Knowledge in the Time of Cholera (36 page)

Whether refining oil or researching disease, Rockefeller displayed a commitment to the epistemology of the laboratory, creating organizations that reflected this commitment. Like bacteriologists studying disease, Rockefeller was trying to tame nature by intervening in natural processes via the laboratory. It was this epistemic resonance, more than class interest, that explains how Rockefeller, a man committed to homeopathy, became “the financial father” (Gates 1911a, 2) of scientific medicine.

Creating a Pure Laboratory

Before the federal government, under President Theodore Roosevelt, busted industrial trusts, corporate behemoths like Standard Oil had accumulated wealth to previously unfathomable levels. Unable to recirculate their prof
its,
the new wealthy elites like Rockefeller, Andrew Carnegie, and Andrew Mellon turned to philanthropy. Part of the impetus for philanthropic giving came from an elitist sense of responsibility, best expressed in Carnegie's
Gospel of Wealth
(1889), which sought to manage wealth and charity in an efficient way so as to benefit society on the whole. But part of it came from a particular ideological hostility toward the rough-and-tumble democratic politics of the Jacksonian period that arose in the Progressive Era. Decrying the poor policy outcomes of egalitarian democracy, the Progressive movement enlisted experts to rationalize the emergent social order (Wheatley 1988). Philanthropy shared many of the same aims as Progressivism, and by 1890, philanthropy was beginning to be seen as a solution to the institutional underdevelopment resulting from “a nation born in a day” (Wheatley 1988, 16). Weary of mass democratic politics, philanthropists sought to circumvent the vagaries of party politics by promoting sober professional expertise as the means to better policy (Wheatley 1988).

The Rockefeller Foundation became the very model of modern philanthropy, deploying its resources to support the rational application of expert knowledge. Demonstrating his hands-off approach to philanthropy, Rockefeller deferred much of his philanthropic decisions first to Frederick T. Gates, Rockefeller's appointed philanthropic adviser—the “tutelary spirit of the Rockefeller philanthropies” (Chernow 1998, 470)—and later to his son, John D. Rockefeller Jr. Besieged by requests for gifts, Rockefeller turned to Gates to manage his philanthropy in 1892, and for the next twenty years, Gates served as the broker between Rockefeller and Welch's network of bacteriologists. More so than Rockefeller, it was Gates, Rockefeller Jr., and later Abraham Flexner who translated a general epistemological resonance into a radical program of medical reform.

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,
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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 re
forms
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).
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