The Great Influenza: The Epic Story of the Deadliest Plague in History - John M. Barry (2004)
Part I. THE WARRIORS
NOTHING ABOUT the boyhood or youth of William Henry Welch suggested his future.
So it is apt that the best biography of him begins not with his childhood but with an extraordinary eightieth-birthday celebration in 1930. Friends, colleagues, and admirers gathered for the event not only in Baltimore, where he lived, but in Boston, in New York, in Washington; in Chicago, Cincinnati, and Los Angeles; in Paris, London, Geneva, Tokyo, and Peking. Telegraph and radio linked the celebrations, and their starting times were staggered to allow as much overlap as time zones made possible. The many halls were thick with scientists in many fields, including Nobel laureates, and President Herbert Hoover’s tribute to Welch at the Washington event was broadcast live over American radio networks.
The tribute was to a man who had become arguably the single most influential scientist in the world. He had served as president of the National Academy of Sciences, president of the American Association for the Advancement of Science, president of the American Medical Association, and president or dominant figure of literally dozens of other scientific groups. At a time when no government funds went to research, as both chairman of the Executive Committee of the Carnegie Institution of Washington and president—for thirty-two years—of the Board of Scientific Directors of the Rockefeller Institute for Medical Research (now Rockefeller University), he had also directed the flow of money from the two greatest philanthropic organizations in the country.
And yet Welch had been no great pioneer even in his own field of medical research—no Louis Pasteur, no Robert Koch, no Paul Ehrlich, no Theobald Smith. He had generated no brilliant insights, made no magnificent discoveries, asked no deep and original questions, and left no significant legacy in the laboratory or in scientific papers. He did little work—a reasonable judge might say he did no work—so profound as to merit even membership in, much less the presidency of, the National Academy of Sciences.
Nonetheless, these hundreds of the world’s leading scientists had measured him as coldly and objectively as they measured everything and found him worthy. They had gathered to celebrate his life, if not for his science then for what he had done for science.
In his lifetime the world had changed radically, from horse and buggy to radio, airplanes, even the first television. Coca-Cola had been invented and rapidly spread across the country before 1900, by the 1920s Woolworth’s had over fifteen hundred stores, and a technocratic makeover of America had accompanied the Progressive Age, culminating in 1930 in a White House conference on children that proclaimed the superiority of experts to parents in child raising, because “it is beyond the capacity of an individual parent to train her child to fit into the intricate, interwoven, and interdependent social and economic system we have developed.”
Welch had of course played no role in those changes. But he had played a large and direct role in an equivalent makeover of medicine and especially American medicine.
He had served first as a kind of avatar, his own experience embodying and epitomizing that of many in his generation. Yet he was no simple symbol or representative. Like an Escher drawing, his life both represented that of others and simultaneously defined the lives of those who followed him, and those who followed them, and those who followed them, down to the present.
For if he did no revolutionary science, he lived a revolutionary life. He was personality and theater; he was impresario, creator, builder. Like an actor on a live stage, his life was a performance given once, leaving its impact upon his audience, and only through them echoing in time and place. He led the movement that created the greatest scientific medical enterprise, and possibly the greatest enterprise in any of the sciences, in the world. His legacy was not objectively measurable, but it was nonetheless real. It lay in his ability to stir other men’s souls.
Welch was born in 1850 in Norfolk, Connecticut, a small town in the northern part of the state that remains even today a hilly and wooded retreat. His grandfather, great-uncle, father, and four uncles were physicians. His father also served a term in Congress and in 1857 addressed the graduates of Yale Medical School. In that speech he demonstrated a significant grasp of the latest medical developments, including a technique that would not be mentioned at Harvard until 1868 and the striking new “cell theory with its results in physiology and pathology,” a reference to the work of Rudolf Virchow, who had then published only in German-language journals. He also declared, “All positive knowledge obtained…has resulted from the accurate observation of facts.”
Yet if it seemed foreordained that Welch would become a physician, this was not the case. Years later he told the great surgeon Harvey Cushing, a protégé, that in his youth medicine had filled him with repugnance.
Perhaps part of that repugnance came from his circumstances. Welch’s mother died when he was six months old. His sister, three years older, was sent away, and his father was distant both emotionally and physically. Throughout Welch’s life he would be closer to his sister than to any other living soul; over the years their correspondence revealed what intimacies he was willing to share.
His childhood was marked by what would become a pattern throughout his life: loneliness masked by social activity. At first he sought to fit in. He was not isolated. Neighbors included an uncle and cousins his age with whom he played routinely, but he longed for greater intimacy and begged his cousins to call him “brother.” They refused. Elsewhere, too, he sought to fit in, to belong. At the age of fifteen, submitting to evangelical fervor, he formally committed himself to God.
He attended Yale where he found no conflict between his religious commitment and science. While the college had begun teaching such practical arts as engineering, it kept a measured distance from the scientific ferment of these years immediately following the Civil War, purposely setting itself up as a conservative, Congregationalist counterbalance to the Unitarian influence at Harvard. But if Welch’s intellectual interests developed only after college, his personality had already formed. Three attributes in particular stood out. Their combination would prove powerful indeed.
His intelligence did shine through, and he graduated third in his class. But the impression left on others came not from his brilliance but from his personality. He had the unusual ability to simultaneously involve himself passionately in something yet retain perspective. One student described him as “the only one who kept cool” during heated discussions, and he would carry this trait through the rest of his life.
There was something about him that made others want him to think well of them. Hazing of freshmen was brutal at the time, so brutal that a classmate was advised to keep a pistol in his room to prevent sophomores from abusing him. Yet Welch was left entirely alone. Skull and Bones, perhaps the single most secret society in the United States, which marks its members powerfully with the embrace of the establishment, inducted him, and he would remain deeply attached to Bones his entire life. Perhaps that satisfied his desire to belong. At any rate, his earlier desperation to fit in was replaced by a self-sufficiency. His roommate on parting left him an extraordinary note: “I ought to try to express my great indebtedness for the kindness which you always manifested toward me, the pure example you set me,…I feel now more deeply the truth of what I often said to others if not to you—that I was utterly unworthy of such a chum as yourself. I often pitied you, to think that you had to room with me, your inferior in ability, dignity and every noble and good quality.”
It is the kind of note that a biographer might interpret as homoerotic. Perhaps it was. At least one other man would later devote himself to Welch with what could only be called ardor. Yet for the rest of Welch’s life he also seemed somehow, in some indefinable way, to generate similar if less intense sentiments in others. He did so without effort. He charmed without effort. He inspired without effort. And he did so without his reciprocating any personal connection, much less attachment. A later age would call this “charisma.”
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.
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 protégé 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.
And no one else in the world had a better sense of what was going on in all the world’s laboratories than Billings.
He traveled to Europe to meet possible candidates for the Hopkins faculty, including established scientists of international renown. But he also sought out young men, the next generation of leaders. He had heard of Welch, heard of his potential, heard that he had exposed himself not to one or two of the great scientists but to many, heard that he seemed to know everyone in Germany, including—even before they emerged as arguably the two greatest medical scientists of the nineteenth or early twentieth century—Robert Koch and Paul Ehrlich. (In fact, when Koch, then unknown, first made his dramatic demonstration of the life cycle of anthrax, Welch was in the same laboratory.)
Billings met with Welch in an ancient Leipzig beer hall, a hall that itself belonged to myth. On the wall were murals depicting the sixteenth-century meeting of Faust and the Devil, for the meeting had supposedly occurred in that very room. Billings and Welch talked passionately of science deep into the night, while the murals endowed their words with conspiratorial irony. Billings spoke of the plans for the Hopkins: unheard-of admission standards for students, labs that filled great buildings, the most modern hospital in the world, and of course a brilliant faculty. They talked also about life, about each other’s goals. Welch knew perfectly well he was being interviewed. In response, he opened his soul.
After the dinner Billings told Francis King, president of the yet-to-be-built Johns Hopkins Hospital, that Welch “should be one of the first men to be secured, when the time came.”
That time would not come for a while. The Hopkins had begun as a graduate school only, without even any undergraduate students, although it quickly expanded to include a college. Further expansion abruptly became problematic since its endowment was chiefly in Baltimore & Ohio Railroad stock. The country had been wallowing in depression for four years when the B&O and the Pennsylvania Railroad cut wages 10 percent, sparking violent strikes by railroad workers in Maryland that soon spread to Pittsburgh, Chicago, St. Louis, and farther west. B&O stock collapsed, and the plans to open the medical school had to be put off. There were no new faculty posts at the Hopkins to fill.
So in 1877 Welch returned to New York desperate for “some opportunity” in science “and at the same time making a modest livelihood.” Failing to find one, he returned to Europe. In 1878 he was back in New York.
At no time in history had medicine been advancing so rapidly. The thousands who flocked to Europe were proof of American physicians’ intense interest in those advances. Yet in the United States neither Welch nor anyone else could support himself by either joining in that great march or teaching what had been learned.
Welch proposed to a former mentor at the College of Physicians and Surgeons that he teach a laboratory course. The school had no laboratory and wanted none. No medical school in the United States used a laboratory for instruction. The school rejected his suggestion but did offer to let Welch lecture—without salary—in pathology.
Welch turned to Bellevue, a medical school with a lesser reputation. It let him offer his course and provided three rooms for it, equipped only with empty kitchen tables. There were no microscopes, no glassware, no incubators, no instruments. Facing the empty rooms, discouraged, he wrote, “I cannot make much of a success out of the affair at present. I seem to be thrown entirely upon my own resources for equipping the laboratory and do not think that I can accomplish much.”
He was also worried. His entire compensation would come from student fees, and the three-month course was not required. He confided to his sister, “I sometimes feel rather blue when I look ahead and see that I am not going to be able to realize my aspirations in life…. There is no opportunity in this country, and it seems unlikely there ever will be…. I can teach microscopy and pathology, perhaps get some practice and make a living after a while, but that is all patchwork and the drudgery of life and what hundreds do.”
He was wrong.
In fact he would catalyze the creation of an entire generation of scientists who would transform American medicine, scientists who would confront influenza in 1918, scientists whose findings from that epidemic still echo today.