halfe a pint of Rhum. The bisness of a Midwife could be purformed 50 years ago for halfe a doller and now it costs a poor man 5 hole ones.^[63]

By raising the standards and standardizing care and prices, physicians gained more personal economic power; the more inexpensive and informal care practiced by folk practioners was “being driven out by the multiplication in numbers of formal medical practioners.”^[64]
Finally, the establishment of these institutions meant more scientific power for the physicians by encouraging scientific advancements and communications among their members. The Massachusetts Medical Society initiated the publication of medical documents and the establishment of medical libraries; in 1785, the Society appointed corresponding Secretaries throughout the state “for the purpose of promoting professional intercourse and progress.” The following year, the Society set aside 20 pounds for the purchase of medical books to start a medical library, and in 1789 the members voted to dedicate another 30 pounds to this project.^[65] Alumni of Harvard Medical School likewise founded other professional institutions that contributed to many scientific advances. The New England Journal of Medicine was founded in 1812 by two professors at Harvard Medical School, John Collins Warren and James Jackson.^[66] Around the same time these two men, along with the Reverend John Bartlett, founded Massachusetts General Hospital. It was staffed by the leading practioners in Boston, most of whom were already connected with Harvard Medical School.^[67]
But did the physicians found these institutions with the explicit intent to gain more power, or was it merely a consequence? At least some of the founding members recognized an opportunity to achieve greater power and control within their field, and they explicitly took advantage of it. Ephraim Eliot described the meeting of the Boston Medical Society in 1780 at which Dr. Warren called for the establishment of a medical school in Boston:
One night, when Dr. Rand returned home from one of his professional meetings, and, addressing himself to me, he said, “Eliot, that Warren is an artful man, and will get to windward of us all. He has made a proposition to the club, that, as there are nearly a dozen pupils studying in town, there should be an incipient medical school instituted here for their benefit. . . He was immediately put up for the latter branches [anatomy and surgery]; and, after a little maiden coyness, agreed to commence a course. . . Now, Warren will be able to obtain fees from the pupils who will attend his lectures on Anatomy and Surgery, and turn it to pecuniary advantage. But he will not stop there; he well knows that moneys have been left to the college for such an establishment as he is appointed to, and he is looking to the professorship. Mark what I say, Eliot; you will probably live to see it happen.^[68]

Warren not only wanted to establish the medical school in order to gain economic power, but he also wanted the social and scientific power that would accompany appointment to a professorship in such an institution.
Inevitably, because of the changes in power occurring this time, conflict developed between medical schools and medical societies concerning which institution should be in charge of granting this new medical authority to an individual. Ephraim Eliot described the clashes that developed between the two organizations in recognizing physicians:
The Massachusetts Medical Society had authority to examine such candidates for the practice of physic as should offer themselves for the purpose, and grant diplomas signifying such persons as they found to be qualified for the profession; but they had no power to give degrees. The medical professors had similar powers, and were quite independent of the Medical Society. The University could give degrees and confer titles upon such as passed examination before their professors. Here, it was supposed, there would be some clashing of interests.^[69]

Eliot further reported that it did not take long for this conflict to indeed develop. In 1788, prior to their graduation from Harvard Medical School, Hall and Fleet presented themselves to the Massachusetts Medical Society for examination; the candidates, having been trained by Dr. Warren, “were probably far better qualified than any who had presented themselves.” But the censors listening to their examinations
heartily joined in putting them down. It was judged that now was the time to mortify their instructor. Various times were appointed for attending to the business, and it was as often postponed; till the young gentlemen actually became confident that the censors, sensible of their own deficiencies, were afraid to encounter them. At length, the time came; and they found it a fiery trial.^[70]

Hall and Fleet were denied certification at first, and only after a re-examination – held just days before their Commencement from Harvard Medical School – did they pass. This conflict continued, though, until 1803 when an agreement was reached that either the Harvard Medical School diploma or examination by the Massachusetts Medical Society was sufficient qualification for a man to begin practice.^[71] In a sense, the argument over who got to distribute this new power validates the importance of its existence.

Conclusion

Thousands of years ago, the Hippocratic Oath defined the role and duties of a physician. But a definition alone does not create a profession; a profession depends on a network of social institutions and concepts. Thus it was not until the late eighteenth century that the medical profession began to emerge in Boston, with the establishment of two types of social institutions: medical schools and medical societies.
An understanding of the context and motivations for the emergence of this professional consciousness can help us to understand more about the field of medicine and also the establishment of abstract concepts of power and authority. The establishment of these social institutions – for which a need had existed for a long period of time – was not due to a single motive but rather to a combination of factors that came together in the late 18^th century in Boston. The Revolutionary War raised awareness of the need for reform, and Enlightenment ideals of standardization combined with a fervent patriotism inspired physicians to take action. Finally, the desire for more personal power – socially, economically, and scientifically – stimulated physicians as well.
Power not only acted as one of the motives in the establishment of these institutions, but it also became an important force of its own in shaping them and defining the field of medicine. The establishment of a discipline affected the distribution of power within the field; as Joseph Rouse wrote, this power is very significant in defining the field itself:
Power has to do with the ways interpretations within the field reshape the field itself and thus reshape and constrain agents and their possible actions. Thus, to say that a practice involves power relations, has effects of power, or deploys power is to say that in a significant way it shapes and constrains the field of possible actions of persons within some specific social context.^[72]

The power set up by these institutions “shape[d] and constrain[ed]” the medical profession in many important ways. One of these ways, as Foucault argued, was that it increased its possible production:
The development of the disciplines marks the appearance of elementary techniques belonging to a quite different economy: mechanisms of power which, instead of proceeding by deduction, are integrated into the productive efficiency of the apparatuses from within, into the growth of this efficiency and into the use of what it produces. . . . These are the techniques that make it possible to adjust the multiplicity of men and the multiplication of the apparatuses of production (and this means not only ‘production’ in the strict sense, but also the production of knowledge and skills in the school, the production of health in the hospitals, the production of destructive force in the army.”^[73]

The professionalization of medicine – as seen in the founding of these institutions –increased the production of medical knowledge. By increasing its social productivity and utility, medicine would be more effective and gain in scientific power.
The new distribution of power had greater effects then merely increasing productivity, though. Foucault discussed the effect of establishing a discipline in a field:
In this task of adjustment, discipline had to solve a number of problems for which the old economy of power was not sufficiently equipped. It could reduce the inefficiency of mass phenomena: reduce what, in a multiplicity, makes it much less manageable than a unity, reduce what is opposed to the use of each of its elements of their sum; reduce everything that may counter the advantages of number. This is why discipline fixes; it arrests or regulates movements; it clears up confusion; it dissipates compact groupings of individuals wandering about the country in unpredictable ways; it establishes calculated distributions.^[74]

The professionalization of medicine that resulted from the establishment of medical schools and societies changed medical care in many ways. By analyzing the state of medicine before the foundation of medical schools and societies in Boston, we can learn about the distribution of power and authority that existed. This allows us to compare it against the situation soon after these institutions were founded to see how they affected the concepts of medical authority and power. We can understand how a new, tangible form of medical authority was constructed by the founders of these institutions and how they set up a system to control and restrict the holders of this power. The organized medical profession both created and regulated power and authority among medical practioners through this system.
In 1869, one of the most well-known graduates of Harvard Medical School, Oliver Wendell Holmes, gave an address entitled “The Medical Profession in Massachusetts.” In the speech he proclaimed grandly, “The state of medicine is an index of the civilization of an age and country – one of the best, perhaps, by which it can be judged.”^[75] Indeed, the state of medicine – and the state of regulations and controls within the medical field – can tell us much about a society and about the distribution of power and authority within it. From Hippocrates to the Harvard Medical School, it is clear that the issues of medical authority and the distribution of power within the medical field are critical issues to be addressed and studied further.

Bibliography

^[1] Hippocrates, The Oath (rpt. Penguin Classics, 1978).
^[2] G. Canby Robinson, Adventures in Medical Education (Cambridge, Massachusetts: Harvard University Press, 1957), 2.
^[3] Joseph F. Kett, The Formation of the American Medical Profession: The Role of Institutions, 1780-1860 (Binghamton, New York: Vail-Ballou Press, Inc., 1968), 179.
^[4] William Frederick Norwood, Medical Education in the United States Before the Civil War (Philadelphia: University of Pennsylvania Press, 1944), 12.
^[5] William G. Rothstein, American Medical Schools and the Practice of Medicine (New York, New York: Oxford University Press, Inc., 1987), 20.
^[6] Henry R. Viets, A Brief History of Medicine in Massachusetts (Cambridge, Massachusetts: The Riverside Press, 1930), 18.
^[7] Norwood, 11.
^[8] Kett, 6.
^[9] Norwood, 14.
^[10] Norwood, 11.
^[11] Robinson, 3.
^[12] Viets, 40.
^[13] Rothstein, 25.
^[14] Robinson, 3.
^[15] Rothstein, 27.
^[16] Norwood, 429.
^[17] Norwood, 36.
^[18] Richard Harrison Shryock, Medical Licensing in America, 1650-1965 (Baltimore, Maryland: The Johns Hopkins Press, 1967), 18.
^[19] Norwood, 9.
^[20] Rothstein, 25.
^[21] Shryock, 4.
^[22] Shryock, 15.
^[23] Shryock, 5.
^[24] Viets, 45.
^[25] Viets, 80.
^[26] Thomas F. Harrington, The Harvard Medical School. A history, narrative and documentary 1782-1905 (New York, NY: Lewis Publishing Company, 1905), 671-2.
^[27] Kett, 9.
^[28] Rothstein, 19.
^[29] Kett, 7.
^[30] Kett, 8.
^[31] John Duffy, The Healers: The Rise of the Medical Establishment (New York, NY: McGraw-Hill Book Company, 1976), 55.
^[32] Norwood, 167.
^[33] Norwood, 57, 59.
^[34] Norwood, 169.
^[35] Duffy, 75.
^[36] Robinson, 8. Interestingly, this type of pressure to improve standards in the field of medicine also happened more recently among physicians after World War II. See Henry K. Beecher, Medicine at Harvard: the first three hundred years (Hanover, N.H.: University Press of New England, 1977), 27.
^[37] Beecher, 55.
^[38] James Bordley III, Two Centuries of American Medicine: 1776-1976 (Philadelphia, PA: W.B. Saunders Company, 1976), 14.
^[39] Duffy, 89.
^[40] Shryock, 19-20.
^[41] Beecher, 31.
^[42] Beecher, 28.
^[43] Harrington, 102.
^[44] “An Act to Incorporate Certain Physicians, by the Name of the Massachusetts Medical Society” (Boston, MA: Benjamin Edes and Sons, 1781), 1.
^[45] Harrington, 102.
^[46] Beecher, 29-30.
^[47] Harrington, 681.
^[48] Harrington, 110-1.
^[49] Harrington, 1309.
^[50] “An Oration, on the Rise and Progress of Physic in America: Pronounced Before the First Medical Society in the Thirteen United States of America Since Their Independence, At their Convention held at Sharon, on the last Day of February, 1780” (Hartford, CT: Hudson and Goodwin, 1780).
^[51] Kett, 13.
^[52] Vern L. Bullough, The Development of Medicine as a Profession (New York, New York: Hafner Publishing Company Inc., 1966), 3.
^[53] Bullough, 3.
^[54] Norwood, 16.
^[55] Kett, 10.
^[56] Rothstein, 30.
^[57] Harrington, 678.
^[58] Beecher, 42.
^[59] Harrington, 290.
^[60] Harrington, 681.
^[61] Harrington, 77.
^[62] Massachusetts Historical Society Proceedings, 1863-64, cited in Harrington, 77.
^[63] Kett, 1.
^[64] Duffy, 110.
^[65] Harrington, 685.
^[66] Beecher, 51.
^[67] Beecher, 59-60.
^[68] Massachusetts History Society Proceedings, 1863-1864, cited in Harrington, 78.
^[69] Massachusetts Historical Society Proceedings, 1863-64, cited in Harrington, 112.
^[70] Massachusetts Historical Society Proceedings, 1863-64, cited in Harrington, 112.
^[71] Shryock, 25.
^[72] Joseph Rouse, Knowledge and Power (Ithaca, New York: Cornell University Press, 1987), 211.
^[73] Foucault, 219.
^[74] Michel Foucault, Discipline and Punish (New York, New York: Random House, Inc., 1979), 219.
^[75] O.W. Holmes, in Address, “The Medical Profession in Massachusetts,” Lowell Institute Lectures, January 29, 1869, cited in Harrington, 117.