Knowledge in the Time of Cholera (35 page)

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Physician Identity
. The epistemology of the laboratory required a shift in the identity of physicians from practitioners of the medical arts to scientists involved with, or at least familiar with, laboratory sciences. As medical knowledge shifted from sorting empirical observations to engineering problems that stressed exactness and precision (Warner 1991), doctors had to be reconstituted as new “epistemic subjects” (Knorr-Cetina 1999). Diagnosis, once deemed a nuanced art of the skilled physician, would now be taken care of by the laboratory, for “no physician who has not had a good experience in the pathological laboratory can be a good diagnostician” (Osler in Thayer 1969, 231). The shift toward seeing themselves as scientists did not go uncontested within allopathy, as evident in the full-time controversy between clinicians and bacteriologists discussed below.

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Medical Education
. The reforms also suggested an entire new medical pedagogy. Medical education would no longer be transmitted through didactic lectures. All facets of medical education would now emanate outward from the laboratory and promote learning through intervening. Students had to be trained as scientists who could ask questions of nature through laboratory analysis (Borrell 1987). Indeed, education reforms would be the primary means by which bacteriologists carried out their revolution, as they replaced proprietary medical schools with scientific medical schools attached to major universities.

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The Role of the Hospital
. With the laboratory established as paramount, physicians required access to labs in order to practice medicine. Because labs were expensive, it made economic sense to pool resources and establish them in some centralized place. Hospitals offered such a place. For the laboratory revolution to happen, the locus of medical practice would have to shift from the home to the hospital, which had access to labora
tory
facilities and technical laboratory workers. Traditionally governed by lay trustees and understood as charitable enterprises (Rosenberg 1987a), hospitals needed to be reorganized around the lab, and in the process, elevated from their marginal role of treating the poor to
the
center of medical practice.

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The Identity of Disease
. As we have seen in its dealings with cholera, the laboratory promised to radically transform the identity of infectious diseases (Cunningham 2002). In the aftermath of Koch's announcement, bacteriologists began a program to have infectious diseases exclusively identified, and defined, by the laboratory. All organizations dealing with disease would be given a laboratory. Furthermore, they would have to become appendages to the lab by engaging in germ hunting. This transformation also would not go unchallenged, no more so than by public health officials, for whom the new identity of cholera clashed with the traditional (and successful) view of cholera as filth.

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The Patient/Doctor Relationship
. In conjunction with the changing identity of disease, the clinical interaction between patients and doctors was re-imagined. This was a subtle, but significant change. Patients' experiential knowledge would no longer have the same weight shaping understandings of disease. With new technologies of observation, physicians would become less dependent on patient testimony in making diagnoses (Rosenberg 2002). This resulted in the “disappearance of the sick man from medicine” (Jewson 1976), as the social distance between the doctor and the patient increased to such an extent that the patient forfeited nearly all control over defining the disease to expert opinion (Katz 2002). The public lacked the technical skill to participate in the conversations over disease. Not only did this shift go against the traditional doctor/patient interaction, it also stood in stark contrast to the democratized epistemologies of other medical sects that recognized patients as active participants in producing knowledge.

The extent of the changes demanded by the laboratory appealed to the professional aspirations of bacteriologists, as they allowed allopaths to reclaim some of their professional mystery (Warner 2002). The laboratory was a restricted space, open and legible only to those who possessed the requisite expertise. Giving medicine back some sense of its “legitimate complexity” (Starr 1982, 59), the laboratory enabled bacteriologists to claim scientific superiority, professional authority, and epistemic privilege. Medical
knowledge,
once relatively accessible to outsiders, would now be confined to restricted laboratories controlled by allopathic physicians.

ROCKEFELLER MEDICINE MEN

There were two obstacles facing bacteriological reformers in carrying out their ambitious, multidimensional reform. The first was economic: laboratories were expensive, as were the broad, diverse reforms needed to position the laboratory at the center of medicine. Reformers needed access to tremendous resources. This economic problem was compounded by a political one. The natural place to look for such resources was the government. However, the bacteriologists' reform program stood in opposition to the ideals of democracy endorsed by government institutions. The epistemology of the laboratory offered an inherently elitist epistemological vision for medicine. The laboratory sought to restrict, rather than promote, transparency and debate, making medical knowledge the sole province of the allopathic profession. Legislatures had repeatedly refused to regulate the medical market, valuing openness and debate over medical issues as the way to ensure that the best knowledge was achieved. Bacteriological reformers knew this and were skeptical that the government offered a viable partner in remaking American medicine. Instead, bacteriologists sought allies outside of the government who could provide the requisite resources to carry out such an ambitious program. They found an unlikely ally in John D. Rockefeller Sr., American industrialist and founder and chairman of Standard Oil. Rather than convince a wide electorate (or their representatives) of the legitimacy of epistemic authority, bacteriologists were able to persuade a few well-placed, well-heeled elites, like Rockefeller, to support a program to radically remake American medicine.

The last decades of the nineteenth century witnessed a profound transformation in the material and social conditions of the country. Industrial growth after the Civil War resulted in the rise of industrial giants, huge corporations, and large-scale bureaucratic operations (Tratchtenberg 2007). Giant corporations transformed the economic landscape, yielding a stunning array of consumer goods, millions of additional jobs, and ever more wealth concentrated into fewer hands (Diner 1998). And almost no one was as adept as Rockefeller in turning this new economic environment to advantage, accumulating tremendous wealth and economic clout in the process.

It is a great irony of history that Rockefeller would become the catalytic
force
behind the emergence of modern scientific medicine, given his own “quackish” commitments. Rockefeller's grandmother, Lucy, known locally as a healer of sorts, dispensed herbal remedies and home-brewed concoctions;
³
his father was a self-styled, itinerant “botanic doctor,” a throwback in the rural Thomsonian mold. As for Rockefeller himself, he remained a devoted patient to homeopathy his entire life. Dr. Henry Biggar, a close confidant and family homeopathic doctor, treated Rockefeller throughout his life and repeatedly petitioned the wealthy industrialist to support homeopathic causes, which Rockefeller often did. In 1875, Rockefeller invested in a short-lived sanatorium specializing in homeopathic medicine and water cures (Chernow 1998, 183). Even after the establishment of the Rockefeller Institute for Medical Research (RIMR), Rockefeller sent strongly worded letters to its directors demanding that homeopathy be given equal support. Despite backing scientific medicine, Rockefeller remained “notably suspicious when it came to the medical profession” (Chernow 1998, 506); not only did he eschew allopathic treatments, he only stepped foot into the state-of-the-art facilities of the RIMR once in his entire life (Chernow 1998, 475).

Given Rockefeller's unorthodox medical views, the fact that he bankrolled the allopathic medical reforms—reforms that did more than anything to kill off homeopathy—has puzzled historians. Some have dismissed Rockefeller's medical philanthropy as a cynical public relations stunt meant to distract from his controversial labor practices. In a proto-Marxist argument, E. Richard Brown (1979) argues that Rockefeller's capitalist ideology squared nicely with the new medical science, for both ignored the social causes of disease, choosing instead to see social and economic problems as technical problems of engineering. According to Brown, the philanthropic work allowed capitalists to portray disease, not poverty, as the root of misery. While it is certainly true that Rockefeller was not acting
against
his capitalist interests in promoting medical science, historians tend to overstate the degree to which the medical reforms were driven by base economic calculations. For one, Rockefeller was loath to take public credit for or even announce his philanthropic work, failing to take full advantage of the potential public relations coup at his disposal (Chernow 1998). Also, Rockefeller erected a rigid boundary between his philanthropies and Standard Oil. The two enterprises were insulated from one another organizationally, and Rockefeller assumed a generous hands-off stance toward his philanthropies. He left their management to others. Thus, popular depictions in the press at the time notwithstanding, Rockefeller was never a puppet master,
manipulating
his philanthropic giving with one hand to promote his capitalist empire with the other.

Instead, Rockefeller's philanthropic interest in medicine, and specifically bacteriology, is better understood as emanating from his own use of the laboratory in gaining competitive edge. often, research in science studies neglects corporate science and, by focusing solely on public science, obscures the long-standing mutual influence between the two (Penders et al. 2009; Shapin 2008). Private sponsorship of public science (like that of the Rockefeller Foundation) is dismissed as driven by base economic motives, rather than reflecting a shared epistemic orientation toward knowledge production. The false dichotomy between
pure
science and more applied research obscures the important role of private research in the development and promotion of science generally. Rather than denigrate the research of Standard Oil as somehow corrupted, it is important to recognize the shared affinity toward the laboratory between bacteriological reformers and Rockefeller's Standard Oil. It is this epistemological affinity that explains Rockefeller's involvement with bacteriology. Just as the democratized epistemologies of homeopathy and Thomsonism resonated with the epistemic cultures of the state legislatures, so too did bacteriologists' epistemology of the laboratory resonate with the epistemic culture of Standard Oil. Once we acknowledge the integral role of the laboratory in industry during this period, industrialists' interest in promoting laboratories in other fields seems less puzzling and, indeed, less cynical. Both Rockefeller and bacteriologists shared a vision of the rationalized production of knowledge by elite experts in laboratories.

In building Standard Oil—“the very modern symbiosis of business acumen and scientific ingenuity” (Chernow 1998, 74)—Rockefeller created an organization that promoted technical innovation as good business strategy. He subscribed to the views of Arthur D. Little, a chemist and early promoter of industrial research, who claimed that “the laboratory has become a prime mover in the machinery of civilization . . . for research is the mother of industry” (quoted in Shapin 2008, 96). Standard Oil cornered the oil industry, not by focusing on the production of crude oil, but through refining. Its profitability depended on scientific, technical acumen to transform crude oil into end products like gasoline, kerosene, and petroleum. Presaging modern research and design departments, Rockefeller created a committee structure of experts within Standard Oil to study the technical problems of oil refining. To increase efficiency and ultimately profit margins, the findings of this cadre of
internal
scientists were made widely available to the entire company. Rockefeller explained his institutional organization of inquiry: “A company of men, for example, were specialists in manufacture. There were chosen experts, who had daily sessions and study of the problems, new as well as old, constantly arising. The benefit of their research, their study, was available for each of the different concerns whose shares were held by these trustees” (quoted in Chernow 1998, 229). Within Standard Oil, technical experts were given space to innovate, to make improvements either in the refining or manufacturing processes, which would then be disseminated throughout the company. Rockefeller created insulated research spaces for scientific tinkering.

Standard Oil's epistemic culture of innovation was evident in one particular episode in the mid-1880s. From its inception, Standard Oil faced the chronic threat of diminishing oil reserves. With his company dependent solely on Pennsylvania oil, Rockefeller perpetually worried about the reserves' depletion. Some of these fears were assuaged by the 1886 discovery of oil in Ohio and Indiana, until it was realized that this oil burned dirtier than Pennsylvania crude. Undaunted, Rockefeller hired a German-born chemist, Herman Frasch, to turn the “Lima crude” into a marketable commodity. Frasch solved the problem, and for fifteen years, his patents “furnished dazzling profits for Rockefeller and Standard Oil and boosted the status of research scientists throughout the industry” (Chernow 1998, 286–287). When Rockefeller first hired him, Frasch was probably the only trained petroleum chemist in the United States, but his success solidified Rockefeller's commitment to the laboratory. By the time Rockefeller retired, there was a lab in every refinery and even one in Standard Oil's headquarters in downtown Manhattan.