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Rockefeller medicine men : medicine and capitalism in America

E. RICHARD BROWN

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Medicine and Capitalism in America

E. Richard Brown

University of California Press, Berkeley, Los Angeles, London

Excerpts from Abraham Flexner,

Abraham Flexner: An Autobiography,

copyright © 1940 by Abraham Flexner and

© 1960 by Jean Flexner Lewison and Eleanor Flexner,

reprinted by permission of Simon & Schuster.

University of California Press Berkeley and Los Angeles, California

University of California Press, Ltd. London, England

Copyright © 1979 by

The Regents of the University of California

First Paperback Printing 1980

ISBN 0-520-04269-7

Library of Congress Catalog Card Number: 7&-65461

Printed in the United States of America

123456789

To Marianne, Delia, and Adrienne

Contents

Acknowledgments xi

Introduction 1

Doctors 5

Other Interest Groups 7

Foundations and the State 8

"Wholesale Philanthropy": From Charity to Social Transformation 13

Creating Private Fortunes and Social Discontent 14

Driving the Reluctant Poor from Poverty 20

Training Scientific Heads to Direct America's "Hard Hands" 24

Carnegie's "Gospel of Wealth" 30

Reverend Gates Introduces Rockefeller to "Wholesale

Philanthropy" 32 The Reverend Frederick T. Gates: The Making of a Rockefeller

Medicine Man 38 The General Education Board: $129 Million for Strategic

Philanthropy 43 Social Managers for a Corporate Society 50

Scientific Medicine I: Ideology of Professional Uplift 60

American Medicine in the 1800s 61

Incomplete Professionalization 67

Medicine as Science 71

Gaining Public Confidence 74

Reducing Competition 80

Technical Requirements of Scientific Medical Education 80

via I Contents

"Nonsectarian" Medicine Undermines the Sects 88 Specialization: Less Competition for the Ehte 91 Gains and Losses 94

3. Scientific Medicine II: The Preservation of Capital 98

Medical Technology and Capital 98

Welch: A Rockefeller Medicine Man 102

Rockefeller Money and Medical Science: A Social Investment 105

Homeopathy: The Conflict Simmers 109

Scientific Medicine and Capitalist Gates 111

Healthier Workers 112

Ideological Medicine 119

Gates' Digression 130

A Permanent Investment 132

4. Reforming Medical Education: Who Will Rule Medicine? 135

Practitioners Gain a Foothold 136

Council on Medical Education 138

Money for Medical Education: Who Will Pay? 141

Help from the Carnegie Foundation 142

The "Flexner Report" 145

The General Education Board: Medical Education Gets a Different

Drummer 156 Full Time: "Gold or Glory" 158 Selling the Full-Time Proposal 164 Boston Brahmins Resist 166 Fear and TrembUng in the Board Room 167 State Universities: Professionals, the State, and Corporate

Liberalism 176 Summing Up 188

5. Epilogue: A Half-Century of Medicine in Corporate Capitalist Society 192

Frederick T. Gates and the Rockefeller Philanthropies 193

RATIONALIZING THE MEDICAL MARKET 795

The Committee on the Costs of Medical Care 195 Doctors and the Capital-Intensive Commodity Sector 197 The State: Rationalizing the Private Market 200 The Growth of Capital-Intensive Commodities 203 The "Corporate Rationalizers" 204 The State and Capitalist Medicine 207

Contents I ix

Up Against the Medical Market 212

National Health Insurance: More of the Same 216

TECHNOLOGICAL MEDICINE 218

Scientific Medicine: Beliefs and Reality 218

Life, Death, and Medicine 219

Tapping the State Treasury 225

A "Superacademic General Staff' 226

The Corporate Class 228

The Medical-Industrial Complex 231

Technology in Crisis 233

Blaming the Victim: New Prominence for an Old Ideology 235

CONCLUSION 238

Notes 243 Index 273

Acknowledgments

The idea for this book grew out of my teaching about the poHtical economy of health care. My students and I asked how the present system came to be. The search for answers led me to histories of medicine, pubhshed materials in journals of the period, and the archival files of the Rockefeller and Carnegie philanthropies. The archives provided a rich record of the thoughts, policies, and actions of some of the most influential persons in the history of American medicine.

The search culminated in this book. But the book would not have been possible without the generous help, enthusiastic interest, and personal support of many people. I am especially grateful to Howard Waitzkin, WilHam Kornhauser, Barbara Ehrenreich, Gert Brieger, and Michael Pincus, all of whom gave me detailed and thoughtful criticisms on major portions of the manuscript together with great encouragement. I also received helpful criticism and support from Anne Johnson, Jon Garfield, Charlene Harrington, Barbara Waterman, James O'Connor, Dan Feshbach, Ivan lUich, David Horowitz, June Fisher, Kathryn Johnson, Jack London, Jane Grant, Tom Bodenheimer, Sara Mclntire, Joe Selby, Larry Sirott, and Myrna Cozen. Howard Berliner has been an exceptional colleague, sharing ideas and material in a cooperative effort to understand these sparsely stud- ied issues.

Marianne Parker Brown, my wife, gave me continuing encouragement and intellectual criticism and support, even when the burdens of family and household fell disproportionately on her shoulders. My daughters, Delia and Adrienne, were under-

xii I Acknowledgments

standing beyond their years while their father was "working on his book."

The staffs of the Rockefeller Foundation Archives and the Rockefeller Family Archives (now combined in the Rockefeller Archive Center) and the Carnegie Foundation for the Advance- ment of Teaching were very helpful in providing convenient working facilities and making my research in New York excitingly productive. The staffs of the Health Sciences Information Service and the Library Delivery Service at the University of California saved me innumerable hours of retrieving books and journals from the far-flung libraries on the Berkeley campus.

Eva Scipio, Ruth McKeeter, and Sandra Golvin skillfully typed portions of the manuscript in its various phases. Estelle Jelinek carefully and thoughtfully copy edited the final manu- script.

Much of the research for the last chapter was done while I was a consultant to the Childhood and Government Project at the University of California Law School. The Health and Medical Sciences Program, also at Berkeley, helped defray the costs of my research trip to the archives in New York.

The Rockefeller Archive Center and the Carnegie Founda- tion for the Advancement of Teaching kindly gave me permission to publish excerpts from their files.

Introduction

The crisis in today's health care system is deeply rooted in the interwoven history of modern medicine and corporate capitalism. The major groups and forces that shaped the medical system sowed the seeds of the crisis we now face. The medical profession and other medical interest groups each tried to make medicine serve their own narrow economic and social interests. Founda- tions and other corporate class institutions insisted that medicine serve the needs of "their" corporate capitalist society. The dia- lectic of their common efforts and their clashes, and the economic and political forces set in motion by their actions, shaped the system as it grew. Out of this history emerged a medical system that poorly serves society's health needs.

The system's most obvious problems are the cost, inflation, and inaccessibiUty of medical care in the United States. Total health expenditures in this country topped $200 billion in 1979, nearly $1,000 for every woman, man, and child. Far more of society's resources now go into medical expenditures than ever before; twice the portion of the Gross National Product was spent on medical care in 1980 than in 1950.

We pay for these costs through our taxes, health insurance premiums, and directly out of our pockets. Public expen- ditures— four out of every ten dollars spent on personal health services — come out of our taxes. Private health insurance and di- rect out-of-pocket payments each account for about three out of every ten dollars. No matter what form it takes, the entire $200 billion originates in the labor of men and women in the society. President Carter estimated that the average American worker

2 / Introduction

works one month each year just to pay the costs of the medical system.'

Most people feel they should be getting a lot for this money, but instead they find that it is difficult even to get the care they need. Primary care physicians — general practitioners, pediatri- cians, internists, and gynecologists — are scarce. Doctors and hospitals are clustered in the "better" parts of our cities and largely absent from the poorer sections and rural areas of our country. For the millions of Americans covered by Medicaid (the government subsidy program for the public assistance-linked poor), the coverage has been as sparse and degrading as the de- meaning clinics it was supposed to replace. The middle class and the poor share at least long waiting periods for doctors, one of the most common constraints on the accessibility of physicians. In- stead of creating a humane and accessible medical care system, Medicare and Medicaid have helped fuel inflation in medical costs by dumping new funds into a privately controlled system ready to absorb every penny into expansion, technology, high salaries, and profits.

A second, somewhat less widely discussed, problem is the relatively small impact medical care makes on the population's health status. Despite a plethora of new diagnostic procedures, drugs, and surgical techniques, we are not as healthy as we beheved these medical wonders would make us. Some critics, Uke social philosopher Ivan Illich,^ accuse medicine of making us sicker — physically, politically, and culturally — than we would be without it. Many analysts have documented the medical profes- sion's social control functions, medical technology's frequently adverse effects on our health, and medicine's neglect of impor- tant physical and social environmental influences on our health.^ Instead of medicine Hberating us from the suffering and depen- dency of illness, we find that its oppressive elements have grown at least as rapidly as its technical achievements.

Why has medical care grown so costly so rapidly? Why is it so plentiful and yet so inaccessible? How did medicine become technically so sophisticated but remain socially unconcerned and even repressive?

A popular but too facile answer is that such problems are characteristic of technology and industrialized societies. Accord- ing to this argument, technology and industrialization impose

Introduction I 3

their own limits on forms of social organization and produce similar kinds of problems that call forth similar solutions. Medical sociologist David Mechanic finds problems of cost, organization, and ethical dilemmas in medicine widespread among industri- alized countries and concludes that "the demands of medical technology and the growth of the science base of medical activity produce pressures toward common organizational solutions despite strong ideological differences.'"^ lUich asserts that "patho- genic medicine is the result of industrial overproduction."^ In this view, technology has a life of its own, imposing its imperatives on individuals and social organization. By focusing on widespread patterns of industrial organization and technological develop- ment, these analysts conclude that technology and industrializa- tion are universal determining forces.

Such technological determinism ignores the particular history in which society and technology interact. In the Marxian view, technology and economic organization constantly shape each other in a dialectical process. Individuals and groups who own the resources and control the organization of production, far from being at the mercy of "neutral" technology, introduce innova- tions that serve their own ends and oppose those that would serve other interests than their own. These innovations may neglect broader community needs and may hurt the interests of others. Machines and factories undermined the autonomy and even the economic existence of independent craft workers. Hospitals and their expensive equipment may tie many health workers to monotonous jobs and use funds that might otherwise go for more widely distributed community clinics. Those affected by these technological developments may resist them and force their modification. Workers may organize into unions and gain some control over the relations of production. Communities may organize to block hospital expansion and force development of more community-based clinics. In sum, the political-economic organization of society generates certain types of technological innovation and not others, and these innovations generate new social forces that modify technology and poUtical-economic relations.^

This book sees scientific, technological medicine not as the determining force in the development of modern health care but as a tool developed by members of the medical profession and the

4 / Introduction

corporate class to serve their perceived needs. Individuals and groups who possess needed resources can apply them to develop certain types of technological innovation in medicine. Those who have the requisite resources can also apply the resulting techno- logical innovation to serve their economic and social needs.

In the United States medicine came of age during the same period that corporations grew to dominate the larger economy. As corporate capitalism developed, it altered many institutions in the society, medicine among them. Its influence was created not simply through cultural assimilation or the demands of industrial organization but by persons who acted in its behalf. This inter- pretation does not suggest that history is made by dark conspira- cies. Rather, it argues that the class that disproportionately owns, directs, and profits from the dominant economic system will disproportionately influence other spheres of social relations as well.

Members of the corporate class, including those who own substantial shares of corporate wealth as well as the top managers of major corporate institutions, naturally try to ensure the survival of capitalist society and their own positions in its social structure. In the case of medicine, members of the corporate class, acting mainly through philanthropic foundations, articulat- ed a strategy for developing a medical system to meet the needs of capitalist society. They believed their goals for medicine would benefit the society as a whole, just as they beUeved that the private accumulation of wealth and private decisions about how to use that wealth and its income were in the best interests of society. In this book, we will examine the strategies they developed during the Progressive era and the reasons for their actions, leaning heavily on the public and private thoughts of some persons centrally involved in these efforts. We will describe and analyze the interests and strategies of the medical profession and of the corporate class as they developed independently, coalesced, and then clashed. We will also see that the government has increasingly taken over the strategies and struggles begun by the corporate class.

The corporate class influenced medicine, but it could not control it absolutely. The market system in medical care provides special interest groups — today including doctors, hospitals, insur- ance companies, drug companies, and medical supply and

Introduction I 5

equipment companies — ^with the opportunity to develop their own bases of economic power, enabhng them to carve out and defend their turfs in the marketplace. The larger business class stands "above" these interest groups, trying to tame and coordi- nate the leviathan but nonetheless committed to private owner- ship and control and also enjoying medicine's legitimizing and cultural functions. The relationships and the contradictions that emerged among the corporate class and these medical interest groups profoundly influenced the organization and content of today's medical system.

DOCTORS

From our vantage point today it is difficult to beheve that in the late nineteenth century the medical profession lacked power, wealth, and status. Medicine at that time was plurahstic in its theories of disease, technically ineffective in preventing or curing sickness, and divided into several warring sects. Existing profes- sional organizations had virtually no control over the entry of new doctors into the field. Physicians as a group were merely scattered members of the lower professional stratum, earning from several hundred to several thousand dollars a year and having no special status within the population.

By the 1930s, however, medicine was firmly in the hands of an organized profession that controlled entry into the field through licensure and accreditation of medical schools and teach- ing hospitals. The profession also controlled the practice and eco- nomics of medicine through local medical societies. "Medicine" had come to mean the field of clinical practice by graduates of schools that followed the scientific, clinical, and research orienta- tions laid down by the American Medical Association (AMA) and by Abraham Flexner in a famous report for the Carnegie Foundation. All other healers were being excluded from practice. Physicians were increasingly drawn only from the middle and upper classes. The median net income for nonsalaried physicians in 1929 was $3,758, above the average for college teachers but below the faculty at Yale University and below the average for mechanical engineers. "^ Overall, doctors were rapidly rising in income, power, and status among all occupational groups.

In the 1970s physicians have continued to climb to the top

6 I Introduction

rungs of America's class structure. The" median net income of office-based physicians — $63,000 in 1976 — places them in the top few percentiles of society's income structure. In 1939 the average earnings of doctors were two and a half times as great as those of other full-time workers, but by 1976 the gap had increased to five and a half times. Doctors rank with Supreme Court justices at the top of the occupational status hierarchy. And in recent public opinion polls, more Americans said they trusted the medical profession than any other American institution — including higher education, government (of course), and organized rehgion.^

Rising "productivity" has been an important factor in physi- cians' efforts to raise their incomes, status, and power. The medical profession has drastically controlled the production of new physicians and has delegated to technicians and paraprofes- sionals below them the tasks they no longer find interesting or profitable. With rapidly expanding medical technology, more and more tasks were shifted down the line to a burgeoning health work force. At the beginning of this century two out of every three health workers were physicians. Of the more than 4.7 million health workers today, only one in twelve is a physician. Thus, doctors have increasingly become the managers of patient care rather than the direct providers of it.^

As medical managers, physicians have found themselves drawn out of private practice into employment in hospitals, re- search, teaching, government, and other institutions. Today four in ten doctors are employed in such institutions, compared with one in ten in 1931 . These physicians have had fewer material inter- ests in common with private practitioners and have shown little pohtical support for the AMA.^°

Physicians entered a struggle to maintain their position at the top of the medical hierarchy soon after that position was won. The challenge has not, for the most part, come from below, except for recent attempts by nurses to increase their authority in patient care. Doctors have found themselves in a struggle with hospitals, insurance companies, medical schools, foundations, government health agencies, and other groups with an interest in a more rationalized health system — one in which the parts are more coordinated hierarchically and horizontally and in which more emphasis is given to capital-intensive services. The conflict has emerged between organized practitioners as one interest

Introduction I 7

group, what Robert Alford calls "professional monopolizers," and all the groups seeking to systematize health care according to bureaucratic and business principles of organization, what Alford calls "corporate rationalizers.'"'

OTHER INTEREST GROUPS

In challenging the power of organized medicine to protect its interests, hospitals, particularly through the American Hospital Association (AHA), have tried to appear the "logical center" of any rationalized health system.'^ In their transformation and growth from asylums for the sick and dying poor to their twentieth-century role as the physician's workshop, hospitals developed a powerful position in modern health care as the major locus of medical technology. Because of physicians' growing reliance on technology, hospitals were absorbing an increasing share of dollars spent on medical care. PubHc and private health insurance (really, medical care insurance) developed as a stable source of income, enabling hospitals to expand their facihties. Collectively, hospitals have become a major force in the medical system, consuming 40 percent of the nation's annual health care expenditures. Blue Cross and Blue Shield (the "Blues"), created in the 1930s and 1940s by hospital associations and medical socie- ties, respectively, together with commercial insurance companies now control 30 percent of medical care expenditures, mostly em- phasizing hospital-based technical care. They have developed economic and political clout commensurate with their dominating fiscal role.

While the insurance industry is a new voice in the chorus of corporate rationalizers, medical schools have been in the van- guard for more than half a century. Although run by physicians — for the reproduction of health professionals and as the research and development arm of the medical industry — medical school interests have often conflicted with the interests of practitioner- dominated medical societies. In the nineteenth century, medical schools were generally run by small groups of doctors for their own financial benefit. During most of the twentieth century, medical schools have been university-controlled and respon- sive to the interests of foundations and, since World War !•, government funding sources. For the brief period from about

8 I Introduction

1900 to World War I , science-oriented medical schools and the AMA joined forces to press for the acceptance of scientific medi- cine. Since that time they have gone their separate ways — the AMA struggling to preserve the dominance and incomes of private practitioners, and medical schools fostering more rationalized medical care, usually with physicians as top management.

Hospitals, insurance companies, and medical schools all have a relatively greater interest than doctors in promoting capital- intensive, rationalized medical care. While expanding medical technology helped doctors increase their status and incomes, it has been the raison d'etre of hospitals, medical schools, and even insurance companies. Medical technology's demands for heavy capital investment also encourage rationalization of medical re- sources— centralization and coordination of capital, facihties, ex- penditures, income, and personnel.

FOUNDATIONS AND THE STATE

Besides these interest groups, two other forces — the govern- ment and foundations — have exerted a powerful influence in favor of rationalizing medical care. Although the government has been the dominant influence since World War II, foundations were the major external influence on American medicine in its formative period from 1900 to 1930. Their source of power has been the purse, generously but carefully appHed to specific programs and policies. Neither foundations nor the government has operated as an interest group in the manner of doctors, hospitals, insurance companies, medical schools, and the drug and hospital supply industries. The enormous sums they expended — from foundations some $300 million from 1910 through the 1930s and from the federal government many billions of dollars since World War II, for medical research and education alone — have not been for their own financial enrichment.

The argument developed and supported in this book suggests that both foundation policy and government policy have served the interests of certain medical groups but only because the interests of these groups coincided with those of the larger corporate class. As evidence from the historical record will show, the programs of foundations earher in this century were explicitly

Introduction I 9

intended to develop and strengthen institutions that would extend the reach and tighten the grasp of capitalism throughout the society.

In medicine the major objectives of foundations were: to develop a system of medicine that would be supportive of capital- ist society; and to rationalize medical care to make it accessible to those whom it was supposed to reach but at the least cost to society's resources. These objectives created their own contradic- tions. At first, foundations aligned themselves with the aims and strategies of the medical profession, but they soon rejected the narrow interests the profession wished to serve and moved quickly to expand the roles of medical schools and hospitals and to support their dominance over all medical care. By World War II, when the role of the State* in governing the capitalist econ- omy was fully established, the federal government took over the foundations' leading role in medicine, continuing the basic stra- tegy adopted by the foundations more than two decades earlier and opening the floodgates of the treasury to implement it.

In the first chapter, we will see how philanthropic foundations emerged from several parallel developments of capitalist society in the latter nineteenth century. While many members of the new wealthy class were supporting charities to ameHorate the disrup- tions and deprivations imposed on large numbers of people by capitalist industrialization, others recognized the need for techni- cally trained professionals and managers and supported the development of universities and professional science. Just after the turn of the century men of great wealth, Uke John D. Rockefeller and Andrew Carnegie, created philanthropic founda- tions with professional managers in charge of their charitable fortunes. With the Rockefeller philanthropies in the lead, these foundations developed strategic programs to legitimize the funda- mental social structure of capitalist society and to provide for its technical needs.

Chapter 2 traces the social and economic role of scientific medicine in the history of the American medical profession.

*Throughout this book, capitalized "State" refers to the political institutions and agencies of government which embody society's political authority. Uncapitalized "state" refers to the individual states in the United States.

10 I Introduction

Modern scientific medicine was not merely a "natural" outcome of combining science and medicine in the nineteenth century. Apart from the concrete scientific developments that permitted the appHcation of scientific thought and investigation to problems of disease, scientific medicine had equally important social and economic origins. It was an essential part of a strategy articulated by reform leaders of the medical profession to enhance the profession's position in society, and it succeeded because it won the support of dominant segments of the American class struc- ture.

Scientific medicine gained the support of the American med- ical profession in the late nineteenth century because it met the economic and social needs of physicians. By giving doctors greater technical credibility in society, it saved them from the igno- minious position to which the profession had sunk. Moreover, scientific medicine became an ideological tool by which the dom- inant "regular" segment of the profession restricted the produc- tion of new doctors, overcame other medical sects, temporarily united leading medical school faculty and practitioners, and otherwise reduced competition.

Despite its appeal for the medical profession, scientific med- icine would have accomplished Httle for doctors if it had not had the support of dominant groups in American society. In Chapter 3 we will see the reasons for this capitalist support, especially through the thinking of Frederick T. Gates, for more than two decades the chief philanthropic and financial lieutenant to John D. Rockefeller and the architect of the major Rockefeller medi- cal philanthropies.

As an explanation of the causes, prevention, and cure of disease that was strikingly similar to the world view of industrial capitalism, scientific medicine won the support of the classes associated with the rise of corporate capitalism in America. Capitalists and corporate managers believed that scientific medi- cine would improve the health of society's work force and thereby increase productivity. They also embraced scientific medicine as an ideological weapon in their struggle to formulate a new culture appropriate to and supportive of industrial capitalism. They were drawn to the profession's formulation of medical theory and practice that exonerated capitalism's vast inequities and its reckless practices that shortened the lives of members of the

Introduction I U

working class. Thus, scientific medicine served the interests of both the dominant medical profession and the corporate class in the United States.

Nevertheless, a contradiction emerged between the interests of the medical profession and those of the corporate class. As we will see in Chapter 4, the private practice profession and the corporate class clashed over attempts to reform medical educa- tion. The financing of scientific medical schools required tremen- dous amounts of capital from outside the medical profession. Those who provided the capital had the leverage to impose policy. The lines of the conflict were clearly drawn: Was medical education to be controlled by and to serve the needs of medical practitioners? Or was it to serve the broader needs of capitalist society and be controlled by corporate class institutions?

The Flexner report, sponsored by the Carnegie Foundation, tried to unify these interests by centering its attack on crassly commercial medical schools. However, the Rockefeller philan- thropies, substantially directed by Gates, exposed the contradic- tion by forcing a full-time clinical faculty system on recipient schools against the interests and arguments of private practition- ers. Gates made it clear that medicine must serve capitalist society and be controlled — through the medical schools that reproduce its professional personnel and innovate its technique — by capitalist foundations and capitalist universities. By 1929 one Rockefeller foundation, the General Education Board, had itself appropriated more than $78 million to medical schools to im- plement this strategy, and Gates' perspective was firmly estab- lished.

Gates was adamant about keeping his strategy free of involve- ment with the State by not giving money to state university medical schools. However, within the Rockefeller philanthropies as within the largest industrial and financial corporations gen- erally, most officers and directors had come to see the State as a necessary aid in rationalizing industries, markets, and institu- tions.

The course that Gates and his contemporaries initiated continued to develop during the next half-century, but with the State assuming the dominant financial and political role in ration- alizing medical care and developing medical technology. As we will see in Chapter 5, the State's emphasis on technological

12 I Introduction

medicine ignored some of the most important determinants of disease and death while the economic and pohtical forces of capitaUst society assured that rationaUzation would not eliminate the developing corporate ownership and control over the medical market. How medicine will be contained and rationalized in this private market system is a contradiction that now plagues the State and the corporate class as the demand for national health insurance grows. How medical resources can be transformed into effective instruments for improving the population's health is a contradiction imposed on the entire society. These contradictions and their resulting crises are the legacy of medicine's develop- ment in capitalist society.

CHAPTER

"Wholesale Philanthropy ": From Charity to Social Transformation

Industrialization in nineteenth-century America created many problems for those who owned and managed the corporations that came to dominate the economy. Industrial capitalists had to arrange for adequate capital, obtain raw materials, organize pro- duction, disciphne a reluctant work force, and develop markets and transportation systems. They also had to deal with the politi- cal structures and methods intended for older relations of pro- duction, centered around agriculture and commerce, that were only slowly adapting to the new industrial, corporate order. Finally, they had to reshape older social institutions or create new ones. Educational, religious, medical, and cultural institutions were some of the glue that held together the ancien regime. In sum, the new corporate class had to transform all these economic, politi- cal, and social institutions to serve their urbanized, industrialized, and corporate society.

The new economic order created different problems for classes that owned little or nothing of the new system. American society had never been tranquil, but industrialization spread deep disaffection and anger among classes who were dislocated by it and among those who suffered as a result of capitalist accumula- tion of wealth. The agrarian and merchant rulers of the formerly dominant towns resented the meteoric rise of urban industrialists and bankers. Native craftsmen, foreign immigrants, and dis-

14 I "Wholesale Philanthropy

possessed farmers reluctantly submitted to the factory system. Unionism, populism, and socialism threatened the power and wealth of corporations and even raised doubts about the contin- ued existence of capitalism.

As we will see in this chapter, corporate capitalists turned to philanthropy, the universities, and then to medicine to solve some of the many problems that grew out of capitalist industrial- ization. For the most part, social transformations were led by the same "unseen hand" that guided the market forces of capitalism; this self-interest provided a limited perspective for social change. Only gradually did leading capitalists and their allies consciously develop broad strategies and supports for the new order they were building. Philanthropic capitalists supported often harsh but hopefully ameliorative charity to control the desperate poorer classes. Others began building universities to meet the new society's needs for trained experts and managers. A new manage- rial and professional stratum developed to direct corporations, universities, science, medical institutions, and philanthropy itself. After the turn of the century, some philanthropists transformed foundations into a truly corporate philanthropy,* modeled after the dominant economic institutions and fueled with their "sur- plus" wealth. Representatives of the emerging corporate liberal- ism made these foundations their chief instruments for transform- ing social institutions, giving corporate philanthropy an historical role beyond the most visionary dreams of early philanthropic capitalists. This union of corporate philanthropy, the manager- ial-professional stratum, and the universities and science spawned the Rockefeller medicine men and their new system of medicine.

CREATING PRIVATE FORTUNES AND SOCIAL DISCONTENT

The Civil War was a watershed in American philanthropy, as it was in nearly all aspects of American life. It was a great wrenching experience in American history, spreading death and destruction, stimulating industrial development, and producing

*In this book, "corporate philanthropy" refers to philanthropy characteristic of corporate capitalism, especially foundations that are philanthropic corporations controlled by members of the corporate class.

"Wholesale Philanthropy" I 15

upheavals within and between all classes of Americans. A new kind of philanthropy, tailored to these new conditions, emerged in the decades following the war.

The Civil War not only freed the black slaves from legal bonds of slavery. It also freed the hand of Northern capital to extend throughout the nation the industrial transformation it had begun mainly north of the Ohio River. As the "underground railroad" was the vehicle and symbol of freedom for ante-bellum slaves, the iron railroad was the vehicle and symbol of industrialization and the ascending capitalist class.

As the railroads were used increasingly to move troops and suppHes for the Union armies, they helped extend and integrate the marketplace, making possible a speciaHzed manufacturing and marketing system that could be coordinated across the continent. The railroads pushed into every region of the country. They brought farm produce to new markets and to ports for ship- ment to distant lands. They carried cotton from Southern fields to New England textile mills. They carried iron ore from Lake Superior to the iron mills and new Bessemer steel furnaces in Pittsburgh, and oil from western Pennsylvania to Cleveland refineries. And they brought the products from the nation's factories to markets in every region. Everywhere, they spread new settlements and development. Despite interruptions during the Civil War, railroad construction added 62,000 miles of new lines in the 1860s and 1870s, tripling the nation's existing track mileage. Railroad construction required iron and later steel rails and bridges. The railroads themselves soon became the biggest customers of America's growing steel industry.

The Civil War and the railroads led some men to their pots of gold. Andrew Carnegie began his rise to fortune as a telegraph clerk for the Pennsylvania Railroad in 1853. By the beginning of the Civil War the ambitious twenty-five-year-old Carnegie was well into railroad management and spent a few months organizing rail transport and telegraph communications for the War Depart- ment. But Carnegie quit his exciting and dangerous war front job and returned to the Pennsy and especially to tend his growing investment in iron manufacturing and coal mining. By 1863 his annual income exceeded $40,000.^

John Davison Rockefeller's fortunes were also helped by the Civil War. In 1861, as the war consumed the energies and lives of

16 I ''Wholesale Philanthropy"

Northerners and Southerners, the twenty-five-year-old Rockefel- ler was building a successful merchandising firm in Cleveland. As war orders poured in, commodity prices rose sharply, and Rockefeller's profits soared. Two years later, Rockefeller had saved enough capital to invest in an oil refining business, and by the end of the war he was worth enough to take control of the company. By 1880, led by Rockefeller's determination to "make money and still more money," combined with relentless com- petition in the marketplace and rebates extracted from the rail- roads, his Standard Oil Company was refining 95 percent of the country's oil.^

While the industrial base had obviously been growing in the decades before the Civil War, it was the changes wrought by the war that cemented the new system's structure. The Southern patrician class, whose position was based on agriculture and slaves, was not crushed, but its subordination to the Northern- controlled capitalist economy was assured. The factory system was extended with the railroad, and an industrial working class was formed out of craftsmen and laborers, native folk and immigrants. Small-town America gradually gave way to industrial and commercial boom, and cities grew faster than their fragile tenements could be built. In the process, the older entrepreneurs and landed gentry were displaced by the new entrepreneurs and their corporations. By the 1870s, for example, only 520, or 5 percent, of the 10,395 businesses in Massachusetts were incorpo- rated. But this 5 percent held 96 percent of the total capital and employed 60 percent of all workers. By 1900 three-fourths of all manufactured goods were produced by corporations. Because of the important logistical role of the railroads, the Civil War has been called the "first railroad war." Yet the war did not rely on an industrial economy. As William Appleman Williams aptly put it, the Civil War "produced an industrial system rather than being fought with one."^ The ultimate victors of the war were the corporations and the men who, for the most part, ruled the new economy.

Not all was smooth for the new barons of the corporate economy, nor did they make life easy for those under them. The owners of each industry, driven to grab what they could of the available market and accumulate as much capital as possible in the shortest time, pushed wages down in order to lower prices

"Wholesale Philanthropy" I 17

and to get a jump on their competitors. Immigrants were inducted into the growing industrial work force. Some 16 million foreign-born were attracted to the country in the second half of the nineteenth century, totaling 15 percent of the population by 1890 and nearly a quarter of the population of the industrialized northeastern states. Craftsmen saw their skills, the basis of modest security and pride, fall to degradation and unemploy- ment before machines that outproduced them and factories that oppressed them. Migrants from failing farms and immigrants from foreign lands filled the factories and cities of the New World. Working men lost their livelihoods or submitted to the harshest labors. Women were drawn out of more traditional homebound work into factories, shops, and stores. Twenty percent of the nation's women were wage laborers by 1900. Children were sucked into the factories as the cheapest labor. Working-class family and social Hfe were shaken and devastated.

Exploitation of workers, unmitigated by either legal restraints or humanitarianism, led to increased organizing by labor. The depression of the 1870s brought wages in 1875 down to $1.50 for a ten-hour day. Riots were common in cities throughout the country. Labor began to organize, and employers used every available power, from lockouts to Pinkertons, to crush the union movement. In 1877 the first nationwide strike, a spreading walkout against the railroads, was put down with a bloodbath that took the lives of scores of workers, their families, and their supporters in city slums around the country. The labor movement grew and strikes continued to spread in the 1880s and 1890s. The Haymarket Square bomb in 1886, the strike at Carnegie's Homestead steel mills in 1892, and the Pullman strike in 1894 were only the most prominent events that made employers and their allies fear for the continued existence of their society. "The times are strangely out of joint," worried a Kentucky politician. "The rich grow richer, the poor become poorer; the nation trembles.""*

Town folk and farmers, especially in the Midwest and South, felt their lives and livelihoods increasingly determined by railroad rates and lines of credit from banks directed from distant cities. Semi-feudal sharecropping kept large numbers of Southern farmers in perpetual debt and poverty. Agrarian opposition to capitalist expansion won broad support. In 1896 the growing

J8 I "Wholesale Philanthropy'

Populist party formed a shallow coalition with the Democratic party around the Democrat Bryan for President and the Populist Tom Watson for Vice-President against McKinley, the candidate of big business. The Populist party was decimated by their defeat, but populist resistance to capitalist wealth and control of agricul- ture continued in the Granges and the Farmers Union well into the new century. To the middle-class professionals who dominat- ed the Progressive movement the society seemed to be breaking up below them because of the greed of those above them. They called for reforms to Hmit the concentration of power and wealth. Many members of the richer class felt called upon to justify the great inequality that angered the working class and worried the middle class. Naturally they did not see themselves as "idle" rich. They viewed their efforts to build industrial empires as productive work, and they considered all the people to be the beneficiaries of those empires. No one said it as well as Rockefeller:

The best philanthropy, the help that does the most good and the least harm, the help that nourishes civilization at its very root, that most widely disseminates health, righteousness, and happiness, is not what is usually called charity. It is, in my judgment, the investment of effort or time or money, carefully considered with relation to the power of employing people at a remunerative wage, to expand and develop the resources at hand, and to give opportuni- ty for progress and healthful labour where it did not exist before. No mere money-giving is comparable to this in its lasting and beneficial results.^

The great benefit of such enterprises is moral, providing employment to otherwise idle hands, and material, "to multiply, to cheapen, and to diffuse as universally as possible the comforts of life."^ Thus, the building up of private industry is the best method of solving the problems that historically grew with industrialization. "Can there be any doubt that cheapening the cost of necessaries and conveniences of life is the most powerful agent of civilization and progress?" asked Charles Elliott Perkins, president of the Chicago, Burhngton, and Quincy Railroad. "The true gospel," Perkins philosophized agreeably, "is to enable men to acquire the comforts and conveniences of life by their own efforts, and then they will be wise and good."''

The class of men and women who provided this largess for the rest of society had varied notions about what to do with their

"Wholesale Philanthropy" I 19

money and their power. Mark Hanna, a Cleveland industrialist, showed fellow capitalists that the President and executive branch of the government, as well as the Congress, could be secured "for the protection of our business interests." Fearing the growing ranks of Populists and their increasing political strength, he established an interlocking political directorate of corporate leaders to organize their common interests and bring their influence more directly into the federal government. With their first Presidential triumph, electing McKinley in 1896, they inau- gurated the modern system of expensive, centrally coordinated national campaigns. Hanna led the formation of a corporate politics that placed the broad class interests of industriahsts and financiers ahead of "pork barrel" tactics favoring narrow interests that had dominated state, national, and local political scenes. Hanna and other leaders of this class put together new aUiances, like the National Civic Federation, with some labor leaders to create a "harmony of interests" out of the class conflicts that threatened the new economic order. The Progressive movement proved an ideal vehicle for the business class to assert its interests by securing additional, needed capital from the Congress and, through reforms in the federal executive branch, creating and controlling regulatory agencies to bring order and consolidation to a number of industries. The politically wise leaders of this class thus demonstrated that with strategic alliances with social reform- ers and conservative union officials, the nation's political institu- tions could be reformed to serve the needs of the corporate order. ^

Not all capitalists, however, could see farther than their own immediate interests in pohtics. John D. Rockefeller, whose Standard Oil Trust was accused by Henry Demarest Lloyd of buying out the legislatures and the executive branches of Pennsylvania and Ohio, was unenthusiastic about his friend Hanna's broader political strategy. Hanna's first major success sent John Sherman to the U.S. Senate in 1885, ironically pro- viding the author of the very law under which the Standard em- pire was eventually broken up. Perhaps Rockefeller suspected such betrayals from politicians who had their own visions of what was good for business, for he customarily reserved his political contributions for candidates closer to the Standard's immediate fields of operations.^

Many wealthy men spent their fortunes on ostentatious luxury

20 I "Wholesale Philanthropy*

that left much of the European aristocracy in shadow. The Vanderbilts, Jim Fisk, Jay Gould, and other financiers built palaces along New York's Fifth Avenue, many of them with marble, furnishings, and statuary scooped up from the crumbling baronies of the Old World. Marshall Field and Potter Palmer built their castles on some of Chicago's most prized residential and lakefront land. Mark Hopkins, Charles Crocker, and Leland Stanford transformed San Francisco's Nob Hill with their resi- dences of splendor, using wealth obtained from promoting and governing the westward expansion of the railroads. Carnegie bought himself a castle in his Scottish homeland. And Rockefel- ler created, not merely a castle, but a royal estate at Pocantico Hills, whose 3,500 acres overlooking the Hudson River was five times the size of Central Park. The spectacle of such living, especially in the midst of tenement-teeming cities, caused con- siderable agitation. The Massachusetts Board of Education had complained even in 1849, "One gorgeous palace absorbs all the labor and expense that might have made a thousand hov- els comfortable." By the end of the century, social scientists cultivated by the wealthy came to their benefactors' defense. A Boston University economics professor retorted to detractors of grandeur, "The notion there is necessarily any causal connection between opulence and poverty is too crude to require serious refutation. "^°

DRIVING THE RELUCTANT POOR FROM POVERTY

Some representatives of the opulent class, both before and after the Civil War, had a broader sense of purpose. They provided luxurious, even princely lives for themselves and their families, but they carefully set aside a share of their wealth for philanthropy. Philanthropy, of course, did not mean giving money directly to the poor. While charity had always implied providing alms for the relief of the poor, the rich and most social reformers in the class immediately below the rich have always been wary of the consequences of giving to the poor. Cotton Mather urged colonial Boston merchants to set a disciplined, moral example and give only to the "poor that can't work." Benjamin Franklin hoped to provide sufficient opportunity in society so there would be no need of poverty, and he tried to

"Wholesale Philanthropy" I 21

develop a strategy for getting the poor to adopt disciplined ways of living. "I think the best way of doing good to the poor," Franklin said, "is not making them easy in poverty, but leading them or driving them out of it."^^

Franklin's maxim and a pitiless Social Darwinist perspective were the heart of the charity organization movement that blossomed in the United States during the last three decades of the century. Patterned after the London Charity Organization Society, founded in 1869, these city and national organizations gave few handouts. Their main purpose was, in the words of a Philadelphia group, to develop "a method by which idleness and begging, now so encouraged, may be suppressed and worthy self-respecting poverty be discovered and relieved at the smallest cost to the benevolent." Even during the vast depression that began in 1873 and lasted until the end of that decade, all takers of charity were suspected of slothfulness and degeneracy. ^^

The poor were a desperate, volatile lot, given to crime, riots, and insolent discontent. Extreme Social Darwinists believed with Herbert Spencer that those who are fit to live do so and those who are not fit die — "and it is best they should die."'^ But the dominant classes of any society need a more positive program than that to deal with oppressed classes' articulated demands for sharing the wealth or even their inarticulate mayhem.

The programs that emerged from charity organization work brought systematic study and the label of "science" to philan- thropic work. The annual meetings of the National Conference of Charities and Correction brought together experts from char- ity organizations, administrators of penal institutions, hospitals and settlement houses, academics from university sociology and economics departments, and clergymen and physicians to coordi- nate their work and develop strategies for uplifting the poor. The attitudes of these "scientific" charity workers ran from harsh to refined, punitive to ameliorative.'"* Over the years these reform- ers turned increasingly to the analytic methods of the social sciences and to the political views of the Progressive movement. Edward T. Devine, in his presidential address to the National Conference in 1906, noted that inmates were entering charitable institutions, insane asylums, prisons, and reformatories "faster than all our educational processes, our relief funds, and even our consecrated personal service" have been able to rehabilitate

22 I ''Wholesale Philanthropy"

them. The role of "modern philanthropy," Devine continued, is to "seek out and to strike effectively at those organized forces of evil, at those particular causes of dependence and intolerable living conditions which are beyond the control of the individuals whom they injure and whom they too often destroy. "^^

Scientific philanthropy must concern itself with "prevention rather than relief," argued Amos Warner, a Stanford economist active in the movement. Warner compared statistics compiled by charity organizations in the United States and Europe and concluded that nearly three-fourths of all poverty is due to per- sonal or social "misfortune" and less than a fourth to "miscon- duct" on the part of the individual.'^ "Prevention" involved inter- vening in the lives of both groups to assist them through their misfortune or change their bad habits and lead them onto the path of righteousness.

Out of this social intervention perspective and the charity organization movement emerged the social work professions. Case workers, settlement house workers, correctional adminis- trators, probation officers, and their academic advisers shared with the middle and upper classes the prevaiHng Social Darwinist view that dependent poverty, crime, and social deviance in general had biological roots. But this new professional class believed that medical and social intervention could remedy "natural" imperfections.'"^

Given the disintegration of older social relations and the increasing fear of working-class revolt — both products of capital- ist industrialization — it is not surprising that wealthy men and women supported the goals and programs of the charity organiza- tions and the social work movement. Charles Hull, who amassed a fortune from Chicago's booming real estate market, gave freely to social rehabilitation programs in the slums and sold cheap land to the poor to give them a stake in the existing society. It was his way of correcting the unequal distribution of land out of which he feared "discontent and revolution will come."'^

Scorning pity and indiscriminate relief as merely reinforcing the poor in their degraded condition, the charity organization movement, social work professions, and wealthy benefactors in general worked instead to uplift, or rehabilitate the poor. They established institutions that would isolate "the poor that can't work" and prevent them from infecting "honest," hard-working

"Wholesale Philanthropy" I 23

poor folk. They also developed programs to give the working poor a loftier vision of life than could otherwise be gotten from the factories and tenements in which they spent their lives. Settlement houses and social workers were established in the slums and ghettos to integrate the foreign-born into American society and to rehabilitate and reintegrate the casualties of an industrial society divided into owners and nonowners. Jane Addams' settlement house, provided by Charles Hull's estate, attempted to fulfill her principal goals to "feed the mind of the worker, to lift it above the monotony of his task, and to con- nect it with the larger world outside of his immediate sur- roundings. ..." Addams opposed the excesses of both capital and labor and worked to bring together these warring classes through programs acceptable to both.'^

Such programs did not suggest that the capitalist social structure itself should be altered. Rather they were intended to ameliorate the harsh conditions of capitalism by helping individu- als escape from its pits and lead both useful and more satisfying lives. While many social workers supported union demands, their work won financial and political support from the wealthy classes because it diverted attention from more militant demands. Social workers held out the hope of ameliorating Hving conditions with social programs while workers demanded union recognition, higher pay, the eight-hour day, and relief from unemployment. All these programs proved more symbolic and ideological than actually ameliorative. The working poor and the unemployed were being taught to blame their own inadequacies for their conditions and to work and wait patiently for their individual rewards.

Some capitalists, however, both before and after the Civil War, were less concerned with revolt brewing below them or were more thoughtful about the future needs of their social system. They developed another line of philanthropy that centered on creating social institutions whose main functions were not even symbolic amelioration but provided for the training of personnel needed by industrial capitalism if it was to survive and grow. Some of these capitalists, particularly in the first half of the nineteenth century, helped to create compulsory pubHc schooHng to socialize working-class and poor children to the rhythms and cooperative needs of factory work and to give

24 I ''Wholesale Philanthropy"

them the rudimentary skills — reading, writing, arithmetic, and vocational skills — needed in an industrial society. ^° Other men and women of wealth understood the country's need for more advanced technical skills. They joined forces with foresighted leaders of the nation's traditional colleges, bringing them out of the orbit of the old agricultural and merchant ruling class and into the service of the ascending industrial and financial order.

TRAINING SCIENTIFIC HEADS TO DIRECT AMERICA'S "HARD HANDS"

On the last day of April in 1846 Edward Everett, the new president of Harvard University, stood before his faculty, students, and alumni and inaugurated a new era of cooperation between industrialists and America's colleges and universities. Harvard would no longer be geared mainly to the needs of the agricultural gentry and wealthy merchants, producing educated clergy, lawyers, and assorted gentlemen. Everett laid before his inaugural convocation a proposal, that Harvard found a "school of theoretical and practical science" to teach "its application to the arts of life," to furnish a "supply of skillful engineers" and other persons who would explore and develop the "inexhaustible natural treasures of the country, and to guide its vast industrial energies in their rapid development."^^

Within a year Abbott Lawrence agreed to underwrite Ever- ett's plans. Lawrence's investments in textile manufacturing and railroad financing had made him a man of wealth and influ- ence in Massachusetts. The industrial revolution in America was in its infancy when he began, but now near midcentury its potential was proven. Lawrence knew first hand the value of the factory system and mechanization in increasing production and profits. He saw that railroad construction brought not only profits on his investment; it also created a demand for iron production and opened up regional and national markets, allowing farmers and factory owners to ship their products to distant markets and increasing America's exports. "Hard hands are ready to work upon our hard materials," he observed. But "where shall sagacious heads be taught to direct those hands?"^^

To answer his own question and help Harvard realize its self-appointed role, Lawrence gave the university the then

"Wholesale Philanthropy" I 25

princely sum of $50,000 to found a school that would apply chemistry and other sciences to the needs of agriculture, engi- neering, mining and metallurgy, and the "invention and manufac- ture of machinery." Thus was the Lawrence Scientific School born. Lawrence was so pleased with the new school that he bequeathed an additional $50,000 for it which Harvard received upon his death in 1855.

Harvard's school was exemplary of the new relationship between science, education, and industrialization. In the nine- teenth century, scientists, industrialists, and college presidents developed a profitable alliance. The usefulness of science to industry, the willingness of industrialists to support scientific research, and the opportunity for colleges to train scientists and engineers and do much of the research needed by industry provided a great deal of common ground. It also opened the door for scientists who wanted to make science a full-time occupation and distinguish themselves from others who used the knowledge and methods of the natural sciences in their work.

The great inventors of the early industrial revolution were mostly practical-minded mechanics, craftsmen, and tinkerers, men and women whose lives embraced science through their work. "In contrast with modern practice," observes Harry Braverman, "science did not systematically lead the way for industry, but often lagged behind and grew out of the industrial arts."" By the 1830s and 1840s a new group of scientists emerged who wanted to be more than "dilettantes." Like their European counterparts, whose support and status they envied, the upper ranks of American scientists wanted to devote themselves to research, but they lacked the necessary financial resources. Although young men in America's colleges were taught science, there was almost no original research being done in the country. As Joseph Henry, the nation's leading physicist, complained, "every man who can burn phosphorous in oxygen and exhibit a few experiments to a class of young ladies is called a man of science."^"*

In 1844 Alexander Dallas Bache, the superintendent of the U.S. Coast Survey, told an attentive audience at the country's first national scientific congress that America's unoriginal and meager science merely aped European science. America's sci- ence, he said, had inadequate institutional support, substituted

26 I "Wholesale Philanthropy'

teaching for scientific research, was overrun with gentleman scientists, and lacked professional scientists. Bache and Henry, together with Harvard mathematician Benjamin Peirce, astrono- mer Benjamin Gould, chemist Oliver Wolcott Gibbs, zoologist Louis Agassiz, and a few other professional scientists fancied themselves the nation's sole custodians of science and its develop- ment. They aggressively sought support for their research and promoted the cause of professional science. In their view, only some men were endowed with scientific talent, and only such an elite should be entrusted with training, facilities for research, and money. As Howard Miller has pointed out, their eHtism won them no support from the assertive, democratic populists of Andrew Jackson's era."

These new men of science won increasing support from the entrepreneurial fortunes of the captains of industry. Lawrence was neither the first nor the last capitalist of the nineteenth century to channel his surplus wealth to colleges in order to put science at the service of industry. In 1846, with the financial help of philanthropists, Yale created two new professorships in agricultural and practical chemistry and appointed the eminent Benjamin Silliman, Jr., to one of them to develop and teach the "application of chemistry, and the kindred sciences to the man- ufacturing arts, to exploration of the resources of the country and to other practical uses." Silliman's prolific accomplishments at Yale included developing the first commercially successful method of refining petroleum. Before the Civil War, Joseph Earl Sheffield, a New Haven man who made his fortune in Southern cotton and in financing Northern railroads and canals, gave the strugghng Yale Scientific School a large contribution. The university appreciatively renamed the school in honor of its benefactor, whose contributions to Yale for applied science totaled more than $1 million by the time of his death in 1882.^*

Perhaps the most symbolic change was the conversion of the Reverend Nathan Lord, president of Dartmouth College. As he assumed the college presidency in 1828, Lord asserted that Dartmouth was not designed for men who were to "engage in mercantile, mechanical, or agricultural operations." His strict adherence to the classics and to preparing gentlemen, however, did not survive several large contributions from wealthy advo- cates of appHed sciences and engineering. By the late 1860s Lord

"Wholesale Philanthropy" I 27

eagerly embraced the "necessity now becoming constantly more evident of a higher education in the 'practical and useful arts of life.' "^'

Some industrialists and finance capitaHsts, not content with the slow and incomplete transformations of the older colleges, started their own engineering schools. In 1824 Stephen Van Rensselaer, a wealthy landlord farmer who organized and backed the construction of the Erie Canal and thereby experienced for himself the lack of adequately trained engineers, founded the institute that bears his name to teach the "application of experi- mental chemistry, philosophy and natural history, to agricul- ture, domestic economy, the arts and manufactures."^* Other engineering and technical schools were begun around the country from fonts of industrial wealth — Cooper Union in New York City, the Massachusetts Institute of Technology, the Stevens Institute in Hoboken, the Case School of Applied Science in Cleveland, the Pratt Institute in New York, and the California Institute of Technology, to name a few.

Philanthropic capitalists left their marks in American higher education in other areas besides science. Joseph Wharton, a wealthy manufacturer of metals, gave the University of Pennsyl- vania some $600,000 for a school of finance and commerce that would train the managers, accountants, and leaders of industry who would direct the engineers and appHed scientists graduating from technical schools. Entirely new universities were founded in the 1870s and 1880s by some of the wealthiest men and women in the country — ^Johns Hopkins, Tulane, Clark, Vanderbilt, Stan- ford, Cornell, and others.

These educational philanthropists were primarily capitalists who disdained the aristocratic pretenses of gentleman farmers and the dabblers' and merchants' ignorance of technique. Re- membering their own lack of preparation as they began their careers, they favored practical educations that would promote endeavors like theirs and create a fertile ground from which their new society would grow. They also perceived a need for trained personnel for the growing industrial and corporate economy. As the organizers of factories and other enterprises that employed increasing divisions of labor, they preferred to train technically skilled managers and reduce the skill levels of their laborers; in the words of Abbott Lawrence, let the "hard hands" do the labor

28 I "Wholesale Philanthropy''

and let "sagacious heads" design and direct the labor process. Impressed with the utility of applied science, they subsidized teaching and research in the natural sciences and engineering, and they supported vocational and applied curricula in colleges against the prevailing classical education. By the end of the century they were delighted with the progress that had been made in creating universities and colleges in their own image. And, of course, they were glad to have combined this self-interest with an appearance of generosity and altruism.

The entrepreneurial scientists and college presidents made the philanthropists' job an easy one. The development of modern universities and the founding of professional science in the United States were largely the products of elite college presidents and men of science inviting captains of industry to recognize the importance of their contributions to the nascent industrial and corporate society. They asked for and got money for their work, their institutions, and themselves.

Scientists offered their talents and their services to the capitalists in return for new laboratories and stipends; they gave up to the colleges a degree of autonomy in return for a legitimized base of operations, some financial security, and a protected role in training new basic and applied scientists as well as conducting research. College presidents acted as brokers, eagerly offering their services and institutions to capitalists and scientists alike, in return for new areas of service that would assure the continued relevance and financial security of their institutions under the ascending economic order. Their new buildings and endowments assured them that they were on the right track. By 1872 philanthropy accounted for nearly half the $13 miUion income received by all the nation's institutions of higher education. ^^

The founding of schools, institutes, and universities was quite a different tack from giving to charity organization societies and creating settlement houses. They were both intended to meet the needs of the developing industrial and corporate society, but in different ways. One was ameliorative: It tried to compensate for the failings of the capitalist social structure. The other was more technical and "preventive": Institutions were developed to meet the needs of the system for technical expertise and industrial and social management. Both were important to the survival and expansion of industry as it was organized in capitalist society.

"Wholesale Philanthropy" I 29

There were limitations, however, in the resources and strate- gies of both approaches. The social work approach was ameliora- tive at a time when most philanthropists were pressing for preventive strategies. The founding of universities and institutes, which had a preventive character, was limited in two ways. First, it often represented an individual action on the part of a particular rich man or woman who founded the institution to reflect a personal perspective of what was needed. While some of them secured the help of visionary university presidents, these institutions often reflected too strongly the personalities and idiosyncratic views of their founders. Only when governance fell to the institution's trustees did it come to reflect a broader perspective within the benefactor's class. Thus, the trustees who implemented Johns Hopkins' bequest for the founding of a uni- versity were able to do what they collectively believed worth- while because their broad charter left them free of detailed instructions from the deceased benefactor while the endowment meant they had "no need of obeying the injunctions of any legislature, the beliefs of any religious body, or the clamors of any press. "^° Most benefactors, especially those who founded their institutions while on this side of their graves, held closer reigns on policies and personnel.

The second Hmitation on the usefulness of the university movement among the wealthy was one of scale. Most of the founders had fortunes big enough to create only one institution, and those who had the wealth to do more nevertheless concen- trated their energies and their money in one place. Thus their direct influence would come from only one place, and their indirect influence would be only as a model. These were often powerful forces. Van Rensselaer's institute claimed, by the middle of the nineteenth century, that it had produced a majority of the country's engineers and naturalists. And the class of wealthy university founders was small and often influenced each other: Ezra Cornell's new university at Ithaca was admired by Leland Stanford, and Stanford's creation in California greatly impressed Jonas Clark and his plans for Massachusetts.^' These exceptions notwithstanding, the general limitations of individual- ism and narrowness of resources reduced the utility of university building for corporate capitalism.

The accolades these "good works" generated didn't mean that

30 I ''Wholesale Philanthropy"

philanthropy could not be done better. And certainly the cap- italist impulse to believe in perfectability in the organization of any enterprise encouraged many philanthropists to look for errors and seek a better way. The obvious constraints of ameliorative social intervention programs drew most of the criticism. But while the create-a-school movement was not criticized explicitly, a successor was soon seen on the horizon. At best the univer- sities were productive models of capitalist rationality and tech- nical modernness in an untamed, competitive marketplace of seemingly incompetent educational institutions. Not surprisingly, it was the philanthropies created by the kings of oil and steel that started American schooling down the same road to vertical organization and centralized control that they had created in their own industries.

CARNEGIE'S "GOSPEL OF WEALTH"

The growing fortunes of the Carnegies and Rockefellers in this country made them prominent symbols of the success as well as the inequities of industrial capitaHsm. It was this weighty responsibility that led Andrew Carnegie to explain the problems associated with great wealth and to lay out the responsibilities that came with its possession. In an influential two-part essay entitled "Wealth," published in the North American Review in 1889,^^ Carnegie with a flush of confidence set out a plan for assuring continued private accumulation of wealth. "The prob- lem of our age," he boldly began, "is the proper administration of wealth, that the ties of brotherhood may still bind together the rich and poor in harmonious relationship." Speaking to a receptive audience among the "haves" more than to the truculent "have-nots," Carnegie identified the accumulation of wealth as the essential factor in the "progress of the race." Whether it be "for good or ill, it is upon us, beyond our power to alter, and, therefore, to be accepted and made the best of. It is a waste of time to criticize the inevitable," he reassuringly added.

Though capitalism's "law" of competition "may be sometimes hard for the individual, it is best for the race because it insures the survival of the fittest in every department," he observed, paraphrasing the then widely idolized Herbert Spencer. Further- more, it produced great material wealth so that all people lived better for it. Society must not only accept; it must welcome "great

"Wholesale Philanthropy" I 31

inequality of environment," specifically the "concentration of business, industrial and commercial, in the hands of a few." It is not to be regretted that capitalists must "soon be in receipt of more revenues than can be judiciously expended upon them- selves." It is simply incumbent upon the wealthy to dispose of their fortunes wisely.

They should not, he warned, leave the bulk of their wealth to their families, for such legacies undermine the moral integrity of the recipients. Nor should the rich man simply bequeath his fortune for public purposes because it is morally reprehensible to accumulate great wealth and not show either the interest or the judgment to spend it wisely. As exciting as Carnegie found his money-making career, it had always seemed to him below the moral and intellectual world to which he aspired. More than two decades before his declarations on wealth, Carnegie had written a memo to himself promising to quit business shortly: "To continue much longer overwhelmed by business cares and with most of my thought wholly upon the way to make more money in the shortest time, must degrade me beyond hope of permanent recovery."" Now Carnegie admonished his peers, "The man who dies thus rich dies disgraced."

It is the duty of the wealthy, Carnegie declared in his article, "to consider all surplus revenues which come to him simply as trust funds," to do what, "in his judgment," is best for the community. The wealthy capitalist is thus a "mere trustee and agent for his poorer brethren, bringing to their service his superior wisdom, experience, and ability to administer" — in a word, "doing for them better than they would or could do for themselves."

He then recommended to men and women of substantial means seven uses for their surplus wealth, declaring the priorities that he followed in the years to come. Topping the list were universities, to which Carnegie gave more than $20 million in his lifetime. Next were free public Ubraries, which, to Carnegie's mind, squared with his goal "to stimulate the best and most aspiring poor of the community to further efforts for their own improvement." Carnegie contributed 2,811 libraries to communi- ties that promised to support them; this most famous of his philanthropies consumed more than $60 million of his wealth. Carnegie also recommended giving money for medical institu- tions, public parks and city beautification, halls for "concerts of

32 I "Wholesale Philanthropy

elevating music" and enlightening lectures, swimming baths, and — last — church buildings. ^"^

Carnegie's round face glowed and his eyes sparkled as he received the adulation of wealthy admirers and fawning suppli- cants. Gladstone sanctified Carnegie's proposals with a review of his article in the prestigious British magazine Nineteenth Century, criticizing only Carnegie's condemnation of inherited wealth. From his celebrated position, Carnegie dismissed the critical reviews of his article. The Reverend Hugh Price Hughes, a prom- inent Methodist minister and Christian populist, condemned this new "Gospel of Wealth," as it had come to be called. "Mr. Carnegie's 'progress' is accompanied by the growing 'poverty' of his less fortunate fellow-countrymen," he wrote. William Jewett Tucker, a Uberal theologian and later president of Dart- mouth College, pointed out that the assumption "that wealth is the inevitable possession of the few, and is best administered by them for the many, begs the whole question of economic justice now before society." "I can conceive of no greater mistake," Tucker protested, "than that of trying to make charity do the work of justice. "^^

Carnegie's giving never aimed at justice; his goal was "to lead people upward." Like his politics, Carnegie's philanthropy was a mixture of moraUstic programs to civilize the masses, impulsive decisions, and sentimentaHty. Libraries, institutes, concert halls, and church organs — 7,689 organs costing more than $6 million — were given to uplift the poor and working classes. In 1904 he provided more than $10 miUion for the Carnegie Hero Fund to honor men and women who are injured or killed while trying to save their fellows; medals were presented to the hero, or his or her surviving family, and occasionally monetary grants, to encourage the masses to follow examples set by "the heroes of civilization." Carnegie also provided his birthplace of Dun- fermline, Scotland, with a $3.75 million fund for parks, recrea- tion, and general beautification.^^

REVEREND GATES INTRODUCES ROCKEFELLER TO "WHOLESALE PHILANTHROPY"

Like Carnegie, John Davison Rockefeller's interest in finan- cial benevolence antedates his most famous philanthropies. From the time of his youth. Rockefeller's life consisted of work, family,

"Wholesale Philanthropy" I 33

and the Baptist church. More like his pious mother than his genial and impulsive father, Rockefeller lived a disciplined life, forever pinching pennies but mindful of his Christian duties. Even in 1855, when he was earning $3.50 a week as a clerk accountant in Cleveland, Rockefeller carefully apportioned about 10 percent of his income to charities and church work. His philanthropy grew with his riches; by 1881 he was giving away more than $60,000 a year.^^ By the end of the century, he and Carnegie were com- peting in their philanthropy — with Carnegie ahead.

Rockefeller was diligent in giving to charity but ungenerous in spirit. Like other men of his day climbing the ladders of business success and those who had reached the top. Rockefeller saw no excuse for poverty. Having gone into business for himself at the age of twenty, the oil king "knew" that hard work and discipUned living were the means to escape poverty. In 1887 Rockefeller answered a poor young man's plea for fifty dollars with a check, a request for an I.O.U. , and a warning: "It will be injurious for him to receive from others what he can in any way secure for himself by his own efforts." And after a visit to a "house of industry" in New York's incomparable slum of Five Points, he complained that although the institution gave free meals to the area's "tramps" only on Thanksgiving Day, he "would give them work and make them earn their food."^^

Whereas Carnegie's secular views led him to Social Darwin- ism as a biological and social explanation for the maldistribution of wealth, Rockefeller's religion exorcised all self-doubts. Partic- ularly as he grew older and more comfortable with his fortune and his role as philanthropist, Rockefeller came to believe that "God gave me my money." When he uttered these words in 1905, "Rockefeller" was not the most revered name in North America. He thus felt called upon to explain: "I believe the power to make money is a gift from God ... to be developed and used to the best of our ability for the good of mankind. I believe it is my duty to make money and still more money and to use the money I make for the good of my fellow man according to the dictates of my conscience. "^^

Rockefeller's conscience led him to heap great benevolence on a wide range of socially uplifting charities. Andrew Carnegie put churches last on his list of recommended philanthropies, but for Rockefeller the Baptist church and its numerous charities and missions were the highest priority. Hospitals and other public

34 I ''Wholesale Philanthropy'

welfare charities were also favorites. He hoped his contributions would enable the denomination to lead all people to live with rectitude and to aid the fallen poor to gain the proper path. In 1890 Rockefeller's contributions to charities and colleges topped $300,000, and the next year half a million dollars.

But in May 1889, one month before Carnegie published the first of his two-part "Gospel of Wealth," Rockefeller committed himself to a particularly ambitious philanthropic project and a relationship with a man who was to write a new chapter in philanthropy. For several years a group of Baptists in the East and another group in the West had been trying to develop a new seminary and university for the denomination. The eastern group wanted the institution to be located in New York while the other group desperately hoped to develop it in Chicago, the rapidly growing metropolis of the nation's westward expansion. Both groups were pressing Rockefeller, the richest Baptist in the world, to contribute the millions needed to endow a first-rate institution. While interested in such a project, Rockefeller was not swayed by the emotionalism of either group's appeal. "^^

The strugghng academies, seminaries, and colleges of the denomination met in Washington in May 1888 to form the American Baptist Education Society, to raise money for Baptist education, and to coordinate its development. They named the fast-rising Reverend Frederick T. Gates executive secretary, a position from which he leaped to the pinnacle of both philan- thropic and corporate power.

Gates immediately conducted a survey of Baptist educational needs throughout the country. Armed with his data, he wrote a detailed and eloquent report. Gates demonstrated that nearly half the country's Baptists lived west of Pennsylvania and north of the Ohio River but that the denomination's educational facilities in this region were practically worthless. He concluded that a new Baptist university should be built "on the ruins of the old University of Chicago," a weak and by then bankrupt denomina- tional institution. While the new university should bring together the most capable specialists in both its classical and scientific departments, it must be "an institution wholly under Baptist control as a chartered right, loyal to Christ and His church, employing none but Christians in any department of instruction, a school not only evangelical but evangelistic.'"*'

Gates' report was the turning point in the denomination's

''Wholesale Philanthropy" I 35

campaign for a university. As he himself put it, "The brothers were 'all torn up' over it." The Chicago proponents coalesced around the report, and the dwindhng supporters of a New York location became even more emotional in their desperate appeals to Rockefeller. The Education Society executive board unani- mously approved the proposal at the December 1888 meeting. Within six months Gates won Rockefeller's approval and an initial gift of $600,000 that soon became a torrent of support, totaling $35 million in the next twenty-one years. Rockefeller was so impressed with Gates that he wrote University of Chicago president Harper in 1889, "I have made up my mind to act in my educational benefactions through the American Baptist Educa- tion Society. '"^^

Rockefeller, worn out by his total immersion in business since the age of twenty, was a physical wreck as he entered his fifties in 1889. He suffered increasingly from nervous fatigue and stomach ailments. He soon lost all his hair, including his eyebrows, because of a nervous disease, generalized alopecia. His doctors had warned him to reduce his activities as much as possible, but his responsibihties were mounting. Although Standard Oil was now in the hands of experienced and trusted lieutenants, there was an increasing flow of requests for large and small portions of his wealth from churches, missionary societies, hospitals, colleg- es, charity organizations, and individuals — once running as high as 50,000 requests in a single month. "^^

In March 1891 Rockefeller sat Gates down and laid out his problem.

I am in trouble, Mr. Gates. The pressure of these appeals for gifts has become too great for endurance. I haven't the time or strength, with all my heavy business responsibilities, to deal with these demands properly. I am so constituted as to be unable to give away money with any satisfaction until I have made the most careful inquiry as to the worthiness of the cause. These investigations are now taking more of my time and energy than the Standard Oil itself. Either I must shift part of the burden, or stop giving entirely. And I cannot do the latter.'*'*

"Indeed you cannot, Mr. Rockefeller," replied Gates, listen- ing with great care and at the same time anticipating the benefactor's point.

"Well, I must have a helper," Rockefeller continued. "I have

36 I "Wholesale Philanthropy"

been watching you. I think you are the man. I want you to come to New York and open an office here. You can aid me in my benefactions by taking interviews and inquiries, and reporting the results for action. What do you say?"

Fervently aware of the wealth and power that would rest in his hands to use on behalf of all the things he believed important, Gates accepted without the slightest hesitation. He thus began a relationship with Rockefeller that transformed the world's larg- est fortune into the most strategically applied philanthropy, estabhshing principles, methods, and directions that were soon emulated by other philanthropists and continued through the next two generations of the Rockefeller dynasty. The numerous medical and public health programs would become the central part of Gates' strategy.

In September 1891, Gates took an office in the Temple Court Building in New York City, not far from Rockefeller's Standard Oil offices at 26 Broadway. He continued his work for the Education Society even while he took charge of Rockefeller's philanthropy. The supplicants who hounded Rockefeller "almost like a wild animal" were sent to Gates' office. "I did my best to soothe ruffled feeUngs, to listen fully to every plea, and to weigh fairly the merits of every cause," Gates recalled of his days at Temple Court. "^^

With the same systematic thoroughness that marked his report for the Education Society, Gates investigated each request that came his way. "I found not a few of Mr. Rockefeller's habitual charities to be worthless and practically fraudulent. But on the other hand I gradually developed and introduced into all his charities the principle of scientific giving, and he found himself in no long time laying aside retail giving almost wholly, and entering safely and pleasurably into the field of wholesale philanthropy.'"^^

Gates' first act on behalf of "wholesale philanthropy" was to increase Rockefeller's contributions to state and regional Baptist agencies and cut off contributions to individual churches, mis- sions, and charity organizations. By forcing every church and mission to get their aid from centralized denominational boards, Gates increased the latter's power over the far-flung flock.'*''

Not long after he moved to New York, Gates took charge of

"Wholesale Philanthropy" I 37

Rockefeller's many investments outside the Standard companies. As with his charities, Rockefeller always intended to check on his investments thoroughly before buying into them. Often he was persuaded by acquaintances to invest in a project or industry they assured him would pay off handsomely. Most of the immense "surplus" wealth that Rockefeller was taking out of oil he was putting, not into charity, but into "a good many different in- dustries." By 1893 he had accumulated, besides the Standard, sixty-seven major investments, valued at $23 million, in railroads, mining, manufacturing, and banks. "It occurred to me," Rocke- feller later recalled, "that Mr. Gates, who had a great store of common sense, though no especial technical information about factories and mills, might aid me in securing some first-hand information as to how these concerns were actually prospering." He asked Gates to investigate some of these investments when he happened to be in the area on Education Society business."^*

Gates checked on several of Rockefeller's distant stakes: an immense land speculation scheme in the Pacific Northwest that two fellow parishioners of Rockefeller's Fifth Avenue Baptist church had persuaded the oil baron to invest in; a $600,000 investment in a West Superior, Wisconsin, steel mill and land speculation fraud, recommended by the same brethren; and a smaller iron furnace in Alabama. Gates demonstrated his varied abilities and singular value to his employer. "His report was a model of what such a report should be," Rockefeller remarked with uncharacteristic praise. "It stated the facts, and in this case they were almost all unfavourable." One investment that Rocke- feller thought was earning $1,000 a day was instead losing that amount.'*^

One more investigation by Gates, of some reputedly rich gold mines in Colorado that turned out to be a complete fraud, settled the matter for Rockefeller. His income was now upwards of $10 million a year, he was physically and emotionally coming apart at the seams, and he desperately needed a heutenant in whom he could place complete confidence. He asked Gates to drop his office in the Temple Court Building and share his private offices at 26 Broadway. "That," wrote Gates, "is how I came to be a businessman. "^°

38 I ''Wholesale Philanthropy"

THE REVEREND FREDERICK T. GATES:

THE MAKING OF A ROCKEFELLER MEDICINE MAN

It is not surprising that Gates should be such an appeahng assistant in both philanthropy and finance. Although he graduat- ed from the Baptist-controlled Rochester University and the Baptist seminary in Rochester and then spent eight years in the ministry, Gates was at heart a businessman in spiritual clothing. As he himself said in his autobiography,

Much of my life has been in fact an unconscious preparation for successful business. My interesting experience in selling harrows, my months as a clerk in a country store, and as cashier of a country bank, my interest in my father's financial affairs and the ways and means of paying our debts, my studies of political economy under Doctor Anderson [at Rochester], my close study of the finances of our church building in Minneapolis, a habit of looking at things in their financial tendencies and relations, my study of denominational finances at home and abroad, all these things had given me a business experience and my mind a financial turn.*'

Gates was nearly thirty-eight years old when he went to work for Rockefeller. His early years were spent in rural poverty. His father had studied medicine but turned to the Baptist ministry for his life's work. The elder Gates' successive congregations were mainly poor farmers in rural New York; his family shared that poverty which bred at least part of Frederick's determination to leave it behind in his own life. When the family moved to Forest City, Kansas, Frederick began but had to quit high school and then taught school to earn money to help his family pay off the accumulating debt on their farm." Through high school and college jobs Gates worked with his characteristic diligence and energy and discovered how much he pleased his employers. His shrewd salesmanship earned him $1,500 for selling harrows. Gates was developing a sense of where his ambition might eventually take him.

Young Gates' experiences with religion were as important in shaping his future life as were his experiences with poverty. "The best that religion had to offer me as a boy," he wrote near the end of his life, "was death and heaven, the very things I most dreaded — being a normal, healthy boy." With his teaching job

"Wholesale Philanthropy" I 39

Gates developed a strong attraction to the intellectual and personal elements of religion, though his conversion was not an emotional one. He found Christ's social and moral teachings very attractive: "I was drawn to his person and character, and feh that throughout my life I wanted to side with him and his friends against the world and his enemies. Such, frankly, was the only 'conversion' I ever had."

He found his seminary training so academic as to leave him poorly prepared for ministerial work. He dispensed with the philosophical idealism the seminary had cultivated, and from his own reading, his life experiences, and examination of the econ- omic and social issues affecting his congregation. Gates took up a pragmatic philosophy that was more in keeping with his personality and his ambition. His fund-raising work for his poor parish in Minneapolis and his less solemn, more modern sermons attracted a bigger congregation and with it, more wealth.

One day George Pillsbury, whose flour fortune made him the wealthiest Baptist in the Northwest, asked Gates' advice in making up his will and especially in leaving $200,000 to a Baptist school. Pillsbury was very pleased with Gates' suggestion that he immediately give $50,000 to the school on the condition that the denomination in Minnesota raise an equal amount — to assure their committed interest in it — and that he bequeath another $150,000 to the school in his will. Baptist leaders were also pleased and commissioned Gates to raise their $50,000 share of the funds. Gates resigned his pastorate and took up the chal- lenge. So effective were his methods of button-holing Baptists in the state that he had soon raised $60,000." Gates knew he had found his calling!

He developed a number of rules for fund raising which he learned "mostly on the pastorate" and a couple of years later wrote them down at the request of his admirers in the trade. Dress well, act in a dignified manner, pretend the visit will be a short one, be good-natured, and "keep your victim also good-natured. . . . Let him feel that he is giving it, not that it is being taken from him with violence." Rule number 7 he followed unswervingly through his nearly four decades of service to Rockefeller: "Appeal only to the noblest motives. His own mind will suggest to him the lower and selfish ones. But he will not wish you to suppose that he has thought of them. He wishes you to

40 I "Wholesale Philanthropy

believe him to be giving only from the highest motives."^"* In a few years Gates rose from pastor of an average Baptist congrega- tion in Minneapolis, to a statewide position with the denomina- tion in Minnesota, to chief officer of the Baptists' national Education Society, to the side of Mr. Rockefeller himself, administering a panoply of investments and an immense philan- thropy.

As soon as he joined Rockefeller's private office to manage his finances. Gates began a meticulous evaluation of all Rockefel- ler's holdings outside the Standard Trust. He was given a free hand in reorganizing investments and corporations alike and was provided with assistants, credit, and confidential information. "I had every needed tool," Gates remembered, "and the machinery was well oiled and without the least friction. No man of serious business responsibilities ever had a happier business life than I. No man was ever furnished with more of the external elements of success, or given better opportunities." In some companies Gates bought enough stock to take control and put in management acceptable to him and Rockefeller. Other investments were sold off completely. In the end. Gates was made president of thirteen corporations in which Rockefeller now had a controlling interest. He added sizeable chunks to Rockefeller's geometrically increas- ing fortune, the grandest chunk being the $55 million profit Gates made on selling the Mesabi iron ore range and associated industries that he had developed. ^^

Although Gates came to Rockefeller's employment a poor man, he soon remedied this unfortunate condition. While executive secretary of the Baptist Education Society, Gates was paid a then-respectable income of $2,500 a year. When he moved East and opened an office in the Temple Court Building, Rockefeller added $1,500 to his income. His added responsibili- ties led to annual increases in salary "always paid by the corporations which I managed," until after ten years with Rockefeller he was getting a salary of $30,000, a very good income in the first decade of this century. Out of his earnings Gates and his wife had saved enough to pay for their Montclair, N.J., home and had invested some $60,000 in the companies he had organized and managed for Rockefeller. That small invest- ment brought him more than $500,000 when he sold his shares in 1902. "Prudent investments with few losses gradually increased

''Wholesale Philanthropy" I 41

this sum." In 1916 Gates began converting all his investments into then-rising and profitable bank stocks and encouraged Rockefel- ler to do the same, recommending especially the Chase National Bank, which was paying dividends of 20 percent on invested capital. By the time of his death in 1929 Gates was a wealthy man though, needless to say, his fortune fell far short of his employ- er's.^^

Though Rockefeller never paid direct compliments to any person, he more than once recorded his appreciation of Gates' "phenomenal business ability." In response to a reporter's question, "Who is the greatest of all the business men you have known?" Rockefeller heaped warm praise on Gates. "He combines business skill and philanthropic aptitude to a higher degree than any other man I have ever known. "^"^ Though Gates was involved with Rockefeller's finances in important ways, his organization of Rockefeller's philanthropies, and especially the medical programs, makes him historically significant.

In 1897, John D. Rockefeller, Jr., graduated from Brown University and was cautiously trying to find a place for himself in a world preempted by his father. His hereditary position in the world of industry and finance left him little room for any achievement that he could call his own. His own name was inseparable from his father's, who was perhaps the most vilified of all the great robber barons. The one area in which he might stake out new ground and at the same time help clear the family name was philanthropy. And thus he entered his father's private offices at 26 Broadway, an imperium presided over by the Reverend Gates. ^^

With difficulty Gates and "Mr. Rockefeller, Junior" devel- oped a working relationship. Junior was then twenty-three years old, inexperienced, and reserved to the point of shyness. Gates, twenty years his senior, did not hide his self-confidence derived from varied experience and personal achievement; he was ebullient. Nevertheless, Junior learned from Gates and from his own successes and failures and built an independent role for himself in both philanthropy and finance. For his part, Gates learned to tolerate this scion of the man he worked for and truly respected. Gates considered Junior "diligent" but unimaginative. "He was home-made and hand-trained," he recalled disdainfully. Rockefeller, Sr., had found, as his biographer Allan Nevins

42 I "Wholesale Philanthropy"

observed, "just the combination of qualities he needed: Gates endowed primarily with imagination, fire, and vision, the son endowed primarily with hard sense, caution, public spirit, and conscientiousness."^^

Gates and Junior investigated new lines of philanthropy and the value of Senior's investments, bringing major proposals for action on both to the financier for final decisions. Gates wrote his views in eloquent reports; Junior relied on oral persuasion. "Gates was the brilliant dreamer and creator," Junior recalled years later. "I was the salesman — the go-between with Father at the opportune moment." Senior seldom jumped into any new venture. "I'll let the idea simmer," he often told his son and Gates. Then weeks, months, or even years later, moved by considerations inscrutable to his assistants, he was ready to act.^°

Gates was also quite a contrast to his employer. As Raymond Fosdick, president of the Rockefeller Foundation for more than a decade, revealed:

Mr. Gates was a vivid, outspoken, self- revealing personality who brought an immense gusto to his work; Mr. Rockefeller was quiet, cool, taciturn about his thoughts and purposes, almost stoic in his repression. Mr. Gates had an eloquence which could be passionate when he was aroused; Mr. Rockefeller, when he spoke at all, spoke in a slow measured fashion, lucidly and penetratingly, but without raising his voice and without gestures. Mr. Gates was overwhelming and sometimes overbearing in argument; Mr. Rockefeller was a man of infinite patience who never showed irritation or spoke chidingly about anybody.

61

From this triumvirate came the influential philanthropies that asserted extraordinary leadership in shaping the social, econom- ic, and political order of the twentieth century. Rockefeller, the individualistic captain of industry from the rough-and-tumble old order that was being transformed at the turn of the century, supplied the money but left the directing to his heutenants. Gates, the transition figure from unbridled individualism to the discipline of the corporation, provided systematic methods and a rudimentary strategy for asserting corporate capitalism's needs for supportive social institutions. Junior, emerging gradually as the nation's foremost representative of modernism in corporate relations with labor and the public, brought a refinement and sensitivity to the philanthropic work being developed by Gates.

"Wholesale Philanthropy" I 43

The programs and strategies that emerged from this center of financial power had an enormous impact, especially on medical care and health systems in the United States and throughout the world."

THE GENERAL EDUCATION BOARD: $129 MILLION FOR STRATEGIC PHILANTHROPY

Gates shared Carnegie's fears that excessive hereditary wealth diminishes individual initiative and achievement, that it saps the participation of its bearer in the social and economic processes that make society strong. "Your fortune is rolling up, rolling up like an avalanche!" he warned Rockefeller. "You must keep up with it! You must distribute it faster than it grows! If you do not, it will crush you, and your children, and your children's chil- dren!""

Having acquired the fortune, it fell to Rockefeller and his associates to maintain it as a trust for the people, just as Carnegie had advocated. "It is the duty of men of means," Rockefeller wrote early in this century, "to maintain the title to their property and to administer their funds until some man, or body of men, shall rise up capable of administering for the general good the capital of the country better than they can." In his view, neither experiences with state and national legislatures nor "schemes of socialism" offered any promise that "wealth would be more wise- ly administered for the general good" than it was by its private owners. ^'^

Since the owners of capital were mortal men, it was incum- bent on them to provide some ongoing trust to see that their wealth would be used wisely even after they passed from the scene. There was nothing new in this concept as understood by the Rockefellers as they launched their first grant-giving founda- tion, the General Education Board, to aid Southern education. Charitable trusts independent of the state and the church have had legal status in Anglo-Saxon law since the "statute of charitable uses" was enacted by Queen Elizabeth in 160L Most of these, however, had been narrowly prescribed uses — endowing a particular hospital, giving relief to wayward girls in Brooklyn, and providing scholarships for young men entering mechanical engineering at a particular college.*

65

44 I "Wholesale Philanthropy"

However, there were a few precedents that greatly influenced the creation of the General Education Board, providing the first of its strategic philanthropic programs aimed at transforming major social institutions. At the close of the Civil War, merchant-banker George Peabody provided $2 million for a Southern education fund. The war had left the South in ruins and its schools destroyed or otherwise defunct; a generation of Southerners was growing up uneducated and essentially illiterate. The Peabody Education Fund hired Barnas Sears, the president of Brown University, to set up a grant program to help schools that were run and generally supported by Southerners. Sears was succeeded by Jabez L. M. Curry, a Confederate politician and planter from Alabama, who had saved his land from confiscation after the Civil War by swearing allegiance to the United States. ^^

The Peabody Fund set an example for John F. Slater, a textile manufacturer from Connecticut, who endowed a $1 million fund in 1882 to educate Southern blacks. By the end of the nineteenth century increasing numbers of Northern businessmen and South- ern reformers were coalescing around the need to develop Southern schools in general and educate Southern blacks in particular. The South was not only economically and educational- ly undeveloped; it was the section of the country from which militant populism still received its widest political support, threatening the ambitions of Southern Hberal reformers and Northern conservative businessmen who wanted to "modernize" and industrialize the region. In 1899 these leaders organized the first of several Conferences for Southern Education. ^^

John D. Rockefeller, Jr., was a guest at the third conference in 1901. Robert C. Ogden, a partner of John Wanamaker and general manager of their New York department store, chartered a special train, dubbed the "millionaires' special" by hostile Southern newspapers, to bring Northern businessmen on a tour of Southern black schools and then to a conference with Southern activists in the cause. Junior and the other guests visited the Hampton and Tuskegee institutes and other schools and ended their tour with a meeting in Winston-Salem. This conference established a permanent organization called the Southern Educa- tion Board (SEB) to raise money among Northerners, assume formal leadership of the campaign to develop Southern schools, and conduct propaganda on its behalf. Though the board's

"Wholesale Philanthropy" I 45

budget was low — not more than $40,000 a year — and they never gave grants as the Peabody and Slater funds were doing, the SEB hired agents to carry their campaign to influential Southerners and state legislatures.^*

Like the Peabody and Slater funds, essentially combined under the leadership of their chief agent J. L, M. Curry, the Southern Education Board unanimously supported only "indus- trial education" for blacks. Schools organized around this model taught the rudiments of Hteracy and emphasized industrial and agricultural skills, disciplined work, thrift, and right living. Hampton Institute, whose chief trustee was Ogden and whose principal was fellow SEB member HoUis Frissell, was the pro- totype of industrial schools for blacks. Booker T. Washington, an early graduate of Hampton, founded a similar school at Tuskegee, Alabama, and became the country's chief black pro- ponent of the graduahst strategy of racial progress. For half a century this model of education guided the work of the move- ment for compulsory schooling, and now it was the centerpiece of the progressive education movement, sweeping educators and businessmen alike into a national educational reform campaign.*^

Northern and Southern businessmen were enthusiastic. "Ev- ery element for success exists in the South," the Manufacturers' Record declared in support,

in raw material, in climate, in the forces of Nature, and above all, in an abundant supply of labor, which when properly trained and dis- ciplined will be the main reliance of the South in the future for its prosperity. It only remains for the South to do its duty to its black population by way of training and educating in the simple manual trades.''"

With the support of Northern money, the industrial schools flourished and the few genuine colleges for blacks struggled under their less than benign neglect. The Southern Education Board and its allies won grudging acceptance of schools for blacks from Southern white supremacist poHtical leaders, and in return Northern members of the SEB campaigned in the North for acceptance of black disfranchisement and Jim Crow laws as the best way to progress for blacks. "The white people are to be the leaders, to take the initiative, to have the directive control of all matters pertaining to civilization and the highest interests of our

46 I ''Wholesale Philanthropy''

beloved land," Curry, former Confederate officer and now chief of staff of the Southern campaign, brazenly proclaimed. "This white supremacy does not mean hostility to the Negro, but friendship for him."^'

For John D. Rockefeller, Jr., his 1901 tour and conference in the South were "one of the outstanding events in my life." Filled with a sense of mission. Junior discussed the new Southern Education Board and its program with his father. Gates, his friend Morris K. Jessup, and Dr. Wallace Buttrick, the portly and jovial secretary of the Baptist Home Mission Society, who also attended the conference and was now a member of the SEB. A small group was formed to develop an ambitious project in support of the Southern work. In January 1902, they outlined a munificent philanthropic enterprise. In February an expanded group met for dinner at Junior's house and worked through the evening. Junior announced a pledge he had secured from his father for $1 million to spend over the next ten years, the first and smallest of many gifts to come. They formed a board of trustees to oversee the expenditures and appointed Buttrick executive secretary.''^ "The South with its varied resources and products," their memorandum of agreement observed, "has immense indus- trial potentialities, and its prosperous future will be assured with the right kind of education and training for its children of both races. "''^

The General Education Board was announced to the press. "The object of this association," they explained, "is to provide a vehicle through which capitalists of the North who sincerely desire to assist in the great work of Southern education may act with assurance that their money will be wisely used."^"*

The General Education Board (GEB), with its large re- sources, quickly became the locus of leadership in the Southern campaign. At its first meeting in 1901 the Southern Education Board had arranged a "community of interest" with the Peabody and Slater funds. By 1903, according to Southern board member Frissell, "the Peabody and Slater boards are now acting very largely through the General Education Board." In fact a more interlocking directorate could not be found, even among the Standard Oil companies. Several trustees of the Slater and Peabody boards were trustees of the GEB. Curry was a member or agent of all four funds. Buttrick was a member of the Southern

"Wholesale Philanthropy" I 47

board, executive secretary of the GEB, and from 1903 to 1910 he was an agent of the Slater Fund — and so on.'''

While the General Education Board developed other pro- grams over the next several decades, medical ones prominently among them, their work in the South remained important and never deviated substantially from their original perspective. Over the years the GEB wo.^ked to make all schools "more responsive to our social, economic, and professional needs." The black population's role in society was clear. The board beUeved "the Negro must be educated and trained . . . that he may be more sober, more industrious, more competent." When the GEB finally came to support full-fledged colleges for blacks, it was not because their general outlook on race relations had changed. College training would be "provided for carefully selected Negroes" who will "lead the race in its efforts to educate and improve itself." The black's leaders "must be trained, so that, looking to them for guidance as he does, he may be as well guided as possible."''^

The GEB was not concerned only with education of blacks. It worked to build up high schools for whites and for blacks throughout the South. Always with an eye to creating "local responsibility for self-help" — what Gates called the "foundation of character and social life itself" — the board's strategy was to stimulate and organize community support for school taxes. The GEB got each state university to create a professorship for secondary education. Then with the university's approval, the board defined the duties of the position and named the person to be hired and, in return, paid the person's salary and all his expenses. The main function of this professor was not to teach but to organize. He would visit the towns of his state — "as an officer of the university, laden with its wisdom and its moral authority" — and develop and channel local support for high schools and taxes to support them. At the end of two decades of work, the GEB had spent a little over $3 million promoting public schools in the rural and urban South. They considered the plan effective "beyond our most sanguine anticipations" and took considerable credit for the 2,000 new high schools built in that period at a cost of $60 million, for which annual appropriations in the Southern states increased from $1.7 million in 1905 to $15 million in 1922 — "all raised by local taxation."^''

48 I ''Wholesale Philanthropy'

The public schools program of the GEB led to a farm demonstration program run for the board by Seaman Knapp and then to the first of a long tradition of public health programs conducted by the Rockefeller foundations. Rooted in the same concern for Southern economic and social development that guided the public schools program, the public health programs, at first in the Southern states and then exported around the world, became important supports for the growing domination by U.S. capital, trade, and military power. ''^ Gates, a charter member of the GEB and its chairman from 1907 to 1917, was the eloquent orator and, in Junior's words, "the brilliant dreamer and creator" of most of these programs.

The permanence of the General Education Board was assured with a broad congressional charter, dedicating the new founda- tion to "the promotion of education within the United States." Senator Nelson Aldrich, Junior's father-in-law and a powerful representative of business in Washington, "took the bill into his own hands and put it through in record time." It was officially chartered in January 1903, a year after it began its first Southern program, yet the most influential work of the GEB was yet to come.^^

Gates took into his own bosom the worries about Rockefel- ler's still-growing fortune. "I have lived with this great fortune of yours daily for fifteen years," he wrote his employer in 1905. "To it, its increase and its uses, I have given every thought, until it has become a part of myself, almost as if it were my own."*°

Recognizing the mortahty that all persons must face, Gates laid out the alternatives to Rockefeller. "One is that you and your children, while living, shall make final and complete disposition of this great trust, for the good of mankind. The other is that you shall not do this, but shall hand it down to unborn generations, for them to decide how this trust shall finally be discharged for humanity."

For Gates, embracing Carnegie's "Gospel" and fearing the "powerful tendencies to social demoralization" of inherited wealth, the first alternative was the only moral one. He proposed that Rockefeller decide what major lines of work for "human progress" he wanted to serve and who should administer the funds and then create an endowment "to provide funds in perpetuity, under competent management, with proper provision for succession."

"Wholesale Philanthropy" I 49

Gates then suggested several funds for different areas of work — ''a great fund for the promotion of a system of higher education in the United States, ... a fund for the promotion of medical research throughout the world, ... a fund for the promotion of the fine arts," and more. 'These funds should be so large that to become a trustee of one of them is to make a man at once a public character." The work of these enterprises should employ "the best talent of the entire human race."

Junior followed this letter with his own enthusiastic endorse- ment of Gates' proposal. Within two weeks Rockefeller, Sr., gave the General Education Board $10 million and followed that a year and a half later with another $32 million. By 1921 Rockefeller's gifts to the GEB totaled more than $129 million. Larger and more numerous endowments began to flow to the Rockefeller Institute for Medical Research, fathered by Gates from his employer's fortune in 1901, and soon discussions began that led from Gates' 1905 letter to the creation of a much larger and broader fund, the Rockefeller Foundation, to which Senior gave more than $182 million.

It is not so clear that Gates' only concern in recommending that Rockefeller himself dispose of his fortune was the danger of inherited wealth to its possessors. The notoriety that accrued to Rockefeller and other robber barons along with their profits cast a long shadow on the future of wealth, and the Rockefellers felt the chill as much as anyone. Henry Demarest Lloyd, in Wealth Against Commonwealth published in 1894, and Ida Tarbell, in a magazine series ending in 1904, had tarred and feathered the Standard Oil Trust. The SociaHst movement was winning the support of working people throughout the country for its program to do away with private capital altogether. And perhaps most frightening of all, upstanding middle-class Americans, profes- sionals and businessmen with values very much like the Rockefel- lers themselves, were joining the call for Progressive reforms. The Progressive movement, while firmly supporting capitalism, was calling for constraints on the accumulation and concentration of private wealth. Roosevelt was elected in 1904 on a platform that at least threatened to break up monopolies.

"I trembled," Gates later recalled, "as I witnessed the unreasoning popular resentment at Mr. Rockefeller's riches, to the mass of the people a national menace." Gates might believe that Rockefeller "used his wealth always and only in the public

50 I "Wholesale Philanthropy"

interest," that his fortune had been created by economies rather than by theft, that his wide investments in industry and finance constituted "vast permanent contributions to the wealth and well-being of the American people." But few people in the country not connected with 26 Broadway agreed with him.^^

In the fall of 1906 the federal government launched a major suit to break up the Standard Oil Trust, and that litigation began its five-year journey through the courts. After Rockefeller gave the GEB $32 million in 1907 to finance Gates' plan to create "a system of higher education in the United States," many respect- able newspapers and magazines suggested that "the purpose of Mr. Rockefeller's large gift is to head off, if possible, the teaching of socialism, which is on the increase ... in a number of universities." Also in 1907 federal Judge Kenesaw Mountain Landis hit the Indiana Standard company with a $29 million fine for obtaining rebates on its railroad shipments, one of the "economies" in which Gates and Rockefeller took pride. "No oriental despot . . . has committed such arbitrary acts of confis- cation as the present administration is responsible for under the forms of law," Gates railed. ^^

The Landis fine was quashed on appeal, but the spectre of dissolution and ultimately of confiscation pursued the Rockefel- lers and many of their class. The Rockefeller philanthropies created new programs and with them new images for the benefactors. The programs appealed to their perceptions of social needs, but in their perceptions, society's needs were indistin- guishable from their own. Colleges were expanded and organized into a system of higher education to produce the professionals and managers the corporate society badly needed, but the GEB for two decades consciously followed Gates' directive to strength- en private rather than state universities because private institu- tions, controlled by men and women like themselves, would be more likely to "direct popular opinion into right channels."*^ The medical philanthropies, outwardly appearing only to fill an obvious social need, helped to develop a medical care system peculiarly suited to the needs of corporate capitahsm, as we will see in subsequent chapters.

SOCIAL MANAGERS FOR A CORPORATE SOCIETY

It is clear that John D. Rockefeller, Sr., was neither the initiator nor the strategist in his philanthropies. In the early years

''Wholesale Philanthropy" I 51

it was Gates and then Gates and Junior whose ideas and strategies shaped the elder Rockefeller's fortune into purposeful programs. In part the insight they showed concerning the needs of capitalist society may be attributed to their individual personal- ities, shaped by their own Ufe experiences. But they were also representative of the new class of men (and very few women at that time) who provided the managerial skills needed by corpo- rate industry and finance. Unhke the individualistic entrepre- neurs who built the enormous industrial and financial empires around themselves in the latter nineteenth century, these new managers were more sensitive to the smooth workings of their enterprises.

In industry, management's role was to rationalize production, to divide the productive process into "efficient" units, and simultaneously to coordinate each with the other to produce a unified organization, hnked in a similarly coordinated fashion with disparate sources of investment capital and raw materials at one end of the production line and with a system of distribution and marketing at the other end. Analogous managerial roles were also developed in government bureaus and departments, then in colleges and the emerging universities. The last major area to which skilled management was directed were the social ser- vices— charity and social welfare programs, philanthropic founda- tions, and medicine.

The foundations were key instruments in early efforts to rationalize social services, public health, and medical care under the control of specially trained managers in those fields, and the foundations themselves became the turf of this same management class. It made little difference whether one owned a substantial share of the country's corporate wealth or whether one simply ran the factories and institutions owned by the wealthy. The actions of each group were essentially the same, and their values were quite similar. They both accepted the prevaihng economic, social, and political system as given, and they sought to make the system work smoothly.

Some of these system managers used charity to try to make capitalist society, whose ideal model is a purely competitive marketplace, a less "rigid and heartless" one, as a recent proponent of this view put it. He believes that philanthropy should "provide at least some softening of the corners and relaxation of the rigid rule of self-interest. "*"*

52 I ''Wholesale Philanthropy"

Others like Gates and John D. Rockefeller, Jr., conceived of a more strategic role for philanthropy — the transformation of social institutions. They worked to make the nation's colleges and universities into a system that would more efficiently yield technically trained and properly socialized professionals and managers for the system. They developed new roles for profes- sionals as managers, and they helped rationalize the institutions in which these professionals worked.

Men like the Senior Rockefeller and Andrew Carnegie knew little of this work. They had understood its relevance to industry where they had been the first ones in oil and steel, respectively, to create vertically integrated corporations, owning or controlling the entire process from oil wells and iron ore mines, to transpor- tation, refining and manufacturing, distribution, and marketing. But running a corporation is different from running a corporate society, and though they understood the need to take more control over social institutions, they did not understand how.

Carnegie, egotistical and individualistic, thought he under- stood. Until Andrew Carnegie began giving away libraries in the 1880s, the world had never seen such a vast fortune apphed to private philanthropy. This remarkable innovation in magnitude of philanthropic wealth — due, of course, to his insatiable ambi- tion in industry rather than to any strategic genius in philan- thropy— gave him a social power so vast that it proved truly befud- dhng. Armed with a crude social philosophy, he set forth to civilize the lower classes and set a model of responsibility for the upper echelons of society. The society he hoped to preserve was one based expHcitly on enormous disparities of wealth. And he attempted to preserve the individualism he and other Social Darwinists revered with a largely individualistic approach to social transformation. His programs represented his own person- alized views, shared in varying degrees by contemporary capital- ists. But Carnegie's vision was a limited one and his programs often stepped over the edge into absurdity. When Carnegie retired from the steel business in 1901, his philanthropic plans were vague and scattered. In the words of his biographer Joseph F. Wall, "For someone who had written so extensively and preached so eloquently as he on the duties of the man of wealth, it is rather surprising that he faced this task better armed with platitudes than with any concrete program of action."^

'85

"Wholesale Philanthropy" I 53

After several years of massive spending without a real plan, Carnegie set up his foundations, and his hired managers began accomplishing what he had not. In 1905 Carnegie began to move from his individualistic method of dispersing money to a more rationalized, systematic model. Appalled by the pitiful incomes of college professors — usually not more than $400 per year — Carnegie had meant to do something about them for some time. But it was Henry S. Pritchett, the president of the Massachusetts Institute of Technology, who moved him to action. While visiting Carnegie at his ancient castle in the Scottish Highlands in the summer of 1904, Pritchett lamented the difficulties he had in attracting young scientists and engineers to teach at MIT. Academic salaries could not compare with those offered by private industry, and few colleges even had pension systems to provide a minimum of financial security for professors. There were more discussions the following winter, and in April 1905 Carnegie announced the creation of his college teachers pension fund with an initial endowment of $10 miUion in U.S. Steel bonds. A board of trustees was selected consisting mainly of the presidents of the most elite universities and colleges in the country. Pritchett was appointed president of the new Carnegie Foundation for the Advancement of Teaching.*^

Under Pritchett's guidance the new foundation set out to recast American higher education. The free pensions became the carrot-at-the-end-of-the-stick that colleges would follow down the path of reform. An applicant college or university had to have a minimum of $200,000 endowment to qualify for the pension program. Neither state colleges nor those controlled by rehgious denominations were eligible. Finally, to be eligible a school had to require of its students a prescribed minimum of high school preparation prior to admission. This last requirement proved a successful attempt by the foundation to "throw its influence" in favor of a "differentiation between the secondary school and the college" in order to create "a system of schools intelligently related to each other and to the ambitions and needs of a democracy." Although only fifty-two of the original 421 appli- cants were eligible for the pension plan, other schools soon modeled themselves on the Carnegie system to make themselves eligible. Denominational colleges cut loose from their controlling churches to take advantage of the plan, and the foundation's rules

54 I "Wholesale Philanthropy"

were changed to include state institutions. Soon virtually every high school and college in the country measured student progress in "Carnegie units." A national system of education was taking shape with the prodding of Carnegie pensions and the Carnegie Foundation as the unofficial accrediting body.^''

Almost immediately after opening the offices of the Carnegie Foundation, Pritchett began consulting with the General Educa- tion Board. His only regret, he told GEB executive secretary Wallace Buttrick, was that "I did not come to you before renting my office for it would be of great benefit to us to be located near you." Pritchett admired Gates, often asked for his advice, and tried to get Carnegie to mend his philanthropic ways. In fact the record left behind suggests that Pritchett's ideas on systematizing higher education were derived from Gates.**

The leadership that attracted this following was Gates' vision of how wealth could rationalize higher education. He described a picture of the GEB, through its "moral influence" as well as its money, fostering cooperation among colleges and universities and securing economies "in administration, in teaching force and in the use of men." He hoped that such a philanthropic board, properly endowed, would "select" and "direct" the resources of higher education, much as the Standard Oil Company had transformed the "universal competitive system" that character- ized the oil industry in 1870.*^

Rockefeller was fortunate to find a man like Gates to develop "wholesale philanthropy" for him. As Junior and other officers of the Rockefeller foundations readily admitted, Gates was the source of most strategic ideas, major programs, and important policies in the foundations' first decade and a half, with Junior developing an increasingly important role. In that time there was no serious challenge raised to Gates' dominance. The board of trustees was the final authority, but other staff members knew that if they had Gates' or Junior's support, "we were on safe ground" and would have little problem winning approval from the board. '«

Gradually, however. Gates' influence declined. While the times changed and the much younger Junior became a leader of the growing image of corporate responsibility and concern. Gates' limitations became apparent. Following the 1914 massacre of striking miners and their wives and children in a Ludlow,

"Wholesale Philanthropy" I 55

Colorado, mining company controlled by the Rockefellers, Junior was held largely responsible by public opinion throughout the nation. But the posture he developed afterward, formulated by consultant W. L. Mackenzie King, made him the leading representative of the new, more benign face of industrial re- lations that was winning support from many corporate execu- tives. When Junior, who had been called before a Presidential commission created to investigate such problems, claimed he thought it perfectly proper for "labor to associate itself into organized groups for the advancement of its legitimate interests," Gates criticized him for adopting a "spirit of conciliation toward those who came to him in the spirit of these Unionists." Yet it was Junior's support of company unions that was assuaging public opinion and winning the respect of other corporate leaders. Gates did not adapt himself to the changing times. ^'

With Gates' leadership passing from the scene, especially following his resignation from the GEB executive committee in 1917, problems of accountability began to be raised. Trustees who had willingly followed Gates now found the foundations without comparable leadership. Other foundation officers had never demonstrated the broad and clear perspective that Gates had shown, and with Gates gone from daily participation in foundation activities, a vacuum was created. Trustees wanted to fill it by increasing their participation. Foundation officers quarreled with one another. The foundations drifted. ^^

With Gates these problems did not arise because his carefully developed and forcefully presented proposals won immediate support. Gates never expected the trustees to play an important role in social innovation. When a trustee suggested that GEB members were appointed to throw new light on "the great problem of education in this country," Gates impatiently ex- plained that he and Rockefeller gave an "overwhelming prepon- derance to business men" in composing the board "to fix the policies of this Board along the lines of successful experience." They knew, he said, that "successful business men would steer the ship along traditional Hnes and would not be carried out of their course by any temporary breeze or even by hurricanes of sentiment. "^^ The trustees were there to assure in perpetuity that Rockefeller's money would be judiciously applied to preserving the system and strengthening it, letting professional educators

56 I ''Wholesale Philanthropy

promote innovative ideas while the trustees supported only those directions which seemed desirable and whose consequences were more certain.

Though Gates ran the GEB with firm leadership and a fiery tongue during his tenure as chairman, he and Junior both wanted the other trustees to take an active interest in the foundation. Without involvement, their interest and sense of responsibility for the fortune would decrease — the very thing to be avoided. "In the remote future," Junior advised his father, "you must of necessity trust to the character and integrity of the men who come after you."^"^

It was clearly just as important to encourage local communi- ties to take "responsibility for self-help." Gates' reasons for this guiding principle were moral, tactical, and strategic. He believed in the moral precepts of self-reliance and self-discipline. He also wanted to enlist the active participation of property owners in community institutions. Although they were not as reliable as the men appointed to the Rockefeller foundations, the local ruHng classes recognized, as did he, that "the right to earn and hold surplus wealth marks the dawn of civilization."^^ Gates, Junior, and Rockefeller all understood that to fund a local institution without requiring contributions and participation from local men and women of wealth would be to lessen these people's sense of responsibility for what goes on in the institution. They had a genuine concern for the preservation of their society, and its preservation required the active involvement of all those who had a stake in it.

Rockefeller's involvement with the University of Chicago is a good example of this principle in action. Rockefeller contributed $35 million to the university during its first two decades compared with $7 million from all other donors. He was consulted about appointments to the board of trustees and approved the initial Hst before it was finalized. But thereafter Rockefeller did not desire to control the university, as many people charged. "He prefers to rest the whole weight of the management on the shoulders of the proper officers," Gates wrote the university president on behalf of his boss in 1892. "Donors can be certain that their gifts will be preserved and made continuously and largely useful, after their own voices can no longer be heard, only in so far as they see wisdom and skill in the management, quite independently of

''Wholesale Philanthropy" I 57

themselves, now." Rockefeller's trust in the management was well founded. There is no evidence that he ever tried directly to influence the university administration to fire teachers who expressed radical views. It was University of Chicago president Harper who took the initiative to drop Professor Edward Bemis after he made a speech, following the 1894 Pullman strike, critical of the railroads. Rockefeller and Gates had merely appointed the "right" men to manage their philanthropic and financial enter- prises, men who were led by values and considerations similar to their own and who could be counted on to do what was expected. In many ways, local authorities in whom Rockefeller placed his trust proved the correctness of this rule.^^

One final and important tactical reason for securing local involvement was to multiply the impact of each grant. The Rockefeller foundations required virtually all recipients to raise an amount equal to, or as much as four times greater than, the grant being given by the foundation. Besides being chosen for their stabilizing influence, foundation trustees were also chosen for "the prestige and authority of their names." Andrew Carne- gie, Long Island Railroad president Wilham H. Baldwin, Har- vard president Charles W. Eliot, Johns Hopkins president Daniel Coit Oilman, pubhsher Walter Hines Page, banker Oeorge Foster Peabody, and other prestigious individuals were appointed to the OEB to "secure general public approval and active and powerful pubhc cooperation" for OEB programs. In gaining public support and in requiring matching contributions from others, the foundation was able to multiply the impact of the grant programs. By 1925 the OEB had given $60 million to the endowments of colleges and universities in the United States for certain reforms they deemed desirable, and they had, by their matching-grant policy, required the institutions to raise an addi- tional $140 million to support these OEB-required changes. By 1928 the Oeneral Education Board had contributed some $50 mil- lion to medical schools for very specific reforms,* generating total resources estimated at ten times that amount for those same reforms.^^

Thus the Rockefeller philanthropies, under the guidance of skilled managers, developed self-consciously strategic programs

*This program is described in detail in Chapter 4.

58 I "Wholesale Philanthropy"

to transform higher education and medical care, among other social institutions. The thrust of their programs was to systema- tize and rationalize these institutions to make them better serve the needs of corporate capitalism.

The rise of industrial capitalism brought with it many new needs that provided opportunities for groups besides the capital- ist class. The work process was reshaped to reduce the costs and increase management's control of production. Scientists devel- oped the basic understandings on which technological innovation was based. Engineers adapted scientific knowledge to produc- tion, designing new methods and machines that reduced the need for skilled workers, increased productivity, and generally gave management more complete control of the entire production process.

A new stratum of managers and professionals emerged in the society's class structure to design and organize production and the institutions that reproduce and control capitalist society's social relations. Colleges and universities became the training and research agencies, producing knowledge and reproducing engi- neers, scientists, lawyers, teachers, and other technicians and social managers. Managers were well paid for their efforts, and some, like Gates, were incorporated into the highest circles of the owning class. But despite their separation from predominant ownership, managers of corporations and institutions alike "still think and act as though the firm belonged to them," as William Appleman WiUiams put it.^* Their commitments to the prevailing economic system are complete.

Out of an earlier mercantilist philanthropy grew a new corporate philanthropy, intended not to ameliorate the lot of industrial capitalism's victims but to shape and guide social institutions. Foundations were, and still are, important ramparts through which private wealth, acting through creative and loyal managers, influences and often controls universities, medical schools, and other "public" institutions. The Rockefeller foun- dations established directions and strategies that other foun- dations followed. Gates led the Rockefeller philanthropies with his "imagination, daring, and an intuitive sense of educational strategy. "^^ Pritchett, following Gates' leadership, made Carne- gie's foundation an engine of social transformation. In many

''Wholesale Philanthropy" I 59

ways, Gates, Pritchett, and other managers understood the workings and needs of capitaHsm better than the ostensible owners of the system did.

Broad social transformations, however, require the participa- tion of more than the ruling class. While the working class suffered greatly from the capitalist reorganization of production, some groups attached themselves to the ascending corporate class and benefited greatly. New occupations, like engineering and social work, and old ones, like law and medicine, gained elevated professional status in return for becoming the new order's managers of production or social relations. Medicine's almost fantastic transformation from rank ignominy to Olympian heights of status exemplifies the powerful consequences of an interest group adapting itself to the needs of the dominant class.

CHAPTER

Scientific Medicine I: Ideology of

Professional Uplift

Throughout the nineteenth century the medical profession was almost constantly frustrated in its attempts to gain public con- fidence and raise professional incomes and status. Despite varied attempts to alter the competitive market economy for medical services, the dominant portion of the profession continued to be plagued by competition within its own ranks and from those beyond the pale of orthodoxy.

In this chapter we will see how the rise of science in the latter part of the century provided the solution that medical reformers had previously sought in vain. Physicians and biological research- ers consciously applied the methods and principles of scientific research to problems of disease, though even in the 1860s their work had Httle support and played a very minor role within the medical profession. At about midcentury, however, leading reformers among elite medical practitioners took up "scientific medicine" as the ideology of professional reform and uplift. Medical science gradually provided practitioners with a some- what more effective medical practice, enabling them to increase their credibility with the public and reduce economic competition within the profession. "Scientific medicine" was adopted as the unifying theory that enabled the dominant profession to develop strong political organization and to win political and financial

Scientific Medicine I I 61

support from wealthy people in society. Perhaps most fundamen- tal, the association of medicine with science won support from the new technical, professional, and managerial groups associated with the growth of corporate capitalism.

AMERICAN MEDICINE IN THE 1800s

In 1800, nearly all American physicians received their training as apprentices at the side of a practicing physician, assisting with simple techniques and mixing medications. In the eighteenth century, medical lectures had not been widely available in this country, so young men from the upper class went abroad for their medical education, especially to Scotland. The handful of Edinburgh-trained physicians in America developed very success- ful practices, with the wealthiest citydwellers for their clients and lucrative consulting practices besides. By 1800 only about a hundred American physicians had attended medical courses at Edinburgh, and only three American medical programs — at Pennsylvania, Harvard, and Dartmouth — were offering lectures to supplement the apprenticeship. The graduates of these institu- tions formed a medical elite, and together with the rank-and-file apprentice-trained physicians they formed the self-styled "regu- lar" profession.^

But most Americans were probably not getting their medical care from "regular" physicians. Whereas most of the populace lived in the countryside or small towns, most apprentice-trained doctors and the few medical school graduates lived in the large towns and cities. In Virginia, by 1800 the eleven largest towns had only 3 percent of the state's population, yet 25 percent of all physicians known to have practiced in Virginia during the eighteenth century lived in those eleven towns. ^

Most Americans, when they were sick, consulted herbal practitioners. These empirical healers had no formal training but apprenticed mainly with other herbalists. Some of the herbalists were midwives, and others were men and women who had experimented with herbs and were known for their abilities to heal the sick. Lay healers were distributed throughout the countryside. They seldom rehed on healing for their entire support and charged little for their services.^ Regular physicians were increasingly plying their art on a full-time basis and charging

62 I Scientific Medicine I

substantially higher fees, often supported by medical societies' pubhshing "fee bills" to place a floor under competing doctors' charges.

The maldistribution of regular physicians and their higher fees were only two reasons why the regular profession was widely unpopular in the first half of the nineteenth century. Very much related to their social, economic, and geographic separation from the populace, the orthodox profession's clinical practice was greatly feared by much of the population. Not only did medicine offer little hope for curing disease, but the heroic methods used by regular doctors were unpleasant and often lethal. The lancet was the physician's indispensable tool for nearly every ailment. Benjamin Rush, the most prominent physician in America from the Revolution through Jefferson's time, urged bleeding for yellow fever "not only in cases where the pulse was full and quick, but where it was slow and tense.'"* When bleeding was not recommended, and even when it was, calomel (chloride of mercury), jalap, or another purgative was administered. The violent vomiting and purging that resulted were more detested than even the pus-filled blisters induced as another form of therapy. After attacking the body as well as the disease with bleeding, blistering, and purging, the physician administered an arsenic tonic to restore the weakened patient's vigor.

Against this distasteful and frequently disastrous treatment by regular physicians, the empirical herbaHsts' mild treatments were pleasanter and at the very least did not interfere with natural rates of recovery. Their mild emetics and stimulants seemed closer to nature than the regulars' profuse blood-letting and harsh purges.^

Still experiencing competition from the empirically grounded herbalists, regular physicians resorted to ever larger doses of their therapies through the first half of the nineteenth century. BeUeving that any desired change in a patient's gross symptoms was to the good and seeking to distinguish their art from lay practice, regular doctors bled their patients more profusely and doubled and tripled their doses of calomel and jalap. The profession's heroic therapy became the focus of increasingly bitter and widespread attacks. Thomas Jefferson called them an "inexperienced and presumptuous band of medical tyros let loose upon the world." By the middle of the century cholera victims were given an even chance of being done in by the disease or by

Scientific Medicine I I 63

the doctor. The profession's fearsome and futile methods reduced pubHc confidence in regular doctors to an all-time low.^

Leading local and regional members of the profession tried many methods of increasing public confidence in doctors and reducing competition. At various times during the nineteenth century, they sought licensing laws, formed new medical sects, started medical schools and issued diplomas, organized state and national medical societies, demanded medical school reforms, and adopted codes of ethics, all with little or no improvement in technical effectiveness, credibility with the public, or their own status and fortunes.

LICENSING

Despite the antipathy of much of the populace, regular doctors at the end of the eighteenth century persuaded fellow gentlemen in the state legislatures to pass medical licensing laws to restrict or prohibit practice by herbal healers. Licensure bestowed exclusively on regular physicians the right to sue for fees. The legally sanctioned economic privilege did not provide the regular profession with an economic monopoly, but it did set them apart from and above lay healers and most other Ameri- cans.

In addition to the public's lack of confidence in regular physicians' clinical methods, populists in the Jacksonian era articulated their opposition to any form of class privilege. By 1850 medical licensing laws were repealed in nearly every state through the efforts of the Popular Health Movement, a loose populist movement of lay healers, herbal practitioners, artisans, farmers, and working people who fought to remove the legal sanctions that protected the privileged position of physicians.''

MEDICAL SECTS AND MEDICAL SCHOOLS

The humiliated profession was badly divided. Many physi- cians, critical of heroic medicine, were attracted to the pleasanter new professional sects, such as homeopathy and eclecticism, that were growing in popularity. These sects built their materia medica around herbal drugs or some distinctive technology or procedure, each adding elements that enabled them to claim the necessity of extended study in their field.

64 I Scientific Medicine I

Homeopathy, as formulated by its founder Samuel Hahne- mann (a German physician), was based on the widely accepted medical view that the symptoms of a disease constitute the disease itself and, a corollary, that eliminating the symptoms constitutes a cure. Hahnemann found that some drugs produced the same symptoms in a healthy person (that is, caused the "illness") that they eliminated in a sick person (whom they "cured"). For example, he found that cinchona bark, at the time used to relieve the symptoms of malaria, produced malarial symptoms in a healthy person. From these observations he developed what he called the law of similia similibus curantur — or "like cures like." Hahnemann also maintained that diluting the dosage of a drug down to one ten-thousandth or one-millionth of its original strength increased the drug's potency.*

Competition between the sects and the lack of decisive public support for any one of them, left none of the sects in a position to establish control through licensing. The orthodox profession and the other sects turned to medical education and degrees as a method of recruiting and certifying new physicians in their ranks and uplifting the profession. Medical schools proliferated throughout the country, and some 400 were founded between 1800 and 1900.^ Local physicians organized schools to supplement their practices with lecture fees paid by medical students and, through their graduates, to fatten their incomes with increased consultations. At a time when physicians considered $1,000 to $2,000 a year a good income, the average part-time medical school faculty member earned more than $5,000 annually from student fees and private practice while more enterprising and popular colleagues earned at least $10,000.^° Like hundreds of general colleges started before the Civil War by rival Protestant sects and political groups, many medical schools were started by rival medical sects to improve their competitive position vis-a-vis other sects. The orthodox profession controlled by far the largest number of schools. ^^

The proliferation of medical schools in the 1800s assured the dominance of diploma-carrying regular doctors over lay healers and physicians of other sects. By 1860 regular physicians outnum- bered other sectarian doctors ten to one.^^ The inexpensive and widely dispersed medical colleges encouraged large numbers of young men and some women to attempt careers in medicine.

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Graduates, many of them from yeoman farming and working- class families, filled the cities, towns, and countryside of Ameri- ca. Elite* regular physicians resented the competition within the dominant sect, but they saved their most venomous denuncia- tions for competing sects. The sectarian doctor was "the greatest foe to the medical profession," argued the dean of the Tulane University medical department, because he was "an obstacle to the financial success of the respectable medical practitioner."'^

As the number of physicians increased, organized doctors became increasingly worried. It was clear to all physicians that producing a lot of doctors would lower rather than raise the status and incomes of the profession as a whole. Lacking the public support necessary for effective medical licensing laws and still smarting from the humiliating defeat of medical licensing earlier in the century, the reformers turned to medical school reform. Raising medical school standards and thereby reducing their enrollment, medical reformers believed, would simultaneously win public confidence in medical practice and reduce the output of doctors. The problem they faced was how to control the independent, proprietary medical schools.

MEDICAL SOCIETIES

Local and state medical societies, representing the practition- ers, fought with medical schools in their areas. In 1847 the societies banded together to form the American Medical Associa- tion (AM A). At the founding convention, leading practitioners passed resolutions that sought to raise requirements for prelimi- nary education prior to admission to medical school. So few Americans had the requisite education at the time that enforce- ment of these standards, according to historian William Roth- stein, "would have closed down practically every medical school in the country, and would have depleted the ranks of formally educated physicians in a few years. "'"*

From its founding onward, the AMA was hostile to the interests of proprietary medical colleges and their faculties. The practitioners wanted to reduce the output of medical schools in

*The term "elite" refers somewhat loosely to physicians who, by their reputations for clinical or research techniques, by income, and/or by organizational leadership positions, had achieved prominence within the profession.

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order to reduce competition within the profession, while the medical faculties opposed any attempted reforms because of their interests in maximizing their lecture fees and future consulting fees. Unfortunately for the practitioners, the reform leadership mistakenly thought that including medical schools in the new national organization would allow the medical societies to control them. This strategic mistake immobilized the AMA as the vanguard of practitioners' interests until 1874 when medical college voting rights in the association were abolished.

CODES OF ETHICS

The AMA's attacks on medical education and especially on other medical sects were supported by a "code of ethics" adopted at their first convention. With the code the AMA hoped to deny the ability of patients to judge their physicians or disagreements between physicians, to encourage attacks on "irregular" doctors and "quacks," and generally to reduce competition among regular physicians. At the same time that the AMA complained about the low standards of medical education, the association commanded patients to trust their doctors. "The obedience of a patient to the prescriptions of his doctor should be prompt and impHcit," the code of ethics instructed. The patient "should never permit his own crude opinions as to their fitness to influence his attention to them."^^

These efforts to bolster the profession's falling economic status and power were legitimized on moral and ethical grounds by the medical societies. Since the colonial period, violation of "ethical codes" had been grounds for ostracizing nonconforming physicians. Codes were used not only against other sects and lay healers but against members of the regular profession who consulted with homeopaths and eclectics and even against the developing medical specialties which offered competition to the general practitioners. The AMA code failed to win public support or stamp out competition although the medical societies' attacks on members for code violations intimidated some doctors and increased intraprofessional antagonisms.'^

In short, conflicts between practitioners and medical faculties, generalists and specialists, and "regular" physicians and other sects kept the profession badly divided throughout the nineteenth century. The incoherent strategy of the regular profession's

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leadership and the weak structure of their organization, the AM A, left the field with no sect able to secure undisputed control over the competitive marketplace.

Medical school output continued unabated. By the end of the nineteenth century, the United States averaged one physician to every 568 people. ^^ Compared with prevailing ratios in European countries (Germany, with one doctor to 2,000 population, was the favorite example), the United States was "overcrowded" with physicians. Physicians' incomes ran the gamut from poor ($200 a year) to wealthy (as much as $30,000 a year for a small number of elite doctors). The chief complaints of the most prominent professional spokesmen by the end of the century were the "surplus" of doctors, "low" incomes, and the low social status of the profession.

Three underlying problems plagued medical reformers who tried to heal these wounds. First, physicians lacked an agreed upon technical basis for settling among themselves disputes between the sects. Without public consensus on technical criteria of effectiveness and validity, all sects competed for business in the medical market. But without sufficient public confidence in the validity of any one sect, no sect could win a monopoly of medical practice and thereby eliminate the competition.

Second, their lack of a technical basis for establishing public support put them all in a weak position to establish political control over entry into medical practice. Earlier efforts to use licensing ended in humiliating defeat for the regular profession because of organized opposition from other sects and a distrustful public.

Third, within at least the dominant sect different economic interests divided those who practiced medicine from those who trained future practitioners. Practitioners wanted to restrict the supply of physicians, and part-time faculty wanted to preserve institutions that were lucrative additions to their own practices.

INCOMPLETE PROFESSIONALIZATION

Without actually having public confidence in their technical ability, physicians throughout the nineteenth century and earlier had nevertheless proclaimed norms to support their authority over the lay public. Demands for recognition of the regular profession's technical competence (in which they undoubtedly

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believed) were the means of legitimating their claims to profes- sional authority. The recognition of that authority, however, was seen as necessary to the profession's controlling the economic conditions of its work. By proclaiming a set of norms and values associated with their work, regular physicians hoped to end the competitive market for medical services and to win a regulated market for themselves.

The basis of professional status and power is still debated by sociologists, who traditionally have posed a set of essential features that are supposed to distinguish professions from the general run of occupations. In 1928, A. M. Carr-Saunders, the father of the sociology of professions, defined a profession as an occupation: (1) based on specialized intellectual training or study, (2) providing a skilled service to others, and (3) in return for a fee or salary. ^^ Thirty years later, William Goode stressed prolonged specialized training in a body of abstract knowledge and a collectivity or service orientation as the "core characteristics" of professions.^^ The list of formal characteristics of professions has been extended by other sociologists to include a systematic body of theory, acceptance of the authority of the professional by all who come to him or her as clients, protection of the professional's authority by the political community, a code of ethics to regulate professional relations, and a set of values, norms and symbols that build solidarity among the profession's members. ^°

However, lists of formal characteristics turn out to be fairly useless in the real world in distinguishing professions from other occupations. Even worse, they tend to gloss over the political and economic dynamics that are essential to the process of profes- sionalization, making professional status and power appear an inevitable and desirable feature of modern societies. In reality, as Eliot Freidson has observed, any occupation wishing professional status creates a systematic body of theory, claims exclusive authority of its practitioners, adopts a code of ethics, tries to build solidarity among its practitioners around formal values, norms, and symbols, and otherwise cloaks itself with the well-known medallions of professions to support its claims. "If there is no systematic body of theory," Freidson argues, "it is created for the purpose of being able to say there is."^^

The commitment to service, argues Harold Wilensky, is "the pivot around which the moral claim to professional status

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revolves."" Like many such professional norms, there remains no clear evidence that a service orientation is in fact strong and widespread among professionals. In reviewing the sociological literature that makes such claims, Freidson has concluded: "the blunt fact is that discussions of professions assume or assert by definition and without supporting empirical evidence that 'service orientation' is especially common among professionals."^^

Indeed, many academic social scientists have been beguiled by their own (usually self-serving) beliefs in "science" and "expertise" into confusing professional norms with the reality of professional practice and motivation. Codes of ethics were accepted by some sociologists as genuine efforts by the profession to guarantee competence and honor. Carr-Saunders believed that "if the foundations of the codes were better understood, they would not be generally regarded with hostility. "^"^

More recently, some sociologists have approached profession- al norms more critically. Everett Hughes, for example, argues that the widespread acceptance of norms, hke the professional "should have almost complete control over what he does for the client" and "only the professional can say when his colleague makes a mistake," have been used by professionals to hide mistakes. ^^

What much of the sociological literature ignores in examining the process of professionalization is how essential political power is in gaining and maintaining professional status. As the history of the medical profession in the nineteenth century demonstrates, without sufficient political power the profession remained unable to control its economic and working conditions. Initial efforts at licensure were defeated by a popular movement of lay healers and other Jacksonian-era populists. Attempts to use medical education as a strategy of reform were thwarted by the organized profession's lack of control over medical schools. The leading reformers organized a national professional association, but the medical school faculties were beyond the reach of the American Medical Association. Ethical codes, articulating prevaihng pro- fessional norms, failed to win public support for the profession and could not overcome intraprofessional competition. What the medical reformers sought was the power to enforce the instru- ments of professionalism that assure high incomes, social status, and continued prosperity for the profession.

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Freidson is adamant in this interpretation of professionaliza- tion. "Not training as such, but only the issue of autonomy and control over training granted the occupation by an elite or public persuaded of its importance seems to be able to distinguish clearly among occupations," he argues. "And the process determining the outcome is essentially poHtical and social rather than techni- cal in character — a process in which power and persuasive rhetoric are of greater importance than the objective character of knowledge, training, and work." The nature of training, as well as the service ideal, ethical code, and body of abstract theory constitute a profession's "ideology, a deliberate rhetoric in a political process of lobbying, public relations, and other forms of persuasion to attain a desirable end — full control over its work."'^

The history of medicine, from this perspective, can be understood as a political process in which the specific reforms — however much they may increase the technical effectiveness of physicians — are also instruments of persuasion and symbols of legitimacy. The goals of reform leaders were to gain collective control for the profession over its working conditions and economics in order to establish a hierarchy of authority and power among healing occupations, to assure that physicians reign firmly at the top of the hierarchy, and to assure them as high incomes as possible in any given historical period.

Support for such interests would have to come from outside the profession. While efforts were made to win the credibility of "the public," leaders of the profession did not see their struggle as a grassroots campaign. Seeking a social and economic position above the majority of the population, they could at best hope for the acquiescence of the people. Active support would have to come from the already higher social classes. In the eighteenth century, practitioners had turned to gentlemen farmers and wealthy merchants in the state legislatures to protect their in- terests. In the nineteenth century a political rebellion from below demonstrated the insufficiency of merely legislated sanctions. Furthermore, political power increasingly rested in a new class in society — those capitalists who controlled great manufacturing and marketing enterprises. These were the men who, for good or bad, were changing the face of the nation. Around their en- terprises grew the great cities. From their factories came the

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steel and machines that enabled the same men to unify the country commercially with railroads, products, and even armies. From their corporations came the demand for foreign resources and the products for foreign markets that were rapidly making America a world power. This was the ascending class in America at the end of the nineteenth century. Those groups in society who connected with their enterprises or their interests could rise with them.

It became clear to increasing numbers of physicians that the complete professionalization of medicine could come only when they developed an ideology and a practice that was consistent with the ideas and interests of socially and politically dominant groups in the society. It was desirable that everyone in society recognize their technical effectiveness, but it was essential that the classes and groups associated with the ascending social order believe in their efficacy. The development and increasing domi- nance of scientific medicine within the profession provided the virtually perfect material and ideological basis for an alliance of the medical profession with other professionals (mainly engineers and lawyers), corporate managers, and all ranks of the capitalist class. The medical profession discovered an ideology that was compatible with the world view of, and politically and economi- cally useful to, the capitalist class and the emerging managerial and professional stratum.

MEDICINE AS SCIENCE

Medical research was flourishing in Germany and France during the nineteenth century, and even in the United States biologists and physicians made their contributions. In 1818 Valentine Mott, a New York physician, was among the first to attempt major arterial surgery near the heart. Other Americans also attempted new surgical procedures while some physicians contributed new understandings to internal medicine. The New York Academy of Medicine, founded in 1847, and the Pathologi- cal Society in Philadelphia promoted discussion of medical research and science.^''

Few of the findings and developments in medical research were directly useful in improving medical practice. It is doubtful that many patients survived the new surgical techniques in the

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absence of aseptic practices. While the differentiation of diseases made observation more precise, the usual heroic treatments were just as likely to do the patient in as before.

Beginning in midcentury, medical research in Europe started producing more applicable findings. In 1858 Rudolf Virchow unveiled a general concept of disease based on the cellular structure of the body. From the findings of cell physiology, anatomy, and pathology, Pasteur, Koch, and other medical researchers developed new concepts and applications of bacteri- ology.^^ In the last quarter of the century specialized German laboratories began to replace the more generalist botanists, biologists, and physicians. Their findings gave medical science a more reductionist and technically more effective turn.

Changes in American medical practice reflected the gradual acceptance of recent developments in Europe. Starting in the 1870s, American physicians flocked to the famous laboratories of German and Austrian universities for a year or more of study — if they were ambitious and could afford the expense of travel and living abroad without income. Between 1870 and the outbreak of World War I in 1914, about 15,000 American physicians studied medicine in Germany alone. ^^

While most American doctors who studied in Europe re- turned to develop lucrative private practices, a few put their main energies into developing laboratory medical sciences in the United States. Carl Ludwig's physiology institute in Leipzig produced several luminaries of America's infant medical science. Henry Pickering Bowditch, one of Ludwig's pupils, founded the country's first experimental physiology department at Harvard University in 1871. William Henry Welch, another of Ludwig's pupils, started America's first pathology laboratory at Bellevue Hospital medical school in 1878.^°

Fifteen years later American medical science came of age with the opening of the Johns Hopkins medical school, modeled after the German university medical schools with a heavy emphasis on research in the basic medical sciences. At Hopkins, for the first time in the United States, the laboratory science faculty were to be full-time teachers and researchers, supported by salaries adequate to live on and unencumbered by the distractions of private practice. Virtually the entire Hopkins faculty was trained in Germany. Hopkins, and then Harvard, Yale, and Pennsylva-

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nia, became the indigenous producers of scientific medical faculty. As scientific medicine gained increasing acceptance, medical schools throughout the country vied for Hopkins gradu- ates to add gleam to their lackluster local faculties.

Medical practice likewise began to change with the increased acceptance of medical science. Physicians began introducing into their work those scientific medical practices that were uncompli- cated and acceptable to their patients and at least seemed effective in reducing suffering and ameliorating the symptoms of disease. ^^ The use of bleeding and calomel began falling off in the 1870s though many physicians continued to use them on a more hmited basis as late at the 1920s.

Physicians who had the money to take an extra year's study in Europe were able to build more prestigious practices than the ordinary American-trained doctor. Usually they would take themselves out of direct competition with the majority of physicians by specializing in gynecology, surgery, opthalmology, or one of the other new branches of medicine. They quickly formed a new elite in the profession, with reputations that brought the middle and wealthy classes to their doors. ^^

As the base of scientific medicine spread out to include more practitioners, the peaks of elite physicians rose even higher. They quickly found that "scientific medicine" not only seemed more effective than the heroics of old, it was also far more profitable.

Professional leaders had tried numerous ways of uplifting the profession during the nineteenth century, but none of them had succeeded. It was medical science that provided the key to professional reform. Medical research yielded new tools of understanding and held out the hope of more effective techniques of prevention and treatment than orthodox medicine offered. But scientific medicine was utilized by professional leaders beyond merely increasing the technical effectiveness of their practice. It became as well the ideology of professionalization, used to gain support from the dominant groups associated with industrial capitalism, to cement the complete dominance of health care by the medical profession, and to raise the incomes and status of physicians as a group.

The obvious advantages to the profession notwithstanding, scientific medicine contained within it the seeds of ultimate destruction for the profession. The remainder of this chapter and

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the rest of this study will examine how this dialectic played itself out — the benefits the profession derived from the adoption of scientific medicine, the contradictions inherent in this historical process that began to undermine the position of the medical profession, and the new forces and contradictions that are now emerging.

GAINING PUBLIC CONFIDENCE

Scientific medicine solved two broad problems the medical profession faced in the late nineteenth century: lack of public confidence in the effectiveness of their service and competition within the medical profession.

Rather than inspiring awe and confidence, the regular medical profession had won the public's fear and ridicule. To win public support and patronage was the major task set by professional leaders during the nineteenth century. The AMA's code of ethics sought to assure the lay public that doctors were ethical and competent and attempted to command the public to place their confidence in regular physicians. But no claims or commands were effective in the absence of convincing personal experience or persuasive propaganda that could substitute for personal experience.

While homeopathy, eclecticism, and osteopathy did not have as much public patronage as the regular profession, they had a strong base of support. They had a following, including many wealthy and influential people, who believed in their absolute effectiveness. Their practitioners were widely believed to be, relatively at least, as effective as and certainly less dangerous than most regular doctors. And they did not demand a monopoly of practice, a wise and practical political course given the disreputa- ble condition of the profession and the almost universal reliance on home remedies for most minor acute and chronic ailments.

For the regular profession to win in their competition with the other medical sects, they needed first of all to gain absolutely and relatively in public confidence. Scientific medicine provided the basis for a concerted and successful campaign to win this public support. The effort never depended on the common folk of America. The campaign for acceptance of scientific medicine was aimed at the wealthy and powerful in society and the new

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"middle" classes. Both of these groups owed their privileged positions to the intensive industrialization that began with the Civil War. They were particularly attracted to a kind of medicine that shared their industrial culture, their values, their world outlook, and their ideologies. "Scientific management" analyzed the labor process in production into its constituent elements and reorganized them under management's control and for manage- ment's profits." In a similar vein, "scientific medicine" analyzed the body into its parts, subjected the parts to the control of scientific doctors, and thereby kept the bodies healthier and more efficient.

The germ theory of disease was especially attractive to both the regular profession and these new industrial and corporate elites. The germ theory emphasized discrete, specific, and exter- nal causal agents of disease. It gave encouragement to the idea of specific therapies to cure specific pathological conditions. ^"^ The payoff for the medical practitioners would be increased technical effectiveness and improved standing in the eyes of the public. That was not the foremost concern of either influential capitalists or medical researchers. These men (there were hardly any women in their ranks) saw in scientific medicine the possi- bility of preventing diseases through technological intervention that identified the offending organism and its means of contagion, and attacked the organism at the source or used it to create an immune response within the body. Disease was thus seen as an engineering problem, surmountable with sufficient talent and resources. To the medical researchers the germ theory and dis- coveries in bacteriology confirmed the value of their craft and assured increased support for their work. For capitalists, bac- teriological investigations and the application of the findings opened the possibility of reducing the toll that disease took of society's resources.

The forerunners of scientific medicine, along with practition- ers in other medical sects, had already greatly improved the classification of diseases. European physicians had long dominat- ed the field of medical discovery although now and then an American made a contribution. In 1836 William Gerhardt, a physician at Philadelphia Hospital, clinically differentiated ty- phoid from typhus. But there was little practical benefit from such classifications when no therapy was forthcoming to cure the

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condition. Bleeding, purging, blistering, and tonics were the standard bag of tricks available to regular physicians. Homeo- paths and eclectics, along with lay healers, used a wide assort- ment of herbs, and many claimed high rates of cures. By the 1880s the regular profession still had only a few drugs that were widely recognized to be curative: Quinine could save the victim of malaria, mercury could cure syphilis, and digitalis was often successful in treating heart disorders. ^^

The field of disease prevention was somewhat more success- ful. In the eighteenth century weahhy Europeans and Americans adopted the practice of variolation, a somewhat dangerous inoculation against smallpox used in the East for centuries. In 1798 Edward Jenner introduced inoculation with cowpox that was effective and somewhat safer than variolation.^^

By the time of the third major cholera epidemic in the United States in 1866, the notion that cholera was a specific and con- tagious disease had finally won near-unanimous support from the medical profession, joining the already strong popular belief in its contagion. Medical support for cleaning up the accumulated fihh in American cities won the backing of the business class and helped prevent the spread of cholera and the high death rates that had characterized the previous epidemics. The success of this preventive effort was credited to sanitary engineering and brought increased support for sanitation programs. ^^

Despite the scant results, leading practitioners and the new class of medical researchers sustained their faith in the eventual success of medical science. The major breakthroughs came from Europe in the 1880s and 1890s. In 1883 and 1884 Edwin Klebs and Friedrich Loeffler isolated the germ involved in diphtheria, a major killer in the nineteenth century. Emil von Behring and his coworkers produced a diphtheria antitoxin in the early 1890s, which although of little significance in reducing the death toll from diphtheria, supported the belief that deadly epidemics that were borne with resignation could in fact be prevented by understanding their causes.^®

These and other discoveries in the 1880s and 1890s were lauded around the world. Medical science benefited with new respect and political and financial support. Success indeed paved the road to fortune. The German government provided laborato- ries for Robert Koch and Paul Ehrlich. In France popular

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contributions supplied a research institute for Louis Pasteur. In England and Japan private philanthropy paid for new medical research institutes.

In the United States private and government support for medical research lagged behind these other countries. Veterinary medicine received help from the Department of Agriculture to stem epidemics that were wiping out livestock investments. Government officials and philanthropists saw little value in researching human disease, as Richard Shryock notes, ''partly because of the nature of medical science prior to 1885 and partly because human welfare brought no direct financial return. Hogs did."-'' Discoveries of the 1880s and 1890s, however, held out the promise that as science uncovered the germs that caused the great pestilences, further investigation would provide not only cures but methods for guarding against infection and for preventing the spread of epidemics. These expectations guided the lives of medical researchers, but they were also spreading rapidly among the middle classes and those who owned and managed America's new industrial empires.

Medical science rescued the medical profession, in particular the practitioners, from the widespread lack of confidence in their effectiveness. These few but significant discoveries, mostly in bacteriology, increased the belief in the technical effectiveness of the profession as a whole. The actual impact of progress against infectious disease was not nearly so great as its proponents claimed. The arsenal of effective weapons against diseases did not increase spectacularly, but its limited advances did provide the basis for persuading the public that scientific medicine reflected on all members of the profession — practitioners as well as researchers — who had been trained in the theory and methods of scientific medical research.

The slight increase in the effectiveness of the new medicine was embellished in propaganda by the profession and the media. From the 1890s on, popular magazines and newspapers joined the leading medical journals in praising the accomplishments and prophesying the future success of medical science. Articles ridiculing "Popular Medical Fallacies" and extolling the "Tri- umphs of Modern Medicine" and the "War Against Disease" appeared in many popular magazines as well as professional journals. They portrayed medicine as an "exact science" and the

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physician as an inquiring and skeptical scientist who avoids "hasty jumping at conclusions or too-ready dependence upon formu- lae. "^°

The increased credibility of medicine was important in convincing the public that doctors with scientific medical training had an expertise worth paying for. If doctors could do little more for a patient than an herbal healer or a patent medicine, there was not much point in people wasting their money on expensive doctors' fees. Scientific medicine wrapped the modern doctor in an aura of therapeutic effectiveness, and the limited improve- ments gave support to that aura. Furthermore, the technical expertise associated with scientific medicine helped to mystify the role and work of the physician more effectively than did older notions of the etiology of disease, unpleasant remedies, and transparent codes of "ethics." Scientific medicine thereby sup- ported the claims of the profession for a monopoly of control over all heahng methods. These benefits provided the basis for other gains and were effective in undermining sectarian medicine, midwifery, and other forms of competition.

In seeking to destroy its competitors' hold on the medical marketplace, the regular profession proffered scientific medicine as more effective than "medicine as art" and "sectarian medi- cine" and "quacks." Not only was it more effective, it was, as each sect before it had claimed, the only truly valid medicine. Scientific medicine was held up as the nonsectarian medical theory and practice — the only one based not on dogma but on verifiable truths. ''^ As the only valid medicine, it should be granted a monopoly of practice; "none but men and women who have an interest in scientific medicine" should be allowed to join any county medical society.*^ But making the claim was not equivalent to having it accepted.

Folk medicine was still widely used in the United States, particularly in the countryside but also in the cities. Every family had its traditional remedies that were part of the family lore, believed in and passed down from generation to generation. Generally, the young woman's own family's remedies prevailed in her new family. "^^ Some of the remedies undoubtedly acted as placebos, but many were certainly effective in providing rehef and even cures. Such traditions were effective obstacles to the acceptance of scientific medicine.

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Most practitioners were also very pragmatic, developing a repertoire of skills and utilizing some new techniques that seemed effective and readily accepted by their patients. These country and city doctors were not much impressed by medical science. They saw it as a tool enabling them to heal more effectively when its claims worked and when its techniques did not require a whole new method of practice.

Robert Pusey, a Kentucky country doctor who practiced in the 1870s and 1880s, used the clinical thermometer, assorted specula, and a syringe. Occasionally, he used the stethoscope although he preferred to place his ear to the patient's chest. With this simple method he could hear and distinguish most conditions as well as his scientifically trained son could with a stethoscope. He used judgments based on practice, read up on cases in the more concrete and concise medical texts, and distrusted journal articles. The older Dr. Pusey vaguely accepted bacteriology, especially as an explanation for infections causing pus but not generally for infectious diseases. He sometimes used calomel, made and sold his own drugs, did not use patent medicines, and often prescribed strichnine and arsenic as tonics. He practiced surgery in which he used chloroform as an anesthetic and asepsis when the knowledge and techniques became available to him."^"*

The propaganda for scientific medicine was sure to be effective, but it would take time. John Shaw Billings, a leading medical reformer in the late nineteenth century, observed that doctors whose practices were not interfered with by quacks were indifferent to reforms while those in need of larger practices were more indignant about such competitors. Many quacks had effected cures where science had failed, Billings admitted. But rather than giving him pause in his rejection of any but scientific medical methods, Billings saw it as a tactical problem of persuading the American public that it is in their interests to suppress quackery. The remarkable achievements of medical science were being brought to the public, but, Billings cautioned, "it is necessary to go slowly and allow such evidence to accumulate. '"^^

The reformers believed scientific medicine would increase the technical effectiveness of the medical profession, and they promoted it as the only effective therapeutic method. Through propaganda they hoped to undermine public resistance to its use,

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increase the public demand for it, and thereby force practitioners to join the new "nonsectarian'' medicine.

REDUCING COMPETITION

As scientific medicine won public and professional credibility, it also solved the second and fundamentally more serious problem facing the profession in the nineteenth century: competi- tion.

Plagued by competition among numerous medical sects, between practitioners and medical school faculty, and within the "crowded" ranks of regular practitioners themselves, the profes- sion was saved from its own internal competitive struggles by the triumph of scientific medicine. First, the technical requirements of teaching scientific medicine provided several advantages for the profession's elite. Second, scientific medicine forged new unity in the interests of elite practitioners and medical school faculty. Third, as it gained increasingly widespread legitimacy, scientific medicine undermined the major medical sects. It thereby imposed unity among those sects in their subordination to the dominant forces in the profession. And, finally, medical science made possible specialization which was largely a response to competition within medicine. The overall impact of scientific medicine within the profession was to legitimize control by elite practitioners and medical school faculty.

TECHNICAL REQUIREMENTS OF SCIENTIFIC MEDICAL EDUCATION

THE NEW ACADEMICIANS

Making the doctor the purveyor of a broad range of skills within a context of mystified knowledge required extensive and esoteric training. Nineteenth-century medical reformers envi- sioned the physician as a bedside scientist. Medical practitioners must think and talk like scientists. They must be trained in anatomy, physiology, bacteriology, pathology, pharmacology, and the physical sciences. They must think of health and disease, not holistically as general relationships between bodily systems or

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between the person and the environment, but in terms of the micro-concepts of physiology and anatomy, bacteriology and cell pathology. These sciences and their reductionist concepts were gradually recognized in the late nineteenth century as the foundations of medical education.

The medical schools of the last century were staffed by practitioners, often very talented men who were heavy on the "art" but less expert on the "science." Increasingly, laboratory science courses were taken away from the local practitioner and given to physicians with special training in the laboratory sciences. The new academic physicians who preferred these laboratory sciences over medical practice prospered with the increased demand for more faculty with training in these fields. Those who could afford to spend a year or two studying in Germany or Austria after medical school had secure, if not lucrative, academic careers awaiting them on their return.

In 1893 Johns Hopkins became the first medical school in the United States to employ these laboratory men full time and to pay them salaries that enabled them to devote all their time and energy to research and teaching. The new full-time organization of the laboratory science faculty was hailed as a great advance for American medical education. It was quickly adopted by other elite schools and gradually became the norm emulated by the average institution. Although the laboratory science faculty gave up private practice incomes of $10,000 a year and more in return for salaries of $3,000 or $4,000, there were more than enough people to fill the demand. "^^

Some of the giants of medical reform, like William H. Welch, loathed medical practice, feared the insecurity of competition among private practitioners, and longed for the opportunity to pursue medical research without the diversions of maintaining a private clientele. Before going off to Europe in 1876 to advance his medical science skills, Welch confided to his sister his fears of trying to set up "by hook or by crook a patronage of some kind." Echoing the pipe dreams of most medical graduates, Welch observed, "it is much finer to hold a chair in a medical college, and to have a salary . . . and to be sought by patients instead of seeking them." His studies abroad would give him a jump on his competitors: "If by absorbing a little German lore I can get a httle

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start of a few thousand rivals and thereby reduce my competitors to a few hundred more or less, it is a good point to tally.'"*''

The emphasis on scientific medicine thus created unprece- dented job opportunities for physicians qua medical scientists. As positions expanded, a core of professionals developed who were more dedicated than ever to seeing medicine as science complete- ly displace medicine as art. These medical scientists' interests and identification were bound up solely with medical schools and not with private practice. As the vanguard of the profession's successful strategy and the recipients of millions of dollars in capital investments in medical research and education, the new medical academicians became the symbol of the new profession. In the 1890s, for the first time in the United States, the medical profession came to exalt the scientist over the practitioner. "** Despite their more modest, middle-class incomes, the scientists were the new elite in the profession.

The faculty at the most prestigious schools won their profes- sional reputations on the basis of their research contributions to their fields. The best reputations attracted the best students and the wealthiest patients. In 1903 Wilham Halsted, a famous sur- geon on the Johns Hopkins faculty, got $10,000 for an appendec- tomy, and his colleague, Howard Kelly, charged $20,000 for a major operation."*^ Unlike the old-time medical faculties, whose material interests were enhanced by student fees and referrals from their many former students, the new academicians' mate- rial interests were tied to the promotion of medical science. It was in their interests to raise the standards of medical schools and to make scientific medicine the only acceptable theory and practice.

The predominant type of medical school, owned by the faculty and existing on student fees, prospered as long as enrollments could be kept high and costs low. However, practi- tioners would prosper only if the production of physicians was decreased, reducing competition within the profession. This conflict of economic interests had divided elite practitioners from medical school faculty throughout the nineteenth century. The ascendancy of scientific medicine transformed the old conflict into the basis for an alliance between the scientific medical faculties and elite practitioners.

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The interests of the new medical scientists in medical educa- tion were thus tied to the dominance of scientific medicine and not to large numbers of students or even large numbers of medical schools. They joined the elite practitioners as the leaders of reform in the profession. Together they gained control of the AMA at the turn of the century and completely reorganized it to make the AMA the profession's instrument of political action as we know it today and to use it and the leading medical schools to alter completely the technical, economic, and social forces within the medical profession.

The technical requirements of developing and teaching scien- tific medicine sharpened the distinction between laboratory science faculty and practitioners, provided new and expanding job opportunities for medical scientists, and hoisted them to ehte and influential positions within the profession. At the same time these developments provided the basis for the aUiance between these new elite faculty and the elite practitioners, giving them sufficient power to take control of the profession and transform it.

"fewer and better"

As a professional consensus developed around scientific medicine, the scientific medical faculty and elite practitioners agreed upon "objective" criteria for judging medical schools. The needs of scientific medical education were pretty clear cut. If students are to be trained as medical scientists, they need to be taught the biological and physical sciences, and they need to be taught how to apply the principles they learn in those sciences to the diseases of real people. Experience as well as common sense argued for laboratory courses in the sciences and hospital experience for the clinical appHcation of those sciences: Learning how is at least as important as learning about.

The technical requirements of teaching scientific medicine suggest fairly clear criteria for judging medical schools. If the premise of training scientists is accepted, then any worthy medical program must have adequate laboratory facilities, clini- cal teaching facilities, and well-trained laboratory and clinical faculty.

While the criteria of what is "adequate" might be (and were)

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argued, the standards were set by those who secured positions of power. The AMA became the vehicle for poHtical action within the profession and the larger society. The reformers used the technical requirements of training medical scientists to set standards and then evaluate medical schools according to those standards. With a few exceptions — Johns Hopkins the shining example among them — virtually all nineteenth-century medical colleges were weak when judged by these standards.

Unquestionably, scientific medical education was and is an expensive affair. The capital outlays for laboratories and hospital facilities were beyond the resources of most nineteenth-century and early twentieth-century medical schools. Student lecture fees could not cover the larger salaries for faculty who devoted substantial time to research and teaching, let alone the increas- ingly widespread full-time salaries for laboratory science faculty. No medical school could exist on student fees and at the same time provide these increasingly necessary medical science pro- grams for their students.

In some states, students who graduated from medical colleges that did not have these programs, facilities, and personnel were barred from taking licensing examinations. Increasingly, state exams were geared to the information and perspectives provided in scientifically oriented schools, and graduates of inadequately equipped schools failed their licensing exams with increasing frequency. ^° Since the schools were supported by students' fees and students had little incentive to attend a school that did not prepare them to pass state board exams, inadequate schools lost out in the competitive market for enrollees and their money. AMA president Charles Reed observed in 1901, "Under the pressure of legal requirements the weight falls with almost fatal force upon the small, private and poorly equipped institutions."^^ The technical requirements of scientific medical education thus brought about the conditions of collapse of proprietary medical schools. As Abraham Flexner later noted, "Nothing has perhaps done more to complete the discredit of commercialism than the fact that it has ceased to pay. It is but a short step from an annual deficit to the conclusion that the whole thing is wrong anyway.""

In Chapter 4 we will see how these conditions provided an opportunity for the AMA and capitalist foundations to transform medical education in the United States. For the moment it is

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enough to note that without sufficient capital and endowments, no medical school could survive in the era of scientific medicine. Schools collapsed and consolidated all over the country beginning in 1905, coinciding with the first year of serious activity by the AMA's new Council on Medical Education. Between 1905 and 1910, thirty schools merged and twenty-one closed down alto- gether." The number of medical schools declined from a high of 166 in 1904 to 133 in 1910, 104 in 1915, and hit a low of seventy-six in 1929. In the reorganization of medical schools the number of students was reduced at many institutions in order to intensify the teaching and research resources within each school. Thus the technical requirements of scientific medical education were used to close schools and decrease the production of new physicians, easing the competition within the profession and raising doctors' incomes.

Furthermore, scientific medical education "required" greater prehminary education. Students must come to medical school, it was argued, having had a full year each of college chemistry, physics, and biology.

The demands for stringent requirements of preliminary edu- cation were not new to the era of scientific medicine. In eigh- teenth-century and nineteenth-century England, where "physi- cians" were a tiny elite above surgeons and apothecaries, it was essential for physicians to be regarded as gentlemen. Because they practiced only among the wealthy, it was important to their pocketbooks to be able to mingle with the upper class. As professions developed, a liberal education became the mark of upper-class origins. "It might not make you a gentleman," W. J. Reader has observed, "but without it a gentleman you could hardly hope to be."^"^ In the United States as well, a college education was the mark of a gentleman. For those who were not born into a privileged class, a college education — if it could be gotten — "rubbed the raw edge off many a country boy," giving them sufficiently proper appearances to make their way to a higher social class. ^^

It is not surprising then that substantial educational require- ments had been declared an imperative in the mid-nineteenth century because it would assure that doctors would be gentlemen. Daniel Drake, probably the most illustrious American physician of the midcentury, criticized his colleagues' ignorance of Latin

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and Greek without which, "whatever may be his genius and professional skill," a physician would still necessarily "appear defective and uncultivated."^^ This persistent concern was echoed by Johns Hopkins' famous Dr. Welch who wrote in 1906, "The social position of the medical man and his influence on the community depend to a considerable extent upon his preliminary education and general culture."^''

Elite physicians frequently complained of the "coarse and common fiber" of much of the profession. ^^ Even a minority of the profession lacking upper-class polish cheapened the status of all doctors. The proliferation of inexpensive proprietary schools enabled a young man to live at home while attending medical school and thereby made medicine a ladder that some farm boys, artisans, and shop clerks could climb to middle-class status and income. It was not only the inadequacies in the training provided in commercial colleges that angered the elite reformers; it was also whom they brought into the profession. Frank Billings, in his presidential address to the AM A in 1903, disdained "these sundown institutions" that provided evening classes and enabled "the clerk, the streetcar conductor, the janitor and others employed during the day to earn a degree. "^^

Prior to the acceptance of scientific medicine, attempts to lengthen the medical school term of instruction and raise pre- liminary education requirements were met with charges of elitism. "There is an aristocratic feature in this movement" by medical societies, Martyn Paine, a faculty member in the New York University medical department, asserted in 1846. "It is oppression towards the poor, for the sake of crippHng the medical colleges. "^^

Even after the turn of the century some education leaders warned against excluding the poor from medicine. In 1908, W. L. Bryan, president of Indiana University, criticized the Association of American Medical Colleges' proposed requirement of two years attendance at a liberal arts college prior to admission. Raising the entrance requirement would "shui out of the medical schools thousands of men who are not ignorant nor incompetent" but who would be excluded because "poverty and other hard conditions" have kept them from the colleges. ^^ The profession's objective was exactly that — to exclude the poorer classes from their ranks.

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Scientific medicine provided an "objective" basis for requir- ing a lengthy preliminary education. If students had to come prepared with college courses in physics, chemistry, and biology, then there could be no argument against lengthening the require- ments. The standard-setting schools raised their requirements from completion of high school to two years of liberal arts college and finally to a bachelor's degree. From the moment it opened its doors in 1893, Johns Hopkins medical school led the way by requiring a bachelor's degree for admission and four years of instruction for its prestigious M.D. degree. When Harvard instituted the baccalaureate requirement in 1901, its entering medical class dropped from an all-time high of 198 students the previous year to sixty-seven.^^ The preliminary education re- quirements were several steps ahead of the great majority of American youth and enabled the profession to draw its recruits from the "better" classes.

Was this an unintended outcome of the technical "require- ments" of medical education, or was it the desired outcome for which scientific medicine provided the mere rationale? Given the goals of professional leaders throughout the nineteenth century — to reduce the numbers of physicians and to raise the social- class standing of the profession— it seems that scientific medicine provided the credible rationale that all previous generations of medical elites had sought in vain. The preHminary requirement would weed out the economically and socially "unfit." Some reformers justified this selectivity by the cost of scientific med- ical education. "It does not pay to give a $5,000 education to a $5 boy," intoned John Shaw Billings in 1886 while helping to organize Johns Hopkins medical training." But most elite physi- cians simply desired to eliminate "professional degeneracy," as Dr. Inez Philbrick put it at the turn of the century. Philbrick, a successful practitioner in Lincoln, Nebraska, rallied his colleagues to "Let fewer and better be our motto. '"^^

In sum, the technical requirements of scientific medical education gave new career opportunities to physicians as medical scientists, creating a whole new position of full-time researcher and teacher and a new group of elite medical school faculty who combined a material interest in medical schools with a commit- ment to promoting scientific medicine. At the same time these technical requirements of the new medical education provided

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the standards and the rationale for reducing the output of medical schools and raising the social class base of the entire profession.

"NONSECTARIAN" MEDICINE UNDERMINES THE SECTS

As scientific medicine gained increasingly wide acceptance, it undermined the other medical sects. Scientific medicine thereby forged unity within the profession by enabling the AMA to subordinate the sects to its own standards of medical education and practice. Overwhelmed by the increased claims of technical effectiveness for scientific medicine, the major sects began incorporating scientific medicine into their own doctrines and practice.

Homeopathy, the most formidable competitor of the regu- lar professions in the nineteenth century, gradually dropped its unique features. Most homeopathic physicians in America broke with pure homeopathic theory in the mid-nineteenth century, taking what they believed valid from regular medicine and discarding especially heroic therapies. They purged the purists from their ranks by founding homeopathic medical colleges, previously believed unnecessary, and requiring training in gener- al medical skills, including surgery. ^^ Most midcentury American homeopaths were regular physicians unhappy with the ineffec- tiveness of regular medicine and with its growing unpopularity. In 1849, 1,000 Ohio physicians and lay people, disaffected by the orthodox profession's inability to reheve suffering during the cholera epidemic, organized a homeopathic society in Cincin- nati.^^

The direct competition that homeopathy posed to regular physicians led to campaigns to exclude them from medical societies and hospital privileges. The Massachusetts Medical Society began excluding homeopaths in 1860. By the 1870s there was a general attack, led by the AMA, on homeopathy and other "exclusive systems of medicine." Physicians violated the AMA code of ethics if they consulted with sectarian physicians or female or black doctors. In the 1870s the restrictions against female physicians were rescinded under pressure from the growing women's rights movement, and the exclusion of blacks was relaxed though local medical societies and hospitals openly

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continued their racist practices. But the attacks on "irregular" doctors continued throughout the century.^''

By the end of the nineteenth century, nearly all homeopaths were using both regular and homeopathic drugs. Leading homeo- paths announced that the great majority of homeopathic doctors did not beheve in infinitesimal doses, rejected the universality of the law of "like cures Hke," and generally used drugs like regular physicians. Homeopaths also became interested in clinical spe- cialties. In 1899 the American Institute of Homeopathy redefined a homeopathic physician as "one who adds to his knowledge of medicine a special knowledge of homeopathic therapeutics."^® Homeopathy, as well as other sects, were being overcome by the competition from scientific medicine.

Nonetheless, the continued popularity of homeopathy and eclectic medicine and the incomplete acceptance of scientific medicine made it difficult for regular professional leaders to win exclusive licensing privileges in the states. With the convergence in practice and education of homeopaths, eclectics, and regular physicians, it was possible to assure the dominance of scientific training and politically necessary to ignore, for the moment, the sectarian separations. Only through the combined efforts of the regular and "irregular" profession could laws be secured to restrict medical practice to scientifically trained physicians. The profession's leaders around the country agreed with William Osier, the most eminent American physician of his day, who advised the Maryland state medical society in 1891, "if we wish legislation for the protection of the public, we have got to ask for it together, not singly. "^^ And together they asked.

Beginning in the 1870s, state legislatures established medical Hcensing examination boards. In 1873 Texas passed the first modern medical practice act, a morale-boosting victory to the profession that offset the bitter memories of the Jacksonian era's repeal of licensure. The Illinois Board of Health, the state's licensing agency, was a model for the nation. Beginning in 1880, it began to hst American and Canadian medical schools according to qualitative criteria set by the Association of American Medical Colleges, an organization of elite, scientifically oriented institu- tions. ^°

Nonregular doctors participated in some way in medical licensing in at least thirty-three of the forty-five states that had

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enacted licensing laws by 1900. Physicians from at least two sects served on the same licensing boards in twenty states.^' By cooperating in licensure, the nonregular profession won inclusion among the respectable. With scientific medicine gaining ground every year, it appeared to the leaders of homeopathy that they had nothing to lose and everything to gain from their association with the regular profession. The president of the AMA even acknowledged in 1901 that "with broadened and increasingly uniform curricula" it made little sense to argue that competing sects did not share the profession's competence. '-

The reform leaders in the regular profession won the biggest rewards. By cooperating with the nonregular sects, they won licensing laws that recognized scientifically oriented reforms as the only valid basis of medical education. In a short time they secured complete control of licensing and the resources for medical education reform. Whether these elite professionals foresaw their ultimate gain from cooperating with the homeo- paths and eclectics or they were guided by expedience undiluted by strategy, the cooperative licensing efforts hastened the elimination of sectarianism amid the growing chorus of support for scientific medicine.

By 1903 the AMA adopted the strategy explicitly. At its annual convention the delegates voted to eliminate the decades- old exclusion of physicians who were trained as homeopaths or eclectics but chose not to "designate" themselves as such.''^ Two years earlier AMA president Charles Reed had drawn attention to the good effects of allowing all licensed physicians into state medical societies. By ending its exclusionary policy, he said, the New York society had reduced the registration of sectarian physicians by "nearly ninety percent."'"*

Scientific medicine was perhaps more effective than homeo- pathy and eclecticism in treating some diseases for which it had developed cures, but it was not, particularly at the turn of the century, the panacea it was believed to be. The reformers' overly optimistic assessment is shared by many contemporary medical historians. WiUiam Rothstein, for example, maintains that "sects could survive in medicine only so long as medically valid therapies constituted a smnU part of the therapies used by physicians. Once medically valid therapies became the dominant

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part of medical practice, medical sectarianism declined marked- ly."'^

In reality the number of medically effective therapies had not increased significantly in the first few years of this century, the period when sectarianism declined in medicine.''^ Rather the campaign to win acceptance for scientific medicine struck a responsive cultural chord among the new technical and manageri- al groups associated with industrial capitalism and with the media they controlled. The campaign established a popular belief in the broad effectiveness of scientific medicine and, together with political action by elite medical reformers, undermined the medical sects that competed with the regular profession.

SPECIALIZATION: LESS COMPETITION FOR THE ELITE

Advances in medical science during the late nineteenth century rapidly developed the technical basis for some physicians to offer highly specialized expertise not available from the ordinary practitioner. Medical advances were presumably usable by any physician, but in reality only those who studied a particular area developed the expertise to apply techniques and inventions. The ophthalmoscope, invented by Helmholz in 1851, required considerable study and practice to know what to look for on the other side of the cornea. Anesthetics, antisepsis, and asepsis made surgery a relatively safer procedure, but the masters of surgical techniques were those who devoted their entire practice to it.

The very existence of medical specialization rested upon a reductionist analysis of the body and disease. Its concrete development was made possible by advances in medical science. Nevertheless, specialization among practitioners was encouraged by economic competition within the profession and grew to take advantage of the new market for more technical, seemingly, more scientific medical services.

With dissatisfaction rampant among more ambitious members of the profession, some 15,000 American physicians studied medicine in Germany alone. They returned to reap the benefits of their advanced training and confidence to specialize in some branch of clinical medicine. '"^ Successful specialists soon earned

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more than twice as much as the better-off general practitioners.''* Elite, scientifically oriented physicians saw specialization as a solution for themselves in the competitive medical market.

The demand for specialists grew with the urban upper middle class. Patients whose own social position was based on the growth of technology and industrialization sought out physicians whose practice suggested the same world view. Gynecological theory viewed most female disease as being rooted in or associated with uterine problems. As Barbara Ehrenreich and Deirdre English have amply demonstrated, Victorian femininity itself was associ- ated with invahdism and physical and emotional frailty. Women of the "better" classes were defined as sick in order to support their role as social ornamentation, demonstrating the financial and social success of their husbands and distinguishing them from lower-class women who were expected to work and were considered sickening.''^

Gynecological surgeons preyed upon the supposedly delicate nature of upper middle-class women and the terrible consequenc- es of having a "tipped" uterus or sexual appetite. Hysterecto- mies, ovariotomies, and cliteridectomies were prescribed for these and other female maladies. Some gynecologists, like Horatio Bigelow writing in the AMA Journal in 1885, favored a "conservative" approach over too rash use of the knife or mechanical devices. He believed that better results could be obtained "by attention to every detail of life, even the most insignificant, for the aggregation of the little things go to the making of the big ones, and also, by attention to psychical conditions and reactions. "*° Such attention, of course, required daily visits from the doctor.

Gynecologists tailored their medical theories to the prevailing notions of the place of women in society and thereby developed a new and lucrative medical market. Upper-class women became the objects of knife-wielding gynecological surgeons or the invalided captives of overly "attentive" gynecological practition- ers. From the early 1890s abdominal and pelvic surgery seemed the profession's own Gold Rush, and surgeons were, in the words of the AMA Journal, "as restless and ambitious a throng as ever fought for fame upon the battlefield."**

General practitioners obviously suffered to the extent that their patients went to specialists with complaints the GPs

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formerly treated. From the 1850s onward, the GP-dominated medical societies attacked what they viewed as unfair competi- tion. In 1874 the AMA's judicial council ruled that specialists could advertise only that their practices were ''limited to diseases peculiar to women" or "diseases of the eye and ear." Such restrictions on specialists denied the claims of scientific leaders that specialism was based on greater expertise not available to the general practitioner. Moreover, few physicians at that time could completely limit their practices to specialties since specialization was not yet widely enough accepted.*^

Conditions soon changed, at least in large and medium-size cities. Specialists promoted the medical sciences through their own societies. Following a rebuff by the AMA, which named a committee of medically conservative professionals instead of distinguished medical scientists to host the 1887 International Medical Congress, specialists and other medical scientists formed the Association of American Physicians. In 1888 all national specialty societies formed an alliance outside the AMA in the American Congress of Physicians and Surgeons. In the last years of the nineteenth century, as scientific medicine increased and the economic base of specialism grew more secure, membership in scientific societies increased — particularly in Eastern cities where medical centers were beginning to dominate medicine — while membership in the AMA languished.*^

Medical specialty societies were intended not only to promote development of the specialty but also to gain acceptance of the specialists by general practitioners. Even though they were competitors, specialists relied heavily on referrals from other physicians for much of their practice. GeneraUsts had to be induced to refer their difficult cases to other physicians. To encourage referrals, many, if not most specialists, gave a portion of their fee to the doctor who made the referral. *"* Fee-splitting became a widespread practice to control competition and gain acceptance of specialists by GPs.

Fee-splitting, however, was a private tool of individuals used to soften competitive relations among themselves. For fee- splitting to be used collectively by the organized profession would require an open admission of its existence and legitimacy within the profession. That would have been worse than the competition that fee-splitting was attempting to regulate because it was a

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purely commercial arrangement that undercut professional claims of expertise and privilege. It thereby reduced public confidence in physicians and further weakened the social and poHtical position of the profession. Fee-splitting could not resolve conflicting interests between specialists and GPs at the national level.

Ultimately, the development of specialties and subspecialties has indeed reduced overall competition within the medical pro- fession. The ratio of primary care physicians has fallen from more than 170 per 100,000 population in 1900 to less than sixty per 100,000 today. ^^ But the division of physician labor into special- ties created intraprofessional problems, pitting general practi- tioner against specialist. The decline in primary care physicians has eased the problem somewhat, but it was still a serious split in the ranks at the turn of the century and an obstacle to the efforts of the scientifically oriented elite practitioners and medical faculty who led the reform movement.

New levels of accreditation of specialists emerged in the twentieth century. The American College of Surgeons was charged with being elitist and un-American for its efforts to restrict surgery to specially licensed physicians and to accredited hospitals. In 1912 Franklin Martin's public relations tour for the College of Surgeons was interrupted with heckhng by hostile GPs. The college fellows were accused either of degrading the profession by forming "a glorified surgical union, along labor lines" or of estabUshing a new oligarchy, "an exclusive Four Hundred in the profession. "^^

The reform leadership gathering in the wings of the AMA included many leading specialists, but they saw the importance of putting the interests of the profession as a whole at the forefront of their campaign. After failing in 1898, they succeeded in 1901 and 1902 in their efforts to reorganize the AMA into a more effective national organization. Their strategy included the delicate issue of unifying the competing specialists and general practitioners and bringing the specialists into the profession's main political arm — the AMA.

GAINS AND LOSSES

Scientific medicine was clearly an effective doctrine for the reform and uplift of the medical profession. It increased the

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technical effectiveness of doctors, providing a basis for increasing public confidence in the profession. The need for research and the teaching of medical sciences created a whole new category of academic medicine. It united the interests of these academic physicians, who sought total victory for scientific medical schools over less adequate ones, with the interests of elite practitioners, who wanted to reduce production of and competition among doctors in order to raise their incomes and status. The require- ments of scientific medical education strained the resources of "commercial" medical education to the breaking point, closing down many medical schools and reducing the production of physicians. It also provided the rationale for requiring extensive preliminary education of medical school applicants, forcing the poorer classes out of medicine and thereby raising the social class base of the profession. Furthermore, scientific medicine under- mined sectarian medicine, uniting most of the divided profession under the banner of "nonsectarian" scientific medicine. Finally, it provided a basis for further decreasing competition within the profession through the development of specialization. Thus, scientific medicine helped complete the professionalization of medicine.

These gains to the medical profession were accompanied by some losses. Some of the losses were borne by less powerful members of the profession. The gains of specialists, the new elite among practitioners, were the losses of the general practitioners. Scientific medicine provided the profession's scientific elite with the means of securing its position and taking complete control.

While society benefited from more effective techniques against infectious diseases, people lost the benefits of traditional techniques and became dependent on technological medicine. The propaganda of the reform-minded elite sold scientific medi- cine as the last word on matters of health and disease. Through their campaign, the medical profession excluded herbal methods of prevention and therapy that are only now regaining popular- ity. They also narrowed the scope of medical inquiry to reduc- tionist concepts, all but ignoring the social and economic contexts of health and disease.

The doctor was portrayed as omniscient and his skill as all- powerful. Patients, accepting the profession's claims and want- ing something for their money, began to expect their doctors

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to provide remedies for their suffering. Not wanting to discourage this profitable attitude, most physicians beheved that, in the words of a late nineteenth-century physician, "he fails of his duty and his privilege who neglects to do something for the patient."*'' However, even this lucrative attribution of physician omniscience was a double-edged sword. Armed with assurances of the near- infallibility of medical science, patients demanded compensation when they were maimed by the therapies or mistakes of scien- tific doctors. The number of malpractice suits from 1900 to 1915 exceeded the number of suits during the entire nineteenth cen- tury.**

Naturally, the most oppressed groups in society suffered the most from the complete professionalization of medicine made possible by scientific medicine. The poorer classes in general and ethnic and racial minorities in particular have suffered doubly — by being excluded from entering the profession and by losing medical care that was indigenous to their communities and accessible to them. By the early 1900s people who could afford specialists increasingly relied on them, often by-passing the general practitioner altogether. The poor filled the waiting rooms and examining tables of teaching hospitals to become the teach- ing and research material for interns, residents, and specialists. The nation's wage earners, excluded from charity clinics by means tests and often unable to afford private specialists' fees, became the bread-and-butter clients of the nonelite general practitioners.*' Following the largely successful doctors' campaigns to rid the country of midwives, working-class and rural women and men lost the services that helped maintain the integrity of their fami- nes during the disruption of childbirth and found themselves hav- ing to pay the higher fees of physicians and the cost of a hospital bed.'° Women suffered from unnecessary surgery and suffocating attention from gynecologists. They, like the working class and racial minorities in general, were also excluded from becoming doctors.

The fewer physicians competing for consumers' dollars, the higher physicians' incomes rose and the fewer doctors who practiced in working-class and poor sections of the cities and in the countryside. The middle class became the main source of income for the majority of the profession. As Morris Fishbein, editor of the AMA Journal, complacently observed in 1927, "The

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physician of the future will deal largely with this group. From them most of the physicians, who are themselves of the middle class, will derive their incomes."^'

The dynamics that lifted white middle-class and upper-class male physicians to the top of a hierarchy were not based on conspiracies or conscious deceptions. Physicians acted in their collective self-interest. While the different interest groups with- in the profession often clashed, their conflicts were gradually overwhelmed by the growing belief that all who embraced scien- tific medicine would benefit. Old-time homeopaths and eclectics, of course, fell by the wayside, and proprietors of crassly commer- cial medical schools lost their lucrative businesses. But most physicians could relate to the purposes of the reform campaign — more respect for their skills, higher social status, more money — and to the necessary means of achieving them. Undoubtedly con- spiracies and conscious deceptions occured along the way (we will see some examples in Chapter 4), but even the reform leaders believed their mission would benefit society as well as the med- ical profession. Nevertheless, it strains the imagination to con- clude that the complete professionalization of medicine served the interests of more than a small minority of the population.

The technical limitations of nineteenth-century medicine were replaced by technical narrowness in the twentieth century; the professional pluralism, by professional monopoly controlled by elite specialists and medical academicians; the culturally diverse and widely distributed group of healers, by a more fully stratified and, for many, inaccessible professional class. These were some, of society's losses that accompanied the profession's gains. The consolidation of a scientific medical profession, however, also provided important gains for the corporate class in America.

CHAPTER

Scientific Medicine II: The Preservation of Capital

Scientific medicine, while providing well for the medical profes- sion, also posed a major and unresolvable contradiction for doctors. Medical science, as it developed in capitalist countries, was built up around technology. The higher the level of technolo- gy, it was believed, the more effective or, at least, salable were the services of practitioners and researchers. But the higher the level of technology, the more capital was required for medical practice as well as for research. Investments in hospital and laboratory facilities and tremendous expenses for highly special- ized faculty and researchers were beyond the resources of physicians themselves.^ Doctors had to turn outside the profes- sion for capital, and in 1900 there was only one class who had such money. Wealthy capitalists were in a position to dictate terms to the profession — policies that served their own interests as much as or even more than those of the profession itself. In this chapter we will see how medical science opened the door to capitalist intervention and the ways scientific medicine served not only the needs of the medical profession but the interests of capitalism as well.

MEDICAL TECHNOLOGY AND CAPITAL

The nineteenth-century family doctor owned a few instru- ments— specula, a thermometer, and a stethoscope for examina- tions, saws for amputations, a chest of medicines to be sold to

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their patients — a small investment indeed. But twentieth-century medicine required greater technology than any single physician could afford. Hospitals, once the institutions to which the poor were taken to die, became the workshop for the doctor. Not only did the hospital provide the doctor with fully equipped operating rooms, x-ray machines, and other diagnostic and therapeutic instruments. It also provided auxiliary personnel who would isolate patients from their families, place them under the control of technical experts, and insure that the doctor's orders were carried out. Just as the buggy carrying the doctor to the patient's house symbolized the nineteenth-century doctor-patient relationship, the patient in the doctor's moderately equipped office and then the doctor and patient in the hospital symbolized the modernized counterparts.

Large-scale development of hospitals in the 1890s followed the development of surgery as a specialized skill. The renowned surgical skills of Halsted at Johns Hopkins and of others at the Mayo Clinic provided popular support for the profession's pleas that hospitals with modern surgical facilities be built. Rosemary Stevens notes, "Most of the hospitals now in existence were founded between 1880 and 1920, and the middle class for the first time entered hospitals on a large scale." In 1873 there were only 178 hospitals in the United States. By 1909 there were 4,359 hospitals with a total bed capacity of 421,000.^

Physicians grew increasingly dependent on hospitals. By 1929, seven out of ten physicians had some kind of hospital affiliation. In New York and Chicago, the average physician, whether gen- eralist or specialist, spent as much as 30 percent of his or her time in hospitals and clinics.^ Even by the turn of the century the medical profession was growing dependent on expensive, institu- tionalized technology.

The capital needed for hospitals, medical education, and research was beyond the means of the profession itself. A fully equipped, medium-sized hospital was an expensive building project. Then, too, room and service charges could not reasona- bly be expected to pay for the annual costs of running the hospital, especially when hospitals were free-of-charge work- shops for the doctor. Patients could be expected to pay a certain amount for their hospital care, but beyond a very vaguely determined limit, any additional hospital charges would reduce

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utilization and cut into the revenues of both hospital and physician. Thus, each year hospitals accumulated deficits that had to be paid off.

Deficit financing reflected the social role of hospitals as charitable institutions. Historically, from their development as medieval refuges for the diseased poor to their more recent role of providing for the sick of all classes, hospitals have consistently reflected the class structure of the society. Fitting their position in the class structure, the rich have been expected to pay the complete costs of their own private space and attentive care. The middle classes, with less commodious faciHties and fewer staff to attend to their wants, have been expected to pay their own costs but not necessarily to support all aspects of the hospital. The poor, until recently, have been expected to pay in accord with their means, and that has been very little. Their care has been categorized as charity, and, consistent with widespread notions of the importance of work and of the slothfulness of the poor, the facilities and care provided for them have been austere at their best and humihating at their worst. Furthermore, with the asso- ciation of increasing numbers of hospitals with medical schools, the poor have become the profession's research and teaching material. To complete the differentiation of class relations re- flected within the hospital as well as to balance the hospital's books, the rich have been called upon to give money to the hospi- tal to pay the costs of care given to the poor. The charitable nature of hospitals gives wealthy people an almost perfect opportunity to demonstrate their noblesse oblige within an institution that publicly reflects and thus reinforces the class structure of society.

The organization and financing of hospitals clearly provides physicians with the facilities to practice their profession and make money, and it benefits the upper-middle and upper classes by providing them with facilities consistent with their social status and opportunities to demonstrate their superior class positions through charity to the hospital. The dependence of the medical profession on the wealthy could create antagonism, but with their compatible interests in the hospital, their relationship has been symbiotic. Local wealthy men and women opened their hearts and loosened their purse strings to hospital fund raisers.

Medical research and medical education were different issues. Hospitals appealed to a local constituency whereas the new

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scientific medical schools drew their students and faculty from at least the state and more often a whole region or even the nation. Medical research was a long-term investment in developing new knowledge and technology that would serve the country as a whole rather than provide a subordinating service to the poor. Medical faculty and researchers were no longer the local physi- cians of distinction; their reputations were made nationally within their own ranks, or not at all. Local rich men and women could be cajoled into providing a laboratory at their nearby medical school through appeals to local pride, but these objects of charity lacked the drama of hospitals serving the poor and providing facihties for physicians known throughout the local community. Medical edu- cation and medical research involved much larger sums of money than hospital construction, and the endowments to support fac- ulty and researchers required still larger investments out of the wealth of the local upper class.

The combination of the larger sums required, the less directly charitable and less visible functions of medical research and education, the long-term investments they represented, and the more national character of their appeal made medical education and medical research the philanthropic objects of a national wealthy class more than of those whose wealth was local in its character or size. By the 1890s a new national capitalist class overshadowed the local business and aristocratic elites.'^ Their wealth was derived from investments in national corporations, and their visions of what was good and necessary for society were broader than their local and lesser counterparts. Many of them gave without strategy in their benefactions, except the courting of good will, but some had strategies and interests of their own.

Just as well-connected local physicians appealed to the local pride and charitable obligations of the local upper-middle class to build a modern hospital for their community, so did academic physicians and medical scientists turn to men and women of broader wealth with appeals to the needs of society. A few illustrious centers of medical education and research were rel- atively well off. Charles Eliot clearly saw that the way to attract large gifts and endowments was to reform Harvard's medical school. Johns Hopkins willed a hospital and medical school as well as a general university from his Baltimore and Ohio railroad fortune; yet more was needed and gotten from wealthy individu- als to open the medical school. These cases were the exceptions.

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"Not half a dozen institutions have received any considerable sums, and very few anything at all," the AMA Journal com- plained in 1900. The endowments necessary to "advancing med- ical education and medical science" must come from outside the profession.^ As some reform leaders foresaw and feared, there was danger in dependence on philanthropy for that capital.

WELCH: A ROCKEFELLER MEDICINE MAN

William H. Welch's personal plight and eventual success are indicative of the rising star of medical research. Returning in 1878 from his pathology studies in Germany, Welch found little support in New York for devoting himself to laboratory research. Although he received mild encouragement from Francis Dela- field at the prestigious College of Physicians and Surgeons, he could not find any space in which to set up a laboratory. Finally, he turned to the lesser-rated Bellevue Hospital medical college and negotiated the use of three rooms, some kitchen tables, and twenty-five dollars in equipment. With frogs gathered from the marshes of his sister's upstate New York home, Welch began the first laboratory course in pathology given in an American medical school. He got by with fees from his six students, a partnership with another doctor preparing medical students for competitive examinations, and assisting Dr. Austin Flint, a rich and socially prominent professor of medical practice at Bellevue.^

Welch's European studies and original work brought him immediate recognition. Within a year the alumni of the College of Physicians and Surgeons contributed enough money to offer Welch a modest pathology laboratory at their alma mater, but Welch felt a commitment to Bellevue and also wanted to hold out for the security and completeness of the chair in pathology at the new Johns Hopkins medical school. Drawn by the "more academic" environment at Hopkins, relief from "the drudgery of teaching," an endowed $4,000 a year salary and paid assistants, Welch shocked the New York medical profession and friends by giving up a future income of "at least $20,000" for provincial Baltimore.''

Welch took the position at Hopkins in 1884. Before going to Baltimore, he spent most of a year studying bacteriology in Leipzig and in Berlin with Koch. He studied bacteriology largely

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because he feared he would be left behind in the growing competition for medical discoveries.^ Welch's singular devotion to his career brought him success. Despite the adulation and social popularity he received, he isolated himself from personal intimacy with any other person, male or female.^

Welch's reputation as a researcher and organizer of research grew even before the Johns Hopkins medical school opened its doors in 1893 with Welch as its first dean. By the turn of the century, Welch's professional reputation began spilling over into lay circles. In 1901 he came to the attention of Frederick T. Gates, the grand master of the Rockefeller philanthropies. Welch was asked to help organize the Rockefeller Institute for Medical Research. He soon became chief adviser to the Rockefeller foundations on medical projects, assisting in important ways in funding medical education in the United States and China, in developing public health programs in the United States and around the world, in organizing and heading this country's first school of public health, and more. In 1930 his eightieth birthday was honored around the world with a live radio broadcast throughout the United States and Europe presided over by President Hoover and simultaneous celebrations in major cities in Europe and Japan.

William H. Welch was indeed a man whose life and career spanned the fortunes of medical science, from its struggling infancy to its prodigious material success. His life combined the perfect mix of ambition, talent, single-minded dedication, and opportunity to make him the ideal of academic medicine in the United States. His gregariousness and wit kept him from being the recluse that his rejection of intimate relationships might have otherwise encouraged. His considerable talent combined with his initially almost frantic ambition to give him a competitive edge in medicine.

Nevertheless, these qualities would have yielded few rewards had the opportunities not come at the right moments. If Welch had not been born a white male into a prosperous class, he would never have had the material support he needed. If Welch had been born fifty years earlier, there would have been no support for scientific medicine. If he had been born fifty years later, he might well have been just another competent medical researcher. If Johns Hopkins medical school had not been filling its faculty

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slots when he was an ascending star in New York medical science, he might have been forced to divert energy into a lucrative private practice and lost his singular immersion in medical academia. If the Rockefeller philanthropies had not sought to develop scientific medical research, to reform medical education, and to develop public health programs, he might not have had a sufficient vehicle for his talents and might not have achieved his reputation as a world statesman and celebrity. While Welch was the right person in the right place at the right time, his spectacular career depended upon more than luck. His sex, race, and social class were crucial conditions for his success. But the development of corporate capitalism was perhaps the most important condition because it provided the ideological and cultural support for scientific medicine and the material support for his research.

It is likely that Welch would have fared well even without the Rockefellers since his reputation would have enabled him to skim off the best positions in medical science. Medical research and education as a whole, however, were helped immensely by the wealth of the Rockefeller fortune. Under the skillful direction of foundation officers, the Rockefeller wealth became the largest single source of capital for the development of medical science in the United States, the conversion of medical education to a scientific research basis, and the development of public health programs in the United States and abroad.

For the first quarter of the twentieth century the Rockefeller officers developed a definite strategy for their capital investment in medicine. That strategy sometimes supported and often opposed different interests in medicine, but such alliances and conflicts were never accidents on the part of the foundation. They were anticipated and necessary consequences of the role of modern medicine in the society, as desired and articulated from the very pinnacles of the American class structure.

Why was so much Rockefeller money — $65 million by 1928 — lavished on a single institution devoted to scientific medical research? What motivated the men at the Rockefeller philanthro- py to spend so much of their energy and money on medicine? How important were their humanitarian feelings for their fellow human beings? Did they envision material benefits from their work? As capitalists and corporate managers, did they beheve it would further their personal interests or their class interests? The

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self-consciousness of their pioneering effort made accessible the concerns and thinking behind the facades constructed in foun- dation-funded histories and authorized biographies.

ROCKEFELLER MONEY AND MEDICAL SCIENCE: A SOCIAL INVESTMENT

On June 2, 1901, New York's newspapers hailed the founding of the Rockefeller Institute for Medical Research. The most celebrated example of private philanthropy supporting medical research, the institute began a new epoch in the United States. More than its predecessors abroad, the Rockefeller Institute would attack a broad range of diseases, seeking understandings of their biological and chemical causes, developing methods of prevention and cure, and training hundreds of researchers for medical science.

The institute began modestly with a commitment of $20,000 a year for research grants and soon after an outright gift of $1 million from John Davison Rockefeller. By 1928 Rockefeller gifts to the institute totaled $65 million, an enormous sum for the period. Although the elder Rockefeller and his son are most widely known for the benefactions, it was Frederick T. Gates who formulated the strategies and initiated the investments in medical research, medical education, and public health.

In 1915 Gates set down his memories of the origins of the institute. His anecdotal recollection stands as the widely quoted history of the origins of Rockefeller medical philanthropy. '° As folklore, it conveys the process and motivations the creator of the Rockefeller Institute wished us to believe about the germination of his interest.

In his retrospective story, Gates describes how the idea for the institute came to him. As minister of the Central Baptist church in Minneapolis from 1880 to 1888, Gates had countless experienc- es with regular and homeopathic doctors. His visits to "hundreds of sick rooms" and his close relations with several physicians confirmed "a profound scepticism about medicine of both schools as it was currently practiced." As for homeopathic medicine, he concluded that Samuel Hahnemann, the founder, was "Httle less than a lunatic." He had little more confidence in the regular, or orthodox, school.

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Then in 1897, six years after joining Rockefeller's staff, he befriended a former member of his Minneapolis congregation who was a medical student in New York. He asked the young man to suggest a readable medical text used in the best medical schools. On his young friend's recommendation, Gates bought himself a copy of William Osier's Principles and Practice of Medicine, first published in 1892, and a pocket medical dictio- nary.

Gates took Osier's book with him to join his family vacation- ing in the Catskills and read through its approximately 1,000 pages of revelations about the state of medicine. Osier laid bare the limitations of current medical knowledge and practice. Gates learned that many diseases were caused by germs, only a very few of which had been identified and isolated but many of which "we might reasonably hope to discover."

When I laid down this book, I had begun to realize how woefully neglected in all civilized countries and perhaps most of all in this country, had been the scientific study of medicine. I saw very clearly also why this was true. In the first place, the instruments for investigation, the microscope, the science of chemistry, had not until recently been developed. Pasteur's germ theory of disease was ver> recent. Moreover, while other departments of science, astrono- my, chemistr>% physics, etc., had been endowed very generously in colleges and universities throughout the whole civilized world, medicine, owing to the peculiar commercial organization of medical colleges, had rarely if ever, been anwhere endowed, and research and instruction alike had been left to shift for itself dependent altogether on such chance as the active practitioner might steal from his practice. It became clear to me that medicine could hardly hope to become a science until medicine should be endowed and qualified men could give themselves to uninterrupted study and investigation, on ample salary, entirely independent of practice. To this end, it seemed to me an Institute of medical research ought to be established in the United States.

In July, Gates returned to his office in the Standard Oil building with "my Osier" in hand and dictated a memorandum to Rockefeller. He laid out his conclusions about the tragic state of medicine in the United States and its immense potential. He pointed out the usefulness of the Koch Institute in Berlin and the Pasteur Institute in Paris. In support of his recommendation for

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an American institute, Gates explained to Rockefeller that Pasteur's discoveries about anthrax and diseases of fermentation "had saved for the French nation a sum in excess of the entire cost of the Franco-German War." He also insisted that an institute founded by Rockefeller would encourage other wealthy men and women to found and endow other research centers, with the total effort yielding "abundant rewards."

While the memo to Rockefeller did not result in immediate action, it did provide the coherent rationale six months later for opposing the affihation of Rush medical college with the Univer- sity of Chicago, at the time Rockefeller's dearest and largest philanthropy. Rush was a respected school of the regular profession, a follower of the scientific vanguard but not among them. Gates got Rockefeller's support for a letter urging the university's administrators to abandon Rush and offering them instead a new medical center, "magnificently endowed, devoted primarily to investigation, making practice itself an incident of investigation. " For some reason, probably related to the influence in Chicago of Rush's wealthy and socially and politically promi- nent practitioner- faculty members, the marriage was consummat- ed anyway. Chicago lost its chance for the proposed institute. Thus was Gates' idea for the institute born and preserved from the clutches of medical sectarianism.

Gates' proposal was carefully considered through 1899 and 1900. Gates and Rockefeller, Jr., who joined the philanthropy staff in 1897, hired Starr J. Murphy, a lawyer friend and Montclair, N.J., neighbor of Gates, to study European institutes and confer with leading medical researchers in this country. L. Emmett Holt, pediatrician to several of Senior's grandchildren and a fellow parishioner at Junior's Fifth Avenue Baptist church in New York, impressed upon Junior the broad and basic biological research that led to the recent discovery of diphtheria antitoxin. What was needed to solve other great problems in medicine, he told the younger Rockefeller, "were men and resources which could be devoted solely to the work of re- search."^^

Finally, in December 1900 John Rockefeller McCormick, the elder R.ockefeller's three-year-old grandson, fell ill with scarlet fever. On the second day of the New Year he died. Any hesitancy the old man, a follower of homeopathy, felt about endowing

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scientific medical research was undermined when he was told by respected New York doctors that they knew Uttle about the cause of scarlet fever and had no cure for it.^^

Gates and the Rockefellers were also concerned about com- petition for their proposed institute. Andrew Carnegie's rival research institute, endowed with $10 million as the Carnegie In- stitution of Washington in 1902, was then in the planning stages. Rockefeller, Jr., was sufficiently concerned about the competi- tion to wring an agreement from the steel king that his institu- tion would not enter the field of medical research. At the same time Henry Phipps was founding an institute for the study of tuberculosis in Philadelphia. Competition struck close to home when Rockefeller's daughter Edith and son-in-law Harold F. McCormick unveiled their plans for a tribute to their son, the John Rockefeller McCormick Memorial Institute for Infectious Diseases in Chicago. ^^

By March 1901 Rockefeller committed himself to funding Gates' proposed institute. The Rockefeller Institute for Medical Research began its work with $20,000 a year for grants to medical researchers and soon thereafter a $1 million gift from Rockefel- ler, a board of directors composed of physicians — including Holt and Welch — with training in pathology and a commitment to bacteriological research, and Dr. Simon Flexner as the executive director.

For more than two years Gates grew increasingly impatient as the "medical gentlemen" restricted themselves to supporting small research projects around the country. ^"^ Finally, in the fall of 1904, the board opened its first laboratories and began its own program of medical research. In November 1907 Rockefeller gave the institute an additional endowment but held back half the $6 million requested by the directors. Finally, in October 1910, after the institute was reorganized — reducing the board of di- rectors to a lesser role as the Board of Scientific Directors and creating a new board of trustees with Gates as chairman — Rockefeller added to the institute's endowment, providing it with the yearly income from $6.4 million of investments. By 1920 the Rockefellers had given the institute $23 million and by 1928 some $65 million.^'

The institute was organized independently of any university primarily for reasons of efficiency and to avoid conflict with

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Senior's commitment to homeopathy. First, Gates and Rockefel- ler, Jr., wanted the institute free of any teaching pressures. The objective of the institute was to produce results in medicine in order to reduce the amount of disease in society, and it would be a diversion of resources to ask the researchers to teach. '^

Second, the handful of scientific medical schools, while nom- inally above medical sectarianism, were the turf of the regular profession's elite. The elder Rockefeller, a lifelong follower of homeopathy, objected to any move that strengthened the regular profession in its conflict with homeopathists. It was undoubt- edly on this basis that Rockefeller in 1898 supported Gates' ob- jection to the alliance between the University of Chicago and Rush Medical College, a creature of the regular profession and an opponent of homeopathy. Columbia and Harvard were briefly considered as recipients of the institute, but they were elite regular medical schools. Although neither Gates nor Junior took the old man's concerns seriously, they had to avoid pro- voking his objections that they were merely supporting one side, the wrong side in the conflict. With the example of the inde- pendent Pasteur Institute before them, the efficiency of a purely research institute as their primary concern, and their desire to assuage Senior's hostihty to regular schools. Gates and Rocke- feller, Jr., agreed to exclude any university affiUation for their project. ^^

HOMEOPATHY: THE CONFLICT SIMMERS

The conflict over homeopathy continued for some years. It is an illuminating example of the workings of the Rockefeller philanthropies, and it suggests an ideological difference between the robber barons like Senior who built up huge industrial empires and the next generation of corporate capitalists who ran the operations.

Rockefeller continued to express his concerns that within the institute and later in his philanthropies' support for medical education, his money was being used to support the regular profession at the expense of the homeopaths. "I am a homeopath- ist," he scolded his staff in 1916. "I desire that homeopathists should have fair, courteous, and liberal treatment extended to them from all medical institutions to which we contribute."^* In

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1919, when he was considering a $45 milHon gift to his General Education Board to support medical education, Rockefeller again warned his son and staff: "Homeopathic teaching should not be excluded ... it should be provided for, the same as Allopathic. "•^*

His son and his staff firmly and repeatedly explained that "scientific medicine has rendered obsolete the former distinctions between the so-called Homeopathic and the so-called regular or Allopathic schools. "^'^ The new medicine is free of dogma, free of values. It represents not "preconceived notions" about the world but only "ascertained facts. "^^ Medical science is devoid of "med- ical dogma of any kind."^^

Furthermore, as the homeopaths and regular schools "are constantly drawing nearer together," a trusted adviser wrote the old man, "the discriminations which formerly were practised against homeopathists are being constantly lessened." Simon Flexner provided assurances that at the Rockefeller Institute "they make no distinction and welcome to their staff qualified men irrespective of the school in which they have been trained. "^^

That John D. Rockefeller personally patronized a homeopath- ist might seem surprising. However, Rockefeller and homeopathy were both products of the nineteenth century. From the mid- nineteenth century on, homeopathy in the United States ap- pealed primarily to the upper classes. It was safer than the heroics of regular medicine, and it was a sign of affluence and taste since it was very fashionable among the European nobility and upper class, who were aped in many ways by wealthy Americans. ^"^ Rockefeller, who was twenty-two at the outbreak of the Civil War, grew up believing that homeopathy was medically and socially desirable.

Furthermore, while Rockefeller used chemists and engineers in developing his Standard Oil empire, his chief assets were an unbridled ambition and an intuitive and cunning sense of opportunity and organization. He accumulated the largest for- tune among all the robber barons by paying his workers as little as possible and by ruthless methods in the marketplace, extracting huge rebates from the railroads for his shipments and cutting the

*"Allopathic" was another term for the regular, or orthodox, sect of the medical profession.

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price of refined oil products to drive his competitors out of business. He did not fully share his son's and his later managers' appreciation of the importance of science in developing the base of industrial capitalism.

In his retirement and devotion to giving away his fortune, Rockefeller generally gave free reign to Gates and his son. He knew that his caution in disposing of his fortune was shared by his trusted lieutenants. Within his philanthropies he had the money but did not take the authority to establish policy. It seemed sufficient to him that his name was no longer the object of spittle, but rather gratitude. Except for occasional questions, taciturn consideration of his advisers' requests for millions of dollars, and objections to the treatment of homeopathists, Rockefeller, Sr., left the running of his philanthropies and his financial empire alike to Gates and his son.

Although Gates and Junior worked together in developing programs and prying gifts from the occasionally reluctant father. Junior himself acknowledged that "Gates was the brilliant dreamer and creator," and "I was the salesman, the go-between with father at the opportune moment. "^^ Fortunately for history. Gates was a prolific writer of his ideas, leaving his thoughts in letters to Rockefeller, Sr., speeches to the various philanthropic boards, and memos to himself and his staff. Given his central role in the Rockefeller philanthropies and the importance of these philanthropies in the development of scientific medicine, it is illuminating to consider Gates' views of the role and consequenc- es of medical science.

SCIENTIFIC MEDICINE AND CAPITALIST GATES

Gates, the premier Rockefeller medicine man, was attracted to medical science. It was not the appeals from medical science that drew his interest or his money. He was, like most educated people of the late nineteenth century, vaguely aware of the march of progress in medicine. He knew of Pasteur and the germ theory of disease. He had read Osier and understood the potential of medical science. But he never heard of Dr. Simon Flexner or Dr. William H. Welch, and he had no contact with other medical scientists until he initiated the medical institute. Nevertheless, he did "intelligently and clearly see that there was a tremendous

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need of medical research." Whatever requests for money for medical science crossed Gates' desk, none was taken seriously until 1907, when McGill University asked for aid to replace two medical school buildings that had been destroyed by fire.^^

Gates was always an autonomous figure in medical philan- thropy. He was moved by his own conceptions of the value of medicine and his own strategies for developing its role in American society. He was certainly influenced by medical men whom he respected, above all Simon Flexner and William Welch, but it was because their ideas and contributions conformed to his plans for the transformation of medicine. What visions did he have of the role and functions of scientific medicine?

We may grant that Gates had genuinely humanitarian motiva- tions. His ministrations to the sick and dying in his Minneapolis parish undoubtedly evoked sympathy for their suffering. In his later years he credited medical science with standing above all other elements of history. None but medicine has "done so much to promote all the forces of civilization, to increase human happiness or to ameliorate human suffering."^''

Typical of Gates, his enumeration of the accomplishments of medical science places the relief of human misery after the promotion of the "forces of civilization." This is not a petty criticism, for Gates' preeminent consideration was the develop- ment and extension of Anglo-American civilization. What he understood that civilization to represent will become clear in the following pages, but in its essence "civilization" meant the values of work and disciplined living, a social life organized around productive labor and frugal consumption. "Civilization" also meant the right and indeed the responsibility of men of wealth to govern society and of industrial societies to direct economically less developed societies. In brief, "civilization" was equated in Gates' mind with industrial capitalism and imperialism.

What value did scientific medicine have for capitalism? Gates envisioned numerous material and social-political consequences flowing from medical science in a never-ending stream of support for capitalist society.

HEALTHIER WORKERS

The material benefit of medicine is a healthier population and thus a healthier work force. What Pasteur's work on anthrax had

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done for the French cattle industry, medical science could do for the whole society. The findings of medical science were most important when applied to preventing disease. "By keeping well," Gates observed, a person "enjoys all the employments, pleasures, and financial gains of continuous health." Gates insisted from the beginning of his career to its end that "the fundamental aim of medical science ought to be not primarily the cure but primarily the prevention of disease."^*

Gates believed that events supported his contention. In the first quarter of the twentieth century, "sanitary science and preventive medicine" had reduced sickness by half, he asserted, citing support from U.S. Census Bureau reports of mortahty rates, insurance company statistics, and reports of state and local health boards. ^^ Although sickness was still a major obstacle to the full utilization of labor, the assault by the forces of science was paying off. Gates cited a report that 20 percent of the employees of large companies were home sick each day, but, he added, triumphantly, "I think that even so high a figure is far below that of the armies of [General] Washington. "^°

Gates was far from a solitary figure preaching the potential of medicine for capitalists. Big business. Gates observed in 1925, sponsored preventive medical care programs on a large scale "because health is found in a variety of ways to be profitable."^' Healthy workers are profitable because they are an employer's "human capital" to be utilized for production of salable goods and services. Just as the capital invested in machines needs to be protected by adequate maintenance programs, so too does human capital require maintenance and repair, a perspective long recognized in many contexts.

Southern slave owners and their physicians viewed their black slaves as a capital investment to be saved from disability or death whenever possible, lending credibility to the myth of paternalistic slavery. In a study of the role of medicine in the ante-bellum South, Walter Fisher concluded that the primary reason why slaves were provided with medical care was the tremendous economic investment they represented to slave owners. ^^ Every planter understood that "to save his capital was to save his negroes," observed Dr. Richard Arnold, an upper-class physician in Savannah. The self-interest of the slave-owning class in the preservation of its investment made Southern slavery "the only

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institution in which Interests and Humanity go hand in hand together," Dr. Arnold wryly added."

It was not only racism and slavery that facilitated "paternalis- tic" self-interest. The U.S. Sanitary Commission, organized in 1861 to provide medical relief to Union soldiers on Southern battlefields, was by its own account no humanitarian enterprise. Run by wealthy Easterners, the commission declared "its ulti- mate end is neither humanity nor charity. It is to economize for the National service the life and strength of the National soldier." Saving a soldier's life, the commission calculated, reduced the monetary cost of the war and preserved the soldier as a "pro- ducer" when he "returned to the industrial pursuits of civil life." Each soldier's life was worth "no less than one thousand dollars" to society. ^"^

With the rapid development of an industrial base in the United States during and after the Civil War, employers in many industries viewed their workers as disposable resources. Particu- larly with increasing mechanization in industrial production, a decreased demand for skilled workers, and an unlimited supply of desperate immigrants, the work force became a sea of men and women to be plucked up by employers as needed and later tossed out. Workers who were maimed, killed, or simply worn out by their jobs were replaced by other bodies from among the unemployed.

As the unemployed work force shrank with the outbreak of war or upswings in the economy, as labor organized to change its working conditions and pay, and as employers found that lost production because of illness and rapid turnover of their workers cost them profits, enhghtened businessmen developed new atti- tudes toward their workers. It was not concern for the workers' needs that led to better conditions and health and welfare pro- grams. Rather these reforms sprang from the industrial unionism and political organization of workers and from the opposing necessity of employers to discipline the work force to the re- quirements of capitalist production. The firm that improved its working conditions reduced work days lost to strikes. The firm that took pains to keep its workers found increased productivity from its capital investment. The firm that offered company housing, shares of stock, and company medical care increased the dependence of the workers on the company and lessened the

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threat of unionization. And, in the early years of this century up to World War I, industries that voluntarily acted could reduce the risk of restrictive legislation demanded by the forces of Progres- sivism. As early as 1892, following the bloody Homestead strike, Andrew Carnegie articulated a more conciliatory policy toward his workers to prevent the loss of experienced workers, though there is little evidence that he or his company followed the policy. "It is impossible," he said, "to get new men to run successfully the complicated machinery of a modern steel plant."" Labor stability became an important element in the productivity and profit strategies of modern industries. "It is good business to conserve life and health," observed John Topping of Republic Steel, for thereby "one of the most important items of economy in production is secured. "^^

Industrialists who weathered the marketplace and emerged among the monopolistic leaders of their industry had the capital and foresight to ward off unionization and stabilize their work forces with health and welfare programs. Steel companies, railroads, oil companies, and others created complete medical care systems for their workers, hiring or contracting with physicians and providing dispensaries or hospitals.

The efforts of slave owners and the U.S. Sanitary Commission to preserve lives by curing disease were aimed at conserving human capital, the one "belonging" to an individual and the other profiting a whole class. The medical programs of individual corporations were aimed more at undermining unionization and stabiHzing their own work forces, with improved health an added benefit rather than the main purpose. Thus, slave owners and industrial corporations exhibited enlightened self-interest while the upper-class sanitary commissioners demonstrated a more far-sighted plan for investing in the whole society's work force. The latter is an articulated interest of an entire class — the interest of the capitaUst class in a stable and healthy work force.

Frederick T. Gates consistently articulated this larger per- spective and shaped his philanthropic programs around it. He understood the importance of a healthy work force to the growth of capital and industrial output. The Rockefeller Sanitary Com- mission, organized by Gates in 1909, sought to eradicate hook- worm disease from the southern U.S. population. Charles Warden Stiles, a government zoologist, convinced Gates and

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Junior that the hookworm was "one of the most important diseases of the South" and a cause of "some of the proverbial laziness of the poorer classes of the white population." Whatever genuine pride the Rockefellers and Gates felt in relieving the suffering of thousands of Southerners, their primary incentive was clearly the increased productivity of workers freed of the endemic parasite. Gates observed that the stocks of cotton mills located in the heavily infected tidewater counties of North Carolina were worth less than mills in other counties of the state where fewer people were infected. "This is due," he explained to Rockefeller, Sr., "to the inefficiency of labor in these cotton mills, and the inefficiency in the labor is due to the infection by the hookworm which weakens the operatives." Gates calculated, "It takes, by actual count, about 25 percent more laborers to secure the same results in the counties where the infection is heavier." It also took 25 percent more houses for the workers, more machinery, and thus more capital and higher operating costs. "This is why the stocks of such mills are lower and the profits lighter."^'

The Rockefellers did not have any significant investment in Southern textile mills. Rather their extensive and widespread investments gave them a concern for the productivity of the entire economy. The Sanitary Commission was a logical extension of their educational programs in the South (discussed in Chapter 1), all directed ultimately to integrating the Southern economy into the national dominion of Northern capitalists.

Through the International Health Commission — the first program of the Rockefeller Foundation established in 1913 — the hookworm and other public health programs were extended worldwide. None of these programs was intended to prop up specific Rockefeller investments abroad. They were directed more generally at improving the health of each country's work force to facilitate sufficient economic development to provide the United States with needed raw materials and an adequate market for this country's manufactured goods. Stacy May, an economist and a director of a Rockefeller-controlled international invest- ment corporation, recently reaffirmed the value of such pro- grams. "Where mass diseases are brought under control, produc- tivity tends to increase — through increasing the percentage of adult workers as a proportion of the total population, [and]

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through augmenting their strength and ambition to work," he observed.^*

Each of these programs can be traced to Gates' and the Rockefellers' broader concern for the permanent economic and social viability of capitalist society. Gates viewed the public health in a larger capitalist class perspective than probably any other important figure in the various medical reform movements of the period. Although his articulated views on the relation between health and capitalism were more complete than other capitalists of his era, he was not alone in maintaining the importance of such programs.

The American Association for Labor Legislation, a Progres- sive era alliance of corporate-liberal business leaders, some labor leaders, and upper middle-class reformers, won business support for its proposal for compulsory national health insurance mainly on the basis of the self-interest of employers. "Illness as well as injury occasion a large economic waste to the company as well as to the employees on account of lost time, idle machinery, and ineffective work," reported Howell Cheney of the Cheney Brothers' Silk Mills. "It is to the direct interest of the company as well as to the individual to bring about a reestablishment of health, and consequently efficiency, by supplying the best con- ditions possible for recovery. "^^

The National Association of Manufacturers committee on industrial betterment supported compulsory sickness insurance against voluntary systems largely because of the importance they attached to a healthy work force. "We know that there are employers who would not comply with the voluntary plan," the NAM committee warned. Even a corporation president who sees the long-run advantages of "enhghtened" industrial relations may bow blindly to maximizing this year's profits. This was an important enough issue, they argued, that the State must "subordinate the independence of the individual to the general good.'"*^

It was not primarily a concern for conserving human life that led America's corporate liberals in the Progressive era to support compulsory health insurance. From Bismarck to the Conservative party in England to the American Association for Labor Legisla- tion and the National Civic Federation, the far-sighted leaders of corporate capitalism believed that government-sponsored sick-

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ness insurance, workers' compensation, and other social security measures would reduce the appeal of radical labor and socialist movements/^ Hoping to depoliticize workers' unhappiness with their lot, corporate leaders joined reformers in calling for such moderate reforms. Despite this expedient application of medical care programs, leaders of many corporations as well as the conservative National Association of Manufacturers believed that medical care, when extended to the whole population, would substantially improve the health of workers and their families, which included future workers.

Sharing the concern of the business class, the vanguard of scientific medicine considered the economic benefits of medicine among its most important effects. The smaller view pervaded the thinking of physicians working in a particular company's health programs. C. W. Hopkins, chief surgeon for the Chicago and Northwestern Railway, told the 1915 annual meeting of the American Academy of Medicine that the railroads found it economically desirable to organize medical care programs be- cause it cost them $500 to train an employee and because experienced and healthy workers were important in reducing accidents that injure passengers and destroy property. "It is now a well-recognized fact among the managements of the railroads," reported Dr. Hopkins, "that it is just as important to care for their sick and injured [workers] as it is to maintain a certain standard of efficiency or perfection of their rolling stock and road bed."^^

Broader views of medicine's material importance to society guided strategies of men who led the medical reform movement at elite universities and the national level. Charles W. Eliot, the Harvard president who launched major medical reforms begin- ning in 1869, considered medical research both pure and appHed. At the dedication ceremonies for the Rockefeller Institute's laboratories in 1906, Eliot characterized research medicine's primary object as striving for "truth in the abstract" and its secondary objects as preventing "industrial losses due to sickness and untimely death among men and domestic animals," and lessening the negative impact of sickness on human happiness. "^^

William H. Welch, at the same ceremony, asserted with pride that scientific medicine made possible the "great industrial

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activities of modern times, efforts to colonize and to reclaim for civilization vast tropical regions, [and] the immense undertaking to construct the Panama Canal/"''' For the most part, academic doctors were content to support the uses of medical science laid down by the philanthropic strategists whose funding programs guided the development and utilization of research. The medical profession thus accepted the capitalist definition of health as the capacity to work.

IDEOLOGICAL MEDICINE

AN INDUSTRIALIST WORLD VIEW

For philanthropist and capitalist Gates, the material conse- quences of medical science were only one of its advantages. Indeed, Gates gave more attention to the other advantages that intrigued him. Probably more than any of his contemporaries, Gates perceived and understood the ideological functions of medicine. Some of his thoughts were implicit understandings of the relation between scientific medicine and industrial capitalist ideology. His most systematic thinking concerned the social value of medical science as ideology and as a cultural force.

Members of any society or social class whose existence is intimately tied to industrialism will find scientific medicine's explanations of health and disease more appealing than mystical belief systems. The precise analysis of the human body into its component parts is analogous to the industrial organization of production. From the perspective of an industrialist, scientific medicine seems to offer the limitless potential for effectiveness that science and technology provide in manufacturing and social organization. Just as industry depends upon science for technical- ly powerful industrial tools, science-based medicine and its mechanistic concepts of the body and disease should yield powerful tools with which to identify, eliminate, and prevent agents of disease and to correct malfunctions of the body.

Gates and other industrial capitalists found a close correspon- dence between this new medicine's concepts of the body and disease and their own world view. The body, Gates believed, is a microcosm of society, and disease is an invasion of external

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elements. Medical research must discover the agents of disease and find the means of preventing their destruction of the body or provide a cure. Health, in Gates' view, is the absence of disease. "Nearly all disease," Gates explained to Rockefeller, "^^

is caused by living germs, animal and vegetable, which finding lodgement in the human body, under favorable conditions multiply with enormous rapidity until they interfere with the functions of the organs which they attack and either they or their products poison the fountains of life.

Nature's healing methods are strikingly similar to the organi- zation of industrial society.

When, for illustration, the skin is cut with a knife, nature at once begins to hurry to the point of disaster squadrons of white corpuscles of the blood and other healing forces. Just as the fire engines start from all quarters on the dead run to a fire when the alarm is sounded, healing forces rush from every part of the body to the point of trouble, some to destroy any poisonous germs that may get into the wound, others to unite the wounded parts as before.

The body in which nature works is constructed like a Lilliputian community, complete with modern social organization and industrial plants.

The body has a network of insulated nerves, like telephone wires, which transmit instantaneous alarms at every point of danger. The body is furnished with a most elaborate police system, with hundreds of police stations to which the criminal elements are carried by the police and jailed. . . . The body has a most complete and elaborate sewer system.

The body's industrial life exists in

an infinite number of microscopic cells. Each one of these cells is a small chemical laboratory, into which its own appropriate raw material is constantly being introduced, the processes of chemical separation and combination are constantly taking place automatical- ly, and its own appropriate finished product is constantly being thrown off, that finished product being necessary for the life and health of the body. Not only is this so, but the great organs of the body like the liver, stomach, pancreas, kidneys, gall bladder, are great local manufacturing centers, formed of groups of cells in infinite number, manufacturing the same sorts of products, just as industries of the same kind are often grouped in specific districts.

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"We are fearfully and wonderfully made," Gates ironically concludes, as though praising some new machine created in God's own image. Because "nature is the great physician," her healing powers have obscured the failing of all pre- and nonscien- tific forms of medicine. Recovery from disease before the advent of scientific medicine, Gates believed, was due entirely to the power of nature as healer. Homeopathic and orthodox medical sects, Christian Science, psychic healers, osteopaths, Indian herb doctors, and patent medicine men all survived by claiming nature's cures as their own.

Only science was able to comprehend nature. "Science has discovered the laboratories where she has stored her reserves and has robbed her of them for use on human beings." Medical researchers in Gates' day were pressing the campaign against disease on two fronts: "they are trying to break into and expose to the Hght many more of the secret processes in nature's laboratories," and "they are working to create new chemical combinations that will cure."

Gates thus appreciated the human body as one of nature's puzzles, to be investigated and understood by science. His view, shared by scientific doctors, engineers, professionals of all sorts, and most corporate executives and owners, envisioned health as the absence of disease and medicine as an engineering task. Science was helping industry reshape the organization of produc- tion by developing machinery to control and cheapen human labor and more cheaply extract from nature a salable product. Science would also extract from nature the secrets of life itself while medicine would apply them to understand disease and develop methods of preventing or curing these pestilences of life and commerce. Improving the health of the population was thus an engineering job that involved understanding and manipulating nature.

Gates' views were not very different from those generally held by medical scientists of his day. While few directly applied the analogy of industrial society, nearly all conceived the body in mechanistic terms that made such an analogy seem natural. The similarity between the constructs of scientific medicine and the world view of industrial capitalism made it seem natural for the new order to support scientific doctors against all "quacks." The medical profession benefited from the compatibility of its theo-

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ries with the perspectives of the newly dominant class, but the capitalist social order won extraordinary ideological and cultural advantages.

INDUSTRIAL CULTURE AND CAPITALIST LEGITIMATION

Scientific medicine's singular concern with the microbiological interaction of the human body and specific disease states had political consequences which Gates and a few others envisioned. In brief, Gates embraced scientific medicine as a force that would: (1) help unify and integrate the emerging industrial society with technical values and culture, and (2) legitimize capitalism by diverting attention from structural and other environmental causes of disease.

Gates and other officers in the Rockefeller foundations believed that medicine had an important cultural role to play. Gates believed that the goal of medicine, the "healing ministra- tion," is "the most intimate, the most precious, the superlative interest of every man that lives." After food, water, sleep, and sex, freedom from disease is the great longing of all peoples. The desire for health is a unifying force "whose values go to the palace of the rich and the hovel of the poor." Medicine is "a work which penetrates everywhere." Thus, "the values of medical research are the most universal values on earth, and they are the most intimate and important values to every human being that lives. "''^

With medicine's unique acceptance by all people, the Rocke- feller Foundation discovered what the missionaries also knew: Medicine can be used to convert and colonize the heathen. In 1909 the Rockefeller philanthropies added pubHc health pro- grams to their earlier efforts to develop public schools and promote agricultural demonstration projects in the South in part because medical care is so seductive to even the most reluctant people.

In China, Gates switched from supporting religious missionar- ies to building a Western medical system. This episode is fascinating both because of the greater value that Gates, a man of the cloth, placed on scientific medicine in promoting Western influence and because of the unabashed imperialist motivations he himself attributed to Rockefeller philanthropies abroad. In 1905 Gates urged Rockefeller, a frequent contributor to Baptist

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missionaries, to donate $100,000 to an organization of Congrega- tional missions/'' "Now for the first time in the history of the world," Gates explained to Rockefeller,

all the nations and all the islands of the sea are actually open and offer a free field for the light and philanthropy of the English speaking people. . . . Christian agencies as a whole have very thoroughly invaded all coasts, all strategic points, all ports of entry and are thoroughly entrenched where they are.

For Gates, transforming heathens into God-fearing Christians was "no sort of measure" of the value of missionaries:

Quite apart from the question of persons converted, the mere commercial results of missionary effort to our own land is worth, I had almost said a thousandfold every year of what is spent on missions. . . . Missionary enterprise, viewed solely from a commer- cial standpoint, is immensely profitable. From the point of view of means of subsistence for Americans, our import trade, traceable mainly to the channels of intercourse opened up by missionaries, is enormous. Imports from heathen lands furnish us cheaply with many of the luxuries of life and not a few of the comforts, and with many things, indeed, which we now regard as necessities.

Industrial capitalism, however, required not only raw materi- als and cheap products. It also needed new markets for its abundant manufactured goods. As Gates added to Rockefeller's receptive ear:

our imports are balanced by our exports to these same countries of American manufactures. Our export trade is growing by leaps and bounds. Such growth would have been utterly impossible but for the commercial conquest of foreign lands under the lead of missionary endeavor. What a boon to home industry and manufacture!

The missionary effort in China was effective for a time in undermining Chinese self-determination. Missionaries were the velvet glove of imperialism, frequently backed up by the mailed fist. Nevertheless, the missionary effort, promoted through schools and medical programs, was still a very transparent attempt to support European and American interests. As J. A. Hobson, an English economist, noted at the time, "ImperiaHsm in the Far East is stripped nearly bare of all motives and methods save those of distinctively commercial origin.

"48

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In China, as throughout the world, the Rockefeller philan- thropists soon concluded that medicine and public health by themselves were far more effective than either missionaries or armies in pursuing the same ends. The Rockefeller Foundation removed the Peking Union Medical College from missionary society control, established it under foundation direction, and developed it into a completely secular, world renowned medical center, spending a total of $45 million for the China medical program.

In the Philippines, the foundation's International Health Commission outfitted a hospital ship to bring medical care and the "benefits of civilization" to the rebellious Moro tribes. The foundation officers were ecstatic that such medical work made it "possible for the doctor and nurse to go in safety to many places which it has been extremely dangerous for the soldier to ap- proach." Their medical work paved "the way for establishing industrial and regular schools" and served as "an entering wedge for permanent civilizing influences. ""^^ Thus, in subduing primi- tive peoples and bringing them into desired colonial relations, medical care has, in the words of foundation president George Vincent, "some advantages over machine guns."^°

Given the openly imperiahst ambitions of the United States early in this century, the Rockefeller philanthropy officers could pubHcly acknowledge their use of medicine to integrate dissenting people into industrial and capitalist society. Their domestic medical programs had exactly the same ends, though Gates and others were far more circumspect in discussing them.

Medicine was increasingly replacing religion as the intimate arm of the social order. In education the teaching of values was obvious, and attempts to reform the schools provoked angry responses from a class-conscious society.^' In 1914 the National Education Association's attacks on the Carnegie and Rockefeller foundations were joined by many newspapers that condemned the foundations for trying to turn "our schools into mills for the manufacture of men and women made according to Rockefeller and Carnegie specifications."" Medicine was more insidious.

For Gates to see medicine as a desirable replacement for religion was indeed an interesting turn of events. Gates, it will be recalled, was successively a Baptist minister, executive secretary of the American Baptist Education Society, and Rockefeller's

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chief lieutenant in charge of the industriaHst's philanthropy and a large part of his financial empire. Like other members of the managerial stratum, Gates identified his own interests and des- tiny with those of his employer.

Shortly after his move from the ministry to directing the largest philanthropic and financial empire in the world, Gates' views on religion began to change. He began to read the Bible more critically and was soon convinced that "Christ had neither founded nor intended to found the Baptist church, nor any church; that neither he nor his disciples during his lifetime had baptized; that the communion was not conceived by Christ as a church ordinance, and that the whole Baptist fabric was built upon texts which had no authority, and on ecclesiastical concep- tions wholly foreign to the mind of Christ. "^^ Gates found himself converted from Baptism to capitalism and scientism!

Medicine was a fundamental part of his new "religion." While theology was being "reconstructed in the light of science," sci- entific medicine was promulgating "new moral laws and new social laws, new definitions of what is right and wrong in our relations with each other." For Gates, the Rockefeller Institute for Medical Research was a "theological seminary, presided over by the Rev. Simon Flexner, D.D."'^

Gates did not fully explain the meaning of his metaphor, but it seems clear that he viewed medicine as industrial society's counterpart to rehgion, carrying moral precepts, "new duties," and the values of science to all people through its universal appeal and irresistible intimacy. This function was understood by leading members of the medical profession as well. Dr. John B. Roberts, in his presidential address to the American Academy of Medicine in 1904, laid out "The Doctor's Duty to the State." The physician "should teach the laity that mental hygiene, or discipHne, is as essential to proper living and happiness as physical hygiene," Roberts said. "Hygiene of the body gives a spirit of religious toleration and calm" whilt "hygiene of the mind gives a healthy digestion and a good income-making body and fits man for this world as well as the next."^^ Scientific medicine was thus an ideal instrument to help unify and integrate the new industrial society and indeed a world order in the values and culture of science, technology, and capitalism.

Western scientific medicine was an uncommonly good vehicle

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for United States efforts to dominate Latin America, Asia, and Africa. But it was equally useful in bringing rural and technologi- cally and industrially naive North Americans to accept the domination of their lives by science and technology. Science had provided a basis for rationalizing industry, for organizing produc- tion consistent with the imperatives of profit and the growth of capital, and simultaneously for undermining the arguments of workers that the new technology eliminated their control over the productive process. The application of science to industry in fact depoliticized the whole productive process and created the appearance that progress is technology's own imperative. Be- neath that rule by technology lay the more fundamental impera- tive— capitalism's need for economic growth. The march of scientific and technological progress appears as an independent variable on which essential economic growth depends. Science and technology are developed mainly in ways useful to capitalist society, and as Jiirgen Habermas has shown, "the development of the social system seems to be determined by the logic of scien- tific-technical progress. "^^

The same mystification that the technological "imperative" pulls over the productive process is extended to all social spheres. Mechanical engineers, led by Frederick Taylor, developed more "efficient" ways of utilizing human labor in the factory, mainly by separating mental from manual labor, reorganizing the labor process under management's control, and substituting unskilled for skilled labor wherever possible. Although it did not particu- larly increase profits, Taylor's "scientific management" proved a very effective form of social control.^'' It provided a moral rationale for demanding obedience to capitalist values of hard work and disciplined living. "Too great liberty," Taylor wrote to Harvard president Charles EHot, "results in a large number of people going wrong who would be right if they had been forced into good habits. "^^ Housewives and mothers were similarly exhorted to be more efficient, for the home was "part of the great factory for production of citizens. "^^ Industrial and social leaders of the Progressive era, whether themselves Progressives or not, hoped to rationalize all social relations. The cult of efficiency firmly established in American culture and intellectual life the notion that technology must be served. Added to the

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already widespread view that science and technology are value- free, the technological imperative became a powerful moral force .

Corporation heads, presidents of elite universities, and phi- lanthropists all joined in support of the new religion of science. "Respect for the man who knows and loyalty to demonstrated truth,'' preached Nicholas Murray Butler, president of Columbia University, ''are characteristics of a civilization that is founded on rock."^«

Research institutes were the temples of the new religion. The Rockefeller Institute for Medical Research will be important in three ways, Butler told the dignitaries assembled for the opening of the institute's laboratories. It will add to mankind's knowledge of medicine, it will help train needed scientists, and it "will help spread abroad in the public mind a respect for science and for scientific method." Each of these contributions is a public ser- vice, he added, "but the last named is perhaps the greatest."^'

Scientific medicine, as part of the fervent campaign for science, helped spread industrial culture, albeit a capitalist in- dustrial culture, throughout the land and indeed the world. But scientific medicine also developed into an ideological perspective that legitimizes the great inequalities of capitalist societies and the misery that results from the private appropriation of human and environmental resources.

At one time, many physicians were in the vanguard of progressive social reform movements. By the mid-1800s social medicine was a highly developed field. Villerme, Buchez and Guerin in France, Neumann, Virchow, and Leubuscher in Germany, and dozens of lesser-known doctors studied the economic, social and occupational causes of disease and worked for reforms to eliminate them. Rudolf Virchow, one of the fathers of modern cell physiology, argued that medicine "must intervene in political and social life. It must point out the hindrances that impede the normal functioning of vital processes, and effect their removal."" Many physicians and sanitarians identified and statistically documented inhuman and dangerous working conditions, unemployment, miserable living conditions, malnutrition, and general poverty as the major causes of the high disease rates and early deaths among Europe's working classes.

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The failure of the revolutionary movement of 1848, in which many of these physicians participated, did not halt their efforts to change the conditions they opposed.

From the time of Pasteur and Koch, however, a more conservative outlook dominated medical research. The clinical, or medical, model focused attention on the individual, while bacteriological research identified discrete, external, and specific agents of disease. This perspective encouraged the idea of specific therapies to cure specific pathological conditions, and it diverted attention from the social and economic causes of disease. When Koch presented his discovery of the tubercle bacillus to the Berlin Physiological Society in 1882, many medical scientists did not share Koch's view that this bacillus causes tuberculosis. Virchow and others argued that since pathogenic micro-organisms lived in healthy bodies, they are not the cause of disease. In their view, invading micro-organisms could cause disease only after the host organism had been weakened by some physiological or environ- mental misery." Pasteur and Koch, nevertheless, won deserved plaudits for their technical accomplishments; they and their followers also won extensive financial support from their govern- ments and wealthy individuals alike. In Europe and the United States elite physicians perceived the opportunities opening before them, and leading capitalists showed their appreciation for medical science's ideological role.

Ideologues for capitalist society promulgated the insufficiency of our mastery of nature, the inadequacy of our technological development as the fundamental cause of misery. "The trouble is," Gates wrote Rockefeller, "that the blanket of happiness seems to be too short. If you pull it up at the head you expose the feet; if you tuck it in on the one side you uncover the other side." While there is probably no way to increase the "sum total of human happiness," it is certain that the Rockefeller Institute "is actually and enormously decreasing the sum total of human misery. "^"^

It is clear whence comes the unhappiness. It comes not from unequal distribution of wealth, sickening working and living conditions, miserable and alienating work, tension caused by frequent and prolonged unemployment, economic insecurity, and competition among those whose sights are set on higher stations in Hfe. "Disease is the supreme ill of human life," Gates

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proclaimed, "and it is the main source of almost all other human ills, poverty, crime, ignorance, vice, inefficiency, hereditary taint, and many other evils. "^^ It is not poverty or one's place in the capitalist class structure that breeds misery; it is disease that is the cause of the misery commonly attributed to poverty. Misery is a technical not a social problem.

While "the great mass of charities of the world" go around helping an individual poor family or indirectly "relieving or mitigating such evils and miseries of society as are due mainly to disease," the Rockefeller Institute reaches "the root of the evil" and cleanses "the very fountains of human misery."^** This human unhappiness can be eradicated through science and technology. The same forces that helped create America's vast and growing industrial base could be turned to eliminating her misery as well. Gates thus joined with others in "medicalizing" all social problems, defining them out of political struggle and even religious morals, and giving them over to technical expertise and professional management.

Rockefeller money did not support medical research that investigated the relationship of social factors to health and dis- ease. In its first decade, the Rockefeller Institute focused its resources on chemistry, biology, pathology, bacteriology, physi- ology, pharmacology, and experimental surgery.^'' It ignored the impact of the social, economic, and physical environment on disease and health. In later years, institute researchers touched on the role of nutrition as a contributing factor in malaria and some other parasitic and infectious diseases, but even then they did not extend their conclusions to the actual social conditions in which people lived. ^^ Of the more than 650 men and women who contributed their skills to the Rockefeller Institute, few — with the notable exception of Rene Dubos — seemed even to understand the role of society and environment as forces affecting the very diseases they studied.

This orientation to biological reductionism pervaded the Rockefeller medical philanthropies. When Gates, Junior, and other men in the Rockefeller Foundation decided to establish the first public health school in the United States, they selected Dr. Welch and Johns Hopkins University as their vehicles, knowing the new school would have a heavy emphasis on the basic sciences and not stray too far into social issues. ^^ Charles Wardell Stiles,

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the government zoologist who brought the hookworm to the attention of the Rockefeller philanthropy and was named scientif- ic director of the campaign to eradicate the parasitic disease, exhibited a capacity for keeping his nose to the parasites and not being distracted by social concerns. In an article on "The Chain Gang as a Possible Disseminator of Intestinal Parasites and Infections," Stiles offered not one word of criticism of chain gangs per se. He limited himself to criticizing the lack of privies and bemoaned the missed "opportunities for rigid discipline" that could "make these penal institutions admirable schools in which the State might easily give its charges some good lessons in cleanUness, hygiene, and sanitation. "''^

GATES' DIGRESSION

Gates genuinely believed in technical solutions for problems of social happiness. But there was another side to Gates. There was a side that recognized the exploitation of labor by capital, that felt compassion for the oppressed men and women of the industrial working class. As a member of the board of directors or chairman of the board of more than a dozen corporations, but not a part of day-to-day management. Gates was never personally involved in labor disputes. From his lofty heights at the top of the Rockefeller financial and philanthropic empires. Gates had a broad view of the needs of his class and a measured strategy for meeting them.

In 1916, two years after the clamorous criticism over the Ludlow massacre and a time when "labor is demanding more wages everywhere," Gates asked himself the strategic question, "shall one oppose this demand or favor it?" In a memorandum for himself, Gates developed his position on "Capital and Labor. "''^ First, unionism is selfish, violent, ignorant, perverse, and mistaken, he believed. Through unions, labor demands "the largest possible wage" and does "the least possible work" whereas the public-spirited citizen, whether wealthy capitalist or poor laborer, does the "largest possible service" and consumes the "least possible amount of the public wealth" by accepting private economy and saving.

Second, the object of labor should be to increase its real wages, not merely get a jump on the next guy. "If a few crafts become thoroughly unionized and secure their demands, it must

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be," Gates observed, "at the expense of all other crafts that are not so unionized." Unions seemed to care little that raising the wages of any one group will result in an increase in the cost of living for all other groups since employers will pass on to workers-as-consumers the increase in wages they grant. The wage earner will have won his battle. Gates concluded, "not merely when he has got his wages, but when he has so got them that they will buy more." Higher wages without a higher cost of living is the object, "and the only way under heaven in which that can be done is by taking the wages out of the returns of the capitalist." Gates believed labor's demand for a greater share of the wealth was just. The laboring classes are "degraded" by the kind of work they have to do, the amount of work required of them, and "the deprivations that they have to suffer." The differences between rich and poor, capitalist and laborer, "are due not to heredity but to environment." The rich and aristocratic have no purer blood than the "misshapen, ill-dressed, half-brutalized men and women" who have worked the mines from childhood.

Shall we hate and despise and look down upon these people whom our social system has made what they are, or shall we pity them and shall we blame ourselves for having made them what they are, for keeping them where they are, and for clothing ourselves with the fruits of their unpaid labor?

Frederick Engels was not more eloquent!

Gates concluded that it was necessary and desirable for capital to voluntarily reduce its return on investments from the prevail- ing 5 percent to 2 percent and give the balance to the workers.

Cut down their hours of labor. Improve their living conditions. Give them opportunities for music, for pictures, for whatever can cultivate them in mind, whatever can beautify and adorn them in body. Let us ourselves share to some extent the manual labor of the world, and instead of a few rising to the top on the backs of the many, let us undertake to build up society in all its parts as a whole to a higher level.

Gates was moved not by compassion but by fear. He and other members of America's ruling class were shaken by the violent labor struggles, widespread working-class consciousness and support for the Socialist party, and unrest among middle- class Progressives. Most of this class antagonism was aimed at the

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great concentrations of wealth in the industrial monopolies and the flaunting of wealth by the Vanderbilts and the Astors. Always an advocate of inconspicuous consumption, Gates now privately and momentarily looked to corporate-liberal social reforms to head off the anticipated cataclysm.

With the entrance of the United States into the European war, full employment and patriotism overwhelmed the Progres- sive reform movement and justified repression of the Socialists and militant working-class organizations. The immediacy of the internal threat passed, and Gates abandoned even his private thoughts of redistributing the wealth. Promoting physical and social science research continued unaltered as the primary foundation program for ameliorating misery although the junior Rockefeller developed new programs in the arts to uplift the people's culture.

A PERMANENT INVESTMENT

In addition to the expected material and political benefits of medical science, Gates believed that endowing the Rockefeller Institute was an ideal investment because of the permanence of its findings. Each generation takes from the past and hands on to the future "only the things that are proven to be permanently useful." The "useless baggage" is dropped and left behind. The one thing that "humanity has got to live with" is "old Nature and her laws in this world," Gates told his friends at the Rockefeller Institute. "These laws do not change and humanity will never outlive them. Whatever we discover about Nature and her forces, and incorporate into our science, that will be carried forward, though all else be forgotten."''^

Despite his naive view of science. Gates viewed endowments for scientific research as permanent social capital, an investment that would continue to return dividends into the distant future. Given his broad and long-range perspective of the needs of capitalist society. Gates was very attracted to this feature of scientific research.

Aside from its permanence, an investment by Rockefeller in an institute for medical research would call forth more money into medical research. This one act of philanthropy would "call public attention to the importance of research" and encourage

Scientific Medicine II I 133

"many thoughtful men of wealth" to endow research in scientific medical schools throughout the country.''^

In the end, private fortunes and public taxes alike flowed in ever-increasing amounts into medical research. In 1911 Gates was pleased that other rich men and women had indeed followed the example of Rockefeller.'''^ By the mid-1920s Gates felt assured that his strategy of encouraging public and private grants had paid off. "Never before were the common people so ready to grasp the extended hand of a liberal philanthropy," he told fellow trustees of the Rockefeller Foundation, "and to cooperate by legal enact- ment, liberal taxation, and private munificence."''^

All this financial support for medical science and the social recognition heaped upon the scientific medical profession by members of the upper class had given physicians a higher and more secure status. Medical research institutes, Gates observed, "have conferred dignity and glory upon medicine," with the consequence that the medical profession was awakening "to a proud and healthy consciousness of the dignity of its vocation." Quite uncynically. Gates believed that "the elevation of the medical profession" would further the interests of the profession itself and help stabilize a sometimes shaky class structure.''^ Capitalist society was gaining another firm supporter as the medical profession, cleansed of any social conscience, increasing- ly recognized its duty to preserve the existing social order.

The philanthropic capitalists who supported medical science believed it would do more than demonstrate their good works. First, reductionist scientific medicine bore a striking, and not incidental, similarity to the capitalist world view. Second, scien- tific medicine would help integrate all members of society, whatever their occupations or social standing, into an industrial- technical culture, unifying the fragmented and often fragile industrial-capitalist social order. Third, scientific medicine would help replace the widespread class theories of misery with the perspective that inequalities and unhappiness are technical problems susceptible to engineering solutions, thus depoliticizing medicine and legitimizing capitalism. Finally, scientific medicine would help elevate the medical profession, encouraging a strong- er identification of its members with the highest class in society and the capitalist order itself.

134 I Scientific Medicine II

Gates believed that all these characteristics and consequences of scientific medicine were good for society, just as he considered socially beneficent the accumulation of wealth by Rockefeller and his private decisions as to how it should be spent. Gates' views on the benefits of scientific medicine and medical research were cleariy shared in practice by other capitalists, government officials, and members of the profession. Seldom laid out for us with even Gates' minimal explicitness and coherence, their perspectives were nevertheless clear in their programs and articulated concerns. Gates' views on scientific medicine were influential beyond the support given the Rockefeller Institute and encouragement given to other programs of medical research. Gates had the interest, the ideas, and the money at his disposal to formulate and launch numerous programs to develop and extend public health work and a major program to reform medical education.

John D. Rockefeller, whose Standard Oil fortune financed the vast philanthropies in his name, and John D. Rockefeller, Jr., who took over his father's financial empire and philanthropies (1921). Rockefeller Archive Center.

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Murphy, Jerome D. Greene. Rockefeller Archive Center

CHAPTER

Reforming Medical Education: Who Will Rule Medicine?

By the end of the nineteenth century, American physicians were still complaining bitterly of their "poverty" and low status in American society. Those who had studied in Europe were especially struck by the low esteem in which American doctors were held compared with their German colleagues. The disparity among physicians' incomes left some well off and some poor. As the New York State Medical Society's journal put it, "There is a handsome income for a few, a competence for the many, and a pittance for the majority."^

Most professional spokesmen blamed the relative poverty of doctors on "overcrowding" in the profession. The AMA Journal argued in 1901 that through death and retirement of old doctors and the increase in population, there was "room for nearly 3,300 new doctors each year," but the nation's 160 medical colleges were producing nearly double that number.^

To deal with these problems, the medical profession adopted an effective strategy of reform based on scientific medicine and the developing medical sciences. Their plan was to gain control over medical education for the organized profession representing practitioners in alliance with scientific medical faculty. Their measures involved large expenditures for medical education and required a major change in the financing of medical schools. Dependent on outside capital, the profession opened the door to

136 I Reforming Medical Education

outside influence. The corporate philanthropies that intervened turned the campaign to reform medical education into a struggle for control between private practitioners, on the one hand, and academic doctors and the corporate capitalist class, on the other. The conflict over who would rule medical education, to which we now turn, was fundamentally a question of whose interests the medical care system would serve.

PRACTITIONERS GAIN A FOOTHOLD

By 1900 the strategy evolved by elite physicians to reduce the number of doctors, increase incomes, and raise the social class base of the profession began to pay off. Medical research, despite its limited financial support, was building pubHc confidence in modern practitioners. Reforms were being pressed in some leading universities, setting a new standard that others would soon be forced to follow. Most states had established medical licensing boards, however varied the standards they imposed. The Illinois Board of Health in particular had begun a crude evaluation of all medical schools in the United States and Canada. Its report pubhshed in 1889 shook more than a few of the 179 schools of the regular sect, twenty-six homeopathic, twenty-six eclectic, thirteen miscellaneous, and thirteen schools condemned as "fraudulent."^

All these advances did not yet resolve two major obstacles to professional uplift. First, medical schools remained unregulated. In the final quarter of the nineteenth century more than 114 new schools had been founded. "^ The finances of medical schools forced their faculties to oppose the reformers' strategy of promoting scientific medicine to reduce output. Medical schools were for the most part small profit-making enterprises, owned mainly by their faculties. The only commodities they could sell were medical degrees. Dependent for their survival as well as their profits on student fees, the schools continued to pour forth their products. Being proprietary in character but profitable only to the faculty directly involved, they were unable to attract outside capital or operating funds to support expensive teaching and research programs necessary to scientific medical education. Thus, "scientific medicine" was taught at only a few university medical schools, and to a limited extent even in those — except for Johns Hopkins, which was far from the norm.

Reforming Medical Education I 137

The second obstacle to implementing the reform strategy was the organizational disarray of the profession itself. The AMA had failed in its mission. It was by-passed in the last part of the century by specialty societies which formed an aUiance in 1888 in the American Congress of Physicians and Surgeons. The Ameri- can Academy of Medicine and other groups were formed to fill the reform role left vacant by the AMA. Membership in local and state medical societies did not confer membership in the national association, isolating it from the majority of practitioners. By 1900, only 8,400 physicians were members of the AMA.^ The national leadership, without structural ties to state and local societies, operated within a vacuum. Structurally weak, numeri- cally small, dominated by traditional doctors only half-heartedly committed to scientific medicine, the "voice of the medical profession" seemed to have laryngitis.

Before the medical profession could secure reforms in medical education, it had to strengthen its own organization. After some stalled attempts at reorganization at the end of the nineteenth century, the reformers won support from state medical societies and completely reorganized the AMA at the 1901 convention in St. Paul. The new organization, which continues to this day, made the local medical society the basic unit of the association. Individual physicians would join a local society. The local society would send representatives to a state society, which in turn would elect delegates to the newly formed house of delegates, the legislative body of the national association. The president of the AMA and a board of trustees were given substantial powers. With the campaign skillfully managed by Dr. George H. Sim- mons, the reform leader recently appointed secretary of the AMA and editor of its Journal, and with the convention sessions presided over by Dr. Charles A. L. Reed, the reorganization plan was instituted without discussion.^

The reorganization created a hierarchical, representative structure. The direct line of authority depended on the strength of the local societies, always the strongholds of professional interests. The new structure gave the state and national organiza- tions stable leadership, which could more effectively coordinate and mobilize resources for the profession's interests. The plan was intended, and succeeded, to federate state societies into the national association and, in the words of the committee on reorganization, "to foster scientific medicine and to make the

138 I Reforming Medical Education

medical profession a power in the social and political life of the republic."''

Doctors with a vision of uniting the profession behind a campaign to elevate it moved from the wings onto center stage. George Simmons invigorated the Journal with the mission of the reform movement. AMA leaders asked physicians around the country to spur legislative reforms, control state licensing boards, and goad medical schools into altering their admission criteria and curricula. The increased effectiveness of the AMA brought support and membership from the many specialists who seemed to have forgotten that they were physicians first and surgeons or gynecologists second. Private practitioners of all types rose to support the coordinated local-state-national vehicle for their common interests. By 1910 some 70,000 doctors were AMA members, more than eight times the membership at the turn of the century.

Although many rank-and-file physicians were unhappy with the centralized control emanating from the AMA's Chicago offices and with the reform strategy itself, most physicians undoubtedly supported the movement.^ Most physicians resented the economic and social conditions of the profession, particularly when they realized that things could be better. They understood that competition among physicians for a greater share of the available medical dollars would help only a few and that the interests of every physician were tied to the interests of the profession as a whole.

The reform leadership, representing a coalition of private practitioners and medical school faculty, articulated the desires of most doctors for financial and social uplift, and offered a viable strategy for achieving them. This coalition controlled the *AMA from the end of the nineteenth century until World War I, sharing the association's presidency and jointly implementing its reform strategy.^

COUNCIL ON MEDICAL EDUCATION

Once in control of the reorganized AMA, the reformers launched their most effective tool for transforming the profes- sion. In 1904 the AMA replaced its temporary committee on medical education with a permanent Council on Medical Educa-

Reforming Medical Education I 139

tion, headed by the energetic and resourceful Arthur Dean Sevan, a successful surgeon and part-time professor at Rush Medical College in Chicago. The new council was armed with a staff to help it exert "a national influence and control of medical education. "^°

To facilitate that control, it invited state licensing boards to a national conference in 1905 to review the status of medical education and set standards. There the council adopted "an ideal standard to work for in the future" — one that would raise U.S. medical education to the same basis as England, France, and Germany — and "a minimum standard for the time being." The temporary standard was: (1) a preHminary education of four years of high school, (2) a four-year medical course, and (3) passing an examination before a state licensing board.''

Bevan urged local and state medical societies to become more active in the reform movement and to see that "the right sort of men" were appointed to the Hcensing boards. Within two years the state medical societies, under the guidance of the Council on Medical Education, dominated the state boards. Through the influence of the state societies and direct contact by the council, the licensing boards increasingly became agents of the council's plan of action.'^

The more the state boards cooperated with the council to accept diplomas only from medical schools "in good standing" and to gear their examinations to the curricula of scientific medical schools, the more uncertain was the future of all medical schools except those elite schools already geared to the needs of scientific medicine. Those schools that could tap sufficient resources to provide laboratories, "cHnical material," and scien- tifically trained faculty had a reasonably good prognosis. The graduates of such schools were allowed by the state boards to take their licensing exams, and they had a fairly good chance of passing. There was little incentive for students to attend and pay the fees of unapproved schools and schools whose graduates tended to flunk the licensing examinations. But state boards were not uniformly in the hands of the state medical societies, so the council developed a new tactic to upgrade medical education, close more schools, and develop a controlling role for itself in the field.

In 1906 the council inspected every one of the country's 160

140 I Reforming Medical Education

medical schools. Each school was personally visited by council secretary Dr. N. P. Colwell or another council member and was rated on the percentage of its graduates who passed the state licensing exams, enforcement of preliminary education require- ments, curriculum, laboratory and clinical facilities and instruc- tion, laboratory science faculty, and whether the school was run for a profit. Reports on each school were sent to the state licensing boards, and the percentage of each school's graduates who failed state board examinations was published in the AMA Journal. ^^

In 1907 the council divided medical schools into classes A, B, and C, depending on their ratings. Of the 160 schools inspected, eighty-two were rated as class A medical colleges, forty-six were class B, and thirty-two class C. The impact of the council's report was significant. Fifty schools agreed to require one year each of college physics, chemistry, biology, and a modern language before admission to the medical program. Sensing doom, a number of schools consolidated with other medical schools in their cities, combining facilities and staffs. Other schools realized that they did not have the resources to survive the heightened competition. By 1910 the number of schools had fallen from a high of 166 to 131.^"

While the practitioner reform leaders were pressing for stiffer standards within medical education, the medical schools them- selves were doing their best to survive. The Association of American Medical Colleges (AAMC), representing about a third of all American medical colleges, sought to differentiate its member schools — "the better classes of medical colleges" — from run-of-the-mill schools. They were concerned that rising stan- dards in admission and instruction would bankrupt even the best schools. As the representative of the elite portion of scientific medicine's rear guard — the schools themselves — the AAMC favored cooperation between itself, the Council on Medical Education, and the association of state licensing boards. The AAMC sought uniform minimum standards for all states so that each state's requirements of medical schools would come "up to, but not beyond," the standard recommended by a joint commit- tee of all three bodies. ^^

Ahhough the Council on Medical Education had neither legal powers nor authority within the profession, council chairman Bevan, AMA secretary and Journal editor Simmons, and other

Reforming Medical Education I 141

professional reformers well understood the role of leadership and the powerful advantage of articulating a strategy consistent with historical forces. Science's time had arrived in medicine: A middle and upper class whose dominance depended on industri- alization was receptive to what scientific medicine advocates within the profession offered. State licensing boards, under the influence or in the hands of the medical societies, assured the dominance of scientific schools and the competitive disadvan- tages of economically weaker schools. The cost of a scientific medical education was shattering the financial arrangements of proprietary medical schools. The council could not order schools closed, but it ralHed poHtical allies in the state boards and the forces of the marketplace to wreck the ancien regime.

MONEY FOR MEDICAL EDUCATION: WHO WILL PAY?

The reforms initiated and pressed by the AMA leadership were clearly having their desired impact. But the profession's power to accomplish its ultimate goals was limited. Scientific medicine was an expensive affair. Nearly all medical schools at the end of the nineteenth century relied for most of their support on students' tuition fees. Most independent medical colleges and many of those nominally associated with universities had no other source of income. Yet the teaching of scientific medicine required expensive laboratory buildings, a teaching hospital and teaching cHnic, and equipment. Some of these facilities could be obtained from local men and women of wealth if faculty members had fashionable private practices. Some facilities could be had if the medical school was affiliated with a well-endowed university. However, more than facilities were needed.

The largest operating expense for a scientific medical school was the faculty to teach the laboratory science courses. A practitioner might be good enough to teach chnical courses, but he usually was not expert enough in physiology, bacteriology, or pathology. The basic medical sciences had to be taught by medical scientists who were specially trained in that area and whose on-going research kept them abreast of developments in their field. These faculty had to devote their full time to teaching and research, and they were the largest operating expense of a turn-of-the-century scientific medical school.

The cost of a scientific medical education was beyond the

142 I Reforming Medical Education

means of students. "It costs more to educate a medical student," Bevan noted, "than he can pay in the way of fees.'"^ The capital investment and operating costs for scientific medical education were also beyond the means of the profession itself. Wealthy physicians might provide a small portion of the capital for a medical college, but the reformers recognized early that most of the capital for scientific medical schools would have to come from outside the profession. ^^ States might be persuaded to support state institutions, but most medical schools and universities — and certainly the most elite — were privately controlled. "The public must be taught the necessities and the possibilities of modern medicine," Bevan argued, and philanthropists must be shown that medicine deserves their endowments. ^^ Because of the amounts involved, much of the money would have to come from the fortunes of the very wealthiest men and women in America. The medical reformers were well aware of the dangers of help from the outside. "Rich men may injure the cause of medical education," the AMA Journal warned in 1901, unless their giving is directed by the profession itself. ^^ With the blessings of the rest of the profession's leadership, Bevan took on the task of getting and guiding endowments for medical colleges. "We must secure for them state aid and private endowment," he told the council's 1907 national conference. "We must start an active, organized propaganda for money for medical education."^"

HELP FROM THE CARNEGIE FOUNDATION

Impressed with the impact of the council's own survey, Bevan turned to the Carnegie Foundation for the Advancement of Teaching. He sought the foundation's help, not just to replicate the council's own work, but to add to their campaign the foundation's developing prestige and image of "objectivity." Bevan understood the foundation's potential for molding public opinion and providing a credible blueprint for philanthropists to follow while channeling their money into medical education. It was also clear that an agency outside the profession could openly attack medical schools that resisted reorganizing themselves or going out of business without once again spHtting medical school faculty off from the reform leadership. At the council's first

Reforming Medical Education I 143

national conference in 1905, Bevan criticized proprietary medical schools as an obstacle to reform, but he felt compelled by the need for diplomacy to urge leniency because of the "property and professional interest" invested in them.^^

In 1907 Bevan invited Henry S. Pritchett, president of the Carnegie Foundation for the Advancement of Teaching, to examine the survey materials collected by the council. Meeting at the Chicago Club, Bevan and Pritchett saw eye-to-eye on the value of a Carnegie-sponsored study of medical education. For Bevan the Carnegie study would be the big guns in the campaign for medical education reform. Pritchett was sympathetic to that concern, but mainly in the context of the foundation's program to reform and rationalize the nation's colleges and universities, including its professional schools. ^^

The foundation had been established in 1905 to upgrade the status of college teachers while creating a uniform system of higher education. Out of discussions between Andrew Carnegie and Pritchett emerged a plan to advance teaching by the carrot- and-stick method. The new foundation provided an initial en- dowment of $10 million to support a retirement program for college teachers. The pensions would be given without any cost to the institution or its individual teachers, but each college must meet the conditions laid down by the foundation. Denomina- tional colleges were not eligible for the pension plan. Religion was, of course, an important moral force, but it would not pro- mote the universality of science; colleges controlled by compet- ing denominations would be more concerned with propagating the faith than with training scientists and engineers. Denomina- tional colleges, hoping to make themselves more attractive to faculty, besieged the foundation with inquiries about how to amend their charters to make themselves eligible for free pen- sions. In addition, the foundation imposed academic and financial requirements designed to force the poorer colleges to match the academic standards of the better colleges and to make higher education follow a uniform pattern throughout the country."

Thus, Bevan's request for a study of medical schools fit well with the foundation's general program and provided an oppor- tunity for the foundation to move into reforming professional education. Pritchett discussed the proposed study with Charles Eliot, president of Harvard and a trustee of the Carnegie

144 I Reforming Medical Education

Foundation, Rockefeller's General Education Board, and the Rockefeller Institute for Medical Research. He also talked with Dr. Simon Flexner, director of the Rockefeller Institute. Flexner suggested a director for the study, his brother Abraham. The suggestion meshed well with Pritchett's conception of the study as contributing to the reform of higher education. ^"^

Abraham Flexner was a professional educator. He got his bachelor's degree from Johns Hopkins in two years of diligent and hard work. He later founded and ran his own college preparatory school in Louisville and afterwards spent a year in advanced study in education at Harvard. While in Heidelberg in the summer of 1908, Flexner wrote The American College, which, in his own words, "fell quite flat." Late in the summer of 1908 Flexner returned from Europe unemployed and "prepared to do almost anything." Hoping to get a job, Flexner initiated a meeting with Pritchett. They talked about higher education and its problems and found they agreed on the necessity for reform. "When I next saw him," Flexner later recalled, "he asked me whether I would like to make a study of medical schools." Flexner was enthusiastic, "but it occurred to me that Dr. Pritchett was confusing me with my brother Simon at the Rockefeller Institute, and I called his attention to the fact that I was not a medical man and had never had my foot inside a medical school."

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