The Great Influenza (7 page)

His class rank entitled him to give an oration at commencement. In an undergraduate essay entitled 'The Decay of Faith,' Welch had decried mechanistic science, which viewed the world as a machine 'unguided by a God of justice.' Now, in 1870, the year after Darwin published
Origin of Species,
in his oration Welch attempted to reconcile science and religion.

He found it a difficult task. Science is at all times potentially revolutionary; any new answer to a seemingly mundane question about 'how' something occurs may uncover chains of causation that throw all preceding order into disarray and that threaten religious beliefs as well. Welch personally was experiencing the pains that many in the last half of the nineteenth century experienced for the first time as adults as science threatened to supplant the natural order, God's order, with an order defined by mankind, an order that promised no one knew what, an order that, as Milton wrote in
Paradise Lost,
'Frighted the reign of Chaos and old night.'

Taking a step backward from what his father had said a dozen years before, Welch rejected the personal God of Emerson and the Unitarians, reiterated the importance of revealed truth in Scripture, argued that revelation need not submit to reason, and spoke of that which 'man could never discover by the light of his own mind.'

Welch would ultimately devote his life to discovering all the world with his own mind, and to spurring others to do the same. But not yet.

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He had studied classics and he had hoped to teach Greek at Yale. Yale did not, however, offer him a position, and he became a tutor at a new private school. That school closed, Yale still offered him nothing, and, with no immediate prospects for employment, with his family importuning him to become a physician, he returned to Norfolk and apprenticed to his father.

It was an old-fashioned practice. Nothing his father did reflected his knowledge of the newest medical concepts. Like most American physicians, he ignored objective measurements such as temperature and blood pressure, and he even mixed prescriptions without measuring dosages, often relying on taste. This apprenticeship was not a happy time for Welch. In his own later accounts of his training, he passed over it as if it had never occurred. But sometime during it his views of medicine changed.

At some point he decided that if he was going to become a physician, he would do so in his own way. Routinely those preparing for medicine apprenticed for six months or a year, and then attended medical school. He had served his apprenticeship. But in the next step he took he marked out a new course. Welch returned to school all right, but he did not attend medical school. He learned chemistry.

Not only did no medical school in the United States require entering students to have either any scientific knowledge or a college degree, neither did any American medical school emphasize science. Far from it. In 1871, a senior professor at the Harvard Medical School argued, 'In an age of science, like the present, there is more danger that the average medical student will be drawn from what is practical, useful, and even essential by the well-meant enthusiasm of the votaries of the applicable sciences, than that he will suffer from the want of knowledge of these' .[We] should not encourage the medical student to while away his time in the labyrinths of Chemistry and Physiology.'

Welch had a different view. Chemistry seemed to him a window into the body. By then Carl Ludwig, later Welch's mentor, and several other leading German scientists had met in Berlin and determined to 'constitute physiology on a chemico-physical foundation and give it equal scientific rank with physics.'

It was highly unlikely that Welch knew of that determination, but his instincts were the same. In 1872 he entered Yale's Sheffield Scientific School to study chemistry. He considered the facilities there 'excellent' certainly better than in any medical school, where chemistry as far as I can learn is very much slighted.'

After half a year of grounding, he began medical school at the College of Physicians and Surgeons in New York City, which was not yet connected to Columbia University. (He disdained Yale's medical school; fifty years later he was asked to give a speech on Yale's early contributions to medicine and replied that there hadn't been any.) It was a typical good American medical school, with no requirements for admission and no grades in any course. As elsewhere, faculty salaries came directly from student fees, so faculty wanted to maximize the number of students. Instruction came almost entirely through lectures; the school offered no laboratory work of any kind. This, too, was typical. In no American school did students use a microscope. In fact, Welch's work in one course won him the great prize of a microscope; he cherished it but did not know how to use it, and no professor offered to instruct him. Instead he enviously watched them work, commenting, 'I can only admire without understanding how to use its apparently complicated mechanism.'

But unlike in many other schools, students at the College of Physicians and Surgeons could examine cadavers. Pathological anatomy (using autopsies to decipher what was happening within organs) enthralled Welch. New York City had three medical schools. He took the course in pathological anatomy at all three.

Then he completed his school's single requirement for an M.D. He passed a final examination. Welch called it 'the easiest examination I ever entered since leaving boarding school.'

Shortly before Welch took this test, Yale finally offered him the position he had so earnestly sought earlier - professor of Greek. He declined it.

To his father he wrote, 'I have chosen my profession, am becoming more and more interested in it, and do not feel at all inclined to relinquish it for anything else.'

He was interested indeed.

* 

He was also beginning to be recognized. Francis Delafield, one of his professors, had studied pathological anatomy in Paris with Pierre Louis and, like Louis, kept detailed records of hundreds of autopsies. Delafield's was the best work in America, the most precise, the most scientific. Delafield now brought Welch into his fold and allowed him the extraordinary privilege of entering his own autopsy findings into Delafield's sacred notes.

Yet huge gaps in Welch's knowledge remained. He still did not know how to use his microscope. Delafield, an expert in microscopic technique who had made his own microtome (a device for cutting exquisitely thin slices of tissue), would sit for hours with one eye glued to the lens, smoking a pipe, while Welch watched impotently. But Delafield did let Welch perform a huge number of autopsies for someone in his junior position. From each one he tried to learn.

That knowledge did not satisfy him. His best professors had studied in Paris, Vienna, and Berlin. Although Welch still intended to practice clinical medicine (not a single physician in the United States then made a living doing research) he borrowed from family and friends and, having run through all that his American professors could teach him, on April 19, 1876, a few months before Huxley spoke at the inauguration of the Johns Hopkins University, Welch sailed for Europe to continue his scientific education. Simon Flexner, Welch's protegé and a brilliant scientist in his own right, declared this trip 'a voyage of exploration that was in its results perhaps the most important ever taken by an American doctor.'

* 

He was hardly alone in seeking more knowledge in Germany, where the best science was then being done. One historian has estimated that between 1870 and 1914, fifteen thousand American doctors studied in Germany or Austria, along with thousands more from England, France, Japan, Turkey, Italy, and Russia.

The overwhelming majority of these physicians were interested solely in treating patients. In Vienna professors established a virtual assembly line to teach short courses on specific aspects of clinical medicine to foreign doctors, especially Americans. These Americans took the courses partly out of desire to learn and partly to gain an edge over competitors at home.

Welch himself expected to have to practice medicine to make a living, and he recognized how helpful to such a career studying in Germany could be. He assured his sister and brother-in-law as well as his father, all of whom were helping support him financially, 'The prestige and knowledge which I should acquire by a year's study in Germany would decidedly increase my chance of success. The young doctors who are doing well in New York are in a large majority those who have studied abroad.'

But his real interest lay with the tiny minority of Americans who went to Germany to explore a new universe. He wanted to learn laboratory science. In America he had already acquired a reputation as knowing far more than his colleagues. In Germany he was refused acceptance into two laboratories because he knew so little. This inspired rather than depressed him. Soon he found a place to start and excitedly wrote home, 'I feel as if I were only just initiated into the great science of medicine. My previous experiences compared with the present are like the difference between reading of a fair country and seeing it with one's own eyes. To live in the atmosphere of these scientific workshops and laboratories, to come into contact with the men who have formed and are forming the science of today, to have the opportunity of doing a little original investigation myself are all advantages, which, if they do not prove fruitful in later life, will always be to me a source of pleasure and profit.'

Of Leipzig's university, he said, 'If you could visit the handsome and thoroughly equipped physiological, anatomical, pathological and chemical laboratories and see professors whose fame is already world-wide, with their corps of assistants and students hard at work, you would realize how by concentration of labor and devotion to study Germany has outstripped other countries in the science of medicine.'

He focused on learning how to learn and stayed constantly alert to technique, to anything offering another window into the new world, anything that allowed him to see more clearly and deeply. 'The chief value' of his work with one scientist was 'in teaching me certain important methods of handling fresh tissues, especially in isolating particular elements.' Of another scientist whom he disliked, he said, 'What is of greater importance, I have acquired a knowledge of methods of preparing and mounting specimens so that I can carry on investigations hereafter.'

By now he was attracting attention from his mentors, who included some of the leading scientists in the world, but they left a more distinct impression upon him. One was Carl Ludwig, whom he called 'my ideal of a scientific man, accepting nothing upon authority, but putting every scientific theory to the severest test' . I hope I have learned from Professor Ludwig's precept and practice that most important lesson for every man of science, not to be satisfied with loose thinking and half-proofs, not to speculate and theorize but to observe closely and carefully.'

Julius Cohnheim, another mentor, taught him a new kind of curiosity: 'Cohnheim's interest centers on the explanation of the fact. It is not enough for him to know that congestion of the kidney follows heart disease' . He is constantly inquiring why does it occur under these circumstances' . He is almost the founder and certainly the chief representative of the so-called experimental or physiological school of pathology.'

Welch began to analyze everything, including his most deeply held beliefs. Five years earlier he had condemned the concept of a world ruled other than by a God of justice. Now he told his father that he embraced Darwin: 'That there is anything irreligious about the doctrine of evolution I cannot see' . In the end our preconceived beliefs must change and adapt themselves. The facts of science never will change.'

He also analyzed the means by which German science had achieved such stature. Its three most important elements, he decided, were the thorough preparation required of students by German medical schools, the schools' independent financing, and the support of research by the government and universities.

* 

In 1877, a year after the Johns Hopkins University opened, its president, Daniel Gilman, laid plans to assemble the greatest medical school faculty in America, one to rival any in Europe. The decision to launch a national (indeed international) search was itself revolutionary. With the exception of the University of Michigan, located in tiny Ann Arbor, every medical school in the United States filled its faculty exclusively from the ranks of local physicians. To perform the search Gilman chose the perfect man: Dr. John Shaw Billings.

Billings lay behind America's first great contribution to scientific medicine: a library. This library grew out of the detailed medical history of the Civil War ordered by the army surgeon general. The army also created a medical 'museum,' which was actually a library of specimens.

Both the museum and the history were remarkable. In 1998 scientists at the Armed Forces Institute of Pathology, a direct descendant of this museum, used specimens preserved in 1918 to determine the genetic makeup of the 1918 influenza virus. And the medical history was extraordinarily precise and useful. Even Virchow said he was 'constantly astonished at the wealth of experience therein found. The greatest exactness in detail, careful statistics even in the smallest matters, and a scholarly statement embracing all sides of medical experience are here united.'

Billings did not write that history, but it did inspire him to create a medical library of comparable quality. He built what one medical historian judged 'probably the greatest and most useful medical library in the world.' By 1876 it already held eighty thousand volumes; ultimately it grew into today's National Library of Medicine.

But he did more than collect books and articles. Knowledge is useless unless accessible. To disseminate knowledge, Billings developed a cataloging system far superior to any in Europe, and he began publishing the
Index Medicus,
a monthly bibliography of new medical books and articles appearing in the Americas, Europe, Japan. No comparable bibliography existed anywhere else in the world.