Founding of the American Medical Association (1847)

Summary

On May 7, 1847, roughly 250 physicians gathered at the Academy of Natural Sciences in Philadelphia and voted the American Medical Association into being.(Griggs, 1981) They had two stated purposes: elevating the standards of medical education and organizing the regular profession. They had a third purpose, unstated in the founding documents but evident in the Code of Ethics they adopted that same day: shutting homeopaths, eclectics, and physiomedicals out of the professional community. The Code’s consultation clause barred any regular physician from consulting with a practitioner “whose practice is based upon an exclusive dogma.”(Gevitz (ed.), 1990) Over the next six decades that clause functioned as the primary legal and social mechanism for marginalizing every non-regular healing tradition in America. When the Flexner Report closed the last eclectic and homeopathic schools after 1910, it was finishing work the AMA had begun in 1847.

Background: The Medical Marketplace in 1840s America

By the standards of European medicine, American medicine in the 1840s was a free market in the most chaotic sense. The public standing of the profession reflected its condition: Jonsen observes that American practitioners were widely disdained as producing a “stupendous humbug,” many were barely literate or dangerous, and even the more educated and competent were often quarrelsome and contentious among themselves.(Jonsen, 2000) A wave of Jacksonian-era political pressure had dismantled state medical licensing laws one by one: Illinois repealed its licensing law in 1826, Ohio in 1833, Mississippi in 1834, New York in 1844.(Haller, 1981) By the Civil War, no effective medical licensing existed anywhere in the United States.(Haller, 1981) Anyone could hang out a shingle.

The schools that trained regular physicians were no more orderly. Between 1800 and 1860 the number of regular medical schools in the United States grew from 4 to 47, and the number of graduates increased more than fifty-fold, from 343 graduates in the decade 1800–1809 to 17,213 in the decade 1850–1859.(Rothstein, 1972) These were mostly proprietary institutions (owned by their faculty, dependent on student fees, and structurally incapable of limiting enrollment without economic self-destruction). Nathan Smith Davis, the young physician who would drive the AMA’s founding, described the resulting competitive dynamic bluntly: the decisive question among schools had become not which provided the best education but “at which college can the student obtain his diploma … with the least expenditure of time and money.”(Rothstein, 1972) American students were being educated in institutions that provided thirteen- to sixteen-week terms with little laboratory work and minimal clinical experience, even as European science was advancing rapidly.(Haller, 1981) The practical consequences of this deficiency were measurable: from 1841 to 1849, only 55 out of 170 applicants passed the Army Medical Board examinations, and only 77 out of 175 passed the Navy Medical Board examinations; the leading cause of failure was insufficient preparatory education and a hurried course of study.(Haller, 1981)

The social meaning of cheap medical education was contested. Some defenders of the proprietary system argued that low-cost training served a genuine democratic function, enabling talented young men from humble circumstances to enter a profession otherwise monopolized by the wealthy.(Haller, 1981) Before the AMA’s consolidating reforms, the financial condition of ordinary practitioners also reflected the fragmented market: in 1850, Lemuel Shattuck’s Massachusetts public health report found the average Massachusetts practitioner billing approximately $800 and earning roughly $600 in income, which placed physicians near artisans rather than professionals in the social hierarchy.(Starr, 1982)

The oversupply of poorly trained physicians created an economic problem that the AMA’s first committees described in vivid terms. By 1847, the first AMA committee on educational standards reported that the country’s twenty million inhabitants were cared for by forty thousand regular physicians and a “long list of irregular practitioners who swarm like locusts in every part of the country,” concluding that “no wonder that the profession of medicine has measurably ceased to occupy the elevated position which once it did.”(Rothstein, 1972)

Those irregular practitioners were not marginal figures. Samuel Thomson (1769–1843) had built a mass botanical movement rooted in a simple vitalist theory and six numbered preparations, beginning with lobelia as an emetic.(Rothstein, 1972) By 1833, Thomson employed 167 agents across the United States, and Thomsonians claimed the support of half the population of Ohio, with regular physicians conceding one-third of the state.(Rothstein, 1972) The Thomsonian movement had been the primary political force behind repealing medical licensing laws, gathering more than 36,000 petition signatures in New York State alone in 1840.(Rothstein, 1972) Homeopathy, introduced into America by Hans B. Gram in 1825 and spreading through German immigrant communities, had by the 1830s won converts among both formerly orthodox physicians and prominent public figures including Henry Wadsworth Longfellow, Nathaniel Hawthorne, and Daniel Webster.(Jonsen, 2000) Homeopathic success during the cholera epidemics of 1832 and 1849 attracted what observers described as “a widespread desertion from orthodox ranks.”(Gevitz (ed.), 1990)

Homeopathy appealed to a fundamentally different social stratum than Thomsonism. Thomsonian clients were largely rural and poor; homeopathic clients were urban middle and upper class, and homeopathic practitioners were predominantly former orthodox physicians.(Rothstein, 1972) As William Rothstein, whose 1972 study American Physicians in the Nineteenth Century remains the foundational sociological account of this period, argues: homeopathy posed a far greater economic and institutional threat to the regular profession than Thomsonism, and the regular profession responded accordingly.(Rothstein, 1972) Kaufman’s analysis in Gevitz’s Other Healers sharpens the point: unlike the poorly educated farmers attracted to Thomsonism, most homeopathic physicians were former orthodox practitioners, and homeopathy presented itself as based on an experimental pharmacology — making it a competitor that claimed scientific standing rather than merely popular appeal.(Gevitz (ed.), 1990) The medical schools had standardized heroic therapy — bloodletting, cathartics, blistering, calomel — across their curricula, and that standardization had created a public backlash that both Thomson and Hahnemann exploited.(Rothstein, 1972) As Oliver Wendell Holmes told the Massachusetts Medical Society in 1860: “I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind — and all the worse for the fishes.”(Griggs, 1981)

The 1846 Convention and 1847 Founding

The proximate cause of the AMA’s founding was a reform initiative by the Medical Society of the State of New York. In 1846, a young physician named Nathan Smith Davis proposed resolutions to the New York Medical Society recommending a standard curriculum and state licensure independent of medical school degree. His resolutions were adopted and supplemented with a call for a national convention “for the elevation of the standards of medical education in the United States.”(Jonsen, 2000)

That convention met in May 1846, but was deemed insufficiently representative and adjourned with a resolution to reconvene the following year. As Paul Starr notes in The Social Transformation of American Medicine, the most influential sociological account of American medical professionalization, the 1846 convention was composed, as Davis himself later recalled, “of the younger, more active, and, perhaps, more ambitious members of the profession.”(Starr, 1982) The founding AMA was not a gathering of established elites but of reformers who felt professionally and economically squeezed.

On May 7, 1847, the follow-up convention met in Philadelphia at the Academy of Natural Sciences. Griggs, in A Green Pharmacy, places the scene precisely: 250 physicians filed into the long galleried hall and voted the American Medical Association into being.(Griggs, 1981) William Rothstein documents the attendance as almost 250 delegates representing more than forty medical societies and 28 medical colleges.(Rothstein, 1972) John Harley Warner and other historians concur that among the founding delegates were Nathan Smith Davis, Alfred Stille, and Isaac Hays.(Haller, 1981)

The new organization adopted four major initiatives: a minimum standard for the preliminary education of medical students; a minimum standard for the curriculum of medical schools; a code of ethics; and the establishment of permanent organization. Isaac Hays drafted the Code of Ethics, drawing heavily on Thomas Percival’s 1803 Medical Ethics but translating it from British class idiom into American idiom: transforming Percival’s “tacit compact” between profession and society into a social contract specifying mutual rights and duties among the profession, patients, and society.(Jonsen, 2000) The code was sophisticated in its ethical reasoning and consequential in its professional politics.

The Consultation Clause and Anti-Sectarian Campaign

The operative weapon against sectarian medicine was Chapter II of the 1847 Code of Ethics, the consultation clause. As summarized in Martin Kaufman’s chapter in Norman Gevitz’s edited volume Other Healers, the clause stated that “no one can be considered as a regular practitioner, or a fit associate in consultation, whose practice is based upon an exclusive dogma, to the rejection of the accumulated experience of the profession.”(Gevitz (ed.), 1990) This meant that an orthodox physician could not consult with a homeopath, could not come to the aid of a patient being treated by a homeopath, and risked expulsion from the local medical society for doing so.

Albert Jonsen, in A Short History of Medical Ethics, is direct about what Chapter II actually accomplished: it “became a weapon to drive irregular practitioners out of business.”(Jonsen, 2000) The chapter’s historian described it as “the heart of the code and the source of the profession’s subsequent troubles during the 19th century.”(Jonsen, 2000)

The AMA moved quickly to institutionalize the exclusion. In 1847, the same year of founding, the organization passed a resolution urging medical colleges not to accept the certificate of any preceptor who was “avowedly and notoriously an irregular practitioner.” Rothstein documents that Nathan Smith Davis himself, then on the faculty of Rush Medical College, wrote to a homeopathic applicant that “the faculty of Rush Medical College will not recommend you to the trustees for a degree so long as they have any reason to suppose that you entertain the doctrines, and intend to trifle with human life on the principles that you avow.”(Rothstein, 1972) Homeopaths were barred from regular medical societies, denied hospital privileges at regular hospitals, excluded from many boards of health, forbidden to serve on the faculties of regular medical schools, and blacklisted from consultations.(Rothstein, 1972)

This exclusionary campaign had a paradox at its center. Rothstein argues that regular physicians’ claim to therapeutic superiority over sectarian physicians was not well-founded. Charles L. Dana observed in 1902 that “the limit of actual medical knowledge and its inefficiency in practice made distinction between the learned and pompous physician and the unlearned vendor of drugs one of little moment at the bedside.”(Rothstein, 1972) William Osler noted that anatomy, physiology, chemistry, histology, and surgery “know no ‘isms’”; the differences among sects existed only in therapeutics, the one domain where the evidence for any school’s claims was weakest.(Rothstein, 1972) The AMA’s campaign was professional, economic, and social long before it was scientific.

Hahnemann himself had given regulars a rhetorical target by coining the term “allopathy” to designate orthodox medicine as itself a dogmatic sect rather than the representative of scientific truth, a move that, as Gevitz observes, gave irregular practitioners genuine conceptual ground to stand on.(Gevitz (ed.), 1990) Unorthodox practitioners consistently turned the label “quack” back on orthodox medicine, calling regular physicians the real source of danger through bloodletting, calomel, and other heroic therapies.(Gevitz (ed.), 1990)

The AMA’s educational standards, meanwhile, were largely unenforceable in the short term. The organization had no power to impose penalties on substandard schools. When it proposed extending the academic term from four to six months, Davis himself acknowledged the response: schools were not opposed in principle, but “they were ready to comply with the request so soon as it shall appear that all the other colleges will do so” — a collective action problem that prevented any single school from acting for fear of losing students to competitors.(Rothstein, 1972)

The Eclectic and Physiomedical Response

The American Institute of Homeopathy had already been founded in 1844, three years before the AMA. Its founding goals included improving homeopathic materia medica and restraining physicians “from pretending to be competent to practice Homeopathy who have not studied it in a careful and skilful manner.”(Rothstein, 1972) Despite decades of exclusionary pressure, homeopathic institutional infrastructure reached its peak breadth by the end of the century: in 1898 homeopaths maintained nine national societies, thirty-three state societies, eighty-five local societies, sixty-six general hospitals, seventy-four specialty hospitals, fifty-seven dispensaries, twenty medical colleges, and thirty-one journals.(Rothstein, 1972) This institutional depth made outright destruction impossible by exclusion alone and helps explain why the AMA’s 1901 reorganization shifted strategy toward absorption rather than continued proscription. The eclectics organized more slowly but with comparable institutional ambition.

Wooster Beach (1794–1868), a medical school graduate who had also studied with botanical practitioners, had founded the movement that would become eclecticism by drawing on Thomsonian, Indian doctor, and herb doctor traditions without adopting any single sectarian dogma.(Rothstein, 1972) His Reformed Medical Academy eventually relocated to Cincinnati, where the Eclectic Medical Institute was chartered in 1845 after a petition signed by “1,100 of the foremost citizens, including the mayor and members of the City Council.”(Rothstein, 1972)

The term “eclectic” had been adopted at the suggestion of a trustee of the Cincinnati school, apparently inspired by the naturalist Rafinesque’s usage, conveying the philosophy of drawing from all available therapeutic traditions rather than adhering to any single dogma.(Wilder, 1901) Wilder’s account of the AMA’s founding purpose was pointed: certain physicians of New York and Pennsylvania met in 1845 to organize the association, and their purpose was soon avowed — “to use every effort at command to undo the work, to procure the restoring of the arbitrary conditions by which they had been supreme.”(Wilder, 1901) In May 1848, the first national convention of reformed practitioners was called at the Eclectic Medical Institute in Cincinnati, led by Wooster Beach and Thomas Morrow, explicitly in response to the AMA.(Wilder, 1901)

The eclectic response to the AMA was to name the conflict directly. The founding convention of what became the National Eclectic Medical Association produced language that Wilder preserves in his 1904 history: “The great struggle of the day in the Medical Profession is between the spirit of freedom, on the one hand, which is seeking for truth in science, and the spirit of conservative despotism on the other, which aims to perpetuate its power and doctrines by organized combinations, and by discountenancing or suppressing every attempt at Reform, whatever may be its merit or its source.”(Wilder, 1904) Alexander Wilder, writing from within the eclectic tradition, was even more pointed: the AMA had established “a code utterly proscribing and practically outlawing all physicians who did not conform to its doctrines and routine of practice.”(Wilder, 1904)

The Eclectic Medical Institute, known within the movement as the “mother institute” of reform medicine, concentrated its teaching on what John M. Scudder (1829–1894) had systematized as “specific medication”: the physician identified a specific symptom-pattern and matched it to a specific botanical remedy, using small doses of pleasant medicines rather than the violent cathartics, emetics, and blisters of heroic practice.(Griggs, 1981) By 1902, the institute’s faculty had written more than one hundred books and had graduated 3,743 students.(Haller, 1994) The school’s students were taught that “the remedies are to be pleasant in form, small in dose, certain in action, relieving the unpleasantness of disease, shortening its duration, and saving life.”(Haller, 1994)

Eclectics also distinguished themselves institutionally on gender. The Central Medical College at Syracuse accepted women as students on equal terms with men, welcoming applicants who had been refused at regular institutions.(Wilder, 1904) From that point, eclectic colleges generally accepted women students, while the dominant school “for many years permitted them to get on by themselves in ‘women’s colleges,’ like Jews in the Ghettoes, separate and apart.”(Wilder, 1904) Rothstein also notes that the Penn Medical University, an eclectic school founded in 1853 in Philadelphia, was probably the first American medical school to offer graded courses and was the first to provide co-educational instruction to large numbers of men and women in the same classes.(Rothstein, 1972)

Despite this, the eclectic movement faced a chronic problem that would ultimately prove fatal. Rothstein argues that eclectic physicians could not clearly define what therapeutically distinguished them from regular physicians. Scudder himself conceded that “many eclectic physicians were ‘a very poor species of old school medicine.’”(Rothstein, 1972) By 1900, eclectics numbered approximately 4,000, the smallest of the three major sects, concentrated in midwestern states.(Rothstein, 1972)

From 1847 to the Flexner Report

The AMA remained structurally weak throughout the second half of the nineteenth century. As Starr documents, by 1900 the organization had only eight thousand members out of roughly 110,000 physicians: its treasury was bare, it had no permanent organization, and most physicians belonged to no professional association whatsoever.(Starr, 1982) The pressure it exerted against sectarians through the consultation clause and local medical societies was real, but the organization itself remained a loose gathering rather than a disciplined hierarchy.

Before that reorganization, homeopathy had already been undergoing internal fragmentation that softened the boundary the AMA was trying to enforce. Many homeopaths had begun repudiating some of Hahnemann’s original doctrines in response to allopathic pressure: some abandoned the infinitesimal doses, others began using orthodox purgatives and the lancet, and by 1871 only eight to ten of the seventy-five homeopaths practicing in Chicago were “pure” Hahnemannians.(Gevitz (ed.), 1990) The educational infrastructure, meanwhile, was being reshaped from outside the profession: the founding of the American Medical College Association in 1876 by twenty-two schools, which disbanded in 1883 but revived in 1890 as the Association of American Medical Colleges, established the organizational framework through which Davis and later reformers would press for enforceable curriculum standards.(Haller, 1994)

That changed dramatically with the 1901 constitutional reorganization, which created a House of Delegates fed by state societies that themselves federated county organizations, making county membership the prerequisite for any higher professional association. Membership shot from 8,000 in 1900 to 70,000 (half of all physicians) by 1910.(Starr, 1982) The 1901 reorganization explicitly pursued the absorption of eclectics and homeopaths, but on terms requiring them to “drop their special designations.” One skeptic captured the dynamic: “How peaceful the regular lion will look, after swallowing the innocent eclectic and homeopathic lambs, 20,000 in number.”(Haller, 1994)

Meanwhile, the educational institutions that served sectarian medicine were under intensifying pressure from state licensing boards. The Illinois State Board of Health’s survey in the 1880s found that of fifty-seven examined institutions (including forty-three regular, ten homeopathic, three eclectic, and one physiomedical school) only fifteen met qualifications for matriculation.(Haller, 1994) The number of eclectic schools fell from fifteen in 1883 to eight in 1893.(Haller, 1994)

The Flexner Report of 1910 was, as Starr argues, not so much the cause as the final act of a closure already in progress: changing licensing requirements had been killing proprietary schools since before 1906, and the schools were already “at the end of their tether” when the report arrived.(Starr, 1982) Abraham Flexner (1866–1959) was a Johns Hopkins graduate and brother of Simon Flexner, director of Rockefeller Institute laboratories, connections that shaped his conclusions.(Haller, 1994) His 1910 survey found that of eight eclectic schools, none offered adequate clinical opportunities, none had sufficient equipment, books, or models, and enrollment had shrunk from 1,014 in 1904 to 413 in 1909.(Haller, 1994) Flexner’s ideological claim was sweeping: scientific medicine made “all historic dogma” obsolete, and sectarian medicine, which had begun with a prepossessed formula or doctrine, no longer served as a defensible alternative; no compromise existed between objective science and dogmatic belief.(Haller, 1994)

The Rockefeller General Education Board directed $91 million between 1910 and 1936 to a select group of medical schools, with seven institutions receiving over two-thirds of funds, actively imposing the research-oriented Johns Hopkins model and determining not just which schools would survive but which would dominate.(Starr, 1982) Griggs notes that this concentrated philanthropic investment effectively ended eclectic medical education: the last eclectic school closed its doors in 1938.(Griggs, 1981)

For homeopathic institutions the post-Flexner squeeze operated through accreditation rather than direct closure. Within ten years of the report, the AAMC and the AMA Council on Medical Education were establishing standards required of every college, and state licensing boards were requiring those standards of every applicant — making independent institutional survival impossible without conformity.(Gevitz (ed.), 1990) The AMA Council on Medical Education and Hospitals then removed homeopathic institutions from its approved list entirely, leaving homeopathic schools with no path to legitimacy other than renaming themselves and abandoning their sectarian identity.(Gevitz (ed.), 1990) New York Homeopathic Medical College voted accordingly to rename itself New York Medical College, a pattern repeated across the remaining homeopathic institutions.

The closure was not without cost to American medical knowledge. Griggs describes what was lost: King’s American Dispensatory, Lloyd’s studies of the constituents of American medicinal plants, the specific medication literature — “an entire tradition of clinical knowledge — imperfect, uneven, but accumulated over decades of practice — disappeared from mainstream medicine almost overnight.”(Griggs, 1981) Eclectics had rejected the laboratory reductionism that was capturing regular medicine,(Haller, 1994) and that resistance, combined with institutional weakness, meant their knowledge could not survive within the emerging credentialing structure.

The medical education consolidation also systematically excluded women and Black Americans. Women’s admissions quotas held at about 5 percent for half a century after 1910; five of seven Black medical schools closed; and by 1930 only one in 3,000 Black Americans was a physician.(Starr, 1982)

Wider Significance

The AMA’s founding is a case study in what Paul Starr calls the conversion of cultural authority into market power and legal privilege. Scientific knowledge must first become cultural authority before scientific advances can be privately appropriated by a profession, but the AMA’s 1847 campaign preceded the scientific revolution in medicine by several decades. The consultation clause was not grounded in demonstrably superior therapeutic outcomes; regular physicians’ claims to superiority over sectarian physicians were not therapeutically well-founded before the rise of scientific medicine.(Rothstein, 1972) The mechanism was organizational and social, not evidential.

Starr’s synthesis in The Social Transformation of American Medicine offers the sharpest framing: knowledge must be “transformed into authority, and authority into market power, before the gains from scientific advance can be privately appropriated by a profession.”(Starr, 1982) The AMA in 1847 began the organizational work of that conversion. The consultation clause was an instrument of market control dressed in the language of medical ethics.

The paradox that Starr identifies in the sectarian story is worth holding: homeopaths and eclectics declined precisely after being accepted into the profession. When they were shunned and denounced, they thrived. The more they gained access to the privileges of regular physicians, the more their numbers fell.(Starr, 1982) Enrollment at eclectic schools peaked at one thousand in 1904 and was down to 256 by 1913; homeopathic schools dropped from twenty-two in 1900 to twelve by 1910.(Starr, 1982) Absorption was more effective than exclusion.

Norman Gevitz’s framework in Other Healers adds an important definitional point: the concept of “unorthodox medicine” is itself produced by the dominant profession.(Gevitz (ed.), 1990) Unorthodox practitioners form a heterogeneous population with no corporate identity; as Gevitz writes, “the only characteristic they share is their alienation from the dominant medical profession.”(Gevitz (ed.), 1990) What the AMA did in 1847 was draw a line, and then use every available institutional mechanism to enforce it. Whether that line corresponded to any genuine therapeutic distinction was, for most of the nineteenth century, secondary.

Scholarly Assessment

The historiography of the AMA’s founding divides roughly along interpretive lines set by two landmark works.

William Rothstein’s American Physicians in the Nineteenth Century (1972), the foundational sociological study, treated orthodox medicine itself as a sect, the most dominant one that gained preeminence over competitors, rather than as the neutral representative of scientific truth.(Gevitz (ed.), 1990) This view was consequential: it shifted the question from whether regular medicine was right to exclude sectarians, to how it achieved the social power to do so.

Paul Starr’s The Social Transformation of American Medicine (1982) provided the more elaborate institutional account, tracing how the AMA converted cultural authority into market control across eight decades. Starr is more sympathetic to the AMA’s long-run effects on medical quality than Rothstein, arguing that the Flexner consolidation genuinely improved care even if it also entrenched monopoly, but he is clear that monopolistic barriers to entry explain a significant part of physician income gains.(Starr, 1982)

John Haller’s Medical Protestants: The Eclectics in American Medicine (1994) provides the most detailed institutional history of eclecticism through the period, documenting both the movement’s genuine achievements (specific medication, botanical pharmacology, coeducation, graded curricula) and its organizational weaknesses.(Haller, 1994) Haller situates the eclectics as genuinely different from the regulars in therapeutic philosophy while acknowledging the educational deficiencies Flexner documented.

Alexander Wilder’s internal eclectic histories (1901, 1904) represent the tradition’s self-understanding: the AMA was a conspiracy of the “privileged class” to restore monopoly that Jacksonian democracy had dismantled.(Wilder, 1901) This reading is polemical but not wrong about the political economy. What distinguishes it from modern scholarship is its reliance on intent rather than structural analysis.

Barbara Griggs’s Green Pharmacy (1981) takes the sharpest critical line: the combined forces of the AMA consultation clause, the Flexner Report, and Rockefeller philanthropic funding constituted a structural elimination of botanical knowledge from American medicine — a knowledge system that, whatever its doctrinal weaknesses, had accumulated genuine clinical experience.(Griggs, 1981) Griggs’s account should be read against Starr and Rothstein, who document real deficiencies in sectarian medical education that the structural critique can obscure.