by Owen Whooley
Whereas Rockefeller shared only a vague commitment to the laboratory with bacteriologists, Gates developed a specific commitment to bacteriology as the future of medical science. After an illness in the spring of 1897, Gates read William Osler’s The Principles and Practice of Medicine (1895) while on vacation in the Catskill Mountains (Markel 2008). Although impressed with the detailed nature of the book that described the new science of bacteriology, Gates was shocked by the backwardness of American medicine, which boasted cures for only a handful of ailments. As he later recalled:
I found further that a large number of the most common diseases, especially of the young and middle aged, were simply infectious or contagious, were caused by infinitesimal germs. . . . I learned that of these germs, only a very few had been identified and isolated. I made a list, and it was a very long one at that time, much longer than it is now, of the germs which we might reasonably hope to discover but which as yet had never been, with certainty, identified, and I made a very much longer list of the infectious or contagious diseases for which there had been as of yet no specific found. (quoted in Corner 1964, 579)
List in hand, Gates cut his vacation short, returning immediately to his Manhattan office with a vision of Rockefeller-funded medical science germinating in his mind (Markel 2008). He was convinced that the scientific study of medicine, “woefully neglected in all civilized countries and perhaps most of all in this country” (quoted in Corner 1964, 579) was on the precipice of dramatic breakthroughs. It just lacked the proper support. In Gates’s budding vision, Rockefeller could provide the support to transform medicine, just as he had the oil business, as “the precise analysis of the human body into its component parts is analogous to the industrial organization of production” (Brown 1979, 119). Just as laboratory analysis solved technical problems of industrial production, so too could it heal the technical problems of the body.
The first step was to create an independent laboratory dedicated solely to primary medical research and shielded from all other concerns. The plan was innovative and daring. And to most within the profession it was foolhardy, for it “seemed quite rash, even quixotic to pay grown men to daydream and come up with useful discoveries” (Chernow 1998, 471). Few beyond those involved recognized the scientific, professional, and epistemic significance that this new laboratory would have on medicine. After gaining support from John D. Rockefeller Jr., Gates sent lawyer and Rockefeller advisor, Starr Murphy to Europe to study the Pasteur Institute and Koch Imperial Health Office, the world’s foremost bacteriological laboratories. He also met with two reform-minded physicians, Emmett Holt and Christian Herter, to solicit names of those who could help shape the institute. The doctors directed him to none other than their former teacher and dean of the Johns Hopkins Medical School, William Welch. Thus began a relationship between Welch and the Rockefeller philanthropies that would last three decades.
The inclusion of Welch linked Rockefeller money to Welch’s network of bacteriologists. As a chief adviser in the search to staff the new institute, Welch sought to extend his program of bacteriological reforms that he had already begun at Johns Hopkins. Welch, who had long recognized that “large endowments are necessary for laboratories especially, and here in the Eastern States at least we must look to private philanthropy for this purpose” (Welch 1920b, 45), now had access to the resources necessary for his program. Assembling a team of a veritable who’s who of American bacteriology that included Hermann Biggs, Simon Flexner, Christian Herter, T. Mitchell Prudden, and Theobald Smith, Welch played an instrumental role in the founding the Rockefeller Institute for Medical Research (RIMR), the first independent medical laboratory in the country, in 1901. Unattached to any municipal organization or educational institution, the RIMR was intended as a place where researchers could pursue basic medical research without any competing commitments. This independence was jealously guarded, as Welch believed that the RIMR would only be successful if researchers were free of distractions to explore what they wished. Agreeing, the editors of the Medical Record (“Rockefeller’s Institution for Medical Research” 1901, 907) predicted that the RIMR “will set free the men of the American medical profession educated in scientific lore, and will permit them to follow the bent of their minds, to the honor of their country and to the good of mankind, untrammeled by sordid considerations.” This independence was codified in the laboratory’s bylaws, which gave the scientists unlimited control over the research agenda. Welch had secured an institutional stronghold that would serve only the dictates of science.
While there was consensus among those involved as to the mission of the RIMR, Rockefeller himself did raise concerns periodically. Prodded by his friend Dr. Biggar, he was especially concerned about the RIMR’s exclusion of homeopathic research. To mollify Rockefeller, Gates drew on a common trope of the medical reformers, appealing to the theoretical neutrality of science. The new science did not seek to replace homeopathy with allopathy; it sought to transcend sectarian medicine altogether. The RIMR was an institution that was “neither allopath nor homeopath, but simply scientific in its investigations into medical science” (Gates in Corner 1964, 582). Medical science was the future, sectarianism the past. Gates stressed the empiricism of discoveries—and drew on the amnesia induced by the lab—to convince Rockefeller that his money was being spent in an agnostic fashion. This was a bit disingenuous, as Gates was a firm critic of homeopathy, deriding Hahnemann as “little less than a lunatic” whose system’s popularity was based on the “ignorance and credulity of . . . patients” (Gates in Corner 1964, 577). He even went so far as to compose a series of detailed memos to Rockefeller, in response to Biggar, critiquing homeopathy. Still, while Rockefeller continued to voice concerns, his age,4 his faith in Gates, and his respect for the autonomy of experts prevented him from intervening any further on behalf of homeopathy.
With the establishment of the RIMR, bacteriologists found themselves in a position of authority unthinkable just a decade earlier when they were exiled to a handful of woefully underfunded laboratories. Not only did the RIMR offer a purified epistemic space under control of bacteriologists; with Rockefeller’s stamp of approval, bacteriologists had access to nearly unlimited resources. And aspiring medical scientists now had career prospects. As medical research became more lucrative and prestigious, they began to seek careers in the laboratory. These ambitious young medical scientists were not content to stay in the RIMR, and the institute became “an incubator for a group which aspired to lead in reforming medicine and medical education” (Wheatley 1988, 39). As the network of bacteriologists grew and dispersed, they brought their influence, and their program to remake medicine around the laboratory, elsewhere.
REMODELING AMERICAN MEDICAL EDUCATION
One lab, however well endowed, does not an epistemological revolution make. To take hold, a new generation would have to be socialized into laboratory science. The epistemological change bacteriologists sought needed pedagogical reforms. Throughout the nineteenth century, U.S. medical education experienced a race to the bottom as proprietary schools lowered standards in an attempt to attract more students and increase profits. Students would graduate without having attended a birth, witnessing an operation, and often without even examining a patient (Ludmerer 1985, 12). When Charles Eliot became president of Harvard in 1869, his proposal to require written examinations for graduation was met with resistance from the director of the medical school who asserted, with little exaggeration, that a majority of his students could hardly write (Burrow 1963, 9). The situation got so bad that, as late as 1887, the Maine State Board of Health had an eight-year-old boy apply to a number of medical schools. More than half accepted him (Duffy 1993, 203).
Despite this race to the bottom, things were not hopeless. In the 1880s, a handful of medical schools began to elevate their standards. These reforms took place in the context of the coming-of-age of American universities (Starr 1982, 112). In the late 1800s, a handful of elite American colleges sought to
remodel themselves along the lines of the German university, with its focus on research, graduate education, and the sciences (Banta 1971; Bonner 1963; Starr 1982; Veysey 1965). Under the German model, higher education was centered on producing knowledge, rather than merely conveying it—the dominant approach of the English universities that had long served as the model for American medical education (Ludmerer 1985). This represented a shift from an education that took theology as its model discipline to one organized around the sciences, reflecting an awareness that the increasing complexity of knowledge could only be addressed by pedagogy that focused on critical thinking rather than rote memorization. Given their strong ties to German institutions and their interventionist epistemology, it is not surprising that bacteriologists embraced the German model as a solution to American medical education (Bonner 1963).
Bacteriologists began to make some real gains along these lines. The most successful of these early efforts were Welch’s reforms at Johns Hopkins University—reforms that would serve as the model for the future of medical education in the United States. As with the establishment of the RIMR, the resources for the educational experiment at Johns Hopkins came from private philanthropic giving. In 1873, Johns Hopkins, a merchant and banker, left $7 million upon his death for the establishment of a modern university in Baltimore, the largest philanthropic gift ever bestowed in the United States at the time. In many ways, Hopkins was an ideal place to experiment with medical education. While “the expense of laboratory teaching [had] been urged to bar it” from most medical schools (AMA 1892b, 111), Hopkins’s generous endowment provided for the modern trappings of a university, including well-equipped laboratories and elite teacher-investigators, poached from other medical departments, to teach in these labs (Banta 1971). And as a new university, it was able to undertake such reforms with a blank slate (Veysey 1965, 129), rather than fight the endless internecine battles with traditional faculty that delayed similar reforms in universities like Harvard.
In 1894, President Daniel Coit Gilman hired Welch to be the dean of a medical school that did not yet exist, giving him the freedom to create the school as he saw fit. Arguing that “the proper teaching of medicine now requires hospitals, many laboratories with expensive equipment and a large force of teachers, some of whom must be paid enough to enable them to devote their whole time to teaching and investigating” (Welch 1920b, 46), Welch envisioned an institution centered on the laboratory sciences. His philosophy for the school—“We hold that the medical arts should rest upon a thorough training in the medical sciences, and that, other things being equal, he is the best practitioner who has that thorough training” (quoted in Flexner and Flexner 1941, 223)—represented a significant pedagogical innovation for the period. The laboratory’s “great service is in developing the scientific sprit and in imparting a living, abiding knowledge, which cannot be gained merely by reading or being told about things,” argued Welch (1920a, 71). “So important are these ends, that it seems difficult to overestimate the value of the laboratory in scientific teaching.” As such, the school’s pedagogy embodied the new interventionist epistemology of the laboratory and reproduced it via the socialization of the next generation of elite physicians by encouraging them to participate in research. The student “no longer merely watches, listens, memories; he does” (Flexner 1910, 53). Learning medicine by doing research, students became better equipped to adapt the new sciences to the practice of medicine: “The knowledge derived from actually seeing, touching, experimenting, is of course more real and impressive than that which comes simply from reading and from listening to lectures” (Welch 1920a, 57). Manipulating disease in the laboratories, students learned to deal with problems scientifically, whether in conducting research or treating patients. And like the RIMR, Hopkins created a pure research environment, where a student or faculty member experienced “freedom from the cares of the world, liberty to pursue the search for truth in his own way, liberty of thought, liberty of utterance” (Osler in Thayer 1969, 305).5
Still, Hopkins was a newcomer in the world of American higher education. Its transformation from an experiment to the model of medical education involved a concerted campaign, carried out through the AMA by bacteriological reformers with ties to Hopkins and access to philanthropic funding. Of key cultural import was the Flexner Report published in 1910.6 In 1904, as part of a general internal reorganization, the AMA established the Council on Medical Education (CME) to reinvigorate its program of educational reforms. Dominated by bacteriologists, the CME decided to carry out an investigation of medical schools, assessing all medical schools in comparison to the laboratory education of Hopkins. Because of the internal resistance to reforms among proprietary school faculty, the CME sought assistance from the Carnegie Foundation to produce an unbiased “outsider” report. The independence of the Carnegie Report, however, was little more than formal window dressing; from the beginning, it was acknowledged that study would be done in conjunction with the CME, as the CME would furnish much of the research and data collection (Berliner 1985; Burrow 1963). To conduct the survey, the Carnegie Foundation chose Abraham Flexner, an educational reformer whose brother was Simon Flexner, a Welch student and future director of the RIMR. As a graduate of Johns Hopkins himself and “a great admirer of William Welch” (Duffy 1993, 208), Flexner, like his brother, was firmly entrenched in Welch’s network of bacteriologists. He saw Hopkins as the standard by which all other medical schools should be judged, as it “was the first medical school in America of genuine university type, with something approaching adequate endowment, well equipped laboratories conducted by modern teachers, devoting themselves unreservedly to medical investigation and instruction, and with its own hospital, in which the training of physicians and the healing of the sick harmoniously combine” (Flexner 1910, 12). So he went about judging schools according to these criteria.
The report itself was the prototype of the agenda-setting surveys that would become a common tool for reformers throughout the Progressive Era (Wheatley 1988). Flexner assessed medical schools along a number of dimensions: (1) entrance requirements, (2) size and training of faculty, (3) nature and extent of endowment, (4) adequacy of labs and lab teaching personal, and (5) availability of clinical resources and nature of clinical appointments. While each dimension was relevant, Flexner made it explicit that adequate laboratories would trump all other factors. If a school lacked adequate facilities for laboratory science, it was declared inferior. Legitimate medical knowledge was equated with laboratory science, and in turn, medical education should revolve around the lab: “For purposes of convenience, the medical curriculum may be divided into two parts, according as the work is carried on mainly in laboratories or mainly in the hospital; but the distinction is only superficial, for the hospital is itself in the fullest sense a laboratory” (Flexner 1910, 57).
In all Flexner visited 155 medical schools, 32 of which were affiliated with alternative sects (Bordley and Harvey 1976). His conclusions were damning: “It is a singular fact that the organization of medical education in this country has hitherto been such as not only to commercialize the process of education itself, but also to obscure in the minds of the public any discrimination between the well trained physician and the physician who has had no adequate training whatsoever” (Flexner 1910, x). Flexner recommended increased entrance standards, a four-year curriculum, and a drastic reduction in the number of medical schools to 31. Overall, the report proposed a wholesale transformation of medical education by which physicians would be trained in the epistemology of the laboratory to become “scientists in terms of treating each new clinical encounter as an exercise in scientific inquiry” (Flexner 1910, 9).
The report garnered much media attention, as it brought to light some egregious inadequacies of many medical schools. And though there was resistance to the report by many schools—F. W. Hamilton, president of Tufts University, argued that Flexner “had adopted certain arbitrary standards as to methods . . . which may be interest
ing to him but is worthless for anybody else” (quoted in Wheatley 1988, 51)—the AMA made effective use of this public outcry. The CME adopted a recurring system of ranking schools based on Flexner’s criteria, ensuring the continued saliency of the report. The CME exerted continuous pressure on medical schools by only recognizing graduates from schools that met these criteria, and later using their influence on licensing boards to essentially legalize these standards. Through this continuous pressure and its later cozy relationship with licensing boards, the CME became, de facto, “a national accrediting agency for medical schools, as an increasing number of states adopted its judgments of unacceptable institutions” (Starr 1982, 121).
While the report focused public attention on medical education and elevated the cultural cachet of Johns Hopkins, its most lasting significance was in capturing philanthropic attention (Duffy 1993). Much of the reforms were less the result of the Flexner Report and more of the carrot offered by foundations (Stevens 1971). To carry out the proposed reforms—“an enormously expensive affair” (Welch 1920b, 59)—reformers needed copious institutional support. Once again, Rockefeller money was paramount. Gates devoured the Flexner Report, viewing it as a road map for future Rockefeller giving. When he invited the author to lunch to discuss it, Flexner pointed to two maps in his book—one showing the locations of the medical schools he visited, the other showing what the country needed. “ ‘How much would it cost to convert the first map into the second?’ Gates asked and Flexner replied, ‘It might cost a billion dollars.’ ‘Alright,’ Gates announced, ‘we’ve got the money, come down here and we’ll give it to you’ ” (quoted in Cher-now 1998, 492). Later, when Gates posed a hypothetical question to Flexner about the best way to invest $1 million in medical science, Flexner replied that he would give the money to Welch to do what he liked with it. Gates agreed, further consecrating Welch’s vision at Johns Hopkins “as the prototype to be emulated by recipients of Rockefeller money” (Chernow 1998, 492). With Gates support, the Rockefeller philanthropies used the Flexner Report to guide their giving, a policy formally institutionalized when Rockefeller invited Flexner to serve on the foundation’s General Education Board (GEB).
