Much as they might have liked to, the scientific reformers of medicine could not simply denounce their regular colleagues and insist that they be outlawed along with midwives, lay healers, and irregular doctors. For one thing, the handful of scientific doctors knew that no reform could be made against the will of the now 120,000-strong rank and file. For another, there were still no “scientific” therapies with which to replace the fumbling therapies of the average doctor. European bacteriology had produced diphtheria antitoxin, but little more of therapeutic value.
The general reform strategy, then, had to be to ignore the sea of incompetence that was turn-of-the-century regular medical practice, and to focus on medical education. Attacking the schools had the advantages of not offending the bulk of the rank and file while circumventing the whole issue of effective therapy. In education the issue was not what doctors did, but who they were and what they knew. The specific reform strategy was of course to add science to medical education. The John Hopkins medical school—the first American medical school to meet German standards—provided the model. There were solid courses in bacteriology, chemistry, pathology, physiology, clinical courses featuring live patients; full-time professors who were also experimental scientists; and, above all, laboratories. After all, what the public meant by science was something that had to do with laboratories, and by a “scientific fact” they meant a piece of information whose lineage could be traced to a neat (preferably quantitative) entry in a dog-eared, chemical-stained lab notebook. To be “scientific,” in the fullest evangelical sense, medicine needed laboratories.
The rationale for scientizing medicine was provided by the Germ Theory of Disease. If all diseases had a single, known cause, as Benjamin Rush had argued, or if they were caused by “bad air” or “unbalanced humors,” as most prescientific doctors believed, there would be no good reason for putting medical students through the trials of a scientific education. If, on the other hand, they were caused by actual physical particles—“germs”—as Pasteur and Koch and the other great figures of European biology claimed, then science was indispensable. Germs, as everyone knew, were invisible to ordinary people. They could be seen only by scientists skilled in microscopy, handled only by the most meticulous laboratory man. If germs caused disease, and if germs could only be ambushed in a well-stocked laboratory, then medicine without laboratories was like law without courts or theology without churches.
So the reasoning went, though there was no evidence that anyone would be a better doctor for having once confronted a purple-stained bacillus at the end of a microscope barrel. From a scientific point of view, there were other problems. Germ Theory did not forge quite as firm a link between medicine and bacteriology as the scientific doctors liked to think. It is true that by 1900 specific germs had been associated with typhoid, leprosy, tuberculosis, cholera, diphtheria, and tetanus—but in what sense the germs caused these diseases was not so clear.
Koch demonstrated that tubercle bacilli could be found in the tissues of all experimental animals which had the disease, but he could not explain the fact that disease-causing germs could also be found in the tissues of healthy animals. Nor could he have explained why Metchnikoff and his colleagues could gulp cholera germs without any more serious effect than mild intestinal discomfort—or why in general one person contracted a disease and another did not, despite exposure to the same germs. As a result, George Bernard Shaw had no trouble demolishing bacteriology as a “superstition” in his play The Doctor’s Dilemma:
B.B. [Sir Ralph Bloomfield Bonington, a scientific doctor]: … If youre not well, you have a disease. It may be a slight one; but it’s a disease. And what is a disease? A lodgement in the system of a pathogenic germ, and the multiplication of that germ. What is the remedy? A very simple. Find the germ and kill it.
Sir Patrick: Suppose there’s no germ?
B.B.: Impossible, Sir Patrick: there must be a germ: else how could the patient be ill?
Sir Patrick: Can you show me the germ of overwork?
B.B.: No; but why? Why? Because, my dear Sir Patrick, though the germ is there, it’s invisible. Nature has given it no danger signal for us. These germs—these bacilli—are translucent bodies, like glass, like water. To make them visible you must stain them. Well, my dear Paddy, do what you will, some of them wont stain. They wont take cochineal: they wont take any methylene blue: they wont take gentian violet: they wont take any coloring matter. Consequently, though we know, as scientific men, that they exist, we cannot see them. But can you disprove their existence? Can you conceive the disease existing without them? Can you, for instance, shew me a case of diphtheria without the bacillus?
Sir Patrick: No; but I’ll shew you the same bacillus, without the disease, in your own throat.
B.B.: No, not the same, Sir Patrick. It is an entirely different bacillus; only the two are, unfortunately, so exactly alike that you cannot see the difference.… There is the genuine diphtheria bacillus discovered by Loeffler; and there is the pseudo-bacillus, exactly like it, which you could find, as you say, in my own throat.
Sir Patrick: And how do you tell one from the other?
B.B.: Well, obviously, if the bacillus is the genuine Loeffler, you have diphtheria; and if it’s the pseudo-bacillus, youre quite well. Nothing Simpler. Science is always simple and always profound.19
Without question, bacteriology had cast a bright light on medicine, but the beam was all too narrow. Germ Theory led to some spectacular victories: effective methods of immunization, antitoxins, and, later, antibiotics—to give a few examples. But at the same time Germ Theory (and the general effort of scientific medicine to search for a single cellular or molecular “cause” for each disease) helped distract medicine from the environmental and social factors in human health—poor nutrition, stress, pollution, etc. The result is a kind of medicine which, for example, is obsessed with finding the cellular “cause” for cancer, even though an estimated 80 percent or more of cancer cases are environmentally induced.20
But none of these reflections deterred the scientific doctors of the turn of the century. Germ Theory seemed to provide a solid scientific basis for medicine, and if there were still a few loopholes which could not be filled up with “pseudo-bacilli” or similar theoretical cosmetics, that was only because there were not enough well-trained men doing full-time research. The important thing was to get science into the medical schools, and that in itself was a problem sufficient to challenge the best scientific minds.
First there was the problem of money. The old two-hundred-dollar-a-year fees would not pay for laboratory equipment and German-trained professors. So, for a start, tuition would have to rise dramatically. That, of course, had some advantages. John S. Billings, one of the leaders of the reform of medical education, pointed out that the new, scientific schooling would be so expensive that poor boys should not even try to become physicians.21 But in fact, middle-class boys wouldn’t be able to either. So unless scientific medical education was to be restricted to young Vanderbilts and Morgans, tuition increases would never cover the costs. Vast sources of outside subsidization would have to be found.
Medicine and the Big Money
The medieval medical profession had depended, directly and indirectly, on the sponsorship of the landed nobility. In colonial America and the early republic, there were no equivalent concentrations of wealth—hence little support for universities, elite professions, or “culture” generally. But by 1900 the money was there. The period of hectic industrialization following the Civil War had produced concentrations of wealth that would have been unimaginable a generation before. Among America’s new plutocrats, no one outweighed John D. Rockefeller and Andrew Carnegie. Through a combination of luck, shrewdness, and sheer plunder, Rockefeller (Standard Oil) and Carnegie (U.S. Steel) had put together fortunes that ran into nine figures. It was this money, extracted from the labor of thousands of American working people and the wreckage of hundreds of smaller businesses, that financed the trium
ph of scientific (previously known as “regular”) medicine in the early twentieth century.
It would be easy enough to find a capitalist conspiracy here. Both Rockefeller and Carnegie subscribed to the “gospel of wealth”—the idea that they had been appointed by some higher power to shape society through the instrument of philanthropy. (Rockefeller, a Baptist, believed he was appointed by God; Carnegie, a devout social Darwinist, believed he had risen through evolutionary natural selection.) Medicine was a traditional outlet for philanthropy; and, within medicine, the two robber-barons-turned-philanthropists would be expected to favor the gentleman-scientist breed of doctor over the sundry competition—“irregulars,” low-class regulars, lady doctors, midwives, etc.
But it was not that simple. Rockefeller, for example, placed his personal trust in homeopathy, that archrival of regular medicine. Moreover, as one otherwise uncritical biographer points out, Rockefeller “had sharp limitations of education and outlook; he was not well read, not much interested in literature, science, or art.…”22 Carnegie presented another kind of problem: he had a profound distrust of “experts” and had made it clear that they were the “last men” he wanted on the board of the Carnegie Institute in Pittsburgh.23 Business entrepreneurs, he believed, were the most progressive force in society and should exert direct control over philanthropic and educational institutions:
Americans do not trust their money to a lot of professors and principals [college presidents] who are bound in set ways, and have a class feeling about them which makes it impossible to make reforms.24
But two things drove Rockefeller and Carnegie, and their money, into the arms of medicine’s scientific reformers. First, there was the philanthropists’ own insistence on absolute impartiality and objectivity in their giving. Recall that these two men were about as widely hated by their fellow country-people as any American could be and expected to ride the streets without a police escort. Their charity had to be as seemingly impartial and detached as their money-making had been ruthless. Rockefeller, for example, refused to endow a medical school at the University of Chicago because the university’s president insisted that the school had to be “regular” and Rockefeller was opposed to supporting any particular medical sect—even the “regular” one. Carnegie, on his part, excluded from his college faculty pension plan any school which showed the slightest trace of denominational leanings. Of course such a determined impartiality contained an inevitable bias toward any cause which could represent itself as purely “scientific.”
Second, Rockefeller and Carnegie simply could not spend their money all by themselves. Despite the “gospel of wealth” which upheld the plutocrat’s unique and personal ability to dispense charity, both men were forced to delegate more and more of the responsibility for managing their philanthropic enterprises. In time philanthropy became institutionalized in corporate-style foundations, but initially there was no one to turn to except, of course, experts—experts in philanthropy. Such men identified with the scientific approach to medicine because it mirrored their own approach to philanthropy. If philanthropy was a matter of sentiment, then rich men could handle it themselves, but if it was a matter of science, then experts would have to do it for them.
The first of the philanthropic experts was Frederick T. Gates, an ex-teacher, ex-farmer, ex-bank clerk, ex-salesman, ex-minister, and, as far as one can tell, general hustler from Minneapolis. When John D. found him in 1891, Gates was heading up something called the American Baptist Education Society and saw himself principally as a minister. But, once established with an office and secretary by Rockefeller, Gates took a more secular turn of mind. To paraphrase one historian, Gates found himself converted from Baptism to Scientism. He came to the conclusion that “the whole Baptist fabric was built upon texts which had no authority.…”25 In his work for Rockefeller, he developed what he called “scientific giving,” which chiefly meant funneling money through relatively large centralized agencies rather than handing it out piecemeal to small agencies.
Then, in 1897, Gates read John Hopkins Professor Osler’s Principles and Practice of Medicine and was converted overnight to scientific medicine. There was not much to the “practise,” as Gates wrote, but the “principles” were first rate. Gates immediately dashed off a memo to John D. Rockefeller urging the support of medical research and the development of scientifically based medicine.
The bait was set, and medicine’s gentleman-scientists began to close in on the money. The story goes that Dr. L. Emmett Holt, pediatrician to the family of John D. Rockefeller, Jr., and a member of the Fifth Avenue Baptist Church attended by the Rockefeller family, converted John D. Rockefeller, Jr., to scientific medicine during a train ride between Cleveland and New York. John Jr. was sufficiently impressed to offer Holt and six of his friends—including the dean of Johns Hopkins medical school and several well-known biological scientists and professors—the money to open a new research institute. These seven men, all united by ties of friendship and common academic interests, accepted twenty thousand dollars from Rockefeller and became the first board of directors of the Rockefeller Institute for Medical Research. The money had begun to come together with the men.
The Rockefeller Institute brought all the glamour and mystery of European laboratory research to America. Here at last was a place where medicine’s pure scientists could labor undistracted by patients or financial worries. But to Gates, it was much more—it was a “theological seminary, presided over by the Rev. Simon Flexner, D.D.”26 It was a model not only of medical science, but of the gentility to which medicine aspired. The main building featured an enormous paneled dining hall in which the researchers, in obligatory jackets and ties, were served by uniformed waiters. The fictional description of the McGurk Institute in Arrowsmith re-creates the effect of the Rockefeller Institute and many of its actual features:
The real wonder of the Institute had nothing visible to do with science. It was the Hall, in which lunched the staff, and in which occasional scientific dinners were given, with Mrs. McGurk as hostess. Martin gasped and his head went back as his glance ran from glistening floor to black and gold ceiling. The Hall rose the full height of the two floors of the Institute. Against the oak paneling of the walls were portraits of the pontiffs of science, in crimson robes, with a vast mural by Maxfield Parrish, and above all was an electrolier of a hundred globes.
“Gosh—Jove!” said Martin, “I never knew there was such a room!”27
By the mid-nineteen sixties, the Rockefeller Institute, with an endowment of close to two hundred million dollars and a staff of over fifteen hundred, remained committed to the patrician ideal. There were chamber music concerts every other week in Caspary Hall; Calders and Klines hanging in the Abby Aldrich Rockefeller dining hall; sherry parties with David Rockefeller. The aim, according to then-president Detlev Bronk, who had been a student and friend of the Institute’s founders, was to produce “gentleman scientists.”
The Rockefeller Institute and Johns Hopkins (the first American medical school with labs and full-time professors) stood out as citadels of scientific medicine and within a few years they were to produce a stream of important discoveries in bacteriology and immunology. But these two institutions could not, by sheer force of example, produce all the desired “reforms” in medicine. The next step was to weed out the “irregular,” non-scientific, and generally low-class medical schools and see that philanthropic funds were channeled into the few institutions which could hope to meet scientific standards. To this end the AMA’s Council on Medical Education, an elite committee composed of research-oriented doctors, approached the Carnegie Foundation in 1907. The Council on Medical Education had already done a nationwide survey of medical schools, rated them, and decided which ones should be purged and which provided for. What they needed from the Carnegie Foundation at this point was not its money, but its imprimatur. The AMA could easily be accused of sectarianism and self-interest, but the Carnegie Foundation, with its board composed of an impecca
ble roster of university presidents, had a reputation for expertise and impartiality. The foundation’s president “at once grasped the possibilities” in the AMA proposal and agreed to finance a new, completely “objective” study of medical education.
To make sure that the Carnegie study would not be tarnished with medical sectarianism of any variety, a layman was hired to do the job—one Abraham Flexner, who happened to be the brother of Simon Flexner, M.D., director of the Rockefeller Institute, and was himself a graduate of Johns Hopkins University. The resulting Flexner Report, which has been hailed by most medical historians as the most decisive turning point in American medical history, was about as unbiased as, say, a television commercial for a cold remedy. There were, according to Flexner, “too many” doctors in the United States and they were too low class—any “crude boy or jaded clerk” was able to get medical training. Some black doctors would be needed, if only to check the spread of disease from black to white neighborhoods: “ten millions of them live in close contact with sixty million whites,” Flexner pointed out. Few women doctors were needed, though, he observed. The evidence? The lack of “any strong demand for women physicians or any strong ungratified desire on the part of women to enter the profession.” (!) As for the different sectarian approaches to medicine, the issue was not which of the existing sects should prevail, he insisted, but whether scientific medicine (i.e., the regular sect suitably reformed) should prevail over all of them.28
For Her Own Good: Two Centuries of the Experts Advice to Women Page 11
