by Owen Whooley
In the end, Flexner provided the blueprint; Gates provided the financial resources and incentives to make Flexner’s suggestions a reality. Controlling the allocation of Rockefeller funds, Gates and Flexner, in consultation with Welch, were able to choose the winners and losers in medical education. And education reform was the chief mechanism by which doctors established bacteriology as a key piece in the professionalization of medicine. For Flexner and his colleagues, rationalizing medical education meant standardizing it as an education focused on scientific research in the laboratory. Previously, there were many possible routes to becoming a doctor; now there was only one—through the laboratory. Reformers did not have to choose a one-size-fits-all model of education; indeed, many clinicians clamored for a medical educational system with multiple tiers (Ludmerer 1985). But Flexner was insistent; an acceptable medical education needed to look like that of Hopkins. By effectively forcing medical schools to adopt the scientific model of medical education in order to receive philanthropic funding, educational reformers dashed any dreams of diversity in medical training. Doctors were to become scientists. Medicine was to have a single epistemological foundation.
These reforms were realized not by popular fiat among the rank and file of the profession—indeed many clinicians disparaged the reforms—nor by convincing state legislatures to back them. Instead, elite bacteriological reformers built a new model of medical education by convincing a few philanthropies to bankroll their program.
EPISTEMIC CLOSURE
While medical education was central because it socialized future generations into the epistemology of the laboratory, other institutions like hospitals, licensing laws, and boards of health were consolidated as well under the laboratory. This consolidation, along a number of different fronts, was not achieved without struggle. Nevertheless, by 1920, medical reformers had achieved epistemic closure by radically remaking the organization of American medicine along the lines of the laboratory. As E. O. Shakespeare imagined with cholera, all diseases would be filtered through the laboratory, which would identify, understand, and then finally eliminate them.
Hospitals and the Full-Time Controversy
During the nineteenth century, the hospital was a marginal institution established to serve the poor (Duffy 1993; Rosen and Rosenberg 1983; Rosenberg 1977, 1987; Rosner 1982; Rothman 1991; Starr 1982). Given the profession’s commitment to bedside empiricism, the locus of medical practice was the patient’s home. Yet as the new epistemology of the laboratory reallocated the valuation of evidence away from idiosyncratic bedside observations to laboratory tests, doctors increasingly needed access to labs to practice medicine. Because the costs of establishing laboratories were prohibitive for all but the most elite practitioners, hospitals became a central location where doctors could access the services of the lab:7 “There ought to be, there must be laboratory facilities in and directly connected with every modern hospital. It requires no demonstration that rational treatment is not possible without a correct and minute diagnosis” (Jacobi 1897, 114). With the ascendency of the laboratory, hospitals assumed a prominent place in medicine, morphing from locally based charitable institutions, under the control of lay trustees, into large-scale bureaucracies committed to medical science (Duffy 1993: Rosenberg 1987a; Rosner 1982).
This reorganization of the hospital was inextricably tied to educational reforms. One of Welch’s innovations at Hopkins was to integrate the hospital into medical education. Welch viewed the hospital, and the clinical work that went on there, as an extension of the lab: “The teaching of the clinical subjects should be carried out along the same general lines as those of the laboratory” (Welch 1920b, 127). In his report, Flexner codified this view in establishing standards for medical education, going so far as to define the hospital as a lab itself (Flexner 1910, 57). When he joined Rockefeller’s GEB, Flexner sought to extend this Hopkins model to all medical schools by requiring clinicians who taught in medical schools to become full-time faculty, to renounce their private practices, and to focus on research and teaching. From the start, faculty who taught the basic laboratory sciences were hired on a full-time basis, an employment status that spoke to the primacy of research in their identity as scientists. Clinical faculty, however, had a more ambiguous status with ties both to the school and to their own private practices. Indeed, hospitals had long served an important role in advancing the careers of local elite doctors (Rosenberg 1987a). Flexner viewed this as a conflict of interest that left clinicians susceptible to the corrupting influence of commercialism and careerism. To remedy this situation, he acquired Rockefeller funding for an experimental clinical full-time program at Hopkins. Satisfied with the results there, he planned to extend the program to all medical schools.
Flexner’s full-time program unleashed a powerful backlash among clinicians who saw medicine more as an art than a science. They denounced the program as a bald attempt to bring clinicians under the control of laboratory technicians, worrying that it “might remove them from the beside to the bench” (Maulitz 1979, 92). While many clinicians welcomed the new tools offered by the laboratory, they were hesitant to privilege laboratory knowledge over clinical experience. After all, the bulk of regulars still practiced in ways far removed from the new ideals of biomedical research (Katz 2002, 41). It was alright for the lab to dictate the practices of public health officials, but when it came to the practice of medicine, clinicians were to have the final word. Some cautioned the profession against succumbing to “bacteriomania” (Jacobi 1885, 172). Others, like Alfred L. Loomis (1888b, 70), the president of the New York State Medical Society, warned those who were in haste to elevate “the experimental above the practical” of the fetishization of the laboratory. Allopathic physicians,
cannot safely forsake the rich storehouses of clinical observations that have been gathered by so many master-minds, and withdraw into the recesses of the laboratory; for although in the work of the laboratory we hope to find the solution to many of the problems with which we are now struggling, it must be remembered that the special field of medical investigation is, and ever will be, the study of disease in its activities. (Loomis 1888b, 70)
Noting laboratory science’s limited impact on therapeutics, clinicians worried that their pupils would lose perspective in an educational program focused primarily on the laboratory, as they whiled away their precious time “in the labyrinths of Chemistry and Physiology” (Bigelow 1871, 8). William Osler, perhaps the most distinguished clinician in the United States, vehemently opposed the full-time program, lamenting “the evolution throughout the country of a set of clinical prigs, the boundary of whose horizon would be the laboratory, and whose only interest was research” (Wheatley 1988, 69).
Pitted against the well-connected and resource-rich network of bacteriologists, clinicians could not compete with the power of Rockefeller’s money. Flexner, refusing to bow to pressure, made the full-time program the centerpiece of the GEB’s reforms; medical schools that sought Rockefeller money had to pass a litmus test to receive funds. No full-time program, no money. Medical schools were all but required to adopt it to survive. As more and more university hospitals embraced the full-time program and used the funds to build up their infrastructures, hospitals generally became organized according to the epistemology of the laboratory. In the internal allopathic debate over medicine as an art versus medicine as a science, science won. Once again, Rockefeller finances dictated the winners and losers. Local cliques of clinical physicians were replaced with a national network of clinical scientists, shifting the power in the hospitals from local communities to Welch’s network of laboratory scientists (Wheatley 1988). And lay trustees, long the governors of hospitals, were elbowed aside as control went to Flexner’s physician/scientists (Rosenberg 1987a).
Hunting Germs
Public health had long frustrated allopathic dreams, offering enticing resources but maintaining an ecumenism that prevented allopathic takeover. After bringing medical education and hospital
s under the control of the laboratory, bacteriologists turned their attention to public health. The germ theory sought to reorient public health away from cleaning up filth toward hunting germs. But like clinicians, public health officials were reluctant to give up their traditional practices, especially since the multiple cosmetic sanitary reforms had won them public esteem. Many public health officials balked at embracing bacteriology, so much so that as late as 1915, the uncompromising bacteriologist and health officer of Providence, Rhode Island, Charles V. Chapin (1934b [1915], 37) complained, “There is probably not a single large municipal health department in the country which is operated along strictly logical lines.” Reiterating “the timeworn phrase about dirt and disease” (Chapin, 1934c [1902], 23), the boards of health had failed to adopt the targeted “rational” approaches suggested by bacteriology. Chapin complained that “the age of bacteriology has produced an immense amount of scattered information. But no one as yet had attempted to draw it all together into a coherent patterns of logical public health principles and measures” (Chapin quoted in Cassedy 1962, 110), and he vowed to bring public health in line with the laboratory.
While upsetting to bacteriologists, this resistance was not overly disconcerting to most reformers, public health officials like Chapin aside. Having consolidated authority in a number of different organizations, regulars were now less dependent on public health for their prestige. As these other organizations gained strength through the laboratory, bacteriological reformers became less concerned about public health and boards of health. As a result, allopathy’s long-felt ambivalence toward public health was allowed full flowering in the twentieth century. Regulars were content to leave sanitation to public officials, as long as these officials were willing to defer to the laboratory in their educational and sanitary programs. The GEB provided funds to establish schools of public health attached to, and controlled by, medical schools, but their graduates were not to be doctors. Organizing public health education in this way, sanitary science became a residual category for allopaths, a mere appendage to the laboratory where the true breakthroughs were happening. Public health was demoted in allopaths’ imagination, no longer placed at the forefront of controlling disease, but reduced to the practical application of laboratory findings. This new understanding of public health was reinforced in the Rockefeller Foundation’s forays into the field, both domestically and abroad, as it only funded programs in which public health interventions were based on the laboratory sciences.
Rather than fight to make public officials doctors, bacteriologists allowed public health to remain in lay hands, provided that boards of health did not encroach on medical practice. The AMA’s strategy toward the boards of health shifted from one aimed at control to one aimed at mitigating their influence and protecting the autonomy of individual physicians. As long as physicians maintained ultimate authority, public health programs would be supported. However, if they started to interfere with the autonomy of the individual practitioner, allopaths ensured their demise. For example, the AMA effectively killed a campaign to develop public health dispensaries, which they viewed as competition (Starr 1982). Thus, while regulars tolerated a degree of ecumenism on the actual boards, they effectively circumscribed their activities.
Homeopathy’s Enfeebled Resistance and the Mirage of Cooperation
The consolidation of multiple organizations under bacteriological control did not bode well for homeopathy, which saw its tenuous grasp of medical practice evaporate in the early twentieth century. Having ceded its claims to the germ theory, every gain by the lab was a gain for allopathy at the expense of homeopathy. Some historians have argued that rather than suffer defeat, homeopaths chose to join allopathy and cooperate with the medical reforms (Rothstein 1992; Starr 1982). But this is history from the viewpoint of the winner. While it is true that some homeopaths did convert, most resisted the laboratory and its vision of medicine. This enfeebled resistance, however, could not withstand the multifaceted reform program backed by Rockefeller resources.
Bacteriological reformers offered a more ambiguous target for homeopaths than past allopathic reformers, as they tempered their exclusionary rhetoric. For decades, homeopaths had made great political hay by exposing the exclusionary practices of the AMA, condemning such efforts as elitist and antidemocratic. Whenever regulars sought to gain some special recognition, homeopaths cried foul to state legislatures, arguing that regulars were trying to illegitimately monopolize medical practice and stifle debate. These arguments resonated with the legislatures, resulting in the universal repeal of state licensing laws and homeopathic inclusion in government bodies. Homeopaths were able to maintain this equal legal standing even during the bacteriological revolution. Between 1870 and 1890, regulars sought to reestablish licensing laws at the state level that targeted newer “quacks,” like osteopaths and chiropractors (Baker 1984). Resigned to the enduring presence of homeopaths and eclectics, regulars hoped to include them in licensing in a manner that would facilitate ultimate allopathic control, proposing legislation for a single board of medical examiners in which regulars were the majority. Alternative sects countered with legislation proposing either separate boards for each sect or a single board with equal representation. As before, state legislatures sided with alternative medical movements, refusing to grant allopathy control over the boards, adopting one of the two alternative proposals.
These de jure, formal legal protections did not preclude homeopaths from being effectively shut out of medical practice de facto. As allopathic physicians seized control of the organizational infrastructure of medicine through the lab, they used their organizational leverage to ensure that homeopaths remained secondary medical citizens, despite their legal equality. The posture they adopted, however, differed from the vitriolic rhetoric of regulars past. Bacteriological reformers framed their interventions as moving beyond both homeopathy and allopathy, transcending the bitter sectarian debates for a medical system committed not to dogma, but to science. Flexner (1910, 156) argued, “Modern medicine has therefore as little sympathy for allopathy as homeopathy. It simply denies outright the relevancy or value of either doctrine.” Whereas the “sectarian begins with his mind made up,” science “believes slowly; in the absence of crucial demonstration its mien is humble, its hold is light,” and in the process, it “brushes aside all historic dogma” (Flexner 1910, 157). Once again, drawing on the forgetfulness of the laboratory, the reformers disavowed theoretical commitments. The future would not be shaped by sectarian theories, but by the “methods of thought and observation and in developing the scientific spirit” (Welch 1920a, 5). Gates justified the actions of the Rockefeller Foundation in similar terms: “The day of dogma and philosophic formulae in science has passed away. . . . Medicine is becoming no longer a creed but a science” (Gates 1911b, 3). Framed as atheoretical and nondogmatic, medical science would lead to the “ebbing vitality of homeopathic schools” in a “striking demonstration of the incompatibility of science and dogma” (Flexner 1910, 161). This more measured tone proved tough for homeopaths to combat, for whoever defended one system over another, whether it was homeopathy, eclecticism, or allopathy, was portrayed by bacteriological reformers as out of touch and retrograde.
This commitment to the atheoretical science of the future was not just a strategic or cynical ploy on the part of the reformers. It resulted in tangible reforms to the way allopaths ran their profession. For decades, the AMA had focused on delineating the boundaries between allopathy and “quackery,” by internally policing its members through the Code of Ethics and no consultation clause. In 1903, bacteriological reformers successfully lobbied for a revision of the Code of Ethics. Arguing that the era of sectarianism was over, they stressed the importance of freedom of inquiry and consultation for the development of the new science. The old Code of Ethics was replaced with a new Statement of Principles. Ostensibly, homeopaths were now welcome to join allopathic professional societies, provided they give up their commitment to
sectarian dogmas. They would be allowed to practice their therapeutics but not to publicly advocate for, or identify with, the homeopathic system.
Homeopaths struggled to respond to allopathy’s new positioning. The AMA’s public display of welcome reduced the rhetorical punch of homeopathy’s traditional arguments that juxtaposed their openness, transparency, inclusiveness, and commitment to debate with the exclusionary practice of allopathy. Now, at least superficially, regulars were abandoning the very practices that homeopaths had long transformed into legislative achievements and public sympathy. Internally, homeopaths debated what this all meant. How genuine was the AMA’s invitation? Could homeopathy have a place in bacteriology? Once again, these debates pitted older homeopaths and veterans of numerous sectarian battles (the “highs”) against the younger homeopaths (the “lows”), for whom the battles of the past had less experiential relevance. DeWitt G. Wilcox (1904, 6) voiced the seduction that the new medical science held for the lows: “We are, to my mind, entering an era of new medicine, not the product of any one school, but the logical outgrowth of scientific research along all lines of life and health. . . . Gentlemen, we have got to get into the bandwagon of progress, or walk; and unless we do get in we have no right to complain because the old school holds the reins and pounds the brass drum.” Lows believed that homeopaths “need not approach the study of bacteriology with the slightest fear that it will destroy the well-grounded temple into which they have built their hopes and allied their dreams” (Maddux 1892, 1). For their part, highs acknowledged that “the spirit of the times is encouraging amalgamation and co-operation,” but they expressed concern that “the dominant school of medicine is not yet ready to accept these conditions” (Wood 1902, 39). Recalling past battles, highs smelled an allopathic trap.