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This chapter focuses on the death of Nathan Smith in 1829, which signified a great loss to the young Medical Institution of Yale College. His reputation as a clinician in conjunction with Benjamin Silliman's reputation as a scientist had been responsible for much of the school's initial success. Silliman now replaced Smith as the driving force behind the Medical Institution. From a pragmatic point of view, Smith had represented one-fifth of the medical faculty, holding the chairs in both medicine and surgery. To replace him Eli Ives was appointed professor of the theory and practice of medicine and Thomas Hubbard, a rural practitioner, became professor of surgery. William Tully took over Ives's former professorship of materia medica.

This chapter describes Yale's Department of Medicine as propelled, from the very beginning, by a remarkable cast of faculty members. Nathan Smith, who was also responsible for lectures in surgery and in obstetrics and gynecology, was revered as a teacher, in part because he lectured on his cases, making his points with models and illustrations and allowing students to question him, rather than following the traditional didactic manner. Smith emphasized moderation in therapeutics, seldom recommending bleeding, preferring cleanliness and rest, and prescribing drugs only when he had established that they were useful. He often rejected commonly held theories. He disagreed, for example, with Benjamin Rush of Philadelphia, one of the outstanding physicians of the day, who believed in vigorous bleeding and constructed a classification of disease that did not at all impress Smith.

This chapter recounts the story of the creation of a national medical society and a national code of medical ethics. It highlights the role played by four key actors: Nathan Smith Davis (1817–1904), John Bell (1796–1872), Gouverneur Emerson (1796–1874), and Isaac Hays (1796—1879). It describes the drama surrounding the Kappa Lambda Society of Hippocrates, a fraternity that became America's first national medical society and a direct precursor to the American Medical Association (AMA). Through Kappa Lambda, Bell, Hays, and Emerson began a decades-long process of adapting Percival's code of medical ethics to the needs of American practitioners. They refashioned Percival's code of medical ethics as an explicit social contract between physicians, their patients, their fellow practitioners, and society. The AMA adopted the resulting four-chapter, eleven-article, fifty-section social contract as its official Code of Ethics in 1847.

This chapter describes the relationship between the medical school and the hospital as one of mutual, although frequently strained, interdependence. Access to patients would be crucial to the success of the new Medical Institution of Yale College, “because theory without practice in this, as well as everything else, is comparatively of little use.” Of the ten incorporators who proposed the State Hospital in 1826, eight were physicians, including four professors at the Medical Institution: Nathan Smith, Eli Ives, Jonathan Knight, and Thomas Hubbard. The fifth Yale representative, Benjamin Silliman, had received an honorary M.D. degree from the Connecticut Medical Society but was not a physician. The solitary layperson, William Leffingwell, became the first president of the General Hospital Society of Connecticut.