Constructing the medical élite in France: the creation of the Royal Academy of Medicine 1814-20.

It is now widely recognized that medical science was dramatically transformed from the mid-eighteenth to the early-twentieth centuries, while, at the same time, the organized medical profession came increasingly to monopolize health care in the western world. Less well known is the parallel shift, during this same period, of institutionalpower within medicine. At the beginning of the eighteenth century, it was vested in a multitude of regional corporate elites; by the end of the nineteenth century, it was wielded by national elites whose power sprang from the control of key institutions, notably medical schools, hospitals, licensing bodies, and public health agencies. In England, corporate elites adapted to new conditions and gradually transformed themselves into an elite of the modern type.' In France, however, this mutation involved a far greater degree of discontinuity between old and new elites. Political intervention, moreover, consistently played a determining role, In many ways, it was the state which created the medical elite and the modern profession of medicine in France. This transformation has not been systematically investigated by historians of medicine more fascinated by the profession's collective appropriation of power, prestige, and wealth. For the historical actors themselves, however, the question of institutional authority had been a consuming preoccupation, with profound implications for the development of medicine. This has been as true of nations where institutional power is relatively decentralized, as it is in France where centralization in nearly all domains has tended to breed chronic forms of rebellion against institutional authorities. The transformation of medical power in France was a gradual process occurring over nearly two centuries. The final four decades of the ancien regime were instrumental in setting the pattern for extensive state intervention in health care. Even more fundamentally, the years from 1794 to 1803 saw the establishment of a state