Disorder: A History of Reform, Reaction, and Money in American Medicine 9780300262872

Citation preview

Disorder

This page intentionally left blank

Disorder

a h i s t o ry o f r e f o r m , r e a c t i o n , and money in american medicine

Peter A. Swenson

New Haven and London

 Published on the foundation established in memory of William Chauncey Williams of the Class of 1822, Yale Medical School, and of William Cook Williams of the Class of 1850, Yale Medical School, and with assistance from the MacMillan Center for International and Area Studies, Yale University. Copyright © 2021 by Peter A. Swenson. All rights reserved. This book may not be reproduced, in ­whole or in part, including illustrations, in any form (beyond that copying permitted by Sections 107 and 108 of the U.S. Copyright Law and except by reviewers for the public press), without written permission from the publishers. Yale University Press books may be purchased in quantity for educational, business, or promotional use. For information, please email sales​.­press@yale​.­edu (U.S. office) or sales@yaleup​.­co​.­uk (U.K. office). Set in Adobe Garamond type by Westchester Publishing Ser­vices Printed in the United States of Amer­i­ca. Library of Congress Control Number: 2021932828 ISBN 978-0-300-25740-3 (hardcover: alk. paper) A cata­logue rec­ord for this book is available from the British Library. This paper meets the requirements of ANSI/NISO z39.48-1992 (Permanence of Paper). 10 9 8 7 6 5 4 3 2 1

Contents

Preface and Acknowl­edgments, vii List of Abbreviations, xv Introduction: Political Transformations in American Medicine, 1

Part One  T H E A M E R I C A N M E D I C A L D I S O R D E R 1  Medical Mayhem, 21 2  Organ­izing for Order, 37

Part Two  D RU G P RO B­L E M S 3  Therapeutic Chaos and Commercial Conquest, 61 4  Heal Thyself, 85 5 ­Legal Remedy, 111

Part Three  P U B L I C H E A LT H A N D T H E B O D Y P O L I T I C 6  Bacillus Politicus and the Diseased State, 137 7  Cattlemen, Commanders, Capitalists, and Crusaders, 164 8  Health or Freedom, 197 v

vi C o n t e n t s

Part Four  S C H O O L I N G P H Y S I C I A N S 9  A Plague of Doctors, 235 10  Unnatural Se­lection and Intelligent Design, 260 11  A G ­ reat Wave of Improvement, 287

Part Five  R E A C T I O N A RY T U R N A N D B E Y O N D 12  Insurgency, 317 13  The Conservative Medico-­Political Order, 360 14  Medical Power Politics, 398 15  A New Medical Progressivism, 441 Notes, 477 Index, 545

Preface and Acknowl­edgments

When I began teaching and researching health-­care politics in Amer­i­ca in the 1990s, warnings had been sounding for at least a de­cade about “emerging infections” from new and dangerous pathogens traveling far and wide across species and national borders. And, as a report by the highly respected Institute of Medicine (IOM) put it, they threatened to overwhelm an American public health system in “disarray.” Now, as the final words of this book are being written, the COVID-19 pandemic of 2020 and 2021 has proven the IOM’s warnings prophetic. For this and other symptoms of a peculiarly American medical disorder, I lay considerable but not sole blame at the feet of the medical profession’s po­liti­cal leadership. As the IOM put it in 1988, some of the prob­lems of public health lay in the “uneasy” relationship, marked by “confrontation and suspicion,” between or­ga­nized medicine and public health institutions. As an or­ga­nized force, the medical profession propagandized for de­cades against public sector interventions in health care. Its medico-­political ideology contributed to deep-­seated sentiments that “government is the prob­lem, not the solution.” Meanwhile, physicians averted their gaze from the social determinants of diseases while rushing in to cure them when it was often too late. Their representatives did nothing about the miserly funding of public health agencies. Thus, the planning of preventive action to protect citizens’

vii

viii

P r e f a c e a n d A c k n o w l ­e d g m e n t s

constitutional rights to life, liberty, and the pursuit of happiness lagged relative to growing threats to those rights. In short, or­ga­nized medicine deserves criticism in my view b­ ecause it has been largely absent without leave from the public health front while it pursues professional goals that are more protectionist and conservative than altruistic and progressive. By progressive medicine, I mean favoring prevention of disease over treating it, even if it is commercially unremunerative; supplying equitably distributed as well as efficient and quality care once illness strikes; and, not least, searching tirelessly for ways to si­mul­ta­neously advance quality, equality, and economy in the entire medical order. I wrote this book in the spirit of the progressive call for a just and efficient “social contract between medicine and society,” a concept discussed in medical and bioethical reform circles. In 2002, it was incorporated into the American Board of Internal Medicine Foundation’s Physician Charter, a professional code promulgated together with the Eu­ro­pean Federation of Internal Medicine. Titled “Medical Professionalism in the New Millennium,” it calls on the profession to uphold its side of a social contract to restore trust with patients and the public. Its first princi­ples include “the primacy of patient welfare,” or “placing the interests of patients above t­hose of physicians.” They include “social justice,” an end to all kinds of discrimination, and “the fair distribution of health care resources.” The profession’s responsibilities include dedication to “continuous improvement” in all dimensions of health care—­and transparency about medical outcomes so the public can judge what it is getting in the deal. In real­ity, as an or­ga­nized social, economic, and po­liti­cal force, what the American medical profession does comes up far short of fulfilling an implicit social contract. When I think of the profession as a societal force, I am referring primarily to its supposedly representative organ­izations, with the American Medical Association (AMA) at their peak. The profession includes many other state and specialty socie­ties that exercise power inside and outside the AMA, lobby Congress, advise the federal bureaucracy, and do more of the same in state legislatures and governments. They also shape public opinion. Unfortunately, a ­great many of them are dependent on industry money and thus unhesitatingly enter into deep institutional conflicts of interest. The AMA, in which specialty associations exercise voting rights, proudly claims that it “represents physicians with a unified voice to all key players in health care.” That is a wild exaggeration. Opinions within the membership are divided on burning questions. The AMA also, it professes, “leverages its



P r e f a c e a n d A c k n o w l ­e d g m e n t s

ix

strength by removing the obstacles that interfere with patient care, leading the charge to prevent chronic disease and confront public health crises and driving the f­ uture of medicine to tackle the biggest challenges in health care.” In fact, it does ­little of that. It does not lead in the strug­gle for universal health care. It is not a driving force for repairing and regenerating the public health system. In response to criticisms like ­these, the “House of Medicine,” as it is sometimes called, protests too much. Flaws in the health-­care system it has s­ haped and defended are legion and well founded. Or­ga­nized medicine’s vehement and successful opposition to universal health care on a single-­payer or other rationally centralized basis created the vacuum that the commercialized and chaotic financing and delivery of medical and hospital ser­vices have moved into since the 1940s. Spending on health care—­now approaching 20 ­percent of the gross domestic product—is untethered from the forces of accountability and rational control. Much expensive care is of questionable efficacy and, therefore, value. Far more per capita is spent on health care than in any other country in the world, despite guaranteed coverage to a smaller share of its population. The chaotic health-­care “system,” according to a fabulously wealthy financier, is “a tapeworm” that eats away at Amer­i­ca’s economic competitiveness. Worse, from average citizens’ standpoint, it taxes away much of their hard-­earned but l­imited disposable income needed for other life essentials. Our so-­called system delivers less than other wealthy countries’ do of the good and timely treatment that can avert deaths caused by medical conditions. Opacity in medical ser­vice and hospital pricing, as well as lack of data about treatment outcomes, makes a sham of market competition, which is supposed to drive prices down while driving quality up, thereby generating ever greater value for more and more ­people. Physician demoralization and burnout result in no small part from dealing with commercial insurance and health-­care bureaucracies’ demands for information. Their value to medical commerce lies in bringing in revenue, not better health outcomes. We have a health-­care system riddled with mono­poly, informational deficits, and no small amount of fraud. Th ­ ere is only weak antitrust action against the monopolistic consolidation of hospital systems, insurance companies, and more. ­There are neither market nor government mechanisms working effectively against price gouging by phar­ma­ceu­ti­cal companies. A lack of outcomes information and advertising replete with noninformation and disinformation make the medical market a lax disciplinarian and therefore a feeble guarantor of

x

P r e f a c e a n d A c k n o w l ­e d g m e n t s

quality medical commerce. In short, all this renders the invisible hand of “the market” all thumbs. “Public health is public wealth,” it has been said, but the huge prob­lem of waste is one of more than money. It concerns lives and well-­being. Thus, a key feature of the American medical disorder is the neglect of prevention. Even the delivery of medical care itself represents a public health threat b­ ecause medical errors and preventable hospital infections are the third-­highest cause of death. Tracking and control of excessive antibiotic prescribing and the resulting emergence of drug-­resistant microbes is sorely lacking. The medical malpractice system fails miserably to deter negligence and incentivize safety improvements and to deliver civil justice to its many victims, most of whom never even suspect error or negligence or, if they do, never see a ­lawyer, a courtroom, or monetary restitution. New as well as old threats to public health loom ever larger while the mass of physicians, or­ga­nized and other­wise, stand idly by. “Action bias” dominates, often unjustifiably, in individualized therapeutics (“­don’t just stand ­there, do something”) but not in collectivized public health. What po­liti­cal scientists call the free-­rider prob­lem turns even the most caring and socially conscious physicians into rationally passive bystanders. They wait forever for their organ­izations to define and do what is necessary for biosurveillance, planning, preparation, and coordinated action against disease. The many liberals among doctors—­a slight majority in recent years—­ exercise their right to vote but do not exercise the special power inherent in their socially conferred expertise, status, and incomes to demand action to reduce the social and environmental determinants of disease, infectious and chronic. As a group, the profession’s electoral participation is surprisingly lower than that of ­others of similar socioeconomic status. One can only hope that the recent politicized and, during the Trump administration, criminally negligent response to the COVID-19 pandemic w ­ ill change that. Such criticisms of the American medical disorder come not only from laypeople like me. In fact, I have arrived at my strong conclusions, which ­were not my opinions at the outset, with input from a large and growing contingent of reform-­minded ­people in the medical community itself. With consternation, they openly supply the lay public with disturbing news about the world of medicine in which they operate. They seek to empower lay allies with the information they need for collaborative reform efforts. As I show in detail in this book, such openness was once considered unprofessional and even taboo. It was heavi­ly suppressed during a long era of conservative medical politics that I examine h ­ ere.



P r e f a c e a n d A c k n o w l ­e d g m e n t s

xi

Medicine’s conservative era began in the 1920s and continued into the 1990s, a de­cade when the AMA persisted in its half-­century ­battle against guaranteeing health care to all. The conservative era cannot be said to have come to a decisive end u ­ ntil 2010, which is when the AMA, for the first time since 1918, supported a major expansion of coverage brought by the Patient Protection and Affordable Care Act. However, ­today’s medical progressives remain highly critical of or­ga­nized medicine for its primary focus on protecting and advancing the income and professional sovereignty of doctors. They are ashamed by or­ga­nized medicine’s pervasive conflicts of interest as mea­ sured by the torrent of money and in-­k ind ser­vices flowing from the phar­ma­ ceu­ti­cal and medical device industries to all realms of medical practice, commerce, research, education, organ­ization, and politics. To the extent they actively agitate for progressive reforms, they largely go around the AMA as more of an obstacle than an ally. In a sense, however, by boycotting the AMA they empower it to continue on its path—on commercial life support. Less than 20 ­percent of its revenues is from member fees. This book shows that the or­ga­nized medical profession has not always been so remiss. The large beginning portion of the book examines the relatively little-­known fact, surprising to most, that at the end of the nineteenth c­ entury and into the 1920s the AMA was a profoundly progressive force that coalesced with lay allies in diverse but overlapping movements for public health, drug, and medical education reforms, some of them partially successful, some not. ­Those reform endeavors w ­ ere themselves pieces of the larger progressive movement of the time. Progressivism’s medical agenda met with fierce re­sis­tance from a kind of reactionary, paranoiac, anti-­elitist, and anti-­scientific pop­u­lism that rears its head periodically in American politics. In the 1910s, the manipulators of pop­u­lism emerged victorious in their ­battle against the progressives’ most impor­tant mission: the creation of a national department of health. ­Because the early era of medical progressivism is so meagerly documented and usually not even acknowledged in the historical lit­er­a­ture, a substantial portion of this book focuses on that. For evidence, I rely on thousands of primary sources as well as hundreds of books, many of them by medical historians. By comparison, relatively few readers ­will be unaware of medical conservatism’s hegemony l­ater in the twentieth ­century. Secondary lit­er­a­ture and journalistic accounts already cover much of it, so my survey of that is less lengthy and detailed. But readers ­will find hundreds of references to primary and secondary sources on the character, depth, and extent of medical conservatism in my notes. They ­will not be entirely surprised by the pervasive

xii

P r e f a c e a n d A c k n o w l ­e d g m e n t s

racism, sexism, and corruption, but I believe they w ­ ill be dismayed by some of the details, especially regarding relations with the phar­ma­ceu­ti­cal industry and, shockingly, even the cigarette industry and politicians from tobacco-­ growing states. The introductory chapter expands on the issues broached h ­ ere and addresses some of the scholarly controversies covered in other chapters. The second and third chapters describe the profound chaos that the early medical progressives sought to remedy and how they radically restructured the AMA into a po­liti­cally potent organ­ization to serve their purposes. The book is structured so that ­after reading the first three chapters, readers might choose—­ without losing sight of the larger narrative arc—to focus on only one or two of the three arenas of progressive reform of par­tic­u­lar interest to them: drugs, public health, and medical education. Each of ­those areas is covered in a part consisting of three chapters. The first in each describes the medical disorder that appalled and energized the progressive reformers, and the following two chronicle their efforts, successes, and failures in bringing order. The final four chapters then examine the AMA’s reactionary turn of the 1920s and what followed up to the pre­sent, including new currents of medical progressivism. I hope readers w ­ ill not detect an unjust animus t­ oward a g­ reat profession in this book. I am not a physician, but I come from what could be called a ­family of physicians and medical professionals, which helps explain my interest in medical reform. My m ­ other was a county public health nurse and my ­father a professor of pulmonology. If they ­were alive ­today, I am certain they would agree that a progressive redirection of or­ga­nized medicine is needed, considering the enormous po­liti­cal power medical politicians wield. Too many physicians have written off the AMA as irredeemable or irrelevant. It may be redeemable, but it is far from irrelevant. Among trade associations, as opposed to individual corporations in energy, finance, and aerospace industries, it has been the country’s third-­biggest spender in legislative lobbying, exceeded only by the U.S. Chamber of Commerce, which professes to represent all of American business, and the National Association of Realtors, whose interests overlap with much of banking and construction. The ­great bulk of the AMA’s money comes not from membership dues but from other revenue sources, some of which betray serious commercial conflicts of interest. Too much of that lobbying has been focused on the economic interests of doctors and of the AMA bureaucracy itself, not on fulfilling a social contract. More of its campaign money in the recent past has gone to legislators who actually vote against its official policies and House of Delegate



P r e f a c e a n d A c k n o w l ­e d g m e n t s

xiii

resolutions. Many of ­those policies and resolutions are highly commendable, but they mostly give the AMA cover to call itself a vigorous leader, not a laggard, in the fight for public health and universal access to excellent medical care. A fully progressive transformation in or­ga­nized medicine w ­ ill not be easy, even though in my view the g­ reat majority of doctors, if asked, would gladly sign on to any reasonably conceived social contract between medicine and society. Indeed, I believe that most physicians are moral beings in Reinhold Niebuhr’s sense: able to consider social and economic interests other than their own. In 1932, the radical Christian theologian lamented in Moral Man and Immoral Society that, as moral actors, social groups are often less than the sum of their parts. In groups, Niebuhr wrote, “­there is . . . ​less ability to comprehend the need of ­others and therefore more unrestrained egoism than the individuals, who compose the groups, reveal in their personal relationships.” At the time, he would have witnessed a reactionary AMA at work, one whose power­ful journal editor called the 1935 Social Security Act “a horse-­laugh on scientific medicine and American patriotism.” As my book argues, it is extremely unlikely that as individuals the majority of physicians would have endorsed such a benighted sentiment. As Niebuhr thought pos­si­ble, the extracurricular education of recent generations of physicians, starting in the 1960s, has refined their sense of justice, while or­ga­nized medicine has been slow to follow. In their daily lives and clinical encounters, the vast majority of physicians cannot be blamed for t­ hings done by an organ­ization pretending to speak with one unified voice for them, just as the organ­ization cannot take credit for their sacrifices and, occasionally, as during an epidemic, even heroism. In 1947, Albert Camus, speaking through the young Dr. Rieux in The Plague, claimed that something about the epidemic in the fictional city of Oran helped individuals like him and his lay friends “rise above themselves.” ­Today, many medical professionals—­and hospital workers of all kinds—­are d ­ oing that courageously at the front lines of the ­battle against the new and deadly coronavirus. It would be good if they could also channel that selflessness by working through, not around, or­ga­nized medicine to act, in solidarity with the lay world, as a more power­ ful force for the entire country’s health and welfare.

I would like to thank many friends, colleagues, and o­ thers for input, encouragement, and other kinds of assistance over the too-­many years I worked on

xiv

P r e f a c e a n d A c k n o w l ­e d g m e n t s

this book. Medical journalist Michael Millenson deserves special thanks for reading and commenting on the entire manuscript and offering good and painful advice about shortening it. I should say that his (also long) book, Demanding Medical Excellence, was revelatory and, more than anything e­ lse, set in motion what fi­nally became this one. My repayment to him is a recommendation to read his book. Po­liti­cal scientist and historian James Morone read more than one version of the manuscript, and his ­great enthusiasm helped persuade me to take his advice seriously about how to better tell my story. Medical historian John Warner also commented extensively on an early version. His advice about framing the book was extremely well taken, and his generous words of encouragement kept my spirits up. Physician and medical historian Scott Podolsky gave me extraordinarily detailed comments and suggestions on the penultimate version. He helped me avoid a few ­mistakes in medical facts but, more importantly, inspired other needed improvements. Other physicians have also given me, in both big and small ways, the invaluable input, assistance, and encouragement I needed as a po­liti­cal scientist to venture audaciously into the politics of how medicine has been taught and practiced, not just the politics of guaranteed insurance, the usual turf of po­ liti­cal scientists. They include my ­brother Erik Swenson, Alan Blum, Paul Genecin, John (Skip) Harris, Lydia Howell, Jerome Kassirer, Harlan Krumholz, George Lundberg, and, fi­nally, Richard and Barbara Peters, son and grand­daughter of John P. Peters Jr., the courageous and inspiring medical scientist and reformer I write about. Someone should write a biography of Peters, as well as about other fascinating medical reformers in my story. My former Yale teachers and now colleagues and good friends David Mayhew and Jim Scott ­were more than generous with their time and valuable comments on the manuscript. Modern medical muckraker Howard Wolinsky helped enormously by supplying newspaper articles on the AMA and some of its internal documents that I would other­wise not have found. Thanks also go out to bioethicists, economists, historians, po­liti­cal scientists, and other -­ists Jason Abaluck, Carl Ameringer, Robert Baker, Christy Ford Chapin, Joseph Gabriel, Steve Latham, Victor Macrinici, Isabel Perera, John Roemer, Ian Shapiro, Eric Solberg, Valerie Summers, and Noah Vaca. Fi­nally, not least, love and thanks to my wife, Lina Daly, who combed through two versions of this book and found hundreds of ways to improve my sometimes clumsy writing for clarity and style. Readers should also be grateful to her.

Abbreviations

AAAS AALL AAM AAMC AAP AAPM AASMI AATL ABIMF ACS ADE ADS AFL AHCPR ALIP AMA AMEA AMPAC ANA APhA APHA APS

American Association for the Advancement of Science American Association for ­Labor Legislation American Acad­emy of Medicine Association of American Medical Colleges American Acad­emy of Pediatrics American Acad­emy of Pain Medicine American Association of State Medical Journals American Anti-­Tuberculosis League American Board of Internal Medicine Foundation American College of Surgeons AMA Drug Evaluations American Drug Syndicate American Federation of ­Labor Agency for Health Care Policy and Research Association of Life Insurance Presidents American Medical Association American Medical Editors Association American Medical Po­liti­cal Action Committee American Nurses’ Association American Phar­ma­ceu­ti­cal Association American Public Health Association American Pain Society

xv

xvi A b b r e v i a t i o n s

ATH AWMA BAI BHCAG BOC CCMC CES CES-­M AC CHPI CME CMMS CMS CNH COH CPC CPG CPT CSMB CTR FBI FDA FDCA FSA FSMB GEB GHA GHC HEW HIP HMO HOLC HUAC IHI ILMS ILO IOM LDS MAC MHS MMS

American Therapeutic Society American ­Women’s Medical Association U.S. Bureau of Animal Industry Business Health Care Action Group U.S. Bureau of Chemistry Committee on the Costs of Medical Care Committee on Economic Security CES Medical Advisory Committee AMA Council on Health and Public Instruction AMA Council on Medical Education Center for Medicare and Medicaid Ser­vices Chicago Medical Society Committee for the Nation’s Health Committee of One Hundred on National Health AMA Council on Pharmacy and Chemistry clinical practice guidelines Current Procedural Terminology Confederation of State Medical Examining and Licensing Boards AMA Committee on Therapeutic Research Federal Bureau of Investigation U.S Food and Drug Administration Food, Drug, and Cosmetic Act of 1938 U.S. Federal Security Agency Federation of State Medical Boards Rocke­fel­ler Foundation General Education Board Group Health Association Group Health Cooperative of Puget Sound U.S. Department of Health, Education, and Welfare Health Insurance Plan of Greater New York health maintenance organ­ization Home ­Owners’ Loan Corporation House Un-­A merican Activities Committee Institute for Health Care Improvement Illinois Medical Society International ­Labor Organ­ization Institute of Medicine Church of Jesus Christ of Latter-­day Saints Medical Advisory Committee U.S. Marine Hospital Ser­vice Mas­sa­chu­setts Medical Society

A b b r ev i at i o n s MSA NAM NARD NASPT NASS NBH NCCL NCF NDH NHS NIH NLMF NMA NPA NPC NWDA PAA PAC PAHCF PFDA PGP PHIC PHMHS PHS PMA PSR RBRVS RSC RUC SSA USP VA WMD

xvii

medical specialty association National Association of Manufacturers National Association of Retail Druggists National Association for the Study and Prevention of Tuberculosis North American Spine Society National Board of Health National Constitutional Liberty League National Civic Federation National Department of Health National Health Ser­vice National Institutes of Health National League for Medical Freedom National Medical Association National Physicians Alliance National Physicians’ Committee for the Extension of Medical Ser­vice National Wholesaler Druggists’ Association Proprietary Association of Amer­i­ca po­liti­cal action committee Partnership for Amer­i­ca’s Health Care ­Future Pure Food and Drugs Act of 1906 prepaid group practice Public Health Institute of Chicago U.S. Public Health and Marine Hospital Ser­vice U.S. Public Health Ser­vice Phar­ma­ceu­ti­cal Manufacturers Association Physicians for Social Responsibility Resource-­Based Relative Value Scale Rocke­fel­ler Sanitary Commission for the Eradication of Hookworm Disease Specialty Society RVS Update Committee Social Security Act United States Pharmacopeia U.S. Veterans Administration Wagner-­Murray-­Dingell Bill

This page intentionally left blank

Introduction p o­l i t i­c a l t r a nsfor m at ions i n   a m e r ic a n m e dic i n e

“The state of medicine is an index of the civilization of an age and country,” observed medical sage Oliver Wendell Holmes Sr. in the 1860s. “Medicine is as sensitive to outside influences, po­liti­cal, religious, philosophical, imaginative, as is the barometer to changes of atmospheric density.”1 Profound, dramatic, and at times tumultuous po­liti­cal changes have indeed occurred in American medicine since the country’s beginnings, just as in other realms of society. To some extent, as Holmes would have predicted, they have been triggered by forces acting on the profession and not only, as might be supposed, by the straightforward march of inductive medical science. Also, changes in the medical profession have had reciprocal impacts on society, reinforcing some changes and arresting o­ thers. The mutually interactive transformations have had wide and deep ramifications for the quality, organ­ization, financing, and delivery of medical care. They have also impacted society’s ability to defend itself against disease in order to make the delivery of medical care unnecessary in the first place. One of the most profound po­liti­cal transformations in American medicine began in the early 1920s, around the time the country entered the post–­ World War I period of po­liti­cal conservatism. The dual changes ­were related, but only partially, as this book ­will show. Succeeding the era of progressive reformism that had begun in the 1870s was a new conservative era marked by a ceaseless strug­gle to limit the interventions of state and federal governments 1

2 I n t r o d u c t i o n

in the provision of health care. The profession circled its wagons against lay interference. Decisions and actions in the 1920s, including the election in 1924 of an ultraconservative physician, William A. Pusey, to the presidency of the American Medical Association (AMA), planted ideas that would soon take root and flourish. In his inaugural address, the new president declared that all forms of “social cooperation” promoted by government would “break down individualism” and “set aside the law of natu­ral se­lection.” They would, further, “counteract Nature’s cruel but salutary pro­cess of eliminating the unfit.” Pusey’s was not a drastically aberrant view. At the time, eugenicists’ calls for “race betterment” or “race hygiene” could be heard in the politest of circles, but they mostly s­topped ­after they became rallying cries of Eu­ro­pean fascism. But the thoughts still reverberated inside or­ga­nized medicine. In 1949, the New York State Journal of Medicine editorialized against compulsory health insurance with the argument that “what keeps the ­great majority of ­people well is the fact that they c­ an’t afford to be ill.” It was, admittedly, “a harsh, stern dictum” that would mean that some cases of early tuberculosis and cancer would go undetected. However, the editorial asked, was it not better for a few to perish “rather than that the majority of the population should be encouraged on e­ very occasion to run sniveling to the doctor?” In short, it was time to “hoist Mr. Charles Darwin from his grave and blow life into his ashes” and thereby revive “his tough but practical doctrine of the survival of the fittest.”2 Five years ­later, moderate Republican president Dwight D. Eisenhower sized up the officialdom of the AMA as “a ­little group of reactionary men dead set against any change.”3 The top officialdom of the AMA was indeed an ideologically homogenous oligarchy that boasted of being “the voice of American medicine.” Just how representative it was of the entire profession, or even its own members, ­will never be known. Opinion surveys ­were simply not taken. In any case, considering the enormous po­liti­cal power the AMA could wield, it would have been impolitic for Eisenhower to utter such thoughts aloud to the public and the profession at large. A large contingent of the nation’s doctors, about 65 ­percent, ­were members. ­Because of its team of full-time professional lobbyists in Washington, according to a 1950 Consumer Reports editorial, it was the nation’s most effective pressure group.4 Furthermore, the AMA’s power in medical affairs was buttressed by its alliances with other conservative forces, including the U.S. Chamber of Commerce, the National Association of Manufacturers, and the American Farm Bureau Federation. Its

Introduction

3

most impor­tant ally was the Phar­ma­ceu­ti­cal Manufacturers’ Association. While the AMA backed their agendas, they in turn aligned with it against its worst fear, compulsory national health insurance. To the AMA’s dis­plea­sure, Eisenhower was seeking a centrist solution to the prob­lem of rising health costs and the inability of retirees and the working poor to afford medical and hospital care. Considering the Demo­cratic Party’s ambition to fix the prob­lem, health-­care costs w ­ ere an electoral liability for Republicans. Eisenhower therefore proposed a modest fix, a federal trust fund to subsidize private insurance coverage for higher-­risk customers. He naively thought that his Health Reinsurance Bill, the fulfillment of a promise he had made in his second State of the Union address to Congress, would satisfy both his own and the medical establishment’s ideological predilections against “compulsion.” But the AMA saw red and lobbied successfully against the bill. It was “an entering wedge of socialized medicine,” a top AMA official and its ­future president warned Congress. ­Because of that, Eisenhower fumed, the AMA was “just plain stupid.”5 The ultraconservative AMA of the 1950s was a far cry from the profoundly progressive organ­ization it once had been. In 1914, only a de­cade before dermatologist William Pusey delivered his address to an assembly of the AMA House of Delegates, bacteriologist and physiologist Victor C. Vaughan told the same body that “too much stress has been laid on the sacredness of private property and too ­little on the duty of all to contribute to the welfare of the ­whole.” Indeed, according to the preeminent public health missionary and dean of the University of Michigan School of Medicine, “Preventive medicine is the most potent ­factor in the socialistic movement of the day with which ­every good man feels himself more or less in sympathy.” 6 In 1901, Vaughan’s fellow progressives had restructured and retooled the AMA for po­liti­cal action and then joined lay forces, especially consumer advocates led by w ­ omen, in a crusade against the drug industry. The result was the 1906 Pure Food and Drugs Act. Then the AMA joined an alliance of lay elites to agitate, unsuccessfully, as it turned out, for creating a cabinet-­level department of health for federal research on and public health mea­sures against the spread of dread diseases. In 1912, AMA reformers welcomed President Theodore Roo­se­velt’s leadership of the short-­lived “Bull Moose” Progressive Party, whose planks included a call for establishing a national department of health. Arthur Dean Bevan, an AMA leader who saw “medicine as a function of the state,” circulated a letter to e­ very physician in his home state of Illinois praising the third party’s platform. The platform also

4 I n t r o d u c t i o n

endorsed compulsory health insurance, as did a significant number of AMA leaders, including Alexander Lambert, Roo­se­velt’s friend and physician—so long as it was sensibly designed to serve both society and the profession well. ­These medical progressives did not know that they would be driven out of the ­house of medicine a de­cade ­later. M E D I C O -­P O L I T I C A L E R A S

This book’s portrayal of an arc of change in medical politics challenges a large body of conventional wisdom about the medical profession as a power player in American politics and society throughout the twentieth ­century. All along, as a po­liti­cal interest group doctors have been, it is often supposed, a profoundly conservative force from or­ga­nized medicine’s beginnings in the 1840s through to the pre­sent. In fact, however, before making its sharp right turn in the 1920s the AMA fought for and often helped win reforms championed by other progressive groups. Progressivism as a medico-­political phenomenon began late in the nineteenth c­ entury. Although almost never mentioned in historical works on the Progressive Era, the medical profession actively cooperated with many other social, economic, and po­liti­cal reformers.7 Physician reformers saw their efforts as contributions to general societal, economic, po­liti­cal, and moral uplift and thus joined alliances that intersected professional, civic, philanthropic, commercial, and governmental lines of activity. Medicine’s reformers ­were animated by optimism about the role of both state and private voluntary action, and a collaborative mix of both, guided by professional and scientific expertise, in governing a rapidly growing but severely disordered cap­i­tal­ist society and polity. Professional redemption was a first step. On that, in a cri de coeur addressed to the elite American Acad­emy of Medicine, professor of ophthalmology and otology Leartus Connor summed up in 1898 what he and other reformers considered to be the many “diseases of the medical profession.” They included “overcrowding; a vast number of incompetents; large numbers of moral degenerates; crowds of pure tradesmen; blatant demagogues; hospitals or­ga­nized and conducted to the damage of both profession, patient and ­people; . . . ​medical socie­ties so conducted as to be a by-­word among honest persons, and yet continued to advance the financial profit of their leaders; domination by commercial interests of drug manufacturers and proprietors of secret and proprietary medicines.”8 To redeem the profession, medical pro-

Introduction

5

gressives like Connor desperately desired to expel the grossly unfit and unify the sparsely or­ga­nized remainder. D ­ oing so would rescue the mainstream of the profession from widespread societal ridicule, disdain, loss of income to alternative healers, and, not least, po­liti­cal impotence. High on the invigorated AMA’s reform agenda was getting po­liti­cal and philanthropic help in cleaning up a system of medical education so rotten that it caused one prominent Illinois public health official to “blush for his country.” Eu­ro­pe­ans, he thought, justifiably regarded American medical diplomas as contemptible.9 Hundreds of for-­profit medical colleges competed with each other to attract impecunious students by keeping tuition fees so low and terms so short that their facilities and teaching ­were utterly “wretched,” according to the Car­ne­gie Foundation’s famous 1910 Flexner report, which the AMA secretly instigated, on medical education in the United States and Canada. Genuine medical knowledge was not to be had, and for many students it would have been undigestible anyway ­because of pitifully minimal to non­ex­ is­tent premedical entrance requirements. The vast majority lacked access to hospitals and clinics where bedside teaching was pos­si­ble, so young male doctors w ­ ere sent out to perform deliveries without ever having seen, much less participated in, a delivery, complicated or not. The medical proletariat of the time, literally a “­great unwashed,” was more a vector than a curer of disease. Along with bad medical schools, the burgeoning phar­ma­ceu­ti­cal industry was one of the greatest ­causes of the American medical disorder in the view of doctor-­reformers. Again, shame drove the reformers. “In no other country has the standard and quality of drugs been left entirely to the manufacturers’ honor,” wrote AMA editor George Simmons, with the result that Eu­ro­pean manufacturers shipped “unethical” and “disreputable” products that they could not sell in their own markets across the Atlantic Ocean. The products ­were advertised with “such utter disregard for truth, that it is well ­ ere to be suspicious of all.”10 Vast numbers of Americans, the reformers knew, w dupes of the drug industry’s mongering of useless concoctions for any and all diseases, many of them, like “ovarian neuralgia,” figments of the florid imaginations of medical entrepreneurs. For that par­tic­u­lar female “disturbance,” even the supposedly reputable manufacturer Eli Lilly and Com­pany recommended a cure: its Femagen (strontium bromide mixed with extracts of buckthorn bark, ­horse nettle, and Eu­ro­pean cranberry bush). Doctors prescribing such t­ hings and worse, especially trademarked “nostrums” with entirely secret ingredients, w ­ ere hoodwinked in part by hundreds of cheap medical journals funded by advertisements that boasted of wondrous curative powers.

6 I n t r o d u c t i o n

Many doctors ­were in fact the industry’s partners in crime, suborned by it to write puff pieces and testimonials about worthless drugs in the drug-­infested journals. Last, but far from least, a supreme goal of the reformist medical elite was public health. Public health, as famously summarized in 1920 by Charles-­ Edward Amory Winslow, one of the day’s premier public health experts and founder of Yale University’s School of Public Health, is “the science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through or­ga­nized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in princi­ples of personal hygiene, the organ­ization of medical and nursing ser­vice for the early diagnosis and preventive treatment of disease, and the development of the social machinery which ­will ensure to e­ very individual in the community a standard of living adequate for the maintenance of health.” Such, Winslow argued, would “enable e­ very citizen to realize his birthright of health and longevity.” For the era’s public health missionaries like him, if it meant fewer visits to the doctor and less swallowing of bogus pills and elixirs, all the better.11 On disease prevention and the educational and po­liti­cal mea­sures required for it, the AMA shared with the medical intelligent­sia of the age the philosophy and goals of the American Public Health Association (APHA). Indeed, the AMA was, according to William Woodward, the chief executive of the APHA in 1911, “in the vanguard of preventive medicine.” The two organ­ izations’ shared vision included the creation of a strong national health agency like ­those in Eu­rope that the reformers envied. ­Because of the movement of ­waters, boats, trains, and merchandise combined with weak federal authority, one state’s misdeeds became another state’s fatalities. B ­ ecause vital statistics w ­ ere not systematically collected across the country, research was not pos­si­ble on the incidence of and best practices against waterborne diseases such as cholera, dysentery, intestinal parasites, and typhoid fever. Advocating for the creation of a national department of health, George M. Kober, dean and professor of hygiene at Georgetown University, told a Senate committee in 1910 that major Eu­ro­pean cities like Munich, Vienna, Berlin, Zu­rich, Hamburg, Paris, and London, which all had national health ministries and better ­water purification practices, had lower death rates from typhoid fever, transmitted by h ­ uman fecal m ­ atter, than ­every major American city between 1902 and 1906. The estimated yearly cost to the United States was $354 million. ­Because of state and federal politicians’ actions and inaction on typhoid,

Introduction

7

Editorial cartoon showing the medical profession as an integral part of the national public health movement. From American Medicine, September 1912.

a­ ccording to one public health missionary, those killed by it were victims of criminals, not just a disease.”12 The progressives’ public health and other reform missions w ­ ere interrelated. In their minds, improved medical education and licensure would serve public health, not just remedy the commercial and therapeutic chaos. Needed, for example, w ­ ere doctors who could competently diagnose and appropriately treat cases of diphtheria, tuberculosis, yellow fever, hookworm anemia, and much more and report them to public health authorities for research on their transmission and for the planning of mea­sures to reduce their spread. Better-­ educated doctors, they hoped, would be more impervious to drugmakers’ specious curative claims and therefore become more interested in preventive medicine through personal and public hygiene. MEDICAL PROGRESSIVISM’S LIMITS

It would be wrong to exaggerate the AMA’s progressivism. The reform ele­ment did not address many burning prob­lems, including some that the

8 I n t r o d u c t i o n

following conservative regime also neglected. The top of the profession was dominated almost entirely by wealthy white Protestant males, like most of Amer­i­ca’s interconnected social, economic, and po­liti­cal elites. The all-­black National Medical Association was formed in 1895 ­after African Americans had failed for a quarter c­ entury to gain admittance to the AMA. A ­ fter the AMA’s reor­ga­ni­za­tion in 1901, medical apartheid was maintained when the AMA’s county and state affiliates continued to reject most black physicians, thus shutting the door on their membership at the national level. In 1906, the famous black sociologist, historian, and civil rights activist W. E. B. Du Bois reported on the tiny number of medical schools training black doctors—­only five small ones—­and the existence of only about 1,250 black prac­ti­tion­ers. By 1923, only about fifty African Americans per year graduated with medical degrees to serve over ten million fellow citizens. That year the Journal of the American Medical Association published its first comment on the ­matter, a short editorial including a nonurgent appeal to philanthropists for financial aid to educate more black doctors. It was also the last such entry before the appearance of a lone article in 1944 by Paul Cornely, a black professor of preventive medicine and public health at Howard University and a civil rights leader of the 1950s.13 That was followed in the 1960s by only a handful of articles reacting to the black civil rights movement. As regards racism, ­there was continuity, not change. Racism among doctors was especially overt in the South, including in its medical socie­ties and journals. According to Victor Robinson, an out­spoken and unusually progressive medical journalist, “The negrophobia of the mob is as much in evidence in the editorial pages of the Southern Medical Journal as in the novels of Mr. Thomas Dixon.” His 1916 article concluded, “­There is a shameful chapter in the history of American medicine, and it is headed: The Negro.” Racism was not a frequent feature of articles and editorials in the staid Journal of the American Medical Association but only perhaps b­ ecause the health, lives, and even the basic humanity of black Americans ­were of ­little concern. But one 1906 article reported with uncritical appreciation the conclusions of Robert Bennett Bean, a V ­ irginia anatomist, about “the negro brain.” The article was published in the American Journal of Anatomy, as well as a ­couple of lay magazines. Bean argued that b­ ecause of variations he claimed to have found in the sizes and structures of the brain, African Americans came up short “in the higher faculties” such as “self-­control, ­will power, ethical and esthetic senses and reason.” L ­ ater, the AMA journal neglected to mention a meticulous discrediting of Bean’s study, published three years l­ater in the same

Introduction

9

anatomy journal, by Bean’s Johns Hopkins medical school mentor, the eminent Franklin P. Mall.14 In 1909, in discussing high tuberculosis rates among Blacks, the AMA journal blamed the victims, asserting that, while enslaved, they had “lived a healthy out-­door life,” and only ­because of “the commercial interests of their ­owners they ­were well fed, clothed and lodged.” Since then, however, they had gravitated to the cities, where t­ here was no one to watch over their well-­ being. “Their happy-­go-­lucky disposition has led them to ignore all princi­ ples of sanitation.” In 1910, the journal published an address to the AMA’s Section on Diseases of ­Children, delivered by a Mississippi health official, on “The Negro as a Health Prob­lem.” It was full of extremely degrading observations about African Americans and their lapse back into their former “aboriginal conditions” and “African condition of irresponsibility.” It asserted smugly that “the darkey,” or at least ­those enslaved by “the better class” of ­owners, had been blessed with better health before emancipation. They had received the “very best treatment” b­ ecause of their enslavers’ “humane motive,” not just “economic consideration” for their expensive pieces of property. Another 1910 article on syphilis in the AMA journal by a ­Virginia medical professor ventured many similarly degrading observations about Blacks and the supposed health benefits of their former enslavement.15 Also, the AMA journal failed to mention W. E. B. Du Bois’s The Health and Physique of the Negro American, appearing in 1906. In it, Du Bois reprinted an article by young sociologist Herbert A. Miller on the overlooked environmental and related psychological ­causes of observed differences between the races. In spite of its frequent attention to the relations between hygiene and disease, the AMA journal ignored the 1906 resolutions of a recent Atlanta University Conference for the Study of Negro Prob­lems, which declared that racial differences in mortality ­were best explained by “conditions of life” and that “no adequate scientific warrant” existed for the assumption that Blacks ­were inferior to other races in “vitality.” That medical wisdom came not out of the medical profession’s top scientists and statesmen but from laypeople. The resolutions w ­ ere drafted by Du Bois, along with Richard R. Wright, the first African American to receive a doctorate in sociology (from the University of Pennsylvania), and Franz Boas, “the founding f­ather of American anthropology,” whose ­later writings would make him famous for, among other ­things, his arguments against prevailing “scientific racism.” Interestingly, a 1914 article in the AMA journal by the famous tuberculosis expert S. Adolphus Knopf on tuberculosis as “a cause and result of poverty” neglected to use the

10 I n t r o d u c t i o n

occasion to bring up the question of racism as a cause of poverty and therefore disease. Even the American Journal of Public Health found it fitting to publish a paper, delivered by a public health advocate to a meeting of the APHA that spoke of “the negro” as a health threat to whites they inevitably came into contact with. Their pathogenic surroundings and be­hav­ior ­were the result of “our neglect” to do what was necessary to compensate for their “­mental equipment,” “superstitions,” “racial weakness,” and “racial inferiority,” as well as their own “ignorant physicians.”16 No medical reformer seemed to have taken an out­spoken stand against eugenics, the scientific study of inherited physical and ­mental pathologies and the less benign advocacy of scientifically unfounded policy mea­sures for the improvement of “the racial stock.” A few, especially Victor Vaughan, strongly endorsed ­things like forced sterilization and helped persuade Michigan legislators to pass a sterilization law. Other such mea­sures to reduce the numbers of “degenerates, delinquents, and defectives” w ­ ere restrictive marriage licensing and immigration controls. Amer­i­ca hosted the intellectual originators of eugenics, and many states served as international vanguards, with mea­sures such as the mass sterilization of institutionalized populations. Hitler was impressed. Surgeons Charles and William Mayo, who had both served stints as AMA president, privately welcomed the influence of eugenics, although neither lent his name to the cause, unlike Vaughan and pioneering bacteriologist and medical educator William H. Welch, an AMA reformer of towering repute. Of course, one cannot as­suredly infer from Welch’s involvement in eugenics research strong agreement with sterilization or other such policies. To his credit, the AMA journal, in the hands of editor George Simmons, treated eugenics with a mix of diffidence and caution in a scattering of editorials and book reviews. Its articles put more stock in removing the environ­ eople, not improving their mental c­ auses of the diseases suffered by white p ge­ne­tic makeup. As a 1907 editorial put it, “If the salvation of the race depends solely on the encouragement of multiplication among desirable citizens and the discouragement or prevention of procreation among o­ thers, impor­ tant as t­ hese objects appear, it seems doubtful how far it w ­ ill ever be attained.”17 Although published AMA material treated w ­ omen with more restraint than Blacks as men’s supposed inferiors, they, too, ­were mostly obstructed from entry into the medical profession and its associational life. The AMA did not demand nondiscrimination by local and state socie­ties as a condition for their incorporation into the federation. That is not to say that t­ here was no support for w ­ omen in medicine among some of the progressive medical reformers. Among them, not surprisingly, was Abraham Jacobi,

Introduction

11

elected AMA president in 1912, whose wife, Mary Putnam Jacobi, ­daughter of the publisher George Putnam, was a physician, medical writer, suffragist, and founder and long-­term president of the Association for the Advancement of the Medical Education of ­Women. She was a “bright par­tic­u­lar star in the firmament in the profession,” thought the eminent and revered William Osler.18 Inadvertently, the progressives’ expensive education reforms also reduced ­ omen’s medical colleges, just as the already small number of badly funded w they had the schools for black physicians. State governments and wealthy philanthropists channeled money to medical schools that took in very few ­women. Nurses’ authority and responsibilities in hospital care w ­ ere suppressed and nursing education constrained. Nurse-­midwives—­often more capable (and cleaner) than licensed male doctors—­were embattled by obstetricians seeking to displace them entirely. Consequently, many more babies and ­mothers died than necessary, given the widespread neglect in medical schools of training in obstetrics.19 I N SU R G E NC Y, C ON S E RVAT I S M , A N D PROGRESSIVE DRIFT

Ironically, as a ­later chapter ­will show, the progressive AMA’s reform efforts and alliances with lay progressives for drug, health, and medical education reform helped sow the very internal division that helped fuel a massive insurgency and the 1920s reactionary turn. One dominant ele­ment in the profession was deposed from power by another oligarchy; the new reactionary ele­ment had dif­fer­ent goals, but working in its f­avor was the fact that none ­were jarringly out of alignment with the perceived economic interests and often benighted clinical practices of the lower and middling ranks of medicine. The progressives’ friendly attitude t­oward a lay movement for compulsory health insurance, largely ­because they saw it as a means to advance public health, was one cause for rebellion. Another was the reformers’ propaganda against useless therapeutics, including the rampant prescription of “patent medicines” with unknown ingredients, and even alcoholic beverages, for a vast array of diseases. The progressives’ campaign against atrocious medical schools would not have endeared them to the thousands of gradu­ates of ­those very schools who proudly displayed their diplomas on their examining room walls. An additional subterranean current of rank-­and-­file disaffection flowed from the fact that public health mea­sures so heartily championed by progressives reduced demand for their clinical ser­vices.

12 I n t r o d u c t i o n

A chapter in the final section of this book w ­ ill survey in detail the main features of American medicine’s conservative era, including, perhaps most importantly, the AMA’s opposition to the inclusion of health insurance in the 1935 Social Security Act and subsequent efforts in the following six de­cades to pass universal coverage. Other related features include its perennial criticism of the Veterans Administration’s coverage of military veterans with non-­ combat-­related conditions and even the rise of private voluntary systems of affordable health care such as “prepaid group practices,” precursors of ­today’s “health maintenance organ­izations” such as Kaiser Permanente. The AMA, it w ­ ill be learned, played no active role in the passage of the 1938 Food, Drug, and Cosmetics Act, which checked the introduction of drugs into the market before they ­were tested for safety. Instead, lay forces in the consumer movement did all the heavy lifting. In 1962, almost twenty-­five years l­ater, the AMA overtly opposed a new law requiring the testing of new drugs in “adequate and well-­controlled” clinical studies to establish clinical efficacy as well as safety. Starting in the 1950s, the AMA vociferously opposed the federally funded expansion of medical schools to deal with a projected shortage of physicians. In 1952, it successfully blocked an amendment to the Social Security system that would have extended benefits to workers who became disabled and lost gainful employment before the official retirement age. In 1953, it balked at a federal executive reor­ga­ni­za­tion plan creating the new U.S. Department of Health, Education, and Welfare (HEW) and could only be appeased by a special visit from President Eisenhower to a meeting of the AMA House of Delegates to promise that the new department would do nothing to socialize any aspect of medical care. The discussion of the AMA’s conservative era ­will reveal its need for po­ liti­cal alliances with lay economic interests to promote overlapping as well as distinct goals in national politics. Without them, it would not have scored many victories. For example, it defended the phar­ma­ceu­ti­cal industry against legislative efforts to eliminate its monopolistic practices and high pricing, a shared goal ­because lucrative drug-­advertising fees charged by the AMA’s journals tapped into the industry’s high earnings. It also sided with the drug industry as a nominal opponent to legislation requiring efficacy as well as safety studies before the introduction of new drugs to physicians’ therapeutic armamentarium. In real­ity, the big drug companies w ­ ere not strongly opposed to that reform, which legislators knew, b­ ecause it would help drive smaller competitors unable to bear the extra costs out of business. Therefore, the AMA, standing alone, lost that b­ attle. The conservative alliance also included the

Introduction

13

tobacco growers and cigarette companies, which gladly joined the AMA in opposition to compulsory health insurance. Despite strong evidence since the early 1950s of the carcinogenic influence of cigarette smoke and, even e­ arlier, coronary artery disease, the AMA expressed doubt into the 1960s about the addictiveness of smoking. As late as 1985, the AMA trustees criticized smokers’ lawsuits against the industry as “in­effec­tive” and urged doctors not to testify for plaintiffs that smoking was a cause of disease. It was not u ­ ntil the early 1990s that the AMA actively joined lay forces in campaigns against smoking. Meanwhile, the AMA’s hostile stance t­ oward government interventions in public health as well as medical m ­ atters made itself felt in the influence that it and its state and local affiliates exercised in the appointment of officials throughout the public health system. Wherever pos­si­ble, it insisted on being allowed to vet prospective appointees and even on the right to nominate doctors who ­were members in good standing and therefore shared or­ga­nized medicine’s medical and po­liti­cal philosophy. Despite solid evidence of widespread poor-­quality practices, unnecessary procedures, and fraudulent billing, the AMA also objected strenuously to public health agencies’ desire to protect taxpayers as well as patients by auditing doctors paid by Medicaid out of state and federal revenues. If such had to happen, it insisted that medical “peers” be chosen by state or county medical socie­ties to conduct the audits. But starting in the late 1960s, a new progressivism, largely outside the profession’s power­ful orga­nizational edifice, was on the rise. The medical profession had begun to suffer a decay in trust, prestige, and po­liti­cal power. The AMA’s opposition to Medicare, passed in 1965 for the retired el­derly population unable to afford private insurance, badly tarnished the shiny, altruistic veneer laid on thickly by public relations efforts. In effect, it called for denying to a large portion of the population access to the profession’s services—­ allegedly the best in the world. Many doctors, not just laypeople, w ­ ere appalled at what they regarded as or­ga­nized medicine’s crass selfishness in insisting that only the indigent el­derly be guaranteed care while modestly well-­off retirees could not afford individual private insurance. The AMA’s paranoiac rhe­toric against compulsory health insurance appeared ridicu­lous in light of the fact that universal health care in Eu­rope had not resulted in socialist dictatorships and atrocious medical care, as the AMA had repeatedly warned. Then, in the 1970s, a series of scandalizing newspaper stories relying on purloined documents delivered to reporters from inside the AMA’s headquarters did more ­ ere about executives’ tawdry financial damage to the AMA. Some of them w

14 I n t r o d u c t i o n

dealings. Even more damaging was the exposure of its illicit relations with the phar­ma­ceu­ti­cal industry and, shockingly, even tobacco farmers and cigarette makers. Another devastating development for the conservative medical regime was the rapid rise of health-­care costs, starting in the 1970s and continuing beyond. The AMA had fiercely defended fee-­for-­service payment for medical care by private as well as public insurers, a model of health-­care delivery that preserved clinical autonomy. It drove up volume rather than value, a medico-­ economic victory that contributed to ­later defeats. ­Because Amer­i­ca’s employers ­were picking up a large share of their workers’ health-­care costs, they saw themselves as major losers to the medical profession. Most aggrieved w ­ ere the larger and therefore more power­ful ones vulnerable to intensifying competition from manufacturers in countries with lower health costs. With that, a power­ful ele­ment in the conservative medical alliance started to split away. Major employers even began thinking friendly thoughts about using compulsory health insurance to limit the shifting of health-­care costs for the uninsured to them by doctors, hospitals, and insurance companies. It would also, they thought, help create a more level competitive playing field by imposing costs on firms competing in the same domestic markets that had lower health costs b­ ecause they did not insure their workers. Then the AMA suffered a crushing blow when a bipartisan, cross-­ ideological deregulatory movement of the 1970s led to a ruling by the U.S. Federal Trade Commission (FTC) in 1979 that declared that since the 1930s the AMA had been engaging in a “national conspiracy in restraint of trade” in violation of the Sherman Anti-­Trust Act. The ruling put an end to or­ga­ nized medicine’s expulsion of members, which had, in effect and intent, blacklisted them from hospital staffing if they defied the AMA’s ethical strictures by participating in the “corporate practice of medicine” and other­wise dissenting from its medico-­economic princi­ples. The FTC decision delivered the conservative medical regime a brutal blow by eliminating the AMA’s ability to compel doctors to join by denying hospital appointments to t­ hose who refused. The FTC ruling’s impact was magnified by employers’ desire to corral their workers into corporate “managed care” arrangements that could play doctors and hospitals off against each other to lower fees and save money. A third power­ful f­ actor added to the mix to hobble the conservative medical regime: the severe erosion of public trust in the profession based on an earlier belief in its delivery of a uniformly high quality of clinical service—­ supposedly based on solid scientific foundations. Medical scientists themselves

Introduction

15

intentionally helped undermine that blind trust. Out of academic medicine and health ser­vices research came astonishing and disturbing findings of massive waste in the delivery of expensive health-­care ser­vices that could only be explained by the ignorance of clinicians about what constituted efficacious practices and therefore eco­nom­ically valuable care. Politicians paid close attention, worried as they ­were about holding taxes down while Medicare was making rapidly rising demands on the federal bud­get. Corporations trying to get their own health-­care costs ­under control also took notice. Meanwhile, influential doctors joined the chorus of lay critics of their own profession. A code of silence about the faults of medicine was broken. Or­ga­ nized medicine, according to the profession’s own vocal critics, was riddled with conflicts of interest as part of a vast “medical industrial complex.” Thus, currents of a new medical progressivism began to flow into, but mostly around and outside of, or­ga­nized medicine. Once a formidable force, it was now shrinking. Hobbled by its heavy baggage as just another special interest group allied with ­others, it was unable to take the lead as a progressive force.20 MEDIC A L TR A NSFOR M ATIONS A ND POW ER POLITICS

Past scholarly inattention to the complex interactions of medical power politics and system transformations helps explain the fact that t­ here is relatively scarce knowledge about medicine’s ­earlier progressivism, no existing narrative on the reactionary turn, and no analy­sis of the current progressive drift in its historical context. Some scholars have failed to detect any progressivism at all in or­ga­nized medicine.21 ­Those who have noted the AMA’s reformism in distinct drug, public health, medical education, and insurance reforms have missed the fact that they ­were all of a piece with a larger progressive agenda.22 ­Others who note a break from progressivism do not offer explanations grounded in detailed evidence. For a speculative explanation, one scholar focuses exclusively on the controversy inside the AMA over compulsory health insurance around 1920, when in fact the internal turmoil leading to the reactionary turn began before that time and continued well beyond it. Another attaches significance to the influence on the medical profession of a relatively moderate po­liti­cal shift to the right in the American polity, when in fact previous developments endogenous to medicine ­were far more impor­tant, and the medical shift was far more extreme and enduring than the po­liti­cal one.

16 I n t r o d u c t i o n

­ thers speculate, with some justification, that a turnover in leadership in the O AMA brought the change but do not explain why that turnover happened in the first place.23 In short, the lit­er­a­ture requires impor­tant corrections, detailed additions, an integrated narrative, and therefore the overall reformulation provided in this book. Some scholars explic­itly reject the idea of a radical break. On the one side are historians who regard the Progressive Era reform efforts to improve undergraduate medical instruction and gradu­ate clinical training as conservative both in intent and effect, made largely to restrict the number of physicians competing for patients’ fees and thereby propping up the profession’s income. ­Later medical politics, it is argued, remained conservative ­because the prime focus remained on securing and expanding professional autonomy, income, and power.24 Ironically, right-­leaning free-­market economists with immodest historical ambitions but l­ittle empirical evidence for their theoretical speculations join historians who see no ­great transformation. Projecting evidence from theory, they also see roots of Progressive Era medical licensing and education reforms in petty bourgeois interests no dif­fer­ent from the protection of every­thing from beauticians and morticians to huge industrial and financial corporations. Supposedly, altruistic claims proffered by hypocritical medical reformers about the advantages for public health ­were, like ­those of other occupational and commercial interest groups, mere subterfuge for selfish interests against competitors threatening to capture their market shares.25 Readers of this book ­will find refutations of the economists’ perspective throughout in discussions about what other economists call “adverse se­lection”—­the perverse effects of economic competition in information-­poor market environments. Progressive Era medical leaders sought to neutralize pervasive adverse se­lection in commercialized medicine, which led to the bad driving out the good, the survival of the foulest, and a race to the bottom— or, as an economist might put it, at least down to a low-­value equilibrium.26 An impor­tant study of American medical politics with an economistic bent, which also portrays a seamless weave of developments from the Progressive Era into the following conservative phase, is sociologist Paul Starr’s The Social Transformation of American Medicine. It deserves special mention ­here, and focused discussion in a l­ater chapter, partly b­ ecause of the book’s enormous success and influence. Starr addresses head-on the question of medical power. Like the economists, for example, he imputes to licensing reformers largely selfish motives. Licensure, he says, was part of a general movement

Introduction

17

in the late nineteenth ­century of “plumbers, barbers, ­horse­shoers, pharmacists, embalmers and sundry other groups.” A low estimation of physicians’ earnings cited in the AMA journal, he suggests, was “self-­serving.” According to Starr, the profession’s reformers wanted to shut down the many cheap medical schools whose degrees w ­ ere recognized by licensing authorities ­because the overproduction of doctors depressed earnings and ­because the working-­class and lower-­middle-­class “riffraff” admitted into practice needed to be “sloughed off” so the profession could become a socially respected and therefore power­ful profession.27 Starr depicts the profession throughout as resolutely in pursuit of mono­ poly income, tight and inclusive organ­ization, autonomous professional self-­ regulation, elevated social status from scientifically and therefore culturally legitimated authority, and, ultimately, po­liti­cal power. Or­ga­nized medicine’s overarching purpose, according to Starr, was to establish “physician sovereignty” before the 1920s and then defend it in the face of lay forces seeking to change how health care was financed, or­ga­nized, and delivered. The varying objectives supposedly had interrelated and mutually reinforcing purposes. For example, “by augmenting demand and controlling supply,” Starr writes, doctors collectively parlayed scientifically legitimated professional authority into “control of markets, organ­izations, and governmental policy.” Thus, from 1900 on and by the 1920s, he maintains, the profession mobilized to install the institutional pillars of a “medical system,” from licensure and medical schooling to hospital management, which conferred nearly uncontested professional sovereignty.28 It was a ­grand unifying strategy of supreme dominion in health care. To be sure, Starr’s book remains in many particulars a valuable study, especially about or­ga­nized medicine’s defeat with the “corporate” transformation of health-­care financing and delivery in the late twentieth ­century. But on the questions of transitions and po­liti­cal power, it needs scrutiny and correction. This book’s chapter titled “Medical Power Politics” ­will critically address the prob­lems of evidence and interpretation. Suffice it to say, ­here, that the considerable but actually l­imited cultural authority that the conservative profession wielded was not demonstrably the product of highly efficacious clinical science, be it real or i­magined. As the following chapters on medicine’s Progressive Era ­will indicate, much of medicine’s cultural authority during the conservative era was established largely b­ ecause its progressive pre­de­ces­sors succeeded in redeeming the profession in the public’s eye as a selfless force for public health—­for prevention,

18 I n t r o d u c t i o n

not the cure, of disease. Their mea­sures promised to reduce, not increase, the demand for physicians and thereby depress their incomes. They also earned public re­spect with their bruising b­ attles against a power­ful and corrupt drug industry, the nation’s biggest economic lobby group. In short, when the post1920s medical politicians seized control of the AMA, they ­were able to lay claim to a large reserve of cultural legitimacy already banked by their pre­de­ ces­sors for reasons other than people’s illusory belief that what doctors practiced on them was based on rigorous training in good medical science. They could then wield the profession’s hard-­won prestige on behalf of a protectionist economic agenda, not the progressive agenda of their socially minded pre­de­ces­sors.

chapter 1

Medical Mayhem

In 1900, before the Thirteenth International Medical Congress in Paris, France, German émigré Abraham Jacobi, in an address titled “Medicine and Medical Men in the United States,” praised the recently surfacing islands of scientific and educational excellence at a few universities, medical publishing ­houses, and professional journals. But the New York medical leader and ­future president of the American Medical Association also painted a grim picture of numerous other medical schools that grew “like toadstools” to propagate spores of “low-­grade prac­ti­tion­ers.” Th ­ ere w ­ ere also no fewer than three hundred “medical, or alleged, medical journals.” Many ­were edited by commercially tainted doctors and published puff articles for worthless trademarked “patent medicines.” Unfortunately, Jacobi added, “the vast majority of the physicians accept them, employ them, and recommend them.” Advertisements ­ ere in “mercenary and meretricious” journals, Jacobi wrote a few years l­ater, w responsible for the disturbing fact that an alarmingly large percentage of doctors’ prescriptions called for remedies containing secret ingredients in unknown quantities.1 At the turn of the twentieth ­century, the business and practice of medicine in Amer­i­ca was hardly less chaotic than other raucously competitive po­ liti­cal, industrial, commercial, and professional realms of life.2 As medical sage Oliver Wendell Holmes Sr. observed in 1869, “The state of medicine is an index of the civilization of an age and country.” Medicine, he wrote, “is as 21

22

The American Medical Disorder

sensitive to outside influences, po­liti­cal, religious, philosophical, imaginative, as is the barometer to changes of atmospheric density.”3 Among t­ hose outside forces that medicine’s critics confronted was Amer­i­ca’s secular religion of the ­free market, which was supposed to create and increase value, or quality worth the price. Instead, the workings of unfettered markets in medicine—as in manufacturing, railroading, and banking—­often depressed standards and, consequently, the profession’s public esteem and po­liti­cal influence. Medical reformers like Jacobi could not easily persuade politicians to pass the legislation they needed to improve their reputation: regulation to control shady competition and elevate the standards of legitimate prac­ti­tion­ers. The joint failure of the market and government to regulate the business of medicine meant that a glut of doctors pumped out by scores of cheap, for-­profit medical schools competed ferociously with each other for patients’ confused minds, strapped resources, and fickle loyalties. Badly trained doctors offered their unwitting patients a chaotic array of dubious cures and treatments. They heaped contempt on each other’s theories and methods—­and on the medical schools that taught them. The multimorbidity and therapeutic chaos of American medicine was in part a consequence of the country’s anarchic entrepreneurial capitalism. Starting around the 1880s, businessmen stampeded into the easy-­entry and thus hypercompetitive drug trade with hosts of unscrupulously advertised, mass-­ produced proprietary (trademarked) cures. The industry’s output in 1904 was twenty times what it had been forty years e­ arlier. Medical anarchy ruled through direct-­ to-­ consumer advertising and therefore widespread self-­ medication, often with dangerous and addictive concoctions. But doctors also served as a vast army of unpaid middlemen for the industry. Hence, according to Bostonian Richard C. Cabot, one of medicine’s most severe internal critics, “I believe that we not only feed the public demand for useless and harmful drugs, but also go far to create that very demand.” 4 Childhood and female ailments w ­ ere particularly profitable sources of advertisement-­induced demand. Recommended for ­women and girls ­were cure-­a lls like Dr. Kilmer’s Female Remedy for “ner­vous or sick headache, stomachache, backache, spineache, bloating, internal heat, scalding urine, chronic weakness, bearing down or perversions incident to life change, uterine catarrh, suppressed or painful periods, ovarian dropsy, suspicious growths disposed to tumor or cancer or hemorrhage, run-­down constitution, and dull tired looks and feelings.” The active ingredients ­were not mentioned on its label. It also advised m ­ others to “give it to your weak and delicate d ­ aughters.”



M e d i c a l M ay h e m

23

The widespread sale and use of power­f ul and potentially fatal drugs as home remedies for teething ­were not just a consequence of greed and ignorance. ­Family doctors shared the blame. Many of them, even into the twentieth c­ entury, considered “dentition” (teething) a potentially fatal condition and therefore prescribed opiates to soothe it. “The readiness to attribute all the diseases of infantile life to teething has destroyed more h ­ uman beings than many of the wars described in history,” growled Jacobi, founder of the country’s first ­children’s clinic and regarded ­today as the ­father of American pediatrics. He had scoffed at the idea of teething as a disease as early as the 1860s.5 Infants who survived that therapeutic assault on their lives faced further ­hazards of medical chaos in the form of surgical attacks on their benignly enlarged tonsils and adenoids. ­Because ­there ­were no antibiotics, many who underwent surgery died from worse infections than t­ hose that caused the swelling. Hemorrhage was another risk. Death by ether or chloroform was yet another. Of course, adults also perished ­under the scalpel and other tools of the medical trade. Chicago’s reform-­minded surgeon Frank Billings, a towering figure in early twentieth-­century medical politics—­elected president of the AMA in 1903—­told first-­year medical students at his city’s Rush Medical College that the degree they sought was a license to commit “murder and lesser sins.” 6 All licensed doctors were legally ­free to call themselves surgeons, even before a hospital internship or surgical residency. ­Women ­were disproportionately represented among the adult victims of medical gradu­ates who boldly ventured into well-­remunerated surgical c­ areers. In 1906, surgeon and AMA reformer Arthur Dean Bevan estimated that about one-­t hird of gynecological operations performed—­a ll entailing substantial risk—­were unnecessary.7 Another common ­hazard of the surgical jungle was “Battey’s operation,” the removal of healthy ovaries, introduced in 1872. Although by 1885 it had already come ­under disrepute among more enlightened gynecologists, “normal bilateral ovariectomy” remained for de­cades a panacea for irregular menses, uterine bleeding, “pelvic neurosis,” “oophoro-­mania,” “oophoro-­epilepsy,” and “certain incurable flexions of the uterus.” In 1909 a stern critic noted that “if the proper remedy for the trou­ble in a ­woman be the removal of the ovaries, it is, to say the least, remarkable that no one has ever suggested removing the testicles for the relief of neuroses and ­mental aberrations in a man.” Another ventured that “­were surgery of such extent and involving the same mutilation of the sexual system to be as commonly applied to the male organs . . . ​the real import of the subject would be apparent.”

24

The American Medical Disorder

Many well-­paid operators had l­ittle gynecological training. Around 1900, in Milwaukee, a hospital superintendent banned students’ presence at operations on w ­ omen where “any exposure” took place. B ­ ehind this was not only common prudery but also female patients’ understandable aversion to young, ill-­mannered, and generally undisciplined male students.8 ­Children and adults alike in the rural South w ­ ere spared dangerous operations, but not diseases that could be prevented or treated safely. ­Because of its stagnant economy, a multitude of dirt-­poor citizens had ­limited access to medical care though they had greater need of it. Unhygienic and unsanitary conditions made poor whites hardly less vulnerable to cholera and typhoid than Blacks. They w ­ ere worse off in one way b­ ecause of their greater susceptibility to hookworm infestation. Hookworms, which lurked in the soil, found their way into the small intestines of victims, leading to severe iron-­ deficiency anemia, intestinal blood loss, protein malnutrition, and—in ­children—­growth retardation and intellectual and cognitive impairments. Thus, at the turn of the ­century as many as seven million, or 40 ­percent, of Southerners hosted hookworms.9 Northerners joked that hookworm was the South’s “germ of laziness” ­because of the South’s economic torpor. In fact, hookworm disease turned many of its hosts into what some nonvictims derided as “lazy white trash”: stunted, yellow-­skinned, physically and mentally slothful beings. ­Because the hookworm was picked up by walking barefoot in areas where ­human feces ­were deposited, shoes and well-­designed privies w ­ ere the best defense. However, grinding poverty, a warm climate, and the con­ve­nience of the socially respectable retreat to privacy in the weeds or woods combined to make them relatively rare. While their Eu­ro­pean counter­parts had known what it was and how to treat it since the 1880s, no Southern doctors knew to offer the cure of thymol, a vermifuge costing an average of fifty cents, and a chaser of Epsom salts. Th ­ ere w ­ ere no good public health authorities to impose preventive mea­sures. On top of all the other societal maladies, bad politics, the “Bacillus politicus,” also made for bad medicine for Americans of all colors and classes. Rampant infectious disease did not even spare well-­to-do whites. The mix of corrupt politics and bad medicine started from the bottom up, from city councils and health authorities all the way to Congress and the federal bureaucracy. Private interests, from the keepers of grimy saloons (often ward heelers in urban party machines) to rich merchants and industrial manufacturers, blocked public sanitation and quarantine mea­sures.10



M e d i c a l M ay h e m

25

In Philadelphia, a host of saloonkeepers fought the efforts of a public health expert, the author of a textbook on respiratory diseases, to have public toilets installed. Like other big American cities, according to a major medical journal, Philadelphia was “shamefully b­ ehind Eu­rope where public accommodations are found in abundance.” Pub ­owners’ ­free but filthy toilet facilities brought in as much trade as the ­free lunches that came with drinks. Petty ward heelers often enlisted publicans to buy votes with ­free drinks, which made them a ­ uman potentially power­ful force in city politics. The bacilli of typhoid in h feces and alcoholism spread together.11 In 1909, typhoid, which brought death in 10 to 30 ­percent of cases, was a good mea­sure of how relatively benighted American civilization was and of the inefficiency of its government. Despite knowledge from bacteriology and widespread Eu­ro­pean experience with its control, typhoid was still a major killer in Amer­i­ca. Thus, according to leftist medical critic James Peter Warbasse, “Typhoid fever has passed beyond the cata­logue of disease.” ­Because of politicians’ actions, “it is a crime.”12 Businessmen ­were in league with corrupt politicians as accessories to typhoid epidemics and other crimes of omission. An outbreak of bubonic plague in San Francisco in 1900 led to a quarantine of Chinatown, where the first cases had been reported. ­Because of the hardship it created, Chinese residents clamored to have the quarantine lifted and succeeded only ­because the business community and newspapers relying on advertising supported the cause. It was not out of sympathy for the Chinese. It was worse for business to spread a bad reputation than a deadly disease. Ten years, l­ater, the New York Times reported that plague remained a threat in California, blaming inferior po­liti­cal leadership. Many thousands survived thanks only to the fact that the American flea was a much less efficient vector of the bacillus than its Eu­ro­pean and Asian relatives.13 The rule of party bosses and their delivery of patronage jobs and benefits for their machine operatives vitiated the l­imited potential of badly funded and managed community hospitals, as well as public health agencies. Health-­ related jobs had to go to po­liti­cal hacks demanding rewards from their victorious patron for helping throw out the incumbent mayor. As Abraham Lincoln said about patronage politics, ­there ­were not enough teats for the piglets. Thus, according to the brilliant clinician and medical critic Richard Cabot, the man­ ag­ers and staff installed in ninety-­nine out of one hundred public hospitals around the country ­were guilty of “ignorance, cruelty, and negligence.” His remedy, a progressive one, was sunshine, the ­great disinfectant: “One live

26

The American Medical Disorder

newspaper reporter to be taken internally three hours before his newspaper goes to press w ­ ill be found sufficient to cure the most virulent case of mismanagement.” The Chicago Tribune sympathetically conveyed his message, but Cook County Hospital would have a very long way to go.14 Industrialists as a supremely power­ful part of American “civilization,” to use Holmes’s word, contributed their share to the medical disorder. They actively resisted laws that emerging medical science recommended and beat down l­abor u ­ nions that might have lobbied for them—or at least collectively bargained for better health and safety standards. In New York, one investigation showed, vast numbers of industrial workers suffered permanent damage from septicemia, or blood poisoning, for the ­simple reason that proper care was not rendered immediately and correctly a­ fter injuries.15 A surplus of cheap, unskilled workers as strikebreakers helped employers resist ­unionization. The vagaries of civil justice as a remedy for employer negligence meant that expensive lawsuits failed to provide an incentive for improvement. In general, Amer­i­ca was ­behind in “industrial hygiene.” Doctors ­were not required, as Eu­ro­pean doctors often w ­ ere, to report statistics on occupational diseases like hatters’ shakes, potters’ rot, paint­ers’ colic and wrist drop, caisson workers’ bends, brass workers’ chills, glassblowers’ cataracts, miners’ asthma, and so on. Many more de­cades would pass before controls ­were legislated on the use of lead, a neurotoxin and endocrine disruptor, in manufacturing operations and ­house­hold paints. CH AO S , C OM EDY, A N D CR I M E

Other victims of Amer­i­ca’s medical disorder w ­ ere doctors themselves, collectively as well as individually. Many citizens justifiably scoffed at orthodox prac­ti­tion­ers’ claims to scientific backing and therapeutic efficacy relative to alternative prac­ti­tion­ers, and preferred the latter’s safer remedies. Among the skeptics ­were no small number of wealthy and power­ful Americans who sought out “irregulars,” especially homeopaths. The homeopathic pharmacopeia, according to the orthodox “regulars,” was at best a harmless cocktail of placebo and mumbo jumbo (exceedingly dilute active substances delivered with a mysterious theory about their special pro­cessing and therapeutic workings). It had spread widely in Amer­i­ca in the nineteenth ­century in direct reaction to the heroic bleedings and harsh purgative toxins administered by the regular prac­ti­tion­ers of the time. Homeopathy thrived even as the regulars gradually abandoned their heroic practices.16



M e d i c a l M ay h e m

27

One of the most notable of homeopathy’s adherents l­ater in the c­ entury was the fabulously wealthy Standard Oil magnate John D. Rocke­fel­ler Sr., who was also eccentrically fastidious about healthy eating as the best way to fend off disease. Presidents James Garfield and William McKinley also sought out distinguished homeopathic prac­ti­tion­ers and furthered the ambitions of their school of medicine. So did Amer­i­ca’s most famous public figure, Mark Twain, whose writings contained serious as well as wry criticism of the homeopaths’ orthodox competitors.17 Many in vari­ous echelons of society also gravitated to the “eclectic” school of irregulars, who, like the homeopaths, had their own presumably safer pharmacopeia—­botanicals. O ­ thers, especially ­women, shunned drugs and surgery altogether, finding medical help in the arms of “Christ, Scientist.” Plenty of public ribbing, sarcasm, and ridicule hounded mainstream medical prac­ti­tion­ers. In 1912 Elbert Hubbard, a well-­k nown American writer, publisher, homespun phi­los­o­pher, and major figure in the Arts and Crafts movement in design and architecture, said, “The medicos are the butt of many a joke.” The highest circles of American medicine noticed Hubbard’s work with embarrassment. His magazine, The Philistine: A Periodical of Protest, administered repeated doses of sardonicism about the medical profession to a readership upward of 125,000. Hubbard’s acquaintances, correspondents, readers, and friends included a president (Theodore Roo­se­velt), a secretary of state (John Hay), major poets and writers (Hart Crane, Philip Crane, Robert Frost, Edward Everett Hale, Robert Green Ingersoll, Carl Sandburg), and a pioneering architect (Frank Lloyd Wright). In one year, 1904, two Supreme Court justices, eight senators, and forty-­six congressmen ­were subscribers. Hubbard was popu­lar in business circles, too, and corresponded sympathetically with the iatrophobe John D. Rocke­fel­ler Sr.18 Hubbard ridiculed doctors’ prescription of useless drugs, a “subterfuge” to suit the whims and prejudices of gullible patients. Medicine was no science, just a “system of guesswork.” Doctors who “know so many t­ hings that are not so” act only too gladly upon that knowledge, he said. They “scare you into fits and then cure them for a modest consideration.” Among the worst ­were “lopsided, one-­sided” specialists. For example, “Most nose specialists w ­ ill treat you for corns, per nasal douche, if they get the chance.” Hubbard’s criticisms ­were not just good-­natured ribbing: in more serious prose, he broadly smeared doctors as mere businessmen who “­will make p ­ eople sick in order to cure them” and their medical socie­ties as mere “labor-­unions, intent on the self-­preservation of their members.”19

28

The American Medical Disorder

In his magazine the nonsmoking teetotaler also proselytized for exercise and healthy living and criticized doctors for failing to do the same. Thus, he declared that the only indispensable doctor was one who “shows us how to do without him.” Few doctors would have missed Hubbard’s eccentric wit ­after two German torpedoes silenced him as he was crossing the Atlantic on the RMS Lusitania in 1915. He would not have suffered such a fate had President Woodrow Wilson not made it pos­si­ble for him to get a passport by pardoning him for mildly bawdy witticisms in his magazine, which ran afoul of the 1873 Comstock Act for the Suppression of Trade in, and Circulation of, Obscene Lit­er­a­ture and Articles for Immoral Use.20 Cutting humor dogged medical reformers as they undertook the goal of imposing medical licensing in the 1870s and 1880s to reduce quackery, elevate therapeutics, and advance public health. In Mas­sa­chu­setts, it was the main device used in a speech delivered and distributed by Richard C. Flower, a notorious faith healer and nostrum peddler (and l­ater mining stock swindler), to mobilize opposition to a license law. With burlesque humor, Flower pointed out the hy­poc­risy of doctors who demanded that drug manufacturers divulge the contents of their remedies in plain En­glish when they themselves would only write their prescriptions “in Latin, or continental Latin, or in Rus­sian Polish Latin, or in dog Latin or something e­ lse.” Calling it “The Allopathic Czar,” Flower first delivered his speech in Boston in 1882 and l­ater in other states where licensing laws w ­ ere on the agenda. The speech was full of fun and specious nonsense, including bogus statistics and fabulous stories about miraculous rescues from the jaws of death a­ fter regular doctors had given up or been dismissed. Patent medicines, he said, ­were “the poor man’s doctor” and had cured “hundreds and thousands of p ­ eople.” But Flower also packed solid punches, pointing out, for example, that even the top brains of the “allopathic,” or regular, school regarded many of its therapeutics as “only an experiment” or—­quoting the influential Paris-­trained therapeutic skeptic Jacob Bigelow—­“ineffectual speculation.” Doctors, Flower said, would prescribe the removal of one ovary and then, if that failed to work, the other one, heartlessly destroying wifehood and motherhood. “­After all,” he said—­putting words in misogynous doctors’ mouths—­“it was only a ­woman.”21 A ­couple of years ­later, twenty-­five-­year-­old Elizabeth Cochran Seaman, ­ nder the name Nellie Bly, subwriting for Joseph Pulitzer’s New York World u jected doctors to further ridicule with her clever investigative reporting. As the country’s most famous w ­ oman journalist, she visited seven reputable New York doctors in 1889 about her chronic headaches and wrote up their wildly



M e d i c a l M ay h e m

29

divergent diagnoses and prescriptions. ­There was almost no overlap in the diagnoses and very l­ittle overlap in their colorful polypharmacy—up to seven medi­cations per doctor. Where ­there was agreement on the diagnosis (two blaming anemia), t­here was disagreement on the remedies. Where the doctors agreed on the remedies, they disagreed on the diagnoses. Three of the seven called for nux vomica (containing strychnine, potentially toxic at pharmacoactive doses) and phenacetin (an effective analgesic, though toxic and carcinogenic). Two of the seven called for arsenious acid (also toxic and carcinogenic). One of the doctors called for all three. Four doctors advised adjunctive nutritional or nonmedicinal approaches. One, having diagnosed anemia, called for a nightly “spinal douche,” and another prescribed abdominal muscle exercises for Bly’s “weak stomach.” A third insisted that she eat only three thin slices of toast with beef shavings a day ­because of her headache-­ inducing dyspepsia. A fourth believed malaria caused her headaches. For some reason her malaria called for abstention from all beer and wine—­with the exception of Rhine wine. One suspects this was a part-­time distributor of German wines. The seven doctors w ­ ere not amused with Bly’s article in the country’s largest newspaper and, despite having not been mentioned by name, threatened a libel suit.22 The most brilliant and witty diagnosis of the disordered medical profession came from the ­great playwright and social critic George Bernard Shaw. Though Irish, ­because of his celebrity in the United States, Shaw’s 1909 play The Doctor’s Dilemma held a mirror up to American doctors ­because their counter­parts in G ­ reat Britain saw some of the same professional diseases caused by overcrowding and poor training. Many American doctors winced upon reading his quip that the main difference between a quack and a regular physician was that only ­those with a license to practice had the ­legal authority to sign death certificates, but witnessing a patient’s demise was something “for which both sorts seem to have about equal occasion.” According to the long preface to his play, many doctors ­were ethically conflicted: being “hideously poor,” they w ­ ere tempted “to prescribe a sham treatment” and charge a fee for it. A poor doctor could no more resist such temptation “than the lungs of his patients can stand out against bad ventilation.”23 On clinical science, Shaw was way ahead of the profession, having studied the pioneering statistical research of Karl Pearson in his journal Biometrika. Shaw insisted that “all treatments are experiments on the patient,” so doctors should at least insist on “control experiments” with placebos. In short, “To all ­these blunders and ignorance” about causal inference, Shaw maintained,

30

The American Medical Disorder

doctors ­were not much wiser than other ­people about ­things medical. “They are not trained in the use of evidence, nor in biometrics, nor in the psy­chol­ ogy of ­human credulity.” They w ­ ere also uninformed about “the incidence of economic pressure” on therapeutic decision-­making. For professional success, they needed to believe what their patients believed, “just as they must wear the sort of hat their patients wear.”24 No Americans w ­ ere more pained by the afflictions of American medicine that gave rise to such satire than the profession’s elite. Some had mixed feelings about the ridicule, admitting that it could be therapeutic. One common reaction to Shaw among American doctors was that of the eminent Chicago physician Henry Baird Favill. Favill was active in or­ga­nized medicine at all levels, including industrial hygiene. He was also a civic reformer popu­lar in upper-­class progressive circles. Shaw’s “flippant” and sometimes “vicious” critique left a bad taste in his mouth, Favill said, but he had to admit that “doubtless t­ here is a mea­sure of ethical purpose in the work.” Indeed, Shaw raised crucial questions for ­those who ­were “disposed calmly, fairly, and intelligently to weigh the ­matters raised.”25 Less offended by Shaw was the aforementioned Warbasse, another prominent medical reformer and author of a two-­volume textbook on surgery, as well as countless scientific and clinical papers. He held that literary figures like Shaw who satirize doctors w ­ ere “public benefactors.” Chief surgeon of General Hospital in Brooklyn and editor of the New York State Medical Journal in the first de­cade of the ­century, Warbasse believed that “holding up to man his follies is an inestimable ser­vice.” To t­hose who thought it would benefit “the dishonest quacks,” he replied that their gain would only be temporary, “while the help to the cause of medicine is fundamental and lasting.” George H. Simmons, the reform-­minded editor of the Journal of the American Medical Association, found it fitting to publish a report from the journal’s regular British correspondent stating that Shaw presented sound criticisms along with his satire and “has to be taken seriously.”26 In Shaw’s lengthy preface to his play, he told of doctor friends whose shop talk was full of each other’s “blunders and errors.” The main ­thing they agreed on was that the public should be spared the internecine criticisms and disputes in order to preserve a belief in the profession’s scientific legitimation. Many physicians in the United States counseled the same, but in vain. Medical rivalries had occasioned the adoption of a code of ethics in 1847, at the AMA’s founding, that admonished doctors to protect each other’s reputations by concealing differences of opinion and suppressing rivalry over patients. But



M e d i c a l M ay h e m

31

in the following half ­century, the code was widely dishonored. The “snarling men and backbiting colleagues” of whom AMA president John Musser spoke in 1904 w ­ ere to be found everywhere—in hospitals, in medical schools, and in the public. As William Osler put it around the same time, “Strife seems rather to be the very life of the practitioner,” against both disease and other prac­ti­tion­ers. “He too often lets his angry passions rise against his professional ­brother.” Indeed, “The quarrels of doctors make a pretty chapter in the history of medicine.”27 “Snapping and snarling physicians” w ­ ere among the subjects of an extraordinarily best-­selling book for doctors, first published in 1882 as Physician Himself and What He Should Add to His Scientific Acquirements, by Daniel Webster Cathell, professor of pathology at the College of Physicians and Surgeons of Baltimore. Repeatedly—­roughly on about e­ very one of four pages of the eighth edition of 1890—­Cathell returned the reader to the ­matter of unhealthy competition among doctors. It involved poaching of patients, underbidding with fees, illicit advertising, and boasting about amazing curative feats. He advised doctors to hold their tongues even if a fellow doctor told the world that he “would not call you to attend a sick kitten.” “Whenever you sow a thistle or a thorn you ­will reap thistles or thorns,” he admonished. Books by other authors published in 1891 and 1905 for aspiring and newly minted doctors also touched on the issue, in part to warn against venturing into the hypercompetitive snake pit in the first place.28 Cathell’s advice was essentially po­liti­cal, calling on doctors to “enhance your profession in public esteem at e­ very opportunity.” Never engage “wide-­ mouthed quacks” in public debate “no ­matter how false or shallow their oily pretenses are, or how easily their weak arguments are refuted,” he counseled. It would “give your opponents an opportunity to make the noise and clamor they desire, and bring them into greater notice, gain for them new partisans, and give them a chance to raise additional false issues.” The press, both religious and secular, he said, delighted in skewering the profession with reports on its futile debates, “arbitrary exclusiveness,” and “intolerant bigotry.” Cathell even counseled against respectful discussions of therapeutic uncertainties and differences and admissions about the experimental nature of clinical decisions. “All who hear or read them conclude that our prescriptions are only a series of guesses, and that medical practice is only a hodge-­podge of uncertainty, inconsistencies and confusion.” He stated that open therapeutic skepticism just fuels lay critics of the entire profession to ask “­whether we can be certain of anything, or be certain that we are certain of nothing” and therefore turn

32

The American Medical Disorder

to a doctor, if at all, “with utter disrespect and distrust.” “The public jest about us, and believe from our kaleidoscopic contradictions that our boasted science of medicine is merely a tissue of guess-­work.” In short, such discussions “work g­ reat harm to physicians who make them and unmea­sur­able harm to the profession at large.”29 Proliferating for-­profit medical schools instilled in young doctors the very manners Cathell wanted to change. As Hubbard quipped, ­every school and sect of medicine “stands ready to show that all . . . ​[­others] are founded on error and ignorance,” adding wryly, “They usually tell the truth about each other.” In Tennessee, public health, medical education, and licensing reformer Thomas J. Happel witnessed “in e­ very city in the state . . . ​as many factions in the regular profession as ­there ­were medical schools, plus one, namely, ­those who ­were not connected with any college.” Nashville, he wrote in 1904, had four regular medical schools and thus “four factions, plus the one represented by the other two ‘isms.’ ” And, of course, each medical school thought itself the best on all ­matters medical. “One favored chloroform as an anesthetic, the other ether; one advocated bleeding for puerperal convulsions, another gave chloral; one would press forward one of its own school for any medical position, and another would do all in its power to defeat the applicant and endeavor to supplant him with one bearing its colors.” So bad was it that “not more than two physicians in any community ­were on social terms or often even on speaking terms, and this ­union of two arose from a . . . ​common desire to down some other physician.” It was a “notorious fact” to the laity that few physicians ­were willing to consult with each other—­even in emergency cases. When a new patient approached a doctor for help, too often the answer was “Dismiss Dr. A. and I ­will call and do what I can for you, but I do not speak to or recognize Dr. A. professionally.”30 Much of the internal rancor stemmed from rivalry between regular and irregular physicians. Perhaps not coincidentally, Cathell began writing his book the year ­after President James Garfield’s homeopaths and allopaths embarrassed the profession with their open squabbling. In his speech against medical licensing, Richard Flower joked about the doctors who had assisted (“scientifically,” he emphasized, prompting laughter) at the president’s deathbed in 1881, unsuccessfully, to extract the bullet of the assassin, Charles Guiteau. Garfield’s treatment “was enough to have killed him ­whether he had been shot or not.” In fact, “no man in Iowa could have stood it,” and indeed “­there is no elephant in India that could have stood it.” Garfield died at their soiled hands despite Lister’s antiseptic teachings, which had been widely



M e d i c a l M ay h e m

33

a­ ccepted by Eu­ro­pean surgeons but not yet American ones. At least a dozen doctors probed the president’s wound with unsterilized fin­gers and instruments. In the end, ­after months of agony and wasting away from the unnecessary deprivation of food, Garfield died of septicemia. In his trial, Guiteau, a disappointed federal office seeker, asserted that the president “died from malpractice” and said, simply, “I just shot him.” Or, more honestly, “The Lord only confirmed my act by allowing the doctors to finish my work.”31 Garfield’s doctors’ intense arguments were leaked to journalists, mostly by two homeopaths among them. They had called for milder methods but w ­ ere gruffly ignored by the regulars, who, they said, arrogantly seized command without consulting Mrs. Garfield, who favored the homeopaths. Bewildering reports on the president’s fluctuating condition became a national obsession that summer and fall. The newspapers added to the cacophony by printing letters offering second opinions from anyone putting an MD ­after his name. ­Later, in 1882, a special congressional committee held hearings at which the bickering doctors ­were delivered a sound public thrashing. In the end, one homeopathic journal editorialized that the medical attention Garfield had received not only had harmed the president but had been “to the ridicule of medical science.” George F. Shrady, a prominent regular physician and medical journal editor, declared that “the best tribute which the medical profession can pay, alike to the memory of our late President and the dignity of the art we practice, ­will be to avoid all carping criticism on the methods of the medical attendants.”32 The story of Garfield’s surgeons was indeed no laughing m ­ atter to the profession. Almost thirty years l­ater, the disgrace of Amer­i­ca in surgical practice still so disturbed the prominent New York City surgeon Norman Barnesby that he defied the growing professional consensus that its dirty linen should not be publicly laundered. The public needed to be informed in order to force the profession to heal itself. Barnesby was the physician of choice for the power­ful New York financier Frank Vanderlip, the president of National City Bank and a public health reformer himself. As he put it in his 1910 book, Medical Chaos and Crime, the costs of doctors’ ser­vices ­were “paid ­every day in mutilated bodies, in wrecked constitutions, in stricken and embittered lives, and in death—­a ghastly national tax which an awakened civilized nation is bound, in the name of humanity, to repeal.” Barnesby corroborated his devastating observations about surgical practice with reports from reputable medical journals published only for professional consumption. Along with the horrors of gynecological surgery, Barnesby devoted a chapter to the

34

The American Medical Disorder

“Amateur Anesthetist.” In Amer­i­ca, he pointed out, a licensed doctor could press “any Tom, Dick or Harry”—­including the office boy—­into ser­vice to assist in the killing of a patient. He quoted the president of the American Gynecological Society, saying that “the general administration of anaesthetics as performed to-­day is the shame of modern surgery, is a disgrace to a learned profession.”33 A review in the New York Times declared that Barnesby’s book surpassed all ­others in its era’s progressive muckraking: “Stockyard revelations and shameful civic exposures are tame and trivial incidents in comparison with the unspeakable horrors contained in its pages.” Barnesby charged surgeons “both ­great and small . . . ​with crimes ranging from minor mutilations to murders.” He anticipated the criticism he would receive from other doctors for indicting the profession in the court of public opinion. Knowing that exposing the awful truth would embarrass the better ele­ment (“a minority of the profession”), he declared that “too many lives have already been sacrificed upon the altar of medical pretension and sham.” If the book resulted “in the saving of but one ­human life” while leading to “the utter de­mo­li­tion of the entire ‘ethical’ edifice,” he would call the price “a bagatelle.” Barnesby grimly concluded that provoking outside action was necessary to disrupt the inertial profession. If the unvarnished truth about surgery and anesthesia “­were known to the laity at large, it would be but a short while before it ­were interfered with by legislative means—­and properly so.”34 T H E N E E D F O R O R G A N ­I Z A T I O N

According to Barnesby, his “disor­ga­nized, demoralized profession” was incapable of cleaning up the mess on its own. Other medical critics and reformers, while disagreeing with Barnesby’s whistle-­blowing, agreed with him on the need for better organ­ization. One was Joseph Nathaniel McCormack, Kentucky’s nationally recognized public health official and soon to be one of the AMA’s most impor­tant leaders. McCormack, among other reformers and reorganizers of their respective state medical socie­ties, called for tight organ­ ization, professional unity, and the esteem and power that would come with them as a first step to remedy the profession’s national disgrace. Without radical reor­ga­ni­za­tion, ­these reformers believed they could not win over the lay public on public health policies and other mea­sures that only state governments, and sometimes only the federal government, could institute. For example, according to the AMA’s National Committee on Organ­ization, created



M e d i c a l M ay h e m

35

in 1900 with McCormack as a key member, while a reform in one state was working its way through the legislature, in another state an identical reform was being wiped out by forces hostile to pro­gress. Physicians in the respective states could be the source of both contradictory changes.35 In 1900, t­here ­were somewhere between thirteen hundred and fourteen hundred medical socie­ties—­local, state, regional, and national. Most of them enlisted only tiny numbers of members. Many of them did not affiliate with the AMA, even though its constitution of 1847 had allowed medical associations of all kinds, shapes, and sizes to join. It was nothing like the orderly federation built from the county level up to the state and national levels that it would soon become. Many of the affiliates had special interests, not general reform agendas, and plenty of them faced off in open and ­bitter rivalry. Fierce medical sectism and the vain individualistic ambitions of contending medico-­politicos fed off each other. New associations started up all the time, some of them splintering off ­after internal disputes while older ones would, McCormack wrote, sink into a state of “innocuous desuetude which makes it hard to decide ­whether they are alive or dead.” Competition among medical associations over members made it problematic to collect dues adequate for effective leadership, staffing, and activity. F ­ ree or cheap medical journals abounded, funded almost entirely with drug advertising, so small socie­ties could not afford to offer high-­quality, nonmercenary, and therefore costly journals to attract members. While many states had multiple competing organ­izations, many counties and cities had none at all. B ­ ecause, among other ­things, t­ hese weak associations w ­ ere often noncoterminous with municipal, county, and state borders, they ­were woefully inadequate for “developing, unifying, concentrating and giving efficient practical expression of the sentiments, wishes and policy of the profession” at vari­ous levels of the po­liti­cal system.36 In short, in 1900 the chaotic AMA hardly deserved its name, which somehow suggested an encompassing, unifying entity that could authoritatively represent the profession’s interests and larger missions. Th ­ ose affiliates situated closer to the AMA headquarters in Chicago ­were more likely to affiliate and attend its yearly meetings. At the meetings, it was impossible to keep track of each affiliate’s membership numbers and thus fairly apportion delegate seats. Verification of delegate credentials was impossible. The general sessions, at which deliberations and votes on impor­tant questions ­were supposed to occur, ­were huge and ungainly: over sixteen hundred delegates ­were allowed to attend in 1900. The organ­ization committee complained that the AMA was

36

The American Medical Disorder

“the largest body in the world which attempts to transact business in a deliberate manner.” The attempts routinely failed. Roll-­call votes of registered delegates took too much time. Voice votes could not be trusted ­because of unregistered intruders in the room with commercial stakes in the outcomes. Only a small handful of hours remained for vital policy-­making a­ fter opening ceremonies, delivery of reports, scientific sessions, and general milling about. According to McCormack’s organ­ization committee report, a paramount purpose of a reformed AMA would be to promote “direct personal and social intercourse between physicians” and therefore “mutual re­spect, personal friendship and unity of sentiment.” Familiarity would breed not contempt but unity, prestige, and then power for the greater good. His committee, which would draw up a blueprint for building a “systematic, all-­pervasive organ­ ization” from the ground up, was abundantly optimistic that “in five years the profession throughout the entire country may be welded into a compact organism, whose power to influence public sentiment ­will be almost unlimited, and whose requests for desirable legislation w ­ ill everywhere be met with that re­spect which the politician always has for or­ga­nized votes.” The profession could, in very l­ittle time, the reformers assured, “demand and receive that re­spect from law-­makers, from government officials, and from the general public to which it is admittedly entitled by reason of its ideals, its education, and its power for d ­ oing good to all mankind.”

chapter 2

Organ­izing for Order

In 1901, the American Medical Association began trying to put Amer­i­ca’s ­house of medicine in order. Its progressive leaders sought reor­ga­ni­za­tion to forge the AMA into an encompassing, streamlined, and potent force able to redeem the medical profession from its internal discord, external disdain, and po­liti­cal impotence. Experiences in the states informed the national mission. Joseph McCormack, the founding f­ ather of Kentucky’s public health department, recalled in 1907 that he had begun his ­career believing that he had joined “a very ­great and highly respected profession.” However, in his first encounter with the state legislature, he learned that doctors ­were held in such low esteem that their lobbying for anything “lessened the chances for passing the bill.” The legislators would often say something like, “Doctor, this bill you ask us to pass looks to be fair upon its face, and in the interest of the ­people, but I have very l­ittle confidence in Doctors.”1 The profession’s po­liti­cal influence was weakened by internal discord. In 1904, Thomas J. Happel, the executive secretary of the state’s medical licensing board, lamented that b­ ecause of “personal rivalries and professional jealousies” unity on any public issue was impossible. For example, in public health ­matters, “one faction opposed anything that another faction would suggest as right and proper.” Without unity, even if desirable laws w ­ ere passed, it would be difficult to enforce them or prevent their repeal. In short, according to

37

38

The American Medical Disorder

McCormack, only a “closer ­union” of the medical profession would enable it “to speak with some show of authority on medical questions having a public or semipublic bearing” and therefore to promote “the welfare of the community.”2 The profession’s reformers hoped that vitalizing the AMA would help bring control of the drug industry, improvements in public health, and reform of medical education. In the coming years, they ­were proven at least partially right. With their efforts and successes, however, they made enemies both inside and outside the profession, which boded ill for them in the ­future. T H E N A T I O N A L O R G A N ­I Z A T I O N C O M M I T T E E

AMA president Charles A. L. Reed, elected to serve a twelve-­month term overlapping 1901 and 1902, set the AMA’s reor­ga­ni­za­tion in motion by appointing a special National Committee on Organ­ization. The AMA’s one-­year presidency straddling two calendar years was what the incumbents made of it, depending in part on their ­will, energies, and force of personality. Reed was one of the doers. Morris Fishbein’s 1946 official history of the AMA called Reed “one of the most in­ter­est­ing and dynamic figures in American medicine.” Reed was the founder of the Pan-­A merican Medical Congress and a cofounder of the American Association of Obstetricians and Gynecologists. He was also the editor of a leading textbook on gynecol­ogy and the progenitor of the medical school of the University of Cincinnati. In 1905, Reed served on the U.S. Commission to Panama and played an impor­tant role in supporting the Yellow Fever Commission’s mosquito eradication efforts ­t here ­under public health titan General William Gorgas, who himself would be rewarded with the AMA presidency in 1910 and 1911. Reed’s most impor­tant role in the AMA, in the capacity of chairman of a Committee on National Legislation, was his mobilization of doctors across the country to lobby for passage of the Pure Food and Drugs Act of 1906.3 Reed appointed George H. Simmons to serve as executive secretary of the National Organ­ization Committee. Simmons had recently in 1899 been chosen to serve full time as editor of the Journal of the American Medical Association b­ ecause of his progressive views as well as his editorial, orga­nizational, and administrative skills. ­Those he had demonstrated in his ­earlier work for the Nebraska State Medical Society. Simmons’s strongest competitor for the editorial position had been the notable Chicago surgeon Bayard Holmes,



O r g a n ­i z i n g f o r O r d e r

39

whose progressive and humanitarian background indicates what the AMA Board of Trustees was looking for in the way of reformism. In previous years, Holmes had campaigned with social reform missionary Florence Kelley and muckraker Henry Demarest Lloyd against Chicago sweatshops, lectured at Jane Addams’s Hull House on public health, run as a Populist candidate for the mayor of Chicago with the support of the liberal ­lawyer Clarence Darrow and followers of Socialist Eugene Debs, and chaired the Chicago Civic Federation’s Public Health Commission.4 ­Under Simmons, the AMA’s journal took on a strongly progressive tone. A 1911 editorial called “Sociology and Medicine” identified all manner of government reforms as “preventive medicine”—­including “child ­labor laws, and laws concerning minimum wage and minimum hours of ­labor for both men and ­women; employers’ liability laws; laws compelling the employment of safety devices in industrial pursuits; laws against the use of injurious chemicals in the arts; the establishment of public playgrounds; laws regulating the building of tenements, factories, ­etc., providing for proper light and air space; school inspection and open air schools; laws to secure better housing conditions, better hygienic conditions in prisons, ­etc.” Another editorial scoffed at doctrinaire “liberty” arguments against government reforms that failed to take into account the need for a “practical” freedom like freedom from disease.5 Serving also as the AMA’s full-­time secretary as well as general man­ag­er, Simmons would soon be both praised and excoriated as the most power­ful person in American medical politics. For the AMA’s reor­ga­ni­za­tion committee, Reed also enlisted fellow Ohioan P. Maxwell Foshay, another dynamic state medical association leader. A Young Turk in the profession, Foshay had earned national credit for rejuvenating the Cleveland Medical Society, a “vigorous active working body of progressive physicians,” according to one admirer. Thereupon Foshay assisted with the reor­ga­ni­za­tion and vitalization of the Ohio State Medical Society, which he ­later served as executive secretary. A strong public health advocate, Foshay was also, as editor of the Cleveland Medical Journal, a sanitizer of commercially infected and therefore bogus medical journalism, a mission that Simmons would soon come to lead at the national level.6 AMA president Reed appointed Kentucky’s McCormack to serve as the chairman of the reor­ga­ni­z a­tion committee and, more importantly, as the AMA’s full-­time traveling or­ga­nizer. Like Simmons and Foshay, McCormack had engineered a major restructuring of his own state’s medical

40

The American Medical Disorder

association, building the Kentucky State Medical Society county by county. Clearly, his purposes w ­ ere humanitarian in nature, not just about the economic interests of doctors. Before taking on the AMA’s reor­ga­ni­z a­tion, he had started and managed the Kentucky State Board of Health. With tireless work and personal sacrifice, he turned it into a saver of lives despite meager appropriations from the state legislature. Practically ­every health-­ related law passed in the state, including its medical licensure act, came from his pen. Over the years he gained the reputation of having drafted laws passed “in many other states dealing with public health, the practice of medicine and medical education.” ­A fter retiring from AMA ser­vice in 1911, McCormack returned to Kentucky to continue leading, along with his son Arthur, the state’s public health work.7 Perhaps no leading figure in the AMA at the beginning of the twentieth ­century better embodied the age’s medical progressivism than McCormack. In the f­ uture medical or­ga­niz­er’s valedictorian address to his fellow medical gradu­ates of the Miami University of Cincinnati, the nascent progressive summoned the courage to expound on the m ­ ental and physical equality of the sexes. In the 1870s, McCormack’s first de­cade as a fledgling clinician in Bowling Green, he weathered ­bitter attacks from the town’s business interests for warning citizens about the arrival of yellow fever. Like many young doctors of the era, he interrupted his practice to further his medical education with stays in London, Edinburgh, and Vienna, where b­ ecause of vigorous public health authorities, typhoid fever rates w ­ ere being reduced to levels Americans would envy. Within ten years of graduating, perhaps in part ­because of a near-­ fatal bout of typhoid, it was clear that public health, not his hugely successful surgical practice, was where his heart was.8 In 1879, at the age of thirty-­t wo, McCormack founded his state’s board of health. In the following de­cade, he began assuming national leadership in public health and medical politics in general. In 1883 he helped found, along with national public health pioneer Stephen Smith, the National Conference of Health Boards in which he held top leadership posts ­until 1893. In that capacity he conducted interstate mea­sures to suppress an imminent cholera epidemic, which earned him, in 1888, a commendation from President Grover Cleveland. Some of McCormack’s Kentucky work redounded to the benefit of p ­ eople in other states. In 1903, he reported a state investigation’s discovery that blankets in railroad sleeping cars ­were laundered only once ­e very six months. In the aftermath, Pullman cars began to be equipped, at least, with laundered sheets u ­ nder the blankets and folded



O r g a n ­i z i n g f o r O r d e r

41

Surgeon Joseph Nathaniel McCormack, MD (1847–1922). A Kentucky and national public health leader, McCormack was the main author of the AMA’s 1901 reor­ga­ni­za­tion plan and then progressive medicine’s itinerant or­ga­nizer and public educator. From Irving A. Watson, Physicians and Surgeons of America (Concord: Concord N.H. Republican Press Assoc., 1896).

over their tops. In 1913 he introduced an invention for the prevention of hookworm infections, the Kentucky Sanitary Privy, a fly-­proof, liquefying, self-­cleaning fa­cil­i­ty connected to a concrete septic tank. The design was ­adopted in Kentucky, in other states, and even in other countries. In 1907 the American Association for the Advancement of Science included him in its list of the one hundred most influential leaders in the fields of medicine, public health, science, and social reform. Soon thereafter, McCormack gave hundreds of speeches throughout the United States and testified in Congress for the creation of a national department of health. He was a member of the Committee of One Hundred on National Health, a lay-­professional alliance created to pursue that end.9 If McCormack’s titanic efforts in ­these affairs are any indication, his own or his fellow physicians’ clinical incomes w ­ ere small worries. His fees ­were attenuated not by having to compete with cheaper operators, including unlicensed quacks, but by foregoing the pursuit of full-­time practice as a prestigious surgeon. For over thirty years of ser­vice in Kentucky, he demanded no increase in his 1879 starting salary of $1,200—­what his stenographer was paid in 1912. In 1900, he personally donated more than that yearly

42

The American Medical Disorder

salary for inspection mea­sures during a smallpox epidemic in thirty-­five Kentucky counties. The board lacked extra funds, and some county board officials had been resigning. In sum, McCormack embodied the integration of the public health movement with other aspects of progressive medical politics, from the licensing movement to professional organ­ization building. A 1922 editorial in the American Journal of Public Health published a­ fter McCormack’s death called him “a ­great or­ga­nizer and a leader of men.” But he was no mere medical trade ­unionist. “No one man in the United States has contributed more valiantly to the advancement of public health than this ­great physician,” the editorial stated.10 M C C O R M A C K T H E O R­G A ­N I Z E R

In Kentucky, before becoming the AMA’s chief or­ga­nizer, McCormack expanded and vitalized the Kentucky Medical Society by persuading community prac­ti­tion­ers to or­ga­nize demo­cratically “from the bottom up” in newly created county units. At the time, the state organ­ization had fewer than 350 members, and no more than a few dozen would show up at meetings, mostly for personal squabbles and formal ­trials for ethical violations like consulting with unorthodox healers and advertising for patients. The plan that McCormack crafted for the AMA’s reor­ga­ni­za­tion was based on what he had instituted in Kentucky, including a model constitution for all state socie­ ties. County units ­were to become the building blocks of each state society and elect delegates to state-­level meetings. ­Those would execute all impor­tant legislative functions and elect executive and judicial officials. According to the reor­ga­ni­za­tion plan, the national association would repeat that pattern, with delegates sent by the counties to state meetings to elect delegates to AMA House of Delegate meetings. ­Those, in turn, would then pass resolutions, confirm appointments to permanent standing councils, and elect national leaders, including presidents and members of the AMA’s power­ful Board of Trustees. Membership in the county society was to become a prerequisite for membership in the state society and thus for AMA membership and eligibility for election to its deliberative and decision-­making body, the House of Delegates. A small minority of voting delegates w ­ ere to be chosen by their “scientific sections” and by the medical departments of the U.S. Army, the U.S. Navy, and the Marine Hospital Ser­vice. With only 150 members in its reincarnation, the House of Delegates was more efficiently able to address and



O r g a n ­i z i n g f o r O r d e r

43

act on medico-­political questions once neglected by the huge and chaotic meetings of the past.11 In 1902, a­ fter approval of the organ­ization plan, McCormack was commissioned to serve as the AMA’s salaried, full-­time traveling “national or­ga­ nizer.” As such, he devoted almost nine years of his life to proselytizing for unity. The tall, handsome, magnetic, and genial man—as described by his admirers—­addressed doctors in e­ very corner of the country with variations of his engaging and often folksy speech “Organ­ization and Its Advantages to the Individual Doctor.” In November 1905, for example, he spent twenty-­five days giving one or more speeches in twenty-­one Texas cities. By the end of his grueling campaign, he had traveled to ­every state in the country, to a majority of their counties, and to around two thousand towns and cities. McCormack’s Kentucky colleagues boasted that he was personally acquainted with more physicians than any other man in the United States. According to historian James Burrow, the itinerant evangelist for nationwide medical order “set a rec­ord for distance traveled and public audiences addressed” unmatched so far in the history of public relations.12 In his speeches, McCormack encouraged doctors to form county organ­ izations and hold regular meetings open to all licensed fellows. Th ­ ese w ­ ere to be opportunities for “acquaintance, comradeship and improvement.” They would help dissolve the ­bitter animosities fostered by living “segregated lives.” He recommended that county socie­ties gather dues to subsidize their members’ education sabbaticals in rotation. Beneficiaries w ­ ere to speak on their newly acquired knowledge. Meetings could also be forums for collaborative discussions of clinical cases to soothe what he called the “canker of envy and jealousy” in the profession. He told of the twenty-­four doctors in Kentucky’s Hardin County who had met weekly for two de­cades to discuss their recent work and seek advice on upcoming surgeries. The result had been a level of open mutual professional admiration that had helped persuade county residents that they had “the best doctors in the world.” Meanwhile, elsewhere in Kentucky, doctors ­were “surrounded more or less constantly . . . ​by an atmosphere of exaggeration, misrepre­sen­ta­tion and falsehood” about each other.13 In his reports and speeches, McCormack discussed how perverse competition among doctors caused many to refrain from pressing even well-­to-do patients for unpaid fees for fear that they would move on to another doctor. Fierce competition combined with social isolation created and preserved a “black cloud of envy and jealousy” that hung over the profession “from the

44

The American Medical Disorder

lakes to the Gulf and from the Atlantic to the Pacific.” Doctors divided by ­great distances could be solid friends “while barely on speaking terms with ­ ehind ­every equally good physicians of their own town or neighborhood.” B malpractice suit, he said, “­there skulks some back-­biting, envious doctor.” Alluding to one of the main items of the AMA’s coming reform efforts—­ reduction in the number of medical schools and elevation of the standards of ­those remaining—­his committee’s report lamented the strife and “petty professional bickerings” resulting from the medical colleges “pouring into the profession each year thousands of illy-­prepared men.” He cited Richard Flower’s satire about President Garfield’s squabbling doctors as an example of the po­liti­cal costs to the profession of discord. Politicians ­were just like the public, which got its impression of doctors “from what they say of each other.”14 McCormack avoided mentioning that some of the defamation and other perverse competition took place between the regulars, the homeopaths, and the eclectics. As medical or­ga­nizer for the entire nation, he thought it essential to tamp down the animosities, just as he had done in Kentucky with his licensing law, which recognized homeopaths and eclectics as legitimate fellows in medicine. His reor­ga­nized Kentucky State Medical Society had also jettisoned the old ethical strictures, backed by expulsion for violations, against regulars consulting with homeopaths and eclectics. Along with that, he had seen to it that any doctor who abjured from espousing an exclusive system of therapeutics, regardless of training, was welcomed as a member of the state medical society. The motivation was partly to ensure passage of desirable state legislation. Homeopaths ­were popu­lar among many wealthy ­people in some states, while eclectics tended to appeal to lower-­income classes and populist politicians. McCormack and other reformers ­were also motivated by the belief that irregulars could be enlisted into public health action; dogmatic or petty differences over therapeutics did not need to get in the way. McCormack’s colleagues on the AMA reor­ga­ni­za­tion committee shared his views on the need for professional peace to promote unity and thereby empower doctors for the greater good. To or­ga­nize Cleveland’s doctors in 1893 in a “progressive” and “liberal” municipal society, Maxwell Foshay had rejected the ethics rule against consulting with homeopaths and eclectics and had won a fierce b­ attle over the rule against older regulars in his state. A newspaper reported on his success with the headline “Knives Out, Doctors Draw Their Scalpels against Each Other.” In 1895, a major eclectic journal praised Foshay’s Cleveland organ­ization for being perhaps the first in the country to “admit reputable prac­ti­tion­ers of all stripes to membership.” Furthermore, his



O r g a n ­i z i n g f o r O r d e r

45

Cleveland Medical Journal vowed that the organ­ization would be “strictly and entirely in­de­pen­dent of clique, faction and school, and w ­ ill aim to represent the ­whole profession in the closest manner pos­si­ble.”15 AMA editor, executive, and reor­ga­nizer Simmons was of like mind. He had first practiced as a homeopath with a degree from Hahnemann Medical College in Chicago in 1882 but l­ater acquired a degree from the same city’s Rush Medical College. Henceforth, he counted himself a regular but signed on to the growing consensus among leading regulars that medical order required a laying down of arms. They all agreed with what medical historian John Harley Warner calls “scientific democracy,” a view that t­here could be no heresy in medicine b­ ecause t­ here could be no orthodoxy in science. The m ­ atter of therapeutics, the reformers thought, would sort itself out naturally, with the ultimate dissolution of orthodoxies: t­ here was only one science of medicine, a­ fter all.16 PROGRESSIVE LEADERSHIP

McCormack’s contemporaries agreed that, more than anyone e­ lse, he deserved credit for constructing a strong organ­ization out of one in which sparsely attended local, county, and specialized associations had stood in chaotic and rivalrous relations to each other. The 1904–1905 AMA president and eminent pathologist, clinician, and educator John Musser called McCormack the profession’s “apostle of organ­ization.” Famous Minnesota surgeon William Mayo declared him, next to the AMA’s journal, “the most valuable asset which we have in our Association.” But other progressive leaders also contributed im­mense energies in dif­fer­ent capacities. A mea­sure of the organ­ization’s progressivism is the character of physicians elected to serve overlapping multiyear terms on its board of trustees, a power­ful executive body, and to the largely but, as Charles Reed demonstrated, not exclusively honorific one-­year AMA presidency. The AMA leader of the time best known to medical historians ­today was William Henry Welch, who served as a trustee from 1903 to 1909 and as an active member of the AMA’s National Legislative Council. In 1910, Welch, the pioneering pathologist, bacteriologist, and medical education reformer, was rewarded by an unusual unan­i­mous vote of the House of Delegates with the one-­year presidency. Called the “dean of American medicine” at the time of the AMA’s reor­ga­ni­ za­tion, he is not well known ­today for his role as a premier advocate of preventive medicine and public health. In 1898, Welch began three de­cades of ser­vice as president of the State Board of Health of Mary­land. He debuted in

46

The American Medical Disorder

the AMA with an 1899 address on state medicine and infectious diseases. An impor­tant topic in his 1910 presidential address included a call for creating a national department of health. In 1916, at Johns Hopkins University, he created the country’s first school of public health, which he directed u ­ ntil 1926.17 Chicago’s Frank Billings was also a power­ful guiding force in the AMA. Soon ­after its reor­ga­ni­za­tion, he served first as president in 1904 and 1905 and ­later, from 1918 to 1924, as executive secretary, the most power­ful position, of the board of trustees. An official history of the AMA by editor Morris Fishbein describes the dynamic medical educator and statesman as “a big genial sympathetic nature, full of humor and h ­ uman kindliness, who radiated power in ­every sphere of ­human activity.” At the time of his death in 1932, according to Fishbein, “it was estimated that fully one hundred of the leading medical teachers and clinicians throughout the country bore the stamp of his stimulating personality.” Billings embodied the AMA’s entire progressive mission. A famous surgeon and medical educator, he graduated from the Chicago Medical College, now Northwestern University Medical School, and then studied in Vienna ­under the celebrated surgeon Theodore Billroth. Billings l­ater visited clinics in Paris and London, where he met Louis Pasteur and Joseph Lister, the ­great pioneers in microbiology and its application in preventing infections. He eventually became professor and dean at Rush Medical College, affiliated with the University of Chicago, which he helped build into one of the country’s top medical schools.18 Billings, like other progressive medical reformers, was a therapeutic skeptic, at least about the value of drugs, though perhaps too much of an optimist about the benefits of surgical removal of teeth and tonsils to ward off the internal spread of “focal infections.” Along with Reed, he was among the fiercest of the many AMA critics of the drug industry and promoters of its reform efforts in that realm. In an address titled “The Limitations of Medicine,” delivered at the opening exercises of Rush Medical College in 1898, Billings told the new and no doubt startled students that the luxuriant materia medica ­were valueless in the cure of all but two infectious diseases, malaria (with quinine) and syphilis (with mercury). Five years l­ater, in his 1903 AMA presidential address, Billings expanded on the theme, damning a huge portion of American clinical practice: “With most of us, our pre­sent methods of clinical observation enable us to do ­little more than name the disease.” To deal with the vast majority of infectious diseases, “we are helpless to apply a specific cure.” Thus, with drugs, a doctor “juggle[s] with the life of his patient” at times when “no help is pos­si­ble.”19



O r g a n ­i z i n g f o r O r d e r

47

If Billings was a therapeutic pessimist, he was a hygienic optimist. Like most of his con­temporary reformers in clinical, scientific, educational, and or­ga­nized medicine, he channeled his skepticism about cures into a passion for pro­gress in public health. In his 1898 address, he told freshman medical students that the ­great unfinished business of scientific medicine was the improvement of public sanitation. Eu­rope was way ahead. Vienna, which Billings offered as an example, had been spared from typhoid fever since the completion of the Semmering aqueduct in 1878, except the year that the aqueduct from the Alps broke and Vienna temporarily resorted to its old ­water supply, the Danube. Meanwhile, typhoid continued to reap a large and preventable toll in many American cities.20 Billings’s zeal for public health was part and parcel of his humanitarianism. The philanthropically minded surgeon regularly treated poor patients for ­free. He helped raise $3 million for the Provident Hospital and Training School to serve Chicago’s African American community. Like other medical reformers, he could draw on lay elites for support. His friends and patients included much of Chicago’s power elite, including cap­i­tal­ists Marshall Field, Gustavus Swift, Philip Danforth Armour, Cyrus McCormick, and progressive politicians like Mayor Car­ter Harrison Sr. His humanitarianism also led him into controversial territory, at least in the minds of many rank-­and-­file doctors. They abhorred his advocacy of publicly or privately endowed “community health centers” to reach poor and underserved areas as well as provide secure salaried employment for doctors hesitant to start practices in ­those locations.21 Billings was one of the top AMA leaders who saw the potential benefits of compulsory health insurance. Another was New York’s Abraham Jacobi, who served as AMA president in 1913 and 1914. In 1873, Jacobi married Mary Corinna Putnam, one of the country’s most accomplished female doctors and a tireless advocate of expanding their numbers. A leading w ­ omen’s suffragist, she cofounded the League for Po­liti­cal Education, a forum for p ­ eople of all classes to discuss demo­cratic reforms and other impor­tant issues of the day. Her husband was of like mind in all ­things and did not shrink from controversy. In 1882, as president of the Medical Society of the State of New York and of the elite New York Acad­emy of Medicine, Jacobi had steered the profession in the direction of scientific democracy by tearing down the wall between regulars and irregulars. Furious dissenters in the state medical society bolted to form a new state organ­ization, but by the time Jacobi was elected president of the AMA, the liberal spirit of conciliation that he had fostered prevailed in his

48

The American Medical Disorder

Abraham Jacobi, MD (1830–1919), once a German socialist revolutionary and later the “­father of American pediatrics.” After escaping from two years in prison, sometimes in solitary confinement, Jacobi fled first to London and then settled in New York, where he became a leader in progressive medical politics. In 1912, he was elected to the AMA’s one-year presidential term. Courtesy of the U.S. National Library of Medicine. © NLM / Science Source

state. By the time of his death in 1919, the venerated “­father of American pediatrics” had held “practically ­every honor which the medical profession can give to its members,” according to an obituary in the AMA journal.22 Jacobi’s progressivism on the health insurance question could have been predicted from his early c­ areer as a radical socialist in Germany. Born and trained in Prus­sia, Jacobi had taken part in the 1848 revolution, and for that crime he spent two years in prison. ­A fter escaping, the twenty-­three-­year-­old doctor first took refuge in London. Karl Marx and Frederick Engels temporarily harbored him in their homes before he moved on to New York City where his prospects of starting a practice looked better b­ ecause of its large community of German emigres. ­There he remained active in socialist ­labor politics for a while. He put that aside in the 1870s only to channel his reformist fervor into progressive medical politics. Thus, despite his history with the Wilhelmine monarchy in Germany, the humanitarian reformer favored Amer­i­ca’s adoption of something like its system of guaranteed health insurance for workers. But more impor­tant to him than guaranteeing sick pay and



O r g a n ­i z i n g f o r O r d e r

49

clinical care ­were public health and preventive medicine. For years, Jacobi called attention to the profession’s therapeutic impotence in the face of the wretched living and working conditions of the laboring classes. While AMA president, Jacobi also served as the honorary president of the American Society of Medical Sociology, which sought collaboration with “economic radicals, statisticians, settlement workers, employees of public institutions, students of social prob­lems, trade ­unionists, and social workers” on health-­related ­matters.23 New York physician Alexander Lambert, elected president in 1918, was another of the AMA’s progressive leaders. As a young doctor in the early 1890s, Lambert had been involved in investigations of tetanus and diphtheria antitoxins. ­Later, at the time of the AMA’s reor­ga­ni­za­tion, he was an assistant bacteriologist in the New York City Department of Health. A close friend and personal physician of former Republican president Theodore Roo­se­velt, Lambert was also the fellow New Yorker’s kindred po­liti­cal spirit. Roo­se­velt had broken with the insufficiently progressive Republican Party to form the “Bull Moose,” or American Progressive Party, whose 1912 platform called for compulsory health insurance. Lambert was not alone among medical leaders in aligning with the new party. If well designed, guaranteed health insurance, he said, “broadens the field of preventive medicine and sanitation and gives wider and better opportunities than are now available” for health departments to implement their regulations.24 “PUBLICIT Y” FOR L AY ENLIGHTENMENT A N D R E ­S P E C T

Politicians often scoffed at medical reformers’ calls for public health mea­ sures. ­Because of that, the AMA’s progressive leaders concluded that the profession had failed as educators of the public to whom politicians listened. To remedy the prob­lem, “publicity” was one of the ­orders of the day. A term commonly used among progressives in other lines of reform, publicity connoted exposure of social, economic, and po­liti­cal evils and advocacy on the means to fix them. Publicity was simply, as the AMA journal put it, one of “the practical objects of organ­ization.” The silencing of backbiting doctors was not enough. A harmonious chorus with a positive message to the outside world was needed, backed by the resources to propagate it. More importantly, it entailed appealing to social, economic, and po­liti­cal elites impressed by emerging bacteriological and epidemiological science and the huge, untapped payoff

50

The American Medical Disorder

of preventive health mea­sures. Public health was public wealth as the public health movement’s slogan of the 1880s had put it.25 According to AMA or­ga­nizer McCormack, the public needed to hear good ­things about what doctors could offer as public health advisors rather than as clinicians. Thus, in 1906 while on the road in Texas—­after more than three years of speaking almost exclusively to doctors—­McCormack began inviting civic leaders to attend special eve­ning lectures in churches, school auditoriums, YMCAs, and other public venues. Soon his speeches drew large audiences of ­lawyers, ministers, teachers, legislators, farmers, business ­people, and city and county officials. They also included large numbers of electorally disenfranchised though socially active and po­liti­cally influential w ­ omen. In Williamsport, Pennsylvania, for example, McCormack attracted a mixed audience of around four hundred doctors and laymen. In October and November of 1906, he spoke to public audiences in twenty-­t wo cities throughout Michigan, usually a­ fter meetings ­earlier in the day with doctors alone. Lectures on eleven of thirteen days in ­Virginia ­were followed by the same in fourteen places over sixteen days in Kansas in 1909. In 1910, tens of thousands of laymen in ninety-­seven cities in eleven states heard his message. He also spoke to elected officials and, while in capital cities, to state legislatures. By the time he returned to Kentucky in 1911 to resume his much lower-­paid public health work—­despite AMA entreaties to keep g­ oing—­McCormack had addressed at least half and maybe up to two-­thirds of the nation’s state legislatures.26 In lectures to laypeople, McCormack invited them to support the newly reor­ga­nized profession in taking on the drug industry for purveying dangerous concoctions of alcohol, morphine, cocaine, and other harmful compounds that added “to a very considerable extent, to the death rate of the country e­ very year.” Employing “­little boy clerks,” retailers of drugs, complicit with their makers, persuaded young men that their remedies would easily treat the gonorrhea they would continue to pass on, thus necessitating what leading surgeons estimated to be “half the surgery done for ­women in this country.” But public health was the central issue in McCormack’s addresses to laymen. In lectures published as “­Things about Doctors Which Doctors and Other P ­ eople ­Ought to Know” and ­later, around 1911, “The New Gospel of Health and Long Life,” reported on in many city and local newspapers, McCormack told listeners that the federal government spent virtually nothing on the preservation of h ­ uman life while lavishing “millions of dollars for the . . . ​promotion of animal husbandry [and] for the cure and prevention of diseases of plant life.” While d ­ oing l­ittle to protect soldiers from the preventable diseases of



O r g a n ­i z i n g f o r O r d e r

51

the field that killed far more of them than e­ nemy bullets, it spent 75 ­percent of its revenue on military pensions as reward “for the slaughter of humanity.” Such facts, he said, showed that “no other nation has been and still is so criminally negligent of the health and lives of both its soldiers and its citizens.” One remedy: “A g­ reat health department at Washington” for scientific research into the ­causes and prevention of disease and its dissemination.27 McCormack complained that even “intelligent congressmen and state legislators” typically suspected doctors of promoting public health reforms for selfish reasons “without stopping to consider that insofar as they prevent sickness they diminish their own incomes.” After all, they had never heard other professionals or businesspeople asking for ­things that would depress demand for their work and wares. Most of what they witnessed from doctors was perverse competition over patients. Thus, in advocating for legislation “the espousal of a bill by the medical profession was often equivalent to its defeat.” Therefore, he asked the public to come to the profession’s aid in promoting disease prevention and supporting the creation of a federal health department. He also personally persuaded presidential hopeful William Jennings Bryan to add that goal to the 1908 Demo­cratic Party platform.28 McCormack often tailored his speeches to audiences with information about their specific local and regional health ­hazards. In 1907, he pointed out to citizens of New Brunswick, New Jersey, that infantile diarrhea caused by impure milk had killed over two thousand of their ­children the year before. In 1908, he told citizens of Vicksburg, Mississippi, that their city’s slaughter­ houses ­were “in an indescribable and utterly unendurable condition,” setting off a local newspaper investigation and exposé. Not surprisingly, he found particularly receptive audiences for such news among w ­ omen. In an address in Lynchburg, or­ga­nized jointly by the ­Virginia Acad­emy of Medicine and the W ­ omen’s Civic Betterment Club, about three-­fourths of approximately five hundred citizens who heard McCormack ­were ­women.29 Thus, what had started as strictly a professional recruitment and organ­ ization drive evolved into much more, a public relations campaign for progressive medicine. In addressing laymen, McCormack acted on an impulse shared by many other progressive physicians. In 1902, fellow orga­nizational reformer Maxwell Foshay told his Ohio colleagues that it was their “duty to undertake the education of the public,” in order to gain re­spect and thus “become a power in po­liti­cal affairs.” Organ­ization was the first means to that end b­ ecause it provided the plans, personnel, and resources for public education and po­liti­cal persuasion. George Simmons declared in 1908 that it was

52

The American Medical Disorder

time for doctors to shed their “cloak of professional dignity” and to change their “attitude of infallibility ­toward the public.” Open engagement with the lay world and their often “well-­grounded” views was necessary.30 Charles Reed, chairman of the AMA’s Committee on Medical Legislation and head of its Bureau of Publicity, asserted in 1910—in explicit opposition to colleagues who w ­ ere shy about taking medical issues to the public—­“If the American public is not informed and enlightened by the reputable medical profession it w ­ ill be biased and influenced by the quack, the charlatan, the manufacturer of impure and adulterated foods and drugs and by all the other selfish interests which have so long preyed on the ­people.” An article in the Chicago Daily Tribune about an upcoming AMA meeting in 1910 discussing medical education, drug regulation, and more suggested that reformers had informed the newspaper about their strategic thinking. The conference, according to the article, “­will stand unique among meetings of the profession held in this country” b­ ecause for the first time, physicians ­were “taking the unprofessional outsider into their confidence.” The article was titled “Dr. General Public Called in Consultation with the American Medical Association.”31 A few medical reformers at the turn of the ­century sought publicity for leverage to clean their own ­house of medicine, not just for public health reforms. According to Arthur Dean Bevan, who would be elected AMA president for its 1918–1919 term, a better-­informed public could assist the profession in self-­reform. “Publicity,” he told the AMA House of Delegates in 1906, was “often the best cure of an evil” and was “bound to lead to correction and improvement.” A leading gynecologist, Ely Van de Warker, agreed about the curative effect of openness regarding the profession’s failings and the resulting external pressure for change it engendered. He hoped, as he told a gathering of the American Gynecological Society in 1906, that public criticism and satire would ultimately “correct the evil of indiscriminate ablation of the ovaries.” Healthy appendixes, he believed, ­were now being spared ­because their ­wholesale surgical removal had been “laughed out of court” by the public. Th ­ ere had been “so l­ittle science about it that it could not survive ridicule.” He even ventured that “reforms in medicine have always come from without the profession, I am ashamed to say.”32 Mostly, however, the drive for publicity was a strategy for enlisting lay allies for public health, drug reform, and stronger licensing laws to suppress the worst quackery. Texas medical editor Ferdinand E. Daniel complained, on the ­matter of the “maladministration of public medical affairs,” that newspapers



O r g a n ­i z i n g f o r O r d e r

53

­ ill seldom publish any “medical or sanitary articles” of a more serious nature w “­unless paid.” While the legitimate profession ignored the popu­lar press as a tool for medical enlightenment, the country’s newspapers w ­ ere only too happy to publish “grotesque and laughable stories fed them f­ree of charge by quackish prac­ti­tion­ers,” according to Thomas G. Atkinson, editor of Chicago’s Medical Standard in 1909. In 1902, progressive-­minded elite Wisconsin physician Ralph Elmergreen complained that “we have no popu­lar medical lit­er­a­ture, no pamphlets popularizing science; no leaflets of convincing medical statistics setting forth the value of certain prophylactic or sanitary mea­sures; no propagandic newspaper-­backing to answer the brazen effrontery of the medical mountebank—­a nd in this lies the explanation of our failure to win the popu­lar ear. We must press forth and make the secular and religious press our battle-­grounds . . . ​Our f­uture lies in education.” That meant honestly and humbly sharing “the sorrows of our failures” as well as the “joys of our successes”—­appealing to an intelligent public in order to earn re­spect.33 To bring change, editor Daniel proposed that the Texas State Medical Society spend part of its current bud­get surplus on public education. What he proposed for Texas, the reor­ga­nized and vitalized AMA a­ dopted for the w ­ hole country—­use of membership fees and subscription revenue to fund public education. In 1907, shortly ­after McCormack had added public education to his speaking agenda, the AMA Committee on Hygiene and Public Health proposed the creation and generous funding of a permanent organ for public enlightenment—­having consulted with the Associated Press and editors of several Philadelphia newspapers about what help they could offer. Its work culminated in 1909 with the formation of a permanent Council on Health and Public Instruction. Into this impor­tant council ­were folded McCormack’s National Organ­ization Committee and the existing Council on Medical Legislation, indicating that organ­izing, educating, and legislating w ­ ere of a piece. Chairing the new council and taking responsibility for its Bureau on Public Instruction was the Chicago physician, public health champion, and revered civic reformer Henry Baird Favill. Among its members in the next few years w ­ ere William C. Woodward, a legally trained doctor and the prominent public health commissioner of Washington, DC; Harvard’s Walter B. Cannon, ­later a famous neurophysiologist (and husband of Cornelia James Cannon, a best-­selling author and feminist reformer); and Walter S. Rankin, a f­ uture president of the American Public Health Association and a leader in the National Tuberculosis Association and the National Association for the Prevention of Infant Mortality.34

54

The American Medical Disorder

With the AMA’s burgeoning membership and therefore expanded resources, Favill’s council and its Bureau on Public Instruction ­were able to or­ga­nize over twenty-­eight hundred lectures delivered to more than 230,000 ­people and send weekly bulletins to almost five thousand newspapers and other outlets, thus reaching tens of millions of readers. The press’s usage rate was gratifying. Titles of some of the first ten disseminated included “Typhoid Fever in Des Moines,” where reporting of cases was not yet required, thus causing ­needless suffering and death during the winter of 1910–1911; “Consumption-­Cure Fakes,” an eighty-­page exposé of useless tuberculosis nostrums; “Need of Caution in the Use of Salvarsan,” about the recently discovered arsenical offering only risky and unreliable treatment of early-­ stage syphilis; “Individual Liberty and the Public Welfare,” on the vacuity of libertarian arguments against government health mea­sures; “Sex Instruction in the Schools,” with ex-­Harvard-­president Charles W. Eliot’s arguments in ­favor; and notably, the ironically titled “Weak Medical Schools as Nurseries of Medical Genius,” authored by the Car­ne­gie Foundation’s Henry Pritchett, a lay ally of the AMA in its attempt to reform medical education. By 1915 the AMA had distributed 164 bulletins reaching hundreds of millions of potential readers.35 ­Women, both lay and professional, ­were central to the AMA’s early public information activities. In line with the spirit of his controversial medical school valedictory address on sexual equality in intellectual and physical capabilities, McCormack especially sought ­women’s participation in the discussions a­ fter his speeches. It produced, he said, “the most satisfactory results.” ­Later, back in Kentucky, he enlisted the Kentucky branch of the Federation of ­Women’s Clubs to conduct a ten-­city sanitary survey. Its depressing revelations resulted in an increased appropriation for his state health bureau. As a state legislator in 1914, McCormack arranged for social reformer and literacy crusader Cora Wilson Stewart to speak before the Kentucky General Assembly about funding a Kentucky Illiteracy Commission. Fighting disease was one impor­tant justification for her mission; her Country Life Readers for national adult illiteracy programs included easy-­to-­read articles on health, sanitation, and nutrition.36 ­Women physicians’ extensive local-­level work across the country was encouraged by a 1909 resolution before the AMA House of Delegates promoting educational committees to act through w ­ omen’s clubs, m ­ others’ associations, and other civic groups to disseminate accurate medical information. Notable in the new AMA’s orga­nizational and public education work,



O r g a n ­i z i n g f o r O r d e r

55

despite widespread exclusion of female doctors from county and state socie­ties, was a pioneer among ­women doctors, Rosalie Slaughter Morton, a Berlin-­and Paris-­educated clinician and medical scientist. Against some out­spoken male supremacist re­sis­tance in the AMA, she assumed the chairmanship of its Public Health Education Committee and spurred it into nationwide action. Morton was ­later to become the first ­woman faculty member in Columbia University’s College of Physicians and Surgeons.37 In her contribution to the Council on Health and Public Instruction’s first report in 1911, Morton lamented the criticism “constantly made, not only by the laity, but even by members of our profession, that physicians do less than any other class of ­people in the pre­sent world-­wide social evolution for higher standards of living.” Instead, all the good work done by colleges, churches, settlements, prison reform associations, the Consumers’ League, the Young Men’s and the Young ­Women’s Christian Associations, the antituberculosis socie­ties, the Child Hygiene organ­izations, and o­ thers of the last thirty years ­were credited to members of the laity. In fact, however, she proudly proclaimed, physicians w ­ ere always among the most active and effective workers in t­ hese and many other agents of reform. And as often as not, they w ­ ere female. Fifteen of the twenty-­two medical movers and shakers she praised for their impor­tant civic work across the country with public health implications ­were ­women. In her autobiography, Morton recalled that medical men, unlike ­women, routinely refused to address the public on prevention, even when the subjects coincided with their own specialties. “They considered it below their dignity to be ­wholesomely helpful and took refuge in claiming that they did not have time for this generous ser­vice.” Many, she said, “considered it a bore ­ ere only interested in and a waste of time to lecture outside a college.” They w acute illnesses “against which they could match their wisdom in defeating death.”38 SUCCESS A ND FA ILUR E

The evidence indicates that the efforts to reor­ga­nize and energize the AMA took rapid effect. In Wisconsin, for example, by late summer 1903, less than six months ­after a visit from McCormack, twenty existing or newly created county socie­ties had requested recognition by their state association. In the de­cade ­after 1901, membership in the AMA and its constituent socie­ties ­rose about ninefold, from about eight thousand to more than seventy thousand, or about half of the physicians in the country, up from only 6 ­percent before. With and

56

The American Medical Disorder

­because of better organ­ization came more fraternal peace. To be sure, according to Jacobi, t­ here had already been a gradual decline of medical fratricide, and an “esprit de corps” had been on the rise within the profession. Charles Reed called it a “catholicity of spirit” and indeed a “progressive spirit.” That was prob­ably ­because of the state-­level licensing promoters’ efforts since the 1870s, who, like Jacobi and other progressives, called for conciliation with the homeopaths and eclectics. But all was not yet well. Maxwell Foshay, McCormack’s associate in the reor­ga­ni­za­tion effort, declared in 1901 that the medical profession’s disagreements ­were only “slowly being silenced” and ­were still “a subject of levity” in public and private conversations.39 By 1910, however, McCormack was able to boast to lay audiences that “ours is rapidly becoming one of the most harmonious of callings.” The vitalized and rapidly growing AMA seemed to have succeeded in silencing much of the fratricidal squabbling. As a first step, in 1903 the AMA revised its old “code of ethics” into a “statement of princi­ples,” drafted chiefly by William Welch, dropping the prohibition against consultation with irregulars. In 1910, the Medical World welcomed the fact that “medical bigotry is on the decline.” In 1913 D. W. Cathell published a revised edition of his 1880s and 1890s Book on the Physician Himself, ­earlier editions of which had contained many mentions of perverse competitive be­hav­ior and public displays of contempt for fellow doctors. In the new version, discussions about discord in the profession and what to do about it ­were few and far between. In his final 1922 revision, Cathell both­ered with only a few short comments on respectful intraprofessional etiquette.40 The salutary effects of reor­ga­ni­za­tion, growth, harmony, and, not least, publicity about the progressive AMA’s public health mission reached all the way to occupants of the White House. In 1905, the AMA journal proudly claimed that President Theodore Roo­se­velt was “not least among our friends and appreciators,” and appreciated in par­tic­u­lar his “speaking loudly his dissent from the too-­prevalent anti-­medical prejudice.” Six years ­later, in 1911, one of the early bulletins distributed to the press by the AMA’s Council on Health and Public Instruction, titled “President Taft’s Message to Physicians,” reported on a “splendid testimonial banquet and reception” for Taft sponsored by the Medical Club of Philadelphia. “No other president has been so honored by the medical profession; and no other president has so honored the physicians of the United States,” the bulletin claimed. The elite Philadelphia doctors especially extolled Taft’s “ser­vices to sanitary science and . . . ​his aid in the advancement of public medicine.” 41



O r g a n ­i z i n g f o r O r d e r

57

According to historian Burrow, the AMA’s reor­ga­ni­za­tion and growth brought it from obscurity to public prominence and “gave promise of making the AMA an effective po­liti­cal force.” Its clout did indeed grow, but it was far from uncontested. For one ­t hing, the reformers’ hopes for unchallenged cultural authority in the larger body politic would not be fulfilled. While many social, economic, educational, journalistic, and po­liti­cal elites ­were won over, the reformers’ success was still spotty in other layers and sectors of American society. In 1910, McCormack lamented that despite the profession’s healthy rejuvenation, a prejudicial feeling “almost as strong as it was a generation ago” still haunted the h ­ ouse of medicine.42 McCormack’s dark assessment was no doubt colored by the sudden mobilization that year of a power­f ul co­a li­tion of external enemies against the AMA. They voiced deep doubts and suspicions, much of them understandable, about many regular prac­ti­tion­ers’ arrogant pretensions of scientific superiority over alternative therapeutics. Unfairly, that hostility rubbed off on the AMA, bringing doubts about the sincerity of its humanitarian arguments for its public health agenda. The precipitant of open conflict was the AMA-­ supported plan to create a cabinet-­level national department of health. As l­ater chapters w ­ ill show, the AMA reformers not only won lay allies among elites for it but made enemies of ­others in their ongoing ­battles, especially for drug regulation. Elite as well as popu­lar forces mobilized against them in 1910. The same year also brought stirrings of internal dissent from below against the AMA’s progressive leadership. Within fifteen years, it would grow into a full-­ blown national insurgency, a reactionary turn, and then, in alliance with external conservative forces, a dif­fer­ent AMA.

This page intentionally left blank

chapter 3

Therapeutic Chaos and Commercial Conquest

If medical sage Oliver Wendell Holmes Sr. was right that “the state of medicine is an index of the civilization of an age and country,” then Amer­i­ca at the turn of the twentieth ­century was in a sorry condition indeed. Corruption in medical commerce, as in other realms of American business, was rampant. Thus, in their search for medical order, one of the medical progressives’ post-­reorganization initiatives was to attack Amer­i­ca’s drug prob­lem: the commercial infestation of pharmacotherapeutics. In numerous editorials and articles, the reformist AMA editor, secretary, and general man­a g­er George Simmons laid out the details of the prob­lem. Government regulation of drugs and their advertising was so lax that manufacturers in E ­ ngland, France, and Germany created inferior product lines exclusively for the more open American market where “the standard and quality of drug have been left entirely to the manufacturers’ honor.” He called the industry’s “patent medicines” and “nostrums” of mysterious composition “a curse to our profession.” Advertised to doctors with preposterous curative claims, ­these products “debauched” and “blighted” medical journalism. Hundreds of medical journals dependent on advertising income seemed to find “no statement too silly, no claim too extravagant, and no falsehood too brazen” to publish. Thus, they “suborned the art of prescribing to the aggrandizement of commercial producers.” The commercial invasion of medical practice even penetrated into the institutions of

61

62

D r u g P r o b­l e m s

medical education. Drugmakers ­were “tainting our textbooks,” Simmons lamented. In medical schools, students w ­ ere deluged with advertising and samples of “discredited nostrums.” It was “a far-­seeing scheme . . . ​to breed up among undergraduates a race of f­uture physicians” for whom the awful merchandise would become “house­hold words.”1 The drug industry’s deceptions and crimes needed exposing, and laws controlling it needed passing. Thus, in 1905 the AMA published The G ­ reat American Fraud, a compilation of a long series of Collier’s Weekly articles mostly by the famous journalist Samuel Hopkins Adams. The drug industry, muckraker Adams wrote, was “founded mainly on fraud and poison.” Bringing down the corrupt industry was ­going to be a daunting task, considering the power of drug money in electoral and legislative politics. That power was backed up by the influence drug firms exercised over popu­lar newspapers and magazines relying on drug advertising to keep their prices down. Their readerships dwarfed Collier’s, of course. They muzzled themselves accordingly, refusing to publish critical stories. As Collier’s revealed, drug companies even extorted editors to publish antiregulation editorials by inserting “red clauses” into multiyear advertising contracts that rendered them null and void whenever reforms managed to get through legislatures in their states.2 The medical press was just as bad, according to the reformers. They longed to displace the many so-­called in­de­pen­dent medical journals—­that is, in­de­ pen­dent of medical socie­ties undergoing reform—­with more legitimate periodicals. It would be no easy task b­ ecause of doctors’ unwillingness to pay high subscription rates for journals that rejected meretricious drug advertising. Reforming medical education to make doctors suspicious of drug makers’ specious claims was also a remedy envisaged. Because drugs were also advertised and sold directly to the public, medicine’s reformers also sought political help from Congress and state legislatures for passage of laws requiring honesty and transparency about their ingredients, especially if they were toxic and addictive. They also sought public health reforms to slow the spread of diseases and thereby stifle demand for drugs that ­were worthless against them. FROM “SYSTEM” TO CHAOS

At the turn of the twentieth ­century, money spent for advertising “proprietary” drugs in Amer­i­ca (i.e., ­those with trademarked names and graphics), sometimes called “patent medicines” (although they did not hold patents for new ingredients), exceeded all other manufactured products on the U.S.



Therapeutic Chaos and Commercial Conquest

63

market. In 1900, upward of two thousand firms purveyed almost $60 million worth of mostly clinically worthless and often addictive and dangerous “remedies.” Five years l­ater the figure reached $100 million. By 1909 it had more than doubled to about $140 million. In 1910, the ninety-­one-­page Druggists’ Circular Price List contained an astounding twenty-­five thousand or so dif­fer­ent medicinal products available for retail sale, none requiring a doctor’s prescription. The ­actual number may have been up to fifty thousand.3 As Francis Edward Stewart, a doctor, pharmacologist, and fervent advocate of “rational therapeutics” put it, “tens of thousands of alleged new remedies have been introduced by advertising during the past quarter of a ­century and not one-­half of one ­percent of them have made good.” It was “polypharmacy,” or shotgun medicine, on a colossal scale. The exact contents of most of ­these so-­called remedies ­were not known to anyone but their makers. The carriers of their advertisements, their ­eager consumers, and even the prescribing doctors often acting as middlemen did not seem to mind. While the advertisements w ­ ere ­silent or ambiguous about the ingredients, they effused about amazing curative properties. Dr. R. C. Flower’s Blood Purifier, for example, was “so near a specific for Scrofula, and t­ hose dreadful diseases so closely allied to it, as well as cancers, tumors, salt rheum, erysipelas, tetter, eczema, e­ tc., that it is justly entitled to the name of ‘King of Blood Purifiers.’ ” Richard Charles Flower, according to McCormack, was “prob­ably the most ignorant and successful quack” ever known in the country, but he was far outnumbered by other successful but less colorful types. Flower started as a ­lawyer and then a preacher before turning to more lucrative ventures. According to McCormack, he had been driven out of a Kentucky church for “gross immorality” in a town where McCormack had once practiced. Flower then moved north for a more profitable calling as a healer and hawker of cures. Still a preacher but now only against medical licensure, he advertised his nostrums to thousands of gullible readers in small newspapers and lowbrow magazines. Many times jailed, the medical swindler became more famous across the country for mining scams and other con jobs he pulled off alongside his medical businesses. In 1907, the New York Times accorded Flower “a place in the front rank of American crooks” for, among other t­ hings, having “discovered how to cure manifold diseases, including the swollen pocket­book malady.” 4 Not surprisingly, medical progressives in the AMA despised Flower and his ilk but focused more of their ire on the spread of the commercial cancer in medical journals, supposedly healthier regions of medicine than the

64

D r u g P r o b­l e m s

newspapers and magazines for layfolk. As AMA leader Frank Billings complained, legitimate-­sounding yet worthless and potentially toxic concoctions found their way out of reputable drug ­houses and onto the pages of supposedly respectable journals like the Medical Rec­ord, the New York Medical Journal, Medical News, American Medicine, and the Boston Medical and Surgical Journal. Advertising in medical journals proved to be money well spent on targeting the country’s poorly educated doctors. Thus, medical education was not spared from attack. In an address to a meeting of the American Pharmacological Association—­where “the air was thick with charges and countercharges” about commercial corruption—­McCormack agreed that his own profession’s educators shared some of the blame. The “loose and hazy teaching of pharmacology and therapeutics” left doctors with few intellectual defenses.5 Consequently, according to evidence presented below, prescription rec­ords kept by pharmacists and examined by inquisitive reformers showed that tens of thousands of the country’s doctors gave manufacturers the benefit of profound doubt by prescribing their nostrums. ­Because of their gullibility, American physicians suffered grave reputational damage that the AMA organizers hoped to fix. Doctors’ habits of prescribing ready-­made proprietary concoctions, the Journal of the American Medical Association stated, “tend utterly to discredit the profession in the minds of thinking laymen.” As one physician wrote, the very fact that a drug prescribed is “ready-­made” corrodes the patient’s confidence in his physician “about as much as one would lose faith in a tailor caught in palming off a ready-­made suit.” According to Samuel Hopkins Adams, drug ads often contained earnest testimonials of efficacy from “renegade” doctors willing to sell praises of their drugs to all bidders. “The average American,” he wrote, “­wouldn’t buy a second-­hand bicycle on the affidavit of any of them, but he ­will give up his dollar and take his chance of poison on a mere newspaper statement which he ­doesn’t even investigate.” 6 Just one example of thousands of questionable drugs widely advertised directly to doctors w ­ ere vari­ous elixirs of “tonga,” a mysterious mix of exotic plant substances collected by Fiji Islanders. The single supposedly active ingredient was first introduced by Parke-­Davis around 1881 for “neuralgia.” Over time, unstandardized tonga preparations with an accretion of vari­ous additives w ­ ere advertised for an expanding number of medical conditions. Manufacturers had learned that “it is commercially impracticable to establish a continued demand for a preparation recommended as a cure for only one disease . . . ​it must be a panacea . . . ​‘good’ for many t­hings.” By 1902 doctors



Therapeutic Chaos and Commercial Conquest

65

learned that one com­pany’s Tongaline—­a mixture of tonga, black cohosh, and three salicylates—­“cures rheumatism, sciatica, lumbago, grippe, neuralgia, malaria, headache, [and] gout,” as well as “many diseases of the kidneys and the liver.” It could do all that ­because it “acts upon the poisonous products of retained excretion or perverted secretion and eliminated [sic] them promptly and thoroughly thus insuring in ­every instance certain results from certain doses in certain time.” Tongaline was even recommended for yellow fever around the time of its 1906 New Orleans outbreak. On Tongaline’s advertisements, Frank Billings exclaimed in an AMA journal article, “Verily, this is too much! . . . ​The practice of medicine with Tongaline is too easy. At this rate t­ here ­will be no reason to die.”7 Tongaline had to compete with thousands of other products “good for” the same ­things that an occupying army of drug manufacturers, advertisers, and retailers shot out over the medical landscape. Starting in the late nineteenth c­ entury, the commercial invasion rolled over feeble re­sis­tance ­because of the medical chaos it encountered. ­There was no well-­organized profession to fight it, and if ­there had been, it was not equipped with anything resembling discipline in therapeutics that could put up an intellectual defense. The profession lacked po­liti­cal clout to lobby successfully for legislative controls. Instead, as the AMA’s reorganizers knew, commercialism routed a medical profession with warring factions, rivalries within ­those, and a medical professoriate that, b­ ecause of its own ignorance and uncertainties, had all but abdicated leadership in educating doctors-­to-be on rational therapeutics. If ­there ever had been anything close to medical order in Amer­i­ca, or at least an intellectual immunity to commercial infection, it was long gone by the 1870s, having gradually degenerated a­fter the country’s early years. Revolutionary-­era medicine, adhered to at least in princi­ple by elite physicians, derived in part from a so-­called “system” of medical thinking inherited from ancient Greece that dated as far back as Hippocrates and spread through the writings of Galen of Pergamon. Sometimes called “humoral,” the doctrine held that good health relied on the balance of four humors, or bodily fluids: phlegm, blood, yellow bile, and black bile. Clinical application of the theory, prescriptions, and creative embellishments varied greatly but mostly involved, not surprisingly, the drainage and chemically induced purging of bodily fluids and the ingestion of other fluids or application of poultices to restore balance. Mass-­produced products w ­ ere not part of the armamentarium; the relatively small number of ingredients needed w ­ ere readily available from a local chemist.

66

D r u g P r o b­l e m s

Among the most fervent and certainly the most enthusiastic and influential prac­ti­tion­ers of “depletion therapy” was Benjamin Rush, a signer of the Declaration of In­de­pen­dence. Bloodletting with venesection was his favorite weapon against disease, which he wielded with ­great gusto, for example, during Philadelphia’s terrible yellow fever epidemic of 1793. George Washington, the sixty-­eight-­year-­old former president, was a victim of this kind of heroic medicine. Washington’s three doctors recorded treating him for a raging throat infection, possibly acute bacterial epiglottitis, by draining up to one gallon of his blood over a period of nine to ten hours. That was more than one-­half of the 230-­pound, six-­foot-­three man’s total blood volume—­and certain death. One of the doctors proposed a tracheostomy, which could have saved his life, but he was ignored.8 Bloodletting was well on its way out of fashion by the 1850s but not the administration of ­great quantities of mercury for its purgative and other properties. In the 1850s, the Commercial Hospital of Cincinnati purged over 50 ­percent of its patients with “calomel” (mercury chloride). Another popu­lar method for delivering mercury was Rush’s Bilious Pills, known as “thunder clappers” for their explosive efficacy. Among many other t­ hings, mercury was not uncommonly prescribed for “hypochondriasis” or “melancholy,” considered by Rush and ­later orthodox prac­ti­tion­ers to be related to abdominal imbalances. During the 1850s, ­future president Abraham Lincoln regularly took mercury delivered in sweetened and flavored “blue mass pills” to deal with his constipation and depressive lethargy. Instead of curing Lincoln, the accumulating neurotoxin prob­ably caused him to suffer from insomnia, forgetfulness, and psychotic rages. His long-­time law partner and biographer William Herndon described Lincoln during one of ­these episodes, in 1859, as “so angry that he looked like Lucifer in an uncontrollable rage.” A ­ fter nearly a de­cade of taking the drug, and soon a­ fter his inauguration, Lincoln quit taking the pills. They made him “cross,” he said.9 The decline of orthodox hegemony began in the 1820s, thereby opening up American medical practice to commercial infiltration. But that was ­limited by the lack of long-­distance communication and transportation infrastructure for mass production and distribution. In therapeutics, a semior­ga­nized competitive pluralism arose, responding in part to populistic and therefore negative attitudes t­oward medical elitism. Competition over patients was a main driver of change. Within the regular profession, Southern and Western doctors graduating from and teaching at their own schools competed with ­those educated in the East for the scarce supply of prestige by propounding



Therapeutic Chaos and Commercial Conquest

67

ideas about therapeutics specifically tailored for distinct regions, climates, and populations. Competition among prac­ti­tion­ers in response to popu­lar preferences and prejudices against the medical elite also drove the trend t­ oward pluralistic disarray. In the pro­cess the brutalist methods that had been imposed from the past, from without and from above, w ­ ere being shouldered aside.10 Supply also met demand with a departure from depletive therapeutics. Instead, ­things like morphine as a palliative, chloral hydrate as a sedative, and alcohol as a “stimulant” ­rose as common therapies. Their pleasing effect was prob­ably far more persuasive to patients than the theories or evidence they ­were delivered with. Starting in the 1820s and flourishing in the 1830s, many patients found refuge in Thomsonianism, a home-­grown herbalist challenge to the elite orthodoxy. Appealing to the same egalitarian, individualist sentiments of the Jacksonian era that swept away medical licensing across the states, it was introduced by the enterprising and bombastic Samuel Thomson, the self-­ educated son of illiterate New Hampshire farmers. Bad experiences with orthodox prac­ti­tion­ers, good experiences with folk healers, and a hatred of pig farming launched him on his medical ventures. Though it was consistent with the po­liti­cal culture of the agrarian hinterland against orthodoxy’s patrician elitism, Thomson’s do-­it-­yourself therapeutics mimicked some of the regulars’ harsh practices. But they relied on botanicals, often of Native American origin, as well as steam and other heat treatments. For twenty dollars, Thomson sold “patents”—­over one hundred thousand of them between 1822 and 1840—to any man or ­woman wishing to use his pharmacopoeia. Only ­these right holders could order Thomson’s herbs and formulas from him or his “agents.” Eventually, a rift among the Thomsonians over his monopolistic control over their neck of the medical woods, conjoined with competing botanical currents, led to the establishment of an “eclectic” school of medicine in the late 1830s. Its adherents, wishing to break Thomson’s mono­poly, professionalize herbalist practices, and incorporate a wider range of therapeutic techniques, set up their own schools to break up another mono­poly: that of regulars who had cornered professional prestige by attracting educated, well-­ paying customers.11 Another addition to medical pluralism and internecine conflict was “hydropathy,” a Eu­ro­pean import. Somewhat popu­lar in and a­ fter the 1840s, this drugless system’s most famous proponent was John Harvey Kellogg, who applied vari­ous inventive hydrotherapies at his ­Battle Creek Sanitarium. Attracting wealthy and famous ­people like Mark Twain, Brigham Young,

68

D r u g P r o b­l e m s

Susan B. Anthony, and Catherine Beecher, bath cures especially appealed to ­women repelled by the regular medical patriarchy and its views on female disorders, just as botanical medicine attracted rural Americans. Following the teachings of hydropathy’s pop­u­lar­izer Mary Gove Nichols, many of its prac­ ti­tion­ers helped redefine ­women’s natu­ral physiological pro­cesses as nonpathological. Their institutes and lit­er­a­ture constituted a forum of early feminism by encouraging ­women, in more ways than one, to declare in­de­pen­dence and carve out greater autonomy. ­Women should, it counseled, take pride in their contributions to economy and society, as well as their sexuality. Its rhetoricians ­were, as a historian points out, “inferentially supportive of the ­women’s rights movements’ concerns.” The network of hydropaths and their institutions “served as a haven for social visionaries” of other sorts as well.12 More impor­tant and numerous combatants against the heroic orthodoxy ­were the homeopaths. Less demo­cratic than Thomsonianism and hydropathy, homeopathy was a German import a­ dopted, starting at midcentury, by thousands of more educated prac­ti­tion­ers. The reductionist school of homeopathic medicine sprang largely from the imagination of Christian Friedrich Samuel Hahnemann, son of a porcelain artisan in Meissen, Germany. A scholar who mastered up to nine languages, Hahnemann cast aside three years of orthodox instruction at medical schools in Leipzig, Vienna, and Erlangen ­ ere translated into En­glish to concoct his own therapeutics. His chief works w and became canonical fare for many ambitious and patient-­hungry doctors in the United States. Homeopathic medical schools sprung up in vari­ous parts of the country, and the certification they provided improved the sectarians’ appeal among an educated public by the 1850s. By 1900 t­here ­were twenty-­ two such schools and more than one hundred homeopathic hospitals and dispensaries.13 Scientifically minded regulars such as Oliver Wendell Holmes Sr. heaped scorn on Hahnemann’s system, thus fueling the ­bitter animosities that ­later reformers like Joseph McCormack tried to still. Homeopathic theory called for the extreme dilution of active agents whose effects in larger doses mimicked the symptoms of the disease to be cured. At numerous stages, each progressive dilution was “succussed,” or struck against a special soft leather pad, in order to further “potentize” or “dynamize” the preparation. A ­ fter all the dilutions and agitations, the liquid to be ingested contained nothing or virtually nothing except ­water (and random contaminants in far greater concentration than the original ingredient itself). Perhaps Abraham Lincoln had been influenced by Holmes in his ridicule of homeopathy during one of his



Therapeutic Chaos and Commercial Conquest

69

famous debates with Illinois Senate opponent Stephen Douglass. Lincoln compared Douglass’s argument on the slavery question for granting the territories state-­like sovereignty to “homeopathic soup . . . ​made by boiling the shadow of a pigeon that had starved to death.” Ironically, in 1854, while still taking his mercury pills, it was Lincoln who lobbied successfully for a state charter for the Hahnemann Medical College of Chicago.14 Despite the ridicule, homeopathy appealed to many educated and well-­ to-do patients such as members of the Chicago elite who had retained Lincoln to obtain the charter. Consequently, the regulars gradually dispensed with all the bleeding, puking, purging, and blistering and even ­adopted medicinal substances, if not their extreme dilutions, used by homeopaths. Competition dissolved the regulars’ system to the point that they had l­ittle to defend except the promise, not the current real­ity, of better, undogmatic science. Some regulars even defected to the homeopathic ranks. As Mark Twain observed, one valuable result of the “war of lancets, and many hard pills to swallow” was that the old-­school bloodletter had been forced “to stir around and learn something of a rational nature about his business.” To Twain, rational therapeutics, as he concluded in the years leading to his death in 1910, meant first ­doing ­little or nothing and thereby bringing better results than ­doing too much. Second, it was to keep an open mind, experiment, and even rely on the power of suggestion. ­Because of the regulars’ competitive adaptation, he was able to declare that even if regulars w ­ ere all you ever employed, “you may honestly feel grateful” for homeopathy’s survival against the regulars’ attacks.15 The dissolution of what medical historian John Harley Warner calls “the spirit of system” helped open the door for the commercial invasion. Ironically, the elite of the regular profession led the drift away from system therapeutics. Usually from the upper class, they had been returning from the citadels of Eu­ro­pean medical education, starting in the 1820s, especially in France and ­later Germany and Austria, with a profound skepticism about therapeutics of any kind. Holmes was among them, causing outrage among fellow regulars for declaring in his 1860 address to the Mas­sa­chu­setts Medical Society a firm belief that the standard materia medica “as now used, could be sunk to the bottom of the sea it would be all the better for mankind, and all the worse for the fishes.” Many pre­sent thought he said “physicians” instead of “fishes,” which added to the insult. Perhaps Holmes’s g­ reat therapeutic pessimism helps explain his exclusive devotion to his famous literary pursuits in subsequent years.16

70

D r u g P r o b­l e m s

In short, although elites like Holmes looked down on homeopathy, they did not come back from Eu­rope with a resounding defense of regular medicine as currently practiced. Mostly, they returned with an optimistic belief that the “numerical method” (statistics) and laboratory science might lead them in the ­future to more rational—­that is to say, effective—­therapeutics, based on rigorous experimental physiology and other scientific investigation. ­There was still hope: all options w ­ ere on the t­ able for rational investigation. In 1900, a Journal of the American Medical Association editorial, prob­ably written by George Simmons, called for less drugging and more experimentation with “dietotherapy, climatotherapy, hydrotherapy, kinesitherapy, electrotherapy, and psychotherapy.” Titled “Therapeutic Pessimism,” it was not quite the “therapeutic nihilism” that is sometimes imputed to attitudes in the higher reaches of medicine. In any case, it was a complete repudiation of medical hubris and a striking indication of regular therapeutics in flux.17 Perhaps more importantly, the medical elite came back impressed with what Boston’s Henry Ingersoll Bowditch, who had studied in Paris, called “state preventive medicine.” Surgeon Joseph McCormack’s postgraduate study in Eu­rope prob­ably prepared him to assume his role as both hygienic optimist and tireless public health reformer. No g­ reat champion of pharmacotherapeutics of any kind, and an advocate of peace with homeopaths and eclectics, an overoptimistic McCormack argued ­later in his ­career that with time and public enlightenment “a large per cent of my profession w ­ ill be acting mainly as medical advisers for families, to keep them well, instead of the more difficult and expensive task of treating them when sick.”18 It was during this evolving theoretical entropy and therapeutic mishmash at the end of the nineteenth ­century that the commercial invasion occurred. It conquered a territory lacking one of the rudiments of defense—­a solidarity of interests backed by hard knowledge and an ability to communicate about how to protect them. Instead, at the level of the common practitioner, it encountered Cathell’s “snapping and snarling physicians” and McCormack’s “black cloud of jealousy and envy.” In short, commercial medicine’s potential combatants w ­ ere weakened both by acrimony within and across camps and a lack of conviction among elite doctors about what worked and was therefore worth defending. Without a unifying therapeutic ideology or demonstrably effective medicines, the profession could not, as an or­ga­nized po­ liti­cal force, withstand the commercial onslaught. Meanwhile, ­great numbers of its individual prac­ti­tion­ers w ­ ere pulverized into submission in ser­vice of commercialism.



Therapeutic Chaos and Commercial Conquest

71

C OM M E R C I A L I N VA S ION

In 1860, Holmes cited Amer­i­ca’s revolutionary élan to explain the ­earlier penchant for Rush’s “extravagance in remedies” and asked: “What won­der that the stars and stripes wave over doses of ninety grains of sulphate of quinine, and that the American ea­gle screams with delight to see three drachms of calomel given at a single mouthful?” In sum, “Medicine, professedly founded on observation, is as sensitive to outside influences, po­liti­cal, religious, philosophical, imaginative, as is the barometer to changes of atmospheric density.” Thus, clinical practices did not pro­gress on a “straightforward inductive path, without regard to changes in government or to fluctuations of public opinion.”19 Strangely, in light of developments ­later in his ­century, Holmes left out economic forces from his list of outside influences. But to ignore medical commerce was not a large oversight. American society was not yet yoked to a corporate, mass-­producing, and mass-­advertising manufacturing industry, although the railroads, with help from the federal government and the country’s growing investment-­banking h ­ ouses, ­were now furiously laying the tracks. By the 1880s, t­ here was a luxuriant and rapidly growing jungle of proprietary medicinal items riding the rails from coast to coast, to and from ­wholesalers into the mouths of citizens. Not that ­there was a shortage of “official” drugs long available for prescriptions. In 1905, hundreds ­were listed in the United States Pharmacopeia (USP), compiled in collaboration with physicians by the American Pharmacists’ Association (APhA). One familiar example was the analgesic and antipyretic Salicylicum acidum, or salicylic acid, complete with its molecular formula, a physical description of its crystalline form, its solubility, its melting point, and its other properties that could be demonstrated in the laboratory to confirm its authenticity.20 The USP’s first edition had been compiled in 1820 by activist physicians wishing to bring some order and uniformity to the country’s materia medica. But its standardized items with dull Latin names could not stand their ground against catchy names for expensively advertised commercial merchandise. ­These trademarked proprietaries w ­ ere advertised directly to the gullible public by thousands of daily and weekly newspapers. A g­ reat many of them ­were cheap or f­ ree church publications. Medical reformers w ­ ere glad to point out their hy­poc­risy concerning where to put one’s faith. Sometimes deceptively called patent medicines, ­there was nothing new and therefore patentable in the merchandise advertised. Many had a good half dozen or more ingredients in a single sweet or alcoholic elixir, a seemingly sensible ­thing to

72

D r u g P r o b­l e m s

an ignorant consumer or doctor, just as choosing a shotgun over a ­rifle would be to a blind man. Reformers at the turn of the twentieth c­ entury placed principal blame for the market’s cornucopia of drugs on the over 5,000 manufacturers, ­wholesalers, and importers of drugs in the United States, its territories, and Canada listed in the Phar­ma­ceu­ti­cal Era Druggists’ Directory. Around 250 of the manufacturers of proprietary drugs ­were or­ga­nized in the Proprietary Association of Amer­i­ca, a formidable po­liti­cal force. A ­ fter New York and alongside Chicago, St. Louis was one of the three largest homes of drugmakers and distributors, a fact best explained by its having the world’s largest and busiest railroad station in the world. The National Druggist, a leading trade magazine, and the Medical Brief, a pseudoscientific medical rag, both operated out of St. Louis. Forming another potent pressure group ­were the up to 450 drug ­wholesalers in the National Wholesale Druggists’ Association. To advance their somewhat distinct interests, a group of about thirty large “ethical” manufacturers (including Parke-­Davis, Squibb, Merck, Abbott, Eli Lilly, Upjohn, and Pfizer) formed the National Association of Phar­ma­ceu­ti­cal Manufacturers in 1912. At the end of the chain ­were some forty thousand retail druggists scattered across the country, practically all displaying proprietary concoctions in their win­dows and displays. They, too, had their po­liti­cal repre­sen­ta­tion in the National Association of Retail Druggists, which had formed to pursue commercial interests neglected by the more scientifically oriented APhA.21 No sector of the overpopulated drug trade abstained from the deceptions needed to stay competitive and profitable. Hypophosphite manufacturers still made profits off the well-­discredited tuberculosis cure by advertising solely—­ and therefore “ethically”—in medical journals. Nostrum makers sometimes competed with more ethical manufacturers by peddling some of their items exclusively to the medical profession, thus devaluing the term ethical. To retaliate, firms such as Parke-­Davis, Seabury & Johnson, Sharpe & Dohme, and Frederick Stearns spun off front companies or contracted out work to ­others. Parke-­Davis came ­under scorn, for example, for manufacturing Danderine, marketed by Knowlton Danderine Com­pany, which claimed its product “Grows Hair and We Can Prove It,” and Nutriola, advertised by the Nutriola com­pany as “the greatest Chemical-­Medical Preparation ever prepared by the skill of man.” Indeed, Parke-­Davis let it be known by its secret proxy that “Nutriola and Nature are the only invincible conquerors of diseases ever known.”22



Therapeutic Chaos and Commercial Conquest

73

COLL A BOR ATOR S

In 1860, Holmes took note of “toadstool millionaires” whose “palaces” ­were recently built on the profits from the quack medicines they touted. Their numbers were still relatively small, however. The explosive growth of drug companies, their worthless medicines, and the doctors who prescribed them a half ­century ­later would have shocked him. At fault, Holmes said, was the public, “which insists on being poisoned.”23 He did not implicate the medical profession. For the time being, it was still sidelined by isolated entrepreneurs and their consumers taking the practice of medicine into their own hands. Between 1859 and 1904, the dollar value of proprietary drugs would increase twentyfold. In 1906, the AMA’s Frank Billings estimated that no fewer than half of the country’s doctors prescribed proprietaries, a scorching indictment of his profession’s capture and recruitment by commercial operators. ­Because of that, he told a medical audience in Boston, “the doctors are dupes.” The majority “do not practice rationally.” They made no well-­ informed diagnoses and randomly threw remedies at symptoms. James  J. Walsh of New York’s Polyclinic School for Gradu­ates in Medicine informed Billings that in recent years about 70 ­percent of all the prescriptions written in New York City contained “some proprietary medicine that ordinarily would be expected to fall u ­ nder the ban of professional use.” Charles Williamson, professor of clinical medicine at the University of Chicago’s College of Physicians and Surgeons, reported in 1906 his findings from a large city of a neighboring state that out of two hundred prescriptions, ninety-­one called for proprietary remedies, an average of over 45 ­percent; in poorer districts the figure was approximately 75 ­percent. The results of other fact-­finding efforts w ­ ere similarly disturbing. A 1901 investigation of prescriptions filled by the three largest druggists in Chicago found that between 20 and 26  ­percent of one thousand prescriptions contained proprietaries. Cited by Abraham Jacobi in 1903, another study of fifty thousand prescriptions recently filled in a number of drugstores, found that somewhere between 20 and 25 ­percent contained proprietary remedies. An APhA study from around 1905, based on twenty-­seven thousand scripts from disparate locations, found that about 20 ­percent contained “a class of compounds with fanciful and catchy names.” Yale’s George Blumer told of a medical student’s 1907 thesis that found an average of about 20 ­percent for the city of New Haven.24

74

D r u g P r o b­l e m s

Another ambitious study traced the commercial onslaught’s pro­gress over time based on an investigation of fifty thousand scripts written from the 1850s to 1905. The first one containing a proprietary appeared in 1874. From 1875 to 1880, about 2 ­percent did. By 1903 that number had risen steadily to 25 ­percent. A similar study found that in 1879 only 8 ­percent contained nostrums, but by 1905 that had risen to 21 ­percent. Averages do not paint the entire picture. Billings cited one large drugstore, “one of the gaudy ones, to which the prescriptions sent in by our fash­ion­able doctors are sent,” where 70 ­percent of the scripts contained proprietary drugs. He also reported that in one large Chicago pharmacy 42 ­percent of the ­orders filled contained nostrums “and ­were signed by doctors of high standing.” In another pharmacy 50 ­percent ­were suspect. A drugstore in Boston reported that of almost fifteen thousand prescriptions received in a year, 38 ­percent contained proprietary medicines. Another filled 48 ­percent of twelve thousand prescriptions with proprietaries. In New Haven, some drugstores filled up to 60 ­percent of their prescriptions with nostrums.25 Thus, somewhere between 20 and 30 ­percent of professional therapeutics, excluding surgery, was territory occupied by the commercial invasion. That could, but need not, mean that of the country’s estimated 120,000 to 135,000 physicians some 30,000 to 40,000 ­were nostrum prescribers. According to prominent Iowa physician and medical activist C. F. Wahrer, “Go into any drug store and notice how the shelves of the prescription department are literally groaning ­under the weight of the proprietary semisecret remedies, almost to the exclusion of the ­simple, standard, well-­k nown remedies.” All of the druggists had to have on hand a panoply of nostrums “to satisfy the whims of the dif­fer­ent physicians” who could not trou­ble themselves to learn about the cheaper standard USP items. Many of the drugs prescribed on a whim w ­ ere dangerous. Doctors pushed cocaine, even though since the mid-1890s ­those attentive to serious medical lit­er­a­ture would have known that it was not clinically useful for anything but local surgical anesthesia. In 1903, a drugstore in Atlanta, Georgia, received and filled more than three thousand prescriptions for cocaine preparations within a period of two months.26 Clearly, complicity was not concentrated among the “unsuccessful and the ignorant physicians,” according to elite Pennsylvania physician and University of Pennsylvania professor Horatio C. Wood. In fact, “The most successful and the most brilliant, the men to whom ­those of the younger generation in the profession have been accustomed to look up,” w ­ ere “responsible to a



Therapeutic Chaos and Commercial Conquest

75

large extent for the continuance of the evil.” In his article “The Physician’s Responsibility for the Nostrum Evil,” Harvard’s Richard Cabot noted that 44 ­percent of the prescriptions filled at one of the best drugstores in Boston’s wealthy Back Bay area w ­ ere for proprietary nostrums. In 1907, lay social uplifter and editor of the Ladies’ Home Journal Edward Bok reported on the preliminary results of an extensive look at five thousand prescriptions written by “leaders” among Philadelphia doctors, which indicated a rise in the number of nostrum prescriptions from 41 ­percent in 1905 to 47 ­percent in 1906.27 When Bok first heard of doctors’ prescribing habits, he initially disbelieved the scandalous state of ­things. Deciding to find out for himself, he examined one hundred prescriptions pharmacists gave him and found that forty-­two contained one or more proprietary items. He then personally called on thirty of the physicians who had written them. Invited in late 1906 by the Philadelphia County Medical Society to speak on his findings, he told them that “two, gentlemen, two out of all the thirty!” knew exactly what they had prescribed. “The rest ­either did not know, or—­what is even more dangerous—­thought they knew when they did not.” He indignantly told of one doctor who had prescribed a remedy containing a large amount of acetanilid, known to cause cyanosis in some patients. The prescribing doctor had earnestly believed the “reputable” manufacturer’s claim that it was f­ ree of dangerous substances and was “dumbfounded” when l­ater informed that it had caused his patient to turn blue and fall unconscious. Another doctor he visited had prescribed a supposedly ethical proprietary for a restless child, not knowing that it contained morphine. It caused the child to “lay in a stupor for two hours.” For physicians like ­t hese, their “direct co-­operation with the ‘patent medicine’ curse” was “nothing short of appalling.” To act so ignorantly, Bok fumed, “closely borders on the criminal line.” Bok’s conclusion about the apparent rise of nostrum prescribing, published in the AMA journal, stated: “Surely we are in a fair way of seeing the science of medicine degenerate into the black art, whence it began.” It tells of his extraordinary commitment to change that editor George Simmons chose to publicize Bok’s scorching criticisms of the profession in the Journal of the American Medical Association.28 “Credulous” was the word reformers most commonly used to describe the many thousands of doctors who engaged in the “abominable habit” of prescribing nostrums, as reformist medical writer William Robinson put it. William Osler of Johns Hopkins blamed “the innocent credulity” of the regular physician, who fell for the “bastard lit­er­a­ture” of the proprietary industry. According to progressive reformer John B. Roberts, in an essay published in his

76

D r u g P r o b­l e m s

Edward William Bok (1863–1930). Editor of Ladies Home Journal, Bok was a vigorous ally of the AMA against “patent medicine” advertising to the public and the profession and a fierce critic of the vast numbers of medical prac­ti­tion­ers who fell for it. From the Library of Congress, George Grantham Bain Collection, LC-­B2-5028-7.

Doctor’s Duty to the State, nostrums ­were “foisted on the profession by men who trade on the innocent credulity of the average doctor.” A Dodge City, Kansas, doctor asked the AMA journal, “What right has medicine to be called a learned profession when its votaries, in the use of remedies of unknown composition, exhibit a credulity that puts them on a level with the aboriginal medicine man, and far below that of the Christian Scientist?” Perhaps the relative impotence of most of the unadvertised USP substances added to the seductive allure of the medical novelties to gullible doctors. According to the el­derly AMA founder Nathan S. Davis in 1906, “Medical men are too prone to accept new drugs as they accept new ideas, b­ ecause they are new, without sufficiently testing them or demanding the approval of recognized authorities.” As Abraham Jacobi observed, doctors “covet what is unknown and high-­ priced.”29 George Blumer added doctors’ “indolence” to the list of prob­lems—an indifference to an ethical imperative to investigate the contents and value of what one administered to overtrusting patients. In lieu of research, naive doctors fell for “testimonials” from fellow professionals displayed in advertise-



Therapeutic Chaos and Commercial Conquest

77

ments, circulars, and inserts in nostrum packaging. Some of the testimony was for hire, and some was just pure fiction; some came from notables, and some came from nonentities. Some no doubt w ­ ere pure fiction—­for example, from dead physicians or from live ones whose names ­were appropriated without their consent. But many w ­ ere au­t hen­tic, and t­ hose paid for them ­violated more than sixty years of AMA ethics. In 1847, the AMA had declared that it was “reprehensible for physicians to give certificates attesting to the efficacy of patent or secret medicines, or in any way to promote the use of them.” One popu­lar and worthless “cure for consumption,” the AMA’s leading pharmacologist Torald Sollman noted, carried testimonials “from two of the most noted medical teachers in the West.” Many, no doubt, w ­ ere bought from eco­nom­ically strapped doctors, as told in a touching short story in a 1907 issue of Appleton’s Magazine. It was about a young physician unable to afford a delivery of coal to heat a home for his wife and their two babies. ­A fter negotiating with his conscience, he ultimately accepted a fee for plugging Nervo-­ Sal, which was advertised for rheumatism, gout, neuralgia, and “similar diseases.” Struggling doctors w ­ ere also paid to put their name on ghostwritten “clinical reports” in journals about a drug’s wondrous workings. In addition to offering “a very fair remuneration,” young doctors received unlimited quantities of the drugs for their “experimental purposes.”30 To be sure, many ­people swallowed nostrums without their doctors’ prompting. No laws ­stopped retail druggists from “­counter prescribing,” and customers could simply pluck promising-­looking items off of druggists’ shelves. But critics within the medical profession blamed their colleagues for much of the over-­the-­counter “ready-­made” drug trade. According to Billings, doctors ­were “primarily to blame” for widespread self-­medicating with over-­the-­ counter nostrums. Sometimes nostrums no longer prescribed by doctors enjoyed large sales to consumers b­ ecause of their e­ arlier “popularization by the medical profession.” According to AMA editor Simmons, when a physician wrote a prescription for a proprietary with “a catchy, easily remembered name,” the patient read all the bogus information about its virtues packaged with it “not only for the disease for which the doctor prescribed it, but for e­ very other real or imaginary ailment.” In that way doctors introduced to the public a host of patent medicines “without a cent of cost for advertising except that to physicians.” In his controversial Large Fees and How to Get Them, which expounded on devious as well as ethical practices in medicine, medical critic Albert Harmon similarly blamed fellow doctors: “The medical catspaw is pulling the

78

D r u g P r o b­l e m s

proprietary monkey’s chestnuts out of the fire, e­ very time he prescribes a proprietary article.”31 Not all doctors prescribing nostrums w ­ ere unwitting accomplices. One doctor wrote “Remedium Spontaneum, Radway” on a script for Radway’s Ready Relief, which was advertised for rheumatism, pleurisy, pneumonia, fevers, dysentery, cholera, and lots more, to make the mostly alcoholic mixture sound legitimate. ­Others stood unabashedly to gain from nostrum prescribing. In some places, such as San Francisco, many doctors demanded commissions from pharmacies—­that is, kickbacks—­a “disgrace to the profession,” McCormack confessed to reform-­minded pharmacists. Some drug companies even paid doctors directly for sending patients to pharmacies with prescriptions for their merchandise. And then ­there ­were “profit-­sharing plans” giving doctors stock in drug companies, thus converting them into pushers of their own products.32 Doctors could be recruited as proxy salespeople for nostrums at medical conferences, where “­great pyramids of proprietary remedies and stacks of lit­ er­a­ture” ­were typically displayed, noted Billings. Hospitals and clinics ­were invaded by the drug manufacturer’s “detail men” or “drummers” to show doctors remedies with names advertising their therapeutic uses, such as Migrainin, Urotropin, Uritone, or Cystogen. More importantly, the army of detailers reached the mass of doctors in their own offices. Often “polite,” “affable,” or a “very pleasant gentleman,” their visits could be a nice diversion for a doctor, generating mutually gratifying goodwill and prescriptions. According to Jacobi, the drummer “dumps his wares . . . ​on your t­ able,” especially drug samples but also “blotters, inkstands, paper-­k nives, pencils, blank books and almanacs.” ­These contributions sometimes arrived daily—­and paid off. In one case, a Chicago physician discovered that within twenty-­four hours ­after a detailer had visited vari­ous offices in his building, its drugstore received prescriptions from six dif­fer­ent doctors for the new remedy the salesman was hawking.33 Wary reformers often described the detailers as “glib,” “suave,” or “smooth-­ tongued.” In Nathan Davis’s experience, “It is often surprising . . . ​how ignorant the detail man is when questioned as to his wares on other points than ­those in the lecture which he has committed to memory.” According to James C. Culbertson, the AMA journal editor in 1892, ­there was “nothing more aggravating” to a discriminating doctor than the drummer’s visit. “I should be the last to claim that ­there is not a legitimate place for the representatives of honest and reputable firms,” said Blumer, “but most of us have



Therapeutic Chaos and Commercial Conquest

79

too often experienced the waste of time which is associated with the dulcet drivel of the detail man.” As Osler put it, “Many of them are good, sensible fellows,” but many o­ thers are as “voluble as Cassio, impudent as Autolycus, and senseless as Caliban.” Preying on the lack of “­mental virility” among general prac­ti­tion­ers, they would glibly extol the “virtues of extract of the coccygeal gland in promoting pineal metabolism” and happily offer “emphatic opinions on questions about which the greatest masters of our art are doubtful.” As unctuous and dishonest as they ­were, Osler and other critics thought detailers all too effective, nevertheless, in achieving their purposes.34 MEDICAL JOURNALS COMMANDEERED

What Abraham Jacobi called “mercenary and meretricious” medical journals did much of the work for the drug industry in negating scientific pro­gress—in effect, subtracting from the sum of medical knowledge. George Blumer expressed par­tic­u­lar outrage at journals that advertised vaccine and serum compounds of a “reputable drug h ­ ouse” for all manner of diseases to physicians ignorant of the fact that “the very essence of serum and vaccine therapy lies in its specificity.” The “haphazard and indiscriminate use” of sera and vaccines “not only brings the w ­ hole subject into disrepute but actually endangers the lives of patients.” The proliferation of medical journals heavi­ly dependent on fraudulent advertising in the 1880s coincided with the commercial invasion. In 1884, Detroit medical reformer Leartus Connor lamented that “just now medical journalism is passing through an epidemic of cheap medical journals.” Six years ­later, Jacobi, reporting on the state of American medicine to his Eu­ ro­pean colleagues, complained that ­there ­were no fewer than three hundred “medical, or alleged, medical journals.” Drug advertising could fund the highly invasive species of medical journal b­ ecause demand for nostrums sustained a price anywhere from ten times to “a hundredfold” what could be profitably charged by a pharmacist for filling out a prescription for the identical quantity of USP ingredients.35 Discussions in reputable journals w ­ ere full of acid words about the “disgrace” and “black infamy” of Amer­i­ca’s medical journalism: its “claptrap” and “rubbish” posing as science; the “badly hoodwinked” and “duped” medical editors who “polluted” their journals with “original articles,” “reading notices,” or “therapeutic notes” that w ­ ere in fact “advertising puffs” or “disguised advertisements.” They “pitifully” swallowed what was sent to them “bait, hook, and tackle.” ­There w ­ ere, of course, editors well aware of the “unblushing falsehood

80

D r u g P r o b­l e m s

and palpable deception”—­George Simmons’s words—­that they spread and ­were therefore partners in crime with the nostrum industry. Editors and contributors toiled away as “the willing slave of their proprietary master,” wrote J. H. Salisbury, a clinical professor in Chicago and critic of “the subordination of medical journals to proprietary interests.” Thus, Amer­i­ca’s medical writers “have occasion to blush for some of their confrères.” ­Because of the AMA journal’s eagerness to air ­these complaints, in­de­pen­dent medical journals as well as the lay press published “canned editorials” penned by drug companies ferociously criticizing the AMA as a “huge trust” acting in its own interest with “misrepre­sen­ta­tion and positive mendacity” as its “stock in trade.”36 Even supposedly respectable physicians gave bad journals an aura of quality by publishing scientific articles in them. One AMA member wrote to its journal, asking, “Why is that men of repute w ­ ill write articles for so-­called medical periodicals whose pages are reeking with advertisements of the worst nostrums?” Prestigious doctors thus lent respectability to drugs that deserved only contempt, and the educative effect of reading such journals was la­men­ ta­ble, according to Jacobi: “Even the mind of the medical man is gradually poisoned.” The renowned pediatrician himself was a victim of a particularly brazen fraud when Pediatrics falsely listed him as a member of its editorial council. The journal published advertisements for “Enteronol, the Greatest Gastro-­Enteric Antiseptic and Germicide known to Medical Science.”37 Phar­ma­ceu­ti­cal pioneer Horatio Wood of Philadelphia concluded from personal experience with a large number of medical journals that their existence “depends on the income from ­these sources.” Three years ­earlier, the Philadelphia Medical Journal had folded b­ ecause it could not find enough advertisers who could meet the high ethical standards of its trustees. They included William Pepper, the celebrated clinician and reformer of medical education at the University of Pennsylvania’s School of Medicine, and John B. Roberts, Philadelphia’s prominent civic as well as all-­around medical reform activist. Another victim of doctors’ price-­sensitive demand for journals was Index Medicus, a periodical compendium of abstracts of articles from the better journals to help physicians track developments in research and find useful articles and books if they had access to a medical library. Without advertisements, it hobbled ­toward the new c­ entury before ­going out of business in 1899—­even though its price was only five dollars a year. The periodical was revived in 1903, but only with the help of the Car­ne­gie Foundation, on whose



Therapeutic Chaos and Commercial Conquest

81

board sat John Shaw Billings, the dynamic public health reformer and founder of the National Medical Library and Index Medicus itself.38 The corruption of medical journalism astonished two vocal laymen. In 1906, muckraker Samuel Hopkins Adams of Collier’s scolded doctors, having been appalled to find that “nine-­tenths of the reputable medical publications in Amer­i­ca” accepted advertisements for proprietary nostrums, many with physician testimonials. Physicians who accepted fees for ­those and other ser­ vices, he said, w ­ ere “prostituting themselves” to the drug trade and should be exposed as being “owned” by the drug interests. Bok of Ladies’ Home Journal decried the fact that the average medical journal was “reeking” with the advertisements of proprietary preparations. He, too, confronted doctors, learning the embarrassing fact that scarcely a single one of the nation’s reputable weekly and monthly magazines for the general public was still accepting patent medicine advertisements. The New York Times, for example, was foregoing at least $50,000 a year, he believed. When he tried to persuade more newspapers to clean up their advertising, publishers would often say, “Why man, ­these preparations ­can’t be so bad as you fellows make out, or they ­wouldn’t be advertised in ­these medical papers.”39 The drug industry even penetrated medical schools, bridgeheads—­like medical journals—of the commercial invasion. Medical professors did not stand in the way. In 1908, AMA editor Simmons lamented that in one school, students w ­ ere “bombarded with ‘lit­er­a­ture’ and samples.” In 1914 they w ­ ere still “polluting the stream at its source,” according to an outstanding student and ­future medical reformer, Ernst P. Boas. The son of Franz Boas, the world-­ renowned anthropologist, Ernst was secretary of the se­nior class at Columbia University’s College of Physicians and Surgeons. He therefore had the dubious honor of receiving from the Pineoleum Com­pany an offer of five cents for each classmate’s name he divulged so the com­pany could send them all a ­free kit with a nebulizer, a pipette, and a b­ ottle of Pineoleum throat spray. Boas also received an offer of a twelve-­vial emergency case of “active princi­ ples” from Abbott Alkaloidal Com­pany for the same list. This was “cool effrontery,” he fumed. This precocious reformer called for better teaching of therapeutics as well as “the social and ethical . . . ​aspects of medicine.” 40 According to Iowa pediatrician C. F. Wahrer, new doctors ­were “vacant brains” that the “wily, smooth-­tongued” drug salesmen “drummed [their] perverted system of therapeutics into.” Torald Sollman wrote, “As has been pointed out time and time again, it is the lack of thorough education and practical

82

D r u g P r o b­l e m s

training in materia medica, chemistry and pharmacy, on the part of many medical gradu­ates which is primarily responsible for their patronage of medicinal articles which are unworthy of support.” The manufacturers’ detail man, Billings complained, despite often being a failed doctor, or an ex-­drug clerk, even won out against “the better medical schools.” 41 Of course, t­ here was always some instruction in materia medica, but according to Yale’s Oliver Osborne, students ­were introduced to pharmacy and prescription writing only with “blackboard exercises and didactic instruction.” His colleague Blumer agreed that “pharmacology is too far removed from therapeutics, and . . . ​therapeutics is too far removed from the living patient.” Sadly, according to Rush’s Billings, “too frequently drug nihilism is taught.” Charles Williamson of Chicago’s College of Physicians and Surgeons complained that teaching of pharmacotherapeutics was typically relegated to the two preclinical years when it was “utter folly” to tell a sophomore that the nitrites are useful in angina pectoris or that digitalis is valuable in many heart lesions undergoing decompensation when the student had “not the remotest ­ ere.” But this just left the idea of what angina pectoris or decompensation w hapless gradu­ate empty-­handed, frustrated, and anxious. Fledgling doctors, the AMA’s Sollman wrote, being ner­vous about “incompatibilities and overdosage” in prescriptions of their own design from the USP, ­were calmed by the knowledge that thousands of experienced doctors ­were prescribing the proprietary products.42 Hospitals w ­ ere also bridgeheads for the commercial invasion. As hospital interns, Osborne observed, young doctors rely on hospital formularies and “forget how to write prescriptions.” According to a pharmacologist who trained residents in Philadelphia’s German Hospital, “The pre­sent day training in the average hospital is certainly not conducive to a true comprehension of the uses or of the limitation of medicines,” a regrettable t­ hing b­ ecause students’ impressions would have a lasting effect on their ­future practices. The pharmacies of too many hospitals, clinics, and dispensaries, according to Sollman, ­were stocked primarily with proprietary preparations “charitably” donated by the manufacturer and used “to the exclusion of other remedies,” including in clinical demonstrations by medical “professors.” A Georgia physician learned from chiefs of staff in hospitals he visited in Philadelphia, Baltimore, and Chicago that “they did not have time to write prescriptions.” Hospital pharmacists w ­ ere typically of l­ ittle help ­because hospital administrators hired untrained young men seeking a stepping-­stone to medical school and salaries to pay for tuition. Thus, according to the AMA’s Martin Wilbert, “­there is ­little won­



Therapeutic Chaos and Commercial Conquest

83

der that a hospital pharmacy in Amer­i­ca never attained the recognition or the development to which it has reached in France, or even in ­Great Britain.” 43 PROFESSIONA L POW ER

With their bold, furious, and caustic charges against Amer­i­ca’s huge and growing drug industry, the AMA’s progressive reformers flailed at an ­enemy that far outgunned them in numbers, wealth, and—at first—­political influence. But the drug industry feared them, nevertheless. In 1909, Henry R. Strong, editor of the National Druggist, a drug industry trade magazine, called the AMA a machine run by a tiny power-­hungry “medico-­political clique,” an “octopus” whose “stealthy tentacles” reached out to gain control of the practice of medicine. Like other monopolies, Strong declared in his book, The Machinations of the American Medical Association, that the AMA was attempting to destroy ­every “collateral calling” such as drug manufacturing, advertising, retailing, and, not least, medical journalism, “­either by legislating it out of existence, or by strangling it to death.” The “octopus” insult put the AMA in the com­pany of two other colossi currently vilified with the same epithet, the Standard Oil Com­pany and the Roman Catholic Church.44 Echoes, if only weak ones, of Strong’s claim reverberate in the current historical understanding of the Progressive Era AMA. As Paul Starr has argued, for example, or­ga­nized medicine was embarking on a ­grand strategy of “augmenting demand and controlling supply.” Reform of the drug industry was, by implication, an early step ­toward “control of markets, organ­izations, and governmental policy.” By ­those means, “physician sovereignty,” largely a goal in itself, not a means to ethical ends larger than the profession itself, could be established and maintained.45 But a desire to establish a lucrative mono­poly stake in drug commerce for the profession, as the middleman between manufacturers and patients, cannot explain the passion and reasoning that the progressive medical reformers brought to bear against the nostrum evil. If anything, the reformers wanted to tamp down demand for drugs, not increase the flow of dollars spent on them that went into doctors’ own pockets. A legislative goal of controlling supply by requiring patients to obtain a doctor’s prescription never came up for discussion. But the medical progressives who turned the AMA into an increasingly potent organ­ization ­after 1901 did indeed have power pretensions: to control the flow of knowledge, or advertising posing as knowledge, reaching doctors and doctors-­to-be through its two main conduits, medical journalism and

84

D r u g P r o b­l e m s

medical education. The goal was to take control of how the profession educated itself to be more suspicious of worthless elixirs and compounds and better informed about what constituted rational therapeutics. That including learning that often, “less is more,” except when prevention was concerned. To do less harm to patients, the profession had to first heal itself.

chapter 4

Heal Thyself

Commercialism “demoralizes” ­people in the world of medicine, wrote editor George Simmons in the Journal of the American Medical Association in 1906. By demoralization, Simmons meant the sometimes degrading rather than uplifting effect of market competition. Un­regu­la­ted commerce unraveled the moral fiber of drug manufacturers, publishers of their advertisements, and pharmacists possessed by the drive to earn more money or even just stay afloat financially by hawking their merchandise. It weighed down on the quality of the products and ser­vices reaching their prescribers and consumers. Competition over patients even drove many physicians into the ethical morass of prescribing drugs they knew w ­ ere of no use for incurable diseases. From drugmakers on down, ­those who other­wise might be honest and professionally conscientious bent u ­ nder commercialism’s yoke.1 By calling for regulation, Amer­i­ca’s medical progressives at the turn of the twentieth c­ entury sought to counteract commercial demoralization, a subset of what economists call adverse se­lection, the suboptimal equilibrium outcome of market competition where consumers are in the dark about the quality of products and ser­vices they buy.2 Competition can enable the survival of the foulest, as it ­were, not the fairest. ­Because of it, the bad can drive out the good. In the drug world, ­there was a race to the bottom down a slippery slope of amoral profit seeking.

85

86

D r u g P r o b­l e m s

By shining light into the dark jungle of competition, reformers wanted to mitigate adverse se­lection and therefore the proliferation of chemical concoctions unfit for consuming. They rejected the ideology about un­regu­la­ted competition leading necessarily to advantageous or even benign outcomes. According to the medical progressives’ perspective, Adam Smith’s invisible hand of their par­tic­u­lar market was all thumbs. Entirely self-­interested merchants of medicine did not serve the public and contribute to the wealth of nations the way that Smith’s bakers and pin manufacturers might. The moral rot observed by medical reformers started in the intensely competitive drug industry’s ability and indeed profit-­driven compulsion to deceive doctors and consumers alike. To tell the truth about drugs’ composition or therapeutic value “would be to stop their sale,” Simmons said.” Thus, honest advertising was “as rare as sweet violets in Ireland.” According to one reform-­minded medical journalist, allegedly reputable drug manufacturers blamed “unscrupulous concerns” for compromising their ethics ­because “­others have done it and they had to.” Drug h ­ ouses wishing to remain ethical complained to him that they had no choice but to market prepackaged and trademarked mixtures “when they saw their trade slipping away from them.”3 In turn, publishers of scores of competing medical journals struggling to hold down their subscription fees yielded to financial pressure by welcoming drug advertisements they knew ­were bogus. “Journals that are trying to be decent l­abor ­under a grievous disadvantage,” a Florida doctor wrote to the Journal of the American Medical Association. According to George Blumer, an eminent medical professor, “Their very multiplicity” and their “constant strug­ gle for existence” turned journals into the “tools of none too scrupulous phar­ma­ceu­ti­cal advertisers who use them for the m ­ ental debauchery of a too trusting and credulous profession.” A ­Virginia doctor learned in reply to his complaint to a journal about its advertisements that it would perish without the advertising revenue its competitors relied on. For that ­matter, it had only gotten less than a half dozen such criticisms. But the editor promised that “whenever we are convinced that the sentiments of our subscribers are becoming in accord with your own, we s­hall then . . . ​decide w ­ hether to continue our journals without advertising or discontinue them altogether.” 4 The bad drove out the good in fiercely competitive drug retailing as well, where ethical pharmacists might have steered customers to doctors who brought them less business, not more. In 1900, no states required a pharmacy degree or any college degree whatsoever as a condition for opening a shop to dispense drugs. Thus, according to American Medical Association (AMA)



Heal Thyself

87

r­eformer Torald Sollman, the small numbers of well-­educated pharmacists “lose heart,” “fall into a ‘rut,’ ” and are reduced “to the irresistible commercial level.” The average pharmacist’s income was so low that “it deters many of the best men from entering or continuing in pharmacy.” One notable medical editor and professor of dentistry noted that the typical pharmacist was “at heart, not only a good fellow but an intelligent and conscientious man,” but he was “­under the screws of ­wholesale dealers of all shades of respectability.” Pharmacists go out of business “­unless they submit not only to an irksome commercialism, but to methods that they recognize as unethical and, potentially, at least, as dishonorable and murderous.” AMA or­ga­nizer and public health missionary Joseph McCormack agreed that druggists, despite being “good citizens,” could not get out of the business of selling the likes of Peruna, which contained 27 ­percent alcohol, and Mrs. Winslow’s Soothing Syrup and Babies’ Friend, which contained large amounts of morphine, thus sending so many babies “to their long home.” Fi­nally, for a doctor not to prescribe something, anything, was to risk losing well-­paying patients to more indulgent prescribers. Thus, as the eminent Boston physician Richard Cabot explained in 1906, “As physicians we are largely responsible for the sale of secret remedies. We help to create the demand. We feed it.” It was a sincere mea culpa, ­because he confessed to have once regularly prescribed proprietary remedies as placebos—­which he knew many other supposedly honest physicians did. It was a shameful lie, Cabot wrote. Patients would e­ ither find out in disgust, or not find out, and be inculcated with false trust in both doctors and the commercial drug racket.5 To medicine’s progressive reformers, good information about drugs would be like sunlight, a good disinfectant. But the information would not shine down ­free of charge on doctors without deliberate ­human agency in funding and creating it. The failure of the medical profession to assume the task was tantamount to criminal negligence, according to the reform-­minded editor of the Cincinnati Lancet-­Clinic. “How absurd it is,” he complained, “for men engaged in commercial pursuits to attempt to solve the g­ reat and intricate prob­lems of medicine, and how criminal it is to permit the statements of such interested parties to have slightest weight in deciding questions of treatment.” 6 That is where or­ga­nized medicine and the state had to come in to jointly administer cures for adverse se­lection. The profession’s scientific legitimacy, as well as its cultural and po­liti­cal authority, ­were at stake. So ­were patients’ lives. With the prob­lems of adverse se­lection in mind, one of the reor­ga­nized AMA’s first proj­ects was to staunch the flow of bad drug information into

88

D r u g P r o b­l e m s

the minds of the profession and give ethical drugmakers with potentially efficacious products a leg up on the competition. Their exertions in that spirit, converging with similar reform currents coming out of leading ranks of pharmacists and pharmacologists, culminated in 1905 with the creation of the AMA’s Council on Pharmacy and Chemistry (CPC). Composed of top AMA leaders and prominent experts in pharmacology, the council saw its ambitious mission as nothing less than “the general reformation of what is debased and debasing in the pre­sent status of therapy.”7 Armed with the CPC’s investigations into commonly prescribed proprietary medicines and the companies that manufactured them, editor George Simmons, a founding member of the council and, as the AMA’s general man­ag­er, its most power­ful official, paraded the names of worthless drugs and their makers in the AMA journal to discredit them in front of the entire medical profession. Most importantly, the CPC instructed reform-­friendly medical editors across the country—­who lacked the resources to conduct investigations on their own—­about which drug advertisements should no longer befoul their journals. Vetting drugs and their marketing was a huge task, considering the tank loads of proprietary elixirs, syrups, oils, tonics, drops, and b­ itters that flooded into clinical practice. Drugs that failed to pass the CPC’s muster w ­ ere written up in the AMA journal’s regular column “New and Non-­official Remedies.” To be approved, for example, a drug’s ingredients had to be accurately specified in its labeling and promotions and in­de­pen­dently verifiable by laboratory experts. The CPC’s “ac­cep­tance” or “approval,” however, did not amount to a confirmation of therapeutic value. The council would only address ­those ­matters and ask for credible evidence from manufacturers if they made dubious curative claims. ­Those violating the CPC’s list of standards ­were written up and exposed for their secrecy, impurity, risks, or fraudulent claims in another column, “The Propaganda for Reform in Proprietary Medicines.” Both series w ­ ere periodically compiled in volumes distributed separately, in the hope that a healthy flow of clean information would help flush commercial pollution out of American therapeutics. With the CPC, the AMA assumed the heretofore neglected task of generating expert knowledge about drugs on the market in order to educate the profession as middlemen between the industry and patients. It was an earnest, if only partially successful, force for counteracting adverse se­lection with arduous efforts to generate and channel good information. By not relying on the power of the state, the strategy was very much in line with the or­ga­nized



Heal Thyself

89

George Henry Simmons, MD (1852–1937). Editor in chief of the Journal of the American Medical Association, 1899 to 1924, and power­f ul AMA official. Simmons was also a founding member of the AMA’s Council on Pharmacy and Chemistry, established in 1905 to advance honest drug advertising and rational therapeutics. Courtesy of the U.S. National Library of Medicine.

voluntarism that characterized other Progressive Era reforms to empower experts and inform the public. F. E . ST E WA RT A N D T HE NAT IONA L BUR E AU IDE A

The modestly empowered but nevertheless efficacious CPC was the end product of a far more ambitious reform movement that predated the AMA’s reor­ga­ni­za­tion. The germ of the CPC reform appeared around 1880. Its thinker and planner was pharmacologist-­physician Francis Edward Stewart. For a de­ cade and a half before the CPC’s formation, Stewart had agitated for an ambitious plan to create the national institutional infrastructure for systematic phar­ma­ceu­ti­cal research and rational therapeutics. In 1880, at the age of twenty-­seven, ­after having completed a degree at the Philadelphia College of Pharmacy, the country’s preeminent institution of its kind, and only a year ­after graduating from Philadelphia’s Jefferson Medical College, F. E. Stewart

90

D r u g P r o b­l e m s

began thinking and writing on the American phar­ma­ceu­ti­cal disorder. The son of a construction com­pany executive, Stewart concluded early on that the “therapeutic boom” currently underway, though well deserving of criticism, was not uniformly bad. ­There w ­ ere valuable innovations, but no doctor could possibly know which they ­were. ­Because of incompetence and dishonesty in the industry, only an institutionalized pro­cess conducted by experts could evaluate drugs and bring order to the chaos. The pharmacologists and physicians responsible for compiling the U.S. Pharmacopeia (USP), the massive compendium of “official” unpatented or nonproprietary medicinal substances and mixes, w ­ ere of ­little help ­because their review and incorporation of newly introduced items only took place once a de­cade. Also, inclusion in the pharmacopeia did not require any evidence of therapeutic efficacy that might justify prescribing risky new drugs.8 Stewart was convinced that only large phar­ma­ceu­ti­cal corporations that paid good-­quality scientists and provided them with well-­equipped research laboratories ­were able to perform the societally necessary task of pharmacological innovation. However, even big companies could not maintain high scientific and ethical standards without integration into a systematic collaboration of nonprofit governmental, scientific, and professional institutions. Having e­ arlier accepted help from the Parke-­Davis corporation in bringing an innovation of his own onto the market, he was stung by medical colleagues’ harsh and prejudicial criticism of the com­pany for “the worst form of quackery” with some of its products. Defying ­those critics, Stewart accepted a salaried position in the large and growing Detroit com­pany—­but only on the condition that he could lead its efforts to improve on what­ever integrity Parke-­ Davis had maintained. Shortly ­after hiring Stewart in 1881, Parke-­Davis announced in medical journals across the country a “war” on trademarked phar­ma­ceu­ti­cals, to be conducted “­under the leadership and direction of Dr. F. E. Stewart.” Stewart’s first salvo was the establishment of the country’s first modern phar­ma­ ceu­ti­cal laboratory. The same year he began offering to a wide medical audience his initial thoughts about what needed to be done above and beyond the level of the individual corporation. In the Therapeutic Gazette, Parke-­Davis’s ­house organ, he wrote about how to “establish therapeutics on a more scientific basis” through overarching collaboration between scientists in ethically inclined phar­ma­ceu­ti­cal firms on the one side and doctors, hospitals, and pharmacologists on the other. He called his initial idea the “Hospital Plan” ­because hospitals ­were to be the main sites for research. The idea was to set



Heal Thyself

91

up collaborations of ­these diverse professions and institutions for careful ­trials of each new drug on at least two dozen patients. The results w ­ ere to be widely disseminated—­and not only the favorable ones, as corporate-­sponsored drug researchers had done before. Every­thing should see the light of day “­whether good bad or indifferent.” At the same time, Stewart also began publishing about how the federal government could contribute to the larger research enterprise.9 Stewart had converted the wealthy bachelor and bon vivant George S. Davis, secretary of the board of directors and part owner of the Parke-­Davis com­ pany, to his mission. Money could be made well—­t hat is to say, honorably—­ Davis hoped, through and to the benefit of science. With Stewart’s guidance and medically superior products, Davis planned to seek elevated ground above the tide of tawdry commercialism. Stewart’s corporate patron also engaged in serious medical publishing, which paid off with praise from medical reformers. John Shaw Billings called Davis “public spirited” for rescuing his Index Medicus, a chronically undersubscribed periodical compendium of scientific article abstracts Billings had founded in 1885. Davis heavi­ly subsidized the advertisement-­free periodical ­until 1895. Thereafter, it languished and died, only to be resuscitated with Car­ne­gie money. In 1895, Davis founded Medicine, to be edited by Harold N. Moyer, a respected Chicago clinician, educator, and proponent of scientific collaboration between medicine and pharmacy. The Cleveland Journal of Medicine, edited by medical reformer and AMA or­ga­nizer Maxwell Foshay, praised Medicine for its editorial excellence, which qualified it for inclusion among the “foremost of American medical journals.”10 Not all of Davis’s ventures in medical journalism ­were ethically pure. His Therapeutic Gazette, which ­later absorbed Davis’s Medicine in 1906, had the sober aura of a scientific journal, but to its discredit it frequently published articles written on the clinical successes of the com­pany’s products—­a ll the while neglecting to identify the connection to Parke-­Davis. One of ­those innovative products was industrially produced cocaine, which Parke-­Davis introduced to the overlapping worlds of clinical practice and drug abuse. The journal broadcast cocaine’s many therapeutic and anesthetic possibilities, including as a remedy for morphine addiction. An article in Parke-­Davis’s Therapeutic Gazette on cocaine’s usefulness to disabuse ­people of morphine got the attention of Sigmund Freud, who quoted it in his widely read “Über Coca” in 1884. In that treatise, Freud also recommended Parke-­Davis’s cocaine for alcoholism, digestive disorders, cachexia (“all diseases which involve

92

D r u g P r o b­l e m s

degeneration of the tissues, such as severe anemia, phthisis [tuberculosis], long-­ lasting febrile diseases, ­etc.”), asthma, and as an aphrodisiac. Freud’s personal experience with vivid dreams and strange ideations from much cocaine use on his part may have helped inspire his move out of conventional clinical practice into psychoanalysis. In effect, Freud shilled for a major American phar­ma­ceu­ti­cal h ­ ouse. In 1885, Parke-­Davis nicely repaid the f­avor, citing Freud’s writings in the Therapeutic Gazette to promote cocaine as a morphine remedy, completing a twisted Moebius strip of scholarly, clinical, and commercial ambition.11 Stewart eventually broke with his host corporation when it strayed from the straight and narrow path he wanted to cut. In 1883, he angrily criticized the com­pany for failing to honor an agreement to publish experimental findings on the com­pany’s products “­whether favorable to the drug tested or other­ wise.” He added, “­These reports must contain the truth, the w ­ hole truth, and nothing but the truth.” In an 1889 letter to Stewart six years l­ater, Davis defended himself, claiming he was victimized by market forces. The com­pany was being crushed between the rocks of stiff competition and the rigid ethics of an “unappreciative and hostile medical profession,” including doctors on his own staff. Parke-­Davis had recently suffered a setback by losing its de facto mono­poly on an impor­tant product ­because it had neither sought a patent for it nor held back information about it, which happened to be in accordance with the AMA’s antimonopoly ethics. By 1903, with Davis no longer at its head, Parke-­Davis had completely lost any trace of progressivism Stewart had introduced ­earlier.12 In short, during the first de­cade of his ­career, Stewart witnessed firsthand the degenerative force of adverse market se­lection when Parke-­Davis was pulled into the surging torrent of commercialized therapeutics. In 1902, a­ fter having left Parke-­Davis for stints at other pharmacy ­houses, he explained that the prob­lem was “destructive competition in which quality is sacrificed for price.” As he told the American Therapeutic Society (now the American Society for Clinical Pharmacology and Therapeutics), which he had founded in 1900, advertising with cheaply concocted disinformation about hastily concocted medicines was the lower but more profitable road.13 It was clear to Stewart from his disillusioning experience with the work­ ouses needed to ings of the ­free market that even the best phar­ma­ceu­ti­cal h be brought into an institutional setting that gave them a chance to preserve their integrity against degrading competition. Thus, he began thinking about



Heal Thyself

93

integrating his voluntarist Hospital Plan of therapeutic research into a government-­sponsored system, which he first described in 1891. At the top would be a federally funded bureau ­housed in the Smithsonian Institution. It would be assisted by the AMA and the American Phar­ma­ceu­ti­cal Association (APhA) as well as the medical departments of the army and the navy and the Marine Hospital Ser­vice. It was a ­grand progressive vision of “experts in the pharmacological arts” investigating and reporting on the materia medica of the entire world, including from many “nations and tribes” and even on items recommended by “a quack, an Indian medicine man, or an old ­woman.” It would set up a National Pharmacologic Laboratory, which was to collaborate with a new National Pharmacologic Society composed jointly of physicians and pharmacists to identify and standardize new medicinal items. It was also to stimulate, coordinate, and disseminate the results of both pharmacological and therapeutic investigations.14 A patent law reform was part of the plan to bring profit incentives in line with the public interest. Stewart insisted that a patent “should never be allowed for a medicine ­unless it be first proved to be a new and useful invention as a therapeutic agent.” Essential to supplying proof of usefulness w ­ ere basic ele­ments of Stewart’s ­earlier Hospital Plan. The federal bureau was to disseminate results of investigations conducted in participating hospitals to the medical and phar­ma­ceu­ti­cal professions and manufacturing h ­ ouses in the form of “Working Bulletins.” They w ­ ere to contain information on every­ thing from basic botany and chemistry to “pharmacodynamics and therapydynamics.” Samples of new substances, accompanied by the reprints of the detailed bulletins, w ­ ere to be delivered ­free of charge to schools of pharmacy and medicine to guide chemists, physiologists, and clinicians and to inform further research. Fi­nally, the government laboratory would publish a periodical journal and an annual report that would collect results from ongoing clinical research in the field and disseminate them far and wide.15 O R ­G A ­N I Z E D M E D I C I N E T A K E S O V E R

F. E. Stewart’s stupendous ambition was quintessentially progressive: the marshalling of professional expertise, private interests, and—­when and to the extent pos­si­ble—­government bureaucracy for well-­ordered cap­i­tal­ist ser ­vice to the public. His ­grand vision did not go unnoticed. Three surgeons general of the two armed ser­vices and the Marine Hospital Ser­vice endorsed

94

D r u g P r o b­l e m s

Stewart’s ideas. So did Spencer F. Baird, the secretary of the Smithsonian Institution, which was supposed to ­house the bureau. In 1891, the not-­yet-­ reorganized AMA also endorsed Stewart. In 1891, a House of Delegates resolution called for the submission of his current plan, now modestly called a “Working Bulletin System,” to Congress. AMA president Henry O. Marcy conveyed the resolution to Washington with the hope that the government could devise a way to effectuate Stewart’s “valuable suggestions.” In 1901, the newly hired editor George Simmons published Stewart’s National Bureau of Medicines plan for “separating the wheat from the chaff.” In advance of the publication, Simmons wrote to Stewart of his admiration, adding overoptimistically that “all that is necessary now is for the scientific men who are working in the phar­ma­ceu­ti­cal field, and honorable physicians, to unite and ask for the creation of such a bureau.”16 But between 1891, when the as-­yet unreconstructed AMA endorsed Stewarts’ ideas, and the formation of the new AMA’s CPC in 1905, not much happened. By 1895, all that had been accomplished was the partial cleansing of the worst nostrum advertising from the AMA journal in response to criticism coming out of lay as well as medical circles. It banned all advertisements of proprietary medicines ­ unless accompanied by “the formula and official chemical name and quantity of each composing ingredient to be inserted as part of the advertisement.” The principal initiator of that move was Solomon Solis-­Cohen, professor of clinical medicine and therapeutics at Philadelphia’s Jefferson Medical College in Philadelphia, Stewart’s alma mater. When Solis-­Cohen complained to the owner of a city newspaper about its nostrum advertisements, the owner—­who was his patient—­embarrassed him by pointing to the AMA’s journal and retorting, “Clean your own h ­ ouse, and then come to me.” Solis-­Cohen’s patient was prob­ably Cyrus Curtis, owner of the Philadelphia Inquirer, the Saturday Eve­ning Post, and the Ladies Home Journal. If it was indeed Curtis, he made the first move anyway. That year, his Ladies Home Journal, ­under son-­in-­law Edward Bok’s editorship, became the nation’s first major national publication to reject nostrum advertising. ­Others would follow.17 The medical reformers’ hopes of government action in the 1890s and into the next ­century ­were discouraged by a decidedly unprogressive congressional leadership, Republican as well as Demo­cratic. Hence, Stewart and the allies he had attracted in medicine and pharmacy began thinking about private, voluntary action as an alternative and perhaps precursor to l­ater gov-



Heal Thyself

95

ernment participation. A plan for just that appeared in 1901 in the AMA journal as a “Plan of Co-­operative Investigation, Standardization, Analytic and Pharmacodynamic Observation” to be headed by a National Bureau of Materia Medica. If not created by the federal government, as preferred, it could be established and run on a voluntary basis by experts connected with the medical and phar­ma­ceu­ti­cal schools and “working ­under the auspices” of the AMA and the APhA. Though equipped to investigate the composition and purity of a new drug submitted to it and the accuracy of its labeling, the bureau would not endorse therapeutic claims. On the other hand, if such claims ­were made, it would evaluate “on what authority” they rested. Implicitly, if the claims ­were out of line with the evidence submitted, official bureau approval would be withheld. How ­these activities ­were to be funded was left unsaid.18 The National Bureau plan floated in the April  1901 AMA journal was similar to a plan Stewart also presented as secretary of his own creation, the American Therapeutic Society (ATS). Its president was Horatio C. Wood, an outstanding Philadelphia physician, biologist, and phar­ma­ceu­ti­cal scientist. A striking difference was that the ATS proposal included examination of pro­cessed foods, not just drugs. The envisioned Bureau of Medicine and Foods would comprise experts associated with medicine and food manufacturers as well as in­de­pen­dent scientists and ­others nominated by the professional socie­ties. The ATS plan stated that, in addition to public funds, the bureau could rely on “private donations, endowments and bequests” for its investigations and other activities. Common to both schemes, however, was a device to induce cap­i­tal­ists to join the phar­ma­ceu­ti­cal reform pro­cess. In exchange for providing information and conducting research to be evaluated by the bureau, manufacturers would be able to proudly advertise approved products as “­under the auspices” of the bureau—in other words, officially stamped as bureau certified—­and so get a partial competitive edge over unscientific operators.19 Stewart’s next step was to gather endorsements and promises of funding from the AMA, the APhA, and other reformist forces. But before that occurred, in October of 1901, he and a group of California physicians and pharmacists moved to create a “private bureau” to serve as the germ for a larger one. The formidable corporate ­lawyer James B. Dill drew up the organ­ization’s charter. Dill had helped J. P. Morgan and Andrew Car­ne­gie form the United States Steel conglomerate, ­after having crafted New Jersey’s corporate law to

96

D r u g P r o b­l e m s

facilitate it. Reynold Webb Wilcox, a medical academician specializing in materia medica and therapeutics and chairman of the USP Revision Committee, was recruited to serve as president of the seminal National Bureau of Medicines and Foods. Stewart himself signed on as secretary while another former Parke-­Davis scientist, the APhA’s Henry Hurd Rusby—­a dynamic explorer and medicinal botanist—­agreed to be trea­sur­er.20 Initially, some of the infant bureau’s operations w ­ ere to be funded out of revenue from a newly formed National Pharmacy Com­pany (NPC) cooperatively owned by doctors and pharmacists. Among the NPC’s stockholders ­were, according to Stewart, “some of the principal physicians and pharmacists of the Pacific Coast.” With its own laboratories for testing drugs, the NPC was to act as a w ­ holesaler for ethical manufacturers and even make its own products along strictly ethical lines.21 Importantly, other funds ­were to come from industry, particularly food manufacturers. The inclusion of food regulation in the tasks of the private bureau, along the lines of Stewart’s ATS plan, was prob­ably inspired by California’s leading medical or­ga­nizer and reformer Philip Mills Jones, a central figure in creating both the fledgling bureau and the NPC. A charismatic figure, Jones had reorganized the California State Medical Association along the lines recommended by Joseph McCormack’s AMA committee. Among his other qualifications, Jones was the principal founder of the California State Medical Journal and presided over the reform-­oriented American Association of State Medical Journals. According to Jones, the cost of the operation would crush a bureau relying entirely on contributions from the NPC and the few ethical phar­ma­ceu­ ti­cal h ­ ouses that might choose to cooperate. In fact, to date, drug industry enthusiasm had been close to nil. By contrast, Jones had learned from conversations with up to twenty large food producers that only two of them staunchly resisted the idea of intervention against “makers of cheap adulterated products.” Many o­ thers ­were favorable to collaboration and ­were convinced of the plan’s practicability. Some even had a “keen desire” to channel funds to a bureau that would stamp foods as well as drugs as compliant with high standards. “They look at it simply and solely as a business proposition,” Jones found, ­because they sought brand distinction from adulterated goods. “It is worth money to them.” The food manufacturers ­were even comfortable with the idea of cross-­subsidizing the private regulation of phar­ma­ceu­ti­cals.22



Heal Thyself

97

The next step was to get the AMA and the APhA to absorb and restructure the bureau into a corporation they jointly funded and controlled. This met with the hearty approval of AMA president Frank Billings, who, sometime in early 1903, handed Jones the job of collaborating with the APhA’s Rusby. A committee of the two associations including physicians Jones, Philadelphia’s phar­ma­ceu­ti­cal reformer Solis-­Cohen, and Nathan Davis, the AMA’s principal founder in 1847, forged a joint proposal that, like the ATS plan and the private bureau, included foods. An AMA committee was formed to discuss the jointly authored plan. The chairman was E. Eliot Harris, chairman of the New York State Medical Society’s Committee on Legislation and a fellow reformer in Jones’s American Medical Editors Association (AMEA). Joining them ­were Solis-­Cohen and H. Bert Ellis, a prominent California physician, medical educator, and reform-­minded member of the AMEA. The AMA committee successfully finished its deliberations with a resolution and materials ready for a vote in the association’s House of Delegates.23 Getting the collaborative proj­ect underway proved to be difficult b­ ecause of re­sis­tance from within the APhA. Before the AMA had a chance to vote on its committee resolution, the APhA killed a resolution in f­ avor of the plan submitted by its own ad hoc committee. The objections varied. An influential contingent of pharmacists in the APhA who w ­ ere employed by the large phar­ma­ceu­ti­cal h ­ ouses “declared with a single voice that they would not for an instant think of accepting the proposal,” according to one account. Charles E. Dohme of Sharpe & Dohme objected to the g­ reat expense involved in supporting the bureau, to the burdensome amount of information demanded about products to be evaluated, and above all to “a loss of moral prestige which must inevitably result when it becomes necessary to have the O.K. mark of any bureau placed upon their packages.” Looking on from medicine’s side, a discouraged Jones observed that purely selfish motives and a failure to understand the plan ­were both to blame, despite the fact that the drug companies “all admit at once the necessity for something of the sort.” Each claimed to be above suspicion while “all the ­others need some supervision of course!”24 Despite their disappointment with the APhA, Jones’s Committee on Medicines and Foods forged ahead. It had been heartened by reports that several phar­ma­ceu­ti­cal firms had dropped their opposition and expressed approval. Thus, it put the joint plan before the next AMA meeting, held in June  1904. ­A fter reference committee deliberations involving McCormack and the AMA’s top legislative activist, Charles Reed, the plan was forwarded

98

D r u g P r o b­l e m s

with a recommendation for passage to the House of Delegates. Unfortunately, however, ­after “considerable” and prob­ably heated debate, the resolution to create a cooperative national bureau failed. Adding insult to injury, the committee was “discharged.”25 Now, the bureau idea was dead and buried in both the APhA and the AMA. But a partial victory for reform, although surely a disappointing one to Jones, was snatched from the jaws of defeat. What exactly happened on the floor of the AMA House of Delegates is not clear. At the outset of debate, the delegates voted to reconstitute themselves as a “committee of the ­whole,” thus allowing for secret deliberations without the recording and publication of minutes and votes. Among the objections aired ­were no doubt ­those discussed a ­couple of weeks before at the American Acad­emy of Medicine (AAM). According to the report of the executive council of this elite, scholarly body, opponents of the bureau plan feared that the commercial interests involved would inevitably corrupt the bureau. Its certifications of quality could conceivably be bought and sold, if perhaps only in subtle, indirect ways. Large salaries would have to be paid to the doctors recruited, given the amount and complexity of the work and in order not to belittle the value of their professional ser­vices. But the promise of high salaries would lead the “self-­seeker to make use of his influence to secure an appointment” and become the same kind of opportunist “who would be willing to be retained by the maker of off-­standard products.” Fi­nally, ­because of bureau reliance on contributions from drugmakers, “the employees of the commission would not be greater sinners or weaker than most of mankind, should they be apt to be lenient ­towards ­those who ­were providing them their livelihood.”26 Out of the debate emerged a compromise proposed by the Michigan State Medical Society, a partial progressive victory in the form of what would come to be called the Council on Pharmacy and Chemistry. The CPC was to be exclusively funded and controlled by the AMA; no commercial money would be needed. Most of the work, therefore, would have to be done by unpaid volunteers. One of the Michigan authors of the compromise may have been ophthalmologist Leartus Connor of Detroit, a b­ itter critic of the subordination of medicine to commerce. Connor, who had been pre­sent at the e­ arlier AAM meeting, had explic­itly rejected the bureau plan b­ ecause of the corrupting “push of commercial ­houses.” If he was not an author, he certainly knew very well about the Michigan surprise ­because during the ­earlier AAM discussion, he informed t­ hose pre­sent about the unan­i­mous decision of the Michigan society to submit an alternative to the bureau plan.27



Heal Thyself

99

H. O. Walker, Connor’s successor as secretary of the Detroit Medical College and a professor of surgery and gynecol­ogy, was chosen to submit the Michigan society’s alternative: a drug “commission” h ­ oused within and funded by the AMA. In two separate but related resolutions, the Michigan contingent requested that the AMA Board of Trustees “provide for the analy­sis of medicinal substances of unknown composition and undetermined effects, and to promptly publish the results in the Association Journal.” For that, they asked that the trustees appoint a “Journal Clearing House Commission . . . ​ to serve without salary, with authority to have analyses made in reliable laboratories, by experts of recognized ability, or to equip a suitable laboratory and employ one or more competent chemists, at a yearly expense not to exceed five thousand dollars.”28 ­A fter rejecting the Jones resolution and disbanding his committee, the House of Delegates tabled the Michigan society’s alternative for further deliberation. In short order, the AMA Board of Trustees seized on the idea of a clearing­house commission. In the planning, the trustees consulted, among ­others, pharmacological luminaries John J. Abel of Johns Hopkins, Arthur R. Cushny of the University of Michigan, and Joseph P. Remington of the Philadelphia College of Pharmacy. Ultimately, in February of 1905, the power­ful AMA board sanctioned the formation of a drug commission and called it the Council on Pharmacy and Chemistry (CPC). The AMA’s House of Delegates retroactively endorsed the formation of the new council during the following July meeting.29 With the exception of Stewart’s, existing accounts of the CPC’s origins, including the AMA’s, make no mention of bureau enthusiasts Stewart and Jones or of the Michigan intervention. In his own accounts, Stewart claimed substantial responsibility, generously praising the CPC’s work even though it could and would do l­ittle in the way of investigations of therapeutic efficacy, his most ambitious long-­term objective. CPC member Torald Sollmann, quoted in Morris Fishbein’s official history of the AMA, identified Simmons as the “­father of the Council, his favored child” from its early, sometimes “tempestuous days.” If true, Simmons would have to have been involved in planning the Michigan intervention.30 No doubt a fair assessment is that Stewart fully deserved to claim joint paternity. His many years of exertion played a major role in placing reform on the agenda, mobilizing allies in both medicine and pharmacy, including Simmons, for his ­grand plan and therefore activating other forces friendly to his mission of bringing rational order to therapeutics.

100

D r u g P r o b­l e m s THE WORK OF THE COUNCIL ON PHAR MACY AND CHEMISTRY

“Clear your own skirts, professors and doctors,” Abraham Jacobi scolded fellow physicians for their rampant prescribing of proprietary medicines in a 1906 issue of the AMA journal. The AMA’s new drug council had by then been up and r­ unning for almost two years to help the profession wash its laundry. Serving that purpose, along with editor and general man­ag­er Simmons, was the CPC’s most impor­tant physician member, the German-­born Torald Sollmann. Sollmann is sometimes remembered as the dean of American pharmacology. With a medical degree from Ohio’s Western Reserve University and postgraduate study in Paris, he served as professor of pharmacy and materia medica at his alma mater. But doctors Simmons, Sollmann, and o­ thers on the fourteen-­member CPC w ­ ere outnumbered by pharmacologists during its first de­cade and beyond. Its first secretary was APhA activist Carl S. N. Hallberg, a professor of pharmacy at Northwestern University. He was followed in that executive position by William A. Puckner, a professor at the Chicago College of Pharmacy and formerly a chemist at Searle. Puckner would serve for twenty-­six years as the council’s most impor­tant scientific brain and administrative brawn. Tellingly, the AMA enlisted Harvey Washington Wiley, a chemist and doctor, from the U.S. Department of Agriculture’s Bureau of Chemistry. Joining Wiley from the same agency was physician Lyman F. Kebler, chief of that bureau’s National Drug Laboratory, and Reid Hunt of the Public Health and Marine Hospital Ser­vice’s Hygienic Laboratory. ­Every council member except Puckner, the full-­time executive secretary, served without remuneration.31 The council’s broad aim, as Sollmann put it, was to render clarity where ­there had been only “turbidity” in therapeutics—to “create order out of the confusion.” In pursuit of its mission, for each drug evaluation the council examined information submitted by and requested from manufacturers, including their advertisements, packaging, pamphlets, and circulars. To be approved, a drug’s ingredients had to be accurately specified in its labeling and promotions and in­de­pen­dently verifiable by laboratory experts employed by the AMA’s new Chemical Laboratory, which was set up in 1906.32 Frequently, the council pestered manufacturers with requests for extra documentation and explanations about their claims. Approval would be delayed or rejected if they replied with murky prevarications and obfuscations. Remedies rejected out of hand included t­ hose being advertised to the public or marketed with



Heal Thyself

101

false or misleading statements about geographic sources, raw materials used, and methods of collection. If labels did not identify poisonous or “potent” substances, rejection was also certain. Among the most impor­tant standards was rule number six of the ten rules: “No article w ­ ill be admitted or retained of which the manufacturer or his agents make unwarranted, exaggerated or misleading statements as to therapeutic value.” If manufacturers wished to make therapeutic claims in their advertisements, they had to submit credible evidence from clinical studies. With rule number four, aiming to reduce over-­t he-­counter prescribing by druggists and self-­medication by the public, the CPC also disqualified any article “whose label, package or circular accompanying the package contains the names of diseases in the treatment of which the article is indicated.” That also meant rejection of drugs whose names suggested specific curative properties, such as Habitina, which contained morphine and heroin and advertised as a sure cure for “morbid drug addictions” even though it contained morphine and heroin. Other offenders w ­ ere Cancerine, Croupine, Epileptine, Fatoff, Nephritin, Tu-­Ber-­Ku, and Utero-­Tonic.33 Drugs satisfying the CPC’s strict approval pro­cess w ­ ere published and widely distributed in reports titled “New and Non-­official Remedies,” including in the AMA journal and other publications. Not surprisingly, the journal, henceforth, restricted all proprietary advertisements to the council’s accepted remedies. The same policy would be ­adopted over the coming years by state medical society journals and a few in­de­pen­dent ones. Starting in 1910 the AMA distributed annual compilations of the reports in a bound volume, also called New and Non-­official Remedies. In 1913 it started publishing a small volume called A Handbook of Useful Drugs for use by medical schools, state licensing boards, and conscientious clinicians. It contained the ethical proprietaries the new council had approved, along with a small subset of the official USP drugs deemed to be of pos­si­ble therapeutic value. The AMA also sought to drive worthless nostrums off the market, not just give ethical drugs a boost. To target unethical manufacturers preying on doctors’ therapeutic ignorance, the AMA scornfully censured them in almost ­every weekly issue of its journal in a feature called “The Propaganda for Reform in Proprietary Medicines.” It was prepared by a Propaganda Department run by Arthur J. Cramp, who had turned to the study of medicine ­after the death of his ­daughter due to the bad ministrations of a quack. For example, the journal challenged the formerly more ethical Parke-­Davis com­pany, whose Detroit facilities had expanded by 1900 to fill almost six city blocks. In 1908

102

D r u g P r o b­l e m s

it withdrew approval of the com­pany’s digestive enzyme Taka Diastase for exaggerating its potency. In 1910 Parke-­Davis earned a dishonorable mention from the CPC for manufacturing Danderine and Nutriola and other nostrums on contract for and to be sold by companies making ridicu­lous claims about the merchandise.34 In 1913, the AMA journal excoriated Parke-­Davis for its extravagant claims regarding its new product line of “phylacogens” for rheumatism, gonorrhea, pneumonia, and much more. ­There was even a shotgun Mixed Phylacogen for anything and every­thing infectious. Phylacogens w ­ ere the metabolic “derivatives” (i.e., waste) filtrated from vari­ous bacterial cultures for injection into infected patients. The dosage standardization of ­these would-be antibiotics was virtually impossible, which increased the risk of toxic and sometimes alarming reactions, including delirium, high fever, and ultimately death. Knowing of likely “chills and other symptoms,” Parke-­Davis advised doctors to “properly prepare” patients to expect unpleasant reactions—­but only ­after giving the injection. That way the patient would “never seriously object” to the pain and other adverse reactions when they occurred. As the AMA journal put it, the com­pany spared no effort “to stampede physicians” into using the peculiar merchandise with advertisements brazenly boasting of a spectacular 90 ­percent recovery rate from four thousand cases of infection. In short, according to the AMA journal, Parke-­Davis showed “no scruples” in launching the product line, which it predicted would inevitably crash “like most proprietary rockets that describe a blazing parabola across the therapeutic heavens.” But before the profession discarded the product, the journal stated, Parke-­Davis would “unctuously rub its hands and murmur: Good business while it lasted!”35 Even more sensational ­were two lengthy and scathing indictments of the huge Abbott Alkaloidal Com­pany, owned by physician Wallace Calvin Abbott. The first, published in December 1907, took Abbott to task for its “subordination of science to commercialism” b­ ecause of the unpre­ce­dentedly expensive promotion of its Hyosin-­Morphin-­Cactin (H-­M-­C) preparation, supposedly a revolutionary breakthrough in obstetrical anesthesia. It was nothing of the sort, just a variant of an existing scopolamine-­morphine combination used to induce a semiconscious “twilight sleep” in birthing ­mothers. A greater number of favorable articles on H-­M-­C ­were published in medical journals than on any other subject in such a short period of time. It was all hype, according to the AMA exposé. Hyoscine, a sedative and antinausea drug



Heal Thyself

103

Wallace Calvin Abbott, MD (1857–1921), founder of Abbott Alkaloidal Co., ­later Abbott Laboratories. The target of a scorching exposé by the AMA journal in 1908 for unethical drug promotion and business practices, Abbott ultimately bent to the AMA Council on Pharmacy and Chemistry’s demands for honest advertising about his drugs.

derived from belladonna, was nothing new, having been introduced much ­earlier in the United States as scopolamine, the identical molecule derived from a dif­fer­ent plant. Hyoscine and cactin, a cactus extract, ­were supposed to interact “synergistically” with morphine to make delivering a baby easy and safe for all involved. According to Abbott’s ads, doctors exulted that the mix was “extinguishing the fear of childbirth.” In fact, the only ­thing new in the mix was the addition of the cactin. This unstandardized substance was currently sold as a cardiac stimulant, although physiologists consulted by the CPC found that even much higher doses of cactin than found in H-­M-C had no mea­sur­able effect on the heart. How cactin might counteract morphine’s risks, especially of losing a child to respiratory failure from morphine, was left unsaid. Simply put, Abbott was adding a “fraud” to nothing new and selling the dangerous mix with lies about its safety.36 The detailed H-­M-­C exposé in the AMA journal was followed a few months l­ater by another power­ful muckraking article titled “The Abbott Alkaloidal Com­pany.” In almost six pages of dense, fine print, it attacked Wallace Abbott for his “methods of working the medical profession.” Among Abbott’s tools was the pretentiously named American Journal of Clinical Medicine, a ­house organ for touting his specious therapeutic “method”—­“active-­ principle therapy” through “alkolometry,” which had spawned a “cult” of “alkaloidal physicians.” The article pointed out that refining active plant-­based agents into alkaloids (like quinine, morphine, atropine, and cocaine) was nothing new and that many of Abbott’s hundreds of preparations, many of them secret nostrums, contained no alkaloids. It also criticized Abbott and

104

D r u g P r o b­l e m s

his vice president, both no longer active prac­ti­tion­ers, for exploiting members of vari­ous medical socie­ties by attending their meetings and flogging Abbott’s theories and merchandise. Furthermore, Abbott and his associates flooded dozens of other medical journals with so-­called original articles ­under their signatures. They w ­ ere pseudoscientific, thinly veiled advertisements on a ­great range of medical m ­ atters that the putative experts could not possibly have had any real clinical experience with. Abbott’s own “literary fecundity” was as impressive as its quality was dubious: he had contributed “more original articles to more medical journals than any other man in the country.”37 The second half of the exposé dealt with Abbott’s finances and how he manipulated doctors for their money and unremunerated advertising ser­vices. For one t­hing, Abbott used his prestige to hawk shares to doctors in silver and other mines that he owned. Worse was Abbott’s “profit-­sharing” scheme, in which “the doctor supplies money to help run the business” and, more importantly, “lends his patronage and cooperation in creating a market for the products.” Discussions among the reform ele­ment of pharmacy called the recently spreading practice “reprehensible” b­ ecause “no man could serve two masters.” In real­ity, the so-­called bonds Abbott sold to unwitting doctors for supposedly rock-­solid returns w ­ ere not legitimate securities, only unsecured promissory notes that could not be sold or transferred. Th ­ ere w ­ ere no limits on how many Abbott could issue, thus increasing the already high risk of default in a market downturn b­ ecause the holders of the com­pany’s legitimately secured bonds had first claims on its assets. Abbott told doctors that their investments would go into buildings and other facilities to expand output and profits even as he transferred some of the com­pany’s properties to his private account. The article speculated that it may have been the revenue from milking doctors and si­mul­ta­neously harnessing them as sales agents that made it pos­si­ble for Abbott to launch larger and more profitable advertising campaigns, such as for H-­M-­C, than any other phar­ma­ceu­ti­cal firm in history.38 To fight back, Abbott produced a forty-­eight-­page pamphlet, An Appeal for a Square Deal: An Answer to Attacks Made in the Journal of the American Medical Association upon the Abbott Alkaloidal Com­pany and Dr. Abbott Personally. But state medical society journals took their cue from the AMA. According to one, some discerning doctors had long felt that Abbott “shamefully prostituted the medical profession to commercial ends,” and it praised the AMA for publicizing the facts in detail. Another claimed that Abbott’s defensive response lacked “any pos­si­ble show of dignity,” being in line with the com­pany’s “all-­pervading atmosphere of commercialism and Abbottism and



Heal Thyself

105

the ever-­present grasping out for the cash.” Indeed, “Not for one moment does the man seem to be able to divorce himself from his dollar-­getting schemes, ­either in his business, his lit­er­a­ture, [or] his journal.”39 At first, many state society journals continued to advertise drugs rejected and criticized by the CPC b­ ecause too few companies with approved remedies bought enough advertisements to keep them afloat. Among ­those that did reject unapproved drugs early on was the Texas State Journal of Medicine, which said that the CPC “has proven to be at the same time our salvation ­ ere and the protection of the honest phar­ma­ceu­ti­cal.” Joining it around 1912 w journals published by the Illinois, Indiana, Iowa, Kansas, Maine, Missouri, Pennsylvania, and South Carolina socie­ties, along with Northwest Medicine, which was jointly published by the Idaho, Oregon, Utah, and Washington associations. Among the journals still taking advertisements for unapproved products, including some with large numbers of readers, w ­ ere ­those sponsored by the state socie­ties of Kansas, Michigan, Minnesota, New Jersey, Ohio, and Oklahoma.40 In 1912, in order to hoist the laggards on board, the AMA trustees established a Co-­operative Medical Advertising Bureau as a shared sales agency and broker to persuade makers of ethical products to buy advertisements in the journals wishing to follow the CPC’s guidance. According to the bureau, ethical drug advertisers had not yet understood the value of state journals as advertising venues, and both sides in the collective transactions ­were grateful for the ser­vice it provided of bringing them together. By 1917, e­ very state society journal except one was in the CPC-­led fold. The Illinois Medical Journal had bowed out. Its owner was the Illinois Medical Society, the first state society controlled by insurgent ele­ ments in the looming national revolt against the progressive AMA leadership.41 As ambitious and successful as the CPC’s educational and leadership role was, its early achievements hardly matched Stewart’s vision or what Philadelphia reformer Solis-­Cohen called “rational empiricism” and “scientific therapeutics.” However, CPC chairman Sollman still harbored that ambition. In 1903, as an advocate of rigorous experimental methods in a “program of pharmacologic research,” Sollman had proposed “comparing the value of drugs supposed to possess equivalent actions.” ­Later, in 1912, he touted “the carefully planned, accurately executed, and intelligently digested ­ uman patients”—­and spoke of modern docstudy of the effects of drugs on h tors’ “moral obligation” to question what they once had concluded on the basis of “slovenly observation and wild deduction.” 42

106

D r u g P r o b­l e m s

It was prob­ably Sollmann who persuaded the AMA Board of Trustees to allocate extra funds in 1912 for a new Committee on Therapeutic Research ­under the CPC. The main function of the new committee was to initiate, fund, and coordinate clinical research conducted in vari­ous institutional settings. By 1916, it had funded twenty-­seven investigations. Among the commonly used drugs studied or ­under investigation with the CPC’s help ­were salicylates, digitalis and other cardiac stimulants, iodides, bromides, hexamethylenamin, pancreatic preparations, opiates, chloroform, epinephrine, and—­still sold as a “cure” for tuberculosis—­hypophosphites. But the volume of the research was modest. It could only have been small, given the l­imited resources available to the CPC, the rudimentary state of clinical experimentation, and, truth be told, the weak demand from rank-and-file AMA members for better guidance from above.43 Despite their zealous efforts, the reform leadership of the AMA could not boast of anything close to a complete victory against unethical commercialism in therapeutics. Some in­de­pen­dent journals, such as the Southern Medical Journal, the Cleveland Medical Journal, the Old Dominion Medical Monthly, Surgery, Gynecol­ogy and Obstetrics, the American Journal of Obstetrics, the Boston Medical and Surgical Journal, and the American Journal of Medical Sciences, followed the AMA. But the vast majority balked. According to the AMA, considerable blame for the per­sis­tence of the “proprietary evil,” despite the CPC’s valiant efforts, should be placed on the continued willingness of thousands of physicians to read cheap journals and prescribe the drugs advertised in them. At least some of the blame had to fall on the reputable and even prominent contributors of scientific articles t­ hose journals published. Among the authors, according to an indignant 1912 editorial in ­ ere such luminaries as William the California State Journal of Medicine, w Mayo, George Crile, and Alton Ochsner. B ­ ecause they submitted articles for publication in the American Journal of Surgery, it leveraged their celebrity and authority for advertising revenue—­without giving the authors a cut except in the form of scholarly exposure.44 Some phar­ma­ceu­ti­cal companies claimed to welcome “any and ­every movement which aims at the separation of the wheat from the chaff” and expressed their hopes that the CPC would “elevate, energize and encourage manufacturing pharmacists to cater exclusively to the profession.” But many ­others, even t­ hose posing as ethical, dug in their heels. Among them was Upjohn, which indignantly snubbed all journals following CPC standards, even



Heal Thyself

107

if some of its products would have passed muster. ­Until the end of the 1930s, it placed no ads in the “influential trade publications,” according to Upjohn’s official history, and relied on other kinds of printed advertisements. Upjohn also relied heavi­ly on a large army of detail men as an efficient way to get dubious information to potential prescribers.45 But by the 1930s, most major drugmakers had submitted to the need for AMA legitimation in order to buy advertising space in the AMA and state society journals. Abbott did not fold quickly. For example, in 1914, six years ­after the AMA journal criticized its H-­M-­C, Abbott was still telling doctors “think H-­M-­C” even though the twilight sleep it induced in birthing ­mothers was starting to fall out of f­avor. Abbott successfully sold it and other products panned by the CPC with mailings, visits from detail men, and major in­de­pen­dent medical journals like the American Journal of Clinical Medicine (still Abbott’s h ­ ouse organ), the Therapeutic Gazette (still Parke-­Davis’s), American Medicine, and the Interstate Medical Journal. They, along with Medical Council and the American Journal of Surgery, ­were four of the “Big Six” in­de­ pen­dents, three of them owned or run for profit by advertising executives. In 1912, they boasted of reaching one hundred thousand physician readers. All six still advertised H-­M-­C and many other drugs like Fellows Syrup of the Hypophosphites, the discredited tuberculosis cure. They also advertised the Martin H. Smith com­pany’s popu­lar Glyco-­Heroin, a sweet-­tasting syrup for cough, asthma, phthisis (tuberculosis), pneumonia, bronchitis, laryngitis, whooping cough, and “kindred affections.” Along with a large dose of heroin, Glyco-­Heroin also contained hyoscyamine (henbane), which is both psychoactive and toxic, and alcohol. It was also trademarked less transparently as Glykeron for over-­the-­counter sale. As late as 1914, advertisements declared Glyco-­Heroin “decidedly preferable to preparations containing codeine or morphine” b­ ecause it “does not produce narcotism, constipation, gastric disturbance nor habituation, even though its administration be protracted.” Smaller doses for c­ hildren ­were recommended.46 So innovative was the new AMA agency that it caught doctors’ attention abroad, inspiring at least one similar effort in Eu­rope. In 1911, the German Society for Internal Medicine, disturbed by its country’s own smaller but growing prob­lem with “new and . . . ​unwelcome preparations,” established its own Phar­ma­ceu­ti­cal Commission (Arzneimittelkommission), the precursor of ­today’s Drug Commission of the German Medical Association. The German commission even sought counsel from CPC secretary Puckner. An excellent

108

D r u g P r o b­l e m s

mea­sure of the CPC’s po­liti­cal significance, and perhaps its effects on drug profits, is the attention paid to it by its enemies. They bitterly reviled the AMA and the medical journals sponsored by state medical socie­ties joining the reform movement. In his The Machinations of the American Medical Association, a 130-­page diatribe against the AMA, National Druggist editor Henry Strong held up the CPC as a kind of prosecutorial agency “to whose w ­ ill journals must submit.” 47 The in­de­pen­dent Charlotte Medical Journal claimed that the AMA was deciding which journals ­were to be “banned and outlawed.” According to the in­de­pen­dent Texas Medical Journal, the AMA (“The Octopus”) issued “ukases” on what was allowed by the CPC to be advertised. “Are we living in Amer­ i­ca, or in darkest Rus­sia? . . . ​A re we freemen, or serfs?” it asked. The Southern Practitioner devoted dozens of pages to rambling philippics against the AMA by G. Frank Lydston, a prominent Chicago surgeon with an ax to grind against the AMA “oligarchy” and its orga­nizational “machine.” The main target of Lydston’s obsessive rants—­for example, in his 1910 “The Rus­sianizing of American Medicine”—­was George Simmons. He flailed Simmons for being a “medico-­political czar” responsible for the AMA’s “despotism,” including through his membership on the CPC.48 Lydston was the first national-­level rabble rouser for the AMA’s coming insurgency, which led to the reactionary turn of the 1920s and the long era of medical conservatism that ensued. MORE TO BE DONE

A not-­uncommon misperception t­ oday about the early twentieth-­century AMA is that it was driven primarily by a need to establish monopolistic authority and income for the regular medical profession and, only secondarily, if at all, by the advancement of progressive reforms. In line with that, two economic historians have asserted that the AMA’s antinostrum campaign was in part selfishly inspired: “Patent medicines w ­ ere a competitive threat” b­ ecause of consumers’ self-­medication. But their premise about such competition and how it was perceived is factually unfounded. Doctors may actually have been the net beneficiaries of direct-­to-­consumer advertising. Bad reactions caused by self-­medication no doubt brought them many patients. According to Simmons, “­There is not a practicing physician . . . ​who, from his own individual experience, can not bear witness to cases in which harm has resulted from their use.” And as one of the AMA antinostrum crusaders put it, aside from the drug industry and its advertisers, “No class receives greater financial benefit



Heal Thyself

109

from ‘patent medicine’ advertising than physicians.” For example, of the countless ­people persuaded by an advertisement for Doan’s Kidney Pills that their lower-­back pain is a symptom of kidney disease, “considerably more than half ­will go to their ­family physician rather than to the drug ­counter.” 49 In short, the reformers ­were concerned that doctors ­were earning money, not losing it, with their complicity in commercialized therapeutics. The progressives in control of the AMA ­were not worried in the slightest about the over-­the-­counter sales as a threat to doctors’ incomes. The story of compulsory prescriptions would be a long and dev­ilishly complicated one that culminated with the 1951 amendments to the 1938 Food, Drug, and Cosmetic Act, which in part still apply ­today. One of the amendments’ main effects was to put an end to microregulation by the Food and Drug Administration (FDA) of specific drugs’ labeling, marketing, and usage instructions when it considered them dangerous for self-­medication and incompetently administered by doctors. The initial movers for the reform ­were not doctors but pharmacists seeking regulation that leveled and stabilized their competitive playing field. Then the drug manufacturers stepped in to make sure their interests ­were also served. The FDA lost out. All the while, the now conservative AMA and drug industry ally quietly stood aside. It was apparently content with the status quo before 1951, in which manufacturers enjoyed wide latitude in deciding ­whether to require doctors’ prescriptions for their drugs.50 In sum, the Progressive ­Era medical leaders’ anguished discussions and angry protests w ­ ere not rhetorical camouflage for primarily selfish interests in drug reform. They earnestly railed against their profession’s own ill-­gotten gains at patients’ expense. They felt that for their fees, their colleagues massively prescribed nostrums to their naive patients’ physical, m ­ ental, and financial detriment. Perceptions of adverse se­lection motivated the doctor-­ reformers to generate and spread good information to counteract the survival of the foulest in the commercial jungle. They sought to neutralize the influence of drug firms investing more in fraudulent advertising than research into genuine therapeutic knowledge. Unlike scientific investigation, medical disinformation cost the drug companies very ­little to concoct while promising hugely profitable returns. ­After giving up on constructing a cohesive co­ali­tion of doctors, pharmacists, and the more ethically inclined drug manufacturers ­behind a governmental or a quasi-­governmental corporatist solution, medicine’s reformers sought to implement a progressive alternative of a voluntaristic, nongovernmental

110

D r u g P r o b­l e m s

nature. They saw good medical journals as the agency to apply and disseminate the arduously but unremuneratively generated information the AMA’s CPC supplied. But they also knew that more was needed than progressive voluntarism. The power of a paternalistic state still had to be summoned to protect citizens from the drug industry’s wolves in sheep’s clothing: toxic and addictive drugs dressed up as gentle remedies for their ills.

chapter 5

­Legal Remedy

In 1906, President Theodore Roo­se­velt signed Amer­i­ca’s first national law to regulate drugs, the Pure Food and Drugs Act (PFDA). The United States was late in a wave of reforms, but not by much. A number of laws had passed across Eu­rope and elsewhere, starting around 1903, for regulating the sale of proprietary drugs advertised directly to the public and dispensed without doctors’ prescriptions. Denmark and Serbia passed laws to control the marketing of ­these generally useless, often dangerous, and sometimes expensive products in 1903, as did many states in Germany. Hungary and Norway followed in 1904. New Zealand and the Australian state of Victoria joined the wave in 1905. In 1906, the Australian federal government established a regulatory regime for the entire commonwealth.1 ­Because Amer­i­ca was the main launching ground of the commercial invasion across the seas, it could be argued that its drug industry induced the other countries to act around the same time the United States did. A traveling Australian Commission looking into the growing patent medicine prob­ lem around the world reported in 1906 that at least 90 ­percent of fraudulent preparations being sold directly to the public could be traced to the United States. Britain was especially receptive, given its low tariffs on American products, while higher ones in Germany and France spared t­ hose countries to a greater degree. As an article in Lancet, Britain’s prestigious medical journal,

111

112

D r u g P r o b­l e m s

put it about the country’s own “deluge” of proprietary drugs, “The United States of Amer­i­ca are the home of all that is worst in the proprietary medicine trade.”2 “The United States of Amer­i­ca is the main hotbed for this stuff . . . ​W hat a reflection on our country!” the AMA’s George Simmons exclaimed to a meeting of the Kentucky State Medical Association ­after seeing an advance copy of the Australian report.3 His disgust was shared by the rest of the AMA’s reformist leadership. Therefore, it is no surprise that the AMA joined a progressive alliance of forces that brought the 1906 PFDA into being. With it, lay and medical reformers sought to achieve “truth in advertising” to the public as well as the profession, at least with regard to the dangerous contents of many drugs. Most impor­tant in its implementation, the law required manufacturers to make doctors, pharmacists, and patients aware of the presence and quantities of opiates, alcohol, cocaine, chloroform, cannabis, chloral hydrate, and acetanilid or their derivatives in a drug. Before the law, such substances could be bought and sold freely, even without a doctor’s prescription, and without so much as a mention of them in advertisements and labels. Now, after 1906, fines and even imprisonment threatened manufacturers who made demonstrably false and intentionally misleading statements about their drugs’ contents on all b­ ottles, packages, and inserts. While lies about contents w ­ ere no longer allowed, secrecy about any ingredient except the relatively few narcotics and poisons listed remained l­egal. That included strychnine, hydrogen cyanide, arsenic, mercury, and other dangerous substances still in medicinal use. The new restrictions only applied to statements attached to or inserted in a drug’s container or packaging, so secrecy and lies in newspaper advertisements remained ­legal. In sum, the ­actual outcome in 1906 was “truth but not the w ­ hole truth in labeling, and anything goes in advertising.” Better laws would have to wait. E A R LY EFFORTS

The 1840s brought the earliest venture into federal reform in the United States, but not much came of it. Eu­ro­pean countries triggered the effort by passing their first quality-­control legislation for drugs sold within their borders. The United States then became a dumping ground for substandard products that Eu­ro­pe­ans could no longer sell domestically. American drugmakers had been watching their profits sink as foreign ships entered the country’s ports loaded with substandard, adulterated, and expired medicines. The U.S.



Legal Remedy

113

Congress responded with the Drug Importation Act of 1848, signed by President James K. Polk. By adopting Amer­i­ca’s own pharmacopeial standards for generic substances, first formulated by physicians and pharmacists in 1820, the law turned the compendium’s private authors into quasi-­governmental authorities. Protecting public health was the 1848 law’s official motive, but the commercial interests of quality-­minded drug manufacturers, most notably physician Edward R. Squibb, brought what he called a “wise and beneficent law” into being. Port examiners in New York, Boston, Philadelphia, Baltimore, Charleston, and New Orleans ­were given the task of enforcing the 1848 act. But by the 1860s, the machinery of politics shredded the law into pulp. Squibb complained that enforcement, once rigorous, had become lackadaisical. Even when bad merchandise was turned away at one city, it would reappear on the docks of another. To protest the state of affairs, a committee chaired by Squibb and consisting of the Medical Society of New York, the New York County Medical Society, the Kings County Medical Society, the New York Acad­emy of Medicine, and the New York City College of Pharmacy formed to convey an appeal to the Lincoln administration. But Secretary of the Trea­sury Salmon P. Chase refused to require port examiners to be gradu­ates of a regular medical college or a college of pharmacy and be vetted by the medical boards of the army or navy. Perfectly qualified to be New York City’s port examiner, Chase thought, was a po­liti­cally connected “money broker of Wall Street.” 4 In 1879, efforts for better drug regulation ­were revived when major food as well as phar­ma­ceu­ti­cal interests joined forces with progressive physicians and pharmacists in a proto-­progressive alliance for regulation. That year, the National Board of Trade, a federation of commercial organ­izations, unanimously recommended passage of a national law, patterned a­ fter legislation being deliberated in Britain, to specify and enforce standards for food and drugs. As regarded drugs, the 1879 reformers’ main objectives ­were to turn the USP standards of strength, quality, and purity into the interstate as well as international regulatory law of the land and to establish an efficient enforcement regime. Physician John Shaw Billings, the prime mover ­behind the creation of a short-­lived National Board of Health the same year, was chosen to lead the drafting pro­cess. Billings hoped his health board would be the agency chosen to enforce the food and drug law.5 Opposing forces gave the bill a congressional burial. Aroused by the “professed standard” clause holding them to account for claims they made about their drugs’ ingredients, they had brought their Proprietary Association of

114

D r u g P r o b­l e m s

Amer­i­ca into being, which would carry on the b­ attle against regulating medicines all the way to 1906. Some opposition also came from companies that supported the idea of reform in princi­ple but feared that the prospective collaboration with “dishonest, combined capital” in implementing the law would adulterate what­ever reform resulted. In the aftermath of the defeat at the federal level, the states of New York, Michigan, Mas­sa­chu­setts, and New Jersey moved ahead with their own laws.6 But t­ hese few state laws w ­ ere badly enforced, much as the federal law of 1848 had been, and they did nothing to stop the coming deluge of trademarked nostrums in and out of ­those states. Pressure for federal action would build again around 1887, applied again by food and drug manufacturers being undercut by the lies and adulterations of their competitors. As before, the movement was almost entirely business driven. Medical forces w ­ ere not prominent in the fight, and consumers w ­ ere still barely in the picture as a po­liti­cal force. Bills introduced in Congress between 1889 and 1892 repeatedly ran aground in one chamber or the other. For example, the 1892 bill, sponsored by progressive Nebraska senator Algernon S. Paddock, narrowly passed through a bitterly divided Senate but died in the House of Representatives. It had a controversial clause holding all drugs ­ ere not named in an ofaccountable to their “professed” standards if they w ficial pharmacopeia. Chemist and civil servant—­and f­uture member of the AMA’s Council on Pharmacy and Chemistry—­Harvey Washington Wiley observed that “­there seemed to be an understanding between the two Houses that when one passed a bill for the repression of food adulteration the other would see that it suffered a lingering death.” The bills not only faced defeat; they faced ridicule and mockery from congressional leaders firmly in control of the legislative pro­cess. They “smugly” looked down upon pure food and drug mea­sures “as the work of cranks and reformers without much business sense.”7 Within five years the debate fired up again, centering on a new bill that closely resembled Paddock’s failed 1892 bill—­except that its “professed standard” clause only applied to the “purity and strength” of USP drugs, not, as in the Paddock bill and the New York and Mas­sa­chu­setts laws, all drugs for internal and external use, including proprietaries. Introduced in the House of Representatives in 1897 by William P. Hepburn, a progressive Iowa Republican, it was followed by two National Pure Food and Drug Congresses in 1898 to 1900, in which prominent business associations beat the drums for congressional action. A slew of professional, public health, w ­ omen’s, farmers, canners, agricultural, and phar­ma­ceu­ti­cal association delegates came to the



Legal Remedy

115

first meeting. President William McKinley showed up at the reception. But the as yet chaotic, unreconstructed AMA gave it no mention in its journal other than a notice about the publication of the first Congress’s proceedings.8 Momentum was also gathering at the state level during the de­cade leading to the 1906 act. At least fifteen state legislatures, including in Kentucky, New Hampshire, Mas­sa­chu­setts, Pennsylvania, Utah, and Wisconsin, deliberated bills to regulate the sale of drugs within their borders. But the bills faced almost insuperable odds, just like the previous one in 1897, when a swarm of bills had “swept over the country . . . ​like unto the locusts that spread over Egypt,” according to the Proprietary Association’s Committee on Legislation. When the Kentucky legislature was considering a law requiring the printing of accurate and complete formulas on patent medicines, the Louisville Times complained that manufacturers in other states would just mail their products directly to customers after advertising them in Kentucky newspapers, thus depriving the state of some $4 million in sales tax revenue. In Kentucky, ­because of the drug industry’s power and despite f­uture AMA reor­ga­nizer Joseph McCormack’s considerable influence, even the licensing law exempted proprietary medicines from the ethical prescribing standards demanded of doctors for USP and other official medicines.9 Medicine makers exercised enormous leverage through state newspapers, which ­were, in effect, extorted to defend the drug industry. Drug companies inserted so-­called red clauses into their long-­term advertising contracts that rendered them null and void “if any law is enacted . . . ​restricting or prohibiting the manufacture or sale of proprietary medicines.” Another typical clause voided advertising contracts with a paper or magazine that dared publish opinions critical of the com­pany, its products, or the proprietary industry in general. In one Western state, for example, no newspaper dared publish the results of a critical analy­sis of vari­ous proprietary medicines conducted by a board of health officer who wanted the truth to be known. Such contract clauses w ­ ere a cheap and efficient way to muster a mercenary army of editorial allies. They w ­ ere the tools of what muckraker Mark S­ ullivan called a “patent medicine conspiracy against the freedom of the press” in a Collier’s exposé. Members of the Proprietary Association committed themselves at their annual meeting to withdrawing all their advertising from all the papers in North Dakota to whip them into editorial action for repealing the law. They also resolved that the members should ship no goods for sale into North Dakota in order to dragoon its druggists into their ­battle as well.10 Such was the bleak outlook at the state level before passage of the 1906 PFDA.

116

D r u g P r o b­l e m s PASSING THE PUR E FOOD AND DRUGS ACT

In January of 1904, a food and drug bill submitted by Iowa progressive Republican William Hepburn passed in the House of Representatives by an impressive majority of 201 against 68. But its success depended entirely on the fact that it had no language for controlling the patent medicine business. No bill, weak or strong, came to a vote that year. North Dakota Republican Porter J. McCumber offered a mea­sure to include proprietary drugs, but it stoked a firestorm of industry opposition that guaranteed its failure. Nevertheless, Hepburn’s bill was strengthened in March 1905 with the help of Republican James R. Mann of Illinois, a member of the Committee on Interstate and Foreign Commerce, by requiring the labeling of dangerous and addictive substances, which now turned the proprietary industry’s rage against the House as well as the Senate. Therefore, ­there was ­little hope for reform given that control of both ­houses of Congress was in the hands of the conservative “Old Guard,” that President Theodore Roo­se­velt was indifferent, and that ­there was no groundswell of public pressure from below. Nevertheless, in the face of ridicule and contempt from the congressional leadership, the progressive forces in the press, ­women’s groups, and a newly mobilized medical profession would not give up the fight. The movement had at its helm an optimistic and tireless crusader in the Department of Agriculture’s Harvey Wiley, a member of both the po­liti­cally mobilized AMA and the American Phar­ma­ceu­ti­cal Association (APhA). According to the AMA and all observers past and pre­sent, the PFDA was “largely the result of the energy, persistency and especially the courage” of Wiley. The tall, witty, boisterous, and morally righ­teous Wiley had experienced what he described as an austere and disciplined but happy childhood on an Indiana farm as the son of a stern Calvinist ­father, an abolitionist who was a “conductor” of the Under­ground Railroad. Having earned a medical degree from Indiana Medical College, Wiley pursued postgraduate training in chemistry at German universities. As an adult he became a fervent moralist and nutritionist, a missionary for healthy living and, to make that easier for Americans, honest commerce, especially in food.11 Wiley believed that un­regu­la­ted competition led inevitably to trafficking in adulterated and other inferior merchandise sold for ­human consumption. Competition, he instructed Congress, was not, as many ­others had testified, “the effective remedy against food adulteration” b­ ecause “one of the ele­ments of competition is to undersell your competitor” by, among other ­things, “mak-



Legal Remedy

117

ing the product at a less cost than he can.” Competitive cost cutting was the sole purpose of food adulteration, so “it is perfectly evident that unrestricted competition tends to increase the evils of food adulteration instead of to lessen them.” Practically speaking, “­every dealer has to ­handle adulterated articles” or go out of business. Furthermore, un­regu­la­ted markets had unhealthy moral as well as physical and economic consequences. Competition in the drug trade puts a “premium on deceit.” No person “can continually deceive his customer and retain that high moral sense which is the very soul of trade.” While consumers may only part with a ­little money with each purchase of cheap goods, “the manufacturers and dealers w ­ ill soon be out of conscience.” Competition, in short, was “demoralizing,” not uplifting.12 As in commercialized drugs, adverse se­lection, the survival of the foulest, was at work in foods as well. Fi­nally, Wiley was a progressive state builder, not just a champion of physical, social, and commercial uplift. He was motivated in ­great part by a desire to preserve and strengthen the Department of Agriculture’s Bureau of Chemistry, which he had headed since 1882. By enlarging the scope of its activities, he garnered private-­sector allies benefiting from regulatory action who could help him expand government power for progressive purposes. Although the early consumer movement of the Progressive Era largely overlapped with ­women’s organ­izations, Wiley focused first and foremost on recruiting allies from the business world. It was an entirely rational strategy, given the po­liti­ cal power of business generally and the fact that, according to historian James Harvey Young, “Producers of food, beverages, and drugs preceded consumers in anticipating, even in desiring, that law’s eventual arrival.” So just as ­ oing on parallel tracks to California medical leader Philip Mills Jones was d create a private bureau of medicines, from the beginning Wiley assiduously rounded up cap­i­tal­ists in an alliance for government action.13 Among Wiley’s most impor­tant business allies to help him beat a path through Amer­i­ca’s po­liti­cal jungle ­were the canning, pickling, preserves, and beer brewing industries. Canners and other food pro­cessors ­were particularly keen for legislation both ­because of price chiseling by cheap competitors and ­because t­ hose ele­ments instilled in many p ­ eople an undiscriminating suspicion of all mass-­produced goods. Most impor­tant of all ­were individuals such as Henry John Heinz, the Pittsburgh manufacturer of ketchup and many va­ri­e­ties of pro­cessed foods. Heinz, who was conservative in his use of preservatives—­favoring great quantities of salt and sugar instead—­had long been a proponent of pure food legislation. Although his costs may have been higher, he gained a brand advantage by advertising his products in nationally

118

D r u g P r o b­l e m s

circulating reform-­friendly magazines like McClure’s, Ladies’ Home Journal, and Collier’s. As a supporter of state and federal agriculture programs for improving the quality and yield of farm products, he was not at all averse to cooperative relations with government bureaucrats. Some of his views on that ­matter ­were influenced by a visit to Germany, where standards of purity in food and beverages ­were strictly controlled by the state in collaboration with major producers.14 Heinz thought federal regulation would help rather than hurt not just his own com­pany but large food manufacturers as a w ­ hole by getting customers to accept their products as readily as they did fresh foods grown, pro­cessed, packaged, and canned on a small scale by trusted locals. He was astonished that other food pro­cessors, ­because of muckraking’s indiscriminate damage to trust in goods transported afar from strange and unknown cities, failed to join his mission. To them, Heinz was an industry “blackleg.” According to Ann Lewis Pierce, who worked for Wiley as the editor of Bureau of Chemistry publications, the Heinz com­pany “took the lead” and did the “pioneer work when government officials and legislators lagged.” Indeed, “the House of Heinz was Dr. Wiley’s first lieutenant.” Wiley himself extolled the personal and staff support Heinz gave him “in the darkest hours of my fight for pure food . . . ​I feel that I should have lost the fight if I had not had that assistance.”15 Another supporter in the Wiley camp was Frederick Pabst, founder of Pabst Brewing Com­pany, who rousted support from ­others in the United States Brewers’ Association and testified in Congress. Like Heinz, he was convinced that the use of chemical preservatives was entirely unnecessary if hygienic conditions ­were maintained in production facilities. He, too, was influenced by Germany, with its famous Reinheitsgebot (purity decree) issued first in 1516 by Duke Wilhelm IV of Bavaria protecting the purity of its beers. Interestingly, Pabst and other Milwaukee brewers ­were among the most labor-­ union-friendly employers in Amer­i­ca; their support for regulatory standards that might impose extra costs on lower-­standard, nonunion brewers may in part explain this eagerness. Most opportunistically, perhaps, Wiley enlisted “straight” whiskey producers who wished to prohibit makers of blended spirits from calling them whiskey. His notable allies therefore included Pennsylvanian Henry K. Frick, the power­ful steel magnate, railroad financier, and owner of Old Overholt whiskey, and Kentucky distillers such as Edmund Taylor of the Old Taylor brand. Chemist and secretary of Kentucky’s Pure Food Department Robert M. Allen, a friend of the Taylor ­family and secretary of



Legal Remedy

119

the National Association of State Food and Dairy Officials, served as Wiley’s key lieutenant in rounding up allies from other businesses and state food agencies. A typical progressive like Wiley, he, too, saw some cap­i­tal­ists as natu­ral and necessary allies of reform ­causes.16 Initially, at least, Wiley and his many allies also got help from parts of the drug industry, especially large phar­ma­ceu­ti­cal h ­ ouses and ­wholesalers dealing primarily in USP medicines, a base of support for reforms since the 1840s. Their interest in the House and Senate bills before 1904 derived from their modest ambition to regulate trade only in the official pharmacopeial drugs marketed exclusively to doctors. That ethical line of business was being undercut by competitors who sold adulterated or entirely bogus versions of the official substances at lower prices. B ­ ecause the bills did not threaten the proprietary makers’ trademark merchandise, the bills’ drug regulations ­were about the least controversial of their many provisions for controlling the adulteration and false and misleading labeling of products for ­human consumption. The ethical manufacturers’ support may have lulled McCumber, chairman of the Senate Committee on Manufactures, into thinking it po­liti­cally practical to expand his bill’s definition of “drugs” to include not only USP items but also e­very substance sold for ingestion or application to “cure, mitigate, or prevent disease.” The request to expand the definition to include proprietaries came from an impor­tant ele­ment of the drug industry itself and was endorsed by a legislative committee of the National Wholesale Druggists Association. Charles  R. Parmele, a manufacturing chemist in New York City, spoke for them in a Senate hearing. Parmele had ­earlier led a 1902 del­e­ga­tion to the Senate that resulted in the creation of a National Drug Laboratory to investigate the adulteration of foods and drugs in Wiley’s Bureau of Chemistry in the Department of Agriculture. Accompanying Parmele in his 1903 del­e­ga­tion to McCumber’s committee was his associate Edward  M. Johnson, formerly of Johnson & Johnson, and Max Breitenbach of the M. J. Breitenbach Com­pany, a trustee of the New York College of Pharmacy. ­Others in the del­e­ga­tion represented phar­ma­ceu­ti­cal ­houses McKesson & Robbins, C.  N. Crittenden Com­pany, and Kress & Owen Manufacturing Com­pany. Two other companies submitted written statements supporting including proprietaries as “drugs” destined to be regulated.17 Parmele was the maker of Arsenauro, Mercauro, Manganauro, and Calcauro, whose active ingredients ­were arsenic, mercury, manganese, and calcium mixed in colloidal suspensions of gold. Neither the therapeutic nor the market value of the gold in the drugs was advertised, but ­there was no

120

D r u g P r o b­l e m s

controversy about its presence in his products. His and his allies’ ethically labeled products often came ­under competitive attack from cheaper “auros” containing no gold at all, but claiming to be good substitutes for Parmele’s products. Part of the prob­lem was the collusion of retail druggists in the perfectly ­legal fraud of buying the fool’s gold and selling it to patients for the price of the real t­ hing. In his advertisements in medical journals, Parmele cried, “Stop Thief!” and warned pharmacists not to write “substitute” on doctors’ prescriptions for his arsenic cure ­because in d ­ oing so “you commit fraud, endanger life, and do damage to the physician.”18 Thus, at the Parmele group’s prompting, Senator McCumber added to his bill the new definition of “drug” as anything sold for treatment or prevention of disease, a modest improvement, he thought, for holding the proprietary industry accountable to no more than the standards they professed in their labeling and packaging. Patent medicine makers would be f­ree not to profess anything, he insisted, if they wished to avoid being charged with making false or misleading statements. But an outraged proprietary industry thought differently and swiftly ­rose in defiance. The practically seamless wall of opposition included even the reformist ele­ments of the National Association of Retail Druggists and the National Wholesale Druggists Association. Most of the Parmele del­e­ga­tion retracted its support for the new definition ­after an angry committee of druggists and drug associations from Philadelphia descended upon them, followed by a deluge of protest letters from drug ­wholesalers around the country. 19 The danger lying in the new definition feared by the opposition was that it opened the door for prosecution and private litigation concerning false and misleading therapeutic claims. That possibility was entailed in the law’s current definition of illegal “mislabeling” as the presence on a package or label of any statement that was false or misleading “in any par­tic­u­lar.” One such “par­ tic­u­lar” could be a therapeutic boast, not just statements about ­things like strength, quality, and purity. Proprietary drugmakers ­were not alone in wor­ holesalers’ rying about the muzzling of therapeutic claims, as indicated by the w opposition. Many of the large makers and distributors of drugs whose ingredients w ­ ere honestly advertised to doctors had side ventures in less ethical trademarked merchandise. And even they made bold claims of therapeutic efficacy on their ethical lines’ packaging and labeling, supportable only with specious physician testimonials and puff pieces in medical journals dressed up as impartial clinical reports. Sometimes the claims ­were almost as extravagant



Legal Remedy

121

as ­those of the nostrum makers who promoted their won­der drugs directly to the public. Kress & Owen, for example, which was represented in the Parmele del­e­ga­tion to the Senate, boasted in inserts for Glyco-­Thymoline (containing thymol and glycerin) of its power against practically e­ very infectious disease when taken internally and as a germicide for external use on the body or on h ­ ouse­hold surfaces. ­These ­were outrageous claims, as the AMA’s chemical laboratory proved ­later: staphylococcus survived contact even with undiluted samples of Glyco-­Thymoline for at least four hours.20 The proposed new definition of drugs fused the entire drug industry into a solid oppositional bloc that made passage unlikely, given conservative control of both ­houses of Congress. The four main phar­ma­ceu­ti­cal organ­izations all beseeched McCumber’s Senate committee to limit reform to the pharmacopeial medicines, leaving proprietaries advertised to the profession and public alike untouched. The Proprietary Association of America (PAA), the National Association of Retail Druggists (NARD), and the National Wholesale Druggists’ Association (NWDA) w ­ ere even joined by the APhA, whose conservative faction consisted of phar­ma­ceu­ti­cal experts on the industry’s payrolls, in their attack against the regulation of proprietaries. In a 1904 hearing of the Senate Committee on Manufactures, the NWDA chairman protested the progressives’ hijacking of legislation, complaining that, in spite of anticipated burdens, the drug organ­izations had played an impor­tant role in “building up the sentiment in f­ avor of a national pure food and drug law.” A NARD leader played on McCumber’s inclination to ­favor business interests and threatened that it would be a “disastrous” t­ hing to adopt anything without “the hearty cooperation and support” of the entire drug industry. Now openly declaring support for the old, weaker version of the bill was the patent medicine sector’s George  L. Douglass, counsel for the PAA. ­A fter elimination of the new definition, he said, “nobody, so far as we know, is opposed to the bill.” Thus, with some reluctance, McCumber appeased the drug industry by removing the expanded definition. But Republican Weldon Hinton Heyburn of Idaho, having in the meantime replaced McCumber as chairman of the Senate Committee on Manufactures, intervened by stalling a vote ­until a ­later executive session. Senator Heyburn’s intransigence all but guaranteed continued legislative deadlock.21 The wall of po­liti­cal opposition to a strong food and drug law fi­nally broke during the spring of 1906 b­ ecause of the publication the previous winter of Upton Sinclair’s The Jungle, about filthy and inhumane working conditions

122

D r u g P r o b­l e m s

in Chicago meat-­packing plants. Practically all accounts of the PFDA treat the novel as a bolt from the blue that woke a ­silent public to the need for federal reform. Wiley, for one, was sure that agitation over meat had at last aroused the oblivious public and focused its generally diffuse attention on what was ­going on in Washington. Sinclair, a socialist, had written the book to spur action against the treatment of ­labor in the meat industry. As he put it, “I aimed at the public’s heart,” but “by accident I hit it in the stomach.” In other words, the drug reform hitched a ­ride on the meat-­packing scandal. A separate law, the National Meat Inspection Act, passed the same day in June as the PFDA.22 Another equally blistering but less widely noticed exposé that helped focus public attention on the patent medicine evil was a series of twelve articles published in Collier’s in the fall of 1905 and winter of 1906, the same time The Jungle became a sensation. In them, Samuel Hopkins Adams, a famous novelist and muckraker, exposed patent medicines such as the popular Peruna that hooked p ­ eople into alcoholic and narcotic addictions; bogus treatments for infectious diseases such as Liquozone, sold as “liquid oxygen,” a weak solution of sulfuric and sulfurous acids; “subtle poisons” for pain, such as Bromo-­ Seltzer, Antikamnia, Phenalgin, and Megrimine, sold without warnings about acetanilide; and drugs that preyed on “incurables,” such as Dr. King’s New Discovery for Consumption, Dr.  Tucker’s Epilepsy Cure, Miles’ Heart Disease Cure, and Rupert Wells’ Radiatized Fluid (for cancer of all things). Other magazine articles exposed all the advertising trickery used to fool the public. One by Mark S­ ullivan, whom Edward Bok had recruited into investigative journalism, told of the red clauses and other tools exploited by the drug industry to rope the press into propagandizing and lobbying against reform. The result, according to Adams, was that in 1905 “gullible Americans” would spend something like $75 million on patent medicines and “swallow huge quantities of alcohol, an appalling amount of opiates and narcotics . . . ​ and, far in excess of all other ingredients, undiluted fraud.”23 Not surprisingly, the alarms resonated with and ­were powerfully amplified by activist ­women, even though they still lacked the vote. Of par­tic­u­lar importance was Alice Lakey of the National Consumers’ League. But given other preoccupations and reluctance to push for what still looked like a losing cause, President Roo­se­velt cold shouldered the reformers. Sinclair’s socialist fervor and impetuous manner annoyed him, as did muckraking in general, a term he coined to derogate, not praise it. Nevertheless, he in­de­pen­ dently verified what he called the “revolting” facts about the meat industry.



Legal Remedy

123

Journalist Adams also influenced Roo­se­velt, but indirectly via Senator Heyburn, who had the president’s ear. It was the muckrakers’ arousal of the public and key legislators that fi­nally moved Roo­se­velt to get off the fence and signal his support.24 It turned out to be critical for the PFDA’s passage in June 1906. O R­G A ­N I Z E D M E D I C I N E ’ S R O L E

Less noticed than the muckrakers in historical discussions of the movers ­behind the PFDA is or­ga­nized medicine. Although physicians w ­ ere among ­those desiring federal and state laws from the beginning, they w ­ ere not particularly active ­until ­after the AMA woke from its slumbers, reor­ga­nized, and mobilized. At the state level as well, as Edward Bok lamented in 1905, medical socie­ties had usually stood idly aside while the PAA’s lobbyists and their newspaper allies ruled the roost. But a­ fter passage of the law, according to the AMA Committee on Medical Legislation, Senator Heyburn declared that the PFDA “could not have been achieved without the power­ful and beneficent influence” of the AMA. The Journal of the American Medical Association’s account boasted flatly that the medical profession was “the strongest and most effective” force outside of Congress b­ ehind the food and drug law. In 1908, not much l­ater, Wiley seemed to agree. “The passage of the law is due to two influences,” he said, “the medical profession, the American Medical Association with 140,000 members, and the 700 w ­ omen’s clubs in the country.”25 In influencing the outcome, the Progressive Era AMA was not channeling pressure from below in the profession. Regrettably, according to the AMA journal in 1906, the country’s some 135,000 doctors had not spontaneously risen up against the drug industry or even eagerly supported the movement, even though ­there was “not a practicing physician who is not conversant with the deadly nature of some ‘patent medicines.’ ” What made the difference was aggressive leadership from the top. At the helm of the AMA’s po­liti­cal work for the drug law was the bold and dynamic Charles Reed. A glutton for work as a surgeon, scientist, educator, professional or­ga­nizer, and medical politician, Reed presided over the AMA during its reor­ga­ni­za­tion and soon chaired its brand-­new Committee on National Legislation. William  Welch, the renowned medical scientist and education reformer who ­later served as AMA president in 1910, joined Reed on the po­liti­cal strategy committee, as did William L. Rodman, who in 1915 founded the National Board of Medical Examiners and served as AMA president that year. A mea­sure of Reed’s

124

D r u g P r o b­l e m s

Surgeon Charles A. L. Reed, MD (1856–1928). AMA president in 1901–1902 during its reor­ga­ni­za­tion, Reed led the AMA’s lobbying for the 1906 Pure Food and Drugs Act. He also played a role, along with ­f uture AMA presidents William Welch, Alexander Lambert, and especially William Gorgas, in making the completion of the Panama Canal pos­si­ble by eradicating the yellow fever mosquito. Courtesy of the U.S. National Library of Medicine.

ambitions as a medical politician was a l­ater unsuccessful run for a U.S. Senate seat in 1908, which was prob­ably hampered by attacks from Ohio newspapers ­under the influence of the drug industry.26 For the purposes of advancing food and drug legislation, Reed formed and led the AMA’s National Legislative Council, composed of over fifty members from e­ very state and territory, plus the surgeons general of the army and the U.S. Public Health Ser­vice. The state medical socie­ties’ representatives on the legislative council, in turn, sponsored the formation of a much larger National Auxiliary Legislative Committee. Its fourteen hundred members chosen from the over two thousand county medical socie­ties generated letters of support for drug reform and executed other propaganda actions. With this new and impressive po­liti­cal machinery, Reed led American physicians’ most ambitious po­liti­cal proj­ect thus far in their history.27 Early in what historian James Harvey Young called “power­ful AMA lobbying efforts,” Reed generated and forwarded to Congress approximately three thousand letters from doctors and hundreds of petitions from medical socie­



Legal Remedy

125

ties across the country supporting a law. In 1905, he arranged a del­e­ga­tion of the National Legislative Council to advise and support Senator Heyburn, who was adamantly refusing to retract the expanded definition of drugs. Subsequently, Reed set in motion a survey of the nation’s county medical socie­ties, which came back unanimously for passage of a strong bill. ­Later, working with delegates of state and county medical socie­ties in the National Legislative Council and its auxiliary body of county representatives, Reed prompted laypeople, their organ­izations, and friendly newspapers across the country to send another flood of letters, resolutions, and newspaper clippings to Congress.28 While in Washington in November 1905, Reed met with President Roo­ se­velt in the White House as a member of a del­e­ga­tion representing a huge constituency of reform interests. Led by the National Consumers’ League, the group included representatives of or­ga­nized private interests like the National Organ­ization of Retail Grocers and vari­ous states’ food regulators. Of par­tic­u­lar importance ­were consumer leader Alice Lakey and regulatory reformer Allen of the National Association of Dairy and Food Commissioners. The November visit helped dislodge an official endorsement of reform from the White House, a big step t­ oward victory. A ­ fter the meeting, Roo­se­ velt fi­nally announced his support in a message to Congress in December 1905 and put pressure on Senate and House leaders Nelson Aldrich and Joseph Cannon to let bills proceed ­toward debates and votes.29 The AMA contributed to the content of the forthcoming law by backing Heyburn against Wiley and McCumber, both of whom had tactically favored appeasing the drug industry by eliminating the definition of drugs that included proprietaries. In Heyburn, who had replaced McCumber as chairman of the Senate Committee on Manufactures, the doctors had found an ally with rock-­solid convictions, a combative disposition, and bottomless energy that dismayed and sometimes exasperated his congressional colleagues. In a speech to the Senate, he eloquently blasted, “We may extend our lines as a country; we may build ­battle ships and navies and constitute ­great armies; but if the health of the ­people is to be undermined by t­ hese concoctions of fraudulent and bogus medicines, of what avail is it?” ­After his death, a fellow Idahoan reminisced about Heyburn’s hatred for “fraud, pretense, and dishonesty in ­every relation of life.” According to Wiley, Heyburn was the “bulwark around which centered the storm” for enforcing as well as passing the law.30 Heyburn’s immobility on the expanded drug definition may have cost his reform a temporary defeat, as the Wholesale Druggists’ Association believed,

126

D r u g P r o b­l e m s

for he was obstructed from bringing his bill to a Senate vote in 1905 by his party’s decidedly unprogressive majority leader, Nelson Aldrich. Aldrich, along with conservative Republicans Orville H. Platt of Connecticut and John C. Spooner of Wisconsin, had repeatedly blocked the bill from reaching the floor of the Senate for a vote, where it was likely to get a majority. But the following year, Aldrich caved to the president’s request to let a vote take place. On February 21, 1906, the day of the vote, Reed arranged on Wiley’s cue to have a letter on ­every senator’s desk attesting to the “unan­i­mous petition of the medical profession from each of over 2,000 counties” and promising the ­ ere to gratitude of over 135,000 physicians if the bill advocated by Heyburn w pass. Heyburn also had the letter read aloud on the Senate floor, ­after which the bill passed with a huge majority of sixty-­three to four.31 Still, passage in the House was far from certain. Mann of Illinois, who Wiley gave “principal credit” for the reform’s success in the House, turned the limited Hepburn bill into something much more threatening to the drug industry—­a nd therefore potentially more difficult to pass. First, it caught up to the Senate’s by incorporating the new expanded definition of drugs to include trademarked proprietaries. Then, in collaboration with Wiley and journalist Samuel Adams, Mann leapfrogged over Heyburn’s Senate bill by adding language explic­itly demanding the accurate identification of a list of dangerous and addictive contents: acetanilid, alcohol, cannabis indica, chloral hydrate, chloroform, cocaine, eucaine, heroin, morphine, and opium. Previous bills had prohibited “dangerous and deleterious” ingredients in food only; in proprietary medicines they ­were fine, ­whether mentioned or not.32 The House fi­nally passed the Hepburn-­Mann bill on June 23, 1906. According to Wiley, the final impetus was President Roo­se­velt’s May 27 message to Speaker Cannon with a handwritten comment saying, “I earnestly ­favor” passage of this bill before adjournment of the session. Cannon obliged him by allowing a vote, and the House passed the bill before a month went by with a huge bipartisan majority of 240 to 17. The Demo­crat dissenters, all ­ ere from the South, w ­ ere “state righters.” The joint Conof whom save one w ference Committee that convened shortly afterward included Heyburn and McCumber from the Senate and Hepburn and Mann from the House. It produced a bill that combined the expanded definition of drugs, requiring accuracy in their labeling statements, including those about cures, plus the House’s compulsory listing of certain dangerous drugs. The conference bill, sent back to both chambers, passed with large majorities on June 29, the last day of the session. Roo­se­velt signed it the following day.33



Legal Remedy

127

­ ecause American drugmakers now had to identify and quantify dangerB ous and addictive substances, journalist Adams thought the law dealt the proprietary drug industry “a complete knockout,” a “complete and overwhelming rout.” The Nation predicted that the nostrum industry had been dealt a “death-­ blow.” ­Because of the law, a New York Times editorial put it, “the purity and honesty of the food and medicines of the ­people are guaranteed.” Empowered by the new law, the Department of Agriculture began pursuing dozens of manufacturers for violating the new law’s requirement of truth “in all particulars.” The immediate and perhaps most noticeable change brought on by the law, according to a pharmacy journal, was “the general reform in the once prevalent extravagant claims for therapeutic properties.”34 A N A DVA NC E , A S E T B AC K , A N D A STA N D ST I L L

The AMA’s efforts through the Council on Pharmacy and Chemistry and the following year’s PFDA ­were significant starts ­toward therapeutic order. The new law jump-­started a new wave of reform attempts at the state level, this time victorious ones. The AMA assisted the states wishing to complement the federal law with regulation of intrastate commerce by compiling, in The ­Great American Fraud, six of Samuel Hopkins Adams Collier’s articles, plus Mark ­Sullivan’s article “The Patent Medicine Conspiracy against the Freedom of the Press,” which detailed how the industry flexed its financial muscles over newspapers. Joseph McCormack acquired 15,000 copies of the first batch of 17,000, which he distributed “not only to doctors, but to ­lawyers, teachers, clergymen, club ­women, and other g­ reat leaders of public opinion” in Kentucky and in the more than one dozen other states he visited to agitate for reforms. With a few improvements on the federal law, McCormack’s 1908 state law was the first to pass. In a short time, the AMA distributed at a price less than cost about 150,000 copies of the 146-­page, richly illustrated volume. Within a few years, close to half a million copies of at least five editions found their way into offices, libraries, and homes across the country.35 By 1913 virtually all states passed their own laws. But even theirs w ­ ere uphill b­ attles. McCormack, who spoke before fifteen state legislatures on the need for state action, witnessed at e­ very capital “a strong force of drug men working ­under the direction of expert lobbyists . . . ​backed by the proprietary interests.” All their expenses w ­ ere paid by the NARD. In e­ very case, the retailers’ organ­ization “systematically and often successfully” confused legislators with decoy bills with “cunningly altered” wording. Legislators ­were

128

D r u g P r o b­l e m s

Cover of a 1905 Collier’s issue featuring one of a series of articles by muckraker Samuel Hopkins Adams that were anthologized and distributed by the AMA in 1906 as The G ­ reat American Fraud. Science History Images / Alamy Stock Photo.

also “literally inundated by letters and tele­grams” from drug companies and newspapers. In Tennessee, the proprietary interests’ lobbyists badly misrepresented the bills, according to the physician who led the fight and “indulged in the most virulent abuse” against the medical profession “using the columns of the daily papers several times for the purpose.”36



Legal Remedy

129

The AMA’s po­liti­cal reach did not extend much beyond assistance to legislatures with the passage of the PFDA and state laws. Prosecutors and courts had to take over where the progressive lay-­medical alliance left off. Early on, some notable judgments went against Gowan’s Pneumonia Cure, Radam’s Microbe Killer, and Munyon’s Asthma Cure, among other false hopes for desperate ­people. One of the first and most celebrated cases was Harper’s Cuforhedake Brane Fude, a “brain tonic.” For false and misleading advertising, a jury found the wealthy Robert N. Harper guilty in 1908 and fined him the maximum but small sum of $500. That was only a pinprick for Harper, who was president of the American National Bank, the Washington, DC Chamber of Commerce, and the city’s Retail Drug Association. A newspaper reported that President Roo­se­velt had urged jailing Harper, an influential ­Virginia Demo­crat. An example needed to be made to show the ­people of the country that the law was t­here to protect them. To a man of his wealth, Roo­se­velt said, such a fine alone was “a ­little less than ridicu­lous.”37 A controversial 1911 U.S. Supreme Court decision slowed pro­gress ­toward therapeutic order. If the AMA had ­limited clout in the electoral and legislative pro­cess, it possessed virtually none in the judiciary. The court’s majority ruled in ­favor of Dr.  Johnson Remedy Com­pany, the maker of Johnson’s Mild Combination Cure for Cancer, a package deal containing Cancerine Tablets, Johnson’s Blood Purifier, and three other tablets and ointments. The com­pany claimed that Cancerine’s role was to “convert the sore from an unhealthy to a healthy condition” and that it “destroys and removes dead and unhealthy tissue.” The Blood Purifier, taken in combination with other t­ hings, “gives splendid results” treating cancer and “other malignant diseases.” Chemical analy­sis by the Department of Agriculture found that Cancerine and the Blood Purifier contained mostly sugar and alcohol with small amounts of inorganic ­matter, ash, glycerin, licorice, burdock root, and senna. The labeling slyly boasted that they ­were “Guaranteed ­under the Pure Food and Drugs Act, June 30, 1906.”38 Associate Justice Oliver Wendell Holmes Jr., speaking for the majority, tersely surmised Congress’s intent to regulate only statements about the “identity of the article, possibly including its strength, quality, and purity,” not curative claims. Congress was not “likely,” he wrote, to have wanted to regulate commerce in food and drugs in ­matters “where opinions are far apart.” Ironically, Holmes was the son of Oliver Wendell Holmes Sr., a therapeutic skeptic par excellence of his generation. In his dissent, Charles Evans Hughes disagreed with Holmes on Congress’s intent, dismissing as naive

130

D r u g P r o b­l e m s

his evenhandedness ­toward all kinds of therapeutic “opinions.” Conceding that ­there was wide disagreement in the medical profession about many ­things, Hughes insisted that “­there still remains a field in which statements as to curative properties are downright falsehoods and in no sense expressions of judgment.” In adjudicating congressional intent, neither Holmes nor Hughes consulted a­ ctual legislative deliberations, or at least did not cite them.39 To the extent curative claims came up for congressional debate, the facts about them support dissenter Hughes. Both the law’s proponents and opponents interpreted the language about false and misleading claims “in any par­tic­u­lar” as an invitation to prosecute for false claims about therapeutic effects or absence of risks to the consumer. In a 1904 Senate hearing, Heyburn held up a b­ ottle of Pepto Mangan, read out “Does not affect the teeth” from its label, and declared it “a statement as to the truth of which the purchaser is entitled to know.” He added that the bill ­under debate “provides that if that statement is untrue” it could be seized by federal authorities and subjected to ­legal action. Thereupon, PAA attorney George  L. Douglass raised the specter of litigation over therapeutic claims r­ unning amok across the country, an implicit but clear acknowledgement of the bill’s intent to silence drugmakers’ lies. Senate floor debate in 1906 confirmed that McCumber, who had first opened and then tried to close the Pandora’s box, agreed in the end with Heyburn about leaving it open despite the drug industry’s unified outcry. “I do not want,” he said, “to give authority to the manufacturer to falsely blow his goods.” Heyburn, addressing Douglass from the PAA, asked, “Can you give any reason why the bill should not protect ­people against misleading or false statements?” Regarding cures, he asked, “How can any man defend the . . . ​right of a party to tell an untruth to an unsuspecting public” about a medicine for a disease “for which ­there is no pos­si­ble—­?”  40 Heyburn was cut off by Indiana senator James A. Hemenway, who introduced a letter from his close friend Albert R. Beardsley—an Indiana politician, president of the Miles Com­pany, and a PAA official—­objecting to the Senate bill’s language for allowing attacks on drugs ­because of statements about their “curative properties.” Senate Demo­crat Hernando de Soto Money of Mississippi also made it clear that the law would allow prosecution of bogus curative claims by offering a substitute bill that contained “nothing regarding claims made in behalf of medicines telling of their merits, e­ tc.” 41 The PAA breathed a sigh of relief, taking comfort from the Holmes ruling declaring that t­ here was “no science in therapeutics.” The practice of med-



Legal Remedy

131

icine, indeed, was “based on opinion and not on definite scientific facts.” Any claim about “the curative properties of any drug, chemical or medicine, is largely a ‘­matter of opinion.’ ” By contrast, progressive medical reformers ­were appalled by the ruling, and large numbers of influential laypeople joined them in outrage. A furious President William Taft, Roo­se­velt’s successor, informed Congress that b­ ecause “­there are none so credulous as sufferers from disease” ­there was an urgent need for a law to “prevent the raising of hopes of speedy cures of serious ailments by misstatement of facts as to worthless mixtures on which the sick w ­ ill rely while their disease progresses unchecked.” 42 Then the pendulum swung back slightly in the direction of therapeutic order. The Holmes decision set in motion attempts to amend the law, including a hotly debated amendment proposed by Democratic representative William Richardson of Alabama. Richardson proposed prohibiting mention of “any remedial property,” not just in labeling but also in general advertising. Fierce industry opposition quickly put a stop to that idea. Fi­nally, in 1912, Congress passed a compromise amendment offered by Representative Joseph S. Sherley, a Kentucky Democrat, who had originally voted against the law. The Sherley Amendment prohibited only false claims that ­were also “fraudulent.” The PAA sighed in relief. Proving falsity was hard, but proving fraudulence—­a conscious intent to deceive—­was even harder. Therefore, according to the National Druggist, the amendment imposed “no hardship” and made “no unreasonable demands.” Wiley called it a “complete victory” for the drug industry.43 The government was badly but not completely disarmed by the “intent” test for fraudulence. One notorious example prosecuted u ­ nder the 1906 act and the Sherley Amendment was Eckman’s Alterative, which contained alcohol, calcium chloride, and cloves for treating tuberculosis. Its label promised it had “cured this disease again and again.” Eckman took his case to the Supreme Court to challenge the Sherley amendment on constitutional grounds. This time, in 1916, it was Justice Hughes who wrote the majority decision. In it, he quoted verbatim from his dissent in the Johnson case. For tuberculosis, Hughes said, the medical profession spoke with virtual una­nim­i­ty against the existence of a cure. Eckman had intended to deceive, for it was simply impossible for him not to know that. But afterward, Eckman simply renamed the product Eckman’s Calcerbs and claimed only that it was good for “weak lungs” and able to “lessen the risk of chronic lung trou­ble.” 44 In ensuing years, many but not all drugmakers muffled their curative claims in this manner. ­Because the 1906 law left advertising to the public completely untouched, publishers and editors who had been rejecting patent medicine advertisements

132

D r u g P r o b­l e m s

mobilized to put the force of law ­behind their private mission. John Irving Romer, publisher of Printers’ Ink, a respected weekly trade journal for major advertisers and publishers, led a crusade for state “truth in advertising” laws. In 1911 Romer published a proposal to make all false advertising a crime. ­A fter the Johnson decision in 1912, he wrote in high praise of the failed Richardson amendment to the PFDA calling for a stop to advertising of any and all therapeutic claims to the public. Opposition to that, he said, “can come only from ­those who desire to deceive.” No federal law resulted, of course, and the few states that passed truth in advertising laws found them hard to enforce. So drugmakers could still advertise and sell soothing syrups for “drugging the baby,” as Wiley put it, containing combinations of morphine, chloroform, and chloral hydrate. Babies ­were still being put to endless sleep, despite pediatrician Abraham Jacobi’s cry a half c­ entury ­earlier about the deadly toll of teething remedies.45 Perversely, the 1906 act offered the drug industry ­free advertising that made up for its ­limited labeling restrictions; demand would rise to compensate for anything Congress had done to weaken the industry. Shortly a­ fter passage the National Druggist actually rejoiced, saying it was “not such a terrible ­thing ­after all.” Frank Cheney, president of the PAA, suggested cheerfully: “­People generally ­will reason, and reason correctly, that preparations which come up to the requirements of a Congressional enactment must be all right, or, certainly, that they are not harmful or dangerous.” 46 THE UNFINISHED SEARCH FOR THER APEUTIC ORDER

Passage of a relatively strong version of food and drug legislation in 1906 was pos­si­ble ­because of the orga­nizational efforts of the newly rebuilt and vitalized AMA. With an infusion of resources from a growing membership and fervent progressive leadership, the AMA was able to achieve an unpre­ce­ dented victory. But the law, in addition to the work of the AMA’s new Council on Pharmacy and Chemistry, did not suffice to usher in a new, rational therapeutic order. In addition to weak labeling restrictions and difficulty in proving fraudulent intent, pro­gress was also stymied by complete freedom of commercial speech and therefore continuing chaos in advertising to the public. The 1906 law left false and misleading claims advertised in the general press unmolested. But the AMA’s Council on Pharmacy and Chemistry could boast of some success in taming the jungle of wild therapeutic claims, at least in the better



Legal Remedy

133

medical journals. Even advertisers in in­de­pen­dent journals began to tone down their therapeutic claims from preposterous to dubious as the professional culture evolved. Among ­those who bent ­under the pressures of change was Wallace Abbott, whose advertisements eventually complied with CPC rules. Another who changed, if only partially, was Charles Parmele, who had once advertised his Arsenauro, the colloidal suspension of gold dust in an arsenic mixture, as a cure for such diverse afflictions as diabetes, chorea, and neurasthenia. By 1914 Parmele’s advertisements for Arsenauro in in­de­pen­dent journals claimed only that it had shown itself over de­cades to be “the most assimilable form in which arsenic can be taken.” But by assimilable, which he left undefined, he suggested safe and therefore advised doctors to “push dosage to point of saturation in each individual patient.” 47 It would take more than thirty years ­after passage of the PFDA for Congress to pass another law to create and empower a Food and Drug Administration (FDA) to slow the introduction of dangerous drugs onto the market; older ones would remain. By then, in 1938, the AMA had under­gone a ­great po­liti­cal transformation, and it played only a passive role relative to lay reformers in bringing about that reform. Yet another thirty years went by before the FDA, in 1962, was legislatively authorized to limit the introduction of new drugs to the market to ­those with some demonstrable therapeutic efficacy and, ultimately, to remove existing unsafe and inefficacious ones. The ultraconservative AMA now vehemently opposed this move ­toward rational therapeutics.

This page intentionally left blank

chapter 6

Bacillus Politicus and the Diseased State

Preventive mea­sures against disease, according to Amer­i­ca’s medical pro­ ere more impor­tant than cures. gressives at the turn of the twentieth ­century, w Known cures w ­ ere as scarce and weak as diseases w ­ ere rampant and deadly, and therapeutic advances ­were slow in coming. Amer­i­ca’s superabundant commercial materia medica filled a large black bag with small hopes. William Osler of Johns Hopkins University medical school, a man with encyclopedic knowledge of diseases, knew of only a tiny number of drugs useful against a huge number of diseases. Thus, like other elites in the profession, Osler was a therapeutic pessimist. According to one of his famous aphorisms, “We put drugs, the action of which we know ­little, into bodies, the action of which we know less.”1 But Osler was a hygienic optimist, and that made him a prodigious public health missionary. He and other medical leaders of the time are not, but should be, duly remembered for their po­liti­cal activism to advance the cause of disease prevention. Likewise, the American Medical Association of the time should be, but is mostly not, remembered as an impor­tant part of the nation’s larger public health movement. It was a po­liti­cal movement led by medical statesmen and institution builders. For example, in 1896, Osler cofounded the Mary­land Public Health Association, one of the first such state organ­ izations, and delivered its first meeting’s keynote address in 1897. In it he

137

138

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

called for restructuring the state board of health to better collect vital statistics and carry out public health mea­sures, including the sanitary inspection of ­every dairy that sent milk to Baltimore, the supervision and control of the city’s w ­ ater supply, the creation of a hospital for infectious disease, and more. ­Future AMA leader William Welch, mostly known t­oday as a pioneering bacteriologist, pathologist, and institution builder in medical science and education, assumed control of the Mary­land State Board of Health in 1898 to implement the kind of reforms Osler called for and served the following three de­cades as its president. Hardly any AMA leader of his time surpassed Welch as a public health leader. Shortly ­after the AMA’s reor­ga­ni­za­tion, he served on its Committee on National Legislation, one of whose main missions was to agitate for creating a national department of health, and at least once he lobbied congressional committees on health-­ related bills. Elected for the 1910–1911 AMA presidential term, he spoke at length in his inaugural address on public health, the need for a uniform system for collecting and reporting vital statistics, and a promising bill in Congress to create a health department.2 In 1916 Welch founded the Johns Hopkins School of Hygiene and Public Health, the first such institution in the country (which he directed ­until 1926), and started a three-­year term as president of the American Social Hygiene Foundation. From the early 1920s ­until his death in 1934, he served on the U.S. Public Health Ser­vice’s Advisory Committee on the Education of Sanitarians as well as in the Health Section of the League of Nations. The mission of medical progressives such as Welch to reor­ga­nize the AMA was intended in part to empower the profession to better promote public health. In 1900, the Journal of the American Medical Association editorial saw a “striking need” to become more like the British Medical Association, which, unlike the AMA, spoke ably “for and in the name of the ­great medical profession,” especially to promote public health action, or as it was sometimes called then, “state medicine.” That year, the AMA Board of Trustees, together with AMA president Charles Reed, set in motion the AMA’s phenomenally successful reor­ga­ni­za­tion. On the board sat William L. Rodman of Kentucky and H.  L.  E. Johnson of Washington, DC, both members along with Welch of the AMA Committee on National Legislation currently agitating for a federal health agency. Thomas J. Happel, a public health activist in Tennessee since the 1890s, was another trustee and legislative committee member. Another board member was Joseph  M. Mathews, president of



B ac i l lu s P o l i t i c u s a n d t h e D i s e a s e d S tat e

139

the Kentucky State Board of Health, which was the creation of Joseph McCormack, the dynamic leader of the AMA’s reor­ga­ni­za­tion and recruitment effort.3 DISE ASED STATE

Amer­i­ca’s progressive medical reformers and reorganizers at the turn of the twentieth ­century ­were painfully aware that deadly diseases made a mockery of the “art and science” of medicine that physicians often proudly boasted about to a skeptical public. Th ­ ere was more art than science, of course, and credulous patients served as canvases for their physicians’ boundless therapeutic creativity. Like cures, clinical mea­sures of prevention, the reformers knew, ­were few and far between. Smallpox vaccination had been around for a c­ entury, ­ ere was since 1796, when Edward Jenner had introduced it in ­England. Th nothing e­ lse ­until Louis Pasteur introduced a rabies vaccine in 1884. Another thirteen years passed before an effective vaccine against typhoid fever appeared in 1897, but availability and distribution to highly vulnerable populations remained problematic for a good while. Only soldiers could count on its benefits, when starting in 1909, the entire U.S. Army was immunized thanks to a military establishment u ­ nder the influence of public health missionaries like the pioneering bacteriologist and army surgeon general George M. Sternberg. Also exceedingly rare ­were clinical cures for killer and even lesser diseases despite recent scientific advances in physiology, pathology, and bacteriology. What worked, though often not very well, was mostly ancient. Mercury, in use since the 1400s, was still utilized for constipation, syphilis, and much more. The cure was often worse than the disease. Some vermifuges used for worm infestations w ­ ere of ancient provenance. Th ­ ere was colchicine, a treatment for gout, which appeared in the Pharmacopoeia Londinensis of 1618 but had already been in use centuries e­ arlier. Quinine, from cinchona bark, a treatment but no sure cure for malaria, came into use in the 1600s. A ­ fter centuries, according to Osler in 1896, cinchona was still “the only specific which we have in the fevers, to the action of which the pharmacopoeia offers no parallel.” 4 Digitalis, a toxic substance from foxglove, had been in use since the 1700s to treat “dropsy,” or edema caused by congestive heart failure, and cardiac arrhythmias. A not uncommon side effect was death. During the 1800s, about all that was added in the way of effective drugs was emetine, an extract of ipecac root for amoebic dysentery—­and it could cause heart failure.

140

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

Thus, except for malaria and syphilis, infectious killers met ­little medicinal opposition ­until the approach of the twentieth ­century. The bacteriological revolution of the 1880s led to a diphtheria antitoxin, which was commercially introduced in the 1890s but far from widely available to the average doctor and, especially, poor patients. Primitive serum treatment of some pneumonias appeared around the same time but for de­cades would remain inefficient and out of reach for most doctors and their patients. Laboratory tests w ­ ere required to identify which specific types of pneumonia were at work. The dif­fer­ ent serums ­were expensive to produce and complicated to administer. Treatment was labor-­and skill-­intensive and therefore based in hospitals with good staff, proper facilities, and access to supplies. In the 1910s, arsphenamine, the first big chemotherapeutic advance from scientific laboratory and clinical investigation, shouldered aside mercury as an improved but still imperfect and complicated treatment for syphilis. Meanwhile, ­there was nothing to beat back other big killers: tuberculosis, yellow fever, typhoid fever, cholera, and many other infectious scourges of the American landscape, especially in poor and crowded urban districts. The country poor suffered disproportionately from other debilitating and deadly parasitic, bacterial, and deficiency diseases like uncinariasis (hookworm disease), trachoma, Rocky Mountain spotted fever, and pellagra. Therapeutic artistry was still no match for deadly typhoid fever, from Salmonella typhi, of which ­there ­were about 350,000 cases and 35,000 deaths in 1900. Its fevered, delirious victims sometimes suffered intestinal hemorrhage and perforation and a resulting septicemia, as well as deadly inflammation of the brain, heart, gallbladder, and bones. Sometimes doctors assisted the bacterial disease, not its victims, by treating its symptoms with opioids. ­Because of their constipating effect, they could obstruct evacuation of the bacteria and even facilitate their invasion of the bloodstream through intestinal perforations. In 1900, typhoid deaths in the nation’s capital w ­ ere inordinately high b­ ecause of the polluted Potomac River. London had installed the first of many sand filtration systems in Eu­rope in 1829; Washington, DC, had to wait for the same u ­ ntil 1905. During that long wait, the fever brought down many of the city’s inhabitants, from the poor and h ­ umble to the high and mighty. President William Henry Harrison prob­ably died from it in 1841, not pneumonia as commonly believed, and it possibly came in the White House ­water supply. The ­water passed through a putrid marsh only a few blocks upstream, a depository for the city’s “night soil”—­that is, h ­ uman excrement, hauled ­there each day. Subsequent White



B ac i l lu s P o l i t i c u s a n d t h e D i s e a s e d S tat e

141

House occupants Henry K. Polk and Zachary Taylor possibly died for the same reason.5 George Kober, a prominent professor of medicine, public health reformer, president of the District of Columbia medical society, and one of the key figures ­behind the belated filtration of Potomac ­water, told a White House Conference of Governors that not a single large American city between 1902 and 1906 had a lower death rate from typhoid fever than Munich, Vienna, Berlin, Zu­rich, Hamburg, Paris, and London. Typhoid deaths in Columbus, Ohio, and Pittsburgh, Pennsylvania, w ­ ere roughly seven and twelve times ­those of Hamburg and Paris, which, like other Eu­ro­pean cities and only a few smaller American ones, had installed filtration systems. The United States lagged stupidly b­ ehind, according to Osler, for the incidence of typhoid fever, he thought, “is an unfailing index of the sanitary intelligence of a community.” 6 Comparing home and abroad, sanitarians like Kober saw profound disorder in the nation’s po­liti­cal class for its unwillingness to beat back disease at the harbors, rivers, and other inroads. They observed that ­after po­liti­cal economists like Britain’s Jeremy Bentham and his disciple Edwin Chadwick called for national governmental institutions for preventing disease, Eu­ro­pean leaders like Benjamin Disraeli and William Gladstone in Britain, Otto von Bismarck in Germany, and Léon Gambetta in Italy soon established what Amer­i­ca still lacked: a national department of health. B ­ ecause of state medicine, according to Irving Fisher, Amer­i­ca’s foremost economist but best known at the time as a missionary for private and public prevention, the life expectancy of citizens in the German state of Prus­sia had increased by twenty-­seven years since the late 1800s. Mas­sa­chu­setts, by contrast, despite having one of the best existing state health departments, had only done half as well.7 Economist Fisher’s medical friends thought their profession shared the blame with politicians for shirking the civilizing work they w ­ ere supposed to do. On the ­whole, rank-­a nd-­fi le doctors lacked interest in a solution—­ sometimes b­ ecause more disease brought more money. In his 1880 presidential address to the American Public Health Association (APHA), the sanitarian John Shaw Billings advised against appointing a regular clinician as chief of a municipal health board ­because “he can hardly avoid the distrust and dislike of his fellow-­physicians if he does his duty” and could not be counted on to act against the interests of wealthy patients who owned and financed polluting industries. Charles Reed, the AMA’s crusader for the 1906 Pure Food and Drugs Act, pointed out that one of the effects of a filtration plant installed

142

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

in a major city “was to deprive one doctor alone of $3,000 of typhoid fever cases in one year.” A 1909 Medical Standard editorial lamented that “the g­ reat rank and file of the medical profession—­and some of its officers too—­are in a state of panic similar to that which possessed the working man at the invention of machinery” out of fear that “the onward march of preventive and state medicine w ­ ill gradually put them out of business.” Therefore, Joseph McCormack spoke not for the rank and file but for reform elites like Billings and Reed when he submitted to a congressional committee in 1910 the AMA’s view that b­ ecause of doctors’ advocacy of a federal health department, theirs was “prob­ably the only vocation which has for years consistently and per­sis­ tently advocated legislation looking to its own elimination.”8 MEDICAL LICENSURE AS A FIRST STEP

The AMA’s progressive reformers came of professional age during the dramatic rise of a nationwide public health movement starting in the late 1860s at state and national levels. The confluence of medical reform and public health action they witnessed early in their medical c­ areers, and sometimes participated in as young reformers, began in the 1870s, partly with the creation of a few badly funded state departments of health. Interestingly, the movement overlapped in personnel and purpose with another movement to introduce “medical practice acts,” or licensing laws, in the same states. Indeed, from the beginning, medical licensing was on the early public health movement’s agenda, and b­ ecause of that, the movement shares enormous responsibility for a wave of licensure laws that resulted. This is a fact almost entirely ignored in the medical history lit­er­a­ture, which misleadingly focuses too much attention on regular physicians’ desire to reduce the supply of competitors.9 Back in 1876, physician Stephen Smith, founder and first president of the APHA, blamed poor standards in the country’s medical profession for the fact that American public health authorities, in international comparison, stood “on the very lowest plane.” The coexistence of bad doctors and abysmal sanitary administration was no coincidence. The relations ­were “so intimate that it is impossible for one to advance without a corresponding advance of the other.” Reaching back to ancient Rome, he noted that its control of medical practice followed a long era of medical anarchy and appalling death rates from disease. Licensing coincided in time and purpose with the introduction of the city’s aqueducts for bringing pure ­water from afar and improving sewerage, public baths, and road drainage. “In the pro­gress of time,” he said, “it became



B ac i l lu s P o l i t i c u s a n d t h e D i s e a s e d S tat e

143

apparent that t­ here was a vital relation existing between the public health ser­ vice and the qualifications of ­those who practiced the medical art.”10 Before the 1870s, licensing laws ­were non­ex­is­tent, having been repealed or rendered defunct for lack of enforcement in the vari­ous states. Colonial and Revolutionary-­era medical practice acts had fallen victim to the pop­u­ lism of the Jacksonian era, which battled elitism and privilege in medicine, as well as in other aspects of politics and commerce. But starting around 1870, seventeen of the thirty-­eight existing states had passed licensing laws by 1878. The profession’s motives for licensing laws included, of course, a desire to raise the profession’s economic and social status by restricting entry into practice to better qualified individuals. Th ­ ere was also a sincere paternalistic drive to, as Osler put it, protect p ­ eople from “the depredations of ignorant gradu­ates and quacks.”11 Most discussions of the licensing movement identify e­ ither Osler’s high-­ minded paternalistic argument or a more selfish desire on the part of common prac­ti­tion­ers to reduce the supply of physicians, or both. Practically unnoticed in the historical lit­er­a­ture, however, is the impor­tant connection that progressive medical reformers like Smith saw between licensure and public health. In 1878, AMA president Tobias G. Richardson, a member of the APHA, complained that a pitifully small number of ­those who called themselves doctors, even ­those with medical degrees, had received any instruction in public hygiene. Doctors, according to Richardson, should be “teachers of the laws of health” and that was essential, he thought, according to a memorial ­after his death, ­because “the hope of true pro­gress in State Medicine lies in the education of the ­people.” In his essay “The Doctor’s Duty to the State,” written while serving as president of the elite American Acad­emy of Medicine, Philadelphia’s John Roberts declared that the greatest benefit of good licensure laws was “the protection of the public health from ignorant physicians.” A doctor should be a teacher, the Latin meaning of the title, and instruct the laity on physical hygiene. The Detroit Medical Society’s president C. J. Lundy likewise called for stringent licensing to restrict entry to prac­ti­ tion­ers trained for “instruction of our citizens regarding the importance of sanitary mea­sures, and the best means of limiting the spread of contagious disease.”12 Reformers also saw a crucial link between licensure and public health in the need for accurate health statistics. Th ­ ere was a woefully unmet need to track and then investigate the origins and spread of infectious diseases as a prerequisite to taking effective preventive action against them. According to

144

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

Charles F. Folsom, the progressive secretary of the Mas­sa­chu­setts Board of Health and a strong proponent of a licensing law in 1877, doctors should be able to diagnose typhoid fever accurately and should cite it as the cause of death instead of its dangerous sequelae (intestinal hemorrhage and pneumonia, for example), as they often did. He complained that even if well educated, they w ­ ere often negligent in filling out death certificates and sometimes failed to report even if asked. The reports of many less-­educated ones ­were laughable. A sample of in­ter­est­ing c­ auses Folsom cited in a report included “artry lung bursted,” “billirm feever,” “canker on brain,” “direars,” “dropsy,” “fitts,” “infermation lungs,” “inward spasm,” “lung fever,” “stopage,” “troubled in the brain,” and “worm fever.” Sometimes babies perished from “teething,” and one baby even fell in b­ attle against “infancy.” An educated doctor informed him that in ­every town in the state, “we have some irregular and incompetent prac­ti­tion­ers of medicine, whose diagnoses would be of doubtful accuracy and not to be relied on for scientific conclusions.” Another complained that the death reports of often grossly ignorant “empirics” ­were granted credibility equal to t­ hose of educated physicians. Thus, Folsom concluded, some system or law regulating the practice of medicine was needed, such as “­legal restrictions upon irregular and incompetent physicians.” Without a diploma from a “responsible medical college,” a person claiming to be a doctor should not have the privilege of signing death certificates.13 So ­great was the need for good vital statistics that in 1882, the AMA’s Section on State Medicine surveyed ­every state to find out which had boards of health that collected them. The yield was disappointing ­because efforts ­were just getting off the ground, and often barely. Iowa’s first medical practice act, passed in 1880, explic­itly required licensed physicians to rec­ord deaths and births and certify the cause of death to county authorities and called for fining them if they failed to do so. In Tennessee, medical leaders ­were still pushing in 1890 for laws to improve both vital statistics and medical licensing. In 1895, an editorial in the Case Western Medical Journal condemned the city of Cleveland’s vital statistics as “absolutely worthless” and for that blamed Ohio’s delay in requiring demonstration of competence in a licensing exam. Experienced undertakers ­there, he said, w ­ ere just as qualified as many doctors to diagnose the ­causes of deaths. Ohio medical leaders considered rigorous exams necessary to “safeguard public interests” because those who passed would be better able to accurately report disease.14 The character and ­careers of key figures ­behind state medical practice acts tell of the often intimate connection between interrelated progressive public



B ac i l lu s P o l i t i c u s a n d t h e D i s e a s e d S tat e

145

health, licensure, and medical organ­izing agendas. The nation’s cadre of licensing reformers markedly overlapped with state and national medical organizers and public health missionaries. At that intersection was Kentucky’s McCormack, who in 1879, at the age of thirty-­t wo, instigated the creation of the Kentucky State Board of Health; three years l­ater he was elected president of the Kentucky Medical Society and, as its most dynamic leader, turned it into the model for the constituent state socie­ties of the AMA, whose reor­ ga­ni­za­tion he ­later led. In 1889, he was fi­nally able to persuade the state legislature to pass a licensing law whose administration was to be conducted by his health board. B ­ ecause of the Kentucky legislature’s miserliness, he was not able to bring an adequately funded and or­ga­nized bureau of vital statistics into being u ­ ntil 1910. In Illinois, the major mover ­behind a licensing law passed in 1877 was a ­giant among the nation’s public health reformers, John Henry Rauch. Tellingly, Rauch’s licensing law of 1877 followed, by only one day, the passage of a companion act he also authored that created the Illinois State Board of Health. AMA founder Nathan Davis, now practicing in Illinois, helped Rauch lobby for them. The board of health was charged with the task of regulating physicians as well as issuing and enforcing sanitary regulations and public quarantines. The board also supervised a new bureau of vital statistics. Earlier in his ­career, Rauch had helped or­ga­nize a board of health for the city of Chicago to produce reports on the sanitary history of the city, drainage, pollution of the Chicago River, need for public parks, and more. The beginnings of the city’s drainage, ­water supply, and park systems (Lincoln Park, for example) and many public works are attributed to his exertions. Gaining stature beyond Illinois, Rauch joined nine other original organizers of the APHA in 1872 and served as its first trea­surer. He became its president three years ­later. That year he also served on the U.S. Interior Department’s Sanitary Committee for the Centennial Commission. In the 1870s he also served on the AMA’s section on State Medicine and Public Hygiene, along with Henry Ingersoll Bowditch, John Shaw Billings, and Agrippa Nelson Bell.15 Alabama’s Jerome Cochran, celebrated as a “yellow fever fighter” and “­father of Alabama public health,” was the progressive force ­behind his state’s medical practice act passed in 1877. He was also, like McCormack, a medical or­ga­nizer and the decisive actor in creating the Medical Society of the State of Alabama. Since his medical school days, Cochran had been interested in disease prevention. In early 1866, he began publishing on malaria, yellow fever, and other epidemic diseases that commercial shippers brought into his

146

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

a­ dopted town of Mobile, Alabama, on the coast of the Gulf of Mexico. In 1871, while serving as professor of chemistry in the Medical College of Alabama and ­later as a professor of public hygiene, Cochran drew up an ordinance a­ dopted by the city of Mobile to create a board of health, which he then ran as its first health officer. For his expertise on and exertions for public health above city and state levels, Cochran was nationally recognized. Only two years ­after passage of the 1877 licensing law, he was appointed a member of the National Yellow Fever Commission, having been nominated for the spot by the APHA. Two years a­ fter passing a bill authored by Cochran establishing the state’s board of health, the Alabama legislature passed a medical practice act, again authored by Cochran. Cochran’s board was also charged with collecting vital statistics, a key concern of his. In 1882, he lamented that vital statistics w ­ ere, despite the law, still not being collected in most counties “with a sufficient completeness to make them of any real value.” For that he chastised county medical socie­ties, acting in their statutory capacity as local boards of health, for being “culpably negligent of their duty.”16 In West ­Virginia it was James Edmund Reeves who, like Rauch, sought the simultaneous establishment of licensing and the creation of a public health agency to administer it. His law passed in 1882. Reeves, yet another progressive medical or­ga­nizer, had founded the Medical Society of West ­Virginia in 1867 to elevate the practice of medicine on scientific grounds and thereby to “render quackery odious.” Like other medical leaders across the states, he saw the new society as a platform to promote medical training that included basic scientific as well as clinically relevant knowledge of anatomy, physiology, chemistry, materia medica, pathology, and more. But to judge from Reeves’s own c­ areer, therapeutics and medical education ­were not his primary concerns. Instead it was public health, for which he was to achieve fame in his state and well beyond. In 1868, early in his c­ areer, Reeves persuaded the Wheeling City Council to establish a health department and hire him to run it. As the city health officer, the progressive-­minded physician developed a concern for the health consequences of industrialization and therefore called for what ­today is known as occupational medicine, or the prevention and treatment of work-­related disease and injury. L ­ ater, as an active member of the APHA from its founding in 1872, Reeves was elected its president in 1885. In 1887 he served as vice president of the section of Public and International Hygiene of the International Medical Congress.17 Reeves celebrated his 1882 success in passing a law creating a public health agency to administer the licensing of doctors with the publication of a lengthy



B ac i l lu s P o l i t i c u s a n d t h e D i s e a s e d S tat e

147

article in the newly created Journal of the American Medical Association. In it he expressed pride in West ­Virginia’s law regulating the practice of medicine and surgery. “Nothing, I am sure, could work more smoothly and consistently with the interest of the public health than its execution as a part of the duties of the Board.” Saying “public health is public wealth,” he praised fellow “progressive minds” in the medical profession for establishing state boards of health in twenty-­eight other states and thereby saving “thousands of lives and hundreds of thousands of dollars.” In his presidential address to the APHA in 1885, Reeves joined Rauch and many other reformers in calling for the creation of a “permanent and well supported national health bureau,” without which it would be “impossible to bring sanitation in this country up to the level of its rapid advancement in Eu­rope.”18 One also finds in California and Texas a connection between public health and licensure in the person of the movers who championed both. In California, the key mover b­ ehind its 1876 medical practice act was reformer Thomas Muldrop Logan, whose 1874 presidential address to the AMA on state medicine identified him as one of the many progressive medical politicians across the country. Like McCormack and many other elite physicians, the future epidemiologist had sought additional training in Paris not long after graduating from medical school in South Carolina in 1828. His 1851 study of “medical topography,” or local environmental influences on disease, had been noted favorably by the AMA’s Standing Committee on Medical Lit­er­a­ture. The AMA’s Transactions ­later published his reports on state medicine, public hygiene, and epidemics in California. So animated by the subject was he that he “voluntarily and without compensation” investigated outbreaks of communicable disease, relying on data from physicians throughout California whom he recruited as correspondents.19 In 1870 Logan cofounded the California State Medical Society and served as its leader. The following year, he helped persuade the state legislature to enact a bill creating a board of health, which he headed as permanent secretary. He then published extensively on malaria, tuberculosis, and other infectious diseases, ventilation of public school rooms, and, in general, the “salubrity of public institutions.” He also wrote extensively on the need for a national department of health. His stint as AMA president in 1873 and 1874, during which time he helped draft California’s medical practice act, followed national recognition of his public health work. The fact that he was chosen for that high honor spoke clearly of progressivism’s wide reach in the profession.20

148

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

The main mover in Texas b­ ehind its 1876 medical practice act was the president of the Texas State Medical Association, Robert Henry Harrison Sr. Harrison’s medical expertise and activism, displayed in publications from 1873 to 1876, mostly concerned local epidemics and efforts to create a state board of health. Around 1875, roughly the same time the state passed its medical practice act, Harrison submitted a bill to the legislature providing for the establishment of a board of health and vital statistics. It passed the lower chamber but died in the upper. In the ensuing fifteen years, he continued the strug­gle to improve the licensing law and to bring a state board of health into existence. Fi­nally, in 1900, Harrison prevailed with a bill establishing a state board of health, which was tasked with, among other ­things, the collection of vital statistics.21 SYSTEMIC CHAOS

Licensing, of course, was only one leg upon which public health could walk. An institutional infrastructure of public health authorities, built from the city and county level up to the national level and coordinated in their policies and activities, was a g­ rand ambition of the early medical progressives well before the AMA’s reor­ga­ni­za­tion. The frustrating strug­gles of state leaders operating at the intersection of local and national medical politics could fill volumes. Kentucky’s McCormack experienced firsthand the maddening “parsimony and incapacity” of town and county officials like ­those responsible in 1898 for a decision not to impose an effective quarantine during a deadly smallpox outbreak in a Kentucky town. It necessitated his forceful and unpop­u­lar intervention with a quarantine and compulsory vaccinations, which required police help to deal with the mayhem they triggered. In Reed’s Ohio, the State Medical Society helped frame a law calling for a competent and adequately paid deputy state health officer in e­ very county in the state with the power to appoint assistants in each city, village, and township. But they ran up against opponents armed with constitutional princi­ples protecting local democracy (and therefore local medico-­political hacks), “so the mea­ sure was dropped.”22 State public health reformers battled against varying degrees of ignorance, stinginess, corruption, electoral reversals, bureaucratic inertia, and interagency rivalries, thus experiencing only an uneven patchwork of pro­gress and sometimes retrograde motion. In 1878, only two years ­after an optimistic address to the International Medical Congress in Philadelphia in which he heralded



B ac i l lu s P o l i t i c u s a n d t h e D i s e a s e d S tat e

149

the arrival of a new “epoch of state preventive medicine,” Boston’s Henry Ingersoll Bowditch resigned his position as chairman of his state’s new board of health when the Mas­sa­chu­setts legislature passed an “obnoxious law” bringing about a “grotesque” merger of his agency with two o­ thers: the Board of Lunacy and the Board of Charity. Justified as an economic move, it was a legislative slap in the face for his investigations of ­water pollution and his lobbying for passage of the state’s Act Relative to the Pollution of Rivers, Streams, and Ponds. The law had actually exempted from its pollution controls the Merrimack and Concord Rivers, which flowed through the city of Lowell, where the power­ful textile industry was concentrated, but that concession failed to weaken manufacturers’ backlash. The new, combined board, Bowditch said, “fell into the hands of self-­seeking cap­i­tal­ists who ­were afraid of the millstreams being cleaned from the pollutions poured into them by the mills owned by evil cap­i­tal­ists.”23 The demo­cratic pro­cess did not bring largesse in protection of voters’ health ­because raising taxes to pay for expensive public health mea­sures was not a good way to get votes. In 1873, the Florida legislature turned down a bill creating a state board of health b­ ecause the $200 appropriation asked for was “exorbitant.” It was not ­until around 1913 that North Carolina hired full-­time county health officers. U ­ ntil 1914, despite James Reeves’s efforts, West ­Virginia legislators gave the state board of health only $2,500 to spend, about fifteen cents per capita, to cover licensing operations as well as public health. Not surprisingly, like twenty-­t wo other states, West ­Virginia lacked the resources to collect mortality statistics of a quality required for inclusion in the U.S. Bureau of the Census’s registry.24 The abysmal state of public health administration in 1900 can easily be ­imagined in light of an AMA survey conducted a good fifteen years l­ater, by which time t­ hings had improved considerably. In it, Rhode Island public health expert Charles V. Chapin reported that a large majority of states ­were still failing to provide all or even most of the following: supervision of local health officers, notification of tuberculosis and other communicable diseases, diagnostic laboratories with the capacity to test blood and stool samples to identify ­t hose diseases, distribution of sera and vaccines, education of the public and especially new ­mothers about proper hygiene, and adequate local ­water and sewage control. Chapin’s conclusion was that “by far the greatest hindrance to pro­gress is the terrible incubus of politics.” State health officers across the country had no better qualification for the job than having been “helpful to the po­liti­cal party which was successful at the last election.”

150

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

Further, politicians ordered their underfunded and over­burdened state bureaus around, commissioning irrational proj­ects to “make a place for a friend.” Even if a good person in a “politics-­ridden” state happened to get chosen and proved “deaf to the spoilsman,” the punishment could be swift. “He ­will be hampered in his work and he ­will lose his place on the first po­ liti­cal upheaval.” Not surprisingly, many qualified ­people ­were therefore disinclined to pursue public health as a ­career.25 While rural areas did l­ittle, some cities took the initiative in enacting reforms in advance of state action. But by the end of the 1870s, ­there ­were still only thirty-­t wo full-­time health boards in 226 major cities. Even where they existed, they ­were hampered by tight-­fisted legislatures, po­liti­cal hacks appointed or elected on a one-­year basis instead of a stable corps of experts, lack of authority to pass and enforce regulations, infrequent and haphazard inspections, and no registries of vital statistics. Many boards failed even to hold meetings u ­ ntil smallpox, scarlet fever, measles, whooping cough, cholera, and other emergencies ­were already upon them, by which time the opportunity for preventive action was lost. In many of the large cities, according to Eugene Foster, chairman of the APHA’s Committee on Vaccination, ­there was “a system of sanitary police in operation which would be discreditable to a heathen; no system of sewerage or drainage; potable ­water secured from wells fearfully polluted with ­human excreta.”26 The New York City Department of Health was a healthy node in a degenerate body politic, a model of considerable probity and efficiency for the rest of the country in the years to come. It enjoyed the confidence of outstanding medical and public health leaders and enlisted their unpaid ser­vices as con­sul­tants on a medical advisory board. Among them w ­ ere Abraham Jacobi, the venerated pediatrician and f­uture AMA president; T. Mitchell Prudden, the nationally prominent bacteriologist, pathologist, and ­later director of the Rocke­fel­ler Institute for Medical Research; Edward G. Janeway; and APHA founder Stephen Smith. A peculiar set of political, social, and economic circumstances during the American Civil War made New York the exception. Shocked by the 1863 Draft Riots against conscription, during which vicious and murderous attacks on black residents took place, a nonpartisan Citizens’ Association of New York formed to pursue vari­ous “purposes of public usefulness,” including public health. Among its members w ­ ere John Jacob Astor, August Belmont, James Brown, Hamilton Fish, Morris Ketchum, and Robert B. Roo­se­velt, all from the uppermost echelons of New York finance, industry, real estate, politics,



B ac i l lu s P o l i t i c u s a n d t h e D i s e a s e d S tat e

151

and society. Theodore Roo­se­velt’s ­uncle, Demo­crat Robert Roo­se­velt, an opponent of his party’s Tammany Hall faction, edited the reform association’s organ, the New York Citizen, to agitate for po­liti­cal as well as public hygiene. Most impor­tant for his untiring energies and lavish expenditures on its proj­ects was Peter Cooper, the phenomenally successful inventor, manufacturer, real estate developer, telecommunications founder (of American Telegraph), insurance executive, philanthropist, and founder of Cooper Union for the Advancement of Science and Art. A Unitarian, he had been active in the antislavery movement and in the lay-­professional New York Sanitary Association and l­ater ran in 1876 as the presidential candidate of the proto-­populist Greenback Party.27 One of the Citizens’ Association’s first acts was to create a Council of Hygiene and Public Health. It included physician and pioneer statistician Elisha Harris, who had helped or­ga­nize the U.S. Sanitary Commission during the Civil War, a relief agency to support sick and wounded soldiers run by Frederick Law Olmsted. APHA founder Stephen Smith led the Citizens’ Association’s effective lobbying efforts. The council’s main task was hiring and supervising a large team of mostly young physicians, many employed by charity dispensaries, to undertake a huge, meticulous, and therefore unpre­ ce­dented investigation of health conditions all across the city. The essence of a massive report of seventeen volumes was compressed into a single volume, The Sanitary Condition of the City, published in 1865. The report brimmed over with horrible details about ­things once hidden from the general public in dark slums, tenement h ­ ouses, and cellars. Readers learned, for example, that the population density in the worst district of the city (192,000 per square mile) was greater than in any Eu­ro­pean city, even East London (176,000). ­There w ­ ere statistics, disease by disease, district by district, accompanied by scorching commentary. About smallpox, the report stated that it was of such epidemic proportions that the council’s sanitary inspectors found fifteen hundred cases in only a few days. It was “an ignoble commentary upon the sanitary neglect and defective intelligence in administration that have rendered such an outbreak of that loathsome malady pos­ si­ble.” The report ended with recommendations about drainage, ventilation, creation of a medical inspectorate and sanitary police force, and collection and study of vital statistics.28 Above all t­ here was a need for good “sanitary government” in the hands of an “enlightened” board of health able to “wisely administer sanitary regulations and laws.” In 1866, the alliance of money men, philanthropists, physicians, and Republicans fi­nally prevailed in the state capital against the

152

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

re­sis­tance of Demo­cratic Party Boss William M. Tweed—­who held a Senate seat—­and his machine cronies, who w ­ ere strongly represented in the legislature. In testimony the year before, they had brought a physician from the Tammany-­controlled city inspector’s department to testify against empowering a municipal health agency by ridiculing the notion that filth could be a cause of disease. Much of the press, especially the conservative Republicans’ New York Times, sided against the law. But even the radical Republicans’ Daily Tribune supported it, despite editor Horace Greeley’s fear that it would strengthen his factional rival. Also of timely assistance was alarm about a cholera pandemic in 1865. The New York Times gloomily predicted in October that its likely spread would not be met with preventive action ­because of po­ liti­cal “logrolling” in Albany. “The masses who w ­ ill suffer the most fearfully are led by their politicians—­men utterly indifferent to anything, except as it brings them power and place.”29 But the Times was proven wrong, in large part ­because of the strong showing of Republicans in the fall elections of 1865. The law creating a municipal board of health passed in February 1866 was drafted for the Citizens’ Association by Stephen Smith and l­awyer Dorman B. Eaton, a fervent e­ nemy of Tammany Hall and all it stood for and l­ater a prominent civil ser­vice reformer and member of the first U.S. Civil Ser­vice Commission from 1873 to 1875. Smith testified at the state legislature in Albany and drew on the details of the council’s report to justify calling the city’s existing sanitary authority a “gigantic imposture.” A key ele­ment of the 1866 Act to Create a Metropolitan Sanitary District and Board of Health Therein for the Preservation of Life and Health and to Prevent the Spread of Disease gave the new agency impressively wide quasi-­legislative sovereignty over health affairs and equally extraordinary in­de­pen­dence from the city’s popularly elected government. Critically, the law handed the state governor direct control over nominations to four of the commission seats on the board—­three of which had to be physicians—­and, in effect, indirect control over o­ thers, including members of the Metropolitan Board of Police from vari­ous boroughs.30 Nevertheless, the city health board had to fight off infection with what Fiorello LaGuardia, a l­ater reform mayor, called the Bacillus politicus. (During his 1930s mayoralty, LaGuardia congratulated the board for keeping f­ ree of the germ of corruption.) An ominous sign, reformers thought, was the appointment in 1889 of Charles G. Wilson, a power­ful and well-­connected corporate l­ awyer and financier to the presidency of the board. Not a notable public health activist, Wilson was the founder and president of the Consolidated



B ac i l lu s P o l i t i c u s a n d t h e D i s e a s e d S tat e

153

Stock and Petroleum Exchange. Smith complained that by appointing Wilson, the politicians had ­violated the original agreement setting up the Medical Advisory Board. It had said that “politics was to be absolutely avoided in order that the best professional ser­vice could be fearlessly rendered to the city.” In 1892 Wilson fired sanitary superintendent William Ewing, a physician who had served long and credibly since the 1870s, and replaced him with a Tammany man, the son of former Demo­cratic mayor Franklin Edson. According to Jacobi, the hire was a “subversion” of the department, threatening to turn it into “a refuge for po­liti­cal place hunters.” Prudden thought the pre­ce­dent could bring “the flotsam and jetsam of the po­liti­cal ocean, from which too often strange, uncouth t­hings are stranded in offices where malfeasance may mean death to some, disease to many.” Other irregularities crept back with the hiring of lower-level workers from Tammany’s shallow talent pool. Recoiling from the tentacles the Tammany Hall faction was trying to wrap around the health board, its eminent medical con­sul­tants resigned in a sensational collective act of protest praised by the New York Times as well as the Journal of the American Medical Association and other medical journals.31 Some large cities in the United States followed New York City in creating their own health boards, but many of ­those ­were weak advisory bodies with none of the resources and authority of New York City’s—or protection from po­liti­cal infestation. From below they pressured state politicians to create strong and authoritative state health agencies better insulated from local politics. By the end of the 1870s, a majority of the states had acted. But New York State was slow to follow its vanguard city, waiting u ­ ntil 1880 to create a state board in Albany. Lay-­professional co­ali­tions like ­those in New York City worked for their establishment, with cap­i­tal­ists, philanthropists, publishers, and politicians of both partisan stripes often aligning with progressive po­liti­ cal and medical reformers. In Mas­sa­chu­setts, for example, which was the first state to establish a board in 1869, Senator Thomas F. Plunkett, a major champion of Henry Bowditch’s Mas­sa­chu­setts Board of Health, was a power­ful Demo­cratic Party boss, manufacturer, insurance executive, railroad builder, and more. It helped, no doubt, that Plunkett’s wife, Harriette, was a fervent and active public health champion.32 FEDER A L OR DER A BORTED: 1879–1884

Progressive medicine’s state leaders such as McCormack, Rauch, Cochran, and Reeves all advocated federal as well as state action for public health and

154

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

for that a strong, well-­funded agency. The action called for by the national vanguard was necessary b­ ecause what one locality did or did not do could affect ­others downstream in ­water and upstream in boats across state lines. The “chaotic” and “kaleidoscopic” spectacle of public health disorder included spasms of irrationality and excess in the imposing of quarantines by one community against another’s outgoing commerce. Ensuing resentment resulted in the latter’s failing to report or flat-­out lying about disease outbreaks. For example, the presence of yellow fever in Louisiana would sometimes be withheld from public knowledge ­until ­a fter a visit from health officials in the neighboring state of Mississippi. Of course, according to John S. Fulton, Mary­land’s top health official and president of the Conference of State Boards of Health of North Amer­i­ca, “Alabama officials, on occasion, do the same courtesy for Mississippi, and Louisiana officials for Texas.”33 “The first priority of southern boards of health had never been the saving of lives but the saving of business,” according to Margaret Humphreys’s history of yellow fever in the South. Many business ­people did not believe it was in their immediate interest to spend money on prevention; the idea that public health was public wealth did not enter into their calculus. Commercial greed, po­liti­cal opportunism, localism, and short termism ­were not confined to the South. When the City of Chicago, in a massive and pioneering feat of civil engineering, reversed the Chicago River in 1900 to divert its copious waste, ­human excrement, and other pollutants—­including from its huge meatpacking plants—­from Lake Michigan’s shoreline ­waters into the Illinois and Mississippi Rivers, American citizens downriver in the neighboring state of Missouri, feared greater risks of typhoid, cholera, and dysentery in their own ­water supply. B ­ ecause no federal agency was empowered to intervene, St. Louis pinned its hopes on the authority of the U.S. Supreme Court to ­settle the ­matter. Six years of Chicago’s filth flowed through Illinois t­oward Missouri before the court de­cided to leave ­things be, concluding that Chicago’s ­water was sufficiently purified or diluted by the time it crossed the border into St. Louis. True or not, it would have been ­little comfort to Illinoisans along the way, who had to try to defend themselves in their own state’s po­liti­cally tainted court system.34 John Shaw Billings, a towering figure in the medical reform politics of the era, headed the first attempt to create a strong national health authority. Billings is known to medical historians for many appreciable ­t hings: developing a system of vital statistics; founding Index Medicus, a periodical for efficient dissemination of medical science; establishing what is now the National



B ac i l lu s P o l i t i c u s a n d t h e D i s e a s e d S tat e

155

Library of Medicine; and designing a hospital and recruiting faculty, including the legendary Osler and Welch, for the country’s flagship medical school at Johns Hopkins University. At the U.S. Bureau of the Census, Billings introduced punch card technology from the textile industry for storage and pro­cessing of medical and demographic data, the basis of ­later computer data pro­cessing. The new tabulating machine’s first use anywhere in the world occurred while Billings served as supervisor for the U.S. Census of 1890. ­These ­were all parts of his mission to create what Billings’s biographer Carleton Chaplain calls “a vast infrastructure” of medical knowledge creation and dissemination to bring “order out of chaos.”35 Less known are Billings’s exertions in creating and ­running a short-­lived National Board of Health (NBH), which was created in 1879. Powerfully working in his f­ avor was public clamor for national action during a particularly bad yellow fever epidemic spreading in 1878 from Southern ports into the nation’s interior. Around one hundred thousand w ­ ere infected in the entire Mississippi Valley, and about twenty thousand died. Memphis, Tennessee, was savaged. ­There, the hemorrhagic fever sickened more than seventeen thousand and killed over five thousand. Around twenty-­five thousand, more ­ ere turned away than half of the population, fled the city, and many of them w 36 at gunpoint from places they sought refuge in. Carried—it was learned only ­later—by mosquitoes, the acute phase of the dangerous viral disease brought several days of headaches and muscle aches, nausea, vomiting, sensitivity to light, and dizziness. Around 15 ­percent of sufferers entered a dangerous toxic phase of recurring fever, abdominal pain, and bleeding (hence black vomit); bleeding from the nose, mouth, and eyes; liver damage (hence jaundice and the name “yellow fever”); delirium; seizures; and coma. The toxic phase was fatal in up to 50 ­percent of cases, making the overall fatality rate for the disease up to 7  ­percent, although in some vulnerable populations fatality could be much higher. The public outcry jolted Congress into action. Some legislators had received threats of vio­lence if they returned to their districts without ­doing something.37 Hence, they created the NBH to assume federal leadership in a range of public health activities but first to coordinate action against the current onslaught of yellow fever. Drafted largely by Billings, the legislation created a collegial board structure and an executive committee in order to enlist top public health experts to deliberate and execute policy. Personnel included public health pioneers such as the APHA’s Smith and John Rauch, the public health and licensing leader in Illinois. O ­ thers ­were drawn from the

156

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

army, the navy, the Department of Justice, and the U.S. Marine Hospital Ser­vice, all of them repositories of significant public health expertise. Harvard pulmonologist Henry Bowditch, the founder of the Mas­sa­chu­ setts health board, served as vice president. As a young man from a blue blood Boston ­family, Bowditch brought back a strain of therapeutic pessimism from medical study in Eu­rope in the early 1830s. Like other privileged medical elites of the time, he studied with Pierre Louis in Paris, the founder of “the numerical method,” or what is known t­ oday variously as clinical epidemiology or “evidence-­based medicine.” With rec­ords of bloodletting and subsequent outcomes, Louis proved, more or less, that bloodletting was of no curative value. Out of his Eu­ ro­ pean education came Bowditch’s therapeutic skepticism—­but also optimism about the possibilities of ­future clinical research. He also returned with an abiding hygienic optimism. His interest in clinically intractable diseases in turn motivated his focus on prevention through empirically justified public health mea­sures. Among them was the drainage of swampy land in residential areas—an impor­tant cause, he believed his research showed, of tuberculosis. In 1876, Bowditch trumpeted the ascendance of “state preventive medicine” to an international medical congress in Philadelphia, and a new epoch “in which the medical profession is aided by the laity” to achieve g­ reat feats in defeating disease.38 Bowditch’s national health mission stemmed from an exceptional humanitarianism. As a young man influenced by William Wilberforce’s abolitionist writings, Bowditch sank ­great energies into attacking what he called “that monster slavery.” In 1841 he walked arm in arm—to icy glares—­with escaped slave and f­ uture friend Frederick Douglass. In 1889, Douglass reminisced to Bowditch that he had been “the friend who first gave me shelter and a place at your board when I began my antislavery ­career . . . ​in Boston.” A member of the abolitionist Boston Vigilance Committee, Bowditch was an operative of the Under­ground Railroad for spiriting escaped slaves to freedom, among them Ellen and William Craft. In 1854 Bowditch helped form and lead the Anti-­Man-­Hunting League—­a secret network of 469 members who abducted slave hunters in order to spring their captives. He succeeded in getting Mas­ sa­chu­setts General Hospital to admit black patients. Embracing ­these c­ auses proved costly in clinical business as well as social regard. Calling himself “a de­cided ­woman’s rights man,” Bowditch tried but failed to persuade Harvard Medical School to admit ­women. His embrace of ­these ­causes cost him a loss of income from clinical practice and esteem among fellow social elites.39



B ac i l lu s P o l i t i c u s a n d t h e D i s e a s e d S tat e

157

The 1879 act transferred over to Billings’s and Bowditch’s National Board of Health all quarantine responsibilities previously ­housed in the U.S. Marine Hospital Ser­vice (MHS). It had been created at Alexander Hamilton’s behest in 1798 and which had gradually taken on certain public health–­related activities, especially quarantines. Congress also empowered the NBH to “obtain information on all ­matters affecting the public health” for its use in crafting legislation. Thus, the bureau commenced right away to “secure a uniform nomenclature of disease, and a uniform system of tabulating mortality statistics” to fulfill Billings’s ambition, declared as president of the APHA in 1880, to generate “a reliable registration of births, marriages, and deaths, and the publication of the results . . . ​in such a form that they can be readily compared with ­those of other States.” In ser­vice of public health information, Billings spent over $500,000 of the NBH’s bud­get to get biomedical research off the ground. The NBH disbursed $34,000 of its total bud­get, including a research del­e­ga­tion led by George Sternberg, the founder of American bacteriology, to Cuba to study yellow fever in its perennial habitat. Out of ­these funds came also the first federal grants for medical research ever channeled into colleges and universities.40 Billings also widely distributed some NBH funds in the hope that they would serve as a “power­ful stimulus” to the creation and improvement of well-­qualified state and city boards of health, the building blocks of a nationwide system for disease prevention. It was the first federal “grants-­in-­aid” program to induce states and localities to carry out a national mission that could not be forced on them b­ ecause of constitutional restrictions on federal authority. With this and its research agenda, the NBH was to fulfill the ambitious state building proj­ect written into the APHA’s two main missions: first, the advancement of sanitary science and second, the promotion of organ­ izations and mea­sures for the practical application of public hygiene.41 But within five years, despite huge energies Billings mustered in its defense, a formidable alliance of bureaucrats, states’ righters, and commercial interests put an end to the NBH. Congress starved the agency of funds and weakened instead of augmented its authority. Criticism from enemies in Congress, bureaucratic rivalries, and furious states’ rights opponents of an enlarged federal government battered the NBH within inches of death. ­A fter popu­lar fears had subsided with the tailing off of the yellow fever epidemic, it was left by Congress to wither on the vine. The shriveled remnant was fi­nally abolished in 1893.

158

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

Helping to starve the NBH of life support ­were officials and allies of the MHS. It was a classic tale of fierce, vitriolic, and even slanderous po­liti­cal warfare. Almost instantly ­after the creation of the NBH, Billings had come to blows with the MHS, first with John M. Woodworth, who died in 1879, and then Woodworth’s handpicked successor, John B. Hamilton. At the root of the conflict was a clash of visions as well as personal ambitions. While Billings had an expansive one, Woodworth’s had been ­limited to beefing up the funding and authority of the MHS for not much more than greater federal quarantine authority. Billings called for collegial leadership by major public health leaders across the country, while Hamilton had sought personal executive control as the typical head of a federal agency. That was anathema to the Billings and Bowditch faction, who had come to consider Woodworth as narrow and power hungry, having observed his be­hav­ior in APHA affairs.42 ­A fter Woodworth’s death, his successor took up the cudgels against the NBH with a vengeance. Hamilton tirelessly lobbied congressional committees to undermine the fledgling agency. He arranged for allies to smear it with charges of wasteful extravagance and corrupt patronage and contracting practices. The U.S. Navy’s medical inspector, an NBH member, raged about having to deal with Hamilton’s “hounds.” “What apes the opponents . . . ​ are!” confided an infuriated Bowditch to Billings. Large commercial centers in Northern climes relatively immune to yellow fever supplied some of Hamilton’s most impor­tant business allies. Their “extreme jealousy,” to use NBH president James L. Cabell’s words, regarding “all quarantine restrictions on commerce,” led them to prefer local agencies deriving their authority “from the consent of a local constituency, and subject to its control.” For his war against the NBH, Hamilton also rounded up allies from the phar­ma­ceu­ti­ cal industry who ­were alarmed about Billings’s ambition to engage the NBH in drug reform. According to Billings, Hamilton schemed to “get the druggists and large drug importers alarmed lest their business may be interfered with.” Hamilton had “an agent in most of the large cities” to mobilize opposition from ­those quarters. Billings hoped—in vain, it turned out—­t hat exposure of Hamilton’s “petty and malicious” motives would help discredit him. But he was up against the mightiest federal bureaucracy of all, the U.S. Department of the Trea­sury. It was, according to Cabell, among the “hostile agencies combined to overthrow the National Board of Health.” The Trea­ sury Department had many friends in Congress and friends of ­those friends in vari­ous groups, including the military, competing for the ­limited and declining federal revenue.43



B ac i l lu s P o l i t i c u s a n d t h e D i s e a s e d S tat e

159

­ ecause of the formidable co­a li­tion of forces against him, an exasperated B Billings resigned in 1882 a­ fter numerous failures to gain incremental funding and authority from Congress. By 1884 the unfunded federal agency survived in name only. While enemies of the NBH found allies in Congress ­eager to deny it funds and authority, Billings and com­pany found few willing to defend their cause. Cabell believed that ­because the board had been selected from experts “without regard to party affiliations” and could dispense “no po­ liti­cal patronage,” ­there was simply “no hearty support from politicians of ­either of the ­great parties of the country.” Hamilton’s targets lacked the “public relations sense” he used to such a ­great effect against them, according to one historical account. According to another, Billings and his allies ­were “good sanitarians but poor politicians.” 44 DEMOCR ACY AND DISEASE

Amer­i­ca’s progressive medical reformers and organizers knew well that achieving medical order through legislative means in a disordered polity would not be easy. Chaos and corruption w ­ ere harsh, unforgiving terrains for their forces. ­A fter visits to the United States in 1883 and 1884, the British jurist, historian, diplomat, and Liberal Party politician Lord James Bryce observed in his astute po­liti­cal study, The American Commonwealth, that its chaotic constitutional structure created “an excessive friction . . . ​a waste of force in the strife of vari­ous bodies and persons created to check and balance one another.” “Power is so much subdivided that it is hard at a given moment to concentrate it for prompt and effective action.” Although he was pre­sent at the time, Bryce did not mention the fierce bureaucratic and legislative attacks on the authority, resources, and survival of the NBH, but they may have helped inform his judgment. Also, the public clamor for action during the 1878 yellow fever emergency that had given rise to the ill-­fated NBH illustrated well his conclusion that only when a strong majority of the ­people ­were “so clearly of one mind” would politicians have no choice but to act decisively.45 John Shaw Billings had similarly bleak views of American demo­cratic institutions b­ ecause, according to a biographer, he feared that as soon as the yellow fever emergency passed, the NBH “would find itself without the support of an educated public opinion, and upon such opinion alone, ­under our form of government, can such an organ­ization securely rest.” By “our form of government,” Billings no doubt meant the same institutional complexities and

160

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

opportunities for obstruction and corruption that Bryce meticulously described. For example, he said, “Conflict with local authorities as to the States rights princi­ple” restricted the NBH’s authority to conduct quarantines. Strangely, indeed, the opposition came from some medical men allying with businessmen or politicians jealously guarding against interference with “local self-­government.”  46 Bryce was also a keen observer and trenchant reporter on po­liti­cal corruption in Amer­i­ca and its baneful effects. Billings, as well, declared corruption in the strug­gle over votes from a mass electorate to be a source of his own po­liti­cal travails. In 1890, he cited Cornell University president Andrew D. White’s observation that demo­cratically elected city governments in the United States ­were “the worst in Christendom—­the most expensive, the most inefficient, and the most corrupt.” Consequences of this “vilest corruption” included filthy streets and bad sewers. White had served as ambassador to Germany from 1879 to 1881, where democracy had made ­little headway, but the autocratic monarchy had brought improvements in the public’s health. The majority of voters, Billings thought, did not use their demo­cratic power “to secure well-­paved, sewered, and lighted streets.” In fact, he thought many in the white male electorate ignorantly “suppose that their interests are rather opposed to ­these t­ hings.” 47 The medical progressives at the dawn of the twentieth c­ entury agreed with Billings about the poor functioning of American democracy. Among the civic as well as medical reformers in the AMA was George Simmons, its most power­ful functionary. Working as a newspaper editor in the 1870s to earn his undergraduate tuition at the University of Nebraska, Simmons led “an attack,” according to his successor as AMA editor, “to take the government of Nebraska out of the hands of the machine politicians,” thereby earning himself a commendation from the state’s Chamber of Commerce. Maxwell Foshay, who served along with Simmons on the AMA’s reor­ga­ni­za­tion committee, was another civic as well as all-­around medical reformer. In 1895, Foshay represented doctors on a Cleveland Joint Committee on Public Sanitation along with the city’s Chamber of Commerce and Civic Federation to pressure its politicians to deal with garbage, sewage, and w ­ ater supply ­hazards. In 1899, as editor of the Cleveland Medical Journal, Foshay published editorials on his city’s “moral disease” and “civic diseases” and in 1899 proudly announced the formation of a Physicians’ Municipal League whose “declaration of princi­ ples,” signed by 250 doctors, included a commitment “to promote the election of competent persons to office in the city government, and to secure the



B ac i l lu s P o l i t i c u s a n d t h e D i s e a s e d S tat e

161

appointment to subordinate positions of ­those of like qualifications.” The end purpose was to bring about “clean, honest, broadminded and businesslike administration of municipal affairs, regardless of the pretended interests of parties, factions, cliques or individuals.” 48 Another eminent municipal reformer in the reor­ga­nized AMA was Henry Favill, a member of civic groups like the Municipal Voters’ League, the City Club of Chicago and the Chicago Tuberculosis Institute, both of which he presided over for a time, and a committee of Chicago progressives for reform of Illinois politics chaired by the young Harold Ickes in 1910. Ickes would go on to become one of President Franklin Roo­se­velt’s key lieutenants in the 1930s. At the time of his death in 1916, Favill was a member of the city’s Public Efficiency Bureau. One of his main public health missions was to reduce injury and disease in industrial employment, which he pursued as a member of the American Association for ­Labor Legislation (AALL). On the AALL agenda ­were, among other ­things, the prohibition of the deadly poison white phosphorous used in the manufacturing of matches and injury compensation and guaranteed sick pay and health care for industrial workers. Favill was memorialized by the AMA journal as “a man of strong personality, a friend of sterling quality, a modern St. Michael in fighting the dragons of inefficiency, corruption and wrong.” 49 Another municipal civic reformer among the progressive medical elite was Philadelphia surgeon John Roberts. Around 1908, Roberts would serve on the AMA’s Committee on Legislation, a main purpose of which was to resurrect something like Billings’s NBH. In the 1880s Roberts had been a member of the Union League of Philadelphia and Municipal League of Philadelphia, as well as the National Civil Ser­vice Reform League. In the 1890s he served as president of the Philadelphia County Medical Society. In a collection of essays published by the AMA called The Doctor’s Duty to the State, Roberts told of a Philadelphia mayor who dismissed reports of typhoid fever from a part of the city, insisting that it was “only” enteric fever (another name for typhoid fever). The fervent civil ser­vice reformer personally experienced the long arm of po­liti­cal corruption reaching out from the nation’s capital from Pennsylvania’s Senator Matthew Quay, the preeminently corrupt and power­f ul state party boss of the late nineteenth ­century who, as a po­liti­cal “kingmaker,” managed Benjamin Harrison’s successful campaign for the U.S. presidency in 1888. As a municipal election overseer, Roberts witnessed infractions of the law so frequent and flagrant, and “the folly” of elections so outrageous, that “I have almost been converted to a belief

162

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

in the superiority of an absolute monarchy over our republican form of government.”50 Of course, what progressive civic as well as medical reformers such as Roberts had in mind as the best cure for the Bacillus politicus americanus was not a return to monarchy but what Chicago’s Henry Favill called ­running the city on a “business basis.” Like lay municipal reformers, Favill advocated for the appointment of expertly qualified, nonpartisan officials guided by civil ser­ vice and other procedural rules to inoculate them against po­liti­cal interference. Without institutional reforms, elected politicians ­were ­free and even compelled by competition over votes to use the bureaucracies ­under them to deliver jobs, dispense ­favors, and other­wise put po­liti­cal gains before health. Likewise, in 1902, William Osler lambasted a Baltimore mayor for the city’s public health prob­lems ­because of endemic corruption. The autocracy required for a well-­run business would be superior, he thought. “Give us a ­couple or three good men and true” who could run the city “as a business corporation,” he said, and “it would not take us a year, then, Mr. Mayor, not a year, to get a start on a sewerage system and an infectious disease hospital, and every­ thing ­else that the public welfare demands.” Osler thought that Washington, DC, by contrast, was better, as exemplified by its early installation of a ­water filtration system for the Potomac River ­water supply. It was an exception ­because its residents ­were “taxed without direct repre­sen­ta­tion,” governed as they w ­ ere by three commissioners chosen by the White House.51 MEDIC A L STATESM A NSHIP A ND L AY ALLIANCES

As public health missionaries, Amer­i­ca’s medical reformers at the turn of the twentieth ­century faced a formidable alliance of dread diseases and electoral politicians who betrayed their duty to protect citizens against them. According to ­future AMA president Abraham Jacobi, therefore, medicine was an inherently po­liti­cal profession. As the founder and first president of the American Pediatric Society, Jacobi closed his 1889 inaugural address with the assertion that the doctor was “by destiny . . . ​a citizen of a commonwealth” with many special “rights and responsibilities.” The physician’s scientific expertise about the sources and transmission of disease “enable him to strike at ­ ere inits root by advising aid and remedies.” AMA progressives like Jacobi w spired by and some, such as William Welch, even trained by Germany’s Rudolf Carl Virchow, a bold medical statesman as well as a pioneering biomedical



B ac i l lu s P o l i t i c u s a n d t h e D i s e a s e d S tat e

163

scientist. In Germany, Jacobi had been exposed as a young medical student and po­liti­cal revolutionary to Virchow’s ideas and quoted them in his MD master’s thesis. Virchow held that his profession had a joint social and clinical mission that was preventive as well as therapeutic. Medicine “as a social science, as the science of h ­ umans” had a duty to set a nation’s goals for social, intellectual, and physical health and si­mul­ta­neously “attempt to establish scientifically how to realize them.”52 Regrettably, Jacobi and his fellow progressives found that in Amer­i­ca, their social scientific advice received more scorn from politicians and governmental authorities than it did in less demo­cratized and corrupt Eu­ro­pean countries. Therefore, they welcomed incremental, second-­best solutions when they offered themselves: public health actions by private allies, including wealthy cap­i­tal­ists and civic groups that w ­ ere inspired by medical progressives. Exceptionally, the part of the federal government least penetrated by patronage and corruption—­the U.S. Army—­a lso threw its weight against disease and its transmission with critical help from the AMA. Together, the medical progressives and their lay allies for public health would go on to score some notable successes.

chapter 7

Cattlemen, Commanders, Capitalists, and Crusaders

In 1912, founder of American pediatrics Abraham Jacobi lamented in his American Medical Association presidential address that “in our country, it is calves that are looked ­after by our government. The babies have no votes yet. They ­will wait.” So would their unenfranchised ­mothers, many of them progressive activists in public health affairs, just as they had been for drug reform. As dean of American medicine William H. Welch put it a few years e­ arlier, if a tenth of what the government spent controlling hog cholera and other diseases of animals could be spent on research and action on ­human diseases, “we should not stand where we are, a by-­word for the nations of the earth ­because of our ignorance and indifference in t­ hese vital m ­ atters.” Indeed, at the turn of the twentieth ­century, American farm animals ­were privileged with protection from disease by a federal government health agency in the Department of Agriculture. Its purpose was to conduct research on diseases specific to farm animals and act swiftly against their spread. At the time Jacobi and Welch spoke, the department’s Bureau of Animal Industry (BAI) had investigated and acted against blackleg, foot-­and-­mouth disease, glanders, swamp fever, Texas fever, and many other exotic-­sounding diseases most Americans had never heard of, much less suffered from.1 Thus, it is no surprise that in 1902, Welch and other members of the AMA’s Committee on National Legislation or­ga­nized a conference of about a dozen

164



C a t t l e m e n , C o m m a n d e r s , C a p­i­t a l­i s t s , C r u s a d e r s 165

other state, city, and port authority health officers, along with the surgeon general of the U.S. Marine Hospital Ser­vice, to deliberate on the best feasible design for a national public health department. The plan was then to lobby Congress for the creation of a strong federal bureaucracy for h ­ uman disease research and prevention of a kind that had long been a fixture in Eu­ro­pean governments. Two de­cades years ­after the creation of the BAI in 1884, Welch expressed the hope that, fi­nally, “our national legislators would take as much interest in the study of ­human diseases as they had already manifested in the study of animal diseases.”2 Such hopes had risen and fallen before since the demise of John Shaw Billings’s National Board of Health in 1884. They had been rekindled by President Grover Cleveland’s 1894 missive to the U.S. Congress, which conveyed his conviction “that we ­ought not to be longer without a National board of health or National health officer charged with no other duties than such as pertain to the protection of our country from the invasion of pestilence and disease.” One of the benefits Cleveland foresaw would be Amer­i­ca’s elevated standing and influence in international cooperation to fight disease. The Journal of the American Medical Association reported with gratification that Cleveland “would lose no time in approving an act establishing a Department ­ ere soon dashed. Farm animals of Public Health.”3 But the reformers’ hopes w would, at least in one regard, be better off for years to come. C AT TLE MEN V ER SUS BOV INE PNEUMONI A

Compared to farmers and their organ­izations over the years, progressive ­ ere po­liti­cally weak. medical leaders at the turn of the twentieth c­ entury w ­Because agriculture was such a huge part of the economy, farmers had more votes and money. They w ­ ere better or­ga­nized than the fractious physicians. For many, farming, not industry, was the cultural essence of Amer­i­ca, and farmers ­were rarely objects of contempt and distrust, unlike industrialists and doctors alike. Thus, even as Congress was cutting life support to the National Board of Health (NBH) in 1884 it brought into being the BAI. Housed in the U.S. Department of Agriculture, it was to become a highly effective and valued agency. A ­ fter its creation, the BAI was able in short order to build an impressive apparatus for researching the c­ auses, prevention, and treatment of farm animal diseases and for taking well-­informed inspection, vaccination, and quarantine mea­sures to control their spread.

166

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

Like the NBH, the BAI resulted in part from international forces that jolted a balky, inherently conservative po­liti­cal system into progressive action. The NBH had come into being ­because yellow fever was being shipped in from foreign ports. By contrast, disease moving in the opposite direction gave rise to the BAI. Reports of diseased animals caused G ­ reat Britain to begin limiting the importation of c­ attle and sheep from Amer­i­ca in 1879. Fearing imported bovine pleuropneumonia and foot-­and-­mouth disease, Germany followed in 1880 with its own ban on American ­cattle. In 1879, Hungary, Italy, and Portugal began turning away U.S. pork products ­because of trichinosis and hog cholera. In the next four years, Germany, Spain, France, Austria, and Denmark followed with their own pork bans. Evidence of American culpability was not always clear, but Eu­ro­pean livestock interests gladly spread anecdotes of imported disease to inspire fear and disgust among their own customers and po­liti­cal representatives. The resulting meat boycotts helped goad Congress into passing legislation for “the suppression and extirpation of . . . ​contagious diseases among domestic animals.” ­Because expensive animals had to be killed before they could be sold as livestock or meat, the BAI was given another preventive task: scientific research about how to prevent animal diseases in the first place. As its name indicated, any improvements the BAI brought to ­humans with healthier meat or less interspecies transmission of disease w ­ ere secondary aims. David  E. Salmon, the eminent Cornell-­educated veterinary scientist who led the forces for creating it and then served as its head, promoted its research mission by emphasizing the millions of dollars farmers lost ­because of preventable disease. With that motivation, therefore, cattlemen across the country helped herd their congressmen, both Demo­cratic and Republican, ­behind the BAI’s creation in 1884. The livestock interests of the Midwest, the Northeast, and Oregon ­were especially ­eager. The Midwesterners, for example, worried about the transmission of bovine pleuropneumonia from ­cattle sent to them from the East for fattening and breeding. The secretary of agriculture, with President Chester A. Arthur’s backing, helped prod the cattlemen to pressure Congress. ­Later, the same interests called for increasing the BAI’s appropriations.4 To be sure, the livestock industry was divided. Southerners objected to the BAI ­because cattlemen to the North and West wanted to stop the summertime movement of their ­cattle out of the South in order to check the seasonal spread of Texas fever into their stocks. They claimed that the Constitution protected them from such federal encroachments on states’ rights. Also, ­because the fever was not yet proven to be caused by a tick-­borne protozoan,



C a t t l e m e n , C o m m a n d e r s , C a p­i­t a l­i s t s , C r u s a d e r s 167

the Southerners argued that quarantining asymptomatic ­cattle had no defensible grounds. Livestock traders also roundly protested creating the BAI, with the just-­formed Chicago Livestock Exchange prosecuting their cause. Despite overlapping interests with the traders, some heavy-­duty support for reform surfaced from the “Big Three” companies that had captured the lion’s share of the canned meat trade, most notably Chicago’s huge Armour and Com­pany. It had recently expanded its exports of canned products, especially to armies and navies stationed in tropical lands. But most meatpackers ­were hostile ­because diseased carcasses brought more revenue as meat and ­little as fertilizer if condemned. Thus, the Chicago Board of Trade, the livestock traders, and the city’s meatpackers preferred trade retaliation against boycotting countries instead of federal regulation.5 ­Because of ­these divisions, the law would not face easy passage. The majority in the House of Representatives was not overwhelming: 155 to 127 for the BAI. But afterward, the new bureau eventually settled into a well-­funded and largely uncontroversial existence. Progressive physicians and politicians, of course, noted the hy­poc­risy of states’ righters objecting to federal action to prevent h ­ uman disease while welcoming the Department of Agriculture’s impressive exertions on behalf of food crops and animals. Except in the realm of meat inspection, the BAI was able over time to gain greater authority and resources from Congress for armies of veterinarians as inspectors, quarantine officials, and researchers on the grounds that they also protected ­humans from diseases such as tuberculosis and actinomycosis (“lumpy jaw”). Indeed, in 1890, BAI scientists discovered the nontyphoidal Salmonella enterica bacterium, named ­after Salmon, the BAI’s dynamic institution builder, which sickens both animals and ­humans. It was a serendipitous finding from research into hog cholera. In 1902, and in the following two years, the BAI investigated and acted against such animal diseases as anthrax, bacterial dysentery, blackleg, hog cholera, epizootic lymphangitis, foot-­and-­mouth disease, gid, glanders, infectious ophthalmia, milk sickness, necrobacillosis, lip-­ and-­ leg ulceration, mange, pseudo-­leukemia, roundworms, sand burn, sarcomatosis, swamp fever, telangiectasis of the liver, and Texas fever. Though many farmers ­were ideologically hostile to a strong central government, they now welcomed federal production and distribution of f­ ree vaccines, just as they had welcomed federal regulation of arbitrary and discriminatory railroad shipping rates. By 1900 the BAI’s Pathological Division was manufacturing and distributing over a million doses of vaccine for blackleg in sheep and ­cattle, a usually fatal

168

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

bacterial disease. By 1910, the BAI employed almost nine hundred veterinary scientists and other experts and spent over $1 million a year on the prevention of animal diseases that almost exclusively killed animals or rendered them unfit for sale.6 AN AR MY VERSUS MOSQUITOES

The creation of the BAI was a slap in the face to public health progressives, coming as it did as the NBH lay on its deathbed. Yellow fever was not an animal disease, so in 1884, well ­after the 1878 epidemic had passed, Amer­ i­ca’s ­battle against it came to a standstill. Winters in the South w ­ ere cold enough to bring an end to localized summertime invasions of the often-­fatal viral hemorrhagic disease, and multiyear hiatuses took the heat off politicians. Meanwhile, medical reformers lacked the organ­ization and prestige they needed to overcome the po­liti­cal inertia working against a revival of something like the NBH. It was the U.S. Army, operating mostly above the partisan, interest group, and bureaucratic fray, that fi­nally put substantial resources into the ­battle against yellow fever. Its mission against the awful disease was at best only remotely related to humanitarian concerns. Instead, fueling the enterprise was the strategic, imperialist drive of American statesmen and military officers to prosecute the nation’s claim to hemispheric domination. Standing in the way of that was the incon­ve­nient fact that the Aedes aegypti mosquito carry­ing the bacillus feasted on the U.S. Army’s soldiers and civilian workers abroad. The invasion of Cuba that started the Spanish-­A merican war of 1898 also set its ­battle against the yellow fever mosquito in motion. Endemic pestilence had weakened the Spanish military against the Americans, but now yellow fever, typhoid, and malaria switched sides. Consequently, the army surgeon general and pioneer bacteriologist George M. Sternberg sent the now-­legendary physician and educator Walter Reed, a former student of William Welch at Johns Hopkins, to study typhoid fever, the most rampant scourge of American encampments. In Cuba, Major Reed was assisted by Victor C. Vaughan, another pioneering bacteriologist and f­ uture AMA president, who jointly discovered that asymptomatic individuals could be carriers and spreaders of typhoid fever in the incubation phase, not just while symptomatic. A fervent public health missionary, Vaughan helped Reed write their study of military camps during the Spanish-­A merican War, which announced typhoid fever’s transmissibility by asymptomatic car-



C a t t l e m e n , C o m m a n d e r s , C a p­i­t a l­i s t s , C r u s a d e r s 169

riers. Thus, they recommended new and more intensive screening and other preventive mea­sures to save soldiers’ lives.7 Walter Reed’s typhoid findings justified sending him back to Cuba in 1900 as head of the U.S. Army Yellow Fever Commission to resume the NBH’s abandoned research. In Havana, one of the worst yellow fever launching sites in the world, Reed made another celebrated contribution to public health with his experimental proof of Cuban physician Carlos Finlay’s theory that Aedes aegypti was the villain in the piece. But Reed’s findings did not automatically put to rest the popu­lar view that “fomites” emanating from filth and squalor caused yellow fever. It took another remarkable army doctor, Major ­ atter. William Crawford Gorgas of the Army Medical Corps, to s­ ettle the m In charge of a Cuban yellow fever camp, the AMA president-­to-be for its 1909–1910 term resolved to conduct a massive test of the mosquito theory. Though still one of the doubters, Gorgas or­ga­nized a systematic drive in 1901 to deprive the mosquitoes of Havana of the ­water they needed to breed. Gorgas enjoyed the resources and power of military command to force large numbers of ­people ­under him, military and civilian, despite their even greater skepticism, to carry out the dirty and labor-­intensive drainage and ­water supply proj­ects, screening of cisterns and win­dows, fumigation, isolation of victims, and more. Granting him that power was Leonard Wood, the military governor of the island, who fully appreciated the scientific grounds for carry­ing out Gorgas’s experiment. Wood was also a doctor, the personal physician of Presidents Grover Cleveland and William McKinley through 1898. With Wood’s authority b­ ehind him, Gorgas brought the number of yellow fever cases down in a single year from fourteen hundred to fewer than forty. In 1902 ­there ­were no more. Deaths from malaria also dropped from 325 in 1900 to 77 in 1902 b­ ecause of a decline in its own vector, another species of mosquito.8 News that Gorgas confirmed what Finlay had theorized and Reed had demonstrated traveled quickly back to the United States. One early convert was the president of the New Orleans City Board of Health, Quitman Kohnke, a fervent sanitarian. In 1901, soon a­ fter Gorgas’s results w ­ ere published, Kohnke began to advocate antimosquito mea­sures in New Orleans, yellow fever’s main port of entry. But lacking the authority and resources of an occupying U.S. Army, Kohnke was met with ridicule and obstruction from local doubters and footdraggers who w ­ ere ill-­disposed to pay in money and incon­ve­nience for the fumigation, drainage, sewerage, and other mea­sures required to keep mosquitoes at bay. Even many if not most New Orleans physicians, although not

170

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

t­ hose in the Orleans County Medical Society, backed up the laymen who ridiculed the mosquito theory. Kohnke learned that “it is a far cry from the discovery of a scientific truth to its general ac­cep­tance by a community,” so the hardest of work was still ahead—­“the instruction of the ignorant and the removal of prejudice against the new doctrine.”9 The same kind of ignorance that thwarted Kohnke in New Orleans infused the politics si­mul­ta­neously surrounding U.S. efforts to construct a canal across the Panamanian isthmus and fight yellow fever in order to make it pos­si­ble. Starting in 1904, the canal proj­ect was essential to President Theodore Roo­se­velt’s designs to expand the reach of American military and commercial might. With it, the U.S. Navy could speedily and eco­nom­ically move from the Atlantic to the Pacific Oceans to h ­ andle far-­flung crises and seize distant opportunities as they arose around the globe. And, of course, becoming a global superpower meant huge opportunities for American industry, commerce, and finance.10 Panama was the gravesite of many thousands of yellow fever victims sent by France to build a canal ­there before it gave up in 1894. Mosquitoes, in alliance with hugely daunting engineering prob­lems, had thwarted France’s own canal aspirations for more than a dozen years. French taxpayers w ­ ere left with nothing to show for the expenditure of three times what was spent on their nation’s successful Suez Canal proj­ect, and even worse, over ten thousand French citizens died—­about one of e­ very three who had worked on the canal—­mostly from yellow fever. The total death toll, including non-­French, had been possibly as high as twenty-­four thousand and included every­one from common laborers to engineers and man­ag­ers, not to mention medical personnel. Now, in 1904, Americans ­were learning, as had the French, that “yellow jack” caused ­labor unrest and desertions, not just low productivity and sick days. According to one of the American canal proj­ect’s chief engineers, visits from this “angel of death” aroused the “diseased imagination” of workers, thus sapping their morale and energies. General “hysteria” led to delays, unanticipated costs, and “chaos and confusion.”11 It was to become clear in a short time that the seven members of the Isthmian Canal Commission, created by an act of Congress, w ­ ere unequal to their huge and complex task. Congress had diffused authority and accountability across the collegial body, rejecting Roo­se­velt’s recommendation of a strict hierarchy with a single chief executive in control. Congress required that five of the seven had to be engineers, and the po­liti­cal favorites that power­ful Congressmen prevailed on Roo­se­velt to appoint had no experience



C a t t l e m e n , C o m m a n d e r s , C a p­i­t a l­i s t s , C r u s a d e r s 171

with similar large proj­ects in hostile terrains and climates. The other two ­were high military officers, neither of whom had absorbed the lessons from the Spanish-­A merican War, when far more soldiers died from germs than bullets. The need for at least one medical man on the commission was not recognized, although the New York Acad­emy of Medicine had insisted on it in 1903. The AMA journal warned that a “lasting disgrace” from a “terrible loss of life” would be the result if a physician ­were not “in full and complete charge.”12 The newly reor­ga­nized and energized AMA stepped in to render assistance. In 1903, a del­e­ga­tion of representatives led by William Welch in his capacity as a leading member of the AMA’s Committee on National Legislation was joined by o­ thers of the New York Acad­emy of Medicine, the Philadelphia College of Physicians, and other medical organ­izations to persuade President Roo­se­velt to put Gorgas, the hero of the yellow fever war in Cuba, at the head of the Panama commission’s medical work. About two thousand local AMA representatives w ­ ere asked to contact their legislators on the ­matter that December. Then the AMA’s 1904 Annual Conference on National Legislation mobilized legislative activists in the association’s state units to wire President Roo­se­velt requesting him to appoint Gorgas to the Canal Commission. Fourteen hundred tele­grams arrived at the White House within forty-­eight hours.13 The request came too late, Roo­se­velt claimed, for he had just named the commission members the day before. Sensibly, however, the lay-­only canal commission appointed Gorgas as “sanitary supervisor”—­but only ­because of Welch’s vigorous intervention. The acclaimed dean of American medicine, he had persuaded Roo­se­velt to insist that the commission consult him about whom to choose. However, Gorgas was not put “in full and complete charge,” as the AMA had insisted, which was “offensive to e­ very self-­respecting physician in the United States,” according to an editorial. Thus, through 1903 and 1904, Gorgas was humiliated and hamstrung at e­ very turn as he tried to repeat what he had accomplished in Cuba, where he had had the backing of General Wood, a physician well-­schooled at Harvard in modern medicine and public health. According to a biography of her husband, Marie Gorgas wrote that Rear Admiral John G. Walker, chairman of the Isthmian Commission, laughed off the mosquito theory as “the veriest balderdash,” despite Gorgas’s hours-­long disquisition to him on the evidence. Get rid of the garbage and dead cats, paint the h ­ ouses, and pave the streets, Walker told him. Canal commissioner General George W. Davis also “set him right.” “On the

172

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

mosquito you are simply wild,” Marie Gorgas quotes him saying. “Get the idea out of your head.”14 At this point, Charles Reed (not related to Walter Reed), the AMA’s tireless national lobbyist and president of the AMA’s Committee on Medical Legislation, seized the moment. Reed, who was spearheading the AMA’s drive for the Pure Food and Drugs Act, published a scathing report for all the world to see about what he had seen during a visit to Panama. The bombshell, titled “The Panama Canal Mismanagement,” appeared in a March 1905 issue of the AMA journal and was picked up by the national press. Lay employees of the Isthmian Commission thwarted Gorgas, Reed wrote, by skimping on funds and manpower for his sanitation efforts. ­There was petty meddling in purchasing decisions, like ordering cheap and worthless microscope lenses instead of the better ones requested. Stingy pay for local doctors, nurses, and orderlies guaranteed low-­quality work. Reed told of “disgusting” and “belittling” treatment of doctors and of the “petty, almost despicable antagonisms” and “humiliating subordination” Gorgas and his aides suffered at the hands of lay authorities. Newspapers across the country entertained readers with one of Reed’s lesser examples of tortuous bureaucracy and false economies: a two-­day delay in procuring a ­bottle with a rubber nipple for a baby whose hospitalized ­mother was unable to nurse. Gorgas’s complaints to the canal commission fell on deaf ears. Bursting with indignation and sarcasm, Reed focused par­tic­u­ lar rage at Commissioner Carl Ewald Grunsky. Engineer Grunsky was responsible for a slew of pigheaded, penny-­wise-­but-­pound-­foolish decisions. Reed concluded that “the responsibility for the pre­sent existence of yellow fever on the Isthmus can be placed nowhere ­else than on the Isthmian Canal Commission.” Hence “the time has arrived when the President o­ ught to redeem his word” to hold the commission responsible for ­handling sanitation properly and therefore “ask for the resignation of the commission.”15 President Roo­se­velt, infuriated by Reed’s impertinently phrased demand for all the public to hear that he “redeem his word,” fumed that Reed had passed ammunition to the expensive proj­ect’s severest critics. However, before a month had passed, Roo­se­velt rolled over a dithering Congress and summarily ordered the complete h ­ ouse­cleaning and streamlining of the commission that he had been planning even before Reed’s exposé. All commissioners, including Grunsky, w ­ ere asked to resign. It was pos­si­ble, speculated the Medical Rec­ord, that “Reed’s indiscretion” had “borne fruit in the forced resignation” by handing Roo­se­velt ammunition for action. Prominent



C a t t l e m e n , C o m m a n d e r s , C a p­i­t a l­i s t s , C r u s a d e r s 173

journalist Mark S­ ullivan thought Roo­se­velt’s junking of the commission was “due in ­great part” to Reed’s report. The AMA journal asserted that, in any event, the public press thought the report “had much to do in justifying the President’s action in the eyes of the ­people.” Marie Gorgas thought the same.16 Nevertheless, Roo­se­velt disappointed the AMA sanitarians one more time by failing to appoint a physician to the commission, and Gorgas was still denied the plenary authority he needed. But by a stroke of luck a few months ­later in the summer of 1905, John Findlay Wallace, the canal proj­ect’s chief engineer, resigned. John Stevens, the replacement, was a builder of large railroad proj­ects in the West. Despite his own doubts about the mosquito theory, Stevens “threw all the weight of the engineering department” b­ ehind mosquito eradication, Gorgas ­later recalled with effusive gratitude. But back in Washington, before Gorgas’s ramped-up work could show results, Theodore Shonts, the new chairman of the canal commission, de­cided to overrule Stevens and replace Gorgas with “a man of more practical views.” Only “cleaning up,” he thought, was required. One physician considered was a fierce opponent of the mosquito theory. Another, a friend of one of the new commissioners, was an osteopath, a believer in a holistic theory of disease according to which germs had ­little chance against healthy ­people, while health could best be restored with manipulations of the spine. That suggestion was a “grotesque joke” according to Marie Gorgas. It took much deliberation and a forceful intervention by Stevens to remove the osteopath from consideration. The commission fi­nally settled on Hamilton Wright, a regular physician and a respected if not prominent sanitarian, to relieve Gorgas of his job.17 Secretary of War William Howard Taft duly accepted Commissioner Shonts’s decision to fire Gorgas and forwarded Wright for Roo­se­velt’s approval. Thinking it wise to get other opinions, Roo­se­velt circled back to Welch, who had helped get Gorgas his position in the first place. Welch thought Wright worthy of re­spect but insisted that the only man for the job was Gorgas. Luckily, Roo­se­velt also consulted Alexander Lambert, a former employee of New York City’s outstanding health department, a leader in New York’s state and county medical socie­ties, and the president’s ­family physician and hunting companion. Lambert, a ­future AMA president, fi­nally tipped the scales back in Gorgas’s ­favor, according to Gorgas’s wife. In a conversation at Roo­se­velt’s summer residence in Oyster Bay, New York, Lambert earnestly lectured the president on yellow fever and the solid science ­behind the mosquito theory. Lambert said it was ­either “failure with mosquitoes or success without” and that success required keeping Gorgas. “Smells and filth,” Lambert explained

174

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

to the president, who was not yet fully disabused of the fomite theory, had nothing to do with the disease. If all you do is clean that up, Lambert said, “you ­will fail, just as the French failed. If you back up Gorgas . . . ​you ­will get your canal.”18 That decisively moved the president, fi­nally, in the right direction. With the president and the commission’s chief engineer Stevens ­behind him, Gorgas got the authority and resources he needed. Commission chairman Shonts authorized Gorgas to spend “im­mense amounts of money”—­far more than Gorgas had even had the temerity to ask for. His efforts led to a dramatic plunge in the overall death rate from a frightful 41.2 per 1,000 in 1906 to only 10.6 in 1909. ­A fter the canal’s completion, Gorgas estimated that the total loss of life from all disease was less than 5,000 over ten years. If the death rate for the American proj­ect’s larger workforce had equaled what the French had experienced, the toll would have been 78,000. Most of the decline was in yellow fever deaths, but general sanitation mea­sures also dramatically reduced typhoid deaths. Likewise, malaria cases dropped away steeply: initially, 80 ­percent of canal employees had suffered in varying degrees from malaria, but by 1910 sanitation mea­sures had brought that figure down to around 20 ­percent.19 By 1905, ­because of the Cuban experience and debate over the Panama proj­ect, knowledge about the role of mosquitoes in yellow fever seeped through to parts of the American public, preparing lay elites for preventive and remedial action. When in 1905 yellow fever made its first surprise visit to New Orleans since 1900, the news sent shock waves northward, and demand for rapid action flowed back. This time New Orleans health official Quitman Kohnke did not encounter a wall of ridicule and re­sis­tance. But bickerers and footdraggers w ­ ere still able to weaken his badly funded efforts with their “dire predictions of defeat” and “libelous statements against the health authorities.” ­Those w ­ ere, he recalled l­ater, extensively published by “many of the yellow journals, and, I regret to say, by a portion of the medical press.” However, an advisory committee of the Orleans Parrish Medical Society vigorously backed emergency antimosquito efforts. Critical outside assistance arrived ­after the mayor and local business organ­izations appealed to President Roo­se­velt. The president obliged with ­limited help. Handed the task but not money or authority, Walter Wyman of the Public Health and Marine Hospital Ser­vice (PHMHS) sent Joseph H. White, the agency’s top physician, and a team of medical officers to command the antimosquito campaign if so asked by the citizens of New Orleans.20



C a t t l e m e n , C o m m a n d e r s , C a p­i­t a l­i s t s , C r u s a d e r s 175

The New Orleans Picayune lamented that “now we rush into the arms of ­Uncle Sam” and sacrifice “our . . . ​Demo­cratic State sovereignty.” In the end, however, the federal leadership was accepted, but the bulk of necessary funds for l­abor, materials, and other large expenses had to be solicited from private citizens. An ad hoc Citizens Yellow Fever Fund Committee, headed by four prominent cap­i­tal­ists and a finance and insurance mogul, raised sizeable contributions from banks and other businesses. The state of Louisiana ultimately contributed about $100,000. Many citizen volunteers pitched in with unpaid ­labor. ­Because they w ­ ere unwelcome in the regular operations, Black citizens formed their own Central Sanitary Association to instruct and assist their ghettoized community.21 Thus, the year 1905 marks the simultaneous banishing of yellow fever from New Orleans and the beginning of its containment in Panama. What once had terrorized the country for over a c­ entury with its many surprise invasions, para­lyzed intra-­and interstate commerce, and killed thousands was never to get a foothold again in the United States. In short order, the combined federal, state, city, and community efforts put an end to the epidemic well before the first frost and thereby checked its spread to other cities. Only about five hundred p ­ eople perished in New Orleans. A terrible calamity had been averted, according to Kohnke. “Never before was so large a b­ attle successfully fought against yellow fever as in New Orleans in 1905.” Better yet, it was “a brilliant demonstration of the correctness, in ­actual practice, of the doctrine of the mosquito conveyance of yellow fever.”22 The victory over yellow fever further south in Panama took longer to complete, but it eventually allowed the opening of the Panama Canal in 1914. With that Walter Reed and William Gorgas repaid American imperialism for the renown they gained from their work in Cuba. It was a public health victory of enormous proportions, which normal demo­cratic politics had only delayed and complicated. B ­ ecause of military money and authority, good medicine prevailed in the end against po­liti­cal disorder. It was a progressive victory accomplished by interpenetrating elites of the medical sciences, organ­ izations, and the military. Five past and ­future AMA presidents ­were involved in ­those overlapping spheres in vari­ous ways in the ­battle against yellow fever: George Sternberg (1898–1899), Charles Reed (1901–1902), William Gorgas (1909–1910), William Welch (1910–1911), and Alexander Lambert (1919– 1920). Most impor­tant of all was Gorgas, a student of Welch, who was honored with the AMA presidency while the Panama Canal was well on its way to successful completion. The year that happened, Gorgas began his ser­vice as

176

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

the twenty-­second surgeon general of the U.S. Army through to the end of World War I and received the National Acad­emy of Science’s first Public Welfare Medal, its most prestigious award. T H E C A P ­I ­T A L ­I S T A N D T H E H O O K W O R M

Like yellow fever, uncinariasis, the iron-­deficiency anemia caused by hookworms, was another scourge of the South, especially in its vast and impoverished rural tracts. But b­ ecause the worm, Necator americanus, did not stalk wealthier citizens, city dwellers, soldiers, or canal builders, it never received the national attention, medical as well as po­liti­cal, that yellow fever did. Southern physicians, being dependent on wealthier patients for their livelihood, paid the worm’s indigent hosts l­ittle attention and therefore never investigated the prob­lem.23 The vari­ous symptoms of hookworm infestation—­abdominal, metabolic, developmental, and behavioral, including “dirt eating”—­were not even recognized by the Southern medical profession as a result of a single disease entity. The hardest-­hit victims of the “vampire of the South” became sickly, listless, and stunted physically and mentally. Small c­ hildren playing barefoot in the dirt ­were the most vulnerable. ­Because of secondary complications, their death rates w ­ ere high. Hookworms in the larval stage journeyed from ­human fecal ­matter across the soil and burrowed into their soft flesh, especially between the toes. From t­ here they flowed through the bloodstream to the lungs, ­were coughed up and then swallowed, and so ended up in the gut. Th ­ ere, as adult worms, they attached to the intestinal lining to feed off the host’s blood, causing bleeding and the resulting iron deficiency and one of its symptoms, a strange impulse to eat clay, chalk, and dirt (geophagia). Excreted onto the ground, the worm’s eggs hatched to begin the cycle anew, finding more ­human hosts with ­every new generation. Close to 40 ­percent of the popula­ ere symptomatic—­ tion in much of the South was infected. Not all w especially Black p ­ eople who had inherited some of their West African ancestors’ ge­ne­tic defenses against hookworm.24 Uncinariasis hobbled the region eco­nom­ically by sapping workers and potential small entrepreneurs of energy. Derisive observers of what they called “shiftless lazy white trash,” the indolent poor of the South, sometimes blamed their geophagia on a wish to get sick and skip work. L ­ abor productivity in Southern textile mills was over 20  ­percent lower in counties heavi­ly infected with hookworm disease, once diagnosed by doctors as “cotton mill



C a t t l e m e n , C o m m a n d e r s , C a p­i­t a l­i s t s , C r u s a d e r s 177

anemia,” which they attributed to the inhalation of lint. Many a “typical cotton-­ mill child”—­a commonly heard epithet—­was stunted: fourteen-­year-­olds could look like they w ­ ere seven, and adults at twenty-­four could be mistaken for 25 fourteen-­year-­olds. A zoologist and specialist in animal parasites employed by the BAI, Charles Wardell Stiles, is credited for definitively establishing the cause of rural Southerners’ low productivity. A mea­sure of its cost to the industry is that a cotton mill association president offered to grant Stiles $50,000 to combat hookworm disease in cotton mills. He had brought to the BAI the benefits of his world-­ class training in Paris, Berlin, and Leipzig. For his doctoral degree, he had studied ­under the famous parasitologist Rudolf Leuckart in Leipzig, whose findings on trichinosis gave Germany’s Rudolf Virchow, the f­ ather of cellular pathology and a fierce champion of social medicine and public health, the ammunition for his campaign to pass meat inspection laws t­ here. ­A fter returning to Amer­i­ca to study parasites in its farm animals for the BAI, Stiles became aware of a common ailment sometimes diagnosed as “continuous malaria” or “chronic anemia” across the South and theorized that it was caused by a hookworm known to create a similarly enfeebled lumpenproletariat in Southern Eu­rope. When army surgeon Bailey K. Ashford, who had heard Stiles’s lectures as a student at Georgetown, delivered him a sample of the hookworms he had found in the intestines of unwell Puerto Ricans, Stiles received his first proof. Ashford had been stationed in Puerto Rico during and since the Spanish-­A merican War. Once again, the American army—an imperial public health agency abroad—­came to the assistance of civilians on home soil. The worm Ashford found was a species similar to that Stiles had seen as a student in Leipzig and was identical to t­ hose subsequently found in diseased students at the University of Texas Medical School. Stiles named it Necator americanus.26 Now Stiles resolved to undertake the difficult task of teaching the medical world that the worm was the cause of a widespread disease not even recognized as such. He also proposed a cheap and s­ imple diagnostic procedure and a fifty-­cent cure that Ashford had used: microscope examination of fecal samples and the administration of thymol, a vermifuge, and Epsom salts (magnesium sulfate), a laxative. To carry out his mission, Stiles resigned from the BAI in 1902 and obtained employment in the Hygienic Laboratory of the PHMHS. The new position allowed him to continue researching and teaching zoology while trying to engage the federal government in mass diagnosis, treatment, and prevention operations. Stiles’s longer-­term plan for

178

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

prevention included persuading the rural population to wear shoes even in hot weather and build privies for defecation. That was no small outlay for ­people in grinding poverty. A s­imple but good-­quality privy—­the famous “Kentucky privy” designed by Joseph McCormack—­cost $10 to build, or about $240 in ­today’s dollars. But the puny PHMHS was strapped for the cash needed. Although Stiles had convinced Walter Wyman, his new employer, of the need for action, they ­were unable to get a single extra dollar for it from Congress. Thus, Wyman could give Stiles l­ittle more than his salary, travel expenses, and the freedom to deliver lectures on the prob­lem to doctors and rural citizens—­and, most importantly, stalk wealthy individuals for donations to a campaign to eradicate hookworm disease.27 In his new job, Stiles combined the role of scientist, reform missionary, and statesman. It was as if he had taken to heart what Virchow, in whose Berlin home he had dined on multiple occasions, had pontificated about medicine and politics. “Politics is nothing more than medicine writ large,” Virchow thought, and physicians had the duty to provide statesmen the scientific basis for improving society. Like Virchow, Stiles had “a missionary streak . . . ​a zeal to carry healing to the afflicted, combined with an urge to exhort, to preach, to recruit converts and apostles to a good cause,” according to journalist S­ ullivan. He sank many demoralizing weeks of travel into a futile effort to raise money. At one point an anonymous titan of Southern railroads, ­ irginia, finance, and philanthropy, prob­ably Joseph Bryan of Richmond, V promised to help but died suddenly before signing any papers. Th ­ ings brightened quickly, however, ­a fter that dark moment ­because of a fortuitous acquaintance Stiles made with a member of President Roo­se­velt’s 1908 Commission on Country Life, a perfect audience for his mission. ­Because it had been mandated to “investigate the economic, social, and sanitary conditions of country life throughout the United States,” Stiles persuaded a friendly William Welch to ask Roo­se­velt to add him to the commission. As its medical attaché, Stiles gained the ear of Walter Hines Page, a New York magazine editor and publisher of Atlantic Monthly, among other t­ hings. Page, who was originally from North Carolina, had been chosen for the commission b­ ecause of his zeal as a champion of Southern educational, social, and economic development.28 Intrigued, Page arranged a meeting between Stiles and Wallace Buttrick, a high functionary in John D. Rocke­fel­ler’s expanding philanthropic enterprises. Buttrick worked for Rocke­fel­ler’s General Education Board (GEB), established in 1902, which had been promoting public education and improved



C a t t l e m e n , C o m m a n d e r s , C a p­i­t a l­i s t s , C r u s a d e r s 179

farming techniques to illiterate, impoverished Southerners. Buttrick, in turn, introduced Stiles to Simon Flexner, chief of the Rocke­fel­ler Institute for Medical Research, and Frederick Taylor Gates, Rocke­fel­ler’s chief adviser in practically all his affairs, industrial and philanthropic, including the formation of the GEB. A man with copious energy, Gates controlled large parts of Rocke­fel­ ler’s vast oil ­giant, Standard Oil, supplying ambitious ideas for what to do with the com­pany’s massive profits. Gates was Stiles’s final link in the chain of personal connections from Welch through Roo­se­velt, Page, Buttrick, Flexner, and ultimately to Rocke­fel­ler himself.29 Thus, Rocke­fel­ler’s backing of Stiles’s war against hookworm was one of ­t hose fortuitous accidents of history—­the right person at the right place and time. Gates’s motives for enlisting Rocke­fel­ler can best be understood in light of his early, short, and discouraging ­career as a Baptist minister. During his pastoral c­ areer in Minnesota, Gates reached the conclusion that disease was a major source of private misery and that both doctors and preachers only wasted time with their ministrations to its victims. According to Gates’s 1928 memoirs, “The ablest and most prominent physician” in Minneapolis had frankly confessed to him that in ninety of one hundred cases, his patients “would have recovered just as certainly and comfortably without him.” Of the remaining ten, he was merely able to make nine a bit more comfortable as they progressed ­toward recovery, death, or something in-­between. Only one in a hundred could actually be cured. Many other physicians had told Gates similar ­things. In 1893, upon entering into Rocke­fel­ler’s ser­vice, he had been “for years convinced that medicine as generally taught and practiced in the United States was practically futile.”30 Gates migrated from his first religious ministry to a new progressive one, that of social salvation through science and rational enterprise. The vis­i­ble hand of philanthropy and the invisible hand of the market could jointly deliver private profits and public goods, he thought. Fortunately for hookworm victims, Gates saw medicine as a wide-­open frontier for philanthropic enterprise that might redound to the benefit of capitalism. During a vacation ­after four years of ser­vice to the Rocke­fel­lers, Gates had picked up and read with fascination William Osler’s nearly one-­thousand-­page medical textbook The Princi­ples and Practice of Medicine. It was a transformative experience. From it he learned that while legions of distinct and often deadly diseases caused ­human suffering, treatments ­were few and feeble. If the sick could be saved from disease, it would have to be prevented or cured with help from new discoveries in biomedical science. And only large sums of money, well used,

180

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

could advance the science and put it into action for both private and general welfare. On t­ hose grounds, Gates turned to Rockefeller—­the disaffected son of a flamboyant snake-­oil salesman—to put up the money for his mission. Despite Rocke­fel­ler’s preference for homeopathy, not the wellspring of biomedical science that inspired Gates, Rocke­fel­ler obliged in 1901 with the money to richly endow the new Rocke­fel­ler Institute for Medical Research, which l­ ater evolved into the Rocke­fel­ler University for postgraduate medical training. In Amer­i­ca at the time, ­there ­were only two government-­funded research institutions up and ­running, the Hygienic Laboratory established by the PHMHS in 1887 and Hermann Biggs’s Bacteriological Laboratory in New York City, set up in 1892. Both ­were rather rudimentary compared to the renowned, partly state-­funded Pasteur Institute in Paris, established in 1887, and the German government’s Robert Koch Institute in Berlin, established in 1891. Gates’s ambition was for the Rocke­fel­ler Institute to become at least the equal of ­those state-­backed Eu­ro­pean pre­de­ces­sors. It was to be run only by stellar physician-­scientists. Among them ­were the experimental pathologist Simon Flexner, its first director, and other public health and scientific luminaries, including Hermann Biggs, T. Mitchell Prudden, and William Welch.31 Simon Flexner played a small but impor­tant role in enlisting Rocke­fel­ler philanthropy ­behind the antihookworm campaign by attesting to Stiles’s scientific qualities and achievements. With that endorsement, Gates proceeded with an ambitious plan of hookworm eradication to help rural Southerners escape from their physical, social, and economic miseries. At Gates’s instigation, Rocke­fel­ler put up the money in 1909 to create the Rocke­fel­ler Sanitary Commission for the Eradication of Hookworm Disease (RSC). Its mission: “To bring about a co-­operative movement of the medical profession, public health officials, boards of trade, churches, schools, the press, and other agencies for the cure and prevention of hookworm disease.”32 To persuade Rocke­fel­ler to endow the RSC, and endow it with $1 million for five years, Gates appealed to his boss both as cap­i­tal­ist and as humanitarian, explaining that the poor output and profits of Southern textile mills in counties heavi­ly infected with hookworm disease w ­ ere the result of the parasite’s effect on ­labor productivity. But among Rocke­fel­ler’s motives for agreeing to the proj­ect, profits could not have been the only or even primary one, for his industrial empire did not include textiles or other labor-­intensive rural industries. Of course, he would have understood that the South’s industrial



C a t t l e m e n , C o m m a n d e r s , C a p­i­t a l­i s t s , C r u s a d e r s 181

development would be a good t­ hing for the American economy generally, as a growing economy would be thirsty for oil. But according to historian John Ettling’s persuasive telling, Rocke­fel­ler’s desire to spend profits from his vast oil-­refining operations for progressive, philanthropic ends was ultimately the decisive ­factor.33 Prob­ably, a wish to shine up Standard Oil’s public image figured as well, tarnished as it was by muckraker Ida Tarbell’s recent Collier’s articles and her 1904 book The History of the Standard Oil Com­pany. Also, ­ nder the Standard Oil was being prosecuted by the Department of Justice u Sherman Antitrust Act. With Stiles on its team, the RSC launched its huge antihookworm proj­ ect in 1909. At its head was Wickliffe Rose, president of the University of Tennessee, whose zealotry in the crusade against the hookworm was fired up in part by a visit to Puerto Rico to see Bailey Ashford’s extraordinary curative feat. In the beginning, medical prac­ti­tion­ers and their organ­izations across the South stood on the sidelines. Some Southern physicians ­were not keen to be told by Stiles, an abrasive Wesleyan-­educated Yankee, that they had been fooled all along by a disease hiding in plain sight, and a few “backwoods” types protested against his preachings on elimination of a disease “which inevitably would reduce their income!” Nor w ­ ere they all grateful to know that the mission to eradicate it was funded by a voracious Yankee monopolist. But ­because of Rose’s tireless orga­nizational efforts and ­great persuasiveness, between 1909 and 1914 the Sanitary Commission was able to test more than a million ­people, well over half of them c­ hildren, in almost six hundred counties. Thirty-­nine p ­ ercent w ­ ere found to be infected, and more than 440,000 ­were treated successfully. In addition to enlisting as many doctors as pos­si­ble, the commission worked with civic leaders and, perhaps most importantly, schoolteachers, in spreading the word about proper sanitation, the value of shoes, and the need to use privies.34 Florida was the only state that declined help from the RSC, but not out of the typical benightedness of public health politics across much of the South. Remarkably, it had one of the best-­funded state health authorities, and ­because of its highly centralized administration it did not display the bureaucratic disorder of many other states. Florida’s deviation in public health affairs began during a particularly bad yellow fever invasion in 1888 and 1889, which had aroused popu­lar demand for aggressive government action. In response, Florida’s governor, whose campaign travels had been badly incon­ ve­nienced by chaotic local quarantines, created the state’s first board of

182

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

health to rule authoritatively over the state’s county boards. It was not only unusually centralized, it was also remarkably well and permanently funded by a special yearly “sanitary tax” bringing in $75,000 a year to fund its work.35 Appointed as the new board’s chief was Joseph Y. Porter, a physician who had distinguished himself by volunteering to take the leadership during a yellow fever outbreak in Jacksonville and supervise the care of around five thousand victims. In 1891, two years into his tenure, Florida sold its quarantine stations to the federal government, surrendering control over expensive quarantine operations to the PHMHS. ­Because his agency was flush with cash, an embarrassment of riches from the proceeds from the sale as well as tax revenue, Porter feared a repeal of the special tax, knowing that other state health authorities often failed to get their appropriations renewed when emergencies passed. Con­ve­niently, Stiles’s hookworm findings and recommendations suggested a new mission to spend the money on and therefore a pos­si­ble new lease on life for his agency.36 If Porter was not the only state health leader persuaded by Stiles, he was the only one with the considerable spare resources and authority to act. Starting in October 1909—­the same year the RSC operations got underway—­ and up through December of the following year, Porter and three assistants traveled a total of 7,620 miles across the state performing almost that many examinations, distributing lit­er­a­ture, arranging laboratory work, and treating indigents. They also gave lectures, especially in schools. In Gainesville, Porter’s lieutenant, physician Hiram Byrd, addressed the state teachers’ association in 1909, giving many of them their first introduction to the worm that turned some of their students into “­little, undersized, pale, sallow, pot-­ bellied, breathless, bloated ­children.” But Porter and Byrd irrationally concentrated their humanitarian mission on poor white Floridians. Noting contemptuously that black Southerners did not suffer as much from the worm’s intestinal ravages, Byrd laid prime responsibility for whites’ suffering at their feet. “The negro,” he said, “is a greater polluter of the soil than the whites, and it seems the irony of fate that he should spread it broadcast over the country to sap the vitality of the whites while the perpetrator goes unscathed and in no wise suffers from his own careless habits.” As an aside, he added, “The negro” also “scatters the seeds of consumption throughout the length and breadth of the land.” Although equal treatment of African Americans would have been rational even out of a racist concern for whites alone, Byrd saw no dereliction of public health duty in the fact that over one



C a t t l e m e n , C o m m a n d e r s , C a p­i­t a l­i s t s , C r u s a d e r s 183

fifteen-­month period he and his colleagues inspected seventy-­nine white schools and lectured their pupils but visited only four black schools and lectured at none of them.37 To be sure, the combined RSC and Florida efforts did not eradicate hookworm disease. With the hygienic education and therapeutic job only half done and reinfestation still a prob­lem given the per­sis­tent aversion to out­houses and a lack of indoor plumbing, Gates and Rocke­fel­ler abruptly disbanded the Sanitary Commission in December 1914, relocating the ­battle to Africa and other tropical and subtropical areas hobbled with hookworm disease and economic stagnation. While the money now flowed to Rocke­fel­ler’s new International Health Commission, again with Wickliffe Rose at its head, state and county agencies in the American South had to conduct the remaining work, although for several years Rocke­fel­ler continued to pick up a considerable share of their expenses. In a letter to the Sanitary Commission justifying the decision to shut it down, Rocke­fel­ler declared that their chief purpose had been accomplished: educating the region’s “physicians, health authorities, and the public regarding the prevalence of hookworm disease and the methods of treating and preventing it.”38 Indeed, according to Charles Chapin’s 1916 survey of state health agencies, the RSC had “brought to the front young, active men, trained in scientific methods” and thereby “proved a ­great stimulus” to public health awareness about hookworm and many other public health concerns. In many of the Southern states, the commission actually helped install the institutional infrastructure to implement the knowledge. According to historian Ettling, the RSC’s most impor­tant legacy was the “network of state and local public health agencies it left in its wake.” In 1909, when the RSC moved in, only three states in the South had departments of health; the year a­ fter the commission pulled up its stakes, ­every state had one up and r­ unning. Funding for public health work in southern states r­ose by 81  ­ percent between 1910 and 1914 and by more than 500 ­percent by 1920. Rocke­fel­ler advisor Gates accorded Wickliffe Rose g­ reat credit for insisting on state contributions as a condition for RSC help, including showing them “models of effective state organ­ization” and training county officials “in the use of all this machinery by employing them as his own agents.” In other words, according to Chapin, the RSC’s educative effect led to a “marked sanitary awakening” in the South.39 Once again, as with yellow fever, a remarkable public health accomplishment was achieved despite the American po­liti­cal disorder—­bypassing the normal po­liti­cal pro­cess almost entirely.

184

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c CRUSADERS AGAINST CONSUMPTION

­ ecause or­ga­nized medicine led by progressive reformers lacked po­liti­cal B clout in domestic demo­cratic politics, it took military research motivated by an imperialist mission to defeat the yellow fever mosquito. Civilian public health officials stood idly by. The hookworm met its match in a zoologist employed by an agricultural bureau concerned about the health of food animals, not ­humans. A cap­i­tal­ist funded the subsequent war against it in Southern states, many of which lacked even rudimentary public health agencies. Tuberculosis, “the white plague,” meanwhile, despite being a far bigger threat than “yellow jack” or the “vampire of the South,” also met no government re­sis­tance as it harvested countless human lives. Consumption or phthisis, as tuberculosis was still sometimes called, ran neck and neck with pneumonia as a leading cause of death.40 At the beginning of the twentieth ­century, government efforts to study how to eliminate the disease ­were virtually non­ex­is­tent, though twenty years had passed since 1882 when the German physician Robert Koch announced his discovery of its bacterial cause and means of spread. In 1899 the Marine Hospital Ser­vice (MHS) built one single sanatorium for merchant seamen and their dependents, but it could accommodate only about thirty-­five infirmary patients and about two hundred ambulatory ones. In 1902 the MHS was still conducting only minimal “miscellaneous” research on tuberculosis. That year, the U.S. Trea­sury Department, in which the MHS was ­housed, acted against the disease, but it was a draconian, ham-­fisted policy of turning away all immigrants trying to enter the country with tuberculosis diagnoses, not just “paupers” who had nowhere to live and no means to get medical attention. The AMA’s George Simmons estimated that about 90 ­percent of “the best men in the profession who have given thought to the subject” agreed with resolutions passed by the elite New York Acad­emy of Medicine that decried the mea­sure as overkill. Adolphus Knopf, a highly respected expert, angrily accused the Trea­sury Department of stirring up “phthisiophobia,” an irrational fear of tuberculosis, causing ­people to be fired from their jobs and socially ostracized and making communities hostile to the location of sanatoriums in their confines.41 Public pressure on politicians for rational and humane action was practically nil. Electoral politicians had more pressing ­things to spend money on than a disease that voters never held them accountable for. In large cities, overcrowded tenements assuring the spread of tuberculosis made bad housing a ­matter of some hand-­wringing, but American businesses that could



C a t t l e m e n , C o m m a n d e r s , C a p­i­t a l­i s t s , C r u s a d e r s 185

have done something about it profited from low wages and taxes and therefore cheap housing. The steady inflow of l­abor from the countryside and abroad to replace sick workers also inured them to the prob­lem. Racism relegated the very high tuberculosis rates among African Americans to the status of a nonproblem, or one that could supposedly be held at bay by a policy of apartheid: quarantining them in ghettos and segregated occupations and public facilities. Yale economist and public health missionary Irving Fisher estimated an economic cost to the nation of more than half a billion dollars from the dangerous disease. Perhaps it is not surprising, therefore, that once again a wealthy, philanthropically minded cap­i­tal­ist stepped up to fill the research and action vacuum. In 1903, steel executive Henry Phipps had just sold more than $50 million in shares of Car­ne­gie Steel to the United States Steel Corporation and then set about looking for creative ways to spend it. Wanting to transcend conventional charity, he took on a more ambitious mission—­the prevention and cure of social miseries, not just amelioration. In response to Phipps’s inquiries about where to pour some of his money, a businessman from the Pennsylvania State Public Board of Charities introduced him to the forty-­ three-­ year-­ old Philadelphia doctor and renowned tuberculosis specialist Lawrence Francis Flick. Flick had recently founded an antituberculosis organ­ization in Pennsylvania, hoping that doctors in other states would follow. Only a discouragingly small number did. In general, doctors w ­ ere individually ambivalent and collectively divided about even reporting the disease and enlisting public health interventions. Some w ­ ere fatalistic about its inevitability and incurability, while many ­others contradicted them, hubristically opining that “the ­family physician is entirely competent to deal with the prob­lem.” Flick did, however, bring a relatively progressive Philadelphia county medical society around to accepting the need for action. Depressed by his failure to get wider collegial support, Flick turned for help to philanthropist Francis Torrance, the founder of the huge Standard enameled plumbing ware com­pany and president of the Pennsylvania State Board of Charities. Torrance put Flick in contact with industrialist Phipps.42 Together the doctor and steel man then embarked on an investigatory tour of Eu­ro­pean hospitals, sanatoriums, and research institutes. They came back with a plan to establish a private biomedical research institute modeled on the Pasteur Institute of Paris but focused on only a single disease, tuberculosis. Hence, the establishment of the Phipps Institute for the Study, Treatment,

186

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

and Prevention of Tuberculosis in Philadelphia. It was a headline event. Endowed with $1 million in 1903, their institute included a hospital for the isolation and treatment of tuberculosis patients with advanced cases and a dispensary for the less advanced or ­those who could not get charity care in a hospital. Two years l­ ater Phipps went further, putting up another million dollars for the building of tenement ­houses in New York City, designed by noted architect Grosvenor Atterbury, with unusually good ventilation, space, and plumbing.43 Phipps was one of two prominent laymen to lead the charge against tuberculosis. An impor­tant but forgotten figure in the story was Clark Bell, the prominent corporate ­lawyer who had drawn up the Pacific Railroad Act of 1862, which gave birth to the enormous Union Pacific Railroad. Before involving himself with tuberculosis in 1901, Bell had presided over the Medico-­ Legal Society of New York for almost thirty years—­the same lay-­dominated organ­ ization that had initiated the move for medical licensing years ­earlier—­and in that capacity had founded its Medico-­Legal Journal, which he edited and bankrolled for twenty years. A curious hodgepodge, the journal focused mostly on questions of medical jurisprudence—­the cause, liability, and culpability for injuries. ­These ­were of par­tic­u ­lar interest to the deep-­pocketed railroads Bell was associated with ­because of lawsuits filed against them by their many workers and passengers injured in and on their property. But Bell’s journal also contained regular discussions of public health issues, especially tuberculosis.44 Bell aspired to assem­ble and lead the forces against tuberculosis in part ­because of what he called the medical profession’s “supineness and inactivity.” In 1901, he called for convening an American congress on tuberculosis, intending to attract delegates and participants, lay and medical, public and private, from all over the country to discuss all aspects of the disease, from ­causes and treatment to prevention. Although he sought a broad alliance with doctors, Bell vehemently insisted on lay leadership—and chose himself for that. It was a poor choice according to many doctors. ­There had been bad chemistry between Bell and prominent physicians since the early 1880s, which casts light on the furious ­battle that ensued. According to the New York Times, doctors had clashed with Bell over a midnight maneuver that allowed him to wrest control over the New York Infant Asylum, which at any one time cared for over two hundred foundlings. Among the doctors on its medical committee was the pioneer sanitarian and American Public Health Association founder Elisha Harris. Their charges of financial and medical



C a t t l e m e n , C o m m a n d e r s , C a p­i­t a l­i s t s , C r u s a d e r s 187

mismanagement ­were backed by a young reform-­minded New York State assemblyman, Theodore Roo­se­velt, a member of the asylum’s board.45 Hostilities erupted anew a­ fter the 1901 meeting of Bell’s American Congress on Tuberculosis, the first of a series he planned. Articles on “spiritual” or paranormal phenomena sprinkled incongruously throughout Bell’s Medico-­ Legal Journal should perhaps have moved them to head off the meeting at the pass. Afterward, the Boston Medical and Surgical Journal declared that Bell had shown so ­little discrimination in choosing the meetings’ participants and papers “that the time of the convention was largely taken up by cranks and by ­those with axes to grind in the shape of self-­lauded special methods of treatment.” Worthless phar­ma­ceu­ti­cals ­were prob­ably hawked, given that the Sanitarian, which defended Bell in the ensuing b­ attle, still relied heavi­ly on advertising proprietary nostrums and other cure-­a lls that the AMA reformers had been mobilizing to fight. Edited by a respected old-­timer among sanitarians, Agrippa Bell (no discernable relation to Clark Bell), the Sanitarian advertised t­ hings like Wheeler’s Compound Elixir, “a nerve food and nutritive tonic” especially useful “for the treatment of consumption.” 46 A fierce b­ attle arose at the next motley convention in 1902, where a rebellious contingent of doctors led by Daniel Lewis, editor of the Medical Review of Reviews, and George Brown, president of the Pine Ridge Sanitarium in Atlanta, Georgia, seized control of the floor. Unable to dislodge Bell from the executive committee, Lewis and Brown split off to form a rival, all-­medical organ­ization. Thereupon the imperious Bell set out to relegate their weak and ineffectual American Anti-­Tuberculosis League (AATL) to irrelevance. For that, he assiduously gathered a slew of endorsements of his own organ­ization from numerous and impressive state, national, and international governmental del­e­ga­tions and even a considerable number of medical organ­izations.47 Among Bell’s fiercest critics was German émigré Adolphus Knopf, an internationally prized expert on tuberculosis. Urging the creation of a strong and v­ iable rival to Bell’s venture, Knopf turned to the AMA for help, enlisting its editor and general man­ag­er George Simmons to expose Bell’s congresses as venues for commercialists and quacks with their “advertising schemes, fads, ­etc.” Lawrence Flick also countered Bell by sponsoring a meeting of about one hundred progressive doctors and laymen at the Phipps Institute in Philadelphia in 1904. Despite their general scientific consensus about tuberculosis, debate about what kind of alternative organ­ization to form was heated. Flick and Knopf insisted on creating an entirely new organ­ization instead of working with the AATL, the Lewis-­Brown breakaway organ­ization. For the sake

188

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

of peace and order, William Osler favored working with and through the AATL, as did William Welch, who asked Flick “­whether the Lewis society is so bad as you think it is.” Adamantly opposed to collaboration, Flick even threatened to withhold the Phipps Institute’s support if the “Baltimore group” got its way.48 It is not hard to piece together a plausible account of why, in the larger context of progressive medical politics of the era, Flick proved persuasive. For one ­thing, the Lewis-­Brown breakaway’s exclusion of laymen like Bell was surely a defect in the mind of reformers like Flick, who recognized the g­ reat need for lay collaboration and money. Also, medical editor Lewis would soon show his colors as a critic of the AMA’s ongoing efforts to clean up commercialized medical journalism and education. Except for Quitman Kohnke of New Orleans, the AATL’s leaders ­were not nationally known public health figures. Not coincidentally, practically all participants in one of its meetings ­were Southerners. Worst of all, a power­ful ele­ment of the AATL insisted that tuberculosis was “curable.” Indeed, according to the organ­ization’s 1905 “creed,” if diagnosed early “it may be destroyed in the individual by the adoption of proper remedial mea­sures.” That clearly signaled openness to useless drug treatments and therefore receptiveness to drug industry money, as suggested by the inclusion of papers submitted to the session on Phymol and Bacillocine, for example. Brown, an Atlanta sanatorium director, owned Brown’s Chemical Com­pany in the same city. It manufactured and distributed a proprietary line of Red Cross remedies, one of which was a “tasteless wine of cod-­liver oil.” This class of “wines” typically contained hypophosphites, which ­were still discreditably advertised and used for treatment of tuberculosis. For example, in 1909, Parke-­Davis’s Manual of Therapeutics—­called “a rather pretentious book for gratuitous distribution” by an AMA journal review—­still identified a strychnine hypophosphite mix as “employed in the treatment of phthisis.” 49 The AMA’s intervention spelled the beginning of the end of both Bell’s and Brown’s organ­izations. What emerged when the dust of ­battle cleared was the National Association for the Study and Prevention of Tuberculosis (NASPT)—­later renamed the American Lung Association. Hermann Biggs, George Sternberg, Edward Livingston Trudeau, and William Welch ­were other eminent physicians joining Flick and Knopf in founding the new organ­ ization. Trudeau, a pioneer in the scientific study and sanatorium treatment of tuberculosis, served as its first president. In the coming years, its presidency was held by New York City’s Hermann Biggs, Chicago surgeon and recent



C a t t l e m e n , C o m m a n d e r s , C a p­i­t a l­i s t s , C r u s a d e r s 189

AMA president Frank Billings, and Boston tuberculosis expert Vincent Yardley Bowditch, son of the previous ­century’s ­great pulmonologist and sanitarian Henry Ingersoll Bowditch. Another was Henry Barton Jacobs, a professor specializing in tuberculosis at Johns Hopkins, who was a good conduit for philanthropic contributions, having recently married the queen of Baltimore high society and civic affairs, Mary Frick Garrett, w ­ idow of Robert S. Garrett, a member of the power­f ul B&O Railroad and banking ­family headed by John Work Garrett. The NASPT’s bylaws called for lay repre­sen­ta­tion, fully in the spirit of medical progressivism but also in recognition of the need for philanthropic support. However, only one-­third of the seats on its board of directors ­were ­ ere of greater prominence than reserved for lay members. The first of them w ­those in Bell’s organ­ization. Among them ­were Otis H. Childs of Car­ne­gie Steel; William H. Baldwin, the widely respected, philanthropically active, and union-­friendly president of the Long Island Railroad; Richard B. Mellon of Alcoa; and Samuel Gompers, the power­ful head of the American Federation of ­Labor. Decorating its letterhead as “honorary vice presidents” w ­ ere former U.S. presidents Grover Cleveland, from 1905 to 1908, and Theodore Roo­se­ velt, from 1908 to 1918.50 It can be said that Clark Bell and the two medical renegades from his organ­ization had performed an invaluable ser­vice by goading what Bell called the “supine” medical reformers into action to create their own organ­ization and thereby marginalize the unsavory ele­ments that sought a piece of the action. By 1909, the NASPT had accumulated almost twenty-­five hundred members nationwide. Close to half ­were laypeople from the worlds of religion, education, or­ga­nized l­abor, w ­ omen’s clubs, fraternal organ­izations, and politics. The quintessentially progressive association also helped spur the formation of myriad national, state, and local organ­izations. Within a few years, practically e­ very state had formed its own association. South Carolina was the last in 1917. By 1911, the total number of state and local associations jumped to 435 from 24  in 1904. The princi­ple of lay participation prevailed across the board: for example, when the Arkansas Medical Society created a tuberculosis committee, it included ten lay members in a total of twenty-­five. The regular collaboration of state and local organ­izations with other civic, ­labor, ­women’s, and po­liti­cal organ­izations was a further mea­sure of their reliance on lay participation. By 1920, the antituberculosis movement, with the NASPT at its peak, became the most impressive example of American volunteerism and associationalism for social, economic, and physical uplift.51

190

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

­ abor ­unions ­were often ­eager activists in the tuberculosis movement. L Workingmen’s antituberculosis associations formed in Buffalo, New York, and ­ nions built sanatoriums in Albany and Newark, New Jersey, and l­abor u Brooklyn. With vari­ous mixes of ­union and employer involvement, “­free bed funds” ­were raised in New Haven, Meriden, and Hartford, Connecticut. Garment industry u ­ nions in New York City worked with employers in a collaboratively funded Joint Board of Sanitary Control, formed in 1910, to survey and remedy conditions conducive to the spread of tuberculosis. Philanthropic cap­i­tal­ists, with Phipps at the lead, w ­ ere no doubt most impor­tant as check writers for many activities. Between 1907 and 1914, the Russell Sage Foundation donated over $200,000 and enlisted the zealous energies of John A. Kingsbury to New York’s Committee on the Prevention of Tuberculosis to breathe life into local associations and their work across the state.52 Indicative of apartheid in medical progressivism, as in the rest of American life, state Negro antituberculosis leagues w ­ ere started in over seven states with some assistance from Charles Wertenbacker, a white PHMHS official who agreed with Charles Stiles’s 1910 observation that “the negro . . . ​is the reservoir for disease in the Southern states” while adding “from which our supply of diseases is constantly being replenished.” In Atlanta at least, some ­limited but significant interracial cooperation evolved b­ ecause of exertions by Lugenia Burns Hope and Rosa Lowe and their Negro Anti-­Tuberculosis Association. The separate state leagues then federated into a National Negro Antituberculosis League. Unfortunately, for their tasks—­more difficult than for the rest of the population—­they ­were disproportionately handicapped ­because of black Americans’ economic and educational privation.53 The Metropolitan Life Insurance Com­pany offers the most in­ter­est­ing example of cap­i­tal­ist engagement in the crusade. ­Behind it was Lee Frankel, head of its industrial department and then a new “welfare department.” Frankel had been hired in the progressive spirit of commercial uplift (and for a public relations face-­lift) in the wake of a 1905 New York State investigation of widespread mono­poly, fraud, and corruption in the insurance industry. Although Metropolitan emerged largely unscathed by scandal, Haley Fiske, its president, a devout Christian, hired Frankel to polish the com­pany’s image. Formerly a professor of chemistry at the University of Pennsylvania, Frankel had distinguished himself in New York philanthropy, especially in directing the social work of the United Hebrew Charities. In ­later years he would serve in the leadership of the National Health Council, the American Public Health Association, the American Social Hygiene Association, the



C a t t l e m e n , C o m m a n d e r s , C a p­i­t a l­i s t s , C r u s a d e r s 191

Child Health Association, and the Milbank Memorial Fund. In 1909, Frankel instituted a program that sent an army of nurses on a million home visits per year to customers with tuberculosis or other life-­threatening diseases—at a cost of $500,000 a year.54 The Metropolitan’s policy was the brainchild of Lillian Wald, director of the Henry Street Settlement on Manhattan’s Lower East Side and one of the nation’s most prominent social workers. Wald personally presented the case for recruiting trained nurses before the Metropolitan’s board. Frankel thus oversaw the hiring of 250 nurses to attend to sick, often impoverished working-­ class policyholders. By the time the com­pany’s nursing ser­vice became obsolete in the early 1950s, it had conducted over one hundred million home nursing visits. Citing German and Belgian practices, Frankel also called for giving policyholders easy access to twenty-­year mortgages financed out of the insurance industry’s vast reserves. Homeownership, he thought, would help remedy the “evil housing conditions” leading to disease and death. At Frankel’s instigation, but not to the extent he had hoped, Metropolitan offered some l­imited home financing. Other insurance companies followed suit in vari­ous ways.55 ­Because t­ here was no cure for tuberculosis, the lay-­professional movement had to attack it with vari­ous preventive means, starting with altering risky be­hav­iors such as spitting on sidewalks—­t hrough gentle persuasion, social censure, and statutory compulsion when necessary. Physicians needed instruction on the diagnosis and clinical treatment of tuberculosis, including in isolated settings when necessary. They also needed compulsion to report the disease and persuasion that compliance was the right ­thing to do. In 1912, the AMA chimed in by adding to its Code of Ethics the solemn duty of reporting contagious disease to public authorities. Some doctors, crusaders said, still needed to abandon their harmful habit of withholding the bad news to patients about their diagnoses. Private as well as public financing had to be mustered for laboratories, dispensaries, clinics, hospitals, sanatoriums, and day camps for diagnosis and care. The movement set much of this in motion with lectures, films, posters, billboards, exhibits, and more, often in collaboration with governments and civic organ­izations. Much of the movement’s funding came from the sale of Christmas Seals—­stamps to adorn mail envelopes—in collaboration with the Red Cross and w ­ omen’s clubs across the country. Christmas Seals brought in over $300,000  in the first two years, starting in 1907. By 1920, about $14 million in total had been raised for local, state, and national antituberculosis organ­izations. Conditional grants out of

192

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

the funds from the NASPT gave it some degree of supervisory control over autonomous organ­izing and activities at state and local levels. The grants could not be used, for example, for building sanatoriums; money for bricks and mortar had to be raised from other sources. In 1904, ­there ­were only 19 special dispensaries and clinics for tuberculosis in the country, but by 1908 ­there ­were already 158, and more would quickly come. The number of hospitals and sanatoriums more than doubled in the same period, from 115 to 240. The total number of beds grew somewhat more slowly, but by 1911 they had more than doubled, from around nine thousand to twenty-­t wo thousand.56 The antituberculosis movement aimed to change common be­hav­iors through exhortation and law. As a result, “common cups” for drinking ­water dis­appeared from schools, trains, and other public places. The American habit of spitting in public also came u ­ nder the movement’s fire. During an 1842 visit, Charles Dickens had been appalled by the “perfect storm and tempest” of spitting by the “gentlemen” he witnessed on vari­ous means of transportation and in lodging places he had no choice but to use. “A considerable amount of illness was referable to this cause,” he presciently thought. As late as 1894, ­ ere carpets and grates in the House wing of the congressional building w slick with stinking tobacco spat out by the nation’s leaders. In 1896, New York City outlawed public spitting at Biggs’s and Prudden’s prompting, but by 1905 only about thirty cities had followed its example. That year President Roo­se­ velt issued an executive order against spitting in all federal government buildings. In 1910 very few cities had their own ordinances—­not more than about eighty cities with more than 30,000 ­people in seven states—­and even ­there, enforcement was often spotty or non­ex­is­tent. Almost one-­third of cities with over 250,000 p ­ eople e­ ither had no ordinances or failed to enforce them. In Philadelphia, police would not enforce the city’s law, leading to “the ridicu­ lous situation,” according to a founding member of Flick’s Pennsylvania Society for the Prevention of Tuberculosis, that all a concerned citizen could do about a spitter was to “buttonhole the man” and ask him to accompany him to visit a judge willing to issue an arrest warrant.57 The slow but sure passage of antispitting ordinances and improvement in their enforcement was good evidence of the value of the growing antituberculosis movement’s educational work, according to the AMA journal. In one instance, ­women members of the St. Louis Anti-­Tuberculosis Society schooled police commissioners and public health officials on the need to make arrests for spitting. Politicians and police w ­ ere reluctant agents of public health, according to one analy­sis, b­ ecause “the real reason . . . ​is, of course, indifference



C a t t l e m e n , C o m m a n d e r s , C a p­i­t a l­i s t s , C r u s a d e r s 193

on the part of the citizens of a community, a lack of civic pride, and a failure to appreciate the danger from . . . ​this vile habit.” W ­ omen, especially schoolteachers, ­were among the most ferocious and effective agitators for better hygiene. In Chicago, they persuaded streetcar companies to print antispitting messages on one hundred million transfer tickets. In Cincinnati, Boy Scouts ­were mustered for painting ­DON’T SPIT on sidewalks.58 In short, Amer­i­ca was witnessing a “modern crusade,” said Theodore Roo­ se­velt on the occasion of his election to the presidency of the 1908 International Congress on Tuberculosis. Saving many of the two hundred thousand lives lost ­every year would remove “a most serious handicap to material pro­ gress, prosperity, and happiness,” especially in ­those walks of life “where the burden is least bearable.” The mix of planning and spontaneity, with funding and action volunteered by many sources, brought, Roo­se­velt said, “hope and bright prospects of recovery to hundreds of thousands of victims of the disease who u ­ nder old teachings w ­ ere abandoned to despair.” Sadly, however, the movement brought ­little cheer to African American citizens—­who needed it most. Prudential’s statistician Frederick Hoffman calculated that they died ­ irginia, of tuberculosis at twice the rate of whites in six cities in 1900. In V the mortality rate for African Americans was three times greater than for whites. In Baltimore, municipal activists carefully mapped, displaying for all to see, the ­great concentration of the disease in the Lower Druid Hill area (“the lung block”) and other ghettos. Every­one knew of the terrible crowding in “dilapidated shacks and filthy alleys” ­there and the connection between such living conditions and the disease. But the mention of a housing program for black Baltimoreans was a po­liti­cal taboo. At least one large insurance com­pany refused to issue any life insurance policies in t­ hose blocks. In 1913, an assistant commissioner of health chimed in with other victim blamers, excusing their indifference and inaction with comments on Blacks’ moral habits and “racial susceptibility.”59 In Philadelphia, the Henry Phipps Institute treated very few black residents u ­ ntil 1914, despite its location next to the city’s “black b­ elt.” Part of the prob­lem was African Americans’ fears of what might befall them in a white institution, and the other part was re­sis­tance from Flick’s colleagues and local medical leaders to treating black Philadelphians. It was not ­until the institute, now run by the University of Pennsylvania, enlisted the help of the John Greenleaf Whittier Centre, a mixed-­race philanthropic institution enjoying good working relations with black benevolent socie­ties, that African Americans began to be treated in growing numbers. Of ­great importance

194

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

was the hiring of Elizabeth Tyler, a black nurse with a mission to educate her ­people about tuberculosis and persuade them to entrust themselves to the institute. Her salary was paid by the Whittier Centre, headed by Henry Landis, a leading expert on tuberculosis and cofounder of the NASPT. The same year the Pennsylvania Department of Health began paying the salary of its first black physician, Henry Minton.60 Roo­se­velt may have been wrong about how much “hope and bright pro­ gress” the crusade was bringing whites as well. ­Because the steady rate of decline in deaths from tuberculosis remained more or less the same as it was before 1900, it cannot be assumed that the crusade made a difference. We can only speculate that the rate of decline may have slowed without it. The ­matter remains a subject of debate among epidemiologists, demographers, economists, and social historians. The doubts ­ were famously sown by Thomas McKeown, who attributed the preantibiotics decline exclusively to improvements in diet and other living conditions associated with economic growth. But evidence and reasoning offered by other authors supports the view that conscious collective action driven by a massive, unpre­ce­dented public health crusade explains at least some of the ongoing decline in tuberculosis deaths.61 THE LIMITS OF VOLUNTA R ISM

In the 1830s French observer Alexis de Tocqueville marveled at how Amer­ i­ca teemed with an “im­mense assemblage of associations” even “for the smallest undertakings.” In France and ­England, by contrast, governments or aristocratic “men of rank” controlled the kinds of ventures for which Americans constantly formed new organ­izations. Tocqueville would not have been surprised to find the hundreds of bustling antituberculosis organ­izations in the first de­cades of the twentieth ­century in American states and localities, linked together and partially funded by a national organ­ization. But to a certain extent, the United States was actually b­ ehind the curve compared to Scandinavia, where the strong and only minimally demo­cratized state helped promote private voluntarism. In 1895, King Oscar II of Sweden collected half a million dollars in private contributions to build sanatoriums to commemorate the twenty-­fifth jubilee of his reign. In 1904 and 1905, Denmark and then Sweden and Norway raised funds for tuberculosis work with the sale of “charity stamps.” The sale of stamps gave the Swedish association its chief source of income between 1905 and 1907 for educational work, among other t­ hings,



C a t t l e m e n , C o m m a n d e r s , C a p­i­t a l­i s t s , C r u s a d e r s 195

including a tuberculosis museum in Stockholm. Inspired by the Scandinavians, the NASPT introduced its Christmas Seals four years afterward.62 Medical progressives harbored no illusions about how much voluntarism could do for the public’s health. The antituberculosis campaign was a product of frustration with government indifference and inaction, not of an antigovernment ideology. They also regarded cap­i­t al­ist philanthropy, like Rocke­ fel­ler’s and Frick’s, as far from adequate given the host of huge public health prob­lems remaining. At first the AMA journal marveled at Rocke­fel­ler’s “magnificent gift” for hookworm eradication but l­ater withheld its breathless appreciation, noting the Florida government’s simultaneous pioneering role. As Kentucky’s g­ reat public health champion Joseph McCormack testified in Washington, the country should not have to wait for “a g­ reat captain of finance” to take an interest in a disease before badly needed research and preventive action could be undertaken. George Kober, Georgetown University’s dean of medicine and professor of hygiene, argued that the federal government should have been able to tackle hookworm disease “without looking to private philanthropy for assistance.” 63 As George Sternberg, army surgeon general and founder of American bacteriology, put it eloquently, “Why should we depend upon . . . ​the munificence of a Henry Phipps or a John D. Rocke­fel­ler for the extinction of tuberculosis and hookworm disease?” “We do not depend upon private enterprise for the defense of our seacoast from foreign foes or for the prevention of infectious diseases among our hogs and c­ attle.” Furthermore, according to Charles Chapin in his survey of state public health authorities, private money often came with unwelcome strings attached. Th ­ ere was “scarcely a health officer” who had not received help from “over-­enthusiastic” private donors with “hastily developed theories” who pressured the departments to divert their own funds “to lines of work of problematical value.” 64 Although Amer­i­ca’s defeat of yellow fever was a singular source of pride to biomedical scientists and public health reformers, they knew it had originated not as part of a public health mission per se but by a Department of War pursuing a strategic military objective. It was unlikely to tackle other diseases irrelevant to that mission. McCormack argued that even soldiers suffered from the lack of a civilian national health agency such as Japan’s. “The ­little brown men of Japan, a nation classed among the heathen, have a far lower death rate than we,” he lamented. It was a “shame and a disgrace” to Amer­i­ca that “the health of their army and navy in a­ ctual warfare so far outclasses ours.” 65

196

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

Thus, in 1907, McCormack joined dozens of medical, military, civic, philanthropic, business, educational, religious, and journalistic elites in a new organ­ization dedicated to the single task of agitating for what the AMA, before as well as a­ fter its reor­ga­ni­za­tion, had long demanded: a national department of health. Their new Committee of One Hundred on National Health, a paragon of progressive organization because of its mix of professional, governmental, business, and philanthropic members, called for stronger, wider-­ reaching, and more permanent institutional machinery for disease prevention than a military apparatus, capitalist philanthropy, or civic activism could ever build.

chapter 8

Health or Freedom

Two years a­ fter the Pure Food and Drugs Act passed in 1906, the proposal to create a power­ful federal health agency appeared on the national po­liti­cal agenda. Among Amer­i­ca’s medical progressives, optimism was in the air. In December 1908, President Theodore Roo­se­velt delivered a message to Congress declaring it a national disgrace that the federal government “takes more pains to protect the lives of hogs and c­ attle than of h ­ uman beings.” He therefore informed it of his desire to consolidate scattered health-­ related agencies into a single strong bureau of public health. Within a few months, his successor, William Howard Taft, called for the same t­hing: “that kind of Bureau which ­shall render, with reference to the ­human being, the opportunities for research and for information that we now through the Agricultural Department offer to the farmers.” The following year, Taft told a National Tuberculosis Congress that if the federal government had the unchallenged constitutional authority to spend $15 million a year to protect ­cattle and h ­ orses, “it does not seem to be a long step or stretch of logic to say that we have the power to tell how we can develop good men and good ­women.”1 ­There appeared to be a much broader and deeper consensus in the country b­ ehind the creation of a muscular federal health agency now than in the contentious 1880s, even if not precipitated by something like a yellow fever

197

198

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

epidemic and a groundswell of public calls for action that led to the creation of the ill-starred National Board of Health in 1879. The Republican Party’s 1908 national platform, endorsed by presidential candidate Taft, had called for “greater efficiency in National Public Health agencies and . . . ​such legislation as w ­ ill effect this purpose.” The Demo­cratic Party’s platform, endorsed by candidate William Jennings Bryan, went further, calling for a “National Bureau of Public Health” that would have “such power over sanitary conditions connected with factories, mines, tenements, child l­ abor, and other such subjects as are properly within the jurisdiction of the Federal Government.”2 Legislative action seemed a sure ­thing. The magazine Science, a publication of the American Association for the Advancement of Science (AAAS), gladly announced that no one seemed to be opposed while “the leaders in education and in hygiene are earnestly in ­favor of it.” Progressives ­were on the rise in both po­liti­cal parties, and they differed ­little if at all on the value of giving the federal government a stronger role in public health. The American Medical Association (AMA), the apparently unified voice of American medicine, had the ears of major politicians. Joseph McCormack, the former head of the Kentucky State Board of Health and now the AMA’s chief reor­ga­ nizer, actually helped draft the 1908 Demo­cratic Party platform to include a health bureau plank. He then got it ­adopted ­after obtaining a written endorsement from candidate Bryan, which he delivered to ­every member at the party convention. Charles Reed, a Republican who had led the AMA’s efforts to pass the Pure Food and Drugs Act, helped secure the inclusion of the health agency plank in the Republican party’s 1908 platform as well.3 The progressives in both parties knew that prominent physicians and eminent laymen stood b­ ehind their plan to consolidate practically all health-­ related responsibilities scattered across the federal bureaucracy into one place. Perhaps it would be a new bureau inside the departments of the Trea­sury, Interior, or Commerce and L ­ abor. Better yet, most medical reformers thought, would be a cabinet department unto itself led by a secretary, a high official confirmed by the Senate who had the president’s ear and was answerable only to him. Currently, chaos and inefficiency reigned ­because of misplacement, fragmentation, duplication, and rivalries across numerous in­de­pen­dent bureaus. For example, vital statistics needed to be collected by health department experts, not the Census Bureau statisticians, to track disease, inform epidemiological research, and monitor the success of prevention mea­sures. It made no sense for the Agriculture Department’s Division on Purification of ­Water Supplies to investigate w ­ ater sources when h ­ umans w ­ ere more at risk



H e a lt h o r F r e e d o m

199

than plants and livestock. Public health disorder would be remedied, according to the eminent public health expert George Kober—­quoting a National Acad­emy of Sciences report—by “a rational correlation of allied branches of scientific work” in the federal government.4 Equally impor­tant, a centralized health bureaucracy would be able to reduce corruption in health policy-­making and implementation. Agencies now charged with health-­related activities ­were often more solicitous of diverse, selfish, and often contradictory bud­getary, revenue, jurisdictional, and commercial interests than the health of the ­people. As the Journal of the American Medical Association put it in 1912, “The only place for the health work of the government is in a department of its own, where h ­ uman life w ­ ill come first, and business considerations ­will take second place.” As long as health ­matters remained in departments “where material, commercial influences prevail, they ­will be hampered, and to a certain extent nullified!”5 THE COMMITTEE OF ONE HUNDRED

The wave of optimism for a national health bureau or department a­ fter 1908 was preceded by the amalgamation in 1907 of a broad array of lay and medical forces in a single new organ­ization called the Committee of One Hundred on National Health (COH). It was sponsored by the AAAS and headed by an economist, Irving Fisher. In 1906, J. Pease Norton, Fisher’s colleague at Yale University, had used his calculations of the country’s huge economic losses from preventable sickness and premature deaths to persuade the AAAS to set up the committee. The COH’s two main tasks w ­ ere to sponsor and coordinate activities to educate the public about health and thereby build support for its second mission, the creation of a national department of health.6 AMA leaders ­were prominent activists in the COH. They had already done much of the groundwork leading to nationwide interest in a national health department in alliance with laypeople, especially t­ hose involved in the antituberculosis movement. In 1906, Joseph McCormack spearheaded the AMA’s public education work during his recruitment travels across the country when he began to include talks to laypeople. His initiative culminated in the formation of the AMA’s Council on Health and Public Instruction, whose Bureau of Public Instruction would be run by Henry Favill, Chicago’s civic ­ abor and medical progressive and member of the American Association for L Legislation. Also in 1906, a national Public Health Defense League formed in New York and absorbed vari­ous state and local entities. It started as an

200

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

antiquackery and antinostrum movement but quickly took on broader public health concerns, including the need for a national health department. It was then taken over in 1907 by the COH and renamed the American Health League, which absorbed other such organ­izations and claimed a subscribership of about three thousand in 1908. William Welch, who would soon serve as AMA president in 1910 and 1911, was one of its vice presidents. One of its directors was physician Livingston Farrand, secretary of the National Association for the Study and Prevention of Tuberculosis and trea­ surer of the American Public Health Association (APHA).7 According to McCormack, the COH’s formation came unexpectedly despite the AMA’s “years of unselfish and apparently unappreciated effort” in promoting a health department. One reason for the delay and surprise was the medical profession’s still tarnished reputation among laypeople, according to a conversation McCormack had with Fisher while together on assignment on President Theodore Roo­se­velt’s National Conservation Commission, appointed in 1908. Roo­se­velt had enlisted Fisher for his conservation commission upon having learned of the COH’s ambitions on behalf of “national health . . . ​our greatest national asset.” At their first encounter, McCormack learned that Fisher, a fanatic for healthy living and, relatedly, a therapeutic skeptic, “had not seen the best side of our profession.” He therefore harbored many unflattering prejudices common among layfolk—­“only more frankly expressed.” McCormack therefore implored Fisher to take a closer look at the medical profession’s or­ga­nized activity, with the result that the “remarkable man” soon became “one of our most appreciative friends.”8 Presidential advisor Fisher was a brilliant economist, celebrated t­ oday for his seminal contributions to mathematical and monetary economics. Writing in 1951, the renowned Austrian economist Joseph Schumpeter declared Fisher to have been the greatest economist that Amer­i­ca had ever produced. ­Later, Paul Samuelson, the twentieth c­ entury’s most influential economist, declared Fisher’s Mathematical Investigations in the Theory of Value and Price “the greatest doctoral dissertation ever written.” Alongside economics, Fisher had a deep and abiding interest in m ­ atters of personal hygiene and public health. Having survived a frightful b­ attle with tuberculosis as a young man, he became a lifelong fanatic for healthy living, jogging to his Yale classes in shorts when the weather permitted and even cycling during the cold New Haven winters. A teetotaler and coffee abstainer, he took his ­family for yearly visits to John Harvey Kellogg’s ­Battle Creek Sanitarium in Michigan for hydrotherapy, exercise, a vegetarian diet, and careful study of their fecal output.



H e a lt h o r F r e e d o m

201

Between 1910 and 1915, Fisher published over seventy health-­related articles. In 1916 he coauthored the popu­lar How to Live: Rules for Healthful Living Based on Modern Science. It assembled, for example, disparate evidence on the health risks of tobacco, including insurance industry research showing a lower life expectancy for users. Ex-­president Taft wrote the foreword.9 Fisher’s least flattering distinction, seen in hindsight, was his enthusiasm for “eugenics,” especially the sterilization of criminals, the insane, and “imbeciles.” However, he rejected radical eugenicists’ social and biological Darwinism, which held that helping the diseased and physically infirm went against the societally hygienic benefits of “natu­ral se­lection.” His interest in physical health also put him among the vanguard of progressives seeking improvement for the American industrial working class with reduced working hours and safer working conditions. On t­ hese t­ hings, he noted, America was ­behind other “civilized countries.” Better industrial hygiene and reduction of occupational disease, he believed, could add up to two de­cades to a worker’s life. Around 1911, with Fisher’s help, the American Association for ­Labor Legislation (AALL), whose Commission on Industrial Hygiene AMA leader Favill chaired, obtained legislation prohibiting the use of white phosphorous in matches. This cause of the dreadfully painful and disfiguring “phossy jaw” had already been prohibited in Eu­rope a full fifteen years ­earlier. ­Later that de­cade Fisher would become an out­spoken advocate of compulsory health insurance, mostly ­because it would serve a preventive function, not just provide sick pay and indemnify the insured for medical bills. “Health insurance ­will afford a very power­ful and pervasive stimulus to employers, employees, and public men to take fuller and speedier advantage of pos­si­ble health saving devices,” he argued in 1917.10 One quarter of the COH’s one hundred founding members w ­ ere from the top of medicine’s overlapping scientific, educational, clinical, military, and orga­nizational reform community. Predictably, the el­derly John Shaw Billings, progenitor of the defunct National Board of Health, was pre­sent in the first list of members. Accompanying him w ­ ere many in the younger generation of reformist prac­ti­tion­ers, professors, and public health leaders in the AMA, the APHA, and the antituberculosis movement. Along with McCormack, other AMA officials and activists ­were Favill, Frank Billings, Charles Reed, George Simmons, and William Welch. Other medical and public health luminaries ­were Farrand, Hermann Biggs, L. Emmett Holt, Adolphus Knopf, George Kober, Quitman Kohnke, Edward Trudeau, and Harvey Wiley. Notable among the laypeople who attached their names as founding members of the COH

202

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

­ ere publishers and journalists Samuel Hopkins Adams, Edward Bok, Norw man Hapgood, Samuel S. McClure, and Walter Hines Page, all of them advocates of vari­ous medical and public health reforms. Current or former university presidents on the COH w ­ ere Charles W. Eliot of Harvard and James B. Angell of the University of Michigan, both engineers of higher education reform, including in medicine. Other members ­were John Ireland, the archbishop of Saint Paul, Minnesota, a friend of multiple progressive presidents and, ­because of his liberalism, a failed aspirant to a cardinalship; Gifford Pinchot, chief forester in the Department of Agriculture and Roo­se­velt’s lead conservationist; Booker T. Washington, the African American community’s premier leader; Jane Addams, the famous Chicago social worker and Hull House leader; and economists and champions of social reforms for the working class John R. Commons and Henry R. Seager, both founding members of the AALL. When invited to join, former U.S. president Grover Cleveland expressed “complete sympathy” but declined on grounds of old age. Standing in for him was his doctor, Joseph D. Bryant, a former New York City health commissioner and the AMA’s president in 1907 and 1908.11 The COH was, in a sense, a cross-­class alliance. Steel industrialist and philanthropist Andrew Car­ne­gie signed on, as did workers and farmers represented by leaders of the American Federation of ­L abor (AFL), the United Mine Workers, and the Grange. Another prominent cap­i­tal­ist, the chairman of the COH’s executive committee, was drug ­wholesaler William Jay Schieffelin of the Wholesale Druggists’ Association, the only somewhat progressive ele­ment of the drug industry. The most impor­tant cap­i­tal­ist contingent on the COH came from the insurance industry. They included Lee Frankel, the antituberculosis crusader from Metropolitan, and Hiram Messenger of Traveler’s Life Insurance Com­pany. The insurance industry’s resounding support for legislation and government action was key, Fisher told a meeting of the Association of Life Insurance Presidents (ALIP), b­ ecause the “best success of any movement is found only when, in a sense, it reaches the commercial stage—in other words, when it is made to pay in some tangible way.” Cap­i­tal­ist philanthropy alone “becomes a broken reed if depended upon for its support continuously or on a large scale.”12 The fire insurance and employer liability insurers had gotten state laws passed “to prevent accidents to life and limb,” Fisher knew, and he hoped the life insurance industry would do the same to prevent deaths. In an appeal for support from the insurance industry, he even expressed a willingness to let



H e a lt h o r F r e e d o m

203

its leaders take the lead in formulating and pushing legislation, even if it was best that the endeavor had a “scientific as well as commercial flavor.” Fisher’s proselytizing paid off. The leading insurance executives created a ­Human Life Extension Committee to assist in passing public health legislation throughout the country. Life insurance companies helped the COH by disseminating health prevention lit­er­a­ture to millions of policyholders. It contained arguments for a national department of health that the policyholders could convey to their po­liti­cal representatives. Satisfied with his work, Fisher observed, “For once dollars have the same interest as lives.”13 THE OW EN BILL

Despite the COH’s impressive lay-­medical and cross-­class lineup, Congress did nothing during the COH’s first three years. Some bills ­were submitted calling only for strengthening the Marine Hospital Ser­vice (MHS; now called the Public Health and Marine Hospital Ser­vice, or PHMHS), perhaps to head the progressive movement off at the pass, but they got nowhere. It was the calm before the storm. Then, on February 1, 1910, Senator Robert Latham Owen of Oklahoma submitted a bill calling for a cabinet-­level department of public health. All departments and bureaus except military ones “affecting the medical, surgical, biological, or sanitary ser­vice, or any questions relative thereto” ­were to be combined. It would gather scientific data on disease and impose and enforce quarantine regulations. The new department was slated to wrest the PHMHS away from the Trea­ sury Department. Even more controversial was the bill’s call, b­ ecause of interspecies transmission, for the federal health department to take over responsibility for “diseases of animal life” from the Bureau of Animal Industry (BAI). For establishing “chemical, biological, and other standards,” the Owen bill also called for the Agriculture Department to hand over most of the work of its Bureau of Chemistry (BOC), which had been charged in 1906 with duties associated with the Pure Food and Drugs Act.14 A populist-­progressive Demo­crat from the new state of Oklahoma, Owen was a champion of other reform c­ auses like tariff reduction, prohibition, and abolition of child l­abor. Part Cherokee, he helped passed legislation in 1901 granting citizenship to Native Americans. L ­ ater, in 1913, he would be the chief Senate sponsor and architect of the law creating the Federal Reserve System, a Progressive Era move to sanitize and stabilize the country’s banking system, which was so far only privately regulated by J. P. Morgan’s “money trust.”

204

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

Owen’s admiration for ­women in civic and po­liti­cal life, and his deference to them on health m ­ atters in par­tic­u­lar, may have helped prod him into action for public health. He often came to the defense of ­women’s ­causes “sometimes to my ridicule, but nobody can laugh it out of me, b­ ecause I believe in them; and I believe they are more interested in the health of the c­ hildren of this country than the men are.” They ­were “a power­ful agency of instruction” for “the preservation of life.” The fervent advocate of ­women’s suffrage was appalled by the benighted views of power­ful men who obstructed pro­gress. When he spoke to the Senate on hookworm disease, he recalled that “two of the able and learned Senators on the floor” r­ ose to denounce the expert—­ perhaps Connecticut’s Charles Stiles—­whom he quoted on the ­matter. They ­were prob­ably Southerners, fellow Demo­crats, worried about the health of their states’ tourist business if fear of hookworm disease got into the heads of potential visitors from the North.15 In an impassioned speech justifying his health department bill on the floor of the Senate, Owen decried the death of seventeen hundred ­human beings ­every day, at a cost of a billion dollars annually, “due to polluted ­water, impure and adulterated food and drugs, epidemics, vari­ous preventable diseases—­ tuberculosis, typhoid and malarial fevers—­unclean cities, and bad sanitation.” Drawing on Fisher’s and Norton’s estimations, he told fellow senators that around three million ­people ­were suffering from serious illness at any one time, adding to the misery and economic costs of preventable deaths. Alluding to the power­ful Department of Agriculture, he asked why plant and animal life should be “worthy [of] a g­ reat department” while h ­ uman life was not. His appeal was not based on “humanity and patriotism alone” but also on “the cold basis that ­ought to appeal to the commercial instinct of the Nation, even if some men in the insane race for commercial and financial power and prestige seem to have forgotten the value of ­human life and of h ­ uman happiness.”16 Noting the irrationality of scattering vari­ous health-­related activities across the federal bureaucracy, Owen focused on the placement of the PHMHS in the Trea­sury Department, where commercial and fiscal interests “triumphed over the interests of the public health.” The PHMHS, a “miserable,” “weak,” and “subordinate ­little bureau,” was “pitiful, if not despicable as an agency of an enlightened Nation.” To illustrate his case, Owen cited San Francisco’s bubonic plague emergency of 1900, when Trea­sury Secretary Lyman Gage, a former and f­ uture bank executive, denied the PHMHS’s request to publicize a report on the plague’s presence, which it had dispatched a commission of preeminent bacteriology and infectious disease experts, Lewellys Barker, Fred-



H e a lt h o r F r e e d o m

205

Senator Robert Latham Owen (1856–1947), circa 1910. An Oklahoma Demo­crat and part Cherokee, Owen sponsored numerous progressive reforms supporting Native Americans, bank regulation, tariff reductions, suffrage for w ­ omen, and AMA-­sponsored bills for a national department of health. From the Library of Congress, LC-­USZ62-115124.

erick Novy, and Simon Flexner, to California to confirm. Gage had submitted to pressure from the California governor, the Southern Pacific Railroad, and three San Francisco newspapers (the Chronicle, the Examiner, and the Bulletin), who wished to suppress the commission’s report. The truth came out only when leaked to the AMA journal, two other medical journals, and the Sacramento Bee. In short, Owen said, “The commercial interests of San Francisco had triumphed over the bureau and compelled the Surgeon-­General . . . ​ by an order of his superior officer, the Secretary of the Trea­sury, to agree to suppress this report.” It was “a national scandal.”17 Curiously, Owen attributed his legislative initiative neither to the COH nor the AMA, maintaining that he had had no prior personal connections with them or knowledge of their activities. Instead, he named his ­brother, Major William Otway Owen, an army surgeon and po­liti­cally active sanitarian, as the progenitor. Indeed, according to Major Owen, he drafted the first version of the evolving Owen bill. It was not the army officer’s first lawmaking endeavor. In 1901, a­fter learning that unhygienic conditions had felled roughly 80 ­percent of Americans who had died in the Spanish-­A merican War,

206

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

mostly ­because of typhoid fever, he drafted legislation protecting medical officers from prosecution for breach of discipline if they argued with line officers on sanitary questions. He also called for court martial proceedings against commanding officers guilty of sanitary negligence that led to deaths ­either from disease or from combat injuries sustained ­because of enfeeblement by a preventable illness.18 It is highly likely, however, that t­ here had been lines of prior communication between some COH members and Owen’s ­brother, especially military members of Fisher’s committee. Perhaps one or more of them had approached Major Owen to recruit his b­ rother to command a bold legislative campaign in the Senate. On Fisher’s committee was army chief of staff General Leonard Wood, who as military governor of Cuba had backed William Gorgas’s war on yellow fever mosquitoes. Gorgas was also on the committee. Other military men ­were army surgeon general Robert M. O’Reilly and navy surgeon general Presley M. Rixey. General George Sternberg, the el­derly former army surgeon general and pioneering bacteriologist, could well have been a source of prodding. The AMA’s president for its 1898–1899 term, Sternberg had once been Major Owen’s superior officer and was in contact, as trea­surer of the National Association for the Study and Prevention of Tuberculosis, with other COH members. He was still active in retirement with tuberculosis and other public health work. As a proponent of “hygienic housing,” he chaired President Roo­se­velt’s Homes Commission in 1908 and, as a member of the Committee on Permanent Relief of the Poor in Washington, DC, pushed for the same.19 A most auspicious moment for the Owen bill came when President Taft began insisting on a new cabinet department instead of just a “strong health bureau” h ­ oused in an existing department. In fact, according to Owen, Taft “told me flatly that he would veto a bill for a Bureau and would approve a bill for a Department.” Now with the wind in their sails, the COH and the AMA happily abandoned their e­ arlier, more modest position on a bureau in the Department of the Interior taken in deference to President Roo­se­velt. Also auspicious was the ease with which Owen and the COH rounded up supportive letters and testimonials from eigh­teen state governors, large numbers of state health departments, and many other private as well as public interests and agencies. The National Grange and the Farmers’ Educational and Cooperative Union, progressive ele­ments in agriculture, expressed support. Despite frequent industrial conflict, especially in the iron, steel, coal-­mining, textile,



H e a lt h o r F r e e d o m

207

and clothing industries, t­ here was nothing but cross-­class harmony over public health. The large United Mine Workers’ Union, eleven AFL u ­ nions, the International Association of Machinists, and the AFL itself responded with earnest expressions of support to the Senate Committee on Public Health and Quarantine. In Senate hearings, an AFL representative argued that employers would profit from lower rates of diseases such as tuberculosis that sapped productivity. Fisher conveyed to the committee the support of forty-­one city chambers of commerce and boards of trade, including from major industrial hubs like Akron, Allentown, Cleveland, Erie, Indianapolis, Minneapolis, Rochester, Syracuse, and Worcester. Although the National Association of Manufacturers and National Chamber of Commerce ­were s­ ilent, possibly b­ ecause of drug interests in their ranks, the AMA’s Committee on National Legislation, chaired by AMA president John B. Murphy, voiced optimism that the two national business organ­izations ­were ready to contribute financially ­toward lobbying efforts for the Owen bill.20 No fewer than twenty insurance industry executives across the country sent letters of endorsement to the Senate. To meet objections that public health mea­sures would require more taxes, the general counsel of the ALIP testified in Congress that the federal government gladly paid for the prevention of animal diseases such as hog cholera. Sadly, however, “I do not believe the American ­people yet understand that it costs money to raise men just as it costs money to raise ­horses.” Metropolitan’s Frankel suggested a benefit associated with longer life expectancy shared by the insurance industry and policyholders alike: more sales of better policies for lower premiums. Equitable’s medical director noted the commercial advantages of good vital statistics—­which the Census Bureau was currently unable to collect for half of the population—­ and other public health information to make efficient pricing and marketing of insurance policies pos­si­ble. Currently, according to the AMA journal, the country’s vital statistics ­were in poor shape ­because in the department of Commerce and ­Labor, which ­housed the Bureau of the Census, “statistics on iron and steel, coal and copper are more highly esteemed than figures on death and disease.”21 The AMA made quick preparations to mobilize medical support and thereby help push through something like the Owen bill, just as it had the 1906 Pure Food and Drugs Act. In 1910, the AMA House of Delegates unanimously ­adopted by a “rising vote” the basic princi­ples of the Owen bill and

208

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

established a Committee on a National Department of Health to advise Owen. The eight-­member committee, which included Hermann Biggs, Joseph McCormack, and other eminent public health leaders, elected AMA president Welch as its chairman. The new committee was to work with and supplement the efforts of the Council on Public Health and Instruction, headed by Favill, on which McCormack also sat. Together they prompted scores of state and county medical socie­ties to send endorsements of Owen’s bill that he could convey to the Senate.22 THE NATIONA L LE AGUE FOR MEDICAL FREEDOM

Optimism in the expansive medical, civic, and cross-­class co­a li­tion for public health action grew with the introduction of the Owen bill in 1910. But then came a rude surprise with the sudden formation of a new National League for Medical Freedom (NLMF) to fight the Owen bill. Its hosts of diverse funders and supporters had one ­thing in common: hatred of the AMA, which it portrayed as the main force b­ ehind the Owen bill. In May 1910, less than two months ­after Owen’s Senate speech, newspaper readers across the country saw large NLMF advertisements announcing its intention “to defeat this or any other such paternal, unnecessary, extravagant, un-­A merican medical legislation.” Within weeks ­after its inception, the NLMF had raised enough money to send 560 lines of advertising type on ready-­to-­use printing matrices to at least one hundred newspapers from coast to coast. Along with them came contract offers for ten thousand more lines. In 1911, the league also began distributing a magazine, Medical Freedom, for a small subscription fee. Local branches of the NLMF that sprang up bought and distributed over one hundred thousand copies of each monthly issue.23 A prominent advertising agency estimated the cost of the 1910 advertisements to have been around $50,000, a large sum for the time. The New York Times ran one of them but published an editorial strongly critical of the NLMF the following day, declaring that “the entire press of the United States” supported the Owen bill. That was inaccurate ­because the New York Herald broke with its other­wise progressive tendencies and supported the NLMF in editorials and front-­page articles. The advertising campaign was an “unheard of” event in the history of the publishing industry, according to the trade magazine Printer’s Ink. Indeed, it was the first modern public relations campaign for a national po­liti­cal movement. The H. E. Lesan Advertising Agency had



H e a lt h o r F r e e d o m

209

persuaded the NLMF to skip the slow and expensive booklet and circular route and go straight to the country’s newspapers for production and distribution. A brilliant success, it yielded within one week around one hundred thousand requests for membership on forms clipped from the newspaper ads. Printers’ Ink, a trade journal for advertising executives, reported furthermore that although the ads had not called for membership fees or donations, “many hundreds of dollars came in e­ very day in small bills.” By 1911, the NLMF boasted of around two hundred thousand nominal members rounded up with ­these methods. If the word of Executive Secretary Paul Harsch can be trusted, the membership peaked at close to a half-million.24 The founder and president of the NLMF was publisher and journalist Benjamin Orange Flower. That came as a surprise to tuberculosis expert and antituberculosis crusader Adolphus Knopf, who had once admired Flower for being “a fighter for every­thing involving the spiritual, social, and physical pro­ gress and humanity.” Indeed, starting in the 1880s, Flower had achieved some fame as a tireless champion of many populist, progressive, and even socialist ­causes. Inheritor of his ­family’s long radical tradition as abolitionists and w ­ omen’s rights advocates, Flower was the editor of three magazines with literary, social, po­liti­cal, and religious content that he had founded in the 1880s—­t he American Sentinel, the American Spectator, and the Arena—­ followed by the Twentieth C ­ entury Magazine, which he started in 1909. He published many hundreds of righ­teous articles and editorials against sweatshops, child and female ­labor, tenement housing, and the evils of corporate industry and monopolies. He advocated for ­labor market reforms, improving the ­legal and po­liti­cal status of ­women, populist economic and tax reforms, elimination of corruption, electoral reforms, conservationism, and the same kind of paternalist eugenics Fisher espoused. He praised reformers and radicals such as social worker Jane Addams and Socialist l­abor leader Eugene Debs. And he extolled other countries’ reformist politics as models to be copied in Amer­i­ca.25 As a favorable historical appraisal of Flower puts it, practically any new idea or reform, “­whether profound or absurd, engaged his curious, sympathetic attention.” But it also concluded that he wielded effusive, repetitive, and humorless prose with only “mediocre ­mental equipment.” Fascinated by “psychic phenomena,” Flower believed that mass telepathy, “by influencing public sentiment,” might even be a force for social reform. Truth be told, some of Flower’s evolving views around 1910 may have been symptomatic of an ongoing ­mental unhinging. A Unitarian, he would descend ­after his NLMF

210

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

phase into a poisonous anti-­Catholic nativism. Flower died in 1918 a­ fter finishing his publishing ­career with Menace, a rabidly anti-­Catholic journal—­ the most successful of a slew of such magazines—­and a forum for his views that the pope had caused World War I and that the Catholic Church was out to destroy American democracy.26 The NLMF’s prob­lem with the Owen bill, Flower insisted, was not its public health purposes. The NLMF advertisements averred that “mind you, the League is not opposed to sanitation or quarantine properly administered . . . ​ nor is it opposed to the needed work of the state, county or municipal authorities along ­these lines.” The prob­lem was that public health was a fraudulent pretext, a Trojan h ­ orse for disgorging sinister forces into the body politic by a grasping, monopolistic, and dictatorial AMA. B ­ ehind the Owen bill was a conspiracy to monopolize and dictate medical practice through federal action. “Do you want government by po­liti­cal doctors? . . . ​Do you want your health and hygiene to be regulated by an army of United States inspectors ­under the direction of a medical bureau?” the NLMF ads asked. In his Twentieth C ­ entury Magazine, Flower wrote that a department of health would result in “a medical hierarchy as dangerous and oppressive as has been any religious hierarchy that has blighted civilization, retarded pro­gress and oppressed ­people in the past.”27 Speaking on behalf of disaffected prac­ti­tion­ers from irregular sects, including some homeopaths and many eclectics, Flower characterized the Owen bill as “the entering wedge in the well-­matured plan of the po­liti­cal doctors of the dominant school to ‘control American medical practice.’ ” Fisher’s committee, despite its illustrious members from a wide range of occupations, was merely the AMA’s tool, as was Robert Owen, who had called the AMA “the greatest medical association in the world.” Thus, the AMA journal argued, the NLMF’s real purpose was not to defeat the Owen bill but to “disrupt the American Medical Association.” Flower’s ferocious hatred of the organ­ization was consistent with his populist inclination to see badness in all bigness, a menace in all mono­poly. The AMA, the Roman Catholic Church, and the Union Pacific Railroad ­were in the same com­pany. Flower may well have authored an NLMF pamphlet called “The Po­liti­cal Doctors’ Slick ­Little Joke,” which asserted that Fisher’s committee had been prophesied in the Bible and that the AMA, “the medical arm of papacy,” was “the pivot on which the old earth of error is to swing into the new heaven and the new earth of revelation.”28 The influential New York Herald lent the NLMF’s paranoid rhe­toric credibility, although it l­ater changed its stance. In “Hoots for Doctors’ Trust,” it



H e a lt h o r F r e e d o m

211

Editorial cartoon in the New York Herald Tribune, 1910, reprinted in the National Druggist, opposing the AMA for its support of the Owen bill for a national department of health.

called the idea of a national health department “medical feudalism,” an AMA proj­ect to create “a power­ful machine” for controlling the practice of medicine. An editorial in the newspaper depicted the AMA as a top-­hatted, bug-­eyed, evil looking “Doctopus,” with tentacles curled around a national department of health, hospitals, quarantine regulation, immigration, food, surgery, vivisection (and a terrified laboratory animal), and, of course, a mortar and pestle labeled “Drug Stores.” The blustery, eccentric Chicago surgeon George Frank Lydston, the AMA’s fiercest internal critic, also lent the NLMF creditability. He bitterly resented, among other ­things, having been overlooked for the editorship of the AMA journal. In his testimony in the House of Representatives, the NLMF’s chief ­legal counsel Fred Bangs quoted from Lydston’s “The Rus­sianizing of American Medicine,” published by the Southern Practitioner: “Medical positions ­under the United States government—­controlled by the machine. Medical appointments ­under the State—­controlled by the machine. Medical officers in city or county—­dispensed by the machine. Number and organ­ization of medical colleges and personnel of medical faculties—­controlled

212

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

by the machine. Journals which s­ hall be published and organ­izations which we may join—­controlled by the machine.”29 DRUGLESS HEALERS

The brains, backbone, and muscle of Benjamin Flower’s anti-­Owen bill movement w ­ ere ­people with money and other sources of power, not average citizens receptive to the NLMF’s populist and paranoiac propaganda against a proj­ect enjoying solid support from Amer­i­ca’s medical, scientific, economic, and civic elites. The two hundred individuals listed as members of the NLMF Board of Advisors included a smattering of somewhat prominent po­liti­cal, professional, and business figures. None had the stature, however, of the COH signatories. Th ­ ere w ­ ere former governors of Mas­sa­chu­setts and New Hampshire; Iowa’s secretary of state; the mayor of Pasadena, California; an ex-­mayor of Indianapolis; an ex-­president of the Chicago Municipal Voters’ League; an attorney with the Civil Ser­vice Commission of Chicago; and the dean of the University of Minnesota Law School. But more industrialists signed on than ­were pre­sent on the COH list of signatories, including the presidents of Western Union and Otis Elevator, as well as executives from an Indianapolis iron works, a large Pittsburgh glass manufacturer, a Milwaukee steel foundry, and a Portland, Oregon, transit and utilities com­pany.30 Prob­ably, many of ­these notables ­were devotees of “drugless healing,” especially Christian Science, and therefore detractors of mainstream medicine. Toledo developer Paul Harsch, for example, the NLMF’s executive secretary, was a Christian Science follower. Christian Science was one of a number of drugless healing sects ferociously hostile to the AMA and therefore anything it touched. Founded by the eccentric Mary Baker Eddy in the 1870s but spreading rapidly of late, Christian Science rejected all medical intervention, be it by physicians or self-­medicators duped by patent medicine advertising. Vaccinations and surgeries w ­ ere also rejected. According to Christian Science, illness, like other forms of evil, was merely the absence of Christian faith and therefore not, strictly speaking, “real.” Thus, doctors’ and their patients’ belief in medical relief and cures w ­ ere but fevered imaginings of the spiritually sick. Regular doctors caused such sickness by merely conjuring fears of disease, a particularly insidious form of iatrogenesis. With faith, psychosomatic manifestations of illness would be exorcised. B ­ ecause of ­these views, spreading since the 1890s and into the first de­cade of the twenti-



H e a lt h o r F r e e d o m

213

eth c­ entury, Christian Scientists w ­ ere not accorded the forbearance that homeopaths and eclectics got from the regular medical profession. Eddy came ­under withering criticism in the AMA journal. Calling her a “profitess,” it publicly diagnosed her as suffering from “­mental malady,” “hysteria,” and “­grand psychosis,” all consistent, supposedly, with her e­ arlier life of tantrums, fits, seizures, obsessive-­compulsiveness, phobias, catalepsies, and megalomania. Furthermore, it pointed out, she had had two failed marriages and had abandoned a young son.31 Eddy’s followers ­were “quacks” and worse, according to regular physicians. They stood by while terrified ­children choked to death during a potentially fatal phase of diphtheria when a tracheotomy could save them. Public health crusaders held that acting as if ­there was no such ­thing as disease, and therefore not reporting it, was a crime against public health. Thus, an AMA journal editorial in 1899 called Christian Scientists “Molochs to infants, and pestilential perils to communities in spreading contagious disease.” Newspapers ­under the sway of mainstream medicine gladly conveyed the sensational message. The New York Times called Christian Scientists “murderous fanatics” and “homicidal charlatans” who “kill, and kill unpunished,” as when a typhoid victim in Ohio died a­ fter his wife refused to carry out a regular practitioner’s ­orders and instead obeyed ­those of their tenant, a Christian Scientist. The AMA’s Charles Reed accused Christian Scientists of wanting to “impose the tyranny of their selfish interests” and of favoring the spread of disease so “they may make money by imposing upon ignorant credulity the ridicu­lous doctrine that ­there is no such ­thing as disease.” He even went so far as to accuse Christian Scientists of “conspiring to propagate disease” for their own monetary benefit by supporting the NLMF.32 Enforcement of licensing laws against Christian Scientists added to the searing insults. Reed, as a member of the Ohio State Board of Medical Registration and Examination in 1898, had vowed to use criminal prosecution to “drive ­these ­people out of practice.” Before 1905, in a total of thirty-­eight states, legislation had been introduced, though only occasionally passed, prohibiting Christian Science in some way or requiring standard scientific training of its prac­ti­tion­ers in compliance with medical practice acts. Occasionally, Christian Scientists w ­ ere prosecuted for accepting money for treating the sick without a license and for manslaughter resulting from failure to intervene medically. Perhaps out of concern for her followers’ welfare, Eddy encouraged them in 1901 and 1902 to report contagious diseases when the law required it

214

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

and to let their c­ hildren be vaccinated where it was compulsory—­while seeing to it “that your mind is in such a state that by your prayers vaccination ­will do the ­children no harm.”33 The fierce antagonism between the regular medical profession and Christian Science and other drugless healers can explain why William D. Baldwin, president of Otis Elevator Com­pany, joined the NLMF advisory board. Baldwin was chairman of the board of trustees of New York City’s Second Church of Christ, Scientist, and for a time its First Reader. But he was a progressive in other regards, as in his friendly relations with skilled trade u ­ nions and a supporter of unemployment insurance. Other industrialists on the advisory board included W. R. Brown, vice president of the Brown-­Ketcham Iron Works of Indianapolis, and Benage S. Josselyn, president of the Portland Railway, Light, & Power Com­pany, who actually advertised himself as a Christian Science practitioner. Board member John Pitcairn, chairman of Pittsburgh Plate Glass Com­pany, was a Swedenborgian and therefore also a devotee of spiritual healing. He was president of the Anti-­Vaccination League of Amer­i­ca, in which many Christian Scientists ­were also to be found. James E. Patton, Pitcairn’s close associate, who headed Pitcairn Varnish Com­pany, a Pittsburgh Plate Glass subsidiary, was an avowed and active Christian Scientist. The wealthy Chicago industrialist Avery Coonley, ­future president of the National Association of Manufacturers and a leading member of the Illinois branch of the NLMF, was chief of his state’s Christian Science publishing operations. Another Christian Scientist among businessmen associated with the league was H. E. Lesan, of the Lesan Advertising Agency, which handled its advertising.34 Benjamin Flower was not a Christian Scientist, but as an admirer of the Social Gospel movement, he welcomed any challenge to mainstream Chris­ tian­ity. Perhaps he was influenced by one of his numerous b­ rothers, the irregular healer Alfred Hollis Flower. A. H. Flower was an 1889 gradu­ate of the American Health College in Cincinnati, chartered in Ohio for teaching the “Religious Spiritual Vitapathic Systems of Health and Life, for Body and Soul.” In 1897, b­ rother Alfred published a tract on w ­ holesome prevention and gentle curatives, “Thought as a Therapeutic Agent,” “The H ­ uman Hand in Disease,” “Good as a ­Factor of Health,” and “Diet for Consumption.” In 1910, Flower published Christian Science as a Religious Belief and Therapeutic Agent, presenting it as “a vital moral agent in a society that was becoming more and more sordid and grossly materialistic.” He feathered the NLMF’s cap by recruiting American Red Cross Society founder Clara Barton to its



H e a lt h o r F r e e d o m

215

Mary Baker Eddy (1821–1910), founder in 1879 of the Church of Christ, Scientist. Eddy was the spiritual leader of advisory board members of the National League for Medical Freedom, which characterized the Owen bill for a national department of health as the AMA’s desired tool for obtaining mono­poly control over the practice of medicine. From the Library of Congress, LC-­USZ61-215.

board, a friend and effusive admirer of Eddy, although she was not a Christian Scientist herself.35 Other drugless healers appeared on the NLMF’s list of advisors, among them Andrew Taylor Still, who founded the new school of osteopathy in 1892, and his son Charles, along with the chairman of the American Osteopathic Association. To be sure, all irregulars did not oppose the idea of a national department of health. Homeopaths, who prescribed drugs, ­were divided. In Pennsylvania, differences w ­ ere associated with a rural-­urban split, with Philadelphians, for example, on the side more friendly to the AMA. Some homeopaths ascribed to a spiritual theory of their school’s efficacy, which might help explain their presence in the NLMF. But many Owen bill supporters came from the leadership ranks of the American Institute of Homeopathy and several state socie­ties. The North American Journal of Homeopathy published an editorial strongly favoring the Owen bill. Homeopath Eugene H. Porter, health commissioner of the state of New York, heartily endorsed the national

216

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

department of health movement. James Gregg Custis, ex-­president of the International Homeopathic Medical Congress, was a member of the Fisher committee. Francis B. Kellogg, president of the California State Homeopathic Society, spoke out aggressively against the NLMF’s efforts to “exploit the homeopathic school.” In 1912, the American Institute of Homeopathy passed a resolution drafted by its most famous practitioner, f­ uture New York senator Royal S. Copeland, in ­favor of the Owen bill.36 While some leading eclectics rejected the NLMF, including ­those in the Michigan State Eclectic Medical and Surgical Society, they w ­ ere more likely than the homeopaths to align against the AMA. For example, the president of the National Eclectic Medical Association signed on as an NLMF advisor. ­There ­were strong currents of antagonism among eclectics ­toward the AMA ­because practically all of their medical schools ­were ­under attack as inferior by its educational reformers due to poor resources and facilities for basic scientific and clinical teaching. They, like Christian Scientists, would have seen good reasons for suspicion of the medical progressives in the fact that in 1906 the AMA had published a proposal advanced by economist Norton calling for a bureau of registration of physicians and surgeons to be included in a national department of health. Its tasks would include efforts to raise the “standard of the profession . . . ​by protecting the exceptional men and barring quacks, charlatans, e­ tc.” While the Owen bill never contained a federal physician registration system, the spiritual and other irregular healers feared that one day the NDH might try to suppress alternative prac­ti­tion­ers on public health grounds. Therefore, nothing the AMA said about the Owen bill could be trusted. According to California senator John D. Works, one of the Owen bill’s greatest enemies—­a nd a champion of Christian Science—­t he AMA was a not a progressive force for the ­people’s health but a corrupt “medicopo­liti­cal and commercial trust.”37 DRUG DEALERS

The NLMF had a lot of money, and it is likely that ­little of that came from irregular medical prac­ti­tion­ers and their patients. It spent extraordinary sums, estimated at about $25,000 per week, on advertising, according to Collier’s magazine. The AMA reported to Senator Owen its estimation that on one par­tic­u ­lar day the NLMF spent approximately $50,000 on its propaganda campaign. Therefore, Owen bill supporters strongly suspected that the money



H e a lt h o r F r e e d o m

217

came from drug dealers, not drugless healers. Indeed, a g­ reat deal of circumstantial evidence supplied for congressional deliberation indicated that commercial drug interests threatened by the AMA and its friends in the federal government w ­ ere the major source.38 The progressive Pearson’s Magazine, like Collier’s, backed the AMA’s claims. According to Pearson’s, “the food adulterators and the ‘patent-­medicine’ fakers are the real foes of the national department of health” and who “skulk in the background . . . ​­behind honest Christian Scientists misled as to the real purpose” of the Owen bill and b­ ehind “vapid legislators who prate of state rights” in defense of “medical freedom.” Collier’s found circumstantial evidence in Benjamin Flower’s past associations with another of his b­ rothers, Richard  C. Flower, “the notorious quack and general humbug.” Richard Flower had been a key figure in and in all probability a major financier of the National Constitutional Liberty League (NCCL) back in the 1880s. The NCCL was in a sense the NLMF’s precursor, a thorn in the side of medical reformers seeking to bring medical licensing to Mas­sa­chu­setts and other states and therefore to put Richard out of business as a medical practitioner, if not snake oil manufacturer and salesman. In 1907, the New York Times accorded Richard Flower “a place in the front rank of American crooks” for, among other ­things, having “discovered how to cure manifold diseases, including the swollen pocket­book malady.” In fact, the NLMF leader had once served as president of his older ­brother’s R. C. Flower Medicine Com­pany. Benjamin Flower’s novelist and essayist friend Hamlin Garland, a Granger and admirer of Henry George, William Jennings Bryan, and Theodore Roo­ se­velt, recalled that b­ ehind Flower’s numerous and not-­so-­profitable journalistic ventures stood Richard, “that ­brother of his pouring out money . . . ​ By the g­ reat hornspoons!”39 Benjamin Flower flatly denied in a sworn affidavit to the U.S. Senate that the NLMF sought or took donations from any drug manufacturers, distributors, or retailers but offered no proof from the organ­ization’s ledgers. It is rather implausible that Benjamin Flower would have righ­teously refused to collect and spend big drug money on the NLMF’s operations in light of the fact that his magazines advertised ­things like J. L. Stephens Morphin Cure, which had been exposed by Samuel Hopkins Adams in “The G ­ reat American Fraud,” as a concoction containing the very t­hing it was supposed to cure a craving for. Flower’s standards for accepting advertising money ­were not high. His Twentieth ­Century advertised Oxydonor, a device submerged in w ­ ater and attached by a cord to the wrist or ankle in order to force oxygen

218

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

into the body and so “cure all forms of disease.” As if to minimize his complicity if exposed, Flower claimed in 1911 that “a g­ reat majority of proprietary medicines are infinitely less dangerous to the public than the majority of regular doctors’ prescriptions” and blamed t­hose doctors, not drugmakers, for “the ­great majority of men who to-­day are ­under the influence of opium, chloral, cocaine, and other habit-­forming drugs.” 40 Though lacking hard evidence, in June 1910 Joseph McCormack proposed a resolution to the AMA House of Delegates claiming that the NLMF was the paid agent of drug interests. “We welcome the opposition of the venal classes long and profitably engaged in the manufacture of . . . ​habit-­producing nostrums . . . ​to the tune of hundreds of millions annually,” it said. The NMLF was a “corrupt and noisy band of conspirators” spreading “monstrously wicked misrepre­sen­ta­tions.” The NLMF’s efforts to discredit the AMA ­were designed to enable drug interests “to continue to defraud and debauch the American ­people.” McCormack had good reason to suspect drug interests as major funders. Charles W. Miller, the NLMF’s second vice president, was among ­others in the organ­ization with drug ties and dependencies. An Iowa state legislator and chairman of the state’s Demo­cratic Party committee, Miller edited the Waverly Demo­crat, which relied heavi­ly on drug advertising. He voted against the state-­level food and patent medicine regulation that the AMA and its state socie­ties ­were currently promoting. In Miller’s view of the facts, published in Flower’s Twentieth C ­ entury Magazine, members of the Committee of One Hundred ­were “creatures” of the AMA. NLMF advisory board member William E. Scripps was a former chairman of the Scripps-­McRae League of over twenty newspapers that also took in huge drug-­advertising revenues. On one day in 1913, the Cleveland Press, the largest in the Scripps chain, contained over thirty ads for ­things like Dr. Miles’ ­Grand Dropsy Cure, some of them puff pieces about drugs disguised as news. Another board member was George P. Engelhard of Chicago, publisher of the Western Druggist and the Medical Standard, which according to Collier’s “carried advertisements of the worst frauds” and actively defended proprietary medicine interests.41 Most notable, perhaps, as a drug industry dependent in the NLMF was Ceylon Spencer Carr, MD, of Columbus, Ohio. Carr edited the Columbus Medical Journal, a “pseudo-­medical sheet advertising some of the worst medical frauds in the country,” according to Collier’s. He also edited the popu­lar Medical Talk for the Home, which spread antivaccination propaganda while advertising potentially dangerous nostrums. Carr was also an employee of the infamous Peruna Com­pany, maker of the country’s most popu­lar alcoholic



H e a lt h o r F r e e d o m

219

beverage sold as a cure for disease. He had started out, according to his own boastful telling, as a charismatic and very popu­lar preacher. He left the pulpit around 1900 b­ ecause serving “comfortable, well-­fed parishioners” had nothing to do with the true ministry of a follower of Christ, who had wandered among “the ignorant, the weak and poor.” But unlike Eddy’s Church of Christ, Scientist, Carr pursued pharmacotherapeutics and mail-­order sales of his own Tissue Remedies (“Not Drugs, But Chemical Foods”), as well as medical journalism to promote them.42 Another direct purveyor of proprietary drugs on the NLMF roster was A. F. Stephens, president of the National Eclectic Medical Association and the second vice president of the Converse Chemical Com­pany of St. Louis. Stephens’s book, The Essentials of Medical Gynecol­ogy, a cata­logue of remedies for w ­ omen’s prob­lems, advertised Echinacea Angustifolium as “the best internal antiseptic known to the profession,” even for deadly puerperal septicemia. It touted Liquor Potassii Arsenitis for “dry, pointed tongue,” among many other ­things. The book steered readers to medicines sold by Lloyd B ­ rothers of Cincinnati, Ohio, possibly a distributor of Stephens’s own eclectic products. Charles Went­worth Littlefield, MD, chairman of the NLMF’s Washington state branch, was also a drug pusher. He advertised and dispensed by mail twelve dif­fer­ent “devitalized tissue builders” for the cure of cancer, tuberculosis, and epilepsy as well as all other ­mental and ner­vous diseases. With it, he boasted, any organ of the body could be “reconstructed” and “its functions reestablished.” In ­future years Littlefield also got into the drugless and spiritual healing business as well. Most notably, he claimed to be able to stop a patient’s bleeding by incanting a passage from the Bible. He published as proof over one hundred photomicrographs of crystalline likenesses of ­things like chickens, fleas, octopuses, f­ aces of saints, Mephistopheles, and “a ­woman carry­ing a dog u ­ nder her arm on a windy day.” The images w ­ ere all reproduced in his book, The Beginning and Way of Life, which also touted his special tissue remedies.43 Prob­ably, major funding for the NLMF was raised by its advisory board member Charles Huhn, president of the National Association of Retail Druggists (NARD), and Charles M. Carr, editor of NARD Notes, a pharmacy trade magazine with a circulation in the tens of thousands. Since 1907, the NARD had been locked in ­battle with the AMA. Their association had mobilized retail druggists across the country against state food and drug regulation laws to complement the 1906 Pure Food and Drugs Act. More recently, the NARD had come ­under majority control of pharmacies or­ga­nized in a new drugstore

220

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

chain, the American Drug Syndicate (ADS)—­over which Charles Huhn also presided. The ADS combined over twelve thousand previously in­de­pen­dent druggists in a large-­scale venture into a new line of proprietary drugs. They had been facing ruinous price competition from the retail pharmacy chains now spreading across the country, such as the United Drug Com­pany, Rexall, and the Liggett companies. ­Those chains vertically integrated the financing, manufacturing, distributing, and retailing of their own brands. In response, the ADS created its own proprietary brand and chain of franchisees to sell them.44 Huhn’s control of both the ADS and the NARD prompted AMA editor Simmons to declare that the nation’s retail pharmacists had sold their “heritage of professional decency” for a “mess of pottage . . . ​that smells to high heaven.” The extent of the ser­vices and money that the NARD’s Huhn and Carr somehow channeled to the NLMF cannot be known, but they ­were prob­ably enormous in light of NARD Notes editor C. M. Carr’s far-­flung business dealings, orga­nizational affairs, and, not least, ser­vice on the Minnesota State Board of Pharmacy. NARD funds could easily explain why the NLMF was able to spend, in Irving Fisher’s estimation, more in a day “than our committee has spent in a year.” 45 The diverse drug interests had reasons for fearing a federal health department. Norman Hapgood, Samuel Hopkins Adams, Edward Bok, and Samuel S. McClure—­publishers and journalists who had gone to ­battle for passage of the Pure Food and Drugs Act of 1906—­were all members of the COH. In his own vision of a health department, the COH’s Norton included a “National Bureau of Registration of Drugs, Druggists and Drug Manufacturers,” with the task of regulating all drugs and “severely punishing all newspapers and manufacturers for the insertion of false or fraudulent advertising m ­ atter calculated to deceive the public.” Harvey Wiley, a founding member of the AMA’s Council on Pharmacy and Drugs and the driving force ­behind the 1906 food and drug law was also on the COH. The Owen bill threatened to make him even more power­ful by shifting his BOC out of the Agriculture Department and into the health department with equivalent cabinet status. ­There, the BOC was to exercise authority to impose new “chemical, biologic and other standards” on the vast drug industry’s products. Recently, Lyman Kebler, Wiley’s lieutenant in the BOC, had published a bulletin that for the first time ever named specific proprietary remedies to be avoided. The bureau was also pushing for stronger action against preposterous curative claims violating the “misbranding” provision of the 1906 act.46



H e a lt h o r F r e e d o m

221

In short, the NLMF was an “unholy and anomalous alliance,” as Fisher called it. To the medical progressives, the NLMF was like an alliance of Baptists and bootleggers, the first favoring a ban on Sunday alcohol sales to save souls and the second, to make more money from drinkers uninterested in salvation. It was a strange mix ­because Christian Scientists scorned every­thing the commercial drug industry profited from. One can only won­der what common Christian Science prac­ti­tion­ers would have thought had they been aware of the influence of drug men and their money in the NLMF. Perhaps both sides saw each other as the lesser evil compared to the AMA. Years before the Owen bill debate, Mary Baker Eddy was alleged to have forbidden her followers to enter into any league with “vendors of patent pills” as well as with occultists, mesmerists, and the like. Such traffic with evil would cost the movement more than it gained in opposing unjust medical laws. Her call for po­liti­cal purity fell on deaf ears. She was nearly ninety when Owen introduced his bill and died that year. She had been “in error” about one week before she died, according to a ­house­hold member. In the opinion of a Newton, Mas­sa­chu­setts, medical examiner, her error was pneumonia.47 MORE NLMF ALLIES: POLITICIANS A ND BUR E AUCR ATS

The unholy Baptist-­bootlegger alliance’s most power­ful friend in Congress was Utah’s Republican senator Reed Smoot. A member of the Church of Jesus Christ of Latter-­day Saints (LDS), Smoot was the nation’s most prominent and influential Mormon. Before coming to the Senate, he had served at vari­ous times as mayor of Provo and Salt Lake City. He was one of more than two dozen ­children sired by Abraham O. Smoot, a leader of Salt Lake City’s Mormon pioneers in the 1840s and 1850s, with a handful of wives. He became an LDS bishop and then, in 1900, one of the church’s Quorum of the Twelve Apostles. It is pos­si­ble that Smoot’s religious views help explain his stance against the Owen bill. Early Mormonism leaned away from mainstream medicine and ­toward faith healing and dietary moderation. Joseph Smith, founder of the LDS movement, once told immigrants arriving in Utah, “The doctors in this region d ­ on’t know much,” and “They want to kill you or cure you, to get your money.” Smith and ­later Brigham Young, the second LDS president, both approved of Thomsonian botanical therapeutics, the popu­lar backlash against the harsh practices of regulars.48

222

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

Ironically, however, Smoot was founder and president of the Smoot Drug Com­pany, the leading drug retailer in central and southern Utah and the first of his many successful ventures as a merchant, banker, and industrialist. According to a 1909 publication by an excommunicated Mormon journalist, a detractor of the Mormon priesthood’s ascent into politics, “Apostle Reed Smoot is the proprietor of a whiskey dispensing drug store with a ‘blind pig’ ­behind the prescription case.” While this witness’s fierce hatred of Smoot casts doubt on his credibility, t­ here is l­ittle doubt about what was up front. Smoot profited handsomely from the sale of nostrums, perhaps mostly innocuous ones, to naive customers inside and outside the store. But his merchandise, advertised in newspapers as late as 1895, included Dr. De Witt’s Colic and Cholera Cure “for ­children, especially infants.” It contained alcohol, opium, ether, and chloroform. Smoot clearly signaled his sympathies with other retail druggists by reading aloud to fellow senators in the Senate Committee on Public Health a tele­gram he had received from the NARD claiming to represent thirty thousand members “strongly” opposing the Owen bill.49 Smoot “occasioned much anxiety to the friends of the legislation” by siding with power­ful federal bureaucrats, according to McCormack’s report to the AMA. To defend the status quo, he submitted decoy bills with incremental increases in funds and responsibilities to the PHMHS. Likewise, the seventy-­four-­year-­old John Shaw Billings entertained “no doubt” that bureaucratic hostilities w ­ ere hurting the Owen bill’s prospects, exactly what had taken down his National Board of Health in 1884. According to Owen himself, the prob­lem was the turf protectionism of federal bureaucrats “scattered in eight departments” and “jealous of each other, the one nullifying and hampering the work of another.” Vari­ous departments, agencies, or bureaus feared losing their health-­related jurisdictions to other entities inside a department of health. Among them was the Department of Agriculture, which was slated by the Owen bill to lose much of its BAI work, as well as the Bureau of Entomology, ­because they both investigated diseases affecting ­humans and animals alike. Not surprisingly, having commercial farmers’ interests close to its heart, department officials balked at surrendering ­those bureaus. The BAI’s 1908 report argued that even when protection of ­human health was at stake, “the prob­lems are mainly agricultural and must be attacked from the agricultural side.” Its “real object” was first and foremost a commercial one: “To provide a sufficient and ­wholesome supply of food.”50 According to a draft of a letter to Irving Fisher, Billings believed that Walter Wyman, head of the PHMHS, was the worst villain in the piece. It was,



H e a lt h o r F r e e d o m

223

indeed, a feisty bureaucracy with a long history of jealous turf protectionism. Before 1902, the PHMHS had simply been the Marine Hospital Service (MHS). Created by an act of Congress in 1798 at Trea­sury Secretary Alexander Hamilton’s behest, its purpose at the time was merely “the relief of sick and disabled Seamen.” Supplying medical and hospital care to be paid for by a per capita payroll tax on the merchant marine sector, in effect it was Amer­ i­ca’s first compulsory health insurance system, albeit one ­limited to private seamen. Prompted by petitions from merchants in Charleston and Boston, Hamilton had called for the mea­sure in “the interests of navigation and trade . . . ​conducing to attract and attach seamen to the country,” all in line with his ambitious national developmental agenda. But the MHS was also “in the interests of humanity . . . ​and a very needy class of the Community.” Over time, it gradually took on a few public health tasks, especially quarantines, and an insignificant amount of research.51 ­A fter the de facto demise of John Shaw Billings’s NBH, which temporarily shouldered aside the MHS as the most impor­tant federal health agency, the medical progressives continued to beat the drums for a more power­ful health department. In 1888, Billings, George Sternberg, and state health department leaders McCormack of Kentucky and Henry Pickering Walcott of Mas­sa­chu­ setts persuaded the House Committee on Commerce to consider a bill that would take away all public health functions except quarantines from the MHS and set up a bureau of health in the Interior Department. The bill did not get out of the committee. The year before, to take some wind out of their sails, MHS surgeon general John B. Hamilton had founded the Hygienic Laboratory on Staten Island, New York, for diagnostic testing for cholera, yellow fever, smallpox, and plague. To set up and run the new laboratory, Hamilton wisely enlisted the highly qualified and effective Joseph James Kinyoun, who had studied bacteriology in New York with Hermann Biggs.52 ­A fter Surgeon General Hamilton’s retirement in 1891, his successor Walter Wyman continued to gain more incremental improvements from Congress, thereby strengthening the MHS’s ability to fend off the reformers. In 1902, Wyman persuaded Congress to add “public health” to its name in a piece of legislation that nominally improved the status, organ­ization, funding, and activities of the ser­vice, including, most significantly, $35,000 for a new building for the Hygienic Laboratory. The MHS was now the PHMHS. But the improvements w ­ ere more symbolic than real. The Hygienic Laboratory’s research bud­get did not even merit an entry in the surgeon general’s annual report u ­ ntil 1907, when it reached the tiny sum of $15,000. It was dwarfed

224

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

by the bud­get of the BAI. Around that time, the BAI employed close to nine hundred animal disease experts. By contrast, the puny PHMHS employed fewer than four hundred people, and only a tiny number of ­those ­were engaged in research on h ­ uman diseases.53 Clearly, Wyman was no progressive with an ambition to do much more than tend and protect his small turf. For a half-­dozen years, he had coldly rebuffed ­women activists’ grassroots pressure, led by Lillian Wald of New York’s Henry Street Settlement House and Florence Kelley of the National Consumers League, to establish a ­Children’s Bureau in the PHMHS to investigate the country’s high infant mortality compared to other industrialized countries. Despite support from President Theodore Roo­se­velt and other notables, Wyman rejected multiple bills for the purpose. As Milton Rosenau, one PHMHS expert of considerable note, put it sardonically, Wyman had been “most emphatic” about not wanting “to complicate his life with the importunities of a group of sentimental ­women who ­were interested solely in the welfare of m ­ others and infants.”54 Fisher believed that Wyman worked assiduously b­ ehind the scenes to sabotage the Owen bill, all the while making vaguely favorable noises about combining all federal agencies into a new cabinet department. But Wyman had declined the invitation to join the Committee of One Hundred and did nothing to agitate for its cause. In fact, in 1909 he had privately dismissed the idea to none other than President Taft. Thus, according to Fisher, Taft was tempted to get Wyman out of the way, hoping to catch him expressing clear opposition to the Owen bill, so that “­there would then be a chance to remove him.”55 But Wyman never showed his cards, and he was never removed ­because he had too many power­ful friends. His best po­liti­cal ally was his departmental boss, Trea­sury Secretary Franklin MacVeagh. ­Because economic growth and tax revenue ­were the Trea­sury Department’s supreme concerns, it was a “Department of Dollars,” not a Department of Health, complained Fisher. One cannot overlook MacVeagh’s private, not just bureaucratic, conflict of interest against reform. A banker, he was also the founder and owner of Franklin MacVeagh and Co., a major Chicago food producer and w ­ holesaler. His merchandise had from time to time come ­under hostile scrutiny by state regulators for “impure” or “adulterated” preserves and other products or for failing to list all their ingredients. On ­those grounds, the speaker of the Wisconsin State Assembly alleged that MacVeagh had “succeeded in making $1,000,000 by cheating the American p ­ eople with adulterated foods.” Not



H e a lt h o r F r e e d o m

225

surprisingly MacVeagh opposed wresting control over food regulation from the Department of Agriculture. It had tried, not always successfully, to rein in regulatory zealot Harvey Wiley, the head of its chemistry bureau, which was responsible for enforcing the Pure Food and Drugs Act of 1906. A national department of health could not be counted on to do the same. In short, as Senator Owen put it, “We have a Public Health Bureau, ­under the Secretary of the Trea­sury, who is expert on finance, and is not expert on health; who is expert in w ­ holesale groceries, but not on the pure-­food act, and who might regard the pure-­food act with aversion.”56 DEFE AT A ND INCR E MENTA LISM

Senators and congressmen w ­ ere deluged by letters and tele­grams prompted by the NLMF shortly ­after Owen introduced his bill in 1910. “Like a flash of lightning” they came, “from Maine to California,” said Owen. ­Virginia’s Thomas Martin, chairman of the Senate committee considering the Owen bill, personally received upward of one thousand tele­grams a­ fter the NLMF’s first newspaper advertisements opposing the bill; committee member Chauncey Depew from New York said that in the course of his twelve years of Senate ser­vice he had never received so many letters and tele­grams. Congressmen surely took notice when, in October 1911, the NLMF or­ga­nized “a very large and enthusiastic mass meeting” at Car­ne­gie Hall in New York City and another rally with two thousand attendees in Chicago in November. Rallies ­were also staged in cities across the country through the winter and into the spring of 1912. COH activists, with their appeal to progressive elites, could not have matched them if they tried. By May of 1912, thousands of signatures from p ­ eople opposing the Owen bill w ­ ere submitted from Owen’s home state of Oklahoma, almost eigh­teen hundred of them from Oklahoma City alone. Printers’ Ink marveled at the “inestimable power along national po­liti­cal lines” of the NLMF’s unpre­ce­dented advertising campaign for having “put a quietus” on the Owen bill.57 The groundswell of public opposition can be explained in part by the residual popu­lar contempt for mainstream medicine that the AMA’s reformers had not entirely dispelled. Lay elites had been easier to turn around with their progressive agenda. But t­here was also popu­lar suspicion of the public health mea­sures that critics called “brass-­buttons medicine,” the sometimes heavy-­handed mea­sures taken by public health and police authorities to prevent the spread of disease. Propaganda against the Owen bill told of poor

226

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

neighborhoods and industrial workplaces stormed by squads of public health officials, sometimes in the dark of night, to forcefully vaccinate inhabitants and workers. Policemen blocked off the egress to prevent their flight and forcibly held them down for the procedure. Sara Josephine Baker, the shaker and mover b­ ehind New York City’s Bureau of Child Hygiene, told indignantly of harrowing experiences that working-­class c­ hildren suffered at the hands of stupid, overzealous doctors descending on a school to perform assembly line tonsillectomies. She put an end to that. But Baker’s participation in the forceful capture and incarceration of Mary Mallon, or “Typhoid Mary,” became a cause célèbre for the medical libertarians. Mallon was an asymptomatic typhoid carrier who defied the New York City health department’s prohibition of her work as a cook in p ­ eople’s homes. NLMF adherents, in contrast, saw Mallon, who was confined for three years on an island in the East River, as a perfectly healthy person deprived of her right to liberty and the pursuit of happiness.58 Medical libertarians took plea­sure in quoting a 1907 speech before the AMA House of Delegates by Samuel L. Dixon, Pennsylvania’s health commissioner and vice president of the state’s Anti-­Tuberculosis Society, in which Dixon declared that “compulsion, not persuasion” was “the keynote of state medicine.” Once commonly used by reformers to describe public health mea­ sures, “state medicine” had become a term of opprobrium tossed about to make progressive reforms sound like incursions on liberty. According to Henry Strong, editor of the National Druggist, Dixon’s proposition was “for the State Establishment of that System of Medicine for which the American Medical Association stands.” Even McCormack’s assertion that “submission to reasonable personal restrictions intended for the welfare of all is the very foundation stone of civilized liberty” became the AMA’s confession of guilt, according to Strong’s book-­length screed, The Machinations of the American Medical Association.59 Lora ­Little’s muckraking sensation of 1906, Crimes of the Cowpox Ring, about a conspiracy of doctors, drugmakers, and politicians ­behind compulsory vaccinations, had primed the NLMF’s pump. In Mas­sa­chu­setts, starting in 1902, all ­children had to be vaccinated by the age of two. Nearly ­every state had or would soon pass similar laws requiring vaccinations before admission into public schools. In 1903, Boston, gripped by a smallpox epidemic starting in 1901, enforced a wave of compulsory vaccinations, thus becoming a “hot-­bed of the anti-­vaccine hysteria.” In her book, ­Little reported that vaccine “farmers” had capital investments of $20 million in their “foul business” and shocked her readers with a list of over three hundred supposed vaccina-



H e a lt h o r F r e e d o m

227

tion casualties, one of them her own son. He had died but prob­ably not ­because of the vaccination, which had been given a full seven months ­earlier at his school. In all likelihood, vaccinations caused very few of the three hundred deaths. But the plausibility of the claim was supported by some two dozen tragic and widely publicized vaccine-­related deaths of c­ hildren in St. Louis, Cleveland, Camden, Philadelphia, and other cities that the anti-­Owen forces ­were legitimately able to cite. The ­children had been vaccinated with tetanus-­ tainted serum manufactured by a firm in the competitive, un­regu­la­ted, and as yet untrustworthy drug industry.60 The Owen bill also had the misfortune of bad timing with re­spect to a dramatic rise in compulsory school inspections. In 1900, only about ten cities across the country carried out inspections of schoolchildren during school hours. New York City had started in 1897 with a corps of 134 medical inspectors. Boston, Chicago, and Philadelphia followed, and by 1905 over fifty cities ­were conducting school inspections. Mas­sa­chu­setts passed the first statewide school inspection mandate in 1906. When Owen submitted his bill in 1910, four hundred cities conducted inspections. In 1911, according to Medical Freedom, an army of sixty nurses assisted over one hundred doctors with inspections in Chicago. Some teachers resented the disruptive intrusions of “medical police.” Parents objected when not asked for permission and ­were mortified if told their ­children ­were “defective.” In Newark, parents protested when inspectors made ten-­to-­fourteen-­year-­old girls remove their clothing in each other’s presence. In Boston, a “storm of protest” from parents followed the “stripping” of eight hundred girls for medical examination at Roxbury High School. In Pittsburgh, according to California senator John D. Works, a fervent NLMF supporter, “at least two hundred ­children are now being vaccinated daily, and the doctors, working in squads of six, are ­going through each school from cellar to garret.” 61 To ­counter the NLMF’s attacks, Fisher and AMA leaders said nothing in defense of public health overreach and ham-­fisted street-­level actions. Addressing politicians for the most part, they vehemently denied the medical libertarians’ main line of attack about the AMA’s alleged desire to extend its tyranny over the medical practices and commerce. Nevertheless, in an attempt to assuage the opposition, Owen added a clause to his bill in 1911 explic­itly promising no discrimination against “any system or school of medicine.” A weakened 1912 bill, calling only for a Public Health Ser­vice, an in­de­pen­dent commission outside of the Trea­sury Department, added it would “have no power to regulate the practice of medicine or the practice of healing, or to

228

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

interfere with the right of a citizen to employ the practitioner of his choice.” Furthermore, all appointments to the department “including the head of the ser­vice, s­ hall be made without discrimination in f­ avor of or against any school of medicine or of healing.” Hostile medical libertarians only scoffed contemptuously at the concessions.62 In response to drug industry opposition, Owen also deleted a controversial reference to “establishing chemical, biological and other standards.” It was to no avail, for the NLMF continued to distort the facts as a pretext for its main mission: to smear and weaken the AMA. In hopes of rescuing the Owen bill, and in vain, Fisher tried to distance the COH from the AMA, insisting that “it has absolutely nothing to do with the American Medical Association; it did not originate with the American Medical Association; it has no secret or other connection with the American Medical Association; it is not controlled by the American Medical Association, nor by any other association.” It was merely allied with the AMA “in the sense that it is allied with the United Mine Workers of Amer­i­ca, or the Grange, or the life insurance companies, or any other of the numerous organ­izations which have cooperated with us in advocating a national department of health.” 63 ­Because of weak support, no version of the Owen bill was ever brought to floor votes in Congress. In the end, sympathetic congressmen ­were prob­ ably relieved at not having to negotiate with their consciences about how to vote. Supporting the bill would have risked an electoral challenge funded by drug interests and stoked by the populist rhe­toric of the medical libertarians. The first Owen bill was referred to the Senate Committee on Public Health and National Quarantine in 1910, which did not act on it that year. The following year the committee held extensive hearings, but again did not pre­sent anything for a vote. In 1912, Owen introduced a revised bill, which the committee weakened by calling for an in­de­pen­dent commission. That version found­ered early in 1913 on the floor of the U. S. Senate on a motion to proceed, with a tied vote of 33 to 33. Owen’s third version, submitted that year, sat dormant and died in committee. Likewise, in the House of Representatives, no bill to create a health department ever got out of its Committee on Interstate and Foreign Commerce for a vote. In 1914, ­after war broke out in Eu­rope, President Wilson, though friendly to the health reformers, announced that the “world situation” made further consideration of the highly divisive Owen bill impossible for the time being.64 ­A fter the PHMHS’s Walter Wyman died in November 1911, his successor Rupert Blue followed in his footsteps. With Trea­sury Secretary MacVeagh’s



H e a lt h o r F r e e d o m

229

support, Blue proposed a law to shorten the name of the PHMHS to the Public Health Ser­vice (PHS) and marginally increase its appropriations to raise federal health officers’ salaries, but not their operating bud­gets. Against his e­ arlier inclinations, President Taft signed the law in August 1912, deflating hopes for more sweeping reform. Historians t­oday see the origin of ­today’s richly funded National Institutes of Health in the law b­ ecause the PHS was now explic­itly tasked with research responsibilities, though still without funding adequate to the task.65 Food and drug regulation remained in the Department of Agriculture u ­ ntil 1940. A ­Children’s Bureau was fi­nally created in 1912 ­after years of pressure from unenfranchised ­women against Trea­sury opposition. It was placed in the Department of Commerce and L ­ abor instead of the PHS, despite its purpose being research and action on infant mortality, birth rates, accidents and diseases of c­ hildren in dangerous occupations and orphanages. The AMA’s Charles Reed told Fisher that the 1912 law was “worse than a farce” ­because it would “block the way to helpful legislation for years to come.” ­A fter the 1918 armistice, Senator Owen continued doggedly u ­ ntil his retirement in 1925 to submit health department bills. They and similar bills sponsored by other legislators routinely died in committees. One of them was favored by Republican President Warren Harding on the advice of Brigadier General in the Army Medical Corps, Charles E. Sawyer, his personal physician and a homeopathic practitioner like Harding’s own doctor parents. It would have created a new cabinet level Department of Public Welfare. Utah’s Senator Smoot carried on as the reformers’ chief nemesis. He even put the brakes on the PHS itself when it requested better funding. In 1921, Smoot responded to a request from PHS Surgeon General Hugh S. Cumming that Cumming was surrounded by men “who had no re­spect for Congress and no mercy on the taxpayer.” Smoot’s fellow senator from Utah, Senator William H. King, went even further to kill an enlarged appropriation of $300,000 for disease research, calling the PHS “a veritable Frankenstein,” a “huge organism whose appetite increases as its victories multiply.” Also a Mormon, King accused the thousands of doctors and employees of the Public Health Ser­vice of wanting to “enter the states and assume a paternal and bureaucratic guardianship over the p ­ eople.” With their “oppressive federalism” the public health missionaries calling for its growth w ­ ere “trying to Rus­sianize this republic.” 66 The consolidation of disparate public health responsibilities in a single federal bureau, including drug regulation, would have to wait u ­ ntil 1939. That year, the Trea­sury Department surrendered the PHS to a new Federal Security Agency (FSA) and took food and drug regulation away from the

230

P u b l i c H e a lt h a n d t h e B o d y P o l i t i c

Department of Agriculture’s BOC. In 1944, the Public Health Ser­vices Act consolidated more disparate federal programs ­under the FSA. And it was not ­until 1953 that the FSA, renamed the Department of Health, Education, and Welfare (HEW), achieved cabinet status. By then, the AMA had become a profoundly dif­fer­ent organ­ization a­ fter its reactionary turn of the 1920s. It expressed fears to President Dwight Eisenhower, who supported the move, that the HEW would become a bureaucratic stronghold for the forces of socialized medicine. Eisenhower reassured the conservative doctors by appointing Oveta Culp Hobby, a conservative Demo­crat from Texas, to be its first secretary. Hobby had obtained no college degree, had no health policy experience, and was a fierce opponent of equal treatment of African Americans. She was not an enthusiast of subsidizing states wishing to distribute f­ ree polio vaccines, calling it a “socialistic step” and a “back door to socialized medicine,” a position she shared with the now ultraconservative AMA.67 AMERICAN EXCEPTIONALISM

In 1910, the AMA House of Delegates a­ dopted a resolution against the NLMF, calling it the representative of “venal classes” earning “hundreds of millions annually.” It closed with “we welcome and w ­ ill wear as a badge of honor the slanders of ­these unholy interests and their hirelings.” It was penned by Joseph McCormack, the nationally famous public health reformer and the AMA’s dynamic reor­ga­nizer and recruiter. It was a haughty and, as it turned out, overconfident throwing of the gauntlet. In the end, the impressive alliance of the progressive medical profession with po­liti­cal, business, civic, educational, and other elites for a national department of health met with defeat against another formidable alliance: righ­teous medical libertarians, mercenary drug interests, and turf-­protecting bureaucrats. The AMA came away badly bruised on the rhetorical battlefield by the medical libertarians’ display of what historian Richard Hofstadter famously called the “paranoid style” in American politics. In this case, paranoiac pop­ u­lism combined with medical libertarianism to make a potent elixir of reaction against elitist progressivism. The NLMF propaganda of 1910 called the progressive AMA a greedy “trust” seeking to monopolize control over the drug industry and enslave doctors and citizens to its therapeutics. Drug interests used variations on the same theme. According to an editorial in Medical ­Century, a journal for homeopaths hostile to the AMA, a health department “could send a half-­baked physician into our schools and, on the plea of pub-



H e a lt h o r F r e e d o m

231

lic health, kill half of the ­children with immunizing injections, for the ­whole gamut of diseases from A to Z.” Furthermore, “­There is nothing in the bill that would prevent the injections of poisonous m ­ atter into the blood of ­every citizen of the United Sates, if deemed necessary by the Department to suppress or prevent disease,” it asserted.68 Armed to the hilt with paranoiac rhe­toric against facts and rationality, the medical libertarians fought on favorable terrain for defending the status quo for the institutional and constitutional reasons British visitor James Bryce had written about in the previous ­century. States’ righters could object to increasing federal powers; power­ful legislative leaders and committee chairmen could stymie the initiatives of presidents, even ­those from their own parties; and federal bureaucrats could ally with committee chairmen and conservative po­liti­cal and commercial interests to defend their turf. Yet another episode in the history of American politics confirmed Bryce’s observation about “excessive friction” and the “waste of force in the strife of vari­ous bodies and persons created to check and balance one another.” What had thwarted John Shaw Billings and his National Board of Health during Bryce’s time came back with a vengeance against l­ater progressives’ resumption of his mission. And again, ­there was also no general public “clearly of one mind” that Bryce thought necessary to overcome po­liti­cal gridlock. The NLMF made sure of that. In short, not much had changed since 1878, when the AMA president at the time lamented that, unlike ­England and Prus­sia, “where po­liti­c al power is concentrated in the hands of a few enlightened statesmen,” the chances for creating a strong national health agency ­were slim.69

This page intentionally left blank

chapter 9

A Plague of Doctors

Systematic reform of medical education in Amer­i­ca ranked high on the agenda of medical progressives at the turn of the twentieth ­century. Along with rational therapeutics and disease prevention, it was one of their key motivations for revitalizing and retooling the American Medical Association. Three years before the AMA’s reor­ga­ni­za­tion, a leading reformer in the Michigan State Medical Society cited as one of his profession’s pathologies the host of medical colleges pumping out “a vast number of incompetents” into medical practice. As for-­profit institutions, a large number of medical schools w ­ ere “or­ga­nized for the advantage of the few at the expense of the many.” The AMA’s key document laying out the reasons and plans for its reor­ga­ni­za­tion decried “the pouring into the profession each year thousands of illy-­prepared men.” The medical profession as a w ­ hole bore responsibility for the resulting evils that “can be corrected only by our own efforts.” An association of medical colleges had tried to bring major reform but failed. ­Until a strengthened AMA took on the task, ­there was “no way for the profession of the country to act upon this question in an or­ga­nized capacity.”1 Medical training reform was not only a goal in and of itself: it was of a piece with the AMA’s larger agenda of drug reform and disease prevention. All three missions recommended po­liti­cal pressure for more stringent state-­ licensing standards. Badly trained and therefore gullible doctors ­were the

235

236

Schooling Physicians

marks of clever advertisers and glib detailers of worthless drugs. They did not care to know, much less research, the risks they asked their patients to run by taking the drugs they prescribed. They w ­ ere ill-­equipped to diagnose and report infectious diseases. And they w ­ ere l­ittle inclined to pass on hygienic knowledge to their patients and the public. Better therapeutic education had a preventive public health role b­ ecause prescribing bad medicines did real harm to the worried well. Because reform of medical schools overlapped with the other progressive missions, often the same individuals participated in several of them. For example, Frank Billings, AMA president for its 1903–1904 term and long-serving member of its board of trustees, was one of the all-­round progressives. He charged medical colleges with recklessly graduating students likely to commit “murder and lesser sins.” He also wrote searing indictments of the drug industry in the AMA journal. A public health reformer, he helped persuade the millionaire industrialist Harold McCormick to establish and fund Chicago’s McCormick Institute in 1902 to “improve the means of prevention and cure infectious disease” and served as one of its first trustees.2 The reform of medical education, just like drug and public health reforms, was not a new mission for the AMA, but its reorganizers of 1901 attacked it with new vigor. In 1888, the Journal of the American Medical Association had condemned vast numbers of badly trained doctors as “an incubus to the profession while they stay in it, and a good riddance when they drop out.” The editorial prob­ably came from the desk of Nathan Smith Davis, the journal’s recent founder and editor. Sometimes called the “Nestor of the medical profession,” Smith was the AMA’s principal founder. His main motivation for bringing together the country’s doctors in a single organ­ization in 1847 had been to coordinate efforts across the states to elevate medical school standards. Four years a­ fter founding the AMA, Davis published his History of Medical Education and Institutions in the United States, which included a scorching condemnation of the country’s medical colleges. In it he decried, for example, the standard and absurdly short two years of instruction with only four to five months of lectures each year. The state of affairs did ­great damage to the prestige of the profession. Noting doctors’ bumbling per­for­mances as witnesses in civil and criminal cases, for example, Davis lamented that t­ here was scarcely a judicial jurisdiction in the country where the lay public had not seen physicians’ cluelessness about elementary medical ­matters on display. The “ends of justice [­were] totally defeated, and the reputation of the profession itself lowered in the estimation of the community.”3



A Plague of Doctors

237

De­cades ­later, in 1901, public health missionary Joseph McCormack, in a sense Davis’s successor as the founder of the new and improved AMA, would still decry how medical schools w ­ ere flooding the country with bad doctors, thereby contributing to “the commercialism, the strife, the petty ambitions and general demoralization” afflicting the profession and shaming it before the public. While t­ here had been some improvements, medical education still had miles to go before reaching a destination somewhere in the vicinity of acceptable quality. It was still abysmal on average in 1910, the year that an AMA-­instigated survey, the famous Flexner report published by the Car­ne­ gie Foundation for the Improvement of Education, came out.4 Between the 1880s, when early but limited reforms began, and 1910, the number of schools remained about the same, and major quality improvements were few and far between—and that was at barely more than a dozen well-endowed medical schools attached to major, mostly private, universities. POOR SCHOOLS, IMPOV ER ISHED DOCTORS

Amer­i­ca’s medical progressives of the late nineteenth c­ entury onward, many of them trained abroad, ­were embarrassed by what passed at home as schooling in the art and science of medicine. In 1877, William Pepper, Pennsylvania’s preeminent medical educator, lamented that “to our shame . . . ​ scarce a month passes without the exposure, in some of the leading foreign papers, of cases of horrible malpractice by ignorant quacks holding a ‘bogus’ American diploma.” Even schools officially chartered by the states in which they operated w ­ ere a huge embarrassment. In 1889, William Eggleston, assistant secretary of the Illinois Board of Health, declared that anyone who compared medical study at the average medical school in the United States with ­those in the rest of the world “is compelled to blush for his country.” St. Louis physician Charles A. Todd complained in 1890 that “diplomas from the United States are regarded as contemptible in Eu­rope.” The same year, J. E. Emerson, a member of the elite American Acad­emy of Medicine, felt “a humiliating sense of inferiority” when he compared medical training in Amer­ i­ca with what was offered across the border in Canada. Obstetrician Samuel Potter, an expatriate Briton, noted that any American physician who found himself in the com­pany of Eu­ro­pean doctors typically encountered “a feeling of contempt for American medical education and persons.” It was so pervasive that “polite as he may be,” the Eu­ro­pean “is never able to wholly disguise it.”5

238

Schooling Physicians

One of the biggest differences between medical colleges on the two sides of the North Atlantic Ocean was the shockingly short courses of study in America. Even those w ­ ere often cut short because colleges allowed applicants to arrive late and matriculate up to the ­middle of the first of two terms in order to bank their tuition fees. Students ­were sometimes allowed to leave before the end of their second terms in the hopes of seeing them return for their second of only two years. In Eu­rope and Canada, five years with longer terms w ­ ere standard, including sometimes a year of basic premedical sciences. Argentina, Brazil, and Uruguay required six years. Sweden, whose training was widely admired, required a minimum of eight. American schools’ curriculum was crowded with sketchy lecture courses offered by badly trained professors. Furthermore, the lecture courses w ­ ere typically not “graded” or “progressive,” which meant that bored and bewildered students had to sit through some of the same dry lectures a second time in their second year. Learning by seeing and d ­ oing in well-­equipped laboratories was rare. Skimpy to non­ex­is­tent in Amer­i­ca, but common elsewhere, was bedside training in clinics and hospitals.6 Medical schools in Amer­i­ca ­were not only worse; there ­were far more of them relative to its population. In 1877, Pepper calculated that each school supplied doctors to no more than 500,000 Americans, while each French school on average supplied doctors to around 6,000,000 citizens, and German schools served around 2,000,000. A de­cade ­later, in 1889, Eggleston told AMA journal readers of similar conditions: one medical school for ­every 520,000 or so Americans while each medical school in Britain supplied about 840,000 Britons. Other Eu­ro­pean schools supplied 1,500,000  in Sweden, 2,400,000 in Germany, 4,500,000 in France, and 6,000,000 in Austria. Yet another de­cade ­later, Arthur Dean Bevan, chairman of the AMA’s Council on Medical Education, complained, “We have almost as many medical schools as the rest of the world—161 to 174 for the rest of the civilized world.”7 Even though many of the schools ­were relatively small, their proliferation resulted in a glut of doctors, especially in the cities, to which recent gradu­ ates gravitated in order to find patients with money to spare for expensive consultations and surgeries. Melvin Sudler, a prominent physician educator in Kansas, worried that Amer­i­ca had four times the number of medical students in proportion to its population as Germany. ­Every year, twice the number of new physicians needed by the population ventured forth into the already overcrowded profession, he concluded. According to a 1901 AMA journal editorial, 160 medical colleges, most of them “doctor factories,” churned



A Plague of Doctors

239

out an annual crop of nearly six thousand gradu­ates, two thousand more than could earn an adequate living. In 1900, according to astronomer and mathematician Henry S. Pritchett, a lay ally of the medical reformers, ­there was about one doctor for e­ very six hundred inhabitants, when one per e­ very two thousand—or perhaps fifteen hundred in thinly settled areas—­would prob­ably have been sufficient despite the high disease rates associated with “pre­sent hygienic conditions.”8 Doctoring “was the poorest way to get rich,” according to Harvard’s and Mas­sa­chu­setts General Hospital’s Richard Cabot, a vocal critic of his profession. He was one of the lucky ones, wealthy both by inheritance and from charging prosperous patients on a sliding scale. A paper-­thin slice of the profession tending very wealthy patients could earn in the range of $25,000 annually, and sometimes much more, according to a 1902 study. Around 50 doctors in the state of New York earned between $25,000 and $30,000, according to the editor of the New York Medical Rec­ord. About 10 doctors earned between $50,000 to $100,000. But more than 100,000 of the 135,000 or so physicians in Amer­i­ca made less than $1,500 a year. Their average income was therefore perhaps around $1,000, a figure brought up by the very high earnings at the upper tail of the skewed distribution. The median would have been lower. Official statistics from around 1910 show that around 40,000 doctors earned a proletarian income of $500 a year, barely above the average for all adult males. A coal miner, steel worker, or machinist could do better. A comfortable practice bringing from $3,000 to $10,000 a year was “very much like the proverbial hen’s teeth,” according to the Cincinnati Lancet-­Clinic. But that was no deterrent to the optimistic young doctor. “He sees the elegant equipage of the successful man and says to himself, ‘I ­will in time be that man’s successor. I too ­will ­ride in an automobile, with a footman.’ ”9 In his 1891 The Physician as Businessman, reform-­minded medical writer J. J. Taylor cited a doctor who estimated that only about one in three or four of his fellow gradu­ates survived exclusively on their practice income. Many ultimately found employment in drugstores or, in disgust, quit the medicine business entirely. Charles Davis, in his book about the travails of a medical ­career, warned young men that they might take in what a carpenter or even a factory hand earned despite four years of study costing about $2,000. As a wealthy Connecticut doctor, local and state politician, and an amateur but linguistically accomplished historian of Egypt, Rome, and Greece, Davis had no personal stake in reducing competition from young medical gradu­ates. He published his book anonymously, prob­ably to spare himself collegial criticism

240

Schooling Physicians

for airing the profession’s dirty laundry—­indeed its “sad state of ignorance.” Poorly educated doctors, he wrote, w ­ ere more dangerous than bad l­awyers, and the yearly influx of them was “as g­ reat an evil in a community as an epidemic.” Sadly, Davis wrote, “Thousands of young men spring into the arena, already crowded to suffocation, untutored, unlearned, uncultivated, and in a swarming host infest our land with their stupidity or knavery.” Medical schools ­were largely to blame ­because they spawned the “horde of competing, struggling, generally poverty-­stricken young men who, in attempting to practice medicine, lead lives of miserable anxiety.”10 The proliferation of doctors outstripped even the rapid growth in the country’s population. Illinois public health official Eggleston calculated in 1889 that in the previous de­cade ­there had been a 5.5 ­percent average annual increase in the number of physicians—­“or persons calling themselves physicians”—­ while the population had increased less than 2 ­percent annually. All told, between 1880 and 1900, the United States population grew by around 52 ­percent. But the number of medical schools more than kept up, increasing by around 68  ­percent. And the number of students they enrolled grew even more breathtakingly—by no fewer than 112 ­percent. Not surprisingly, doctors’ real incomes fell on average. A survey in 1907 of nine states found no rise in doctors’ nominal incomes in twenty-­five years despite an increase in the cost of living of about 24 ­percent in the previous de­cade alone.11 ­There w ­ ere both po­liti­cal c­ auses and consequences of what Billings, in 1898, called the “blight” of for-­profit medical schools in his none-­too-­cheery talk about the profession to first-­year students at Rush Medical College. Nathan Davis pointed out in 1851 that if a state legislature was “so stupid as not to perceive the necessity of establishing a new school, a bargain is soon struck with some literary college, already possessing the right to confer degrees, to furnish the necessary diplomas, and straightaway a new medical college with all the honors and privileges springs into existence.” Soon, legislatures would no longer get in the way ­because of the general incorporation laws they started passing. Getting a charter for a medical school became as easy as it was to form any for-­profit corporation. In the ­great majority of states, a charter could be obtained by “any coterie of men who pay the prescribed fee,” according to the AMA journal. In Illinois, for example, all it took was a l­ittle paperwork and six dollars to obtain a state charter in 1890. The states, complained Pepper in 1894, w ­ ere “reckless” in issuing charters to schools in numbers “grotesquely excessive in proportion to the population.” In 1901, New York dentist-­reformer William Carr decried the continued existence of duly char-



A Plague of Doctors

241

tered diploma mills and their mail-­order operations as “stench in the nostrils of decent men.”12 The court of public opinion did not threaten the survival of numerous competing and even warring medical schools. Joseph McCormack learned during his organ­izing travels that schools regaled their students with “exaggeration, misrepre­sen­ta­tion, and falsehoods” about competing schools. Wars of survival between schools ­were often “ludicrously b­ itter,” according to the Car­ne­gie Foundation’s 1910 Flexner report. Acrid disputes even arose within schools, according to the report, leading to splits and the spawning of more venomous combatants. The discredit that rubbed off on all doctors from the war of all against all sometimes hindered t­hose serving as dedicated public health officials from carry­ing out their tasks. In a 1901 article in the AMA journal, Inez Philbrick, a gradu­ate of the ­Women’s Medical College of Pennsylvania, contemplated the “ ­little esteem in which the profession is held by laity and government.” A major cause, she concluded, was the number and quality of the medical schools spewing out unfit prac­ti­tion­ers. “Let fewer and better be our motto,” the ­future Nebraska suffragist said.13 SUBSTA NDA R D DOCTOR M ATER I A L

According to the medical progressives, rigorous premedical entrance requirements ­were high on the list of needed reforms. Even basic literacy in En­glish was too much for many medical schools to demand of its customers. In his 1903 AMA presidential address, Billings said American medical schools “prostituted” themselves by showing “a most degraded disregard of the moral and ­mental qualifications of the matriculates.” Among them ­were nighttime “sundown institutions” for “the clerk, the street-­car conductor, the janitor and ­others employed during the day.” The low quality of matriculates explained the incessant “buffoonery and rowdyism” of medical students described by the AMA’s Nathan P. Colwell. Eu­ro­pean admission standards ­were, the reformers knew, both more exacting and uniform across their systems. British medical schools, on average worse than ­those in other countries, required twelve years of preliminary education, although the quality of that was often low. That, combined with the survival of a good number of proprietary medical schools willing to take on ill-­suited students, also resulted in the production of too many less-­than-­qualified doctors. The situation was much better in Germany, where all of its medical schools were state run and connected with universities. They also required twelve years

242

Schooling Physicians

of preliminary education. The last of ­those had to be spent at a selective Gymnasium, which adhered, unlike British schools, to uniform and rigorous standards for graduation. Austria, France, Italy, Spain, and Switzerland had comparable requirements.14 Applicants to American medical schools w ­ ere often atrocious spellers, and two or three years of defective medical study did not necessarily help much with that. The University of Michigan’s George Dock, a renowned clinician, scientist, and educator with Eu­ro­pean experience, lamented in 1909 that b­ ecause of bad preparation and study habits, students’ examination books ­were full of spelling howlers, as well as more alarming signs of unsuitability for the healing profession, even into their third year at Michigan. Examples ­were “bowals,” “conjenital,” “dissease,” “indivigual,” “inflaimed,” “simtom,” “tempiture,” and “tetnas.” One doctor-­to-be tartly replied that he “did not come to learn En­glish” a­ fter Dock corrected him “as kindly as pos­si­ble” for saying that a patient’s “pulse are rapid.” Bad spelling was symptomatic of less entertaining prob­lems. “Almost without exception,” Dock wrote, the student who writes ‘cracentric’ . . . ​does not understand the real characteristics of a ‘crescentic’ eruption; the one who writes ‘Koplik’ as . . . ​[Caplex, Koplig, Kolpig, Poplik, e­ tc.] never knows when and where ‘Koplik’s spots’ occur, how they look or what they signify.” All this was terrible for the medical profession, Dock said, not just patients. The widespread display of illiteracy caused it to be “looked on with condescension by educated men and w ­ omen.”15 ­Because medical schools hesitated to fail paid-up students, large numbers who graduated still lacked a basic command of the En­glish language, not just medical terms and concepts. Around 1884, the Illinois Board of Health discovered from its correspondence related to licensing that t­ here ­were at least seven hundred current and prospective prac­ti­tion­ers in the state who could not spell “diploma” correctly. In that de­cade, the U.S. Naval Medical Board received letters of inquiry from degree holders about navy jobs addressed, for example, to the “Navel medicle bord.” It rejected large numbers of licensed job applicants for orthographical butcheries and medical nonsense in the written exams it administered. Erroneous answers from degree holders included “the blud should be clened of its impurrities e­ very spring.” Practical exams ­were at times as funny as “comic opera and minstrel per­for­mances,” as when one applicant “demonstrated a spermatic cord . . . ​in a female subject.” Other per­for­mances w ­ ere downright disturbing, such as writing prescriptions with fatal doses of dangerous substances “which it would have been eminently



A Plague of Doctors

243

proper, in the interests of humanity, to have required the exhibitor to have swallowed.”16 ­A fter written examinations for state licensing began to be introduced in the 1890s, reformers on licensing boards got plentiful material for comedy and horror. In V ­ irginia, one gradu­ate wrote that in acute edema of the glottis, which can cause asphyxiation, he would amputate, but only “within three or four months if it was a bad case.” Another said that the proper hypodermic dose of morphine for a five-­year-­old would be from one-­fourth to one-­half grain—­enough to spare the child from pain forever. A licensing examiner from Minnesota saw answers such as “One of the principal symptoms of scarlet fever is malice on the part of the child.” Pos­si­ble sequelae ­were “death or recovery.” The dark comedy and foreshadowings of tragedy in examination answers continued into the new ­century. In 1907, a member of Mary­land’s Board of Medical Examiners heard from medical gradu­ates that “acute glaucoma is a cancer of the tongue” and that the purpose of the kidneys was to “secrete urea and have a hand in helping the liver to store up sugar for f­ uture use.” Blood coagulation resulted from exposure to “extreme cold or to sudden and violent fright” or was “caused by indigestion or some foreign substance getting into the blood vessels and is hastened by being overheated, and can be retarded by cooling on ice, agitation, addition of glycerine, &c.” Sleep, one degree holder answered, was “the relaxed condition of the body in general and the spinal cord in special,” while another said the cause of sleep was “always the result of over work.” He added, “In sleep we pass into a period of rest, and should have eight hours of rest, but I have only had four for a number of years, simply preparing for this time.”17 SH A BBY PR ECLINIC A L TR A INING

According to Clark Davis’s How to Be Successful as a Physician, vast numbers of newly minted doctors acquired all their medical knowledge “by sitting six months on benches each year for two years, trying to digest five or six lectures a day, the lecture rooms so thick with tobacco smoke as to stupify [their] brains.” William Osler invited fellow AMA members to “picture if you can the ­mental condition of such a gradu­ate: an incoherent ­jumble of theories, a chaotic assortment of practical tips.” The Illinois Board of Health’s Eggleston sneered that “one can be no more fitted to practice medicine by listening to lectures than he can learn mineralogy by looking at magic-­lantern

244

Schooling Physicians

views of the canyons of Colorado.” The result, at best, was “canned science” and “book medicine.”18 Thus, by the turn of the ­century, reformers inspired by advancing biomedical science insisted that medical students receive hands-on experience in well-­ equipped laboratories. Learning by d ­ oing was the order of the day. Preeminent surgeon William Keen, AMA president in 1900 and 1901, listed in his inaugural address around a dozen essential laboratories, expensively staffed and equipped for anatomy, histology, embryology, physiology, chemistry, physiological chemistry, pharmacy and pharmacology, practical obstetrics, surgery, pathology, morbid anatomy, and bacteriology. At the time, medical schools that had virtually none of the above boasted about them anyway to lure applicants. The fraudulent advertisers w ­ ere never prosecuted. Virtually all actually had dissecting rooms, but in many of them, nothing much was ever learned. According to the 1910 Flexner report, Chicago’s Bennett Medical College, an eclectic school nominally affiliated with Loyola University, had a messy anatomy room containing only “a few cadavers as dry as leather.” A quiz on anatomy was witnessed “in a room without a skeleton, bone, or chart.” That resources for teaching anatomy ­were unsatisfactory was not entirely the fault of the medical schools, given the difficulty procuring “teaching material.” Not many ­people would volunteer their posthumous assistance to for-­ profit medical science and education, so grave robbing was a common way of obtaining corpses, commonly dark-­skinned ones.19 The conditions of other laboratory facilities that Keen recommended ­were very often laughably ill-­equipped and had lighting so poor that it hindered learning. Not aty­pi­cal was what Mary­land Medical College, a school with ninety-­five students, had to offer. “The school building is wretchedly dirty,” according to the Car­ne­gie report’s author, Abraham Flexner, who personally visited the place. “Its so-­called laboratories are of the worst existing type: one neglected and filthy room is set aside for bacteriology, pathology, and histology: a few dirty test-­tubes stand around in pans and old cigar-­boxes.” Th ­ ere was no real laboratory “equal to the teaching of elementary chemistry.” Th ­ ere ­were “no teaching accessories of any sort whatsoever,” not even a library. Even Yale University’s medical school, while having well-­equipped laboratories for physiology, organic chemistry, and pharmacy, lacked good facilities for teaching bacteriology, pathology, and anatomy, Flexner found.20 Private philanthropists ­were no more inclined to endow proprietary medical colleges with the funds necessary to build and staff modern laboratory facilities than they would have been to subsidize cap­i­tal­ist drug manufactur-



A Plague of Doctors

245

ers to help them reform their ways. Medical leftist Bayard Holmes calculated in 1892 that medical schools had pitiful endowments totaling a ­little over $600,000. If revenue to state medical colleges was taken into account, assuming a constant flow, that brought the total capitalization of nonfee resources for medical training up only somewhat, to less than $1,500,000. Schools of theology, by contrast, benefited from well over $17,000,000, although t­ here ­were twice as many medical students as theology students. In 1900, AMA president Keen lamented that only a small share of the dramatically rising “tide of charity” from $20 million to $80 million in philanthropic bequests between 1894 and 1899 went to medical schools. Practically all went to universities, hospitals, museums, and libraries. Even schools of theology did better.21 SCARCE CLINICAL TR AINING OPPORTUNITIES

Most of the American public would have been dismayed to learn how their doctors had been starved of direct, hands-on instruction in therapeutics while being force-­fed with dry and confusing preclinical lectures. Reformers wrung their hands over the fact, exposed in an 1885 AMA journal editorial, that students, even at better colleges, could gradu­ate “without ever having so much as felt a man’s pulse or listened to a diseased lung.” Four years l­ater, another article decried the fact that “we have colleges from which a student may be graduated without having seen a patient except over the rail of the amphitheatre.” Typically, diplomates never saw a baby delivered or learned how to apply surgical dressings or ban­dages. They w ­ ere likely to have no clue how to do a urinary analy­sis, to distinguish normal from diseased tissue ­under a microscope, and to carry out a postmortem examination. William Osler fumed that “it makes one’s blood boil to think that t­ here are sent out year by year scores of men called doctors, who have never attended a case of ­labor . . . ​who may never have seen the inside of a hospital ward, and who would not know Scarpa’s space from the sole of the foot.”22 The teaching of obstetrics was particularly deficient. It was “sadly neglected” practically everywhere, declared an 1890 editorial in the AMA journal. Despite an unending supply of babies, the flow bypassed the medical students who, upon graduation and a lax licensing pro­cess, would soon be called upon to deliver them. Harvard was one exception, albeit an unimpressive one, in that it required each student to attend and report on only four deliveries. Almost fifteen years l­ater, all that some colleges required was a

246

Schooling Physicians

course of lectures on obstetrics delivered over a few days—­“a subject as impossible to teach with didactic lectures as it is to teach a man to swim by a course in a correspondence school,” according to another editorial. Even better institutions continued to fail in obstetrics, according to Flexner’s report. At Yale, he found clinical teaching that varied in quality across areas, but “the very worst showing” was in obstetrics. Other schools w ­ ere far worse, like ­those whose didactic teaching, only sometimes with manikins, was “utterly worthless.”23 Johns Hopkins professor of obstetrics J. Whitridge Williams learned from colleagues in 120 schools he surveyed in 1911 that students in only eight of them had the opportunity to witness anything like a satisfactory number of deliveries. According to the candid replies of many of his fellow specialists, the teaching in obstetrics was “depressing,” “deplorable,” and “appalling.” They ­were frustrated by the ­limited teaching time and resources their schools ­were willing to devote to their subject. Too much emphasis and time was given to surgery, including gynecological, in what a University of Kansas obstetrician called “the more spectacular surgical clinic.” In short, Williams lamented in an AMA journal article, obstetrical teaching was “a very dark spot in our system of medical education.” Authors of other articles agreed. One said that although obstetrics was about the most impor­tant subject in the medical curriculum, its neglect had resulted in “thousands of unnecessary deaths and physical wrecks.” The deaths and disfigurements ruined the reputation of many doctors who caused them, according to another.24 The “shocking laxity” that Osler had observed about clinical training applied almost universally in the teaching of drug therapeutics. That made it hard for young doctors to abide by his aphorism: “Remember how much you do not know. Do not pour strange medicines into your patients.” One young reformer spent four months as a student and visitor in the largest and best-­ equipped medical colleges and hospitals in New York, Philadelphia, and Baltimore and reported in 1896 his surprise at what was modeled for medical students: the “careless, almost slovenly, manner in which prescriptions w ­ ere written.” According to his look at one hundred prescriptions submitted at the University of Pennsylvania’s teaching hospital, one of the best in the nation, 48 ­percent of prescriptions c­ ontained notable errors. At Johns Hopkins, the figure was a ­little better—36 ­percent. At its dispensary, however, where outpatient clinical training took place, 67 ­percent of prescriptions ­were incorrectly formulated.25 According to Perry H. Millard, a leader in the Minnesota State Medical Society, acting army surgeon general, and progenitor of the state’s licensing



A Plague of Doctors

247

law, “The ­people of this country take too many drugs” ­because of their doctors’ faulty education. According to Iowa pediatrician C. F. Wahrer, new doctors w ­ ere “vacant brains” that the “wily, smooth-­tongued” drug salesman “drummed [their] perverted system of therapeutics into.” While t­here was usually some instruction in materia medica, according to the University of Chicago’s Charles Williamson, it was “utter folly” to tell a sophomore student, for example, that the nitrites are “useful in angina pectoris” or that digitalis “is a most valuable drug in many heart lesions in the stage of decompensation” when he had not the remotest idea of what angina pectoris or decompensation was or how to diagnose it. According to O. T. Osborne, Yale’s medical students got only blackboard and other didactic instruction in pharmacy and prescription writing in the second through fourth years. ­Later, as interns, they mindlessly drew from the hospital formularies and forgot how to write prescriptions. The AMA’s phar­ma­ceu­ti­cal reformer William Puckner judged the typical professor to be lacking pharmacotherapeutic knowledge and indifferent to the need to create and disseminate it. Not surprisingly, therefore, in 1910 Henry Beates Jr., the president of the Pennsylvania State Examining Board, estimated that fewer than 4 ­percent of the annual crop of new doctors w ­ ere capable of correctly writing a prescription.26 ­Because of this state of affairs, “Is it any won­der,” asked the AMA journal, “that the gradu­ate, in his ­mental confusion . . . ​should fall back upon patent preparations or proprietary formulae?” On that ­matter, Williamson pointed out, poor instruction in medicinal therapeutics made doctors “easy prey” for detailers touting the won­der drugs they hawked, especially ­because they could brandish fee-­for-­service testimonials from authoritative-­sounding doctors about their prescriptions’ remarkable cure rates. “We have been, and are being, made the cat’s paws of the nostrum men, who laugh at us ­behind our backs,” he said. One detailer told Williamson he thought about 120,000 of the 140,000 doctors of the country “are densely ignorant of any scientific therapeutics or materia medica.”27 The state licensing laws of the 1870s and 1880s requiring medical degrees for licensure did nothing to force medical schools to make knowledge of drugs and the drug industry’s deceitfulness a condition for graduation. Amendments to the laws of the late 1880s gradually introduced licensing examinations, but many still did not include practical sections for demonstrating diagnostic and therapeutic skills. By contrast, in Eu­ro­pean countries, practical examinations w ­ ere routine. In France, for example, practical tests w ­ ere required in dissection, pathology, surgery, anatomy, and obstetrics. In Germany,

248

Schooling Physicians

examiners required displays of practical skills in internal medicine, surgery, ophthalmology, pediatrics, and ner­vous diseases. The examinations could take up to three weeks. Without such ordeals ahead of them, American students skimped on or entirely shirked clinical study, all the better to cram for facts to regurgitate on paper. As one critic of exclusive reliance on written examinations put it, “Even if facilities for practical work are given the student, his mind is ever on the necessity of preparation for the examination ahead, rather than on the careful observation of clinical cases and of the ­ ecause medical examinations prosecution of the practical work at hand.” B fed the “habit of cramming and memorizing facts as laid down in books,” they had “an injurious influence on the preparation of the candidate for his ­f uture work.”28 Not a lot of pro­gress occurred between the 1880s and 1910 in terms of bedside teaching. According to Flexner, only about one-­third of the ninety mainstream schools feeding gradu­ates into state examining systems in 1910 exposed students to clinical instruction of any sort, even in lecture format. The opportunities for students of homeopathic and eclectic medicine w ­ ere no better, and usually worse. Even when they claimed to require clinical training of their students, medical colleges’ professed standards of clinical teaching w ­ ere ambiguous ­because “bedside” was usually not specified. Instruction at chaotic, overcrowded outpatient dispensaries was sometimes the best students could hope for. And even where the standards w ­ ere clear, school administrators simply ignored the ones that w ­ ere impossible to satisfy.29 A ­G R E A T U N W A S H E D

Given the woefully rudimentary state of therapeutic knowledge at the turn of the twentieth c­ entury—so thought most reformers—­then the best ser­vice medical training could give to students was in the area of prevention. But instruction in private and public hygiene was skimpy to non­ex­is­tent. Of course, ­because they had to make a living as clinicians, few students could be turned into fervent public health missionaries. But they w ­ ere not even well instructed about iatrogenesis, or the spreading of illness and injury by the giving of care, including infections acquired during examinations, surgeries, and deliveries. In 1909, a subcommittee of the AMA’s Council on Medical Education heard from Boston sanitary engineer Robert Spurr Weston “that the average medical gradu­ate is woefully deficient in the princi­ples of even ordinary personal



A Plague of Doctors

249

hygiene; in fact, the subject is better taught in many universities than in some medical schools.”30 In 1909, according to James Warbasse, one of the profession’s most left-­ wing progressives, no medical college in the country had a course in public health and sanitation truly worthy of the name. Bayard Holmes, another left-­ wing medical reformer, fumed that preventive hygiene was “pathogenically” neglected, often in “unmentionably nasty medical school buildings.” A multifaceted surgeon who served on the Chicago Civic Federation’s Committee on Public Health and as secretary of the Association of American Medical Colleges (AAMC) from 1895 to 1900, Holmes said professors cared l­ittle about “the health of the medical student body.” They therefore bore considerable responsibility for the fact that students “drink too much, smoke too much, and are too f­ree with w ­ omen.” Not much had changed since 1851 when Nathan Davis complained that many students oscillated “between the h ­ ouse of ill-­fame and the grog-­shop” when they w ­ ere supposed to be studying. Students “befoul the lecture-­rooms and amphitheatres with tobacco smoke and expectoration,” and janitors “seem to be selected b­ ecause they are already tuberculous or have all the habits which make them early succumb to the disease.” In short, the young doctor was miserably prepared to “go forth to counsel the ­people who become his patients in all the manners of life by which disease may be forestalled.”31 The lack of hygiene and public health training made murderers of the very same doctors whom medical patriarchs held up as superior to midwives. Crusaders against midwives gladly told horror stories about them but not about the same kinds of tragedies inflicted by many males with supposedly respectable medical degrees. According to physician Inez Philbrick, an iconoclastic social reformer and defender of contraception and euthanasia as well as midwifery, male physicians delivered “ofttimes barbarous treatment” to birthing ­mothers along with badly mistaken diagnoses and general incompetence. The rare statistical comparisons available did not support the patriarchs. Obstetrics professors responding to Williams’s inquiry estimated the general prac­ti­tion­ers coming out of their schools to be more likely than midwives to spread fatal puerperal (streptococcal) infections, sometimes ­because of “ill-­judged and improperly performed operations.” Th ­ ere was no excuse for this, obstetrics reformers thought, ­because the works of Lister and Pasteur in the 1880s had driven home the truth of Oliver Wendell Holmes’s findings, already well disseminated in the 1850s, that dirty hands and instruments

250

Schooling Physicians

caused childbed fever. In this regard at least, perhaps, poor American ­mothers ­were often the luckier ones. According to a recent study, in the ­century ­after 1830 t­ here was an inverse relation between maternal mortality rates and social class, “in part b­ ecause of unwise and botched interventions.”32 Some crude statistics from the time suggest that babies as well as their ­mothers ­were more at risk at the hands of doctors than midwives. In Newark, New Jersey, midwives ­were pre­sent at proportionately fewer cases of infant mortality than doctors in 1915 and 1916. New York City’s public and child health reformer Josephine Baker reported statistics from Manhattan around the same time indicating that doctors caused many more tragedies than midwives as mea­sured by stillbirths and puerperal septicemia. She added that in Washington State, where births attended by midwives ­were dramatically falling from 50 to 15 ­percent in the years from 1903 to 1912, infant mortality in the month a­ fter delivery was rising. Pediatrics reformer Abraham Jacobi noted that of 116 cases of preventable and potentially blinding neonatal conjunctivitis treated in the Mas­sa­chu­setts Eye and Ear Infirmary one year, a strikingly disproportionate 114 ­were in infants attended by physicians and only 2 by midwives. “If it ­were wise and proper to generalize,” he concluded in his 1912 president’s address to the AMA’s House of Delegates, “the doctors should be replaced by midwives.” Jacobi thought that if those male doctors kept their jobs, many of them should lose sleep. “­Every case of death of sepsis in the m ­ other should burn hell into the conscience of whoever permits it,” he thundered.33 Thousands of medical degrees ­were being handed out ­every year to young men who also missed out on instruction in more abstract ­things than the hand washing essential to their roles as stewards of public health. Echoing playwright and Fabian socialist George Bernard Shaw’s observation that “doctors are . . . ​not trained in the use of evidence, nor in biometrics,” George Chandler Whipple, a civil engineer, microbiologist, and cofounder of the Harvard School of Public Health, told the AMA’s Council on Medical Education that “doctors as a rule do not make good health officers for the reason that the average physician has no quantitative sense.” A subcommittee of the council members reported having heard it frequently stated that charity and social workers w ­ ere “much more efficient in the educational, statistical and even practical phases of tuberculosis” than many doctors and had done “much to stimulate medical men to a knowledge of their own limitations.”34 For the progressive reformers, such knowledge should have already been inculcated in medical schools and flowing in the other direction.



A Plague of Doctors

251

NO STUDENTS PAST THIS POINT

Progressive medical reformers regarded hospitals as the best pos­si­ble places to cut good clinicians out of the quality cloth of carefully selected and scientifically trained students. Sadly, many schools lacked access to hospitals as training grounds. An AMA journal editorial in 1889 lamented that barely a dozen schools in the country offered bedside learning, for “clinical teaching has been prohibited by the governing boards of many of the institutions for the sick.” The dystopian real­ity was that medical professors ­were widely regarded by hospital man­ag­ers and medical staff as “intruders and interlopers,” according to historian Kenneth Ludmerer, unwelcome applicants for access to patients other than t­ hose they personally had admitted. Their young male students ­were “despised” for their buffoonery and lack of hygiene.35 Hospitals that ­were open to students ­were often managed in a way that militated against good teaching. Thus, in order to guarantee high-­quality teaching and research opportunities in the f­uture, the reformers agreed, all medical schools needed access to teaching hospitals over which they could assert administrative control. In 1893, Harvard’s Frederick Shattuck noted that no single school “absolutely controls sufficient clinical material” for quality clinical instruction. Even the University of Pennsylvania’s teaching hospital, established in 1874 as the country’s first university-­controlled teaching fa­cil­ i­ty, was too small for adequate instruction. Once more, Amer­i­ca was far ­behind Eu­rope, where education, science, and charity care ­were often combined ­under the large roof of an internationally renowned hospital.36 Even the efforts of better university-­based schools like Harvard, Yale, and Columbia to gain a greater mea­sure of control over hospitals had long been rebuffed and continued to be so well into the twentieth ­century’s first de­cade. Harvard had failed in 1886 to recruit the ­great medical education reformer William Osler from McGill University’s medical school in Ontario ­because Boston hospitals would not do the medical schools’ bidding. Yale lost its chance in 1906 to recruit Harvey Cushing, the rising star of neurosurgery, ­because the New Haven Hospital was so stingy with access. Mas­sa­ chu­setts General Hospital only ceded control to Harvard a­ fter hearing in 1908 that the university planned to establish its own teaching hospital. The Peter Bent Brigham, a private Boston hospital endowed by the millionaire businessman of that name, only reluctantly ceded control to Harvard’s medical college upon its opening in 1913, even though Harvard was by then at the vanguard of reform. Thus, the Johns Hopkins hospital, b­ ecause of Osler’s

252

Schooling Physicians

work, got a head start on the rest to become the flagship of reform in clinical teaching. A work in pro­gress in 1893, by 1900 Johns Hopkins had become the shining showcase of excellent medical training integrated with high-­quality care. For some time to come, it would remain an island of excellence in a vast sea of mediocrity and failure.37 Without school control, staffing was too chaotic for good education. Johns Hopkins professor William Thayer thought a ­great impediment to clinical research and training was the widespread rotation of key staff appointments, what Shattuck called “broken hospital ser­vice.” As Thayer put it, the best instruction “cannot be given to students in wards presided over only by a visiting physician and young, annually appointed, assistants.” Furthermore, “in no ser­vice where the head of the department changes e­ very three or four months can ­really valuable investigation be accomplished.” Needed was a permanent corps, if only a small one, with a fixed staff of assistants. Regrettably, most schools ­were forced to pick clinical teachers from hospital staffs appointed for reasons other than teaching qualifications. Teachers with broader profes­ ere from outside the area, ­were not even sional recognition, especially if they w considered. That was a “grave defect,” according to J. Collins Warren, a Harvard surgery professor.38 Chaotic staffing with ill-­qualified physicians made other desiderata impossible to achieve. Among t­ hose ­were the rational organ­ization and administration of laboratory facilities for combined diagnostic, scientific, and pedagogical purposes. A patient’s sputum, blood, urine, stools, and tissues—­ assuming appropriate protection of confidentiality—­should have been but ­were not part of the academic commons. Yale’s George Blumer envisioned pharmacologists and internists collaborating on controlled experimental investigation as well as education in a hospital setting: “The pharmacologist needs the leavening power of the internist just as much as the internist needs the scientific stimulation of the pharmacologist.” That was utopian thinking at the time. Many physicians balked at keeping patient rec­ords even for their own purposes, so essential data in patient histories ­were unavailable to teacher, student, and researcher. Hospital and education reformers therefore threatened the fiercely protected autonomous domain of the private physician.39 Chaotic hospitals, fi­nally, could not satisfy the needs of what had become the gold standard in the education reformers’ minds: the “clinical clerkship.” What passed for “section teaching” at the bedside was usually ­little more than a short demonstration or bedside lecture, with students standing silently by. This was but a slight improvement over sitting in an amphitheater craning



A Plague of Doctors

253

and straining to see and hear what the lecturer was talking about. At Johns Hopkins, William Osler introduced a radical improvement inspired by Eu­ ro­pean practices and what he had personally experienced at McGill University in Montreal. ­A fter two preclinical years, students ­were assigned a half dozen or so patients whose care they would be actively involved in. They would take histories, perform physical examinations, conduct laboratory tests, make therapeutic suggestions, and carry out some routine procedures. They would learn by d ­ oing, following the relationship between treatment and pro­gress with individual patients over an extended period of time. Other abstracted, fractured, disjointed, arms-­length ways of clinical learning ­were “bastard substitutes” for the clinical clerkship, Osler argued, inadequate as antidotes to the “ ‘nickel-­in-­the-­slot’ attitude of mind which has been the curse of the physician in the treatment of disease.” But ­those substitutes ­were about all that hospitals open to teaching would begrudgingly allow. Only about five hospitals actively embraced the clerkship by 1910 while another half dozen or so offered it only on a ­limited basis.40 One root cause of the educational failures of hospitals was electoral and patronage politics. The Bacillus politicus infected large municipal hospitals, potentially ideal and sometimes the only pos­si­ble sites for clinical teaching and research. Chicago’s Cook County Hospital, controlled by an elected board of county commissioners, suffered from the same disease afflicting the rest of the county’s politics and administration. Just another territory to be captured and controlled by the voracious po­liti­cal machine, its “warden,” a layman, operated with near absolute power and was naturally u ­ nder pressure to use it to make all personnel decisions, including physician staffing, at vari­ous commissioners’ behest. In theory, medical policy was made by a hospital board, but it was elected on an annual basis by the staff physicians hired and fired at the warden’s whim. According to one critic, ­these, of course, ­were “not the ablest exponents of the princi­ples and practice of medicine.” 41 Trench warfare over the control and even the existence of clinical teaching in Cook County Hospital meant that for the fifteen-­year period a­ fter 1880 the city’s vari­ous medical schools “sent out to the world . . . ​some 30,000 doctors to whom she never gave an opportunity to learn practical medicine by bedside study.” In 1880, a dispute between the county hospital board and staff physician James P. Ross, a professor of clinical medicine and chest diseases at Rush Medical College, led to the adoption of a draconian rule prohibiting all bedside instruction. Students could be pre­sent in clinical amphitheaters, but only if the patient consented, and only upon payment of a “hospital ticket

254

Schooling Physicians

fee.” ­These impediments prompted Ross and o­ thers to have Rush Medical College build its own teaching hospital in 1883, ­later named the Presbyterian Hospital. But Rush was exceptional, and its hospital had only 150 beds available for instruction. Access to the Cook County Hospital was still needed.42 Sometime around 1895, a new regime was instituted by a warden willing to make the Cook County Hospital’s patients accessible for teaching. But all was not yet well, for appointments to the staff positions needed for clinical training remained ­under the control of a warden who could freely reject the Chicago Medical Society’s recommendations. And recurring biennial elections to the Cook County Board of Commissioners, which w ­ ere always attended by “unrest and strife,” guaranteed f­ uture instability. Thus, in 1902 bedside instruction was once again banned. Furthermore, so was all gynecological teaching at public outpatient clinics. Such instruction had already “shocked the sensibilities” of the warden, and some “discourteous” be­hav­ior by medical students settled the m ­ atter. According to the AMA journal, his ruling burned down the h ­ ouse to roast the pig. Th ­ ere w ­ ere other remedies to the prob­lem. A Milwaukee public hospital superintendent quickly followed the Chicago example, banning student presence at operations on ­women in which “any exposure” at all was necessary.43 ­These same students, upon earning a medical degree and getting state licenses, would have no l­egal limits on their privileges to operate on the w ­ omen of Illinois, Wisconsin, and elsewhere across the country where their degrees w ­ ere recognized. Chicago may have been extreme, but politics was a common scourge in other municipal hospitals whose facilities ­were needed for teaching. Boston City Hospital around the turn of the c­ entury served as the pet of legendary mayor and party boss Michael Curley, who pressed it for ­favors during his extraordinary reign from 1913 to 1949. But he also lavished it with resources in return, thus helping it achieve a reputation as one of the country’s best hospitals. Nevertheless, it still refused to submit to Harvard Medical School’s pressure for control in 1910. In St. Louis, in 1905, eleven medical socie­ties coalesced to banish politics from municipal hospitals, where, according to the AMA journal, “all appointees, from the hospital superintendent down to the humblest employee, are subjects of po­liti­cal patronage.” Despite the unusual concord among squabbling physicians on this one ­matter, the prospects for reform ­were dimmed by the fact that the city health department was ner­vous about retaliation from politicians who would be incon­ve­nienced. Related ­battles ­were no doubt staged in other cities.44



A Plague of Doctors

255

HERD MEDICINE

As the Progressive Era medical reformers understood it, too many bad medical schools w ­ ere producing too many bad doctors, and fierce competition among them did the opposite of elevate standards, which is what unfettered markets ­were supposed to do. If anything, medical schools and their products ­were engaged in a race to the bottom, or at least a fight to capture a share of the market’s low ground. Excess competition over patients led to the survival of the foulest. According to Abraham Jacobi, overcrowding subjected “the morals of the profession . . . ​to a most severe strain.” As an 1888 AMA journal editorial on “Competition, Supply and Demand, and Medical Education” put it, “Unwholesome competition tends only to make the morally loosely-­inclined physician worse; but it does not make the conscientious physician better, or more careful, or more scientific.” The glut of competitors could only “lower the moral tone of physicians.” In other words, the prob­lem was the most pernicious kind of adverse se­lection.45 Patients “too frequently suffer from dishonorable practices,” according to reformer Perry Millard, ­because of “sharp” competition among doctors struggling to make a living. It led to indiscriminate overprescribing of risky drugs to credulous paying patients. Some desperate physicians hired “drummers” to walk up and down train aisles to snag customers. William Pepper dismissed the idea that the sovereign medical consumer could rule over such an industry. It was impossible for people to distinguish between worthy and unworthy physicians “as they can between good and bad butter or bread.” According to Illinois public health official Eggleston, ­because ordinary p ­ eople could not “examine the wares,” they often had no choice but to assume that the physician recommending a drug or treatment was competent and honest ­until proven other­wise—­when it might be too late. The innocent-until-​provenguilty assumption was very risky regarding surgeons. Operators in surplus supply induced patients in scarce supply to undergo inadvisable surgeries. Meanwhile, unbeknownst to naive patients, general practitioners referred them to surgeons for dubious operations, and demanded in exchange secret kickbacks from the surgeons’ large fees. Complaints about “fee splitting,” “secret commissions,” and “rebates” ­were legion among reformers outraged by the “graft” perpetrated on unsuspecting patients. McCormack frequently heard from “apparently reputable men” that it was unthinkable to send a case to a surgeon who would not “divide his fees” with them.46

256

Schooling Physicians

Over the de­cades, similar observations w ­ ere repeated. The 1888 AMA editorial asserted that overcrowding led to “the production or increase of quackery” and lowered “the moral tone of the physician.” According to a 1904 editorial in the Medical Visitor, a homeopathic journal, b­ ecause of overcrowding, “graft is worming and sliming its way into all the nooks and crannies of the profession.” Many an “erstwhile honest doctor” felt compelled “to smother his conscience, quietly strangle his inborn ideas of ethics, and sally forth, suave and smiling” with one hand held out for fees from a gullible public and the other “carry­ing a stiletto for his professional neighbors.” AMA journal editor George Simmons summed it up in 1910: “When six or eight ill-­trained physicians undertake to make a living in a town which can support only two, the ­whole plane of professional conduct is lowered, and, in the strug­gle which ensues . . . ​public health and sanitation are neglected, and the standards of the profession tend to demoralization.” 47 A similar diagnosis of adverse se­lection applied to the overcrowded field of medical education. In How to Be Successful as a Physician, Charles Davis noted that many a new medical college was “the unripe fruit of the morbid ambitions of aspiring ‘professors.’ ” A title as dean or professor of medicine was sure to attract more and better paying, if not more discerning, patients. As William Pepper put it, the proliferating schools ­were “poisonous mushrooms springing up in the rank soil of selfish interests.” The result was “calamitous.” Likewise, patients had no way of distinguishing the twenty-­dollar “letters of marque” printed by duly chartered diploma mills from certificates awarded by colleges struggling conscientiously to provide better training.48 The survival of the foulest in medical education was guaranteed by market forces. Even if a badly prepared student applied for admission well into the start of a short term, Nathan Davis wrote in 1850, “the faculty dare not refuse him, lest he turn on his heel and walk directly into the halls of some rival institution.” The market called for leniency in e­ very regard, from admissions to exam grading. A balm for medical faculty’s burning consciences was the belief “that they examine quite as rigidly as any of their neighbors and rivals.” Before setting in motion the AMA’s founding in 1847, Davis had sought fellow New York doctors’ help in persuading the state’s schools to fight the market. But the New York schools feared stepping out ahead of their competitors with higher tuition and longer terms b­ ecause that would just “drive students to the neighboring schools of Philadelphia and other cities in other states.” Thus, at age forty, Davis called a gathering of about 250 delegates from medical socie­ties and colleges in twenty-­three states to plan a coordinated,



A Plague of Doctors

257

multistate drive for a specific set of educational improvements. The Philadelphia assembly resolved itself into the first incarnation of the AMA along the lines of a plan Davis helped draft. Representatives sent by some of the nation’s medical schools deliberated on a voluntary reform strategy, but they disappointed Smith by refusing to commit to extend each year’s course of study to six months from only four or five. Instead they “contented themselves with the declaration, that they w ­ ere ready to comply . . . ​so soon as it s­ hall appear that all the other colleges ­will do so too.” Only the University of Pennsylvania steered onto a higher path, unilaterally extending its term, but the g­ amble failed. “Not a single other school followed its example,” according to William Pepper, the university’s ­later provost. Enrollment plummeted, and within six years it had to return to the bazaar with its standard cheaper wares.49 Thirty years l­ater, in 1877, Davis took note of some nominal improvements in the standard curriculum offered but a real decline in quality as terms had been shortened, requirements for graduation reduced, and written exams replaced with “a few oral questions in the mysterious ‘greenroom.’ ” While individual colleges yearned for general improvement, “each waits for the other to move first, lest by placing higher requirements upon the time and resources of the student it should cause its own halls to be deserted for ­those of its less exacting neighbor.” The “controlling influence” was the students’ desire to get licensed in the shortest time and thus at the least cost. Pepper would still observe in 1894, almost two de­cades ­later, a race to the bottom: “The downward course is ever the easiest.” Yet another fourteen years ­later, according to Arthur Dean Bevan, the AMA’s chief education reformer, competition over students’ tuition fees was still holding down the quality of applicants accepted, the tuition fees charged, and the time of study required. The result: the “graduation of unfit men.”50 While many lay critics of the AMA scored it as a medical trade ­union desirous of reducing the supply of doctors in order to increase their income, the reformers from the 1850s onward had lay allies with a dif­fer­ent understanding of the organ­ization. The most eminent among them was John Eaton, the U.S. Interior Department’s commissioner of education, a councilor of the American Public Health Association, and the vice president of the American Association for the Advancement of Science. Celebrated in his time and since as a g­ reat education reformer, Eaton worked a­ fter the American Civil War as a high official in the Freedman’s Bureau, hoping against the odds to assimilate black Southerners into the economy as landowning in­de­pen­dent yeomen. A fervent advocate of nursing education, Eaton also championed the gullible

258

Schooling Physicians

victim of low-­quality American medical schools, the hapless medical student who got “no calculable equivalent” to the tuition paid. “He asks for bread and receives a stone,” Eaton wrote in 1884 in the federal Bureau of Education’s thirteenth annual report. He pitied the truly capable gradu­ates who ­were inevitably “jostled, crowded, shouted down and trampled upon” by hordes of competitors and thus reduced to a standard of living perhaps worse than the industrial class from whence they came—­that is, ­unless they supplemented “their scant incomes by arts and devices that his nature and training forbid him to join in.” Eaton therefore ridiculed a certain “widely known and much respected medical teacher and author” who argued pretentiously that “the law of supply and demand w ­ ill properly control the professional expansion.” His successor in the Bureau of Education in 1893 agreed. B ­ ecause of “the ease with which deception can be practiced in the healing art,” l­egal regulation of medicine was called for to “secure at least the presumptive evidence that medical prac­ti­tion­ers are qualified for their responsible duties.”51 Indeed, as Eaton suggested, some medical educators trumpeted f­ ree market ideology against intervention in their business. That prompted an 1888 AMA journal editorial, prob­ably written by editor Nathan Davis, to state that “just as soon as anyone remarks on the surplus of medical colleges and the excessive production of physician . . . ​another person assumes an air of superior wisdom and importance and replies: ‘Competition is the life of trade’; or ‘Supply and demand regulate the ­whole ­matter.’ ” On the contrary, countered Davis—­echoing language heard in recent congressional debate about railroad regulation—­“wholesome competition is the life of trade; unrestricted competition may be the death of it.” Even in manufacturing, he maintained, un­ regu­la­ted supply and demand did not guarantee quality. High demand and ­limited supply, he said, might induce a manufacturer “to put out an inferior article, ­because it can be made quicker and at less cost.” Or, faced with low demand and overproduction, the producer “has to put out an inferior article so as to un­der­bid competitors.” By similar logic, medical colleges “must, in order to exist, un­der­bid the other colleges, ­either by lower fees, or shorter courses and terms of study, or less rigid requirements for entrance and or for graduation, or all of ­these.”52 In 1889, Eggleston also heaped scorn on t­ hose who thought that “medical education w ­ ill regulate itself” b­ ecause of the workings of supply and demand— in par­tic­u­lar, the demand of ignorant applicants for medical training. As he saw it, student demand had no more to do with the quality of medical schools “than has the f­ ree agency of potatoes to do with their production and



A Plague of Doctors

259

growth.” Another trenchant critique was that of Theodore W. Schaeffer, writing in 1913 when conditions had only just begun improving, that the “laissez faire opinion” that the evils of market competition “­will fi­nally adjust themselves” was “illusory.” The crass utilitarian dogma of the “survival of the fittest” was “unmoral” ­because what survived might be “the degraded organism which crowds out higher species.” It was “the survival of the low, shrewd and cunning.” ­There was, in a sense, a Gresham’s law of excessively competitive medicine in Schaeffer’s view, as valid in medical education as in finance. The bad could drive out the good.53 INVISIBLE HAND, ALL THUMBS

The Progressive Era’s medical reformers sharply disagreed with the view that un­regu­la­ted forces of supply and demand raised medical standards the way they might in other markets where the quality of their goods and ser­ vices was transparent to the consumer and producer alike. They saw the race to the bottom d ­ oing its insidious work in commercialized medical education, just as in the drug industry from production and advertising to prescribing and dispensing. Even if doctors’ fees ­were kept down by the excess supply of doctors, the aggregate social return on their bad medical education—­that is to say the ratio of therapeutic benefits to costs borne by medical students and the patients who ­later paid their fees—­was depressed, not elevated. Clearly, t­ here was no informed and discriminating demand for good doctoring in the general population. Had ­there been, doctors-­to-be would have insisted on better and longer instruction, and many fewer would have been able to afford the resulting higher tuition. If the public had known about the dramatic variation in quality of the degrees issued, medical schools would have competed for students on the basis both of the training they offered and of applicants’ ability to absorb it, not just ability to pay. Hospitals would have competed for paying patients able to discriminate among them on the basis of their demonstrably good end results. They would therefore have demanded better qualifications of their medical staff, using the relative standing of their medical schools as one among other bases for judgment. But this market utopia would never exist. Something other than market forces alone needed to intervene, and that is where voluntary and government action came in, spurred on when pos­si­ble by or­ga­nized medicine.

ch a pter 10

Unnatural Se­lection and Intelligent Design

In 1910, an audience of members of the American Medical Association’s Council on Medical Education and its Committee on Medical Legislation listened appreciatively as Cornell University president Jacob Gould Schurman denounced medical education in the United States as “a disgrace to the nation and an outrage on humanity.” The cause, according to the moral phi­ los­o­pher, was a “pernicious” profit motive. Already back in 1892, his first year as Cornell’s president, Schurman had professed contempt for the idea that a quality medical school could ever run on tuition fees alone, that is to say without special endowments and quality control over its spending by lay overseers. It was, he thought, a “fraud on the public” to establish a medical school without the capital assets needed for advanced scientific instruction in the curriculum. No other high-quality degree program a university could offer required the same level of funding. In 1898, he began putting his princi­ples into action at Cornell by attracting a huge endowment from a wealthy industrialist for a medical college and insisting that even eminent faculty members submit to university control over their earnings and distribution of the school’s resources. Some deans and professors of “private enterprise” schools, Schurman said, “felt it an affront” and called him “mercenary and autocratic.”1 But Schurman also noted the gradual transition in private universities like Cornell, and a few public ones as well, toward quality medical education. He 260



U n n a t u r a l S e ­l e c t i o n a n d I n t e l l i g e n t D e s i g n

261

was pleased to say that “the general spirit of the age” was moving ­toward the position he had taken back in 1892. The spirit was a characteristically progressive one that moved laypeople to join forces with medical professionals for drug regulation, public health action, and the elevation of medical education scientifically and ethically. The AMA’s reformers w ­ ere both witnessing and contributing to the so­cio­log­i­cal and po­liti­cal forces straining upward against market competition’s downward pressure on educational quality and value. As at Cornell, the countervailing forces propelled some schools that ­were already in the upper stratum ­toward a higher plane. But only a handful ­were able to achieve world-­class excellence before the turn of the twentieth c­ entury. The net result was increasing heterogeneity but with the ­great bulk of the distribution still heavily concentrated t­ oward the bottom. ­ ere the medical Among the vanguard schools of the 1880s and 1890s w departments of Harvard University, the University of Pennsylvania, and Johns Hopkins University. Not surprisingly, only medical schools with university affiliations could afford to escape the downward clawing of the market. Each of them benefited greatly from private philanthropy, which never went to for-­profit institutions. Cornell Medical School, for example, would enter the elite competitors’ race to the top with assistance from steel, oil, and tobacco tycoon Oliver H ­ azard Payne. The University of Michigan, the “­mother of state universities,” was the first public university to attempt to follow the vanguard. It was an unusual governor, however, not a philanthropist, who made that pos­si­ble with state tax revenue. Other state universities hobbled slowly ­behind, handicapped as they w ­ ere by the difficulty in persuading miserly state legislatures to raise taxes or divert money from other t­ hings, especially when that amounted to unfair competition in the minds of medical education’s entrepreneurs and their po­liti­cal friends. H A RVA R D : T H E E A R L I E ST R I S E R

Ironically, the early decline of f­ ree enterprise medical education could not have happened without the help of phenomenally successful cap­i­tal­ists. Massive industrial corporations generated the surplus for counteracting the petty bourgeois entrepreneurialism of for-­profit medical schools. ­Toward the end of the nineteenth ­century, philanthropists began slowly endowing a few choice medical schools for better, longer, and more costly medical training. Harvard University showed them the way. U ­ ntil the 1870s, its medical college was only nominally affiliated with the university b­ ecause it operated with full financial

262

Schooling Physicians

and administrative autonomy. Its medical department paid lower salaries to its stable of prestigious professors than any other faculty, tolerable to them no doubt ­because their professorial status attracted wealthy patients. However, according to a history of the Harvard Medical School it was no more than “a money-­making institution, not much better than a diploma mill.”2 Radical change came to Harvard in the 1870s, but not without ­bitter re­ sis­tance from within the school itself. The reform required bold and resolute action by eminent lay forces, not physicians. Scientist Charles William Eliot, Harvard’s newly appointed university president, was the engineer and driver of change. The other, the switchman, was l­ awyer Charles Francis Adams, son of and grand­son of two U.S. presidents, a former Mas­sa­chu­setts congressman, Abraham Lincoln’s ambassador to London, and now a member of Harvard’s board of overseers. In 1869, the upper-­crust elite who controlled Harvard had recently chosen fellow blue blood Charles Eliot as president for his view, published in Atlantic Monthly, that a “thoroughgoing” reformation of American higher education focusing on practical, scientific learning was necessary to take the country out of its “wilderness, physical and moral.” Medical schools came ­under his sharpest scrutiny. The ignorance and incompetence of the average medical gradu­ate turned loose on the community was “something horrible to contemplate,” he said. Therefore, upon arriving at Harvard, Eliot chose its medical school as the first place to start reforming the university. Fixing medical education t­ here would, he hoped, show the way to redemption for the entire country.3 Educated as a chemist in Germany and at Harvard u ­ nder Josiah Cooke, a pioneer in spectroscopy and mea­sure­ment of atomic weights, Eliot was imbued with the unconventional notion of learning by d ­ oing in a laboratory setting, not just by passive absorption from books and lectures. While pursuing postgraduate studies in Eu­rope, Eliot closely observed the science-­ based German system of medical education. B ­ ecause of his scientific bent, Eliot’s reforms, initiated in 1871, included new and expanded laboratories for teaching and investigation. Se­nior faculty members grumbled. Even more contentious was Eliot’s subjugation of the medical school to the financial and administrative control of the university. That entailed ending the practice of dividing student fees among the faculty. Salaries w ­ ere to be paid instead, set from above and flowing out of the university trea­sury into which all student fees w ­ ere paid. Only students with basic literacy and foundational scientific knowledge ­were to be admitted. Previously about the only qualification other than an



U n n a t u r a l S e ­l e c t i o n a n d I n t e l l i g e n t D e s i g n

263

acceptable age, sex, and race had been money. The curriculum was to be extended from two four-­month yearly terms (compressible into one year) to three years of nine-­month terms. The terms w ­ ere to be “graduated”—­that is, students could no longer repeat classes taken the year before. Extensive preclinical laboratory study was to precede clinical training. Fi­nally, students ­were to be subjected to a series of written examinations in each course and written finals in all subjects for graduation. Previously, ­there had only been perfunctory five-­minute orals (“green room” exams in common parlance) in only five of nine subjects. Student fees w ­ ere to be raised. B ­ ecause that, as expected, would bring a dramatic drop in enrollment, additional resources would come out of external funds raised by the university in the years to come. Eliot’s fiercest opponent was Henry Jacob Bigelow, Boston’s leading surgeon and an eminent medical thinker. Bigelow was a “dogmatic, intolerant, flamboyant, and strong willed” man, according to historian of American medical education Kenneth Ludmerer. Other faculty members backed him with sometimes “mercenary, cynical and selfish” objections, according to Eliot’s biographer. Even if Harvard w ­ ere to supply the overhead costs for improvement, Bigelow complained that professors would have to make painful sacrifices in the form of longer teaching terms and other irritating encroachments on time for treating rich patients and publishing impressive scientific studies. Bigelow and his allies questioned the value of laboratory sciences to therapeutics, having been influenced by their training in France, which focused on bedside clinical teaching and investigation. “Medical teaching,” Bigelow insisted, “rests largely on clinical opportunity.” But Eliot had formidable medical allies against Bigelow. Although initially opposed, professor of anatomy Oliver Wendell Holmes, another of the country’s g­ reat medical minds, eventually got “out from u ­ nder . . . ​Dr. Bigelow’s thumb,” as Eliot put it. Also, ju­nior faculty members “chafing ­under Bigelow’s domination” supported Eliot. Many of them had studied in Germany and Austria and returned with the conviction that knowledge of basic sciences was essential for good medical training and steady pro­gress.4 Bigelow had exercised total control of the school according to Eliot. But he was not cowed by Bigelow’s forceful personality, rapier wit, and “picturesque language.” He criticized Bigelow’s surgical lectures, which ­were “strongly repetitive from year to year,” and praised ­those of Holmes, who lectured with “remarkable vivacity” using diagrams, prints, engravings, and specimens. When Eliot insisted on written examinations, Bigelow scoffed that more than half of the students “can barely write.” It was a pointless reform ­because “of

264

Schooling Physicians

course they ­can’t pass written examinations.” He scorned scientific faddishness and grumbled about laypeople’s “popu­lar and specious cry” for raising standards. He argued that instead of looking t­ oward Germany for improving preclinical laboratory training one should emulate Vienna’s large hospital, which the Austrian government made available for bedside clinical teaching and even examinations of students. But American hospital and municipal politics, Bigelow knew, would not allow this. In sum, he thought it best for the sake of quality, prestige, and profits that Harvard Medical School not change course. “­A fter all,” he maintained, “the drive to attract larger classes had motivated previous improvements in Harvard’s program.” Large classes of students ­were “at once the seed and . . . ​fertilizer” for a bountiful harvest of doctors from which to glean t­ hose of high grade.5 According to Eliot, a fortuitous “unforeseen happening” settled the b­ attle of outsized w ­ ills: the last-­minute intervention of Charles Francis Adams, a member of Harvard’s board of overseers. Adams carried weight. He had declined Harvard’s presidency before it was offered to Eliot. During the overseers’ first two meetings on Eliot’s plan, Adams said nothing. But with a reddened face and “a fierce glare in his eyes” at the third meeting, Adams told the story of a young Harvard medical gradu­ate who had killed two laborers with overdoses of morphine and was in the pro­cess of killing a third when an older physician intervened. Adams ended his story with the observation that “I suppose this young doctor was one of ­those gradu­ates of the Harvard Medical School who w ­ ere required to pass only five examinations out of nine to obtain the degree.” A ­ fter ­little further discussion, a vote was taken, giving Eliot a strong majority.6 In 1878 Eliot dropped another bomb on Harvard’s mostly conservative medical faculty by calling for admitting ­women on an equal basis with men. On this he failed. No believer himself in the equality of the sexes and only a lukewarm advocate of higher education for w ­ omen, he was more interested in an enticing offer of $10,000 for the school’s endowment from Marian Hovey, ­daughter and trustee of a philanthropic fund established by her deceased ­father, George O. Hovey. George Hovey had been a Boston merchant, insurance executive, and one of around two hundred “life members,” almost all of them laymen, of the Female Medical Education Society, or­ga­nized in 1848, which boasted more than eight hundred annual dues payers in 1854. Harvard’s board of overseers and the corporation, the university’s two governing bodies, w ­ ere tentatively interested ­until they encountered fierce re­sis­ tance from some of the medical faculty. A majority was, however, able to



U n n a t u r a l S e ­l e c t i o n a n d I n t e l l i g e n t D e s i g n

265

coalesce around an unrealistic counterdemand of $200,000, the minimum insurance they regarded as necessary against “loss from the irrevocable admission of ­women.” Subsequent faculty pressure persuaded a joint committee of the overseers and corporation to reject Hovey’s l­imited sum, which she then gave to Boston University’s Homoeopathic Medical School.7 Only two years ­later, in 1881, a number of pioneering ­women physicians, hospital found­ers, and medical educators took over the mission, now offering $50,000. A letter presenting the offer was signed by Mary Putnam Jacobi, founder and president of the Association for the Advancement of the Medi­ aughter of publisher George Putnam, she was cal Education of ­Women. D married to the progressive pediatrician and f­ uture AMA president Abraham Jacobi. Mary Jacobi was also a leading feminist, suffragist, and social reformer in a wide spectrum of affairs. Other eminent signers of the offer letter ­were Emily Blackwell, dean of the ­Women’s Medical College in New York City. She had cofounded the college with her s­ ister Elizabeth, known as the country’s first w ­ oman doctor. Another signer was Marie Elizabeth Zakrzewska, who founded the all-­female New E ­ ngland Hospital Medical Society ­because the Mas­sa­chu­setts Medical Society refused to accept w ­ omen. Emma Call, ­ ngland w ­ omen’s society, also signed president and secretary of the New E the letter.8 A resounding medical faculty majority voted against admitting w ­ omen, arguing that it would entail “a serious risk of detriment to the interests of medical education now given to men.” According to Jacobi, a frequent argument against admitting ­women was that it would “lower the value” of male Harvard gradu­ates’ diplomas “long ago earned and paid for.” She concluded that the “mass of argument, sarcasm, ridicule, invective, and downright calumny” that had poured down upon ­women wanting to study medicine was the pathetic response of men “menaced” by a loss of their trea­sured mono­ poly privileges. The small minority in support of accepting the gift included James R. Chadwick, a cofounder and ­later president of the American Gynecological Society. In a lay journal, Chadwick surveyed ­women’s medical education elsewhere in the world, concluding that none of the predicted “social, moral, or educational calamities” had tran­spired. Henry Ingersoll Bowditch, Harvard professor emeritus of clinical medicine, who called himself “a de­ cided ­women’s rights man,” also weighed in against his former colleagues. Though he had recently served as AMA president, Bowditch was—­since his abolitionist days—­still a radical humanist and thus not exactly representative of his profession. Holding his tongue would mean “incurring my own

266

Schooling Physicians

self-­contempt.” He scornfully indicted Harvard and the Mas­sa­chu­setts Medical Society for irrationally perpetrating an injustice on intelligent, dedicated ­women as well as on the public that needed their medical ser­vices.9 The large sum of money at stake for Harvard spoke louder to Eliot than the words of medical patriarchs, monopolists, and misogynists. For his “Jesuitical” working of Harvard’s governors, Eliot earned a tongue lashing from the Boston Medical and Surgical Journal. A majority of the Harvard overseers sided with him in January 1882, but then came more maneuvers and meetings. Rumors spread about disgruntled male faculty planning to sabotage the reform. One resolution submitted in a medical faculty meeting warned that professors “­will ­labor with much less zeal and with much less benefit to the ­ ere discommunity” if their views about governance of the medical school w regarded by the university. ­There w ­ ere rumors of a mass resignation. Fi­nally, in March 1882, the overseers lost heart in the face of hardening faculty re­sis­ tance.10 Sixty-­three years passed before Harvard fi­nally admitted the first ­women to medical study in 1945. Clearly, as Harvard’s experience showed to other universities, large sums of money w ­ ere needed for reforms that went against the grain of commercial medical education, including Harvard Medical School’s quasi-­commercial operations. Charles Eliot could not have succeeded with his vast improvements in Harvard’s all-­male medical school without a flow of outside money. Interestingly, early reforms could accelerate the flow. “From the time we introduced the three-­year course in 1871 we began to be endowed,” Eliot recalled years ­later. Indeed, Harvard’s gains from philanthropic contributions more than made up for the loss of tuition fees and its enrollment even recovered, now with better educated and wealthier students.11 P E N N S Y LVA N I A A N D M I C H I G A N

Reformers at other schools took notice of Harvard and followed suit with requests to philanthropists looking for worthy places to place their cap­i­tal­ist bounty. The University of Pennsylvania came in second ­after Harvard in the new race for external funds. In 1873, huge outside contributions enabled the university to establish its own teaching hospital, a critical move t­ oward major reforms in policy and curriculum implemented in 1877. They in turn helped pry loose even more philanthropic support. In 1871, the situation at the University of Pennsylvania had been depressing. One doctor who graduated around 1869 was rejected by the U.S. Navy for medical ser­vice ­because of his



U n n a t u r a l S e ­l e c t i o n a n d I n t e l l i g e n t D e s i g n 267

examination responses, including, “The boiling point of Fahrenheit is about 300° while that of the centigrade scale not so high.” And: “The normal temperature of the ­human body is from 112° to 140°.” In Penn’s case, it was a physician, not a layman, who led the charge for change—­the dynamic young pathologist and clinician William Pepper Jr. According to Pepper, the under­ lying prob­lem to be solved at Penn and elsewhere was the “working of the inexorable laws of trade” in medical degrees by schools “conducted in the interests, not of the medical profession, not of the community, certainly not of medical science, but of the members of the faculty alone.” Pepper expressed ­great disgust at “the growing degeneracy of the American system of medical education” caused by the “­free and unfettered operation of the laws of supply and demand.” They resulted in the proliferation of inferior schools and “the lowering of professional tone, the diminution of public confidence, and the prevalence of unblushing quackery.”12 Pepper’s ultimate success depended on power­ful lay support from among the university trustees and, possibly, embarrassing public exposure. Like Eliot at Harvard, he got a divided and mostly chilly response from the Penn faculty. L ­ ater, he reminisced that a­ fter five years of ­bitter conflict his victory caused a loss of “old friendships and the allegiance of valued associates.” The medical school’s dean, Robert E. Rogers, led the re­sis­tance and when defeated, resigned to take a position elsewhere, almost taking several colleagues with him. A l­ittle medical muckraking may have helped by focusing the lay public’s attention on a prob­lem that physicians mostly kept secret. In 1875, Pepper’s eminent colleague Horatio C. Wood published in Lippincott’s Magazine an exposé about the country’s degraded medical education system. In it, the professor of materia medica and pharmacy declared that so many gradu­ates of abysmal quality ­were being produced that it was “fearful to contemplate.” American medical education was committing “legalized murder.” Clearly implicating the University of Pennsylvania, he asserted that it needed to take the lead with reform.13 Pepper’s other medical allies w ­ ere, like Eliot’s, mainly younger faculty members. Their existence and support w ­ ere the result of an e­ arlier achievement of Pepper’s, also made pos­si­ble by lay support: the creation of the country’s first teaching hospital fully controlled by a medical faculty and committed to bedside teaching. In 1870, at the age of only twenty-­seven, Pepper had envisioned a hospital that could efficiently serve educational and scientific as well as humanitarian ends. In the summer of 1871, he visited the most famous medical institutions in London, Paris, Berlin, and Vienna for inspiration and

268

Schooling Physicians

upon his return set about seeking funds. In a short time, he raised $350,000 from wealthy benefactors, including $50,000 from Philadelphia banker Henry C. Gibson, who continued to donate money l­ater and for whom a wing for treatment of chronic lung and heart diseases was named. Pepper then garnered an additional $200,000 from the state legislature for construction costs and endowment. With that he was easily able to purchase from the city some suitable land in West Philadelphia for only $500.14 Philanthropic support for the hospital enabled the hiring of a number of new, young adjunct “hospital professors,” Pepper’s core support base for his 1877 reforms. He owed that fortuitous faculty expansion to support from emeritus professor George Bacon Wood (Horatio Wood’s u ­ ncle). George Wood persuaded the university’s trustees to bypass the old guard for the hospital’s clinical staffing and find new blood instead. The young hospital staff ­were denied a vote in faculty meetings ­because the se­nior chaired professors did not want their control over student fees diluted. But their voices w ­ ere heard, nevertheless. The adjuncts authored their own report, endorsed by Harvard’s Eliot, which persuaded the university trustees to defy the se­nior faculty and institute the 1877 changes. Among them ­were more stringent admission requirements, three years of five-­month terms, a progression instead of repetition of courses over t­hose years, yearly and final written examinations, and fixed salaries for professors paid out of the university trea­sury.15 A large infusion of money also made the University of Michigan the home ­ other of state universiof the first outstanding public medical school. “The m ties,” it was the only sizable and flourishing state university at the time. A series of reforms initiated in 1880 brought a three-­year curriculum, advanced laboratory instruction, and the first assignment of grades. B ­ ecause it was a state university medical school already admitting ­women, Michigan was to be the first top-­tier school with female students, although they remained a small minority and w ­ ere shunted into segregated lectures u ­ ntil 1903 and laboratories u ­ ntil 1908. That Michigan could defy the gravitational force of the market depended on a fortuitous circumstance not yet enjoyed by other state universities: forceful po­liti­cal leadership from university president James Burrill Angell. Angell was, like Eliot, in the country’s league of pioneer university executives bent on lifting American higher education to a higher place. In 1873, he was able to convince a large majority of the Michigan legislature to enact a special mill tax, which gave the university a large and stable operating bud­get. No restrictions ­were imposed against shifting resources around within the university for reasons of academic excellence. The inoculation



U n n a t u r a l S e ­l e c t i o n a n d I n t e l l i g e n t D e s i g n 269

against the Bacillus politicus thereby enticed private individuals to top off its public bud­get with special bequests for buildings, endowments, and research in the knowledge that politicians would not somehow abuse or feed off their beneficence.16 Angell, whose background was in modern languages, history, publishing, and diplomacy, sought medical guidance from the eminent biochemist and public health missionary Victor C. Vaughan, ­later dean of the medical school and president of the AMA in 1914. Like other lay-­medical alliances for reform, Angell and Vaughan also met some medical re­sis­tance, especially from the school’s old lion, Alonzo B. Palmer, who vehemently denied the value of recruiting new faculty members with modern scientific credentials. But Palmer actually supported other improvements, such as lengthening the yearly term to nine months even though it made it impossible for him to teach at both Bowdoin, in Brunswick, Maine, and in Ann Arbor, Michigan.17 ­Because ­t here was l­ittle nationwide momentum for Michigan-­style largesse, by 1908 only a handful of states such as California, Illinois, Minnesota, and Wisconsin followed Michigan’s strong lead in supplying substantial funds. But at least twenty states and the city of Cincinnati, Ohio, ­were advancing ­limited resources for infrastructure such as buildings, equipment, and teaching hospitals, an acknowl­edgment that it cost more to educate medical students well than all but the very rich could afford to pay. The sluggish movement ­toward betterment was prob­ably attributable to the country’s large “tribe . . . ​of ­idiots howling against taxation for higher education,” according to Michigan history professor Charles K. Adams.18 It is no small irony that Charles Eliot was one of the leaders of the lay opponents of state funding of universities and thus the kinds of improvements that Angell made pos­si­ble—­ all the while fiercely defending Harvard’s tax-­sheltered status. JOHNS HOPKINS AND DEMANDING W ­ OMEN

By the early 1890s, about a dozen medical schools had risen well above the crowd to offer something starting to resemble the quality of training that could be found in Eu­rope. Among them ­were Columbia University’s College of Physicians and Surgeons, in part ­because of an 1884 donation from William Henry Vanderbilt, the largest ever to a medical school. In the 1890s, top private universities such as Chicago, Cornell, Rush, Yale, Northwestern, and state universities in Minnesota and California also began pursuing ambitions for quality medical education and the money to realize them. Suddenly, in

270

Schooling Physicians

1893, Johns Hopkins University surged from ­behind to create the nation’s flagship medical school from scratch. Among its other distinguishing features ­were especially rigorous premedical entrance requirements, greater integration of scientific investigation with medical education and therapeutics, more extensive clinical training enhanced by students’ direct involvement in hospitalized patients’ care, and last, but not least, the admission of ­women to top-­shelf medical training. As in the other cases, the reform involved a typically progressive lay-­ professional alliance, although this time the main benefactor was a ­woman, Mary Elizabeth Garrett, a fervent champion of ­women’s higher education. The story began with the death in 1873 of Johns Hopkins, Baltimore’s most power­ful financier and largest shareholder of the Baltimore and Ohio (B&O) Railroad. Hopkins’s ­will included $7 million for the eventual establishment of a new university, complete with a world-­class medical school and teaching hospital. It was to date the largest philanthropic gift in American history, explainable by Hopkins’s Quaker and abolitionist background, friendship with George Peabody (the “­father of modern philanthropy”), and childless bachelorhood. A likely influence on Hopkins’s interest in medical education was a neighbor, Patrick Macaulay, physician and early director of the B&O Railroad. Macaulay’s 1824 Medical Improvement and other publications by him ­were on Hopkins’s bookshelves. In his tract, Macaulay called for a “speedy and radical change in the system of our medical education.” He admonished the trustees and professors of universities and colleges to extend the time of study required for a medical degree. Especially impor­tant in his remarkable vision of reform was the integration of hospital administration and medical training. “Then, and not till then, ­shall we fix the profession on its true foundations,” he proclaimed.19 On the unan­i­mous advice of Eliot of Harvard and Angell of Michigan, the trustees of the new university, established in 1876, turned to Daniel Coit Gilman, a nationally known higher education reformer, to serve as the university’s first president. As professor of physical geography, Gilman had headed the Sheffield Scientific School at Yale before taking on the presidency of the University of California for a short stint. In California, Gilman acted on his own views about quality medical education by helping set up a medical department ­there. For the medical school in the works, the trustees, led by Hopkins’s friend Francis T. King, another Quaker businessman and philanthropist, acted on Hopkins’s insistence that only preeminent educational and medical reformers be enlisted. Gilman therefore recruited the public health



U n n a t u r a l S e ­l e c t i o n a n d I n t e l l i g e n t D e s i g n

271

missionary and authority on hospital construction and management John Shaw Billings to take charge of creating the academic-­medical center. Billings hired the brilliant pathologist and also public health titan William Welch, whose training included a period with Robert Koch in Berlin, as the medical school’s prospective first dean. A firm believer in the need for intensive bedside instruction, Billings chose William Osler to be the teaching hospital’s physician-­in-­ chief. In that role, Osler was to launch the country’s first program of clinical clerkships, which involved assigning specific patients to third-­year students charged with managing their treatment and observing their pro­gress.20 Unfortunately for the medical school builders, dividends from Hopkins’s B&O railroad stock held in trust for the medical school dwindled to almost nothing in the 1880s. The picture remained bleak ­until 1893, when another philanthropist came to the rescue. She was Mary Garrett, the ­daughter of John W. Garrett, the im­mensely power­ful president of the B&O Railroad. A friend of Hopkins, John Garrett had encouraged the philanthropist to develop his vision of a g­ reat medical school. A ­ fter his death, d ­ aughter Mary took up his cause with iron determination. Alan Chesney, who received his undergraduate degree from Johns Hopkins in 1908 and who l­ ater served as dean of its school of medicine, declared that “to this lady, more than any other single person, save only Johns Hopkins himself, does the School of Medicine owe its being.”21 By force of ­will as well as money, Garrett revived the dead proj­ect, but only if it met several of her demands. For one, unpre­ce­dentedly stringent premedical requirements had to stay. The money prob­lems had persuaded the found­ers to abandon that ambition, fearing that the requirements would dry up the pool of applicants able to pay the fees to keep the school afloat. More controversial was Garrett’s demand that w ­ omen be included on an equal basis with men. A leading missionary for ­women’s ­causes, Garrett was the hub of a “Friday Night” group of unmarried, mostly young ­women activists who, starting in 1878, met in each other’s homes for discussions about advancing ­women in higher education. In 1885 Garrett generously endowed Baltimore’s Bryn Mawr School, a college preparatory school for girls; in 1893, while helping with the Johns Hopkins proj­ect, she began heavi­ly supporting Bryn Mawr College itself. She would l­ater serve as a leader and fundraiser for the National American ­Woman Suffrage Association.22 In 1890, when Gilman was proving unable to find a wealthy benefactor for the Johns Hopkins proj­ect, Garrett and her Friday Night friends saw an opening for action. She was possibly fired up by the memory of President

272

Schooling Physicians

Mary Elizabeth Garrett (1854–1915). Philanthropist, suffragist, and champion of ­women’s higher education, Garrett became the founding benefactor of the Johns Hopkins University School of Medicine only ­a fter it satisfied her demands for admission of ­women and rigorous premedical training. The 1877 photograph is from the Bryn Mawr College Photo Archives, Bryn Mawr College Special Collections, PA_Garrett_Mary_017.

Gilman’s refusal in 1876 to allow her to take undergraduate science classes at Hopkins. What she called the Friday Night “scheme” involved the formation of fifteen regional committees to raise the money to build the medical school. Pioneering w ­ omen doctors Mary Jacobi and Emily Blackwell—­who had failed to buy entrance for ­women at Harvard—­headed the New York contingent. ­Others enlisted ­were Elizabeth Cabot Agassiz, Grace Osler, and Mary Cadwalader Mitchell, wives of prominent scientists and physicians Louis Agassiz, William Osler, and S. Weir Mitchell. Caroline Scott Harrison, wife of Benjamin Harrison, the current U.S. president, presided over both the national fund­rais­ing committee and the District of Columbia’s regional subcommittee. The first lady’s f­ather was a Presbyterian minister, a professor of science and mathe­matics, and the first president of the Oxford Female Institute, her alma mater. Her president husband was also an education enthusiast and, as senator from Indiana, allied with fellow Presbyterian abolitionist and education reformer John Eaton, who agitated for integrating black citizens into the American economy, society, and po­liti­cal order. According to the New York



U n n a t u r a l S e ­l e c t i o n a n d I n t e l l i g e n t D e s i g n

273

Times, Garrett or­ga­nized two receptions in Baltimore for the first lady, one with over two hundred in attendance at the hospital and another for which she issued fifteen hundred invitations, at her Mount Vernon mansion. At the latter, “all of fash­ion­able Baltimore was t­here,” according to the New York Times. ­Because of the journalistic coverage, their activities brought the issue of ­women in medicine before a broad national public for the first time.23 The ­women’s campaign raised only the woefully inadequate sum of $64,000, so Garrett added about $47,000 of her own money. The following year she offered yet another $100,000 out of her inheritance, but to speed up the pro­cess, conditioned her gift on the raising of the remaining $300,000 needed by February 1892. When that money did not materialize, Garrett caved in and offered up the balance. According to Garrett’s partner Carey Thomas, the president of Bryn Mawr and chief negotiator with the Johns Hopkins president and trustees, Garrett had de­cided to contribute the large sum “to force the trustees to open.” The force of money was needed ­because of Hopkins president Gilman’s profound reluctance to admit ­women. Even Welch, the prospective dean, was dismayed by Garrett’s demand and embarrassed by the idea that he would have to explain indelicate ­things to female students. Among other recalcitrants was the distinguished pathologist William  T. Councilman, who would l­ater resign in protest and take a job at Harvard. To be sure, the w ­ omen had some distinguished champions in three of Johns Hopkins’ founding faculty members: William Osler and Henry M. Hurd, who ­were both “vehemently in ­favor,” and Howard Kelly. But many other prospective faculty members “preferred never to have a medical school at all rather than to have one to which ­women ­were to be admitted,” according to Thomas. They fought against Garrett, she said, “in the dark with treachery and false reasons,” spinning “a tangle of hatred, malice, detraction that beggars description.”24 In the end, the Johns Hopkins trustees gave in, fearing that some of the ­great male talents currently being recruited would be snatched away by other prestigious schools offering secure appointments. It was a g­ reat victory for the ­women reformers at a time when fewer than 7 ­percent of medical students ­ omen and fewer than 5 ­percent of physicians w ­ ere ­women.25 In 1893, three w ­were admitted out of a class of eigh­teen. But it was a pyrrhic victory, however, for two of them would drop out, and many de­cades would pass before ­ ere admitted to study medicine at Johns Hopsignificant numbers of ­women w kins. Structural, institutional, and garden-­variety interpersonal sexism seated

274

Schooling Physicians

deep in the American society and economy, including in its primary and secondary school system, made sure of that. B R I N G I N G U P T H E R E S T: J O H N   H . R A U C H A N D T H E V I S ­I ­B L E H A N D S O F T H E S T A T E S

In the 1870s and 1880s, faculty members in some medical schools strug­ gled unilaterally to improve what training they could offer, but mightier market forces pushed back. An alternative was for medical colleges to take cooperative action, what AMA founder Nathan Davis had called for back in 1847. But that yielded virtually nothing over the next thirty years. However, in 1877, as cash was flowing into Harvard, Davis helped lead another attempt at simultaneous interstate action. It was to be coordinated by a new Association of American Medical Colleges (AAMC). Along with Davis, other AAMC found­ers ­were J. M. Bodine of the University of Louisville, J. B. Biddle of Jefferson Medical College in Philadelphia, and Leartus Connor of Detroit Medical College. It did not take long a­ fter the AAMC’s founding for its members to learn that coordinated commitments to improve still stood ­little chance against a power­ful “spirit of business enterprise.” AAMC leaders decried the “loss of dignity” that came from competing with sharp operators who poached students by undercutting them with lower tuition fees and shorter courses of study. The business spirit also spilled over into politics. Proprietary schools sometimes roped politicians into their ser­vice by giving them ­free “blank certificates” promising reduced tuition fees that they could hand out to the sons of influential constituents to fill out. The scholarships turned legislators into their advertising agents as well as protectors. Within five years, by 1882, the AAMC lay moribund. Of its original twenty-­t wo founding members, eleven withdrew that year ­because they ­were unable to attract enough students while enforcing the AAMC’s minimum standard of three years of study. It was still “equivalent to suicide” to adopt the reform when o­ thers would not.26 The AAMC’s failure notwithstanding, by the end of the 1880s, noticeable improvements had occurred. The three-­year course of study became virtually universal, and the four-­year standard was close b­ ehind. In 1889, the Journal of the American Medical Association observed that improvements in instructional methods, facilities, and premedical entrance requirements had been more marked during the 1880s “than during any similar period in the history of the country.” According to the Boston Medical and Surgical Journal in 1890,



U n n a t u r a l S e ­l e c t i o n a n d I n t e l l i g e n t D e s i g n

275

the rapid changes ­were “in ­great mea­sure” due to the educational requirements of the law in one state alone, Illinois. It was a remarkable and indeed puzzling claim, considering the national, not just state-­level scope of the change. But the ­Virginia Medical Monthly agreed, identifying one Illinois reformer who deserved thanks. It was John Henry Rauch, the president and secretary of the Illinois State Board of Health. What Rauch had done in Illinois had been ­behind “the recent commendable and rapid strides made by medical colleges ­towards a higher and more perfect system of education.” In 1889, Perry Millard, the first dean of the University of Minnesota medical school, called Rauch “the true f­ ather” of the reform movement underway. He had “directed the attention of both the profession and public of the g­ reat need of the pre­sent attempted reform” and “we are only following in his footsteps.” The  U.S. Commissioner of Education’s report for 1892–1893 echoed widespread reviews that Illinois and Rauch w ­ ere “the prime cause” of the wave of improvement.27 In 1894, the year of Rauch’s death, the Sanitarian eulogized him saying that “to him more than to anyone e­ lse, indeed more than to all ­others, is due the Medical Practice Acts of other States, weeding out quackery, and the extended terms of medical colleges from three to four years, requiring additional study preliminary to conferring the medical degree.” In its obituary, the AMA journal chimed in to say, “No one can doubt that it was almost solely due to the action of the Illinois Board of Health” that the length of study was increasing across the board. “The time was ripe for the movement,” for within one year from the time the Illinois State Board gave public notice, the medical schools throughout the country had raised their admission standard, and lengthened their collegiate year.”28 If one man alone could have plausibly made such a big difference, it was Rauch. A steam locomotive among public health and medical reformers, he was a fierce e­ nemy of incompetency and fraud in medicine and not shy about using politics for his ends. He made his first major mark in the rising public health movement by bringing into simultaneous being his state’s board of health and its licensing law in 1877. One reason was the plague of bad doctors in his state. But a central motivation for the law had also been public health; as chairman of the AMA’s Section on State Medicine nine years l­ ater, he declared it his purpose to have advanced “sanitary science and public hygiene.” Before his licensing and medical education efforts, Rauch had achieved fame in municipal, state, and national public health circles, meriting his election to the presidency of the American Public Health Association in 1876 and 1877. Before that he had been the medical director of the Army of the

276

Schooling Physicians

Potomac and of the Nineteenth Army Corps during the American Civil War, where he had observed firsthand the consequences of army camp filth—­more deadly than Confederate bayonets, bullets, and cannonballs. In 1871, Rauch planned and enforced the sanitary mea­sures for 112,000 p ­ eople made homeless by the three-­day-long ­Great Chicago Fire.29 Rauch’s radical innovation as head of the Illinois Board of Health was a stringent regulation allowing licenses to be issued only to students with diplomas from medical schools “in good standing” with his department, be they in Illinois or elsewhere. For that, in 1881 he began compiling and tabulating the information he had gathered from the well over one hundred schools currently in operation in the United States and Canada about their programs and distributed it to other state licensing authorities for their own use. In 1883 he included in the board’s fifth yearly report discussions and t­ ables based on the findings. The reports sent shock waves throughout the country. It set in motion unilateral improvements in some individual schools whose gradu­ates had their sights on pos­si­ble practice in Illinois. More impor­tant, it inspired other state licensing authorities to seek the same authority or use what authority they already had to use Rauch’s data and standards in their own states. Thus, in 1893 the eminent Harvard surgeon J. Collins Warren declared that Rauch’s reports “exerted a more power­ful influence on the movement in education than any other publication which our medical lit­er­a­ture has produced.” The multiple volumes prepared by him w ­ ere “a monument to his ability, sagacity and untiring zeal in the cause of higher medical education.”30 Rauch’s 1877 law had allowed the Illinois Board of Health to refuse licenses to gradu­ates of any medical school that it alone judged as lacking the faculties, facilities, curriculum, and policies required to train worthy candidates for licensure. It was similar to a provision first introduced in California the year before. Implementation of such clauses was problematic b­ ecause whim and caprice in assessing “good standing” invited lawsuits on due pro­cess grounds, judicial writs of mandamus forcing the issuing of licenses, and even constitutional challenges to the laws themselves. So in 1880 Rauch drew up the first of his Schedule of Minimum Requirements to serve as an objective yardstick with which to mea­sure a school’s standing. The requirements for a reputable school included a high school diploma or an entrance examination covering mathe­matics, En­glish composition, and elementary sciences. Most importantly, students had to attend at least two years’ terms of “progressive” or “graded” (nonrepetitive) lectures lasting five months or more and spend substantial time in clinical and hospital training. Instruction had to take place



U n n a t u r a l S e ­l e c t i o n a n d I n t e l l i g e n t D e s i g n 277

John Henry Rauch, MD (1828–1894), founding president of the Illinois Department of Health and president of the American Public Health Association, both in 1877. Rauch made many enemies as well as friends as a fierce public health missionary and a pioneer in nationwide medical education reform. Courtesy of the U.S. National Library of Medicine.

in the branches of medicine specified in the AAMC standards (anatomy, physiology, chemistry, materia medica and therapeutics, pathology, surgery, obstetrics and gynecol­ogy). Notably, Rauch, the public health missionary, added public hygiene to the AAMC’s list. Fi­nally, to achieve good standing, a school had to show that it had “a sufficient and competent corps of instructors, and the necessary facilities for teaching, dissections, clinics, ­etc.” Diplomas from schools that ­were not in compliance by the academic year 1883–1884 ­were to be rejected as a ticket to medical practice.31 ­A fter formulating the standards, Rauch and his lieutenant William Eggleston began the laborious task of compiling pertinent information about existing medical school programs to guide them in their decisions to grant Illinois licenses to students trained in-­state or elsewhere. The Illinois Supreme Court solidly upheld Rauch’s policy of rejecting applicants on the basis of the schools they went to, as did neighboring Missouri’s court ­after the state quickly followed suit. The 1883 Missouri court decision held its law to be perfectly proper in order “to provide for the sanitary welfare of the ­people” and to rid

278

Schooling Physicians

the state of “that class of medical pretenders known by the vari­ous designations of empirics, mountebanks, charlatans and quacks.” Rauch’s Missouri counterpart praised him for his frequent assistance in assessing the standing of its own schools. Court challenges in other states w ­ ere fi­nally put to rest in 1889, when the U.S. Supreme Court upheld the West ­Virginia law’s insistence ­either on an examination or a degree from a “reputable” medical college, which Rauch had heartily praised. Dent v. West ­Virginia was an essential victory for the progressive reform movement combining medical licensing and public health.32 ­A fter Missouri, Minnesota was next to follow the Illinois model in 1883. By 1891, approximately nineteen states and the territory of New Mexico had laws allowing or requiring licensing authorities to restrict the right to practice medicine to gradu­ates of medical colleges that mea­sured up. That year, the AMA journal characterized recent actions in Kentucky and Indiana as largely due to the work laid down by Rauch, the “honored servant” of reform. “The w ­ hole complexion” of the situation across the country had changed by 1893, according to J. Collins Warren, professor of surgery at Harvard, ­because of the “clarifying influence of the state licensing boards.”33 Despite Warren’s observations and many more like them made at the time, medical historians have largely overlooked the role of state licensing laws and boards in the gradual improvement of medical schools.34 Kenneth Ludmerer asserts, for example, that up to 1910, state licensing laws and practices had been “an insignificant f­actor in the development of medical education.” For evidence, Ludmerer cites the fact that almost all medical schools had instituted the four-­year standard by the late 1890s, while “very few state boards had yet made that a mandatory requirement.” While it is true that in 1898 only a minority of states did so, they numbered over a dozen, a sizable minority. This was actually more than a very few b­ ecause of the impact they had beyond their borders—as Illinois had when it moved first to impose standards on out-­of-­state schools whose gradu­ates wanted the option to practice ­there. Many schools would have had difficulty attracting the most desirable students if, as gradu­ates, they ­were unable to get licenses in other large, impor­ tant states requiring four years of medical study. Furthermore, in 1898, twenty-­seven state licensing boards ­were requiring examinations, an additional incentive for schools in other states to improve their teaching.35 To justify his conclusion about the nonimpact of licensing, Ludmerer also notes that ­there was “almost no mention” of licensing authorities and none at



U n n a t u r a l S e ­l e c t i o n a n d I n t e l l i g e n t D e s i g n 279

all about Rauch in the rec­ords he examined from schools undertaking reforms.36 He infers from that silence that their improvements resulted overwhelmingly from medical educators’ autonomous drive for excellence, not external pressure. Indeed, many professors genuinely wished to gain self-­ respect and the re­spect of ­others for a job well done. That explains the formation of the AAMC. But it is essential to note that state laws and licensing practices did more than force reform on heeldraggers. They also had a liberating effect on ­those held back by the same market forces of adverse se­lection that had made AAMC members abandon their reforms and quit the association. Stiffening licensing laws and practices, even if only in neighboring states, encouraged and enabled ambitious medical educators to move forward with reforms they already wanted. It was now no longer suicide ­because competitors for students w ­ ere now or would soon be held to higher standards. And ­those that did not rise would lose the better students—­often wealthier ones—­ willing to study longer and pay more. Hence, reform-­minded deans and faculty members would have been unlikely to rec­ord on paper that they acted ­under external compulsion. It was a m ­ atter more of an opportunity opened up by ­legal reform rather than the whip of enforcement. Tellingly, the laws prob­ably explain the fact that the moribund AAMC came back to life in 1891 a­ fter its entirely voluntarist efforts had failed so miserably within six years a­ fter its founding in 1877. During its eight-­year dormancy, according to AAMC official J. W. Holland, licensing bodies had been “created ­under legislative authority to carry on the work initiated by the colleges.” Having helped agitate for better state laws, Holland said, reformist educators could congratulate themselves for prompting the ­legal changes. Now the po­liti­cal and therefore market environment had changed so greatly that it lent reformist educators the leverage they had once lacked, the vis­i­ble hand of the state, to accelerate further reform. Henceforth, t­ here was a harmonious concertation of efforts by the small number of schools in the AAMC and the state authorities in the Confederation of State Medical Examining and Licensing Boards (CSMB), which Rauch had founded in 1891.37 It is pos­si­ble that the education reformers schemed with state boards, promising to go ahead with the four-­year course of study on the condition that the boards extend the requirement to other schools. The boards, in meetings of the CSMB, no doubt planned concerted action as well. As the AMA journal put it, the sudden, massive surge t­ oward the four-­year standard in 1895 and 1896 “has been accomplished by the coordinate action of the vari­ous State

280

Schooling Physicians

boards of health and by the cooperation of the better class of medical schools.” Between 1891 and 1894, eleven schools began requiring four years for a degree; two years ­later t­ here ­were almost seven times as many.38 As Rauch’s 1884 report put it, medical laws w ­ ere needed to protect earnest but naive applicants to medical school by establishing a floor on quality so they “would have some assurance that the money and time they spent would be of some value to them afterwards.” According to Abraham Flexner years ­later, “The law that protects the public against the unfit doctor should in fairness protect the student against the unfit school.” But alongside government influence on the supply of improved medical schools was also a demand side effect. By triggering the compilation and dissemination of information—­“a public good” according to economists—­about medical schools’ policies and reputability, the laws helped equip prospective students to choose rationally and thus enabled them as consumers to drive up the supply of higher-­quality schools. According to Rauch’s lieutenant Eggleston, ­there was “a supply and demand system that is arousing the low-­grade colleges of the country to a sense of their duty.” That was b­ ecause “intelligent students, and t­ hose that know of the medical laws of the States in which they intend to practice, are beginning to see the necessity of obtaining their medical education in the higher-­ grade colleges.”39 In short, government action empowered as well as protected. State laws and regulations improved the efficiency of the market by increasing the supply of good information, the only t­ hing that enables consumers to discipline producers on their own. The spread of compulsory state licensing examinations also exposed medical miseducation to discriminating applicants. As the rates of success and failure in board examinations experienced by students from specific schools became available, the better schools could use them for self-­promotion and denigration of competitors. By 1903, only about a half dozen states and territories still required no more than a diploma from an apparently reputable school along with some premedical education. As the AAMC’s Holland stated in 1889, “The schools vying with each other” for better per­for­mance on board exams “feel a lift such as no other power has imparted.” Medical schools now needed to choose and prepare their students with greater care “or lose in reputation and patronage.” Thus, Holland reported about a de­cade ­later that state examiners w ­ ere witnessing “a very perceptible improvement” in recent gradu­ ates. Seeing “the dawn of a better era,” neurology professor at the Detroit College of Medicine J. E. Emerson speculated that “evolution and the survival



U n n a t u r a l S e ­l e c t i o n a n d I n t e l l i g e n t D e s i g n

281

of the fittest w ­ ill in the end bring order out of chaos.” But he also believed that forceful individuals in government, specifically mentioning Rauch, could “measurably direct and hasten this desirable pro­cess.” In short, the commercial education market functioned more efficiently in the presence rather than absence of government intervention—to the extent that it created an information-­rich market environment, not the information-­poor environment that gives rise to adverse se­lection.40 FROM R AUCH TO R E ACTION IN ILLINOIS

The year 1891 was the pinnacle of John Rauch’s illustrious c­ areer and the precipice from which it fell. That year he founded and presided over the Confederation of State Medical and Licensing Boards to coordinate further reform efforts and, notably, accepted the honor and power attached to a seat on the AMA Board of Trustees. But it was rapidly downhill from t­ here. The same year, b­ ecause of the enemies he made in and outside the medical profession, power­ful Illinois politicians forced his ouster as the executive of his own creation, the state health board. During Rauch’s fourteen-­year tenure, the number of physicians in Illinois actually dropped by over one thousand. Many fled to neighboring states. But many of ­those aggrieved pressured state politicians to run Rauch out of town instead, and they succeeded. Already in 1879, only two years a­ fter passage of his combined health board and medical practice law, Rauch’s enemies persuaded six of a thirty-­two member state Senate committee to support censuring Rauch as “a confirmed and habitual drinker of spirituous liquors,” for being “unprofessional and discourteous,” and for using “grossly profane language.” It was a harbinger of ­things to come. Indeed, Rauch was pugnacious. Once, in Chicago’s fancy Palmer House h ­ otel, he allegedly “tore down and carried away, without any authority of law, the sign of one L.  A. Edminster, who was a guest at said ­house,” claiming to do so “by virtue of police powers vested in him.” One assumes Edminster was an advertising quack. Among his other “Herculean ­labors,” Rauch incessantly pursued polluters of the Chicago River, “notably the pork-­ packers and proprietors of slaughter­houses and distilleries, men with almost unlimited pecuniary means at their command,” according to one obituary. Another cowritten by Rauch’s b­ rother Cyrus mentioned that he was disliked by many legislators b­ ecause he was “not always as tactful . . . ​as he might have been.” But Rauch’s board colleagues praised him for his “wise aggressiveness,”

282

Schooling Physicians

along with “untiring energy,” “vigilance,” “sagacity and per­sis­tence,” and for the “personal sacrifices” he made for public health and educational ­causes. A friend of the fierce reformer noted that “Dr. Rauch had faults; t­ hose of us who knew him can relate them,” but he “was greater than his faults.” 41 In the end Rauch was a victim of his own zeal. He did not shy from mov­ ere able to enlist influing against very prominent healers, some of whom w ential attorneys, citizens, and newspapers like the Peoria Transcript and the Bloomington Eye to help them retaliate. Among the targets of his wrath w ­ ere “the notorious quacks McCoy and Wildman,” according to Chicago’s Medical Standard. Henry G. Wildman was actually able to persuade Illinois governor Richard J. Oglesby to have his license reinstated on a technicality. According to the V ­ irginia Medical Monthly, the newspapers allied with his targets “for the specific purpose of destroying Dr. Rauch or—­what amounted to the same ­thing—­the usefulness of the Illinois State Board of Health.” Their complaint: “He was their means of their losing large amounts of advertising from quacks whom Dr. Rauch succeeded in driving from the State.” 42 Rauch also made enemies of medical schools. A handful of Chicago schools, such as the Chicago Correspondence University, the National University, and the Chicago College of Science, perished along with up to twenty ­others around the country b­ ecause of Rauch’s ­doings. It is likely that Rauch also made enemies in other medical schools that ­were publicly embarrassed and therefore financially incon­ve­nienced by a loss of applicants. Some “used their po­liti­cal influence to retaliate,” according to historian Winton Solberg. That would not be surprising ­because, according to Perry Millard, even supposedly reputable schools worked “arm in arm with the long-­haired quack” to block reforms. At the end of Rauch’s c­ areer, a comment making the rounds in medical journals had it that “for ten years Dr. Rauch has been a thorn in the side of the fraudulent diploma mills, of the advertising nostrum makers, of the traveling charlatans, and, fi­nally, of the quack-­fed newspapers.” Now, however, “they have united in one supreme effort to drive him out of official position. He has waged unrelenting warfare with them; but he was never able to crush them. And now they seem to have grown stronger than he.” 43 The beginning of the end of Rauch’s c­ areer came with a move in the Illinois legislature to abolish the state board of health ­unless he could be dislodged. One “influential and wealthy resident of Chicago” much aggrieved by Rauch’s action against his favorite physician was among ­those prompting it.



U n n a t u r a l S e ­l e c t i o n a n d I n t e l l i g e n t D e s i g n

283

In 1889, state representative Orin P. Cooley, who charged an allegedly autocratic Rauch with turning his board into a “star chamber,” held up appropriations for the board of health ­until Rauch promised to resign as a board member and president. Despite help from prominent Illinoisans, Rauch failed to get reinstated. U ­ nder relentless pressure from the legislature to retire, he fi­nally vacated the secretaryship as well in 1891.44 With Rauch out of the picture, the Illinois Board of Health fell ­under the sway of the grimy patronage politics of Chicago and Illinois. In 1897, the power­ful secretaryship was handed to a recently appointed board member, James A. Egan, a mediocrity and a po­liti­cal hack, according to reformers in control of the state medical society. For Egan, using the Illinois Board of Health to control medical schools was not the high priority it had been for Rauch. The Illinois Journal of Medicine decried the development of “intimate relations existing between the low-­grade schools and the State Board of Health.” Egan’s erratic suspensions and then reinstatements of a handful of medical schools, despite any real improvements, made him persona non grata in the medical reform community. U ­ nder Egan, questionable night schools started popping up and gaining the state board’s ac­cep­tance. Weary students, abysmal artificial lighting for laboratory work if ­there was actually equipment for it, and no possibility of bedside teaching b­ ecause of eve­ning hours did not seem to make a difference. The distinct malodor of graft and nepotism also wafted out of the licensing business on Egan’s watch. Two young sons of George Webster, the president of the state health board, one of them a minor, ­were hired by the board as examination monitors. The source of that information had witnessed monitors during one test and was impressed by their “youthfulness and inattention.” 45 Many years ­later, the AMA journal recalled that a rapid multiplication of medical schools followed Rauch’s demise. “For a de­cade all pressure t­oward the improvement of medical education was apparently withdrawn.” Faculty of Northwestern University’s W ­ omen’s Medical School complained in 1895 that Illinois examinations w ­ ere so easy that a student they had failed for her utter incompetence was able to pass the license exam anyway. By 1899, ­after much general improvement across the country, the Illinois law markedly lagged b­ ehind the majority. As late as 1907, public health missionary and AMA renovator Joseph McCormack, who claimed to have received his first lessons for his Kentucky reform ­career from Rauch, observed that “the united forces of quackery have . . . ​an easy time of it” ­because the Illinois medical laws ­were

284

Schooling Physicians

“practically broken down.” In 1906, ­after Egan had been in control of the state health board for nine years, Arthur Dean Bevan, head of the AMA’s newly formed Council on Medical Education, put Illinois in its list of “five specially rotten spots” in the country that “are responsible for most of the bad medical instruction.” 46 ­Because of his miserable treatment, fellow progressive Victor Vaughn, the nationally eminent medical scientist, public health missionary, Michigan educational reformer, and soon-to-be AMA president, dubbed the embittered Rauch “John the Baptist of reform in medical education in this country.” According to a subsequent president of the Illinois board, George W. Webster, even the state’s physicians as a w ­ hole stood aside passively. “During his last few years,” Webster said, Rauch was “crushed by the ingratitude of ­those he had so faithfully served” and, in 1894, “died a broken-­hearted man.” An old Pennsylvania friend said he was “wearied, worried, despondent and in ill health.” Having never thought of personal gain, according to an obituary, he died in poverty at his ­brother’s home in Lebanon, Pennsylvania.47 MORE TO BE DONE

In the de­cades from 1870 to 1900, American medical education made some l­imited pro­gress. In the 1870s, despite vehement re­sis­tance from medical libertarians, states began passing licensing laws in the hopes of raising standards. Medical progressives—­hygienic optimists and therapeutic pessimists—­ agitated for them to prevent disease as well as “quackery.” But b­ ecause of their unintended, counterproductive consequences, the new medical practice acts w ­ ere only the first clumsy steps ­toward professional uplift. By making a degree from a duly chartered medical school the sole criterion for a license, and ­because of lax general incorporation laws, the licensing requirements perversely triggered the creation of a glut of state-­chartered for-­profit schools of often shockingly low quality. In reaction, reformers persuaded state legislatures and licensing authorities to adopt the informal accreditation standards that the nationally famous medical education and public health reformer John Rauch had introduced in Illinois, which required only degrees from reputable “schools in good standing.” That, too, proved to be a clumsy tool, given the absence of a truly rigorous and reliable inspection and accreditation system. Schools lied about or exaggerated their faculties, facilities, and curriculums. By way of illustration, Rauch welcomed the fact in 1891 that, in part b­ ecause of his leverage in other



U n n a t u r a l S e ­l e c t i o n a n d I n t e l l i g e n t D e s i g n

285

states, practically e­ very school in the country included hygiene in their curriculum, but he had to add, regretfully, that in many the amount of instruction in disease prevention was “so small as to be of but ­little value.” 48 Reformers’ recognition of the difficulties involved in establishing reputability thus led them to push for state licensing examinations for students who graduated from nominally reputable schools. The improvements still came up far short of the ambitions of the medical progressives, who restructured the AMA to turn it into a more power­ful force for change. The average quality of medical schools was rising, pulled up by dramatic improvements at the slim upper tail of the distribution in a number of private as well as a few state universities. The medical corps of the army, navy, and Marine Hospital Ser­vice also helped pull up the average, given the presence of committed public health enthusiasts in them. They administered such difficult examinations that, according to one reformer, “soldiers and sailors, in distant territories and seas” had the benefit of better-­educated physicians “than citizens of New York, Philadelphia or Boston.” 49 But, all in all, ­there ­were only modest improvements at the mode of the distribution. Therefore, at the turn of the twentieth ­century, American medical schools and the doctors they produced still embarrassed the country’s reformers, who mea­sured themselves against and ­were mea­sured by Eu­ro­pean schools and physicians. Ironically, where democracy was more advanced, the quality of public health and medical ser­vices for the mass of the population lagged ­behind. In Eu­rope, across the board, the franchise was still ­limited to a small, eco­nom­ically advantaged electorate, and central state bureaucracies, often ­t hose more impervious to partisan po­liti­c al control, exercised more power relative to elective bodies.50 In short, elections, working hand in hand with market liberties, held pro­gress back. White male voters preoccupied with other ­things w ­ ere entirely ignorant of the scandalous state of medical affairs. Many ­ ere even hostile to the physician elites seeking to improve standards of them w for entry to their profession. Thus, gradual improvements in the design and administration of licensing laws to stimulate education reform ­were not driven from below by groundswells of popu­lar demand but from above by elites. The public remained in the dark about the abysmal education their doctors had received. The most impressive pro­gress was driven instead by rich cap­i­tal­ist philanthropists, lay reformers of higher education, licensing officials, and the progressive physicians who advised them. But the progress was not fast enough

286

Schooling Physicians

for the new AMA. To energize and harness ­t hose same forces, it embarked in 1904 on a plan of investigation and exposure inspired in part by John Rauch but with far more resources to carry it out and disseminate its results. The plan was to lay bare for the unsuspecting public the deplorable state of American medical education, galvanize the po­liti­cal and economic elite as Rauch had not done, and thereby accelerate the disappointingly slow pace of reform.

chapter 11

A ­Great Wave of Improvement

Around 1901, the year of the American Medical Association’s reor­ga­ni­za­ tion, the number of medical schools in Amer­i­ca ­stopped rising. By 1904, it began falling, though only slowly. But a­ fter another six years, the trend accelerated dramatically. Lesser medical colleges suddenly merged with better ones or simply closed their doors. Although proprietary schools dis­appeared, philanthropic endowments flowed as never before into private nonprofit universities’ medical departments. State legislatures granted their public universities unpre­ce­dented support for high-­quality teaching facilities and faculties, luxuries that student fees could not have paid for. Looking back in 1928, the AMA’s top educational reformer recalled nothing less than “a g­ reat wave of improvement.”1 At the beginning of the new c­entury, the AMA’s medical progressives’ optimism about a steady march of pro­gress from ­earlier efforts had been flagging. Retrograde forces ­were still powerfully at work. ­There ­were still far too many schools of medicine. Educational philanthropy benefited only small numbers of rising stars. Improvement was glacially slow despite the premedical entrance requirements, longer periods of study, better facilities, more clinical teaching opportunities, and written examinations that state licensing authorities had started imposing in the 1880s. But premedical requirements w ­ ere not always enforced. Longer courses of study often meant only that lackadaisical

287

288

Schooling Physicians

training was thinly spread over more months of the year. B ­ ecause practically no state authorities had adequate staff and bud­gets for routine inspection of schools, they still had to rely on medical colleges’ often fanciful claims in their cata­logues and announcements. Sometimes they shamelessly boasted of abundant clinical teaching facilities when in fact they lacked access to a single hospital. Unfortunately, according to an Ohio licensing board official, “The announcement of a medical college is like the advertisements of proprietary medicines, of patent medicines, or of any commercial proposition in this country.”2 Weak enforcement and mendacity ­were not the only prob­lems. Although compulsory board examinations, the hoped-­for remedy of the inspection and monitoring prob­lem, had spread to about twenty-­three states by 1901, they ­were subverted by medical schools’ other immune responses. According to discussions recorded in 1909 and 1910 in meetings of the Confederation of State Medical Examining and Licensing Boards (CSMB), medical schools started to concentrate on rote instruction tailored to the exams. Publishers obliged teachers and students with “quiz-­compends” of questions likely to appear in f­uture years gathered from previous exams. The almost seven-­hundred-­ page Answers to Questions Prescribed by Medical State Boards was frequently used as a textbook by schools “of the lower order.” The secretary-­treasurer of the CSMB lamented that examinations forced students and applicants “to cram and disgorge, rather than to digest and demonstrate.” The secretary of the Mas­sa­chu­setts Board of Registration in Medicine regarded the situation in 1909 as “alarming,” even worse than fifteen years e­ arlier “when the facilities for cramming ­were less numerous.” Terrible schools w ­ ere getting surprisingly good pass rates for their gradu­ates. Although many test takers failed on the first attempt, they would just “go out and stuff” again, and a “­great percentage” of them would ultimately pass.3 Astonishingly, according to Ohio board official William Means, “the worst school in Chicago makes the best rec­ord before the State Board.” George Dock, an eminent University of Michigan professor of internal medicine, explained why: “The student who is so misguided and unfortunate as to go to a high class medical school and spend his time studying in the wards, in the laboratories, in the out-­patient department . . . ​is absolutely discriminated against” by written examinations. They seemed actually to ­favor gradu­ates of schools that “cram men up.” Dock, therefore, like a growing number of reformers, called for practical examinations alongside written ones to foil the



A ­G r e a t W a v e o f I m p r o v e m e n t

289

cram schools. Standard Canadian and Eu­ro­pean practices, he said, made nonsense of counterarguments about impracticality and inefficiency. According to Murray G. Motter, secretary-­treasurer of the CSMB, a pharmacology expert, and a public health official, oral exams with a patient or laboratory materials at hand was a ­simple way to find out if gradu­ates had more than a superficial ability to recite facts about heart disease or urinalysis. “Now, if you find the man knows nothing about examining the heart, what is the use of examining him any further?” 4 Enlisting po­liti­cal help was another immune response to reform of the inferior schools. ­Because of medical school lobbying, po­liti­cally clean boards ­were often unable to persuade legislators to fix the weak or badly written laws that hobbled them. According to professor of oral surgery William Carr, ­later dean of the Dental College of New York, “conspicuously unfit boards” ­were appointed for po­liti­cal reasons in some states. Being underfinanced, many boards could not afford to defend themselves against mandamus suits brought by low-­grade schools to get judges to reverse their “not reputable” evaluations. The blowback from enforcement efforts was sometimes intense. Henry Beates, president of the Pennsylvania State Board of Medical Examiners, told colleagues that he was vigorously attacked by inferior schools for “putting on the screws.” The attacks could not be disarmed even by showing that their gradu­ates’ answers proved them to be “so illiterate and so ignorant as to be unable of comprehending medicine.”5 At the time, even the Association of American Medical Colleges (AAMC), the putatively selective club of better colleges, did not systematically inspect its affiliates in order to verify their quality claims. It hesitated to enforce its standards at the expense of membership loss, so suspicious state boards regarded its member list as an unreliable source of information. But the boards could not effectively take up the slack in enforcement. Slim bud­gets and political headwinds held things back. For example, a proposal to have Pennsylvania’s board actively inspect medical schools went nowhere, according to Beates. He alleged that one college kicked back 10 ­percent of hundreds of thousands of dollars granted to it and its hospital over the years to the legislative committee that appropriated the money. When the committee watered down revisions of the state’s medical practice act, the reformers threw up their hands in defeat. Meanwhile, the commercial ele­ment was pressuring to get rid of the most zealous reformers on the state board. Politics—in the “bad sense”—­and commercialism w ­ ere “in too close affiliation.” 6

290

Schooling Physicians THE NE W A M A A ND EDUC ATION R EFOR M

AMA president Frank Billings titled his 1903 inaugural address to the House of Delegates “Medical Education in the United States.” In it, he invoked Nathan Smith Davis, “the ­Father of the Association,” who in his own presidential address had put “the improvement of our system of medical education” first before “advancement of medical science and practice” as the AMA’s founding purposes. Billings also invoked John H. Rauch’s groundbreaking work in Illinois, which in the 1880s had forced medical schools elsewhere to raise their standards so their gradu­ates could obtain licenses to work in Illinois. Other states, according to Billings, followed suit, “with the result that the standard of education in the country was very much improved.” But up u ­ ntil now, the AMA itself had only wielded “moral” influence. To speed up pro­gress, its influence had to be many times greater. Now, empowered by better organ­ization, it should try to “drive out of existence” faculty-­ owned medical schools conducted to make money or confer prestige on professors to help them lure wealthy patients into their private practices. Medical science, the profession, and the ­people demand better, and together they “look to the American Medical Association as the chief influence which ­shall accomplish this end.”7 To take on the daunting task, Billings chose Arthur Dean Bevan, his surgeon colleague from Rush Medical College. Bevan would become to medical education what Joseph McCormack was to the AMA’s reor­ga­ni­za­tion and what Charles Reed was to the AMA’s efforts on behalf of the Pure Food and Drugs Act of 1906. A celebrated and wealthy surgeon, Bevan was a progressive in more than medicine. In 1912, when former U.S. president Theodore Roo­se­velt formed his breakaway “Bull Moose” party—­because of William H. Taft’s insufficiently progressive leadership of the Republican Party—­Bevan came on board. Joining him in the new Progressive Party ­were George Krei­ der, editor of the Illinois Medical Journal, and William A. Evans, a notable Chicago public health leader. Bevan and Evans, according to Kreider’s journal, circulated a letter to ­every physician in Illinois praising “certain planks” in Roo­se­velt’s Progressive Party platform. The medically related ones ­were for a national department of health and compulsory health insurance for industrial workers.8 Bevan was to chair an entirely new Council on Medical Education (CME), formed in 1904. Before, the AMA’s education committee lacked a full-­time secretary, and the turnover in its membership was extremely high. By con-



A ­G r e a t W a v e o f I m p r o v e m e n t

291

trast, ­because the CME was a council, not a committee, it was given permanent headquarters, a bud­get for a full-­time executive secretary, and personnel to ­handle correspondence and prepare statistical reports. Public health missionary Victor C. Vaughan, the dean of the University of Michigan medical school, served alongside Bevan. So did William T. Councilman, a professor of pathology at Harvard. Like Vaughan, Councilman was a pioneering specialist in infectious disease. Nathan Porter Colwell, a young pulmonologist, was enlisted as the council’s full-­time secretary, a post he served with g­ reat industry and efficacy over many years to come.9 The well-­resourced CME would quickly step into the breach left by po­ liti­cally hamstrung state medical boards and the toothless AAMC. Just as Reed had done for drug reform, Bevan would induce the state medical socie­ ties to mobilize for action. By 1907, state committees on medical education had sprung up in forty-­five states; only Nevada and five Southern state socie­ ties had not yet followed suit. Next, the CME convened a series of meetings of state committees and other bodies for a “mutual interchange of ideas, fact gathering, consensus formation, and strategizing.” ­Under Bevan’s leadership, the CME sponsored its first consultative conference in Philadelphia in December 1904, its second in Chicago in April 1905, and a third in Portland the following July. Numerously represented along with state socie­ties ­were state licensing and examination boards, nonproprietary university medical departments, and state and national public health agencies. The AAMC and the Southern Medical College Association also sent representatives. The ultimate aim of the conferences was to generate consensus about what standards to use for a system of accreditation based on on-­site inspections. Medical schools ­were to be triaged e­ ither as acceptable, in need of g­ reat improvement, or worthy only of being shut down. At the third meeting in Portland in July 1905, a set of minimal acceptable standards was drawn up, an “American standard,” relating to, among other ­things, premedical admission requirements, facilities and curriculum, and access to hospitals and clinics for practical training. It was then submitted to and approved by the House of Delegates of the AMA already assembled ­in Portland.10 ­A fter publicizing the criteria for classifying schools, the CME’s next step was bold and unpre­ce­dented: to send Nathan Colwell, its full-­time secretary, on a fact-­gathering visit to e­ very single medical school in the country. It was a “large and onerous task,” according to Bevan. In previous years, Rauch and other state licensing authorities had relied almost entirely on colleges’ self-­ reported information in cata­logues and advertisements. Now, the AMA was

292

Schooling Physicians

g­ oing to find out for itself and make the information available to the state boards. In 1906, Colwell, or a member of the council, and sometimes both, traveled to ­every single school, scoring them on a point system based on (1) the showing of gradu­ates in state board examinations, (2) enforcement of good premedical training requirements, (3) character and extent of the curriculum, (4) physical plant, (5) laboratory facilities and instruction, (6) dispensary facilities and instruction, (7) hospital facilities and instruction, (8) full-­time faculty devoted to instruction during the first two years as well as original research, (9), the extent to which the school was conducted for the profit of the faculty rather than teaching, and (10), “libraries, museums, charts, ­etc.”11 The results of the CME inspections gave the lie to what the Journal of the American Medical Association called the “poetry of the medical school cata­ logues and advertisements.” A l­ ittle over half, or 81 of the 160 schools, received more than seventy points, an admittedly low cut-­off for what could be considered “acceptable.” Th ­ ese schools w ­ ere divided into classes A, B, or C. Placed in classes D and E w ­ ere 47 very weak but potentially redeemable schools receiving fifty to seventy points. Fi­nally, 32 schools received fewer than fifty points and therefore a grade of F. According to Bevan, they w ­ ere “absolutely worthless, without any equipment for laboratory teaching, without any dispensaries, without any hospital facilities; some which are no better equipped to teach medicine than is a Turkish-­bath establishment or a barbershop.” Many offered barely more than “quiz classes” in which students ­were “drilled for the purpose of passing state examinations.”12 In June 1906, ­after its inspections, the CME sent a letter to 153 schools asking them to commit to implementing the AMA’s premedical requirement of one or more years of collegiate science and language study before admission. Holding out the possibility of a higher grade, the council extracted promises from 50 schools. In 1907, a year ­later, the CME reported that 46 medical schools ­were already in compliance or planning to be so by 1910; 19 had already voted to require at least two years of preliminary college work, and 8 ­others intended to do so soon. The council also took a page from Rauch’s book by compiling and publishing licensing exam failure rates of students, school by school. As Bevan put it, it would be “of value” to the schools to publish their gradu­ates’ failure rates in the AMA journal. His personal experience at Rush was that “having our attention called to the number of candidates rejected” put the faculty “upon its mettle.”13 In April 1908, the CME’s fourth national conference brought eighty-­eight delegates to Chicago from twenty-­one state examining boards, twenty-­one



A ­G r e a t W a v e o f I m p r o v e m e n t

293

state medical socie­ties, three government agencies, two confederations of examining boards, two college associations, two national medical associations, and thirty medical and liberal arts colleges. Bevan and Colwell reported extensive pro­gress, mostly in the adoption of higher premedical requirements. While only eleven schools had followed Johns Hopkins and Harvard in requiring additional courses in physics, chemistry, and biology ­after four years of high school, at least forty schools ­announced plans to do so in the next two years. On the other hand, pro­gress was still sluggish in terms of years of study, curriculum, laboratory facilities, and clinical teaching. CME inspections in 1908 found only eight more colleges to add to the thirty-­one previously deemed unsatisfactory. While many state boards began to use the AMA’s “acceptable” rating as grounds for judging schools reputable, ­there ­were still eigh­teen state boards that had no or only l­imited power to refuse to recognize schools or to examine their gradu­ates. Twenty-­five states w ­ ere still not requiring their schools to reject applicants who had failed to complete four years of high school.14 All in all, the AMA’s work seemed to have a mea­sur­able though not yet dramatic effect. Between 1904 and 1906, the number of schools slid downward from a peak of 166 to around 160. Some of ­those 6 may have been casualties of the AMA journal’s 1905 publication of board exam failure rates of gradu­ates of 42 schools. According to Bevan, the exposure of their failure rates had “­great influence in urging the medical schools to put their ­houses in order.” Some schools not achieving acceptable AMA grades ­were disappearing ­because state licensing boards began refusing to examine their gradu­ates. The number slid further between 1906, the year of the CME’s first inspections, and 1910, down to around 130. The exact number cannot be known, given the flux. In other words, in six years, somewhere between 20 and 30 schools had vanished or merged with o­ thers, and about 15 of ­those dis­appeared between 1907 and 1909.15 But b­ ecause the growth in the number of schools had decelerated up to 1904, it is impossible to say how much the AMA’s efforts contributed to the trend that followed. In any event, pro­gress was still slow and lumbering, and much more needed to be done. T H E 1 9 1 0 F L E X N E R R E P O R T: A JO LT TO T H E S Y ST E M

Something was done, and b­ ecause of it, pro­gress took off in a way no one had predicted. Around 20 medical schools shut down in 1910 and 1911 alone.

294

Schooling Physicians

By 1915, the number of schools had dropped from its dizzying peak of 166 to only 95. By 1920, 10 more dis­appeared, leaving only 85 still standing. The number of students fell precipitously too. ­Because inferior schools ­were the ones to dis­appear, the average quality of the remaining ­rose with a leap.16 Much credit for the rapid acceleration of improvements in American medical education ­after 1910 is commonly accorded not to the AMA but to the now-­famous “Flexner report” published that year by the Car­ne­gie Foundation for the Advancement of Teaching. Written by lay education reformer Abraham Flexner, it was a shocking exposure to many unsuspecting citizens of the abysmal training their doctors had obtained. In his exposé, Flexner named names and listed their shames—­state by state, city by city, and college by college. The shabbiest schools ­were mercilessly and contemptuously criticized. In his report’s lengthy and impressively illuminating preface, Flexner expressed ­little faith in most state licensing authorities. With the exception of ­those in Colorado, Michigan, and Minnesota, they ­were administratively and po­liti­cally weak. So ­were the licensing laws in some states, which made it easy to “mandamus” a licensing board and force it to issue a license it had withheld from an unworthy applicant. Their miserly funding made l­egal b­ attles prohibitive, so they dared not antagonize schools prepared to sue. Some ­were simply “well-­meaning but incompetent.” ­Others ­were “cunning, power­ful, and closely aligned with selfish and harmful po­liti­cal interests.” In many states, appointments to the boards ­were “po­liti­cal spoils.” Where they ­were not, board executives typically had ­little staff help to counteract the g­ reat po­liti­cal “pull” that inferior medical schools could exercise.17 The biggest shock to the world outside of the profession delivered by the 1910 report was its appraisals of individual schools. Flexner was sparing with praise for the best ones, and even some of ­those took a hit. Yale’s medical school enjoyed, he said, access to only a small number of beds in the New Haven Hospital but none in the obstetrical and gynecological wards. ­There was no ward for clinical teaching about contagious diseases, and postmortems w ­ ere scarce. For the inferior schools, Flexner gushed caustic words. Boston’s College of Physicians and Surgeons, he reported, offered instruction in laboratory facilities that ­were “wretched, ill-­lighted, dirty, and poorly equipped.” It claimed to have the same clinical teaching opportunities as Harvard, but no member of the faculty had an appointment in Boston’s City Hospital. Students ­were permitted “­limited attendance . . . ​at a miserable dispensary” an hour away from the college.18 Flexner found most schools open to his requests to inspect. But at one he had to shake off a dean at the railroad station, sneak back to the school, and



A ­G r e a t W a v e o f I m p r o v e m e n t

295

bribe the janitor to open the doors to its so-called laboratories. None had anything more than chairs, a small table, and a small blackboard. “No equipment was in sight.” Out of the 148 American schools Flexner visited, ­there ­were 32 sectarian schools, 15 for homeopaths, 8 for eclectics, 8 for osteopaths, and a “physiomedical” school in Chicago. He was especially brutal in his attacks on the fledgling osteopathic schools, which taught drugless healing based on a unifying theory about all ailments and how to treat them with manual manipulations. The osteopathic colleges “fairly reek with commercialism,” Flexner said. Their “mercenary” character was displayed in cata­logues stuffed with “hysterical exaggerations, alike of the earnings and of the curative power of osteopathy.” The recruits they exploited w ­ ere “crude boys or disappointed men and w ­ omen.” The leading American School of Osteopathy in Kirksville, Missouri, founded in 1892 by Andrew Taylor Still, was typically pathetic, Flexner found, noting that the dissecting room was “foul” and that the so-­ called professors in charge of histology, pathology, and bacteriology ­were merely se­nior students.19 Only three of the eight eclectic schools ­were spared Flexner’s tongue lashing. But none of them had anything remotely resembling the laboratory equipment boasted of in cata­logues, despite the sect’s heavy reliance on botanical drugs, and none had “decent clinical opportunities.” The rest w ­ ere described as “filthy,” with, at best, “grimy ­little laboratories.” The California Medical College in Los Angeles was “a disgrace to the state whose laws permit its existence.” Atlanta’s Georgia College of Eclectic Medicine and Surgery had a building excelling only in its squalor; its single cadaver was “indescribably foul,” and its chemical laboratory had a few ­bottles “without ­water, drain, lockers, or reagents.” Pathology and histology students had to make use of “a few dirty slides.” For teaching obstetrics t­ here was a “tattered manikin.”20 On the ­whole, the homeopathic colleges got better grades. The best of them paid more than lip ser­vice to the need for scientific training and investigation. But only five of the fifteen schools—­Boston University’s School of Medicine, the New York Homeopathic College, Philadelphia’s Hahnemann Medical College, and the University of Michigan’s separate homeopathic school—­ merited ­limited praise for their laboratory or clinical facilities. Boston’s school received special commendation for its teaching resources. Rarely ­were the “drug provings” that Samuel Hahnemann had called for witnessed at any school, an unfair dig b­ ecause clinical testing of drugs was also a rarity in the regular schools. Only two of the five better schools required at least a high

296

Schooling Physicians

school education for entrance. Four other homeopathic schools w ­ ere generally 21 “weak and uneven.” That left six that w ­ ere “utterly hopeless.” As far as dif­fer­ent regions ­were concerned, the South fared badly. Not a single school located ­there looked good. But Illinois and many of its thirteen schools, all in Chicago, came away with some of the worst beatings. The bleak landscape following John Rauch’s banishment from the Illinois Board of Health he had created proved the importance of strong, uncorrupted state medical authorities. B ­ ecause of squalid medical politics in Illinois, Flexner often found only “nominal compliance” with the law requiring a high school degree. Not surprisingly, the schools had a hand in choosing the board’s medical examiners. Therefore, “the written examination has been transformed into an informal after-­dinner conversation between candidate and examiner.” Furthermore, he added, “With the indubitable connivance of the state board,” legal criteria for determining a school’s good standing ­ ­ were “flagrantly ­violated.” Chicago’s National Medical University, a night school owned by its dean, had once been deprived of its favorable standing by the board, but then its suspension was inexplicably revoked, allegedly a­ fter no genuine improvements. Only a­ fter per­sis­tent requests was Flexner allowed to see its dissecting room. It contained “a putrid corpse, several of the members of which had been hacked off.” Its “chemical laboratory” was a large room with spotless ­tables. Its equipment, he was told, was “locked up.” For clinical teaching it had only “two lonely patients on the top floor of the school-­building.” Chicago’s Bennett Medical College, nominally affiliated with Loyola University, was in real­ ity “a stock com­pany, practically owned by the dean.” The school building was “in wretched condition.” One messy room devoted to anatomy contained “a few cadavers as dry as leather.” In short, Chicago, ironically the AMA’s host city, was “the plague spot” of the country.22 ­B E H I N D T H E F L E X N E R R E P O R T

It is l­ittle known that the AMA’s Arthur Bevan was the instigator of the Car­ne­gie Foundation’s 1910 exposé, not Flexner himself, and not Henry Pritchett, president of the foundation, who hired him. Without Bevan’s impetus, they would have been busy ­doing something e­ lse. At the time, it was a well-­ kept secret that the AMA had anything to do with the report. Unlike the Car­ ne­gie Foundation, it had observed ­great discretion about individual schools by not naming t­ hose it found wanting. Although the CME had reported its recent classifications of specific schools to state licensing boards as well as the schools themselves, no specifics made their way to the public. The AMA’s jour-



A ­G r e a t W a v e o f I m p r o v e m e n t

297

nal published only the overall distribution of schools in the dif­fer­ent classes. The only indiscretion Bevan allowed himself was to call Illinois, Missouri, Mary­land, Kentucky, and Tennessee “rotten spots” in his 1906 report to the AMA House of Delegates b­ ecause of their disproportionately large number of low-­grade schools.23 But that was not enough, Bevan thought. The fine details of the entire ugly picture had to be displayed for all to see. The prob­lem was that using the AMA to deliver the disturbing facts would roil the organ­ization’s internal relations and expose Bevan personally to challenges from below. The AMA’s entire reform mission could be undermined. In short, secrecy about the AMA’s role was a tactic for an effective overall strategy: to outrage the public and mobilize financial and po­liti­cal muscle for reform that the medical profession could not bring about on its own. Bevan hinted at the strategy in the CME’s report to the AMA House of Delegates in June 1906, declaring that negative exposure—­“often the best cure of an evil”—­was needed.24 He did not, however disclose to the delegates what the tactic would be: using the Car­ne­gie Foundation as the stalking h ­ orse to hide b­ ehind. Bevan’s comment about exposure reflected his faith in what he called “publicity” as a remedy for the profession’s maladies. In 1904, he had unleashed ­great irritation in the Chicago Medical Society for arguing that ­because ­there was no known drug cure for pneumonia “the sooner the physician w ­ ill acknowledge this to the public and set to work to discover some specific to save pneumonia patients, the better for all concerned.” Some colleagues w ­ ere angered, but mostly b­ ecause newspapers got wind of his statement and sported headlines like “Drugs Useless for Pneumonia.” One can reasonably won­der if Bevan leaked the story himself. In 1906, while busy with the CME, he submitted a letter unflattering to many fellow surgeons to Surgery, Gynecol­ogy and Obstetrics, which was then reprinted and discussed in other journals. Ironically, he wrote, with the advent of aseptic procedures a “curse” had arisen alongside its benefits—­“the ­doing of operations that are unnecessary or un­ omen he warranted.” ­Women ­were the most likely victims. Nine out of ten w guessed w ­ ere inclined to believe a doctor who told them that one of their sexual organs, or perhaps a kidney, was at fault for their ills and therefore needed relocation, repair, scraping, trimming, or removal. Many gynecologists, including a very prominent one, ­were enraged. Some denied the facts, while ­others objected to the act of publishing them even in a professional forum ­because they could always find their way to the public.25 Thus, Bevan worried about using the AMA to deliver the unpleasant news to the public. His colleagues’ reactions to his ­earlier pronouncements on

298

Schooling Physicians

Surgeons Arthur Dean Bevan, MD (1861–1943), and Frank Billings, MD (1854–1932). Billings and Bevan served as AMA presidents in 1903–1904 and 1918–1919, respectively. Both ­were key figures in the AMA’s drive for medical education and other progressive reforms. Courtesy of Rush University Medical Center Archives.

gynecological surgery, drugs for pneumonia, and especially his own state of Illinois as one of the “rotten spots” of medical education served as warnings. Although he had not named the rotten schools themselves, he set off a furious controversy inside the Illinois Medical Society and in the pages of its journal. Also, according to CME member Victor Vaughan, even though individual schools ­were not named in the CME’s first published report, it had raised a “­great furor.” Indeed, “Most violent denunciations w ­ ere hurled at the Council and its members.”26 Consequently, with muckraking aforethought and before the ink was dry on the CME’s first inspection report, Bevan schemed to enlist laymen as the ­bearers of bad news. In 1907, he approached a pleasantly surprised Henry Pritchett of the Car­ne­gie Foundation for the Advancement of Teaching, who promised to “assist materially.” Pritchett was surprised ­because the American Bar Association had shown no interest in a similar exposé of law schools. A mathematician and astronomer, Pritchett had recently served as president of the Mas­sa­chu­setts Institute of Technology. A missionary for advanced scientific education, he was in league with other eminent champions of improved



A ­G r e a t W a v e o f I m p r o v e m e n t

299

higher education like Charles Eliot, Daniel Gilman, and James Angell. ­Because of that, Andrew Car­ne­gie had chosen him to run the Car­ne­gie Foundation, which in 1905 provided the seed money for what evolved into the TIAA-­CREF retirement fund system for college faculty. To help promising universities attract and retain quality teachers, Car­ne­gie endowed them with funds for generous pensions to make up for their rather unattractive salaries. ­Under Pritchett’s control, the foundation took the next logical step of inspecting colleges and universities to assess ­whether they merited the gifts.27 Bevan and Pritchett agreed that a report on the results of medical school inspections was sure to induce dismay and panic in many a dean and professor and furor if it had the AMA’s fingerprints on it. A g­ reat many AMA members displayed diplomas in their offices from colleges that Flexner would pillory. Rank-­and-­file prac­ti­tion­ers would not fathom or approve of the calculus ­behind airing the profession’s dirty laundry in public to mobilize lay help to clean it. The power­f ul drug industry’s reaction was also to be feared. According to McCormack, that “power­ful, alert and implacable foe,” backed by the lay press, was ready to exploit any divisions in the profession, including “school interests.”28 ­Those interests included homeopathic and eclectic medical schools destined for embarrassing exposure. The AMA could not allow itself to come down hard on them, given its need to maintain diplomatic relations on state licensing boards on which irregulars sat. And the AMA had to preserve its tone of magnanimity ­because a substantial part of the public was hostile to mainstream medicine. Therefore, according to the minutes of a December 1908 CME meeting, Pritchett agreed that “to avoid the usual claims of partiality,” AMA ­people should not be mentioned any more than other sources of information. In short, the Car­ne­gie report was to “have the weight of an in­de­pen­dent report of a disinterested body.” Including Canadian schools in the survey would help. ­Because it would be published by a seemingly neutral source, it would “do much to develop public opinion.” Likewise, in November 1909 Pritchett promised that Flexner’s report would be “ammunition in your hands,” but it was still desirable to maintain “a position which does not intimate an immediate connection between our two efforts.” The reason: “As an in­de­pen­dent agency disconnected from ­actual practice, we may do certain ­things which you perhaps may not.” It would be a “hand in glove” operation: the Car­ne­gie glove would hide the AMA hand.29 A “metal gauntlet” would have been a better description. Flexner, a well-­ known and respected advocate for modernizing American secondary and

300

Schooling Physicians

higher education, was not known for his subtlety. He was chosen despite and maybe b­ ecause of his sometimes abrasive and arrogant manner as well as an ability to charm and persuade. His The American College, finished in June 1908, had vigorously criticized colleges—­even the elite schools—­for their chaotic curriculum, excessive reliance on large lectures, and quasi-­commercial obsession with maximizing the number of fee-­paying students. Perhaps for that reason, Nicholas Murray Butler, president of Columbia University, and most other members of the Car­ne­gie board, also university presidents, voiced qualms about Flexner. Harvard’s president, Charles Eliot, who may have suggested Flexner, supported Pritchett on the choice and it prevailed.30 Although Flexner wrote the report, the AMA gave him much of his material. During his inspections between January 1909 and April 1910, he was often accompanied by the CME’s Colwell. How many times is not known. In his memoirs, Flexner said “many” but in another private context, hardly more than a half dozen. Editor Morris Fishbein’s 1949 history of the AMA claimed that Colwell visited “­every school” with Flexner and furthermore “provided far more guidance in this famous survey than is generally known.” That is consistent with Pritchett’s original plan to be guided “very largely” by investigations the CME had already conducted. Flexner no doubt consulted Colwell’s notes. Certainly, Colwell would have briefed Flexner on what to look for and what he was likely to find in his solo visits. According to Pritchett’s introduction, e­ very detail was consistent with facts shared by the AMA and the Association of American Medical Colleges, a near-­admission of the hand-­ in-­glove collaboration.31 BANNER HEADLINE NEWS

The Car­ne­gie Foundation printed and distributed fifteen thousand copies of Flexner’s report, some sent upon request in exchange for modest postage costs. Many went to newspapers. On June 6, 1910, the Los Angeles Times headlined its story with “MEDICAL EVIL IS POINTED OUT: Startling Report Issued by Car­ne­gie Foundation.” The same day’s Chicago Daily Tribune story was headlined with “SCORES MEDICAL SCHOOLS: Car­ne­ gie Foundation Says This City In That Line Of Education Is Plague Spot Of The Country.” The Washington Post’s June 7 headline read, “TOO MANY PHYSICIANS: Car­ne­gie Foundation Assails Medical Colleges And Would Abolish Majority.” A New York Times editorial immediately praised the Car­



A ­G r e a t W a v e o f I m p r o v e m e n t

301

New York Times front-­page story of July 24, 1910, on the Flexner report. Secretly instigated by the AMA, the Car­ne­gie Foundation’s exposé shocked the nation with its reporting on the inferior quality of American medical schools.

ne­gie report but called it “slightly contentious and unnecessarily irritating.” But the following month a front-­page banner headline for a two-­page story screamed, “FACTORIES FOR THE MAKING OF IGNOR ANT DOCTORS: Car­ne­gie Foundation’s Startling Report That Incompetent Physicians Are Manufactured By Wholesale In This Country.” Among its embarrassing

302

Schooling Physicians

specifics ­were the depiction of Chicago as the “plague spot.” Many other newspapers repeated that sensational tidbit. The Times story included Flexner’s comment about “the indubitable connivance” of the Illinois Board of Health with the unhealthy schools. The article quickly summarized the state-­by-­state, school-­by-­school appraisals. Acceptable medical education was “not now to be had in Alabama.” Tennessee “protects more low-­grade medical schools than any other Southern state.” Iowa had two to three times as many doctors as ­were needed, and one school located ­there was “a disgrace to the State and should be summarily suppressed.” Some of Mary­land’s schools “belong to the worst type of American school.” Mas­sa­chu­setts had one “wretched institution” that needed wiping out and two ­others lacking compelling reasons for continued existence.32 And so on. Many other large city newspapers carried stories about the Flexner report, including the Cincinnati Enquirer, the Hartford Courant, the Indianapolis Star, the Los Angeles Times, the Louisville Courier, the Nashville Tennessean, the New York Tribune, and the St. Louis Post-­Dispatch. Few newspapers ran stories or editorials critical of the report. An exception was the Baltimore Sun, which devoted its story almost entirely to complaints from a half dozen medical school deans and professors from embarrassed schools in the city. The dean of Baltimore Medical College called Flexner’s report “unjust” and “unworthy of consideration,” and the dean of Mary­land Medical College called it “false and outrageous.” It was “utterly untrue and without foundation,” “a piece of impertinence,” and “contemptible,” according to o­ thers. Flexner had written that Baltimore’s Mary­land Medical College occupied a “wretchedly dirty” building, its dissecting room was “foul,” and its room for instruction in bacteriology, pathology, and histology contained only “a few dirty test-­tubes standing around in pans and old cigar-­boxes.” Baltimore’s Atlantic Medical College was a “blot on the state of Mary­land.” For bedside training, t­ here was “a small private hospital several miles off.” Three members of its teaching staff had graduated only the year before; one of them had entered a­ fter failing out of the local College of Physicians and Surgeons. Another had failed the state board exam.33 Unpublished criticism included questions about Flexner’s qualification, as a layman, to say anything about medical education worth listening to. Some schools bitterly complained that Flexner spent no more than fifteen minutes inspecting them, which may have been true if he relied on Colwell’s notes. Also, as Flexner said, “You d ­ on’t need to eat a w ­ hole sheep to know it’s tainted.” Not surprisingly, the cries of foul from Illinois ­were about the loudest. Flexner’s



A ­G r e a t W a v e o f I m p r o v e m e n t

303

accusations of corruption ­were “maliciously false,” according to James Egan, secretary of the Illinois health board. Flexner betrayed “a deplorable ignorance as to what constitutes a medical college.” The reverend H. S. Spalding protested that the Car­ne­gie Foundation’s anti-­Catholic bigotry lay b­ ehind Flexner’s damning characterization of Chicago’s Bennett Medical College, a Jesuit institution, as “frankly commercial.” Flexner had written that it ­stopped advertising itself as an eclectic college as a “business move.” ­There was also a whiff of bigotry against the Jewish author. According to Monsignor Thomas Shannon, Flexner was “the cruelest incarnation of anti-­Christianity that you could pack into 5 feet, and . . . ​the bitterest foe of Christian education in the universe.” Flexner reminisced l­ater that he received “anonymous letters warning me that I should be shot if I showed myself in Chicago.”34 A critical editorial in New York’s Medical Rec­ord implicitly confirmed the impression the AMA wanted to convey about the Car­ne­gie Foundation’s in­ de­pen­dent role. It asserted that Flexner’s work seemed “a waste of effort and an ­ eedless expenditure of Mr. Car­ne­gie’s hard-­earned money.” Vari­ous medical associations, physicians, and medical educators “had already done and would continue to do a splendid job.” The clueless writer was no doubt referring to the AMA as one of the associations. In the New York State Journal of Medicine, another unwitting editor claimed that instead of helping the profession Flexner damaged it by subjecting doctors’ training grounds to “ridicule in the pages of more than one daily paper.” Nowhere in the report, he said, “has any credit been given to the medical profession for the earnest and sincere efforts which it has been making this quarter of a ­century to improve the status of medical education.”35 To be sure, in his introduction to the Flexner report Pritchett acknowledged Bevan’s and Colwell’s “constant and generous assistance,” as well as that of William Welch, who was serving a stint as AMA president at the time. But ­those names ­were blended in with ­others, as if equal in importance, such as Abraham’s ­brother Simon Flexner of the Rocke­fel­ler Institute and Fred C. Zapffe of the AAMC. Likewise, the AMA journal did not let on to its subscribers, many of them gradu­ates of the miscreant colleges, what went on ­behind the scenes. A ­ fter the report’s publication, the journal skirted around the ­matter of AMA collaboration entirely, highlighting the Car­ne­gie Foundation’s larger mission and its past efforts for reform of all higher education. “Coming from an agency outside and in­de­pen­dent of the medical profession,” an editorial said, “claims of partiality or prejudice cannot be made against it.”36

304

Schooling Physicians

Communications between Pritchett and the AMA ­after the work was done confirm that the plan had been to conceal the AMA’s role. In 1912, Pritchett wrote to Colwell to explain his criticism of the AMA’s “incongruous” inclusion of rather weak schools in its class A list along with stellar places like Johns Hopkins. Instead of complaining, Colwell said criticism of the AMA’s work was, if anything, “too mild.” It was happy to look like the nice cop. To make the critique “very much stronger” would be “fully justified.” He entirely agreed with Pritchett’s reasoning about helping the AMA “strengthen its acts,” saying that the negative publicity “would ­really strengthen our hands and enable us to draw the lines a ­little tighter than would other­wise be pos­ si­ble.” AMA journal editor Simmons also reassured Pritchett, saying, “I wish you could make it stronger; criticize us for not putting some schools in a lower class than that in which we have placed them.” Perhaps assisted by Pritchett’s prodding, the following year the AMA bumped up the best of the class A schools into an A-­plus group, which sowed some disgruntlement among schools left ­behind in the regular A class.37 Between 1913 and 1915, Bevan and Pritchett contemplated a similar secret collaboration, a survey of the deplorable condition of many American hospitals. It was standing in the way of better bedside training “in keeping with modern scientific medicine.” Embarrassing disclosure could catalyze further reform. An example they discussed was the University of Nebraska’s College of Medicine in Omaha. Its dean, a surgeon employed by the Union Pacific Railroad, “the g­ reat po­liti­cal power in Nebraska,” was obstructing the university’s effort to improve its medical school by disqualifying his privately owned hospital as a teaching site. Public exposure could tip ­things in the right direction. Therefore, to give hospital reform a jolt, Pritchett offered to help by publicly criticizing the AMA for inaction—­“to throw stones” at the CME and “warm them up to ­doing their work.”38 That collaboration never came to pass. The American College of Surgeons (ACS) would instead undertake its own hospital survey without AMA help, which found that of 692 hospitals with one hundred beds or more, only 89 met rather minimal quality standards in terms of staff coordination, preoperative examinations, surgical practices, rec­ord keeping, and follow-up of patient pro­gress ­after surgery. The shockingly poor numbers ­were publicized, but the individual hospitals, perhaps regrettably, w ­ ere spared the public dis­ ere as chaotic as the majority. In grace. Some of the very prestigious ones w 1919, to prevent a scandal, the individual rec­ords ­were incinerated in the base-



A ­G r e a t W a v e o f I m p r o v e m e n t

305

ment of New York City’s Waldorf Astoria H ­ otel. It was the beginning, however, of the ACS’s hospital “standardization” campaign and what became an accreditation system formed in 1951 and jointly run by the ACS, the AMA, the American College of Physicians, and the American Hospital Association.39 A FTER M ATH

Arthur Bevan’s negative publicity strategy worked. In the case of Washington University in St. Louis, even the mere threat of bad publicity did the job. Flexner’s draft of an entry about the university’s medical department for his forthcoming report was shown to philanthropist Robert S. Brookings, the university’s president and biggest endower. Brookings, who was proud of the university he had helped develop into a prestigious institution, was appalled that the world would hear that its medical school was “absolutely inadequate in ­every re­spect” and only “a ­little better than the worst.” When he protested, Flexner returned to give him an eye-­opening personal tour. In short order, Brookings initiated a radical reor­ga­ni­za­tion of the school, backed by a huge new endowment of $1.5 million—­just in time for Flexner to praise the school in his report for its current reor­ga­ni­za­tion “on modern lines.” 40 ­A fter his report appeared, according to Flexner, “schools collapsed right and left, usually without a murmur.” In September 1911 he told a meeting of the American Hospital Association that 20 schools had folded in the last year. He attributed the closing of some “mercenary” schools “that trade on ignorance and disease” to their being boycotted by hospitals ­after it was made known to the public that they allowed professors from inferior schools to give instruction in their wards. By 1915 ­there ­were only 95 schools left due to closings and mergers among the approximately 130 that had existed around 1910. The shuttered schools w ­ ere mostly the rotten, low-­hanging fruit needing impossibly large investments to make the grade; ­others merged with ­viable schools. Another 10 schools dis­appeared by 1920, leaving only 85. Small proprietary schools unattached to universities w ­ ere heading into extinction. Other major casualties w ­ ere sectarian schools, most of them having exceedingly low entry standards and paltry resources.41 The numbers did not say every­thing, according to Pritchett in 1912. The “internal improvements” ­were “more remarkable and significant” than just reduction in numbers. One quantifiable indicator was the rise in the number of schools requiring two years of collegiate premedical training. In 1914, the

306

Schooling Physicians

AMA journal noted that state licensing boards, emboldened by the Flexner report, ­were using their authority to discriminate against inferior medical colleges by using the AMA’s class A as a quasi-­official accreditation. Thus, for example, the Missouri State Board of Health fi­nally got around in 1912 to rejecting gradu­ates of the ill-­reputed St. Louis College of Physicians and Surgeons. In 1917, the federal government stepped in to enhance the power of the post-­Flexner state authorities. On an order from President Woodrow Wilson, the surgeon general gave young men an exemption from the draft if they w ­ ere admitted to schools recognized by at least 50 ­percent of the states’ licensing boards. By 1918, thirty-­t wo state boards ­were recognizing only colleges adhering to the CME’s two-­year, A-­level standard for premedical training. By 1922, diplomas granted by some medical schools w ­ ere not recognized in as many as forty-­six states. Pressure from the state boards taking their cues from the CME led to more and more colleges improving their standards in order to achieve the AMA’s blessing, rising from around 30 ­percent in 1913 to 72 ­percent in 1921.42 Medical historians ponder the unanswerable question of ­whether developments in the four years before the Flexner report indicated that pro­gress afterward might have continued had it never been published. According to Robert Hudson, appraisals range from almost no effect to revolutionary in impact. In his own view, the report was “catalytic.” Among prominent historians, William Rothstein is prob­ably the least impressed with Flexner’s impact, remarking that ­there is no reason to think that ­earlier trends would have ceased without the Flexner report. They may not have, but the rate of improvement would no doubt have been slower. It is entirely clear, however, that the AMA was the prime mover both in speeding up reform before 1910 and then, ­because it was the instigator of the Flexner report, afterward. The AMA’s rating pro­cess became “a part of the official machinery of the country’s licensing system,” according to the president of the Rocke­fel­ler Foundation in 1920, whose huge funds allowed it to assume leadership of lay forces for improving medical education.43 Arthur Bevan’s strategy succeeded. “Without a doubt,” he had maintained back in 1906, the CME’s most impor­tant role would be “the careful collecting of all the facts on medical education and giving publicity to ­these facts, so that the state licensing bodies, the state medical socie­ties and the medical colleges may be given as accurate pre­sen­ta­tion of existing conditions.” Exposing the truth, he had predicted, was “bound to lead to correction and improvement.” But Bevan’s strategy included broadcasting good news, not just



A ­G r e a t W a v e o f I m p r o v e m e n t

307

casting shadows over the bad schools. B ­ ecause good, noncommercial educational institutions required generous endowments, Bevan thought, the public must be taught the “possibilities of modern medicine.” Consequently, Pritchett’s introduction to the report and Flexner’s lengthy discourse prefacing his cata­logue of horrors constituted a primer for educated and wealthy laypeople on what well-­endowed, university-­based private schools like Johns Hopkins, and state universities in Eu­rope and Canada, could accomplish in the way of superior medical training. It schooled the philanthropic community in how they might give away their money for ­great effect as well as personal glory—to usher in an era of modern, scientific, and therefore efficacious medical practice.44 Without such information, rich p ­ eople naturally preferred giving their money away to more fruitful ­causes. For example, money that might have been available in the past for the training of healers flowed instead ­toward preventers—­like John D. Rocke­fel­ler’s grants to the Rocke­fel­ler Sanitary Commission and Henry Phipps’s for his Phipps Institute for the Study, Treatment, and Prevention of Tuberculosis. Thus, the AMA and the Car­ne­gie Foundation helped push medical schools to the front of the line for cap­i­tal­ ists’ beneficence. The Flexner report and his subsequent fund­rais­ing activities ­were instrumental in persuading the public that it was “in its own interest to support medical schools generously,” according to medical historian Ludmerer. “Once the neglected stepchild of philanthropy,” he writes, medicine became “the most vigorously supported of any cultural, scientific or humanitarian activity.” Flexner helped medical philanthropy to become “a national preoccupation.” 45 ­Things happened quickly. Aided by Flexner’s designation of it as a worthy recipient, Yale University’s medical school, which was not yet a leader, set to work in June 1910 to raise $2 million in large and small donations and quickly reached its goal. Up to that time, it had strug­gled to get gifts of more than $2,000. A ­ fter working for the Car­ne­gie Foundation, Flexner signed on as assistant secretary and then secretary of the Rockefeller-­funded General Education Board (GEB). By 1913, he had turned the GEB into the single most power­ful force in medical philanthropy. Among the sources he tapped into was Rochester industrialist George Eastman, of Eastman Kodak, who Flexner persuaded to set up a quality medical school from scratch at the University of Rochester. Eastman characterized the hypnotically persuasive Flexner as “the best salesman I have ever seen” and on another occasion as “the worst highwayman that ever flitted into and out of Rochester.” Flexner worked him

308

Schooling Physicians

so well that he “cleaned me out of a thundering lot of my hard-­earned savings.” At Flexner’s prompting, Julius Rosenwald of Sears, Roebuck, and Co. helped the University of Chicago; steel industrialist and Car­ne­gie associate Edward Harkness helped Columbia; and financier J. P. Morgan helped Cornell. ­There w ­ ere, of course, hosts of smaller givers, inspired by the big ones, who helped bring many other places up to AMA standards. Flexner also personally helped arrange a few marriages between hospitals and medical schools: New Haven Hospital with Yale; Wesley with Northwestern; and Bellevue with Cornell, Columbia, and New York University. In time, Flexner distributed more than $78 million of Rocke­fel­ler’s fortune to medical schools.46 From the standpoint of educational philanthropy, the Flexner report was fabulously well-­timed. In January 1911, the Atlanta Constitution’s headline announced, “Purses of Rich Folks Wide Open during 1910.” It was a “record-­ breaking year for gifts for public purposes.” The New York Times headline reported that $163,197,125 was given in 1910 for philanthropy, about $76 million of which went to education. Since 1895, huge manufacturing employers, consolidated during the ­great merger movement in the following years, had encountered much hostility from the public about the mono­poly evil, and militant workers ­were organ­izing and agitating for living wages and humane working conditions. Big employers responded in part with “welfare capitalism,” or com­pany benefits to promote worker loyalty and effort, to reduce turnover, and of course to quell worker militancy and fend off ­unions. ­Later, the corporate world also sought to please the broader public. As the numbers of millionaires ­rose rapidly, so did populist suspicions about how they had come by their money. It was therefore becoming fash­ion­able to unburden themselves of some of it in self-­flattering ways.47 Flexner also set to work as time went on drumming up support for medical education at state universities just as they ­were rising in importance in the American society and economy. Economic growth provided a growing tax base for governors seeking to advance themselves with universities to be proud of—­and that could stimulate more economic growth. His report had already helped Edmund J. James, president of the University of Illinois, to get money from the state legislature to turn the university’s medical school into a worthy institution. Citing Flexner’s recent “plague spot” comment about Illinois, James was able in October 1910 to get $100,000 a year for the next three years from the Illinois legislature. Toward the end of his GEB c­ areer, Flexner focused practically all of his efforts on public medical schools, especially in fiscally strapped Southern and Western states. The first to benefit from the GEB’s help w ­ ere Iowa, Colorado, Oregon, V ­ irginia, and Georgia.



A ­G r e a t W a v e o f I m p r o v e m e n t

309

According to medical historian Hudson, as Flexner and the GEB anticipated, “State rivalries erupted around the few schools selected for financial assistance.” Indirectly, Flexner also helped dislodge money out of state trea­suries for their medical schools by turning them into more prestigious institutions.48 COLL ATER A L DA M AGE: W ­ OMEN AND BL ACK DOCTORS

In 1901, the radical physician Inez Philbrick published a searing indictment in the Journal of the American Medical Association of the medical profession and the schools that w ­ ere flooding it with medical ignoramuses and worse. The Nebraska practitioner and teacher had graduated as salutatorian from the University of Iowa in 1886 and with the highest grades in her class at the Quaker-­founded ­Woman’s Medical College of Philadelphia in 1891. A member and former vice president of the Nebraska State Medical Society and president of the Nebraska Association of Medical ­Women, Philbrick devoted time to ­women’s ­causes of all kinds, including four years as president of the Nebraska Equal Suffrage Association. She was particularly appalled by the female and infant victims of badly trained male physicians, who, along with mistaken diagnoses and general incompetence, delivered “ofttimes barbarous ­ others. Risking collegial censure from fellow Nebrastreatment” of birthing m kans, she argued that the excess supply of medical education was so harmful that for Nebraska to maintain even one medical school, much less its two in Lincoln and Omaha, with their stagnant populations of around one hundred thousand and forty thousand, “is in contravention of the fundamental law of professional pro­gress.”  49 Philbrick may have been encouraged by the AMA’s efforts for what she called “fewer but better” but discouraged by their effects on w ­ omen’s medi­ omen’s medical colleges dis­ cal education. A ­ fter 1910, two of the extant w appeared, having been unable to raise the resources necessary to make the grade. Of the fourteen ­women’s medical colleges founded ­after the American Civil War, only three remained, all having strug­gled for survival on the basis of meager tuition fees and scarce hospital privileges made scarcer by prejudice against w ­ omen. They had been founded largely ­because of what Mary Jacobi, also a gradu­ate of the ­Woman’s College of Philadelphia and the founder in 1872 of the Association for Advancement of the Medical Educa­ omen tion of ­Women, called the “peculiar bitterness” of male opposition to w in medicine. It produced spectacles like young ­women being “hissed and

310

Schooling Physicians

stampeded out of hospital wards and amphitheaters” even when the patients ­were ­women and female nurses w ­ ere welcome.50 The coeducational colleges’ absorption of ­women students helped sap the life out of all but the three ­women’s schools that remained in 1910. ­A fter 1910, the resource prob­lem only worsened. Only Jacobi’s ­Woman’s Medical College of Pennsylvania, the first of its kind in the world, survived ­until 1970, when it started taking male students and changed its name to the Medical College of Pennsylvania and ultimately became the Drexel College of Medicine in 2002. But coeducation failed to stop the decline of ­women’s enrollment in medical studies. It fell dramatically from an unimpressive 1,280 in 1902 to 921 in 1909 and then further to only 526 in 1913. The number of gradu­ ates fell from 254 to a miniscule 162  in the same years. Coeducation had therefore been no more than a symbolic victory. Even Johns Hopkins would end up taking in far fewer ­women students than Mary Garrett had hoped and paid for. At the University of Michigan, a pioneer among state schools in medical coeducation, ­women as a proportion of medical students plummeted from an e­ arlier peak of almost 20 ­percent in 1894 to l­ ittle more than 5 ­percent in 1910. The Kansas Medical College proportion fell even more drastically, from 31 ­percent female in 1893 to only 4 ­percent in 1907. In the 1920s and well beyond, admissions officers in most schools applied quotas to keep w ­ omen students at no more than 5 ­percent of the total. Between 1890 and 1900, about 5 ­percent of medical students w ­ ere ­women; between 1910 and 1928, the average was even less, about 4.5 ­percent.51 To explain the pre-1910 trend, Flexner speculated that ­women ­were showing “a decreasing inclination” to enter medicine even as coeducation was becoming common. But his better argument was that t­here was no “strong demand” for w ­ omen physicians. Had t­ here been more demand, ­there would have been a greater supply. The medical patriarchy continued to inculcate deep prejudices, most injuriously in obstetrics, whose overwhelmingly male prac­ ti­tion­ers wished to displace midwives, even well-­trained licensed ones. Patients and hospital administrators acted on their prejudices about female incompetence. As medical education improved, tuition r­ ose as well, which prob­ably worked more against ­women than men ­because parents ­were less willing to fund their d ­ aughters’ education and b­ ecause of ­women’s more ­limited ­career chances to pay off loans. As hospitals became more welcoming to students in general, they remained closed to the small numbers of ­women needing internships ­a fter graduating. The problem worsened ­a fter 1915, when Pennsylvania and New Jersey began insisting on an internship year before granting



A ­G r e a t W a v e o f I m p r o v e m e n t

311

licenses. By 1920, ten state licensing boards started requiring an internship year for a license. By 1955, twenty-­five more states had followed, and seven more joined them by 1959. As a consequence, ­there ­were fewer ­women physicians in 1950 than t­ here had been in 1900.52 The AMA efforts to produce fewer and better medical schools also inflicted injury on African American medical education. Medical training and therefore medical care for African Americans was already scarce due to even more vicious prejudices than against w ­ omen. Relatedly, Jim Crow laws and general discrimination blocked black ­people’s upward mobility and their ­children’s access to the premedical education qualifying them for entry into the improving medical schools. Only three of the seven extant black schools survived the AMA’s ratings beyond 1914, and one of ­those vanished in 1923. The five that dis­appeared had been “in no position to make any contribution of value,” according to Flexner. Only Meharry Medical College in Nashville, Tennessee, and Howard University Medical College in Washington, DC, w ­ ere “worth developing.” Howard in par­tic­u­lar, Flexner thought, was “an asset the like of which is in this country extremely rare,” and “it is greatly to be hoped that the government may display a liberal and progressive spirit in adapting the administration of this institution to the requirements of medical education.” ­Today, what Flexner wrote on “the negro” in his report for the Car­ne­gie Foundation sounds patronizing and condescending but short of rank racism. “He has rights and due and value as an individual,” Flexner wrote, a rebuke for whites’ massive denial of ­those t­hings. He therefore recommended greater leniency ­toward Howard and Meharry than white schools. In the years ­after his work for the Car­ne­gie Foundation, he became increasingly passionate about racial injustice in Amer­i­ca, admiring Blacks’ efforts in the face of crushing odds against them, and devoted much of his energies to advancing their educational opportunities.53 Lacking lavish endowments, Howard and Meharry could do nothing to take up the slack left by the black schools that had perished. Medical leaders, cap­i­tal­ist philanthropists, and politicians put no pressure on all-­white schools to recruit African Americans, despite the severe shortage of white doctors willing to treat poor whites much less black patients, especially in rural areas. Although most white schools in the North and West left their doors ajar for black applicants, they took in only tiny numbers, and some simply left them shut. In the early 1920s, the dean of Yale Medical School instructed its admissions committee to “never admit more than five Jews, take only two Italian Catholics, and take no blacks at all.” Medical school admissions officers

312

Schooling Physicians

turned away black applicants, arguing that their affiliated hospital or hospitals would not open their doors to them for clinical instruction. In many states, even Blacks who managed to get clinical training w ­ ere unable to obtain a license ­because, just as for w ­ omen, their compulsory internship year turned hospital walls into blockades between African Americans and medical licensure.54

Before 1910, the general public had no inkling of the alarming truth about where their doctors received their training—in what Abraham Flexner called “wretched,” “disorderly,” “dirty,” “putrid,” and “foul” places. For the first time, the public’s eye was opened by the AMA-­instigated Car­ne­gie Foundation report about the defective products that the f­ ree market in education was manufacturing and delivering to unwitting patients. In the eight years before its publication, starting in 1902 with Lincoln Steffens’s The Shame of the Cities, then Ida Tarbell’s 1904 The History of the Standard Oil Com­pany, followed in 1906 by David Graham Phillips’s “Treason in the Senate” series in Cosmopolitan and Upton Sinclair’s The Jungle, American readers had learned about po­liti­cal corruption in their cities, states, and Congress and in the oil and meat-­packing industries. Famous Progressive ­Era reforms followed from the muckraking reportage they and other subjects received: municipal civil ser­ vice reforms; the direct primary, direct election of senators; the antitrust prosecution and breakup of Standard Oil; and the Meat Inspection Act. Indeed, in the medical realm Flexner’s Medical Education in the United States and Canada was to the actions of state medical authorities for medical education reform what Samuel Hopkins Adams’s 1906 The G ­ reat American Fraud, another power­ful exposé, was to Congress’s 1906 drug law. The progressive medical reformers eagerly wielded the power of such “publicity” in both the po­liti­cal and market sphere. With it, they expected, both politics and markets would function better as d ­ rivers of efficiency. Exposure of low-­quality medical education would galvanize the elite public to ally themselves with the medical reformers. Furthermore, the progressives thought, the consumers of medical training would be empowered by transparency to make quality rise. In the nineteenth ­century, physician leaders Nathan Davis, William Pepper, and John Rauch understood the prob­lem of adverse se­ lection in medical education: the survival of the foulest wherever opacity ruled. The invisible hand of the market could not select the truly fit from the unfit in the overcrowded education market and hypercompetitive profession. As one



A ­G r e a t W a v e o f I m p r o v e m e n t

313

progressive physician of the next c­ entury put it, the equation of market success in medicine and natu­ral se­lection in biology was flawed ­because scientific and ethical superiority was not needed for survival. Competition even benefited “the low, shrewd and cunning.” Thus, wrote Theodore W. Schaefer in 1913, his commercialized profession had drifted “acephalically” into a mire out of which it had proved unable to lift itself.55 Intelligent design had to come from outside the profession’s market system, medical progressives thought. Help from the lay world was needed ­because the profession could not pull itself up by its ethical bootstraps. Power­ ful laymen who engaged themselves in health-­related reforms saw the adverse se­lection prob­lem just as their medical counter­parts did. Back in the 1880s, John Eaton of the U.S. Bureau of Education ridiculed the idea that “the law of supply and demand” would tame the dark jungle of medical education and its unruly growth. In 1902, businessman and philanthropist Frederick Gates, John D. Rocke­fel­ler Sr.’s right-­hand man and employer of Flexner for his GEB work, thought that for commercial competition to be fair, “the two parties must both know the value of the article or ser­vice.” Un­regu­la­ted commerce in potatoes, unlike medicine, was fair ­because both grocers and their customers knew a lot about potatoes. “But as to the value or skill of a doctor’s ser­vices, one of the two parties knows nothing; he has got to take it at the word of the other.”56 In his introduction to the Flexner report, the Car­ne­gie Foundation’s Henry Pritchett wrote that as a rule, “Americans, when they avail themselves of the ser­vices of a physician make only the slightest inquiry as to what his previous training and preparation have been.” Standing in the way of consumer-­driven pro­gress was medical colleges’ view that they w ­ ere “private institutions,” so the public was only entitled “such knowledge of their operations as they choose to communicate.” Abraham Flexner echoed all of the above, writing that competition could be “stimulating”—­for example, in excellent university departments where scientists vied for prestige with exciting discoveries. But competition could also be “demoralizing.” Thus, regulation of commerce in medical education with stringent licensing laws was necessary to “protect the student against the unfit school” as well as the public “against the formidable combination made by ignorance, incompetency, commercialism, and disease.”57 The need for a progressive alliance of such like-­minded medical and lay forces of reform reverberated in both camps. As surgeon Arthur Dean Bevan put it in his parting words to the AMA in 1928, “Medical education and

314

Schooling Physicians

medical practice are functions of modern civilization in which the entire community is vitally interested.” As such, they “cannot be left safely in the hands of the medical profession alone.” Likewise, layman Pritchett declared that medicine is “a quasi-­public profession.” State-­chartered institutions “are in truth public ser­vice corporations.” Consequently, “the public has a right to know the facts concerning their equipment and ability to furnish education.” The medical profession, still disordered and disreputable in many regards, “­will never gain its rightful place ­until the intelligent layman, the legislator, the citizen, realize . . . ​their own obligations as to its support, its standards and its regulation.”58 Neither the medical nor the lay progressives ­were calling for the professional sovereignty that sociologist Paul Starr argues was or­ga­nized medicine’s overarching agenda. The progressives in charge of the AMA welcomed shared control, a mutually beneficial social contract. They believed that a progressive alliance of lay and medical forces was needed to remedy the American medical disorder. But their views ­were not as influential throughout the profession as they would have liked. Many members of the medical profession would have regarded Bevan as disloyal for insisting on public control of the medical profession and Pritchett as an arrogant meddler for challenging its autonomy. Indeed, in 1910, ­there ­were rumblings of discontent from within about the AMA’s progressive leadership, agenda, and actions in medical education and other arenas, just as ­t here ­were, from without, about its call for a national department of health. Internal dissension grew in volume and spread across the country in the course of the next de­cade. An insurgency and a reactionary turn ­were on their way. By 1924, the AMA was no longer a progressive organ­ization.

chapter 12

Insurgency

Progressivism came with a high price for the reformers dominating ­or­ga­nized medicine. With their agenda and actions, the American Medical Association’s leaders ultimately divided the very profession they had assembled into a larger, more encompassing, and streamlined organ­ization a­ fter 1901. ­Every cause the progressives pursued left some segment of the membership coldly indifferent, passively dissatisfied, or actively furious. Th ­ ere was grumbling in the ranks about the AMA’s policy of tolerance ­toward ­irregulars like homeopaths and eclectics carried over from the progressive licensing movement of the 1870s and about its current restraint ­toward new medical cults like osteopathy. By ­going to war against the corrupt drug industry, the progressives antagonized doctors who routinely prescribed the proprietary medicines advertised in cheap drug-­funded “in­de­pen­dent” medical journals. ­Those hostile journals also created allies within the profession by publishing what the AMA and state medical society journals rejected in the name of quality medical science and truth in advertising. By aligning with lay reformers to purge the Augean stables of its low-­grade schools, the ­ ere their reformers diminished the status of thousands of doctors who w gradu­ates. Even the AMA’s public health mission caused disgruntlement among some lowly prac­ti­tion­ers ­because they stood to lose the business that disease drummed up for them. Last, but not least, many members resented

317

318

Reactionary Turn and Beyond

the elite progressives for their indifference to the mundane economic prob­ lems of struggling doctors, even if closing many medical schools offered pos­si­ble relief from a glut of competitors. In 1906, about a half de­cade ­after the AMA’s reor­ga­ni­za­tion and mobilization for progressive reform, resentment in the ranks percolated into open insurgency against the rising progressive forces in or­ga­nized medicine. Ironically, it started in Chicago, where the AMA headquarters ­were located. In June  1910, a dissident ele­ment took control of the huge Chicago Medical Society. Some of the insurgents’ grievances concerned the leadership of the Illinois Medical Society (ILMS), located in Springfield, the state capital. Several years later, 1913, the Chicago dissidents captured the state society as well. Thus began a nationwide revolt against medical progressivism. Chicagoans would be well represented in the national forces seeking to overturn the “old guard” reformers, joined by rebellious leaders from other states who rode in on a wave of diverse and distinct grievances. Ten years a­ fter the insurgency toppled the progressive leadership of the ILMS in 1913, the same was about to happen to the entire AMA. Why that occurred has been neither chronicled nor explained by historians of the medical profession. It is commonly perceived that the disappearance of medical progressivism in 1924 is related to the AMA’s dalliance with compulsory health insurance, starting in 1917. But as the following narrative shows, the revolt from below began well before the controversy over insurance erupted and continued well a­ fter the progressive AMA leaders distanced themselves from it. ­There w ­ ere many other c­ auses.1 CHICAGO AND ILLINOIS: HEARTL AND OF THE INSURGENCY

Covering all of Cook County, the Chicago Medical Society (CMS) was the largest local unit of or­ga­nized medicine in the country—­larger than some of the AMA’s state socie­ties. It was prob­ably also the most fractious of the large county socie­ties in the years following the AMA’s reor­ga­ni­za­tion in 1901. Like the ILMS and the AMA, it was led by progressives—­mostly elite physicians and especially surgeons who w ­ ere educators and public health enthusiasts. They ­were resented by many rank-­and-­file prac­ti­tion­ers, the constituency ­ ere called, who began mobilizing as early as 1906 of the “insurgents,” as they w to clear out the old guard. That year, a well-­organized group of disaffected physicians mobilized supporters in meetings across Cook County to discuss

Insurgency

319

their objectives, plan their attack, and recruit contestants for seats in the governing body of the CMS. The old guard—or the “aristocrats” as some called them—­held their ground in 1906 by electing distinguished physicians and nationally notable scientists, educators, and public health leaders to the CMS Council, its governing body. The honorific presidency of the CMS was handed to medical education reformer George W. Webster, a vice president of the National Confederation of State Examining and Licensing Boards and president of the Illinois Board of Health. Also elected to the CMS Council was Frank Billings, the famous surgeon and 1903–1904 AMA president, and William A. Evans, soon to be the progressive commissioner of Chicago’s health department. The other two of the five councilors ­were prominent surgeons, educators, and scholars Lewis  L. McArthur, Fernand Henrotin, and Charles  S. Bacon. In 1906 Henrotin expressed support for the adoption of compulsory insurance in Amer­i­ca as a natu­ral stage in “the development of our republican form of government.” Bacon was another radical progressive. In 1893, he called for medicine to become a “function of the state,” largely for preventive purposes. On that, he quoted En­glish phi­los­o­pher and economist John Stuart Mill as an authority on the salutary effect of fixed salaries on the state of mind needed for good doctoring; fee-­for-­service medicine clouded physicians’ thinking about their clinical decisions with calculations of their profitability. Only recently, Bacon had led a CMS collaboration with Jane Addams, the philanthropist social worker, and her famous Hull House, in a study and report affirming the need for properly trained, licensed, and supervised midwives.2 ­Every year ­after their failed effort of 1906, the insurgents regrouped to put forward a new slate of challengers. According to CMS official Albert J. Ochsner, one of the country’s most eminent surgeons, the Chicago society was being “disintegrated by partisan methods and po­liti­cal self-­seeking.” Four years ­later, the disintegration of the progressive CMS was complete. At its yearly meeting in 1910, vindictive and personal recriminations flew through the air. Relative unknowns defeated officials like Ochsner and the equally notable Ludvig Hektoen, the renowned pathologist and bacteriologist. Specialist groups affiliated with the CMS lost their privileged repre­sen­ta­tion in the CMS council. Now, as a Chicago Tribune headline put it, “Insurgents Rule Medical Society.” Surgeon James B. Herrick reminisced many years ­later that the former “successful, high-­priced, Gold Coast doctors,” his fellow “high-­brows,” complained that the former “outs,” the “low-­brows,” had stuffed and stolen ballot boxes. Insurgents paid the dues of delinquent members so their votes

320

Reactionary Turn and Beyond

could be counted. To Ochsner they w ­ ere “the Hinky Dinks and Bath House Johns of the profession,” engaging in the same kind of “rotten politics” that Cook County was famous for. Not giving up right away, Hektoen, joined by AMA leaders Billings, John B. Murphy, and Henry A. Favill, sought to regain control in 1911, but they w ­ ere outdone by the far better or­ga­nized and numerous Cook County insurgents.3 Among the victors in the rebellion was surgeon Charles J. Whalen, a fierce critic of the medical aristocrats for their indifference to the economic concerns of the rank and file. That was not entirely fair ­because the old guard had tried to help common prac­ti­tion­ers by establishing a business bureau to buy up the debts of deadbeat patients. But the bureau’s mismanagement and ultimate failure possibly contributed to the insurgents’ frustrations. In 1908, Whalen began agitating against “abuses of medical charities,” allegedly a ­matter of only minor concern to the old guard. Hospitals, dispensaries, big employers, and medical colleges in Chicago ­were providing ­free care to patients who, Whalen alleged, ­were well able to pay in­de­pen­dent office-­based doctors’ fees. His arguments against ­free or subsidized care ­were ideological, not t­ hose of a mere medical trade u ­ nionist. Why, he asked, would p ­ eople live healthy lives “when advice and medicines are ­free?” The beneficiary of such charity “­will grow shiftless and lazy.” Indeed, according to the social Darwinist, “indiscriminate medical charity must bear the responsibility for a large part of the degradation and dissatisfaction of mankind.” Whalen’s agitation led to the formation in 1909 of a Committee on Abuse of Medical Charities to put pressure on the abusers to investigate patients’ economic means before offering ­free ser­vices.4 An attempt the same year to form a doctors’ ­union in Chicago attests to the intensity of rank-­and-­file frustrations. Its purpose was to drive up the share of what surgeons paid generalists out of their fees for referrals. It was class conflict within medicine. Many successful surgeons regarded “fee splitting,” or kickbacks for surgical referrals, as profoundly corrupt. Among ­those battling referral “commissions” was elite surgeon John Murphy, who had joined the attempt to retake control of the CMS in 1911. In 1912, Murphy helped establish the American College of Surgeons (ACS) to fight fee splitting as well as elevate surgical standards and reform hospitals. ­Because membership in the ACS was limited to surgeons able to prove their quality to the organ­ization’s examiners, it constituted a prestigious specialty certification useful for attracting wealthy patients without referrals. Chicago insurgent Henry F. Lewis, who had championed the ­union’s fight for generous refer-

Insurgency

321

ral commissions in 1909, ­later blasted Murphy’s new and exclusive ACS as a “self-­appointed nobility,” an alien development in a country where privilege was supposed to have given way to democracy.5 ­After the insurgents took control of the CMS, the old guard worked around it. In 1915, as one of the country’s leading medical scientists, James B. Herrick formed the Society of Internal Medicine in Chicago, which Frank Billings and Nathan Davis Jr., son of the AMA founder, joined. The CMS tried unsuccessfully to absorb and control the new society and then did what it could to undermine it. In 1922, Herrick, credited t­ oday for discovering coronary thrombosis as a cause of heart attacks and sickle-­shaped red blood cells as a cause of severe anemia and other disorders, founded the Association for the Prevention and Relief of Heart Disease, which allied with lay donors and board members to serve the needy poor with skilled care. A CMS grievance committee tried unsuccessfully to expel the heart association’s members, which would have meant automatic expulsion from the Illinois society and the AMA. It charged that the association’s announcements and appeals for philanthropic support constituted violations of the AMA’s ethical rules against advertising.6 Public health issues w ­ ere inextricably entangled in the concerns of the CMS insurgents before and ­after their takeover. In 1909, some had hotly criticized William A. Evans, Chicago’s public health commissioner, for “interfering with the livelihood of the profession.” His sin was to make vaccines freely available to the public during epidemics. Allegations ­were made and disseminated in Illinois newspapers that doctors ­were charging patients for the vaccinations and pocketing the money. The intent and effect of the complaints ­were to shorten Evans’s tenure as health commissioner. It had already been precarious ­because he had angered dairy interests with his drive for pasteurization of milk and antagonized other industrial and commercial interests by seeking to improve Chicago’s air quality.7 ­After taking control of the CMS, the new regime immediately campaigned to have Chicago mayor Car­ter Harrison replace Evans. Whalen may have been particularly keen to do so, for a previous mayor had replaced him with Evans as commissioner in 1907. Mayor Harrison had a dangerous path to negotiate between the two factions of doctors, whom he called the “Short Hairs” in the CMS and the “Long Hairs” still in control of the state medical society. Harrison favored the Long Hairs—­his personal physician Frank Billings being one of them. But the mayor stood to benefit by placating the CMS ­because of its enormous po­liti­cal clout in Cook County. None other than Harold Ickes, the state chairman of Theodore Roo­se­velt’s Progressive Party and ­later a

322

Reactionary Turn and Beyond

power­ful figure in President Franklin D. Roo­se­velt’s administration, blasted the CMS’s Public Relations Committee, which Whalen headed, for its arm-­t wisting of Cook County politicians.8 Hoping to replace Evans with someone acceptable to both sides, Mayor Harrison started by soliciting nominees from the CMS but then rejected all of its suggestions. One was too connected with meatpacking interests by marriage into the Gustavus Swift ­family. O ­ thers ­were prac­ti­tion­ers of no note, and one, possibly G. Frank Lydston (see below), was a specialist in venereal diseases and therefore “discreditable.” Harrison concluded, as confided to tuberculosis expert and hospital reformer Clarence  W. Leigh, that the CMS “had as its purpose the landing of any individual” in city positions allied with it, regardless of his credentials. For more suggestions, Harrison consulted Chicago’s nationally respected Henry Favill, the all-­around progressive reformer in Chicago civic life as well as public health, industrial hygiene, and AMA affairs. He also sought the advice of Emilio C. Dudley, a prominent gynecologist and ­future president of Northwestern University’s medical school. In the end, hoping to bridge the divide, Harrison chose a non-­Chicagoan, George B. Young, from the Public Health and Marine Hospital Ser­vice. Not happy with the reformist carpetbagger, the Chicago doctors retaliated by mobilizing, according to their own estimation, twenty-­five thousand votes for Harrison’s opponent in the subsequent mayoral election. Harrison thought it helped cause his defeat.9 The new CMS quickly turned its sights on state-­level politics as well. Heretofore, Whalen said, “our legislators considered the medical profession a po­liti­cal non-­entity,” and he was determined to change that. As chairman of both the Legislative Committee and the Public Relations Committee of the CMS, Whalen headed efforts to stymie bills before the legislature for licensing osteopaths and opticians and for allowing school nurses to perform medical ser­vices on pupils. In 1910, shortly ­after the regime change, Whalen became the “prime mover,” as reported by the Chicago Tribune, in a concerted effort to round up rank-­and-­file doctors’ endorsements of state legislative candidates who agreed with the CMS on legislative issues, to get them to talk up their candidates to one hundred or so friends and patients, and to threaten to “punish” legislators who defied the CMS agenda. State legislators thus faced a “bombardment” of doctors’ turf-­protecting attacks on bills favoring optometrists, osteopaths, and school nurses. Whalen boasted that the mobilization had led to those bills’ defeat with greater ease than in ­earlier legislative sessions.10

Insurgency

323

Internecine conflict in state medical affairs intensified over time. Some of the most inflamed conflict revolved around the Illinois Board of Health and its secretary, James E. Egan, a mediocrity and po­liti­cal hack according to the reformers. Egan, who enjoyed the support of the Chicagoans, was ­under attack from the progressives dominating the Illinois society for what they saw as a downward slide of the state’s medical schools since John H. Rauch’s ouster and especially during Egan’s tenure. The reformers blamed the degeneration on the entanglement of medical schools and their gradu­ates with city and state politicians. They considered Egan a po­liti­cal opportunist and therefore only a hesitant warrior for public health. Some of Egan’s fellow gradu­ates of Chicago’s Northwestern Medical College alleged that his academic per­for­mance had been lackluster and that only his po­liti­cal connections could explain his appointment to the state health board so soon ­after graduation. In 1897, Egan had been handed the Illinois board’s power­ful secretaryship by the state governor, one of whose key backers was Fred Busse, a power­ful po­liti­cal boss based in Chicago’s North End, the medical insurgents’ most impor­tant stronghold. Egan’s hands ­were not entirely clean on public health ­matters, according to an article in the Journal of the American Medical Association. In 1908, he had circulated an article attempting to prove that pasteurization of milk did not reduce the spread of disease. According to an investigation reported to Abraham Flexner by John L. Fogle, an Illinois State Bar Association attorney, Egan’s article gave ammunition to certain milk shippers hoping to lift the ban on their entry into the city issued by its health board. Generally, the progressive ele­ment believed that, ­because of Egan, Illinois was being surpassed in public health by the neighboring states of Michigan, Wisconsin, and Indiana in tuberculosis control, public education, and more.11 In short, as Joseph McCormack observed in 1907, t­ here had been a “more or less open antagonism” between the progressive leaders of the ILMS and the state board of health ­under Egan, which in turn had “begotten a spirit of apathy and hopelessness” about improving and enforcing both the licensure and health laws. As controversy surrounding Egan heated up in 1910, Carl  E. Black, chairman of the ILMS Council, openly denounced Egan and called for a “trained sanitarian” to replace him. Black also vigorously defended Arthur Dean Bevan and the Flexner report in the face of outrage about their stinging criticisms of Chicago medical schools. But the winds of change w ­ ere against Black and his reformist cohort. The next year, at the 1911 meeting in Aurora, the CMS ominously flexed its muscles by mustering a fifty-­four to forty vote majority on practically ­every controversial m ­ atter u ­ nder consideration.

324

Reactionary Turn and Beyond

­ ecause the CMS council controlled the se­lection of all Cook County deleB gates to the state society’s House of Delegates, according to the Illinois Medical Journal, twenty-­nine of the forty insurgent votes w ­ ere cast by CMS p ­ eople. The editorialist boldly and perhaps recklessly claimed that “bosses Lorimer or ­Sullivan never had more obedient henchmen at a state po­liti­cal convention than did . . . ​the leaders of the Chicago del­e­ga­tion.” They had been “handpicked, trained, instructed and showed no variation in their votes.” Only a faction of “down state men” in the Southern Illinois Medical Association managed to muster any concerted action against the “disturbers.”12 During the 1911 state society meeting, James F. Percy, a former chairman of the state society and now chairman of its Committee on Medical Education, delivered a scathing report about the state board of health. He decried the “intimate relation” between the low-­grade schools and the board. The result was medical colleges whose laboratories “would not muster as chicken coops on a moderately well-­regulated farm in Illinois,” as he had described them on an e­ arlier occasion. The f­ uture doctors t­ here ­were in dire need of “a cake of soap and a towel.” To the Aurora audience, a wrathful Percy charged that “certain men sitting in the Chicago del­e­ga­tion ­were ­there solely to look ­after the interests of ­these schools and to defend the misdeeds of the State Board of Health.” Only “professional greed and official graft” made the continued existence of the schools pos­si­ble. His address unleashed a storm of outrage. The following year, the reformers took the health department war into the state’s gubernatorial politics when medical reformers, some of them active in Theodore Roo­se­velt’s breakaway Progressive Party, agitated for a cleansing of the entire health board.13 The final reckoning between the Illinois insurgents and progressives came in 1913. The Chicago Short Hairs, with help from dissidents elsewhere in the state, captured control of the ILMS and swept the Long Hairs out. Among the insurgents’ grievances against the progressive ele­ment in the ILMS and the AMA was Bevan’s comment in his 1906 report to the House of Delegates about Illinois as one of five “specially rotten spots” in medical education. AMA or­ga­nizer Joseph McCormack of Kentucky followed that up in 1907 with another stinging insult. In one of his routine reports on his travels across the country, he called Illinois a “veritable paradise for quackery in ­every conceivable form” ­because of its lax control of medical schools and licensing. He mourned its degeneration from pioneer to laggard among states since John Rauch’s sad demise, ­under whose leadership McCormack received his first lessons in public health and education reform. While the Illinois Medical

Insurgency

325

Journal said McCormack “speaks the truth,” the Chicago Clinic called him arrogant and ­either ignorant or malicious for spreading “false doctrines” and “ferment and discord.” More damage to the progressives’ standing with the insurgent ele­ment came with the 1910 Flexner report’s assessment of Chicago as a “plague spot” and a quip in the London Lancet, reported in the Illinois Medical Journal in 1913, that “Chicago conferred medical degrees with the same ease and fa­cil­i­ty with which she killed hogs.”14 One of the rebels’ first acts was to elect Charles Whalen to the presidency, a handsome reward for his vigorous leadership of the Chicago insurgents. Unlike Kreider and ­others in the old guard, Whalen was no missionary for public health. Although he had been appointed Chicago’s health commissioner in 1905, his replacement by the progressive Evans in 1907 is prob­ably explainable by his failure to mea­sure up to the old guard’s standards. To be sure, Whalen’s 1899 article on “the doctor as a politician” had mentioned the importance of preventive health work, but by 1911 he would speak of public health successes only to highlight their threat to healers’ incomes, not to raise the issue of how to wield professional power to advance it further.15 “In medicine, as in other forms of business, unification for mutual protection must be brought about,” Whalen had written as head of the CMS’s Public Relations Committee in 1910. Medical practice “is a business and requires guardianship the same as other interests,” he wrote ­after his rise in the state society in 1913. From that time on, Whalen would distinguish himself exclusively as a proponent of what he called “medico-­economic agitation.” The downward pressure on in­de­pen­dent prac­ti­tion­ers’ “pitiable” incomes of about $800 a year resulted, he maintained, in part from improving public health and partly b­ ecause of destructive competition from vari­ous institutional suppliers of medical care. B ­ ecause doctors’ u ­ nion strikes w ­ ere doomed by the oversupply of potential strikebreakers, other kinds of action ­were called for, including refusing to consult with or refer patients to doctors “addicted to and fostering” institutions providing ­free or subsidized care. Above all, better local and state organ­ization of rank-­a nd-­fi le doctors was needed for po­liti­cal influence over state lawmaking. In Illinois, for example, Whalen agitated against the law’s automatic licensing of army, navy, and marine hospital physicians ­because they had passed the military ser­vices’ exceptionally difficult examinations. Requiring military and Public Health Ser­vice doctors to take and pass the Illinois exam before seeing private patients on the side, he thought, might reduce the number of patients stolen from civilian prac­ti­tion­ers.16

326

Reactionary Turn and Beyond

In light of his medico-­political work, the Chicago-­based Medical Standard hailed Whalen in 1914 as a “man of the ­people,” a “demo­crat” against the “plutocrats.” His was a victory of the “­great seething, struggling mass” of doctors who ­were fed up with being “ ‘governed by ­people who profess to be better than they are, and are anxious to tell them what they need and ready to give it to them w ­ hether they want it or not.” The journal’s enthusiasm for the regime change can be explained by its dependence on dubious phar­ma­ceu­ti­cal advertising for survival, and it was therefore the kind of publication that had been criticized by the Illinois society journal. The Medical Standard also hailed Whalen as a rising warrior in a ­future ­battle against the “ringsters in control of the machinery of the American Medical Association,” the ­great ­enemy it shared with drug interests and insurgents alike.17 Among the casualties, not surprisingly, considering his medical education and background in public health, medical organ­ization, and commercially unconflicted medical journalism, was George Nobel Kreider, editor of the state society’s journal. Kreider had served u ­ nder John Rauch in the 1880s on the Illinois Board of Health and ­later in 1901 as president of the ILMS. He had striven for medical excellence throughout his ­career. Not satisfied with his weak medical training in New York, Kreider had traveled to Eu­rope on multiple occasions over three de­cades from 1885 to 1908 to learn from professors of medicine in London, Paris, Berlin, Vienna, Jena, Göttingen, Strasburg, and Heidelberg. He had founded both the Pennsylvania Medical Journal in 1897 as well as the Illinois society’s journal in 1899. Kreider was one of the active members of Roo­se­velt’s Progressive Party, and he even put his hat in the ring for nomination as congressman of Illinois. ­A fter being rolled over by the 1913 capture of the ILMS by the Chicago-­based insurgents, the all-­around progressive called the rout nothing short of a “po­liti­cal revolution.”18 A NATIONA L INSURGENC Y

Medico-­economic agitation was percolating elsewhere in the country. In 1913, John J. McGovern, a director of the Wisconsin Anti-­Tuberculosis Association and a member of the Wisconsin Medical Society’s Committee on Public Policy and Legislation, called on the AMA House of Delegates to appoint a committee to investigate the ­causes of unrest among physicians that ­ ere at the time cannot be known. “seem to prevail.” Just how prevailing they w The unrest did not go away. In 1922, according to Horace Brown, president-­ elect of a tristate association of Illinois, Iowa, and Wisconsin doctors, “­There

Insurgency

327

is unrest and dissatisfaction in the county socie­ties with the state socie­ties and in the state socie­ties with the American Medical Association.”19 It is not clear whether conflict over public health and medical schools generated the same degree of acrimony in states other than Illinois. It is certain, however, that preventive medicine was not a mission shared by insurgent leaders elsewhere. The progressives’ public health agenda certainly could not have generated enthusiasm from below. According to the Medical Standard, “The g­ reat rank and file of the medical profession—­and some of its officers too—­are in a state of panic similar to that which possessed the working man at the invention of machinery.” The onward march of preventive and state medicine, doctors feared, “­will gradually put them out of business.” William F. Zierath, president of an association of officers of state and county medical socie­ties, heard a colleague ridicule the anti-­tuberculosis movement as “farcical and fruitless and ­ought to stop.” On the survival of the fittest grounds, he added, “­those who contracted tuberculosis ­ought to perish, ­because they ­were physically unfit.”20 Rank-­and-­file indifference or even hostility t­ oward public health activism had objective economic c­ auses. In 1900, the Philadelphia Medical Journal noted, “Altruistic medicine is lessening its own work and diminishing its own income.” Typhoid fever “was formerly the standby” for a “fair bulk” of general prac­ti­tion­ers’ steady incomes in many communities. Diphtheria and even ­ ere on the decline, too, making life malaria in some parts of the country w hard for the “overcrowded medical profession.” AMA leader Charles Reed noted that the effect in a Western city of a filtration plant recommended by local medical reformers “was to deprive one doctor alone of $3,000 worth of typhoid fever cases in one year.” Reed told the National Education Association that the profession, “through its own activity in the prevention of disease during the last twenty-­five years, has deprived itself of nearly 40 per cent of its previous employment.”21 What vari­ous public health missionaries experienced on the ground may have been the tip of an iceberg of indifference and even hostility. Around 1900, Philadelphia doctors horrified David Linn Edsall, a pioneer in the application of chemistry and physiology to the study of disease, with their complaints about plans for a w ­ ater purification system drafted by the College of Physicians of Philadelphia and the city’s W ­ omen’s Health Protective Association. It would “decrease their practice,” they said. During the Rocke­fel­ler Foundation’s campaign against hookworm disease in the South, Charles Stiles encountered physicians who protested his “preaching a doctrine which inevitably

328

Reactionary Turn and Beyond

would reduce their income.” According to Josephine Baker, the chief of New York City’s Bureau of Child Hygiene, some thirty not-­so-­intelligent Brooklyn doctors petitioned the mayor for her bureau’s abolition, complaining that “it was ruining medical practice by keeping babies well.” In California, physician Adelaide Brown’s similar work for the Bureau of Child Hygiene met with suspicion from country doctors worried about losing patients and their fees. Around 1914, according to Hermann Biggs, the New York City health board met with sharp objections from a large proportion of doctors when it required dispensaries and hospitals to report their patients diagnosed with syphilis. It was a repeat per­for­mance of the 1898 attack against compulsory tuberculosis reporting, in part ­because they feared losing patients to other doctors tasked with supervising syphilis carriers.22 G. FR A NK LY DSTON: ONE M A N AG A INST THE A MA “MACHINE”

Public health was not a m ­ atter of concern to venereal disease and sexual deviancy specialist George Frank Lydston, the one man who more than anyone ­else took the torch of insurgency around the country against the progressive leadership of the AMA. A manically attention seeking and in his view vastly underappreciated professor of genitourinary surgery at the College of Physicians and Surgeons of the University of Illinois, Lydston was surely the most eccentric figure in the history of American medical politics. A medical demagogue, his sharp rhe­toric and crude propaganda reverberated in the halls of or­ga­nized medicine, rousing many doctors eco­nom­ically, culturally, and ideologically disaffected with the progressive spirit of the age. Beginning in 1908, while the Chicago insurgency was still building steam, Lydston was already setting his sights on a purge of the top AMA leadership. He had possibly just been overlooked by Mayor Harrison for the city’s top health job ­because of old guard warnings about him. Lydston narrowly focused his attacks on AMA editor and official George Simmons, portraying him as a dishonest, greedy, and power-­hungry tyrant. One piece of evidence was Simmons’s central role, along with or­ga­nizer McCormack, in rewriting the AMA constitution in 1901 in a way that facilitated the accumulation of power in the hands of himself and a small “clique” of medical politicians. Lydston fixed on the fact that the hugely industrious and efficient Simmons aggrandized power by serving not only as the AMA’s power­ful editor but also as its general man­ag­er and executive secretary. Indeed, Simmons did have a

Insurgency

329

g­ reat degree of influence over the large and growing organ­izations’ publications, finances, and personnel decisions and ­because of that, no doubt, policies as well. Lydston’s focus on Simmons left out the fact that Simmons’s policy interests resonated with a large number of progressive medical leaders all across the country. Lydston’s first salvo was a 1908 pamphlet called “The Man in the Glass House,” a “philippic,” as the Chicago Tribune put it, against Simmons. Lydston sent his diatribe out to medical journals across the country, including, for example, the staid Boston Medical and Surgical Journal, which mentioned receiving it but dignified it no further by publishing or commenting on it. The following year, however, it was published in at least two in­de­pen­dent medical journals. Calling for Simmons’s removal, Lydston focused not on the AMA’s policies but on the editor’s allegedly unethical past, which proved him “intellectually and morally unfit” for his job. That consisted of his ­earlier ­career “quacking it” as a homeopath in Nebraska. Lydston alleged that Simmons had v­ iolated ethical strictures against advertising, producing as evidence a newspaper advertisement of the Lincoln Medical Institute, a hospital in Lincoln, Nebraska, which listed Simmons as a staff member. “The Man in the Glass House” was marked by baroque, long-­winded prose and peevish sarcasm. Referring to a letter Simmons wrote him claiming he had no recollection of the advertisements, Lydston wrote, “And Simmons has forgotten! Ye gods of ­those dark recesses of the mind wherein memory sits enthroned, forgive this man his evasion of the issue! Members of the AMA, believe not that this, our puissant omniscient master, stands self-­confessed of premature and doddering senilescence.”23 From 1909 through 1911, Lydston fired off another half dozen screeds against the “oligarchy,” or “ring,” that Simmons allegedly dominated inside the AMA. In his self-­published and widely distributed pamphlets costing thousands of dollars, the garrulous surgeon called for an end to “machine control” of the AMA and its state society “satellites” by Simmons and his “clique.” Echoing the drug industry, the in­de­pen­dent medical journals, and the National League for Medical Freedom in their own attacks, Lydston called the AMA a “medical trust,” a “combine,” or, alternatively, an “octopus” whose tentacles, the state medical socie­ties, grasped for mono­poly control of the drug industry, medical journalism, medical licensing, and more. In his 1910 “The Rus­sianizing of American Medicine,” Lydston alluded to physician Wallace C. Abbott, owner of the huge Abbott Alkaloidal Com­pany, who had been “malevolently assailed and labeled as a fraud” in the pages of the AMA journal.

330

Reactionary Turn and Beyond

He alleged that Simmons ruthlessly silenced and expelled dissidents and had them blacklisted by the prestigious Army Medical Corps. With perhaps only one exception, Lydston’s pamphlets and articles all appeared in in­de­pen­dent or, as it w ­ ere, drug-­dependent journals like the Texas Medical Journal, Nashville’s Southern Practitioner, and the Medical Brief, published in St. Louis, home to a large share of the country’s many patent medicine producers.24 Lydston paid remarkably ­little attention to the AMA’s ­actual policies. Without elaborating, he simply called them “a stench in the nostrils of decent and fair-­minded men.” Readers could fill in the blanks with their diverse peeves and grievances. ­A fter his first salvo, Lydston added the charge that Simmons had illicitly acquired a degree from Chicago’s Rush Medical College ­after abandoning homeopathy. Allegedly, Simmons had not attended lectures and had proxies take quizzes and answer roll calls. Lydston obtained some of his material from private detectives dispatched to Omaha and Lincoln and paid by Abbott. According to the Texas State Journal of Medicine, the detectives made a “minute investigation of Dr. Simmons’ early life, ransacked prescription files, coroners’ offices for death certificates, back numbers of Lincoln newspapers, college rec­ords, ­etc.” Extremely unflattering affidavits ­were obtained from Margaret Simmons, whom Simmons had divorced more than fifteen years e­ arlier. Allegedly a morphine addict, at least during their marriage, she told of his performing abortions in Nebraska, of how he got his degree from Rush, and of the cruel treatment she suffered at his hands. Abbott himself met with Simmons’s ex-­wife to get dirt on him, in exchange for which he promised to recover money she alleged that her ex-­ husband stole from her. Lydston, to his credit perhaps, did not publish such ­things ­under his name, but somehow the affidavits found their way into the hands of AMA detractors and even into publication.25 The Texas State Journal of Medicine denounced Lydston’s attacks as “vicious.” Instead of publishing them, it portrayed Lydston as a crank, using snippets of some of his proclamations on race, sex, crime, religion, eugenics, socialism, Shakespeare’s nonexistence, and a fatal flaw in Newton’s law of gravity. A mischievously slanted take on one of Lydston’s writings on miscegenation made him sound like he was in ­favor of race mixing. The Illinois Medical Journal was prob­ably the only official state journal that published one of Lydston’s jeremiads, a paper read at a recent Chicago Medical Society meeting. It was followed in the same issue by a response, prob­ably written by editor Kreider, explaining why Simmons and the AMA journal coolly ignored

Insurgency

331

Lydston’s “campaign of personal vilification.” No fruitful discussion could be had, it said, with someone who “abuses one’s opponents” with venomous slander. According to James Herrick’s reminiscences, for years Simmons stoically and silently weathered Lydston’s “vicious, slanderous, personal attacks.”26 Simmons’s champions sometimes attributed Lydston’s fury to his having been overlooked in the choice of the new editor in 1899. Morris Fishbein, the ­future AMA editor who started as an assistant editor u ­ nder Simmons, corroborated this. The Chicago Tribune attributed Lydston’s ­bitter animus to Simmons’s criticism of him for publishing in in­de­pen­dent journals, the only ones that would give him a forum, and thereby advancing proprietary drug interests. Another contributing ­factor may have been that the AMA journal never published anything he wrote concerning medico-­economic or medico-­ political issues. According to a Lydston supporter, dissident Chicagoans never had any luck getting their criticisms published. Lydston’s last letter that Simmons published was in 1904, before his first attack on the editor. It concerned a hospital cooperative in Chicago that planned to hire doctors on salary for care of low-­income citizens. In it Lydston accused the hospital’s philanthropic founder of “graft” and “imparting a veneer of respectability to deadbeatism.”27 ­Later the journal refused to dignify Lydston’s criticisms by publishing or even mentioning them. Lydston’s quixotic attacks on Simmons accomplished l­ittle except to turn himself into an inspiring cause célèbre for dissidents outside Illinois. Unsurprisingly, he won a vote for a resolution censuring Simmons at an April 1909 meeting of the North Shore branch of the CMS, the insurgents’ stronghold, with 196 out of 200 members pre­sent. Elsewhere he got mixed results. In October that same year, Lydston was prohibited from speaking at a meeting of the Mississippi Valley Medical Association in St. Louis. But two weeks ­later, he was given the floor at the Ohio Valley Medical Association, of which he was the second vice president. Shouts of “Hear him!” and “Lydston!” had sounded from all parts of the hall a­ fter a move to muzzle him. In a 1910 ILMS meeting, a debate and vote on a resolution Lydston submitted was averted by a vote to adjourn. His resolution would have required the society to pre­sent a list of demands for a revision of the AMA constitution to de­moc­ra­tize control of the association. It would have introduced referenda and recalls and strengthened county medical socie­ties’ role, at the expense of their state organ­ izations, in sending representatives to the House of Delegates. A ­ fter the adjournment, Lydston convened a rump group that approved his resolution.

332

Reactionary Turn and Beyond

­ hether enough ­were even pre­sent for a quorum was disputed. Afterward, W Lydston managed to dupe the Chicago Tribune into reporting that “Doctor Lydston Wins One Fight in State Medical Society.” In 1911, he lost a fight at the ILMS meeting over having the minutes of the previous year’s rump meeting reported.28 ­A fter 1910, Lydston’s main line of attack was to have some members of the AMA Board of Trustees removed b­ ecause they had been elected in AMA meetings held outside Illinois, while the organ­ization’s Illinois charter required elections inside the state. His demand for quo warranto proceedings for removal, if successful, might have revoked Simmons’s and other officers’ contracts and, by extension, all their decisions and policies. Also, a success could have given insurgents persuasive grounds for holding a raucous, hard-­to-­ control constitutional convention. Lydston’s ­legal b­ attle, which like his pamphlets cost a g­ reat deal of money of unknown origin, wended its way through the state courts ­until the Illinois Supreme Court fi­nally put an end to it in 1918, upholding an appellate court decision that nonprofit corporations chartered in Illinois could hold their elections in other states.29 ­A fter losing the l­egal b­ attle in 1918, Lydston dis­appeared from the stage as a medical rabble rouser. His ­career as a surgeon and scientist ended as it had started, with publicity-­attracting articles and addresses to medical and lay audiences on criminality, race, sexuality, and more. One of his earliest publications, an article in the 1891 issue of the AMA journal, had declared that deviations in skull and jaw shapes w ­ ere more pronounced in Amer­i­ca than in Eu­rope ­because of the immigration of criminals. Perhaps in an effort to show impartiality, the journal continued to publish Lydston’s “scientific” work despite his attacks on Simmons. Four of his last seven articles in the journal, from 1916 to 1918, concerned the implantation of testicles from recently deceased men, even “onto” w ­ omen, for treatment of or experimental investigation of “physiosexual inefficiency,” hypertension, delay or amelioration of senility or “male climacteric” (menopause), certain dermatologic conditions, and morbid appetite loss. Lydston thereby contributed to a long-­lasting gland-­grafting fad, although not, as he bitterly insisted, as its inventor. A ­ fter his death from pneumonia in 1923, Lydston’s newspaper obituaries, even in the Chicago Tribune, neglected all the other ­doings and writings of the peculiar doctor but did remark on his prominent role as a “gland grafter.”30 Nevertheless, the caricature he painted of the AMA machine and its dictatorial ambitions lived on in the rhe­toric of demagogic medical dissidents outside of Illinois.

Insurgency

333

THE MEDIC A L A DV ISORY COMMITTEE

It did not take long ­after Lydston’s disappearance from the scene before another elite doctor, Francis Hoeffer McMechan, assumed more effective leadership of the national insurgency. Unlike Lydston, McMechan articulated ­actual grievances experienced by doctors in the rank and file and even by some elite prac­ti­tion­ers. In 1921 he charted a new and better plan of coordinated attack laid out in a “circular letter” mailed to e­ very constituent state and county unit of the AMA as well as to the editors of all the medical journals in the country. It was, of course, reprinted in full by the Illinois Medical Journal, along with high praise. The letter was endorsed by the modestly named Medical Advisory Committee (MAC) and identified McMechan as its executive secretary.31 One of the nation’s leading anesthesiologists and an impor­tant medical editor from Ohio, McMechan had recruited two other doctors to the MAC: James F. Rooney, president of the Medical Society of the State of New York, and Edward H. Ochsner, a prominent Chicago surgeon who would soon be elected president of the Chicago Medical Society. In late December 1921, or early January 1922, McMechan mailed his committee’s call for a “nation-­wide referendum” to seize control of the AMA and reverse its course. It was a mini-­ manifesto, a call to action on the burning medico-­political issues of the day. The committee’s overall goal was, using one of Lydston’s favorite terms, to overturn the AMA’s “oligarchic” leadership and retool the organ­ization for an entirely new agenda. To achieve it, the MAC appealed to state medical socie­ties to send their delegates to AMA meetings with instructions on how to vote on issues of concern to the insurgents. The committee quoted an editorial from the Indiana medical society’s journal saying it was time to know exactly what the attitudes ­were of the men sent to the House of Delegates ­because members w ­ ere sometimes “betrayed” by their delegates. If they ­were not sent with explicit instructions, the MAC manifesto said, “constructive protection of medical interests” was not pos­si­ble. The appeal ended with “Self-­ protection is the first law of life. Act now!”32 The MAC foresaw a revolt from below, starting with instructions from county socie­ties to their delegates to their state-­level meetings. The county delegates would then forward instructions to state delegates chosen for the next AMA meeting in St. Louis, in May 1922, to vote for “a change of policy and leadership in the AMA.” The MAC also called for constitutional changes. A major prob­lem was that each single delegate sent by the AMA’s fifteen

334

Reactionary Turn and Beyond

“scientific sections” was given a vote in House of Delegate meetings; the rest of the votes cast belonged to delegates chosen at state society meetings. It was “undemo­cratic and unfair” b­ ecause the academics, prob­ably most of them in the progressive camp, w ­ ere already represented by their state socie­ties. As Whalen’s Illinois Medical Journal put it, it was a “vicious scheme” already eliminated in Chicago and Illinois, an “open sesame for chicanery” put in place by “medical-­political milkmaids” for their “malicious usurpation and aggrandizement of power.” Especially infuriating to the insurgents about “polluting the AMA” with t­ hese “super-­delegates” was the defeat of a June 1921 motion submitted by the Chicago, New York, Michigan, and New Hampshire del­e­ga­tions condemning “state medicine” in its vari­ous forms. The motion was defeated by only seven votes, and thus, it was charged, the scientific section delegates had betrayed the majority by voting against it. In short, “the public and profession are being sold out.”33 Unlike Lydston, McMechan’s committee abjured from ad hominem attacks against Simmons or other leaders. Some potential recruits to their cause knew the editor as a gentlemanly, decorous man who, though strong-­willed, spoke and wrote in mea­sured, diplomatic ways. More wisely, the committee listed a half dozen substantive areas where it thought the AMA members’ interests w ­ ere being betrayed. A united opposition was needed to combat “menacing movements” in the country’s medical politics ­because “your so-­ called leaders are ­either openly fostering” them or “more subtly giving them ­ ere prob­ably of full fling by camouflaged neutrality.”34 Some of the issues w minimal concern, if any, to many of the rank and file. ­Others ­were framed as existential questions for the entire profession. By enumerating a range of issues, McMechan appealed to a diverse range of potential supporters in order to patch together a strong majority co­a li­tion. The infractions listed ­were notably short on details and examples; readers had to fill in the blanks with their own experiences or hearsay. One of the complaints, the “exploitation of the specialties by lay technicians,” helps explain why McMechan took the lead. But as with the other items, the MAC letter did not elaborate or offer examples. It prob­ably alluded to three currently controversial areas of lay encroachment: the operation of X-­ray machines, the per­for­mance of diagnostic laboratory work, and the administration of anesthesia. The hiring of nurse anesthetists was McMechan’s own grievance. In 1912, as a medical publisher and or­ga­nizer, he had led a push to have anesthesiology recognized as a specialty. A ­ fter repeated snubs from the AMA, he helped or­ga­nize the American Association of Anesthe-

Insurgency

335

Francis Hoeffer McMechan, MD (1879–1939). A founder of the medical specialty of anesthesiology, McMechan played a leading role in the successful national insurgency against progressive AMA leaders and policies. Courtesy of Wood Library-­Museum of Anesthesiology, Schaumburg, Illinois.

tists and a regional Interstate Association of Anesthetists. He also agitated for an unusual and hugely controversial resolution passed by the Ohio State Medical Society against allowing nurses to administer anesthesia. The rising anesthesiologists had appreciable grounds for concern. The results of amateurism w ­ ere often fatal, including for large numbers of ­children ­under the knife for removal of tonsils and adenoids. But t­ here ­were also economic considerations: in 1919 McMechan complained that surgeons and hospital superintendents w ­ ere exploiting patients and nurses by paying the nurses three dollars for an anesthetic while collecting ten to fifteen from the patient.35 McMechan’s arguments carried ­little weight with elite surgeons, a much more power­ful group in the AMA. Top surgeons had come to rely on trained nurses and ­were underwhelmed by the case against them. The famous Mayo ­brothers, Charles and William, had been instrumental in spreading the practice. According to them, a nurse could become a surgeon’s invaluable protégé—­ not only cheaper but better than any internist or community practitioner available. Nurse anesthetists also played a useful role in training interns and residents. Thus, in 1916 and 1917, McMechan’s fellow Ohioan George W. Crile, the dynamic surgical pioneer, a major innovator in anesthesia, and a founder of the famous Cleveland Clinic, lobbied successfully against McMechan’s

336

Reactionary Turn and Beyond

legislative efforts to ban the administration of anesthesia by nurses. Two years a­ fter the MAC initiative, the elite-­dominated American College of Surgeons came out against any ­legal restrictions on nonphysician anesthetics. Many of its members, and some of the leading surgeons of the land, ­were also active in the AMA, like the Mayo ­brothers, Frank Billings, and Arthur Bevan.36 Another m ­ atter for which the AMA was to be held responsible was the prob­lem of “philanthropic foundation control of medical education.” ­Here McMechan and com­pany alluded to an ongoing campaign spearheaded by lay education expert Abraham Flexner, now working for the Rocke­fel­ler Foundation’s General Education Board (GEB), to put the faculties of a rising number of leading medical schools on a salaried full-­time basis. The so-­ called full-­time plan would make it pos­si­ble for clinical professors to devote themselves more to clinical research and teaching and ­free them up to do clinical work for related reasons, not money. Generous endowments from the Rocke­fel­ler Foundation and other sources would pick up the tab for the full-­timers’ salaries. Between 1913 and 1920, the GEB spent millions underwriting the full-­time plan at Johns Hopkins, Washington University, the University of Chicago, Yale, Rochester, Vanderbilt, and Columbia. The University of Michigan ­adopted the full-­time plan without Rocke­fel­ler money in 1919.37 The full-­time plan was supposed to accelerate the advance of clinical science, just as basic biomedical science had with salaried professorships in preclinical subjects. Also, according to full-­time proponent Hugh Cabot, dean of Michigan’s medical school, current questionable practices done only for the fees would decline. Professors should ­favor salaries over fees ­because when a large sum was in the offing, it was very difficult for an ethical surgeon “to be certain in his own mind that he is not influenced by the thought of the money.” Other eminent medical academics like William Welch of Johns Hopkins favored the full-­time plan, but not all of them. Some in the university-­based medical elite at prestigious universities that accepted GEB funds had to give up the chance at making fortunes working on the side for wealthy private patients.38 Many lesser physicians in the schools’ environs prob­ably agreed with the elite opponents, but for their own reasons. B ­ ecause wealthy patients gravitated to prestigious university specialists, it was a cause of “town-­gown” conflicts between academicians and community prac­ti­tion­ers. Often the schools hired medical notables from outside the community, a symbolic if not always

Insurgency

337

material injury to local physicians. Prestigious clinical professors could attract well-­heeled patients wanting to be cared for by famous doctors and thus deprive locals of high fee earnings. A case in point was the University of Michigan, which u ­ nder Victor Vaughan’s deanship a­ dopted the full-­time plan in 1919. It came ­under heavy fire for providing ­free ser­vices not just to indigents but also to middle-­class and wealthy patients seeking care from some of the nation’s most outstanding doctors. As the editor of the Indiana State Medical Association’s journal claimed to Cabot, Vaughan’s successor as dean in 1921, the school had done more to “pauperize the community” (i.e., create a habit or culture of de­pen­dency) than any other institution in the Midwest. Michigan doctors, and even doctors in some contiguous states, commonly remarked that it was “exceedingly difficult to secure even a very ordinary fee from many well-­to-do ­people” ­because they claimed they could just go to Ann Arbor and, except for the hospital charges, “have their work done for nothing.” With its “flagrant” action, the school was engaging in “unfair competition.”39 In 1921, an ad hoc House of Delegates committee recommended tabling the m ­ atter of full-­time salaried teaching pending further investigation and deliberation. ­Because the AMA took no stand against the full-­time plan, the MAC saw its neutrality as a case of “camouflaged support.” That was not correct. Even Bevan, who had instigated Flexner’s 1910 report for the Car­ne­gie Foundation, criticized full-­time clinical professorships.40 But the MAC no doubt saw good propaganda value in stirring memories of the 1910 Flexner report, which badly reviewed and ultimately destroyed medical schools that many in the rank and file had graduated from. Having to consider taking down their diplomas from their office walls must have left a bad taste in their mouths about rich laymen meddling in medical affairs. Other MAC complaints concerned “hospitals u ­ nder university or po­liti­ cal control,” ­under “lay board domination,” or run on a “closed-­shop basis.” Again, examples ­were not given, much less evidence that the AMA actively promoted the practices, so scattered local controversies must be consulted. A particularly divisive example was a hospital-­based group practice in Ann Arbor, Michigan, whose lay board of regents set salaries for the full-­time staff and served disadvantaged patients for low or no fees. Grievances about such ­things w ­ ere similar to t­ hose concerning the full-­time plan: unfair competition. Hospitals often ran afoul of the insurgents’ medico-­economic agenda when their altruistic, educational, administrative, and economic goals did not align with the interests of rank-­and-­file community prac­ti­tion­ers. Hospitals

338

Reactionary Turn and Beyond

­ nder lay control with lay financing often collaborated with medical schools u to fill staff positions with professors, not regular in­de­pen­dent prac­ti­tion­ers. Many combined teaching within their walls or in their community clinics with ­free or subsidized care for nonindigent patients who community doctors felt could easily afford doctors’ fees. For example, complaints ­were voiced at the New York State Medical Society’s meeting in 1922 about a certain “medical department of a State University” which had accepted many thousands of dollars from “one of the large foundations” on the condition that its clinic or dispensary “was not to be used for the sick or injured poor, but for the so-­ called ­middle class of society who cannot afford to pay the prevailing fees of specialists.” 41 Relatedly, in 1915 the University of Minnesota set off a fierce and protracted conflict with doctors across the entire state when it negotiated an affiliation with the Mayo Clinic in Rochester, Minnesota, a phenomenally profitable corporate multispecialty group practice, for a pioneering program in gradu­ate training. Corporate group practices ­were already a subject of controversy in the profession. In­de­pen­dent surgeons and even some professors practicing in Minneapolis and Saint Paul deeply resented the university’s bestowal of extra prestige on the Mayo Clinic and therefore an increased supply of wealthy patients for the surgeons and physicians employed by it. Greed, they thought, not a philanthropic or educational mission, motivated the Mayos to grant about $1.6 million to create and affiliate the new Mayo Institute for high-­ quality residency training. In 1917, seventy-­eight doctors signed a petition to state lawmakers to support a bill ending the affiliation and in ­doing so, according to the Journal-­Lancet, represented the sentiments of a “majority of medical men.” They lost the b­ attle b­ ecause “the p ­ eople of the state, and many ­people in other states” w ­ ere in sympathy with the Mayos. Also controversial in vari­ous states was the hiring of physicians by college health ser­vices, in loco parentis, for undergraduate students at universities such as Michigan, Minnesota, Stanford, and Wisconsin. Recently, in 1920, the University of Minnesota’s student health ser­ vice director, John Sundwall, had founded the American Student Health Association (­today’s American College Health Association) and enlisted officials from over a dozen other universities to improve and propagate the innovation. It remained controversial well into the de­cade and beyond as “a most obnoxious form of contract practice.” Critics thought that parents should pay out of pocket for their ­children’s visits to in­de­pen­dent physicians in their college communities.42

Insurgency

339

The “closed-­shop” hospital, which the MAC also vilified, ­violated a common rank-­a nd-­fi le belief that hospitals should serve as the profession’s commons—­free workshops open to all duly licensed comers and their patients. Elite doctors often thought differently. Back in 1907, Chicago old guard progressive Albert Ochsner, the insurgent Edward’s ­brother, strongly favored selectivity in hospital staffing for quality control. Celebrated surgeon Robert T. Morris, the founder of Ithaca Hospital in New York in 1893, pointed out that selectively staffed hospitals served patients and personnel better. In open hospitals, chaos ensued when an attending physician who was not a member of the official staff gave o­ rders to nurses and assistants. It was the same confusion “as would occur in a railroad office ­under parallel conditions.” But ­there was a serious drawback, Morris learned, an “inevitable conflict between the ‘ins’ and ‘outs.’ ” In the end, ­bitter rivalries forced him to open his hospital to all Ithaca-­area doctors. In real­ity, however, closed-­shop hospitals w ­ ere well on the decline by the 1920s. The number of hospitals was rising rapidly, and ­because of that their interests aligned with the insurgents’: a thirst for fee revenue from the patients doctors brought in to fill their beds. They could no longer afford to be choosy b­ ecause they had to compete over doctors who could deliver paying patients.43 But for the MAC, lingering resentments, as well as ­those in areas without hospital growth, could still be capitalized on, even if the AMA had not actually resisted their decline. Its neutrality was, it was insinuated, support camouflaged as neutrality. The MAC could, however, plausibly blame the AMA for university control of hospitals ­because its Council on Medical Education had pushed for philanthropic and state government efforts to expand medical schools’ access to bedside teaching facilities. The insurgents ­were right that medical school control could affect the physician ­labor market. Hiring on the grounds of academic merit ­limited community physicians’ access to desirable staff positions, if not admitting privileges. As insurgents saw it, the prestige that faculty gained in the eyes of the local community constituted a form of illicit advertising for business. Community prac­ti­tion­ers complained that ­after referring patients to university specialists they would never see them again. In effect, the MAC aggregated many local town-­gown frictions into a national campaign for the townies, even if the real­ity was that the economic impact of the professoriate was prob­ably small.44 Another item on the MAC’s list of AMA sellouts was the “legislative dictation of fees.” The reference was to state workmen’s compensation laws passed

340

Reactionary Turn and Beyond

over the preceding de­cade, which introduced guaranteed disability insurance for injuries in industrial workplaces. Industrial accident insurance laws, the first major piece of the American welfare state before the Social Security Act of 1935, ­were passed in almost ­every state between 1911 and 1920. They ­were not widely popu­lar in the medical profession even though they brought it an entirely new income stream. Most w ­ ere passed without consultation with state medical socie­ties and neglected to include doctors in administrative positions or advisory boards. The laws affected physicians directly ­because they required insurance authorities or carriers to hire medical examiners to determine the nature, extent, and duration of injuries and to pay clinicians for medical treatment to help get workers back to work. The rules varied considerably, but around thirty states’ authorities ­were allowed to fix fees paid for the ser­vices, and by 1920 about eight had done so.45 In 1914, in New York, MAC member James F. Rooney’s state, the medical society first assented to but then repudiated the system’s “fee bill” ­after the insurance carriers applied it as a maximum schedule of fees instead of a floor. It was insultingly low, critics charged, and also irrationally rigid, considering the variability of costs associated with treating cases in the same nominal category. The insurance carriers’ “feverish effort” to “use it as a club to lower the regular bills of physicians throughout the state attending compensation cases” resulted in “conflict, discord, and discontent.” Many doctors in the vari­ous states with fee schedules resented being paid fees lower than the prevailing ones charged in private practice. They w ­ ere also aggrieved by some state laws that did not allow for f­ree choice of physician on the part of injured workers. That meant employers and insurance carriers could recruit doctors willing to accept the offending rates and thereby divide the profession against itself.46 According to administrators of the compensation systems, ­actual practices ­were quite varied and often not eco­nom­ically injurious to doctors. Compensation commissions and some physicians who investigated the ­matter concluded that the laws ­were actually often beneficial. They “increased rather than diminished the income of the medical profession,” according to a Bureau of ­Labor Statistics analy­sis. Although the itemized fees ­were set relatively low, that was made up for by the ­great “certainty of payments.” That was no small blessing ­because doctors groused constantly about their difficulties in collecting fees from private patients. On deadbeat patients, doctors ­were fond of the poem about how God and the doctor ­were highly valued “on the brink of danger,” but a­ fter that passed “God is forgot, and the doctor slighted.” Thus,

Insurgency

341

the Ohio Industrial Commission defended itself with evidence that before its law was passed, no pay had been received for medical ser­vice rendered for 50 to 75 ­percent of industrial injuries. Now the pay was guaranteed.47 The MAC also blamed the AMA oligarchy for the “legislative dictation of therapy.” That clearly alluded to the provisions of the National Prohibition (Volstead) Act of 1919 and the Willis-­Campbell Act of 1921. They had passed into law, the manifesto implied, ­because of the AMA’s “inability to properly represent the profession” and “dereliction of duty” to fight them, as MAC member Rooney put it. Back in 1914, Illinois insurgent Whalen had complained that in California, Kansas, Ohio, Maine, and Nevada new laws ­were curtailing physicians’ rights by allowing them only to prescribe, not dispense, alcohol. Now ­things had gotten much worse with the federal legislation. The Volstead Act required doctors to obtain permits to prescribe alcoholic beverages for therapeutic reasons and ­limited prescribing whiskey or brandy to one pint ­every ten days. The Willis-­Campbell Act regulated the prescription of wine and prohibited medicinal beer and malt liquors entirely. Rooney claimed, hyperbolically, that they ­were “merely the beginning of an attempt to completely control therapeutic methods.” The prohibition laws had shamed and humiliated the profession and “undoubtedly, cause[d] unnecessary suffering and perhaps death” to patients. It was a “usurpation by Congress of the therapeutic rights of the medical profession.” 48 Prohibition had come up for debate in 1920 in the House of Delegates, and much acrimony about it would boil up again in the next two years. Since 1902 the AMA journal had published articles claiming that alcohol had no clinical value. In 1917, the AMA House of Delegates even passed a resolution declaring that alcohol’s use in therapeutics or as a tonic, stimulant, or food had “no scientific basis,” and therefore “the use of alcohol as a therapeutic agent should be discouraged.” Prompted by an appeal to the AMA from the International W ­ omen’s Christian Temperance Union, which appended a similar decision of the Rus­sian Medical Association, the resolution was submitted by Victor Vaughan’s Council on Health and Public Instruction. The scientific Section on Pharmacy and Therapeutics agreed in principle but warned against such a strongly worded resolution. In the end, it was outweighed by the substantial ele­ment of AMA progressives who had joined the ranks of the growing temperance movement.49 Rank-­a nd-­fi le opinion was deeply divided on alcoholic therapeutics. In December 1921, editor Simmons sent out a “referendum” on the medicinal use of alcohol to almost fifty-­four thousand physicians, about 37 ­percent of

342

Reactionary Turn and Beyond

the entire profession. The results surely dismayed the AMA’s therapeutic rationalists and temperance proponents. Of the 85 ­percent responding, 51 ­percent regarded whiskey as a “necessary therapeutic agent.” Oddly, the figures for wine and beer w ­ ere only 32 and 26 ­percent, although their ethyl alcohol is identical. But ­there was ­little agreement among the alcohol prescribers about what it was good for: heart disease, regulating blood pressure, cancer, diabetes, anemia, rheumatism, uremia, asthma, shock, phenol poisoning, catarrh, dyspepsia, neuritis, insomnia, colds, dysmenorrhea, toxemia of pregnancy, lactation, convalescence, debility, snake bites, and “diseases incident to old age.” About 22 ­percent of the respondents believed that the prohibition laws caused unnecessary suffering, including blindness and death, b­ ecause of bad bootleg whiskey.50 Clearly, the progressive AMA was far ahead of the troops on rational therapeutics. The charge of outside meddling in therapeutic decision-­making fell on the receptive ears of prac­ti­tion­ers who w ­ ere indifferent about the Council on Pharmacy and Chemistry’s (CPC) mission against the drug industry and its advertising and therefore physicians’ unseemly prescribing practices. Much of the profession had been unenthused about drug reform since 1906 when an editorial in the AMA journal declared it strange that “our profession is not earnestly supporting the movement for controlling the sale of [proprietary] preparations.” In 1915, the CPC complained about the “subserviency” of much of the medical press to the drug industry, which was in part at fault for “the inertia of the medical profession.” Despite the ­great sacrifice of its volunteer members’ time and energy for the mission, the “odium,” the “malicious libel,” and the “abuse” they received from drug manufacturers and medical journals ­were not well compensated for by “active, hearty support of the profession, individually and collectively.” Much, no doubt, had been accomplished, “but the practical results do not seem in proportion to the efforts put forth.” More could have been accomplished but for “the indifference of the medical profession.” The demoralized council members even threatened to close shop ­unless they received a vote of confidence from the House of Delegates, which they got in 1915.51 But it was only a short-­lived morale boost. In 1919 and 1920, the AMA journal praised the CPC for “working week in and week out without remuneration” and not giving up in disillusionment about continued rank-­a nd-­ file indifference—­measurable by the unabated success of cheap commercial journals. An editorial from the Journal of the Missouri State Medical Association,

Insurgency

343

reprinted in other state journals, commiserated that the CPC was “the unloved child” and “black sheep” of the “entire f­ amily of subsidiary bodies of the association.” One reason, the author speculated, is that a practitioner might not appreciate being exposed as a dupe of the manufacturer of a certain drug they regularly prescribed. A doctor “may have credited much of his success in treating certain conditions” to this or that preparation receiving the CPC’s scorn. Together the manufacturer and the doctor then “emit a loud and vicious roar against the Council ­because they both lose money.”52 The drug industry, through its allied medical journals, helped fuel the national insurgency. One of them was the Illinois Medical Journal, which since 1913 had been ­under the control of the reactionary faction. According to the Missouri state society’s journal that year, by accepting unethical advertising Illinois doctors had allowed themselves “to be prostituted” a­ fter having fought for years to be “consistent, respectable and ethical.” In 1923, the drug-­dependent Western Medical Times reprinted Charles Whalen’s recent editorial from the Illinois journal, “The AMA Becomes an Autocracy.” It was a Lydston-­like screed full of fantastic claims, such as “the entire medical profession of the United States, in so far as its organ­ization is concerned, is ­today at the mercy of one man.” In Simmons’s hands, allegedly, the AMA’s journal “absolutely controls the Association to which it belongs.” ­Because of Simmons, AMA councils and committees w ­ ere full of “nonpracticing physicians” and even “men who had never practiced medicine; or of theorists; or of men who admit that they ­were failures in the practice of medicine.” The entire board of trustees was “subservient to him.” The House of Delegates exercised only “perfunctory powers and the rank and file have nothing to say.” Readers in vari­ ous states receiving the Western Medical Times learned from the power­ful Illinois leader that the AMA had been so slowly and shrewdly converted “from a democracy to an absolute autocracy” that even the members of the House of Delegates w ­ ere oblivious to “the overthrow of self-­government and the substitution of an oligarchy for a rule of the ­people.”53 Drugmakers may have put money directly into the hands of some insurgents in the hopes that a medical regime change would weaken the AMA’s CPC and its journal’s campaign against them. The secretary of one county medical society thought a widely distributed circular sent out by Ohio’s Washington County Medical Society applauding the insurgents’ resolutions was too expensive to have come out of the small group’s own funds. Printed on

344

Reactionary Turn and Beyond

“good heavy stationery,” it would have “cost a good deal of money to send to physicians all across the country.” Drug interests, he speculated, w ­ ere possibly attacking the CPC from inside the medical profession as well as from outside lay organ­izations. An insurgent periodical also emanated from that source, funded with drug advertising and containing satirical cartoons similar to ­those used in ­earlier propaganda against the AMA.54 The MAC also cast a wide net for rank-­and-­file support by blaming the AMA for an ongoing “demoralization of medical standards by the expansion of cults.” Indeed, the AMA and its state socie­ties had not strenuously lobbied against medical sectarians’ often successful lobbying efforts for special licenses requiring no rigorous training and examinations, even in basic anatomy and physiology. According to one Louisiana physician, the “jelly beans” of the AMA deserved only disgust for their supine attitude. They ­were being “spat upon” by cultists and should have responded in kind. Most infuriating to insurgent leaders like Rooney ­ were the chiropractors, spine manipulators whose theory of disease etiology and therapeutic approach was derivative of the older osteopaths. Other unwelcome newcomers w ­ ere “Naprapathists, Spondlytherapists, and Neuropaths,” all of whom, according to a scornful article in the insurgent-­friendly and drug-­dependent Western Medical Times, blamed the same diseases on spinal disturbances (“subluxations,” “bony lesions,” “ligatights,” e­ tc.) and therefore advocated dif­fer­ent manipulative interventions (“moves,” “thrusts, “directos,” e­ tc.). The fact that the newcomers ­were drugless healers was certainly not lost on the journal.55 In 1923, the AMA’s Billings told an audience of McMechan’s Ohio colleagues that the charge against the AMA regarding the new irregulars’ successes was “so preposterous and irrational that it is unworthy of further time and discussion.” But the insurgents had a point. The AMA had indeed maintained a policy of tactical restraint. Official tolerance, for the sake of professional peace and therefore public goodwill, was a legacy of the 1870s licensure movement and the AMA’s organ­ization drive starting in 1901, both led by medical progressives. Early licensure reformers, who ­were more concerned about public health than therapeutics, had sought to still the b­ itter conflicts between regulars and their main competitors and thereby put a more flattering face on the profession in the eyes of lay elites, especially t­ hose attracted to homeopathy. New York, a homeopathic stronghold, had been the site of particularly fierce controversy, which had led to a schism among regulars in 1883 and the creation of a competing society of regulars. The bolting rank and fil­ ere ers had resented the elite specialists in control of the state society who w

Insurgency

345

happy to overturn the traditional stricture against consulting with homeopaths and eclectics. That rule had prohibited regular specialists from taking patients, often wealthy ones, on referral from irregulars. But in 1904 the rival New York organ­izations merged into one ­after the watering down of homeopathic doctrine, the drift of patients t­oward regulars, and the absorption of many homeopathic prac­ti­tion­ers—­like Simmons—­into regularism.56 The AMA’s policy of tolerance was forcefully reaffirmed in June 1921, shortly before the MAC’s attack on the AMA. It was occasioned by a “disturbance in the ranks” about the new irregulars, especially in some Western states. In a report submitted to the House of Delegates on behalf of the Council on Health and Public Instruction, Victor Vaughan, the quin­tes­sen­tial medical progressive, argued that aggressive efforts to suppress medical sects in the past had been short-­sighted, ill-­advised, undignified, and self-­defeating. The public would not be disabused with scientific arguments against irregulars, he said, while “partisan and repressive mea­sures” only inflamed m ­ atters. “Fantastic methods of treatment” conceived by visionaries like osteopathy’s Andrew Taylor Still, chiropractic’s Daniel David Palmer, naprapathy’s Oakley Smith, and spondylotherapy’s Albert Abrams would always be able to sweep up medical fanatics and a part of the public attracted by “anything new and fantastic.” Opposition would only feed their followers’ martyr-­like righ­ teousness and religious devotion.57 The remedy, considering the trickiness of “popu­lar psy­chol­ogy,” lay in attacking the cults indirectly with educative efforts about rational public health and therapeutics. ­People needed to be taught how to discern “pseudo-­ scientific propaganda” from sober medical claims made by creditable ­people and institutions. With time, the cults would eventually discard their “distinctive and absurd doctrines” and ­either dis­appear or be absorbed into the general medical profession. The natu­ral history of cultish medical beliefs in the past had shown they would gradually dissolve in the medium of scientific discourse. That pro­cess, he pointed out, was “now ­going on in osteopathy.” In 1922, in the wake of the MAC’s attack, the AMA journal published Henry C. Macatee’s “remedy for professional unrest,” which echoed Vaughan. Macatee, a District of Columbia medical and public health leader, predicted that the osteopaths would follow the homeopaths away from unifying theory and therapeutic fetishes. Like the homeopaths, they would temper “pride with humility” and enter medical competition “equipped by both science and art.”58 The article prob­ably persuaded very few critics and, worse, prob­ably outraged the dissidents.

346

Reactionary Turn and Beyond “SOCI A LIZED STATE MEDICINE”

By far the MAC’s most impor­tant line of attack on the AMA was for its support for “socialized state medicine.” ­After the turn of the twentieth ­century, “state medicine” had gradually become a term of opprobrium and no longer the property of public health pioneers like Henry Bowditch, who meant by it governmental mea­sures to prevent disease. Now it meant government supply of subsidized or f­ ree clinical care through vari­ous means, compulsory health insurance being the worst of them. Physicians striving for high incomes and positions on the social ladder were repelled by the thought of well-­to-do patients gravitating to cheap alternatives instead of paying the large fees they could surely afford and recommending them to other rich patients. Social Darwinist ideology and private economic interest reinforced each other. In 1920, ­future MAC member Edward Ochsner claimed that insurance would “penalize the strong, industrious, clean-­living and thrifty and ­favor the weakling, the lazy, the shiftless and immoral.” ­Later, in 1934, Ochsner would publish a book on social insurance with more of the same that blamed economic assistance to the poor for the “­human parasitism” that led to the fall of Rome, the ­Great Depression, and the rise of Hitler’s dictatorship. Paternalism, the result of the “mollycoddle sentimentalism” of “dilettantes and ultra-­ intellectuals,” led to socialism and communism and then “back into feudalism” (which was “in vogue” in Eu­rope at the time of the American Revolution) and “serfdom”—or, alternatively, to “race degeneracy,” along a path that “must inevitably lead to the jungle.”59 Compulsory health insurance ignited the accumulating dry tinder of insurgency in 1916, when Rupert Blue, the newly elected AMA president, declared in his inaugural address that it would soon be “the next g­ reat step in social legislation.” Before 1916, only lay groups advocating for ­labor, consumer, and ­women’s interests had called for health insurance. Most impor­tant was the American Association for ­Labor Legislation (AALL), a progressive organ­ ization b­ ehind worker compensation laws, industrial safety, and other l­abor reforms. It was led by economist John B. Andrews, a former student of University of Wisconsin economist John R. Commons, Amer­i­ca’s dean of social insurance and mentor of Edwin Witte, Franklin Roo­se­velt’s key advisor b­ ehind the Social Security Act of 1935. The AALL’s Model Bill, which it drafted for consideration by state legislatures, called for sickness pay to tide industrial workers and their poor families over during short periods of incapacity and lost wages. It would also pick up the tab for clinical attention, ideally to get

Insurgency

347

workers back on the payroll.60 The AALL was able to persuade politicians in at least eight states to put the issue on the legislative agenda. Between 1915 and 1920, California, Mas­sa­chu­setts, New Jersey, Connecticut, Illinois, Ohio, Wisconsin, and Pennsylvania appointed official commissions to investigate the subject. The medical progressives in control of the AMA only added health insurance to their agenda ­after their lay counter­parts approached them for support. But ­there had already been some interest in the issue. In 1906, Frank Billings had told a gathering of the elite Chicago Physicians’ Club that ­because of the spread of government-­sponsored insurance in Eu­rope, it would inevitably cross the Atlantic. Thus, it was better to get on board to make sure it was properly designed and administered. In 1908, Abraham Jacobi, one of the 1848 German revolutionaries, even mustered praise for his old country and Otto von Bismarck, its former “ruthless absolutist,” for building a sound social insurance system, including health insurance for workers. In 1912, Arthur Bevan endorsed the platform of Theodore Roo­se­velt’s Progressive “Bull Moose” Party, which called for compulsory health insurance. In 1914, Bevan reaffirmed his stance on guaranteed care for “the submerged 10 or 20 per cent of the population which does not and cannot provide proper medical care for itself.” The day was coming when some state insurance scheme would care for the poor as in Germany and ­England. “If the profession in this country is far sighted it w ­ ill recognize t­ hese coming events and direct them wisely.” 61 Meanwhile, the AMA journal had maintained an open-­minded but decidedly neutral stance through 1914 and even portrayed certain features of Eu­ ro­pean schemes as t­ hings to fend off. Negative experiences, mostly with fee setting and patient choice of doctors in Germany and Britain, proved that a united front was needed. Better-­organized Norwegian doctors seemed to have made sure that their law of 1909 was entirely satisfactory regarding fees and choice. On a positive note, the editorial said, the British law of 1911 practically eliminated the need for medical charity and “so stops the enormous drain on physicians.” Even better, it gave medical attention to the neediest and therefore most susceptible to diseases that could be spread to o­ thers. Fi­nally, medical education might benefit. If the government assumed responsibility for providing medical ser­vices, it would be keener to “exercise more rigid supervision over medical colleges and the character of medical instruction.” 62 Despite cautiously optimistic views among AMA leaders, none took the initiative to make insurance an AMA proj­ect. Among the likely ­causes for diffidence was the low regard that therapeutic rationalists held for the quality

348

Reactionary Turn and Beyond

of care that would be provided by the average badly educated doctor. Given the current state of clinical science and pharmacotherapeutics, even well-­ educated doctors had l­ittle to offer. Such reasoning was openly expressed in 1917 by the iconoclastic Mas­sa­chu­setts General Hospital surgeon Edward Amory Codman. A therapeutic rationalist par excellence, Codman was a bold critic of fellow Boston surgeons, even the elite among them. With unpre­ce­ dented and unmatched fervor, he promoted the statistical study of “end results” of surgical and clinical work to find out what worked and failed. He flatly rejected insurance on the grounds that therapeutics w ­ ere still far too mediocre and chaotic. Scarce resources would be wasted distributing instead of improving medical care. Insurance had to wait. Relatedly, industrial hygiene leader Otto Geier also counseled delay, but again not on princi­ple but ­because therapeutics ­were still so rudimentary. Taxpayer money would be better spent on beefing up public health expenditures, he argued.63 The AMA’s active involvement only began when the AALL requested the AMA’s input on how to design and administer medical ser­vice benefits. It was entirely in the spirit of medical progressivism for AMA leaders to welcome collaboration with laypeople—as in the past with licensing, public health, drug regulation, and medical education. It also made good sense to help the AALL and other lay reformers head off the kind of criticism they had brought upon themselves by not consulting with doctors on the design and administration of worker compensation laws. George Simmons thought that health insurance was “bound to come,” thus the AMA should step in to help the reformers profit from what German and British doctors had learned from defects in their systems. In that spirit, therefore, Alexander Lambert, former president Theodore Roo­se­velt’s physician, joined progressive physician Henry Favill of Chicago on the AALL board in 1916. Favill was already t­ here ­because of his active concerns for occupational safety and hygiene. Lambert had reason for optimism about getting the medical profession ­behind health insurance in part ­because workers’ compensation had proven to be a reliable source of fees. He thought the same would be the case with health insurance.64 The same year, the AMA trustees set up a special Committee on Social Insurance u ­ nder the aegis of Victor Vaughan’s Council on Health and Public Instruction. They chose Lambert as chairman and Isaac M. Rubinow, a medically trained statistician and insurance expert, as executive secretary. Favill joined them ­until his untimely death and was replaced by the noninsurgent Chicagoan Malcolm L. Harris. ­Others to serve on the AMA committee ­were Frederick L. Van Sickle, executive secretary of the Pennsylvania State Medi-

Insurgency

349

cal Society and editor of its journal, and Sigismund Goldwater, commissioner of health and director of Mt. Sinai Hospital in New York City. In June of 1916, and again in 1917, the social insurance committee submitted reports largely favorable to the idea of health insurance but calling for further study. The 1917 report strongly criticized many doctors’ “blind opposition, indignant repudiation, and ­bitter denunciation” concerning the state laws ­under consideration and counseled engagement rather than obstinacy to avert bad legislation. The report ended with a resolution to be put before the AMA House of Delegates calling for continued discussion with lay reformers and further study about legislative details. In an attempt to reassure opponents, the committee also asked the delegates to insist that any legislation provide for freedom of choice of physician, adequate remuneration, and repre­sen­ta­tion of doctors in insurance administration. The resolution passed.65 Only the medical reformers’ public health mission can explain what­ever eagerness they showed about joining the lay progressives on health insurance.

Alexander Lambert, MD (1863–1929), friend and physician of President Theodore Roo­se­velt; AMA president in 1919–1920. Lambert was the AMA’s strongest advocate of compulsory health insurance as a public health measure and as such became the target of fierce criticism from AMA insurgents. From the U.S. National Archives. Photographer: American Red Cross.

350

Reactionary Turn and Beyond

It was decidedly not ­because they ­were in a hurry to spread the flawed clinical practices of gradu­ates from the many bad medical schools now defunct or still in need of improvement. Sickness prevention, barely mentioned by historians of the debate, was central from the beginning in the arguments of the AALL’s John Andrews. The AMA committee’s reports heartily endorsed the AALL Model Bill’s provision of sick pay (two-­thirds of wages for up to twenty-­six weeks), a distinguishing feature of the German system, on the grounds that if workers got paid to stay at home, it would reduce the severity and spread of disease. That in turn would reduce poverty from long-­term unemployment, another contributor to disease. Even more impor­tant than sick pay was a “stimulus” to prevention that would be built into a good health insurance system. The AALL had used the same prevention logic to promote the workers’ compensation laws. B ­ ecause the laws reduced employers’ payments in step with falling injury claims, the country’s first social insurance schemes had helped inspire a nationwide “safety first” movement among employers. In the case of health insurance, the stimulus to prevention would lie in a three-­way sharing of premiums among employers, workers, and governments. As physician B. S. Warren and statistician Edgar Sydenstricker of the Amer­i­can Public Health Association argued, the system’s financing would incentivize the very ­people sharing responsibility for causing illness to act cooperatively to prevent it. Better health would keep premiums down.66 In his 1916 presidential address to the AALL, economist Irving Fisher, the AMA’s recent ally in the fight for a federal department of health, argued that as impor­tant as indemnification was for income loss and medical expenses, it was “far less impor­tant than prevention.” The states’ health insurance agencies would have the motives and means to educate and coordinate doctors, patients, and employers. The “stimulus to prevention” would even help increase enthusiasm and funding for the scientific study of disease. Progressive medical leaders echoed the progressive laymen. Following Fisher’s address, Lambert spoke on the role of “salaried medical referee officers” employed by state health insurance agencies not only to certify illnesses but also to investigate and report on the unsanitary conditions that w ­ ere causing them. In his view, the corps of medical referees would thus become an integral part of the public health infrastructure already at work. During the discussions, Frank Billings said he expected communities wanting to economize on health expenses would take mea­sures to make typhoid fever, diphtheria, and smallpox all but dis­appear. “Every­t hing known to be communicable ­will be dimin-

Insurgency

351

ished.” Such results could only be achieved with state action, “and I know of no state supervision which w ­ ill equal state compulsory insurance.” 67 Other nationally prominent medical leaders and activists who expressed support or at least strong interest w ­ ere, not surprisingly, William Gorgas, the U.S. Army’s yellow fever fighter and former AMA president, and Rupert Blue, the surgeon general of the U.S. Public Health Ser­vice and si­mul­ta­neously AMA president in 1916–1917. In Blue’s inaugural address dealing almost exclusively with public health issues, he called for health insurance to incorporate incentives for disease prevention. Among other impor­tant supporters ­were full-­time salaried officials in the AMA like Frederick Green, executive secretary of the Council on Health and Public Instruction, and Alexander Craig, the AMA general secretary since 1911. Not least was Isaac Rubinow, the secretary of the AMA’s social insurance committee. He was a nonpracticing doctor with an 1898 medical degree from New York University. A ­ fter only a few years of practice, Rubinow grew disillusioned with the Sisyphean task of treating the urban poor and enrolled in Columbia University to study po­ liti­cal science. In 1913, Rubinow published Amer­i­ca’s only substantial book on social insurance a­ fter acquiring im­mense expertise as a statistician, first in the U.S. agriculture and l­abor departments and then in the private insurance industry. A ­ fter about five years in the insurance industry, Rubinow signed up to help Lambert make health insurance a v­ iable cause for medical progressives.68 Many other out­spoken medical supporters of health insurance w ­ ere state and municipal figures of national repute like Benjamin  S. Warren of the U.S. Public Health Ser­vice and Emery R. Hayhurst, a con­sul­tant on industrial hygiene for the Ohio State Department of Health. Alice Hamilton, a pioneer in the field of industrial medicine, was also in ­favor. Municipal health officials ­were well represented by William Evans, former progressive Chicago health commissioner, and especially by New York City public health officers Josephine Baker, Haven Emerson, Sigismund Goldwater, and Louis I. Harris. Boston pulmonologist Edward Osgood Otis, a director of the National Association for the Study and Prevention of Tuberculosis, also championed health insurance. The author of a popu­lar book on tuberculosis, Otis extolled Germany for its employer and union-­run sickness funds, calling it one of the country’s “most admirable” institutions fighting tuberculosis. They had constructed a good number of the best and largest sanatoria in the country, where diseased workers ­were treated ­free of charge. In 1907, Otis

352

Reactionary Turn and Beyond

noted in his book, the sickness funds spent millions of dollars on a campaign of public education about preventing the spread of tuberculosis.69 The AMA’s Social Insurance Committee’s reports hit a hornets’ nest of doctors and their leaders already nursing grievances about “state medicine” dating as far back as 1910 and summarized in the MAC manifesto. They w ­ ere not the slightest bit moved by the public health logic for insurance. Some of the fiercest insurgent rhe­toric came out of Illinois and New York. According to Illinois insurgent Whalen, health insurance would not reduce poverty and resulting disease but rather increase it “by creating what might be called a ­human scrapheap.” James  J. O’Reilly of Brooklyn, “the Patrick Henry of the American medical profession,” according to the MAC’s Ochsner, gushed with similar stuff. “The solemn, sacred duty of protecting the public from disease and death,” he said, “is inseparable from the duty of protecting Society and the State from social disease and degeneration and from po­liti­cal disease and waste through vicious Public Health Legislation, in what­ever guise it may appear.” It was classic reactionary, social Darwinist rhe­ toric. According to Eden V. Delphey of New York County, even “a beneficent paternalism” was dangerous ­because it “destroys individualism and discourages thrift.” Health insurance was simply “un-­A merican.”70 Surprised and rattled by the vehement reaction across the country, the national level AMA leadership backtracked, starting in 1919. The AMA journal quickly distanced itself from Lambert’s committee and chose not to contradict a tidal wave of hyperbolic claims and stinging insults about him and his motives. Early in 1919, it respectfully called attention to the evidence and arguments proffered by insurance expert Frederick L. Hoffman of Prudential Insurance Com­pany. Hoffman purported to show how insurance in Germany had failed to save money and lives. The editorial called for serious study of Hoffman’s evidence for further reflection but neglected to publish any rebuttals. Economist Irving Fisher would have been happy to provide them. By early 1920, the AMA Board of Trustees ordered the Council on Health and Public Instruction to cease distributing its eight pamphlets presenting the social insurance committee’s findings and views. But the tumult would not die down. During the May 1920 AMA meeting, the MAC’s Rooney submitted a resolution supported by Whalen and Frederick C. Warnshuis of Michigan calling for blanket opposition to “any scheme” of compulsory health insurance. Delegates from all three states ­were instructed by their meetings to do every­thing pos­si­ble to get their resolution passed. According to Whalen, their move was designed to put “a halt on the machinations of Dr. Alexander Lambert and his consorts of . . . ​medical po­liti­cal milkmaids.”71

Insurgency

353

A less sweeping resolution designed to head off the more radical one ultimately passed by an overwhelming majority. Submitted by New Yorker Edward L. Hunt, it declared the AMA’s opposition to any insurance plan “which provides for medical ser­vice to be rendered” and which is to be “controlled or regulated” by any government authority. Hunt’s alternative, possibly inserted by insurance proponents, left the door open for a compulsory system offering sick pay only, thus leaving medical attention and therefore doctors largely out of the system. But now all social insurance was taboo to insurgents repulsed by its “un-­A merican” nature. By 1921, former insurance supporters, stung by the criticisms and overwhelmed by the 1920 House of Delegates, dropped the subject entirely. Malcolm Harris, the Chicagoan on Lambert’s committee, and Frederick Green, the Health and the Public Instruction Council’s secretary, openly retracted their ­earlier support in addresses and articles published in 1920 and 1921. In 1921, Vaughan, who as AMA president in 1914 had openly welcomed socialistic tendencies in health governance, explic­itly argued against it. In 1921, Billings’s retraction came in the form of a complaint that he had been misquoted in the AALL journal for having said in 1917 that he was “unequivocally” for compulsory health insurance.72 The progressives’ abject retreat on health insurance did nothing to neutralize the insurgents’ campaign to capture control of the AMA. Other grievances predating it continued to fuel the dissidents’ fires, as the MAC manifesto of 1921 was to show. In 1922, as Horace Brown of Milwaukee said, ­there was still widespread “unrest and dissatisfaction” with the AMA. In 1923, MAC secretary McMechan would help keep the insurgency alive by editing a special journal for that purpose, with article reprints, editorial cartoons, and solicitations for subscriptions sent out in ­great number to officers and members of medical socie­ties across the country. Except for its retreat from health insurance, the progressive leadership of the AMA did ­little e­ lse to quell the insurgency, and prob­ably could not have. In 1922, the AMA journal published an article by Henry Macatee, a proponent of healthy and affordable housing for the poor, that was a tone-­deaf insult to the insurgents. It attributed the rank and file unrest to irrational fear (“a primitive biological attribute”), prickly know-­it-­a ll-­ism, and excessive materialism. The AMA’s critics w ­ ere forming a bloc “to stem the tide of a social stream.” Their success would “do vio­lence both to our intelligence and to our convictions.” Macatee’s article would have only inflamed insurgents righ­teously proud of their pure motives, infallible intelligence, and ideological convictions.73 It bears repeating and emphasizing that the progressives’ backtracking on health insurance did not end the insurgency, just as the AMA leadership’s

354

Reactionary Turn and Beyond

dalliance with it did not start the insurgency in the first place. The revolt’s first big local and state successes came in 1910 and 1913, then built up steam b­ ecause of other “menacing movements,” and then succeeded in 1924, well ­after the insurance idea was buried. Having been abandoned, it merited no mention in the MAC manifesto as a form of “socialized state medicine.” Instead, the insurgents complained of state medicine on the march in the form of “community health centers.” By 1920 approximately seventy health centers of vari­ ous kinds had cropped up in fifty communities, and more than thirty ­were proposed or in the planning stages. ­Behind the heterogeneous mix of community centers ­were localities, states, and private philanthropies, often in collaborative ventures with civic groups, many of them active in the antituberculosis movement. Their main facilities and activities included medical and dental clinics, nurse visitations, child welfare work, milk stations, venereal disease control, public education, and shared diagnostic resources like X-­ray machines and laboratories, possibly staffed by lay technicians. To the insurgents, ­because they mixed public health activities with ­free or subsidized medical treatment, they w ­ ere all of a piece with other menacing movements. As the MAC’s Ochsner put it, “Before Compulsory Health Insurance went into coma or expired, the beast gave birth to a litter of vicious pups answering to the name of State or County Subsidized Community Health Centers.”74 As with other so-­called menaces, the AMA neither initiated nor openly supported the health center movement, so its sin was to not take up arms against it. The driving forces ­were the American Red Cross, ­under the direction of Livingston Farrand, an antituberculosis crusader and soon-­to-be Cornell University president, and Hermann Biggs, the power­house ­behind New York City’s pioneering Department of Health and now commissioner of health of the state of New York. In 1919, Farrand had retooled the Red Cross for public health work a­ fter the war in Eu­rope instead of disbanding its corps of battlefront nurses and other paramedical and administrative staff. In 1920, he proposed a health center bill that would provide state aid for county, city, or district centers for disadvantaged populations with hospitals, clinics, laboratories, public health nursing, health education, and school health programs. Prevention would piggyback on clinical care. ­There would be “facilities for an annual medical examination to detect physical defects and disease, and to indicate methods of correcting the same.” The centers would also h ­ ouse medical libraries with meeting halls as well as books, pamphlets, periodicals, leaflets, exhibits, moving-­picture films, and other educational resources. Part of the purpose was to attract doctors away from the glutted city markets

Insurgency

355

with steady incomes and modern facilities that their increasingly expensive and sophisticated training led them to demand.75 Insurgents saw only economic threats in the community health center movement, even though its principal beneficiaries ­were supposed to be the disadvantaged and underserved in low-­income and often rural communities. Medico-­economic agitators suspected more “charity abuse” was on its way, given their experience with urban dispensaries and university teaching facilities. The centers’ evils also included contracting with group practices or exclusive panels of doctors for diagnostic and clinical work for f­ ree or for reduced rates and employing laboratory technicians. ­These ­were the closed-­shop evil and lay encroachment in new forms, all posing a risk of a loss of patients to prac­ti­tion­ers of state medicine. Although the AMA had no hand in the health center movement, the insurgents targeted its leaders as advocates. Victor Vaughan came ­under fire for his alleged promotion of state medicine through community hospitals. Billings, now the secretary of the AMA Board of Trustees, was another whipping boy. The MAC’s Ochsner surreptitiously led the attack by having an anonymous sheet attacking Billings distributed to delegates at the 1921 AMA meeting in Boston. It charged that Billings, who was up for reelection as a trustee, wanted health centers “paid for by the State and manned by physicians paid by the State.” Billings protested vehemently, saying he opposed “paternalist” medical care provided by government physicians ­because it was “likely to become bureaucratic and occasionally . . . ​subject to po­liti­cal debasement.” He survived the vote, but it would be his last for a power­ful position in the AMA.76 Missing from the MAC’s cata­logue of grievances was the 1921 Maternity and Infancy (Sheppard-­Towner) Act of 1921, a major irritant to the medical insurgents as a form of state medicine. Sheppard-­Towner had only just become law about a month before the manifesto was mailed out. ­Later, however, McMechan mentioned “childbirth” along with alcohol as an area where Congress had “invaded the dictation of therapy” in a letter to the Kansas ­ hildren’s medical society’s journal.77 The law, to be administered by the U.S. C ­ abor, gave federal subsidies to Bureau of the Department of Commerce and L states for prenatal and postnatal infant and maternity clinics and ser­vices, staffed and provided by public health nurses. ­Behind the Sheppard-­Tower Act, signed by President Warren G. Harding, w ­ ere mostly lay forces in the broad public health movement, especially newly enfranchised ­women motivated by the country’s very high infant and maternal death rates and frustrated by the U.S. Public Health Ser­vice’s indifference to their cause.

356

Reactionary Turn and Beyond

In only a very ­limited sense did the AMA bear any responsibility for Sheppard-­Towner. In 1912, it had championed the founding of the ­Children’s Bureau in the Department of Commerce and ­Labor by the extraordinary social reformer Julia C. Lathrop, who as the first ­woman to head a federal bureau was the law’s driving force and ­future administrator. In 1921, an AMA journal editorial actually criticized the law, but only on the grounds that preventive maternal and infant care was a ­matter for the states, not the federal government. It did not express a principled objection to governments and nurses treading on medical territory. But the AMA’s Section on Diseases of ­Children warmly endorsed the law in 1921, thereby heightening the insurgents’ resentment of the AMA’s scientific sections’ superdelegates. Thus, the Sheppard-­ Towner law quickly joined the insurgents’ cata­logue of grievances against the AMA.78 ­Because House of Delegate votes w ­ ere rarely recorded or reported, it is difficult to gauge exactly how much progressive re­sis­tance ­there was to the

Julia Clifford Lathrop (1858–1932), director of the U.S. ­Children’s Bureau. The first ­woman ever to head a federal agency, Lathrop helped draft the 1921 Sheppard-­Towner Act for maternal and child nursing care to reduce Amer­i­ca’s internationally high rate of infant and maternal mortality. Pressure from the conservative-­ era AMA led to the demise of the law. From World’s Work 24 (1912).

Insurgency

357

growing insurgency. The stormy debate preceding a fifty-­three to fifty-­three vote in 1921 on a resolution sponsored by Vaughan against prescribing alcohol as a medicine indicates it was large, at least on some m ­ atters. The insurgents, though numerous, also failed to pass a strongly worded resolution against almost all forms of state medicine, not just insurance, involving “treatment of disease.” ­A fter a heated debate in the Committee of the Whole, what New York’s Rooney called a “shilly-­shally” resolution was passed instead. It said only that the AMA endorsed all “proper” efforts of state and federal governments “directed to the prevention of disease and the preservation of the public health.” What constituted proper or improper was not enumerated, leaving the possibility of treatment for prevention’s sake. It supposedly gave Congress the impression that the Sheppard-­Towner Act was a legitimate ­ atters. The insurgents intrusion of the federal government in medical m blamed their defeat on the extra votes cast by some of the delegates representing the organ­ization’s fifteen scientific sections.79 ALLIES AND APPEALS

Just as the AMA’s progressives had lay allies among a wide array of educational, professional, philanthropic, journalistic, and po­liti­cal reformers, the insurgents had their own friends outside the profession. On health insurance, they got the backing of the burgeoning insurance industry as well as the National Civic Federation (NCF), which had representatives from both capital and l­abor. NCF member Samuel Gompers, the president of the American Federation of ­Labor, opposed health insurance ­because he believed that social insurance would reduce workers’ reliance on the elite crafts ­u nions’ benefit funds and thus weaken their loyalties. But Gompers’s vehement opposition misrepresented l­abor as a w ­ hole, for ­t here was no real unity on the issue. In New York, for example, l­abor leaders sided with the insurance advocates.80 One of the insurgents’ key allies was a long-­time ­enemy of the AMA, the National Association of Retail Druggists (NARD). In Illinois, high NARD official Samuel C. Henry joined leading medical insurgents in a 1921 symposium on how to halt the march of the vari­ous “allied dangers” of state medicine. Henry ventured that the state insurance laws ­under consideration meant “the absolute elimination of 75 per cent of the phar­ma­ceu­ti­cal business carried on by the pharmacists of the United States.” Although nothing in the proposed laws validated such fears, he i­magined it pos­si­ble that insurance

358

Reactionary Turn and Beyond

beneficiaries would be required to get all their drugs and medical supplies “from certain places” so that drug prices, not just physicians’ fees, “­will be set by the State.” Edward Ochsner and New York insurgent John J. A. O’Reilly, head of the Professional Guild of King’s County, a co­a li­tion of Brooklyn’s medical society with its organ­izations of dentists and druggists, also participated in the joint symposium. O’Reilly’s alliance had active committees in each of Brooklyn’s New York State legislative assembly districts. His “guild plan” for enlisting drug interests in the ­battle was copied in New Jersey and possibly in other states as well.81 ­There w ­ ere huge differences between the insurgents and progressives in argument and rhe­toric as well as lay supporters. According to Rooney, the state medicine ­people used “very subtle and capable” propaganda to achieve their goals. The insurgents, by comparison, w ­ ere verbal swashbucklers. Lit­er­a­ture distributed in 1919 by O’Reilly’s co­ali­tion called compulsory insurance “wretched,” “debasing,” “vicious,” “Un-­American,” and “Unsafe, Uneconomic, Unscientific, Unfair and Unscrupulous.” It was “a Legislative Monkey Wrench which is to be cast into the Machinery of Society without regard to any result save that some politicians and some professional Philanthropists and Sociologists may get some jobs.” B ­ ehind it w ­ ere “Paid Professional Philanthropists, busybody Social Workers, Misguided Clergymen and Hysterical ­women.” They had “no Princi­ple; it is all Interest and ­those most interested in it are the smug Uplifters, pungent with the odor of mock sanctity.” Other insurgents painted progressives as unmasculine or androgynous deviants. In 1922, Wisconsin insurgent Horace Brown referred to the medical progressives’ lay allies as “the fat-­thighed man and the skinny hipped w ­ oman” and “the long-­haired man and the short-­haired ­woman.” By “reforming mankind,” ­these “epicenes” w ­ ere undermining manly individualism. Prompting a round of applause, he said, “If a man is a man he does not need any help. If he is not a real man, and you help him, he comes back for more help all the time.”82 The reactionary rhe­toric also appealed to nationalist and xenophobic sentiments. According to O’Reilly, reformers bore “the stench of the infamous Kultur whence this foul Legislation sprung from the conclave of the International ­Labor group of which this so-­called American Association for ­Labor Legislation is an integral part.” In 1919, Charles Whalen compared the progressives with Otto von Bismarck, Germany’s “Iron Chancellor,” whose arguments for social insurance ­were a “velvet glove” covering “the mailed fist.” Insurance had “so dulled the sensibilities of the German ­people and destroyed

Insurgency

359

initiative and self-­reliance” that it strengthened Bismarck’s autocratic domination. By 1920, ­after the 1917 Rus­sian Revolution, “Bolshevism” became a common rallying cry against progressive health reforms and reformers. Whalen even applied the term to another unsuccessful bill submitted in 1920 by Oklahoma progressive senator Robert Owen for a national department of health, once a supreme goal of AMA progressives past. The “germ of Bolshevism,” Whalen claimed, was also breaking out in calls for a federal department of education, federal aid for maternity and childcare, physical education in schools, and even increased funding for the Vital Statistics division of the Census Bureau. In short, Washington, DC, was “a hotbed of Bolshevism.” So was the AMA. In 1921 Whalen called on “the real Americans” in the profession to stomp on the “Soviet Government bugs” that had infested the AMA.83 Whalen surpassed himself with his take on the Sheppard-­Towner Act: it was “another piece of destructive legislation sponsored by endocrine perverts, derailed menopausics and a lot of other men and w ­ omen who have been bitten by that fatal parasite, upliftus putrifaciens.” Imbalanced, fevered, and crazed, they ­were “working overtime to devise means to destroy the country.”84 His and other insurgents’ hyperbolic, bigoted, social Darwinist, and paranoid-­xenophobic rhe­toric seemed to appeal to large and appreciative medical audiences. It helped bring about, in 1924, a new medico-­ political era to finish the insurgency started in Chicago a de­cade and a half ­earlier. A dramatic turnover in the AMA leadership brought in a younger and dif­fer­ent breed of medical politicians to replace the old guard. In time, the new leaders would cultivate the next cohort of medical politicians to replace them, who in turn would repeat the pro­cess in coming de­cades. Using some of the same rhe­toric and allied with power­ful lay forces, the new medical politicians would carry the conservative baton all the way to the end of the twentieth c­ entury.

ch apter 13

The Conservative Medico-­Political Order

From the 1920s to the end of the ­century, the American Medical Association emerged as one of the most conservative forces in American politics on divisive social as well as medical issues. In the 1930s, its spokespeople reviled the New Deal social legislation. From the 1940s onward, it was a sturdy pillar of a conservative interest group co­a li­tion that included the National Association of Manufacturers and the American Farm Bureau. Together they supported Southern Demo­crats and conservative Republicans who sought to check civil rights reforms and expansion of the welfare state. Or­ ga­nized medicine became a po­liti­cal force to be reckoned with by liberal politicians and counted on for ideological and other support by conservative politicians. It has been posited that the origins of the AMA’s dramatic reactionary turn can be traced to the xenophobic “Red Scare,” an antiradical hysteria that swept Amer­i­ca following the Rus­sian Revolution of 1917. That coincided with the AMA’s dalliance with compulsory health insurance. The temporal coincidence suggest that po­liti­cal shocks from the world outside of the medical profession galvanized its insurgency against “state medicine.” Indeed, the xenophobic rhe­toric of the time reverberated in the insurgents’ inflammatory charges against the old progressive guard. A few years ­later, the 1920 election of President Warren  G. Harding inaugurated twelve years of Republican

360



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

361

control of the White House. Amer­i­ca’s Progressive Era was over. Then, in 1922, an insurgent majority in the AMA House of Delegates passed a spate of resolutions that brought the AMA’s own progressive phase to a complete and permanent halt. By 1924, the year of Republican Calvin Coo­lidge’s election to the presidency, almost e­ very progressive leader of the AMA was gone. It was as if or­ga­nized medicine bent with the prevailing winds of outside po­liti­cal forces. But no sustained analy­sis, much less agreement and clarity, can be found in what medical historians have written about the AMA to support the idea that the external politics of the era had a decisive effect on the internal politics of the medical profession.1 ­There are in fact good reasons to doubt that exogenous forces w ­ ere anything more than accelerants. The localized medical insurgency in Chicago and then Illinois of the early 1910s had predated the Red Scare. The national hysteria was a reaction to a spike of industrial disputes involving the radical Industrial Workers of the World and bombs set off by immigrant anarchists in eight cities and mailed to prominent members of the U.S. po­liti­cal and economic elite. By contrast, the medical reactionaries attacked mostly Anglo-­Saxon Protestant reformers characterized by peaceful associationalism, veneration of scientific expertise, rational discourse, and regulatory legislation. They ­were, to coin a phrase, rational and genteel orderists, nothing like violent anarchists preaching “the propaganda of the deed” or Bolsheviks espousing Marxist-­Leninist theory. In short, the Red Scare did not engender the medical reaction. It is unclear, too, just how far to the right the po­liti­cal climate actually turned in the 1920s compared to the AMA’s reactionary turn. In word, spirit, and action, President Harding was not a blowhard reactionary. His rhe­toric was bland: “Not heroics, but healing; not nostrums, but normalcy; not revolution but restoration; not agitation but adjustment; not surgery but serenity; not the dramatic but the dispassionate.” It was far from a snarling repudiation, like the AMA’s, of all ­t hings socially progressive. Harding’s landslide against Demo­crats James M. Cox and his vice presidential candidate Franklin D. Roo­se­velt was less about their progressivism than their unlucky association with Demo­cratic president Woodrow Wilson. Wilson had presided over terrible years of war, the deadly “Spanish flu” pandemic, a decline in growth, recent inflation rates reaching over 20 ­percent, and then a deep recession by election day, major strikes in the meat-­packing, steel, mining, and lumber industries, large-­scale race riots in major cities, and anarchist attacks on Wall Street—­a dreadful combination for any incumbent party. Harding’s

362

Reactionary Turn and Beyond

campaign was not about rolling back specific progressive reforms. “The ­people, indeed, do not know what ideas Harding or Cox represent,” according to Brand Whitlock, a prominent journalist and politician. “Neither did Harding or Cox,” he said. “­Great is democracy.”2 That was not quite fair to Harding. He was in fact a thoughtful, moderate, and knowledgeable progressive, respected by both wings of his party. He openly welcomed w ­ omen’s suffrage and, in a speech in Birmingham, Alabama, called for po­liti­cal and economic rights for African Americans. He urged a strong law against lynching, which the vast majority of his fellow Republicans—222 of the 239 in the House—­voted for in 1922. The bill failed in the Senate only ­because of Southern Demo­crats’ filibusters. He ended President Wilson’s practice of excluding black citizens from federal appointments. Harding even released Socialist leader Eugene Debs from prison and granted a general amnesty to almost two dozen alleged anarchists and socialists. Before his first year in office was over, he had fought for and signed into law the Sheppard-­ Towner Act, the first federal welfare program in U.S. history other than the generous pensions for veterans ­after the American Civil War. He had spoken out for it in his Justice Day speech in the fall of 1920. Sheppard-­Towner passed during a special session of Congress that President Harding had called for in 1921, partly for that purpose. He pressured antisuffragist Republicans to vote for it, and it passed overwhelmingly in both chambers. Against substantial re­sis­tance, the AMA then fought mightily to end its services for at-risk babies and mothers and eventually got its way in 1929.3 Harding also endorsed a quintessentially progressive reform, the creation of a cabinet-­level Department of Public Welfare. With it he foresaw integrating federal education, social ser­vices, and public health functions currently spread over dozens of bureaus, commissions, and departments. His top advisor on the ­matter told congressional committees that public health was the most impor­tant reason for creating a new department. Advancing public health would also stimulate commercial and industrial pro­gress.4 On that count, Harding was more progressive than the current AMA, which never tried to resurrect the cause that, from the 1800s u ­ ntil World War I, it had ­earlier championed. In short, unlike the AMA’s, Amer­i­ca’s po­liti­cal mood swing to the right was neither extreme nor long in duration—­more a fluctuation in the weather than po­liti­cal climate change. In the 1922 midterm elections, Republicans suffered major losses in both the House and the Senate, while the farm states’ progressive ele­ment in the Republican Party gained seats. Even Harding’s



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

363

vice president and successor Calvin Coo­lidge, elected in 1924, had progressive credentials. A de­cade e­ arlier, he had written a section of the Mas­sa­chu­setts Republican Party’s platform calling for support of “­every means of compulsory and public education, vocational and technical, merited retirement pensions, aid to dependent ­mothers, healthful housing and fire protection, reasonable hours and conditions of l­abor, and amplest protection to the public health, workingmen’s compensation and its extension to interstate railroads, . . . ​highest care and efficiency in the administration of all hospital and penal institutions, . . . ​care and protection of ­children and the mentally defective, rural development, urban sanitation, . . . ​and e­ very other public means for social welfare consistent with the sturdy character and resolute spirit of an in­de­pen­dent, self-­supporting, self-­governing, and ­free ­people.” ­Later, as Mas­sa­chu­setts governor in 1919 and 1920, Coo­lidge’s ardor cooled for progressive policies and the creation of administrative agencies to execute them, albeit for fiscal restraint’s and efficiency’s sake, not for reactionary reasons. During his presidency, he proposed constitutional amendments for a minimum wage for ­women and restriction of child ­labor in industrial employment. He supported the Railway L ­ abor Act, the first federal law giving workers a right to or­ga­nize and collectively bargain. He also called for economic and po­liti­cal rights and increased education support for African Americans and for effective laws against lynching.5 Republican Herbert Hoover, who succeeded Coo­lidge a­ fter the 1928 election, was in some ways even more of a progressive than Harding and Coo­ lidge. It is impossible to see in Hoover an inspiration to the ultraconservative AMA. Many Republican progressives had favored Hoover over Harding to be the party’s presidential nominee in 1920. He was “progressivism incarnate” of the Theodore Roo­se­velt stamp, according to biographer Kenneth Whyte, and only late in his presidency started identifying as a conservative. Liberal journalist Walter Lippman looked back at him in 1964 as a “natu­ral heir of Woodrow Wilson.” Like both his pre­de­ces­sors, Hoover had supported ­women’s suffrage. While the AMA attack on the Sheppard-­Towner Act was building steam, Hoover’s campaign material called him, with reason, a “benefactor of ­children.” Child welfare advocates Grace Abbott and Julia ­ hildren’s Bureau had g­ reat hopes for a Lathrop of the ­Labor Department’s C Hoover presidency. They w ­ ere to be disappointed, however, b­ ecause Hoover did not openly defend the Sheppard-­Towner Act to prevent Congress from letting its funding lapse. No ­union basher, as a mining engineer Hoover had concluded back in 1909 that l­abor u ­ nions w ­ ere “normal and proper antidotes

364

Reactionary Turn and Beyond

to unlimited cap­i­tal­ist organ­izations.” As Coo­lidge’s secretary of ­labor in 1924, he had welcomed collective bargaining agreements in the coal industry as good for both coal miners and the industry. He admired ­labor leader John L. Lewis for his “sound conception of statesmanship” and his concern for the long-­run interests of “the p ­ eople and the industry he serves.” He signed into law the Davis-­Bacon Act of 1931, which ordered prevailing ­union wages to be paid for all federal building proj­ects. L ­ ater he praised the New Deal federal minimum wage law of 1938. If anything, bad luck and caution rather than extreme right-­wing rigidity explains Hoover’s unflattering reputation as a failure in the face of the ­Great Depression of the 1930s.6 A final and perhaps most compelling reason to question the impact of national politics on or­ga­nized medicine is the fact that the nation’s po­liti­cal climate change of the 1930s did nothing to warm the AMA to liberal reformers. Instead, it dug in its heels and bent resolutely against the New Deal de­ cade’s more radical progressivism, now called “liberalism.” Or­ga­nized medicine had leapfrogged the rest of the country to the right and stayed t­ here, steadfastly in place. Sensitivity or impressionability to outside politics cannot explain the reactionary turn any more than its ­later rigidity. All in all, the evidence indicates that the po­liti­cal transformation in medicine was the function of endogenous more than exogenous po­liti­cal and economic forces. PROGRESSIVES ROUTED AND BANISHED

At its 1922 session, the AMA House of Delegates passed resolution a­ fter resolution repudiating the organ­ization’s progressive past. Most importantly, a majority called for a sweeping condemnation of anything smacking of state medicine. Based on a version submitted by New York’s James Rooney, the resolution stated that ­because of its “ultimate harm . . . ​to the public weal,” all forms of medical treatment “provided, conducted, controlled or subsidized” by a federal, state, or municipal government w ­ ere to be condemned and fought. Despite President Harding’s and Congress’s support for the Sheppard-­Towner law, another resolution called for repeal of the “imported socialistic scheme unsuited to our form of government.”7 But ­there was still division. In a side meeting, the AMA’s Section on Diseases of C ­ hildren rebelled by passing a resolution supporting Sheppard-­Towner. Thereupon the House of Delegates sent a del­e­ga­tion to “reprimand the Pediatric section.” The progressive pediatricians met the reactionaries’ “committee of wrath” with “unrepentance and jeers.” To silence such progressive



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

365

re­sis­tance, a majority passed a resolution to prevent all AMA councils, committees, and sections from taking in­de­pen­dent policy positions in the ­future. Scientific sections like the pediatricians’ w ­ ere now confined to presenting papers and sponsoring social events. A constitutional change eliminating the sections’ superdelegates and thus ending the “balance of power” they held in the House of Delegates was placed on the agenda for the next session. All fifteen sections passed resolutions in their separate meetings against the proposal. Another constitutional change proposed for a ­future meeting called for restrictions on group medical practices on the grounds that advertising their ser­vices constituted a serious breach of ethics. That prompted a discussion among progressives about bolting to create a separate, breakaway medical association.8 Other dramatic policy reversals passed by the 1922 House of Delegates included a condemnation of the Prohibition era’s Volstead Act for its encroachment on physicians’ sovereign territory. By making it unlawful for a doctor to prescribe alcohol in any quantity deemed therapeutically necessary, the resolution said, the law was a “serious interference with the practice of medicine” b­ ecause “the dosage, method, frequency and duration of administration of this drug in any given case . . . ​is not to be determined by l­egal or arbitrary dictum.” Those were, allegedly, a matter of “scientific therapeutics,” not politics. The House of Delegates even passed a resolution criticizing the Red Cross for promoting the community health center movement. The AMA Board of Trustees responded by formally endorsing the new positions. With t­ hese actions, many of the desiderata listed by the insurgents’ Medical Advisory Committee ­were now AMA policy.9 The following year, seventy-­three-­year-­old Victor Vaughan, the epitome of the public health missionary and paragon of medical progressivism, resigned. That in itself was an insurgent victory. Vaughan had served since 1919 as chairman of the AMA’s impor­tant Council on Health and Public Instruction (CHPI). Before that he had also served on the Council on Medical Education from 1904 to 1913 and as AMA president in 1914 and 1915. In his inaugural address, Vaughan had lamented Amer­i­ca’s excessive worship of private property and disregard for the general welfare. Preventive medicine, he thought, was “the most potent f­actor in the socialistic movement of the day.” He had argued that the state’s most impor­tant function was “to advance to the highest degree the health, intelligence and morality of its citizens, not help businessmen to become millionaires.” He had decried the combined presence of “palatial homes of the ultra-­rich, the splendid

366

Reactionary Turn and Beyond

t­ emples of trade and commerce” in American cities with their “slums of want and poverty.” Five years ­later, Vaughan criticized the “unreasoning opposition” and “sweeping and often erroneous general arguments” against compulsory health insurance.10 Hardly anything could have galled insurgents more than Vaughan’s quintessentially progressive proposal, made the year before his departure, that state and local medical socie­ties create special sections on public health and sanitation that nonphysicians could join as “associated members” of the AMA. Frank Billings, Hugh Cabot, and Hermann Biggs, all personae non gratae with the insurgents, assisted Vaughan in formulating the proposition. When in 1923 the AMA Board of Trustees bent with the reactionary winds by handing over the CHPI’s role as the sole voice of the AMA on social policy issues to a newly created Bureau of ­Legal Medicine and Legislation, Vaughan resigned. Th ­ ere seems to be no rec­ord of any protest on his part. If he was b­ itter, he left in dignified silence. He barely mentioned the AMA in his autobiography, published in 1926, and said nothing at all about his hard work in it. Entirely upbeat, he wrote only of his multifaceted c­areer as a pioneering bacteriologist, as a public health official, and as Michigan’s preeminent medical educator. Perhaps ­because of that, biographies of Vaughan take ­little to no note of his leadership in AMA politics.11 Former AMA president Frank Billings served out the end of his part-­time ser­vice on the board of trustees in 1924, on which he had sat since 1918. Billings had been one of the most fervent and energetic proponents of the AMA’s work with drug and medical education reform. Despite having distanced himself from compulsory health insurance and rejected employment of salaried physicians in community health centers, he remained a hated figure among insurgents. They would not have forgiven him for proposing in 1922 to “medicinize the social movement” instead of socializing medicine by placing more doctors in lay welfare organ­izations in which they would collaborate with churches, businesses, and community members “to rationally direct the health crusade.” That was to complement Vaughan’s idea of bringing nonphysicians into the AMA as associate members with a similar mission. The public could thereby be moved to supply resources for hospitals and diagnostic centers, staffed by rotating specialists in rural areas, to be operated only “through and by the medical profession.” Billings also recommended subsidizing community health centers. “An old ­enemy with a new mask,” said George E. Frothingham, a leading Michigan insurgent. Like Vaughan, Billings left medical politics for good and threw all his energies into his scientific, educational, and



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

367

surgical work. Biographical treatments of Billings, like t­ hose of Vaughan, also ignore his years of medico-­political activism.12 Other leading progressives left with Billings in 1924. Most momentous was the retirement of full-­time AMA editor and executive George H. Simmons. He had been chief editor of the AMA journal since its reor­ga­ni­za­tion in 1901 and, as such, was the main target of the venomous words of insurgents like Frank Lydston and Charles Whalen. Some internecine hostility ­toward Simmons was the b­ itter fruit of his work on the Council on Pharmacy and Chemistry, especially from the many doctors who read and published in the cheap drug-­dependent “in­de­pen­dent” medical journals. Along with national and international medical acclaim, Simmons’s editorial l­abors made fraternal enemies. He had to sign rejection letters to authors of about twelve hundred to fifteen hundred articles submitted ­every year, around 80  ­percent. ­ ere letters and other contributions of a po­liti­cal nature, Some of the rejects w many of them no doubt written in the high dudgeon of the day’s insurgents. But the ­great bulk of rejects consisted of scientific efforts, many of them truly poor in style as well as substance. Authors of unsuccessful papers unjustly threw their sour grapes at Simmons. According to Charles Reed, Simmons stoically served as the “stalking ­horse” for the many scientific experts he consulted about article manuscripts from the AMA Board of Trustees, editorial committees, and outside specialists. Anger over rejections fueled some ­ ecause the journal counseled caution during the rapid rise of the insurgency. B of radiological therapy around 1910, Heber Robarts, an exuberant enthusiast for radium treatment of cancer, was forced to publish his claims elsewhere. For that he mostly blamed Simmons but also ­those he called the profession’s “supermen” like William Mayo and William L. Rodman, both active in the AMA. In comments published in the Illinois Medical Journal, edited by insurgent Whalen, Robarts said the two surgeons “supinely played the harp string which Simmons tuned for them.” It was Simmons’s “caballing,” Robarts claimed, that made the House of Delegates give Rodman the AMA presidency in 1915, not Rodman’s extraordinary leadership in cancer research, medical education reform, and more.13 Like Vaughan and Billings, Simmons also left without ­bitter parting words, even though for years he had fearlessly and unshakably weathered “vicious, slanderous, personal attacks,” according to fellow progressive and admirer James Herrick. Billings called Simmons “the man most undeservedly abused and criticized” of all AMA leaders. Morris Fishbein, Simmons’s successor as editor, mentioned only Simmons’s declining health and vigor as a

368

Reactionary Turn and Beyond

reason for his retirement at sixty-­six years of age in his history of the AMA. But George Lundberg, a f­uture Journal of the American Medical Association editor with access to inside rec­ords, intimates that Simmons retired u ­ nder pressure. ­Because Simmons burned all his personal papers a­ fter leaving, certainty about that is not pos­si­ble.14 By 1924 all but one of the old progressive guard w ­ ere gone. Their numbers had already dwindled for other reasons. Joseph McCormack had retired from AMA ser­vice in 1910 and returned to Kentucky to continue his public health mission ­there. As the insurgency was building steam, old age removed William Welch from the scene, and death did the parting for past AMA presidents John B. Murphy in 1916, Abraham Jacobi in 1919, and William Gorgas in 1921. Chicago’s Henry Favill, the public health and industrial hygiene missionary, died of pneumonia at age fifty-­six in 1916 while serving on Lambert’s Committee on Social Insurance. The only major progressive figure in the AMA to remain active in the organ­ization beyond 1924 was Arthur Dean Bevan, the driving force b­ ehind medical education reform and the instigator of the 1910 Flexner report. Elected AMA president for the 1918–1919 term, he was one of the most notably progressive of presidents. In his inaugural address, Bevan had called medicine a “function of the state,” now an indigestible concept in the belly of the profession. His having distanced himself from compulsory health insurance and l­ater opposing the introduction of mandatory full-­time clinical professorships, one of the ­things that the insurgent Medical Advisory Committee had found baneful, may have made it pos­si­ble to continue as chairman of the Council on Medical Education ­until 1928.15 But Bevan’s strong progressive streak as a therapeutic rationalist ultimately put an end to his AMA ­career. Like both lay and medical progressives, he decried the large numbers of “bootlegging prescriptions” written by doctors. In 1927, Bevan told a meeting of medical educators that ninety-­nine out of ­ ere “a disgrace to the g­ reat medical one hundred prescriptions of whiskey w profession.” Several major newspapers reported on that, and a deluge of protests followed. In an Illinois Medical Journal editorial, Whalen called Bevan a “Judas.” B ­ ecause of the “odoriferous egg” he had laid, he had “clearly outlived his usefulness” as head of the AMA’s education council. In 1927, a move to oust Bevan from the Chicago Medical Society and therefore from the AMA failed, but his critics succeeded in passing a blistering statement of censure. The following year, Bevan was out. His belief in the strategic airing of the profession’s dirty laundry was his undoing. Nevertheless, he was allowed to publish a farewell article in the AMA journal in which he surveyed the “­great



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

369

wave of improvement” in medical education he had helped set in motion. In a true progressive spirit, he praised medicine’s alignment with lay forces to achieve it. Indeed, he said, “medicine cannot be left safely in the hands of the medical profession alone.”16 With that, one could say, Bevan delivered medical progressivism’s parting shot. THE NEW GUARD

“Many changes ­were ­under way,” wrote editor Morris Fishbein in his 1969 memoirs about 1924, the year he took the AMA journal’s helm from George Simmons. “New men” w ­ ere replacing “older men.”17 An understatement, it obfuscated the nature and extent of change. Indeed, the newcomers w ­ ere on average about ten years younger than the old guard. The MAC insurgents ­ ere fifty-­five, fifty-­ Francis McMechan, Edward Ochsner, and James Rooney w six, and forty-­five in 1924, and Illinois editor Whalen was fifty-­five. Fishbein was only thirty-­five. Of greatest symbolic, personnel, and policy significance was the election of fifty-­nine-­year-­old William A. Pusey as AMA president in 1923 for the term starting in 1924. Pusey won a tight race with a vote of sixty-­six to sixty-­t wo in the House of Delegates. The election was marked by an unusual frenzy of deals and promises that reached “fever heat,” according to Fishbein. Pusey was the perfect choice for proclaiming a new conservative era of medical politics. Speaking on “the social prob­lems of medicine” in his inaugural address, he held forth at length in the spirit of social Darwinism, eugenics, and medico-­ economic militancy. Medicine was being “appropriated” by lay organ­izations and the state, resulting in the decay of individualism and a halt to humankind’s advancement. He invoked Herbert Spencer, the famous biologist, sociologist, and conservative po­liti­cal theorist of the bygone Victorian era. Spencer’s thinking was “cold,” he said, but he insisted its lessons ­were as sound as ever. Asking the “eco­nom­ically fit and competent” to take care of the weak and “socially hopeless defectives” was to “set aside the law of natu­ral se­lection and to counteract Nature’s cruel but salutary pro­cess of eliminating the unfit.” Defying this natu­ral law promoted a “cult of incompetence.” The AMA’s job, as an enlightened and influential minority, was to ­battle “socialized mediocrity” and thus be the “salvation of democracy.”18 Pusey’s main medico-­political mission concerned medical education, which put him at odds with Bevan, the progressive holdout. Reviving the “poor boy” argument for weakened standards, Pusey thought progressives had

370

Reactionary Turn and Beyond

gone too far in thinning out the ranks of hypercompetitive prac­ti­tion­ers with stringent premedical requirements, long years of study, and excessive focus on research and specialty training. Implicitly rejecting the adverse se­lection prob­lem, he asserted that medical competition was actually “­wholesome.” It “stimulates vigor, initiative and resourcefulness in its members and benefits directly the profession, and, indirectly, society which it serves.” A bad side effect of the reforms, he thought, was that new doctors gravitated to larger cities in a quest for higher incomes to pay for their lengthy training and modern hospital facilities to make use of it. The reformers, who had lacked “unquestioning, united support” from the rest of the profession, ­were to blame for the disappearance of doctors from small towns and the filling of the vacuum by quacks and cultists. The solution was not, as the progressives had proposed, to build community health centers in poor areas to attract well-­educated doctors, but to turn back the clock to make small rural medical schools more affordable and open to poorer and less-­educated youths.19 Pusey had been a private practitioner in Chicago since 1915, when he left his professorship in dermatology at the Illinois College of Physicians and Surgeons. He had been an avid experimenter with radiation and a pop­u­lar­izer of its use on skin disorders. Back in 1906, Pusey had angrily challenged University of Pennsylvania professor of medicine David Linn Edsall, who warned of the dangers of X-­rays and lamented the deplorably haphazard research on radiation’s therapeutic value. The contrast between Pusey, the ­future medical politician, and his progressive detractor could not be starker. Edsall had helped found the American Society for Clinical Investigation in 1909 and l­ater became professor of Hygiene and Preventive Medicine at Washington University in St. Louis. Then, starting in 1918 as dean of Harvard Medical School, Edsall introduced a full-­time plan for clinical teaching and si­mul­ta­neously served as dean of the university’s famous School of Public Health from 1922 to 1935.20 Though no longer an academician, Pusey continued to publish his clinical observations, but not experimental research. Although he wrote extensively on syphilis, he never took the lead in promoting public or private mea­sures to prevent its spread. One notable private effort, begun in 1920, was conducted in his own city by the Public Health Institute of Chicago (PHIC). It enjoyed financial backing from International Harvester, Pullman, Carson Pirie Scott, Sears Roebuck, Marshall Field, and other major companies whose executives sat on its board. Pusey stood s­ilent when the Chicago Medical Society (CMS), of which he was a recent president, waged war on the PHIC for



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

371

“unethical advertising” of its ­free or low-­priced diagnostic, therapeutic, and counseling ser­vices to prevent the spread of syphilis. In 1929, the CMS expelled Louis E. Schmidt, professor of genitourinary surgery at Northwestern University, an outstanding expert on syphilis and active philanthropist, ­because of the support he received from the PHIC. Schmidt’s Social Hygiene League had previously been providing f­ ree treatment to indigents referred to him by the institute. The AMA supported Schmidt’s banishment. Prob­ably alluding to the PHIC, Pusey himself criticized “corporations or­ga­nized for the especial purpose of practicing medicine.”21 Over time, a declining number of Pusey’s successors stood out as clinicians, much less medical scientists, and none w ­ ere public health leaders. Presidents elected in the years before 1924, like Keen, Gorgas, Blue, the Mayo ­brothers, Murphy, Welch, and Sternberg, as well as John H. Musser, George de Schweinitz, and Ray Lyman Wilbur, all merit mention by medical historians for far more than their brief stints as AMA presidents. A ­ fter the 1930s, rewarding medical politicians who lacked similar distinctions with the presidency became the norm and “reached its extreme ­after 1950,” according to Fishbein. For example, Edward H. Cary, elected in 1932, had by the 1920s left ­behind his ­earlier ­career as the founder of Baylor Medical College and author of dozens of articles based on his clinical observations as an eye, ear, nose, and throat specialist. Thereafter, he spent huge energies on other enterprises, not least cap­i­tal­ist ones. He headed the Cary-­Schneider Investment Com­pany, the major developer that built the Medical Arts Building, the first Dallas skyscraper, in 1921, with offices primarily for physicians. He was president of a surgical instrument manufacturing com­pany and served as a director of the Texas Republic Bank, one of the state’s largest financial institutions. He also served for a time as president of the very conservative Southern Medical Association based in Alabama. ­A fter his AMA presidency, he obtained a seat on its power­ful board of trustees and spearheaded a major propaganda effort against a revived movement for compulsory insurance, this time on a national scale.22 Cary and Pusey exemplified the simultaneous ascendance of conservative Southerners and Chicagoans. Pusey had been CMS president in 1918–1919. When he assumed the AMA presidency in 1924, the CMS’s current president, J. H. Walsh, was elected to the AMA Board of Trustees. Walsh replaced progressive Billings as the board’s power­ful secretary and served in that role ­until 1933. The year 1924 also marks the entrance of conservative Southern doctors into full-­time executive leadership. Tennessean Olin West was chosen

372

Reactionary Turn and Beyond

as the AMA’s full-­time executive secretary and general man­ag­er and served ­until 1946 as one of the AMA’s most impor­tant spokesmen in politics and public affairs. Chicagoan Fishbein, the AMA journal’s new editor, was as impor­tant and even more vis­i­ble and vocal than West as medical conservatism’s full-­time po­liti­cal advocate. Fishbein also exercised enormous power in internal AMA affairs alongside West. The quality of the journal’s scientific articles did not seem to suffer u ­ nder Fishbein, who had benefited from years of Simmons’s tutelage. They w ­ ere even coauthors of a handbook on quality medical journalism, which came out in 1925. Fishbein had never practiced medicine himself, unlike Simmons. As a recently licensed young doctor, he began working ­under Simmons in 1912. What his medico-­political views ­were at the time remain Fishbein’s secret. Among his colorful mix of companions ­ ere the medical gadfly before 1924, some well to the left of the mainstream w Paul De Kruif, Socialist leader and presidential candidate Eugene Debs, iconoclastic journalist H. L. Mencken, and leftist author Sinclair Lewis. Lewis found Fishbein “a won­der” for his conversance with history, lit­er­a­ture, arts, and philosophy. ­Later, as a medical politician, Fishbein was as brash, voluble, vis­i­ble, and conservative as Simmons had been decorous, restrained, and progressive. No longer did he move in an eclectic circle of lay friends. One of his favorite companions was Elmer Bobst, an extraordinarily wealthy phar­ma­ceu­ti­cal executive. ­A fter Fishbein took over in 1924 as editor of Hygeia (called ­Today’s Health from 1950 onward), the AMA’s magazine for doctors’ waiting rooms, it became a propaganda organ against socialized medicine as well as a creditable source of information about hygiene, nutrition, exercise, and therapeutics. A 1939 Hygeia article, for example, extolled the quality and sufficiency of traditional charity care offered by individual doctors, warning that by accepting compulsory health insurance, the American ­people would “discard a medical system that has made them the healthiest nation in the history of man.”23 PU B L IC H E A LT H P O L I T IC S I N T H E C ON S E RVAT I V E E R A

William Pusey’s 1924 address to the House of Delegates signaled the AMA’s indifference to public health in the coming de­cades. Among the t­hings he thought would ultimately weigh down the nation with intolerable expenses ­were programs against drug and alcohol abuse; preventing the spread of



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

373

venereal disease; promoting child welfare and providing care for the injured, crippled, and “defective”; and even “socialized” recreation activities and facilities. The Sheppard-­Towner Act needed to be shut down b­ ecause m ­ others and babies could count on private clinicians to deal with high infant and maternal mortality. “It is not for the good of the ­people of the country that they should be spoon-­fed,” he said.24 ­A fter its reactionary turn, the AMA made common cause with a wide array of conservative lay forces determined to roll back the federal government’s intrusions into medicine like the Sheppard-­Towner Act. Citing weak evidence, the AMA journal claimed the money spent to reduce infant and maternal mortality was all wasted and thus asked readers to send letters protesting the “pernicious” legislation to their legislators in Washington. Fi­nally, in 1929, Congress cut off federal assistance to state maternal medicine programs. ­Because of the AMA’s dogmatic position, its leading pediatricians broke away to form the American Acad­emy of Pediatrics (AAP). Ironically, during the ­battle against Sheppard-­Towner, the male-­dominated specialty began expanding its turf by moving into preventive perinatal consultations as a new source of practice income. As a result, the lay movement for maternal medicine, which had introduced the practice, saw its main mission—care for low-­income m ­ others and babies—betrayed by private prac­ti­tion­ers who neglected families unable to afford their fees.25 The new AMA never overtly denied the importance of public health, but medico-­economic concerns became top priorities. Before 1922, AMA journal discussions ­under the rubric “Social Medicine and Medical Economics” almost exclusively dealt with public health m ­ atters and related economic prob­ lems in American society. But that year, “social medicine” dis­appeared from the section’s name, and medical economics referred to something new: the economics of private practice. That change may have been an attempt by Simmons to appease the insurgents. Or­ga­nized medicine and the American Public Health Association, which once had shared leaders, drifted apart. The AMA stood quietly aside when public health and industrial hygiene advocates challenged power­ful monied interests. Amer­i­ca’s unique, long-­lasting, and tragic indifference to the neurotoxic effect of lead in industrial pro­cesses and consumer products is a case in point. Starting in the 1920s, Eu­ro­pean countries clamped down on the use of lead in paint and other industries b­ ecause it could cause severe anemia, encephalitis, and other central ner­vous system disorders, especially in c­ hildren who chewed paint chips from walls, cribs, and other surfaces in the home. By the

374

Reactionary Turn and Beyond

1940s, most Eu­ro­pean countries had instituted bans. But b­ ecause of the indifference of the medical profession and the po­liti­cal clout of the paint industry, the United States lagged far b­ ehind. Physician and leading industrial health expert Alice Hamilton got no collegial help for her campaign against lead ­because it was considered “tainted by socialism or feminine sentimentalism in ­favor of the poor.” Articles in the AMA journal ­after 1924 implicitly blamed the victims by focusing on parents of c­ hildren with nutritional deficiencies and their failure to control their c­hildren’s impulses to eat paint chips. The idea of holding industrial and commercial interests and their po­ liti­cal allies accountable did not come up. Meanwhile, or­ga­nized medicine stood on the sidelines while public health crusaders fi­nally achieved victory in having lead-­based interior paint banned in 1978, more than a half c­ entury ­after its dangers ­were widely known to doctors.26 In 1971, to rebut liberal critics in Congress who said that it had long put doctors’ interests above public health, the AMA cited only three ­things worthy of note about the 1930s, one of them a resolution sent to toy makers warning ­ ere of the ­hazards of sharp edges and projections on toys. The other two w calls for reducing w ­ ater pollution and controlling the use of barbiturates. In fact, the 1930s was a de­cade in which laypeople looked with righ­teous dismay at or­ga­nized medicine’s increasingly icy hostility to the public health movement. That both­ered William H. Ross, the president of Long Island’s Suffolk County Board of Health. Exceptionally, he was also a leading figure in the New York State Society of Medicine. Elected president for a term during 1930 and 1931, Ross strove mightily but vainly to set t­ hings right. His most impor­ tant initiative was to establish and run a Public Relations Committee. He also wrote a regular column in the New York State Journal of Medicine, one of which chided physicians for “getting our thoughts twisted” by fears of overzealous, overreaching civic forces on the attack against physicians’ autonomy, mono­poly, and income. In another, he noted that the “public” was justifiably getting out ahead of the profession. It was humiliating to some doctors, but the perceived insult, he argued, was only a “speck of dust on the eyelash,” not a mountain obscuring the view. In short, medical “statesmanship” was needed to solve “the g­ reat prob­lems of health and sickness.”27 In a 1931 New ­England Journal of Medicine article, Ross took his pleas beyond his own state. Before, he wrote, or­ga­nized medicine had “never forgotten its public ser­vices.” But now, he lamented that a “dangerous gap” with the public was opening up b­ ecause the “myopic, individualistic, and too often selfish profession” was taking po­liti­cal risks by being on the defensive in



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

375

“continuing warfare” against lay organ­izations. Its opposition was “a potent ­factor in public unrest regarding the cost of illness, the availability of curative medicine, [and] proper organ­ization for the distribution of modern preventive mea­sures for the control of disease.” Public health imperatives, he claimed, abhorred the leadership vacuum. The densely populated urban industrial society was creating increasingly complex “socio-­medical prob­lems” that or­ga­ nized medicine could only h ­ andle by cooperating with government entities, especially ­because the costs of medical care w ­ ere rising even as the need for it increased. He lamented the growth of specialization and the eclipse of the modestly paid f­ amily physicians working on the front lines against disease—­ where prevention was as impor­tant as therapeutics. He even regretted that New York doctors showed only aloofness t­ oward passage of the state’s Public Welfare and Old Age Pension legislation. Summing up his experience with his Public Relations Committee, he claimed to have made some pro­gress but admitted that forging trustful relations between recalcitrant physicians and impatient lay reformers was an uphill ­battle.28 Ross’s pleas did not resonate in the halls of or­ga­nized medicine then or ­later. In 1937, editor Fishbein decried the federal government’s appropriation of $750,000 a year for the control of cancer and discussions about further funding of research on infantile paralysis, syphilis, and other diseases. The danger of government takeover of the practice of medicine was nigh, he warned. Nothing changed over the next two de­cades. In 1955, an AMA House of Delegates resolution protested the federal government’s provision of ­free vaccines against the poliovirus, insisting that “the purchase and distribution of Salk vaccine be carried on by the presently available commercial ave­nues used for other immunizing agents.” F ­ ree distribution to speed up prevention of infantile paralysis trampled on the princi­ple of f­ ree, competitive traffic in medicine and medicines.29 The following year, Edward R. Pinckney, a Napa County, California, health official and l­ater an out­spoken critic of the AMA, wrote in the AMA journal of an “abyss” between medical prac­ti­tion­ers and public health officials, “two branches of the same profession.” Had he explic­itly implicated or­ ga­nized medicine in any way, his article would no doubt have been rejected. But between the lines one can read a criticism. Although the AMA retained its impor­tant role in regulating medical education, it did nothing against medical schools that, he said, too often “presented the health department as a bumbling, bureaucratic agency interfering in the medical field.” As a result, gradu­ates “envision the health department as existing only ­because it has to

376

Reactionary Turn and Beyond

fulfill certain l­egal and necessary functions that have no direct bearing on the ­actual practice of medicine,” including “the useless accumulation of morbidity statistics.”30 Characteristically, as environmental and related public health threats came to the fore in the 1960s and 1970s, the AMA showed l­ittle concern. In response to biologist Rachel Carson’s ­Silent Spring, the famous alarm bell about the dangers of pesticides to h ­ umans as well as animals, a ju­nior editor of the AMA journal, a young ­woman just out of her internship, wrote a disparaging review comparing the biologist to a “zealous and overanxious m ­ other.” John H. Talbott, the chief editor, no doubt approved of the tone. Two years before, he had contradicted the U.S. Surgeon General of the Public Health Ser­vice, Leroy E. Burney, who had concluded that t­ here was solid evidence from multiple studies that cigarette smoking was the principal cause of the rise in lung cancer. Talbott advised physicians that they need not advise against smoking on the specious grounds that the studies Burney cited “did not explain why, even when smoking patterns are the same, case rates are higher among men than among men and among urban than among rural populations.”31 In the AMA’s Archives of Internal Medicine, editor William Bean called Rachel Carson’s book “so much hogwash.” He had read it “word for word with some trauma.” It kept reminding him “of trying to win an argument with a ­woman.” Indeed, “It can not be done.” In 1962, AMA News suggested its members read an “information kit” prepared by the National Agricultural Chemicals Association. It included Facts and Fancy, a widely disseminated pamphlet written to refute Carson. When eminent biologists and other experts on President Kennedy’s Scientific Advisory Committee issued their 1963 report on pesticides, AMA publications did not review it or inform members that it vindicated Carson’s warnings and calls for action.32 Throughout its conservative era, or­ga­nized medicine’s hostility ­toward government interventions in public health as well as other medical ­matters made itself felt in the influence that it exercised in the appointment of officials throughout the public health system. Wherever pos­si­ble, medical socie­ties insisted on being allowed to vet prospective appointees and even the right to nominate doctors who ­were members in good standing and therefore shared or­ga­nized medicine’s medico-­economic and po­liti­cal philosophy. In 1969, an AMA House of Delegates resolution objected vehemently to public health agencies’ ambitions to monitor and audit doctors paid by Medicaid for poor patients with state and federal revenues despite solid evidence of widespread poor-­quality practices, unnecessary procedures, and fraudulent billing. Prac­



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

377

ti­tion­ers with impor­tant preventive tasks like optometrists, dentists, and podiatrists ­were among ­t hose known for poor ser­vice and fraudulent billing. According to deputy commissioner of the New York City Health Department Lowell Bellin in his 1970 Senate testimony, when New York initiated audits of Medicaid prac­ti­tion­ers “to protect the patient from biological peril, the taxpayer from piracy, and the typical practitioner from unwarranted smear,” or­ga­nized medicine cried out in “apocalyptic terms” that the city health department had “accelerated the advent of 1984.” If ­there had to be on-­site auditing, the AMA insisted, then it should be by medical “peers” handpicked by state or county medical socie­ties. Bellin objected, saying that the medical profession could not be trusted to regulate itself any more than any other trade or commercial sector.33 Strains between the medical profession and public health authorities ­were partly a legacy of the AMA’s successful opposition to guaranteed health insurance. According to U.S. Assistant Surgeon General John  J. Hanlon in 1973, the lack of coverage for the low-income population “trapped” local health departments into providing prevention-related medical ser­vices in their own hospitals and clinics. Their direct provision of such ser­vices not only antagonized local medical socie­ties but also sowed division within the public health world itself. A regrettable consequence of the decentralized mix of preventive and clinical ser­vices was a plethora of conflicting and therefore inefficient policies, ordinances, and programs. ­There was pervasive “distrust, provincialism, status consciousness, competition, and, above all, inadequate communication” among public health agencies within and between ­every level of government. ­There was “pernicious and destructive jealousy” all around. The chaos was “indecent and inequitable.”34 According to a 1976 article in the American Journal of Public Health by Milton Terris, an eminent and revered public health missionary, the chaos also resulted from the farming out of public health tasks to private interests and agencies without regard for their competence to perform them. Thus, he argued, since the Second World War, the public health system had been marked by atrophy and entropy. Despite the possibilities of improved prevention opened up by major strides in epidemiological research, t­ here was “confusion and pessimism about the f­ uture role of health departments.” Implicitly, with reference to “vested interests” in the way, Terris implicated the AMA for its contribution to the “neoliberal triad” of government bud­get cutting, deregulation, and privatization in public health. ­Because of or­ga­nized medicine’s ideological hostility to government in general and self-­interested antagonism

378

Reactionary Turn and Beyond

t­oward public health agencies in par­tic­u­lar, Amer­i­ca’s chaotic public health system lacked the po­liti­cal constituency it needed most for public re­spect, adequate funding, and rational organ­ization.35 ­Little improvement came the following de­cade. In 1988, an extensive Institute of Medicine report told of a public health system “in disarray.” Some of its po­liti­cal prob­lems lay in the “uneasy” relationship between or­ga­nized medicine and public health institutions. The relationship was, it complained, too often marked by “confrontation and suspicion.” In a 1991 keynote address to a meeting of the American Public Health Association (APHA), William  H. McBeath was unable to report on any improvements. Echoing Terris, McBeath complained that the preceding fifteen years of conservative governments had idealized “individual responsibility” in order to justify reducing public expenditures, commercializing the delivery of health ser­vices, and promoting “prevention initiatives” to change unhealthy behavior. It was po­liti­cally expedient and cheaper, he said, to “blame the victims” by preaching individual lifestyle change when the most pervasive risk ­factor for disease and injury was poverty. The way forward required new leadership for a “massive effort . . . ​to prevent the diseases of poverty, and to promote health among the disadvantaged.” He called on the federal and other governments, public health professionals, and the APHA to provide the necessary leadership. Tellingly, he did not mention the AMA. Apparently, or­ga­nized medicine was irrelevant—or worse.36 M E D I C O - ­E C O N O M I C S A N D P O L I T I C S

On medico-­economic issues, the AMA maintained a steady conservative course from the early 1920s into the end of the c­ entury. “State medicine” in all its forms, usually called “socialized medicine” a­ fter the 1930s, remained an unmitigated evil. In 1926, the House of Delegates passed a resolution calling for repeal of the 1924 World War Veterans’ Act provision allowing the Veterans Administration (VA) to provide ­free hospitalization and related ser­ vices to honorably discharged veterans for illness or disability unrelated to their military ser­vice. Signed into law by Republican president Coo­lidge, it was “state medicine pure and ­simple” according to AMA president William  P. Haggard. It would “pauperize” nearly five million Americans. To the AMA Board of Trustees, VA care was “communistic medicine” smuggled in “­under the cloak of patriotism.” The likes of this “obnoxious state medicine,” according to the AMA journal, could spread to other federal



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

379

employees. In the following de­cades, the AMA complained perennially about hiring VA prac­ti­tion­ers on a full-­time salaried basis, therefore violating “medical individualism.”37 Compulsory health insurance remained off the country’s po­liti­cal agenda ­until the massive depression of the 1930s hit, and liberal Demo­crats took control of Congress and the presidency. Much has been written by historians on or­ga­nized medicine’s fierce opposition that de­cade and onward. L ­ ittle needs 38 repeating ­here. In 1934, President Franklin Delano Roo­se­velt appointed the now-­famous Committee on Economic Security (CES) to deliberate what was to become the Social Security Act (SSA) of 1935. Health insurance was on the agenda ­because doctors and patients alike stood to benefit by helping the unemployed sick to pay their under-­or unemployed doctors. For that, the CES appointed a Medical Advisory Committee (CES-­M AC), one of whose diverse members was AMA president Walter L. Bierring. Another medical conservative on the CES-­M AC was Yale neurosurgeon Harvey S. Cushing, the father-­ in-­law of Roo­se­velt’s son James. Cushing strongly advised the administration against including health insurance. In the end, Roo­se­velt tabled the m ­ atter, believing that b­ ecause of the AMA’s g­ reat influence in Congress the entire social security bill would fail if health insurance w ­ ere included. Ten days a­ fter Roo­se­velt signed the act into law, the AMA journal rewarded him with a cold, unenthusiastic report on the SSA and its substantially increased funding for public health work and ser­vices to vulnerable populations. It allegedly “designed to work a revolution in the social and po­liti­cal relations of the ­people and of the several states to the federal government.”39 In the second half of the 1940s, the AMA again faced off against a formidable co­a li­tion of compulsory health insurance advocates. Senator Robert F. Wagner, a New York Demo­crat, led the forces for versions of what would be known as the Wagner-­Murray-­Dingell (WMD) bills for a contributory scheme of hospital and medical insurance. Unlike Roo­se­velt, who had remained noncommittal, his successor Harry F. Truman gave national health insurance an enthusiastic endorsement. This time the AMA mobilized a massive public propaganda and lobbying campaign, spearheaded by Morris Fishbein. To maintain its tax-­exempt status, the AMA set up a nominally in­de­pen­dent and externally funded National Physicians Committee for the Extension of Medical Ser­vice (NPC). Year a­ fter year, congressional committees invited NPC testimony and refused to pass on the WMD bills for floor votes. Meanwhile, across the Pacific Ocean, the AMA sent a “mission” to Japan in 1948 to advise General Douglas MacArthur and the Supreme Allied Command against

380

Reactionary Turn and Beyond

allowing the occupied country to establish a national health insurance system. They ­were told it would “inevitably push the Japa­nese farther along the road of centralization of power back to totalitarianism.” 40 In the late 1950s and early 1960s, government insurance advocates set their sights lower. By then, ­because of AMA opposition to compulsory insurance, major employers had stepped in to cover a ­great many working-­age citizens, thus reducing popu­lar interest in a universal government plan. Instead, therefore, liberal Demo­crats aimed only to assist the retired el­derly with hospitalization expenses. To minimize AMA opposition, they left out payment of doctors’ bills for their ambulatory ser­vices and ­those they performed on the patients they admitted to hospitals. Insurance companies w ­ ere divided; many large ones made supportive noises, knowing that covering the el­derly on a voluntary basis was a losing proposition. B ­ ecause of their financial distress, many hospitals ­were won over to the idea of compulsory hospitalization coverage as long as private Blue Cross plans ­were allowed to ­handle the administration of benefits. The AMA attempted, but failed, to rally the American Hospital Association against Medicare by mobilizing staff physicians to dissuade hospital administrators. It also failed to strong-­arm nurses into joining the co­a li­tion against Medicare with threats that members of the American Nurses’ Association might lose their jobs. The AMA’s allies included the National Association of Manufacturers and the U.S. Chamber of Commerce, which mostly represented smaller firms. Large employers, by contrast, stayed ­silent, and t­ here is strong evidence that they, too, ­were actually favorable to Medicare b­ ecause it promised to bail them out of their expensive commitments to cover workers a­ fter they retired.41 Despite Medicare’s ­limited aims, the AMA girded for ­battle as before. This time it lost both the b­ attle and a g­ reat deal of public sympathy. In part b­ ecause of a Demo­cratic landslide in the 1964 congressional and presidential elections and big business’s tacit approval, Medicare passed with large majorities in both ­houses of Congress, with many Republicans voting in ­favor. In the end, ­because of the fortuitous intervention of ranking Republican Ways and Means member John W. Byrnes, Medicare included medical ser­vices (Part B), as well as hospitalization (Part A). Ironically, this was actually an economic victory for the medical profession, according to none other than Morris Fishbein, ­because it brought in extra income for the profession without taking away clinical sovereignty. B ­ ecause of its intense opposition, he wrote in his autobiography, the AMA “plucked victory out of total defeat.” It was a victory



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

381

b­ ecause the law “explic­itly prohibited the federal government from exercising authority over how medicine was to be practiced.” First, to assuage the profession, the law’s preamble denied the federal government the power of “supervision or control over the practice of medicine or the manner in which medical ser­vices are provided.” To make it harder to violate that princi­ple, key ele­ments of standard practice in private insurance ­were incorporated in the administration of the benefits. As Fishbein put it, “The basic princi­ples of personal relationship between doctor and patient, the right of the patient to choose a physician, the right of patient and physician to choose a hospital, and similar princi­ples which represented the major policies for which it fought for over fifty years.” In short, the AMA “played a vital part in determining the form of the legislation for medical care of the aged.” 42 The most impor­tant of the “similar princi­ples” Fishbein referred to was fee-­for-­service payment of individual doctors and hospitals. In effect, the prohibition of government control over medical decision-­making ruled out practically any other way of contracting with and paying doctors. The resulting arms-­length relationship between the government as payer and doctors and hospitals as providers led to an almost unfettered expansion of commerce in high-­priced medical goods and ser­vices. In effect, according to historian Christy Ford Chapin, the federal government imported the insurance model that had already been jointly crafted by the private insurance industry and or­ga­nized medicine to serve their partially overlapping purposes.43 The insurance industry was able to make separate peace with medical providers because it could easily pass cost increases onto premiums for workers’ employer-sponsored fee-for-service plans. Workers took the hit with smaller yearly take-home wage increases. Congress rescued Medicare from rising costs by raising payroll taxes to cover them because the Medicare law did not allow the government to violate physician sovereignty by reducing the volume of inefficacious and wasteful practices. The new flood of federal dollars for elderly medical care lifted physician income and hospital revenues steadily. That money helps explain why a 1970 AMA resolution now allowed that it was “the basic right of every citizen” to get adequate health care. Even more novel was the resolution’s exhortation to the medical profession to use “every means at its disposal” to secure that right. That surely raised the ire of many AMA members. One year later, a revision shifted the responsibility for guaranteeing care to all back onto “the citizens or society.” The medical profession no longer had to use the political means at its disposal to help.44

382

Reactionary Turn and Beyond

­ ecause of its adamant opposition to socialized medicine, the conservaB tive AMA fought aggressively against government employment of physicians to care for unemployed and other­wise uninsurable populations. In 1963, it suc­ ental ceeded in getting Congress to scale back President John F. Kennedy’s m health bill for the care and rehabilitation of disabled persons who w ­ ere ware­ housed, isolated, and often badly treated in large state-­run asylums. The bill called for medical and other salaried professionals to be paid salaries for ­mental health programs run by community institutions and facilities. The AMA’s Council on M ­ ental Health, consisting of prominent psychiatrists, had endorsed the staffing provisions, and one of its members was known to have been an author of the bill. But they ­were challenged and voted down in the House of Delegates, which gave AMA lobbyists the go-­a head to gut the legislation. In the end, the Community M ­ ental Health Act contained no federal money for states and communities to pay psychiatrists, psychologists, nurses, and social workers. Only ­after their landslide electoral victories of 1964 ­were President Johnson and congressional Demo­crats emboldened to defy the AMA and offer ­limited funding for professional staff.45 Or­ga­nized medicine’s warfare from the 1930s onward against a compulsory insurance solution naturally diverted some health insurance advocates’ energies into private, voluntary means for expanding access to affordable medical care. “Prepaid group practices” (PGPs), in which salaried physician groups promised to deliver care to enrollees in exchange for relatively low monthly fees, ­were one way. But even experiments with PGPs, starting in the 1920s, aroused intense opposition from the conservative AMA and its component socie­ties. All forms of what they called “contract practice” or “the corporate practice of medicine,” they maintained, w ­ ere unethical. Fishbein called the arrangements “medical soviets.” Thus, in 1932, when the famous blue-­ribbon Committee on the Costs of Medical Care (CCMC), financed by eight major philanthropic foundations, recommended them as a high-­quality way to deal with rising medical costs and low coverage, he called the CCMC’s report and recommendations “an incitement to revolution.” 46 Even physician-­ run group plans paying themselves on a traditional fee-­for-­service basis ­were ethically suspect, especially when anything even remotely resembling advertising was used to attract patients away from in­de­pen­dent fee-­for-­service prac­ti­tion­ers. From the 1920s to the 1940s, however, the AMA tactfully refrained from criticizing the many power­ful employers, such as railroads, that contracted with a panel of physicians in PGPs to provide f­ ree ser­vices for their workers.



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

383

In the 1940s onward, or­ga­nized medicine made peace with conventional forms of employer-­sponsored private insurance, commercial or nonprofit, that allowed patients to see any licensed physician. Many state medical socie­ties sponsored open-­panel nonprofit Blue Shield medical ser­vice plans to head off a government solution. World War II gave a jump start to nonprofit and then commercial group arrangements ­because, in the context of ­labor scarcity, large industrial employers ­were allowed to offer health and other social benefits to come out from u ­ nder wage controls and recruit, retain, and expand large ­ fter the war, armies of workers to meet huge ­orders for military goods. A employment-­based insurance expanded rapidly in part b­ ecause of the Revenue Acts of 1942 and 1954, favored by both capital and ­labor, that exempted health benefits from workers’ taxable income.47 It was a win-­win-­win solution for capital, l­ abor, and medicine. The medical profession adapted happily, just as they would l­ater to Medicare, b­ ecause the employment-­based insurance system preserved clinical autonomy with traditional fee-­for-­service payments—­and opened up new revenue streams into doctors’ pockets. A huge exception to the peace between big business and or­ga­nized medicine emerged during the 1930s and then expanded during and ­after World War II in the form of the Kaiser Permanente system of PGPs for industrial and then broader employee groups and their dependents. The germ of the system was planted in the early 1930s to provide integrated physician and hospital ser­vices to attract and serve the armies of workers needed for building the Colorado River Aqueduct in Southern California’s Mojave Desert and then the G ­ rand Coulee Dam on the Columbia River in Washington State. A consortium of builders of the aqueduct and another for the dam contracted with the dynamic and entrepreneurial physician Sidney R. Garfield, his hospital, and a group of doctors that he recruited, many of leftish persuasion, to provide essential care for sick and injured workers. Henry J. Kaiser, the largest of the two proj­ects’ contractors, replicated the arrangement for other gigantic construction and manufacturing enterprises, especially shipbuilding, steel, and other military work on the West Coast during World War II. But local and state AMA affiliates used ­every device available to deter doctors from signing up with what came to be called Permanente, Garfield’s medical group: social ostracism, slander, expulsion, and blacklisting by hospitals. According to Kaiser’s and Garfield’s Senate testimony in 1942, doctors agreeing to care for Kaiser workers’ families even received threats emanating from current and former AMA officials on the War Manpower Commission’s

384

Reactionary Turn and Beyond

Procurement and Assignment Ser­vice that they would be drafted into war ser­vice if they participated. The AMA had begrudgingly accepted the arrangement for war industry workers but not their dependents. Major newspapers picked up on the story to the AMA’s embarrassment.48 In the end, or­ga­nized medicine was no match for the cross-­class alliance of big l­abor with Kaiser Steel, Kaiser Shipbuilding, and Kaiser Aluminum, which, like the war­time government that contracted with them, had no qualms about employing Garfield’s “medical soviet.” The Kaiser Permanente “Health Maintenance Organ­izations,” as the AMA feared, w ­ ere the heavi­ly armored vanguards of what Paul Starr calls the “corporate transformation” in health care and its challenge to physician sovereignty. That transformation was, from the beginning, a po­liti­cally brokered one and a major ­factor in the later decline of the AMA as a power­ful conservative force.49 PHAR MACOPOLITICS

One legacy of the AMA’s reactionary turn of the 1920s was the suspension of the progressive era’s radical mission, however modest in its pursuit and results, of advancing rational therapeutics by educating doctors about worthless proprietary drugs and promoting clinical studies of more promising ones. That had begun with the creation in 1905 of the AMA’s Council on Pharmacy and Chemistry (CPC), whose first task was to rid medical journals of advertisements for bogus concoctions and thus limit physicians’ prescriptions to the better class of drugs. But the ambition was to go further with what reformer Solomon Solis-­Cohen called “scientific therapeutics.” His belief in the need for sophisticated clinical research was in the air among reformers, among them the highly influential CPC member (and often chairman) Torald Sollmann. In 1903, shortly before the CPC’s creation, Sollmann had ardently advocated a “program of pharmacologic research” with rigorous experimental methods. Among other t­hings, that would involve “comparing the value of drugs supposed to possess equivalent actions,” what is now called “comparative effectiveness research.” In 1912, Sollmann spoke of the modern doctor’s “moral obligation” to question what he had once concluded on the basis of “slovenly observation and wild deduction” and to “establish by exact observation that it is a fact, and not a figment of his imagination.” Therefore, Sollmann touted “the carefully planned, accurately executed, and intelligently digested study ­ uman patients.” Responding to his initiative, the of the effects of drugs on h AMA began funding a new Committee on Therapeutic Research (CTR)



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

385

­ nder the CPC. The CTR’s main function was to initiate, fund, and coordiu nate clinical research to be conducted in vari­ous institutional settings. By 1916, it had funded twenty-­seven investigations, a modest but significant start, especially given the l­imited resources available and weak interest in better science behind their therapeutics among the rank and file.50 The AMA’s conservative regime allowed the CTR to live a twilight existence as a vestigial relic of ­earlier progressivism. It was never given more than a very small bud­get (about $13,000 in 1945), barely more than half of what the Council on Physical Medicine received. No evidence can be found of its survival past that time. In the 1920s ­until 1933, the AMA actually repudiated rational therapeutics by lobbying for repeal of the prohibition laws’ limits on the prescribing of alcohol. More importantly, in 1955 the AMA took away the CPC’s authority to deny a “seal of approval” to dubious drugs, thus preventing their advertising in AMA journals as well as state journals adhering to CPC standards. ­Because of the CPC’s control, over time many drug companies had been gravitating to in­de­pen­dent journals with lax advertising standards as well as relying more on armies of “detailers” to hawk questionable products in doctors’ offices. Flagging advertising revenues since the 1940s and a study in 1953 by the big marketing firm Ben Gaffin and Associates persuaded the AMA trustees to take the job of vetting advertisements away from the expert pharmacological volunteers in the CPC and hand it to an “advertising review committee” of regular employees dependent for their salaries on the AMA’s trea­sury, which in turn was filled by revenue from journal advertising. In 1969, Edward Pinckney, then a disaffected former associate editor of the AMA journal, testified in Senate hearings that its advertising committee during his time as editor in the late 1950s had been “nothing more than one ­woman, medically untrained, who glanced at the ads, and seemingly did nothing more than admire them for overall appearance.” No overtly misleading statements ­were ever corrected. Although the AMA claimed to have “advertising princi­ples,” he said, they “never ­really existed in fact.”51 The AMA had been one of the driving forces b­ ehind the 1906 Pure Food and Drugs Act but was anything but that for its replacement, the entirely new Food, Drug, and Cosmetic Act (FDCA) of 1938. Most impor­tant as regards drugs, the new law gave the Department of Agriculture’s Food and Drug Administration (FDA) the rulemaking power to block the marketing of new ­ ere not adequately tested for safety. Now, the making of curadrugs if they w tive claims that the bulk of medical scientists would not defend was declared

386

Reactionary Turn and Beyond

“misleading” and therefore prohibited—­unless the existence of controversy was disclosed in labels, packages, and inserts. The Federal Trade Commission was given extra power to control drug advertising. The progressive AMA would have been delighted, but for as-­yet obscure reasons, not its conservative incarnation. Pos­si­ble reasons for its inertia w ­ ere revealed to the interested public the year ­after the law’s passage by radical muckraker James Rorty. In his book, American Medicine Mobilizes, Rorty detailed the AMA journal’s heavy dependence on advertising of proprietaries and the cozy relationship that had evolved since the 1920s between editor Fishbein and the companies whose drugs passed the AMA drug council’s low hurdles. Among other t­ hings, the CPC did not require evidence of safety and allowed access to advertising space for any company’s approved drug only half of its other drugs had also passed muster. Rorty also exposed the beginnings of the AMA’s friendly relations and dependence on advertisements for cigarettes to doctors.52 Instead of the medical profession, the key promoters of the 1938 law ­were ­women’s and consumer groups and the FDA employees who assisted them. The AMA actually submitted a brief complaining of the discretionary rulemaking powers that w ­ ere to be conferred on the FDA. The phar­ma­ceu­ti­cal profession, represented by the American Phar­ma­ceu­ti­cal Association, the National Association of Boards of Pharmacy, and the American Association of Colleges of Pharmacy, also supported a strong new law. Some FDA staff “keenly resented” the AMA’s less than enthusiastic, noncommittal backing of drafts of the law. One provision in a Senate bill that fell by the wayside, perhaps b­ ecause medical support was lacking, defined as false advertising any claim that a drug was useful in treating thirty-­six incurable diseases listed. It would also have given the FDA the power to subtract or add to the list.53 The FDA’s Theodore Klumpp, who would soon head its new regulatory arm, wrote to his former Yale colleague and a bold AMA dissident John Punnett Peters Jr. that reformers “who have the public interest at heart have been disappointed that they have not received more vigorous support from the medical profession.” Congressman Virgil Chapman, one such reformer, penned a letter to Peters and other “outstanding physicians” for help. Klumpp hoped that Peters would respond and send supportive letters to Chapman and other members of the House subcommittee crafting the bill. Elite medical support, Klumpp said, was needed to counteract “the massed opposition of ­those who have a material interest in emasculating the bill.” A few months ­later, Peters managed to collect a large amount of inside information, perhaps from Klumpp, that could explain why the AMA would only pay “lip ser­vice” to the bill. He told Harvard professor of pediatrics and fellow liberal medical



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

387

reformer Allan Butler that he hoped to use it to embarrass the AMA about its cozy relations with the drug industry. “Advertising, patenting and secret pro­cesses together are establishing prohibitive prices for the public and I think ­here the medical profession has unconsciously connived at a nuisance.” At the time, Peters and fellow dissidents ­were locked in a fierce b­ attle with editor Morris Fishbein. “If Fishbein is to be cornered,” he said, “this is the best m ­ atter on which to catch him.”54 Given the AMA’s diffidence, the 1938 law might not have made it through Congress had it not been for the Elixir of Sulfanilamide tragedy. The mixture of a ­bitter sulfa drug, suspended in and sweetened by poisonous ethylene glycol, caused 107 extremely painful deaths, mostly of c­ hildren. This gave a galvanic jolt to a sluggish Congress. It got another such jolt in 1962 from the thalidomide scandal, making pos­si­ble another major regulatory reform, the Kefauver-­Harris amendment to the FDCA. One major change in the 1962 law was the requirement that drug companies conduct large, controlled clinical t­rials demonstrating efficacy as well as safety and submit the results to the FDA for review before they could advertise new prescription drugs to doctors—​ but only for the specific conditions investigated. The bill fi­nally passed through a reluctant Congress following press reports on the deaths of thousands of fetuses and infants from thalidomide taken by their ­mothers while pregnant for nausea and sleeplessness and on the severe deformation of limbs and internal organs of the babies that survived.55 Most of the victims ­were in Eu­rope; American babies ­were largely spared ­because a feature of the 1938 law had allowed Frances Kelsey, a young, extraordinarily well-­trained, resourceful, and determined FDA pharmacologist, to delay its introduction in the United States pending the submission of better evidence of safety. Kelsey, in communication with a network of mentors and other experts, had learned that thalidomide caused peripheral neuropathy (pain, coldness, numbness, tingling) in the extremities of some ­people who took it. That prompted the courageous, recently hired Kelsey to demand, in the face of intense drug com­pany pressure, further research on the drug from its maker about the possibility it could pass the placental barrier and have far worse effects on a fetus. Interestingly, Kelsey had worked ­under Austin Smith as an associate editor of the AMA journal from 1950 to 1954, and that experience no doubt gave her firsthand knowledge of drug companies’ research and advertising ethics, about which she was l­ ater keenly ­ ntil 2010, of suspicious. A search of the journal finds no acknowledgement, u what the American public learned from newspapers and tele­vi­sion of her heroic role in 1962.56

388

Reactionary Turn and Beyond

The AMA, whose alliance with the phar­ma­ceu­ti­cal industry was no longer obscure, openly opposed the amendments. Had it not done so, the reform might have passed without the thalidomide scandal, which caused President Kennedy’s switch from neutrality to strong support. To oppose reform, the drug industry used Cold War rhe­toric to portray the American phar­ma­ceu­ti­ cal industry as the world’s leader ­because of its freedom from the heavy hand of the state. Likewise, the AMA portrayed American medicine as the best in the world for the same reason, including the lack of compulsory health insurance. In his testimony, chairman of the AMA Board of Trustees Hugh H. Hussey declared that a doctor “should not be deprived of the use of drugs that he believes are medically indicated . . . ​by a governmental ruling or decision.” The reason: “We believe that only the physician has the knowledge, ability and the responsibility to make decisions about what par­tic­u­lar drug works for a par­tic­u ­lar patient.” It was an utterly “specious” argument, testified Louis Goodman, coauthor of a standard textbook on pharmacological therapeutics and a recent president of the American Society for Pharmacology and Experimental Therapeutics.57 Shortly ­after the reform’s passage, the AMA House of Delegates called for repealing it. A de­cade ­later, vari­ous state del­e­ga­tions still called for repeal, and the House of Delegates obliged them with “repeal or amend” resolutions to take the FDA’s foot off the brake on the marketing of new drugs. As late as 1977, the AMA appeared to stand firm against the alliance of forces for rational therapeutics and phar­ma­ceu­ti­cal governance. That year, Representative Steven D. Symms, a right-­wing Idaho Republican, invoked AMA policy for his “medicine freedom of choice” bill designed to weaken the FDA. It attracted 105 cosponsors, but with Demo­crats in control of the House of Representatives, it never made it out of committee for a vote. Well into the 1990s, the AMA remained a conservative po­liti­cal ally of the drug industry. As physician and Pfizer executive Mike Magee recalled (and regretted) l­ater, ­because of the relationships he cultivated with the AMA as well as other medical institutions in the 1990s, he had been “enabling and solidifying” the hidden operations of Amer­i­ca’s power­ful “medical industrial complex.”58 MEDIC A L EDUC ATION A ND THE CR E ATION A ND DIFFUSION OF CLINICAL SCIENCE

Reform of medical education had been a big part of the progressive agenda. ­There was no significant retrograde motion during medicine’s conservative



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

389

era but no pressure for improvements in instruction in epidemiology and prevention e­ ither. Less prestigious and wealthy schools of public health w ­ ere left to take up all the slack, thereby perpetuating what physician, economist, and epidemiologist Kerr L. White called a “schism,” a “tragic separation” of public health from medical training and activity. Instead, u ­ nder the conservative AMA, economic protectionism ­rose in importance relative to the quality and health concerns of the ­earlier progressives. In his 1934 inaugural address, delivered when almost a quarter of the American workforce was unemployed, AMA president Walter Bierring focused on the acute economic prob­ lems of prac­ti­tion­ers, not the dearth of patients able to pay them. The solution, a “fine piece of educational work,” he thought, would be to shut down half of the seventy-­odd medical schools.59 In the 1950s and 1960s, the AMA fed the fire of its liberal critics by attacking the federal subsidization of medical schools to deal with doctor shortages and to help schools hard-­pressed since the war to afford up-­to-­date facilities and rising operating expenses. Federal subsidization, the AMA testified, was a “dangerous device” the government would use to get baneful control over medical education. “Academic freedom” was at stake ­because “state medicine,” the old boogeyman, was haunting medical education. It was a “back door approach to socialized medicine.” To prove that ­there was no need for government assistance, the AMA pledged in 1950 a rather paltry $500,000 out of funds left over from the successful drug industry–­subsidized b­ attle against the Truman-­era movement for guaranteed health care. It hoped that businesses, individual philanthropists, and even l­abor ­unions would join in the charitable gesture.60 For another eigh­teen years the AMA rejected arguments for federal help advanced by the American Association of Medical Colleges (AAMC). Starting in the 1950s, medical schools ­were able to rescue themselves from financial disaster by paying faculty and funding their overhead out of research grants from the National Institutes of Health (NIH). Federal research funds flowed freely not b­ ecause of AMA pressure but ­because of the so-­called Lasker Lobby. Mary Lasker was a dynamic layperson who, along with the equally forceful Florence Mahoney, rounded up other laypeople, prominent physicians, and key legislators to raise money from Congress to build up the NIH. The AMA did not accept the need for federal research money ­until around 1960. Not ­until 1968 did the AMA relent and agree that medical schools needed direct federal support to meet both quality and quantity goals. Furthermore, in performing its delegated, quasi-­governmental role—­a longside

390

Reactionary Turn and Beyond

the AAMC and the American Hospital Association—in the accrediting of medical schools, gradu­ate specialty training, and continuing medical education programs, the AMA neglected almost entirely to promote unconflicted pharmacotherapeutic instruction. Instead, it allowed drug marketing dressed up as educational material to swamp every­thing ­else.61 The AMA also sided with town against gown on ­things that threatened community prac­ti­tion­ers’ hold on patients and their prized clinical autonomy. In 1965, according to Mike Gorman, the director of a presidential commission proposing it, the AMA lobbying “totally emasculated” a bill championed by President Lyndon Johnson and sent by the Senate to the House of Representatives calling for the construction of 60 regional heart disease, cancer, and stroke centers and networks of 450 “community stations” built around university medical centers for treatment of, research on, and instruction on the big killer diseases. According to Michael DeBakey, the famous surgical pioneer and the chief architect of the plan, the purpose was to integrate in­de­ pen­dent prac­ti­tion­ers into the networks to bring them more quickly up to speed with and give them access to the latest preventive, therapeutic, and surgical advancements. In a “hyperbolic and b­ itter campaign,” however, according to a historical account, the AMA claimed that the centers would take business away from community prac­ti­tion­ers and put the federal government in control of the practice of medicine. In the end, according to Gorman, the House was “clubbed . . . ​into submission” by AMA lobbyists into accepting an amputated version of the Senate bill. Among the clubs wielded was a threat directed at President Johnson that the AMA would not cooperate with the implementation of Medicare if the unamended Senate bill became law.62 MEDIC A L A PA RTHEID A ND PATR I A RCH Y

No discussion of the conservative era could be complete without a discussion of medical racism. The impact of public health disarray fell disproportionately on the inner-­city and rural poor. Or­ga­nized medicine facilitated disproportionately high levels of African American morbidity and mortality by abandoning its Progressive ­Era focus on public health and preventive education as well as its obstinate rejection of community health centers. One impor­tant mea­sure of the health consequences of medical racism is infant mortality, which is especially amenable to reduction with good, timely medical counseling and well-­trained midwives or obstetricians. Between 1950 and



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

391

1965, neo-­and postnatal mortality rates in the black population barely declined, while the rates for white infants fell steadily. B ­ ecause of lack of treatment on top of poor and overcrowded living conditions, the percentage of black p ­ eople ­dying of tuberculosis remained, as e­ arlier in the c­ entury, far higher. In 1985, the tuberculosis morbidity rate for black males was five times higher than for whites. Urban air pollution is a contributing cause of asthma and triggers potentially fatal asthma attacks, especially in the elderly lacking air conditioning. Exposure of young inner-­city c­ hildren to high lead levels in paint and gasoline contributes to learning disabilities, attention deficit hyperactivity disorder, impulse control prob­lems, and crime. The list could go on. In a sense, or­ga­nized medicine benefited Southern agricultural interests in cheap l­abor by standing s­ ilent on and even perpetuating Jim Crow institutions and practices. Their congressional champions returned the f­ avor by opposing guaranteed health insurance. The dearth of black medical schools and integrated hospitals contributed to the ills of the African American population, North and South. In 1938, a “goodwill” committee of the separate but unequal National Medical Association (NMA) entreated the AMA to accept membership in the NMA as an alternative to membership in the AMA’s white-­only county and state affiliates—­especially ­those in the South, where most black p ­ eople lived. The request was ignored. Because hospitals required AMA membership for admission privileges and other essentials of a medical c­ areer, such as internships and residencies, medical schools, in turn, cited that lack of access as a pretext for rejecting black applicants. Medical boards in many states refused licenses for black gradu­ates who had not been able to get hospital internships. Not surprisingly, the number of African American prac­ti­tion­ers stagnated even as the population grew. Between 1932 and 1942, the number of white doctors r­ose 12  ­percent, but black doctors dropped by 5 ­percent. In the mid-1950s, black physicians ­were only 2.2 ­percent of all physicians, though African Americans w ­ ere 10 ­percent of the population. In 1974, the African American physician-­to-­population ratio was actually lower than in the 1940s.63 The AMA registered its approval of medical apartheid before and even during the civil rights movement. A ­ fter the 1946 Hill-­Burton law supplied federal funds to build hospitals in needy areas, it supported their expenditure on white-­only hospitals if the flimsiest of arguments could be made that “separate but equal” facilities ­were available. In 1948, the AMA sent a letter to ­every medical school in the country warning them not to admit young civil rights activist H. Jack Geiger, a white University of Chicago premedical student,

392

Reactionary Turn and Beyond

Herblock editorial cartoon in the Washington Post. Organized medicine was able to maintain medical apartheid largely by making it difficult or impossible for African American physicians to obtain hospital appointments, specialty certification, malpractice insurance, and more. A 1963 Herblock Cartoon © The Herb Block Foundation.

­because of his “extracurricular activities.” Geiger had or­ga­nized a large student and faculty walkout to end discrimination against black patients in the University of Chicago’s teaching hospitals and black applicants to its medical school. Montague Cobb, the NMA president and dean at Howard Medical School, alerted Geiger about the letter. Cobb only knew about it b­ ecause the AMA, “not being too swift,” according to Geiger, had sent it to Howard and



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

393

the other black medical school, Meharry. In 1964, the AMA stood ­silent on the Civil Rights Act, which, along with Medicare in 1965, effectively ended segregated hospitals. But late in the 1960s, according to the NMA, hundreds of African American doctors in the South w ­ ere still being denied hospital privileges b­ ecause of their inability to obtain membership in the AMA’s county affiliates. Nevertheless, it was the opinion of Milford Rouse, the AMA president from Texas, that “we cannot find a single state . . . ​[or county] . . . ​medical association where any discrimination exists.” 64 A shocking instance of or­ga­nized medicine’s and therefore the government’s indifference to African Americans’ lack of medical care and public health ser­vices occurred in Tuskegee, Alabama. Starting in 1932, white researchers for the United States Public Health Ser­vice (PHS) conducted the now infamous Tuskegee “Study of Untreated Syphilis in the Negro Male,” which followed black men infected with syphilis for thirty years to mea­sure and trace its effects. ­Because it would undermine their study, the researchers did not advise their subjects to get treatment, much less offer it themselves. When the United States entered World War II, the PHS obtained draft exemptions for the men so that military doctors could not treat them and ruin the study. ­A fter the discovery of penicillin, one of the leading researchers said, “I hope that the availability of antibiotics has not interfered too much with this proj­ect.” Had t­here been plenty of black doctors in Tuskegee authorized to prescribe antibiotics, the experiment would not have been pos­si­ble. Lives would have been saved well before August 1972, when the scandal was exposed by an Associated Press reporter, Jean Heller, and covered in Time magazine. Since then, oral tradition among African Americans about Tuskegee, including the mistaken notion that its victims w ­ ere experimentally infected with syphilis, contributes to a rather common fear of doctors among black p ­ eople that inhibits their seeking timely and effective care or participating in research studies. It validated preexisting lore handed down across generations about experimentation on unwitting subjects and robbing black bodies from their graves to sell to medical schools for teaching anatomy.65 In 1968, the relatively liberal Mas­sa­chu­setts Medical Society submitted a resolution to the House of Delegates requiring the AMA’s Council on Ethical and Judicial Affairs to expel any medical society that excluded physicians on racial or religious grounds. Many delegates w ­ ere astonished when a delegate speaking for the Mississippi society supported the resolution, declaring that “we have never discriminated against anyone in Mississippi on race, creed, or ethnic grounds.” Spokesmen for other Southern state socie­ties also did not

394

Reactionary Turn and Beyond

object to the Mas­sa­chu­setts resolution. It was not a difficult call for them ­because by then Southern hospitals had to grant privileges to black doctors or face the loss of millions of dollars in Medicare and Medicaid funds for violating the 1964 Civil Rights Act. The resolution passed in 1968 with 170 votes, more than the two-­thirds majority required. Nevertheless, sixty-­nine delegates voted against the resolution, which required the AMA’s Ethical and Judicial Affairs Council to investigate and sanction constituent socie­ties for refusing black members. It never had to b­ ecause the racist medico-­politicos had reason to fear the U.S. Department of Justice even more.66 Medical patriarchy was less brutal. Unlike African Americans, w ­ omen ­were not locked out of the AMA. But ­because of discrimination by medical schools and other reasons for the l­ imited supply of ­women doctors, the patriarchy’s entrenchment was firm. Well into the 1950s, some medical schools refused to admit any w ­ omen at all and o­ thers “just enough,” as the joke went, “to form a dissecting team.” Female faculty members w ­ ere too rare to inhibit or militate against the demoralizing insults and assaults suffered at the hands of male students and faculty alike. In 1946, only about 42 ­percent of internships and 34 ­percent of residencies w ­ ere nominally open to w ­ omen, but men ­were routinely prioritized in filling them.67 The Medical W ­ omen’s National Association, l­ ater the American W ­ omen’s Medical Association (AWMA), was never able to put up much of a fight. It had been formed in 1915 during medicine’s progressive phase by a group of feminists in Chicago, in part ­because only two of the city’s hospitals had ­women interns. The AMA recognized the association but controlled its members “in a gentlemanly fashion,” according to historian Regina Morantz-­ Sanchez. In 1927, for appearances sake, the AMA Section on Obstetrics sought to have a token ­woman pre­sent a paper. But ­because of discrimination from the county level upward, no ­women found their way into AMA offices or even the House of Delegates. In the 1930s, AMWA president Josephine Baker, New York City’s leading public health advocate for ­children, asked indignantly, “Where are the ­women?” The AMA rebuffed a resolution initiated by Emily Dunning Barringer, exceptionally supported by the New York State Medical Society, calling for guaranteeing one ­woman a seat in the House of Delegates. It also rejected the AMWA’s call for ­women to be commissioned with the same status as men for military ser­vice in the Army and Navy Medical Corps. In time, the New York State Medical Society ­adopted the cause, but it took the war­time crisis, with help from key congressmen and the American Legion, to force through that change in 1943.68



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

395

To be sure, AMA attitudes ­toward w ­ omen, ranging from indifference ­to hostility, were not much dif­fer­ent from ­those of the rest of the professional world. ­Women doctors trying to survive in clinical practice absorbed the medical individualism of their male colleagues, while ­those who refused often gravitated to poorly paid and less prestigious jobs in public health agencies. Patriarchal as well as capitalistic attitudes among more conservative w ­ omen doctors, plus o­ thers’ defeatism about changing anything, turned the AMWA into an increasingly conservative and deferential organ­ization ­after its militant found­ers had moved on. They even rejected the preventive medical ideals that had once put the AMWA on the side of the Sheppard-­Towner Act. During the course of the 1920s, before the repeal of Sheppard-­Towner, the AMWA turned tepid about public health and eventually rejected the mixing of preventive and therapeutic ser­vices by public health agencies. In 1926, the Medical ­Women’s National Association Bulletin even published an opinion piece declaring that “maternity education should only be directed by physicians” and rejecting the tax-­subsidized medical attention that Sheppard-­Towner was offering indigent w ­ omen. The only unconservative orientation left in the medical w ­ omen’s movement concerned getting better repre­sen­ta­tion for clinicians in the AMA and the armed forces. In short, the AMWA became just another “special interest group,” according to the 1968 critique W ­ omen in Medicine by feminist Carol Lopate.69 The power of specialist male physicians had interrelated and far-­reaching adverse consequences for w ­ omen both as medical professionals and as patients. The AMA’s obstruction of guaranteed health insurance contributed to high maternal mortality. Or­ga­nized medicine obstructed the training and enlistment of midwives and nursing specialists for high-­quality care at lower cost while rising costs and declining insurance coverage put physicians’ and hospital ser­vices out of reach for many low-­income citizens. Hospitalization costs driven upward by the power­ful male-­dominated medical and hospital organ­ izations tapped away what might have been available from out-­of-­pocket payments or insurance reimbursements for hiring more nurses for critical labor-­ intensive monitoring and care of patients. In recognition of such prob­lems, the American Nurses’ Association (ANA) s­topped playing “handmaid” to the AMA in the early 1960s and endorsed Medicare. ­After failing to get the ANA and its state affiliates to withdraw its support, the AMA resorted to “grassroots” tactics against the activist nurses. In 1962, ANA president Mathilda Scheuer complained of “unethical pressures” on hospital administrators to intimidate their nurses into lining up obediently b­ ehind the doctors’ lobby.70

396

Reactionary Turn and Beyond

The possibility cannot be dismissed that the “overutilization” of costly, risky, often unnecessary, and sometimes fatal procedures on ­women, such as ovariectomies, hysterectomies, episiotomies, Caesarian sections, and radical mastectomies, as well as perhaps even tonsillectomies on c­ hildren, might have been lower had men not virtually monopolized gynecol­ogy, obstetrics, and surgery. Many surgeries ­were performed on female patients without their consent while they ­were ­under anesthesia for diagnostic purposes. Breast Cancer Informed Consent Legislation introduced into around two dozen state legislatures in the 1980s met with stiff re­sis­tance from state medical associations and the American Cancer Society. They regarded the laws as threats to physicians’ professional autonomy, illegitimate intrusions into the doctor-­patient relationship, and ­hazards to w ­ omen who ­were, they alleged, too emotional about their bodies to make good decisions.71 One elective operation not performed often enough, however, according to women’s groups and their allies, was abortion. During the Depression, an article in the New Republic by a critic of the AMA posited that access to abortions would have been a huge social gain for struggling families ­were it not for the “tragic inertia” of the medical profession. Into the 1970s, or­ga­nized medicine’s refusal to support anything but “therapeutic abortions” to save the lives of m ­ others contributed to many tragedies experienced by w ­ omen who sought illegal abortions from unqualified operators. Thus it guaranteed that women still suffered disproportionately from “medical chaos and crime,” which surgeon Norman Barnesby had argued back in 1910.72

The AMA’s reactionary turn of the 1920s left an indelible stamp on medical politics for the remainder of the ­century. It was a radical break, a g­ reat po­liti­ cal transformation prob­ably without parallel in the history of American interest group politics. Outside po­liti­cal forces may have helped, to a degree, to quicken the insurgency before the reactionary turn and harden its conservativism afterward. But if so, the exogenous forces ­were accelerants and reinforcers, not determinants. The decisive f­ actors w ­ ere endogenous to the medical politics and policies that the Progressive Era physician leaders pursued. The medical profession, as a po­liti­cal animal, became and remained a power­ful ally of lay forces for conservatism in the de­cades to come. It would stay to the far right of the po­liti­cal spectrum and resist being pushed t­ oward the center by the prevailing po­liti­cal winds. It rigidly adhered to what AMA editor Morris Fishbein called, in 1939, its po­liti­cal “platform” of opposing the entire



T h e C o n s e r v a t i v e M e d i c o - ­P o l i t i c a l O r d e r

397

welfare state. Accordingly, he wrote, “All forms of security . . . ​even against old age and unemployment, represent a beginning invasion by the state into the personal life of the individual, . . . ​a taking away of individual responsibility, a weakening of national caliber, a definite step t­ oward e­ ither communism or totalitarianism.” That was four years ­after passage by a large bipartisan majority in Congress of the Social Security Act, which included grants to states for maternal and infant health programs as the Sheppard-­Towner law had. It was the same year that Congress appropriated funds to the Social Security Administration for crippled ­children’s ser­vices and amended the SSA to add child, spouse, and survivor benefits to the retirement system. Apparently, only a small number of legislators agreed with the AMA that ­these ­were ominous steps t­ oward communism or totalitarianism.73 The stability of organized medicine’s ultraconservative medico-political regime since the 1920s was remarkable, considering the rapidity with which it had been installed and countervailing shifts in the external political environment. That stability can be explained in part, as the next chapter shows, by the purposeful and effective exercise of power by the leaders of the AMA and its constituent units over the medical profession itself. The internal discipline and therefore the projection of an illusory solidarity to the outside world helped the AMA assert extraordinary power, in alliance with other conservative forces, in national medical politics.

chapter 14

Medical Power Politics

Time ­after time in the United States, from the 1910s to the 1990s, with the exception of Medicare in 1965, stiff conservative opposition thwarted efforts to pass compulsory health insurance. By the 1940s, with the exception of Switzerland, ­every other eco­nom­ically advanced democracy across the Atlantic Ocean had universal coverage. ­A fter its first failures in several American states in the 1910s, guaranteed health care reappeared on the federal agenda for pos­si­ble inclusion in President Franklin D. Roo­se­velt’s social security legislation. During the ­Great Depression, reascendant progressive forces saw it as a remedy for unemployment and poverty caused by disease and disability and vice versa. But it was set aside as po­liti­cally impractical; re­sis­tance from or­ga­nized medicine threatened to torpedo the entire Social Security Act if health care was included. When plans for universal health care returned with presidential backing from Harry Truman in the 1940s, Richard Nixon in the 1970s, Jimmy Car­ter in the 1980s, and Bill Clinton in 1990s, one by one they ­were buried in Congress thanks to the AMA and its conservative allies. If the American medical profession had not repeatedly raised its voice in angry criticism of reformers, poured money into the campaign funds of congressional and senatorial allies, and lobbied the halls of Congress in full force, the United States would prob­ably not have remained a laggard. To be sure, the AMA was not all-­powerful. It battled guaranteed health care for the retired el­derly, but Medicare passed in 1965. The AMA lost that time in part 398



Medical Power Politics

399

b­ ecause it had been abandoned by its erstwhile allies among large corporate employers, a po­liti­cal force more power­ful than or­ga­nized medicine. Medicare promised to bail them out of the high and rising costs of coverage they had promised their retirees.1 Despite the AMA’s predictions of doom for the world’s best doctors and medical care—­and democracy to boot—­Medicare proved to be far from an unmitigated disaster. B ­ ecause of the AMA’s strenuous opposition, lawmakers had designed Medicare to incorporate the private insurance industry’s fee-­ for-­service system to pay for ­every clinical intervention delivered at doctors’ unfettered discretion. It thereby left the sovereign medical profession on its throne. ­Because of a provision in the law that Wilbur Mills, the power­f ul chairman of the House Ways and Means Committee, promised the AMA, it even increased the autonomy and bargaining power of hospital specialists such as anesthesiologists and radiologists vis-­à-­vis the hospitals that contracted with them. Physicians’ income rapidly ­rose a­ fter 1965 b­ ecause Medicare increased the supply of el­derly patients while giving doctors ­free rein to increase the volume of individual ser­vices for their frequent ailments and chronic disorders. Looking back in 1969, former American Medical Association Journal editor Morris Fishbein mused that b­ ecause of Medicare’s final design, the AMA actually “plucked victory out of total defeat.”2 How did the AMA exercise such power to preserve a conservative medical regime in the face of repeated challenges? One pos­si­ble answer is that the profession’s propaganda against “state medicine” and “socialized medicine” resonated with an allegedly unique American po­liti­cal culture of individual and ­family responsibility first and government welfare only as a last resort. But such arguments fail to withstand incontrovertible facts about the Social Security Act and Medicare, both of which enjoyed popu­lar support during and especially a­ fter passage. Numerous popularly elected governors and presidents supported compulsory health insurance, including Demo­cratic governor Al Smith of New York in 1919, Republican governor Earl Warren of California in the 1940s, and Republican governor Nelson Rocke­fel­ler of New York in the 1960s. Demo­cratic president Roo­se­velt was well disposed t­ oward it in the 1930s while l­ater presidents Truman, Kennedy, Nixon, Ford, Car­ter, and Clinton all voiced support and sometimes actively took up the cause. None w ­ ere socialists or other­wise “un-­A merican.” That governors and presidents repeatedly failed can reasonably be attributed to another explanation for Amer­i­ca’s exceptionalism: the “excessive frictions” of the po­liti­cal pro­cess and the resulting gridlock so astutely observed

400

Reactionary Turn and Beyond

by British visitor James Bryce in the 1880s. Efforts at major reforms regularly bog down and stall out in an impassable institutional landscape. On this phenomenon, po­liti­cal scientists refer to a multiplicity of “veto points” in the lawmaking pro­cess where minorities, even small ones, can obstruct major change. Indeed, legislatures are where health insurance reforms have repeatedly gone to die, often never being reported out of committees and brought to floor votes for passage. For example, the power of a single Republican committee chairman may have blocked the passage and signing of a compulsory insurance law in New York in 1919. The Demo­cratic governor supported it, it had passed in the state Senate with the help of some progressive Republicans, and a similar majority of the state Assembly might have voted for it had it come to a vote.3 Congressional opposition held Franklin Roo­se­velt back despite the liberal Demo­cratic landslide of 1932, President Bill Clinton could not get his reform through Congress, and even President Lyndon Johnson’s Medicare and President Barack Obama’s 2010 Affordable Care Act had to traverse extremely rocky po­liti­cal terrain to reach their destinations. To be sure, both a relatively strong but not universal aversion to government intrusions on the private sphere and Amer­i­ca’s constitutional particularities have to be considered as plausible contributory ­factors to Amer­i­ca’s health-­care exceptionalism. But they fail, even together, as an explanation without or­ga­nized medicine’s resolute exercise of power in shaping public opinion and strategically exploiting institutions to block reform. One pos­si­ ble reason the AMA succeeded as an obstructive force is offered by sociologist Paul Starr, who argues that the medical profession it claimed to represent had established formidable “cultural authority” deriving largely from presumptions about its rigorous training and therefore scientific credentials. Supposedly, that authority had swept away what Tocqueville observed back in the 1830s, a lack of deference and loyalty t­oward healers all but especially the regular profession with its complex and mystifying theories and dogmas. The deference to modern medicine’s “legitimate complexity,” to use Starr’s concept, might have helped the AMA persuade a critical mass of the public and po­liti­cal elite that American health care would only suffer if the incompetent and corrupt hand of government seized control.4 An inadequacy in Starr’s ­angle on medical power emerges when one examines the speciousness of or­ga­nized medicine’s claims about the scientific virtues of ­actual medical practice in the field as opposed to what the best of the profession was ­doing before and ­after the 1920s. To be sure, Starr reasonably



Medical Power Politics

401

surmises that belief alone in the widespread and skillful therapeutic application of medical science was enough to confer power; ­actual competence was not required for cultural authority. Many p ­ eople’s naive faith that t­ here was scientific method in the therapeutic madness was perhaps transferred from the manifest won­ders they experienced firsthand of theoretically grounded, experimentally tested, and practically applied advances in chemistry, metallurgy, and mechanical and electrical engineering. Nevertheless, as a m ­ atter of fact, much of the population showed precious l­ittle deference ­toward mainstream medicine. In the 1910s, for example, widespread doubts about regular prac­ti­tion­ers’ skills and ethics helped mobilize their many detractors to dash the progressives’ fond hopes of creating a national department of health. Their nemesis, the National League for Medical Freedom, was empowered by ­people’s per­sis­tent faith in alternative schools and cults and their consumption of profitable “patent” medicines advertised directly to them by for-­profit corporations.5 The therapeutic rationalists and public health scientists swept out of power in the AMA in the 1920s would have agreed that the common prescribing practices of the time ­were not based on solid research and breakthrough discoveries. Although ­there ­were significant antimicrobial advances before sulfa drugs and modern antibiotics—­for example, serotherapy and bacteriophage therapy for pneumonias and other infections—­they w ­ ere not widely administered by common prac­ti­tion­ers and ­were normally out of reach of low-­ income patients. Citizens who idealized doctors as scientific prac­ti­tion­ers could not have known that over seventy treatments recommended by a medical textbook published in 1927 for a long list of diseases ­were, according to a 1980 study, actually “valueless.” Another fifty-­t wo had been “marginally helpful” at best. For example, arsenic trioxide (Fowler’s solution) was still being recommended for at least forty diseases, including tuberculosis, pellagra, gastroptosis, and Sydenham’s chorea. Only twenty-­three treatments endorsed by the textbook ­were effective, most of them only moderately. As ­later discussion ­will show, the academic medical dissidents of the 1930s and 1940s continued to be unimpressed by what passed as pro­gress from clinical experience and word of mouth alone and drug companies’ breathlessly touted new merchandise. It was not ­until the late 1940s that antibiotics, the truly power­ful won­der drugs for infectious bacterial diseases, started becoming generally available, de­cades ­after the bacteriological breakthrough in medical science. But even antibiotics ­were vastly abused and misused

402

Reactionary Turn and Beyond

b­ ecause, to a g­ reat extent, of irresponsible, medically indefensible advertising in what medical historian Scott Podolsky calls the pre-1960s “regulatory vacuum” perceived by leading pharmacologists.6 If the medical profession exercised social, economic, and po­liti­cal power ­because of false scientific legitimacy, it was ­because it shielded the public from the facts. The AMA engaged in what historian Robert Proctor calls “agnotology,” the purposive cultivation of ignorance. The asymmetry of information preserved between profession and public was pervasive, and therefore adverse se­lection, the survival of the foulest, was still at work. In the case of surgery, much of what was done by e­ ager operators was useless and deadly. Patients paid them high fees, while hospitals charged them nothing for use of their facilities. Expensive specialty training was not required of them. According to one respondent in an impor­tant 1937 survey of the country’s medical elite, butchery by surgeons “with practically no qualification whatsoever, except the lack of conscience” was widely witnessed. But it was a well-­kept secret ­because warning the public about it was harshly frowned upon as a breach of medical “ethics.”7 Therefore, b­ ecause of patients’ clueless choices and the absence of professional self-­regulation, the quality of surgeons and their work was extremely uneven. In the 1937 survey, one respondent posited that half of all surgeries ­were performed by unskilled operators. In 1959, more than two de­cades l­ater, the same estimate was offered by Paul R. Hawley, director of the American College of Surgeons (ACS). Bad surgeons made extra work for good ones. An internationally renowned surgeon told Hawley that half his practice consisted of attempts to correct the bad work of untrained and uncertified scalpel wielders. In 1962, surgeon Loyal Davis, president of the ACS, said that requiring only a medical degree made for “legalized mayhem,” not medical order regulated by scientific knowledge and professional oversight. No one could know, he added, how many surgeries w ­ ere “bungled.” Research on unnecessary surgeries from the early 1950s to the early 1970s found that 30 ­percent or more of appendectomies and hysterectomies ­were unnecessary. What percentage of ­those ­were bungled was not studied. A 1971 study of six New York hospitals published in the New York State Journal of Medicine found that of 140 appendectomies performed, often by badly trained surgeons, 15  ­percent w ­ ere “not indicated” and inappropriate procedures ­were used in 6 ­percent. The hysterectomy totals were even more alarming. Of 148 performed, 43 percent were uncalled for. Inappropriate procedures were used ­ ere not reported explic­itly but had in 31 percent of them. ­Those percentages w



Medical Power Politics

403

to be calculated by readers from detailed ­statistical tables—­perhaps to prevent their being sensationalized in the public press. The art in this branch of medicine was often artless; the science—fiction.8 To be sure, the conservative medical profession did benefit from some measure of cultural authority. Much of its prestige in the eyes of lay elites had prob­ably rubbed off from the Progressive Era AMA leaders, but not ­because they had boasted about the profession’s curative powers. Instead, they had elevated the stature of the medical profession with their drug reform, public health, and medical education missions, not therapeutic breakthroughs. Wherever it came from, and however large it was, the profession’s cultural authority during the conservative era prob­ably lent credibility to the AMA’s warnings about the woe and ruin government-­g uaranteed health care would bring. But more impor­tant than cultural authority was their skillful and resolute exercise of power through coercion, silencing, propaganda, lobbying, campaign finance, and dealmaking. T HE IN WA R D E X ERCISE OF P OW ER

The medical profession’s control in American medical politics required the constant, purposive, and skillful exercise of medical power within and over the profession, not just on the outside world. The inward exercise of power was needed for the AMA to speak with one conservative voice in the outward exercise of soft, persuasive power—as if speaking for the vast majority of doctors. But amassing that power, based on high membership levels and the apparent absence of internal dissent, required the use of sharp tools: coercion to join, suppression of dissent, and punishment of be­hav­iors that might give life to and legitimize contrary points of view about how to finance and deliver health care effectively and fairly. With coercion, the AMA was able to corral a large majority of the country’s doctors into its ranks. A peak of 75 ­percent was reached by 1960, a stunningly large figure, greater even than or­ga­nized ­labor’s, which never or­ga­nized more than 35 ­percent of wage and salary earners. In effect, threats of blacklisting from hospitals and expulsion of recalcitrants from their county medical socie­ties ­were the whips used to corral physicians into the AMA and keep them in line. Exploiting control over hospitals began with the AMA leadership’s approval in 1935, followed by passage the following year by the House of Delegates of the so-­called Mundt resolution. Its author, G. Henry Mundt, was a Chicago insurgent leader in the 1910s and ­later a delegate sent by the

404

Reactionary Turn and Beyond

reactionary Illinois Medical Society to the turbulent House of Delegates meeting of 1921. In 1927 and 1928, Mundt served as the Illinois society’s president. His resolution called for the AMA’s Council on Medical Education and Hospitals to deny accreditation of a hospital’s internship program u ­ nless ­every single one of its staff and admitting physicians was an AMA county society member.9 At the 1936 House of Delegates meeting, an additional resolution strengthened the Mundt rule by withholding accreditation of hospitals’ residency training programs ­unless the hospitals ­were staffed exclusively by members of the AMA’s county units. The resolutions delivered a mighty blow to medical dissidents b­ ecause many hospitals w ­ ere financially dependent on attracting recent gradu­ates for very low-­pay internships and residencies with extremely long hours. Fully qualified doctors who ­were not AMA or state society members by virtue of county society membership lost their hospital privileges. Nonmembers who applied for them w ­ ere turned away. Being rejected by a hospital ruined a medical ­career, for patients needed doctors who could have them admitted, and their doctors needed the income (roughly half their total in the 1960s) from ser­vices they could only perform in a hospital setting. In effect, as AMA journal editor Morris Fishbein put it, the Mundt Resolution “placed hospital staffs u ­ nder the control of county medical socie­ties.”10 In most states, county society membership meant automatic enrollment in the AMA. The high membership numbers thusly amassed conferred legitimacy on the AMA leadership’s claim to speak for the entire profession. ­A fter 1934, the AMA further strengthened its grip on the profession by persuading medical specialty socie­ties to make membership a prerequisite for admission to their accredited hospital residency programs and thus for specialist certification. Specialization, especially in surgery, was key to making more than a very modest income, and many hospitals required specialist certifications for choice staff positions.11 As a consequence of ­these practices and more, membership in the AMA for most doctors became quasi-­compulsory. With time, other side benefits of county society membership accumulated, including ­legal assistance and bill collection. Informal sanctions like denial of referrals and painful social ostracism could also make nonmembership prohibitively costly. One of the most power­ful means to round up members was using membership as a qualification for affordable group malpractice insurance. Nonmembers had to pay up to double the group premiums. Often, commercial insurance companies even refused to insure them ­because the norm against testifying against other doc-



Medical Power Politics

405

tors only applied to doctor-­plaintiffs who ­were members in good standing. Or­ga­nized medicine thus became a kind of protection racket for vulnerable doctors—­providing insurance against the very threats it heightened.12 Around the time of the Mundt resolution, AMA membership had fallen to around 60 ­percent. It then began to rise to around 67 ­percent in 1940. Th ­ ere it stagnated ­until 1946, only to rise once again to a final peak of about 75 ­percent in 1960. Much of that latter growth phase possibly resulted from the federal Hill-­Burton Act of 1946, which provided money for the construction of hospitals in underserved low-­income counties. For privileges in the new hospitals, previously unmotivated doctors now ­were incentivized to join. By the 1960s, the remaining nonmembers w ­ ere mostly blacks barred from Southern socie­ties, retirees, young and relocated doctors not yet meeting county residency requirements, salaried physician-­employees of prepaid group practices, universities, research institutes, the Veterans Administration and other government entities, and in­de­pen­dent prac­ti­tion­ers in remote rural areas where incentives to join ­were negligible and membership fees burdensome.13 The same coercive incentives and disincentives kept the bulk of the profession in line with the conservative AMA’s medico-­economic princi­ples, including fee-­for-­service payment and ­free choice of physician. ­A fter 1934, doctors could be expelled from or denied membership in their county medical socie­ties for r­ unning afoul of the AMA’s newly revised Princi­ples of Medical Ethics. Thereafter, defiance of AMA authority on medico-­economic policy meant “professional suicide” for all but the relatively few with some kind of institutional job security, according to one analy­sis. The most impor­tant violation of the 1934 ethical code was participation in proto-­insurance arrangements, be they government sponsored or private, that enrolled a pool of patients and contracted with groups of physicians for payment on a salary or per-­patient lump sum basis to serve them. The main material infractions of ­these “prepaid group practices” (PGPs) w ­ ere their owner­ship and administration by laypeople, exclusive panels of doctors from which members could choose, and advertising for members.14 Harvard and Mas­sa­chu­setts General internist Richard Cabot argued in 1916 that group practices in which generalists and specialists shared modern equipment and knowledge could provide “better doctoring for less money.” In 1932, the blue-­ribbon, foundation-­funded Committee on Costs of Medical Care (CCMC) had argued the same—­that small, affordable monthly payments and PGPs economies of scale and proximity would help the country solve, without compulsory insurance, the prob­lem of rising costs and

406

Reactionary Turn and Beyond

inadequate coverage. But conservative doctors representing the AMA on the CCMC submitted a minority dissent, arguing that PGPs would deliver bad care, attract patients away from solo practices, and be “forerunners of compulsory insurance.” As Fishbein warned the AMA journal’s readers, PGPs ­were foreign objects in the body politic—­as “medical soviets” they were “an incitement to revolution.”15 The 1934 revision of the AMA’s conservative Princi­ples of Medical Ethics came in response to a flurry of experiments with prepaid plans starting in 1929 and then the CCMC’s 1932 report. The American College of Surgeons (ACS) had also just recommended prepayment plans. For that, it was scolded by the AMA House of Delegates, which claimed that the AMA, representing the entire profession, not just elite surgeons, was the only body entitled to make such recommendations. It even called on the regents of the ACS to answer for their impropriety. That was “pure fascism of the Italian type,” declared the Mayo Clinic’s Hugh Cabot, Richard’s ­brother. Cabot was the successor of AMA progressive Victor Vaughan as dean of the University of Michigan’s medical school, and soon to become one of the AMA’s most vocal and acerbic internal critics. Some local medical socie­ties had already begun expelling or other­wise harassing doctors participating in PGPs even before the 1934 code of ethics change. In 1930, for example, the East Baton Rouge Medical Society ejected its members serving Standard Oil of Louisiana’s employee cooperative, the Stanacola Medical and Hospital Association. Mostly, in the past, or­ga­nized medicine had looked the other way when it came to im­mensely power­ful industries such as railroads, steel, mining, and forestry. Their companies often established group plans for comprehensive medical and hospital care, especially in remote areas where it was hard to attract doctors without offering secure salaries, attractive places to live, and good facilities for diagnosis and treatment, including hospitals. By 1937, the ACS had examined and approved over eight hundred medical plans run by companies with over five hundred employees, many of them huge establishments.16 To the AMA, a national medico-­economic policy was needed to justify punishing doctors participating in these allegedly illicit ways of organizing medical practice, at least outside of big employers’ safe harbor. One of the most successful nonindustrial PGPs to come u ­ nder attack was founded in 1929 by eminent surgeon Donald Ross, a Canadian who had worked for the Canadian Pacific Railroad’s employee group health plan, and H. Clifford Loos, a



Medical Power Politics

407

former president of San Diego’s County Medical Society and a member of its board of health. Their Ross-­Loos Clinic would start by serving over two thousand employees of Los Angeles County and its Department of ­Water and Power. For that they w ­ ere expelled from the Los Angeles County Medical Society in 1934, although the AMA’s Judicial Council voided the decision on procedural grounds to fend off bad publicity. Other local harassment followed. Nevertheless, by 1935 the Ross-­Loos Clinic served around thirty thousand in and around Los Angeles.17 Another notable example of a non-­industrial PGP was the Elk City, Oklahoma, Farmers Union Hospital Association, owned by a lay cooperative of farmers with support from the Oklahoma Farmers’ Union. Its instigator was Michael Shadid, a Syrian immigrant and avowed socialist. Set up in 1931, by 1939 it was serving around fifteen thousand farmers and their families in Southwest Oklahoma. The local medical society banished Shadid not by expelling him, which would have required a complicated and embarrassing trial, but by disbanding and reassembling without him ­later. The state society tried to have his medical license revoked, but Governor William “Alfalfa Bill” Murray denounced it and threatened to fire members of the medical board if they dared. More harassment of the hospital association followed, including attempts to run out of town doctors Shadid had recruited from the outside and even efforts to persuade physicians’ exchanges and nurses’ registries not to list Shadid’s Community Hospital positions that needed filling. The worst personal cost to Shadid was the loss of malpractice insurance when he would most need it against doctors more than e­ ager to testify against him. According to Shadid, “My Oklahoma enemies ­were carefully ‘coached’ by an AMA official as to the best, i.e. worst, manner in which to attack me.”18 Most county socie­ties ­adopted the AMA’s ethical code and thus excluded or expelled doctors working for PGPs and blacklisted doctors who worked alongside them in hospitals. Therefore, about the only way for a PGP to survive the AMA’s sweeping assault was to have its own hospital. That way it could pay adequate salaries and supply enough patients to doctors willing or desperate enough to exile themselves from the rest of their profession. The Ross-­Loos Clinic, for example, had access to a hospital previously owned by Clifford Loos. The wealthy Shadid financed the Community Hospital with his own money plus fifty-­dollar shares sold to the members of the plan. The only and rare alternative to hospital owner­ship, a large and often prohibitive capital expense, was to enlist power­ful po­liti­cal and ­legal allies to sue the AMA

408

Reactionary Turn and Beyond

and its constituent parts to end their blacklisting and boycotting. That is how Washington, DC’s Group Health Association (GHA), set up in 1937 to care for the many federal employees of the Home ­O wners’ Loan Corporation (HOLC), survived. By 1950, the GHA had eigh­teen thousand federal employee members and then well over forty thousand in the 1960s. Initially, participating doctors w ­ ere expelled from the district society, and hospitals refused to grant them privileges. The Roo­se­velt administration’s assistant attorney general Thurman Arnold successfully prosecuted the case against the AMA and the District of Columbia Medical Society as a conspiracy in restraint of trade and thus a violation of antitrust law. A ­ fter an appeal, the U.S. Supreme Court ruled against the AMA in 1943. It was a headline grabbing event.19 But the 1943 victory was a pyrrhic one for the group health movement. The ruling only applied to the capital district where, exceptionally, the federal Sherman Anti-­Trust Act, not a state antitrust law, applied. Medical opposition had a mostly ­free hand elsewhere against PGPs ­because they ­were not engaged in interstate commerce. Furthermore, in the 1940s state medical socie­ties succeeded in pressing state legislatures to pass revisions of their medical practice acts to outlaw the “corporate practice of medicine” by lay ­owners and man­ag­ers contracting with l­imited panels of doctors. Only a few states failed to do or­ga­nized medicine’s bidding. The state of Washington, where lumber and railroad industry plans w ­ ere common, refused to pass such a law. Thus, its King County Medical Society was left to its own coercive devices in its ­battle against the Puget Sound Group Health Cooperative (GHC). The GHC filed a civil suit against the medical society, and a unan­i­mous state supreme court ruled in its f­avor, making it impossible for the state’s medical socie­ties and hospitals to discriminate against PGPs. In 1963, a law was passed in New York State prohibiting its hospitals from discriminating against doctors participating in PGPs. That came in response to constant guerrilla warfare against medical groups contracting with the Health Insurance Plan of Greater New York (HIP). It had been instigated in 1944 by New York mayor Fiorello LaGuardia on behalf of city employees. Only one of the HIP’s separate medical groups had been able to contract with the Montefiore Hospital run by socially progressive physicians and the Albert Einstein College of Medicine’s teaching hospital. The ­others had only been able to offer medical ser­ vices, not hospital care, in their clinics.20 The PGP movement relied for its success on a mix of power­ful lay allies, often of liberal or leftist persuasions. The Elk City plan had the essential help of a farmer’s u ­ nion and a governor who was contemptuous of elite professional



Medical Power Politics

409

groups’ monopolistic ambitions. Puget Sound’s GHC was or­ga­nized in 1946 by area farmers, ­labor ­unions, and consumer cooperatives. The Ross-­L oos Clinic relied on large, unionized public sector employee groups in Los Angeles. Washington, DC’s GHA got its start from employees of the HOLC, which was set up during the ­Great Depression to administer the New Deal’s 1933 Home ­Owners’ Loan Act for refinancing homes in default and relatively easy terms for financing the purchase of o­ thers. Not surprisingly, wealthy cap­i­tal­ists could also neutralize the power of or­ ga­nized medicine when it served their profit interests. By far the most successful prepaid group plan was sponsored by Henry J. Kaiser, owner of huge general contracting operations before World War II and then heavy industry during and a­ fter the war. During the war, the Kaiser plan—­and all of the hospitals built to serve it—­covered over 100,000 shipyard, airplane, and other workers on the West Coast. When it was made available to employees of other companies ­after the war, what came to be called the Kaiser Permanente system of integrated hospitals and medical groups would grow to enroll over 150,000 members in 1950, around 700,000 in 1960, 2.1 million in 1970, 3 million in 1980, and 6.5 million in 1990. The number continued to grow to 8.6 million in 2010.21 The huge system started in the 1930s with the building of the ­Grand Coulee Dam on Washington’s Columbia River, a Kaiser proj­ect and, indeed, a New Deal one as well, funded by the Roo­se­velt administration for job creation and economic development in the West. Key ­people instigating the system ­were, first, the dynamic and enterprising physician Sidney Garfield, who modernized a small hospital for the purpose and assembled its first group of doctors, ultimately called the Permanente Group. The second was Kaiser’s son Edgar, who saw the health plan as a way to quell ­labor unrest, attract and retain a large ­labor force, return injured workers to the job, and maintain the health of the rest. From then on, ­labor ­unions became a power­ful constituency of Kaiser Permanente PGPs, which came to be called health maintenance organ­izations (HMO). Or­ga­nized medicine in the San Francisco Bay area put up a fight, including having Garfield’s medical license suspended by the California Board of Medical Examiners in 1947. A wrathful Henry Kaiser intervened, personally meeting with medical society representatives and chastising them for crass selfishness as well as foolishness for fighting a system that could help ward off a compulsory government solution. He threatened a federal lawsuit on the basis of the Sherman Anti-­Trust Act. ­L abor ­unions, which had become e­ ager proponents of contracting with Kaiser

410

Reactionary Turn and Beyond

Shared room in the Kaiser Permanente Hospital, Oakland, California, circa 1948. Kaiser Permanente’s extension of health coverage to industrial workers’ dependents, many of them African Americans, provoked strong opposition from the AMA as a further illegitimate encroachment on the in­de­pen­dent practitioners’ turf by what came to be called health maintenance organ­izations. Courtesy of Kaiser Permanente.

Permanente HMO plans for their members, also came to Garfield’s defense. In the end, the doctors backed down. It took a power­ful cross-­class alliance of capital and l­abor against medicine to win that b­ attle.22 ENFORCING THE PARTY LINE

Coercion, although only partially successful in disciplining the profession, yielded extraordinarily high AMA membership levels, which in turn generated financial resources for its political activities and to impress and reward politicians. In 1969, Edward R. Pinckney, a disaffected former associate editor of the AMA journal, ventured that “more than half the pre­sent membership would resign” if not for the compulsion. “The same AMA that fights so hard” for patients’ “­free choice” of a physician, he said, never allowed the physician to make a “­free choice” in regard to his membership. “Thus, a g­ reat many doctors, with nothing to say about it, indirectly contribute to the false circu-



Medical Power Politics

411

lation figures of the AMA’s publications and consequently contribute to increased AMA revenues.”23 But more was needed to create an appearance of unity to the outside world. For that, the AMA propagated an ideological line that empowered its comrades in arms in its state and local socie­ties to smear vocal dissenters as social and po­liti­cal deviants. A constant drumbeat of internally directed propaganda helped maintain the outward visage of solidarity, which gave lay conservatives the propaganda material to activate external allies against reform and throw liberals with re­spect for physicians off balance. In 1938, AMA president Irvin Abell advocated a norm of what Vladimir Lenin, the Rus­sian Communist revolutionary, called demo­cratic centralism. “I would urge you,” he told the House of Delegates, to consider it an “obligation” to speak “with a united voice.” Open dissent against official AMA policy was painted as a “breach of decency,” according to po­liti­cal scientist Oliver Garceau in his 1941 Po­liti­cal Life of the American Medical Association. The public should not be shown any “dirty linen,” interviewees told him.24 Much reactionary propaganda was aimed at the medical profession to cultivate disdain for liberal doctors and disgust for citizens who would take advantage of the reforms they favored. In 1932, Edward Ochsner, one of the early Chicago insurgents and a member of the national insurgency’s Medical Advisory Committee in 1921, published a dozen articles in multiple medical journals depicting relief for the poor and social insurance as steps ­toward socialism, communism, and then feudalism. Government health care would inevitably produce “slave doctors” to treat “­human parasites.” The journals had a combined circulation of around 140,000. In an anthology of his journal articles and other pieces, Ochsner cited German physician Erwin Liek, sometimes known as “the f­ather of Nazi medicine,” for similar views about social legislation as a cause of “race degeneration” in Germany. More disdain for parasitic “malingerers” reappeared in 1949, when George William Kosmak, an early New York insurgent and now chief editor of the New York State Journal of Medicine, warned fellow doctors that “any experienced general practitioner ­will agree that what keeps the ­great majority of ­people well is the fact that they ­can’t afford to be ill.” It was “a harsh, stern dictum,” he granted, and “­under it a certain number of cases of early tuberculosis and cancer, for example, may go undetected.” But, he asked, was it not “better that a few should perish rather than have the majority of the population on e­ very occasion to run sniveling to the doctor?”25

412

Reactionary Turn and Beyond

­ ecause repetition of debatable claims in a debate-­free context, even to B well-­educated p ­ eople, can fabricate “illusory truths,” journal editors routinely refused to expose readers to rebuttals and dissenting views. They vilified doctors bold enough to defy the censorship, thereby deterring the more fainthearted from doing the same. A dramatic instance was the AMA journal’s refusal to allow Yale University medical school’s John Punnett Peters Jr. and a group of like-­minded critics of the profession’s deficits to engage other doctors in ­free and open debate about the quality and availability of medical care. Peters was a pioneer in blood chemistry and urinalysis and a leading light for the current and coming generation of nephrologists. He also had an abiding interest in social justice. His politics dated from his college and medical school days at Columbia, when he or­ga­nized meetings for New York garment workers and for transit employees during their 1917 strikes. In the 1920s, ­after coming to Yale, he took on the cause of workers at New Haven’s Winchester Repeating Arms plant and helped generate support for the Republican faction in the Spanish Civil War.26 In 1937, Peters enlisted Hugh Cabot, a Mayo Clinic surgeon; Milton Winternitz, the dean of Yale medicine; L. Emmett Holt  Jr., the famous Johns Hopkins pediatrician; Clifford Loos of the Los Angeles PGP; and other elite physicians to create a Committee of Physicians for the Improvement of Medical Care (Committee of Physicians). The committee’s purpose was to generate knowledge about prob­lems in the quality and distribution of medical care across the country and to deliberate on how to improve both. Other medical notables in the extended committee, sometimes called the Committee of 430, included Philip King Brown of California, Allan M. Butler of New York, Channing Frothingham of Mas­sa­chu­setts, and Frothingham’s colleague Robert B. Osgood. The more active members of the Committee of Physicians assisted Peters in drafting a document modestly called “Princi­ples and Proposals” about the “inadequate” and only slowly improving quality of medicine as currently practiced by American doctors. They also proposed modest mea­sures to remedy the inequitable distribution to underserved populations of preventive, diagnostic, and therapeutic ser­vices. In short, they said, a comprehensive national strategy for continuous improvement in preventive and clinical care was needed, and related to that, federal and state funding of biomedical research, diagnostic facilities, and hospitals. Federal government assistance for private institutions, as well as for state and local governments, was needed for all of the above, which in turn necessitated “a functional consolidation of all fed-



Medical Power Politics

413

Yale nephrologist John Punnett Peters Jr., MD (1887–1955). A pioneer in blood chemistry and metabolism, Peters founded and led a committee of dissident physicians to ­counter the AMA’s rigid conservatism from the inside. A victim of AMA red baiting and McCarthyism, Peters was fired without due pro­cess from ser­vice in the National Institutes of Health for alleged “disloyalty.” Used by permission of Barbara Ann Peters, MD.

eral health and medical activities, preferably u ­ nder a separate department.” With that, their manifesto called in effect for a revival of the progressive ­battle for a national department of health.27 When the Peters committee published its “Princi­ples and Proposals” in early November 1937 and began gathering signatories who supported them, the AMA struck back furiously. As editor Fishbein saw it, the Committee of Physicians had declared American doctors incompetent and incapable of lifting themselves up by their own bootstraps. In effect, Peters and com­pany declared the AMA leadership negligent by calling on the government to improve public health and medical care and to enlist “experts,” not medico-­ politicos, to assist it. Medical journals countered the dissidents with distorted criticisms and denied them a chance to respond. For example, a long article by Harrison H. Shoulders in the Journal of the Tennessee State Medical Society, which he edited, denied the existence of any prob­lems or that the AMA was negligent on any account. Shoulders sneered that “this revolting group of doctors” was denying that “the best medical ser­vice to be had on earth is enjoyed by the population of the United States.” The Committee of Physicians, he claimed, was actually against “the princi­ple of pro­gress to which or­ga­nized medicine subscribes.”28

414

Reactionary Turn and Beyond

In words reminiscent of the National League for Medical Freedom—­the progressive AMA’s nemesis in the campaign for a national department of health—­Shoulders said the dissidents wanted “a centralized authority in Washington which w ­ ill take over the complete command of medicine and by edict and by subsidy dominate the w ­ hole of medicine in the United States.” It would be “an oligarchy in medicine with absolute power.” He charged that the committee’s “revolting” leaders had an ulterior motive—­“getting their hands in the federal trea­sury” to “secure their personal fortunes.” Shoulders refused to print a rebuttal, even though one was offered by Hugh J. Morgan, chairman of the Vanderbilt University Department of Medicine. The Johns Hopkins-­educated Morgan was one of the country’s most outstanding internists.29 ­Later Morgan would become president of the American College of Physicians and chief medical con­sul­tant to the surgeon general of the U.S. Army during the Second World War. Shoulders’s claim of distinction was his short stint as AMA president in 1946 and 1947. Shoulders’s take on the “Princi­ples and Proposals” was “poisonous,” according to Peters. The Tennessee editor was following Morris Fishbein’s cue from the year before. Fishbein’s 1937 editorial depicted Peters and com­pany as enemies of the profession, not leaders of a loyal opposition seeking respectful and open debate. He charged that by recommending subsidies to medical schools struggling to maintain high standards and advance clinical science, the dissidents wanted to turn over to the federal government “the control and standardization of medical schools” and even “put the government right into the practice of medicine.” It would all be to the detriment of medical science and pro­gress. Government support for hospitals for underserved populations was dangerous, for it would also hand over the practice of medicine to hospital administrators. Many of the several hundred signatories ples and Proposals” had been duped, Fishbein claimed, of the “Princi­ “through misrepre­sen­ta­tion.” The “unthinking endorsers,” therefore, “owe to the medical profession some prompt disclaimers.” Peters saw that as a barely veiled call for peer pressure on them to recant.30 Fishbein also played cleverly to the national press’s tendency to sensationalize in order to spread anxiety among reform-­minded doctors about endorsing the “Princi­ples and Proposals.” ­Because of his efforts, he boasted, newspapers “heralded” the Committee of Physicians’ efforts to gather signatories as “a revolt against the American Medical Association.” According to correspondence between Peters and fellow reformers, rumors that the committee had broken away from the AMA ­were spread to “frighten the medical



Medical Power Politics

415

­ eople and our committee.” In order to c­ ounter the press reports, the comp mittee authorized Milton Winternitz to insist on its “allegiance to the AMA.”31 The Peters committee got unusually favorable treatment from Waldemar Kaempffert, science editor of the New York Times, and John Pfeiffer, science and medicine editor of Newsweek. But their employers ­were not pleased, Peters told Cabot, b­ ecause they “fear Fishbein” and w ­ ere “­under pressure from advertisers.” Pfeiffer, for one, “was held to account” and forced to publish one of Fishbein’s attacks. Fishbein’s reach also extended into the federal government, or so he boasted in order to intimidate. A ­ fter members of the Committee of Physicians met with President Roo­se­velt in 1938 regarding health reforms, Fishbein personally told Peters that he had “informers watching the government” and that he had gotten “telephone reports of our meeting” within fifteen minutes ­after its end. At one point a canard was unleashed, possibly by Fishbein, that the Committee of Physicians was being directed by the liberal president.32 Meanwhile, according to Peters’s letters, Fishbein was lying to doctors all over the country that all the original signatories ­were deserting. He fumed about Fishbein’s “lack of scruples” and “indecent” personal allusions and aspersions. “We are dealing with an unprincipled liar,” Cabot responded. Fishbein privately boasted to Peters that “he has never retracted anything,” thus implying, Peters thought, that “he does not intend to change his habits.” His complaints to the AMA Board of Trustees about Fishbein’s refusal to let him respond to lies fell on deaf ears. Cabot wrote that getting the trustees to fire the editor for rank dishonesty was unlikely “­because he owns them.” He suspected that Fishbein had evidence about the activities of most of them “that would effectively keep their mouths shut.”33 According to Peters, Fishbein threatened liberal doctors in New York City with losing their positions in the state society u ­ nless they “retracted.” Already in late November 1937, Peters was receiving withdrawals “in rather a ­wholesale manner from California.” Medical power t­ here was “quashing all liberal opinion.” According to Cabot, Clifford Loos of Los Angeles “has been shamefully treated.” But not every­one was afraid. The editor of the New ­England Journal of Medicine treated Peters’s committee fairly, but Cabot suspected that he “jeopardized his own position,” as the journal was the property of the Mas­ sa­chu­setts State Medical Society. Cabot had to admire one signatory, Hermon C. Bumpus Jr., a Mayo Clinic urologist, for having “a good deal of courage.” Bumpus had volunteered to take the committee’s case to the AMA House of Delegates.34

416

Reactionary Turn and Beyond

Morris Fishbein, MD (1889–1976), editor in chief of the Journal of the American Medical Association, 1924 to 1949. A red baiter of liberal physicians, Fishbein was a power­house inside the conservative AMA and its loud voice in the public’s ears. From the Library of Congress, Harris and Ewing photo­graph collection, LC-­H22-­D-­4255.

Many more w ­ ere not as bold as Peters, Cabot, and Bumpus, who had the luxury to be mavericks ­because of their secure positions in prestigious institutions like Yale and the Mayo Clinic. ­There w ­ ere few “signs of spontaneous vitality” that Peters hoped for from committee members and signatories. Cabot was not seeing any ­either. The Midwesterners among the signatories ­were, according to Cabot, “a timorous lot.” They w ­ ere in “constant fear of every­thing, including themselves.” Even most of the Mayo Clinic ­people ­were “reticent.” No one in Minneapolis and St. Paul had “both convictions and the courage of them.” Channing Frothingham, a professor of clinical medicine at Harvard, was “badly tied up” b­ ecause he was president of the Mas­sa­chu­setts society, according to Cabot. He told Peters that Harold S. Diehl, the recently hired dean of the University of Minnesota, was unlikely to open his mouth for fear of being fired. Walter C. Alvarez, an eminent internist at the University of Minnesota’s Mayo Foundation for gradu­ate training, was punished for his signature with the cancellation of a lecture he was to give at the Postgraduate Committee of the Acad­emy of Medicine of Toledo. The cancellation was explic­itly “in protest” against his endorsement of the “Princi­ples and Proposals” ­because they ­were “officially disapproved by



Medical Power Politics

417

the Council of our society, the Ohio State Medical Association and the AMA.” In fact, ­t here had been no such official disapproval voted on by the AMA House of Delegates.35 ­Because Cabot doubted w ­ hether ­there ­were many signatories who had the stomach for the “raw food” of open ­battle, he thought it wise to take the prob­ lems of medical care and pro­gress to the public via the lay press. Peters disagreed. Open public controversy would lose the “Princi­ples and Proposals” a large number of signatories, he thought. It would “create a split in the Committee.” The ­great majority “are utterly opposed to any recourse” to the press. To most members, it was “preeminently impor­tant that we merely be called gentlemen by the Trustees.” Thus, “the greatest care” was needed in approaching the press, and indeed, Peters never issued harsh public criticism of the AMA or of the perfidious Fishbein.36 The campaign to repress debate and maintain an appearance of professional unity worked. Keeping signatories from withdrawing and finding new ones proved daunting. By mid-­December 1937, hardly more than a month a­ fter publication of the “Princi­ples and Proposals,” around thirty had unconditionally withdrawn, and up to forty on the original list asked that their names no longer be used publicly. More w ­ ere being gained than lost, however, and the number was approaching 700. By 1940, t­ here ­were about 1,000 signatories and another 150 not daring to sign but interested in receiving mailings. But ­these ­were still pitifully small numbers. It was hard to get signatures from the high as well as low in the profession, and the old as well as young. Physician Wilbur A. Sawyer, director of the International Health Division of the Rocke­ fel­ler Foundation, excused himself for not signing ­because of his institution’s need for professional goodwill. Results of attempts to get signatures from medical academia ­were “monotonously uniform,” according to Peters. They had “refused to do anything, b­ ecause they ­were lazy or afraid,” he wrote to George Baehr, a pioneering internist. The Bostonians ­were “timorous,” according to Cabot. Relatively few “have any considerable supply of intestines.”37 Doctors in the lower ranks of the profession had good reason to be timorous. In Pennsylvania, one county society’s members ­were given written notice that t­ here was no unmet medical need in their community, contrary to what the dissidents said. The notice had been preceded by another “demanding po­liti­cal affiliations of each member.” Peters reassured one reluctant that his choice not to sign was understandable, saying, “­There are a ­great many ­here in Connecticut who are taking the same stand.” Young doctors felt especially vulnerable. One from a small New York town wrote to Peters that

418

Reactionary Turn and Beyond

the Committee of Physicians gave “open force and expression” to his own ideals, but he only dared to reveal them “in a most guarded and clandestine fashion.” A newly formed Association of Medical Students voted in 1937 to approve the “Princi­ples and Proposals” but de­cided not to report the vote publicly, fearing it could cost members hospital internships.38 In the spring of 1938, Peters looked dismally upon the results of Fishbein’s campaign of threats and vilification. He believed that the ­great majority of American physicians knew of the “Princi­ples and Proposals” but w ­ ere badly misinformed about their content. If they ­were actually to receive accurate material about them, they ­were likely “to throw it in the scrap basket as something poisonous and then object to their being approached at all.” Only through personal contacts and face-­to-­face discourse could any new signatures be collected, he thought. Signatory Bertram Bernheim, a leader in blood transfusion and cardiovascular surgery, corroborated Peters’s view about in-­person persuasion. In 1939, Bernheim recounted a talk that Pennsylvania’s York County Medical Society had invited him to give in defense of the Committee of Physicians. Before the talk, he had experienced only hostility and smug agreement with the AMA. A ­ fter a long, impassioned, and fact-­filled talk on the faults, injustices, and tragedies of American medicine, he received a standing ovation and effusive praise. “They had never heard such an exposition.”39 Peters, of course, came in for some of the worst professional vilification. In effect, they ­were shots across the bow of the many who silently agreed with him. In 1939, Fishbein lumped the perfectionist educator, clinician, and scientist and his committee together with the “Medical Section of the Communist Party” as agents—­a longside chiropractors and “commercial quacks”—­trying to “disrupt, destroy and ruin” the AMA and “the standards of scientific medicine.” He alleged that the communist doctors had issued a “manifesto” urging support for Peters’s committee. The red baiting of medical reformers like Peters began in earnest the following year. In 1940, AMA president-­elect Nathan Van Etten warned the House of Delegates that “the subversive influence of so-­called ‘fifth columns,’ already ­here, ­will grow stronger in our national administration and we may be compelled to follow dictation which may destroy the practice of medicine as we know it and as we hoped it might become.” 40 Although at the time “fifth column” mostly referred to fascist infiltration, the insinuation made clear that communism was the threat. What Peters’s



Medical Power Politics

419

friend Ernst Boas called “medical McCarthyism” was on its way. Boas, a cardiologist and pioneer in the study and treatment of chronic diseases of the aged, would be one of its most vis­i­ble targets. He was a prominent proponent of “social medicine” in the spirit of Rudolf Virchow, whose hand he once shook as a young boy while in Germany with his f­ ather, Franz, the founder of American anthropology. Having been energized by the Peters committee’s “Princi­ ples and Proposals,” Boas led a dissident faction in the New York County Medical Society that became, in 1943, the Physicians Forum. It was to be the only or­ga­nized voice to buck the AMA’s regime of propaganda and repression. A 1945 editorial in the AMA journal described the Physicians Forum, mostly New Yorkers, as “a group of several hundred physicians, mostly inclined ­toward Communism.” Fishbein refused to publish Boas’s letter of rebuttal.41 In 1941, the New York County Medical Society had tried to suffocate Boas and his allies by applying a gag rule, newly added to its bylaws, that prohibited activity out of line with state society’s politics. They fought back success­ ings got uglier fully at a meeting of the state society’s House of Delegates. Th and scarier when, l­ ater that de­cade, the House Un-­A merican Activities Committee (HUAC) cited Boas, along with Peters and Edward Barsky, a founder of Boston’s Beth Israel Hospital, as a “fellow traveler” for his membership in numerous communist “front organ­izations.” In 1952, in an editorial called “Communists and Medicine,” New York Medicine printed verbatim the testimony of a witness before the Senate Subcommittee on Internal Security that the Physicians Forum was “established primarily by the Communist Party” and that communists in key positions w ­ ere able to “utilize the organ­ization.” It did not allow a rejoinder from Boas.42 All along, Boas was “reviled, condemned and harassed,” but he stood his ground. For years he had to strug­gle to keep his teaching position at Columbia. When, in 1949, the majority of the county medical society pressed him to say w ­ hether or not he was a communist, he refused to answer. It was, Boas said, “a deliberate cold-­blooded technique, a­ dopted by reactionaries just ­because it is so effective.” A ­ fter Boas’s death in 1955, his friend Bernhard Stern of the New School for Social Research declared that “many other medical men weakened before the violent assault and retreated, although in their hearts and minds they knew that the cause was right.” 43 Efforts to disgrace and silence the defiant members of the Physicians Forum in the 1940s no doubt helped persuade many other liberal doctors to keep

420

Reactionary Turn and Beyond

their heads down and mouths shut. The relatively few who courageously or naively went ahead with po­liti­c al activity risked their hospital privileges, membership in county medical socie­ties, or jobs in the Public Health Ser­vice (PHS) or VA hospitals. For example, one cause that the Physicians Forum took on was that of eight interns and a nurse dismissed by the Philadelphia General Hospital for refusing to sign loyalty oaths, a requirement for public employees in Pennsylvania. Another was the case of three Los Angeles doctors dismissed by the Cedars of Lebanon Hospital b­ ecause of their po­liti­c al beliefs. The mere advocacy of compulsory health insurance was sometimes risky, and not only ­because of shaming or institutional exile. In 1947, Paul A. Dodd, dean of the University of California, Los Angeles, College of Letters and Science, wrote of an eminent physician who told him he could not afford to speak in ­favor of health insurance ­b ecause he was a specialist who relied on patient referrals from other doctors.44 Red baiting by the AMA to silence liberal doctors continued into the 1950s. In a 1950 guest editorial in the AMA journal, Federal Bureau of Investigation (FBI) director J. Edgar Hoover, one of the nation’s top ideological hygienists, implored doctors to “keep Amer­i­ca healthy.” Hoover warned readers that “the germs of an alien ideology, Communism, are attempting to infect the blood stream of American life.” Ominously, he wrote, American physicians could protect their country’s health “by reporting immediately to the FBI” any information concerning subversive activities that came their way. In 1951, Peters and Boas came u ­ nder continued attack as medicine’s “vitriolic enemies” for their membership, along with fellow medical dissenters such as Allan Butler, Bertram Bernheim, and industrial health missionary Alice Hamilton of the Committee for the Nation’s Health (CNH). The CNH included prominent liberal laypeople such as Ray Stannard Baker, Stuart Chase, Morris Llewellyn Cooke, Michael M. Davis, Abe Fortas, Albert and Mary Lasker, James Roo­se­velt, and Lessing Rosenwald. Despite the CNH’s mainstream liberal credentials, AMA president Elmer Henderson told AMA journal readers that many CNH “officers, directors and most vocal members” had been listed in HUAC files for “subversive connections or activities.” ­Behind the CNH and its “full-­scale attacks” on the AMA was a “sinister design” to take away doctors’ rights as citizens to speak for themselves and on behalf of “able-­bodied p ­ eople of the community about the economic health and social well-­being of the nation.” Theirs was a “pseudo liberalism.” In



Medical Power Politics

421

fact, Henderson said, the CNH had a “pinkish pigmentation,” adding, “and that’s a mild way of saying it!” 45 In 1951, a secret paid in­for­mant for the FBI named Peters as a member of the Communist Party. It was a preposterous charge. Although he had lent his name to liberal and left-­wing entities l­ater accused of being communist front organ­izations, he had done so to support the ­causes, like health insurance, that they advanced. Communism, he said, was “quite alien to my inherent curiosity and my scientific training.” Furthermore, “I heartily subscribe . . . ​ to the princi­ples of Voltaire and Jefferson. I fear suppression of thought and speech . . . ​lest the spirit of suppression grow on us.” In a 1948 letter to civil rights leader Alfred Baker Lewis, Peters wrote that he was “firmly convinced that the best answer to the spirit of suppression which we dislike in Rus­sia is not the support of similar activities in our own country.” The in­for­mant’s smear led to Peters’s dismissal by a Department of Justice Loyalty Board from unpaid ser­vice in the National Institutes of Health, the PHS’s research arm. The paid in­for­mant was Louis Budenz, a former Communist whose credibility even the FBI found wanting at times. In one of his loyalty hearings, Peters mentioned Fishbein’s 1939 editorial as a pos­si­ble inspiration for the smear. A grueling ­legal b­ attle led by Thurman Arnold against Assistant Attorney General Warren Burger ended with a Supreme Court victory on the grounds that Peters had been denied due pro­ cess by not being allowed to confront and cross-­examine his accusers. That, he would never have a chance to do. Budenz’s responsibility remained a secret ­until revealed by Jonathan Bressler, a Yale undergraduate history major, in his prize-­winning 2007 se­nior thesis. Afterward, Peters told the press: “We older fellows have got to carry the fight. . . . ​The young men are not in a position to speak out.” The stress had been enormous. In 1955, seven months a­ fter the court decision, a heart attack fi­nally silenced the courageously out­spoken Peters. According to his f­amily, the persecution shortened his life and prevented him from completing the one t­ hing he had wanted to do in his professional life—­finish a massive revision of his landmark clinical chemistry textbook.46 In Peters’s years and beyond, a ­great deal of silencing took place at the county level and therefore u ­ nder publicity’s radar, and it continued, though attenuated, into the 1960s. Around 1965 somewhere on the West Coast, according to eminent pharmacologist and reformer Louis Lasagna, a neurologist had been unable to join a county society dominated by right-­wingers

422

Reactionary Turn and Beyond

An editorial cartoon by Bill Mauldin in the St. Louis Post-­Dispatch, May 2, 1962. It depicts an AMA intolerant of internal dissent and determined to maintain a united front against the passage of Medicare. Copyright by Bill Mauldin (1962). Courtesy of Bill Mauldin Estate LLC.

b­ ecause he refused to take a loyalty oath. He had to sue to regain his hospital privileges. He was almost without income ­because he depended on referrals from other doctors, most of whom boycotted him. He likely moved elsewhere. Even nonphysicians could be vulnerable. According to Lasagna, in Fort Wayne, Indiana, the county society threatened local pharmacists with “harsh economic reprisals” if they attended a talk before the pharmacists’ association by Senator Birch Bayh, a Medicare supporter.47



Medical Power Politics

423

T HE OU T WA R D E X ERCISE OF P OW ER

The assiduously manufactured appearance of professional unity, achieved with a mix of reactionary propaganda, monetary benefits, coercive incentives, and defamation of dissidents helped elevate conservative-­era AMA leaders to a commanding position in American medical politics. But more was needed. Before the 1940s, they w ­ ere able to stave off national health insurance without paid lobbying operatives. But that changed as mass public and po­liti­cal support for action grew. In 1944, the year ­after President Roo­se­velt called for a comprehensive “cradle-­to-­grave” system of social insurance, the AMA began funding a permanent lobbying apparatus to fight off insurance legislation sponsored by Senator Robert Wagner of New York, Senator James Murray of Montana, and Representative John Dingell of Michigan. The following year, President Harry Truman endorsed a version of the Wagner-­Murray-­ Dingell bill. By 1949 and 1950, the AMA was spending more than any other registered lobbying group—­over $1.3 million in 1950 alone—to combat the ongoing legislative movement. According to an editorial in Consumer Reports, the AMA became “the nation’s No.  1 po­liti­cal lobby.” Lobbying experts claimed that its operatives ­were so effective that it was “the only organ­ization in the country that could marshal 140 votes in Congress between sundown Friday and noon on Monday.” 48 Campaign donations help open legislators’ ears to lobbyists, so over time the AMA mastered the art of raising and channeling money. In the 1940s and into the 1950s, campaign fund­rais­ing efforts for state and federal legislators ­were still the province of scattered county and state socie­ties’ voluntary and meagerly funded “healing arts committees.” In the few years following or­ga­ nized ­labor’s creation of the first national po­liti­cal action committee (PAC) in 1943, however, the AMA’s state affiliates formed their own PACs. But in the 1950s, congressmen who put their heads in “the chopping block” by supporting the AMA agenda chided lobbyists for not channeling any money their way in fair exchange. ­A fter John F. Kennedy campaigned in 1960 on a platform including Medicare, his election fi­nally triggered the decision to form an American Medical Po­liti­cal Action Committee (AMPAC). Or­ga­nized medicine was thus the first economic interest group a­ fter l­abor to create a national PAC. In 1962, the AMA appropriated money for an AMPAC field staff for mobilizing doctors, opening their pockets, and working with local and state society officials on policy ­matters.49

424

Reactionary Turn and Beyond

Around 1970, not yet ten years ­after forming AMPAC, the AMA was “one of the nation’s richest sources of po­liti­cal campaign contributions,” according to the Congressional Quarterly. That year, AMPAC collected over $1 million. Campaign finance expert Herbert Alexander reported that the AMA’s fund­rais­ing machine “had so much money it has a hard time distributing it.” As late as 1982, according to the Washington Post, AMPAC was still the “all-­ world champion of campaign finance.” Part of its job was the “po­liti­cal education” of doctors—­needed ­because it was hard to get them to volunteer their time and money, or even vote correctly. One target was naive party loyalists, Demo­crats no doubt, who needed “to behave in a schizophrenic fashion” by supporting candidates in the “other party” b­ ecause of their stances on medical issues.50 Additionally, the conservative AMA wielded power with expensive public relations campaigns. The AMA, by contrast, had set up its Council on Health and Public Instruction to prevent disease. To influence public opinion, editor Morris Fishbein served ­until 1949 as a one-­man whirlwind of opinionizing and speechmaking, using a crude mix of caustic insults, pretentious humor, and sloppy statistics. It was old-­school bluster that Fishbein had learned from the 1920s insurgents. All countries with health insurance, he claimed, “move inevitably into a socialized state in which mines, banks, transportation and practically all public ser­vices become nationalized, private responsibility and owner­ship dis­appear, individual initiative is destroyed and the result is a socialized state.” To complement Fishbein’s work, the AMA leadership created the nominally autonomous National Physicians Committee for the Extension of Medical Ser­vice (NPC) to collect money and spread bad news about health insurance. The epigraph of one of its publications, Compulsion: The Key to Collectivism, quoted AMA president Ernest E. Irons calling national health insurance “part of a deeper plan evolved by a few seekers ­a fter power who, u ­ nder the guise of social betterment, would change our democracy through the centralization of power in bureaucracies, into a totalitarian government.”51 The rhe­toric triggered the gag reflex of many “medical politicos,” as Fishbein called them, who thought him “too acrid, too pugnacious, or too sarcastic,” according to the editor of the Delaware State Medical Journal. Many thought he was too fast and loose in pretending to speak for all doctors, especially in dismissing any form of private medical insurance as a way to head off government intervention. For example, Fishbein even criticized physician-­controlled medical plans like the California Medical Society’s



Medical Power Politics

425

California Physicians Ser­vice, l­ater called California Blue Shield. The AMA came out badly bruised in the eyes of much of the public as well, especially among well-­educated, well-­traveled ­people who scoffed at Fishbein’s fast and loose relationship with facts about health insurance abroad. Thus, in 1946, moderate ele­ments in the AMA House of Delegates failed in a vote of 60 to 106 to remove Fishbein but succeeded in prompting the board of trustees to retain the public relations firm Raymond T. Rich and Associates for advice on how to fix the damage. The firm recommended ditching the NPC and yanking Fishbein. A ­ fter three more years of turmoil, the moderates dominating the California, Colorado, Delaware, Michigan, New Jersey, Oregon, and Washington del­e­ga­tions outgunned Fishbein’s defenders in Illinois, Indiana, New York, Pennsylvania, and vari­ous Southern and New E ­ ngland states. The AMA Board of Trustees disbanded the NPC and, in 1949, asked the ­human “steam calliope,” as Harper’s Milton Mayer called Fishbein, to resign.52 The AMA then turned for help to the highly successful po­liti­cal consultancy Campaign Inc., run by the husband-­and-­wife team of Clem Whitaker and Leone Baxter, the parents of modern campaign consulting. Whitaker and Baxter had a fifteen-­year rec­ord of fifty-­eight wins to five losses for the California politicians who had retained them. They had also been retained by California physicians to help kill Republican governor Earl Warren’s state health insurance plan. Thus, the chaotic reactionary style of the 1920s gave way to more efficient and expensive public relations, lobbying, and electoral strategies. The AMA’s “National Education Campaign” cost it about $5 million between 1949 and 1952, a sum dwarfing what l­ abor ­unions and other supports could muster for the Demo­cratic Party’s cause.53 Whitaker and Baxter helped mobilize or­ga­nized medicine’s entire edifice of national, state, and county socie­ties to spread mountains of pamphlets and copy for speechmakers. In October 1950, they spent $1.1 million of AMA money firing off a “Big Bertha” of large advertisements in eleven thousand newspapers and many magazines. Although slickened and toned down, the rhe­toric continued to call compulsory health insurance a first step ­toward totalitarianism. But unlike Fishbein and the NPC, the new propaganda wisely offered the alternative of private, voluntary health insurance u ­ nder physician control. Pamphlets and booklets ­were adorned with Luke Fildes’s famous 1889 painting of a pensive doctor hunched over a sick l­ittle girl, with a frightened f­ather and a weeping ­mother in the background. “Keep politics out of this picture” was the caption.54

426

Reactionary Turn and Beyond

Ronald Wilson Reagan (1911–2004), screen actor and ­f uture U.S. president. For his engaging rhetorical skills, the AMA hired Reagan in 1962 to speak in opposition to Medicare as a step fi ­ rst toward medical totalitarianism followed by a loss of all civil and political liberties. Glass­house Images / Alamy Stock Photo.

In the 1960s, the AMA largely dispensed with outside con­sul­tants and began relying on in-­house operations like AMPAC. In 1961, it paid actor and ­future U.S. president Ronald Reagan to give speeches against Medicare. It also made a vinyl recording of his mellifluous voice in which he warned that ­ eople “has been one of the traditional methods of imposing socialism on a p by way of medicine.” In their “Operation Coffee Cup,” doctors’ wives in the AMA’s ­Women’s Auxiliary then played the recording for friends and neighbors in living rooms across the country. They also brought out pens and stationery for their guests to write letters, then and t­ here, to their representatives in Congress. If ­people did not write, Reagan warned in his closing sentence, “one of ­these days you and I are ­going to spend our sunset years telling our ­children and our ­children’s c­ hildren, what it once was like in Amer­i­ca when men ­were ­free.”55 HEALER DEALERS

The AMA’s alliance with formidable lay forces was also critical for it to achieve its po­liti­cal ends. A semblance of professional unity, vigorous lobbying, huge campaign spending, and massive propaganda was not enough. In



Medical Power Politics

427

1924, now ­under ultraconservative control, the AMA became a member association of the U.S. Chamber of Commerce. This would ensure that the organ­ization would include appropriate material on medical issues in its lit­ er­a­ture to hundreds of thousands of businesses. By the end of the 1940s, around twelve thousand trade associations, twenty-­seven hundred chambers of commerce, and almost nine thousand civic and community ser­vice clubs ­were contacted and supplied with materials against health insurance by Whitaker and Baxter. For strategizing and lobbying politicians, the AMA locked arms with other conservative groups like the National Association of Manufacturers (NAM), the American Farm Bureau Federation, the American Bar Foundation, and the National Association of Small Businessmen, all of which sided with or­ga­nized medicine against national health insurance in the 1940s.56 In 1951, AMA leaders attended the first of a long series of joint meetings, extending into the 1960s, of secret “Greenbrier Conferences” for coordinating po­liti­cal strategy and activities. AMA president Francis Blasingame served as chairman at an opulent resort ­hotel in West ­Virginia. The conferences ­were initiated by the NAM, whose leadership overlapped with the infamous ultraconservative John Birch Society. Its president publicly denounced Republican president Dwight D. Eisenhower as “a dedicated, conscious agent of the Communist conspiracy.” To him, the Republican Party’s calm ac­cep­tance of the New Deal welfare state had been tantamount to treason.57 The AMA marched together with its lay allies in support of a constitutional amendment, which President Eisenhower opposed, to limit both the federal government’s ability to enter into international treaties and conventions and presidents’ executive authority to implement special agreements with foreign governments and entities. Of special repugnance to the AMA ­were “conventions” a­ dopted by the International L ­ abor Organ­ization (ILO) concerning health and disability insurance, maternity protection, social security, workers’ compensation, and weekly working hours. Eisenhower had rejected the AMA’s view that disability insurance was part of a “piecemeal approach to the socialization of medicine” when in 1955 he supported social security benefits for the permanently disabled. But the AMA secretary and general man­ag­er George F. Lull told senators in 1958 that the ILO’s agenda was a “serious threat” to the high standard of American medical care and would bring “major changes in the teaching and practice of medicine.” By promoting such ­things “repugnant to American thinking,” said Lull, the ILO was trying to “remake the social and economic structure in the United States.”58

428

Reactionary Turn and Beyond

Among the AMA’s staunchest allies in medical power politics ­were tobacco growers and the cigarette industry. In 1968, investigative journalists Drew Pearson and Jack Anderson called it “the weirdest lobbying alliance in legislative history.” The AMA was highly solicitous of Southern states b­ ecause their conservative Demo­cratic congressmen and senators chaired key committees and thus could block the movement of bills t­ oward floor votes. Their perpetual reelection as “Dixiecrats” in the “Solid South” gave them the se­niority that automatically qualified them for chairmanships. Meanwhile, tobacco and cotton growers relying on Jim Crow laws to oppress black sharecroppers no doubt appreciated the role of the many sympathetic Southerners in the AMA leadership. With Fishbein in charge, the AMA journal published its first lucrative tobacco ads in 1933 and only ceased twenty years l­ater when bad publicity and pressure from some members—­and even some embarrassed phar­ma­ceu­ti­cal advertisers—­called for it to stop.59 Evidence had been accumulating since the 1920s about the risks, especially cardiovascular, of smoking. But it was not ­until 1964, ­after the U.S. surgeon general issued a report conclusively linking it to cancer, that the AMA House of Delegates fi­nally took a stand against the tobacco habit. Perversely, despite its 1964 proclamation, AMA officials assisted the industry as a “merchant of doubt” by insisting that more research on smoking was needed before it could demand resolute government action. That year, the AMA accepted $10 million in funding from the six major tobacco companies to sponsor the extra research allegedly needed. The next year, it opposed regulation of cigarette advertising and labeling by the Federal Trade Commission, calling it a ­matter for legislative, not executive, action—an unlikely event, of course, considering the veto power of the Dixiecrats.60 The AMA’s key expert on its committee charged to coordinate the research on smoking and interpret its findings was Maurice Seevers, an esteemed professor of pharmacology on the payroll of the tobacco industry as a con­sul­tant and recipient of its research funds. Seevers was one among other AMA figures who shared information and ideas b­ ehind the scenes with tobacco executives about their po­liti­cal strategies. ­Because he was influential in the public health world, his views ­were responsible for a quarter-­century’s delay in classifying smoking as addictive. It was, according to Seevers, merely “habit forming” ­because nicotine-­withdrawal symptoms ­were mild in comparison with narcotics. Back in the 1930s, Seevers had defended amphetamine makers with the argument that, being stimulants, not depressants, amphetamines ­were not addictive. Not surprisingly, American Tobacco considered him to be “a friend”



Medical Power Politics

429

of its research department. He even offered the industry advice about how to increase the addictiveness of cigarettes by increasing their nicotine content.61 By 1968, when the AMA was still calling for more research, it had received in total $18 million in research funds from the industry. Its footdragging was prob­ably a major ­factor in the PHS’s similar stalling, for it apparently did not want to antagonize the AMA. In exchange for the AMA’s help, tobacco and its friends pledged solid opposition to Medicare. That alliance must have been what Sir Philip Rogers, the head of the British Tobacco Association, had in mind when he noted privately that “the AMA appears more concerned with safeguarding the financial interests of doctors through po­liti­cal lobbying than with the doctors’ patients.” But by 1971, the AMA began wishing it could slink quietly out of the tobacco alliance, according to an American Tobacco Institute official, b­ ecause it was “blackening” or­ga­nized medicine’s image. Nevertheless, according to Rogers, the AMA was “most anxious to avoid any incident which w ­ ill create dis­plea­sure with . . . ​tobacco area Congressmen.” He had been told by Ernest Howard, the AMA’s executive vice president, that “the AMA needs their support urgently” to fight off universal health care, the next big item on the insurance reform agenda ­after Medicare.62 In July 1982, the Journal of the American Medical Association killed an article it had planned to feature by award-­winning public health specialist David J. Fletcher on the Philip Morris tobacco com­pany’s six-­year l­egal success in suppressing for years a British antismoking movie, Death in the West. Fletcher was told about a week before his article was to appear that it was g­ oing be pulled on the grounds that the AMA might be sued by Philip Morris if the article appeared. Two years ­later, Chicago journalist Howard Wolinsky challenged that story, citing a top-­level AMA insider who told him that the AMA had been seeking support from tobacco state senators and congressmen for a bill exempting it from the 1979 FTC antitrust ruling that declared its fight against the spread of prepaid group practice arrangements to have been a “nationwide conspiracy in restraint of trade.” An internal September 1982 memorandum that Wolinsky obtained supported the po­liti­cal rather than ­legal pretext. In it, the recently hired editor George Lundberg, who had eagerly asked Fletcher to submit the article, conveyed to the journal’s staff that the journal was ­under high-­level pressure to “exercise caution” in articles dealing with “particularly sensitive po­liti­cal questions.” The first of the examples listed was “tobacco and control of tobacco use.” 63 The following year, Alan Blum, the editor of the New York State Journal of Medicine (NYSJM), which was owned by the Medical Society of the State

430

Reactionary Turn and Beyond

of New York (MSSNY), exercised the opposite of editorial caution by publishing a large theme issue devoted to the “world cigarette pandemic,” with editorials and cover stories that attacked the tobacco companies and their cigarette brands by name. Since his medical school days, Blum had been a tireless or­ ga­nizer and agitator against the industry, and in 1977 as a resident in ­family medicine at the University of Miami, he founded the national antismoking activist group DOC (Doctors O ­ ught to Care). In December 1983, he published the first theme issue on smoking ever published by an American medical journal. The 122-­page, 60-­author issue, titled “The World Cigarette Pandemic,” was then published for public distribution as The Cigarette Underworld in 1985. It contained multiple articles with implicit and sometimes not-­so-­subtle criticisms of or­ga­nized medicine’s outward silence and po­liti­cal passivity concerning the deadly consequences of smoking, leaving the lay public and Demo­cratic politicians to attack the tobacco industry on their own. The least flattering of the articles noted the AMA’s gradual and belated “increasing commitment” to a reduction in smoking, but made it clear that the pressure for change was coming from below in the House of Delegates and that its board of trustees was dragging its feet.64 In December 1985, four months ­after Blum published an even more in-­ depth 200-­page, 80-­author theme issue of the NYSJM on the cigarette pandemic, he was summarily fired by George Lawrence, the executive vice president of the MSSNY. Lawrence flatly denied that his decision had anything to do with Blum’s antismoking agenda but would divulge no motive to him or anyone e­ lse. Protests flowed in, including from the Annals of Internal Medicine editor Edward  J. Huth who praised Blum’s remarkable editorial work and remarked on the apparent lack of “ethical and procedural care” in his dismissal. Indeed, Blum had been widely admired for quickly transforming the NYSJM from what was derisively regarded as the society’s “house organ”—­even a “rag”—­into a highly respected medical journal. He had recently done the same as editor of the Medical Journal of Australia (MJA), and published his first theme issue on cigarettes ­there, the first in the world of medical journalism. One admirer of Blum’s ­earlier work at the MJA wrote that Blum “completely revolutionized medical journalism in this country with his undoubted idealism.” Blum was also praised by an appalled and dismayed John P. Naughton, dean of the SUNY Buffalo school of medicine, not only for his transformation of the New York journal but for being “an outstanding person of integrity, an indefatigable worker, . . . ​and a teacher who is charismatic and inspirers loyalty in his students.” 65



Medical Power Politics

431

Surgeon General and antismoking campaigner C. Everett Koop, one of Blum’s authors, also expressed concern about “forces at work” to remove Blum, whom he knew to have put the New York journal “on the map” both in the United States and abroad. The prominent New York neuropathologist Bennett M. Derby, who complained of the journal being of a “pusillanimous and degraded nature” before Blum’s editorship, noted that Blum’s firing gave at least the appearance that it was ­because the state society had “stepped on the toes of the tobacco industry” and was likewise “knuckling ­under to the drug industry” too. With its action, the state society “bared to the world how the Society is operated, blatantly impugning what­ever we might have to say” about other issues.66 Blum could not have been entirely surprised, given his view expressed before that “a medical editor is an especially vulnerable role. Po­liti­cal and commercial considerations always seem to be just beneath the surface and can come up at any time.” He regarded Lawrence, who fired him, as an unregenerate medico-­political “hack.” Lawrence had testified on behalf of the state society in Congress back in 1961 against Medicare. The person in or­ga­nized medicine he most admired, he once remarked to Blum, was Joe D. Miller, ­ ntil 1983, Miller who had served as the first executive director of AMPAC. U was the right-­hand man of the AMA’s chief executive officer, James Sammons, who resigned in 1990 ­under fire ­after newspaper exposés of his financial improprieties. When Miller left the AMA, it kept him on as a well-­paid con­sul­ tant while he was si­mul­ta­neously employed as a Washington lobbyist for the government of Apartheid-­era South Africa.67 It cannot be known if Blum’s antismoking work had any direct connection to his firing, but he had long been persona non grata with AMA’s top brass on tobacco issues. As an elected member of the governing council of the AMA’s Resident Physician Section in 1979, he had internally criticized, to no avail, the AMA Members Retirement Plan’s $1.4 million stake in Philip Morris and R. J. Reynolds tobacco com­pany stocks. When a 1981 House of Delegate resolution he helped initiate was rejected in a divided voice vote, the AMA continued to refuse to rid itself of the lucrative investments. It only did so a­ fter Blum channeled the information about the stocks to the press, a source of extreme embarrassment leading to a begrudging divestment.68 Just days before Blum was unceremoniously dismissed four years l­ater, he was quoted in a national Associated Press story responding to a question about a recent House of Delegates resolution to ban cigarette advertising by saying, “The product with the longest shelf life in Amer­i­ca is an AMA resolution.”

432

Reactionary Turn and Beyond

That could not have gone down well. Blum repeated the quip in an interview published by Wally Phillips, Chicago’s “king of morning radio,” noting that the AMA had yet to back up antismoking resolutions with the kind of “substantive financial or lobbying commitment” that it brought to bear against universal health insurance.” Lending further plausibility to the pecuniary motives imputed by Blum and o­ thers for his firing is the fact that in 1988, three years ­later, Blum was offered a contract for the editorship American ­Family Physician, owned by the American Acad­emy of ­Family Physicians, that explic­ itly demanded he not focus too much on a single issue, adopt “a team player attitude,” and accept the legitimacy of the acad­emy’s “chain of command.” That was in the same breath that it called for him “to determine which issues are impor­tant enough to ‘­battle’ and which are not.” Cigarette smoking was clearly not one of the impor­tant ones. The contract explic­itly forbade him from “speaking on smoking for a period of one year.” The Acad­emy was still accepting lucrative advertising and conference support from the food subsidiaries of RJ Reynolds and Philip Morris. Blum rejected the job.69 By far the AMA’s strongest if not weirdest ally in medical power politics was the hugely profitable phar­ma­ceu­ti­cal industry. B ­ ecause of that and the cigarette connection, three prominent science writers for the New York Herald Tribune called AMA leaders “healer-­dealers.” Before the 1920s, the drug industry had been one of the AMA’s bitterest enemies and an ally of other lay groups at war with the progressive medical politicians. According to his editor-­successor Fishbein, George Simmons had conferred with drug com­ pany representatives “with suspicion and grave doubt, like diplomats working on an armistice.” Relations warmed somewhat over time but only on the AMA’s terms: compliance with the ethical standards of the Council on Pharmacy and Chemistry (CPC) for access to advertising pages in the AMA’s and most state socie­ties’ journals. A ­ fter 1924, u ­ nder Fishbein, the thaw accelerated. Drug advertising paid for an increasingly large share of the AMA’s growing operating expenses, including salaries, while privileged access to advertising space guaranteed high profits, especially for larger drug ­houses. Fishbein personally intervened in 1932 to force the Archives of Internal Medicine, the AMA’s first specialty journal, to accept drug advertisements, a move that caused the entire editorial board of what he called “high-­minded” physicians to resign. Indicative of the thaw was the AMA passivity in the debate leading to the passage of the 1938 Food, Drug, and Cosmetics Act.70 Although Simmons had warned his successor that working with phar­ma­ ceu­ti­cal manufacturers was “about the same as Faust trying to make a deal



Medical Power Politics

433

with Mephistopheles,” Fishbein prided himself in his close relations with major com­pany executives and boasted especially of a close and enduring bond with Elmer Bobst of Hoffman-­La Roche. Ironically, Bobst, an anti-­Semite, entertained Fishbein on many occasions on his yacht. For Fishbein, Bobst made a profitable exception; it was liberal East Coast Jews in the news industry whom he found especially abhorrent. Shortly before his ouster in 1949, Fishbein groomed Austin Smith, the CPC chairman, to take over editorship of the AMA journal. Tellingly, the Phar­ma­ceu­ti­cal Manufacturers Association (PMA) ­later hired Smith away from the AMA to serve as its president, further nurturing the alliance with the AMA. Smith would then move on to an even more lucrative job as president of Parke-­Davis. In 1963, to replace him, the PMA hired Joseph Stetler, the AMA’s executive vice president and director of its l­egal and socioeconomic division, to take over as its own executive vice president. Two years ­later Stetler would become PMA president.71 While top officials circulated from the AMA into the drug industry, money circled back. The symbiotic monopoly-­sharing alliance was built on three pillars: government patents and trademark protections for prescription drugs, the AMA’s control of journals in which expensive prescription drugs ­were advertised profitably for both sides, and the AMA’s coercive power to maintain high membership and therefore journal subscription rates. The AMA and the PMA ­were conjoined at the head and hip pocket. But the AMA was the weaker partner ­because “detailing” by drug representatives, doctors’ main source of information about new drugs, was apparently even more profitable to drug companies, constituting about 60 ­percent of their total marketing expenditures. Thus, when its advertising revenues w ­ ere dwindling in the 1950s, the AMA sought to increase and tap into the revenue stream from direct personal marketing. It was able to do so by selling to drug companies access to its modern computerized registry, using IBM punch cards, of all physicians living in the United States, which it had started compiling in the late 1940s. ­Later called the AMA Physician Masterfile, it listed license numbers, dates of birth, medical schools attended, practice addresses, and specialties—­but not names. However, the drug companies ­were able to link that information with prescription rec­ords they bought from pharmacies to identify individual targets for detailers touting the most profitable drugs.72 Concerted po­liti­cal action cemented medicine’s alliance with phar­ma­ceu­ ti­cals. The drug industry locked arms with or­ga­nized medicine against liberal initiatives in drug regulation as well as health-­care financing, organ­ization, and distribution. In 1937, Elmer Bobst offered to donate $100,000 to the AMA

434

Reactionary Turn and Beyond

on the condition that other drug firms contribute another $400,000 for a large-­ scale radio campaign to preserve the “American system of medicine.” It was therefore prob­ably Bobst, together with Fishbein, who instigated the aforementioned National Physicians Committee a few years l­ater. The name cleverly disguised its true nature. Of the almost $1 million the NPC collected to spend on pamphlets, speeches, radio talks, and print advertising between 1940 and 1945, about 90 ­percent was drug money. When, with Medicare, compulsory health insurance once again loomed on the horizon in the early 1960s, seventeen of the largest drug firms gave nearly $1 million to AMPAC in its first three years. That helped it set up offices around the country, cover administrative overhead, and solicit individual contributions from doctors and ­others to hand over to power­ful legislators.73 In 1955, the AMA took away from its Council on Pharmacy and Chemistry the power it had been given in the progressive period to withhold its approval of drugs. By 1960 it had cut the council’s bud­get in half. What came to be called its “seal of approval” had been the ticket for entry into the AMA journal’s advertising pages, granted a­ fter expert scrutiny of a drug’s composi­ ere made, claims about therapeutic efficacy. ­Because of tion and, if they w the CPC’s relatively high standards, in the 1940s drug companies had drifted over to in­de­pen­dent journals with looser standards and direct detailing. Advertising revenues flagged, so the AMA turned to Ben Gaffin and Associates, a marketing consultancy, which advised it in 1953 to drop the seal of approval program. Henceforth, instead of pharmacological experts, a committee of full-­time AMA staffers dependent on advertising revenue for their salaries would decide what passed muster. The resulting loosening of standards led to a dramatic recovery of advertising revenues, which generated over half the AMA’s income in 1959.74 Edward Pinckney, associate editor of the AMA journal in the 1950s, ­later testified to senators that at least during his time the journal’s advertising committee—actually only one person—did little more than make sure that the advertisements accepted were esthetically presentable. Their honesty was no longer investigated. Pinckney failed to get permission to publish an editorial to enlighten the AMA journal’s naive readers about the extreme unreliability of the information supplied in drug advertisements and to disabuse them of the commonly held notion that a drug’s appearance in the journal was somehow an endorsement of its worthiness. It was flatly rejected by the AMA’s most power­ ful full-­ time official, executive vice president Ernest Howard. To explain the decision to the Senate, Pinckney quoted Howard



Medical Power Politics

435

saying that “advertising is the journal’s principal source of revenue and I hope it ­will continue for many years to come.” The relationship was downright “unwholesome,” Pinckney complained, one in which the AMA was a “panderer of drugs rather than a scientific evaluator.” It induced “the doctors of this country [to] prostitute themselves” for the industry’s benefit.75 In 1962, the AMA joined its best po­liti­cal friends in fighting the 1962 Kefauver-­Harris amendments to the 1938 Food, Drug, and Cosmetics Act. Estes Kefauver, Senate Antitrust and Mono­poly Subcommittee chairman, “the conscience of the Senate,” and a ­viable candidate for the presidency, conducted the hearings. B ­ ecause Kefauver had set his sights on the huge profits earned from mono­poly pricing in the industry and b­ ecause of that high and rising prices, the PMA joined Republicans in arguing that un­regu­la­ted capitalism in the drug industry was helping Amer­i­ca win “the h ­ uman race” against the Soviet Union. Joining the AMA del­e­ga­tion to testify in 1961 was AMA general counsel and soon-­to-be PMA president Joseph Stetler. The AMA in turn vehemently objected to the proposed requirement that drug companies test drugs in “adequate and well-­controlled” clinical studies to establish clinical efficacy as well as safety before putting them on the market. According to Hugh Hussey, the power­ful chairman of the AMA Board of Trustees, no doctor should be prevented from prescribing any drug “by a governmental ruling or decision.”76 Ironically, the big drug companies in control of the PMA did not worry much about the efficacy testing feature. It was more a threat to the market share of small companies lacking the resources to conduct expensive ­trials. As Kefauver noted, “On this issue the AMA’s position was to the right of the industry’s.” Nevertheless, the PMA declared that ­there was “no relevant difference” between the AMA’s and the PMA’s position. It also returned the AMA’s ­favor by joining the brewing ­battle against Medicare. In 1963, former AMA editor Austin Smith, and now Stetler’s successor as president of the PMA, called Medicare legislation a foot in the door for socialized control of medical practice, which would inevitably “place in jeopardy our medical care ­ ere it not system, the superiority of which is universally recognized t­ oday.” W for the thalidomide scandal and, relatedly, President John F. Kennedy’s belated intervention, the conservative alliance of doctors and drugmakers might have prevented the FDA from acquiring the internationally unpre­ce­dented power to control the flow of new drugs on the market on efficacy grounds.77 In the early 1960s, the AMA’s Council on Drugs (COD), previously called the Council on Pharmacy and Chemistry and renamed in 1957, was no

436

Reactionary Turn and Beyond

longer what its progressive creators had had in mind. Now it had to confine itself to scientific activities and publications instead of critical evaluations of drugs and their advertising. One of the COD’s members, was Maurice Seevers, the tobacco-­friendly pharmacologist who sought cigarette industry input on who to nominate to serve as AMA officials. But ­there ­were still eminent reformers like John Adriani, Louis Goodman, Harry Dowling, and Max Wintrobe, who volunteered their ser­vices on the council at vari­ous times. They refused to testify against the 1962 Kefauver-­Harris amendments, and Goodman, coauthor of a standard pharmacology textbook and a recent president of the American Society for Pharmacology and Experimental Therapeutics, even told senators he thought the AMA’s argument against the need for efficacy evaluations vacuous in the extreme. In 1972, the AMA fi­nally shut the COD down. The year ­earlier, it had researched, published, and distributed a large bound compendium called AMA Drug Evaluations (ADE) to help clinicians see through the thick haze of drug advertising for thousands of commonly prescribed drugs on the market. Their unpaid l­abors involved writing cross-­referenced discussions of specific drugs and medical conditions amenable to drug therapy. With Adriani, a preeminent anesthesiologist and pharmacologist, as chairman, it laboriously gathered reports from over three hundred experts to give clinicians the objective advice they so desperately needed to navigate the pharmacotherapeutic jungle.78 One of the ADE ’s sins was to rank some companies’ drugs above ­others as first-­line treatments for specific indications. Worse for many drugmakers was the blanket condemnation of their highly profitable drug combinations as “not recommended” b­ ecause they ­were “irrational” or even “dangerous.” The most dangerous ­were amphetamine mixes for weight loss. Other commonly prescribed combinations it condemned w ­ ere for treating anemias, anxiety, blood clotting, coughs, colds, depression, hormonal disturbances, hypertension, muscle spasms, obstructive pulmonary diseases, pain, and rheumatoid arthritis. Also declared highly irrational ­were mixes of antibiotics. The prescribing of such cocktails was already widely discredited, and many had been removed by the FDA. But ­others remained on the market. The pharmacological consensus about t­hese brand-­name and therefore expensive shotgun medicines was that dif­fer­ent antibiotics sometimes worked at cross-­purposes or not at all, and prescribing them hastened the development of drug-­resistant bacteria. The chairman of the AMA Board of Trustees told the organ­ization’s official historian that the ADE set off “a big yow-­wow” in the House of Delegates ­because the mixtures ­were very popu­lar with prac­ti­tion­ers for their con­



Medical Power Politics

437

ve­nience and ­imagined efficaciousness. According to Adriani’s Senate testimony, manufacturers fumed about the COD’s impudence, prompting the AMA Board of Trustees to send it packing, citing only bud­getary reasons. That was not entirely dishonest ­because drug advertising revenues ­were again on the decline and, according to Adriani, might have suffered further had the COD been allowed to produce, as planned, updated and expanded editions of the ADE in the coming years.79 THE NEW OLIGARCHY

With characteristic bombast, Chicago insurgent G. Frank Lydston had alleged in 1913 that the AMA “oligarchy” was so power­ful in its control of all ­things medical that, in comparison, “Standard Oil is a puny, piffling ­thing.” Actually, the power over medical commerce that the progressive AMA enjoyed in Lydston’s time pales in comparison to its successors’ “nationwide conspiracy in restraint of trade” that the U.S. Federal Trade Commission found in the 1970s, a subject addressed in the next chapter. On the conservative era AMA oligarchy, po­liti­cal scientist Oliver Garceau observed that “active minorities” controlled “strategic posts” throughout or­ga­nized medicine and “knew how to make the machinery run.” They handpicked delegates to state meetings, which in turn chose who to send to national meetings. Occasional disrupters could be rolled over by packing local meetings with loyal but normally inactive members. Between 1922 and 1938, b­ ecause of l­ittle turnover about two-­t hirds of AMA delegates served more than five years, and over 40 ­percent served eight or more years. A highly critical 1954 study of the AMA and its use of power published in the Yale Law Journal by a team of Yale law students concluded that it was run by a “self-­perpetuating minority” who recruited and groomed leaders from the county level up for ser­vice in House of Delegate meetings, where members of the board of trustees ­were elected and who in turn chose who would serve as power­ful full-­time salaried officials. The Yale student researchers called themselves “Anonymous,” perhaps out of fear that medical socie­ties across the country could block their employment in the prestigious law firms they retained. ­Later it became known that one of them was David R. Hyde, the chief editor of the Yale journal and four years ­later assistant U.S. attorney for the Southern District of New York .80 Back in the 1910s, the progressives had defended themselves against the insurgents’ charges that they w ­ ere power hungry and even greedy with the argument that day-­to-­day control of the AMA by a small number of ­people

438

Reactionary Turn and Beyond

was only natu­ral and rational considering the practical impossibility of direct democracy or the gross inefficiency of rapid turnover in leaders and officials. The real­ity was well characterized by the Italian-­German sociologist Roberto Michels, who in 1911, around the same time, famously wrote that “who says organ­ization says oligarchy.” A corollary of Michels’s aphorism might be “who says oligarchy says misrepre­sen­ta­tion,” for the progressives’ aims ­were far afield from rank-­and-­file concerns. Not much changed a­ fter the reactionary turn. In the 1950s, as President Dwight D. Eisenhower put it, the AMA was run by “a l­ittle group of reactionary men dead set against any change,” implying that their views could not be taken a priori as t­ hose of the profession as a ­whole.81 ­Because oligarchy and misrepre­sen­ta­tion tend to go hand in hand, one can justifiably ask if the medical conservatives of the 1920s and l­ater ­were any more representative of rank-­a nd-­fi le physicians than their pre­de­ces­ sors. According to medical historian Thomas Bonner, it was scarcely pos­si­ ble that Illinois Medical Society leader and journal editor Charles Whalen’s reactionary fulminations of the 1920s and 1930s actually reflected the views of the average physician. In 1925, for example, Whalen had warned against a constitutional amendment prohibiting child ­labor, supported as it was “by ­every red and communist in the United States.” On the other hand, Bonner muses, ­there is no evidence that Whalen did not represent the common medical practitioner. ­Either way, Whalen suffered no consequences. Ten years ­later, he blasted away at the newly passed Social Security Act as “a horse-­ laugh on scientific medicine and American patriotism,” even though it did not include health insurance. Although Morris Fishbein’s pronouncements ­were tamer, they cannot simply be assumed to have been representative.82 As Garceau concluded, doctors in general w ­ ere detached, indifferent, and too busy for medical politics. “Doctors look a ­little askance at ‘politics,’ both big and l­ittle,” and for that reason, “they would rather leave it to o­ thers.” Thus, they w ­ ere “saved from the awkward predicament of having to think.” Bertram Bernheim’s Pennsylvania talk cited e­ arlier, which apparently turned his audience 180 degrees around about Peters’s committee, suggests clearly that the AMA’s rigid policies in no way reflected fixed, uniform, and clear views shared by the entire profession. ­These caveats notwithstanding, in all probability the conservative-­era AMA better represented rank-­and-­file opinion a­ fter the reactionary turn of the 1920s than before. A 1935 survey of doctors in California found that a substantial but not crushing majority of 62 ­percent



Medical Power Politics

439

­ ere against state-controlled compulsory health insurance. In 1948 about two-­ w thirds of AMA members, or about half the profession, volunteered twenty-­ five dollars ­toward a war chest to fight national insurance legislation. On the other hand, they did so in response to “assessments”—­a word smacking of compulsion—­sent by their county socie­ties, and therefore some prob­ably felt vulnerable to what delinquency might bring. However, by 1949 only a l­ ittle less than half of the Mas­sa­chu­setts state society had paid up. Eleven other state socie­ties’ yields w ­ ere even lower. New York’s Kings County medical society actually officially opposed the assessment.83 Even if ­there was majoritarian opposition to compulsory health insurance, that does not mean ­there ­were similar levels of agreement with all of the AMA’s conservative policies and strategies. All speculation on that is futile. But speculation is merited about ­whether the opposition to health insurance would have been so strong had ­there not been a quarter ­century of incessant and fervent propagandizing by the active and cohesive minority in control of medical socie­ties from the bottom up. The AMA’s “po­liti­cal education” involved histrionic rhe­toric about health insurance’s high costs to doctors and the quality of medical care. It also involved the forging of a strong tribal identity for an occupational group desiring to preserve its reputation for having a near-­ monopoly on superior scientific, experiential, and even humanitarian qualities. The ideological education also involved conjuring up an ­enemy tribe: lay reformers imbued with foreign po­liti­cal values, greedy for control, who ­were constantly laying siege to the in­de­pen­dent practitioner’s rightful territory. The AMA certainly acted as if it w ­ ere true that manufactured tribalism was necessary for achieving unity against health insurance. It pitched its arguments to a self-­selected occupational group with desires, sensibilities, and anx­i­eties that made them receptive to ideological lessons of a conservative nature. In 1919, at the height of the insurgency, George Kosmak of New York noted that “ninety-­nine out of one hundred men ­will say that they took up the practice or the profession of medicine as a means of earning a livelihood,” not a power­ful desire to heal or an interest in science and certainly not to further public health. That explained, he thought, a widespread fear that compulsory health insurance would only be used to drive down doctors’ income. Such a fear could easily be stoked by shrill propaganda conjuring up hordes of power-­hungry laypeople shedding crocodile tears for the struggling masses. In 1938, Bernheim, one of the original signatories of the Committee of Physicians’ “Princi­ples and Proposals,” observed that most doctors w ­ ere “easily led” by the ultraconservative medical establishment and “drilled in silence

440

Reactionary Turn and Beyond

individually and collectively.” Organized medicine could “crush the spirit of all but the daring few.” ­Because many doctors chose their profession only to rise “in the social scale,” they had no time for in­de­pen­dent reading and reflection, even about medicine itself, while struggling to make a decent living. That reinforced their parochial “narrow-­mindedness” on social, economic, and po­liti­cal issues. On the w ­ hole, they w ­ ere incapable of understanding “the growing social and economic implications of medical practice” and how ­those should affect their clinical work.84 Frank Campion, the author of an official history of the AMA ­from the 1940s to the 1980s, explained the profession’s conservatism as the result of many young men’s “intense desire for in­de­pen­dence,” as well as a comfortable standard of living. One successful obstetrician-­g ynecologist told Campion that the most impor­tant ­career advice he had received was his ­father’s. He did not care what his son chose. “But do something where you work for yourself.” In short, “that’s what de­cided me on medical school.” Few doctors fit the mold, Campion maintained, of the “organ­ization man” comfortable working ­under hierarchical supervision. Doctors as small entrepreneurs easily absorbed teachings that “state medicine” and even vari­ous forms of “corporate medicine” would, as the rhe­toric of the 1940s put it, regiment and even “enslave” the medical profession. As former chairman of the AMA Board of Trustees Hugh Hussy told Campion, the physician’s “distinct sense of in­de­ pen­dence . . . ​carries over into other ­things.”85 ­Those would include a distrust of all medical as well as lay forces allegedly conspiring, through po­liti­cal and other means, to subvert the honorable “art and science of medicine.”

ch a p t er 15

A New Medical Progressivism

Starting in the mid-1960s, the American Medical Association began shrinking. According to its unpublished count, its “market share” had dropped to about 46  ­percent of physicians in 1980 from around 75  ­percent in the 1950s and early 1960s.1 Growing numbers of doctors regarded it with disdain as currents of a new progressivism began to flow through the unor­ga­nized reaches of the profession. Medical students and recent gradu­ates, including increasing numbers of ­women, called for change. In the approach to the new millennium, reformists in the profession called for tackling prob­lems that medical conservatives had left unsolved and even worsened with complicity or negligence: unfair distribution of access to health care, irrational therapeutics, uncontrolled spending, l­imited interest in public health, and systemic conflicts between the profession’s ethical mission and economic interests. In the 1980s, the AMA’s stagnation continued, with membership levels sagging to around 40 ­percent of doctors. Its prestige outside the profession had also waned in the 1970s and did not recover in the 1980s. In 1988, George Lund­ berg, editor in chief of the Journal of the American Medical Association, which was now called JAMA as its quasi-­official name, published an editorial called “American Medicine’s Prob­lems, Opportunities, and Enemies.” In it he lamented an “increasing lack of trust by the public in the medical profession.”

441

442

Reactionary Turn and Beyond

Pos­si­ble ­causes that Lundberg thought needed investigating and fixing if necessary included failure to pay heed to the public criticisms about clinicians’ failure to listen to patients; rising health-­care costs; neglect of preventive medicine; failure to care for the poor; inappropriate use of resources; low quality of care; a conspiracy of silence about medical errors; and entrepreneurialism instead of professionalism—­and therefore conflicts of interest, greed, and hucksterism.2 Ninety years before Lundberg’s editorial appeared, Leartus Connor, an ophthalmologist and otologist and recent president of the American Medical Editors’ Association, had lamented to the American Acad­emy of Medicine about the multiple “diseases preying on the medical profession.” Connor’s address preceded by two years the AMA’s reor­ga­ni­za­tion and retooling for a progressive mission, one he played a partial role in.3 Lundberg’s editorial also presaged changes in the AMA. By the 1990s, for example, somewhat moderate leaders began replacing the hard-­liners of the past. But the changing AMA lacked the missionary zeal of the progressives a c­ entury ­earlier. Its rudderless leaders reacted to hostile external attacks and internal criticism with belated, desultory, and sometimes begrudging moves. Some of the movement was retrograde. One of them was Lundberg’s ouster in 1998 for exercising too much editorial in­de­pen­dence. All in all, the reform currents swirling around the relatively impermeable AMA moved t­hings only weakly inside it. And they had l­ittle effect on its lobbying and campaign financing, which continued to be devoted largely to the economic interests of the profession. D E F E AT, S C A N D A L , AT TA C K , A N D D E C A Y

The AMA’s progressive drift of the 1980s onward was not sparked by a wave of insurgency and mass turnover in leadership as occurred in the 1920s. The first rumblings of change came in the aftermath of Medicare’s passage in 1965, a huge symbolic defeat for the organ­ization and, worse, an embarrassing blot on its rec­ord in the minds of growing numbers of lay and medical critics. Two years ­later, as if in petulant defiance, the AMA House of Delegates elected as president the ultraconservative Milford O. Rouse of Dallas, a former director of Texas billionaire Howard L. Hunt’s right-­wing Life Line Foundation. Rouse’s conservative credentials ­were solid. In 1956, as the president-­ elect of the Texas Medical Association, he had expressed regrets about the passage of the Social Security Act. In his 1967 inaugural address to the House of Delegates, Rouse reaffirmed the AMA’s philosophy as “faith in



A New Medical Progressivism

443

private enterprise and individual initiative.” The concept of health care “as a right rather than a privilege” was one of the AMA’s “prob­lems and challenges,” not an aspiration.4 ­Because of its unrepentant conservatism, the AMA failed to recruit many young doctors entering the profession as their elders retired. Increasingly, medical specialty associations exercised greater pull and began to compete with the AMA for po­liti­cal and economic influence. The rising generation of doctors knew full well that in Eu­rope and elsewhere universal health care had not been a step t­ oward totalitarianism, medical or other­wise. In fact, prac­ti­ tion­ers discovered ­a fter Medicare’s passage in 1965 that the long-­predicted damage to their earnings and professional authority did not come to pass. Instead, between 1965 and 1975, their nominal earnings doubled, faster than inflation, and their clinical autonomy remained untouched. Only or­ga­nized medicine came through worse for wear. Major newspapers played a power­ful role in tarnishing the AMA’s already negative image in the eyes of liberal doctors and other Americans. They reported on loud dissidents disrupting the AMA’s 1969 meeting and conservative delegates who threw cigarette ashtrays at them. Many delegates w ­ ere still smokers five years ­after the surgeon general of the U.S. Public Health Ser­vice had released a first report definitively holding cigarettes a leading cause of death. Meanwhile, the AMA tiptoed gingerly around that burning public health issue. It had just helped derail President Nixon’s appointment of John H. Knowles, a liberal physician and public health champion, as assistant secretary for Health and Scientific Affairs in the Department of Health, Education, and Welfare (HEW). The St. Louis Post-­Dispatch carried a cartoon depicting Senator Everett Dirksen, a power­ful conservative Republican, toting a medical bag marked “AMA” with a small Nixon peering out. A Washington, DC, physician charged the AMA with “Neanderthal, Know-­Nothing, proverbial thumb-­ sucking stupidity” for implying that Knowles was a left-­wing “card-­carrying fellow-­traveler.” Knowles ­later took revenge by shaming the AMA for lobbying to cut the HEW’s bud­get for public health mea­sures.5 A spate of embarrassing scandals in the mid-1970s accelerated the AMA’s loss of prestige. A new era of medical muckraking inflicted what felt like “death by a thousand cuts” to “the already cracked image of or­ga­nized medicine,” according to an AMA official. Most of the investigative reportage was based on documents purloined by an AMA insider dubbed “Sore Throat” (­after the recent Watergate scandal’s “Deep Throat”) by reporters. The mysterious conduit turned out to be a Scientologist spymaster whose ring of thieves

444

Reactionary Turn and Beyond

had infiltrated not only the AMA but other enemies of Scientology, including the Internal Revenue Ser­vice and even the Central Intelligence Agency. L. Ron Hubbard, Scientology’s founder, was seeking revenge on the AMA ­because it had attacked his cult for its criticism of psychiatry. In the summer and fall of 1975, reporters at the New York Daily News, the Chicago Sun-­Times, the Washington Post, and the New York Times posted stories based on the leaked documents, and other newspapers around the country reprinted or followed up on them.6 One story told of the AMA’s participation with representatives of the tobacco, oil, heavy industry, rubber, and, of course, phar­ma­ceu­ti­cal industries in a 1970 fund­rais­ing function for Arizonan Paul J. Fannin, a conservative hard-­ liner and member of the power­ful Senate Finance Committee. It made the AMA look like “just another big corporation using its muscle to get what it wants.” The AMA’s secret collaboration in 1969 with the Nixon White House on lobbying for Supreme Court nominee Clement Haynsworth, a Southerner opposed by l­abor and civil rights groups, also came to light. The following year, the public learned that the AMA lobbied for G. Harold Carswell, another Southerner attacked by civil rights and feminist groups for his history of support for segregation, white supremacy, and opposition to ­women’s rights.7 Another story exposed the AMA efforts in 1969 to curry f­ avor with Hale Boggs, the House majority whip and power­ful Ways and Means Committee member, with a campaign donation and a $15,000 retainer for his son’s law firm. It had lobbied Congress to keep the AMA’s exemption for its advertising revenues, worth millions of dollars, in the tax code. Other articles shone light on the AMA’s reach into the federal bureaucracy with a sophisticated system for making sure that physicians nominated for posts on over three hundred federal advisory panels had the correct “medical and po­liti­cal philosophy.” Developed by consulting firm Arthur Young and Co. for $30,000, the system was kept secret for fear that it would not be “properly understood” by the government, the public, and even AMA members.8 Some of the most damaging stories opened the public’s eyes to the AMA’s shady relations with the phar­ma­ceu­ti­cal industry. One story in the Washington Sun-­Times on the pervasive conflicts of interest exposed how the AMA had welcomed MD-­holding drug executives into its committee for organ­izing “the entire scientific program at the annual and clinical conventions.” Another story concerned AMA executive vice president James Sammons’s brazen violation of the association’s official policy against the use of its name in advertising. Sammons had given special permission to the Upjohn Com­pany to send its



A New Medical Progressivism

445

eleven-­hundred-­member salesforce out with a letter he had written on AMA letterhead to four hundred state and county medical socie­ties defending the use of tolbutamide, a highly controversial and very profitable oral hypoglycemic. In the letter, which Upjohn’s detailers showed their marks, Sammons said that the “opinions” of a considerable number of experts contradicted an impressively large and long-­term prospective study showing that tolbutamide was causing as many as fifteen thousand deaths from heart disease a year. ­Because of remaining doubts, he said, doctors should trust their own judgment and continue prescribing the drug, even if the study showed that dietary restrictions, sometimes with insulin, worked just as well. The public learned of the ethical violation thanks to Sore Throat. What the AMA or Sammons gained for the ­favor to Upjohn, which dominated the $100 million tolbutamide market, was never revealed.9 A 1975 Washington Post story exposed that from 1962 to 1965 major drug firms had donated $851,000 to the American Medical Po­liti­cal Action Committee (AMPAC). The article quoted the 1973 congressional testimony of John Adriani, an eminent anesthesiologist and pharmacologist, who said that the AMA was “captive of, and beholden to, the phar­ma­ceu­ti­cal industry.” Adriani had been chairing the AMA Council on Drugs when it was shut down in 1972 at the behest of the drug industry. Another 1975 article in the New York Times told of AMA efforts five years e­ arlier to ­battle legislation and regulations to stop Medicare from reimbursing hospitals for expensive brand name drugs if cheaper and equally effective generics ­were available. AMA lobbyist William Colley, who had previously worked for the Phar­ma­ceu­ti­cal Manufacturers’ Association, instructed his colleagues to find doctors to lobby e­ very single senator against the bill b­ ecause of its threat to their clinical autonomy. The story smeared the profession’s white coats ­because of the AMA’s extensive holdings in drug stocks. Further damage was done with leaked documents about pos­si­ble tax and postal fraud in the AMA’s reporting of membership dues and drug-­advertising revenues.10 Newspapers also embarrassed the AMA by exposing its attack on chiropractors, which a federal judge ­later deemed an illegal “conspiracy in restraint of trade.” It had conducted a boycott with the intention to “contain and eliminate” the rival healers by declaring it unethical for regular physicians to consult with and refer patients to them on the grounds that their lack of scientific training made them a “health h ­ azard.” Medical staff and physician administrators of hospitals ­were also admonished not to do X-­rays for and other­wise grant access to chiropractors. ­Because chiropractic was a

446

Reactionary Turn and Beyond

licensed profession administering to at least five million Americans a year, many of whom distrusted regular doctors, the AMA’s reputation took another hit.11 The warnings of AMA leaders during the Progressive Era had been prophetic: the profession risked shooting itself in the foot by attacking alternative healers. In 1982, a new volley of embarrassing newspaper stories uncovered AMA lobbyists’ arm-­t wisting of legislators funded by AMPAC to help it overturn a 1979 Federal Trade Commission (FTC) finding that or­ga­nized medicine had long engaged in a “nationwide conspiracy in constraint of trade” by, among other ­things, forcing hospitals to blacklist doctors who did not abide by its “protectionist” medico-­economic ethics. The ruling meant that hospitals could no longer discriminate, as they had since the mid-1930s, against doctors who had been banned from their county socie­ties for engaging in medical practice on a salary or capitation basis in prepaid group practices. Despite the AMA’s lobbying, Congress declined in 1982 and 1983 to change the antitrust law ­a fter the Supreme Court had already declined to reverse the FTC’s reading of its current language. An impressive bipartisan, cross-­ideological co­a li­tion supported it, including FTC official Michael Pertschuk, who had been an acolyte of Ralph Nader, the crusading consumer advocate.12 ­Because of the FTC’s findings and the l­ ater newspaper reports, the AMA’s reputation suffered with conservatives and business interests, its former staunch allies. Republicans w ­ ere on a deregulatory mission against market manipulation. Corporate Amer­i­ca was on the warpath against the AMA’s medical individualism by employing prepaid group practices or other “managed care” organ­izations to reduce health-­care costs without sacrificing quality for their employees as the Kaiser-­Permanente system had been doing. The conservative medico-­political co­a li­tion crumbled. With its ruling, the FTC broke down the AMA’s barriers against “corporate medicine,” for better or worse, and therefore hastened the gradual decline of the solo practitioner that the AMA glorified. In the 1980s, a­ fter the FTC bombshell, AMA membership continued to fall from around 46 ­percent in 1980 to 40 ­percent in 1990. In the next two de­cades, it slipped to around 20 ­percent. In 2011, it was only 15 ­percent ­after excluding medical students, interns, residents, and ­others paying reduced dues. In 2016, the total membership rate still fluctuated around 20 ­percent. But revenues from dues w ­ ere actually sagging b­ ecause of targeted fee reductions, and the AMA became increasingly reliant on other revenue streams of debatable ethical character.13



A New Medical Progressivism

447

A NEW PROGRESSIVISM OUTSIDE THE AMA

An inaugural event in the emergence of a new medical progressivism in Amer­i­ca was the creation in 1970 of the Institute of Medicine (IOM), now called the National Acad­emy of Medicine. The IOM’s progenitor was Irvine H. Page, a pioneering physiologist and member of the renowned Cleveland Clinic. Page’s idea was to have the National Acad­emy of Science elect a body of widely respected medical and other scientific experts to sponsor research and deliberate on policy solutions to health-­related prob­lems. The fact that 25 ­percent of its members w ­ ere to be from the fields of engineering, economics, ethics, law, and more reflected the progressive spirit in which the IOM was founded. F ­ ree of economic or other conflicts of interest in the world of health care, it would serve as a consultancy to legislators and policy-­makers as well as a source of public enlightenment about the financing and provision of health care and a wide range of other public health issues. Page first conceived of a new institute in 1964 as an antidote to the AMA ­because of its “grumbling hostility” to all government mea­sures in the health field. The idea was not entirely new. In 1937, John P. Peters and other AMA critics envisioned the formation of a “medical advisory council” as a conduit of unconflicted medical expertise to government decision-­makers. It would be an auxiliary body to a cabinet-­level national department of health. Likewise, Page called for an institute that would be beholden to no special interests and therefore be able to speak to the public “with authority and dignity” and restore medicine “to a position of re­spect” in the eyes of the public. By that he insinuated that the AMA’s economic and po­liti­cal entanglements undermined the profession’s cultural authority and left its dignity and re­spect in disgrace. ­Because of the scientific and moral vacuum the AMA created, countless groups and entities competed with it for po­liti­cal influence, so “the advice government receives and the intellectual relationships among government officials, research workers, and practicing physicians” was too chaotic for reaching a rational demo­cratic consensus.14 According to economist Rashi Fein, one of the IOM’s charter members, the AMA’s po­liti­cal interventions ­were a cause of, not a potential solution, to “the health-­care mess” resulting from years of conservative control. Fein taught at Harvard University’s School of Medicine and its Kennedy School of Government. He had been a se­nior staff member on the Council of Economic Advisers ­under President John  F. Kennedy and had participated in early

448

Reactionary Turn and Beyond

deliberations on Medicare. Another IOM charter member was ­labor economist John T. Dunlop, dean of Harvard’s Faculty of Arts and Sciences and the country’s preeminent expert on industrial relations, an arena where l­abor and capital jousted with or­ga­nized medicine over questions of cost and quality in health ­matters. The impulse to engage in dialogue with laymen like Fein and Dunlop was expressed by Ivan L. Bennett Jr., another IOM founder, in his 1965 commencement speech at the Johns Hopkins School of Medicine. Bennett, the school’s and its hospital’s chief pathologist, called his speech “Strangers and ­Brothers” b­ ecause the physician brotherhood’s orga­nizational mission to obstruct social change “tends to make them strangers to the public.” He lamented how hard it was to talk to medical outsiders in order to “increase and enrich our common culture and understanding.” But, Bennett warned—­echoing ­earlier progressive Arthur Dean Bevan on the relations between medicine and society—­“We must recognize that medicine is not now and never has been our private preserve but is something in which all ­people have a vital stake.”15 Bennett also verbally firebombed or­ga­nized medicine for its “abiding faith in the belief that what is good for the doctor—­financially—is good for the country.” It was spending large sums of money on propaganda so it could “hang on to lucrative privileges.” The AMA’s and its state socie­ties’ arguments against Medicare ­were “mealy-­mouthed phrases” and “gassy, vague, and pretentious generalization” about “socialized medicine.” Not since 1953 had ­there been such a public breach of the profession’s unwritten code of silence about ­things that undermined public confidence in it. That year Loyal Davis, professor of surgery at Northwestern University’s medical school, and Paul R. Hawley, a retired medical director of the Veterans Administration and president of the American College of Surgeons, provoked stinging rebukes and even calls to be expelled from the AMA for speaking out publicly against widespread commercialism and unethical be­hav­ior by physicians. Specifically, they decried the rise of “fee splitting” (kickbacks from surgeons for referrals from generalists, which induced generalists to shop for surgeons offering the best kickbacks) and a huge volume of unnecessary and prob­ably “bungled” surgeries by doctors lacking gradu­ate training and specialty certification. Bennett, like Davis and Hawley, enjoying a secure institutional position, was not cowed by the rage against his “attack” on the profession, as related in stories in Baltimore newspapers. In a letter to the Baltimore Sun, one doctor blasted Bennett for his “one-­sided diatribe against the AMA,” saying that “very few physicians can ever, fortunately, preen themselves in, and issue manifestoes



A New Medical Progressivism

449

from the lofty, relative security of an academic position such as Dr. Bennett enjoys.”16 Five years l­ater, along with Page, Bennett would go further than Davis and Hawley by creating the IOM in 1970 (now the National Academy of Medicine) as a forum for expert discussion and examination of medicine’s flaws, including in publications. However at least two decades would pass before it began to fulfill that promise. A more important development in the 1970s was an outpouring of statistical research by a relatively young cohort of public health experts, clinical epidemiologists, and health ser­vices researchers such as Robert Brook, David Eddy, William Roper, and John Wennberg. With his work Wennberg, a gradu­ate of Harvard’s schools of medicine and public health and a member of the IOM’s Committee on Health Data Systems, confirmed Davis’s and Hawley’s charges about unnecessary surgery and thereby scientifically debunked the conservative era’s my­ thol­ ogy about Amer­i­ca’s uniformly distributed best-­in-­the-­world medicine. In 1973, along with biostatistician Alan Gittelsohn, Wennberg published a study titled “Small Area Variations in Health Care Delivery” in the prestigious journal Science. The title was unsensational, but the subtitle signaled heresy ­toward medicine’s conservative po­liti­cal ideology: “A Population-­Based Health Information System Can Guide Planning and Regulatory Decision Making.”17 Based on data Wennberg had collected as director of the federally funded Northern New ­England Regional Medical Program in Burlington, Vermont, the article showed that across the state, and therefore prob­ably everywhere ­else in the country, ­there ­were large variations and excesses in surgical practice and therefore a squandering of resources better spent on ­people needing less expensive and dangerous medical attention. The chaotic variations surprised even Wennberg b­ ecause they w ­ ere far too large to be accounted for by regional variations in morbidity. A scientific basis was lacking for choosing or rejecting expensive and always potentially dangerous surgical procedures like appendectomies, C-­sections, hysterectomies, mastectomies, prostatectomies, tonsillectomies, and more. ­There was huge waste, and therefore unfairness, ­because no one knew when and where the best practices ­were being implemented while payers ­were blindly footing the bill for the worst. According to two accounts, when Wennberg first presented his findings as an assistant professor at the University of Vermont’s school of medicine, he was in effect “run out of town” ­because higher-­ups dropped “strong hints” that he had no f­uture ­there. The code of silence about medicine’s flaws was still at work for a young physician like Wennberg, though it failed to inhibit

450

Reactionary Turn and Beyond

a power­ful surgeon such as the Cleveland Clinic’s George Crile Jr. During a 1970 American College of Surgeons clinical congress, the sixty-­three-­year-­old Crile spoke to journalists about the routine per­for­mance of radical mastectomies despite good experimental evidence that they ­were often not necessary. When attacked by other surgeons for this and other such public transgressions, he struck back hard in popu­lar magazines and even on tele­vi­sion. In 1973, the same year Wennberg’s article appeared in Science, Crile unabashedly suggested to the public that American surgeons, unlike abroad, clung to the dangerous, painful, and disfiguring procedure over more conservative ones out of something akin to religious fervor. Perhaps worse from the standpoint of fellow surgeons, he also accused them of being motivated by the radical procedure’s substantially higher fees. The Cleveland Medical Acad­emy censured Crile’s actions as “reprehensible.”18 ­Because of the ominous hints from above, Wennberg left Vermont to take a position as an untenured assistant professor of preventive and social medicine at Harvard University. Meanwhile, top medical journals refused to publish his and Gittelsohn’s article. He submitted it to Science instead, an even better forum for gaining wide public attention and provoking change. Ultimately, Wennberg’s ­career took off at Dartmouth University medical school’s Department of Community and ­Family Medicine. Michael Zubkoff, the department’s dean, whose hiring had been controversial ­because he was an economist, not a doctor, had been able to fund a permanent position for Wennberg. In 1988, Wennberg founded the Dartmouth Institute for Health Policy and Clinical Practice, which continues ­today to generate evidence for advancing quality and cost-­effectiveness in medical care. In 2010 he published Tracking Medicine, an indispensable survey of the origins and course of his health ser­vices research and where its findings should take us.19 ­A fter publication of the 1973 Science article, national legislators and corporate executives took notice of what Wennberg would come to call “the intellectual confusion in the heartland of scientific medicine” and an “intellectual crisis in the scientific basis of clinical practice.” Astonished by private and Medicare expenditure growth rates approaching 15 ­percent per year, a House of Representatives committee invited Wennberg to testify in 1975 and 1978 on how the lack of statistics about the quality of care could help explain the trend and what their collection and analy­sis could do to put on the brakes. He would return to the House and the Senate at least a dozen more times in the following de­cades to promote the development of cost-­ effective clinical and surgical care. Hardly a federal legislator involved at the



A New Medical Progressivism

451

time in deliberating the issues had not heard of Wennberg’s pioneering research and subsequent work. In the 1980s, together with Robert Brook, David Eddy, and William Roper, Wennberg lobbied for government funding of “health ser­vices research” and “comparative effectiveness research” to complement the basic biomedical research already generously supported by the National Institutes of Health. The result was the bipartisan creation of the more modestly funded Agency for Health Care Policy and Research (AHCPR) in 1989 to conduct and coordinate research into best practices and develop, on that basis, “clinical practice guidelines” for use by clinicians starved of clear information about what to do for their patients.20 The public reception of resurgent, scientifically grounded criticism of real-­ world medical practice helps explain medical historian John Harley Warner’s 1985 observation that “the notion that the progressive infusion of scientific knowledge and methods into medicine inevitably improved patient care has steadily lost ground.” By the 1990s, Demo­cratic legislators had digested the policy implications of the lit­er­a­ture, brought to the lay world’s attention, on the need for evidence-­based medicine and its or­ga­nized application, well ­after scholarship on it had accumulated since the 1960s in Canada and Britain as well as the United States. President Bill Clinton’s special Advisory Commission on Consumer Protection and Quality in the Health Care Industry consulted with Wennberg and cited him in its 1998 report Quality First: Better Health Care for All Americans. It called attention to avoidable errors, the underutilization of good medical ser­vices and the overuse of ­others, and their continued unexplained variation. It advocated public-­private partnerships to seek remedies, among them development of information systems for quality mea­sure­ment and reporting, in part to make market forces work more efficiently with flows of information about quality as well as prices to achieve greater value. To counteract adverse se­lection, therefore, it called for more, not less, investment in “clinical, preventive, and health ser­vices research.”21 Corporate Amer­i­ca was also duly impressed by the weakness of the evidentiary foundations for medicine as commonly practiced. Large employers picking up accelerating health care costs for their workers joined the new medical progressives in efforts to diagnose and treat the diseases of the medical profession. According to l­egal scholar Clark Havighurst, a deregulatory guru of the 1970s and a member of the IOM’s Board of Health Care Ser­vices, the eye-­opening research “seriously undermined an essential cornerstone of the professional paradigm of medical care—­namely, the notion that autonomous clinicians, left to their own devices as responsible scientist and professionals,

452

Reactionary Turn and Beyond

could be trusted to arrive at appropriate clinical standards.” Th ­ ere was now “power­ful proof that all was not well inside the black box of clinical medicine,” and it “greatly strengthened the case for allowing private corporations to override professional prerogatives.” According to sociologist Jill Quadagno, corporate purchasers of health care began to challenge the profession’s clinical sovereignty and “instead of passively paying medical bills, began asking what they w ­ ere receiving for their money and w ­ hether medical ser­vices w ­ ere worth the expense.” In short, having “alienated their allies,” physicians’ “institutions and authority w ­ ere vulnerable to attack.”22 The corporate world’s contribution to the AMA’s decline in prestige and conservative influence is mea­sur­able by a survey showing that almost 80 ­percent of corporate benefit officers involved said “fundamental change” in health care was needed, but only 2 ­percent said that meant “less government.” About 93 ­percent said utilization review was an acceptable way to discourage unessential procedures. Over 80  ­percent favored restraints on the expansion of health-­care facilities in order to check the prob­lem of what health economists call “supply-­induced demand” for medical care that is profitable but lacking evidentiary foundations. In 1982, ­there ­were around seventy city and regional co­a li­tions, headed by large businesses, for collaborative efforts that challenged physician autonomy for the purpose of reducing costs and improving quality. That year, ­labor economist, industrial relations expert, and charter IOM member Dunlop sought to give the business-­led co­ali­tion movement a boost by assembling his “Group of Six,” consisting, most importantly, ­ ere of the 198 huge corporations in the Business Roundtable. Also invited w representatives of the American Federation of ­Labor and Congress of Industrial Organ­izations (AFL/CIO), the American Hospital Association, Blue Cross Blue Shield, Health Insurance Association of Amer­i­ca, and even the outgunned AMA. Spontaneous business-­led initiatives taken at the local level may have been more impor­tant. One successful co­a li­tion was the Business Health Care Action Group (BHCAG) of Minneapolis and Saint Paul, Minnesota, started in 1991 by huge manufacturers Dayton Hudson, General Mills, Honeywell, Pillsbury, and two major banks. In their early discussions with doctors and hospitals, they cited Wennberg’s and ­others’ embarrassing findings of huge, unexplained practice variations and the paucity of health outcome data to help payers sort out what was valuable medicine. By late 1983, ­there ­were a total of 123 business co­ali­tions, with at least another 40 to come in the following year. Alongside health education and promotion, their most common activities ­were



A New Medical Progressivism

453

“utilization review” (scrutiny of medical ser­vices for economy and efficiency), alternative delivery systems, fa­cil­i­t y planning, and legislative activity ­toward ­those ends.23 Nephrologist John M. Burns was one ambitious medical progressive who took the initiative for reform in alliance with the business world. As an active participant in Minnesota’s Ramsey County Medical Society, Burns had listened with dismay to colleagues who admitted that 40 ­percent of what they did was medically unnecessary. As president of the county society, he in turn dismayed his colleagues by inviting a corporate executive, prob­ably Honeywell’s CEO, to discuss medical reform. To some enraged members, it was even worse that he brought Walter McClure, a lay evangelist for quality measurement. McClure was the founder of a health research outfit called the Center for Policy Studies, and an advocate of the “Buy Right” approach to health-­care provision. ­A fter working for Honeywell’s health management department, Burns would go on to become the Minneapolis-­Saint Paul area employers’ most impor­tant medical adviser. To put pressure on local providers, he threatened that the BHCAG might build its own hospitals if they refused to cooperate with employers’ efforts to change their practices. Employers around the country took notice, and some took similar initiatives ­after visiting and consulting with the BHCAG.24 Notable among the new generation of medical progressives to take the national stage was pediatrician Donald R. Berwick, holder of a master’s degree from Harvard’s Kennedy School of Government. In the mid-1980s, while he was the Harvard Community Health Plan’s vice president for Quality-­ of-­Care Mea­sure­ment, Berwick began a prolific publishing and speaking ­career proselytizing for restructuring health-­care systems and implementing evidence-­based medicine and comparative effectiveness research. He advocated initiatives for implementing “continuous quality improvement,” a modern scientific management concept from the aeronautics and manufacturing industry associated with the internationally famous physicist and statistician W. Edwards Deming. Among other health-­care systems, the data-­ driven approach was implemented by the Mayo Clinic on the prompting of  Minneapolis’s BHCAG. In 1991, Berwick cofounded the now-­famous Institute for Health Care Improvement (IHI) in Boston, whose forums attracted thousands of physicians, other health-­care professionals, and health-­ care system administrators.25 In 1997 and 1998, Berwick served as a key member of President Clinton’s advisory commission on quality in health care. An admirer of aspects of the

454

Reactionary Turn and Beyond

United Kingdom’s National Health Ser­vice (NHS), he advocated adopting something like its National Institute for Health and Clinical Excellence, which evaluates the costs and effectiveness of treatments covered by the NHS. Berwick was knighted in 2005 for his work creating new care models for five sectors of the NHS—­acute care hospitals, multispecialty groups, accident emergency rooms, ­mental health, and nursing homes. In April 2010, President Barack Obama appointed Berwick director of the Center for Medicare and Medicaid Ser­vices (CMMS), where he was in a position to use the government’s huge regulatory and purchasing clout, and language in the Affordable Care Act, to influence provider be­hav­ior. But he was forced to resign in February 2011 ­after badly chosen words about the need for medical “rationing”— by which he meant evidence-­based husbanding and spending of scarce resources. It stoked a firestorm of conservative criticism and Republicans’ promise to reject his confirmation a­ fter his recess appointment ended.26 In 2000, a number of large employers joined with public agencies to create the Leapfrog Group, funded by the Business Roundtable and the Robert Wood Johnson Foundation to consolidate their purchasing power and bring consumers and clinicians into the mix to promote health-­care quality. One of its cofound­ers was an internist, Robert Galvin, a member of the IOM’s Board on Health Care Ser­vices, who e­ arlier had taken a job at a General Electric (GE) jet engine factory to manage health-­care ser­vices for its workers. Ultimately, Galvin found his way to the top as the GE executive responsible for the design and administration of the huge corporation’s $2.5 billion health benefits, including for 230 clinics, 600 physicians and nurses, and 1.5 million patients. Galvin, impressed by John Wennberg’s work, the huge waste and errors he had experienced firsthand, and the lack of transparency in health system per­for­mance, set about extending reform efforts beyond GE, such as the Business Roundtable’s Leapfrog proj­ect. Once underway, the Leapfrog Group began publicizing reports on the pro­gress hospitals ­were making with the adoption of safety programs to spare thousands of lives. T ­ oday the Leapfrog Group uploads its yearly “Hospital Safety Grade,” where patients and purchasers can search for information on their area hospitals’ safety per­for­mance.27 Another mea­sure of the demise of the unofficial code of silence about medicine’s flaws and the rise of a new medical progressivism was a stream of books by physicians, one of them Berwick, written in the early 2000s for popu­lar and professional consumption about the country’s medical disorder. In 2002, surgeon Atul Gawande could write without expecting a firestorm of



A New Medical Progressivism

455

recriminations that as many as 5 ­percent of practicing physicians w ­ ere “actually unfit to see patients.” One mea culpa, called How We Do Harm, was by Otis Webb Brawley, chief medical and scientific officer and executive vice president of the American Cancer Society from 2007 to 2018. In it he told of getting “furious” ­every time he heard assertions that the American health-­ care system was “the best in the world.” Instead, he saw widespread injustice, irrationality, malfunctioning, mediocrity, and failure.28 Other books by medical critics, often very prominent ones, reported without professional rebuke on orga­nizational and therapeutic chaos; undertreatment of some populations ­because of poor insurance coverage, racism, and distribution of facilities; overtreatment of o­ thers by doctors and hospitals ­because of fee-­for-­service insurance remuneration; lack of rationality, transparency, and accountability in hospital administration; systemic sources of errors and infections; and pervasive conflicts of interest associated with medical researchers,’ schools,’ journals,’ and organ­izations’ dependence on money from phar­ma­ceu­ti­cal and medical device manufacturers. In 2001, the IOM published Crossing the Quality Chasm, calling for transparency about medicine’s failures. Systems of health provision needed to “be accountable to the public; to do their work openly; to make their results known to the public and professionals alike; and to build trust through disclosure, even of the system’s own prob­lems.” Other IOM publications of the new millennium exposed high numbers of deaths due to medical errors, such as To Err Is ­Human, and unhealthy relations between physicians and medical industries, such as Conflict of Interest in Medical Research, Education, and Practice, published in 2000 and 2009, respectively.29 One physician-­founded entity animated by the spirit of the new medical progressivism was the American Board of Internal Medicine Foundation (ABIMF). Endowed by the American Board of Internal Medicine in 1989, ­after 1999 it was governed by an in­de­pen­dent board of trustees. In 2002, together with the Eu­ro­pean Federation of Internal Medicine, the ABIMF promulgated a new professional code, or Physician Charter, calling upon the profession to uphold its side of a “social contract” in order to restore trust with patients and the public. Called “Medical Professionalism in the New Millennium,” the charter asserted as its first princi­ples: “the primacy of patient welfare,” “patient autonomy,” and “social justice.” To fulfill t­hose princi­ples, it enumerated vari­ous commitments, including maintaining the public’s and patients’ trust “by managing conflicts of interest” in the “pursuit of personal or orga­nizational interactions with for-­profit industries, including medical

456

Reactionary Turn and Beyond

equipment manufacturers, insurance companies, and phar­ma­ceu­ti­cal firms.” Patients’ welfare was to be advanced by collective efforts to improve the quality of care, promote new scientific knowledge, and ensure its appropriate use. Patients should be at the center as informed coparticipants in clinical decisions, entailing physician honesty and efforts to “empower” patients to make informed decisions about which of vari­ous pos­si­ble treatments suit their and their families’ life circumstances and goals. Most interestingly, the charter stated that the medical profession must “promote justice in the health care system, including the fair distribution of health care resources” and “work actively to eliminate discrimination in health care, w ­ hether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.”30 Impor­tant moves to put the princi­ples of the new medical progressivism into practice included a revival of Harvard surgeon Edward Amory Codman’s call in the 1910s for tracking, reporting, and analyzing “end results” to guide improvements in clinical practice. Codman’s call for physician accountability fell on his colleagues’ deaf—­because hostile—­ears. He suffered professionally and eco­nom­ically for it. A c­ entury ­later, many minds in the medical community ­were opened to the blindingly obvious strategy of what is now called “outcomes research” against therapeutic disorder, and ­those who advocated it ­were spared vilification. They called for “patient-­centered” outcomes research linking individual patients’ conditions and preferences to subjective as well as objective results of alternative treatments. Their advocacy led to the not-­uncontroversial creation of the 2010 Affordable Care Act’s Patient Centered Outcomes Research Institute (PCORI), which funded $2 billion worth of research infrastructure and activity between 2010 and 2017. The new progressivism also promoted widespread mea­sure­ment and reporting of hospital and other provider entity per­for­mance in specific areas such as antibiotic stewardship, hospital-­acquired infections, and avoidable readmissions ­after vari­ous procedures to allow for comparisons and therefore to trigger and guide efforts to improve.31 At the forefront of both of ­these innovations ­were ­people such as the aforementioned Robert Galvin and Yale cardiologist Harlan Krumholz, a founding board member of PCORI and director of Yale’s Center for Outcomes Research and Evaluation (CORE). Krumholz was the 2019 recipient of the American Heart Association’s Clinical Research Prize for being a “founding leader in the field of outcomes research.” By  2020,  CORE had constructed more than 50  hospital and outpatient-­based  process and outcomes metrics used by Medicare, private health care entities in the United



A New Medical Progressivism

457

States, and even abroad. The codification and quantification of quality in medicine, fueled by medical progressives in collaboration with government, professional socie­ties, corporations, and public health organ­izations influenced health care payers seeking to remunerate providers for quality and value—­ not volume and throughput as with the conservative era’s fee-­for-­service practices. Such efforts have inculcated in the average physician an evolving sense of accountability for patients’ health outcomes, joint responsibility for improvement in therapeutics, and even recognition of the need for cost effectiveness.32 In sum, the twenty-­first c­ entury’s medical progressivism began to mitigate adverse se­lection in the medical marketplace with a massive amount of new knowledge efficiently disseminated with advanced information technology. It responded to the call for the kind of rational therapeutics envisioned by medicine’s early progressives and promised to help lift the American health care system out of its low-­value equilibrium. In the early 2000s, or­ga­nized medical dissidents w ­ ere no longer smeared as un-­A merican or communists as John Punnett Peters and Ernst Boas had in the conservative era. In 2009, Lydia J. Vaias, a general surgeon with Kaiser Permanente, formed a National Physicians Alliance (NPA) with, as she put it, a core mission of aligning “payers’, providers’, and hospitals’ incentives to keep patients at the center of care” and to promote social justice through health care reform. Vaias first entered dissident medical politics in 1993 as an or­ga­nizer of six new chapters of the American Medical Student Association. In 2008, the NPA, with around twenty thousand members, was the first physician group to join Health Care for Amer­i­ca Now, an alliance of one thousand national and state-­based organ­izations pushing for universal health care. The NPA lobbied for the Sunshine Act section of the 2010 Affordable Care Act, which created the federal government’s Open Payments website, enabling anyone to search physicians by name to learn details and amounts of their financial relationships with industry. The NPA was an impor­tant instigator of the ABIMF’s program, “Choosing Wisely,” to cata­logue and exhort against hundreds of dubious, potentially dangerous, and expensive but common clinical practices in numerous specialties.33 The larger Physicians for Social Responsibility (PSR), with about fifty thousand members in the 2010s, was founded in 1961 to fight against nuclear weapons. Also notable for w ­ omen in its leadership, it was resurrected in 1978 ­after years of lying fallow by pediatrician Helen Caldicott, among o­ thers. Eventually, like the NPA, PSR included firearm and environmental threats to health in its protest agenda. In 2009 it released a groundbreaking summary of medical

458

Reactionary Turn and Beyond

lit­er­a­ture on coal pollution and related disease, coauthored by Barbara Gottlieb, PSR’s Director of Environment and Health. ­Later, Gottlieb collaborated with Concerned Health Professionals of New York, formed by biologist Sandra Steingraber and pediatrician Larysa Dyrszka, to conduct a comprehensive impact assessment of hydraulic fracturing for oil and natu­ral gas. In 2020, they produced a massive 475-­page seventh edition of scientific articles and investigative reporting on fracking’s air and ­water contamination, radioactive releases, noise and light pollution, earthquakes, flood risks, threats to agriculture and forests, and not least, fracking workers’ occupational health ­hazards.34 CHANGES IN THE AMA

In 1982, while progressive currents outside or­ga­nized medicine w ­ ere slowly gathering strength, the AMA hired George Lundberg, chair of pathology at the University of California, Davis, to become the Journal of the American Medical Association’s editor in chief. Having already served on JAMA’s editorial board, Lundberg was known for his excellence in that realm, and b­ ecause of it, according to one assessment, he turned the conservative era’s “forgettably mediocre ­house organ” into a highly respected journal. In terms of scientific impact, it would rank fourth among general medical journals a­ fter the New ­England Journal of Medicine, the Lancet, and the Annals of Internal Medicine. ­It was not known that he would also become a conduit of reformist thinking into the journal. Lundberg’s strong streak of in­de­pen­dence was tested early on. In his first year as editor, CEO James Sammons warned him that the journal had to exercise “appropriate caution” in writing about nuclear war, abortion, and even tobacco and smoking. Hardly a day went by when he and his staff “­didn’t have to worry about offending AMA members, AMA politicians, and the AMA Washington office” with something they published.35 About a year ­later, Lundberg came ­under fire when Pfizer Inc. threatened to pull its advertisements ­unless he published an article about the off-­label uses of one of its drugs. An e­ arlier article had only mentioned its competitors’ similar drugs. Lundberg caved, but l­ater regretted it. A disgruntled editorial staffer leaked the embarrassing story to Chicago Sun-­Times reporter Howard Wolinsky. I­ n 1987 and 1988, to fend off more of the same, Lundberg published statements asserting strong princi­ples of editorial in­de­pen­dence from financial and other pressures on its contents. For example, he risked censure by openly airing his



A New Medical Progressivism

459

Pathologist George David Lundberg, MD (1933–), editor in chief of the Journal of the American Medical Association, 1982 to 1999. Lundberg vigorously asserted JAMA’s editorial in­de­pen­dence, which survived despite his firing in 1999 for his critical and controversial views on vari­ous aspects of medicine in Amer­i­ca. Courtesy of the Department of Pathology and Laboratory Medicine, University of California, Davis.

worries about the long list of prob­lems the medical profession was being blamed for. He even called for strengthening the IOM, which had been brought into being as an antidote to the AMA’s conservatism and whose purpose was to research and disseminate—­not bury—­facts about medicine’s prob­lems.36 In the 1980s, liberal criticism of the AMA began to have impacts on its internal policy-­making. A 1981 resolution passed called for an end to federal tobacco price supports and divestment of the AMA’s tobacco stocks. In 1985, b­ ecause of intense rank-­and-­file pressure, especially from medical residents, the AMA begrudgingly and belatedly divested its pension funds of tobacco stocks. But the AMA Board of Trustees, two of which owned tobacco farms, defied the reformers by criticizing smokers’ lawsuits against the cigarette industry as “in­effec­tive” and urged doctors not to testify for the plaintiffs. Although Joseph F. Boyle, the AMA president and recently the chairman of its board of trustees, spoke out earnestly about the dangers of air pollution, he chose not to challenge the trustees’ position against tobacco lawsuits. He

460

Reactionary Turn and Beyond

was a chain-­smoking pulmonologist who feared his severe addiction might kill him, and it did.37 The AMA’s position is likely to have been inspired by a desire to weaken medical malpractice ­lawyers and cement its alliance with corporate America against product safety and other tort litigation. Had the AMA supported smokers’ damage suits, the ­family of Rose Cipollone, who died of cancer, may not have given up in 1992 trying to appeal the reversal of a lower court award of $400,000 to be paid by the Liggett Group of cigarette makers. They gave up because the crushing costs of further litigation dwarfed that sum. Instead, ­behind the scenes, Ernest Howard, a former AMA CEO, had undermined the case, Cipollone v. Liggett Group, Inc., by declaring in a 1986 court deposition that smoking was only a likely “trigger” of cancer. He had trou­ble with the word “cause” b­ ecause p ­ eople who smoked heavi­ly for thirty years did not always get cancer. “If it ­causes cancer,” he asked feebly, “why ­don’t they all develop cancer?” It was not u ­ ntil 1994 that the AMA began conducting earnest campaigns against smoking funded by the Robert Wood Johnson Foundation funds. Antitobacco lobbyists complained, however, that the AMA would not spend any of its own money or use its enormous lobbying clout to help them ban smoking on airplanes, prohibit tobacco advertising, and promote public education against smoking.38 The AMA was hard to cleanse of other moral infirmities, including financial ones. In 1989 Wolinsky and Tom Brune of the Chicago Sun-­Times exposed misuse amounting to embezzlement of AMA funds by CEO Sammons, a hard-­driving Texas conservative who had ­earlier run AMPAC’s po­ liti­cal operations. The Illinois State Medical Society warned that an angry eight thousand of its eigh­teen thousand members w ­ ere considering quitting. The groundswell of indignation forced Sammons to resign in 1990. James S. Todd, who hoped to improve the AMA’s image, was chosen to replace Sammons. On Todd’s watch, the AMA issued new ethical guidelines in 1991 against the gifts, f­ ree dinners, and travel junkets individual doctors received from the phar­ma­ceu­ti­cal industry. It also declared it unethical for doctors to refer patients to diagnostic and clinical facilities they invested in and even controlled. But the guidelines ­were “voluntary” and the violations of them not exposed and criticized. Other than frowning on the drug industry’s dispensing of ­favors to individual doctors, the AMA said ­little and did even less against the well-­documented, widely publicized, and even growing financial tentacles of the vast medical-­industrial complex branching into medical practice, education, research, journals, and, of course, organ­izations.39



A New Medical Progressivism

461

The most dramatic event characterizing what Todd overoptimistically called “the new AMA” was its House of Delegates’ approval of a 1990 report called Health Access Amer­i­ca, which recommended efforts to expand health-­ care coverage to the entire population. Among other ­t hings, it proposed a mandate for all large employers to provide health insurance. In the spirit of the report, CEO Todd and editor Lundberg defied strong conservative ele­ ments by approving of its constructive attitude toward universal health care. The AMA’s new lliberal-­leaning moderation brought wrath not only from below but also from the White House. John Sununu, George  H.  W. Bush’s chief of staff, who had a reputation for haughty arrogance and extremely coarse language, bullied AMA officials to shut up on health insurance if they wanted presidential help with their economic agenda. According to an unflattering roman à clef about the top AMA officialdom by James Stacey, who had served as the organ­ization’s media and information ser­vices director, Sununu unsuccessfully pressured the AMA board to fire Todd and Lundberg for putting wind in the Demo­cratic Party’s sails.40 In 1993, a majority of the divided House of Delegates repudiated the efforts to work with Demo­cratic president Bill Clinton, who the previous year had campaigned on a platform including guaranteed health care. Clinton proposed a mandate requiring all employers to contribute up to 80 ­percent of the cost of qualified health insurance plans offered on proposed public exchanges. Many doctors w ­ ere employers themselves who did not contribute to health insurance for their office staff. A ­ fter cancer struck, bringing Todd’s resignation in 1996, the ill-­starred John Seward, also an endorser of Health Access Amer­i­ca, took his place. But only about a year and a half later, Seward had to resign b­ ecause of new public embarrassment. To pump up the organ­ ization’s sagging finances, five top AMA officials had cut a deal with Sunbeam Products for the AMA to receive millions of dollars in exchange for endorsing Sunbeam’s home health products such as blood pressure monitors, thermometers, bathroom scales, heating pads, and vaporizers. Other “cobranding” corporate partnerships were being explored. Many members joined fierce public critics of the new business model, a massive institutional conflict of interest. To add injury to the self-­inflicted injury, Sunbeam sued for breach of contract when the AMA pulled out of the deal, which cost the organ­ization $10 million in restitution and another $4 million in l­egal fees. An AMA committee appointed to examine the fiasco enlisted Booz Allen Hamilton, a consulting firm whose thirty-­page report concluded that the AMA was riven with division, distrust, and crass politicking among fractured units and rival

462

Reactionary Turn and Beyond

executives. The drive for “power and control” meant “po­liti­cal considerations take pre­ce­dence over the profession’s needs.” ­Those needs included an ability to listen to lay stakeholders in health ­matters.41 One of the AMA’s few progressive moves in the 1990s was the creation in 1997 of a National Patient Safety Foundation to conduct research and activities to quantify, explain, and prevent the vast number of medical errors committed e­ very year throughout the health-­care system, especially in hospitals. It was jointly endowed by the 3M Com­pany, Schering-­Plough, and CNA HealthPro (a malpractice liability insurance com­pany), so how much of the AMA’s own money went into it is unclear. It was “an act of courage,” according to an AMA official, to depart from its previous line that t­here ­were only “isolated ­mistakes.” But it was courage triggered by fear ­because it came in response, once again, to a spate of alarming newspaper stories about errors in hospitals and, perhaps most unnerving, an item in Ann Landers’s hugely popu­lar syndicated advice column. Thus, the era when the AMA had “pretended the prob­lem d ­ idn’t exist or that it was extremely rare” was over, according to Lucian L. Leape, a nationally respected expert on medical errors at the Harvard School of Public Health.42 Some of the AMA’s progressive face-­lifting involved the election of African Americans and w ­ omen to its one-­year presidency, a relatively weak position compared to the CEO’s and seats on the AMA Board of Trustees. In 1994, the House of Delegates elected its first black president, Lonnie Bristow, a specialist on sickle cell anemia and coronary care and an advocate of guaranteed health insurance and other socioeconomic and public health mea­sures for the medically underserved. Back in 1985, Bristow had been the first black member elected to the AMA Board of Trustees, but that occurred only a­ fter a march on the AMA building in Chicago by around two hundred medical students. Led by the famous liberal pediatrician Benjamin Spock, they w ­ ere protesting against the AMA’s support for the South African Medical Association’s membership in the World Medical Association, which the AMA dominated.43 Electing Bristow president was also a po­liti­cally wise move to curry ­favor with a sitting Demo­cratic president with a mission to improve the cost-­effectiveness as well as distribution of health care. In 1998, f­amily and community medicine specialist Nancy Dickey was the very first ­woman elected AMA president ­after de­cades of external criticism and increasing internal criticism of medical patriarchy. Bristow’s and Dickey’s elections w ­ ere indicative of some substantive change, especially in the passing of the increasingly progressive resolutions and pol-



A New Medical Progressivism

463

icy statements drafted by AMA committees. But in 1999, the AMA tarnished its image further by firing editor Lundberg. Throughout his tenure, Lundberg had received irate telephone calls and letters from AMA members, state medical socie­ties, and AMA officers “threatening po­liti­cal action” against him for opening the journal to ideologically objectionable pieces, discussions unflattering to the profession’s image, and reforms that might hurt its “ability to earn money.” One sin, for example, was publicizing surgeon Lucian Leape’s disturbing findings about the astonishing number of fatal medical errors made each year. Editorials favoring gun control also roused fury from many gun-­owning AMA members.44 Lundberg caused another tempest with a 60 Minutes tele­vi­sion interview about the dramatic decline and therefore “sorry state of the autopsy.” Choking off that source of clinical learning threatened the quality of ­future medical care, Lundberg had argued in editorials that CBS noted. Asked bluntly by journalist Mike Wallace if doctors ­were burying their ­mistakes by not insisting on autopsies, Lundberg agreed. E. Ratcliffe Anderson, the AMA’s CEO, attempted to fire him, but the board of trustees demurred. The last straw, but not the main reason for Lundberg’s firing, was the publication of the results of a three-­page Kinsey Institute survey asking students at a large Midwestern university about their sexual be­hav­ior. In it, 59 ­percent said they did not consider oral-­genital contact as “having had sex.” The article was scheduled to appear shortly a­ fter the start of the Senate trial of President Bill Clinton for lying to a g­ rand jury about such intimate relations with a White House intern. Lundberg’s many antagonists attacked the editorial decision as a patent attempt to influence the Senate and public opinion in Clinton’s ­favor. Three years ­later, Lundberg returned the ­favor with a book, based on his experiences, about the “severed trust” between the profession and society, caused in part by his former employer’s errors of omission and commission.45 Another retrograde move in the larger House of Medicine was the publicly noted firing six months l­ater of Jerome Kassirer, formerly a professor of nephrology at Tufts University, from the chief editorship of the New ­England Journal of Medicine, the property of the Mas­sa­chu­setts Medical Society (MMS). Kassirer believed that the premier international journal’s exercise of editorial in­de­pen­dence, a tradition solidified by his pre­de­ces­sors Franz Ingelfinger, Arnold Relman, and Marcia Angell, had become intolerable to the MMS’s leaders, one of whom served on the AMA Board of Trustees, as well as to many rank-­and-­file members. In Kassirer’s view, one ­factor in his firing was obstruction of the MMS’s plans to cash in on his journal’s brand of

464

Reactionary Turn and Beyond

excellence by putting its name on other profitable advertising-­funded publications whose contents were not to undergo the kind of rigorous scrutiny that he strove for. He was fired only a few days a­ fter publishing a fourth article critical of the AMA, which, he said, the MMS was “loathe to irritate.” An ­earlier one had embarrassed the AMA for plans to create its own, low-­bar route to specialty certification in order to attract more members. The last article blasted the AMA for firing Lundberg. Both Kassirer and Angell would go on to write searing exposés published in 2004 and 2005 of the drug industry’s corrupt practices and the financial benefits they bestowed on individual physicians, medical journals, medical schools, and medical socie­ties.46 All in all, the 1990s was a turbulent time for the externally bruised and internally disordered AMA. In 1994, Howard Wolinsky, whose reporting had brought down James Sammons, published along with coauthor Tom Brune a hard-­hitting and meticulously researched book, Serpent on the Staff, on “the unhealthy politics” of the AMA. Its survey of the unflattering recent history of the AMA ensured that the organ­ization could never again credibly claim to be “the” voice of American medicine. Even its own voices ­were increasingly dissonant. William Rial, who had served as AMA president in 1982 and 1983 and who had been outraged by the Sammons scandal, praised Serpent on the Staff as “a wake-up call” for physicians interested in repairing “their AMA and its public image.” 47 MEDICAL DISORDER IN THE T WENT Y-FIRST CENTURY

By 1998, AMA membership had sunk to around 32 ­percent from 40 ­percent of all physicians in 1990. While it continued to dwindle to around 25 ­percent in 2015 and to perhaps as low as 17 ­percent of active prac­ti­tion­ers, other medical socie­ties and organ­izations, especially t­hose representing medical specialties, w ­ ere growing in wealth and influence. ­Because of declining membership fees and advertising revenue, the AMA increasingly relied on other sources of money, including earnings on investments. In 2008, the organ­ization received about $44 million in members’ dues, only about 16 ­percent of total revenue. Most of the rest came from copyrighted products. Much of that was drug money. From the AMA, phar­ma­ceu­ti­cal companies bought the names and other information on all doctors in the country, i­ncluding non-AMA members, in its copyrighted Physician Masterfile. It data mined that information by collating it with individual physicians’ prescribing histories sold to them by



A New Medical Progressivism

465

pharmacies, thus making it pos­si­ble to tailor and target promotions to specific doctors and then evaluate the effectiveness of their sophisticated sales strategies. Some of the money also flowed from insurance companies and many other users of the AMA’s copyrighted Current Procedural Terminology (CPT), an extensive cata­logue of codes for thousands of ser­vices and procedures used for recording and reimbursing medical ser­vices.48 The AMA’s misfortunes of the 1970s ­were augmented by the rise in number and size of medical specialty associations (MSAs), which fractured what is sometimes called the House of Medicine or­gan­i­za­tion­a lly. In 1977, b­ ecause of sinking membership in county-­and state-­level socie­ties, which ­were supposed to represent the local and general interests of the profession, one hundred new seats in the House of Delegates, each to represent one specialty association, w ­ ere added. In 1997, MSAs w ­ ere granted proportional repre­sen­ta­ tion in the House of Delegates based on the number of AMA members who opted for their specialty organizations to represent them instead of their state medical associations; ­later rules apportioned seats based on the number of AMA members in each association. The Progressive Era reformers’ system of aggregating general physician interests at the county and then state and national levels thus gave way to increasingly chaotic special interest repre­sen­ta­tion. By 2019, national specialty groups sent 124 voting participants to House of Delegates meetings of more than six hundred participants. No fewer than thirty-­three of them w ­ ere surgery related, six of them for orthopedic or spine specialists and six for plastic, cosmetic, or hair specialists. Th ­ ere w ­ ere four involved with oncology next to the dozen or so older groups such as the academies, colleges, or socie­ties of every­thing from anesthesiologists to urologists.49 The rising influence of MSAs inside as well as outside the AMA did not mean a reduction in conflicts of interest. In 2007, Jerome Kassirer complained that too many MSAs ­were “toadying up to” the phar­ma­ceu­ti­cal, device, and biotechnology companies for practically all of their activities such as journals and other publications, continuing medical education material, and more. They ­were invading national meetings with “vulgar circus-­like displays” and company-­sponsored symposia that blurred the line between advertising and information. Astonishingly, in 2020, specialty socie­ties could qualify for group membership and voting rights in House of Delegates meetings even if only a ­ ere physicians (!). A clue as to who t­ hose lay bare majority of their members w members might have been lies in the fact that, according to the 2008 estimate of pulmonologist, journal editor, and medical reformer Lawrence Grouse, it was not unusual for industry to provide up to 80 ­percent of a typical MSA’s

466

Reactionary Turn and Beyond

revenues. Only estimates of the sums ­were pos­si­ble ­because of secrecy; the AMA and its member organ­izations are not required to and do not post their IRS 990 forms. Additionally, the AMA’s criteria for allowing specialty society membership and voting rights did not include limits on commercial funding. The MSAs, Grouse concluded, “simply replicated” what the twentieth-­century AMA had practiced.50 The specialty associations’ eagerness to take drug and device corporations’ money could not have been based on a view that they ­were philanthropic organ­izations. It was public knowledge that Pfizer, for example, paid close to $5 billion in penalties and settlements between 2000 and 2020 ­after prosecutions and lawsuits for false claims, illegal advertising, kickbacks and bribery, price fixing and other anticompetitive practices, safety and environmental violations, and more. In that same period, together with Pfizer, GlaxoSmithKline, Johnson & Johnson, Merck, and Teva paid almost $20 billion. The top ten paid out over $27 billion. The top ten medical device, equipment, and supply firms, with Baxter International and Boston Scientific in the lead, paid almost $2 billion in vari­ous penalties.51 Another source of ­great indignation for the therapeutic rationalists was the physicians “on the take,” as Kassirer described them, who served on specialty socie­ties’ committees responsible for drawing up the clinical practice guidelines (CPG) that doctors consult in the oft-­mistaken belief that they are unconflicted sources of advice about diagnostics and best therapeutic practices. A 2016 study found that 63 ­percent of PMAs that published CPGs on the National Guideline Clearing­house website in 2012 reported receiving funds from biomedical companies. But only 1 ­percent of their published CPGs disclosed the sources of their funding. The study calculated that the CPGs that had significantly more positive and fewer negative recommendations regarding prescription drugs w ­ ere produced by organ­izations with relatively weak conflict of interest policies, such as disclosure requirements. In 2007, the Senate Finance Committee reported that as many as 59 ­percent of authors of CPGs, many published by MSAs, had financial backing from companies “whose drugs might be affected by ­those guidelines.” An example was the five-­ thousand-­member Heart Rhythm Society, a publisher of guidelines on the use of drugs, catheters, and defibrillators to control irregular heartbeats. In 2010 it received nearly half of its $16 million bud­get from the makers of ­those products. Twelve of the AMA affiliate’s eigh­teen board members ­were paid speakers or con­sul­tants for the companies, and its president’s research was industry funded. Authors of twenty-­six CPGs published by the American Soci-



A New Medical Progressivism

467

ety of Clinical Oncology, also an AMA affiliate, ­were riddled with conflicts of interest. At least 75 ­percent of 314 authors had verifiable financial conflicts of interest; 55 of them actually declared no conflicts in their guidelines. That contradicted industry data submitted to the federal government and available on its Open Payments website. Many of the remaining 25 ­percent prob­ably had conflicts, but ­because they ­were not U.S. residents, or ­were affiliated with a nonprofit organ­ization—­including industry-­supported patient advocacy groups—­they w ­ ere exempt from the reporting requirements included in the Affordable Care Act of 2010.52 Another AMA affiliate that produced CPGs was the North American Spine Society (NASS). According to the 2008 Senate testimony of Charles Rosen, a professor at the University of California at Irvine, the NASS and its board members received enormous sums of money from companies that made the plates, screws, and other devices used in spinal surgery. In 1994, a surgeon on the NASS board founded a Center for Patient Advocacy to wage a lobbying war against the federal Agency for Health Care Policy and Research (AHCPR), created in 1989, when it began invading the specialty socie­ties’ territory by conducting comparative effectiveness research and issuing its own guidelines. The AHCPR had published studies suggesting that spinal fusion surgery, a huge source of income for orthopedic surgeons, was often in­effec­tive and sometimes harmful. The NASS personally attacked the chief author of the AHCPR work, surgeon Richard A. Deyo, and successfully lobbied key Republican members of Congress to eliminate the agency’s bud­get. A bipartisan rescue operation restored 75  ­percent of the 1994 cut, but the agency lost its authorization to issue comparative effectiveness guidelines. It was renamed the Agency for Health Research and Quality—to remove “policy” from its name.53 Lay and medical critics of or­ga­nized medicine w ­ ere profoundly disturbed by the role of the American Acad­emy of Pain Medicine (AAPM), another AMA affiliate, in the new millennium’s first major public health crisis, an epidemic of opioid addiction. A Senate Homeland Security Committee inquiry led by two-­term Missouri Demo­crat Claire McCaskill (soon to be defeated by Republican Josh Hawley, a fierce supporter of Donald Trump) found that the AAPM and its affiliated foundation w ­ ere the recipients of over $1.5 million between 2012 and 2017 from five opioid makers. Almost half of that came from Purdue Pharma, the maker of the widely prescribed OxyContin, alone. The AAPM and around a dozen other medical professional and patient advocacy groups involved in opioid policy lobbying received almost $9 million

468

Reactionary Turn and Beyond

from the five companies. ­Because of its recommendations regarding opioid prescribing, the AAPM was blamed for contributing to more than 702,000 deaths from drug overdoses from 1999 to 2017, a leading cause of all deaths. In 2017, almost 68 ­percent of them involved a prescription opioid or an illicitly manufactured and distributed equivalent. In 1996, a joint committee of the AAPM and a physician-­led patient advocacy group called the American Pain Society (APS) issued a consensus statement called “The Use of Opioids for the Treatment of Chronic Pain,” which reassured doctors that the risk of addiction to opioids prescribed for chronic pain was extremely low. Its chair was physician and dentist J. David Haddox, a paid speaker for Purdue Pharma. Haddox became a Purdue executive in 2000 and continued in that role ­until at least 2017. Physician Russell Portenoy, who helped write the landmark consensus statement, was president of the APS as well as director of the American Pain Foundation.54 The AAPM and the APS ­were links in a vast network of addiction denialists who believed, based on the flimsiest of evidence, that therapeutic prescriptions of opioids for pain lead to addiction in only 1 ­percent of cases. The deadly statistical canard was cited affirmatively over 350 times in medical journals between 1989 and 2009. It bounced around inside what the Center for Public Integrity called a vast “pro-­painkiller echo chamber.” The flow of money and influence from Purdue and other companies extended even into the Federation of State Medical Boards (FSMB), most of whose members ­were nominated by their respective state medical socie­ties. The FSMB received around $2 million from the addiction denialists between 1997 and 2012. Purdue subsidized the FSMB’s distribution in 2007 of seven hundred thousand copies of “Responsible Opioid Prescribing: A Physician’s Guide,” written—­with input from a Purdue executive—by Scott Fishman, a recent president of the AAPM. Even the AMA’s and the American Hospital Association’s Joint Commission (formerly Joint Commission for Hospital Accreditation) sought Purdue’s counsel for their CPGs and money for producing and distributing continuing medical educational material on prescription narcotics to hospitals and other provider organ­izations. The Joint Commission declared that “some clinicians have inaccurate and exaggerated concerns” about addiction and overdoses b­ ecause “­there is no evidence that addiction is a significant issue when persons are given opioids for pain control.”55 In 2012, the AMA joined the drug industry in blocking an expert panel’s recommendation to the FDA that doctors who prescribed power­ful painkillers be required to receive special training in pain management. Instead, the FDA issued voluntary guidelines and recommendations for training. In 2015,



A New Medical Progressivism

469

it reported that only about half of the eighty thousand physicians it hoped would receive the training had done so. The AMA also opposed laws requiring doctors to check databases to identify patients who had reaped multiple opioid prescriptions from other doctors and to avoid prescribing the drugs if they would interact dangerously with other medi­cations being taken.56 It is not surprising, in light of the economic interests involved, that the subdivision of the House of Medicine into small condominiums of special medical interests dependent on industry money did nothing to change its overall po­liti­cal profile. Campaign spending by specialist socie­ties’ PACs skewed Republican, and the higher the specialists’ income, the more Republican they leaned. But many Demo­crats received money too, mostly to keep their doors open to lobbying about the profession’s economic interests and need for autonomy but usually pitched as what served patients best. Much of the AMA’s operating expenses in the twenty-­first c­ entury ­were for its more than fifty lobbyists. In 2016, the AMA was the country’s third-­biggest “trade group” spender in legislative lobbying, exceeded only by the U.S. Chamber of Commerce, which professes to represent all of American business, and the National Association of Realtors, whose interests overlap with much of banking and construction.57 ­Because the AMA does not report on the allocation of lobbying hours and dollars ­toward dif­fer­ent legislative ­matters, one cannot know what share goes ­toward lobbying strictly to advance public health. The AMA’s lobbying clout had failed to reverse the 1979 FTC ruling against its monopolistic practices, which made physician earnings vulnerable to the monopsonistic buying power of managed-­care organ­izations and other corporate health-­care entities. But its ability to control physician earnings was actually increased by federal legislation proposed by the George H. W. Bush administration in 1989, approved of by the AMA, and implemented in 1992. Accordingly, the CMMS instituted a new fee system, still operative in the 2000s, called the Resource-­Based Relative Value Scale (RBRVS). Private insurance companies and managed-­care organ­izations also quickly a­ dopted the CMMS system for paying physicians, laboratories, and hospitals. The CMMS routinely a­ dopted the recommendations handed to it by the AMA’s Specialty Society RVS Update Committee (RUC) for setting and updating fees for over nine thousand ser­vices and procedures. In the RUC, the specialists who dominate the AMA vastly outvote f­amily and primary care physicians twenty-­nine to five. In the 1990s and into the 2000s, specialists’ fee income r­ ose significantly faster than the o­ thers.58 By holding down payments to generalists for impor­tant consultative, preventive, and referral ser­vices to patients, the system reduced the appeal of their

470

Reactionary Turn and Beyond

line of work to new medical gradu­ates. Between 1997 and 2009, the percentage of medical school gradu­ates choosing to enter f­amily practice fell from around 14 ­percent to 6 ­percent, and the proportion of gradu­ates choosing any primary care specialty, including general internal medicine, fell from 60.7 ­percent in 1997 to 42.1 ­percent in 2006. The undersupply of primary care prac­ti­tion­ers represented a par­tic­u­lar hardship for rural and urban low-­income families and an obstacle to what many medical critics regarded as the reason for other countries’ more efficient organ­ization and delivery of health care. Harvard economist William Hsiao, the originator of the fee system but not its implementation, lamented about the RUC’s operations and impacts: “You do not turn this over to the ­people who have a strong interest in the outcome.” Tom Scully, a former CMMS administrator, declared it “pretty wild” that $100 billion in federal spending is based on fixed prices set in a secretive pro­cess by an “industry trade association.” Having the AMA dictate implementation of the RBRVS system was “crazy from the beginning.”59 ­Because of the RBRVS, the AMA as a corporate bureaucracy acquired a strong conflict of interest with re­spect to the fee-­for-­service system of paying doctors and therefore has not called for reforms emerging from other quarters to or­ga­nize care in ways that rely more on primary care specialists. Fee-­ for-­service medicine dominated by specialists and their high-­cost ser­vices, according to a strong consensus among reformers, had long been a source of high costs for a large volume of ser­vices whose efficacy and therefore cost-­ effectiveness w ­ ere questionable. The AMA earned over $70 million a year in royalties paid by the many users of its copyrighted Current Procedural Terminology (CPT), which contains the procedures listed in the RBRVS. That was well over twice what membership fees brought in. The AMA used its CPT copyright to frustrate efforts to increase transparency in medical billing and therefore informed decision-­making by individuals, corporations, and institutions struggling to make eco­nom­ically as well as medically wise decisions. According to Republican Trent Lott, a former Senate majority leader, by suing websites and other sources of information that post comparisons of physician and hospital fees, the AMA imposed on the nation its “obviously self-­interested policy” against comparison shopping for medical care. Transparency in prices would have allowed for smoking out waste, m ­ istakes, and fraud—­a potent way “to combat the routine double-­digit increases in health care costs that keep millions of Americans uninsured.”60 It would be remiss to ignore AMA activities of a scientific rather than medico-­political nature, especially its vast medical publishing enterprises—­



A New Medical Progressivism

471

most importantly, JAMA and nine specialty journals—­that advance medical knowledge and evidence-­based clinical practice. The AMA also took a significant step t­ oward recognition of the need for rational therapeutics in 2000 when it or­ga­nized the Physician Consortium for Per­for­mance Improvement (PCPI). The PCPI’s main task was to develop per­for­mance mea­sures and registries for health-­care organ­izations to assess and compare medical outcomes and their improvements resulting from innovations in clinical organ­ization and practice. In 2015, it became an in­de­pen­dent foundation, which included dozens of other medical organ­izations as members. In 2018, the AMA contributed $2 million to its operations.61 With that, the AMA materially advanced an impor­tant item on American medicine’s new progressive agenda. But the AMA lumbered, often clumsily, in dif­fer­ent directions, especially as a force in the medico-­economic and medico-­political arena. In 2016, the AMA enthusiastically endorsed Republican physician-­congressman Tom Price, President Donald J. Trump’s nominee for secretary of the Department of Health and H ­ uman Ser­vices. Its approval told loudly of the organ­ization’s threadbare commitment to progressive, conflict-­free medicine. Once an orthopedic surgeon, Price was a member of the right-­wing Association of American Physicians and Surgeons, which formed in 1943 to oppose universal health insurance and long thereafter boasted of being “the only national organ­ization consistently supporting the princi­ples of the ­free market in medical practice.” Currently, it criticizes all controls on gun purchases and carrying rights, calls public health research on gun vio­lence “junk science,” and repudiates other medical organ­izations’ recommendation that physicians discuss with patients the wisdom of keeping guns in their homes. As a congressman from Georgia and a devout Presbyterian, Price opposed regulating tobacco as a drug by the FDA, funding global programs to prevent malaria, AIDs, and tuberculosis, and financing stem cell research.62 Price had led the Republican charge to overturn Obamacare and its expansion of Medicaid to low-­income citizens. He opposed expanding m ­ ental health ser­vices and supported reducing funding for the federal C ­ hildren’s Health Insurance Program and the complete privatization of Medicare. In his 2009 alternative bill, the Empowering Patients Act, Price inserted a provision sheltering drug and device companies from punitive damages for harm their products caused when prescribed for off-­label (not FDA approved) purposes. All a com­pany needed for defense against liability for such an injury was soft evidence that “qualified” experts “generally” recognized the drug was safe for that use. High-­quality clinical research on off-­label usage was not

472

Reactionary Turn and Beyond

needed as it was for initial FDA approval of drugs only for clinical uses proved to be merited by rigorous testing. While serving as chair of an impor­tant House committee, Price had traded more than $300,000 worth of phar­ma­ceu­ ti­cal and medical device stocks and then sponsored legislation that their companies’ share prices stood to gain from. One of them, for example, was a maker of joint replacements, whose stock he bought less than a week before introducing legislation to delay a federal regulation expected to reduce its sales.63 It would be an injustice to many AMA members and their representatives in its House of Delegates to blame them for Price’s endorsement. A petition in protest signed by over 6,400 physicians declaring that the AMA “reneged on a fundamental pledge that we as physicians have taken—to protect and advance care for our patients” was prob­ably the tip of an iceberg of indignation inside as well as outside the organ­ization. They ­were not appeased by the AMA president’s rather limp defense that Price had consistently shown over the years “an interest in a dialogue on how to strengthen the ability of physicians to serve their patients.” The extent of internal division was revealed in 2019, when a resolution to drop the AMA’s opposition to a single-payer “Medicare for All” reform came within a stone’s throw of success, with a vote of 47 ­percent in f­avor and 53 ­percent opposed. But the opposition’s high tally persuaded the AMA to drop out of the Partnership for Amer­i­ca’s Health Care ­Future (PAHCF), a co­a li­tion of phar­ma­ceu­ti­cal and device companies, medical associations, health plans, insurance companies, hospital associations, chambers of commerce, manufacturing associations, and other business groups against a single-­payer health insurance system. The AMA had reported to the IRS contributions of more than $2 million in 2018 to the PAHCF’s massive lobbying and advertising campaigns across the states to stop universal health care on a single-­payer basis. During the 2020 presidential election campaign, therefore, the PAHCF had to rely mostly on for-­profit corporations and their organ­izations, although it benefited from contributions from vari­ous specialty groups, such as radiologists and neurosurgeons. In 2017, the American College of Radiology Association contributed $300,000, and in 2020, two associations of neurosurgeons ­were members of the PAHCF.64 The diversity of opinions inside as well as outside the AMA is assured in part by the fact that JAMA no longer suppresses progressive opinions about health insurance and other reform issues. Despite his ouster in 1999, Lundberg’s successors resolutely maintained JAMA’s editorial in­de­pen­dence and therefore provided the venue for debate that he had created in the 1990s. ­Because of internal division, some of the AMA’s progressive moves still come



A New Medical Progressivism

473

slowly, sometimes only in response to outside pressure and events. In 2008, ­after Barack Obama’s election, the AMA’s immediate past president, Ronald Davis, fi­nally issued a formal apology for more than a c­ entury of AMA policies that had excluded African Americans from membership and the privileges that came with it. More like the medical progressives of the early twentieth c­ entury, Davis was a preventive medicine specialist, medical director for the Michigan Department of Public Health, and director of the Centers for Disease Control and Prevention’s Office on Smoking and Health. In 2009, responding to looming state legislation as well as criticism mostly from young doctors inside and outside the organ­ization, the AMA allowed all doctors to opt out of inclusion in its Physician Masterfile in order to stay out of drug companies’ sights. And, fi­nally, in 2010 the AMA supported and subsequently defended the large expansion of better and more affordable—­but not exactly guaranteed—­health coverage to indigents and the working poor with the Affordable Care Act.65 Gradual changes in AMA politics, including legions of reform-­minded resolutions and policy pronouncements, reflect a changing profession and a desire to recruit more members who no longer fit the profile of the in­de­pen­ dent white male office-­based practitioner that the AMA had once glorified and protected. Vast numbers of doctors are on the payroll of vari­ous forms of “managed care” that contract with them as medical groups, not individuals. ­Because of that, over 50 ­percent of medical students who graduated in 2010 started in group practices with over one hundred members. The once sovereign white male physician is off the throne; in 2017, for the first time ever, the majority of medical students ­were ­women. Still, however, while African Americans are about 13 ­percent of the U.S. population, they comprise only about 8 ­percent of medical students. But the AMA’s many reformist resolutions and policy statements that harmonize with the changing profession are, as history tells, words that may not be translated into po­liti­cal action. For example, the many House of Delegates resolutions against cigarette smoking and the tobacco industry in the 1980s had no immediate effect on the AMA officialdom. Other evidence of a gap between words and action can be found in studies showing that a g­ reat deal of the campaign money AMPAC raised in the 1980s and 1990s went ­toward legislators who actually voted against the AMA’s official, liberal sounding, and pro–­public health policies. The disjunction is still pre­sent ­today. What the AMA does with its lobbying time and dollars is not made public. But the AMA’s endorsement of Tom Price says a g­ reat deal about what kinds of

474

Reactionary Turn and Beyond

President Barack Hussein Obama (1961–) pitching health-­care reform to the 2009 AMA House of Delegates meeting in Chicago before passage of the 2010 Patient Protection and Affordable Care Act. The act was the first federal law for expanding health-­care coverage ever supported by the AMA. UPI Photo / Brian Kersey.

actions in the form of lobbying are still being taken for the profession’s special economic interests and ­those of the “medical-­industrial complex.”  66

The words of the brilliant German physician and medical scientist Rudolf Carl Virchow, one of the g­ reat progressive medical statesmen of all times and all places, still ring true. The nineteenth ­century’s most internationally influential public health missionary argued that ­because of the often devastating and unequally distributed injuries of economic, po­liti­cal, and social institutions, the profession’s knowledge about their injuries to health inevitably leads it “into the social field” and therefore “in a position of confronting directly the ­great prob­lems of our time.” In that time, Virchow investigated a deadly louse-­ borne typhus epidemic in Upper Silesia that was responsible for the deaths of thousands of p ­ eople, many of them from starvation. Ten p ­ ercent of the population in one district perished. Gross neglect of the economic, nutritional, social, psychological, cultural, and of course medical needs of the working classes w ­ ere the medical sequelae of po­liti­cal disenfranchisement combined with “an absurd concentration of capital and landed property.” 67



A New Medical Progressivism

475

Almost two centuries l­ater, t­ oday’s economic system, racism, sexism, and po­liti­cal corruption still inflict injuries to both body and spirit. Democ­ ratization turned out not to be the remedy that the po­liti­cally radical Virchow hoped it would be. Our eco­nom­ically advanced cap­i­tal­ist democracy, in which growth never erases poverty and its attendant ills, still places shared responsibility for public health on the medical profession. But b­ ecause it is badly disordered and financially conflicted, it is incapable of fulfilling any reasonably conceived social or fiduciary contract between medicine and society. For that, an or­ga­nized movement is needed that is dedicated to true professionalism: the striving for interests larger than the individual physician’s own.68 True professionalism, collectively as well as individually pursued, ­will require another revolution inside or­ga­nized medicine. The AMA was once captured by reactionaries in the 1920s. In the 2020s, a c­ entury l­ater, a growing contingent of progressive physicians could in princi­ple take it back and turn it into a force for public health and patients’ interests even when they are out of alignment with prac­ti­tion­ers’ interests in autonomy and income. A g­ reat many reform-­minded physicians w ­ ill disagree about the possibility or even necessity of changing the AMA, having written it off as irredeemable or irrelevant. They may be right, but ­there should be debate about w ­ hether they are wrong, and if so, what to do. In this layperson’s mind, it is not beyond the realm of possibility that a progressive AMA could energetically push for and therefore help pass universal health care as well as improve its quality and efficiency. For public health’s sake, it could help get government action to rescue millions of American ­house­holds from food insecurity, a source of bodily and ­mental illness. It could lobby for more transparency and research on deadly carcinogens and the tragic effects on c­ hildren’s bodies of endocrine disruptors in consumer products and even the w ­ ater supply. Not least because cigarette companies target youths and young adults who are more likely than older people to become long-term smoking addicts, it could fully redeem itself for its former years of complicity with the hugely profitable industry by conducting aggressive attacks against it as the most dangerous vector of Americans’ biggest killers—cardiovascular disease, cancer, obstructive pulmonary disease, and strokes. All physicians and their organ­izations should be fervent environmentalists, focused on preventing environment-related disease instead of just more money for research on cures and palliatives. It could aggressively challenge the agribusiness, fossil fuel, chemical, and other industries that, like the cigarette industry once did, hire “merchants of doubt” to deny what the vast majority of scientists, including medical ones, agree are great toxic, carcinogenic,

476

Reactionary Turn and Beyond

endocrinological, as well as global warming effects caused by the extraction and burning of fossil fuels. It could join forces with the environmental justice movement and should do so aggressively for the simple reason that the harm to bodies and lives brought by pollution, heat, and extreme weather events is disproportionately visited on disadvantaged populations. Facing the specter of superbugs in a postantibiotic world, it could mobilize to protest the meat industry’s as well as clinicians’ squandering of a ­limited and shrinking supply of antibiotics—­precious assets for doctors’ stewardship, not just use, whose creation is only possible because of the societal and governmental infrastructure that the pharmaceutical industry critically depends on for its huge profits. And, of course, the AMA could lobby aggressively to fix the public health system, long in a condition of “disarray,” as the IOM put it in 1988, to be better prepared for emerging new infectious diseases. The list could go on. Needed reforms may require many physicians who are not now members to join the atrophic AMA, not boycott it, and thereby assume, not abdicate, collective moral responsibility for public health and efficient medicine. Activist physicians believe they can adequately pursue sociomedical justice by working around the AMA and through dif­fer­ent channels and means. That should continue of course. But boycotting the AMA and leaving it in the hands of ­others does not weaken it or make it irrelevant. It only empowers an organ­ization that is on commercial life support and therefore only weakly dedicated to reformist action despite its earnest resolutions and declarations suggesting otherwise. A more encompassing professional democracy could help right the balance between protecting economic interests and pursuing public health. Greater revenue from membership dues could wean or­ga­nized medicine from its commercial ventures and from industry subsidization. Members could demand transparency about where the AMA puts its lobbying resources. Membership dues could fund extensive public education and— above all—lobbying operations for progressive ends. As worthy as they are, the AMA’s scientific and educational activities are not enough. Only by returning to its former progressivism can the profession fulfill what Virchow called medicine’s ­grand obligation “to intervene in the polity” and thereby help maintain society’s “normal functioning of vital pro­cesses.” By joining and reforming the American Medical Association, currently unor­ga­nized doctors can better become what medical progressive Donald Berwick calls “moral determinants of health.” 69

Notes

INTRODUCTION

1. Oliver Wendell Holmes, “The Medical Profession in Mas­sa­chu­setts [1869],” 313, and “Currents and Counter-­Currents in Medical Science [1860],” 193, in Holmes, Medical Essays, 1842–1882 (Boston: Houghton, Mifflin, 1883). 2. William Allen Pusey, “Some of the Social Prob­lems of Medicine,” JAMA 82:24 (June 14, 1924), 1905–1906; Pusey, “A Breeze from Down ­Under,” NYSJM 49:16 (August 15, 1949), 1905; Pusey, “License for Illness,” NYSJM 49:18 (September 15, 1949), 2130. 3. Stephen E. Ambrose, Eisenhower: The President (New York: Simon and Schuster, 1984), 199. 4. Harold Aaron, “The Doctor in Politics,” Consumer Reports, February 1950, 75. 5. Joseph A. Loftus, “Ban on Health Plan a Defeat to ­People, Eisenhower Says,” NYT, July 5, 1954. 6. Victor C. Vaughan, “The Ser­vice of Medicine to Civilization,” JAMA 57:26 (June 27, 1914), 2012. 7. Useful introductions to the Progressive Era are Robert H. Wiebe, The Search for Order, 1877– 1920 (New York: Hill and Wang, 1967), and Arthur Stanley Link, Progressivism (Arlington Heights, IL: Davidson, 1983). An extensive compendium on ­people and t­hings medical in the Progressive Era is Ruth Clifford Engs, The Progressive Era’s Health Reform Movement: A Historical Dictionary (London: Praeger, 2003), although within it the AMA gets barely a mention. 8. Leartus Connor, “The Prevention of Diseases Now Preying on the Medical Profession,” BAAM 3:9 (October 1898), 4. 9. William G. Eggleston, “Our Medical Colleges,” JAMA 12:21 (May 25, 1889), 747. 10. George H. Simmons, “The Commercial Domination of Therapeutics and the Movement for Reform,” JAMA 48:20 (May 18, 1907), 1645; Simmons, “Proprietary Medicines: Some General Considerations,” JAMA 46:18 (May 5, 1906), 1336. 11. C.-­E . A. Winslow, “The Untilled Fields of Public Health,” Science 51:1306 (January 9, 1920), 30; Winslow, “The Untilled Field of Public Health,” MM 2 (1920), 183–191.

477

478

notes to pages 7–15

12. William C. Woodward, “The American Medical Association and Its Relation to Public Health Work,” JAPHA 1 (1911), 329; U.S. Senate, Committee on Public Health and National Quarantine, Proposed Department of Public Health (Washington, DC, 1910), 105, 106; James Peter Warbasse, Medical Sociology: A Series of Observations Touching upon the Sociology of Health and the Relations of Medicine to Society (New York: D. Appleton, 1909), 20–21. 13. W. E. Burghardt Du Bois, ed., The Health and Physique of the Negro American (Atlanta, GA: Atlanta University Press, 1906), 95–97; “Education of the Negro Physician,” JAMA (April 28, 1923), 1244; Paul Cornely, “Distribution of Negro Physicians in the United States,” JAMA 124:13 (March 25, 1944), 826–830. 1 4. Victor Robinson, “The Negro in American Medicine,” MRR 22:7 (July 1916), 481, 484; Robinson, “The Negro Brain,” JAMA 47:20 (November 17, 1906), 1660; Robert Bennett Bean, “Some Racial Peculiarities of the Negro Brain,” American Journal of Anatomy 5:9 (September 1906), 379; Franklin P. Mall, “On Several Anatomical Characters of the H ­ uman Brain,” American Journal of Anatomy 9:1 (January 1909), 1–32; Stephen Jay Gould, The Mismea­sure of Man (New York: W. W. Norton, 1996), 111–112. 15. “The National Negro Antituberculosis League,” JAMA 52:12 (March 20, 1909), 969–970; H. M. Folkes, “The Negro as a Health Prob­lem,” JAMA 55:15 (October 18, 1910), 426; Thomas W. Murrell, “Syphilis and the American Negro,” JAMA 54:11 (March 12, 1910), 846–849. 16. Herbert A. Miller, “Some Psychological Considerations of the Race Prob­lem,” in Du Bois, Health and Physique of the Negro American, 95–104; Du Bois, Health and Physique of the Negro American, 110; Du Bois, “Review of Race Traits and Tendencies of the American Negro, by Fredrick L. Hoffman,” AAAPSS 9 (January 1897), 127–33; Charles E. Terry, “The Negro: His Relation to Public Health in the South,” AJPH 3:4 (April 1913), 304. 17. Victor C. Vaughan, “The Functions of Dentistry and Medicine in Race Betterment,” Journal of the American Dental Association 1:4 (October 1, 1914), 14–15; Vaughn, “Eugenics from the Point of View of the Physician,” in Morton A. Aldrich, ed., Eugenics: Twelve University Lectures (New York: Dodd, Mead, 1914), 41–77; Randall Hansen, Sterilized by the State: Eugenics, Race, and the Population Scare in Twentieth ­Century Amer­i­ca (New York: Cambridge University Press, 2013), 84–86; Eugene Perry Link, The Social Ideas of American Physicians, 1776–1976: Studies in the Humanitarian Tradition in Medicine (London: Associated University Presses, 1992), 181, 183, and 191; Garland E. Allen, “The Eugenics Rec­ord Office at Cold Spring Harbor, 1910–1940,” Osiris 2 (1986), 238; “The Science of Eugenics,” JAMA 49:20 (November 16, 1907), 1681. 18. Abraham Jacobi, “­Women Physicians in Amer­i­c a,” in William J. Robinson, ed., Collectanea Jacobi: Contributions to Pediatrics, vol. 2 (New York: Critic and Guide, 1909), 305–314; Rhoda Truax, The Doctors Jacobi (Boston: L ­ ittle, Brown, 1952), 138, 143, 178, 242. 19. Mary Roth Walsh, “Doctors Wanted: No ­Women Need Apply”: Sexual Barriers in the Medical Profession, 1835–1925 (New Haven, CT: Yale University Press, 1977); Janet Brickman, “Public Health, Midwives, and Nurses, 1880–1930,” in Ellen C. Lagermann, ed., Nursing History: New Perspectives, New Possibilities (New York: Teachers College Press, 1983). 2 0. Mike Magee, Code Blue: Inside Amer­i­ca’s Medical Industrial Complex (New York: Atlantic Monthly Press, 2019). 21. See, for example, John C. Burnham, “Medical Specialists and Movements t­ oward Social Control in the Progressive Era,” in Jerry Israel, ed., Building the Orga­nizational Society Essays on Associational Activities in Modern Amer­i­ca (New York: ­Free Press, 1972); George Rosen, The Structure of American Medical Practice, 1875–1941 (Philadelphia: University of Pennsylvania Press, 1983); E. P. Link, Social Ideas of American Physicians. 22. James Harvey Young, Pure Food: Securing the Federal Food and Drugs Act of 1906 (Prince­ton, NJ: Prince­ton University Press, 1989); John Duffy, The Sanitarians: A History of American Pub-



notes to pages 16–17

479

lic Health (Urbana: University of Illinois Press, 1990); George Rosen, “The Committee of One Hundred on National Health and the Campaign for a National Health Department, 1906– 1912,” AJPH 62:2 (February 1972); Kenneth M. Ludmerer, Learning to Heal: The Development of American Medical Education (Baltimore: Johns Hopkins University Press, 1985). A partial exception is James G. Burrow, whose two books survey a range of the AMA’s activities during the Progressive Era but fail to pre­sent a coherent, integrative understanding of medical progressivism. Also, by ignoring the role of or­ga­nized medicine’s changing societal allies, a major focus of this book, Burrow fails to place its actions in a larger context of social and economic power. James G. Burrow, AMA: Voice of American Medicine (Baltimore: Johns Hopkins University Press, 1963) and Or­ga­nized Medicine in the Progressive Era: The Move t­ oward Mono­poly (Baltimore: Johns Hopkins University Press, 1977). 23. Regarding health insurance, see Ronald L. Numbers, Almost Persuaded: American Physicians and Compulsory Health Insurance, 1912–1920 (Baltimore: Johns Hopkins University Press, 1978), 110–114. Regarding the national po­liti­cal shift, see Thomas Neville Bonner, Medicine in Chicago, 1850–1950: A Chapter in the Social Development of a City (Urbana: University of Chicago Press, 1991), 213–219. On the leadership turnover, see Rosemary Stevens, American Medicine and the Public Interest: A History of Specialization (New Haven, CT: Yale University Press, 1971), 142, and John Gordon Freymann, “Leadership in American Medicine,” NEJM 270:14 (April 2, 1964), 715. 2 4. Gerald Markowitz and David Rosner, “Doctors in Crisis: A Study of the Use of Medical Education Reform to Establish Modern Professional Elitism in Medicine,” American Quarterly 25:1 (March 1973), 84, 91, 107. Markowitz and Rosner maintain that the “basic conservatism and elitism” of the medical profession into the 1970s not only evolved out of but ­were “inherent” in the education reform movement. Supposedly, the driver of reform was a “near obsession” with a huge glut of doctors. “Only the physician viewed the profession as ‘overcrowded,’ for only he suffered from the surplus of competitors.” In sum, the reform was “conservative in both intent and effect.” Burrow, in Or­ga­nized Medicine in the Progressive Era, also ignores the radical right turn of the AMA, leaving the impression that the subsequent “move to mono­ poly”—­a nalyzed in detail in this book—­was consistent with Progressive Era motivations. 25. Milton Friedman, Capitalism and Freedom (Chicago: University of Chicago Press, 1962), 152, 153, 158; George Stigler, “The Theory of Economic Regulation,” Bell Journal of Economics and Management Science 2:1 (Spring 1971), 15; Reuben A. Kessel, “The A.M.A. and the Supply of Physicians,” Law and Con­temporary Prob­lems 35 (1970), 268, 271; Ronald Hamowy, “The Early Development of Medical Licensing Laws in the United States, 1875–1900,” Journal of Libertarian Studies 3 (Winter 1979), 84, 88, 93, 101. Nobel laureate Friedman, for example, declares tendentiously and with greater certainty than evidence that licensure increases the cost and reduces “both the quantity and the quality of medical practice.” George Stigler, a fellow Chicago school economist and also a Nobel laureate, equates the motives of doctors with ­t hose of huge corporations in the oil, airline, trucking, and banking industries seeking shelter from profit-­squeezing competition. According to Reuben Kessel, a like-­minded Chicago schooler, the medical reformers’ lay allies w ­ ere merely “dupes” of a medical profession disguising its “highly parochial interests.” Ronald Hamowy, a historian of public health, charges the profession with “unblushing hy­poc­risy” for its professions of concern for the public’s health. Their “almost evangelical euphoria” about a crusade for “nothing short of a sanitary utopia” was just “specious identification of the profession’s interests with ­t hose of the public at large.” 26. On adverse se­lection, see chapter 4, especially note 2. 27. Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (New York: Basic Books, 1983), 8–9, 24, 85, 103, 116–117, 232. 28. Ibid., 8–9, 24, 232.

480

notes to pages 21–26 CHAPTER 1. MEDICAL M AYHEM

1. Abraham Jacobi, “Medicine and Medicine Men in the United States (Part I),” JAMA 35:7 (August 18, 1900), 427, 429, 430; Jacobi, “Medicine and Medicine Men in the United States (Part II),” JAMA 35:8 (August 25, 1900), 496; Jacobi, “Proprietary Medicines,” JAMA 47:13 (September 29, 1906), 978. 2. On the competitive conditions in medicine, see George Rosen, The Structure of American Medical Practice, 1875–1941 (Philadelphia: University of Pennsylvania Press, 1983). On the Progressive Era generally, see Richard Hofstadter, The Age of Reform (New York: Vintage, 1960), and John Whiteclay Chambers, The Tyranny of Change: Amer­i­ca in the Progressive Era, 1890– 1920 (New Brunswick, NJ: Rutgers University Press, 2000). 3. Oliver Wendell Holmes, “The Medical Profession in Mas­sa­chu­setts [1869],” 313, and “Currents and Counter-­Currents in Medical Science [1860],” 177, in Holmes, Medical Essays, 1842–1882 (Cambridge, MA: Riverside Press, 1891). 4. Richard C. Cabot, “The Physician’s Responsibility for the Nostrum Evil,” JAMA 42:13 (September 29, 1906), 982–984. 5. Abraham Jacobi, “Dentition and Its Derangements” and “Dentition,” in William J. Robinson, ed., Collectanea Jacobi: Contributions to Pediatrics (New York: Critic and Guide, 1909), 159– 173, 403–411; Rhoda Truax, The Doctors Jacobi (Boston: L ­ ittle, Brown, 1952), 145, 225. 6. Yandell Henderson, “Report of Committee on Anesthesia,” JAMA 58:24 (June 15, 1912), 1909; Ann Dally, “Status Lymphaticus: Sudden Death in C ­ hildren from ‘Visitation of God’ to Cot Death,” Medical History 41:1 (January 1997); Frank Billings, “The Limitations of Medicine,” JAMA 31:17 (October 22, 1898), 952. 7. Arthur Dean Bevan, “Unnecessary Operations on W ­ omen,” Surgery, Gynecol­ogy, and Obstetrics 3:4 (October 1906), 591–592. 8. Michel Thiery, “Battey’s Operation: An Exercise in Surgical Frustration,” Eu­ro­pean Journal of Obstetrics and Gynecol­ogy 81 (1998), 243–246; “Removing the Ovaries,” MS 32:8 (August 1909), 403; Henry P. Newman, “Special Considerations in Surgical Treatment of the Female Pelvic Organs,” JAMA 57:24 (December 9, 1911), 1879; “Cook County Hospital and Politics,” JAMA 35:22 (December 1, 1900), 1412–1413; “Prudery or Politics,” JAMA 38:6 (February 8, 1902), 404– 405. 9. John Ettling, The Germ of Laziness: Rocke­fel­ler Philanthropy and Public Health in the New South (Cambridge, MA: Harvard University Press, 1981), 2, 5, 25, 43–48, 234; C. F. Strosnider, “Hookworm Disease,” JAMA 56:14 (April 8, 1911), 1024. 10. Ernest C. Levy, “Advantages and Difficulties of Publicity in Connection with Municipal Public Health Work,” JAMA 52:9 (February 27, 1909), 684. 11. Victor Robinson, “Public Toilets in American Cities,” MRR 22:4 (April 1916), 244–248. 12. James Peter Warbasse, Medical Sociology: A Series of Observations Touching upon the Sociology of Health and the Relations of Medicine to Society (New York: D. Appleton, 1909), 20–21. 13. Marilyn Chase, The Barbary Plague: The Black Plague in Victorian San Francisco (New York: Random House, 2003), 61, 184; “Bubonic Plague Still a Menace,” NYT, April 23, 1910; Guenter Risse, “ ‘A Long Pull, a Strong Pull, and All Together’: San Francisco and Bubonic Plague, 1907–1908,” BHM 66:2 (Summer 1992), 260–286. 14. “Hospital Ills Need Expose,” Chicago Daily Tribune, May 14, 1911; Harry F. Dowling, City Hospitals: The Undercare of the Underprivileged (Cambridge, MA: Harvard University Press, 1982), 93–97. 15. “Darlington Writes of Doctors’ Bills,” NYT, May 9, 1915. 16. Oliver Wendell Holmes Sr., Homoeopathy and Its Kindred Delusions: Two Lectures Delivered before the Boston Society for Useful Knowledge (Boston: Ticknor, 1842); Paul Starr, The Social



notes to pages 27–32

481

Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (New York: Basic Books, 1983), 96–102. 17. Ron Chernow, Titan: The Life of John D. Rocke­fel­ler, Sr. (New York: Random House, 1998), 11, 38, 42, 126, 406–407, 465; Martin Kaufman, Homeopathy in Amer­i­ca: The Rise and Fall of a Medical Heresy (Baltimore: Johns Hopkins University Press, 1971), 110–124; K. Patrick Ober, Mark Twain and Medicine: “Any Mummery W ­ ill Cure” (Columbia: University of Missouri Press, 2003), 191, 195. 18. Elbert Hubbard, “Heart to Heart Talks with Philistines by the Pastor of the Flock,” Philistine 35:3 (August 1912), 135; Bruce A. White, Elbert Hubbard’s The Philistine, 1895–1915: A Major American “­Little Magazine” (Lanham, MD: University Press of Amer­i­ca, 1989), 2–22, 48–49, 142–43; “A Writer Who Made Amer­i­ca Think,” Current Opinion (April 1, 1923), 419–421. 19. Elbert Hubbard, “Heart to Heart Talks,” Philistine 226:4 (March 1908), 102–103; aphorism from the Philistine 37:2 (July 1913), n.p.; Victor Robinson, “Elbert Hubbard and Quackery,” MRR 22:5 (May 1916), 328; Hubbard, “Clara Barton,” in The Elect: Selected Writings of Elbert Hubbard, vol. 5 (New York: William H. Wise, 1922), 326–328. 2 0. “Hubbard Just Pardoned: President Restored Citizenship to Give Passport for Trip,” NYT, May 9, 1915. 21. “Editorial Comments—­‘Allopathic Czar Parties,’ ” Medical News 62:14 (April 8, 1893), 388; Reginald H. Fitz, “The Legislative Control of Medical Practice,” BMSJ 131:1 (July 5, 28, 1894), 2; Richard C. Flower, The Allopathic Czar (Boston: Mas­sa­chu­setts Medical Liberty League, 1888), 11, 14, 15, 19–21, 22, 24, 32–33; Jacob Bigelow, “On Self-­Limited Diseases,” in Modern Inquiries: Classical, Professional, and Miscellaneous (Boston: L ­ ittle, Brown, 1867), 143. 22. Nellie Bly, “Nellie Bly’s Doctors—­Seven Well-­K nown Physicians Disagree about Her Case!,” New York World, October 27, 1889, 13; Brooke Kroeger, Nellie Bly: Daredevil, Reporter, Feminist (New York: Random House, 1994), 136, 187, 558. 23. George Bernard Shaw, “Preface on Doctors,” in The Doctor’s Dilemma (Baltimore: Penguin Books, 1954), 20–21, 25. 2 4. Ibid., 53, 65–66. 25. Henry Baird Favill, “The Public and the Medical Profession, a Square Deal,” Pennsylvania Medical Journal, November 1915, reprinted in John Favill, ed., Henry Baird Favill, 1860–1916: Life, Tributes, Writings (Chicago: privately printed, 1917), 419–420. 26. James Peter Warbasse, The Doctor and the Public: A Study of the Sociology, Economics, Ethics, and Philosophy of Medicine, Based on Medical History (New York: Harper and ­Brothers, 1935), 295; Warbasse, Medical Sociology: A Series of Observations Touching upon the Sociology of Health and the Relations of Medicine to Society (New York: D. Appleton, 1910); “Bernard Shaw on Physicians: Socialistic Criticism of the Profession,” JAMA 52:10 (March 6, 1909), 783–784. 27. Shaw, “Preface on Doctors,” 15, 29; John H. Musser, “Some Aspects of Medical Education: President’s Address at the Fifty-­Fifth Annual Session of the American Medical Association,” JAMA 42:24 (June 11, 1904), 1533; William Osler, “On the Educational Value of the Medical Society,” in Aequanimitas: Addresses to Medical Students, Nurses and Prac­ti­tion­ers of Medicine (Philadelphia: P. Blakiston’s Son, 1904), 352. 28. D. W. Cathell, Book on the Physician Himself and Th ­ ings That Concern His Reputation and Success (Philadelphia: F. A. Davis, 1890), 31, 55, 56; J. J. Taylor, The Physician as Businessman: How to Obtain the Best Financial Results in the Practice of Medicine (Philadelphia: Medical World, 1891), 20; Joseph McDowell Mathews, How to Succeed in the Practice of Medicine (Philadelphia: W. B. Saunders, 1905), 64. 29. Ibid., 193, 217, 220. 30. Robinson, “Elbert Hubbard and Quackery,” 329; T. J. Happel, “The Importance of Medical Organ­ization in Securing and Enforcing Medical Laws,” JAMA 42:3 (January 16, 1904), 139.

482

notes to pages 33–41

31. Flower, Allopathic Czar, 11–15, 19–24, 32–33; H. G. Hayes and C. J. Hayes, A Complete History of the Trial of Guiteau, Assassin of President Garfield (Philadelphia: Hubbard B ­ rothers, 1882), 27; H. H. Alexander, The Life of Guiteau and the Official History of the Trial of Guiteau (Philadelphia: National, 1882), 579, 658, 828. 32. “The Pro­gress Made Yesterday,” NYT, September 9, 1881; “Dr. Bliss Explains the Case,” NYT, September 13, 1881; “Medical Ser­vice Claims,” NYT, July 4, 1882; Philo G. Valentine, “Poison Working in the Medical Profession,” St. Louis Clinical Review 4:12 (February 15, 1882), 461; Ira Rutkow, James A. Garfield (New York: Henry Holt, 2006), 134–135; George F. Shrady, “The End at Last,” Medical Rec­ord 20 (1881), 350. 33. Norman Barnesby, Medical Chaos and Crime (New York: Mitchell Kennerley, 1910), 174–191, 299. 34. “Doctors Denounced: Hot Shots Poured into the Ranks of the Medical Profession by a New York Practitioner,” NYT, January 21, 1911; Barnesby, Medical Chaos and Crime, 9–10. 35. Barnesby, Medical Chaos and Crime, 299; Joseph N. McCormack et al., “Preliminary Report of the Committee on Organ­ization,” JAMA 36:21 (May 25, 1901), 1441. 36. Quotes in this and the following paragraphs are from McCormack et al., “Preliminary Report,” 1436–1445.

C H A P T E R   2 . O R G A N ­I Z I N G F O R O R D E R

1. Joseph N. McCormack, “­Things about Doctors Which Doctors and Other ­People O ­ ught to Know,” JMSMS 6:1 (January 1907), 31. 2. T. J. Happel, “The Importance of Medical Organ­ization in Securing and Enforcing Medical Laws,” JAMA 42:3 (January 16, 1904), 139–142; Joseph N. McCormack, “The Practical Object of Organ­ization,” JAMA 42:2 (May 21, 1904), 1360. 3. Morris Fishbein, A History of the American Medical Association from 1847 to 1947 (Philadelphia: W. B. Saunders, 1947), 683–684; James G. Burrow, AMA: Voice of American Medicine (Baltimore: Johns Hopkins University Press, 1963), 59; “American Medical Association 1900: President-­Elect C.A.L. Reed,” Medical Mirror 11:7 (July 1900), 340–341. 4. “Dr. G. H. Simmons Is Chosen,” Chicago Daily Tribune, February 18, 1899; “G. H. Simmons, Retired Medical Director, 85, Dies,” NYHT, September 2, 1937; Thomas N. Bonner, “A Forgotten Figure in Chicago’s Medical History,” Journal of the Illinois State Historical Society 45:3 (Autumn 1952), 212–219. 5. “Sociology and Medicine,” and “Individual Liberty and the Public Welfare,” JAMA 56:15 (April 15, 1911), 1100–1112. 6. “A Few More Opinions,” CJM 1:5 (May 1896), 251; P. Maxwell Foshay, “The Organ­ization of the Medical Profession,” Forum 32:2 (October 1901), 166–168; Foshay, “The New Era in Medicine: What It Means to Cleveland,” JAMA 38:10 (March 1902), 627; “Cleveland Journal of Medicine,” CJM 1:1 (January 1896), 23; Foshay, “Medical Ethics and Medical Journals,” JAMA 34:17 (April 28, 1900), 1041–1043. 7. James G. Burrow, Or­ga­nized Medicine in the Progressive Era: The Move ­toward Mono­poly (Baltimore: Johns Hopkins University Press, 1977), 16–28; Burrow, AMA, 36–44; “Dr. John [sic] Nathaniel McCormack, 1847–1922,” AJPH 12:7 (July 1922), 619; “Death of Dr. J. N. McCormack,” Optical Journal and Review 49:19 (May 11, 1922), 50. 8. Arthur Thomas McCormack, “Some Personal Sketches,” KMJ 21 (January 1923), 22. 9. “Dr. John [sic] Nathaniel McCormack,” 619; “Sanitation in Sleeping Cars,” NYT, October 29, 1903; A. T. McCormack, “Some Personal Sketches,” 2; “McCormack, Joseph Nathaniel,” in John E. Kleber, ed., The Kentucky Encyclopedia (Lexington: University Press of Kentucky, 1992), 592.



notes to pages 42–50

483

10. “Dr. John [sic] Nathaniel McCormack,” 619; A. T. McCormack, “Some Personal Sketches,” 22; “Conference of Health Officials,” NYT, July 27, 1884; “Smallpox in Kentucky,” NYT, January 29, 1900; “Wide Smallpox Epidemic,” NYT, February 5, 1900; “Statement of Dr. W. W. Richmond,” KMJ 10:2 (February 15, 1912), 166. 11. Joseph N. McCormack et al., “Preliminary Report of the Committee on Organ­ization,” JAMA 36:21 (May 25, 1901), 1435–1451. 12. Joseph N. McCormack, “Organ­ization and Its Advantages to the Individual Doctor,” TSJM 1:7 (January 1906), 225–229; “Dr. J. N. McCormack’s Ser­vices throughout the United States,” KMJ 21:1 (January 1923), 36–39, 44, 47–48; “Statement of Dr. L. S. McMurtry,” KMJ 10:2 (February 15, 1912), 160; “The Organ­ization of the Medical Profession,” Northwest Medicine 3 (October 1905), 296; “Dr. J. N. McCormack’s Ser­vices throughout the United States,” KMJ 21:1 (January 1923), 39; Burrow, Or­ga­nized Medicine, 23, 177. 13. Joseph N. McCormack, “Dissensions and Their Remedy,” Journal of Medicine and Science 10:9 (August 1904), 301; Joseph N. McCormack, “About the Discord Still Existing in Some County Socie­ties,” KMJ 14:6 (June 1, 1916), 292; J. N. McCormack, “Organ­ization and Its Advantages,” 227. 1 4. J. N. McCormack, “Organ­ization and Its Advantages,” 225–226; J. N. McCormack, “About the Discord,” 292; J. N. McCormack, “Dissensions,” 301; Joseph N. McCormack, “Medical Organ­ization, Methods and Benefits,” JAMA 41:9 (August 29, 1903), 569; J. N. McCormack et al., “Preliminary Report,” 1449. 15. Clyde L. Cummer, “Medical Socie­ties in Cleveland from 1890 to 1945,” Ohio Archaeological and Historical Quarterly 57:4 (October 1948), 350–354; “Official Proceedings of the Cleveland Medical Society,” CJM 6:1 (January 1901), 47; “Cleveland Medical Society,” Eclectic Medical Journal 55:9 (September 1895), 526; “Cleveland Journal of Medicine,” CJM 1:1 (January 1896), 21–23. 16. John Harley Warner, “The 1880s Rebellion against the AMA Code of Ethics: ‘Scientific Democracy’ and the Dissolution of Orthodoxy,” in Robert Baker et al., eds., The American Medical Ethics Revolution (Baltimore: Johns Hopkins University Press, 1999), 62–63. 17. Fishbein, History of the American Medical Association, 712–716. 18. Ibid., 688–691. 19. Robert V. Gibbons, “Germs, Dr. Billings, and the Theory of Focal Infection,” Clinical Infectious Diseases 27:3 (September 27, 1998), 627–633; Frank Billings, “The Limitations of Medicine: Address Delivered at the Opening Exercises of Rush Medical College,” JAMA 31 (October 22, 1989), 951–955; Billings, “Medical Education in the United States,” JAMA 40:19 (May 9, 1903), 1271–1273. 20. Billings, “Limitations of Medicine,” 951. 21. “Death of Billings,” Time, October 3, 1932. 22. “Deaths: Abraham Jacobi,” JAMA 73:3 (July 19, 1919), 211; Warner, “1880s Rebellion against the AMA Code of Ethics,” 62–63. 23. Russell Viner, “Abraham Jacobi and German Medical Radicalism in Antebellum New York,” BHM 72:3 (Fall 1998), 434–463; Abraham Jacobi, “Address Delivered on German Day at the Tuberculosis Exhibition,” in William J. Robinson, ed., Collectanea Jacobi, Volume VII: Miscellaneous Addresses and Writings (New York: Critic and Guide, 1909), 616; “Physicians Or­ga­nize to Study Social Prob­lems: Doctors Jacobi and Robinson at Head of Society with Radical Programme,” NYT, November 13, 1910. 2 4. Fishbein, History of the American Medical Association, 744–747; “Discussion: Alexander Lambert,” Proceedings of the Conference on Social Insurance (Washington, DC: U.S. Department of ­L abor, Bureau of L ­ abor Statistics, 1917), 726–727. 25. Kevin Stoker and Brad L. Rawlins, “The ‘Light of Publicity’ in the Progressive Era,” Journalism History 30:4 (Winter 2005), 177; J. N. McCormack, “Practical Object of Organ­ization,”

484

notes to pages 50–57

1360; Erastus Brooks, “Public Health is Public Wealth: What the State Owes the ­People,” The Sanitarian 9:94 (January 1881), 15. 26. “Dr. J. N. McCormack’s Ser­vices,” 44–45; “Report of the Council on Health and Public Instruction,” JAMA 57:1 (July 1, 1911), 63. 27. J. N. McCormack, “­Things about Doctors,” 34, 36; Joseph N. McCormack, “The New Gospel of Health and Long Life,” reprinted in KMJ 21:1 (January 1923), 26. 28. J. N. McCormack, “­Things about Doctors,” 31; J. N. McCormack, “New Gospel,” 7; “Physicians Ask Aid,” Indianapolis Star, October 8, 1907; “Wants Federal Bureau,” Baltimore Sun, December 9, 1907; “Bryan F ­ avors Health Plank,” Louisville Courier-­Journal, July 4, 1908. 29. J. N. McCormack, “­Things about Doctors,” 31; “McCormack in V ­ irginia,” 1281; “Babies Killed by Milk” NYT, February 13, 1907; “Dr. McCormack in Mississippi,” JAMA 50:18 (May 2, 1908), 1446. 30. Foshay, “New Era in Medicine,” 626; “Comment on ‘Mr. Bok’s Article—­a Criticism,’ ” JAMA 50:14 (April 4, 1908), 1139. 31. Charles A. L. Reed, “Report of the Committee on Medical Legislation—­Bureau of Publicity,” JAMA 54:24 (June 11, 1910), 1972, 1974; “Dr. General Public Called in Consultation with the American Medical Association,” Chicago Daily Tribune, February 27, 1910. 32. Arthur D. Bevan, “Report of the Council on Medical Education,” JAMA 46:24 (June 16, 1906), 1853, 1855; Ely Van de Warker, “The Fetich [sic] of the Ovary,” American Journal of Obstetrics and Diseases of ­Women and ­Children 54 (July–­December 1906), 373. 33. “A ‘Campaign of Education,’ ” TMJ 15:12 (June 1900), 638; H. A. West, “Maladministration of Public Medical Affairs in the State of Texas,” TMJ 15:11 (May 1900), 562; T. G. Atkinson, “Medical Education through the Lay Press,” MS 32:4 (April 1909), 185; Ralph Elmergreen, “The Medical Mountebank,” Transactions of the State Medical Society of Wisconsin 36 (1902), 190– 191. 34. Fishbein, History of the American Medical Association, 251, 267–268. 35. “Bureau on Public Instruction,” JAMA 57:1 (July 1, 1911), 64; William L. Rodman, “The Work of the American Medical Association,” International Rec­ord of Medicine and General Practice Clinics 101:26 (June 26, 1915), 1302. 36. J. N. McCormack, “­Great Work Being Done in Texas,” 1134; “The Public Health Movement in Kentucky,” AMAB 5:2 (November 15, 1909), 182–186; Willie Nelms, Cora Wilson Stewart: Crusader against Illiteracy (Jefferson, NC: McFarland, 1997), 47–50; Valerie Summers and Gordon Tobin, “J. N. McCormack, His Allies and the Public Health Legacy of Kentucky,” Journal of the Kentucky Medical Association 109:11 (November 2011), 304–308. 37. Fishbein, History of the American Medical Association, 251, 263, 267–268, 273, 333, 998, 999, 1022. 38. “Report of the Council on Health and Public Instruction,” JAMA 57:1 (July  1, 1911), 67; Rosalie Slaughter Morton, A ­Woman Surgeon (New York: Frederick A. Stokes, 1937), 165–176. 39. Ronald L. Numbers, “Public Protection and Self-­Interest: Medical Socie­ties in Wisconsin,” in Ronald L. Numbers and Judith Walzer Leavitt, eds., Wisconsin Medicine: Historical Perspectives (Madison: University of Wisconsin Press, 1981), 90–91; Burrow, AMA, 49; Abraham Jacobi, “Address Delivered at the Complimentary Dinner Tendered to Dr. Jacobi, May 5, 1900,” in Jacobi, Miscellaneous Addresses and Writings (New York: Critic and Guide, 1909), 440; Charles A. L. Reed, “The Twentieth ­Century Surgeon,” Railway Surgeon 8 (October 1902), 129; Foshay, “New Era in Medicine,” 672. 40. “Our Monthly Talk,” MW 28:2 (February 1910), 88; D. W. Cathell, Book on the Physician Himself from Graduation to Old Age (Philadelphia: F. A. Davis, 1922), 45, 77–79. 4 1. “President Taft’s Message to Physicians,” JAMA 56:19 (May 13, 1911), 1393–1394. 42. Burrow, AMA, 58; J. N. McCormack, “About the Discord,” 292.



notes to pages 62–67

485

CHAPTER 3. THER APEUTIC CHAOS AND COMMERCIAL CONQUEST

1. Oliver Wendell Holmes, “The Medical Profession in Mas­sa­chu­setts,” in Medical Essays, 1842– 1882 (Boston: Riverside, 1891), 313; George H. Simmons, “Proprietary Medicines: Some General Considerations,” JAMA 46:18 (May  5, 1906), 1336, 1337; “Our Duty Regarding Patent-­Medicine Legislation,” JAMA 46:9 (March 3, 1906), 659; Simmons, “The Commercial Domination of Therapeutics and the Movement for Reform,” JAMA 48:20 (May 18, 1907), 1645, 1646; Simmons, “Promoting Nostrums among Medical Students,” JAMA 50:19 (May 9, 1908), 1530. 2. Samuel Hopkins Adams, The G ­ reat American Fraud: Articles on the Nostrum Evil and Quacks Reprinted from Collier’s Weekly (Chicago: American Medical Association, 1905), 3; Mark ­Sullivan, “The Patent Medicine Conspiracy against Freedom of the Press,” Collier’s, November 4, 1905. 3. James G. Burrow, AMA: Voice of American Medicine (Baltimore: Johns Hopkins University Press, 1963), 70; James Harvey Young, “From Hooper to Hohensee: Some Highlights of American Patent Medicine Promotion,” JAMA 204:1 (April 1, 1968), 3; Donna J. Wood, Strategic Uses of Public Policy: Business and Government in the Progressive Era (Marshfield, MA: Pitman, 1985), 214–215; “Boston Medical Library Meeting,” JAMA 46:3 (January 20, 1906), 218; U.S. House of Representatives, Committee on Interstate and Foreign Commerce, The Pure Food and Drugs Act, Part II (Washington, DC: U.S. Government Printing Office, 1912), 174; James Harvey Young, Pure Food: Securing the Federal Food and Drugs Act of 1906 (Prince­ton, NJ: Prince­ton University Press, 1989), 258. 4. F. E. Stewart, “A Proposed Board of Control of Materia Medica Standards,” Phar­ma­ceu­ti­cal Era 45 (October 1912), 665; flower advertisement in Fact: A Monthly Magazine Devoted to ­Mental and Spiritual Phenomena 6:1 (January 1887), 16; Joseph N. McCormack, “­Things about Doctors Which Doctors and Other P ­ eople O ­ ught to Know,” JMSMS 6:1 (January 1907), 36–37; “Dr. Flower Again Held as Swindler,” NYT, November 24, 1907; “Dr. R. C. Flower, $1,000,000 Crook Dies in Theatre,” New York Eve­ning World, October 5, 1916; Laurence Yadon and Robert Barr Smith, Old West Swindlers (New Orleans: Pelican, 2011), 235–246. 5. Frank Billings, “The Medical Profession and the Medical Journals in Relation to Nostrums,” BMSJ 154:9 (March 1, 1906), 232; “Doctor McCormack’s Address,” Bulletin of Pharmacy 21:10 (October 1907), 420. 6. “Tongaline,” JAMA 60:19 (May 10, 1913), 1478; W. C. Wescott, “The Special Package Evil,” JAMA 60:5 (February 1, 1913), 387; Adams, G ­ reat American Fraud, 68. 7. Billings, “Medical Profession and the Medical Journals,” 232; “Tongaline,” 1477; “The Story of Tongaline,” Western Medical Review 7:1 (January 15, 1902), 30. 8. Vibul V. Vadakan, “The Asphyxiating and Exsanguinating Death of President George Washington,” Permanente Journal 8:2 (Spring 2004), 76–79. 9. John Harley Warner, The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in Amer­i­ca, 1820–1885 (Prince­ton, NJ: Prince­ton University Press, 1997), 117–121; Norbert Hirschhorn, Robert G. Feldman, and Ian Greaves, “Abraham Lincoln’s Blue Pills: Did Our 16th President Suffer from Mercury Poisoning?,” Perspectives in Biology and Medicine 44:3 (Summer 2001), 315–312; Joshua Wolf Shenk, Lincoln’s Melancholy: How Depression Challenged a President and Fueled His Greatness (Boston: Houghton Mifflin 2005), 57–62. 10. William G. Rothstein, American Physicians in the Nineteenth ­Century: From Sects to Science (Baltimore: Johns Hopkins University Press, 1972), 125–197, 217–246. 11. James Harvey Young, The Toadstool Millionaires: A Social History of Patent Medicines in Amer­ i­ca (Prince­ton, NJ: Prince­ton University Press, 1961), 45–48; John S. Haller Jr., The ­People’s

486

notes to pages 68–74

Doctors: Samuel Thomson and the American Botanical Movement, 1790–1860 (Carbondale: Southern Illinois University Press, 2000). 12. Susan E. Cayleff, Wash and Be Healed: The Water-­Cure Movement and W ­ omen’s Health (Philadelphia: T ­ emple University Press, 1987), 53, 133, 139; Erika Janik, Marketplace of the Marvelous: The Strange Origins of Modern Medicine (New York: Beacon Press, 2014), 92–104. 13. On homeopathy and its reception in the United States, see Rothstein, American Physicians, 152–170; Harris L. Coulter, Divided Legacy: The Conflict between Homoeopathy and the American Medical Association (Richmond, CA: North Atlantic Books, 1973), 1–236. 1 4. Oliver Wendell Holmes Sr., Homoeopathy and Its Kindred Delusions: Two Lectures Delivered before the Boston Society for Useful Knowledge (Boston: Ticknor, 1842); Milton Shutes, Lincoln and the Doctors: A Medical Narrative of the Life of Abraham Lincoln (New York: Pioneer Press, 1933), 94; Allen D. Spiegel and Florence Kavaler, “The Role of Abraham Lincoln in Securing a Charter for a Homeopathic Medical College,” Journal of Community Health 5 (October 2002), 357–380. 15. K. Patrick Ober, Mark Twain and Medicine: “Any Mummery ­Will Cure” (Columbia: University of Missouri Press, 2003), 191, 195. 16. John Harley Warner, Against the Spirit of System: The French Impulse in Nineteenth-­Century American Medicine (Baltimore: Johns Hopkins University Press, 2003); Oliver Wendell Holmes, “Currents and Counter-­Currents in Medical Science,” in Medical Essays, 1842–1882, 203; Warner, Therapeutic Perspective, 33. 17. Warner, Therapeutic Perspective, 235–257; “Therapeutic Pessimism,” JAMA 35:8 (August 25, 1900), 503; James Harvey Young, “Drugs and the 1906 Law,” in John B. Blake, ed., Safeguarding the Public: Historical Aspects of Medicinal Drug Control (Baltimore: Johns Hopkins University Press, 1970), 150. 18. Arthur T. McCormack, “Some Personal Sketches,” KMJ 21 (January 1923), 22; Joseph N. McCormack, “The New Gospel of Health and Long Life,” reprinted in KMJ 21:1 (January 1923), 28. 19. Holmes, “Currents and Counter-­Currents,” 177, 193. 20. Edward Kremers and George Urdang, History of Pharmacy, 3rd ed., rev. by Glenn Sonnedecker (Philadelphia: J.  B. Lippincott, 1963), 232–240; The Pharmacopoeia of the United States of Amer­ic­ a: Eighth Decennial Revision (Philadelphia: Blakiston Sons, 1905), xlv. 21. “Membership of the Proprietary Association of Amer­i­ca,” JAMA (November 18, 1905), 1589– 1592; Proceedings of the National Wholesale Druggists Association (Chicago: March and Grant, 1900), 400–424; U.S. House of Representatives, Pure Food and Drugs Act, Part II, 235, 238, 241–242, 332. 22. Simmons, “Proprietary Medicines,”1335; Frank Billings, “The Secret Nostrum Evil,” JAMA 45:23 (December 2, 1905), 1702; “Phar­ma­ceu­ti­cal Manufacturers and the ­Great American Fraud: How Phar­ma­ceu­ti­cal Houses Aid and Abet the Nostrum Evil,” JAMA 55:1 (July 2, 1910), 40. 23. Holmes, “Currents and Counter-­Currents,” 186. 2 4. “Boston Medical Library Meeting,” 220; Billings, “Secret Nostrum Evil,” 1704; Charles Spencer Williamson, “The Attitude of the Physician t­oward the Nostrum Evil,” IMJ 10:2 (August 1906), 166–167; Daniel R. Brower, “A Protest against the Use of Proprietary Remedies,” JAMA 36:9 (March 2, 1901), 558; Abraham Jacobi, “Proprietary Medicines,” JAMA 47:13 (September 29, 1906), 978; “Symposium on Nostrums and Nostrum Prescribing,” JAMA 50:18 (May 2, 1908), 1454; George Blumer, “The Need of Reor­ga­ni­za­tion in the Methods and Teaching of Therapeutics,” BMSJ 169:8 (August 21, 1913), 263. 25. “Symposium on Nostrums,” 1454; Jacobi, “Proprietary Medicines,” 978; Henry P. Hynson, “Nostrums and Proprietaries versus U.S. Pharmacopoeia and National Formulary Preparations,” JAMA 48:15 (April 13, 1907), 1244; “Boston Medical Library Meeting,” 220; Billings, “Secret Nostrum Evil,” 1704.



notes to pages 74–80

487

26. “The Medical Profession as an Economic F ­ actor,” MW 20:3 (March 1902), 126–127; C. F. Wahrer, “Responsibility of the Medical Profession for the Use of Nostrums,” Transactions of the Section on Pharmacology and Therapeutics (Chicago: AMA, 1908), 204; D. Bryson Delavan, “The Use and Abuse of Cocaine,” JAMA 23:12 (September 22, 1894), 452; “The Cocaine Question,” JAMA 40:11 (March 14, 1903), 719. 27. “Symposium on the Prescribing of Nostrums,” JAMA 49:25 (December 21, 1907), 2114; Richard Clarke Cabot, “The Physician’s Responsibility for the Nostrum Evil,” JAMA 42:13 (September 29, 1906), 982; Edward Bok, “My ‘Attack’ on Doctors,” JAMA 50:12 (March 21, 1908), 959. 28. “Symposium on the Prescribing of Nostrums,” 2115; Edward Bok, “The Physician and the Nostrum,” JAMA 48:8 (February 23, 1907), 690; Bok, “My ‘Attack,’ ” 959. 29. William J. Robinson, “The Relation of the Physician to Proprietary Remedies,” JAMA 43:23 (December 3, 1904), 1678; William Osler, “Chauvinism in Medicine,” in Aequanimitas: With Other Addresses to Medical Students, Nurses and Prac­ti­tion­ers of Medicine, 2nd ed. (Philadelphia: P. Blakiston’s Son, 1906), 301; John B. Roberts, The Doctor’s Duty to the State: Essays on the Public Relations of Physicians (Chicago: American Medical Association, 1908), 20; N. H. Graves, “Amenoretts,” JAMA 46:12 (March 24, 1906), 898; N. S. Davis, “Effect of Proprietary Lit­er­a­ture on Medical Men,” JAMA 46:18 (May 5, 1906), 1339; Jacobi, “Proprietary Medicines,” 978. 30. Code of Ethics of the American Medical Association (Philadelphia: Turner Hamilton, 1871); Torald Sollman, “Relations of Pharmacy to the Medical Profession: I,” JAMA 34:16 (April 21, 1900), 987; Churchill Williams, “The Edge of Circumstance,” Appleton’s Magazine 10:6 (December 1907), 780–789; Martin I. Wilbert, “Materia Medica and Pharmacy in Hospital Practice,” JAMA 49:20 (November 16, 1907), 1660. 31. “Boston Medical Library Meeting,” 220; “Symposium on Nostrums and Nostrum Prescribing,” JAMA 50:18 (May 2, 1908), 1454; Simmons,” Commercial Domination,” 1647; Simmons, “Proprietary Medicines,” 1336; Albert V. Harmon, Large Fees and How to Get Them: A Book for the Private Use of Physicians (Chicago: W. J. Jackman, 1911), 184. 32. Jacobi, “Proprietary Medicines,” 978; Robinson, “Relation of the Physician,” 1677; Joseph N. McCormack, “Let Us Have Peace,” Bulletin of Pharmacy 21:10 (October 1907), 422; Torald Sollman, “The Broader Aims of the Council on Pharmacy and Chemistry, Part XVIII,” JAMA 51:4 (July 25, 1908), 330; P. Henry Utech, “The Pressing Need for Propaganda Work,” N.A.R.D. Notes 10:9 (June 2, 1910), 542. 33. “Boston Medical Library Meeting,” 220; Cabot Lull, “Physicians, Proprietary Preparations and the Detail Man,” JAMA 54:6 (February 5, 1910), 482; Jacobi, “Proprietary Medicines,” 978; Torald Sollman, “Relations of Pharmacy to the Medical Profession: VII,” JAMA 35:1 (July 7, 1900), 27; Billings, “Secret Nostrum Evil,” 1704; Adolph Koenig, “The Relation of the Physician to Proprietary Remedies,” JAMA 43:23 (December 3, 1904), 1679; Daniel R. Brower, “A Protest against the Use of Proprietary Remedies,” JAMA 36:9 (March 2, 1901), 559. 3 4. Nathan S. Davis, “Effect of Proprietary Lit­er­a­t ure on Medical Men,” JAMA 46:18 (May 5, 1906), 1339; J. C. Culbertson, “Drug Manufacturers as Medical Teachers,” JAMA 18:18 (April 30, 1892), 563; Blumer, “Need of Reor­ga­ni­za­tion,” 263; Osler, “Chauvinism in Medicine,” 301. 35. “Dr. Jacobi Refuses to Endorse Promoter of Unethical Advertising,” JAMA 53:23 (December 4, 1909), 1931; Blumer, “Need of Reor­ga­ni­za­tion,” 264; Leartus Connor, “The American Medical Journal of the ­Future as Indicated by the History of American Medical Journals in the Past,” Gaillard’s Medicine Journal 38:1 (July 1884), 106–107; Abraham Jacobi, “Medicine and Medicine Men in the United States (Part I),” JAMA 35:7 (August 18, 1900), 430; Billings, “Medical Profession and Medical Journals,” 234. 36. Simmons, “Commercial Domination,” 1645; J. H. Salisbury, “The Subordination of Medical Journals to Proprietary Interests,” JAMA 46:18 (May 5, 1906), 1337–1338; “Canned Editorials,”

488

notes to pages 80–85

JAMA (May 19, 1906), 1541; “Subsidized Medical Journals: Canned Editorials,” JAMA 46:21 (May 26, 1906), 1627. 37. A. E. Conter, “Encouragement of the Nostrum Evil by ‘Reputable’ Physicians,” JAMA 56:10 (March 10, 1911), 761; Jacobi, “Proprietary Medicines,” 978; “Dr. Jacobi Refuses to Endorse Promoter,” 1931. 38. “Philadelphia County Medical Society,” JAMA 46:3 (January 20, 1906), 219; James Hendrie Lloyd, “The Demise of the Philadelphia Medical Journal,” JAMA 40:25 (June 20, 1903), 1734– 1735; “Boston Medical Library Meeting,” 221; Frank R. Kellerman, Introduction to Health Sciences Librarianship (Westport, CT: Greenwood Press, 1997), 51. 39. Samuel Hopkins Adams, “Medical Support of Nostrums,” MMJ 49:2 (February 1906), 64; CSJM 4:3 (March 1906), 96–98; Bok, “Physician and the Nostrum,” 689. 40. Simmons, “Promoting Nostrums among Medical Students,” 1530; “The Propaganda for Reform: Pineoleum Advertising Methods,” JAMA 73:18 (November 1, 1919), 1380; Ernst Boas, “Polluting the Stream at Its Source,” JAMA 57:25 (June 20, 1914), 1980. 4 1. Wahrer, “Responsibility of the Medical Profession,” 202; Sollman, “Relations of Pharmacy to the Medical Profession: VII,” 28; Billings, “Medical Profession and the Medical Journals,” 231. 42. Oliver Osborn, in Robinson, “Relation of the Physician,” 1679; Blumer, “Need of Reor­ga­ni­ za­tion,” 263; Billings, “Secret Nostrum Evil,” 1703; Charles Spencer Williamson, “The Responsibility of the Medical Teacher for Existing Conditions,” JAMA 46:18 (May 5, 1906), 1343; Sollman, “Relations of Pharmacy to the Medical Profession: I,” 988. 43. Osborn, in Robinson, “Relation of the Physician,” 1679; Sollman, “Relations of Pharmacy to the Medical Profession: I,” 988; Wilbert, “Materia Medica and Pharmacy,” 1659. 4 4. Henry R. Strong, Machinations of the American Medical Association: An Exposure and a Warning (St. Louis: National Druggist, 1909), 28, 37. 45. Starr, Social Transformation, 8–9, 24, 232.

CHAPTER 4. HE AL THYSELF

1. George H. Simmons, “Proprietary Medicines: Some General Considerations,” JAMA 46:18 (May 5, 1906), 1333. 2. Instead of advantageous se­lection, most economists would say that in information-­poor competitive environments, markets sink into a suboptimal, low-­value equilibrium. In a sense, competition can lead to the bad driving out the good, or at least coexisting with the good. When buyers lack good information about the products or ser­vices available, sellers find the market to be a lax disciplinarian. In efficient markets, where quality information is plentiful, prices tend to fall, and quality tends to rise. Higher prices signal higher quality to the consumer. Improved information ­causes demand, output, and employment to rise in markets for higher-­ value goods and ser­vices. With adverse se­lection, intense competition drives prices downward, quality is attenuated to reduce costs, and the value to consumers—­the general welfare—­suffers. See Kenneth J. Arrow, “Uncertainty and the Welfare Economics of Medical Care,” American Economic Review 53:5 (December 1963); George A. Akerlof, “The Market for ‘Lemons’: Quality Uncertainty and the Market Mechanism,” Quarterly Journal of Economics 84:3 (August 1970); Joseph E. Stiglitz, “Information and the Change in the Paradigm in Economics,” American Economic Review 92:3 (June 2002). ­Free market economists dismiss or downplay adverse se­ lection in medical as well as other markets and see only monetary costs to consumers in quality regulation, including medical licensing and drug controls. See Milton Friedman, Capitalism and Freedom (Chicago: University of Chicago Press, 1962), 152, 153, 158; George Stigler, “The Theory of Economic Regulation,” Bell Journal of Economics and Management Science 2:1 (Spring



notes to pages 86–93

489

1971); Dale H. Gieringer and Sam Peltzman, “The Benefits and Costs of New Drug Regulation,” in Richard L. Landau, ed., Regulating New Drugs (Chicago: University of Chicago Press, 1973), 114–211. 3. George H. Simmons, “The Commercial Domination of Therapeutics and the Movement for Reform,” JAMA 48:20 (May 18, 1907), 1649; William J. Robinson, “The Relation of the Physician to Proprietary Remedies,” JAMA 43:23 (December 3, 1904), 1677. 4. A. E. Conter, “Encouragement of the Nostrum Evil by ‘Reputable’ Physicians,” JAMA 56:10 (March 10, 1911), 761; Blumer, “Need of Reor­ga­ni­za­tion,” 263; W. K. McCoy, “Nostrums and Advertising,” JAMA 47:14 (October 6, 1906), 1117. 5. Torald Sollman, “Relations of Pharmacy to the Medical Profession: IV,” JAMA 34:19 (May 12, 1900), 1178; “Cheapness in Pharmacy,” JAMA 51:7 (August 15, 1908), 614; A. L. Benedict, “The Relation of Physicians to Dentists and Pharmacists,” BAAM 6:15 (December 1904), 849–850; Joseph N. McCormack, “­Things about Doctors Which Doctors and Other ­People O ­ ught to Know,” JMSMS 6:1 (January 1907), 36; Richard C. Cabot, “The Physician’s Responsibility for the Nostrum Evil,” JAMA 47:13 (September 29, 1906), 982. 6. J. C. Culbertson, “Drug Manufacturers as Medical Teachers,” JAMA 18:18 (April 30, 1892), 563. 7. Torald Sollmann, “The Broader Aims of the Council on Pharmacy and Chemistry: Part I,” JAMA 50:13 (March 21, 1908), 1054. 8. F. E. Stewart, “The Standardization of Materia Medica Products,” Monthly Cyclopaedia and Medical Bulletin 2:6 (June 1909) and 2:7 (July 1909), 335–341, 397–403; Joseph M. Gabriel, “A ­Thing Patented Is a ­Thing Divulged: Francis E. Stewart, George S. Davis, and the Legitimization of Intellectual Property Rights in Phar­ma­ceu­ti­cal Manufacturing, 1879–1911,” JHM 64:2 (April 2009), 135–172; Gabriel, Medical Mono­poly: Intellectual Property Rights and the Origins of the Modern Phar­ma­ceu­ti­cal Industry (Chicago: University of Chicago Press, 2014), 77, 113– 116, 133–139, 233–234; F. E. Stewart, “The ‘Therapeutic Boom’ and Unscientific Advertising,” Medical and Surgical Reporter 43:22 (November 26, 1880), 465–468. 9. Parke-­Davis Com­pany, “To the Medical Profession” [with cover letter submitted by F. E. Stewart], in “The Relation of Pharmacy to Medicine,” College and Clinical Rec­ord 2:4 (April 15, 1881), 95; Parke-­Davis announcement and advertisements in Annals of Anatomy and Surgery 31 (January 1881); Pacific Medical Monthly 2:1 (May 1881); “An Innovation Tending to Establish Therapeutics on a More Scientific Basis: The Hospital Plan,” Therapeutic Gazette 2:7 (July 15, 1881), 269; “A New Scientific Work,” Therapeutic Gazette 3:2 (February 15, 1882), 44–47; F. E. Stewart, An Old System and a New Science (Detroit: George S. Davis, 1882); Stewart, “The Materia Medica of the ­Future,” TAMA 32 (1881) 169. 10. Milton Hoefle, “The Early History of Parke-­Davis and Com­pany,” Bulletin of the History of Chemistry 25:1 (2000), 29–34; John S. Billings and Robert Fletcher, “The Index Medicus,” JAMA 4:13 (March 28, 1885), 364; George S. Davis, “The Passing of Index Medicus,” JAMA 24:24 (June 15, 1895), 944; “The Index Medicus,” JAMA 25:3 (July 20, 1895), 126; “Pharmacy in Medical Socie­ties,” Western Druggist 14:5 (May 1892), 162; “Medicine,” Cleveland Journal of Medicine 1:2 (February 1896), 65. 11. Sigmund Freud, “Über Coca,” Zentralblatt für die gesamte Therapie 2 (1884), 289–314; Robert Byck, ed., Cocaine Papers by Sigmund Freud (New York: Stonehill, 1974), 14–21, 129, 143–144, 326; Joseph F. Spillane, Cocaine: From Medical Marvel to Modern Menace in the United States, 1884–1920 (Baltimore: Johns Hopkins University Press, 2000), 18, 44–57, 68–73; Frederick C. Crews, “Physician, Heal Thyself, Part II,” New York Review of Books (October 13, 2011). 12. Spillane, Cocaine, 181; Gabriel, “­Thing Patented,” 156, 160–161. 13. “A National Bureau of Foods and Medicines,” Phar­ma­ceu­ti­cal Journal 69 (July 19, 1902), 46. 14. F. E. Stewart, “A Proposed Board of Control of Materia Medica Standards,” PharmEra 45 (October 1912), 665–667; Stewart, “Standardization,” 339–340.

490

notes to pages 93–100

15. F. E. Stewart, “The Working Bulletin System, National Pharmacological Association, National Laboratory,” JAMA 17:17 (October 24, 1891), 627. 16. “On Materia Medica and Pharmacy,” JAMA 17:18 (October 31, 1891), 677–678; F. E. Stewart, “Report of Committee on National Bureau of Materia Medica,” Therapeutic Monthly 2:5 (May 1902), 186; “Proposed Bureau of Materia Medica,” JAMA 35:17 (April 27, 1901), 1185; Stewart, “Standardization,” 340. 17. “Philadelphia County Medical Society,” JAMA 46:31 (January 20, 1906), 219. 18. F. E. Stewart, “Proposed National Bureau of Materia Medica,” JAMA 35:17 (April 27, 1901), 1175–1178. 19. “Report of Committee on National Bureau of Materia Medica,” Transactions of the American Therapeutic Society, 1900–1902 (American Therapeutic Society, 1903), 62–66; “Report of Committee on National Bureau of Materia Medica,” Therapeutic Monthly 2:5 (May 1902), 183–189; Stewart, “Proposed National Bureau,” 1175–1178. 20. “A National Bureau of Foods and Medicines,” Phar­ma­ceu­ti­cal Journal 69 (July 19, 1902), 45– 47; F. E. Stewart, “Bibliographic and Chronologic Statement,” American Medicine 1:7 (October 1906), 444; Corporations of New Jersey: A List of Certificates Filed in the Department of State during the Year 1902 (Trenton, NJ: Department of State, 1903), 136; George A. Bender, “Henry Hurd Rusby: Scientific Explorer, Societal Crusader, Scholastic Innovator,” Pharmacy in History 23 (1981), 71–85. 21. Stewart, “Standardization,” 341; “The Graduating Class of the College of Physicians and Surgeons Visits the Laboratories of the National Pharmacy Com­pany,” Pacific Medical Journal 46:11 (November 1903), 669–671. 22. Philip Mills Jones, “National Bureau of Medicines,” ILMJ 5:5 (October 1903), 293; Proceedings of the American Phar­ma­ceu­ti­cal Association (Baltimore: American Phar­ma­ceu­ti­cal Association, 1903), 72–73. 23. Stewart, “Proposed Board of Control,” 665; “National Bureau of Medicines and Foods,” JAMA 40:25 (June 20, 1903), 1736–1738; “Report of the Committee on the Establishment of a National Bureau of Medicine and Foods,” NYSJM 4:7 (July 1904), 236–237; “Second Annual Meeting of American Association of State Medical Journals,” SoPract 27:6 (June 1905), 341. 2 4. “The Convention of the Year,” Bulletin of Pharmacy 17:9 (September 1903), 360; Jones, “National Bureau of Medicines,” 293. 25. “Report of Medicine and Food Bureau Again Referred,” JAMA 42:25 (June 18, 1904), 1640; “Report on Medicine and Food Bureau Not Concurred In,” JAMA 42:25 (June 18, 1904), 1644. 26. “Report of the Council on Dr. Ellis’ Paper,” BAAM 6:14 (October 1904), 826–828. 27. Ibid., 828–829. 28. “Michigan Resolutions Referred,” JAMA 42:24 (June 11, 1904), 1579; “Journal Clearing House Commission,” JAMA 42:24 (June 11, 1904), 1577. 29. Simmons, “Commercial Domination,” 1646; “Discussion of Board of Trustees’ Report,” JAMA 45:4 (July 22, 1905), 276. 30. F. E. Stewart, “The Work of the American Medical Association Chemical Laboratory,” JAMA 67:22 (November 25, 1916), 1596; Morris Fishbein, A History of the American Medical Association, 1847–1947 (Philadelphia: W. B. Saunders, 1947), 867–868. 31. Abraham Jacobi, “Proprietary Medicines,” JAMA 47:13 (September 29, 1906), 978. For other treatments of the CPC and its work, see Harry Marks, The Pro­gress of Experiment: Science and Therapeutic Reform in the United States, 1900 to 1990 (Cambridge: Cambridge University Press, 1997), 23–41, and Eric W. Boyle, Quack Medicine: A History of Combatting Health Fraud in Twentieth-­Century Amer­i­ca (Santa Barbara, CA: Praeger, 2013), 17–89. 32. Torald Sollmann, “The Broader Aims, Part II,” JAMA 50:14 (April 4, 1908), 1134; W. A. Puckner, “The Work of the AMA Chemical Laboratory,” JAMA 79:20 (November 11, 1922), 690– 691.



notes to pages 101–108

491

33. “Report of the Council on Pharmacy and Chemistry,” JAMA 46:12 (March 24, 1906), 896. 3 4. “Report of an Examination of the Diastase Ferments,” JAMA (July 11, 1908), 135; “Phar­ma­ ceu­ti­cal Manufacturers and the G ­ reat American Fraud,” JAMA 55:1 (July 2, 1910), 40. 35. “Phylacogens: A Warning and a Protest,” JAMA 40:5 (February 1, 1913), 373; “This Phylacogen Business,” JAMA 40:5 (February 1, 1913), 384; Franklin McClean, “Death Following the Administration of Phylacogen,” JAMA 40:8 (February 22, 1913), 588. For more on Cramp and his department, see Boyle, Quack Medicine, 61–69. 36. “The ‘Hyoscin-­Morphin-­Cactin’ Anesthesia: An In­ter­est­ing Example of the Subordination of Science to Commercialism,” JAMA 49:25 (December 21, 1907), 2103–2106; Samuel C. Hughes, Gershon Levinson, and Mark A. Rosen, eds., Shnider and Levinson’s Anesthesia for Obstetrics, 4th ed. (Philadelphia: Lippincott Wilkinson and Williams, 2002), 117. 37. “The Abbott Alkaloidal Com­pany: Modern High Finance and Methods of Working the Medical Profession,” JAMA 50:11 (March 14, 1908), 897–899. 38. “Abbott Alkaloidal Com­pany,” 897–900; “Denounce Profit-­Sharing in Nostrums,” PharmEra 39:13 (March 28, 1908), 406; Robert D. B. Carlisle, A C ­ entury of Caring: The Upjohn Story (Elmsford, NY: Benjamin, 1987), 33. 39. “Editorial Notes,” JISMA 1:4 (April 15, 1908), 153; “Concerning the Abbott Alkaloidal Com­ pany,” TSJM 4:6 (October 1908), 159; “Dr. Abbott’s Controversy,” TSJM 4:6 (October 1908), 141–142; “Profit-­Sharing Exploitation,” CSJM 6:4 (April 1908), 113–114. 40. “Unethical Advertising,” TSJM 7:4 (August 1911), 110; “Stick to the Council on Pharmacy and Chemistry,” JMoSMA 10:5 (November 1913), 173; “Lack of Support,” CSJM 9:7 (July 1911), 203. 41. “Report of Board of Trustees: Cooperative Medical Advertising Bureau,” JAMA 76:24 (June 11, 1921), 1658; “Report of Board of Trustees: Cooperative Medical Advertising Bureau,” JAMA 48:23 (June 9, 1917), 1714; “What’s the M ­ atter with Illinois?,” JMoSMA 10:5 (November 1913), 173. 42. Solomon Solis-­Cohen, “Pro­gress in Therapeutics,” Proceedings of the Philadelphia County Medical Society 21:3 (March 1900), 120, 122, 124; Torald Sollmann, “Research Prob­lems of Pharmacology,” JAMA 13:29 (November  28, 1903), 1330, 1332; Sollmann, “Experimental Therapeutics,” JAMA 58:4 (January 27, 1912), 242–244. 43. Torald Sollmann, “The Therapeutic Research Committee of the Council on Pharmacy and Chemistry,” JAMA 62:20 (November 11, 1916), 1439–1442. 4 4. “Do Men Think?” CSJM 10:3 (March 1912), 85. 45. “Special Report on the Work of the Council on Pharmacy and Chemistry,” JAMA 65:1 (July 3, 1915), 67, 70; Austin Smith, “The Council on Pharmacy and Chemistry,” Food Drug Cosmetic Law Quarterly 1 (June 1946), 188–189; “ ‘Citrocarbonate’: A Disclaimer,” JAMA 84:9 (February 28, 1925), 697; Carlisle, ­Century of Caring, 81–82. 46. Judith Walzer Leavitt, Brought to Bed: Childbearing in Amer­i­ca, 1750 to 1950 (New York: Oxford University Press, 1986), 128–140; “The Big Six: Six Reasons for the Perpetuation of the Proprietary Evil,” JAMA 43:18 (October 31, 1914), 1594–1595; “Glyco-­Heroin, Smith,” JAMA 42:23 (June 6, 1914), 1827. 47. Bruno Müller-­Oerlinghausen, “Die Arzneimittelkommission der deutschen Ärzteschaft: Eine Geschichte von Erfolgen und Niederlagen,” in Volker Koesling and Florian Schülke, Pillen und Pipetten: Facetten einer Schlüsselindustrie (Leipzig: Koehler and Amelang, 2010), 187; “The Arzneimittelkommission,” Cleveland Medical Journal 12:1 (January 1913), 51–52; Strong, Machinations of the AMA, 33; “Censorship of the Medical Press: Czar Methods of the Octopus,” TMJ 22:11 (May 1907), 431–433. 4 8. “  ‘Organ­i zation’ War on ‘In­de­pen­dent’ Medical Journals,” Charlotte Medical Journal 30:4 (April 1907), 220; “ ‘Unifying the Profession’ in the Interest of the ­Great Medical Journal Trust,” TMJ 22:9 (March 1907), 346; “Censorship of the Medical Press,” TMJ 22:11 (May 1907), 431; “Our ‘Comment,’ Having Been Asked for, Is Given,” SoPract 30:1 (January 1908), 42–45; G.

492

notes to pages 109–116

Frank Lydston, “The Rus­sianizing of American Medicine and the Medical Dreyfus,” SoPract 32:1 (January 1910), 7–36. 49. Marc T. Law and Gary D. Libecap, “Determinants of Progressive Era Reform: The Pure Food and Drug Act of 1906,” in Edward L. Glaeser and Claudia Goldin, eds., Corruption and Reform: Lessons from Amer­i­ca’s Economic History (Chicago: University of Chicago Press, 2006), 330; “Our Duty Regarding ‘Patent-­Medicine’ Legislation,” JAMA 46:9 (March 3, 1906), 658; Arthur J. Cramp, “The Nostrum and the Public Health,” JAMA 72:21 (May 24, 1919), 1532. 50. Harry M. Marks, “Revisiting ‘The Origins of Compulsory Drug Prescriptions,’ ” AJPH 85:1 (January 1995), 109–115; Gregory Reilly, “The FDA and Plan B: The Legislative History of the Durham-­Humphrey Amendments and the Consideration of Social Harms in the Rx-­OTC Switch” (unpublished manuscript, Harvard University, 2006).

C H A P T E R   5 . ­L E G A L R E M E D Y

1. “The Trade in Secret and Proprietary Medicines: Part II,” Lancet 168:4343 (November 24, 1906), 1463–1465. 2. Ibid., 1462. 3. “Pure Food and Drug Legislation: How We Do It in Tennessee,” KMJ 5:11 (December 1907), 24. 4. Curt Paul Wimmer, The College of Pharmacy of the City of New York (New York: n.p., 1929), 208–209; James Harvey Young, Pure Food: Securing the Federal Food and Drugs Act of 1906 (Prince­ton, NJ: Prince­ton University Press, 1989), 15–18. 5. “Report of Committee on Adulterations,” Proceedings of the Convention of Druggists, and of the Illinois Phar­ma­ceu­ti­cal Association, vol. 1 (Chicago: Chandler and Engelhard, 1881), 75; Young, Pure Food, 52–56. On Billings and the National Board of Health, formed in 1879, see chapter 6. 6. Bess Furman, A Profile of the United States Public Health Ser­vice, 1798–1950 (Washington, DC: U.S. Department of Health, Education, and Welfare, 1974), 167; Alexander Wynter Blyth, Foods: Their Composition and Analy­sis (London: Charles Griffin, 1882), 569; Samuel W. Abbott, “Modern Legislation Relative to Adulteration of Food and Drugs,” BMSJ 110:11 (March 13, 1884), 244; “Food and Drugs,” Sanitary Engineer 4:14 (June 15, 1881), 330. 7. “The Paddock Bill,” Philadelphia College of Pharmacy Alumni Report 28:5 (March 1892), 98; Harvey W. Wiley, An Autobiography (Indianapolis: Bobbs-­Merrill, 1930), 202–203. 8. Proceedings of National Pure Food and Drug Congress (Washington, DC: 1898); “Journal of Proceedings of National Pure Food and Drug Congress,” JAMA 31:25 (December 17, 1898), 1487. 9. “Report of Committee on Legislation,” Fifteenth Annual Report of the Proprietary Association of Amer­i­ca (New York: Robertson and Wallace, 1987), 106; U.S. House of Representatives, Committee on Interstate and Foreign Commerce, Hearings on the Pure-­Food Bills for Preventing the Adulteration, Misbranding, and Imitation of Foods, Beverages, Candies, Drugs, and Condiments (Washington, DC: U.S. Government Printing Office, 1906), 228, 230. 10. Mark S­ ullivan, “The Patent Medicine Conspiracy against the Freedom of the Press,” Collier’s, November 4, 1905; Samuel Hopkins Adams, “The G ­ reat American Fraud,” Collier’s, October 7, 1905; ­Sullivan, “Patent Medicine Conspiracy.” 11. “The Pure Food Bill Passes,” American Druggist and Phar­ma­ceu­ti­cal Rec­ord 44 (January 25, 1904), 54; “The Food and Drugs Act and Dr. Wiley,” JAMA 50:14 (April 4, 1908), 1126; Wiley, An Autobiography, 27–31, 40–41; Young, Pure Food, 100, 169–170; James Harvey Young, The Toadstool Millionaires: A Social History of Patent Medicines in Amer­i­ca before Federal Regulation (Prince­ton, NJ: Prince­ton University Press, 1961), 229–232.



notes to pages 117–124

493

12. U.S. House of Representatives, Hearings before the Committee on Interstate and Foreign Commerce on the Pure Food Bills (Washington, DC: U.S. Government Printing Office, 1902), 257. 13. Daniel Carpenter, The Forging of Bureaucratic Autonomy: Reputations, Networks, and Policy Innovation in Executive Agencies, 1862–1928 (Prince­ton, NJ: Prince­ton University Press, 2001), 201–205, 257–270; Young, Pure Food, 95, 125–127; Ilyse Barkan, “Industry Invites Regulation: The Passage of the Pure Food and Drugs Act of 1906,” American Journal of Public Health 75:1 (January 1985), 18–26. 14. Quentin R. Skrabec, H. J. Heinz: A Biography (Jefferson, NC: McFarland, 2009), 101–102, 148– 154, 171–174; Stephen Potter, The Magic Number: The Story of ‘57’ (London: Max Reinhart, 1959), 67. 15. Robert C. Alberts, The Good Provider: H. J. Heinz and His 57 Va­ri­e­ties (Boston: Houghton Mifflin, 1973), 166, 171–172, 176. 16. Thomas C. Cochran, The Pabst Brewing Com­pany: The History of an American Business (New York: New York University Press, 1948), 204–206; Skrabec, Heinz, 100–101, 246–249; Clayton A. Coppin and Jack High, The Politics of Purity: Harvey Washington Wiley and the Origins of Federal Food Policy (Ann Arbor: University of Michigan Press, 1999), 47–48, 53–54, and 62; “Kentucky—­for Better Milk,” JAMA 47:23 (December 8, 1906), 1924. On the role of food producers, see Donna J. Wood, Strategic Uses of Public Policy: Business and Government in the Progressive Era (Marshfield, MA: Pitman, 1986), 108–151. 17. “Report of the Committee on Legislation,” Proceedings of the National Wholesale Druggists’ Association, November 15–19, 1904 (Indianapolis: 1905); G. W. Wiley, “Drugs and Their Adulterations and the Laws Relating Thereto,” Washington Medical Annals 2:3 (July 1903), 217–218, 221–222; U.S. Senate, Adulteration of Foods, 72, 84, 93. 18. “The ­Great Fraud on the Doctors: Substitution,” TMJ 17:3 (September 1901), 99–101. 19. U.S. Senate, Committee on Manufactures, Adulteration of Foods, ­etc., Report No. 1029 (Washington, DC: U.S. Government Printing Office, 1904), 77–78, 85, 87, 95; “Report of the Committee on Legislation,” Proceedings of the National Wholesale Druggists’ Association, 158; U.S. Senate, Adulteration of Foods, 72, 73, 83; Young, Pure Food, 170. 20. “Report of the Legislative Committee,” Phar­ma­ceu­ti­cal Era 33:18 (May 4, 1905), 498; “Glyco-­ Thymoline: Report of the Council on Pharmacy and Chemistry,” JAMA 63:15 (October 10, 1914), 1312–1313. 21. U.S. Senate, Adulteration of Foods, 79, 82, 88, 89, 91, 92, 100, 101. 22. Wiley, History of a Crime, 265–266, 400; Young, Pure Food, 253; Upton Sinclair, “What Life Means to Me,” Cosmopolitan, October 1906, 594. 23. Samuel Hopkins Adams, “Peruna and the Bracers,” Collier’s, October 28, 1905; Adams, “Liquozone,” Collier’s, November 18, 1905; Adams, “The Subtle Poisons,” Collier’s, December 2, 1905; Adams, “Preying on the Incurables,” Collier’s, January 13, 1906; S­ ullivan, “Patent Medicine Conspiracy”; Adams, “The Nostrum Evil,” Collier’s Weekly, October 6, 1905. 2 4. Lorine Swainston Goodwin, The Pure Food, Drink, and Drug Crusaders, 1879–1914 (Jefferson, NC: McFarland, 1999), 152–209, 220–225, 246, 257; Young, Pure Food, 183–186, 231–235; Robert M. Crunden, Ministers of Reform: The Progressives’ Achievement in American Civilization, 1889–1920 (New York: Basic, 1982), 188. 25. Edward Bok, “Works and Not Words: An Appeal to the Medical Profession,” JAMA 44:20 (May 20, 1905), 1628–1629; “Our Duty Regarding ‘Patent Medicine’ Legislation,” JAMA 46:9 (March 3, 1906), 658; “Report of Committee on Medical Legislation,” JAMA 42:23 (June 8, 1907), 1966; “Pure Foods and Drugs: Dr. H. Wiley Tells Us What the New Act Does for Us,” Chautauquan Daily, July 29, 1908, 4–5. 26. “The Pure Food Law,” JAMA 47:2 (July 14, 1906), 117; “President-­Elect C. A. L. Reed,” Medical Mirror 11:7 (July  1900), 340–334; “The Opportunity of the Ohio Profession,” American Medicine 3:10 (October 1908), 441–442.

494

notes to pages 124–132

27. James G. Burrow, AMA: Voice of American Medicine (Baltimore: Johns Hopkins University Press, 1963), 58–60. 28. Young, Toadstool Millionaires, 234; Congressional Rec­ord, 58th Cong., 1st Sess. (1904), 128; “Tinkering with the Pure Food Bill,” JAMA 46:14 (April 7, 1906), 1036; L. M. Halsey, “Dear Doctor,” Journal of the Medical Society of New Jersey 2:8 (February 1906), 250. 29. Goodwin, Crusaders, 163–164. 30. Congressional Rec­ord, 58th Cong., 1st Sess. (1904), 4, 350; Oscar Anderson, The Health of a Nation (Chicago: University of Chicago Press, 1958), 164–165; Addresses of Henry Cabot Lodge of Mas­sa­chu­setts, Burton L. French, of Idaho, and Joseph Howell, of Utah, in U.S. Congress, Weldon Brinton Heyburn: Memorial Addresses (Washington, DC: U.S. Government Printing Office, 1914), 18, 67, 90. 31. “Report of Committee on Legislation,” Proceedings of the National Wholesale Druggists’ Association, October 3 to 7, 1905 (Indianapolis: Hollenbeck, 1905), 54–55; Congressional Rec­ord, 59th Cong., 1st Sess. (1906), 2748; Young, Toadstool Millionaires, 235, 236, 238–239; Young, Pure Food, 209–210. 32. Young, Toadstool Millionaires, 242; Young, Pure Food, 219–220, 256–257. 33. “Pure Food Bill Passed by the House,” NYT, June 24, 1906; Young, Pure Food, 254–255, 261–262. 34. Samuel Hopkins Adams, “Curbing the ­Great American Fraud,” Collier’s (July 21, 1906); Adams, “Patent Medicines u ­ nder the Pure Food Law,” Collier’s, June 8, 1907; “Guaranteed,” NYT, July 2, 1906; Paul B. Dunbar, “Memories of Early Days of Federal Food and Drug Enforcement,” Food, Drug, and Cosmetic Law Journal 14:2 (February 1959), 123. 35. “Discussion,” ­after Cooke, “Pure Food and Drug Legislation,” 26; Young, Toadstool Millionaires, 224. 36. State Pure Drug Laws Enacted since the Passage of the National Food and Drugs Act (Chicago: Bond Bros., 1913), 3–6; Joseph N. McCormack, “ ‘Let Us Have Peace,’ ” Bulletin of Pharmacy 21:10 (October 1907), 418; Cooke, “Pure Food and Drug Legislation,” 21. 37. James Harvey Young, The Medical Messiahs: A Social History of Medical Quackery in 20th ­Century Amer­i­ca (Prince­ton, NJ: Prince­ton University Press, 1967), 4–11; Henry Beach Needham, “The First Pure-­Food-­L aw Conviction,” Collier’s, April 25, 1908; James Harvey Young, “Drugs and the 1906 Law,” in John B. Blake, ed., Safeguarding the Public: Historical Aspects of Medicinal Drug Control (Baltimore: Johns Hopkins University Press, 1970), 149. 38. Cancer “Cures” and Treatments (Chicago: American Medical Association, 1922), 30. 39. United States v. Johnson, 221 U.S. 488 (1911); G. Edward White, Justice Oliver Wendell Holmes: Law and the Inner Self (New York: Oxford University Press, 1993), 10–13; “Currents and Counter-­Currents in Medical Science,” American Journal of the Medical Sciences 40:80 (October 1860), 467. 40. Hemenway: “That is exactly what I seek to avoid by my amendment.” U.S. Senate, Adulteration of Foods, 97–99; Congressional Rec­ord, 58th Cong., 1st Sess. (1904), 4350; Congressional Rec­ ord, 59th Cong., 1st Sess. (1906), 2725–2727. 4 1. Congressional Rec­ord, 59th Cong., 1st Sess. (1906), 2661, 2724. 42. “The President and the Food and Drugs Act,” Science 34:863 (July 14, 1911), 53. 43. “Still Striking at the Drug Trade,” National Druggist 42:1 (January 1912), 2–3; “Legislative ­Matters at Washington,” National Druggist 42:8 (August 1912), 358; “The Sherley Amendment to the Food and Drugs Act,” National Druggist 42:9 (September 1912), 370; “Sherley Bill Becomes Law,” American Druggist and Phar­ma­ceu­ti­cal Rec­ord 60:10 (October 1912), 77. 4 4. Seven Cases of Eckman’s Alterative v. United States, 239 U.S. 510 (1916); “Eckman’s Calcerbs,” JAMA 71:6 (August 10, 1918); Young, “Drugs and the 1906 Law,” 150. 45. Arthur J. Cramp, “The Nostrum and the Public Health,” JAMA 72:21 (May 24, 1919), 1531; “To Amend Food and Drugs Act to Prevent Lying,” Printers’ Ink 78:4 (January 25, 1912), 85– 86; “Crystallizing the Idea,” Hearst’s International 39:6 (June 1921), 57; Harvey W. Wiley, “Drugging the Baby,” in The Child Welfare Manual: A Handbook of Child Nature and Nurture for



notes to pages 132–143

495

Parents and Teachers (New York: University Society, 1915), 193–194; Wiley “Another Soothing Syrup Victim,” Good House­keeping 60 (June 1915), 709–710; Rhoda Truax, The Doctors Jacobi (Boston: L ­ ittle, Brown, 1952), 145. 46. “Rules and Regulations,” National Druggist 36:7 (July 1906), 210; “Interview with Col. Frank J. Cheney,” National Druggist 36:11 (November 1906), 372. 47. Arsenauro and Mercauro advertisements in TMJ 17:3 (September 1901); Pacific Medical Journal 47:2 (February 1904); MRR 20:12 (December 1914), xii; American Journal of Clinical Medicine 22:7 (July 1915); Medical Council 20:12 (December 1915), 91.

CHAPTER 6. BACILLUS POLITICUS A ND THE DISE ASED STATE

1. H. C. Jones, “Some Se­lections from Osler,” Illinois Medical Journal 8:5 (November 1905), 449. 2. H. Barton McCauley, Mary­land Public Health Association, 1897–1902 (Baltimore: Mary­land Public Health Association, 1967), https://­mdpha​.­org​/­misc​/­history​/­mdphahistory​.­pdf; “Conference of the Committee on National Legislation,” JAMA 38:16 (April  19, 1902), 1024; William H. Welch, “Fields of Usefulness of the AMA,” JAMA 54:25 (June 18, 1910), 2015–2016. 3. “The Department of Public Health,” JAMA 33:9 (August 26, 1899), 551; “Committee on National Legislation,” JAMA 34:24 (June 16, 1900), 1547, 1549. 4. William Osler, “The Study of the Fevers of the South,” JAMA 26:21 (May 23, 1896), 1002. 5. Sarah E. Hinman et al., “Spatial and Temporal Structure of Typhoid Outbreaks in Washington, D.C., 1906–1909,” International Journal of Health Geographics 5:1 (January 3, 2006), 13; Jane McHugh and Philip A. Mackowiak, “Death in the White House: President William Henry Harrison’s Aty­pi­cal Pneumonia,” Clinical Infectious Diseases 59:7 (2014), 990–995. 6. Proceeding of a Conference of Governors in the White House, Washington, D.C., May 13–15, 1908 (Washington, DC: U.S. Government Printing Office, 1909), 528–529; Osler, “Fevers of the South,” JAMA 26:21 (May 23, 1896), 1000. 7. Irving Fisher, “Economic Aspect of Lengthening H ­ uman Life,” February 5, 190, Fisher papers, series III, box 5, fol. 366, Sterling Memorial Library, Yale University, 1, 2, 7, 8. 8. John Shaw Billings, “The President’s Address,” Public Health Papers and Reports 6 (1880), 9; Proceedings of the Twenty-­Fifth Annual Meeting of the Conference of State and Provincial Boards of Health of North Amer­i­ca, 1910 (St. Paul: Volkszeitung, 1912), 76; “When the Interests of the Doctor and Public Clash,” MS 32:1 (January 1909), 4–5; U.S. House of Representatives, Committee on Interstate and Foreign Commerce, Health Activities of the General Government (Washington, DC: U.S. Government Printing Office, 1910), 22. 9. See, for example, Richard Harrison Shryock, Medical Licensing in Amer­i­ca 1650–1965 (Baltimore: Johns Hopkins Press, 1967), especially 57. An exception is Samuel L. Baker, “A Strange Case: The Physician Licensure Campaign in Mas­sa­chu­setts in 1880,” JHM 40:3 (July 1985), 173–197. William G. Rothstein, in American Physicians in the 19th ­Century: From Sects to Science (Baltimore: Johns Hopkins University Press, 1985), 305–310, 311, does not mention public health in the context of licensing discussions except to suggest that regular physicians came to ­favor public health departments a­ fter their creation when they “realized that they could be used as licensing agencies to control the supply of physicians.” James C. Mohr, in Licensed to Practice: The Supreme Court Defines the American Medical Profession (Baltimore: Johns Hopkins University Press, 2013), explic­itly rejects the public health motive, at least in the case of West ­Virginia (see l­ater discussion of that state). 10. Stephen Smith, “On the Reciprocal Relations of an Efficient Public Health Ser­vice and the Highest Educational Qualifications of the Medical Profession,” Public Health Reports and Papers 2 (1876), 190, 199.

496

notes to pages 143–147

11. Samuel  L. Baker, “Physician Licensure Laws in the United States, 1865–1915,” JHM 39:2 (April  1984), 175–177; Tobias  G. Richardson, “Address of the President,” TAMA 29 (1878), 102–103; William Osler, “License to Practice,” JAMA 12:19 (May 11, 1889), 649–650. 12. Richardson, “Address of the President,” 107; Stanford E. Chaillé, “The Professional Ser­vices of Tobias Gibson Richardson,” New Orleans Medical and Surgical Journal 20:11 (May 1893), 814; John H. Roberts, “The ­L egal Control of Medical Practice by a State Examination,” JAMA 4:10 (March 7, 1885), 256–259; Roberts, The Doctor’s Duty to the State: Essays on the Public Relations of Physicians (Chicago: American Medical Association, 1908), 20; Clayton J. Lundy, “State Regulation of Medical Practice,” JAMA 8:3 (January 15, 1887), 60. 13. Charles F. Folsom, “Registration of Deaths and Diseases,” Eighth Annual Report of the Mas­sa­ chu­setts State Board of Health (Boston: State Board of Health, 1877), 233–271. 14. “Special Reports by Members of Section on State Medicine,” TAMA 33 (1882), 318; “Vital Statistics,” Seventh Biannual Report of the Board of Health of the State of Iowa (Des Moines: Hagsdale, 1893), 284; “Vital Statistics,” Western Reserve Medical Journal 3:5 (February 1895), 182; “Professional Duty and the Vital Statistics Law,” State of Ohio First Annual Report of the Bureau of Vital Statistics, 1909 (Springfield: Springfield, 1911), 51. 15. John M. Harris Jr., Professionalizing Medicine: James Reeves and the Choices That S­ haped American Health Care (Jefferson, NC: McFarland, 2019), 124–125; Harvey B. Hurd, ed., Revised Statutes of the State of Illinois (Chicago: Chicago ­L egal News, 1877), 663–664; 934–935; John H. Rauch, “Address in State Medicine,” JAMA 6:24 (June 12, 1886), 646; Howard Atwood Kelly, “Rauch, John Henry (1828–1894),” A Cyclopedia of American Medical Biography (Philadelphia: Saunders, 1912), 957–958; “The Late John H. Rauch, M.D.,” JAMA 22:13 (March 31, 1894), 471; Bonj Szczygiel and Robert Hewitt, “Nineteenth-­Century Medical Landscapes: John H. Rauch, Frederick Law Olmsted, and the Search for Salubrity,” BHM 74:4 (Winter 2000), 708– 734; “Minutes of the Section on State Medicine and Public Hygiene,” TAMA 26 (1875), 296. 16. Robert Partin, “Dr. Jerome Cochran, Yellow Fever Fighter,” Alabama Review 13 (January 1960), 21–39; W. H. Sanders, “The History, Philosophy, and Fruits of Medical Organ­ization in Alabama,” Transactions of the Medical Association of the State of Alabama, 1914, 514–515; John T. Morris and Barbara Ann McClary, Jerome Cochran: His Life, His Works, His Legacy (Cullman, AL: Mulberry River Press, 1998), 69–70, 96–97, 163, 188, 201, 207; Douglas L. Cannon, “Alabama’s Eighty-­Nine Years of Medical Organ­ization,” Journal of the Medical Association of the State of Alabama 5:10 (April 1936), 350; Sanders, “History, Philosophy, and Fruits of Medical Organ­ization, 526–527; Jerome Cochran, “The Theory and Practice of Quarantine,” Transactions of the Medical Association of the State of Alabama, 1880, 336–389. 17. “James Edmund Reeves,” New Orleans Medical and Surgical Journal 48:8 (February 1896), 501– 502; John M. Harris, “James Edmund Reeves,” AJPH 104:3 (March 2014), 417. 18. James E. Reeves, “The Eminent Domain of Sanitary Science, and the Usefulness of State Boards of Health in Guarding the Public Welfare,” JAMA 1:21 (December 1, 1883), 612–618, especially 617; Reeves, “The President’s Address,” Public Health Papers and Reports 11 (1885), 6–7. For more on Reeves, including the view that medical licensure was part of the larger public health mission, see Harris, Professionalizing Medicine, 118–149. According to historian James Mohr, passing West ­Virginia’s medical practice act had nothing to do with public health, arguing that that the board’s creation “had never been solely an end in itself; it was principally a means of obtaining the power to license physicians.” Public health was a “stalking ­horse” ­behind which licensing was hidden from politicians resisting its introduction. Mohr, Licensed to Practice, 64, 66. He firmly bases his conclusion on a speech by Reeves published in Transactions of the Medical Society of the State of West ­Virginia (Wheeling, WV, 1882), 714–730. However, I cannot find grounds for such a conclusion in that speech. 19. Thomas M. Logan, “Medical Topography,” TAMA 4 (1851), 474; Logan, “State Medicine and Public Hygiene in California,” TAMA 25 (1874), 383–385; Logan, “Report on the Topography



notes to pages 147–153

497

and Epidemics of California,” TAMA 16 (1866), 494–569; Logan, “Land Scurvy: Its Pathology, Symptoms, C ­ auses and Treatment,” Southern Medical Reports 2 (1850), 468–480; “California ­Will Entertain American Medical Association,” Weekly Bulletin of the California State Board of Health 2:19 (June 23, 1923). 2 0. Guy P. Jones, “Thomas M. Logan, M.D.,” California and Western Medicine 63:1 (July 1945), 6–10; Cephas L. Bard, “A Contribution to the History of Medicine in Southern California,” Southern California Practitioner 9:8 (August 1894), 311; Henry Gibbons, “A Brief Sketch of the History of the Medical Law of California,” Transactions of the Medical Society of the State of California (Sacramento, CA: T. A. Springer, 1883), 231; Gibbons, “Valedictory Delivered at the Commencement Exercises of Cooper Medical College,” Occidental Medical Times, January 1893, 2. 21. Lewis E. Daniel, “Dr. R. H. Harrison, Sr.,” Types of Successful Men of Texas (Austin: L. E. Daniel, 1890), 296–297; “Texas State Medical Association,” TMJ 15:12 (June 1900), 623; “Only a Diploma Required,” TMJ 15:6 (December 1899), 336–337; H. A. West, “Maladministration of Public Medical Affairs,” TMJ 15:11 (May 1900), 562; “Vital Statistics and Sanitation,” TMJ 15:5 (November 1899), 280; “Public Health Department,” TMJ 15:9 (March 1900), 523–526. 22. Michael Willrich, Pox: An American History (New York: Penguin, 2011), 46–59; Twenty-­Third Annual Report of the State Board of Health of the State of Ohio for 1908 (Springfield, OH: Springfield, 1909), 6. 23. Charles F. Folsom, “Henry Ingersoll Bowditch,” Proceedings of the American Acad­emy of Arts and Sciences 28 (May 1892–­May 1893), 321; John T. Cumbler, Reasonable Use: The P ­ eople, the Environment, and the State, New E ­ ngland, 1790–1930 (Oxford: Oxford University Press, 2001), 112–122. 2 4. Albert V. Hardy and May Pynchon, Millstones and Milestones: Florida’s Public Health from 1889 (Jacksonville: Florida State Board of Health, 1964), 11; Valerie Summers, The McCormack Machine: Or­ga­nized Medicine and Public Health in Kentucky, 1883–1943 (unpublished manuscript); Fifteenth Biennial Report of the North Carolina State Board of Health, 1913–1914 (Raleigh: Edwards and Broughton, 1915), 10, 25, 27; Charles  V. Chapin, A Report on State Public Health Work Based on a Survey of State Boards of Health (Chicago: American Medical Association, 1916), 58–59. 25. Chapin, State Public Health Work, 2–3, 193–195, and t­ ables following. 26. Peter William Bruton, “The National Board of Health” (PhD diss., University of Mary­land, 1974), 47, 48, 413, 415; Eugene Foster, “The Municipal Organ­ization of the American Public Health Ser­vice,” Public Health Papers and Reports 7 (1881), 98. 27. Rossiter W. Raymond, Peter Cooper (New York: Houghton, Mifflin, 1901), 63. 28. Gert H. Brieger, “Sanitary Reform in New York City: Stephen Smith and the Passage of the Metropolitan Health Bill,” BHM 40:5 (September–­October 1966), 420–421; Sanitary Condition of the City: Report of the Council of Hygiene and Public Health of the Citizens Association of New York (New York: Appleton, 1865), liv, lviii, lxxi, cxxvii. 29. Brieger, “Sanitary Reform,” 415, 426; John Duffy, A History of Public Health in New York City, 1625–1866 (New York: Russell Sage Foundation, 1968), 560, 563, 566; “The Advance of the Cholera,” NYT, October 20, 1865. 30. Brieger, “Sanitary Reform,” 424; Michael P. Roth, Historical Dictionary of Law Enforcement (Westport, CT: Greenwood, 2001), 239–240. 31. Morris Schaeffer, “William H. Park (1863–1939): His Laboratory and His Legacy,” AJPH 75:11 (November 1985), 1330; “Driven Out By Politics,” NYT, June 25, 1892; “Politics and the Health Board,” NYT, July 3, 1892; “New York Board of Health,” JAMA 29:6 (August 6, 1892), 176; “The Health Board of Cities,” JAMA 29:32 (July 9, 1892), 54; “The New York City Board of Health,” Mary­land Medical Journal 27:12 (July 16, 1892), 824–825; T. Mitchell Prudden, “The Public Health: The Duty of the Nation in Guarding It,” C ­ entury Illustrated Magazine 46

498

notes to pages 153–160

(June 1893), 247; Elizabeth Fee and Evelynn M. Hammonds, “Science, Politics, and the Art of Persuasion: Promoting the New Scientific Medicine in New York City,” in Rosner, Hives of Sickness, 158–159. 32. John Duffy, The Sanitarians: A History of American Public Health (Urbana: University of Illinois Press, 1990), 148; T. G. Richardson, “Address of the President,” TAMA 29 (1878), 102– 103; Harriette Merrick Plunkett, ­Women, Plumbers, and Doctors; or House­hold Sanitation (New York: Appleton, 1885); Mary Logan, The Part Taken by W ­ omen in American History (Wilmington, DE: Perry-­Nalle, 1912), 902–903. 33. John  S. Fulton, “Quarantine: The Delirium Ferox of American Sanitation,” Public Health Papers and Reports 31:1 (1905), 252–254. 34. Margaret Humphreys, Yellow Fever and the South (New Brunswick, NJ: Rutgers University Press, 1992), 177; Peter Annin, The G ­ reat Lakes W ­ ater Wars (Washington, DC: Island Press, 2006), 85–91. 35. James H. Cassedy, John Shaw Billings: Science and Medicine in the Gilded Age (Bethesda: Xlibris, 2009), 180–189; Carleton B. Chaplain, Order out of Chaos: John Shaw Billings and Amer­ i­ca’s Coming of Age (Boston: Boston Medical Library, 1994), xiii, 241–242, 339–341. 36. Thomas H. Baker, “Yellowjack: The Yellow Fever Epidemic of 1878 in Memphis, Tennessee,” BHM 42:3 (May–­June 1968), 245, 247, 260. 37. Bruton, National Board of Health, 410; Stephen Smith, “On the Pro­g ress of Public Health Organ­izations,” Public Health Papers and Reports 27 (1902), 24. 38. John Harley Warner, The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in Amer­i­ca, 1820–1885 (Prince­ton, NJ: Prince­ton University Press, 1997), 243; Henry I. Bowditch, Consumption in New ­England (Boston: Ticknor and Fields, 1862); Bowditch, “Address on Hygiene and Preventive Medicine,” in John Ashhurst, Transactions of the International Medical Congress, 1876 (Philadelphia: International Medical Congress, 1877), 26. 39. Vincent Y. Bowditch, The Life and Correspondence of Henry Ingersoll Bowditch, vol. 2 (Boston: Houghton, Mifflin, 1902), 271–283, 337; Stephen Kantrowitz, More than Freedom: Fighting for Black Citizenship in a White Republic, 1829–1889 (New York: Penguin, 2012), 75–81; John H. Felts, “Henry Ingersoll Bowditch and Oliver Wendell Holmes: Stethoscopists and Reformers,” Perspectives in Biology and Medicine 45:4 (2002), 545–546; Charles F. Folsom, “Henry Ingersoll Bowditch,” Proceedings of the American Acad­emy of Arts and Sciences 28 (May 1892–­May 1893), 315–316, 321; Bowditch, “The Medical Education of ­Women,” BMSJ 105:5 (1881), 109–110. 40. Bess Furman, A Profile of the United States Public Health Ser­vice, 1798–1948 (Washington, DC: U.S. Department of Health, Education, and Welfare, 1974), 155, 159, 178; W. G. Smillie, “The National Board of Health,” AJPH 33:8 (August 1943), 930. 4 1. Furman, Profile of the Public Health Ser­vice, 156, 177; Billings, “President’s Address,” 1. 42. Mike Stobbe, Surgeon General’s Warning: How Politics Crippled the Nation’s Doctor (Berkeley: University of California Press), 19–20; Chaplain, Order out of Chaos, 88; Duffy, Sanitarians, 166–167; Smith, “Pro­gress of Public Health Organ­izations,” 24; Cassedy, Billings, 135, 142–145. 43. James  L. Cabell, “A Review of the Operations of the National Board of Health,” Public Health Papers and Reports 8 (1882), 71, 99, 101; Stobbe, Surgeon General’s Warning, 29; Furman, Profile of the USPHS, 167, 184, 190; Smillie, “National Board of Health,” 929; Cassedy, Billings, 159; Fielding H. Garrison, John Shaw Billings: A Memoir (New York: Putnam, 1915), 166; Humphreys, Yellow Fever, 63. 4 4. Cabell, “Operations of the NBH,” 101; Bruton, National Board of Health, 418; Stobbe, Surgeon General’s Warning, 32; Smillie, “National Board of Health,” 930. 45. James Bryce, The American Commonwealth, vol. 1 (London: Macmillan, 1889), 175–176, 295. 46. Garrison, Billings, 163–164.



notes to pages 160–167

499

47. John Shaw Billings, “Public Health and Municipal Government,” supplement, AAAPSS, February 1891, 15–17; Andrew D. White, “The Government of American Cities,” Forum 10 (December 1890), 357–372; C. G. Roland, “Osler’s Rough Edge,” Annals of Internal Medicine 81:5 (November 1, 1974), 690–692. 48. Morris Fishbein, A History of the American Medical Association, 1847 to 1947 (Philadelphia: W. B. Saunders, 1947), 351, 683; “Civic Diseases,” Cleveland Journal of Medicine 4:9 (September 1899), 400; “Moral Disease,” Cleveland Journal of Medicine 4:3 (March 1899), 137–137; “Municipal Affairs in Cleveland,” Cleveland Journal of Medicine 4:4 (April 1899), 183–184. 49. “Henry Baird Favill, M.D.,” JAMA 46:9 (February 26, 1916), 671; “Progressive Movement in Illinois,” and “Industrial Conferences in Chicago,” Public 13:637 (June 17, 1910), 562. 50. John B. Roberts, “The Po­liti­cal Side of Medicine,” in The Doctor’s Duty to the State: Essays on the Public Relations of Physicians (Chicago: AMA Press, 1908), 35; Roberts, An Experience of a Republican Citizen of a Corrupt and Contented Philadelphia (Philadelphia: n.p., 1905), 3, 4. 51. Billings, “Public Health and Municipal Government,” 16–17; Andrew D. White, “The Government of American Cities,” Forum 10 (December 1890), 357–372; “Dr. Osler On Municipal Government,” Baltimore Sun, February 4, 1902; Roland, “Osler’s Rough Edge,” 690–692. 52. Abraham Jacobi, “The Relations of Pediatrics to General Medicine,” Transactions of the American Pediatric Society 1 (1890), 17; Abraham Jacobi, “Virchow as a Citizen,” Medical News 79 (October 19, 1901), 614; Russell Viner, “Abraham Jacobi and German Medical Radicalism in Antebellum New York,” BHM 72:3 (Fall 1998), 434–463; “Our ­Great Men,” JAMA 17:19 (November 7, 1891), 733; “The Virchow Jubilee,” JAMA 21:23 (December 2, 1893), 859; William H. Welch, “Rudolf Virchow, Pathologist,” BMSJ 125:18 (October 29, 1891), 453–457; William Osler, “Rudolf Virchow, the Man and the Student,” BMSJ 125:17 (October  22, 1891), 425–427; Rudolf Virchow, Mittheilungen über die in Oberschlesien herrschende Typhus-­ Epidemie (Berlin: Reimer, 1848), 22; Virchow, “Was die ‘medicinische Reform’ ­w ill,” Medicinische Reform 1 (July 10, 1848), 2, 73; Virchow, “Der Armenarzt,” Medicinische Reform 18 (November 3, 1848), 125.

C H A P T E R   7 . C A T T L E M E N , C O M M A N D E R S , C A P­I­T A L ­I S T S , AND CRUSADERS

1. Abraham Jacobi, “The Best Means of Combating Infant Mortality,” JAMA 58:23 (June 8, 1912), 1739; Manfred Wasserman, “The Quest for a National Health Department in the Progressive Era,” BHM 49:3 (Fall 1975), 359; “Public Health Bills in Congress,” JAMA 38:12 (March 22, 1902), 775. 2. “Bureau of Animal Industry,” JAMA 42:25 (June 18, 1904), 1649. 3. “The President’s Message,” JAMA 23:23 (December 8, 1894), 873. 4. Ulysses Grant Houck, The Bureau of Animal Industry of the United States Department of Agriculture (Washington, DC: Houck, 1924), 8–15; Alan L. Olmstead and Paul W. Rhode, Arresting Contagion: Science, Policy, and Conflicts over Animal Disease Control (Cambridge, MA: Harvard University Press, 2015), 33–34; Suellen Hoy and Walter Nugent, “Public Health or Protectionism? The German-­A merican Pork War, 1880–1891,” BHM 63:2 (Summer 1989), 193–224. 5. Olmstead and Rhode, Arresting Contagion, 47, 51–53, 56–57; Fred Wilbur Powell, The Bureau of Animal Industry: Its History, Activities and Organ­ization (Baltimore: Johns Hopkins University Press, 1927), 10; Susan D. Jones, Valuing Animals: Veterinarians and Their Patients in Modern Amer­i­ca (Baltimore: Johns Hopkins University Press, 2003), 16, 30, 83; Bessie Louise Pierce, A History of Chicago, Volume III: The Rise of a Modern City, 1871–1893 (New York: Knopf, 1957), 131, 188, 375n60; Olmstead and Rhode, Arresting Contagion, 162.

500

notes to pages 168–175

6. Twenty-­Fifth Annual Report of the Bureau of Animal Industry for the Year 1908 (Washington, DC: U.S. Department of Agriculture, 1910), 9, 37; L. Z. Saunders, “History of the Pathological Division of the Bureau of Animal Industry, 1891–1921,” Veterinary Pathology 26 (November 1989), 539; Twenty-­Fifth Annual Report of the BAI, 150. 7. Vincent Cirillo, Bullets and Bacilli: The Spanish-­American War and Military Medicine (New Brunswick, NJ: Rutgers University Press, 2004), 72–74, 80–81. 8. William C. Gorgas, “The Practical Mosquito Work Done at Havana, Cuba,” Washington Medical Annals 2:3 (July 1903), 170–180; Mark S­ ullivan, Our Times: The United States, 1900–1925, vol. 1 (New York: Scribner, 1926), 435–442; National Public Health: Papers, Opinions, Letters, Etc. Relative to the National Public Health, U.S. Senate, 61st Cong. (1910), 54. 9. Margaret Humphreys, Yellow Fever and the South (New Brunswick, NJ: Rutgers University Press, 1992), 151–153; Gordon Patterson, The Mosquito Crusades: A History of the Anti-­mosquito Movement from the Reed Commission to the First Earth Day (New Brunswick, NJ: Rutgers University Press, 2009), 55; Quitman Kohnke, “The Yellow Fever Epidemic of 1905 in New Orleans,” Public Health Papers and Reports 32:1 (1907), 93. 10. Edmund Morris, Theodore Rex (New York: Random House, 2001), 271–294. 11. William C. Gorgas, “The Part Sanitation Is Playing in the Construction of the Panama Canal,” JAMA 53:8 (August 21, 1909), 598–599; David McCullough, The Path between the Seas: The Creation of the Panama Canal, 1870–1914 (New York: Simon and Schuster, 1976), 235; Julie Greene, The Canal Builders: Making Amer­i­ca’s Empire at the Panama Canal (New York: Penguin Press, 2009), 42; Miles P. DuVal Jr., And Mountains ­Will Move: The Story of the Building of the Panama Canal (Palo Alto, CA: Stanford University Press, 1947), 175–176, 188. 12. “Medical Member of the Canal Commission,” JAMA 40:2 (January  10, 1903), 105; “The Sanitary Prob­lems of the Panama Canal,” JAMA 40:13 (March  28, 1903), 853; Jonathan Dine Wirtschafter, “The Genesis and Impact of the Medical Lobby,” JHM 13:1 (January 1958), 33–38. 13. “Medical Member of the Canal Commission,” JAMA 40:2 (January 10, 1903), 105; “The Sanitary Prob­lems of the Panama Canal,” JAMA 40:13 (March  28, 1903), 853; ­Sullivan, Our Times, 1:458; “Report of the Committee on Medical Legislation,” JAMA 42:24 (June 11, 1904), 1577–1578. 1 4. “Work of Medical Legislation Committee,” JAMA 42:11 (March 12, 1904), 726–727; “Sanitation and the Panama Canal,” JAMA (April 2, 1904), 896–897; “The Panama Canal Commission and Medical Ser­vice at the Isthmus,” JAMA 42:17 (April 23, 1904), 1082; Marie D. Gorgas and Burton J. Hendrick, William Crawford Gorgas: His Life and Work (Garden City, NY: Garden City, 1924), 162–165. 15. C. A. L. Reed, “The Panama Canal Mismanagement: Report to the Government,” JAMA 44:10 (March 11, 1905), 812–818. 16. “Scathing Is Doctor Reed’s Report on the Workings of the Canal Commission,” Cincinnati Enquirer, March 9, 1905; “Big Shakeup Ahead,” WaPo, March 14, 1905; DuVal, And Mountains ­Will Move, 156–157; “Dr. Reed’s Indiscretion,” Medical Rec­ord 67 (April 1, 1905), 13; ­Sullivan, Our Times, 1:463; “Sanitation at Panama,” JAMA 44:14 (April 8, 1905), 1120; Gorgas and Hendricks, Gorgas, 194–195. 17. McCullough, Path between the Seas, 467; Ian Cameron, The Impossible Dream: The Building of the Panama Canal (New York: William Morrow, 1972), 129; Gorgas and Hendrick, Gorgas, 196–202; DuVal, And Mountains W ­ ill Move, 190. 18. Gorgas and Hendrik, Gorgas, 197–202. 19. William C. Gorgas, Sanitation in Panama (New York: Appleton, 1915), 283; Gorgas, “Part Sanitation Is Playing,” 599; “Sanitation in Panama,” JAMA 44:15 (April 9, 1910), 1214. 20. Kohnke, “Yellow Fever Epidemic,” 93. 21. Patterson, Mosquito Crusades, 49; Rubert Boyce, Yellow Fever Prophylaxis in New Orleans, 1905 (London: Liverpool School of Tropical Medicine, 1906), 25–26, 60–62; Humphreys, Yellow



notes to pages 175–183

501

Fever, 161–163; Alan M. Kraut, Goldberger’s War: The Life and Work of a Public Health Crusader (New York: Hill and Wang, 2003), 57. 22. Kohnke, “Yellow Fever Epidemic,” 89–90. 23. Charles Wardell Stiles, “Early History, in Part Esoteric, of the Hookworm (Uncinariasis) Campaign in Our Southern States,” Journal of Parasitology 25 (August 1939), 288–289. 2 4. Charles Wardell Stiles, “Hookworm Disease in Its Relation to the Negro,” Public Health Reports 24:31 (July 30, 1909), 1085; Philip R. P. Coelho and Robert A. McGuire, “Racial Differences in Disease Susceptibilities: Intestinal Worm Infections in the Early Twentieth-­Century American South,” Social History of Medicine 19:3 (December 2006), 478. 25. U.S. Senate, Report on Condition of ­Woman and Child Wage-­Earners in the United States, vol. 17 (Washington, DC: U.S. Government Printing Office, 1912), 9, 36–37; Stiles, “Early History,” 299. 26. Charles Wardell Stiles, Tapeworms of Poultry: Report upon the Pre­sent Knowledge (Washington, DC: U.S. Department of Agriculture, 1896); ­Sullivan, Our Times, 3:308–311; Bailey K. Ashford, A Soldier in Science (San Juan: Editorial de la Universidad Puerto Rico, 1998 [1934]), 41–47, 95; John Ettling, The Germ of Laziness: Rocke­fel­ler Philanthropy in the New South (Cambridge, MA: Harvard University Press, 1981), 22–35. 27. ­Sullivan, Our Times, 3:309–310, 318; Ettling, Germ of Laziness, 33, 38–48. 28. Ettling, Germ of Laziness, 15, 97–108; S­ ullivan, Our Times, 3:317; Rudolf Virchow, “Der Armenarzt,” Medicinische Reform 1:18 (November 3, 1848), 125; Virchow, Mitteilungen über die in Oberschlesien herrschende Typhus-­Epidemie (Berlin: Reimer, 1848), 22; Natalie J. Ring, The Prob­ lem South: Region, Empire, and the New Liberal State, 1880–1930 (Athens: University of Georgia Press, 2012), 31, 34–37, 86, 138–139, 152–153, 166. 29. Ettling, Germ of Laziness, 85–91, 101–103. 30. Ibid., 59–66; Frederick T. Gates, Chapters in My Life (New York: F ­ ree Press, 1977), 180. 31. Gates, Chapters in My Life, 179–184; Howard S. Berliner, A System of Scientific Medicine: Philanthropic Foundations in the Flexner Era (New York: Tavistock, 1985), 53–91. 32. Ettling, Germ of Laziness, 102; Rocke­fel­ler Foundation, “The Rocke­fel­ler Commission for the Eradication of Hookworm Disease: By-­L aws,” http://­rockefeller100​.­org​/­fi les​/­original​/­470044 a80313d2c3c4a3893c082c04cb​.­pdf. 33. Brown, Rocke­fel­ler Medicine Men, 116, 254; Ettling, Germ of Laziness, 52–57. 34. Ashford, Soldier, 96–98; Ettling, Germ of Laziness, 41–43, 215; Allen Tullos, “The G ­ reat Hookworm Crusade,” Southern Exposure 6 (Summer 1978), 40–49. 35. Albert V. Hardy and May Pynchon, Millstones and Milestones: Florida’s Public Health from 1889 (Jacksonville, FL: Florida State Board of Health, 1964), 11; Humphreys, Yellow Fever, 125–126; Charles V. Chapin, A Report on State Public Health Work Based on a Survey of State Boards of Health (Chicago: American Medical Association, 1916), 15, 192; John Duffy, The Sanitarians: A History of American Public Health (Urbana: University of Illinois Press, 1990), 228. 36. Humphreys, Yellow Fever, 173; J. Willis Burke, The Streets of Key West: A History through Street Names (Sarasota, FL: Pineapple Press, 2004), 109. 37. “Uncinariasis in the Public Schools of Florida,” Florida Health Notes 4:3 (March 1909), 34–38; The Rocke­fel­ler Sanitary Commission for the Eradication of Hookworm Disease: Organ­ization, Activities, and Results Up to December  31, 1910 (Washington, DC: Office of the Commission, 1910), 33. 38. Tullos, “­Great Hookworm Crusade,” 48; John D. Rocke­fel­ler to the Rocke­fel­ler Sanitary Commission, August 12, 1914, https://­rockfound​.­rockarch​.­org​/­documents​/­20181​/­35639​/­Letter​+from​ +John+D​.­+Rockefeller+Sr​.­+to+the+Rockefeller+Sanitary+Commission%2C+1914+August+12​ .­pdf . 39. James H. Cassedy, Charles V. Chapin and the Public Health Movement (Cambridge, MA: Harvard University Press, 1962), 196; Ettling, Germ of Laziness, 195, 220–221; Frederick Gates to John D. Rocke­fel­ler, August 10, 1914, https://­rockfound​.­rockarch​.­org​/­documents​/­20181​/­35639​

502

notes to pages 184–189

/­Letter+from+Frederick+T​.­+Gates+to+John+D​.­+Rockefeller%2C+1914+August+10​.­pdf; Chapin, State Public Health Work, 8. 40. Centers for Disease Control and Prevention, U.S. Department of Health and H ­ uman Ser­vices, “Achievements in Public Health, 1900–1999,” http://­w ww​.­cdc​.­gov​/­mmwr​/­preview​/­mmwrhtml​ /­mm4829a1​.­htm#fig2. 4 1. F. C. Smith, “The Public Health Ser­v ice Tuberculosis Sanatorium at Fort Stanton,” Public Health Reports 27:35 (August 30, 1912), 1414–1430; Annual Report of the Surgeon General of the Public Health and Marine Hospital Ser­vice for 1902 (Washington, DC: Public Health and Marine Hospital Ser­vice, 1903), 395–397, 444; S. Adolphus Knopf, “Another Chapter on Phthisiophobia,” Medical News 80:18 (May 3, 1902); Knopf, “A Plea for Justice to the Consumptive,” Medical Rec­ord 65:1 (January 2, 1904). 42. Lawrence F. Flick, “The Crusade against Tuberculosis,” Columbus Medical Journal 31:11 (November 1907), 497; Michael E. Teller, The Tuberculosis Movement: A Public Health Campaign in the Progressive Era (New York: Greenwood, 1988), 28–29; Richard Harrison Shryock, National Tuberculosis Association, 1904–1954: A Study of the Voluntary Health Movement in the United States (New York: National Tuberculosis Association, 1957), 51–52. 43. Ella M. E. Flick, Beloved Crusader: Lawrence F. Flick, Physician (Philadelphia: Dorrance, 1944), 175–191; “Henry Phipps Institute W ­ ill Be Established for Treatment of Tuberculosis,” NYT, January 10, 1903; Shryock, National Tuberculosis Association, 54; Barbara Bates, Bargaining for Life: A Social History of Tuberculosis, 1876–1938 (Philadelphia: University of Pennsylvania Press, 1992), 99–101; Christopher Gray, “Streetscapes: Henry Phipps and Phipps Houses: Millionaire’s Efforts to Improve Housing for the Poor,” NYT, November 23, 2003. 4 4. “Hon. Clark Bell,” ­Lawyer and Banker 5:5 (October 1912), 336–337; “Clark Bell Dies in Union League Club,” NYT, February 23, 1918. 45. Clark Bell, “Congresses on Tuberculosis,” JAMA 42:1 (January 2, 1904), 45. The following paragraphs rely in part on S. Adolphus Knopf, A History of the National Tuberculosis Association: The Anti-­tuberculosis Movement in the United States (New York: National Tuberculosis Association [NTA], 1922), 22–29, and Robert G. Paterson, Antecedents of the National Tuberculosis Association (New York: NTA, 1945), 9–22; “Charges against Clark Bell: Trou­bles in the New-­ York Infant Asylum,” NYT, October 7, 1883; “The Mismanaged Asylum,” NYT, November 14, 1883; “They Remain in Control,” NYT, June 8, 1885. 46. “American Congress of Tuberculosis,” BMSJ 144:21 (May 23, 1901), 509; “American Congress on Tuberculosis,” Sanitarian 51:407 (October 1903), 355–358; Clark Bell, ed., Spiritism, Hypnotism and Telepathy (New York: Medico-­L egal Journal, 1904); “Corrigenda: The International Congress on Tuberculosis,” Sanitarian 52:411 (February 1904), 163–164. 47. “Tuberculosis Congress Says Doctors Bolted,” NYT, November 16, 1906. 48. “Tuberculosis Congresses,” JAMA (December 12, 1903), 1478. 49. Flick, Beloved Crusader, 205–211; Teller, Tuberculosis Movement, 29–30, 39; “American Anti-­ tuberculosis League,” JAMA 44:17 (April 29, 1905), 1389; “The American Medical Association,” MRR 13:5 (May 1907), 388; “Transactions of the American Anti-­tuberculosis League,” Colorado Medical Journal 11:12 (December 1905), 442–446; Lucian Lamar Knight, A Standard History of Georgia and Georgians, vol. 5 (Chicago: Lewis, 1917), 2597; “Tasteless Wine of Cod-­Liver Oil,” Practical Druggist and Review of Reviews 24 (October 1908), 523; Samuel Hopkins Adams, “The Fundamental Fakes,” Collier’s, February 7, 1906; Manual of Therapeutics Referring Especially to the Products of Parke, Davis and Com­pany (Detroit: Parke, Davis, 1909), 414; “Manual of Therapeutics,” JAMA 53:11 (September 11, 1909), 890. 50. Philip P. Jacobs, The Campaign against Tuberculosis in the United States (New York: National Association for the Study and Prevention of Tuberculosis), 236; “Tuberculosis Congresses,” JAMA, December 12, 1903, 1478. 51. “Laymen Rival the Doctors,” Physician and Surgeon 31:7 (July 1909), 332; Jacobs, Campaign against Tuberculosis, 448; Teller, Tuberculosis Movement, 39, 123.



notes to pages 190–195

503

52. Working Men’s Organ­izations in Local Anti-­tuberculosis Campaigns (New York: National Association for the Study and Prevention of Tuberculosis, 1916); Nancy Tomes, The Gospel of Germs: Men, W ­ omen, and the Microbe in American Life (Cambridge, MA: Harvard University Press, 1998), 212–216; Teller, Tuberculosis Movement, 38, 49. 53. Charles P. Wertenbaker, “My Experiences in Organ­izing Negro Anti-­tuberculosis Leagues,” in James E. McCulloch, ed., The Call of the New South (Nashville: Southern So­cio­log­i­cal Congress, 1912), 216–220; Charles W. Stiles, “Hookworm Disease,” in Biennial Report of the Tennessee Department of Public Health (Nashville: Department of Public Health, 1911), 382; Stiles, “Discovery, Distribution and Consequences of Hookworm Disease,” Tennessee State Medical Journal 3:2 (June 1910), 35; Tomes, Gospel of Germs, 222–232; Marion M. Torchia, “The Tuberculosis Movement and the Race Question, 1890–1950,” BHM 49:2 (Summer 1975), 152–168; John A. Kenney, “Health Prob­lems of the Negroes,” AAAPSS (March 1, 1911), 110–120. 54. Thomas W. Lawson, Frenzied Finance: The Crime of Amalgamated (New York: Ridgeway-­ Thayer, 1905), ix, 413–486; “Dr. Lee K. Frankel,” Medical Insurance 33:5 (April 1924), 504. 55. Diane Hamilton, “The Cost of Caring: The Metropolitan Life Insurance Com­pany’s Visiting Nurse Ser­vice, 1909–1953,” in Patricia D’Antonio, ed., Nurses’ Work: Issues across Time and Place (New York: Springer, 2007), 141–164; Duffy, Sanitarians, 250; “Life Assurance Socie­ties in the Public Health Campaign,” TSJM 5:11 (March 1910), 413; Lee K. Frankel, “Insurance and Home Building,” Survey 26:10 (June 3, 1911), 357–369; “Conservation of Life by Life Insurance Companies,” AAAPSS 70 (March 1917), 82–89. 56. Robert Baker, Before Bioethics: A History of American Medical Ethics from the Colonial Period to the Bioethics Revolution (Oxford: Oxford University Press, 2013), 222; Knopf, History, 65; Teller, Tuberculosis Movement, 42; Jacobs, Campaign against Tuberculosis, 445, 447; Livingston Farrand, “The National Association for the Study and Prevention of Tuberculosis,” JAPHA 1:5 (May 1911), 335, 336. 57. Charles Dickens, American Notes and Pictures from Italy (New York: Scribner’s, 1900), 115, 175– 176, 188; Ventilation of the House of Representatives: Report of the Committee on Ventilation and Acoustics, House Report 853, 53d Cong. (1894), 10; Knopf, History, 217; Robert J. Newton, “The Enforcement of Anti-­spitting Laws,” Transactions of the National Association for the Study and Prevention of Tuberculosis (Philadelphia: Wm. F. Fell, 1910), 109–114, 131. 58. “The Enforcement of Anti-­spitting Laws,” JAMA 44:10 (March 11, 1905), 798; Newton, “Enforcement of Anti-­spitting Laws,” 117; Robert J. Newton, “How the Tuberculosis War Is Spreading throughout the Union,” NYT, June 19, 1910; “Discussion of Papers by Mr. Newton and Dr. Stoll,” Transactions of the National Association for the Study and Prevention of Tuberculosis, (Philadelphia: William F. Fell, 1910), 131; Teller, Tuberculosis Movement, 59, 70. 59. Knopf, History, 143, 144; Hoffman, “Industrial Insurance,” 353; Cynthia A. Connolly and Mary E. Gibson, “The ‘White Plague’ and Color: ­Children, Race, and Tuberculosis in ­Virginia, 1900–1935,” Journal of Pediatric Nursing 26:3 (June 2011), 233; Samuel Kelton Roberts Jr., Infectious Fear: Politics, Disease, and the Health Effects of Segregation (Chapel Hill: University of North Carolina Press, 2009), 136. 60. J. Margo Brooks Carthon, “Life and Death in Philadelphia’s Black B ­ elt: A Tale of an Urban Tuberculosis Campaign, 1900–1930,” Nursing History Review 19 (2011), 29–52; Roberts, Infectious Fear, 63–64. 61. Thomas McKeown and R. G. Rec­ord, “Reasons for the Decline of Mortality in E ­ ngland and Wales during the Nineteenth C ­ entury,” Population Studies 16 (1962), 94–122; McKeown, The Role of Medicine: Dream, Mirage, or Nemesis (London: Nuffield Provincial Hospitals Trust, 1976), 49; Leonard G. Wilson, “The Historical Decline in Tuberculosis in Eu­rope and Amer­ i­ca,” JHM 45:3 (July 1990), 395; Emilia Vynnycky and Paul Fine, “Interpreting the Decline in Tuberculosis,” International Journal of Epidemiology 28:2 (April 1999), 333. 62. Alexis de Tocqueville, Democracy in Amer­i­ca, vol. 2, part 2, chap. 5 (Chicago: University of Chicago Press, 2000 [1835]), 489; “The Preventive Value of the Christmas Seal,” Journal of

504

notes to pages 195–201

Outdoor Life 7:12 (December 1910), 365; Edward O. Otis, The G ­ reat White Plague: Tuberculosis (New York: Thomas W. Crowell, 1909), 206–207. 63. “The Rocke­fel­ler Gift for the Extermination of the Hookworm,” JAMA 53:19 (November 6, 1909), 1568; “The Rocke­fel­ler Commission for the Eradication of Hookworm Disease,” JAMA 56:18 (May 6, 1911), 1332–1333; U.S. House of Representatives, Committee on Interstate and Foreign Commerce, Health Activities of the General Government, pt. 1 (Washington DC: U.S. Government Printing Office, 1910), 44. 64. U.S. Senate, Committee on Public Health and National Quarantine, Hearings to Establish a Department of Health and for Other Purposes (Washington DC: U.S. Government Printing Office, 1910), 133; Chapin, State Public Health Work, 107. 65. “McCormack in V ­ irginia,” JAMA 52:16 (April 17, 1909), 1281.

C H A P T E R 8. H E A LT H OR F R E E D OM

1. “The Washington Campaign: 1908 Messages to Congress,” American Health 2:1 (March 1909), 12; Manfred Waserman, “The Quest for a National Health Department in the Progressive Era,” Bulletin of the History of Medicine 49:3 (Fall 1975), 367; U.S. Senate, National Public Health: Papers, Opinions, Letters, Etc. Relative to the National Public Health (Washington DC: 1910), 5. 2. Lawrence F. Schmeckebier, The Public Health Ser­vice: Its History, Activities, and Organ­ization (Baltimore: Johns Hopkins University Press, 1923), 33. 3. “The Committee of One Hundred,” Science 28:174 (November 13, 1908), 677; Joseph N. McCormack, “In ­Favor of a G ­ reat National Department of Health,” JAMA 51:6 (August 8, 1908), 522; “Bright Prospects for a National Health Department,” TSJM 4:4 (August 1908), 93; U.S. Senate, National Public Health, 7; “Report of the Committee on Organ­ization,” JAMA 54:25 (June 18, 1910), 2064. 4. Health Activities of the General Government, 28; Irving Fisher and Emily F. Robbins, Memorial Relating to the Conservation of ­Human Life (Washington, DC: U.S. Senate, 1912), 40–41; U.S. Senate, National Public Health, 19, 21–22; U.S. House of Representatives, Committee on Interstate and Foreign Commerce, Health Activities of the General Government, pt. 1 (Washington, DC: 1910), 28; “Report of Committee on Conduct of Scientific Work ­under the United States Government,” Science 29:736 (February 5, 1909), 219. 5. “Why the Owen Bill Should Pass,” JAMA 58:2 (January 13, 1912), 122. 6. William Jay Schieffelin, “Work of the Committee of One Hundred on National Health,” AAAPSS 37:2 (March 1911), 77–78; J. Pease Norton, “The Economic Advisability of Inaugurating a National Department of Health,” JAMA 47:13 (September 29, 1906), 1003–1007; National Public Health, 8. 7. “The Public Health Defense League,” JAMA 47:21 (November 24, 1906), 1745; “The Illinois Branch of the Public Health Defense League,” Bulletin of the Chicago Medical Society 6:39 (June 29, 1907), 3–4; Irving Fisher, “Proposed National Department of Health,” Pennsylvania Medical Journal 10:9 (June 1907), 698; “The American Health League,” JAMA 50:14 (April 4, 1908), 1128; John Harvey Kellogg, “The American Health League,” Good Health 43:2 (February 1908), 106–107. 8. “Report of the Committee on Organ­ization,” 2063. 9. Joseph Schumpeter, Ten ­Great Economists from Marx to Keynes (New York: Oxford University Press, 1951), 223; William J. Barber, “Irving Fisher: ­Career Highlights and Formative Influences,” in Hans-­E . Loef and Hans G. Monissen, eds., The Economics of Irving Fisher (Cheltenham, UK: Edward Elgar, 1999), 4; Robert Loring Allen, Irving Fisher: A Biography (Cambridge, MA: Blackwell, 1993), 82, 138–139; Irving Fisher and Eugene Lyman Fisk, How to Live: Rules for Healthful Living Based on Modern Science (New York: Funk and Wagnalls, 1916), 250–271.



notes to pages 201–209

505

10. Irving Fisher, “The Importance of Hygiene for Eugenics,” Proceedings of the First National Conference on Race Betterment (­Battle Creek, MI: Race Betterment Foundation, 1914), 472– 476; “National Conference on Race Betterment,” JAMA 62:7 (February 14, 1914), 566–569; Fisher, “Industrial Hygiene as a ­Factor in H ­ uman Conservation,” Proceedings of the Acad­emy of Po­liti­cal Science in New York 2:2 (January 1912), 4; John B. Andrews, “Industrial Diseases and Occupational Standards,” Survey 24:23 (September  3, 1910), 783; “White Phosphorus,” JAMA 56:14 (April  8, 1911), 1038–1039; Fisher, “The Need for Health Insurance,” American ­Labor Legislation Review 7:9 (1917), 16–18. 11. National Public Health, 7; “Committee of One Hundred to Aid in Securing a Department of Health,” JAMA 48:3 (January 19, 1907), 251–252. 12. Irving Fisher, “Economic Aspect of Lengthening ­Human Life,” February 5, 1909, 1, 2, 7, 8, Fisher Papers, series III, box 5, fol. 366, Sterling Library, Yale University. 13. “Report of Committee on Proprietary Goods,” Proceedings of the National Wholesale Druggists’ Association (New York: Burr, 1906), 254; Schieffelin, “Work of the Committee,” 80–82; Irving Norton Fisher, My ­Father Irving Fisher (New York: Comet Press, 1956), 147–148; Fisher, “Economic Aspect of Lengthening H ­ uman Life,” 9–11; “The Committee of One Hundred on National Health,” Weekly Underwriter 83 (December 3, 1910), 444; “Life Assurance Socie­ties in the Public Health Campaign,” TSJM 5:11 (March 1910), 413; Irving Fisher, “A Department of Dollars vs. a Department of Health,” McClure’s Magazine, July 1910, 330. 14. Robert  L. Owen, “Department of Public Health,” Congressional Rec­ord, March  24, 1910, 3677. 15. Wyatt W. Belcher, “Po­liti­cal Leadership of Robert L. Owen,” Chronicles of Oklahoma 31 (Winter 1953–1954), 361–371; Kenny L. Brown, “A Progressive from Oklahoma,” Chronicles of Oklahoma 62:1 (Spring 1984), 237–248. 16. Owen, “Department of Public Health,” 3656. 17. Ibid., 3654–3656; Philip A. Kalisch, “The Black Death in Chinatown: Plague and Politics in San Francisco, 1900–1904,” Arizona and the West 14:2 (Summer 1972), 127, 129–130. 18. William O. Owen, “Preventable Disease in the Army of the United States,” JAMA (October 26, 1901), 1110–1117. 19. Martha L. Sternberg, George Miller Sternberg: A Biography (Chicago: American Medical Association, 1920), 201–203; Roy Lubove, The Progressives and the Slums: Tenement House Reform in New York City, 1890 (Pittsburgh: University of Pittsburgh Press, 1963), 176; Harold M. Malkin, “The ­Trials and Tribulations of George Miller Sternberg: Amer­i­ca’s First Bacteriologist,” Perspectives in Biology and Medicine 36:4 (Summer 1993), 666–678; George Miller Sternberg, Report of Committee on Building of Model Houses (Washington, DC: President’s Homes Commission, 1908). 20. National Public Health, 137–140, 145–146, 151–281; “Report of Committee on National Department of Health,” JAMA 60:26 (June 28, 1913), 2082. 21. Fisher and Robbins, Conservation of ­Human Life, 56–57; “Why the Owen Bill Should Pass,” JAMA 58:2 (January 13, 1912), 122. 22. “Resolutions Regarding Owen Bill,” JAMA 54:25 (June 18, 1910), 2068; “The Committee on a National Department of Health,” JAMA 56:13 (April 1, 1911), 982. 23. “The Committee of One Hundred of the American Association on National Health,” Science 28:174 (November 13, 1908), 677; NLMF advertisement, Washington Times, May 19, 1910; “100,000 Petition Signers in Ten Days of Advertising,” Printers’ Ink 71:9 (June 2, 1910), 48; “Announcement!,” Medical Freedom 1:4 (December 1911), 16. 2 4. “Sherlock Holmes on the Owen Bill,” JAMA 58:5 (February 3, 1912), 350; “Medical Freedom,” NYT, May 18, 1910; First Report of the National League for Medical Freedom (New York: National League for Medical Freedom, 1910), 8; “100,000 Petition Signers,” 48–49; Congressional Rec­ord, July 6, 1911, 2662.

506

notes to pages 209–215

25. S. Adolphus Kopf, “The Owen Bill for the Establishment of a Federal Department of Health and Its Opponents,” Popu­lar Science Monthly 77:26 (October 1910), 376; Stephen Petrina, “Medical Liberty: Drugless Healers Confront Allopathic Doctors, 1910–1931,” Journal of Medical Humanities 29:4 (December 2008), 208–209. 26. Allen J. Matusow, “The Mind of B. O. Flower,” New ­England Quarterly 34:4 (December 1961), 493–494, 509. 27. B. O. Flower, “The B ­ attle for Medical Freedom,” Twentieth C ­ entury Magazine 4:25 (October 1911), 656–657. 28. B. O. Flower, “National Health and Medical Freedom,” ­Century Illustrated 85:4 (February 1913), 512–513; Owen, “Department of Public Health,” 3652; “A New Combination against the AMA,” JAMA 54:22 (May 28, 1910), 1792; “The Opposition to a Department of Health,” JAMA 55:1 (July 2, 1910), 80. 29. First Report of the NLMF, 8; “The New York Herald and Progressive Medicine,” JAMA 58:4 (January 27, 1912), 281; Morris Fishbein, Morris Fishbein, M.D.: An Autobiography (Garden City, NY: Doubleday, 1969), 36; G. Frank Lydston, “The Rus­sianizing of American Medicine and the American Dreyfus,” Southern Practitioner 32:1 (January 1910), 30. 30. First Report of the NLMF, 4–5; “The Fight for Medical Freedom,” Twentieth C ­ entury Magazine 2:10 (July 1910), 366; Health Activities of the General Government, 200–201. 31. Nevin O. Winter, “Paul Arthur Harsch of North Toledo,” in A History of Northwest Ohio, vol. 2 (Chicago: Lewis, 1917), 1048; “California and Christian Scientists,” JAMA 36:10 (March 9, 1901), 672; “Mrs. Mary Baker Eddy’s Case of Hysteria,” JAMA 48:7 (February 16, 1907), 614. 32. “Christian Science and Medical Prac­ti­tion­ers,” JAMA 33:17 (October 21, 1899), 1049; “Punish the Impostors,” NYT, November 25, 1898; Charles A. L. Reed, “The Medical Inspection of Schools and Medical Freedom,” Journal of Proceedings and Addresses of the Fiftieth Annual Meeting of the National Education Association (Ann Arbor, MI: National Education Association, 1912), 277. 33. “Christian Science Inquiry,” NYT, November 16, 1898; Rennie B. Schoepflin, Christian Science on Trial: Religious Healing in Amer­i­ca (Baltimore: Johns Hopkins University Press, 2003), 140, 164, 179–180, 182; “Bills to Permit Vari­ous Healers to Practice the Healing Art,” Eclectic Medical Journal 77:5 (May 1917), 252; “The Surrender of Eddyism,” JAMA 39:21 (November 22, 1902), 1326; Margery Fox, “Conflict to Coexistence: Christian Science and Medicine,” Medical Anthropology 8:4 (Fall 1984), 294. 34. Petrina, “Medical Liberty,” 212; “Directory of Christian Science Prac­ti­tion­ers,” Christian Science Journal 19:12 (March 1902), xliii; “For Preparedness against Unemployment,” Survey 35:22 (February 26, 1916), 638; Christopher Gray, “Two Congregations Unite, and No. 2 Becomes No. 1,” NYT, December 25, 2005; “List of Churches of Christ, Scientist,” Christian Science Journal 22:12 (March  1904), xxiii; “An Announcement,” Christian Science Journal 39:12 (March 1922), 564; Anne Taylor Kirschmann, A Vital Force: W ­ omen in American Homeopathy (New Brunswick, NJ: Rutgers University Press, 2004), 32; “Fight for Medical Freedom,” 366; Health Activities of the General Government, 200–202; “The Owen Bill,” City Club Bulletin 5:15 (June 8, 1912), 242; “The Lectures,” Christian Science Sentinel, June 16, 1910; “Prayers for Profit,” JAMA 69:25 (December 22, 1917), 2139; U.S. Senate, Committee on Public Health and Quarantine, Proposed Department of Public Health (Washington, DC: U.S. Government Printing Office, 1910), 24–25. 35. B. O. Flower, “The Founder of Christian Science,” Twentieth ­Century Magazine 4 (1911), 52; Matusow, “Mind of B. O. Flower,” 494; “B.O. Flower, Editor, Dies,” NYT, December 25, 1918; B. O. Flower, Christian Science as a Religious Belief and Therapeutic Agent (Boston: Twentieth ­Century, 1910); Charles Sumner Young, Clara Barton: A Centenary Tribute (Boston: Richard G. Badger/Gorham Press, 1922), 192–193; Percy H. Epler, The Life of Clara Barton (New York: Macmillan, 1915), 417.



notes to pages 216–222

507

36. Fisher and Robbins, Conservation of H ­ uman Life, 68–70. 37. Norton, “Economic Advisability,” 1006; Congressional Rec­ord, July 6, 1911, 2665. 38. “A Bad Bunch,” Collier’s, May 6, 1911, 10; U.S. Senate, Committee on the Judiciary, Maintenance of a Lobby to Influence Legislation, vol. 1 (Washington DC: U.S. Government Printing Office, 1913), 256. 39. Earl Mayo, “Public Health against Private Gain,” Pearson’s Magazine 26:4 (October 1911), 446; “Liberty,” Collier’s, June 3, 1911, 9; “Some Officers of the National League for Medical Freedom,” JAMA 57:26 (December 23, 1911), 2091–2092; Nostrums and Quackery, 2nd ed. (Chicago: American Medical Association Press, 1912), 297–301; “Dr. Flower Again Held as Swindler,” NYT, November 24, 1907; Keith Newlin and Joseph B. McCullough, eds., Selected Letters of Hamlin Garland (Lincoln: University of Nebraska Press, 1998), 68–69, 402. 40. “AMA Politicians Arouse Unexpected Opposition,” National Druggist 40:6 (June 1910), 261– 262; Congressional Rec­ord, July 6, 1911, 2666, 2669–2670; B. O. Flower, “Protecting the Health of the ­People,” Twentieth ­Century Magazine 4:23 (August 1911), 467. 4 1. “Report of the Committee on Organ­ization,” 2064; “Opposition to a Department of Health,” 80; First Report of the NLMF, 4–5; “Some Officers of the National League for Medical Freedom,” JAMA 57:26 (December 23, 1911), 2091–2092; “More Freedom,” Collier’s, June 10, 1911, 9; Charles W. Miller, “Proposed National Medical Legislation and the Doctor’s Trust That Is Promoting It,” Twentieth ­Century Magazine 2:11 (August 1910), 424–426; “By His Deeds,” Collier’s, March 1, 1913. 42. “Calls Homeopaths Quacks,” Columbus Medical Journal 32:9 (September 1908), 470; C. S. Carr, A Preacher Preaching to Himself (Columbus: Light of Truth, 1900), 6–20; “Medical Talk,” Clinical Reporter 14:9 (September 1901), 376; “Globules,” American Physician 31:4 (April 1905), 134; “What Tissue Remedies Are D ­ oing,” To-­Morrow 3:10 (October 1907), 82; “Foreword from the Publisher,” Columbus Medical Journal 32:1 (January 1908), 1–4; T. M. Wood­house, “Medical Laws Not Constitutional,” Medical Talk for the Home, January 1906, 304–305. 43. A. F. Stephens, The Essentials of Medical Gynecol­ogy (Cincinnati: Scudder ­Brothers, 1907), 4, 17, 21; “Some Officers of the NLMF,” 2092; Martin Gardner, Fads and Fallacies in the Name of Science (New York: Dover, 1957), 119–122; J. Rodolfo Wilcock, The T ­ emple of Iconoclasts (San Francisco: Mercury House, 1972), 23–24. 4 4. “The Pharmacist and the Nostrum Business,” JAMA 54:2 (January 8, 1910), 136; “Physicians and Pharmacy,” JAMA 54:8 (February 19, 1910), 630–631. 45. “Corporations Could Not Operate ‘Chains,’ ” Phar­ma­ceu­ti­cal Era 42:3 (March, 1910), 237; “American Druggists Syndicate,” JAMA 54:3 (January 15, 1910), 221; “The American Druggists Syndicate,” JAMA 54:4 (January 22, 1910), 304; “Charles H. Huhn,” Northwestern Druggist 27:2 (February 1919), 69. 46. “Government and Public Health,” American Medicine 1:4 (July 1906), 235; B. O. Flower, “Why We Oppose the Bills to Establish a National Department of Health,” Twentieth ­Century Magazine 2:10 (July 1910), 341, 347. 47. “Opposition to a Department of Health,” 80; “Mrs. Eddy and the National League for Medical Freedom,” JAMA 58:8 (February 24, 1912), 559; “Mrs. Eddy Dies of Pneumonia,” NYT, December 5, 1910. 48. “Public Health Ser­vice Bill,” AJPH 2:4 (April 1912), 312; Steven R. Simmerman, “The Mormon Health Traditions: An Evolving View of Modern Medicine,” Journal of Religion and Health 32 (Fall 1993), 190–191. 49. Josiah Francis Gibbs, Lights and Shadows of Mormonism (Salt Lake City: Salt Lake Tribune, 1909), 533; advertisements, Smoot Drug Com­pany, Provo City Eve­ning Dispatch, September 17, 1895; Seventeenth Report of the Dairy and Food Commissioner to the Governor of Connecticut (Hartford: State of Connecticut, 1908), 17; U.S. Senate, Proposed Department of Public Health, pt. 2 (Washington DC: U.S. Government Printing Office, 1910), 209.

508

notes to pages 222–227

50. Waserman, “Quest for a National Health Department,” 365; Twenty-­Seventh Annual Report of the Bureau of Animal Industry for the Year 1910 (Washington, DC: U.S. Department of Agriculture, 1912), 16. 51. Milton Terris, “An Early System of Compulsory Health Insurance in the United States, 1798– 1884,” BHM 15:5 (May 1944), 433–444; Alexander Hamilton, “Report on Marine Hospitals, April 17, 1792,” in Harold C. Syrett, ed., Papers of Alexander Hamilton, vol. 11 (New York: Columbia University Press, 1966), 294–296; Hamilton, “The Utility of Union in Re­spect to Commercial Relations and a Navy,” Federalist Papers, No. 11, 1787; Gautham Rao, “Sailors’ Health and National Wealth: Marine Hospitals in the Early Republic,” Common-­Place 9:1 (October 2008). 52. James H. Cassedy, The New Age of Health Laboratories, 1885–1915 (Bethesda: National Library of Medicine, 1987), 13; “The Marine Hospital Ser­vice and the Proposed National Bureau of Health,” New York Medical Journal 47 (March 24, 1888), 324. 53. Bess Furman, A Profile of the United States Public Health Ser­vice, 1798–1948 (Washington, DC: U.S. Department of Health, Education, and Welfare, 1974), 194–196, 199; Victoria A. Harden, Inventing the NIH: Federal Biomedical Research Policy, 1887–1937 (Baltimore: Johns Hopkins University Press, 1986), 12, 17–20, 26, 61; Twenty-­Fifth Annual Report of the BAI, 9, 37; “The United States Public Health and Marine Hospital Ser­vice,” JAMA 43:10 (September 3, 1904), 666. 54. Wilson G. Smillie, Public Health: Its Promise for the ­Future (New York: Macmillan, 1955), 468. 55. Waserman, “Quest for a National Health Department,” 365. 56. Fisher, “Department of Dollars,” 329; Waserman, “Quest for a National Health Department,” 375; “Opposition to a Department of Health,” 79; “Why the Owen Bill Should Pass,” JAMA 58:2 (January 13, 1912), 122; Waserman, “Quest for National Health Department,” 360–361, 363–365; “Adulterated Preserves,” American Food Journal (March 15, 1909), 22; “Calls MacVeagh Products Impure,” American Food Journal (May 15, 1909), 12; “A Privileged Coward,” American Food Journal (June 15, 1909), 20; F. W. Traphagen, Food Adulteration, Bulletin No. 38, Montana Experiment Station (October 1902), 16; Robert L. Owen, “The Conservation of Life and Health,” Life and Health 25:6 (June 1910), 325. 57. U.S. Senate, Proposed Department of Public Health, 66; “Opposition to a Department of Health,” 80; “Debate in the Senate on the Owen Bill,” JAMA 58:17 (April 27, 1912), 1300–1301; “Further Debate on the Owen Bill,” JAMA 58:19 (May 11, 1912), 1467; “100,000 Petition Signers,” 49; Petrina, “Medical Liberty,” 212–213. 58. W.  B. Clarke, “Police Power and Vaccination,” Columbus Medical Journal 32:9 (September 1908), 475; S. Josephine Baker, Fighting for Life (New York: Macmillan, 1939), 140–142, 163; “Stamping Out Tuberculosis,” California Eclectic Medical Journal 5:1 (January 1912), 40. 59. Proposed Department of Health, 98; Samuel G. Dixon, “Law, the Foundation of State Medicine,” JAMA 48:23 (June 8, 1907), 1926–1927; Strong, Machinations, 58, 60. 60. James Colgrove, State of Immunity: The Politics of Vaccination in Twentieth ­Century Amer­i­ca (Berkeley: University of California Press, 2006), 61; Michael Willrich, Pox: An American History (New York: Penguin Press, 2011), 388n40; Petrina, “Medical Liberty,” 216; Porter F. Cope, “Compulsory Vaccination,” Columbus Medical Journal 32:7 (July 1908), 360–361; Lora C. ­Little, Crimes of the Cowpox Ring: Some Moving Pictures Thrown on the Dead Wall of Official Silence (Minneapolis: Liberator, 1906), 6, 10–58; Gareth Williams, Para­lyzed with Fear: The Story of Polio (New York: Palgrave Macmillan, 2013), 252; Willrich, Pox, 168, 178, 233–240; W. B. Clarke, “State Medicine,” Homeopathic Recorder 25:7 (July 1910), 290. 61. Luther H. Gulick and Leonard P. Ayres, Medical Inspection of Schools (New York: Russell Sage Foundation, 1913), 13, 16–17; “Sixty Nurses,” Bulletin of the Chicago School of Sanitary Inspection 5:50 (December 16, 1911), 302; Petrina, “Medical Liberty,” 216–218; “Stripping Girls,” Medical Freedom 1:5 (January 1912), 4; Congressional Rec­ord, July 6, 1911, 2665.



notes to pages 228–239

509

62. U.S. Senate, United States Public Health Ser­vice, Report No. 619, vol. 2 (Washington, DC: U.S. Government Printing Office, 1912), 2. 63. Health Activities of the General Government, 101. 64. “The Movement for a National Health Department,” JAMA 60:18 (May 3, 1913), 1384–1385; Woodrow Wilson to Irving Fisher, October 20, 1914, Irving Fisher Papers, box 3, fol. 38, Sterling Library, Yale University. 65. Waserman, “Quest for a National Health Department,” 361, 375–377; Furman, United States Public Health Ser­vice, 288; Harden, Inventing the NIH, 38–39. 66. James A. Tobey, “Public Health Legislation,” AJPH 14 (1924), 643; James Alner, “Views of the President on Public Health,” Nation’s Health 3:10 (October 15, 1921), 537–539; Jonathan Davidson, A ­Century of Homeopaths: Their Influence on Medicine and Health (New York: Springer, 2014), 153; “Public Health Notes,” AJPH, 1921, 383. 67. William M. Blair, “Mrs. Hobby Terms F ­ ree Vaccine Idea a Socialistic Step,” NYT, June 15, 1955; “Mrs. Hobby Terms ­Free Shots Costly,” NYT, June 17, 1955; Colgrove, State of Immunity, 122. 68. “Resolutions Regarding Owen Bill,” JAMA 54:25 (June 18, 1910), 2068; Richard Hofstadter, “The Paranoid Style in American Politics,” Harper’s Magazine, November 1962, 77–86; “A.M.A. Politicians Arouse Unexpected Opposition,” National Druggist 40:6 (June 1910), 260; “Bills Before Congress,” Medical ­Century 18:3 (March 1911), 82–83. 69. James Bryce, The American Commonwealth, vol. 1 (London: Macmillan,1889), 295; “Address of T. G. Richardson,” TAMA 29 (1878), 104.

CHAPTER 9. A PL AGUE OF DOCTORS

1. Leartus Connor, “The Prevention of Diseases Now Preying on the Medical Profession,” BAAM 3:9 (October 1898), 4; Joseph N. McCormack et al., “Preliminary Report of the Committee on Organ­ization,” JAMA 36:21 (May 25, 1901), 1441. 2. Frank Billings, “The Limitations of Medicine,” JAMA 31:17 (October 22, 1898), 952. 3. “Competition, Supply and Demand, and Medical Education,” JAMA 11:11 (September 15, 1888), 383; Nathan S. Davis, History of Medical Education and Institutions in the United States (Chicago: S.  C. Griggs, 1851), 119, 177–179; Davis, History of the American Medical Association (Philadelphia: Lippincott, Grambo, 1855), 20–23, 26–28; Isaac Newton Danforth, The Life of Nathan Smith Davis (Chicago: Cleveland Press, 1907), 47; William G. Rothstein, American Physicians in the 19th ­Century: From Sects to Science (Baltimore: Johns Hopkins University Press, 1985), 114–116, 170–171, 174. 4. “Preliminary Report of the Committee on Organ­ization,” JAMA 36:21 (May 25, 1901), 1441. 5. William Pepper, Higher Medical Education, the True Interest of the Public and of the Medical Profession (Philadelphia: Collins, 1894), 29; William G. Eggleston, “Our Medical Colleges,” JAMA 12:21 (May 25, 1889), 747; Charles A. Todd, “Medical Legislation in the State of Missouri,” JAMA 16:15 (April 11, 1891), 533; J. E. Emerson, “The Requirements for Preliminary Education,” JAMA 14:8 (February 2, 1890), 272; Samuel O. L. Potter, “American versus Eu­ro­pean Medical Education,” JAMA 15:3 (July 19, 1890), 81. 6. Davis, History of Medical Education, 183, 187; “The Crowded Medical Curriculum,” JAMA 53:7 (August 14, 1909), 560–561. 7. Pepper, Higher Medical Education, 67; Eggleston, “Our Medical Colleges,” 743, 745; Arthur Dean Bevan, “Medical Education: The Need of a Uniform Standard,” JAMA 51:7 (August 15, 1908), 567; Bevan, “Chairman’s Address, Council on Medical Education,” JAMA 48:20 (May 18, 1907), 1702. 8. Melvin Sudler, “The Prob­lem of Medical Education in Amer­i­ca,” Journal of the Kansas Medical Society 6 (August 1, 1906), 324; “Oversupply of Medical Gradu­ates,” JAMA 37:4 (July 27,

510

notes to pages 239–245

1901), 270; Henry S. Pritchett, “The Obligations of the University to Medical Education,” JAMA 54:14 (April 2, 1910), 1110. 9. “Cabot: Poorest Way to Get Rich,” Boston Daily Globe, March 4, 1910; Remsen Crawford, “Big Salaries and Fees,” Success Magazine, November 1905, 736–737; C. F. Taylor, “The Medical Profession as an Economic F ­ actor,” Medical World 20:3 (March 1902), 126–127; Scott Nearing, Wages in the United States, 1908–1910 (New York: Macmillan, 1914), 127; “The Medical Profession as an Economic F ­ actor,” Cincinnati Lancet- ­Clinic 48 (March 15, 1902), 280. 10. J. J. Taylor, The Physician as a Businessman: How to Obtain the Best Financial Results in the Practice of Medicine (Philadelphia: Medical World, 1891), 23, 83; Charles H. S. Davis, How to Be Successful as a Physician: Heart to Heart Talks of a Successful Physician with His ­Brother Prac­ti­ tion­ers (Meriden, CT: Church, 1902), 18, 59. 11. Eggleston, “Our Medical Colleges,” 742; A. L. Benedict, “The Economics of the Graduation of the Medical Candidates,” JAMA 52:5 (January 30, 1909), 378; “Report of the Council on Medical Education,” JAMA 57:1 (July 1, 1911), 83; James G. Burrow, Or­ga­nized Medicine in the Progressive Era: The Move ­toward Mono­poly (Baltimore: Johns Hopkins University Press, 1977), 14–15. 12. Billings, “Limitations of Medicine,” 952; Davis, History of Medical Education, 118; “Incorporation Laws and Medicine,” JAMA 49:18 (November 2, 1907), 1532; Illinois State Board of Health, Medical Education, Medical Colleges and the Regulation and Practice of Medicine, 1765–1891 (Springfield, IL: Rokker, 1891), 44; Pepper, Higher Medical Education, 66; William Carr, “The Appointment of State Boards of Medical and Dental Examiners,” JAMA 37:1 (July 6, 1901), 5. 13. Abraham Flexner, Medical Education in the United States and Canada (New York: Car­ne­gie Foundation, 1910), 7; Joseph N. McCormack, “The Organ­ization of the Minnesota State Medical Association,” Transactions of the Minnesota State Medical Association (Chicago: American Medical Association, 1904), 43–44; Inez C. Philbrick, “Medical Colleges and Professional Standards,” JAMA 36:24 (June 15, 1901), 1700–1702. 1 4. Billings, “Medical Education,” 1271–1272; Nathan P. Colwell, “The Hospital’s Function in Medical Education,” JAMA 88:11 (March 12, 1927), 781; Bevan, “Medical Education,” 569; James Russell Parsons, “Preliminary Education, Professional Training and Practice in New York,” JAMA 26:24 (June 13, 1896), 1151. 15. George Dock, “Spelling as an Index to the Preparation of the Medical Student,” JAMA 52:15 (April 10, 1909), 1177–1178. 16. Albert L. Gihon, “Medical Education and Medical Ethics,” JAMA 2:2 (January 12, 1884), 30, 32, 35; “The Illinois State Board of Health, and Medical Education,” BMSJ 122:11 (March 13, 1890), 257. 17. Tenth Annual Report of the State Board of Health of Illinois (Springfield, IL: Springfield, 1890), xix; Richard J. Dunglison, “Report on Laws Regulating Medical Practice,” JAMA 16:4 (January 24, 1891), 109–110; “Report of the State Board of Medical Examiners,” Mary­land Medical Journal 50 (July 1907), 283–285. 18. Davis, How to Be Successful, 59, 67; William Osler, “License to Practice,” JAMA 12:19 (May 11, 1889), 649–654; Eggleston, “Our Medical Colleges,” 747. 19. William W. Keen, “The President’s Address,” JAMA 34:23 (June 9, 1900), 1448–1449; Flexner, Medical Education, 87, 210; David C. Humphrey, “The Social Origins of Cadavers in Amer­ i­ca, 1760–1915,” Bulletin of the New York Acad­emy of Medicine 49:9 (September 1973), 823–824. 20. Flexner, Medical Education, 199–200, 237. 21. Bayard Holmes, “The Report of the Bureau of Education on Professional Education,” JAMA 20:2 (January 14, 1893), 41; Keen, “President’s Address,” 1447. 22. “Medical Education and the AMA,” JAMA 4:9 (February 28, 1885), 243; Eggleston, “Our Medical Colleges,” 740–741; William Osler, “License to Practice,” JAMA 12:19 (May  11, 1889), 649–654.



notes to pages 246–252

511

23. “Clinical Teaching of Obstetrics,” JAMA 14:19 (May 10, 1890), 691; “Medical Education and Preliminary Requirements,” JAMA 42:19 (May 7, 1904), 1206; Flexner, Medical Education, 117. 24. J. Whitridge Williams, “Medical Education and the Midwife Prob­lem,” JAMA 58:1 (January 6, 1912), 1, 2; George Clark Mosher, “The Teaching of Obstetrics,” JAMA (August 14, 1909), 572; “Medical Education and Preliminary Requirements,” JAMA 42:19 (May 7, 1904), 1206. 25. W. S. Thayer, “Osler, the Teacher,” Johns Hopkins Hospital Bulletin 30:341 (July 1919), 199; Henry E. Slack, “Prescription Writing and Pharmacy in Our Large Hospitals and Dispensaries,” JAMA 37:3 (July 18, 1896), 143. 26. C. F. Wahrer, “Responsibility of the Medical Profession for the Use of Nostrums,” in Transactions of the Section on Pharmacology and Therapeutics (Chicago: American Medical Association, 1908), 202; Perry Millard, “The L ­ egal Restriction of Medical Practice,” JAMA 13:14 (October 5, 1889), 472; William J. Robinson, “The Relation of the Physician to Proprietary Remedies,” JAMA 43:32 (December  3, 1904), 1679; “The Pressing Need for Propaganda Work,” N.A.R.D. Notes 10:9 (June 2, 1910), 542; Charles Spencer Williamson, “The Responsibility of the Medical Teacher for Existing Conditions,” JAMA 46:18 (May  5, 1906), 1343; W. A. Puckner, “The Nostrum from the Viewpoint of the Pharmacist,” JAMA 46:18 (May 5, 1906), 1340. 27. “The Teaching of Materia Medica and Therapeutics,” JAMA 27:12 (September 19, 1896), 658– 659; Charles Spencer Williamson, “The Attitude of the Physician t­ oward the Nostrum Evil,” ILMJ 10:2 (August 1906), 168, 169, 172. 28. “State Board Examinations and Medical Education,” JAMA 49:7 (August 17, 1907), 605; C. H. Alden, “Examinations in Medicine,” JAMA 28:2 (January 2, 1897), 1. 29. Flexner, Medical Education, 105–124. 30. “Report of the Subcommittee on Hygiene, Medical Jurisprudence and Medical Economics,” AMAB 5:1 (September 15, 1909), 111, 112. 31. James Peter Warbasse, Medical Sociology: Observations Touching upon the Sociology of Health and the Relations of Medicine to Society (New York: Appleton, 1909), 249; Bayard Holmes, “Practical Hygiene in the Medical School,” Lancet-­Clinic 102:17 (October  23, 1909), 452; Davis, History of Medical Education, 189. 32. Ian Robert Dowbiggin, A Merciful End: The Euthanasia Movement in Modern Amer­i­ca (New York: Oxford University Press, 2003), 46; Williams, “Medical Education and the Midwife Prob­lem,” 1–7; Oliver Wendell Holmes, Puerperal Fever as a Private Pestilence (Boston: Ticknor and Fields, 1855); Irvine Loudon, “Maternal Mortality in the Past and Its Relevance to Developing Countries ­Today,” American Journal of Clinical Nutrition 72:1S (August 2000), 243S. 33. Julius Levy, “The Maternal and Infant Mortality in Midwifery Practice in Newark, New Jersey,” American Journal of Obstetrics 77:1 (January 1918), 43–45; S. Josephine Baker, “The Function of the Midwife,” ­Woman’s Medical Journal 23:9 (September 1913), 196–197; Abraham Jacobi, “The Best Means of Combating Infant Mortality,” JAMA 58:23 (June 8, 1912), 1739, 1744. 34. George Bernard Shaw, “Preface on Doctors,” in The Doctor’s Dilemma (Baltimore: Penguin Books, 1954), 53, 65–66; “Report of the Sub-­committee on Hygiene,” 111. 35. “The Neglect of Clinical Teaching,” JAMA 12:10 (March 9, 1889), 343–344; Kenneth M. Ludmerer, “The Plight of Clinical Teaching in Amer­i­ca,” BHM 57:2 (Summer 1983), 224; Ludmerer, “The Rise of the Teaching Hospital in Amer­i­ca,” JHMAS 38:4 (October 1983), 390. 36. Frederick C. Shattuck, “Methods of Teaching Clinical Medicine,” JAMA 21:19 (November 4, 1893), 678. 37. Ludmerer, “Plight of Clinical Teaching,” 223, 228; Gerard N. Burrow, A History of Yale’s School of Medicine: Passing Torches to O ­ thers (New Haven, CT: Yale University Press, 2002), 60–61; Harry F. Dowling, City Hospitals: The Undercare of the Underprivileged (Cambridge, MA: Harvard University Press, 1982), 110.

512

notes to pages 252–259

38. William Sydney Thayer, “Observations on the Teaching of Clinical Medicine,” JAMA 41:1 (July 4, 1903), 3; J. Collins Warren, “Medical Education in the United States,” JAMA 21:11 (September 9, 1893), 381. 39. George Blumer, “The Need of Reor­ga­ni­za­tion in the Methods and Teaching of Therapeutics,” BMSJ 169:8 (August 21, 1913), 265–266; Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth ­Century (Baltimore: Johns Hopkins University Press, 1989), 57– 59. 40. William Osler, “The Fixed Period,” in Aequanimitas (Philadelphia: P. Blakiston’s Son, 1914), 406; Ludmerer, “Plight of Clinical Teaching,” 219–221. 41. W. Franklin Coleman, “Clinical Instruction and the Cook County Hospital,” JAMA 18:9 (February 27, 1892), 273. 42. Thomas A. Davis, “The Clinical Value of the ­Free Dispensary,” JAMA 26:6 (February 8, 1896), 276; W. Franklin Coleman, “Clinical Instruction and the Cook County Hospital,” JAMA 18:9 (February 27, 1892), 272–273; “The Cook County Hospital,” JAMA 27:18 (October 31, 1896), 965, 966; “Chicago Letter,” JAMA 1:3 (July 28, 1883), 9. 43. “The Medical School,” University Rec­ord 3:1 (January 1917), 12; “Cook County Hospital and Politics,” JAMA 35:22 (December 1, 1900), 1412–1413; “Prudery or Politics,” JAMA 38:6 (February 8, 1902), 404–405. 4 4. Dowling, City Hospitals, 40, 90–93; “Hospital Management in St. Louis,” JAMA 48:17 (April 27, 1907), 1438. 45. Abraham Jacobi, “Address Delivered at the Complimentary Dinner Tendered to Dr. Jacobi on His Seventieth Birthday,” in Miscellaneous Addresses and Writings (New York: Critic and Guide, 1909), 439; “Competition, Supply and Demand,” 382–383. On adverse se­lection, see chapter 4, especially note 2. 46. Millard, “­L egal Restriction of Medical Practice,” 472; Theodore L. Hatch, “Whither Are We Tending?,” JAMA 32:1 (January 7, 1899), 39–40; Pepper, Higher Medical Education, 24; Eggleston, “Our Medical Colleges,” 743; “The Commission Evil,” JAMA 31:20 (November  12, 1898), 1183–1184; Melvin Sudler, “The Secret Commission Evil,” JAMA 56:13 (April 1, 1911), 987– 988; Joseph N. McCormack, “Oregon Practically an Unor­ga­nized State,” JAMA 45:24 (December  9, 1905), 1819; “Business Methods and Professional Morals,” JAMA 46:10 (March  10, 1906), 727–728. 47. “Competition, Supply and Demand,” 382–383; “Graft in the Medical Profession,” Medical Visitor 20:8 (August  1904), 296; “The Car­ne­gie Foundation Report on Medical Education,” JAMA 54:24 (June 11, 1910), 1949. 48. Davis, How to be Successful, 67; Pepper, Higher Medical Education, 29, 66. 49. Davis, History of Medical Education, 180, 183, 187; Danforth, Life of Nathan Smith Davis, 43– 45, 47, 112; Pepper, Higher Medical Education, 24, 61. 50. Nathan S. Davis, Contributions to the History of Medical Education and Medical Institutions in the United States, 1776–1876 (Washington, DC: U.S. Bureau of Education, 1876), 44, 48; Pepper, Higher Medical Education, 29; Bevan, “Medical Education,” 566–567. 51. Stephen Joseph Ross, “Freed Soil, Freed ­L abor, Freed Men: John Eaton and the Davis Bend Experiment,” Journal of Southern History 44:2 (May 1978), 213–232; Report of the Commissioner of Education for the Year, 1882–83 (Washington, DC: U.S. Department of Education, 1184), clxviii, clxix; Report of the Commissioner of Education for the Year, 1892–93, vol. 2 (Washington, DC: U.S. Department of Education, 1895), 1620. 52. “Competition, Supply and Demand,” 382–383. 53. Eggleston, “Our Medical Colleges,” 745–746; Theodore W. Schaeffer, “Contract Practice and Other Social Evils That Are a Menace to the Medical Profession,” Medical Council 18:9 (September 1913), 359–360.



notes to pages 260–267

513

C H A P T E R   1 0 . U N N A T U R A L S E ­L E C T I O N AND INTELLIGENT DESIGN

1. Jacob Gould Schurman, “The Relations of the University to the Medical School,” JAMA 54:16 (April 16, 1910), 1281. 2. Franklin Staples, “Concerning Medical Education in the United States: A Brief History,” JAMA 27:21 (November 21, 1896), 1100; Henry K. Beecher and Mark D. Altschule, Medicine at Harvard: The First 300 Years (Hanover, NH: University Press of New E ­ ngland, 1977), 87. 3. This discussion of Harvard relies on Kenneth M. Ludmerer, Learning to Heal: The Development of American Medical Education (Baltimore: Johns Hopkins University Press, 1985), 48– 53; Ludmerer, “Reform at Harvard Medical School, 1869–1909,” BHM 55:3 (Fall 1981), 343–350; Beecher and Altschule, Medicine at Harvard, 87–96; Henry James, Charles W. Eliot: President of Harvard University, 1869–1909 (Boston: Houghton Mifflin, 1930), 278–290; Charles W. Eliot, “The New Education,” Atlantic Monthly 23 (February 1869), 203. 4. Ludmerer, Learning to Heal, 49; Hugh Hawkins, Between Harvard and Amer­i­ca: The Educational Leadership of Charles W. Eliot (New York: Oxford University Press, 1972), 60; Charles W. Eliot, “Oliver Wendell Holmes,” Harvard Gradu­ates’ Magazine 31:124 (June 1923), 460; James, Eliot, 281–283. 5. Eliot, “Holmes,” 460; James, Eliot, 459; Charles W. Eliot, Harvard Memories (Cambridge, MA: Harvard University Press, 1923), 28; Henry J. Bigelow, Medical Education in Amer­i­ca (Cambridge, MA: Welch, Bigelow, 1871), 13, 17, 58–60, 73–76, 79–82. 6. Eliot, Harvard Memories, 31–33; Charles W. Eliot, “The Traditions of Harvard College,” Harvard Alumni Bulletin 24:24 (March 16, 1922), 563–564. 7. Fifth Annual Report of the Female Medical Education Society, and the New E ­ ngland Female Medical College (Boston: Female Medical Education Society, 1854), 3–10; “The Medical School,” Harvard Register 1:2 (January 15, 1880), 23; Thomas Francis Harrington, The Harvard Medical School: A History, Narrative and Documentary, vol. 3 (New York: Lewis, 1905), 1223–1235. 8. Harrington, Harvard, 1224; Hawkins, Between Harvard and Amer­i­ca, 194, 357; Carla Bittel, Mary Putnam Jacobi and the Politics of Medicine in Nineteenth C ­ entury Amer­i­ca (Chapel Hill: University of North Carolina Press, 2009), 204–225. 9. Thomas Neville Bonner, To the Ends of the Earth: ­Women’s Search for Education in Medicine (Cambridge, MA: Harvard University Press, 1992), 124, 144; ­Women’s Medical Association of New York City, ed., Mary Putnam Jacobi: A Pathfinder in Medicine (New York: Putnam, 1925), 394–395; James R. Chadwick, The Study and Practice of Medicine by ­Women (New York: A. S. Barnes, 1879), 470; John T. Cumbler, From Abolition to Rights for All: The Making of a Reform Community in the Nineteenth ­Century (Philadelphia: University of Pennsylvania Press, 2008), 120–123; Henry I. Bowditch, “The Medical Education of ­Women: The Pre­sent Hostile Position of Harvard University and of the Mas­sa­chu­setts Medical Society,” BMSJ 105:13 (September 29, 1881), 289–293. 10. “Harvard University and Female Physicians,” BMSJ 102:4 (January 22, 1880), 88; Harrington, Harvard Medical School, 1243. 11. “Discussion on Preliminary Education and the Suggested Standard Medical College,” JAMA 50:19 (May 30, 1908), 1836. 12. Albert L. Gihon, “Medical Education and the Fundamental Facts in Medical Ethics,” JAMA 2:2 (January 12, 1884), 32; Vincent Lo Re III and Lisa M. Bellini, “William Pepper, Jr., M.D. (1843–1898): Portrait of a Nineteenth-­Century Medical Educator,” Journal of Medical Biography 14:3 (August 2006), 173; Pepper, Higher Medical Education, 21–22, 24–25, 29. 13. Pepper, Higher Medical Education, 61; Horatio C. Wood, “Medical Education in the United States,” Lippincott’s Magazine 16 (December 1875), 708–711.

514

notes to pages 268–275

1 4. Lo Re and Bellini, “William Pepper,” 171; “Alumni Notes: The William Pepper Laboratory of Clinical Medicine,” University Medical Magazine 8 (January 1896), 287–288. 15. Thomas S. Huddle, “Competition and Reform at the Medical Department of the University of Pennsylvania, 1847–1877,” JHM 51:3 (July 1996), 286–289; Edward Potts Cheyney, History of the University of Pennsylvania, 1740–1940 (Philadelphia: University of Pennsylvania Press, 1940), 274–276. 16. Catherine J. Whitaker, The Early Years of the University of Michigan Medical School (Ann Arbor: University of Michigan, 1982), 7–8; John S. Brubacher and Willis Rudy, Higher Education in Transition: An American History, 1636–1956 (New York: Harper and ­Brothers, 1958), 362; Richard Rees Price, The Financial Support of the University of Michigan (Cambridge, MA: Harvard University Press, 1923), 35; Charles A. Sink, “Legislature Meets University’s Needs,” Michigan Alumnus 41:22 (June 8, 1935), 407; Elizabeth M. Farrand, History of the University of Michigan (Ann Arbor: Register, 1885), 218–219. 17. Ludmerer, Learning to Heal, 56–57; Henry S. Frieze, Memorial of Alonzo Benjamin Palmer (Cambridge, MA: Riverside, 1890), 144, 184. 18. “States, Municipalities and Medical Education,” JAMA 51:7 (August 15, 1908), 606–607; Brubacher and Rudy, Higher Education, 157, 362. 19. Kathleen W ­ aters Sander, Mary Elizabeth Garrett: Society and Philanthropy in the Gilded Age (Baltimore: Johns Hopkins University Press, 2008), 95; Patrick Macaulay, Medical Improvement (Baltimore: Lucas and Coale, 1824), 28–34; Franklin Parker, “Influences on the Founder of the Johns Hopkins University and the Johns Hopkins Hospital,” BHM 34:2 (March–­ April 1960), 148–153; John C. French, “Mr. Johns Hopkins and Dr. Macaulay’s ‘Medical Improvement,’ ” BHM 27:6 (November–­December 1953), 562–566. 20. Alan M. Chesney, The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine, Volume 1: Early Years, 1867–1893 (Baltimore: Johns Hopkins University Press, 1943), 30, 31, 36–37, 47; Gert Brieger, “The California Origins of the Johns Hopkins Medical School,” BHM 51:3 (Fall 1977), 346–347; John Shaw Billings, “Suggestions on Medical Education,” Bulletin of the Institute of the History of Medicine 6 (January 1, 1938), 314; Carleton B. Chapman, Order out of Chaos: John Shaw Billings and Amer­i­ca’s Coming of Age (Boston: Boston Medical Library, 1994), 99–105; Thomas S. Huddle and Jack Ende, “Osler’s Clinical Clerkship,” JHM 49:4 (October 1994), 484, 486–495. 21. Sander, Garrett, 78–79, 124–127, 149, 159–160; Chesney, Johns Hopkins Hospital, 204. 22. Sander, Garrett, 98, 124–127, 149, 159–160. 23. Ibid., 160–174; Charles W. Calhoun, Benjamin Harrison (New York: Times Books, 2005), 39– 40, 91–92; John Eaton, “Sheldon Jackson, Alaska’s Apostle and Pioneer,” Review of Reviews 13 (June 1896), 695; “In Honor of Mrs. Harrison,” NYT, November 15, 1890. 2 4. Helen Lefkowitz Horo­witz, The Power and Passion of M. Carey Thomas (New York: Knopf, 1994), 236–237; Donald Fleming, William H. Welch and the Rise of Modern Medicine (Baltimore: Johns Hopkins University Press, 1954), 98–99; Simon Flexner and James Thomas Flexner, William Henry Welch and the Heroic Age of American Medicine (Baltimore: Johns Hopkins University Press, 1993), 217; Mary Roth Walsh, “Doctors Wanted: No W ­ omen Need Apply”: Sexual Barriers in the Medical Profession, 1835–1925 (New Haven, CT: Yale University Press, 1977), 177; Chesney, Johns Hopkins Hospital, 197; Sander, Garrett, 164, 176–182, 194. 25. Report of the Commissioner of Education, 1892–1893, 1618, 1628. 26. J. W. Holland, “The Association of American Medical Colleges,” BAAM 3:6 (April 1898), 369; Dean F. Smiley, “History of the Association of American Medical Colleges, 1876–1956,” Journal of Medical Education 32:7 (July 1957), 512–514. 27. “The Illinois Report on Medical Education,” JAMA 12:9 (March 2, 1889), 308–309; “The Illinois State Board of Health, and Medical Education,” BMSJ 122:11 (March 13, 1890), 257; “Dr. John H. Rauch Resigns the Illinois State Board of Health,” ­Virginia Medical Monthly



notes to pages 275–282

515

18:6 (September 1891), 515; Perry Millard, “The L ­ egal Restriction of Medical Practice,” JAMA 13:14 (October 5, 1889), 472; Report of the Commissioner of Education, 1892–1893, 1617. 2 8. Sanitarian 32:293 (April  1894), 420–422; “The Late John  H. Rauch, M.D.,” JAMA 22:13 (March 31, 1894), 471. 29. John H. Rauch, “Address in State Medicine,” JAMA 6:24 (June 12, 1886), 646; “Obituary: John H. Rauch, M.D.,” 421. 30. J. Collins Warren, “Medical Education in the United States,” JAMA 21:11 (September 9, 1893), 378. 31. Fifth Annual Report of the Illinois State Board of Health (Springfield, IL: Rokker, 1883), 3–5. 32. “The Illinois Medical Practice Act,” New York Medical Journal 39 (June 14, 1884), 680; “Supreme Court of Missouri; Decision Relating to State Board of Health,” St. Louis Courier of Medicine 13:1 (January 1885), 36–39; Dent v. West ­Virginia, 29 U.S., 114; John M. Harris, Professionalizing Medicine: James Reeves and the Choices That S­ haped American Health Care (Jefferson, NC: McFarland, 2019), 133–141, 154–155; James C. Mohr, in Licensed to Practice: The Supreme Court Defines the American Medical Profession (Baltimore: Johns Hopkins University Press, 2013), 139–154. 33. Rauch, “Address in State Medicine,” 647; George Homan, “A Pioneer in the Fight against Quackery,” JAMA 51:23 (December 5, 1908), 1989; Illinois State Board of Health, Medical Education, Medical Colleges and the Regulation and Practice of Medicine in the United States and Canada, 1765–1891 (Springfield, IL: Rokker, 1891), xxi–­x xii; “Dr. John H. Rauch,” JAMA 17:2 (July 11, 1891), 79; Warren, “Medical Education,” 378. 34. According to Haller, schools in the 1890s “simply required a diploma,” suggesting any diploma at all. John S. Haller, American Medicine in Transition, 1840–1910 (Urbana: University of Illinois Press, 1981), 223. Bonner says only that the “voluntary efforts of medical educators” and their allies in universities brought reform. Thomas N. Bonner, Becoming a Physician: Medical Education in Britain, France, Germany, and the United States, 1750–1945 (Baltimore: Johns Hopkins University Press, 1995), 284. Rothstein, however, gives some due credit to state action. William Rothstein, American Physicians in the Nineteenth ­Century (Baltimore: Johns Hopkins University Press, 1992), 286. 35. Ludmerer, Learning to Heal, 235, 326–327n6; William T. Slayton, “Higher Medical Education,” Transactions of the Vermont State Medical Society (Montpelier: Vermont State Medical Society, 1898), 188–189; Slayton, “Licenses to Practice,” JAMA 30:17 (April 23, 1898), 995. 36. Ludmerer, Learning to Heal, 326–327n6. 37. Holland, “Association,” 371; William Warren Potter, “The Relation of State Examining Boards to the State, to the Schools and to Each Other,” JAMA 36:20 (May 16, 1896), 952. 38. “Medical Standards and Medical Teaching,” JAMA 30:7 (September 1896), 657; William T. Slayton, Medical Education and Registration, United States and Canada (Burlington, VT: Lamoile, 1897), 76–86. 39. Illinois State Board of Health, Conspectus of the Medical Colleges of Amer­i­ca (Springfield, IL: Rokker, 1884), xxvi; Eggleston, “Our Medical Colleges,” 745. 40. “The Diploma vs. Examination,” JAMA 40:8 (February 21, 1903), 522; Holland, “Association,” 372; J. E. Emerson, “The Requirements for Preliminary Education,” JAMA 14:8 (February 22, 1890), 271–272. On adverse se­lection, see chapter 4, especially note 2. 4 1. Journal of the Senate of the Thirty-­First General Assembly of the State of Illinois (Springfield, IL: Weber, 1879), 421; “In Memoriam: Death of Dr. John H. Rauch,” Tenth Annual Report of the State Board of Health of the Commonwealth of Pennsylvania (Harrisburg: Pennsylvania State Board of Health and Vital Statistics, 1895), 392; Rauch and Reynolds, “John Henry Rauch,” 105, 107; J. F. Percy, “Dr. John H. Rauch: A Pioneer in the Fight against Quackery,” JAMA 51:24 (December 12, 1908), 2074. 42. “A Memorial to Dr.  John  H. Rauch,” ILMJ 15:1 (January  1909), 59; “State Items,” Medical Standard 2:3 (September  1887), 93; “The Cases of Drs. McCoy and Wildman,” Medical

516

notes to pages 282–289

and Surgical Reporter 60:4 (January 26, 1889), 121; “The State Board of Health of Illinois,” St. Louis Medical and Surgical Journal 61:1 (January 1889), 67; “Dr. John H. Rauch Resigns,” 515. 43. Winton U. Solberg, Reforming Medical Education: The University of Illinois College of Medicine, 1880–1920 (Urbana: University of Illinois Press, 2009), 144; Perry H. Millard, “The Propriety and Necessity of State Regulation of Medical Practice,” JAMA 9:16 (October 15, 1887), 491; “Dr. J. H. Rauch,” Western Druggist 13:7 (July 1891), 248; “The Arrogance of Quackery,” New York Medical Journal 51:26 (June 28, 1890), 728. 4 4. Cyrus H. Rauch and Arthur R. Reynolds, “John Henry Rauch, M.D.,” Bulletin of the Society of Medical History of Chicago 1:2 (August 1912), 104, 106; “Dr. John H. Rauch Resigns,” Chicago Daily Tribune, June 13, 1889; “Dr. Rauch Steps Out,” Chicago Daily Tribune, February 14, 1890; “Desire the Reinstatement of Rauch,” Chicago Daily Tribune, July 16, 1891; “Dr. Rauch ­Will Retire,” Chicago Daily Tribune, June 29, 1891; “The Medical Profession and John H. Rauch,” JAMA 52:2 (January 9, 1909), 106, 117. 45. Solberg, Reforming Medical Education, 144, 146–147; “The Aurora Meeting,” ILMJ 19:6 (June 1911), 757; “Physicians’ Club of Chicago,” ILMJ 7:2 (February 1905), 186–195; “Scores Chicago’s Medical Schools,” Chicago Daily Tribune, June 6, 1910; John L. Fogle to Abraham Flexner, June 23, 1909, box 22F, Abraham Flexner papers, Manuscript Division, U. S. National Archives, Washington, DC. 46. “A Quarter ­Century’s Pro­gress in Medical Education,” JAMA 85:8 (August 22, 1925), 610; Marie J. Mergler, “Quid Custodiet ipsos Custodes?,” JAMA 24:16 (April 20, 1895), 604; “Proposed Medical Legislation in Illinois,” JAMA 32:6 (February 11, 1899), 316; Joseph N. McCormack, “Organ­ization Work in Illinois,” JAMA 48:2 (January 12, 1907), 169; Arthur D. Bevan, “Report of the Council on Medical Education,” JAMA 46:24 (June 16, 1906), 1853–1855. 47. Victor C. Vaughn, A Doctor’s Memories (Indianapolis: Bobbs-­Merrill, 1926), 439; “State Boards of Health Convene,” Chicago Daily Tribune, May 20, 1890; George W. Webster, “The Medical Profession and John H. Rauch,” JAMA 52:2 (January 9, 1909), 147; M. Guilford, “The Burial Place of Dr. John H. Rauch,” JAMA 51:26 (December 26, 1908), 2228; Rauch and Reynolds, “John Henry Rauch,” 108. 48. Illinois State Board of Health, Medical Education, Medical Colleges, and Regulation, xxi–­x xii. 49. John H. Roberts, “The L ­ egal Control of Medical Practice by a State Examination,” JAMA 4:10 (March 7, 1885), 257. 50. Martin Allen Shefter, “Party and Patronage: Germany, E ­ ngland, and Italy,” Politics and Society 7:4 (December 1977), 403–450.

C H A P T E R   1 1 . A ­G R E A T W A V E O F I M P R O V E M E N T

1. Arthur Dean Bevan, “Cooperation in Medical Education and Medical Ser­vice,” JAMA 90:15 (April 14, 1928), 1175. 2. See Proceedings of the National Confederation of State Medical Examining and Licensing Boards, June 7, 1909 [hereafter Proceedings of the CSMB, 1909]; and Proceedings of the National Confederation of State Medical Examining and Licensing Boards, June 6, 1910 [hereafter Proceedings of the CSMB, 1910]. 3. Robert B. Ludy, Answers to Questions Prescribed by Medical State Boards (Philadelphia: McVey, 1905); Proceedings of the CSMB, 1909, 56; Proceedings of the CSMB, 1910, 22, 55. 4. Proceedings of the CSMB, 1909, 35; Proceedings of the CSMB, 1910, 68–69, 96–97. 5. William Carr, “The Appointment of State Boards of Medical and Dental Examiners,” JAMA 37:1 (July 6, 1901), 6; Proceedings of the CSMB, 1910, 54. 6. Mark D. Bowles and V ­ irginia P. Dawson, With One Voice: The Association of American Medical Colleges, 1876–2002 (Washington, DC: Association of American Medical Colleges, 2003), 36–37; Proceedings of the CSMB, 1909, 34–35.



notes to pages 290–300

517

7. Frank Billings, “Medical Education in the United States,” JAMA 40:19 (May 9, 1903), 1271, 1272, 1276. 8. “The Campaign and Election of 1912,” ILMJ 22:6 (December 1912), 729–730. 9. Arthur Dean Bevan, “Chairman’s Address,” JAMA 48:20 (May 18, 1907), 1701–1702. 10. Ibid., 1707; “Council on Medical Education,” JAMA 44:18 (May 6, 1905), 1470; “Standards of Medical Education,” JAMA 47:8 (August 25, 1906), 627. 11. Bevan, “Chairman’s Address,” 1702. 12. “The Influence of the Car­ne­gie Foundation on Medical Education,” JAMA 53:7 (August 14, 1909), 56; Bevan, “Chairman’s Address,” 1702; Bevan, “Cooperation in Medical Education,” 1175. 13. Bevan, “Chairman’s Address,” 1705–1706; Arthur Dean Bevan, “Report of the Council on Medical Education,” JAMA 46:24 (June 16, 1906), 1853. 1 4. “Council on Medical Education,” JAMA 50:19 (May 9, 1908), 1544–1546; “Council on Medical Education,” JAMA 50:20 (May 16, 1908), 1637–1638, 1645. 15. “State Board Examinations during 1904,” JAMA 44:18 (May 6, 1905), 1454–1456; Bevan, “Cooperation,” 1174–1175; Bevan, “Report of the Council” (1906), 1853; Bevan, “Cooperation in Medical Education,” 1174–1176; “Report of the Reference Committee on Medical Education,” JAMA 54:25 (June 18, 1910), 2061–2062; “Medical Colleges of the United States,” JAMA 55:8 (August 20, 1910), 679. 16. Bevan, “Cooperation in Medical Education,” 1175–1176. 17. Abraham Flexner, Medical Education in the United States and Canada: A Report to the Car­ne­gie Foundation for the Advancement of Teaching (Boston: Updike, Merrymount, 1910), 167, 170–171. 18. Ibid., 200, 206, 242; Flexner, Henry S. Pritchett: A Biography (New York: Columbia University Press, 1943), 111. 19. Flexner, Medical Education, 162–164, 253. 20. Ibid., 162, 190, 205. 21. Ibid., 59–160, 241, 284. 22. Ibid., 32, 170, 210, 212, 213, 216. 23. Bevan, “Report of the Council” (1906), 1853. 2 4. Ibid., 1855. 25. “Yellow Medicine,” St. Louis Medical Review 49:6 (February 6, 1904), 87; George A. Gilbert, “A Word for Venesection,” New ­England Medical Monthly 23:2 (February 1904), 63; Arthur Dean Bevan, “Unnecessary Operations on W ­ omen,” Buffalo Medical Journal 62:5 (December 1906), 283–285; “Are Gynecologists Ignorant or Unscrupulous?,” Chicago Clinic 19:12 (December 1906), 380–381. 26. Carl E. Black, “Medical Education in Illinois,” ILMJ 17:2 (February 1910), 190–194; James A. Egan, “Medical Education in Illinois,” ILMJ 17:3 (March 1910), 338–344; Black, “Medical Education in Illinois,” ILMJ 17:3 (March 1910), 344–348; “Letter from Dr. J. A. Egan,” ILMJ 17:4 (April 1910), 491–496; “Adams County Passes Resolutions on Medical Education,” ILMJ 17:5 (May 1910), 638. 27. Flexner, Pritchett, 108; Thomas Neville Bonner, Iconoclast: Abraham Flexner and a Life in Learning (Baltimore: Johns Hopkins University Press, 2002), 74; Robert Bocking Stevens, Law School: ­Legal Education in Amer­i­ca from the 1850s to the 1980s (Union, NJ: Lawbook Exchange, 2001), 112. 28. “Report of the Committee on Organ­ization,” JAMA 46:2 (June 16, 1906), 1870. 29. “Minutes of Business Meeting of the Council on Medical Education,” December 28, 1908, quoted in Kenneth M. Ludmerer, Learning to Heal: The Development of American Medical Education (Baltimore: Johns Hopkins University Press, 1985), 314n9; Henry S. Pritchett to Arthur Dean Bevan, November 4, 1909, Car­ne­gie Foundation for the Advancement of Teaching, 44/6 [AMA 1909–1914, Series IIIA], Columbia University, Butler Library. 30. Bonner, Iconoclast, 63, 66–68, 317–318; Abraham Flexner, The American College: A Criticism (New York: C ­ entury, 1908); Michael Nevins, Abraham Flexner: A Flawed American Icon (Bloomington, IN: iUniverse, 2010), 2–3.

518

notes to pages 300–308

31. Abraham Flexner, I Remember: The Autobiography of Abraham Flexner (New York: Simon and Schuster, 1940), 115; Bonner, Iconoclast, 77; Morris Fishbein, A History of the American Medical Association, 1847 to 1947 (Philadelphia: W. B. Saunders, 1947), 893; Flexner, Medical Education, viii. 32. “Medical Evil Is Pointed Out,” Los Angeles Times, June 6, 1910; “Scores Chicago’s Medical Schools,” Chicago Daily Tribune, June 6, 1910; “Too Many Physicians,” WaPo, June 7, 1910; “The Making of Doctors,” NYT, June 12, 1910; “Factories for the Making of Ignorant Doctors,” NYT, July 24, 1910. 33. “Flays Medical Schools,” Baltimore Sun, June 6, 1910; “Another Bombshell for Medical Schools,” Baltimore Sun, June 18, 1912; “The University of Mary­land and Dr. Flexner’s Criticism as Means to Get The Hopkins Some of the Car­ne­gie Funds,” Baltimore Sun, June 8, 1910; “Dr. Streett Protests,” Baltimore Sun, June 20, 1910; “Scores Flexner Report,” Baltimore Sun, June 7, 1901; Flexner, Medical Education, 32, 237–238. 34. Bonner, Iconoclast, 307; Flexner, I Remember, 131. 35. “The Report of the Car­ne­g ie Foundation on Medical Education,” Medical Rec­ord 77:26 (June 25, 1910), 1097; “The Car­ne­gie Foundation,” NYSJM 10:11 (November 1910), 483–484. 36. “The Car­ne­gie Foundation Report,” JAMA 54:24 (June 11, 1910), 1949. 37. Henry S. Pritchett to Nathan P. Colwell, December 26, 1912; Colwell to Pritchett, December 30, 1912; George H. Simmons to Pritchett, December 30, 1912, Car­ne­gie Foundation for the Advancement of Teaching, 44/6 [AMA 1909–1914, series IIIA], Columbia University, Butler Library; Henry S. Pritchett to Nathan P. Colwell, January 31, 1913; Colwell to Pritchett, February 4, 1913, Car­ne­gie Foundation for the Advancement of Teaching, 44/6 [AMA 1909– 1914, Series IIIA], Columbia University, Butler Library. 38. Arthur Dean Bevan to Henry S. Pritchett, February 5, 1913; Bevan to Pritchett, February 15, 1913; Nathan P. Colwell to Pritchett, March 19, 1913; Pritchett to Bevan, March 5, 1915, Car­ne­ gie Foundation for the Advancement of Teaching, series IIIA, box 44, fol. 6 (AMA 1909–1914), Butler Library, Columbia University. 39. Loyal Davis, Fellowship of Physicians: A History of the American College of Surgeons (Chicago: American College of Surgeons, 1973), 216–221; James S. Roberts et al., “A History of the Joint Commission on Accreditation of Hospitals,” JAMA 258:7 (August 21, 1987), 938. 40. Flexner, Pritchett, 111; Donna Bingham Munger, “Robert Brookings and the Flexner Report,” JHM 23:4 (October 1968), 358; Flexner, Medical Education, 254–255. 41. Flexner, Medical Education, 89; “Attacks Hospital Men,” New York Tribune, September 22, 1911; Abraham Flexner, “Hospitals, Medical Education, and Research,” Transactions of the American Hospital Association 13 (September 19–22, 1911), 363–373. 42. Ernest Victor Hollis, Philanthropic Foundations and Higher Education (New York: Columbia University Press, 1938), 210; “Choice of a Medical School,” JAMA 63:8 (August 22, 1914), 691; “Well Recognized Medical Schools,” Monthly Bulletin of the Federation of State Medical Boards 3:7 (October 1917), 196; “Report of the Council on Medical Education,” JAMA 72:24 (June 14, 1919), 1752; “Choice of a Medical School,” JAMA 79:8 (August 19, 1922), 638; “State Board Statistics for 1921,” JAMA 78:17 (April 29, 1922), 1305. 43. Robert P. Hudson, “Abraham Flexner in Perspective,” BHM 46:6 (November–­December 1972), 545; William G. Rothstein, American Medical Schools and the Practice of Medicine (New York: Oxford University Press, 1987), 146–147; George E. Vincent, “The Needs and ­Future of Medical Education,” JAMA 74:11 (March 13, 1920), 759. 4 4. Bevan, “Report of the Council” (1906), 1853; Council on Medical Education,” JAMA 48:20 (May 18, 1907), 1703; Munger, “Brookings and Flexner,” 363. 45. Ludmerer, Learning to Heal, 187, 191–192. 46. Ibid., 151, 192–193, 198, 204, 228–229; Steven C. Wheatley, The Politics of Philanthropy: Abraham Flexner and Medical Education (Madison: University of Wisconsin Press, 1988), 57; Abraham Flexner, Abraham Flexner: An Autobiography (New York: Simon and Schuster, 1960), 81–83, 180–185.



notes to pages 308–319

519

47. “Purses of Rich Folks Wide Open During 1910,” Atlanta Constitution, January  1, 1911; “$163,197,125 Given in 1910 for Philanthropy,” NYT, January 1, 1911; Sanford Jacoby, Modern Manors: Welfare Capitalism since the New Deal (Prince­ton, NJ: Prince­ton University Press, 1997); Olivier Zunz, Philanthropy in Amer­i­ca: A History (Prince­ton, NJ: Prince­ton University Press, 2012). 48. Winton U. Solberg, Reforming Medical Education: The University of Illinois College of Medicine, 1880–1920 (Chicago: University of Illinois Press, 2009), 151–156; Wheatley, Politics of Philanthropy, 101–106; Joel L. Fleishman, J. Scott Kohler, and Steven Schindler, Casebook for the Foundation: A ­Great American Secret (New York: Perseus, 2007), 10; Hudson, “Abraham Flexner in Perspective,” 561. 49. Inez C. Philbrick, “Medical Colleges and Professional Standards,” JAMA 36:24 (June 15, 1901), 1700–1702; “Dr. Inez Cecelia Philbrick,” Find a Grave, https://­w ww​.­findagrave​.­com​/­memorial​ /­117032985​/­inez​-­cecelia​-­philbrick. 50. Mary Putnam Jacobi, “­Shall W ­ omen Practice Medicine?” [1882], in W ­ omen’s Medical Association of New York City, ed., Mary Putnam Jacobi: A Pathfinder in Medicine (New York: Putnam, 1925), 367. 51. Flexner, Medical Education, 112, 178, 296; “Classification of Medical Colleges,” JAMA (August 19, 1922), 644; Thomas Neville Bonner, To the Ends of the Earth: W ­ omen’s Search for Education in Medicine (Cambridge, MA: Harvard University Press, 1992), 145, 156; Mary Roth Walsh, “Doctors Wanted: No W ­ omen Need Apply”: Sexual Barriers in the Medical Profession, 1835– 1925 (New Haven, CT: Yale University Press, 1977), 193, 242–243; Regina Morantz-­Sanchez, Sympathy and Science: W ­ omen Physicians in American Medicine (Chapel Hill: University of North Carolina Press, 2000), 249. 52. Flexner, Medical Education, 178–179; Walsh, “Doctors Wanted,” 219–224; Bonner, To the Ends of the Earth, 156–159; Morantz-­Sanchez, Sympathy and Science, 254; Reginald Fitz, “The Confused State of the Internship,” JAMA 116:11 (March 15, 1941), 1037; Stiles D. Ezell, “­Future of the Internship from the Standpoint of the State Licensing Board,” JAMA 158:13 (July 30, 1955), 1161; Bureau of ­L abor Statistics, Occupational Outlook Handbook (Washington, DC: U.S. Department of L ­ abor, 1959), 59. 53. Flexner, Medical Education, 180–181; W. Michael Byrd and Linda A. Clayton, An American Health Dilemma: Race, Medicine, and Health Care in the United States, 1900–2000, vol. 2 (New York: Routledge, 2002), 98–100; Bonner, Iconoclast, 117–119, 295. 54. Byrd and Clayton, American Health Dilemma, 117–118. 55. Theodore W. Schaefer, “Contract Practice and Other Social Evils That Are a Menace to the Medical Profession,” Medical Council 18:9 (September 1913), 358–361. 56. “Conspectus of the Medical Colleges of Amer­i­ca,” in Sixth Annual Report of the State Board of Health of Illinois (Springfield, IL: Rokker, 1885), xx; Frederick T. Gates, “Competition vs. Cooperation,” box 1, fol. 17, FA028, Frederick T. Gates Papers, Rocke­fel­ler Archive Center, Sleepy Hollow, New York. 57. Flexner, Medical Education, ix–­x iii, xv, 144, 167, 173. 58. Bevan, “Cooperation in Medical Education,” 1176; Flexner, Medical Education, ix, 154; Henry S. Pritchett, “The Medical School and the State,” JAMA 63:8 (August 22, 1914), 648.

CHAPTER 12. INSURGENCY

1. The best extant source on the insurance debate inside the AMA is Ronald L. Numbers, Almost Persuaded: American Physicians and Compulsory Health Insurance, 1912–1920 (Baltimore: Johns Hopkins University Press, 1978). 2. “Doctors Honor Webster,” Chicago Tribune, June 21, 1906; C. S. Bacon, “Should Medicine and Dentistry Become a Function of The State?,” JAMA 20:12 (March 25, 1893), 334; “The Midwives

520

notes to pages 320–326

of Chicago,” JAMA 50:17 (April 25, 1908), 1350; “The Relation of the Physician to Compulsory Sickness and Invalidity Insurance,” JAMA 46:19 (May 12, 1906), 1472. 3. James B. Herrick, Memories of Eighty Years (Chicago: University of Chicago Press, 1949), 202; “Aristocrats and Insurgents Vie to Rule Medical Society,” Chicago Tribune, April 28, 1910; “Insurgents Rule Medical Society,” Chicago Tribune, June 15, 1910; “Doctors in Hot Campaign,” Chicago Tribune, June 11, 1910; “Doctors Seek Lost Power,” Chicago Tribune, June 12, 1911. 4. Thomas Goebel, “American Medicine and the ‘Orga­nizational Synthesis’: Chicago Physicians and the Business of Medicine, 1900–1920,” BHM 68:4 (Winter 1994), 650–651; Charles J. Whalen, “The Abuse of Medical Charities in Chicago,” ILMJ 25:1 (January  1909), 2; “Doctors Shift Their Fight,” Chicago Tribune, December 12, 1908. 5. “Chicago Doctors in Union,” NYT, March 13, 1909; “An American College of Surgeons Or­ ga­nized,” Journal of the National Association of Retail Druggists 17:7 (November 1913), 406; Loyal Davis, Fellowship of Surgeons: A History of the American College of Surgeons (Chicago: American College of Surgeons, 1960), 87–88, 95–100; 130–133; 135–142. 6. Herrick, Memories, 202–203; Thomas Neville Bonner, Medicine in Chicago, 1850–1950: A Chapter in the Social Development of a City (Urbana, IL: University of Chicago Press, 1991), 131. 7. “Slandering the Medical Profession,” ILMJ 22:5 (November 1912), 619; Charles Edward-­A mory Winslow, “William A. Evans and the Health Department of Chicago,” World ­Today 19:6 (June 1910), 731–732. 8. Car­ter H. Harrison, Stormy Years: The Autobiography of Car­ter H. Harrison (Indianapolis, IN: Bobbs-­Merrill, 1935), 297–300, 341–342; Bonner, Medicine in Chicago, 127. 9. Thomas Goebel, The ­Children of Athena: Chicago Professionals and the Creation of a Credentialed Society, 1878–1920 (Hamburg, Germany: LIT Verlag, 1996), 273–274; Harrison, Stormy Years, 297–300, 341–342; Emilius C. Dudley, The Medicine Man: Being the Memoirs of Fifty Years of Medical Pro­gress (New York: J. H. Sears, 1927), 291–293. 10. “Doctors Plunge Into Campaign,” Chicago Tribune, September 8, 1910; Whalen, “The Outlook for the Medical Profession from Legislative and Economic Viewpoints,” ILMJ 20:3 (September 11, 1911), 331, 335; “Public Relations Committee,” Bulletin of the Chicago Medical Society 10:39 (June 24, 1911), 7. 11. Solberg, 146–147; John L. Fogle to Abraham Flexner, June 23, 1909, box 22F, Abraham Flexner papers, Manuscript Division, U.S. National Archives, Washington, DC; Richard Allen Morton, Justice and Humanity: Edward F. Dunne, Illinois Progressive (Carbondale: Southern Illinois University Press, 1997), 6, 45, 48–49, 54, 129; Henry Bixby Hemenway, “The Scarlet Fever Epidemic,” JAMA 50:14 (April 4, 1908), 1115–1121. 12. Joseph N. McCormack, “Organ­ization Work in Illinois,” JAMA 48:2 (January 12, 1907), 169; Carl E. Black, “Medical Education in Illinois,” ILMJ 17:3 (March 1910), 345–346, 348; “The Aurora Meeting,” ILMJ 19:6 (June 1911), 757. 13. “Aurora Meeting,” 757; Percy, “Some Facts,” 486–487; “The Campaign and Election of 1912,” ILMJ 22:6 (December 1912), 730. 1 4. “Report of the Council on Medical Education,” JAMA 46:24 (June 16, 1906), 1853; “Report of Reference Committee on Legislation and Po­liti­cal Action,” JAMA 60:26 (June 28, 1913), 2088; McCormack, “Organ­ization Work,” 169; “Dr. McCormack’s Report on Conditions in Illinois,” ILMJ 11:2 (February 1907), 171; “A Gentleman from Kentucky,” Chicago Clinic 20:4 (April 1907), 105; “The Death of Dr. James A. Egan,” ILMJ 24:1 (July 1913), 67. 15. “The Peoria Meeting of 1913,” ILMJ 23:6 (June 1913), 662, 664; Charles J. Whalen, “The Doctor as Politician,” JAMA (April 8, 1899), 759. 16. Whalen, “The Needs and Purposes of the State Medical Society,” ILMJ 26:1 (July 1914), 1, 3, 4; Whalen, “Public Relations Committee Report,” Bulletin of the Chicago Medical Society 12:24 (March 22, 1913), 4. 17. “Notes by the Way,” MS 37:7 (July 1914), 270; “Our Congratulations,” MS 37:7 (July 1914), 253.



notes to pages 326–332

521

18. Historical Encyclopedia of Illinois, vol. 2 (Chicago: Munsell, 1912), 1373; “The Campaign and Election of 1912,” ILMJ 22:6 (December 1912), 729–730; “Illinois Primary Election, Sept. 9, 1914,” Chicago Daily News Almanac and Year Book for 1915 (Chicago: Chicago Daily News, 1914), 523; “The Election and Revolution,” ILMJ 23:6 (June 1913), 662. 19. “Report of Reference Committee on Legislation and Po­liti­cal Action,” JAMA 60:26 (June 28, 1913), 2088; “Your American Medical Association,” ILMJ 41:3 (March 1922), 166. 20. “When the Interests of the Doctor and Public Clash,” Medical Standard 32:1 (January 1909), 4–5; W. F. Zierath, “Annual Address of the President of the Association of County Secretaries and State Officers,” Wisconsin Medical Journal 11:3 (August 1912), 101. 21. “The Overcrowded Medical Profession,” Philadelphia Medical Journal 6:17 (October 27, 1900), 765; Charles A. L. Reed, “The Medical Inspection of Schools and Medical Freedom,” Proceedings and Addresses of the Fiftieth Annual Meeting of the National Education Association (Ann Arbor, MI: National Education Association, 1912), 276. 22. Joseph C. Aub and Ruth K. Hapgood, Pioneer in Modern Medicine: David Linn Edsall of Harvard (Boston: Harvard Medical Alumni Association, 1970), 51–52; Charles Wardell Stiles, “Early History, in Part Esoteric, of the Hookworm Campaign,” Journal of Parasitology 25 (August 1939), 297; Josephine Baker, Fighting for Life (New York: Macmillan, 1939), 137–140; Meredith Eliassen, “Got Pure Milk? Dr. Adelaide Brown’s Crusade for San Francisco’s Safe Milk Supply,” Argonaut 18:1 (Spring 2007), 46; “Remarks by Dr. Adelaide Brown,” Transactions of the Commonwealth Club of California 16:7 (September 1921), 243–244; Hermann M. Biggs, “The State Board of Health,” NYSJM 21:1 (January 1921), 8. 23. G. Frank Lydston, “The Man in the Glass House,” Pacific Medical Journal 52:1 (March 1, 1909), 140; Lydston, “Georgius Hierarchus Simmonus,” Texas Medical Journal 24:9 (March 1909), 367; “Gong for a Medical Combat,” Chicago Tribune, March 9, 1909. 2 4. “Censorship of the Medical Press: Czar Methods of the Octopus,” Texas Medical Journal 22:11 (May 1907), 431–433; G. Frank Lydston, “The Rus­sianizing of American Medicine and the Medical Dreyfus,” Southern Practitioner 32:1 (January 1910), 7–36; Lydston, “Are AMA Elections ­L egal?,” Medical Brief (May 1910), 272–274; Lydston, “A Privileged Medical Class: The Latest Move of Medical Trust Mono­poly,” Southern Practitioner 35:2 (February 1913), 55–67; Lydston, “Why the Medical Profession Is ­Going Backward: A Critique of the Medical Trust,” Southern Practitioner 35:5 (May 1913), 199–220. 25. Morris Fishbein, A History of the American Medical Association, 1847 to 1947 (Philadelphia: W. B. Saunders, 1947), 260; G. Frank Lydston, “Answers That Do Not Answer,” Medical Brief (September 1910), 516; “Simmons and His Rec­ord,” Jim Jam Jems (June 1913), 18–32; Charles McCormick, A System of Mature Medicine as Taught in McCormick Medical College, vol. 2 (Chicago: McCormick Medical College, 1922), 297–302. 26. “Reply of Dr. Simmons to Charges Preferred against Him in the Chicago Medical Society,” TSJM 5:3 (July 1909), 130–131; “Lydston Would Have Whites and Negroes Marry,” TSJM 5:7 (November 1909), 284–285; G. Frank Lydston, “Are Reforms Necessary in the AMA and Its Constituent Bodies?,” ILMJ 19:5 (May 1911), 603–613; “Dr. Lydston and the AMA,” ILMJ 19:5 (May 1911), 621; Herrick, Memories, 250. 27. “Dr. Lydston Gains Allies,” Chicago Tribune, April 7, 1909; Morris Fishbein, Morris Fishbein M.D.: An Autobiography (Garden City, NY: Doubleday, 1969), 36; H. F. Lewis, “Discussion,” ILMJ 19:5 (May 1911), 613; G. Frank Lydston, “The Medical Gold Brick of Chicago,” JAMA 43:2 (July 9, 1904), 135. 28. “Doctors’ War Grows ­Bitter,” Chicago Tribune, March 10, 1909; “Lydston Barred as Speaker at Medical Meet,” Chicago Tribune, October 13, 1909; “Denounces Medical Body,” Indianapolis Star, November 11, 1909; E. A. Weis, “Resolutions Not A ­ dopted,” JAMA 54:23 (June 4, 1910), 1886; “Dr. Lydston Wins One Fight in State Medical Society,” Chicago Tribune, May 20, 1910; “Lydston Faction Beaten,” Chicago Tribune, May 17, 1911.

522

notes to pages 332–338

29. “Versatile Insurgent Doctor W ­ ill Attack Association Charter,” St. Louis Post-­Dispatch, June 8, 1910; “Disposition of Lawsuits,” Handbook for the House of Delegates (Chicago: American Medical Association, 1918), 45–49. 30. G. Frank Lydston and E. S. Talbot, “Studies of Criminals: Degeneracy of Cranial and Maxillary Development in the Criminal Class,” JAMA 17:24 (December 12, 1891), 903–923; Lydston, “Sex Gland Implantation,” JAMA 66:20 (May 13, 1916), 1540–1543; “Dr. Lydston, Pioneer Gland Surgeon, Dies,” WaPo, March 15, 1923; “Dr. G. F. Lydston, Noted Surgeon, Dies in West,” Chicago Tribune, March 15, 1923. 31. “A ‘Medical Advisory Committee’: A Circular Letter and Proposed Resolution,” AMAB 16:1 (January 15, 1922), 3–6; “What Is the Medical Advisory Committee?,” JAMA 78:3 (January 21, 1922), 199; “A Call for Reform of the American Medical Association,” ILMJ (February 1922), 143–144. 32. “Editorial Note,” JISMA 14:11 (November 15, 1921), 391; “Medical Advisory Committee,” 5. 33. “Medical Advisory Committee,” 4; “Multiple Voting Privileges,” ILMJ (February 1922), 141– 143; “Resolutions on State Medicine,” JAMA 76:24 (June 11, 1921), 1682; “Vari­ous Resolutions,” JAMA 76:25 (June 18, 1921), 1756–1757. 34. “Medical Advisory Committee,” 3. 35. Fishbein, History of the AMA, 319; Rosemary Stevens, American Medicine and the Public Interest: A History of Specialization (Berkeley: University of California Press, 1971), 238–239; “Report of the Committee on Anesthesia,” JAMA 58:24 (June 15, 1912), 1909; Ralph M. W ­ aters, “The Development of Anesthesiology in the United States,” JHM 1:4 (October 1946), 596; Douglas R. Bacon, “The World Federation of Socie­ties of Anesthesiologists,” Anesthesia and Analgesia 84:5 (May 1997), 1130–1135; F. H. McMechan, “Anesthetists in Hospitals,” JAMA 72:5 (February 1, 1919), 367. 36. Stevens, American Medicine, 239; ­Virginia S. Thatcher, The History of Anesthesia with Emphasis on the Nurse Specialist (Philadelphia: Lippincott, 1953), 72–76, 81, 111–118. 37. Steven C. Wheatley, The Politics of Philanthropy: Abraham Flexner and Medical Education (Madison: University of Wisconsin Press, 1988), 57–82, 86; Horace  W. Davenport, University of Michigan Surgeons, 1850–1970 (Ann Arbor: Historical Center for Health Sciences, University of Michigan, 1993), 62. 38. W. Bruce Fye, “The Origin of the Full-­Time Faculty System,” JAMA 265:12 (March 27, 1991), 1555, 1559; “Reform for Doctors,” Boston Daily Globe, February 28, 1914. 39. “The ­Future of Medicine and the Medical Profession,” ILMJ 41:4 (April  1922), 308–309; Dr. Hugh Cabot’s Medical Socialistic Schemes for Michigan,” JISMA 14:10 (October 15, 1921), 359; “Dr. Hugh Cabot’s Socialistic Schemes,” JISMA 14:11 (November 15, 1921), 384–386; Davenport, University of Michigan Surgeons, 62–63. 40. Arthur Dean Bevan to Henry S. Pritchett, October 5, 1921, Car­ne­gie Foundation for the Advancement of Teaching, 44/7 [AMA 1915–1939], Columbia University, Butler Library; Fishbein, History of the AMA, 322–323, 324. 4 1. Horace W. Davenport, Not Just Any Medical School: The Science, Practice, and Teaching of Medicine at the University of Michigan 1850–1941 (Ann Arbor: University of Michigan Press, 1999), 184; “The Establishment of Pay Clinics by a University Is Inimical to the Best Interests of the Public,” ILMJ 41:4 (April 1922), 300; E. Eliot Harris, “Report of the Speaker to the House of Delegates,” NYSJM 22:5 (May 1922), 206. 42. “Why the Mayo Affiliation with the University Should Be Terminated,” Journal-­Lancet 37:6 (March 15, 1917), 198–200; “The Anti-­a ffiliation Bill,” Journal-­Lancet 37:9 (May 1, 1917), 313; Maurice B. Visscher, “A Medical School Dean Ahead of His Time,” in Owen H. Wangensteen, ed., Elias Potter Lyon: Minnesota’s Leader in Medical Education (St. Louis: 1981), 32–55; W. Bruce Fye, Caring for the Heart: Mayo Clinic and the Rise of Specialization (Oxford: Oxford University Press, 2015), 49, 53–58; Heather Munro Prescott, Student Bodies: The Influence of



notes to pages 339–346

523

University Health Ser­vices in American Society and Medicine (Ann Arbor: University of Michigan Press, 2007), 73. 43. Albert J. Ochsner and Meyer J. Sturm, The Organ­ization, Construction and Management of Hospitals (Chicago: Cleveland Press, 1907), 54–57; Robert T. Morris, Fifty Years a Surgeon (New York: E. P. Dutton, 1935), 59; Morris, Doctors versus Folks (Garden City, NY: Doubleday, 1915), 24–26; Homer  F. Sanger, “Hospital Facilities and the Medical Profession,” JAMA 84:13 (March 28, 1925), 952; William G. Rothstein, American Medical Schools and the Practice of Medicine: A History (New York: Oxford University Press, 1987), 133. 4 4. Kenneth M. Ludmerer, Time to Heal: American Medical Education from the Turn of the ­Century to the Era of Managed Care (Oxford: Oxford University Press, 1999), 116–118. 45. Carl Hookstadt, Comparison of Workmen’s Compensation Laws of the United States and Canada (Washington, DC: U.S. Department of L ­ abor, Bureau of L ­ abor Statistics, 1920), 106. 46. Albert T. Lytle, “Medico-­Industrial Relations of the New York State Workmen’s Compensation Law,” NYSJM 22:2 (February 1922), 71–73. 47. “God and the Doctor,” JAMA 37:6 (August 10, 1901), 417; Hookstadt, Workmen’s Compensation Laws, 106, 110–111. 48. Whalen, “Needs and Purposes,” 5; “Report of the Committee on Legislation,” NYSJM 21:6 (June 1921), 204, 211; James F. Rooney, “Report of the President,” NYSJM 22:5 (May 1922), 203–204. 49. Fishbein, History of the AMA, 319, 321, 326–327, 331; “The Therapeutic Value of Alcohol,” JAMA 38:14 (April 5, 1902), 878–879; “The Action of the House of Delegates of the AMA on the Alcohol Question,” JAMA 69:3 (July  21, 1917), 226; “Communication from the National WCTU,” JAMA 68:23 (June 9, 1917), 1721. 50. “The Referendum on the Use of Alcohol in the Practice of Medicine,” JAMA 78:3 (January 21, 1922), 210–211. 51. “Our Duty Regarding ‘Patent-­Medicine’ Legislation,” JAMA 46:9 (March 3, 1906), 658; “Special Report on the Work of the Council on Pharmacy and Chemistry,” JAMA 65:1 (July 3, 1915), 67, 70. 52. “Helping the Council,” JAMA 75:19 (November 6, 1920), 1275; “Council on Pharmacy and Chemistry,” JAMA 74:18 (May 1, 1920), 1235; “Accepted by the Council on Pharmacy and Chemistry,” JMoSMA 16:7 (July 1919), 223–224. 53. “What’s the M ­ atter with Illinois?,” JMoSMA 10:5 (November 1913), 173; “The AMA Becomes an Autocracy,” WMT 42:9 (March 1923), 291–298; “The AMA Becomes an Autocracy,” ILMJ 42:6 (December 1922), 478–484. 54. “Resolutions of Washington County (Ohio) Medical Association,” “The Recurring Propaganda,” and “Concerning Resolutions,” AMAB 18:3 (March 15, 1923), 286–290. 55. George H. Tichenor, “The Licensure Farce,” WMT 42:1 (July 1922), 8; Edward Podolsky, “Princi­ples Promulgated by the So-­Called Spinal Adjusters for the Relief of Bodily Disorders,” WMT 42:1 (July 1922), 9–10. 56. Frank Billings, “The American Medical Association, Its Accomplishment and Purposes,” OSMJ 19:8 (August 1923), 596; John Harley Warner, “The 1880s Rebellion against the AMA Code of Ethics,” in Robert B. Baker, Arthur L. Caplan, Linda L. Emanuel, and Stephen R. Latham, eds., The American Medical Ethics Revolution (Baltimore: Johns Hopkins University Press, 1999), 57–63. 57. “Report of the Council on Health and Public Instruction,” JAMA 76:24 (June 11, 1921), 1666– 1667. 58. H. C. Macatee, “A Remedy for Professional Unrest,” JAMA 78:12 (March 25, 1922), 857–858. 59. Edward H. Ochsner, “Compulsory Health Insurance, a Modern Fallacy,” ILMJ 38:2 (August 1920), 78; Ochsner, Social Insurance and Economic Insecurity (Boston: Humphries, 1934), 14, 20–21, 26, 202, 207, 208, 223, 229, 242, 277.

524

notes to pages 347–355

60. Rupert Blue, “Some of the Larger Prob­lems of the Medical Profession,” JAMA 66:25 (June 17, 1916), 1901; “A Model Bill for Health Insurance,” JAMA 65:21 (November 20, 1915), 1824. On the debates, see especially Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive Amer­i­ca (Chapel Hill: University of North Carolina Press, 2001), and Numbers, Almost Persuaded. 61. “Relation of the Physician to Compulsory Sickness and Invalidity Insurance,” 1471; Abraham Jacobi, “Address Delivered on German Day at the Tuberculosis Exhibition,” in William J. Robinson, ed., Miscellaneous Addresses and Writings by A. Jacobi, vol. 7 (New York: Critic and Guide, 1909), 616; “Campaign and Election of 1912,” 729–730; Arthur Dean Bevan, “Medicine a Function of the State,” JAMA 62:11 (March 14, 1914), 823. 62. “Industrial Insurance in Germany,” JAMA 54:3 (January 15, 1910), 225–226; “Club Practice and State Insurance in G ­ reat Britain, Germany, Austria and France,” JAMA 54:9 (February 26, 1910), 725–726; “Medical Insurance Abroad,” JAMA 61:26 (December 27, 1913), 2314–2316; “Socializing the British Medical Profession,” JAMA 59:21 (November 23, 1912), 1890–1891. 63. E.  A. Codman, “A Wise Preliminary to Compulsory Health Insurance,” BMSJ 176:12 (March 22, 1917), 435–438; “General Discussion,” ALLR 7:1 (March 1917), 119–120. 64. Numbers, Almost Persuaded, 30; Alexander Lambert to Gertrude Beeks, National Civic Federation, March 15, 1916, National Civic Federation Papers, IV/box 251/fol. 1, New York Public Library. 65. Numbers, Almost Persuaded, 102; Fishbein, History of the AMA, 297–298, 307, 313. 66. John B. Andrews, “Health Insurance and the Prevention of Tuberculosis,” Medical Rec­ord 89:9 (February 26, 1916), 372; B. S. Warren and Edgar Sydenstricker, Health Insurance: Its Relationship to Public Health (Washington, DC: United States Public Health Ser­vice, 1916), 5. 67. Irving Fisher, “The Need for Health Insurance,” ALLR 7:1 (March 1917), 16–23; Alexander Lambert, “Medical Organ­ization ­under Health Insurance,” ALLR 7:1 (March 1917), 39; “General Discussion,” ALLR 7:1 (March 1917), 54. 68. Blue, “Some of the Larger Prob­lems,” 1901; Numbers, Almost Persuaded, 33–36, 57; Theodore M. Brown and Elizabeth Fee, “Isaac Rubinow: Advocate for Social Insurance,” AJPH 92:8 (August 2002), 1224–1225; J. Lee Kreader, “Isaac Max Rubinow: Pioneering Specialist in Social Insurance,” Social Ser­vice Review 50:3 (September 1976), 402–425. 69. Numbers, Almost Persuaded, 57; Hoffman, Wages of Sickness, 70–73; Edward O. Otis, Tuberculosis: Its ­Causes, Cure, and Prevention (New York: Crowell, 1914), 198–200. 70. Charles J. Whalen, “Health Insurance from the Standpoint of the Physician,” ILMJ 37:4 (April 1920), 266; Ochsner, “Compulsory Health Insurance,” 78; Eden V. Delphey, “Arguments against the ‘Standard Bill’ for Compulsory Health Insurance,” JAMA 48:20 (May 19, 1917), 1500. 71. “The Failure of German Compulsory Health Insurance,” JAMA 72:5 (February 1, 1919), 347– 348; Fishbein, History of the AMA, 318, 320–321; “New Business,” JAMA 74:18 (May 1, 1920), 1256; “Exposing the ‘Con’ in Social Economy,” ILMJ 39:6 (June 1921), 555. 72. M. L. Harris, “The Effects of Compulsory Insurance on the Practice of Medicine,” JAMA 74:15 (April 10, 1920), 1041; Frederick R. Green, “The Social Responsibilities of Modern Medicine,” JAMA 76:22 (May 21, 1921), 1478–1471; Numbers, Almost Persuaded, 104; “State Medicine,” Pennsylvania Medical Journal 24:9 (June 1921), 662; Frank Billings, “A Correction,” ILMJ 41:4 (April 1922), 318–319. 73. “Your American Medical Association,” 166; “The Recurring Propaganda,” AMAB 18:3 (March 15, 1923), 289; Macatee, “Remedy,” 857–858. 74. Edward H. Ochsner, “Our Medical Economics Prob­lems,” ILMJ 42:5 (November 1922), 366. 75. James A. Tobey, “The Health Center Movement in the United States,” MH 14:3 (March 1920), 211–213; E. A. Peterson and W. H. Brown, “The American Red Cross and Health,” MM 3:2 (February 1921), 73–80; Milton Terris, “Hermann Biggs’ Contribution to the Modern Concept of the Health Center,” BHM 20:3 (October 1946), 389.



notes to pages 355–361

525

76. “Betrayal of the Medical Profession of the United States by Medical Men Holding High Positions,” ILMJ 41:3 (March 1922), 222; George E. Frothingham, “State Medicine,” JMSMS 21:1 (January 1922), 43–44; Fishbein, History of the AMA, 324–325; Billings, “Correction,” 318–319; Frank Billings, “The F ­ uture of Private Medical Practice,” JAMA 76:6 (February 5, 1921), 352–354. 77. “The Willing Horse Bears the Load,” Journal of the Kansas State Medical Society 22:2 (February 1922), 54. 78. “Federal Care of Maternity and Infancy,” JAMA 76:6 (February 1921), 383; Fishbein, History of the AMA, 323–324. 79. “Doctors Defer Vote on Alcohol,” Boston Globe, June 10, 1921; Rooney, “Report of the President,” 204. 80. Hoffman, Wages of Sickness, 93–136. 81. “Symposium on Compulsory Health Insurance and Allied Dangers,” ILMJ 39:4 (April 1921), 294–309; “Physicians in Five States to War against Health Insurance,” Journal of the Medical Society of New Jersey 17:12 (December 1920), 430; “Report of the Committee on Legislation,” Proceedings of the Fiftieth Annual Session of the New Jersey Phar­ma­ceu­ti­cal Association (Somerville, NJ: Unionist-­Gazette, 1920), 84, 91; “Happenings in the Drug World,” NARD Journal 31:22 (March 3, 1921), 888. 82. Rooney, “Report of the President,” 204; “A Symposium on Compulsory Health Insurance,” Long Island Medical Journal 13:12 (December 1919), 445, 447; “Your American Medical Association,” 166–168. 83. “Health Insurance,” ILMJ 35:1 (January  1919), 1; Paternalism R ­ unning Wild,” IMJ 37:5 (May 1920), 341–342; “Exposing the ‘Con’ in Social Economy,” 555. 84. Charles J. Whalen, “Doctors Write Your Senators and Congressmen at Once Opposing the Sheppard-­Towner Maternity Bill,” ILMJ 39:2 (February 1921), 143.

C H A P T E R 13. T H E C ON SE RVAT I V E M E D I C O -­P O L I T I C A L O R D E R

1. Medical historian George Rosen, in The Structure of American Medical Practice, 1875–1941 (Philadelphia: University of Pennsylvania Press, 1983), finds no po­liti­cal discontinuity worthy of mention. In American Medicine and the Public Interest: A History of Specialization (Berkeley: University of California Press, 1971, 142–143), Rosemary Stevens notes that the AMA leadership passed “from progressivism to conservatism” without suggesting a cause other than, for unspecified reasons, a turnover of leadership from medical academicians to “prac­ti­tion­ers.” Thomas Neville Bonner, Medicine in Chicago, 1850–1950: A Chapter in the Social Development of a City (Urbana: University of Chicago Press, 1991), 217–218, touches on the same question, noting only rank-­and-­file frustration with a “concentration of power in the hands of a few specialists” and then, unrelated to that, a collective po­liti­cal shift with and ­because of a change in the “national temperament” a­ fter World War I. In his book on the compulsory insurance controversy, Ronald L. Numbers, in Almost Persuaded: American Physicians and Compulsory Health Insurance, 1912–1920 (Baltimore: Johns Hopkins University Press, 1978), 110–113, ponders a “conservative revolution” in the AMA but not ­because of an ascendance of nonspecialist prac­ti­tion­ers over “specialist-­academics.” The latter’s numbers in the AMA House of Delegates, he shows, actually increased between 1917 and 1920. Also, Numbers notes, the AMA’s elites themselves retreated from compulsory insurance ­because they ­were persuaded it was a bad idea, not b­ ecause of pressure from lower ranks. He dismisses the importance of World War I and its aftermath, observing correctly that the opposition to health insurance predated Amer­i­ca’s involvement in the war. Instead, he argues, also correctly, that the economic and control threats to the profession that health insurance seemed to pose explains the reaction to insurance. But ­because his narrative and evidence focus almost exclusively on the transitory

526

notes to pages 362–366

insurance controversy and its immediate aftermath, Numbers’s book should not be read as an explanation of the complete reactionary turn analyzed h ­ ere. His discussion ends before the massive leadership takeover a full four years a­ fter the progressive elite had distanced themselves from compulsory insurance. Also, the evidence presented in this book indicates that the reformers dropped the issue not b­ ecause they de­cided it was a bad idea a­ fter all but ­because of the furor it had aroused from below and a desire to quell the insurgency. That effort failed ­because they ­were guilty in the insurgents’ eyes of many more sins of commission and omission than friendliness t­ oward government health insurance. 2. Brand Whitlock, The Letters and Journal of Brand Whitlock, vol. 2, ed. Allan Nevins (New York: Appleton, 1936), 639. 3. “Harding Says Negro Must Have Equality in Po­liti­cal Life,” NYT, October 27, 1921; Jeffrey Jenkins, Justin Peck, and Vesla Weaver, “Between Reconstructions: Congressional Action on Civil Rights, 1891–1940,” Studies in American Po­liti­cal Development 24:1 (April 2010), 71; J. Stanley Lemons, “The Sheppard-­Towner Act: Progressivism in the 1920s,” Journal of American History 55:4 (March 1969), 777. 4. “Harding Proposes a New Department: Wants ‘Public Welfare’ Division to Carry Out Policy of Social Justice,” NYT, October 2, 1920; U.S. Congress, Department of Public Welfare: Joint Hearings before the Committees on Education Congress of the United States (Washington, DC: U.S. Government Printing Office, 1921), 7, 8; James A. Tobey, “Public Health Legislation,” AJPH 14 (1924), 643; James Alner, “Views of the President on Public Health,” Nation’s Health 3:10 (October 15, 1921), 537–539. 5. Arthur S. Link, “What Happened to the Progressive Movement in the 1920’s?,” American Historical Review 64:4 (July 1959), 833–851; Robert Sobel, Coo­lidge: An American Enigma (Washington, DC: Regnery, 2012), 90. 6. Kenneth Whyte, Hoover: An Extraordinary Life in Extraordinary Times (New York: Knopf, 2017), 205, 378–379, 555, 610; Kriste Lindenmeyer, Right to Childhood: The U.S. ­Children’s Bureau and Child Welfare, 1912–46 (Champaign: University of Illinois Press, 1997), 163; Judith Sealander, The Failed ­Century of the Child: Governing Amer­i­ca’s Young in the Twentieth ­Century (Cambridge: Cambridge University Press, 2003), 231; Peter A. Swenson, Cap­i­tal­ists against Markets: The Making of ­Labor Markets and Welfare States in the United States and Sweden (New York: Oxford University Press, 2002), 150–151, 160. 7. “Proceedings of the St. Louis Session,” JAMA 78:22 (June 3, 1922), 1709, 1715. 8. “Evil of Too Much Specialism by Doctors Stressed,” St. Louis Post-­Dispatch, May 27, 1922; Marshall Carleton Pease, American Acad­emy of Pediatrics, 1931–1951 (Evanston, IL: American Acad­emy of Pediatrics, 1952), 17–18; “Sixteen Scientific Sections of AMA Assem­ble,” St. Louis Post Dispatch, May 24, 1922; “Doctors Hint of Bolting Session,” Louisville Courier-­Journal, May 24, 1922. 9. “Proceedings of the St. Louis Session,” 1709–1711; “Report of the Board of Trustees,” JAMA 78:21 (May 27, 1922), 1618, 1619; “Doctors Urge Impor­tant Mea­sures in Medical Field,” St. Louis Post-­Dispatch, May 22, 1922. 10. Victor C. Vaughan, “The Ser­vice of Medicine to Civilization,” JAMA 57:26 (June 27, 1914), 2003–2012; “Report of the Council on Health and Public Instruction,” JAMA 72:24 (June 14, 1919), 1750. 11. “Propositions to be Laid Before the Council on Public Health and Legislation,” JAMA 76:24 (June 11, 1921), 1666; Michael M. Davis, “Physician and Layman,” Survey, April 16, 1921, 83; “Proceedings of the St.  Louis Session,” 1709; Morris Fishbein, A History of the American Medical Association, 1847 to 1947 (Philadelphia: W.  B. Saunders, 1947), 336–337; Victor  C. Vaughan, A Doctor’s Memories (Indianapolis: Bobbs-­Merrill, 1926); Horace W. Davenport, Victor Vaughan: Statesman and Scientist (Ann Arbor: University of Michigan, Historical Center for the Health Sciences, 1996); Richard Adler, Victor Vaughan: A Biography of the Pioneering Bacteriologist, 1851–1929 (Jefferson, NC: McFarland, 2015).



notes to pages 367–372

527

12. Frank Billings, “The Medical Profession,” Journal of the Iowa State Medical Society 12:2 (February 1922), 43–44; “The Medicinizing of Socialization,” ILMJ 41:4 (April 1922), 301; George E. Frothingham, “Committee on Civic and Industrial Relations,” JMSMS 21:8 (August 1922), 342; Edwin Frederick Hirsch, Frank Billings: The Architect of Medical Education, an Apostle of Excellence in Clinical Practice, a Leader in Chicago Medicine (Chicago: University of Chicago Press, 1966). 13. Billings, “American Medical Association,” 596–597; “C. A. L. Reed to Frank Billings, May 2, 1923,” Ohio State Medical Journal 19:8 (August 1923), 601; Heber Robarts, “The Dose of Radium,” ILMJ 42:1 (July 1922), 15–16. 1 4. James B. Herrick, Memories of Eighty Years (Chicago: University of Chicago Press, 1949), 250; Frank Billings, “The American Medical Association, Its Accomplishment and Purposes,” Ohio State Medical Journal 19:8 (August 1923), 596–597; Fishbein, History of the AMA, 336–337; George D. Lundberg, Severed Trust: Why American Medicine ­Hasn’t Been Fixed (New York: Basic, 2002), x; Eric J. Topol, “Lundberg at 80: Reflections on His ­Career and the JAMA Firing,” Medscape, December 10, 2018, https://­w ww​.­medscape​.­com​/­viewarticle​/­821436. 15. Arthur Dean Bevan, “Medicine a Function of the State,” JAMA 62:11 (March 14, 1914), 823; “Report of the Council on Medical Education and Hospitals,” JAMA 76:24 (June 11, 1921), 1671; Bevan to Henry S. Pritchett, October 5, 1921, Car­ne­gie Foundation for the Advancement of Teaching, 44/7 [AMA 1915–1939], Columbia University, Butler Library. 16. “Rum Prescriptions Flayed,” Los Angeles Times, February 15, 1927; “Whiskey Prescriptions Called 99 P.C. Bootleg,” NYHT, February 15, 1927; “Assail Bevan for Medical Booze Charge,” Chicago Tribune, March 23, 1927; “Booze and Bevanism,” ILMJ 51:3 (March 1927), 172–174; “Constructive Suggestion to Dr. Bevan on Medical Ethics,” ILMJ 51:5 (May 1927), 337; “Prescription Racket Is Laid to Minority,” Boston Globe, April 20, 1932; Arthur Dean Bevan, “Prescribing of Alcoholic Liquors by Physicians,” JAMA 98:17 (April 23, 1932), 1494; Bevan, “Cooperation in Medical Education and Medical Ser­vice: Functions of the Medical Profession, of the University and of the Public,” JAMA 90:15 (April 14, 1928), 1176. 17. Morris Fishbein, Morris Fishbein, M.D.: An Autobiography (Garden City, NJ: Doubleday, 1969), 90. 18. William A. Pusey, “Some of the Social Prob­lems of Medicine,” JAMA 82:24 (June 14, 1924), 1906, 1907. 19. William A. Pusey, “Some Tendencies in the Business of the Practice of Medicine,” JAMA 90:23 (June 9, 1928), 1898. 20. David L. Edsall, “The Attitude of the Clinician in Regard to Exposing Patients to the X-­R ay,” JAMA 47:18 (November 3, 1906), 1425–1429; William A. Pusey, “The Danger of X-­ray Exposures,” JAMA 47:23 (December 8, 1906), 1932–1933; Edsall, “The Dangers of the X-­ray,” JAMA 47:25 (December 22, 1906), 2102–2103; Ellen R. Brainard, “History of the American Society for Clinical Investigation, 1909–1959,” Journal of Clinical Investigation 38:10 (October 1959), 1790. 21. William A. Pusey, “The Venereal Disease Prob­lem,” JAMA 68:8 (February 24, 1917), 639–640; Pusey, The History and Epidemiology of Syphilis (Baltimore: Charles C. Thomas, 1933), 94–105; Conrad Seipp, “Or­g a­n ized Medicine and the Public Health Institute of Chicago,” in William G. Rothstein, ed., Readings in American Health Care: Current Issues in Socio-­Historical Perspective (Madison: University of Wisconsin Press, 1995), 25–39; “The Chicago Public Health Institute Has a Newspaper Holiday,” JAMA 92:16 (April 20, 1929), 1935; Pusey, “Some Tendencies,” 1898. 22. Fishbein, Morris Fishbein, M.D., 183; James Pittman, Tinsley Harrison, M.D.: Teacher of Medicine (Montgomery, AL: New South Books, 2013), 227–228; Booth Mooney, More than Armies: The Story of Edward H. Cary, M.D. (Dallas: Mathis, Van Nort, 1948), 20, 58. 23. George H. Simmons and Morris Fishbein, The Art and Practice of Medical Writing (Chicago: AMA, 1925); Richard R. Lingeman, Sinclair Lewis: Rebel from Main Street (New York: Random House, 2002), 206; Lowell Lawrance, “Dollar-­a-­Month Man,” Hygeia, October 1939, 919.

528

notes to pages 373–379

2 4. Pusey, “Social Prob­lems,” 1906. 25. “Protest the Sheppard-­Towner Act,” JAMA 86:6 (February 6, 1926), 421; “The Perpetuation of the Sheppard-­Towner Idea,” JAMA 86:19 (May 8, 1926), 1458; “The Attempt to Perpetuate the Sheppard-­Towner Act,” JAMA 91:22 (December 1, 1928), 1722; Carolyn M. Moehling and Melissa  A. Thomasson, “Saving Babies: The Impact of Public Education Programs on Infant Mortality,” Demography 51:2 (April 2014), 367–386; Sidney A. Halpern, American Pediatrics: The Social Dynamics of Professionalism, 1880–1980 (Berkeley: University of California Press, 1988), 101, 204–205; Sheila M. Rothman, W ­ oman’s Proper Place: A History of Changing Ideals and Practices, 1870 to the Pre­sent (New York: Basic, 1978), 142–153. 26. Judith Rainhorn, “The Banning of White Lead: French and American Experience,” in Lars Bluma and Judith Rainhorn, eds., History of the Workplace: Environment and Health at Stake (London: Routledge, 2014), 40; John C. Ruddock, “Lead Poisoning in ­Children,” JAMA 82:21 (May 24, 1924), 1682–1684; Richard Rabin, “Warnings Unheeded: A History of Child Lead Poisoning,” AJPH 79:12 (December 1989), 1668–1674. 27. U.S. Senate, Presidential Commissions: Hearings on Implementation of Recommendations of Presidential and National Commissions (Washington DC: U.S. Government Printing Office, 1971), 336; William H. Ross, “Presidential Comments on Current Events—­No. 9,” NYSJM 30:21 (November 1, 1930), 1290–1291; “Presidential Comments on Current Events—­No. 18,” NYSJM 31:6 (March 15, 1931), 355. 28. William H. Ross, “What Is Or­ga­nized Medicine’s Attitude to Public Health Administration?,” NEJM 2006:1 (January 7, 1932), 6–8. 29. “Subsidized Medicine,” NYT, October 25, 1937; “Miscellaneous Actions,” Journal of the Michigan State Medical Society 55:1 (January 1956), 24. 30. Edward  R. Pinckney, “The Physician and the Public Health Department,” JAMA 160:17 (April 28, 1956), 1450. 31. M. Therese Southgate, “­Silent Spring,” JAMA 182:6 (November 10, 1962), 704; John H. Talbott, “Smoking and Lung Cancer,” JAMA 171:15 (December 12, 1959), 2104. 32. William B. Bean, “The Noise of ­Silent Spring,” Archives of Internal Medicine 112:3 (September 1963), 311; Paul Brooks, The House of Life: Rachel Carson at Work (Boston: Houghton Mifflin, 1972), 297, 303–304; David Kinkela, DDT and the American C ­ entury (Chapel Hill: University of North Carolina Press, 2011), 126, 214. 33. U.S. Senate, Committee on Finance, Medicare and Medicaid, pt. 2, April, May, and June 1970 (Washington, DC: U.S. Government Printing Office, 1970), 515, 527, 529, 530. 34. John J. Hanlon, “Is ­There a ­Future for Local Health Departments?” Health Ser­vices Reports 88:10 (December 1973), 898–901. 35. Milton Terris, “The Epidemiologic Revolution, National Health Insurance, and the Role of Health Departments,” AJPH 66:12 (December 1976), 55–64. 36. Institute of Medicine, The ­Future of Public Health (Washington, DC: National Academies Press, 1988), 1, 6, 19–34, 75, 123, 135; William H. McBeath, “Health for All: A Public Health Vision,” AJPH 81:12 (December 1991), 1563–1565. 37. “The Care of the Veteran,” JAMA 83:20 (November 15, 1924), 1591; “Address of President-­Elect William P. Haggard,” JAMA 84:22 (May 30, 1925), 1664; “Report of the Board of Trustees,” JAMA 84:22 (May 30, 1925), 1648; “Veterans’ Relief Legislation: State Medicine,” JAMA 86:4 (January 23, 1926), 278–280; “Federalized Medical Treatment versus the Private Practitioner,” JAMA 86:24 (June 12, 1926), 1840; James R. Burrow, AMA: Voice of American Medicine (Baltimore: Johns Hopkins University Press, 1963), 158–160, 164, 314–316, 383–384, 388. 38. Some excellent sources are Daniel S. Hirshfield, The Lost Reform: The Campaign for Compulsory Health Insurance in the United States from 1932 to 1943 (Cambridge, MA: Harvard University Press, 1970); Monte M. Poen, Harry S. Truman versus the Medical Lobby: The Genesis of Medicare (Columbia: University of Missouri Press, 1979); Jaap Kooijman, And the Pursuit of



notes to pages 379–385

529

National Health: The Incremental Strategy t­ oward National Health Insurance in the United States (Amsterdam, NL: Rodopi, 1999); Colin Gordon, Dead on Arrival: The Politics of Health Care in Twentieth-­Century Amer­i­ca (Prince­ton, NJ: Prince­ton University Press, 2003). 39. “The Social Security Act and the Medical Profession,” JAMA 105:8 (August 24, 1935), 600– 601. On the 1930s, see especially Hirshfield, The Lost Reform, and Kooijman, Pursuit of National Health. 40. Poen, Truman, 46–48, 85–86, 142–143; Sugita Yoneyuki, Japan’s Shifting Status in the World and the Development of Japan’s Medical Insurance Systems (Singapore: Springer, 2019), 183. 4 1. Christy Ford Chapin, Ensuring Amer­i­ca’s Health: The Public Creation of the Corporate Health Care System (New York: Cambridge University Press, 2015), 202, 220, 222; James Sund­quist, Politics and Policy: The Eisenhower, Kennedy, and Johnson Years (Washington, DC: Brookings Institution, 1968), 310; Michael J. O’Neill, “Siege Tactics of the AMA,” Reporter, April 26, 1962, 31; Peter A. Swenson, “Misrepresented Interests: Business, Medicare, and the Making of the American Health Care State,” Studies in American Po­liti­cal Development 32:1 (April 2018), 1–23. 42. Peter A. Swenson, “B Is for Byrnes and Business: An Untold Story about Medicare,” Clio: Newsletter of Politics and History 16:2 (Spring/Summer 2006), 39–42; Fishbein, Morris Fishbein, M.D., 185. 43. Chapin, Ensuring Amer­i­ca’s Health, 4–5, 27–30, 230–232. 4 4. “AMA Takes Tough Aid Stand,” WaPo, June 24, 1971. 45. U.S. Senate, Presidential Commissions, 320; “The House of Delegates,” JAMA 185:1 (July 6, 1963), 33; Henry A. Foley, Community M ­ ental Health Legislation: The Formative Pro­cess (Lexington, MA: Lexington Books, 1975), 67–73; Steven S. Sharfstein, “What­ever Happened to Community M ­ ental Health?,” Psychiatric Ser­vices 51:5 (May 2000), 616. 46. Morris Fishbein, “The Committee on Costs of Medical Care,” JAMA 99:23 (December 3, 1932), 1950, 1951. 47. Robert M. Cunningham Jr. and Robert Cunningham III, The Blues: A History of the Blue Cross and Blue Shield System (DeKalb: Northern Illinois University Press, 1997); Beth Stevens, “Blurring the Bound­a ries: How the Federal Government Has Influenced Welfare Benefits in the Private Sector,” in Margaret Weir et al., The Politics of Social Policy in the United States (Prince­ ton, NJ: Prince­ton University Press, 1988), 123–148; Selma Mushkin, “The Internal Revenue Code of 1954 and Health Programs,” Public Health Reports 70:8 (August 1955), 791–800. 48. Rickey Hendricks, A Model for National Health Care: The History of Kaiser Permanente (New Brunswick, NJ: Rutgers University Press, 1993), 11–41; Mark S. Foster, “­Giant of the West: Henry J. Kaiser and Regional Industrialization, 1930–1950,” Business History Review 59:1 (Spring 1985), 1–23; Kaiser Clashes with Fishbein on Health Plan,” NYHT, November 7, 1942; “Kaiser Fights to Get Doctors for Workers,” WaPo, November 7, 1942; “Dr. Fishbein Denies Charge of Coercion,” Atlanta Journal-­Constitution, November 7, 1942; “Or­ga­nized Medicine Assailed in Probe of Supply of Doctors,” Baltimore Sun, November 7, 1942. 49. Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (New York: Basic, 1982), 320–327. 50. Solomon Solis-­Cohen, “Pro­gress in Therapeutics,” Proceedings of the Philadelphia County Medical Society 21:3 (March 1900), 120, 122, 124; Torald Sollmann, “Research Prob­lems of Pharmacology,” JAMA 13:29 (November  28, 1903), 1330, 1332; Sollmann, “Experimental Therapeutics,” JAMA 58:4 (January 27, 1912), 242–244; Sollmann, “The Therapeutic Research Committee of the Council on Pharmacy and Chemistry,” JAMA 62:20 (November 11, 1916), 1439–1442; “Investigations of the Therapeutic Research Committee,” JAMA 82:24 (June 14, 1924), 1987. For more on the AMA and rational therapeutics, see Harry Marks, The Pro­gress of Experiment: Science and Therapeutic Reform in the United States, 1900–1990 (Cambridge: Cambridge University Press, 1997), 23–41.

530

notes to pages 385–391

51. Austin Smith, “Safeguards in the Use of New Drugs,” Bulletin of the New York Acad­emy of Medicine 25:2 (February 1949), 120–121; U.S. Senate, Committee on Education and ­Labor, National Health Program (Washington, DC: U.S. Government Printing Office, 1946), 581; Howard Brody, Hooked: Ethics, the Medical Profession, and the Phar­ma­ceu­ti­cal Industry (Lanham, MD: Rowman and Littlefield, 2006), 145–146; Fishbein, Morris Fishbein, M.D., 138, 247–249, 309–310; Marc A. Rodwin, Conflicts of Interest and the F ­ uture of Medicine (Oxford: Oxford University Press, 2011), 104–108; U.S. Senate, Competitive Prob­lems in the Drug Industry: Hearings before the Subcommittee on Mono­poly of the Select Committee on Small Business, pt. 14 (Washington, DC: U.S. Government Printing Office, 1969), 5727. 52. James Rorty, American Medicine Mobilizes (New York: Norton, 1939), 157–196. 53. Charles O. Jackson, Food and Drug Legislation in the New Deal (Prince­ton, NJ: Prince­ton University Press, 1970), 45, 129, 211; David  F. Cavers, “The Food, Drug, and Cosmetic Act of 1938,” Law and Con­temporary Prob­lems 2:42 (Winter 1939), 9, 12, 24, 35; Daniel Carpenter, Reputation and Power: Orga­nizational Image and Phar­ma­ceu­ti­cal Regulation at the FDA (Prince­ton, NJ: Prince­ton University Press, 2010), 80–82. 54. Theodore G. Klumpp to John P. Peters Jr., February 13, 1938, box 4, fol. 117; Peters to Allan M. Butler, May 23, 1938, box 1, fol. 24; Peters to Hugo Freund, July 30, 1938, box 1, fol. 35; all in series I, John Punnett Peters Papers, Sterling Library, Yale University. 55. Jackson, Food and Drug Legislation, 163–168, 171, 177, 183–184, 210; Carpenter, Reputation and Power, 85–108. 56. Carpenter, Reputation and Power, 213–226, 238–256; Morton Mintz, “ ’Heroine’ of FDA Keeps Bad Drug Off of Market,” WaPo, July 15, 1962; “Dr. Kelsey ­Will Receive a High Presidential Award,” NYT, August 5, 1962; Bridget M. Kuehn, “Frances Kelsey Honored for FDA Legacy,” JAMA 304:19 (November 17, 2010), 2109–2111. 57. Dominique Tobbell, Pills, Power, and Profits: The Strug­gle for Drug Reform in Cold War Amer­ i­ca (Berkeley: University of California Press, 2012), 89–121; U.S. Senate, Subcommittee on Antitrust and Mono­poly, Drug Industry Antitrust Act, pt. 1 (Washington, DC: U.S. Government Printing Office, 1961), 45, 216. 58. “Regulation and Drug Development,” Congressional Rec­ord, June 13, 1977, 18747–18748; Mike Magee, Code Blue: Inside Amer­i­ca’s Medical Industrial Complex (New York: Atlantic Monthly Press, 2019), 323. 59. Kerr L. White, Healing the Schism: Epidemiology, Medicine, and the Public’s Health (New York: Springer, 1991), vii; Walter L. Bierring, “The F ­ amily Doctor and the Changing Order,” JAMA 102:24 (June 26, 1934), 1997. 60. Robert K. Plumb, “Fight on Subsidies Is Opened by AMA,” NYT, December 17, 1950. 61. U.S. House of Representatives, Committee on Interstate and Foreign Commerce, Construction of Medical Schools (Washington, DC: U.S. Government Printing Office, 1955), 68–69; Ed Cray, In Failing Health: The Medical Crisis and the AMA (Indianapolis: Bobbs-­Merrill, 1970), 116–122; Stevens, American Medicine, 359–360; Judith Robinson, Noble Conspirator: Florence S. Mahoney and the Rise of the National Institutes of Health (Washington, DC: Francis Press, 2001), 115–227; Jeremy A. Greene and Scott H. Podolsky, “Keeping Modern in Medicine: Phar­ma­ceu­ ti­cal Marketing and Physician Education in Postwar Amer­i­ca,” BHM 83 (2009): 331–377. 62. U.S. Senate, Presidential Commissions, 305–306; “A $3 Billion Plan,” Time, December 18, 1964, 64; Stephen Parks Strickland, The History of Regional Medical Programs: The Life and Death of a Small Initiative of the ­Great Society (Lanham, MD: University Press of Amer­i­ca, 2000), iv, 18–19; U.S. Department of Health, Education, and Welfare, Conference on Regional Medical Programs (Washington, DC: U.S. Government Printing Office, 1967), 7. 63. John Dittmer, The Good Doctors: The Medical Committee for H ­ uman Rights and the Strug­gle for Social Justice in Health Care (New York: Bloomsbury, 2009), 12; George W. Bowles, “The Presidential Address,” Journal of the National Medical Association 31:5 (September 1939), 193–194;



notes to pages 393–399

531

“9-­Year ­Battle Won By Medics Against AMA,” New York Amsterdam News, October 21, 1939; Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington, DC: National Academies Press, 2003), 107. 64. John Dittmer, “Interview with Dr. H. Jack Geiger,” Civil Rights History Proj­ect, Southern Oral History Program, March 16, 2013, https://­cdn​.­loc​.­gov​/­service​/­a fc​/­a fc2010039​/­a fc2010039​ _­crhp0076​_­Geiger​_­transcript​/­a fc2010039​_­crhp0076​_­Geiger​_­transcript​.­pdf; H. Jack Geiger, “Contesting Racism and Innovating Community Health Centers,” in Anne-­Emanuelle Birn and Theodore M. Brown, eds., Comrades in Health: U.S. Health Internationalists, Abroad and at Home (New Brunswick, NJ: Rutgers University Press, 2103), 108; Rouse, “To Whom Much Has Been Given,” 87. 65. Harriet A. Washington, Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Pre­sent (New York: Anchor Books, 2006), 164– 166; “Medicine: A ­Matter of Morality,” Time, August 7, 1972; Vanessa ­Gamble, “­Under the Shadow of Tuskegee: African Americans and Health Care,” AJPH 87:11 (November 1997), 1773– 1777; Susan Reverby, Examining Tuskegee: The Infamous Syphilis Study and Its Legacy (Chapel Hill: University of North Carolina Press, 2009), 1, 200–202. 66. Dittmer, Good Doctors, 207, 240; Lucius Lampton and Richard D. deShazo, “Opening the Door of the G ­ reat Republic,” in deShazo, ed., The Racial Divide in American Medicine: Black Physicians and the Strug­gle for Justice in Health Care (Jackson: University Press of Mississippi, 2018), 183–184; Robert B. Baker, “African American Physicians and Or­ga­nized Medicine, 1846– 1968: Origins of a Racial Divide,” JAMA 300:3 (July 16, 2008), 312. 67. Regina Morantz-­Sanchez, Sympathy and Science: W ­ omen Physicians in American Medicine (Chapel Hill: University of North Carolina Press, 2000), 254; Susan M. Hartmann, The Home Front and Beyond: American W ­ omen in the 1940s (Boston: Twayne, 1982), 109. On ­women and medicine in this period, see also Mary Roth Walsh, Doctors Wanted: No ­Women Need Apply; Sexual Barriers in the Medical Profession, 1835–1975 (New Haven, CT: Yale University Press, 1979), 268–283. 68. Morantz-­Sanchez, Sympathy and Science, 253–254, 275, 332, 339, 340–341. 69. Ellen S. More, Restoring the Balance: ­Women Physicians and the Profession of Medicine, 1850– 1995 (Cambridge, MA: Harvard University Press, 1999), 209–211, 213; Carol Lopate, ­Women in Medicine (Baltimore: Johns Hopkins University Press, 1968), 17. 70. Barbara Car­ter, “Medicine’s Forgotten ­Women,” Reporter, March 1, 1962, 37; O’Neill, “Siege Tactics,” 31. 71. Theresa Montini, “Resist and Redirect: Physicians Respond to Breast Cancer Informed Consent Legislation,” ­Women and Health 26:1 (October 1997), 85–105. 72. Richard Rorty, “What’s Stopping Birth Control?,” New Republic, February 3, 1932, 314; Raymond Tatalovich, The Politics of Abortion in the United States and Canada (Armonk, NY: M. E. Sharpe, 1997), 37–41; More, Restoring the Balance, 206–212; Carole R. McCann, Birth Control Politics, 1916–1945 (Ithaca, NY: Cornell University Press, 1994), 62, 76–77; Norman Barnesby, Medical Chaos and Crime (New York: Mitchell Kennerley, 1910). 73. “The Platform of the American Medical Association,” JAMA 113:27 (December 30, 1939), 2428.

CH A PTER 14. MEDIC AL POW ER POLITICS

1. Peter A. Swenson, “Misrepresented Interests: Business, Medicare, and the Making of the American Health Care State,” Studies in American Po­liti­cal Development 32:1 (April 2018), 7–15. 2. Wilbur J. Cohen, “Reflections on the Enactment of Medicare and Medicaid,” Health Care Financing Review (December  1985, suppl.), 7; Paul Starr, Remedy and Reaction: The Peculiar American Strug­gle over Health Care Reform (New Haven, CT: Yale University Press, 2013), 48; Herman Miles Somers, Medicare and the Hospitals (Washington, DC: Brookings Institution,

532

notes to pages 400–405

1967), 148; Morris Fishbein, Morris Fishbein, M.D.: An Autobiography (Garden City, NY: Doubleday, 1969), 185; Christy Ford Chapin, Ensuring Amer­i­ca’s Health: The Public Creation of the Corporate Health Care System (New York: Cambridge University Press, 2015). 3. James Bryce, The American Commonwealth, vol. 1 (London: Macmillan, 1889), 295; Ellen M. Immergut, “The Rules of the Game: The Logic of Health Policy-­Making in France, Switzerland, and Sweden,” in Sven Steinmo, Kathleen Thelen, and Frank Longstreth, eds., Structuring Politics: Historical Institutionalism in Comparative Analy­sis (Cambridge: Cambridge University Press, 1992), 57–89; Sven Steinmo and Jon Watts, “It’s the Institutions, Stupid: Why Comprehensive National Health Insurance Always Fails in Amer­i­ca,” JHPPL 20:2 (Summer 1995), 331–333; Carolyn Hughes Tuohy, Accidental Logics: The Dynamics of Change in the Health Care Arena in the United States, Britain, and Canada (New York: Oxford University Press, 1999); Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive Amer­i­ca (Chapel Hill: University of North Carolina Press, 2003), 166–167. 4. Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (New York: Basic, 1982), 54–59, 140–142. 5. Starr, Social Transformation, 5, 6, 140; Ronald L. Numbers, “The Rise and Fall of the American Medical Profession,” in Judith Walzer Leavitt and Ronald Numbers, eds., Sickness and Health in Amer­i­ca (Madison: University of Wisconsin Press, 1985), 192–193; John Harley Warner, “­Grand Narrative and Its Discontents: Medical History and the Social Transformation of American Medicine,” JHPPL 29:4–5 (August–­October 2004), 767–768. 6. Scott H. Podolsky, Pneumonia before Antibiotics: Therapeutic Evolution and Evaluation in Twentieth ­Century Amer­i­ca (Baltimore: Johns Hopkins University Press, 2006), 19–72; Paul  B. Beeson, “Changes in Medical Therapy during the Past Half C ­ entury,” Medicine 59:2 (March 1980), 79–99; Podolsky, The Antibiotic Era: Reform, Re­sis­tance, and the Pursuit of a Rational Therapeutics (Baltimore: Johns Hopkins University Press, 2015), 30–37, 84. 7. Robert N. Proctor, Agnotology: The Making and Unmaking of Ignorance (Palo Alto, CA: Stanford University Press, 2008). American Medicine: Expert Testimony out of Court, vol. 1 (New York: American Foundation, 1937), 472–482, quote at 474. 8. Ibid., 473; Farnesworth Fowle, “Half of Surgery Considered Inept,” NYT, May 28, 1959; Harry Nelson, “Surgery by Untrained MDs Called Legalized Mayhem,” Boston Globe, October 19, 1962; Ira M. Rutkow, “Unnecessary Surgery,” Surgical Clinics of North Amer­i­ca 62:4 (August 1982), 617; Jacob Fine and Mildred A. Morehead, “Study of Peer Review of In-­Hospital Patient Care,” NYSJM 71:16 (August 15, 1971), 1969. 9. “Committee on Attendance,” ILMJ 68:1 (July 1935), 53; Digest of Official Actions, 1846–1958 (Chicago: American Medical Association, 1959), 418–419. 10. Digest of Official Actions, 419; Jon R. Waltz and Fred E. Inbau, Medical Jurisprudence (New York: Macmillan, 1971), 32–34; Anonymous, “American Medical Association: Power, Purpose, and Politics in Or­ga­nized Medicine,” Yale Law Journal 63:7 (May 1954), 952–953; Elton Rayack, “Restrictive Practices of Or­ga­nized Medicine,” Antitrust Bulletin 13:2 (1968), 667, 668; Fishbein, History, 899; Morris Fishbein, An Autobiography (Garden City, NY: Doubleday, 1969), 214. 11. Rosemary Stevens, American Medicine and the Public Interest (Berkeley: University of California Press, 1998), 248, 262; Anonymous, “American Medical Association,” 940. 952, 953. 12. Anonymous, “American Medical Association,” 948–953; Joseph T. Karcher,” Malpractice Claims against Doctors,” American Bar Association Journal 53:4 (April 1967), 328–329; Kenneth S. Abraham, The Liability C ­ entury: Insurance and Tort Law from the Progressive Era to 9/11 (Cambridge: Harvard University Press, 2008), 109. 13. Andrea Park Chung, et al., “Subsidies and Structure: The Lasting Impact of the Hill-­Burton Program on the Hospital Industry” (Working Paper 22037, National Bureau of Economic Research, 24–25), https://­w ww​.­nber​.­org​/­papers​/­w22037​.­pdf; Anonymous, “American Medical Association,” 941–942.



notes to pages 405–413

533

1 4. Anonymous, “American Medical Association,” 953; Carl F. Ameringer, The Health Care Revolution: From Medical Mono­poly to Market Competition (Berkeley: University of California Press, 2008), 29–30; 15. Richard C. Cabot, “Better Doctoring for Less Money,” American Magazine 81 (April 1916), 7–9, and American Magazine 81 (May 1916), 43–44, 76–79; Committee on the Costs of Medical Care, Medical Care for the American P ­ eople (Chicago: University of Chicago Press, 1932); Morris Fishbein, “The Committee on Costs of Medical Care,” JAMA 99:23 (December 3, 1932), 1950, 1951. 16. “Freedom of Speech within the Medical Profession,” NEJM 218:1 (January 6, 1938), 45–46; Richard H. Shryock, “Freedom and Interference in Medicine,” AAAPSS 200 (November 1938), 56; Oliver Garceau, The Po­liti­cal Life of the American Medical Association (Hamden, CT: Archon, 1961), 106; American Medicine, 1066, 1319–1330. 17. Mary Ross, “The Case of the Ross Loos Clinic,” Survey Graphic 24 (June  1935), 300–304, 315–316; “Dr. H. Clifford Loos, Coast Physician, 78,” NYT, September 1, 1960; “Dr. Donald Ross, Pioneer in Prepaid Health Care,” WaPo, June 18, 1981; “Judicial Council Action in Ross-­ Loos Case,” JAMA 106:4 (January 25, 1936), 300–301. 18. Michael A. Shadid, Crusading Doctor: My Fight for Cooperative Medicine (Boston: Meador, 1956), 130–142, 146–148, 149, 151–155; Shadid, A Doctor for the P ­ eople: The Autobiography of the Founder of Amer­i­ca’s First Co-­operative Hospital, 134, 202. For one of the best of many short treatments of the Oklahoma and other PGPs discussed below, see Elton Rayack, Professional Power and American Medicine: The Economics of the American Medical Association (Cleveland: World, 1967), 180–195. 19. Ameringer, Health Care Revolution, 31–36. 20. AMA v. U.S. 317 U.S. 519; Ameringer, Health Care Revolution, 26–36; Group Health Cooperative v. King County Medical Society, 39 Wash. 2d 586 (1951); Rayack, Professional Power, 185–191. 21. Rickey Hendricks, A Model for National Health Care: The History of Kaiser Permanente (New Brunswick, NJ: Rutgers University Press, 1993), 2, 72–73; James W. Henderson, Health Economics and Policy (Boston: Cengage, 2011), 211. 22. Rickey Hendricks, “Medical Practice Embattled: Kaiser Permanente, the American Medical Association, and Henry J. Kaiser on the West Coast, 1945–1955,” Pacific Historical Review 60:4 (November 1991), 447–449. For another instance of capital and ­labor against medicine, see Peter A. Swenson, “Good Distribution, Bad Delivery, and Ugly Politics: The Traumatic Origins of Germany’s Health Care System,” in Ian Shapiro, Peter A. Swenson, and Daniella Donna, eds., Divide and Deal: The Politics of Distribution in Democracies (New York: New York University Press, 2008). 23. U.S. Senate, Select Committee on Small Business, Competitive Prob­lems in the Drug Industry: Hearings before the Subcommittee on Mono­poly of the Select Committee on Small Business, pt. 14 (Washington, DC: U.S. Government Printing Office, 1969), 5731. 2 4. Garceau, Po­liti­cal Life of the AMA, 77, 81. See also Oliver Garceau, “Or­ga­nized Medicine Enforces Its ‘Party Line,’ ” Public Opinion Quarterly 4:3 (September 1940), 408–428. 25. Edward H. Ochsner, Social Insurance and Economic Insecurity (Boston: Humphries, 1934), 36; George W. Kosmak, “A Breeze from Down ­Under,” NYSJM 49:16 (August 15, 1949), 1905; Kosmak, “License for Illness,” NYSJM 49:18 (September 15, 1949), 2130. 26. Donald W. Seldin, “Scientific Achievements of John P. Peters,” American Journal of Nephrology 22:2–3 (July 2002), 192–196; Peters to Lydia Allen DeVilbiss, April 29, 1938, series I, box 1, fol. 34, John Punnett Peters Jr. Papers, Sterling Memorial Library, Yale University [hereafter, Peters Papers]. 27. “Princi­ples and Proposals for Medical Care,” NEJM 217:20 (November 11, 1937), 793–794; “More on ‘Princi­ples and Proposals,’ ” NEJM 217:21 (November 18, 1937), 843–844; “Still More

534

notes to pages 413–420

on ‘Princi­ples and Proposals,’ ” NEJM 217:22 (November 25, 1937), 884–885; “The American Foundation Proposals for Medical Care,” JAMA 109:16 (October 16, 1937), 1280. 28. Harrison H. Shoulders, “An Analy­sis of Certain Princi­ples and Proposals Drafted and Promulgated by a Self-­Appointed Group of Doctors,” Journal of the Tennessee State Medical Society, December 1937, 481–486. 29. John P. Peters to C. F. N. Schram, April 20, 1938, fol. 33; Peters to Thomas Addis, June 2, 1937, fol. 31, both in series I, box 1, Peters Papers. 30. Peters to Graeme Mitchell, April 25, 1938, series I, box 1, fol. 34, Peters Papers; “American Foundation Proposals,” 1281. 31. “Princi­ples and Proposals of the Committee of Physicians,” JAMA 109:22 (November 27, 1937), 1816; Peters to William G. Lennox, November 12, 1937, fol. 31; Peters to Schram, April 20, 1938, fol. 33; both in Peters Papers. 32. Peters to Cabot, March 22, 1938; Peters to Cabot, March 14, 1938; both in series I, box 1, fol. 26, Peters Papers. 33. Peters to Henry A. Christian, January 8, 1938, fol. 33; Peters to C. F. N. Schram, March 16, 1938, fol. 33; Peters to Schram, April 20, 1938, fol. 33; Cabot to Peters, March 16, 1938, fol. 26; Cabot to Peters, March 28, 1938, fol. 26; all in series I, box 1, Peters Papers. 34. Peters to George Baehr, n.d., fol. 23; Peters to Cabot, November 22, 1937, fol. 25; Peters to Allan M. Butler, May 23, 1938, fol. 23; Cabot to Peters, December 6, 1937, fol. 25; Cabot to Peters, March 16, 1938, fol. 26; Cabot to Peters, February 24, 1938, fol. 26; all in series I, box 1, Peters Papers. 35. Peters to Cabot, March 17, 1938, fol. 26; Cabot to Peters, March 21, 1938, fol. 26; Cabot to Peters, March  28, 1938, fol. 26; Cabot to Peters, December  6, 1937, fol. 25; Cabot to Peters, July 9, 1938, fol. 27; S. R. Salzman to Walter C. Alvarez, January 13, 1938, fol. 33; Peters to Walter C. Alvarez, July 23, 1938, fol. 35, all in series I, box 1, Peters Papers. 36. Cabot to Peters, March 16, 1938, fol. 26; Peters to Cabot, March 24, 1938, fol. 26; both in series I, box 1, Peters Papers. 37. Peters to Mills Sturtevant, December 15, 1937, fol. 32; Peters to Thomas Addis, December 6, 1937, fol. 32; Peters to W. A. Sawyer, November 23, 1937, fol. 31; Peters to George Baehr, November 18, 1938, fol. 23; Cabot to Peters, December 6, 1937, fol. 25; all in series I, box 1, Peters Papers. 38. Peters to J. H. Mason Knox Jr., July 25, 1938, fol. 35; Peters to C. F. N. Schram, January 14, 1938, fol. 33; Stuart E. Krohn to Peters, April 7, 1938, fol. 34; all in series I, box 1, Peters Papers; Bertram M. Bernheim, Medicine at the Crossroads (New York: William Morrow, 1939), 246– 247. 39. Peters to Lydia Allen DeVilbiss, April 29, 1938, series I, box 1, fol. 34, Peters Papers; Bernheim, Medicine at the Crossroads, 240–245. 40. “We Are Advertised by Our Loving Friends,” JAMA 112:5 (February 4, 1939), 435; “Address of President-­Elect Nathan B. Van Etten,” JAMA 114:25 (June 22, 1940), 2472. 41. Jane Pacht Brickman, “Medical McCarthyism: The Physicians Forum and the Cold War,” JHM 49:3 (July 1994), 385, 390; Brickman, “Minority Politics in the House of Medicine: The Physicians Forum and the New York County Medical Society, 1938–1965,” Journal of Public Health Policy 20:3 (September 1999), 292. 42. “Communists and Medicine,” New York Medicine 8:2 (October 20, 1952), 13–14. 43. “Medical Body Kills County ‘Gag Rule,’ ” NYT, May 7, 1940; “House Committee Cites M.D.’s and O ­ thers,” series I, box 1, fol. 8, Peters Papers; Brickman, “Medical McCarthyism,” 400, 402, 406, 408; “Communists and Medicine,” New York Medicine 8 (October 20, 1952), 13–14; “Tributes to Ernst Boas,” Physician’s Forum Bulletin (September 1955), 5–7. 4 4. Garceau, Po­liti­cal Life of the AMA, 77–78, 81, 91, 98–99, 103; “Address of President Irvin Abell,” JAMA 111:13 (September 24, 1938), 1194; Brickman, “Medical McCarthyism,” 405; Paul A.



notes to pages 421–427

535

Dodd, “Committee on Medicine and the Changing Order,” AAAPSS 253 (September 1947), 238. 45. John Edgar Hoover, “Let’s Keep Amer­i­ca Healthy,” JAMA 144:13 (November 25, 1950), 1094– 1095; Elmer Henderson, “The President’s Page,” JAMA 145:8 (February 24, 1951), 567. 46. Jonathan Bressler, “The Red Badge of Infamy: John Punnett Peters and the Fate of the Federal Employment Loyalty Program” (unpublished BA se­nior thesis, Department of History, Yale University, 2007), RU 331, series accession 2008-­A-044, box 1, fol. 3, Peters Papers; Peters to Lewis, January 26, 1948, series I, box 4, fol. 119, Peters Papers; “Peters Desires Broader Ruling,” NYT, 7 June 1955; John P. Peters v. Oveta Culp Hobby, 349 U.S. 331(1955); “Dr. John Peters of Yale, 69, Dies,” NYT, December 30, 1955; Richard M Rocco, “John P. Peters: McCarthyism and the Unfinished Revision of Quantitative Clinical Chemistry,” Journal of Medical Biography 25:1 (2015), 2–9. 47. Louis Lasagna, “Why Are Doctors Out of Step?,” New Republic, January 2, 1965, 13; Lasagna, Life, Death, and the Doctor (New York: Knopf, 1968), 9. 48. Harold Aaron, “The Doctor in Politics,” Consumer Reports, February 1950, 75; Luther A. Huston, “AMA Is Potent Force among the Lawmakers,” NYT, June 15, 1952. 49. Anonymous, “American Medical Association,” 957; Frank D. Campion, The AMA and U.S. Health Policy since 1940 (Chicago: Chicago Review Press, 1984), 210–216. 50. “AMA Is Rich Source of Po­liti­cal Campaign Funds,” Congressional Quarterly Weekly Report 27:2 (July 4, 1969), 1169–1170; Howard Wolinsky and Tom Brune, The Serpent on the Staff: The Unhealthy Politics of the American Medical Association (New York: Putnam, 1994), 90; Ward Sinclair and Thomas B. Edsall, “All-­Night, All-­Day Lawmaking,” WaPo, December 18, 1982; Campion, AMA and U.S. Health Policy, 220. 51. “Dr. Morris Fishbein Dead at 87,” NYT, September 28, 1976; Morris Fishbein, “Health and Social Security,” JAMA 138:17 (December 25, 1948), 1256; Compulsion: The Key to Collectivism: A Treatise on and Evidence of Attempts to Foist on the American ­People Compulsory Health Insurance (Chicago: National Physicians Committee, 1946), 1. 52. Campion, AMA and U.S. Health Policy, 118–125; Fishbein, Morris Fishbein, 305–320; Milton Mayer, “The Rise and Fall of Dr. Fishbein,” Harper’s, November 1949, 77; “Remedy for Fishbein,” Time, July 15, 1946. 53. Campion, AMA and U.S. Health Policy, 158. 54. Scott M. Cutlip, The Unseen Power: Public Relations (Hillsdale, NJ: Erlbaum, 1994), 615; Campion, AMA and U.S. Health Policy, 158, 160. 55. YouTube video, “Ronald Reagan Speaks Out against Socialized Medicine,” https://­w ww​ .­youtube​.­com​/­watch​?­v​=­Bejdhs3jGyw; Jeffrey St. Onge, “Operation Coffee Cup: Ronald Reagan, Rugged Individualism, and the Debate over ‘Socialized Medicine,’ ” Rhe­toric and Public Affairs 20:2 (Summer 2017); Max Skidmore, “Ronald Reagan and ‘Operation Coffeecup’: A Hidden Episode in American Po­liti­cal History,” Journal of American Culture 12:3 (Fall 1989). 56. Campion, AMA and U.S. Health Policy, 163. 57. Earl Ubell, Stuart H. Loory, and Joseph R. Hixson, “AMA: Healer-­Dealers,” NYHT, June 21, 1964; Fishbein, History, 844; Campion, AMA and U.S. Health Policy, 163; Cutlip, Unseen Power, 616; J. Richard ­Piper, Ideologies and Institutions: American Conservative and Liberal Governance Prescriptions since 1933 (New York: Rowman and Littlefield, 1997), 133; Donald R. Hall, Cooperative Lobbying: The Power of Pressure (Tucson: University of Arizona Press, 1969), 191–196; Robert Welch, The Politician (Belmont, MA: Robert Welch, 1963), 5–6, 13–14, 267; Swenson, “Misrepresented Interests,” 10–12. 58. George F. Lull to Senator Estes Kefauver, in U.S. Senate, Treaties and Executive Agreements: Hearings before a Subcommittee of the Committee on the Judiciary (Washington DC: U.S. Government Printing Office, 1958), 424–426; “AMA Attacks Aid to Disabled,” NYT, July 23, 1955.

536

notes to pages 428–433

59. Drew Pearson and Jack Anderson, The Case Against Congress: A Compelling Indictment of Corruption on Capitol Hill (New York: Simon and Schuster, 1968), 329–330. On the long entanglements and their slow unraveling of the AMA and the cigarette industry, see Wolinsky and Brune, Serpent, 145–173. 60. Harold M. Schmeck, “Firm AMA Stand on Smoking Urged,” NYT, June 23, 1964; “Smoking and Health,” JAMA 205:10 (September 2, 1968), 695; “Tobacco Companies Give A.M.A. $10 Million for Smoking Study,” NYT, February 8, 1964; Francis J. L. Blasingame, “Full Text of AMA Letter to F.T.C.,” JAMA 188:1 (April 6, 1964), 31. 61. Sarah G. Mars and Pamela M. Ling, “Meanings and Motives: Experts Debating Tobacco Addiction,” AJPH 98:10 (October 2008), 1795–1796; American Tobacco Com­pany, “1961 Expenditures for Research and Development Activities outside the Com­pany,” Truth Tobacco Industry Documents, https://­w ww​.­industrydocumentslibrary​.­ucsf​.­edu​/­tobacco​/­docs​/­#id​=­qtwv0141; Eric Solberg, “The Conspiracy Theory and Tobacco Litigation” (unpublished manuscript, March 1997), https://­c sts​.­ua​.­edu​/­fi les​/­2018​/­11​/­1997​-­03​-­Conspiracy​-­Theory​-­Tobacco​-­Litigation​ -­wm​.­pdf, 19, 25; Proctor, Golden Holocaust, 236–237; Richard Kluger, Ashes to Ashes: Amer­i­ca’s Hundred-­Year Cigarette War, the Public Health, and the Unabashed Triumph of Philip Morris (New York: Knopf, 1996), 360–362. 62. Allan Brandt, The Cigarette C ­ entury: The Rise, Fall and Deadly Per­sis­tence of a Product That Defined Amer­i­ca (New York: Basic, 2007), 249–250; David Kessler, A Question of Intent: A ­Great American ­Battle with a Deadly Industry (Cambridge, MA: Public Affairs, 2001), 207–208; Wolinsky and Brune, Serpent, 152; Solberg, “Conspiracy Theory,” 11. 63. David J. Fletcher, “Death by Nicotine,” Hustler, August 1984, 54; Howard Wolinsky, “AMA Kills Story on Smoking,” Chicago Sun-­Times, March 25, 1984; George Lundberg, “Confidential Memorandum: Particularly Sensitive Po­liti­cal Issues,” September 7, 1982, document supplied by Howard Wolinsky. The other two issues mentioned ­were nuclear war and abortion. On prepaid group practices, see chapter 13; on the FTC decision, see chapter 15. 64. Alan Blum, ed., The Cigarette Underworld: A Front Line Report on the War Against Your Lungs (Secaucus, NJ: Lyle Stuart, 1983); Jessica Rosenberg, “The AMA Tackles Smoking,” in ibid., 124–125. 65. Edward J. Huth to Daniel F. O’Keefe, January 6, 1986, copy of letter given to me by Alan Blum; R. J. Epstein, “That Image Again,” Medical Practice, February 1983, 2; John P. Naughton to Charles D. Sherman, March 3, 1986, copy of letter given to me by Alan Blum. 66. C. Everett Koop to Daniel F. O’Keefe, January 9, 1986, copy of letter given to me by Blum; Bennett M. Derby to the MSSNY, January 24, 1986, copy of letter given to me by Alan Blum. 67. Stella Lowry and Richard Smith, “Become a Medical Journalist or Editor,” in How to Do It, 2nd ed. (London: British Medical Association, 1985), 133; Howard Wolinsky, “The South African Connection,” Physician’s Weekly 10:22 (June 21, 1993), 1. 68. Correspondence with Alan Blum; “An Embarrassing M ­ atter of the AMA’s Investment in Tobacco Stocks: The Unfiltered Truth About Smoking and Health,” Center for the Study of Tobacco and Society, University of Alabama, n.d., https://­c sts​.­ua​.­edu​/­a ma​/­tobacco​-­stock​-­in​-­a ma​ -­pension​-­f unds​/­. 69. Wally Phillips, Way to Go: Surviving in This World ­until Something Better Comes Along (New York: William Morrow, 1985), 117; Blum, “Smoking and the New York State Journal of Medicine,” Social Medicine 5:2 (June 2010), 108; “Terms of Agreement American Acad­emy of ­Family Physicians/Alan Blum, M.D,” n.d., document provided by Blum. 70. Earl Ubell, Stuart H. Loory, and Joseph R. Hixson, “AMA: Healer-­Dealers,” NYHT, June 21, 1964; Fishbein, Morris Fishbein, 137, 247. 71. Fishbein, Morris Fishbein, 249–250, 368, 388, 396, 398, 401, 402, 413, 419; Melvin Small, The Presidency of Richard Nixon (Lawrence: University Press of Kansas, 1999), 182, 227; Ken Ringle, “Nixon Library Shelves Plan,” WaPo, April 12, 1997.



notes to pages 433–440

537

72. Marc A. Rodwin, Conflicts of Interest and the ­Future of Medicine (Oxford: Oxford University Press, 2011), 104–108; Jeremy Greene, “Phar­ma­ceu­ti­cal Marketing Research and the Prescribing Physician,” Annals of Internal Medicine 146 (2007), 742–745. 73. James Rorty, American Medicine Mobilizes (New York: Norton, 1939), 172–173; Monty Poen, Harry S. Truman versus the Medical Lobby (Columbia: University of Missouri Press, 1979), 47; Campion, AMA and U.S. Health Policy, 136. 74. U.S. Senate, Select Committee on Small Business, Competitive Prob­lems in the Drug Industry, pt. 5 (Washington, DC: U.S. Government Printing Office, 1968), 2002–2004; Jeremy  A. Greene and Scott  H. Podolsky, “Keeping Modern in Medicine: Phar­ma­ceu­ti­cal Marketing and Physician Education in Postwar Amer­i­c a,” BHM 83 (2009), 344–334; Howard Brody, Hooked: Ethics, the Medical Profession, and the Phar­ma­ceu­ti­cal Industry (Lanham, MD: Rowman and Littlefield, 2006), 145–­; Rodwin, Conflicts of Interest, 104–108, 105, 106n33. 75. U.S. Senate, Select Committee on Small Business, Competitive Prob­lems in the Drug Industry, pt. 14 (Washington, DC: U.S. Government Printing Office, 1969), 5727. 76. Dominique Tobbell, Pills, Power, and Profits: The Strug­gle for Drug Reform in Cold War Amer­ i­ca (Berkeley: University of California Press, 2012), 116; U.S. Senate, Committee on the Judiciary, Drug Industry Antitrust Act, pt. 2 (Washington, DC: U.S. Government Printing Office, 1961), 45. 77. Estes Kefauver, In a Few Hands (New York: Pantheon, 1965), 73; Tobbell, Pills, Power, and Profits, 108; U.S. Senate, Committee on the Judiciary, Drug Industry Antitrust Act, pt. 4 (Washington, DC: U.S. Government Printing Office, 1961), 2011; U.S. House of Representatives, Committee on Ways and Means, Medical Care for the Aged, pt. 3 (Washington, DC: U.S. Government Printing Office, 1964), 2383. 78. Mars and Ling, “Meanings and Motives,” 1796; U.S. Senate, Drug Industry Antitrust Act, pt. 1, 216; AMA Drug Evaluations (Chicago: American Medical Association, 1971); John Adriani, “The Concept of the AMA,” Drug Information Bulletin 4:1 (January 1970), 94. 79. Campion, AMA and U.S. Health Policy, 412; U.S. Senate, Subcommittee on Mono­poly of the Select Committee on Small Business, Competitive Prob­lems in the Drug Industry, pt. 23 (Washington, DC: U.S. Government Printing Office, 1973), 9616. For more on Adriani, see Mack A. Thomas, “The John Adriani Story,” Ochsner Journal 11:1 (Spring 2011), 8. 80. For an exhaustive account of or­ga­nized medicine’s mono­poly agenda, see Elton Rayack, Professional Power and American Medicine: The Economics of the American Medical Association (Cleveland: World, 1967), especially 150–272; G. Frank Lydston, “Why the AMA Is ­Going Backward,” Southern Practitioner 35:5 (May 1913), 205, and Southern Practitioner 35:6 (June 1913), 271; Garceau, Po­liti­cal Life of the AMA, 34–35, 52–55, 61, 94–95; Anonymous, “American Medical Association,” 945–947. The other authors w ­ ere Payson Wolff, Anne Gross, and Elliott Lee Hoffman. 81. Stephen Ambrose, Eisenhower: The President (New York: Simon and Schuster, 1984), 199; Frank Billings, “The American Medical Association, Its Accomplishments and Purposes,” OSMJ 19:8 (August 1923), 602–603; Robert Michels, Po­liti­cal Parties: A So­cio­log­i­cal Study of the Oligarchical Tendencies of Modern Democracy (New York: ­Free Press, 1962), 365. 82. Thomas N. Bonner, Medicine in Chicago, 1850–1950: A Chapter in the Social and Scientific Development of a City, 2nd ed. (Urbana: University of Illinois Press, 1991), 222; “The Child Belongs to the State, ILMJ 47:2 (February 1925), 88. 83. Garceau, Po­liti­cal Life of the AMA, 63, 96, 101, 136; Anonymous, “American Medical Association,” 947, 1013. 84. “A Symposium on Compulsory Health Insurance,” Long Island Medical Journal 13:12 (December 1919), 435; Bernheim, Medicine at the Crossroads, 13, 15, 41, 66, 68–69. 85. Campion, AMA and U.S. Health Policy, 64.

538

notes to pages 441–447 CH A PTER 15. A NEW MEDIC A L PROGR ESSI V ISM

1. “Summary of AMA Membership in Relation to Physician Population” (document supplied by Howard Wolinsky). 2. George D. Lundberg, “American Medicine’s Prob­lems, Opportunities, and Enemies,” JAMA 259:21 (June 3, 1988), 3174. 3. Leartus Connor, “The Prevention of Diseases Now Preying on the Medical Profession,” BAAM 3:9 (October 1898), 455–466. 4. U.S. Senate, Committee on Finance, Social Security Amendments of 1955, pt. 1 (Washington, DC: U.S. Government Printing Office, 1956), 411; Milford O. Rouse, “To Whom Much Has Been Given . . . ,” JAMA 201:3 (July 17, 1963), 87. 5. Dean J. Kotlowski, “The Knowles Affair: Nixon’s Self-­Inflicted Wound,” Presidential Studies Quarterly 30:3 (September 2000), 443–463; Don Oberdorfer and Laurence Stern, “AMA Shows Clout in Knowles Affair,” WaPo, May 25, 1969; St. Louis Post-­Dispatch, June 29, 1969; Sandra Blakeslee, “Dispute among Doctors in AMA’s House,” NYT, July 20, 1969; T. E. Mattingly, “The AMA on Dr. Knowles,” WaPo, May 29, 1969; Frank Ashley, “Dr. Knowles Assails Nixon’s Public Health Policies,” Louisville Courier-­Journal, March 21, 1970. 6. Stuart Auerbach, “ ‘Sore Throat’ Gives AMA High Fever,” WaPo, July 13, 1975; Howard Wolinsky, Contain and Eliminate: The American Medical Association’s Conspiracy to Destroy Chiropractic (Palmerton, PA: Sportelli, 2020), 29–47. 7. Auerbach, “ ‘Sore Throat’ Gives AMA High Fever”; Allan Parachini, “AMA Embarrassed by Lobbying Links,” St. Louis Post-­Dispatch, July 29, 1975; “Secret AMA, Nixon Link Reported,” Chicago Tribune, July 4, 1975; William Hines, “ ‘Sore Throat’ Is More than a Pain in the Neck to AMA,” Chicago Sun-­Times, August 14, 1975. 8. Stuart Auerbach, “AMA Sought Influence through Hale Boggs’ Son,” WaPo, June 16, 1975; David Burnham, “AMA Develops Referral System to Put Doctors on Health Advisory Panels,” NYT, June 29, 1975. 9. Allan Parachini, “Conflicts of Interest in the AMA,” Chicago Sun-­Times, July 9, 1975; “Doctors Cautioned By AMA Council About Diabetes Pill,” NYT, October 23, 1970; David Burnham, “AMA Aide Let Upjohn Use Letter to Sell Drug,” NYT, July 8, 1975. 10. Stuart Auerbach, “Drug Firms Gave AMA $851,000,” WaPo, July 1, 1975; AMA Drug Evaluations (Chicago: American Medical Association, 1971); David Burnham, “AMA Joined Drug Makers in ’70 Drive to Kill Bill Setting Prices,” NYT, July 20, 1975; Stuart Auerbach, “AMA Invests Millions in Drug Firms,” WaPo, June 25, 1973; Richard D. Lyons, “Citizen Groups Charge AMA May Owe $21 Million in Taxes,” NYT, July 29, 1975; Stuart Auerbach, “AMA Probed for Pos­si­ble Postal Fraud,” WaPo, July 16, 1975; Stuart Auerbach, “Nader Groups Urge Hill to Probe AMA Taxes,” WaPo, July 30, 1975. 11. David Burnham, “AMA Criticized on Chiropractic,” NYT, October 29, 1975. 12. James Coates, “Medical Lobby Gifts Linked to FTC Bill,” Chicago Tribune, September 17, 1982; “Lobby Group Links Votes to AMA Contributions,” Chicago Tribune, December 4, 1982; “FTC Power to Review Doctors’ Businesses Upheld by House Panel,” Wall Street Journal, May 11, 1983; Stuart Auerbach, “AMA Defeat Costly,” WaPo, December 21, 1982; Carl F. Ameringer, The Health Care Revolution: From Medical Mono­poly to Market Competition (Berkeley: University of California Press, 2008), 100–134; Michael Pertschuk, ­Giant Killers (New York: Norton, 1986), 82–114. 13. “Membership Woes Continue,” Canadian Medical Association Journal 183:11 (August  9, 2011), E713; American Medical Association, Born to Do This: 2016 Annual Report, https://­ www​.­a ma​-­a ssn​.­org​/­sites​/­a ma​-­a ssn​.­org​/­fi les​/­c orp​/­media​-­browser​/­a ma​-­a nnual​-­report​-­2 016​ .­pdf, 23. 1 4. American Medicine: Expert Testimony out of Court, vol. 2 (New York: American Foundation, 1937), 1106–1107; Irvine H. Page, “Needed: National Acad­emy of Medicine,” Modern Medi-



notes to pages 448–453

539

cine (July 20, 1964), 77; Page, “A Current Look at the Rationale of the IOM,” JAMA 260:14 (October 14, 1988), 2102–2104. 15. Julius B. Richmond and Rashi Fein, The Health Care Mess: How We Got into It and What It ­Will Take to Get Out (Cambridge, MA: Harvard University Press, 2005), 214–216; Edward D. Berkowitz, To Improve ­Human Health: A History of the Institute of Medicine (Washington, DC: National Academies Press, 1998), 2, 4, 13; Thomas T. Fenton, “New Doctors Hear Attack on the AMA,” Baltimore Sun, June 10, 1965; Louis Lasagna, Life, Death, and the Doctor (New York: Knopf, 1968), 3. 16. Loyal Davis, Fellowship of Surgeons: A History of the American College of Surgeons (Chicago: American College of Surgeons, 1973), 414–436; “­Needless Surgery: Interview with Paul M. Hawley,” U.S. News and World Report 34:8 (1953), 47; “Doctors Ask Disciplining of Dr. Hawley for ‘Scurrilous’ Remarks,” NYT, March 24, 1953; Roy Gibbons, “Medics Strike Back at Critic in Own Ranks,” Chicago Tribune, May 23, 1953; M. Hanford Hopkins, “Unwise Guidance,” Baltimore Sun, June 26, 1965. 17. John E. Wennberg and Alan Gittelsohn, “Small Area Variations in Health Care Delivery: A Population-­Based Health Information System Can Guide Planning and Regulatory Decision Making,” Science 182:4117 (December 1973). 18. Michael L. Millenson, Demanding Medical Excellence: Doctors and Accountability in the Information Age (Chicago: University of Chicago Press, 1997), 45; Maggie Mahar, “Braveheart,” Dartmouth Medicine (Winter 2007), 15–16; C. G. McDaniel, “MDs Rapped on Cancer Surgery,” Pittsburgh Post- ­Gazette, November 26, 1970; Wayne Durham, “Specialists to Debate: What Surgery for Breast Cancer?,” Chicago Tribune, November 25, 1972; George Crile Jr., “A Vote for Partial Mastectomy,” Chicago Tribune, October 2, 1973; Nicholas von Hoffman, “Medical Fashion: Radical Chic,” WaPo, September 19, 1973; Crile, “The Surgeon’s Dilemma: The Built-­In Conflict of Interest in Medical Fees,” Harpers Monthly, May 1975, 33; Crile, The Way It Was: Sex, Surgery, Trea­sure, and Travel, 1907–1987 (Kent, OH: Kent State University Press, 1992), 317. 19. John E. Wennberg, Tracking Medicine: A Researcher’s Quest to Understand Health Care (Oxford: Oxford University Press, 2010). 2 0. John E. Wennberg, “Improving the Medical Decision Making Pro­c ess,” Health Affairs 7:1 (Spring 1988), 99, 100; U.S. House of Representatives, Committee on Interstate and Foreign Commerce, Getting Ready for National Health Insurance (Washington, DC: U.S. Government Printing Office, 1975), 73–90; U.S. House of Representatives, Committee on Interstate and Foreign Commerce, Health Ser­vices Research and Health Statistics Amendments of 1978 (Washington, DC: U.S. Government Printing Office, 1978), 231–248; Bradford H. Gray et al., “AHCPR and the Changing Politics of Health Ser­vices Research,” Health Affairs Web Exclusive, June 25, 2003, 283–307. 21. John Harley Warner, “Science in Medicine,” in Sally Kohlstedt and Margaret Rossiter, eds., Historical Writing on American Science (Baltimore: Johns Hopkins University Press, 1985), 38; Jeanne Daly, Evidence-­Based Medicine and the Search for a Science of Clinical Care (Berkeley: University of California Press, 2005); President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry, Quality First: Better Health Care for All Americans (Washington, DC: 1998), 27, 38, 39, 68, 72. 22. Clark C. Havighurst, “Starr on the Corporatization and Commodification of Health Care,” 952–953, and Jill S. Quadagno, “Physician Sovereignty and the Purchasers’ Revolt,” 831–832, both in JHPPL 29:4–5 (August–­October 2004). 23. Robert Pear, “Co­a li­tion Seeks to Curb Rising Health Cost,” NYT, January 15, 1982; Allen S. Meyerhoff and David Crozier, “Health Care Co­a li­tions: The Evolution of a Movement,” Health Affairs 3:1 (Spring 1984), 120–127; Millenson, Demanding Medical Excellence, 226–227, 231, 234– 240. See also Linda Bergthold, Purchasing Power in Health: Business, the State, and Health Care Politics (New Brunswick, NJ: Rutgers University Press, 1990).

540

notes to pages 453–457

2 4. Millenson, Demanding Medical Excellence, 228; John B. Richardson and Roger Feldman, “Exporting the Buyers’ Health Care Action Group Purchasing Model: Lessons from Other Communities,” Milbank Quarterly 83:1 (2005), 149–176. 25. Millenson, Demanding Medical Excellence, 244–245, 251–267. 26. Robert Pear, “Rising Calls to Replace Top Man at Medicare,” NYT, March 7, 2011. 27. Robert S. Galvin et al, “Has the Leapfrog Group Had an Impact on the Health Care Market?,” Health Affairs 24:1 (January/February 2005), 228–233; Galvin, “A Conversation with the Editor on Health Care Systems in a Post-­Managed Care World,” Baylor University Medical Center Proceedings 18:3 (July 2005), 259–265; Arnold Milstein, Robert S. Galvin, Suzanne F. Delbanco et al., “Improving the Safety of Health Care: The Leapfrog Initiative Effective,” Effective Clinical Practice, November/December 2000, http://­ecp​.­acponline​.­org​/­novdec00​/­milstein​.­htm. 28. Atul Gawande, Complications: A Surgeon’s Notes on an Imperfect Science (New York: Holt, 2002), 94; Otis Webb Brawley, How We Do Harm: A Doctor Breaks Ranks about Being Sick in Amer­ i­ca (New York: St. Martin’s Griffin, 2011), 21. 29. Donald M. Berwick, Escape Fire: Designs for the F ­ uture of Health Care (San Francisco: Wiley, 2004); David Lawrence, From Chaos to Care: The Promise of Team-­Based Medicine (Cambridge, MA: Perseus, 2002); Thomas H. Lee and James J. Mongan, Chaos and Organ­ization in Health Care (Cambridge, MA: MIT Press, 2009); Arnold S. Relman, A Second Opinion: Rescuing Amer­i­ca’s Health Care (New York: C ­ entury Foundation, 2007); Ezekiel J. Emanuel, Healthcare, Guaranteed: A ­Simple, Secure Solution for Amer­i­ca (New York: Public Affairs, 2008); John Abramson, Overdosed Amer­i­ca: The Broken Promise of American Medicine (New York: Harper, 2004); Nortin M. Hadler, Worried Sick: A Prescription for Health in an Overtreated Amer­i­ca (Chapel Hill: University of North Carolina Press, 2008); H. Gilbert Welch, Over-­Diagnosed: Making ­People Sick in the Pursuit of Health (Boston: Beacon, 2011); Marty Makary, Unaccountable: What Hospitals W ­ on’t Tell You and How Transparency Can Revolutionize Health Care (New York: Bloomsbury, 2012); Makary, The Price We Pay: What Broke American Health Care—­and How to Fix It (New York: Bloomsbury, 2019); Marcia Angell, The Truth About the Drug Companies: How They Deceive Us and What to Do About It (New York: Random House, 2004); Jerome P. Kassirer, On the Take: How Medicine’s Complicity with Big Business Can Endanger Your Health (Oxford: Oxford University Press, 2005); Jerry Avorn, Power­ful Medicines: The Benefits, Risks, and Costs of Prescription Drugs (New York: Vintage, 2008); Crossing the Quality Chasm: A New Health System for the 21st ­Century (Washington, DC: Institute of Medicine/National Acad­emy Press, 2001), 79; To Err Is H ­ uman: Building a Safer Health System (Washington, DC: Institute of Medicine/National Acad­emy Press, 2000); Conflict of Interest in Medical Research, Education, and Practice (Washington, DC: Institute of Medicine/National Acad­emy Press, 2009). 30. “Medical Professionalism in the New Millennium: A Physician Charter,” Annals of Internal Medicine 136:3 (February 5, 2002), 243–246. 31. Susan Reverby, “Stealing The Golden Eggs: Ernest Amory Codman and The Science and Management of Medicine,” BHM 55:2 (Summer 1981), 156–171; Donald M. Berwick, “E.A. Codman and the Rhe­toric of ­Battle,” Milbank Quarterly 67:2 (1989), 262–267; John K. Iglehart, “The Po­liti­cal Fight Over Comparative Effectiveness Research,” Health Affairs 29:10 (October 2010), 1757–1760; U.S. Government Accountability Office, “Comparative Effectiveness Research,” March 23, 2018, https://­w ww​.­gao​.­gov​/­products​/­gao​-­18​-­311. 32. American Heart Association, “American Heart Association’s Clinical Research Prize,” November  17, 2019, https://­newsroom​.­heart​.­org​/­news​/­a merican​-­heart​-­a ssociations​-­clinical​-­research​ -­prize​-­awarded​-­to​-­yale​-­outcomes​-­research​-­pioneer​-­harlan​-­m​-­krumholz​-­m​-­d; Author communication with Harlan Krumholz, May 25 2021. 33. Jean Silver-­Isenstadt, “New Kid on the Block Turns Ten: The Brief, Remarkable History of the National Physicians Alliance,” Permanente Journal 19:3 (Summer 2015), 85–89; Choosing Wisely,” Clinician Lists,” http://­w ww​.­choosingwisely​.­org​/­clinician​-­lists​/­.



notes to pages 458–462

541

34. Concerned Health Professionals of New York and Physicians for Social Responsibility, Compendium of Scientific, Medical, and Media Findings Demonstrating Risks and Harms of Fracking https://­s ecureservercdn​.­net​/­166​.­62​.­1 12​.­150​/­ejr​.­4 eb​.­myftpupload​.­c om​/­w p​-­c ontent​/­uploads​ /­2021​/­02​/­CHPNY​-­PSR​-­Fracking​-­Science​-­Compendium​-­7​_­20210219​.­pdf. 35. Elizabeth Knoll, “The American Medical Association and Its Journal,” in William F. Bynum, ed., Medical Journals and Medical Knowledge (London: Routledge, 1992), 160–161; George D. Lundberg, “Confidential Memorandum: Particularly Sensitive Po­liti­cal Issues,” September 7, 1982 (document supplied by Howard Wolinsky); Bruce Japsen, “Ex-­E ditor Blasts AMA Interference,” Chicago Tribune, February 17, 1999. 36. Howard Wolinsky, “AMA Journal Appeased Big Advertiser,” Chicago Sun-­Times, January 15, 1984; Wolinsky, “AMA Journal Placated Advertiser with Story,” Detroit ­Free Press, January 17, 1984; George D. Lundberg, Severed Trust: Why American Medicine H ­ asn’t Been Fixed (New York: Basic, 2002), 149; Lundberg, “Goals for the Journal,” JAMA 248:5 (August 6, 1982), 553; Lundberg, “Key and Critical Objectives for the Journal,” JAMA 258:18 (November 13, 1987), 2567; Lundberg, “Editorial Freedom and Integrity,” JAMA 260:17 (November 4, 1988), 2563; Lundberg, “American Medicine’s Prob­lems, Opportunities, and Enemies,” JAMA 259:21 (June 3, 1988), 3174; Lundberg, “Still Needed: A National Acad­emy of Medicine,” JAMA 260:14 (October 14, 1988), 2105. 37. Howard Wolinsky and Tom Brune, Serpent on the Staff: The Unhealthy Politics of the American Medical Association (New York: Putnam, 1994), 159–173; Don Colburn, “Top Doc: The AMA’s Joseph Boyle,” WaPo, January 30, 1985. 38. Robert Pear, “Proposals for Limits on Medical Malpractice Suits,” NYT, April  19, 1985; Thomas O. McGarity, Freedom to Harm: The Lasting Legacy of the Laissez Faire Revival (New Haven, CT: Yale University Press, 2013); Charles Strum, “Major Lawsuit On Smoking Is Dropped,” NYT, November 6, 1992; Ernest Howard, deposition in Cipollone v. Liggett Group et al., January 7, 1986, cited in Eric Solberg, “The Conspiracy Theory and Tobacco Litigation” (unpublished manuscript, March  1997), https://­csts​.­ua​.­edu​/­files​/­2018​/­11​/­1997​-­03​-­Conspiracy​ -­Theory​-­Tobacco​-­Litigation​-­wm​.­pdf, 24; Shari Rudavsky, “Foundation Grants $10 Million to Help Antitobacco Effort,” Wall Street Journal, August 15, 1994; Wolinsky and Brune, Serpent, 173. 39. Howard Wolinsky and Tom Brune, “$353,000 Bailout Trips AMA Exec,” Chicago Sun-­Times, October 29, 1989; Mark Bloom, “Money Scandal Shakes AMA,” WaPo, November 7, 1989. On the wide range of medical conflicts of interest, see Kassirer, On the Take; Stephen R. Latham, “Conflicts of Interest in Medical Practice,” in Michael Davis and Andrew Stark, eds., Conflicts of Interest in the Professions (Oxford: Oxford University Press, 2001), 279–301; Howard Brody, Hooked: Ethics, the Medical Profession, and the Phar­ma­ceu­ti­cal Industry (Lanham, MD: Rowman and Littlefield, 2006); Alexander C. Tsai, “Conflicts between Commercial and Scientific Interests in Phar­ma­ceu­ti­cal Advertising for Medical Journals,” International Journal of Health Ser­vices 33:4 (October 2003), 751–768. 40. Lundberg, Severed Trust, 63–64; James Stacey, The Medicine Men (Baltimore: PublishAmerica, 2006), 100. 4 1. Howard Wolinsky, “Report Calls AMA a House Divided,” CST, November 11, 1998; Ashish Nanda and Kimberly Haddad, “The American Medical Association-­Sunbeam Deal: The Denouement” (Harvard Business School Case 9-802-091, January 14, 2002). 42. Millenson, Demanding Medical Excellence, 72; Millenson, “How the US News Media Made Patient Safety a Priority,” BMJ 324:7355 (April 27, 2002), 1044; Gina Kolata, “Medical Laboratory ­Faces Charges in Cancer Deaths,” NYT, April 13, 1995; Ron Winslow, “Hospitals’ Weak Systems Hurt Patients,” WSJ, July 5, 1995; Lawrence K. Altman, “Medical Errors Bring Calls For Change,” NYT, July 18, 1995; Ann Landers, “AMA Urged to Do More for Patients’ Safety,” Los Angeles Times, September 25, 1995; Sandra G. Boodman, “Diagnosing Medical Errors,” WaPo, November 19, 1996.

542

notes to pages 462–468

43. Howard Wolinsky, “The AMA and Race: A Chronology,” Chicago Sun-­Times, June 12, 1994; “Timely Protest,” Philadelphia Inquirer, March 25, 1985; “South Africa,” St. Louis Post-­Dispatch, April 10, 1985. 4 4. Interview with George D. Lundberg, October 23, 2020. 45. David Brown, “Medical Journal Editor Fired,” WaPo, January 16, 1999; Suzanne W. Fletcher and Robert H. Fletcher, “Medical Editors, Journal ­O wners, and the Sacking of George Lundberg,” Journal of General Internal Medicine 14:3 (March 1999), 200–202; Lucian L. Leape, “Error in Medicine,” JAMA 272:23 (December 21, 1994), 1851–1857; Lundberg, Severed Trust, 155, 248–249; Stephanie A. Sanders and June M. Reinisch, “Would You Say You ‘Had Sex’ If . . . ?,” JAMA 281:3 (January 20, 1999), 275–277. 46. Jerome P. Kassirer, Unanticipated Outcomes: A Medical Memoir (Wellesley, MA: Kassirer, 2017); Angell, Truth about the Drug Companies; Kassirer, On the Take. 47. Wolinsky and Brune, Serpent, back jacket cover. 48. Yuji Noto, “American Medical Association and Its Membership Strategy,” Harvard School of Public Health, June 1999, 14, https://­cdn1​.­sph​.­harvard​.­edu​/­w p​-­content​/­uploads​/­sites​/­114​/­2012​ /­10​/­rp157​.­pdf; Kevin Drum, “The AMA Represents Only about One-­Sixth of All Doctors,” ­Mother Jones, December 27, 2016, https://­w ww​.­motherjones​.­c om​/­kevin​-­d rum​/­2 016​/­12​/­a ma​ -­represents​-­only​-­about​-­one​-­sixth​-­a ll​-­doctors​/­; Scott Becker, “Is the AMA the Worst Trade Association Ever?,” Becker’s ASC Review, April  7, 2010, https://­w ww​.­beckersasc​.­com​/­news​ -­a nalysis​/­is​-­the​-­a ma​-­the​-­worst​-­trade​-­a ssociation​-­ever​.­html; Sidney M. Wolfe, “The AMA and Its Dubious Revenue Streams,” Public Citizen Health Letter 28:11 (November 2012), 1–3. 49. Frank D. Campion, The AMA and U.S. Health Policy (Chicago: Chicago Review Press, 1984), 87–88; American Medical Association, House of Delegates Reference Manual, November 2019, https://­w ww​.­a ma​-­a ssn​.­org​/­system​/­fi les​/­2019​-­11​/­hod​-­reference​-­manual​.­pdf. 50. Jerome P. Kassirer, “Professional Socie­ties and Industry Support: What Is the Quid Pro Quo?,” Perspectives in Biology and Medicine 50:1 (Winter 2007), 7–17; American Medical Association, “Admission of Specialty Organ­izations to our AMA House,” https://­policysearch​.­ama​-­assn​.­org​ /­policyfinder​/­detail​/­600​.­020​?­u ri​=­%2FAMADoc%2FHODGOV​.­x ml​-­0 ​-­8​.­x ml; Lawrence Grouse, “Physicians for Sale: How Medical Professional Organ­izations Exploit Their Members,” Medscape Journal of Medicine 10:7 (July 21, 2008), 169. 51. Good Jobs First, “Violation Tracker: Phar­ma­ceu­ti­cals,” https://­violationtracker​.­goodjobsfirst​ .­org​/­industry​/­pharmaceuticals [accessed October 4, 2020]. 52. Paul Campsall et al., “Financial Relationships between Organ­izations That Produce Clinical Practice Guidelines and the Biomedical Industry,” PLOS Medicine, May 31, 2016, https://­ journals​ .­p los​ .­o rg ​ /­p losmedicine​ /­a rticle​ /­f ile​ ?­i d​ =­1 0​ .­1 371​ /­j ournal​ .­p med​ .­1 002029&type​ =­printable, 2–3; David J. Rothman et al., “Professional Medical Associations and Their Relationships with Industry,” JAMA 301:13 (April 1, 2009), 1370; Lisa Cosgrove and Emily E. Wheeler, “Drug Firms and Bias in Clinical Guidelines,” Journal of Law, Medicine, and Ethics 41:3 (Fall 2013), 644; Charles Ornstein and Tracy Weber, “Financial Ties Bind Medical Socie­ ties to Drug and Device Makers,” ProPublica, May 5, 2011; Ramy R. Saleh et al., “Undisclosed Financial Conflicts of Interest among Authors of ASCO Clinical Practice Guidelines,” Cancer, November 15, 2019, 4071. 53. Bradford H. Gray, Michael K. Gusmano, and Sara R. Collins, “AHCPR and the Changing Politics of Health Ser­vices Research,” Health Affairs (June 25, 2003), https://­w ww​.­healthaffairs​ .­org​/­doi​/­pdf​/­10​.­1377​/­hlthaff​.­W3​.­283; Richard A. Deyo et al., “The Messenger ­under Attack: Intimidation of Researchers by Special Interest Groups,” NEJM 336:16 (April 17, 1997), 1176. 54. U.S. Senate, Homeland Security and Governmental Affairs Committee, Ranking Member’s Office, Fueling an Epidemic: Exposing the Financial Ties between the Opioid Industry and Third Party Advocacy Groups, 2018, https://­w ww​.­documentcloud​.­org​/­documents​/­6025332​-­Report​



notes to pages 468–472

543

-­Fueling​-­a n​-­Epidemic​-­E xposing​-­t he​.­html; Thomas Catan and Evan Perez, “A Pain Drug Champion Has Second Thoughts,” Wall Street Journal, December 17, 2012. 55. Pamela T. M. Leung et al., “A 1980 Letter on the Risk of Opioid Addiction,” NEJM 376:22 (June 1, 2017), 2194–2195; Sarah Zhang, “The One-­Paragraph Letter from 1980 That Fueled the Opioid Crisis,” Atlantic, June 2, 2017; John Fauber, “Follow the Money: Pain, Policy, and Profit,” MedPage ­Today, February 19, 2012; Neeraj Chhabra and Jerrold B. Leiken, “The Joint Commission and the Opioid Epidemic,” JAMA 318:1 (July 4, 2017), 91–92. 56. Barry Meier, “Opioid Prescribing Gets Another Look,” NYT, May 2, 2016. 57. Steven L. Bern­stein et al., “Professional Socie­ties, Po­liti­cal Action Committees, and Party Preferences,” AJPH 105:1 (January  2015), 1–11; Open Secrets, “The American Medical Association,” https://­w ww​.­opensecrets​.­org​/­orgs​/­summary​.­php​?­id​=­D000000068. 58. Lauren A. McCormack, “Diffusion of Medicare’s RBRVS and Related Physician Payment Policies,” Health Care Financing Review 16:2 (Winter 1994), 164–165; John D. Goodson, “Unintended Consequences of RBRVS Reimbursement,” JAMA 298:19 (November  21, 2007), 2308–2310; Uwe E. Reinhardt, “The L ­ ittle Known Decision Makers for Medicare Physicians Fees,” NYT, December 10, 2010, https://­economix​.­blogs​.­nytimes​.­c om​/­2 010​/­12​/­10​/­t he​-­l ittle​ -­k nown​-­decision​-­makers​-­for​-­medicare​-­physicans​-­fees​/­. For a deep exploration of ­t hese issues, Miriam J. Laugesen, Fixing Medical Prices: How Physicians Are Paid (Cambridge, MA: Harvard University Press, 2016). 59. Donna B. Jeffe et al., “Primary Care Specialty Choices of Medical Gradu­ates,” Academic Medicine 85:6 (June 2010), 947–958; Gabrielle Redford, “Looming Doctor Shortage Could Impact Patient Care,” AAMC News, April 30, 2018; John Geyman, Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans (Friday Harbor, WA: Copernicus Healthcare, 2011), 116; Barbara Starfield and Leiyu Shi, “Policy Relevant Determinants of Health: An International Perspective,” Health Policy 60:3 (March 2002), 201–218; Lewis G. Sandy et al., “The Po­ liti­cal Economy of Primary Care,” Health Affairs 28:4 (July/August  2009), 1136–1145; Anna Wilde Mathews and Tom McGinty, “Physician Panel Prescribes the Fees Paid by Medicare,” WSJ, October 26, 2010; Brian Klepper, “The RUC Is Bad Medicine,” Medscape, August 12, 2013. 60. Avik Roy, “Why the American Medical Association Had 72 Million Reasons to Shrink Doctors’ Pay,” Forbes, November 28, 2011. 61. PCPI, “PCPI History,” https://­w ww​.­t hepcpi​.­org ​/­page​/­History [accessed October 31, 2020]; ProPublica, “American Medical Association: Form 990-­O for Period Ending December 2018,” https://­projects​.­propublica​.­org​/­nonprofits​/­d isplay​_­9 90​/­360727175​/­0 2​_­2 020​_­prefixes ​_ ­35​ -­38%2F360727175​_­201812​_­990O​_­2020020117097690, Schedule I [accessed October 31, 2020]. 62. Walter F. Carroll, “Association of American Physicians and Surgeons,” in Greg Lee Car­ter, ed., Guns in American Society (Santa Barbara, CA: ABC-­Clio, 2002), 37–38; Mike Magee, Code Blue: Inside Amer­i­ca’s Medical Industrial Complex (New York: Atlantic Monthly Press, 2019), 202–203. 63. H.R.3400. Empowering Patients First Act, 111th Cong. (2009–2010), Section 507(c), https://­ www​.­congress​.­gov​/­bill​/­111th​-­congress​/­house​-­bill​/­3400​/­text; James V. Grimaldi and Michelle Hackman, “Donald Trump’s Pick for Health Secretary Traded Medical Stocks While in House,” Wall Street Journal, December 22, 2016; “Tom Price’s Dubious Trades in Health Care Stocks,” NYT, January 18, 2017; James Grimaldi, “HHS Secretary Tom Price Tripled His Investment on a Biotech Stock Bought at Discount,” Wall Street Journal, April 5, 2017. 64. “The AMA Does Not Speak for Us,” Clinician Action, November 30, 2016, https://­medium​ .­com​/­@ClinicianAction​/­the​-­ama​-­does​-­not​-­speak​-­for​-­us​-­d697511267d5; “AMA Response to Our Open Letter,” Clinician Action, January 4, 2017, https://­medium​.­com​/­@ClinicianAction​/­a ma​ -­response​-­to​-­our​-­open​-­letter​-­cf6bdbea6035; Dylan Scott, “The Nation’s Most Prominent Doctor Group Almost Dropped Its Opposition to Medicare for All,” Vox, June 12, 2019, https://­

544

notes to pages 473–476

www​.­vox​.­c om​/­p olicy​-­a nd​-­p olitics​/­2 019​/­6​/­1 2​/­18662722​/­a ma​-­medicare​-­for​-­a ll​-­single​-­payer​ -­vote​-­2020; Joanne Finnegan, “Opposition to Medicare for All Remains, but AMA Drops out of Co­a li­t ion Fighting Single-­Payer System,” Fierce Healthcare, August 16, 2019; Karl Evers-­ Hillstrom, “Big Pharma, Insurers, Hospitals Team Up to Kill Medicare for All,” Center for Responsive Politics, March 7, 2019, https://­w ww​.­opensecrets​.­org ​/­news​/­2 019​/­03​/­big​-­pharma​ -­insurers​-­hospitals​-­team​-­up​-­to​-­k ill​-­medicare​-­for​-­a ll​/­; Adam Cancryn, “The Army Built to Fight ‘Medicare for All,’ ” Politico, November 25, 2019, https://­w ww​.­politico​.­com​/­news​/­agenda​ /­2 019​/­1 1​/­25​/­medicare​-­for​-­a ll​-­lobbying​-­0 72110; American College of Radiology Association, Form 990, 2017, https://­w ww​.­documentcloud​.­org​/­documents​/­6245303​-­A merican​-­C ollege​-­of​ -­R adiology​-­A ssociation​-­990​-­2017​.­html; Partnership for Amer­i­ca’s Health Care ­Future, “About Us,” https://­a mericashealthcarefuture​.­org​/­about​-­us/ [accessed October 31,2020]. 65. Telephone interview with George D. Lundberg, October 30, 2020; Ronald M. Davis, “Achieving Racial Harmony,” JAMA 300:3 (July 16, 2008), 323–325; Davis to the National Medical Association, July  30, 2008, https://­w ww​.­a ma​-­a ssn​.­org​/­sites​/­a ma​-­a ssn​.­org​/­fi les​/­c orp​/­media​ -­browser​/­public​/­a ma​-­history​/­a ma​-­apology​-­a frican​-­a mericans​.­pdf; Wolfe, “AMA and Its Dubious Revenue Streams,” 2; Peter ­Sullivan, “AMA Opposes GOP Obamacare Replacement Bill,” Hill, March 8, 2017, https://­t hehill​.­com​/­policy​/­healthcare​/­322889​-­largest​-­doctors​-­group​ -­opposes​-­gop​-­obamacare​-­bill. 66. David Muhlestein and Lia Winfield, “Preparing a New Generation of Physicians for a New Kind of Health Care,” NEJMCatalyst, February 28, 2018, https://­catalyst​.­nejm​.­org​/­doi​/­f ull​/­10​ .­1056​/­C AT​.­18​.­0246; Michael Alison Chandler, “­Women Are Now a Majority of Entering Medical Students Nationwide,” WaPo, January  22, 2018; Alan Blum and Howard Wolinsky, “AMA Rewrites Tobacco History,” Lancet 346:8970 (July 29, 1995), 261; Solberg, “Conspiracy Theory,” 6–7; K. Robert Keiser and Woodrow Jones, “Do the AMA’s Campaign Contributions Influence Health Care Legislation?,” Medical Care 24:8 (August 1986), 761–766; Joshua M. Sharfstein and Steven S. Sharfstein, “Campaign Contributions from AMPAC to Members of Congress: For or against the Public Health?,” NEJM 330:1 (January 6, 1994), 32–37; Joshua M. Sharfstein, “1996 Congressional Campaign Priorities of the AMA,” AJPH 88:8 (August 1998), 1233–1236; John D. Wilkerson and David Carrell, “Money, Politics, and Medicine: The American Medical PAC’s Strategy of Giving in U.S. House Races,” JHPPL 24:2 (April 1999), 335– 355; Karen Gutermuth, “The American Medical Po­liti­cal Action Committee: Which Senators Get the Money and Why?,” JHPPL 24:2 (April 1999), 357–382. 67. Rudolf Carl Virchow, Mitteilungen über die in Oberschlesien herrschende Typhus-­Epidemie (Berlin: Reimer, 1848), 175. 68. On professionalism and the social contract, see Ralph Crawshaw, Lonnie Bristow, George Lundberg et al., “The Patient-­Physician Covenant,” JAMA 273:19 (May 17, 1995), 1553; Matthew K. Wynia and Stephen R. Latham et al., “Medical Professionalism in Society,” NEJM 341 (November 18, 1999), 1612–1616; “Medical Professionalism in the New Millennium: A Physician Charter,” Annals of Internal Medicine 136:3 (February 5, 2002), 243–246; Jacob E. Kurlander, Karine Morin, and Matthew K. Wynia, “The Social-­C ontract Model of Professionalism,” American Journal of Bioethics 4:2 (Spring 2004), 33–36; Richard L. Cruess and Sylvia R. Cruess, “Expectations and Obligations: Professionalism and Medicine’s Social Contract with Society,” Perspectives in Biology and Medicine 51:4 (Autumn 2008), 579–598; Michael S. Sinha, “Rousseau at the Roundtable: The Social Contract and the Physician’s Responsibility to Society,” AMA Journal of Ethics 13:10 (October 2011), 703–706; Lynette Reid, “Medical Professionalism and the Social Contract,” Perspectives in Biology and Medicine 54:4 (Autumn 2011), 455–469. 69. Rudolf Carl Virchow, Die Einheitsbestrebungen in der wissenschaftlichen Medicin (Berlin: Reimer, 1849), 48; Donald M. Berwick, “The Moral Determinants of Health,” JAMA 324:32 (July 21, 2020), 325–326.

Index

Page numbers in italics indicate illustrations. 202, 230, 244, 257, 272, 311–312, 362, 363, 390–394, 405, 410, 428, 462, 473 Agassiz, Elizabeth Cabot, 272 Agency for Health Care Policy and Research (AHCPR), 451, 467 alcohol, 11, 25, 50, 67, 71, 78, 87, 107, 112, 122, 126, 129, 131, 218, 221, 222, 341–342, 355, 357, 365, 368, 372, 385 alcoholism, 25, 91, 140, 372 Aldrich, Nelson, 125–126 Alexander, Herbert, 424 Allen, Robert M., 118–119, 125 alliances, progressive and conservative, 2, 3, 4, 11, 12, 14, 41, 57, 109, 112, 113, 117, 129, 151, 153, 157, 186, 199, 202, 208, 221, 230, 269, 270, 313, 314, 358, 360, 380, 384, 388, 397, 410, 426, 428, 429, 433, 435, 446, 452, 453, 457, 458, 472 Alvarez, Walter C., 416–417 AMA Drug Evaluations, 436, 437 American Acad­emy of F ­ amily Physicians, 432

Abbott, Grace, 363 Abbott, Wallace Calvin, 102–104, 103, 107, 133, 329–330 Abbott Alkaloidal Com­pany, 72, 81, 102–105, 107, 329 Abel, John J., 99 abortions, 330, 396, 458 Abrams, Albert, 345 Adams, Charles Francis, 262, 264 Adams, Charles K., 269 Adams, Samuel Hopkins, 62, 81, 122–123, 126–127, 128 Addams, Jane, 39, 202, 209, 319 Adriani, John, 436–437, 445 adverse se­lection, ix–­x, 16, 85–86, 87, 92, 109, 117, 255, 256, 259, 279, 281, 312, 313, 370, 402, 451, 457, 488n2 Affordable Care Act (2010), xi, 400, 454, 456, 457, 467, 471, 473, 474 African American physicians, 8, 194, 391–393, 392, 394, 473 African Americans, 8–10, 11, 24, 47, 150, 156, 175, 176, 182–183, 185, 190, 193–194, 545

546 I n d e x

American Acad­emy of Medicine, 4, 98, 143 American Acad­emy of Pain Medicine, 467–468 American Acad­emy of Pediatrics, 373 American Anti-­Tuberculosis League, 187–188 American Association for ­Labor Legislation (AALL), 201, 202, 346–347, 348, 350, 353 American Association of Anesthesiologists, 334–335 American Association of Obstetricians and Gynecologists, 38 American Bar Foundation, 427 American Board of Internal Medicine Foundation, 455–456 American College Health Association, 338 American College of Surgeons (ACS), 320–321, 336, 406 American Drug Syndicate (ADS), 220 American Farm Bureau, 360, 427 American Gynecological Society, 265 American Health League, 200 American Hospital Association (AHA), 305, 380, 390, 452, 468 American Lung Association, 188. See also National Association for the Study and Prevention of Tuberculosis (NASPT) American Medical Editors Association, 97 American Medical Po­liti­cal Action Committee (AMPAC), 423–424, 426, 431, 434, 445, 446, 460, 473 American Nurses’ Association, 380, 395 American Pain Society (APS), 468 American Public Health Association (APHA), 6, 141, 142, 143, 145, 146, 147, 150, 151, 155, 157, 158, 186, 200, 201, 378 American Social Hygiene Foundation, 138 American Society for Clinical Investigation, 370 American Society for Clinical Pharmacology and Therapeutics, 92 American Society for Pharmacology and Experimental Therapeutics, 388

American Society of Clinical Oncology, 466–467 American Society of Medical Sociology, 49 American Therapeutic Society, 95 American ­Women’s Medical Association (AWMA), 394–395 Andrews, John B., 346, 350 anesthesia, 34, 74, 91, 102, 334, 335, 336, 396 anesthesiologists, 333, 334, 335, 399, 436, 445, 465 anesthetists, 34, 334, 335, 399 Angell, James Burrill, 202, 268–269 Angell, Marcia, 463, 464 animal diseases, 50, 164–168, 177, 184, 195, 197, 203, 204, 207, 222, 224, 376 Anthony, Susan B., 68 antibiotics, x, 23, 102, 194, 393, 401, 436, 456, 475 anti-­Catholic nativism, 210 anti-­communism, 360, 413, 418–421, 427, 438 antitrust enforcement, ix, 181, 312, 408, 429, 435, 446 Anti-­Vaccination League of Amer­i­ca, 214 appendectomies, 52, 402, 449 Arnold, Thurman, 408, 421 arsenic, 112, 119–120, 401 Ashford, Bailey K., 177, 181 Association for the Advancement of the Medical Education of ­Women, 11, 265 Association for the Prevention and Relief of Heart Disease, 321 Association of American Medical Colleges (AAMC), 249, 274, 277, 279, 280, 289, 291, 303, 389, 390 Association of American Physicians and Surgeons, 471 asthma, 26, 92, 107, 129, 342, 391 Atkinson, Thomas G., 53 Atterbury, Grosvenor, 186 Australia, 111–112, 430 Austria, 6, 69, 166, 200, 238, 242, 263, 264 autopsies, 463

Index Bacillus politicus, 152, 162, 253, 269 Bacon, Charles S., 319 Baehr, George, 417 Baird, Spencer F., 94 Baker, Ray Stannard, 420 Baker, Sara Josephine, 226, 250, 328, 351, 394 Baldwin, William D., 214 Baldwin, William H., 189 Bangs, Fred, 211 Barnesby, Norman, 33–34, 396 Barringer, Emily Dunning, 394 Barsky, Edward, 419 Barton, Clara, 214–215 Baxter, Leone, 425, 427 Baxter International, 466 Bayh, Birch, 422 Bean, Robert Bennett, 8–9 Bean, William, 376 Beardsley, Albert R., 130 Beates, Henry, Jr., 247, 288, 289 Beecher, Catherine, 68 Bell, Agrippa, 187 Bell, Clark, 186–187, 189 Bellin, Lowell, 377 Bennett, Ivan L., Jr., 448–449 Bennett Medical College (Chicago), 296 Bentham, Jeremy, 141 Bernheim, Bertram, 418, 420, 438–440 Berwick, Donald R., 453–454, 476 Bevan, Arthur Dean, 3–4, 23, 52, 238, 257, 284, 287, 290–293, 296–299, 298, 303, 304, 305, 306–307, 313, 314, 323, 324, 336, 337, 347, 368–369, 448 Bierring, Walter L., 379, 389 Bigelow, Henry Jacob, 28, 263–264 Biggs, Hermann, 180, 188, 192, 201, 208, 223, 328, 354, 366 Billings, Frank, 23, 46–47, 64, 65, 73, 74, 77, 78, 82, 97, 142, 188–189, 201, 236, 240, 241, 290, 298, 319, 320, 321, 336, 344, 347, 350–351, 353, 355, 366–367, 371

547

Billings, John Shaw, 81, 91, 113, 141, 145, 154–155, 157–160, 161, 165, 201, 222, 223, 231, 271 Billroth, Theodore, 46 Bismarck, Otto von, 141, 160, 347, 358–359 Black, Carl E., 323 blacklisting, 14, 330, 383, 403, 407–408, 446. See also Mundt resolution Blackwell, Emily, 265, 272 Blasingame, Francis, 427 Blue, Rupert, 228–229, 346, 351, 371 Blue Cross, 380 Blue Cross Blue Shield, 452 Blue Shield, 383, 425 Blum, Alan, 429–432 Blumer, George, 73, 76, 78–79, 82, 86, 252 Bly, Nellie (Elizabeth Cochran Seaman), 28–29 Boas, Ernst P., 81, 419–420, 457 Boas, Franz, 9 Bobst, Elmer, 372, 433–434 Boggs, Hale, 444 Bok, Edward, 75, 76, 81, 94, 122–123, 202, 220 Bonner, Thomas Neville, 438, 515n34, 525n1 Boston City Hospital, 254, 294 Boston College of Physicians and Surgeons, 294 Boston Homoeopathic Medical School, 265, 295 Boston Scientific, 466 Bowditch, Henry Ingersoll, 70, 145, 148–149, 153, 156, 157, 158, 189, 265–266, 346 Bowditch, Vincent Y., 189 Boyle, Joseph F., 459 Brawley, Otis Webb, 455 Breast Cancer Informed Consent Legislation, 396 Breitenbach, Max, 119 Bressler, Jonathan, 421 Bristow, Lonnie, 462 British Medical Association, 138

548 I n d e x

Brook, Robert, 449, 451 Brown, Adelaide, 328 Brown, George, 187, 189 Brown, Horace, 326–327, 358 Brown, Philip King, 412 Brune, Tom, 460, 464 Bryan, Joseph, 178 Bryan, William Jennings, 51, 198, 217 Bryant, Joseph D., 202 Bryce, James, 159, 160, 231, 400 bubonic plague, 25, 204–205, 223 Budenz, Louis, 421 Bumpus, Hermon C., Jr., 415–416 Bureau of Animal Industry (BAI), 164–168, 177, 203, 222, 224 Bureau of Chemistry (BOC), 203, 220 Burger, Warren, 421 Burney, Leroy E., 376 Burns, John M., 453 Burrow, James G., 43, 57, 479n22, 479n24 Business Health Care Action Group (BHCAG), 452–453 Busse, Fred, 323 Butler, Allan, 387, 412, 420 Butler, Nicholas Murray, 300 Buttrick, Wallace, 178, 179 Byrnes, John W., 380 Cabell, James L., 158, 159 Cabot, Hugh, 336, 337, 366, 406, 412, 415–417 Cabot, Richard C., 22, 25–26, 75, 87, 239, 405 Caldicott, Helen, 457 Call, Emma, 265 calomel. See mercury campaign finance, xii, 398, 403, 423–424, 426, 442, 444, 469, 472, 473 Campaign Inc., 425 Campion, Frank, 440 Camus, Albert, xiii Canada, 237–238, 276, 289, 299, 307, 406, 451

cancer, 2, 22, 63, 101, 122, 129, 219, 243, 342, 367, 375, 376, 390, 396, 428, 455, 459, 460, 461 Cannon, Joseph, 125, 126 Cannon, Walter B., 53 Car­ne­gie, Andrew, 95–96, 202, 299 Car­ne­gie Foundation for the Advancement of Teaching, 5, 80–81, 237, 241, 244, 246, 293–300, 301. See also Flexner report Carr, Ceylon Spencer, 218–219 Carr, Charles M., 219 Carr, William, 240–241, 289 Carson, Rachel, 376 Carswell, G. Harold, 444 Car­ter, Jimmy, 398 Cary, Edward H., 371 Cathell, Daniel Webster, 31–32, 56, 70 Center for Outcomes Research and Evaluation (CORE), 456–457. See also rational therapeutics Chadwick, Edwin, 141 Chadwick, James R., 263 Chapin, Charles V., 149–150, 183, 195 Chapin, Christy Ford, 381 Chaplain, Carleton, 155 Chapman, Virgil, 386 Chase, Salmon P., 113 Chase, Stuart, 420 Cheney, Frank, 132 Chesney, Alan, 271 Chicago Medical Society (CMS), 318–322 Chicago Sun-­Times, 444, 458, 460 Chicago Tribune, 26, 52, 300, 319, 322, 329, 331, 332 Childs, Otis H., 189 chiropractic, 345, 445 chiropractors, 344, 445–446 cholera, 24, 78, 140, 152, 154, 222, 223 Christian Science, 27, 76, 212–215, 217, 219, 221 Christmas Seals, 191, 195 cigarettes. See smoking; tobacco industry Citizens’ Association of New York, 150–151

Index civil rights, 8, 360, 391, 393, 394, 421, 444 Civil Rights Act (1964), 393 civil ser­vice reform, 152, 162, 212, 312 Civil War, Spanish, 412 Civil War, U.S., 150, 151, 257, 276, 309, 362 Cleveland, Grover, 40, 165, 169, 189, 202 Cleveland Medical Society, 39 clinical practice guidelines (CPGs), 466–468 Clinton, Bill, 398, 400, 451, 454, 461, 463 Cobb, Montague, 392 cocaine, 74, 91–92, 103, 218 Cochran, Jerome, 145–146 code of ethics, medical, viii, 30–31, 56, 191, 405, 406, 407, 455 code of silence, 15, 419, 420, 439, 442, 448, 449, 454 Codman, Edward Amory, 348, 456 College of Physicians and Surgeons, Chicago (now University of Illinois), 73, 82, 328, 370 College of Physicians and Surgeons, Columbia University, 55, 81, 269 Collier’s, 62, 81, 115, 118, 122, 127, 128, 181, 216, 217, 218 Colwell, Nathan Porter, 241, 291–293, 300, 302 Committee for the Nation’s Health (CNH), 420 Committee of One Hundred on National Health (COH), 41, 196, 199–203, 220–221, 224, 225 Committee of Physicians for the Improvement of Medical Care, 412–418, 439–440 Committee on Abuse of Medical Charities, 320 Committee on Costs of Medical Care (CCMC), 405–406 Committee on Social Insurance, 348 Committee on Therapeutic Research (CTR), 106, 384–385 Commons, John R., 202, 346

549

community health centers, 47, 338, 354–355, 365, 366, 370, 390 comparative effectiveness research, 384, 451, 453, 467. See also rational therapeutics compulsory health insurance, 2–3, 4, 11, 13–15, 47, 49, 201, 223, 226, 290, 318, 319, 346, 347, 349, 351–354, 358, 360, 366, 368, 371, 372, 379, 380, 382, 388, 398–400, 405, 406, 409, 420, 425, 434, 439. See also socialized medicine Confederation of State Medical Examining and Licensing Boards (CSMB), 279, 288 conflicts of interest, viii, xi, 15, 224, 442, 444, 447, 455, 456, 461, 465, 467, 470 Connor, Leartus, 4–5, 79, 98, 274, 442 consumer movement, 3, 12, 55, 117, 122, 125, 224, 346, 386, 446, 454 Cooke, Josiah, 262 Cooke, Morris Llewellyn, 420 Coo­lidge, Calvin, 361, 363, 364, 378 Cooper, Peter, 151 Co-­operative Medical Advertising Bureau, 105 Cooper Union for the Advancement of Science and Art, 151 Copeland, Royal S., 216 Cornell University Medical School, 160, 166, 260–261, 269, 308, 354 Cornely, Paul, 8 corruption, xii, 18, 24, 25, 61, 62, 64, 81, 98, 148, 152, 158–163, 190, 199, 209, 216, 218, 296, 303, 312, 317, 320, 400, 464, 475 Councilman, William T., 273, 291 Council on Ethical and Judicial Affairs, 393–394 Council on Health and Public Instruction, 199, 424 Council on Medical Education (CME), 248–249, 290–293, 296–300, 339, 368–369 Council on Pharmacy and Chemistry (CPC), 88, 98–108, 342–343, 384–385, 386, 432

550 I n d e x

Cox, James M., 361, 362 Craft, Ellen, 156 Craft, William, 156 Craig, Alexander, 351 Cramp, Arthur J., 101 Crile, George, Jr., 450 Crile, George W., 106, 335–336 Cumming, Hugh S., 229 Curley, Michael, 254 Current Procedural Terminology (CPT), 465, 470 Curtis, Cyrus, 94 Cushing, Harvey S., 251, 379 Daniel, Ferdinand E., 52–53 Darrow, Clarence, 39 Dartmouth Institute for Health Policy and Clinical Practice, 450 Darwinism. See social Darwinism Davis, Charles, 239–240, 243, 256 Davis, George S., 91, 92 Davis, George W., 171–172 Davis, Loyal, 402, 448–449 Davis, Michael M., 420 Davis, Nathan, Jr., 321 Davis, Nathan Smith, 76, 78, 97, 145, 236, 237, 240, 249, 256–258, 274, 290, 312 Davis, Ronald, 473 DeBakey, Michael, 390 Debs, Eugene, 39, 209, 362, 372 De Kruif, Paul, 372 Delphey, Eden V., 352 Deming, W. Edwards, 453 democracy, 149, 159–162, 210, 285, 321, 362, 369, 398, 399, 424, 438, 475, 476 Denmark, 111, 166, 194 Department of Health, Education, and Welfare (HEW), 12, 230, 443 Depew, Chauncey, 225 de Schweinitz, George, 371 Deyo, Richard A., 467 Dickens, Charles, 192 Dickey, Nancy, 462 Diehl, Harold S., 416

Dill, James B., 95–96 Dingell, John, 423 Dirksen, Everett, 443 Disraeli, Benjamin, 141 Dixon, Samuel L., 226 Dock, George, 242, 288 Dohme, Charles E., 97 Douglass, Frederick, 156 Douglass, George L., 121, 130 Dowling, Harry, 436 drug advertising, 12, 22, 25, 35, 61–64, 72, 76–79, 81, 83, 86, 89, 92, 94, 103–109, 112, 115, 122, 129, 131, 132, 187, 212, 216–218, 220, 259, 282, 317, 326, 342–344, 385–387, 432, 436, 437, 445 Drug Importation Act (1848), 113 Du Bois, W. E. B., 8, 9 Dudley, Emilio C., 322 Dunlop, John T., 448 Dyrszka, Larysa, 457 dysentery, 78, 139, 154, 167 Eaton, Dorman B., 152 Eaton, John, 257–258, 272 eclectic school of medicine, 27, 44, 56, 67, 70, 210, 213, 216, 219, 244, 248, 295, 299, 303, 317, 345. See also Thomsonianism Eddy, David, 449, 451 Eddy, Mary Baker, 212–215, 215, 219, 221. See also Christian Science Edsall, David Linn, 327, 370 Egan, James E., 283, 284, 323 Eggleston, William, 237–240, 243–244, 255, 258–259, 277–280 Eisenhower, Dwight D., 2–3, 12, 230, 427, 438 Eli Lilly, 5 Eliot, Charles W., 54, 202, 262–266, 267, 268, 269, 270, 299, 300 Ellis, H. Bert, 97 Elmergreen, Ralph, 53 Emerson, Haven, 351 Emerson, J. E., 237, 280–281

Index employers, 14, 26, 39, 118, 190, 201, 202, 207, 340, 350, 351, 399, 451, 453, 454, 460, 461 employer-­sponsored health insurance, 14, 308, 351, 380, 382–383, 451, 460, 461 Engels, Friedrich, 48 ­England, 6, 61, 139, 194, 231, 347 environmentalism, 149, 376, 457–458, 459, 475 Ettling, John, 181, 183 eugenics, 2, 10, 201, 209, 330, 346, 369 Eu­rope, 2, 5, 6, 13, 24, 25, 26, 33, 47, 67, 69, 70, 79, 107, 111, 112, 140, 141, 147, 151, 156, 163, 165, 166, 177, 180, 185, 201, 228, 237, 238, 241, 242, 247, 251, 253, 262, 269, 285, 289, 307, 326, 332, 346, 347, 354, 373–374, 387, 443, 445 Evans, William A., 290, 319, 321, 322, 325, 351 evidence-­based medicine, 156, 451, 453, 454, 471. See also outcomes research; rational therapeutics Ewing, William, 153 Fannin, Paul J., 444 Farrand, Livingston, 200, 354 Favill, Henry Baird, 30, 54, 161, 162, 199, 201, 208, 320, 322, 348, 368 Federal Security Agency (FSA), 229–230 Federal Trade Commission (FTC), 14, 386, 428, 429, 437, 446, 469 Federation of State Medical Boards (FSMB), 468 fee-­for-­service medicine, 14, 247, 319, 381–383, 399, 405, 455, 457, 470 fee splitting, 255, 320, 448 Fein, Rashi, 447–448 Female Medical Education Society, 264 feminism, 53, 68, 265, 374, 394, 395, 444. See also ­women’s suffrage Finlay, Carlos, 169 Fishbein, Morris, 38, 46, 100, 300, 331, 367–368, 369, 371–372, 375, 380–381,

551

382, 386, 387, 396–397, 399, 404, 406, 413–419, 416, 421, 424–425, 428, 432–433, 434, 438 Fisher, Irving, 141, 185, 199–203, 204, 206, 207, 209, 210, 216, 220, 221, 222, 224, 227, 228, 229, 350, 352 Fishman, Scott, 468 Fiske, Haley, 190 Fletcher, David J., 429 Flexner, Abraham, 244, 246, 248, 280, 294–296, 299–300, 301, 302–303, 305, 307, 308–313, 323, 325, 336 Flexner, Simon, 179, 180, 205 Flexner report, 5, 237, 241, 244, 246, 248, 293–302, 301, 303, 306, 307, 308, 313, 323, 325, 337, 368. See also Car­ne­gie Foundation for the Advancement of Teaching Flick, Lawrence Francis, 185–188, 193 Flower, Alfred Hollis, 214 Flower, Benjamin Orange, 209–212, 214, 217–218 Flower, Richard C., 28, 32, 44, 63, 217 Folsom, Charles F., 144 Food, Drug, and Cosmetic Act (1938), 12, 109, 385, 432 Food and Drug Administration (FDA), 109, 133, 385–386, 387, 388, 435, 436, 468, 471–472 Fortas, Abe, 420 Foshay, P. Maxwell, 39, 44–45, 51, 56, 91, 160–161 Foster, Eugene, 150 fracking, 457 France, 6, 21, 61, 69, 83, 111, 166, 170, 194, 238, 242, 247, 263 Frankel, Lee, 190–191, 202, 207 Freud, Sigmund, 91–92 Frick, Henry K., 118, 195 Friedman, Milton, 479n25 Frothingham, Channing, 412, 416 Frothingham, George E., 366 Fulton, John S., 154

552 I n d e x

Gaffin, Ben, 385 Galvin, Robert, 454, 456 Gambetta, Léon, 141 Garceau, Oliver, 411, 437, 438 Garfield, Sidney R., 383–384, 409 Garfield, William, 27, 32–33, 44 Garland, Hamlin, 217 Garrett, John W., 271 Garrett, Mary Elizabeth, 189, 270–273, 272, 310 Gates, Frederick Taylor, 179, 180, 183 Gawande, Atul, 454 Geier, Otto, 348 Geiger, H. Jack, 391–393 General Education Board (GEB), 178–179, 307, 308, 309, 313, 336 German Medical Association, 107–108 Germany, 6, 48, 61, 68, 69, 107, 111, 118, 141, 160, 162–163, 166, 177, 231, 238, 247, 262, 263, 264, 347, 351, 352, 358, 411, 419 Gibson, Henry C., 268 Gilman, Daniel Coit, 270–273, 299 Gittelsohn, Alan, 449 Gladstone, William, 141 GlaxoSmithKline, 466 Goldwater, Sigismund, 349, 351 Gompers, Samuel, 189, 357 Goodman, Louis, 388, 436 Gorgas, Marie, 171–173 Gorgas, William Crawford, 38, 124, 169–176, 206, 351, 368, 371 Gorman, Mike, 390 Greeley, Horace, 152 Green, Frederick, 351, 353 Group Health Association (GHA), 408 Grouse, Lawrence, 465–466 Grunsky, Carl Ewald, 172 gun control, 463, 471 gynecological surgeons/surgery, 23–24, 28, 33–34, 52, 246, 396 gynecologists/gynecol­ogy, 5, 22, 38, 52, 99, 106, 219, 254, 265, 277, 294, 297–298, 322, 399, 440

Haddox, J. David, 468 Haggard, William P., 378–379 Hahnemann, Samuel, 68–69, 295 Hahnemann Medical College (Philadelphia), 295 Haller, John S., 515n34 Hamilton, Alexander, 157, 223 Hamilton, Alice, 351, 374, 420 Hamilton, John B., 158, 159, 223 Hamowy, Ronald, 479n25 Hanlon, John J., 377 Happel, Thomas J., 32, 37, 138 Harding, Warren G., 229, 355, 360–363, 364 Harmon, Albert, 77–78 Harper, Robert N., 129 Harris, E. Eliot, 97 Harris, Elisha, 151, 186 Harris, Louis I., 351 Harris, Malcolm L., 348, 353 Harrison, Benjamin, 161, 272 Harrison, Caroline Scott, 272 Harrison, Car­ter, 47, 321, 322, 328 Harrison, Robert Henry, Sr., 148 Harrison, William Henry, 140 Harsch, Paul, 209, 212 Harvard Medical School, 53, 54, 156, 202, 239, 245, 251, 252, 254, 261–266, 268, 269, 270, 272, 273, 274, 276, 278, 291, 293, 294, 300, 370, 386, 405, 416, 447, 448, 449, 450, 453 Harvard School of Public Health, 250, 462, 470 Havighurst, Clark, 451–452 Hawley, Josh, 467 Hawley, Paul R., 402, 448–449 Hayhurst, Emery R., 351 Health Care for Amer­i­ca Now, 457 health maintenance organ­izations (HMOs), 384, 409. See also managed care; prepaid group practices (PGPs) heart disease, 82, 103, 122, 139, 140, 247, 268, 289, 321, 342, 390, 445, 466 Heart Rhythm Society, 466 Heinz, Henry John, 117–118

Index Hektoen, Ludvig, 319–320 Heller, Jean, 393 Hemenway, James A., 130 Henderson, Elmer, 389–390 Henrotin, Fernand, 319 Henry, Samuel C., 357 Henry Phipps Institute, 187, 188, 193, 307 Hepburn, William P., 114, 116, 130 heroin, 101, 107, 126 Herrick, James B., 319, 321, 331, 367 Heyburn, Weldon Hinton, 121, 123, 125–126 Hill-­Burton Act (1946), 391, 405 Hobby, Oveta Culp, 230 Hoffman, Frederick, 193, 352 Hoffman–­La Roche, 433 Hofstadter, Richard, 230 Holland, J. W., 279, 280 Holmes, Bayard, 38–39, 245, 249 Holmes, Oliver Wendell, Jr., 129–130, 131 Holmes, Oliver Wendell, Sr., 1, 21–22, 26, 61, 68, 69, 70, 71, 73, 249, 263 Holt, L. Emmett, Jr., 201, 412 homeopathy, 26–27, 32–33, 44, 45, 56, 68–70, 180, 210, 213–216, 229, 230, 248, 256, 265, 295–296, 299, 317, 329, 344–345 Home O ­ wners’ Loan Corporation (HOLC), 408 hookworm, 7, 24, 41, 140, 176–183, 184, 195, 204, 327–328 Hoover, Herbert, 363–364 Hoover, J. Edgar, 420 Hope, Lugenia Burns, 190 Hopkins, Johns, 270, 271 hospitals, ix, 3, 4, 5, 10, 11, 14, 17, 24, 25, 26, 31, 47, 66, 68, 78, 82–83, 90, 93, 138, 140, 150, 156, 162, 185, 186, 191, 192, 211, 223, 238, 245, 246, 247, 251–254, 259, 264, 265, 266, 267, 268, 269, 270, 271, 273, 276, 288, 289, 291, 292, 294, 302, 304–305, 308, 309–310, 312, 320, 322, 328, 329, 331, 335, 337, 339, 348, 349, 354, 355, 363, 366, 370, 377, 380,

553

381, 383, 391, 392–393, 394, 395, 399, 402, 403–404, 405, 406, 407, 408, 409, 410, 412, 414, 419, 420, 422, 445, 446, 452, 453, 454, 455, 462, 468, 469, 470, 472 House Un-­A merican Activities Committee (HUAC), 419, 420 Hovey, George O., 264 Hovey, Marian, 264–265 Howard, Ernest, 429, 434–435 Howard University, 8, 311, 392 Hsiao, William, 470 Hubbard, Elbert, 27–28, 32 Hubbard, L. Ron, 444 Hughes, Charles Evans, 129–130, 131 Huhn, Charles, 219, 220 Humphreys, Margaret, 154 Hungary, 111, 166 Hunt, Howard L., 442 Hurd, Henry M., 273 Hussey, Hugh H., 388, 435 Huth, Edward J., 430 Hyde, David R., 437 hydropathy, 67–68, 70 Hyosin-­Morphin-­Cactin, 102–104, 107 hypophosphites, 72, 106, 107, 188 iatrogenesis, 212, 248. See also medical errors Ickes, Harold, 161, 321–322 Illinois Medical Society (ILMS), 318, 323–326, 331, 332 Index Medicus, 91, 154–155 industrial hygiene. See occupational health/medicine Industrial Workers of the World, 361 infant mortality, 23, 51, 53, 213, 224, 229, 250, 309, 355, 356, 373, 387, 390–391 influenza pandemic (1918), 361 Ingelfinger, Franz, 463 Institute for Healthcare Improvement (IHI), 453 Institute of Medicine (IOM), 447–448, 454, 455, 459, 476

554 I n d e x

International ­Labour Organ­ization (ILO), 427 interns/internships, 23, 82, 247, 310–311, 312, 335, 376, 391, 394, 404, 418, 420, 446 Ireland, John, 202 Irons, Ernest E., 424 Italy, 166, 242 Jackson, Andrew, 143 Jacobi, Abraham, 10–11, 21, 22, 23, 47–49, 48, 56, 73, 76, 78, 79, 80, 100, 132, 150, 153, 162–163, 164, 250, 255, 265, 347, 368 Jacobi, Mary Putnam, 11, 47, 265, 272, 309, 310 Jacobs, Henry Barton, 189 Janeway, Edward G., 150 Japan, 195, 379–380 Jenner, Edward, 139 Jim Crow laws, 391, 428 John Birch Society, 427 Johns Hopkins University School of Hygiene and Public Health, 138 Johns Hopkins University School of Medicine, 9, 75, 99, 137, 138, 155, 168, 189, 246, 251–253, 261, 269–274, 293, 304, 307, 310, 336, 412, 414, 448 Johnson, Edward M., 119 Johnson, Lyndon B., 382, 390, 400 Johnson & Johnson, 119, 466 Jones, Philip Mills, 96–99, 117 Kaempffert, Waldemar, 415 Kaiser, Edgar, 409 Kaiser, Henry J., 383, 409 Kaiser Permanente, 12, 383–384, 409, 410, 446 Kassirer, Jerome, 463–464, 465, 466 Kebler, Lyman F., 100, 220 Keen, William, 244, 245, 371 Kefauver, Estes, 435 Kefauver-­Harris amendments to Food, Drug, and Cosmetics Act (1962), 387, 435–436 Kelley, Florence, 39, 224

Kellogg, Francis B., 216 Kellogg, John Harvey, 67–68, 200 Kelly, Howard, 273 Kelsey, Frances, 387 Kennedy, John F., 376, 382, 388, 399, 423, 435, 447 Kennedy School of Government, 447, 453 Kessel, Reuben, 479n25 King, William H., 229 Kingsbury, John A., 190 Kinyoun, Joseph James, 223 Klumpp, Theodore, 386 Knopf, S. Adolphus, 9–10, 184, 187–188, 201, 209 Knowles, John H., 443 Kober, George M., 6, 141, 195, 199, 201 Koch, Robert, 184, 271 Kohnke, Quitman, 169, 170, 174–175, 188, 201 Koop, C. Everett, 431 Kosmak, George William, 411, 439 Kreider, George, 290, 325, 326, 330 Kress & Owen Manufacturing Co., 119, 121 Krumholz, Harlan, 456 ­labor u ­ nions, 189, 190, 202, 206–207, 363–364, 409–410, 425, 427, 452 Ladies’ Home Journal, 75–76, 81, 94, 118 LaGuardia, Fiorello, 152, 408 Lakey, Alice, 122 Lambert, Alexander, 4, 49, 173–174, 348, 349, 350, 352 Lasagna, Louis, 421–422 Lasker, Albert, 420 Lasker, Mary, 389, 420 Lathrop, Julia Clifford, 356, 363 Lawrence, George, 430, 431 lay-­medical alliances. See alliances, progressive and conservative League of Nations, 138 Leape, Lucian L., 462, 463 Leapfrog Group, 454 Leigh, Clarence W., 322 Leuckart, Rudolf, 177

Index Lewis, Alfred Baker, 421 Lewis, Daniel, 187, 188, 189 Lewis, Henry F., 320–321 Lewis, John L., 364 Lewis, Sinclair, 372 licensing, medical, 142–148, 213, 235–236, 243, 247, 257, 263–264, 267, 275–279, 280, 283, 284–286, 288, 294, 296, 495n9 life insurance industry, 190, 193, 202–203, 228 Lincoln, Abraham, 25, 66, 68–69, 113, 262 Lippman, Walter, 363 Lister, Joseph, 32–33, 46, 249 ­Little, Lora, 226–227 Littlefield, Charles Went­worth, 219 Lloyd, Henry Demarest, 39 lobbying, xii, 2, 37, 122, 123, 124, 127, 128, 149, 151, 172, 207, 289, 344, 379, 382, 385, 390, 403, 423, 425, 426, 427, 428, 429, 431, 432, 442, 443, 444, 445, 446, 460, 467, 469, 472, 473, 476 Logan, Thomas Muldrop, 147 Loos, H. Clifford, 406–407, 409, 412, 415 Lopate, Carol, 395 Lott, Trent, 470 Louis, Pierre, 156 Lowe, Rosa, 190 Ludmerer, Kenneth, 251, 263, 278–279, 307, 513n3 Lull, George F., 427 Lundberg, George, 368, 429, 441–442, 458–463, 459, 464, 472 Lundy, C. J., 143 Lydston, George Frank, 108, 211, 322, 328–332, 333, 334, 343, 367, 437 MacArthur, Douglas, 379–380 Macatee, Henry C., 345, 353 Macaulay, Patrick, 270 MacVeagh, Franklin, 224–225 Magee, Mike, 388 Mahoney, Florence, 389 malaria, 29, 46, 65, 139, 140, 145, 147, 168, 169, 174, 177, 204, 327, 471

555

Mall, Franklin P., 9 malpractice, x, 33, 44, 237, 392, 404, 407, 460, 462 managed care, 14, 446, 469, 473. See also health maintenance organ­izations (HMOs); prepaid group practices (PGPs) Mann, James R., 116, 126 Marcy, Henry O., 94 Marine Hospital Ser­vice (MHS), 157, 158, 165, 174, 184, 223, 285. See also Public Health and Marine Hospital Ser­vice (PHMHS) Markowitz, Gerald, 479n24 Martin, Thomas, 225 Marx, Karl, 48 Mathews, Joseph M., 138 Mauldin, Bill, 392 Mayer, Milton, 425 Mayo, Charles, 10, 335, 336, 338, 371 Mayo, William, 10, 45, 106, 335, 336, 338, 367, 371 Mayo Clinic, 338, 406, 415, 416, 453 McArthur, Lewis L., 319 McBeath, William H., 378 McCarthyism, 413, 419 McCaskill, Claire, 467 McClure, Samuel S., 202, 220 McClure, Walter, 453 McClure’s, 118 McCormack, Joseph Nathaniel, 34–45, 41, 50–51, 53, 54–57, 63, 64, 68, 70, 78, 87, 96, 97, 127–128, 139, 142, 145, 147, 148, 153, 178, 195–196, 198, 199, 200, 201, 208, 218, 222, 223, 226, 230, 237, 241, 255, 283–284, 290, 299, 323–325, 328, 368 McCormick, Harold, 236 McCumber, Porter J., 116, 119–121, 125 McGill University, 253 McGovern, John J., 326 McKeown, Thomas, 194 McKesson & Robbins, 119 McKinley, William, 27, 115, 169

556 I n d e x

McMechan, Francis Hoeffer, 333–336, 335, 344, 353, 355, 369 Means, William, 288 meatpacking industry, Chicago, 154, 167, 281, 322 Medicaid (1965), 376–377 Medical Advisory Committee (MAC), 333–345, 354–355, 365 medical conservatism, xi, 108, 360–397, 438, 441 medical device industry, xi, 217, 455, 465, 466, 467, 471, 472 medical education/schools, 5, 8, 11, 12, 17, 21, 22, 31, 32, 44, 46, 54, 62, 66, 67, 68, 80, 81, 82, 156, 216, 235–313, 323, 324, 336, 337, 338, 339, 350, 370, 375, 389, 390, 391, 392–393, 394, 412, 414, 440, 455, 470 medical errors, x, 30, 221, 442, 451, 454, 455, 462, 463 medical industrial complex, 15, 388 medical journalism, 39, 61, 79, 81, 83, 91, 188, 219, 326, 329, 372, 430 medical journals, 5, 8, 21, 30, 33, 35, 39, 45, 61, 62, 63, 64, 72, 79, 80, 81, 86, 90, 91, 96, 102, 104–108, 110, 111, 120, 133, 144, 153, 160, 205, 218, 282, 290, 317, 324–325, 326, 327, 329, 330, 333, 334, 342, 343, 367, 368, 384, 411, 413, 424, 430, 450, 458, 464, 468 medical power politics, viii, x, xi, xii, xiii, 2, 4, 11, 13, 14, 15, 16, 17, 34, 36, 44, 51, 57, 62, 83, 89, 115, 123, 124, 138, 211, 212, 231, 253, 267, 281, 285, 287, 290, 294, 299, 312, 313, 325, 355, 373, 382, 384, 388, 395, 396, 397, 398–440, 443, 461–462, 476 medical practice acts. See licensing, medical medical progressives/progressivism, xi, xii, 4, 15, 40, 61, 63, 83, 85, 86, 137, 138, 148, 160, 163, 189, 190, 195, 197, 199, 216, 221, 222, 235, 237, 284, 285, 287, 313, 318, 344, 345, 347, 348, 351, 358,

365, 368, 369, 441, 447, 451, 453, 454, 455, 473, 476 medical specialty associations (MSAs), 45, 465–466 Medical ­Women’s National Association, 394 Medicare (1965), 13, 15, 380, 381, 383, 390, 393, 394, 395, 398–399, 400, 422, 423, 426, 429, 431, 434, 435, 442, 443, 445, 448, 450, 454, 456, 469, 471, 472 Medico-­L egal Society of New York, 186 Meharry Medical College, 311, 393 Mellon, Richard B., 189 Mencken, H. L., 372 Merck, 466 mercury, 46, 66, 69, 112, 119, 139, 140 Metropolitan Life Insurance Com­pany, 190–191, 202–203, 207 Michels, Robert, 438 midwives, 11, 249–250, 310, 319, 390, 395–396 Mill, John Stuart, 319 Millard, Perry H., 246–247, 255, 275, 282 Miller, Charles W., 218 Miller, Joe D., 431 Mills, Wilbur, 399 Minton, Henry, 194 Mitchell, Mary Cadwalader, 272 Mohr, James C., 495n9, 496n18 mono­poly, ix, 12, 17, 67, 83, 92, 108, 181, 190, 209, 210, 215, 230, 265, 308, 329, 374, 396, 409, 433, 435, 439, 469 Morantz-­Sanchez, Regina, 394 Morgan, Hugh J., 414 Morgan, John Pierpont, 95–96, 203, 308 Mormons, 67, 221, 229 morphine, 50, 67, 75, 87, 91–92, 101, 102–103, 107, 126, 132, 217, 243, 264, 330. See also opioids; opium Morris, Robert T., 339 Morton, Rosalie Slaughter, 55 Motter, Murray G., 289

Index muckrakers/muckraking, xiv, 34, 39, 62, 81, 103, 115, 118, 122–123, 128, 181, 226, 267, 298, 312, 386, 443 Mundt, G. Henry, 403–404 Mundt resolution, 403–405 Murphy, John B., 207, 320–321, 368 Murray, James, 423 Musser, John, 31, 45, 371 Nader, Ralph, 446 National Acad­emy of Medicine, 447 National Acad­emy of Science, 176, 447 National Agricultural Chemicals Association, 376 National American ­Woman Suffrage Association, 271 National Association for the Study and Prevention of Tuberculosis (NASPT), 188–195 National Association of Manufacturers (NAM), 360, 380, 427 National Association of Phar­ma­ceu­ti­cal Manufacturers, 72 National Association of Retail Druggists (NARD), 72, 121, 357 National Association of Small Businessmen, 427 National Board of Health (NBH), 113, 155, 157–160, 161, 165, 166, 168, 169, 201, 222, 223, 231 National Bureau of Medicines and Foods, 96–98 National Civic Federation (NCF), 357 National Civil Ser­vice Reform League, 161 National Conservation Commission, 200 National Constitutional Liberty League (NCCL), 217 National Consumers’ League, 122, 125 national department of health, movement for, xi, 3, 6, 12, 41, 46, 57, 138, 141, 196, 199, 203–230. See also Owen bill National Health Ser­vice, British (NHS), 454

557

National Institutes of Health (NIH), 229 National League for Medical Freedom (NLMF), 208–221, 211, 225–228, 230–231, 329, 401 National Library of Medicine, 154–155 National Meat Inspection Act (1906), 122 National Medical Association (NMA), 8, 391–393 National Patient Safety Foundation, 461–462 National Physicians Alliance (NPA), 457 National Physicians Committee for the Extension of Medical Ser­vice (NPC), 379, 424, 425, 434 National Wholesale Druggists’ Association (NWDA), 72 National Yellow Fever Commission, 146 Naughton, John P., 430 newspapers, 13, 25, 26, 29, 33, 44, 50, 51, 52, 53, 54, 62, 63, 64, 71, 81, 94, 112, 115, 123, 124, 125, 127, 128, 129, 160, 172, 205, 208, 209, 211, 213, 218, 220, 222, 225, 282, 297, 300, 302, 321, 329, 330, 332, 368, 384, 387, 414, 425, 431, 443, 444, 445, 446, 448, 462 New York City Bureau of Child Hygiene, 226, 328 New York City Department of Health, 49, 150, 153, 173, 202, 226, 354, 377 New York Herald Tribune, 210, 211, 432 New York Times, 25, 34, 63, 81, 127, 152, 186, 208, 213, 217, 273, 300, 301, 308, 415, 444, 445 New Zealand, 111 Nichols, Mary Gove, 68 Niebuhr, Reinhold, xiii Nixon, Richard, 398, 443 North American Spine Society (NASS), 467 Northwestern University Medical School, 46, 100, 269, 308, 322, 323, 371, 448 Northwestern University ­Women’s Medical School, 283

558 I n d e x

Norton, J. Pease, 199 Norway, 111, 194 nostrums (secret remedies), 5–6, 28, 54, 61–62, 64, 72, 74, 75, 76, 77, 78, 79, 80, 81, 83, 94, 101, 102, 103, 108, 109, 114, 121, 127, 187, 200. See also proprietary drugs Numbers, Ronald L., 525n1 nurses, nursing, 6, 11, 172, 191, 194, 227, 257, 310, 322, 334–336, 339, 354, 355, 356, 380, 382, 395, 407, 420, 454. See also midwives nutrition, 24, 29, 54, 116, 372, 374, 474 nutritional diseases, 24, 140, 374 Obama, Barack, 400, 454, 473, 474 Obamacare. See Affordable Care Act (2010) obstetricians/obstetrics, 11, 38, 102, 106, 237, 244, 245–246, 247, 249–250, 277, 294, 295, 297, 310, 355, 390, 394, 396, 440 occupational health/medicine, 26, 130, 146, 161, 201, 322, 340–341, 346, 348, 351, 368, 373, 374, 457 Ochsner, Albert J., 319, 339, 369 Ochsner, Alton, 106 Ochsner, Edward H., 333, 346, 354, 355, 411 official drugs. See United States Pharmacopeia (USP) Oglesby, Richard J., 282 Olmstead, Frederick Law, 151 opioids, 140, 467–469 opium, 106, 126, 218, 222 O’Reilly, James J., 352 O’Reilly, John J. A., 358 O’Reilly, Robert M., 206 orthopedic surgeons/surgery, 465, 467, 471 Osborne, Oliver T., 82, 247 Osgood, Robert B., 412 Osler, Grace, 272 Osler, William, 11, 31, 75, 79, 137–138, 139, 141, 143, 155, 162, 179, 188, 243, 245, 246, 251–252, 253, 271, 272, 273

osteopaths/osteopathy, 173, 215, 295, 317, 322, 344, 345 Otis, Edward Osgood, 351–352 outcomes research, viii, ix, 456, 471. See also rational therapeutics Owen, Robert Latham, 203–206, 205, 208, 210, 216, 221, 222, 225, 227, 228, 229, 359 Owen, William Otway, 205–206 Owen bill, 203, 205–208, 210–212, 215–217, 220, 221–222, 224, 225, 227, 228 OxyContin, 467 Pabst, Frederick, 118 Paddock, Algernon S., 114 Page, Irvine H., 447 Page, Walter Hines, 178–179, 202 Palmer, Alonzo B., 269 Palmer, Daniel David, 345 Panama Canal, 38, 124, 170–175 paranoid style, 210, 230, 359 Parke-­Davis, 64, 72, 90–92, 96, 101–102, 107, 188, 433 Parmele, Charles R., 119–120, 121, 133 Partnership for Amer­i­ca’s Health Care ­Future (PAHCF), 472 Pasteur, Louis, 46, 139, 249 Pasteur Institute (Paris), 180, 185 pasteurization, 321, 323 patent medicines. See nostrums; proprietary drugs Patient Centered Outcomes Research Institute (PCORI), 456 Patient Protection and Affordable Care Act. See Affordable Care Act (2010) Payne, Oliver ­Hazard, 260, 261 Peabody, George, 270 Pearson, Karl, 29 Pepper, William, 80, 237, 238, 240, 255–257, 267–268, 312 Percy, James F., 324 Pertschuk, Michael, 446

Index Peruna, 87, 122, 218–219 perverse competition, 16, 43, 44, 51, 56. See also adverse se­lection Peter Bent Brigham Hospital, 251 Peters, John Punnett, Jr., 386–387, 412–421, 413, 438, 447, 457 Pfeiffer, John, 415 Pfizer, 72, 388, 458, 466 Phar­ma­ceu­ti­cal Manufacturers Association (PMA), 433, 435 Philbrick, Inez, 241, 249 Philip Morris, 429, 431, 432 Phillips, Wally, 432 Phipps, Henry, 185–186, 190, 193, 195, 307 Physician Charter, 455 Physician Consortium for Per­for­mance Improvement (PCPI), 471 Physicians for Social Responsibility (PSR), 457 Pierce, Ann Lewis, 118 Pinchot, Gifford, 202 Pinckney, Edward R., 375, 385, 410–411, 434–435 Platt, Orville H., 126 Plunkett, Thomas F., 153 pneumonia, 78, 102, 107, 129, 140, 144, 184, 221, 297, 298, 332, 368, 401 Podolsky, Scott, 402 polio, 230, 375 Polk, Henry K., 141 Polk, James K., 113 pop­u­lism, xi, 39, 44, 66, 143, 151, 203, 209, 210, 212, 228, 230, 308 Portenoy, Russell, 468 Porter, Eugene H., 215–216 Porter, Joseph Y., 182 Potter, Samuel, 237 prepaid group practices (PGPs), 382–383, 405–409, 412. See also health maintenance organ­izations (HMOs); managed care preventive medicine. See public health Price, Tom, 471–474

559

Pritchett, Henry S., 239, 296, 298–300, 301 Progressive (“Bull Moose”) Party, 3, 49, 290, 321–324, 326 Progressive Era, 4, 16, 17, 83, 89, 109, 117, 203, 255, 259, 312, 361, 384, 390, 396, 403, 446, 465 progressivism, 93, 179, 361, 363, 364. See also medical progressivism Prohibition, 203, 341–342, 365, 368, 385 Proprietary Association of Amer­i­ca (PAA), 72, 115, 121, 123 proprietary drugs, 4, 21–23, 28, 62–65, 71–79, 80, 81, 82, 94, 100, 101, 102, 106, 111, 112, 115, 116, 119, 120, 126, 127, 128, 187, 188, 218, 219, 220, 221, 247, 288, 317, 331, 342, 384 Prudden, T. Mitchell, 150, 153, 192 Prus­sia, 48, 141, 231 public health, vii–­xiii, ix, 3, 5, 6, 7, 8, 10, 11, 13, 15–17, 24, 25, 28, 32–34, 37, 38–47, 49–57, 62, 70, 81, 87, 113, 114, 137–208, 210, 213, 216, 223, 225–231, 236, 237, 240, 241, 248–250, 255, 256, 261, 269–271, 275, 277, 278, 282–285, 289–291, 317–328, 344–352, 354, 355, 357, 362, 363, 365, 366, 368, 371–379, 389, 390, 393–395, 401, 403, 413, 428, 429, 439, 441, 443, 447, 449, 462, 467, 469, 471, 473–476 public health, schools of, 6, 46, 138, 250, 370, 462 Public Health and Marine Hospital Ser­vice (PHMHS), 174, 177–178, 180, 204–205, 222–224. See also Marine Hospital Ser­vice (MHS) Public Health Defense League, 199–200 Public Health Institute of Chicago (PHIC), 370–371 Public Health Ser­vice (PHS), 229–230 public relations, 13, 43, 51, 159, 190, 208, 322, 325, 375, 424, 425 Puckner, William A., 100, 107, 247 Purdue Pharma, 467–468

560 I n d e x

Pure Food and Drugs Act (1906), 3, 38, 111–112, 115, 116, 122, 123, 127, 129, 132, 133 Pusey, William A., 2, 3, 369–373 Quadagno, Jill, 452 quarantines, 148, 154, 157, 158, 165, 223 Quay, Matthew, 161 racism, xii, 8–10, 24, 176, 182–183, 185, 193–194, 311, 390–394 radiologists, 399, 472 Rankin, Walter S., 53 rational therapeutics, 63, 65, 69, 70, 73, 84, 89, 99, 105, 132, 133, 235, 342, 345, 347, 368, 384, 385, 388, 401, 436, 441, 466, 471. See also evidence-­based medicine; outcomes research Rauch, Cyrus, 281, 284 Rauch, John H., 145, 146, 147, 153, 155, 275–286, 277, 290, 291, 292, 296, 312, 323, 324, 326 Raymond T. Rich and Associates, 425 reactionaries. xi, xiii, 2, 11, 314, 343, 358, 361, 364, 380, 404, 419, 438, 475, 526n1 reactionary rhe­toric, xi, xiii, 230, 352, 358, 411, 423, 425, 438 reactionary turn, xii, 11, 15, 57, 108, 230, 314, 360, 361, 364, 366, 373, 384, 396, 438 Reagan, Ronald, 426 Red Cross, American, 191, 214, 354, 365 Red Scare, 360, 361 Reed, Charles A. L., 38–39, 45, 46, 52, 56, 97, 123–125, 124, 126, 138, 141–142, 148, 172–173, 198, 201, 213, 229, 290, 291, 327, 367 Reed, Walter, 168–169, 175 Reeves, James Edmund, 146–147, 149, 153, 496n18 reform/reformers. See medical progressives/ progressivism Relman, Arnold, 463 residencies/residents, 23, 82, 335, 338, 394, 404, 431, 446, 458

Resource-­Based Relative Value Scale (RBRVS), 469–470 Rial, William, 464 Rich, Raymond T., 425 Richardson, Tobias G., 143 Richardson, William, 131 Rixey, Presley M., 206 R. J. Reynolds, 431 Robarts, Heber, 367 Robert Koch Institute, 180 Roberts, John B., 75–76, 80, 143, 161–162 Robert Wood Johnson Foundation, 454, 460 Robinson, Victor, 8 Robinson, William, 75 Rocke­fel­ler, John D., Sr., 27, 178–183, 195, 307, 308, 313, 406, 437 Rocke­fel­ler, Nelson, 399 Rocke­fel­ler Foundation, 306, 327, 336, 417 Rocke­fel­ler Institute for Medical Research, 150, 179, 303 Rocke­fel­ler Sanitary Commission for the Eradication of Hookworm Disease (RSC), 180–183 Rodman, William L., 123 Rogers, Philip, 429 Rogers, Robert E., 267 Romer, John Irving, 132 Rooney, James F., 333, 340, 341, 351, 358, 369 Roo­se­velt, Franklin D., 161, 322, 346, 361, 363, 364, 379, 398, 399, 400, 408, 409, 415, 423 Roo­se­velt, James, 379, 420 Roo­se­velt, Robert B., 150–151, 178 Roo­se­velt, Theodore, 3–4, 27, 49, 56, 111, 116, 122, 123, 125, 126, 129, 131, 170–174, 178, 179, 187, 189, 192, 193, 194, 197, 200, 202, 206, 217, 224, 290, 321, 324, 326, 347, 348, 349, 363 Roper, William, 449, 451 Rorty, James, 386 Rose, Wickliffe, 181, 183 Rosen, Charles, 467 Rosen, George, 525n1

Index Rosenau, Milton, 224 Rosenwald, Lessing, 389 Rosner, David, 479n24 Ross, Donald, 406–407 Ross, James P., 253–254 Ross, William H., 374–375 Rothstein, William G., 495n9, 515n34 Rouse, Milford O., 393, 442–443 Rubinow, Isaac M., 348, 351 Rusby, Henry Hurd, 96–97 Rush, Benjamin, 66, 71 Rush Medical College, 23, 45, 46, 82, 240, 253–254, 269, 290, 292, 330 Russell Sage Foundation, 190 Salisbury, J. H., 80 Salmon, David E., 166, 167 Sammons, James, 431, 444–445, 458, 460, 464 Sawyer, Charles E., 229 Sawyer, Wilbur A., 417 Schaeffer, Theodore W., 259 Scheuer, Mathilda, 395 Schieffelin, William Jay, 202 Schmidt, Louis E., 371 Schumpeter, Joseph, 200 Schurman, Jacob Gould, 260–261 scientific democracy, 45, 47 scientific therapeutics, 105, 247, 365, 384. See also evidence-­based medicine; outcomes research; rational therapeutics Scientology, 443–444 Scripps, William E., 218 Scully, Tom, 470 Seager, Henry R., 202 Seevers, Maurice, 428, 436 Serbia, 111 Seward, John, 461 Shadid, Michael, 407 Sharpe & Dohme, 72, 97 Shattuck, Frederick, 251, 252 Shaw, George Bernard, 29–30, 250 Sheppard-­Towner Act (1921), 355–357, 362–364, 373, 395, 397

561

Sherley, Joseph S., 131 Sherman Anti-­Trust Act, 14, 181, 408–410 Shonts, Theodore, 173, 174 Shoulders, Harrison, 413–414 Shrady, George F., 33 Simmons, George Henry, 5, 10, 30, 38–39, 45, 51–52, 61, 62, 70, 75, 77, 80, 81, 85, 86, 88, 89, 94, 99, 100, 108, 112, 160, 184, 187, 201, 220, 256, 304, 328, 329–332, 334, 341, 343, 345, 348, 367–368, 369, 372, 373, 432 Sinclair, Upton, 121–123 smallpox, 42, 139, 148, 151, 223, 226–227 Smith, Adam, 86 Smith, Al, 399 Smith, Austin, 387, 433, 435 Smith, Joseph, 221 Smith, Oakley, 345 Smith, Stephen, 40, 142, 150–153, 155 smoking, 13, 28, 243, 249, 376, 428–432, 458, 459–460, 470, 473. See also tobacco industry Smoot, Reed, 221–222, 229 social contract between medicine and society, viii, xiii, 314, 455, 544n68 social Darwinism, 2, 201, 320, 346, 369 socialized medicine, 3, 230, 346–357, 372, 378, 382, 389, 399, 448 Social Security Act (1935), xiii, 12, 340, 346, 379, 397, 398, 399, 427, 438, 442 Solberg, Winton, 282 Solis-­Cohen, Solomon, 94, 97, 105, 384 Sollmann, Torald, 77, 81–82, 87, 99, 100, 105–106, 384 Spain, 166, 242 Spanish-­A merican War (1898), 168–169, 177, 205–206 Spanish flu pandemic (1918), 361 specialists, 27, 319, 336, 338, 339, 344, 345, 366, 367, 375, 395, 399, 404, 405, 420, 465, 469, 470. See also medical specialty associations (MSAs) Spock, Benjamin, 462 Spooner, John C., 126

562 I n d e x

Squibb, Edward R., 113 Stacey, James, 461 Standard Oil Com­pany, 179, 181, 406, 437 Starr, Paul, 16–17, 83, 314, 384, 400–401 state medicine, 46, 138, 141, 142, 143, 144, 145, 147, 226, 275, 327, 334, 346, 354, 355, 357, 358, 360, 364, 378, 389, 399, 440. See also socialized medicine Steingraber, Sandra, 457 Stephens, A. F., 219 Stern, Bernhard, 419 Sternberg, George M., 139, 157, 195, 206 Stetler, Joseph, 435 Stevens, John, 173, 174 Stewart, Francis Edward, 63, 89–96, 99, 105 Stigler, George, 479n25 Stiles, Charles Wardell, 177–182, 190, 204, 327–328 Still, Andrew Taylor, 295, 345 Strong, Henry R., 83, 108, 226 Sudler, Melvin, 238 Sulfanilamide tragedy, 387 ­Sullivan, Mark, 115, 122, 127 Sunbeam Products, 461 Sundwall, John, 338 Sununu, John, 461 surgeons, 23, 33, 34, 50, 216, 255, 297, 318, 319, 320, 335, 336, 338, 348, 402, 406, 448, 450, 467, 471, 472, 443 surgeons general (of U.S. Public Health Ser­vice and U.S. Army), 139, 165, 168, 176, 195, 205, 206, 223, 229, 246, 306, 351, 376, 377, 414, 428, 431 surgery, 23, 27, 30, 33, 34, 43, 50, 74, 106, 107, 147, 211, 212, 238, 244, 246, 247, 248, 277, 297, 298, 304, 396, 402, 404, 448, 449, 465, 467 Sweden, 194, 238 Swift, Gustavus, 322 Switzerland, 6 Sydenstricker, Edgar, 350 Symms, Steven D., 388 syphilis, 9, 46, 54, 139, 140, 328, 370–371, 375, 393

Taft, William Howard, 56, 131, 173, 197–198, 201, 206, 224, 229, 290 Talbott, John H., 376 Tammany Hall, 151–153 Tarbell, Ida, 181 Taylor, J. J., 239 Taylor, Zachary, 141 teething, 23, 132, 144 temperance movement. See Prohibition Terris, Milton, 377 Teva drug com­pany, 466 thalidomide tragedy, 387, 388, 435 Thayer, William, 252 therapeutic rationalists, 342, 347, 348, 368, 401, 466 Thomas, Carey, 273 Thomsonianism, 67, 221. See also eclectic school of medicine tobacco industry, xii, 201, 243; AMA and, 13–14, 376, 386, 428–430, 458–460. See also smoking Tocqueville, Alexis de, 194, 400 Todd, Charles A., 237 Todd, James S., 460–461 Torrance, Francis, 185 town-­gown conflict, 336, 337, 339, 390 Trudeau, Edward Livingston, 188 Truman, Harry S., 379, 389, 398, 399, 423 Trump, Donald, x, 467, 471 tuberculosis, 2, 7, 9–10, 53, 54, 55, 72, 92, 106, 107, 131, 140, 147, 149, 156, 161, 167, 184–195, 197–202, 204, 206, 207, 209, 219, 226, 250, 307, 322, 323, 326–328, 351–352, 354, 391, 401, 411, 471 Tuskegee syphilis study, 393 Twain, Mark, 27, 67, 69 Tweed, William M., 152 Tyler, Elizabeth, 194 typhoid fever, 6–7, 24–25, 40, 47, 54, 139, 140, 141, 142, 144, 154, 161, 167, 168, 169, 174, 204, 206, 213, 226, 327, 350 Typhoid Mary (Mary Mallon), 226

Index uncinariasis. See hookworm ­unions. See ­labor ­unions United States Pharmacopeia (USP), 71–72, 74, 76, 79, 82, 90, 96, 101, 113, 114, 115, 119 United States Steel, 95–96 University of Michigan Medical School, 3, 99, 202, 261, 268–269, 291, 295, 310, 336, 337, 338 University of Pennsylvania Medical School, 246, 251, 257, 261, 266–268 Upjohn, 72, 106–107, 444–445 U.S. Chamber of Commerce, xii, 2, 129, 160, 207, 380, 427, 469 vaccination, 139, 148, 214, 218, 226–227, 230–231, 375 Vaias, Lydia J., 456–457 Vanderbilt, Henry, 269 Vanderlip, Frank, 33 Van de Warker, Ely, 52 Van Etten, Nathan, 418 Van Sickle, Frederick L., 348–349 Vaughan, Victor C., 3, 10, 168, 269, 291, 298, 337, 341, 345, 348, 353, 355, 357, 365–366, 367, 406 Veterans Administration (VA), 12, 378 Virchow, Rudolf Carl, 162–163, 177, 178, 419, 474–476 vital statistics, 6, 138, 144, 145, 146, 148, 149, 150, 151, 154, 157, 198, 207, 359 Volstead Act (1919), 341, 365. See also Prohibition Wagner, Robert F., 379, 423 Wagner-­Murray-­Dingell (WMD) bills, 379, 423 Wahrer, C. F., 74, 81, 247 Wald, Lillian, 191, 224 Walker, H. O., 99 Walker, John G., 171–172 Wallace, John Findlay, 173 Wallace, Mike, 463 Walsh, James J., 73

563

Walsh, J. H., 371 Warbasse, James Peter, 25, 30, 249 Warner, John Harley, 45, 69, 451 Warren, Benjamin S., 350, 351 Warren, Earl, 399, 425 Warren, J. Collins, 252, 276, 278 Washington, Booker T., 202 Washington, George, 66 Washington Post, 300, 392, 424, 444, 445 Webster, George W., 283, 284, 319 Welch, William Henry, 10, 45–46, 56, 123, 124, 138, 155, 162, 164, 165, 168, 171, 173, 175, 178, 179, 180, 188, 200, 201, 208, 271, 273, 303, 336, 368, 371 Wennberg, John, 449–451, 454 West, Olin, 371–372 Weston, Robert Spurr, 248–249 Whalen, Charles J., 320–322, 325–326, 334, 341, 343, 352, 358–359, 367, 368, 369, 438 Whipple, George Chandler, 250 Whitaker, Clem, 425, 427 Whitaker and Baxter, 425 White, Andrew D., 160 White, Joseph H., 174 White, Kerr L., 389 Whitlock, Brand, 362 Whyte, Kenneth, 363 Wilberforce, William, 156 Wilbert, Martin, 82–83 Wilbur, Ray Lyman, 371 Wilcox, Reynold Webb, 96 Wildman, Henry G., 282 Wiley, Harvey Washington, 100, 114, 116–119, 122, 123, 125, 126, 131, 132, 201, 220, 225 Williams, J. Whitridge, 246, 249 Williamson, Charles, 73, 82, 247 Wilson, Charles G., 152–153 Wilson, Woodrow, 228, 361–362 Winslow, Charles-­Edward Amory, 6 Winternitz, Milton, 412, 415 Wintrobe, Max, 436 Witte, Edwin, 346

564 I n d e x

Wolinsky, Howard, xiv, 429, 458, 460, 464 ­women patients, 5, 22, 23, 24, 50, 52, 68, 219, 254, 297, 332, 396 ­women physicians, 10, 23–24, 54, 55, 254, 264–266, 268, 269–273, 309–311, 312, 394–395, 441, 457, 462 ­women’s medical education, 11, 156, 241, 264–266, 268, 269–273, 283, 295, 309–310, 312, 394, 441, 473 ­women’s organ­izations, 3, 47, 50, 51, 54, 55, 114, 116, 117, 122, 123, 127, 189, 191, 204, 224, 271, 327, 341, 346, 358, 359, 386, 396, 426 ­women’s suffrage, 11, 47, 122, 204, 205, 209, 229, 241, 265, 271, 272, 309, 355, 362, 363 Wood, George Bacon, 268 Wood, Horatio C., 74–75, 80, 95, 257 Wood, Leonard, 169, 206 Woodward, William C., 6, 53 Woodworth, John M., 158

workers’ compensation, 161, 339–341, 346–350, 363, 427 Works, John D., 216, 227 World War Veterans’ Act (1924), 378 Wright, Hamilton, 173 Wright, Richard R., 9 Wyman, Walter, 178, 222–224, 228 Yale University, 6, 185, 199, 251, 270, 437 Yale University Medical School, 244, 246, 247, 251, 270, 294, 307, 308, 311, 336, 412, 416, 421 yellow fever, 7, 38, 40, 65, 66, 124, 140, 145, 146, 154, 155, 157, 158, 159, 166–176, 181, 182, 183, 195, 197–198, 206, 223, 351 Young, Brigham, 67, 221 Young, George B., 322 Young, James Harvey, 124 Zakrzewska, Marie Elizabeth, 265 Zierath, William F., 327 Zubkoff, Michael, 450