View larger version (113K): [in this window] [in a new window]   Figure 1. Frederick Taylor Gates (1853 to 1929) as a young man and later in life.

Born in Broome County, New York, Frederick Gates was the son of a small-town clergyman. William Osler also was the son of a clergyman, but the similarities end there. Although Featherstone Osler could afford to send his eighth child to a boarding school where natural science and Sir Thomas Browne's Religio Medici shaped the boy's interests, Granville Gates needed his son's help to keep the family from living in poverty. Young Frederick Gates acquired business acumen through such activities as selling harrows to farmers and buying their calf hides for a tannery 20 miles from home. He worked his way through college and seminary, led the Fifth Avenue Baptist Church of Minneapolis through a successful fundraising campaign, and came to the attention of such prominent Midwest Baptists as George A. Pillsbury, the flour magnate. In 1888, Gates left the pulpit to help form the American Baptist Education Society, and he became its executive secretary. He stated, "This Society, under my administration, founded the University of Chicago, for which I raised the first million dollars, and in this way became acquainted with Mr. John D. Rockefeller" [8].

Rockefeller was impressed with the "extraordinary ability" of Gates "to get at facts, to analyze them, and to draw sound conclusions from them" [9]. In 1891, Gates moved to the eastern United States to help Rockefeller with his philanthropic endeavors. Although a study in contrasts-the taciturn, fastidious Rockefeller was a model of self-restraint and Gates, by his own admission in 1891, was "eager, impetuous, insisting, and withal exacting and irritable" [10] -they got along famously. Rockefeller was beset by thousands of requests for contributions each year. As Gates phrased it, Rockefeller was "constantly hunted, stalked, and hounded almost like a wild animal" [11]. Gates established a policy of refusing all individual requests for funds and concentrated on agencies that could be held accountable. Rockefeller also sought the help of Gates with investments and thereby learned that he had often been swindled by others. In 1893, Rockefeller brought Gates to his private New York offices at 26 Broadway as a full-time adviser.

In effect, Rockefeller became Gates's congregation of one. Gates counseled him in private and defended him in public, calling him a man whose "ruling passion was by no means a love of money" but rather "a taste for excellence" and whose genius was "for taking pains, doing everything possible just as well as it can be done by steady observation, reflection, and rigid self discipline day by day" [12]. Gates gave practical advice laced with spiritual prognosis: "Your fortune is rolling up, rolling up like an avalanche! You must distribute it faster than it grows! If you do not, it will crush you, and your children, and your children's children" [13]. The textbook by Osler convinced Gates that an excellent investment for the Rockefeller fortune would be scientific medicine.

The Reading of The Principles and Practice of Medicine

Gates embellished the story with time, especially in response to a request in 1920 from Harvey Cushing for biographical information about Osler. Cushing wrote [14]:

"Nothing can possibly interest me more ... than the note pasted on the fly-leaf of your Principles and Practice ... . If you could bring yourself to write the narrative of your first encounter with Osler's "Practice", with the subsequent reaction of Mr. Rockefeller, all of which led up to the gift to the Johns Hopkins after the fire, to the Rockefeller Institute, and much else beside. it would certainly be one of the most interesting stories I shall have to tell. I would greatly like to have it in your own words."

When Gates prepared his autobiography in 1928, he used the same version that he had given to Cushing [15, 16]:

"I read the whole book without skipping any of it. I speak of this not to commemorate my industry but to illustrate Osler's charm. Osler's Principles and Practice of Medicine is one of the few scientific books possessed of literary attraction. There was a fascination about the style itself that led me on and, having once started. I found a hook in my nose that pulled me from page to page, and chapter to chapter, until the whole of about a thousand closely printed pages brought me to the end."

Although almost a quarter of a century elapsed between Gates's reading of the book and Cushing's request for a good story, several facts are beyond dispute.

First, Gates did not pick up the textbook by chance. A great-grandfather and several other relatives had been physicians, and his father had read about medicine on his own for 3 years before choosing to enter the clergy. Gates "had been for years convinced that medicine as generally taught and practiced in the United States was practically futile" [17]. He had witnessed his older brother and only sibling, Frank, being bled from the temporal artery to cure brain fever and later watched helplessly as Frank died of rheumatic heart disease. He had seen his first wife, Lucia Fowler Perkins Gates, "the gentlest spirit that ever drew breath," die of an undiagnosed illness the year after they were married. He himself had survived a life-threatening illness that was never diagnosed. He had heard physicians in his Minneapolis congregation confide that much of what they did was humbug. By 1897, Gates "determined at length that I would find out what really lay in the minds of doctors in active practice. I would read the text books they studied" [18]. For reading advice, he turned to Elon O. Huntington, a former parishioner from Minneapolis who, being alone in New York City as a medical student, sometimes spent weekends with the Gates family in Montclair, New Jersey. Huntington prescribed Osler. Gates purchased the textbook from a bookstore in New York City and packed it for vacation.

Second, the vacation was designed to benefit the Gates children, not medicine. Believing that the best learning occurs in large families and that well-educated persons have a special duty to procreate, Gates was in both respects his own best example. The 1897 summer entourage of Gates and his wife, Emma Lucille Cahoon Gates, included four sons and three daughters who ranged in age from 7 months to 10 years. Like earlier vacations on the New Jersey coast, the trip to the Catskills was "arranged by us on the modern theories of education, to give our children fresh interests and experiences in the greatest possible number and variety" [19]. Lake Liberty afforded "endless play in the water," a carpenter's shop, and a dam that provided "a small water-power for which the boys made a suitable wheel, to which they attached a small churn, and actually made butter from the cream saved from the morning cereal." Moreover, "many happy hours spent in frogging supplied our family Table with frogs' legs." Gates completed the reading of an entire textbook of medicine while on vacation because, like Osler, he had learned to manage his time, balance sociability and solitude, and focus his energy.

Finally, the episode was unquestionably pivotal to the Rockefeller philanthropic endeavors. The considerable evidence for this includes a 1902 letter in which Gates introduced himself to Osler for the first time [20]:

"Some years ago, in carrying out a determination to become more intelligent as a layman on the subject of the current and common diseases, I purchased a copy of your "Principles and Practices of Medicine," on the advice of a bright young medical friend. Happening to receive it just as I was about to start on a vacation, I took the book with me and read it from beginning to end, with absorbing interest, and with a medical dictionary at my side."

"In reading it, I was impressed specially with the vast number of diseases that are certainly or probably originated by bacteria and with the success that has attended the efforts to isolate the germs of disease in so many instances, and equally with the fact that as yet only one specific seems certainly to have been found, in the antitoxin of diphtheria; and the vast possibilities for good lying in this field of research opened up before my imagination and fired my enthusiasm. I acquainted myself in a general way with what is being done in Paris and Berlin, and with the fact that with the exception of the work of Johns Hopkins, comparatively little seems to have been accomplished in the United States."

Gates later elaborated that Osler's

"... chapter on any particular disease would begin with the definition of the disease and its extension throughout the world, the history of discovery about it, the revelations of innumerable post mortems, the symptoms, cause, and probable results of the disease, and the permanent complications and consequences likely to follow; but when he came to the vital point, namely the treatment of the aforesaid disease, our author, who had up to this time been treading on solid ground with the confidence and delight of sure knowledge, would almost invariably lapse into a mental attitude of doubt, scepticism, and hesitation [21]."

Gates decided that the United States needed a medical research institute similar to the Koch Institute in Berlin and the Pasteur Institute in Paris, where scientists could work unfettered by outside demands.

On 24 July 1897, Gates returned to New York City, brought the book by Osler to the Rockefeller headquarters, and dictated his vision for John D. Rockefeller Sr. Gates never saw the memorandum again. However, the following October, he gained a valuable ally when John D. Rockefeller Jr., a recent graduate of Brown University, chose to work with him rather than with the Standard Oil Company. Thereafter, the younger Rockefeller approached his father at opportune moments with well-reasoned proposals from Gates. In this setting, Gates thrived as the ultimate corporate liberal. He eventually came to view health as an index of social progress, medicine as a way to reduce tensions in society, and science as a supplement to religion [22, 23]. Science, education, and health would thereafter dominate the Rockefeller philanthropic endeavors [24].

The first endowment was the Rockefeller Institute for Medical Research (now Rockefeller University), which opened in 1901. Through his association with this research facility, Gates met William H. Welch, a pathologist who was Osler's colleague at Johns Hopkins University and who became president of the scientific directors at the Rockefeller Institute [25]. After the institute became established, the General Education Board was chartered in 1903, the Rockefeller Foundation was incorporated in 1913, and the Laura Spelman Rockefeller Memorial was founded in 1918. An initiative that began as the Rockefeller Sanitary Commission for the Eradication of Hookworm Disease evolved into the Rockefeller Foundation's hugely successful International Health Board. Gates also became preoccupied with the structure and function of clinical departments at medical schools in the United States, which led to a controversy between Gates and Osler.

The Full-Time Controversy

The decision to keep the Rockefeller Institute for Medical Research separate from existing medical schools was made in part because Gates had unhappy memories of a failed 1894 attempt to merge Rush Medical College with the University of Chicago. However, a movement to combine medical education and research within the university framework had begun in the 1870s and had gained momentum when The Johns Hopkins University School of Medicine opened with its own hospital, close ties to its university, and an emphasis on research. As is well known, a report by Abraham Flexner in 1910 on the poor condition of most medical schools in the United States featured Johns Hopkins University as a paradigm for comparison [26, 27]. During the heady early days of Johns Hopkins University, however, a serious rift between basic science and clinical faculty developed over the issue of whether faculty members should be in private practice. Osler, whose own practice became quite lucrative [28], held that third- and fourth-year students should be taught by clinicians who were responsible for patients and the treatment of disease. Franklin Paine Mall, an anatomist who had returned from training in Germany, was convinced that clinical professors should eschew practice-derived income to focus on teaching and research. When Osler left Baltimore in 1905 to become Regius Professor of Medicine at Oxford University, he saw the tide running in Mall's favor. At the end of his final faculty meeting at Johns Hopkins University, he turned to Mall and said: "Now I go, and you have your way" [29].

In 1911, Gates invited Flexner to lunch and asked him what he would do if he were given $1 million with which to start reorganizing medical education. Flexner answered that he would give the money to Welch [30]. Gates consulted Welch, who replied that "unless you inform me to the contrary I shall include the hospital side, as well as the laboratories in my statement of our needs" [31]. The idea that medical school departments should be organized and funded on the same basis as other departments within the university system appealed to Gates; indeed, he had previously reached the same conclusion. Gates therefore reinforced Welch's support of the so-called full-time plan for clinical faculty, an idea that Flexner did not originate but of which he became the avowed champion [32-36]. Rockefeller patronage of medical research would extend to the clinical departments of medical schools, where professors would no longer benefit financially from private practice. When the younger Rockefeller proposed the idea to his father in August 1911, he included a memorandum by Gates that indicated that The Johns Hopkins University School of Medicine would be "as free from commercialism as the Rockefeller Institute" [37]. Osler, who by 1911 had been Regius Professor of Medicine at Oxford University for almost 6 years, was among those who received a copy of the proposal.

Osler did not like it. He circulated a "family letter" addressed to Ira Remsen, president of Johns Hopkins University, in which he pleaded that the money not be accepted on the Rockefellers' terms. Remsen, the letter continued, should "divert the ardent souls who wish to be whole-time clinical professors from the medical school in which they are not at home to the Research Institutes to which they properly belong, and in which they can do their best work" [38]. Osler's protest failed. In 1913, shortly after Flexner became secretary of the General Education Board. Johns Hopkins University accepted a $1.5 million endowment to establish its departments of medicine, surgery, and pediatrics on a full-time basis. Osler later complained that the full-time plan "had been forced on the profession by men who know nothing of clinical medicine, and there has been a ‘mess of pottage’ side to the business in the shape of big Rockefeller cheques at which my gorge rises" [39]. By 1928, the General Education Board had spent $60 million to support medical education, most of which went to implement the full-time plan [40]. Although clinical faculty would eventually be allowed to secure some private practice (the so-called geographic full-time plan or the Harvard plan) and Osler would modify his own views toward the end of his life, he had correctly seen the passing of an era.

In retrospect, Osler missed an opportunity to influence the eventual outcome by failing to cultivate a close personal relationship with Gates. When Osler thanked Gates in 1904 for a $500 000 Rockefeller gift to Johns Hopkins University, Gates wrote back [41]:

"Medical science has made comparatively small progress until lately, because chemistry and physics have until very lately never furnished medical science with suitable instruments of research ... . It has seemed to me that if now medical science, with its new workshop, could be given the same financial encouragement that other sciences have received, we might expect in the next generation or two to reduce medicine, if not to an exact science, certainly to something approximating an exact science, and we might reasonably expect results as revolutionary, as far-reaching, as beneficent on human well-being as any which have been derived from the practical applications of physical and chemical sciences ... . Am I not right in this train of reflections? Right or wrong, I have made lists for Mr. Rockefeller and his son of achievements already accomplished, and other and yet longer lists of problems needing to be solved."

Gates admired Osler as "the greatest modern physician," and Osler had sent Gates most of his publications [42]. Osler may have missed the opportunity to influence Gates well before the direct involvement of Abraham Flexner with the General Education Board. In fairness to Osler, he was a very busy man on the verge of burnout [43]. In fairness to Gates, clinical science as we know it might not have evolved had part-time professorships remained the norm. Gates eventually acknowledged that the Rockefellers' intentions with the first full-time gift to Johns Hopkins University were "not yet fully disclosed. We aimed at nothing less than a wide reform in the teaching and ultimately in the practice of medicine, and Hopkins was only the place of beginning" [44]. A century has passed since Gates read the textbook by Osler, and the extent to which clinical professors should engage in private practice remains an issue [45].

Epilogue

Gates, Osler, Welch, and Flexner deserve major credit for sponsoring scientific medicine and academic departments of medicine in the United States, but their perspectives sometimes differed in ways that still reverberate today. Gates, whose main cause was research, eventually believed that academic medicine in the United States should rely extensively on seven great privately endowed universities: Harward University, Johns Hopkins University, Yale University, the University of Rochester, Vanderbilt University, the University of Chicago, and Washington University at St. Louis. Flexner, whose main cause was educational reform, believed that all medical schools should aspire to the standards set at Johns Hopkins University. In 1922, Gates and Flexner clashed on whether the General Education Board should aid a state-supported medical school, the test case being the University of Iowa. Flexner prevailed [46]. Gates's influence on medical education declined, but his interest did not, and he was never reluctant to express his views.

In 1925, Gates again opposed Rockefeller aid to state medical schools in a paper that listed 10 "basal facts" about medicine (Table 1) [47]. He maintained that clinical medicine should be subordinate to basic research and disease prevention [47].

"What is the practical object of the science of medicine? It is not to multiply physicians and Medical schools, nor is it primarily to cure disease ... The place of the cure is secondary. The high aim and ideal of the science of medicine is no less than to prevent sickness altogether, to usher humanity into a new world, by banishing sickness from human life and bringing about universal health, an object of course never to be fully obtained ... . This practical aim, of health, dominates the science itself, and prescribes the logical order of its research ... . The order is to study the diseases severally, to trace each to its cause; when the cause is found to find out how the disease may be prevented, and to publish the findings immediately, far and wide; then as a final, terminal incident, to seek the cure for those cases that can not be humanly prevented ... . Physicians, as curative agents, pure and simple, have a necessary place, but it is a subordinate and declining place. For, as health increases we shall need ever fewer physicians and Medical schools, and health is increasing."

In conclusion, Gates quipped [47]: "I wonder who can tell me where, after finishing this paper, I borrowed something like the following: ‘Medicine must always be a science, or else an empirical method of getting a living out of the ignorance of the human race.’" Today, many articulate spokes-persons within medicine would criticize this viewpoint as narrowly preoccupied with the science of medicine-the biomedical model of disease-to the detriment of the "art" of medicine [48, 49]. Yet how does the public really value medicine in social, political, and economic terms? We should not forget that informed, concerned, and energetic laypersons, such as Gates, will probably have the final word.

Life was kinder to Gates than it was to Osler, who died broken-hearted after his son and only surviving child, Revere, was killed in World War I. Gates lived to see all seven of his children begin successful careers, marriages, or both. All four of his sons finished college and were elected to Phi Beta Kappa; two of them survived the war as combat aviators, and one was a medical graduate of Johns Hopkins University and became a researcher at the Rockefeller Institute. Gates retired comfortably and devoted his time to hobbies, such as golf and farming, and to his 17 grandchildren. Unlike Osler, Gates derived enormous personal benefit from medical research. In 1923, Gates and his wife, who both had diabetes, were among the first persons to receive insulin. The dramatic results