The Great Influenza Read online

  Most leading physicians around the world, including in the United States, agreed with a prominent American public health expert who declared in 1885: 'What was theory has become fact.'

  But a minority, both in the United States and Europe, still resisted the germ theory, believing that Pasteur, Koch, and others had proven that germs existed but not that germs caused disease - or at least that they were the sole cause of disease.*

  The most notable critic was Max von Pettenkofer, who had made real and major scientific contributions. He insisted that Koch's bacteria were only one of many factors in the causation of cholera. His dispute with Koch became increasingly bitter and passionate. With a touch of both Barnum and a tightrope walker about him, Pettenkofer, determined to prove himself right, prepared test tubes thick with lethal cholera bacteria. Then he and several of his students drank them down. Amazingly, although two students developed minor cases of cholera, all survived. Pettenkofer claimed victory, and vindication.

  It was a costly claim. In 1892 cholera contaminated the water supply of Hamburg and Altona, a smaller adjacent city. Altona filtered the water, and its citizens escaped the disease; Hamburg did not filter the water, and there 8,606 people died of cholera. Pettenkofer became not only a mocked but a reviled figure. He later committed suicide.

  There was still no cure for cholera, but now science had demonstrated (the dead in Hamburg were the final evidence) that protecting the water supply and testing for the bacteria would prevent the disease. After that only an isolated and discredited group of recalcitrants continued to reject the germ theory.

  By then Welch had arrived at the Hopkins. It had not been an easy journey to Baltimore.

  *

  When the offer finally came in 1884, Welch had become comfortable in New York, and wealth was his for the asking. Virtually every student who had ever passed through his course had the utmost respect for him, and by now many were physicians. He had already made a reputation; that and his charm entered him into society as much as he desired.

  His closest friend was his preparatory school roommate Frederick Dennis, wealthy son of a railroad magnate and also a physician who had studied in Germany. At every opportunity Dennis had advanced Welch's career, extolling his talents to editors of scientific journals, using his society connections to help him in New York, occasionally even subsidizing him indirectly. Indeed, Dennis behaved more like a lover trying to win affection than a friend, even a close friend.

  But Dennis had always demanded a kind of fealty. Welch had heretofore been willing to give it. Now Dennis demanded that Welch stay in New York. When Welch did not immediately agree, Dennis orchestrated an elaborate campaign to keep him there. He convinced Welch's father to advise him to stay, he convinced Andrew Carnegie to donate $50,000 for a laboratory at Bellevue, and he convinced Bellevue itself to pledge another $45,000; that would match any laboratory in Baltimore. And not only Dennis urged Welch to stay. A prominent attorney whose son had studied under Welch warned him that going to Baltimore would be 'the mistake of your life. It is not in a century that a man of your age has acquired the reputation which you have gained.' Even the president of the United States Trust Company sent a message that 'however bright the prospect is in Baltimore it is darkness compared with the career' before him in New York.

  The pressure was not without effect. Dennis did get Welch to set conditions that, if met, would cause him to stay. For Welch had his own doubts. Some related to his own fitness. He had done almost no real science in the years since returning from Germany. He had only talked for years about how his need to make a living prevented him from conducting original research.

  The Hopkins expected more than talk. It had been open for eight years and, tiny as it was, had earned an international reputation. Welch confessed to his stepmother, 'Such great things are expected of the faculty at the Johns Hopkins in the way of achievement and of reform of medical education in this country that I feel oppressed by the weight of responsibility. A reputation there will not be so cheaply earned as at Bellevue.'

  Yet precisely for that reason the Hopkins offered, he wrote, 'undoubtedly the best opportunity in this country.' Declining would reveal him as a hypocrite and a coward. Meanwhile in New York, the conditions he had set were not met, although Dennis considered them to have been.

  Welch accepted the Hopkins offer.

  Dennis was furious. His friendship with Welch had been, at least on Dennis's side, of great emotional depth and intensity. Now Dennis felt betrayed.

  Welch confided to his stepmother, 'I grieve that a life-long friendship should thus come to an end, but' [i]t looks almost as if Dr. Dennis thought he had a lien upon my whole future life. When he appealed to what he had done for me I told him that was a subject which I would in no way discuss with him.'

  Later Dennis sent Welch a letter formally breaking off their friendship, a letter written with enough intensity that in the letter itself he asked Welch to burn it after reading.

  For Welch too the breaking off of the friendship was intense. He would not have another. Over much of the next half century, Welch's closest collaborator would be his protegé Simon Flexner. Together they would achieve enormous things. And yet Flexner too was kept distant. Flexner himself wrote that after Welch's estrangement from Dennis, 'Never again would he allow any person, woman or colleague, close' . The bachelor scientist moved on a high plane of loneliness that may have held the secret of some of his power.'

  For the rest of his life Welch would remain alone. More than just alone, he would never dig in, never entrench himself, never root.

  He never married. Despite working with others in ways that so often bind people together as comrades, with the single possible exception of the great and strange surgeon William Halsted (and that exception only a rumored possibility*) he had no known intimate relationship, sexual or otherwise, with either man or woman. Although he would live in Baltimore for half a century, he would never own a home there nor even have his own apartment; despite accumulating considerable wealth, he would live as a boarder, taking two rooms in the home of the same landlady, then moving with his landlady when she moved, and allowing his landlady's daughter to inherit him as a boarder. He would take nearly every dinner in one of his gentlemen's clubs, retreating to a world of men, cigars, and the conversations of an evening for the rest of his life. And he would, observed a young colleague, 'deliberately break off relationships which seemed to threaten too strong an attachment.'

  But if he lived on the surface of ordinary life, his life was not ordinary. He was free, not just alone but free, free of entanglements of people, free of encumbrances of property, utterly free.

  He was free to do extraordinary things.

  *

  At the Hopkins (it became simply 'Hopkins' gradually, over several decades) Welch was expected to create an institution that would alter American medicine forever. When he accepted this charge in 1884, he was thirty-four years old.

  The Hopkins went about achieving its goal both directly and indirectly. It served as home, however temporary, to much of the first generation of men and women who were beginning the transformation of American medical science. And its example forced other institutions to follow its path - or disappear.

  In the process Welch gradually accumulated enormous personal power, a power built slowly, as a collector builds a collection. His first step was to return to Germany. Already he had worked under Cohn, to whom Koch had brought his anthrax studies, Carl Ludwig, and Cohnheim, three of the leading scientists in the world, and had met the young Paul Ehrlich, his hands multicolored and dripping with dyes, whose insights combined with his knowledge of chemistry would allow him to make some of the greatest theoretical contributions to medicine of all.

  Now Welch visited nearly every prominent investigator in Germany. He had rank now, for he happily reported that the Hopkins 'already has a German reputation while our New York medical schools are not even known by name.' He could entertain with stories, recite a Sha
kespeare sonnet, or bring to bear an enormous and growing breadth of scientific knowledge. Even those scientists so competitive as to be nearly paranoid opened their laboratories and their private speculations to him. His combination of breadth and intelligence allowed him to see into the depths of their work as well as its broadest implications.

  He also learned bacteriology from two Koch protegés. One gave a 'class' whose students were scientists from around the world, many of whom had already made names for themselves. In this group too he shined; his colleagues gave him the honor of offering the first toast of appreciation to their teacher at a farewell banquet. And Welch learned the most from Koch himself, the greatest name in science, who accepted him into his famous course (given only once) for scientists who would teach others bacteriology.

  Then, back in Baltimore, years before its hospital or medical school actually opened, even without patients and without students, the Hopkins began to precipitate change. For although the Hopkins medical hospital did not open until 1889, and the medical school until 1893, its laboratory opened almost immediately. That alone was enough.

  In just its first year, twenty-six investigators not on the Hopkins faculty used the laboratories. Welch's young assistant William Councilman (who later remade Harvard's medical school in the Hopkins's image) kept them supplied with organs by riding his tricycle to other hospitals, retrieving the organs, and carrying them back in buckets suspended from the handlebars. Many of these guests or graduate students were or became world-class investigators, including Walter Reed, James Carroll, and Jesse Lazear, three of the four doctors who defeated yellow fever. Within a few more years, fifty physicians would be doing graduate work at the same time.

  And the Hopkins began assembling a faculty. Its institutional vision combined with Welch himself allowed it to recruit an extraordinary one. Typical was Franklin Mall.

  *

  Mall had gotten his medical degree from the University of Michigan in 1883 at age twenty-one, gone to Germany and worked with Carl Ludwig, done some graduate work at the Hopkins, and had already made a mark. He expected (required) the highest conceivable standards, and not just from his students. Victor Vaughan, dean of the Michigan medical school and second only to Welch in his influence on American medical education, considered the school's chemistry lab the best in America and comparable to the best in the world. Mall dismissed it as 'a small chemical lab' and called his Michigan education equal to that of a good high school.

  When Welch offered Mall a job, Mall was at the University of Chicago where he was planning the expenditure of $4 million, an enormous sum (John D. Rockefeller was the major donor to Chicago) to do what Welch was attempting, to build a great institution. Mall responded to Welch's offer by proposing instead that Welch leave the Hopkins for Chicago at a significant increase in salary.

  By contrast, the Hopkins was desperate for resources but Welch rejected Mall's proposal and replied, 'I can think of but one motive which might influence you to come here with us and that is the desire to live here and a belief in our ideals and our future' . They will not appeal to the great mass of the public, not even to the medical public, for a considerable time. What we shall consider success, the mass of doctors will not consider a success.'

  Mall considered the alternatives. At Chicago he had already, as he told Welch, 'formulated the biological dept, got its outfit for $25,000 and have practically planned its building which will cost $200,000,' all of it funded, with more to come from Rockefeller. At the Hopkins there was a medical school faculty and, by now, a hospital, but no money yet with which to even open the school. (Its medical school finally opened only when a group of women, many of whom had also recently founded Bryn Mawr College, offered a $500,000 endowment provided that the medical school would accept women. The faculty and trustees reluctantly agreed.) But there was Welch.

  Mall wired him, 'Shall cast my lot with Hopkins' . I consider you the greatest attraction. You make the opportunities.'

  *

  Yet it was not Welch's laboratory investigations that attracted, that made opportunities. For, unknown to Gilman and Billings, who hired him, and even to Welch himself, he had a failing.

  Welch knew the methods of science, all right, could grasp immediately the significance of an experimental result, could see and execute the design of further experiments to confirm a finding or probe more deeply. But he had had those abilities during his six years in New York, when he did no science. He had told himself and others that the demands of making a living had precluded research.

  Yet he had no family to support and others did magnificent science under far greater burdens. No scientist had faced more adverse conditions than George Sternberg, an autodidact whom Welch called 'the real pioneer of modern bacteriologic work in this country' [who] mastered the technique and literature by sheer persistence and native ability.'

  In 1878, as Welch met Billings in the same beer hall where legend had Faust meeting the Devil, Sternberg was an army medical officer in combat with the Nez Perce Indians. From there he traveled by stagecoach for four hundred and fifty miles (enduring day after day after day of the stink of sweat, of bone-shattering bumps that shot up the spine, of choking on the dust) only to reach a train, then by train for another twenty-five hundred miles of steaming discomfort, jostling elbows, and inedible food. He endured all this to attend a meeting of the American Public Health Association. While Welch was bemoaning his lack of facilities in New York, Sternberg was building a laboratory largely at his own expense at a frontier army post. In 1881 he became the first to isolate the pneumococcus, a few weeks before Pasteur and Koch. (None of the three recognized the bacteria's full importance.) Sternberg also first observed that white blood cells engulfed bacteria, a key to understanding the immune system. He failed to follow up on these observations, but many of his other achievements were remarkable, especially his pioneering work taking photographs through microscopes and his careful experiments that determined both the temperature at which various kinds of bacteria died and the power of different disinfectants to kill them. That information allowed the creation of antiseptic conditions in both laboratory and public health work. Sternberg began that work too in a frontier post.

  Meanwhile, in New York City Welch was swearing that if only he were free of economic worries his own research would flower.

  In Baltimore his work did not flower. For there, even with talented young investigators helping him, his failing began to demonstrate itself.

  His failing was this: in science as in the rest of his life, he lived upon the surface and did not root. His attention never settled upon one important or profound question.

  The research he did was first-rate. But it was only first-rate (thorough, rounded, and even irrefutable, but not deep enough or provocative enough or profound enough to set himself or others down new paths, to show the world in a new way, to make sense out of great mysteries. His most important discoveries would be the bacteria now called Bacillus welchii, the cause of gas gangrene, and the finding that staphylococci live in layers of the skin, which meant that a surgeon had to disinfect not only the skin surface during an operation but layers beneath it. These were not unimportant findings, and, even in the absence of any single more brilliant success, if they had represented a tiny piece of a large body of comparable work, they might have added up to enough to rank Welch as a giant.

  Instead they would be the only truly significant results of his research. In the context of an entire lifetime, especially at a time when an entire universe lay naked to exploration, this work did not amount to much.

  The greatest challenge of science, its art, lies in asking an important question and framing it in a way that allows it to be broken into manageable pieces, into experiments that can be conducted that ultimately lead to answers. To do this requires a certain kind of genius, one that probes vertically and sees horizontally.

  Horizontal vision allows someone to assimilate and weave together seemingly unconnected bits of informati
on. It allows an investigator to see what others do not see, and to make leaps of connectivity and creativity. Probing vertically, going deeper and deeper into something, creates new information. Sometimes what one finds will shine brilliantly enough to illuminate the whole world.

  At least one question connects the vertical and the horizontal. That question is 'So what?' Like a word on a Scrabble board, this question can connect with and prompt movement in many directions. It can eliminate a piece of information as unimportant or, at least to the investigator asking the question, irrelevant. It can push an investigator to probe more deeply to understand a piece of information. It can also force an investigator to step back and see how to fit a finding into a broader context. To see questions in these ways requires a wonder, a deep wonder focused by discipline, like a lens focusing the sun's rays on a spot of paper until it bursts into flame. It requires a kind of conjury.

  Einstein reportedly once said that his own major scientific talent was his ability to look at an enormous number of experiments and journal articles, select the very few that were both correct and important, ignore the rest, and build a theory on the right ones. In that assessment of his own abilities, Einstein was very likely overly modest. But part of his genius was an instinct for what mattered and the ability to pursue it vertically and connect it horizontally.

  Welch had a vital and wide curiosity, but he did not have this deeper wonder. The large aroused him. But he could not see the large in the small. No question ever aroused a great passion in him, no question ever became a compulsion, no question ever forced him to pursue it until it was either exhausted or led him to new questions. Instead he examined a problem, then moved on.

  In his first years at the Hopkins he would constantly refer to his work, refer to his need to return to the laboratory. Later he abandoned the pretense and ceased even attempting to do research. Yet he never fully accepted his choice; to the end of his life he would sometimes express the wish that he had devoted himself to the laboratory.