John Buchanan s Philadelphia Diploma Mill and the Rise of State

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1 John Buchanan s Philadelphia Diploma Mill and the Rise of State Medical Boards DAVID ALAN JOHNSON SUMMARY: The absence of medical licensing laws in most states during the years following the American Civil War made it possible for unscrupulous individuals to capitalize upon the weak governmental role in medical practice and educational charters. The practices of John Buchanan during much of his tenure at the Eclectic Medical College of Pennsylvania, in issuing thousands of dubiously earned diplomas, caused a national and international scandal. The traffic in diplomas became so flagrant that regulatory oversight of physicians and their practice, such as that conducted by the Illinois Board of Health led by Dr. John Rauch, developed rapidly across the United States. Though multiple factors prompted the rebirth of medical licensing laws, professional, educational, journalistic, and public concerns for bogus diplomas played an important role. KEYWORDS: John Buchanan, diploma mill, Eclectic Medical College of Philadelphia, medical licensing, John Rauch, Illinois Board of Health 1

2 In the early hours of August 17, 1880, the Philadelphia Camden ferry launched for another run across the Delaware River. The night was mild after a pleasant day topping out just below eighty degrees. 1 The boat carried only a handful of people at one o clock that morning, but among them was a short, heavyset man standing near the rail named John Buchanan dean of the Eclectic Medical College (EMC) of Pennsylvania and the architect behind the country s most notorious diploma mill. The prior week had been emotionally and financially draining for Buchanan. A federal grand jury indicted Buchanan for mail fraud, forcing him to use his home as security to obtain funds for his fifteen-thousand-dollar bail. While arrest and indictment would understandably weigh heavily upon any man, for Dr. John Buchanan this hardly represented a new experience. Authorities arrested him four times between 1872 and 1876 for medical malpractice, printing obscene circulars, and obtaining money under false pretenses. 2 Two of the arrests stemmed directly from his apparently thriving business in medical diplomas. A combination of good fortune, connections and perhaps connivance by those who should have moved these cases forward had saved Buchanan in each instance. Indeed, none of the cases ever came to trial but were quietly dropped. As he stood near the railing observing the dark waters below, Buchanan surely sensed this time was different. The luck, pluck, and criminal guile used to elude state and local authorities had proven inadequate this time. The federal charges culminated a long spring and summer of exposé reporting and heightened scrutiny drawing attention from a variety of quarters: state and federal officials, medical journals, the 2

3 daily press, and even the humor magazine Puck (Figure 1). The latter s cartoonists satirized several Philadelphia schools including EMC as physician factor[ies] manufacturing quacks to prey upon the community. The Puck cartoon appeared in April, one month after Philadelphia Record city editor John Norris secured key evidence leading to Buchanan s arrest and indictment after he used the U.S. Postal Service to purchase eight bogus diplomas from Buchanan. 3 (Figure 1.) That same spring, various journals and newspapers published a letter from the American ambassador in Germany, Andrew White, to the U.S. secretary of the interior detailing German authorities frustration with the dubious diplomas originating from America and now being presented as bona fide credentials in their country. 4 As a reform-minded educator and the driving force behind the establishment of Cornell University, White s undergraduate experiences in European institutions in the 1850s made him an advocate for more modern scientific educational methods. 5 The antiquated pedagogy of many American institutions of higher learning had long irritated White; but the Philadelphia-based trade in dubiously issued diplomas was a disgrace marring the image of American education abroad. Prominent among this trade were the diplomas signed by John Buchanan, M.D. White s letter included his own experiences in Berlin where he personally examined these sham diplomas, now so common as to have entered German popular culture as devices for comic and melodramatic effect in plays and novels. 6 The American ambassador failed to share the amusement of German audiences for this literary conceit featuring America as the refuge of frauds and scoundrels. Facing arraignment the 3

4 next day, an increasingly despondent Buchanan clambered over the boat railing, uttered an audible Good-bye, and jumped. The outgoing tide and the dark waters quickly did their work, drawing Buchanan to his death and bringing an end to a sad, sordid tale. 7 Or was it? Within twenty-four hours, the citizens of Philadelphia would be reading another twist in a story murkier than the waters of the Delaware. The extent to which Dr. John Buchanan s Philadelphia-based diploma mill has been forgotten is surprising given that it was one of the most unique episodes impacting America s post Civil War medical education, licensing, and physician communities. Over the course of approximately fifteen years, thousands of questionably-issued diplomas originated from Buchanan and the EMC with the fallout from this practice reverberating through all three communities. For those physicians trained in the eclectic philosophy of medicine, Buchanan and EMC presented an acute embarrassment hindering their efforts to secure greater professional respect and making an easy target for their critics within the regular or orthodox medical community. For the progressive elements in the medical education community interested in admission standards and curricular reform, EMC was a case-in-point example of the flaws potentially inherent to proprietary and non-university-affiliated medical schools, institutions that routinely lacked sufficient funding to evolve their commercial business model. For the nascent state medical board community arising in the 1870s, Buchanan and EMC offered a compelling example justifying the need for state-based medical regulation as the best long-term mechanism for closing the doors of such institutions. To fully appreciate the impact of John Buchanan, it is 4

5 necessary to pick up the story a decade earlier when he was near the height of his career and influence. The year 1870 opened in promising fashion with Buchanan as an EMC faculty member soon to assume the position of dean, replacing Joseph Sites one of the school s founders twenty years earlier. In January, the school hosted a meeting of the Eclectic Medical Society of Pennsylvania at the EMC s 514 Pine Street location. Buchanan was in the midst of a long run as secretary for the society dating back to He was also enjoying his second year as editor for the Eclectic Medical Journal of Pennsylvania; and his pen flowed so freely that, in addition to editing, Buchanan found the time to author multiple works on medicine and surgery. In fact, four of his Text Books were required materials for the school s students a curricular feature nicely supplementing his income (Figure 2). 9 Buchanan s interests extended beyond medicine to include local politics as well. He served as an election watcher for the Republicans in the Twenty-Sixth Ward in 1870 one year after his unsuccessful race for the Philadelphia city council s Fifth Ward. 10 Undeterred by defeat, Buchanan launched an unsuccessful bid in 1871 for Fourth District representative to the state legislature. Running as an Independent Republican, Buchanan courted African American voters in the city s Seventh and Twenty-Sixth Wards who were expected to vote in large numbers following the recent adoption of the Fifteenth Amendment asserting that the right to vote could not be denied or abridged based upon race or color. Buchanan s pamphlet, To My Colored Brothers of the Fourth Legislature District, cataloged their grievances at the hands of an ungrateful incumbent and Republican Party. 11 5

6 (Figure 2.) The school itself seemed favorably situated to outward appearances. Originally chartered in 1850 by Thomas Cooke, Henry Hollemback, and Sites, the school gathered a strong faculty in the 1850s with the additions of William Paine (Berkshire Medical Institute), James McClintock (Jefferson Medical College), John Fondey (University of Pennsylvania), and Marshal Calkins (Worcester). 12 All of these men appear to have been well respected within the eclectic community of physicians. For many years the school was situated at Sixth and Callowhill, before moving to Pine Street in A description of the facilities cited its expansive rooms, splendid laboratory, and space to accommodate three hundred students. 13 It had not always been smooth sailing. The EMC survived a rancorous split among its faculty in A splinter group (led by Paine and McClintock) withdrew and secured the charter of a school moribund since 1853 the American College of Medicine in Pennsylvania. In reactivating this school near Race and Fourth Streets, Paine opted to rename it by appending and Eclectic Medical College of Philadelphia to its original name, signaling an intent to contest which eclectic medical college would survive. Paine later relinquished the fight by renaming the school in 1875 (Philadelphia University of Medicine and Surgery), dropping the eclectic title entirely. 14 Later, critics would point to this split, the subsequent name changes, and myriad school charters floating about Pennsylvania as the beginning of the period when the issuance of diplomas became suspect. 6

7 At the same time, the post Civil War era represented a period of strength in American eclectic medicine. Despite the ignominy of the diploma scandal that unfolded in Philadelphia, nine eclectic schools operated in a half dozen states in the mid-1870s. 15 Like homeopathy and Thomsonianism, eclectic medicine took firm hold in America during the second quarter of the nineteenth century. All three represented alternative philosophies of medicine that rejected conventional or regular medicine, which relied heavily upon the use of caustic, purgative, and blood-letting treatments as well as potentially toxic chemicals and minerals. Eclectic medicine traced its lineage to physicians like Wooster Beach, Thomas Vaughn Morrow, John Milton Scudder, and others who blended a largely botanic approach to medicine with the pragmatic creed Prove all things and hold fast [to] that which is good. 16 The eclectics rejection of metaphysical concepts of disease in favor of an empirical experience complemented their willingness to draw upon the best features of medicine regardless of its origin. Beach and other eclectics viewed themselves as practitioners of a reformed or American system medicine. (The term eclectic did not adhere to the movement until the 1840s.) 17 In the mid-nineteenth century, a limited scientific understanding and therapeutic basis for the practice of medicine created an environment in which theoretical systems predominated because the effectiveness of none could be proved conclusively. These various approaches to medicine (e.g., allopathic, homeopathic, eclectic) expended enormous energy in drawing distinctions between themselves while inculcating a rigidity among their respective followers. Those in the majority (i.e., allopathic physicians) commonly labeled other groups as medical sectarians, irregulars, or 7

8 worse: quacks and charlatans. 18 Eclectics detested the irregular label and were not above responding with vituperation of their own. They characterized allopathic physicians as a base pack of yelping hounds eager to bleed and blister patients for every trifling illness. 19 Their strongest response was promoting their own brand of medicine featuring milder, usually botanically based treatments, an aversion to bloodletting and a willingness to accept women into the medical schools they established practices that found a receptive audience among in the southern and western regions. 20 Just as eclecticism flourished in the post Civil War years, so too did EMC, which gave the appearance of a successful venture through its publications. The school conferred medical degrees upon eighty-six individuals in June 1869, a figure more than double the thirty-six graduates reported two years earlier in the school s Eclectic Medical Journal of Pennsylvania. Buchanan claimed there were a thousand graduates of the school dispersed throughout Philadelphia and the country. Whether this was accurate or not, there was nothing especially suspicious about these figures given the numbers reported at other eclectic and Philadelphia medical schools. During the period from 1855 to 1868, the mother school of eclectic medicine the Eclectic Medical Institute of Ohio averaged fifty-five graduates annually. Philadelphia medical schools ranged from Hahnemann Medical College s 21 graduates to the much larger graduating classes at the University of Pennsylvania Medical Department and Jefferson Medical College with 140 and 171 annual graduates, respectively. 21 8

9 The EMC facilities included a newly established chemical laboratory and a museum whose varied and splendid collection included anatomical specimens (natural and modeled), osteological and obstetrical specimens, materia medica, and other medical training aids. 22 The presence of an anatomical museum carried significance in nineteenth-century American medical education. Such facilities were viewed as invaluable learning tools for students, providing them with access to anatomical and pathological specimens worthy of study by prospective physicians. Just as important, these museums symbolized an institution s commitment to scientific medicine and not merely experiential and empirically based practice. 23 Despite the promising outlook for Buchanan and the school, the first hints of an emerging regulatory movement were appearing a movement that would limit who could practice medicine and look closely at the schools graduating physicians. In his capacity as Journal editor, Buchanan had spied this augur of change but cited it almost in passing. A special notice in the March 1869 issue of the Journal commented on states passing laws to require a diploma from a medical school in order to practice medicine. Buchanan blithely used this as a marketing opportunity, encouraging readers lacking the credential to qualify for practice by obtaining a medical degree. 24 The upshot was clear an EMC medical degree would render such bothersome legislation irrelevant. In addressing this topic, what he had noted were the early signals of post Civil War medical licensing laws in the United States. Buchanan may not have grasped fully the implications of this movement; he would, however, soon feel their impact. 9

10 Licensing laws in America specifically, attempts to regulate the practice of medicine by limiting entry into the profession to individuals deemed knowledgeable through education or training date to the colonial era. 25 These laws reflected a pragmatic approach to medical regulation predicated upon local control, often haphazardly applied, and usually administered by physician peers organized into local medical societies. For many reasons, these laws collapsed or were repealed in most states beginning with Illinois in Scholars have speculated on various factors in the demise of licensing laws: popular embrace of alternative approaches (e.g., botanic) to medicine, a rejection of traditional medicine for its therapeutic failures, the proliferation of medical schools and subsequent denigration of the medical degree, the Jacksonian Era milieu rejecting the perceived privileges and power of sociopolitical elites. 27 Regardless of the reasons for the demise of state licensing laws, when Buchanan secured his medical degree and later rose to prominence at the EMC in the 1860s, physicians and medical educators in America enjoyed a free hand unfettered by governmental restraints in the form of licensing and school accreditation as well as marginal limitations on institutional chartering. 28 When and how John Buchanan arrived upon this scene in Philadelphia is somewhat unclear. Based upon federal census information, Buchanan was born in Scotland in 1829 and arrived in America in He claimed to have obtained his medical training in Scotland at the Royal Infirmary in Glasgow, a biographical detail shared with students at EMC. One former student drafted a sketch of Buchanan years later and claimed Buchanan earned a medical degree from Glasgow though he also said that Buchanan obtained a degree from EMC before later 10

11 joining its faculty. 30 The earliest evidence for Buchanan practicing as a physician in Philadelphia is from 1860 when that year s census and a city directory reported John Buchanan, M.D. as residing at 1833 Callowhill Street. 31 However, if contemporary newspaper accounts critical of Buchanan are accurate, he arrived in the city much earlier, working for a time as a porter at Thomas Potter s oil cloth factory on Arch Street before what many saw as a suspiciously rapid transition to medical educator. 32 Regardless, Buchanan would have been hard-pressed to find a better location to practice medicine than Philadelphia. The city enjoyed a reputation as the center of American medicine. In part, this derived from several firsts the city enjoyed in the medical field: the country s first hospital (1751) and medical school (1765). Medical education flourished in mid-nineteenthcentury Philadelphia as the city hosted numerous medical schools at the end of the Civil War: the University of Pennsylvania, Jefferson Medical College, the Homeopathic Medical College of Pennsylvania (later to become Hahnemann Medical College), the Women s Medical College of Pennsylvania, and two institutions later undone by the events of 1880 EMC and Philadelphia University of Medicine and Surgery. 33 Glimpses into Buchanan s character and personality survive through a handful of written descriptions. A former student considered him brilliant, a strong lecturer who worked without notes as he was deeply versed in his subject matter. Buchanan the orator was full of ideas... he had but to open his mouth and they flowed forth. These trait of self-assured loquaciousness was later perceived quite differently by newspapermen. Buchanan proved unflappable even when 11

12 caught unawares by reporters, one of whom came away with a grudging respect calling him shrewd, educated, self-possessed... and... well-calculated to take care of himself. 34 Trouble for Buchanan and the school became glaringly public in 1871, though precisely when the sale of diplomas became their raison d être is unclear. Such activities may have begun quite early in the prior decade. One can imagine the disruptions of the Civil War providing a convenient backdrop against closer scrutiny. All of the city s medical schools experienced significant declines in enrollment during the war though a collection of hospitals were set up to treat more than a hundred thousand wounded soldiers during the war. 35 These realities likely overshadowed any whispers of improper issuance of diplomas at EMC though the school s 1864 announcement touting a recent significant endowment raised suspicions in the eclectic circles. 36 Certainly by 1867, if not earlier, Buchanan s traffic in diplomas accelerated when he obtained a charter for the American University of Philadelphia. 37 Unlike the early EMC, which originated and existed for some period with legitimate purposes, the American University appears to have been created for no other purpose than providing another institution to sell diplomas. In addition, it appears the American University advertised heavily (circulars and newspaper ads) with an eye toward international customers who represented not only a new market but an opportunity to redirect potential scrutiny away from EMC. 38 A series of press reports in 1871 brought what one writer characterized as common report about questionable practices into the open, for example, the sale of diplomas for a fee without attendance at lectures or submission of a thesis. Transactions took place on-site but also 12

13 through an agent of the school or through the mail. In May, the New York Tribune ran an article titled M.D., $40 C.O.D., naming Buchanan and referencing the profusion of similarly titled schools in Philadelphia with more corporate names... [than] a Spanish prince of the Blood has titles. 39 In hindsight, it is clear that the naming conventions created a beneficial fog of confusion for those running these schools with dishonorable intent. School names that included Pennsylvania in the title (e.g., Eclectic Medical College of Pennsylvania) might be confused with the long-established University of Pennsylvania. Similarly, schools with Philadelphia in the title (e.g., Philadelphia University of Medicine and Surgery) might similarly be mistaken as an adjunct to the state s major university. Even if the intent were not to mistake a school for Penn, the use of eclectic medical college in the title would resonate with those sufficiently knowledgeable to be familiar with similarly named, legitimate institutions located elsewhere. 40 (See Table 1 for the lineage of these schools.) (Table 1). More sensational stories followed in late August when the death of a New York woman, Alice Bowlsby, during an abortion performed by the holder of an EMC diploma, prompted a Herald-Tribune sting of Buchanan and one of his agents selling a diploma. 41 Buchanan mounted a public defense by pointing an accusing finger at his former colleague, William Paine, now at the Philadelphia University of Medicine and Surgery, hinting that the slanders and dubious activities actually emanated from there

14 The Pennsylvania legislature responded by forming an investigative committee. The committee s charge called for investigating corrupt issuing of medical diplomas by any medical college in the state. The committee heard testimony and took depositions in February and March 1872 from an array of witnesses: EMC and Philadelphia University faculty, former students of the schools, investigative newspaper reporters, and so on. In addition, the committee accepted written evidence (e.g., advertisements) from the editor of the Philadelphia Medical and Surgical Reporter and officials with the University of Pennsylvania. Buchanan testified and denied any wrongdoing while attempting to explain the distinction among the three diploma types issued by the college: honorary, addendum, meritorious. According to Buchanan, the latter was conferred after prescribed course of study, specifically, three years study under a preceptor, completing two courses of lectures, a thesis, and examination by the faculty. He claimed the first two were granted either as an honorific or a degree conferred on top of a degree already held by the individual and not intended as a credential to satisfy the legal practice of medicine. The committee s final report was unequivocal. They dismissed any notions of wrongdoing at Jefferson Medical College and the University of Pennsylvania and cited ample evidence that John Buchanan (EMC and American University of Philadelphia) and William Paine (Philadelphia University) openly engaged in the sale of diplomas. The committee recommended the repeal of statutes incorporating the schools. 43 The legislature repealed the charters of EMC and Philadelphia University in March 1872 though apparently not that of the American University. 44 An infuriated Paine published Pennsylvania Frauds, contesting the 14

15 committee s evidence and pointing an accusatory finger at authorities with the University of Pennsylvania, editors for Philadelphia s Medical and Surgical Reporter, and pliant legislators. 45 An unexpected twist to the story came the following year when the Pennsylvania Supreme Court struck down the legislature s decision, ruling that the state constitution in effect when EMC was chartered did not confer authority to the legislature to repeal such charters without judicial proceedings. 46 In retrospect, an even more surprising development followed: after the Supreme Court decision, there were no official efforts to pursue the matter to its final resolution through the judicial proceedings identified as necessary at least, none until the events of 1880 as prompted by the Philadelphia Record exposé. Press coverage in 1880 included numerous theories for the failure of authorities to finish the matter in 1873 and afterward. One common theory involved Buchanan s influence and connections in local political circles. A contemporary Philadelphia physician, Daniel Garrison Brinton, editor of the Medical and Surgical Reporter and a leader in the early field of American anthropology, followed the legislative investigation closely in the pages of the Reporter. He acknowledged that Buchanan had been a power in the pot-house politics of this city years earlier. Brinton speculated that having made himself useful, Buchanan benefitted from indirect but efficient assistance by unnamed parties. 47 Some of these political connections emanated from within the EMC faculty as two of his faculty colleagues, Joseph Sites and Joseph Fitler, served on the Philadelphia Common Council as Sixteenth Ward representatives in the 1850s. 48 The editor of another Philadelphia publication, the Hahnemannian Monthly, echoed similar sentiments. As the journal 15

16 of Hahnemann Medical College, a homeopathic school predating the EMC, the Hahnemannian was well acquainted with Buchanan and bristled at the tendency of some to place homeopathic physicians in the same category of irregulars as graduates of EMC and American University. The Hahnemannian asserted bluntly that Buchanan owned somebody high in authority. 49 To some extent these suspicions were confirmed by later press accounts that alluded to threats and inducements targeting the legislative committee in 1872 and an 1881 confession by Buchanan that identified money spent in the hopes of favorable decisions by the legislative committee and later the Pennsylvania Supreme Court. 50 The other common explanatory thread given for Buchanan s ability to reengage in the diploma trade after 1873 stemmed from the factionalism among medical practitioners of that era. The rise in the 1830s of alternative philosophies in medicine led to deep divisions among American practitioners. Deviations from perceived medical orthodoxy drew extreme criticism from practitioners aligned through the American Medical Association (AMA) and a subsequent branding of homeopathic and eclectic practitioners as members of sects and irregulars. Tensions rose even higher after the AMA adopted a clause to its code of ethics prohibiting its members from consulting professionally with homeopathic and eclectic physicians. In the early 1870s, homeopathic and eclectic practitioners were still decades away from the absorption that incorporated many of them into a newly expanded definition of medical orthodoxy when the AMA dropped the consultative clause in

17 Thus, one explanation for Buchanan s success between 1873 and 1880 was that orthodox practitioners had no compelling motive to join forces with legal authorities to pursue the matter as his practices represented self-inflicted wounds to the eclectic school of medicine greater than any they could inflict. Others rationalized inaction and silence as the best course because direct movement against Buchanan and EMC would only trigger cries of persecution arising from professional jealousy. 52 In addition, some in the eclectic medical community pointed to the practice of bestowing honorary degrees by Old School institutions that bordered on practices uncomfortably similar to Buchanan s a line of inquiry largely skirted by the legislative committee. 53 Evidence gathered by the committee hinted at the circular nature of the diploma problem. As the diploma trade became more active, some states attempted to forestall the practice by passing laws forbidding the sale of diplomas, for example, Pennsylvania in May Yet this scrutiny and legal restrictions simply made the activity riskier and thus potentially more lucrative as registration laws drove up the demand, and subsequently the price, for the spurious documents. 54 This same effect can be seen with the rise of medical licensing laws during the 1870s. Years later, Frederick Waite cited this same dynamic in describing a 1920s era diploma scandal. The medical degree had become a prized credential because it was the only pathway to obtaining a medical license and, after the Harrison Narcotic Act (1914) and Volstead Act (1919), legal access to controlled substances

18 Despite gaining a favorable outcome in Allen v. Buchanan, the remainder of the 1870s proved challenging for Buchanan (and by extension EMC and American University) as he experienced multiple arrests on a series of charges. In 1874, a coroner s jury delivered a finding of criminal malpractice against Buchanan in the death of Emily Vandegrift. 56 Though Buchanan s treatment of Vandegrift appears to have been limited to cupping the patient, he was arrested by police detectives on September However, the matter appears to have been quietly dropped as no further mention is made of the case. In one regard, the medical malpractice accusation against Buchanan is not surprising and may have had little to do with his standing within Philadelphia s medical community. Beginning in the mid-nineteenth century, what had once been a seldom-raised allegation (medical malpractice) became an increasingly common charge brought against physicians by patients or their families reacting to real, or perceived, negative outcomes. That Vandegrift s family pressed the matter against Buchanan reflected evolving patient perceptions of what constituted acceptable care/outcomes and the potential vulnerability of even established physicians possessing assets sufficient to warrant a plaintiff s legal effort to secure damages. 58 Buchanan s activities came under more scrutiny in April 1876 when he was arrested for selling obscene materials. Though the Philadelphia Inquirer account offers no details, it seems reasonable to assume the material dealt with female hygiene and/or contraception in light of various accounts linking Buchanan to abortion and the 1873 passage of a federal law for the suppression of obscene literature (i.e., the Comstock law) that provided a legal basis for such 18

19 prosecutions. 59 Buchanan posted a thousand-dollar bond and then quietly disappeared amid press speculations that he had fled to Europe. 60 In early June, a constable assigned to secure the EMC property against creditors liens found workmen emptying the premises of all its contents. In following a wagon load of the school s goods into Camden, New Jersey, Philadelphia authorities found a cache of material from the property, but not before having to fend off alleged New Jersey authorities claiming that they were securing the property for creditors on their side of the Delaware River. Buchanan reappeared several months later when he was arrested near the college in September. U.S. Customs authorities at the Philadelphia port alerted police to Buchanan s possible presence when they identified a shipment consigned to him that contained blank diplomas. 61 Despite his arrest and release on two charges (obscene materials, customs seizure of fake diplomas) in 1876, not to mention his failure to appear for trial at least once, Buchanan does not appear to have been convicted in either matter. This string of legal matters is difficult to interpret. Were these arrests indicative of a concerted effort to squelch Buchanan s activities that local authorities were determined to make it untenable for him to remain in Philadelphia? Or should these events be read primarily in light of the apparent failure to convict in any of these matters, that is, that Buchanan retained some measure of connection among politico-legal authorities? Perhaps these events were an indication that Buchanan had grown careless or desperate in the conduct of his affairs? Regardless, the combination of mid-1870s legal matters without any resulting convictions and the failure of authorities to follow up after the Allen v. Buchanan decision left him in a position 19

20 to conduct his activities for the remainder of the decade. His timing, however, proved poor as momentum toward establishing medical licensing laws accelerated rapidly beginning in the 1880s. Efforts at establishing legal requirements for the practice of medicine (i.e., obtaining a medical degree, passing a licensing examination) arose seemingly in organic fashion among states and territories across the country in the late 1860s. 62 Historians addressing medical licensure generally cite several factors in the creation of these laws: (1) the emergence of medicine as a profession and the concomitant desire for socioeconomic status as professionals, (2) the efforts of medical societies and the AMA to secure legislation defining and limiting the practice of medicine, and (3) complementary efforts by educational reformers and the American Association of Medical Colleges (AAMC) to place all medical schools within the academic confines of a formal university system. 63 All of these offer compelling prima facie explanations though they may overemphasize internal considerations at the expense of factors external to medicine and the profession, for example, changing societal expectations of the government s role, the influence and impact of the press in its coverage of sensational medical cases, and the claims of a burgeoning nineteenth-century patent medicine industry. Whatever their genesis, twenty jurisdictions passed medical practice laws prior to 1880 beginning with Ohio in 1868 (Table 2). 64 There were several often overlapping approaches in crafting these laws. Most were registration laws simply requiring physicians to file their name and place of business with a county clerk. Such laws called for registering physicians to present a diploma or evidence of 20