The Great Influenza: The Epic Story of the Deadliest Plague in History - John M. Barry (2004)

Part I. THE WARRIORS

Chapter 4

AMERICAN MEDICAL EDUCATION needed a revolution. When the Hopkins medical school did at last open in 1893, most American medical schools had still not established any affiliation with either a teaching hospital or a university, most faculty salaries were still paid by student fees, and students still often graduated without ever touching a patient. Nor did Welch exaggerate when he said that, other than the Hopkins, no American “medical school requires for admission knowledge approaching that necessary for entrance into the freshman class of a respectable college…. [S]ome require no evidence of preliminary education whatever.”

By contrast, the Hopkins itself, not student fees, paid faculty salaries, and it required medical students to have not only a college degree but fluency in French and German and a background of science courses. Indeed, these requirements were so rigorous that Welch and Osler worried that the Hopkins would attract no students.

But students did come. They came flocking. Motivated and self-selected, they flocked to a school where students did not simply listen to lectures and take notes. They trooped through hospital rooms and examined patients, made diagnoses, heard the crepitant rales of a diseased lung, felt the alien and inhuman marble texture of a tumor. They performed autopsies, conducted laboratory experiments, and they explored: they explored organs with scalpels, nerves and muscles with electric currents, the invisible with microscopes.

Those at the Hopkins were hardly alone in seeking reform. The need had been recognized for decades. Leaders at a few other medical schools—especially Vaughan at Michigan, William Pepper Jr. at the University of Pennsylvania, William Councilman (Welch’s assistant until 1892) at Harvard, others at Northwestern, at New York’s College of Physicians and Surgeons, at Tulane—were advancing the same values that Welch and the Hopkins were, and they were doing so with equal urgency. The American Medical Association had pushed reform since its inception, and individual physicians sought better training as well; the thousands who studied in Europe proved that.

But relatively little change had occurred in the bulk of medical schools, and even at Harvard, Penn, and elsewhere, change had often come only after violent infighting, with continual rear-guard actions fought by reluctant faculty. William Pepper had made Penn good enough that the Hopkins raided its faculty, yet after sixteen years of fighting he spoke not of achievement but of “long and painful controversy.”

Even where change had occurred, a gap between the Hopkins and elsewhere still remained. Harvey Cushing trained at Harvard and came to Baltimore as Halsted’s assistant. Nothing in Boston had prepared him for the difference. He found the Hopkins “strange…. The talk was of pathology and bacteriology of which I knew so little that much of my time the first few months was passed alone at night in the room devoted to surgical pathology looking at specimens with a German textbook at hand.”

The Hopkins did not limit its influence to medicine. Half a century after it opened, of 1,000 men starred in the 1926 edition of American Men of Science, 243 had Hopkins degrees; second was Harvard with 190. Even Harvard’s Charles Eliot conceded that the Harvard Graduate School “started feebly” and “did not thrive, until the example of Johns Hopkins…. And what was true of Harvard was true of every other university in the land.”

But in medicine the Hopkins made its chief mark. As early as 1900 Welch noted that at the Harvard-run Boston City Hospital “they have only Hopkins men there, and want no others.” By 1913 a European acknowledged that research in the United States in his field rivaled that done in any European country and gave credit “to one man—Franklin P. Mall at the Johns Hopkins University.” Of the first four American Nobel laureates in physiology or medicine, the Hopkins had trained three, while the fourth had received his highest degree in Europe.

In patient care its impact was similar. As with all medical schools, most of its graduates became practicing physicians. And within thirty-five years after opening, more than 10 percent of all Hopkins graduates had become full professors, with many younger graduates on track to do so. Many of these men transformed entire medical schools at other universities—people like Councilman and Cushing at Harvard, William MacCallum at Columbia, Eugene Opie at Washington University, Milton Winternitz at Yale, George Whipple (a Nobel laureate) at Rochester.

Howard Kelly, for all his strangeness—a fundamentalist who preached to prostitutes on street corners of whom one student said, “The only interest he manifested in my classmates was whether they were saved”—revolutionized gynecology and pioneered radiation therapy. And no individual had more impact on patient care than William Halsted, who introduced rubber gloves into surgery, who insisted upon preparation and thought prior to every step. He took such care that William Mayo once joked that his patients were healed by the time he finished, but the Mayo brothers also stated that they owed him a tremendous debt. So did all of American surgery: of seventy-two surgeons who served as residents or assistant residents under him, fifty-three became professors.

In the meantime, Henry James described the Hopkins as a place where, despite “the immensities of pain” one thought of “fine poetry…and the high beauty of applied science…. Grim human alignments became, in their cool vistas, delicate symphonies in white…. Doctors ruled, for me, so gently, the whole still concert.”

Behind this still concert lay Welch, the impresario. By the first decade of the twentieth century, Welch had become the glue that cemented together the entire American medical establishment. His own person became a central clearinghouse of scientific medicine. Indeed, he became the central clearinghouse. As founding editor of the Journal of Experimental Medicine, the first and most important American research journal, he read submissions that made him familiar with every promising new idea and young investigator in the country.

He became a national figure, first within the profession, then within science, then in the larger world, serving as president or chairman of nineteen different major scientific organizations, including the American Medical Association, the American Association for the Advancement of Science, and the National Academy of Sciences. Stanford president Ray Wilbur neither flattered nor overstated when in 1911 he wrote him, “Not to turn to you for information in regard to the best men to fill vacancies in our medical school would be to violate all the best precedents of American medical education.” Welch had, said one colleague, “the power to transform men’s lives almost by the flick of a wrist.”

But his use of power in placing people in positions—or for that matter using it for such things as defeating antivivisection legislation, which would have prevented using animals as experimental models and thus crippled medical research—was trivial in its impact compared to his application of power to two other areas.

One area involved completing the reform of all medical education. The example of the Hopkins had forced more and faster reforms at the best schools. But too many medical schools remained almost entirely unaffected by the Hopkins example. Those schools would learn a harsh lesson, and soon.

Welch’s second interest involved starting and directing the flow of tens of millions of dollars into laboratory research.

In Europe governments, universities, and wealthy donors helped support medical research. In the United States, no government, institution, or philanthropist even began to approach a similar level of support. As the Hopkins medical school was opening, American theological schools enjoyed endowments of $18 million, while medical school endowments totaled $500,000. The difference in financial support as well as educational systems largely explained why Europeans had achieved the bulk of medical advances.

Those advances had been extraordinary, for medicine in the late nineteenth and early twentieth centuries was experiencing arguably its most golden age—including anytime since. The germ theory had opened the door to that progress. Finally investigators began using that door.

In 1880 Pasteur—who observed, “Chance favors the prepared mind”—was trying to prove he had isolated the cause of chicken cholera. He inoculated healthy chickens with the bacteria. They died. Then chance intervened. He had put aside a virulent culture for several days, then used it to inoculate more chickens. They lived. More significantly, those same chickens survived when exposed to other virulent cultures. Crediting Jenner for the idea, he tried to weaken, or “attenuate,” his word, cultures and use them to immunize birds against lethal bacteria. He succeeded.

He began applying these techniques to other infections. With anthrax he was not the first to experiment with weakened cultures, but his work was both definitive and very public. While a gallery of newspapermen and officials watched, he inoculated cattle, then exposed them to anthrax; the inoculuated ones lived, while the controls died. Three years later 3.3 million sheep and 438,000 cattle were vaccinated against anthrax in France. He also saved the life of a boy bitten by a rabid dog by giving him gradually stronger injections of fluid containing the pathogen. The next year, 1886, an international fund-raising drive created the Pasteur Institute. Almost immediately the German goverment funded research institutes for Koch and a few other outstanding investigators, and research institutes were founded in Russia, Japan, and Britain.

Meanwhile, public health measures were containing cholera and typhoid, and in Germany, Richard Pfeiffer, Koch’s greatest disciple, and Wilhelm Kolle immunized two human volunteers with heat-killed typhoid bacilli. In Britain Sir Almroth Wright advanced upon this work and developed a vaccine against typhoid.

All these advances prevented infectious disease. But no physician could yet cure a patient who was dying of one. That was about to change.

One of the deadliest of childhood diseases was diphtheria. Usually it killed by choking its victims to death—by generating a membrane that closed the breathing passages. In Spain the disease was called el garrotillo, “the strangler.”

In 1884, German scientist Friedrich Loeffler isolated the diphtheria bacillus from throats of patients, grew it on a special medium (laboratories today still use “Loeffler’s serum slope” to grow the bacteria from suspected cases), and began careful experiments in animals that took several years. His work suggested that the bacteria themselves did not kill; the danger came from a toxin, a poison, that the bacteria excreted.

In 1889 Pasteur’s protégés Émile Roux and Alexandre Yersin grew broth thick with diphtheria bacteria and used compressed air to force the broth through a filter of unglazed porcelain. (The filter was designed by Charles Chamberland, a physicist working with Pasteur; though only a tool, the filter itself would prove to be immensely important.) No bacteria or solids could pass through the porcelain. Only liquid could. They then sterilized this liquid. It still killed. That proved that a soluble toxin did the killing.

Meanwhile, an American physiologist named Henry Sewall at the University of Michigan was studying snake venom, which chemically resembles many bacterial toxins. In 1887 he immunized pigeons against rattlesnake poison.

If pigeons could be immunized, humans likely could be too. As they had with cholera, French and German scientists raced each other, building upon Sewall’s and each other’s advances, studying both diphtheria and tetanus. In December 1890, Koch protégés Emil Behring, who would later win the Nobel Prize, and Shibasaburo Kitasato showed that serum—the fluid left after all solids are removed from blood—drawn from one animal made immune to tetanus could be injected into a different animal and protect it from disease.

The paper shook the scientific world. Work on diphtheria at a level of intensity heretofore unknown proceeded in laboratories. Over the Christmas holiday in 1891 in Berlin, the first attempt to cure a person of diphtheria was made. It succeeded.

Scientists had discovered a way not simply to prevent a disease. They had found a way to cure disease. It was the first cure.

Over the next few years work continued. In 1894, Émile Roux of the Pasteur Institute read his paper summarizing experiments with diphtheria antitoxin before the International Congress on Hygiene in Budapest.

Many of the greatest scientists in the world sat in the audience. As Roux finished, these men, each renowned in his own right, began to clap, then stood on their seats, their hands making thunderous sounds, their voices shouting applause in half a dozen languages, their hats thrown to the ceiling. Welch then reported American experiences confirming the work of both the French and Germans. And each delegate returned to his home with a bottle of this marvelous curative agent in his possession.

In the keynote speech at the next meeting of the Association of American Physicians, an association created to foster scientific medicine, Welch said, “The discovery of the healing serum is entirely the result of laboratory work. In no sense was the discovery an accidental one. Every step leading to it can be traced, and every step was taken with a definite purpose and to solve a definite problem. These studies and resulting discoveries mark an epoch in the history of medicine.”

His comment was a declaration not of war but of victory. Scientific medicine had developed technologies that could both prevent and cure diseases that had previously killed in huge numbers, and killed gruesomely.

And if French and German scientists had found the antitoxin, Americans William Park, chief of the laboratory division of the New York City Health Department, and Anna Williams, his deputy and perhaps the leading female bacteriologist in this country—possibly anywhere—transformed it into something that every doctor in the developed world had easy access to. They were an odd couple: he with an original and creative mind but staid, even stolid, extremely precise and well organized; she, wild, risk taking, intensely curious, a woman who took new inventions apart to see how they worked. They complemented each other perfectly.

In 1894 they discovered a way to make a toxin five hundred times as potent as that used by Europeans. This lethality made a far more efficient stimulator of antitoxin and slashed the cost to one-tenth what it had been. Park then broke the production process into tasks that ordinary workers, not scientists, could perform and turned part of the laboratory into a virtual factory. It soon became by far the cheapest, most efficient, and reliable producer of the antitoxin in the world. Diphtheria-antitoxin production today is still based on their methods.

The lab distributed it free in New York and sold it elsewhere. Park used the money to subsidize basic research and make the city laboratories into arguably the best medical research institution in the country at the time. Its annual reports soon contained, according to one historian of medicine, “a body of research of which any Institute in the world would be proud.”

And the antitoxin suddenly became available around the world. Diphtheria fatality rates quickly fell by almost two-thirds, and country doctors began to perform miracles. It was only the first miracle of what promised to be many.

As the use of this antitoxin was becoming widespread, Frederick Gates, an intellectually curious Baptist minister who had a gift for seeing opportunities to exploit and was an assistant to John D. Rockefeller, picked up a medical textbook written by William Osler called The Principles and Practice of Medicine, a textbook that would go through many editions and find a readership among both physicians and informed laymen. In it Osler traced the evolution of medical ideas, explored controversies, and, most significantly, admitted uncertainty and ignorance.

Gates had started working for Rockefeller as a philanthropic adviser, but nothing limited him to eleemosynary concerns. He organized several Rockefeller business ventures, pulling, for example, a $50 million profit out of the Mesabi iron range in Minnesota. Rockefeller himself used a homeopathic physician, and Gates had also read The New Testament of Homeopathic Medicine, written by Samuel Hahnemann, founder of the movement. Gates decided that Hahnemann “must have been, to speak charitably, little less than lunatic.”

Osler’s book impressed Gates in very different ways for it presented a paradox. First, it showed that medical science had immense promise. But it also showed that that promise was far from being realized. “It became clear to me that medicine could hardly hope to become a science,” Gates explained, “until…qualified men could give themselves to uninterrupted study and investigation, on ample salary, entirely independent of practice…. Here was an opportunity, to me the greatest, which the world could afford, for Mr. Rockefeller to become a pioneer.”

Meanwhile, John D. Rockefeller Jr. talked about the idea of funding medical research with two prominent physicians, L. Emmett Holt and Christian Herter, both former students of Welch. Both eagerly endorsed the idea.

On January 2, 1901, Rockefeller Sr.’s grandchild John Rockefeller McCormick, also the grandchild of Cyrus McCormick, died of scarlet fever in Chicago.

Later that year the Rockefeller Institute for Medical Research was incorporated. It would change everything.

Welch declined the offer to head the new institute but he assumed all the duties of launching it, chairing both the institute board itself and its board of scientific directors. That scientific board included Welch’s old friend T. Mitchell Prudden, Holt, Herter, two other prominent scientists who had been students of Welch, and Harvard’s Theobald Smith. Smith, one of the leading bacteriologists in the world, had been Welch’s first choice for director but had declined because he had done most of his research on animal diseases—for example, developing a vaccine to prevent hog cholera—and thought it would be more politic to have a director who had investigated human disease.

So Welch offered the position to Simon Flexner, who had left the Hopkins to take a highly prestigious professorship at the University of Pennsylvania’s medical school. (Flexner had rejected an offer of an $8,000 salary from Cornell to take the position at Penn at $5,000.) But his appointment had been contentious, and at the meeting where he was chosen one faculty member said that accepting the Jew as a professor did not involve accepting him as a man. Daily he fought with other faculty over both personal and substantive issues.

Flexner accepted Welch’s offer, and a raise. But the launching of the institute remained firmly under Welch’s control. In this, Flexner said, Welch “accepted no assistance, not even clerical. Every detail was attended to with his own hand, every letter handwritten.”

The European research institutes were either dedicated to infectious disease or designed to allow freedom to individuals such as Pasteur, Koch, and Ehrlich. The Rockefeller Institute saw medicine itself as its field; from its earliest existence, scientists there studied infectious disease, but they also laid the groundwork in surgery for organ transplants, established links between viruses and cancer, and developed a method to store blood.

At first the institute gave modest grants to scientists elsewhere, but in 1903 it opened its own laboratory, in 1910 its own hospital. And Flexner began to come into his own.

There was a roughness about Simon Flexner, something left over from the streets, from his growing up the black sheep in an immigrant Jewish family in Louisville, Kentucky. Older and younger brothers were brilliant students, but he quit school in the sixth grade. Sullen and flirting with delinquency, he was fired even by an uncle from a menial job in a photography studio. Next he worked for a dry-goods dealer who defrauded people and fled the city. A druggist fired him. His father gave him a tour of the city jail to try to frighten him into obedience, then arranged a plumbing apprenticeship, but the plumber balked when Simon’s old principal warned him “not to have anything to do with Simon Flexner.”

At the age of nineteen Flexner got another job with a druggist, washing bottles. The shop had a microscope and the druggist forbade him to touch it. He ignored the order. Flexner hated any kind of tedium, and taking orders. What the microscope showed him was not at all tedious.

Abruptly his mind engaged. He was fascinated. He began making sudden impossible leaps. In a single year he finished a two-year program at the Louisville College of Pharmacy and won the gold medal for best student. He began working for his older brother Jacob, another druggist who also had a microscope; now Simon did not have sneak to use it. Simultaneously he went to a medical school—at night. Flexner later recalled, “I never made a physical examination. I never heard a heart or lung sound.”

But he did get an M.D. His younger brother Abraham had graduated from the Hopkins, and Simon sent some of his microscopic observations to Welch. Soon Simon was studying at the Hopkins himself.

Welch took to him though they were opposites. Flexner was small and wiry, almost wizened, and no one ever called him charming. He had an edgy insecurity and said, “I have never been educated in any branch of learning. There are great gaps in my knowledge.” To fill the gaps, he read. “He read,” his brother Abraham said, “as he ate.” He devoured books, read everything, read omnivorously, from English literature to Huxley and Darwin. He felt he had to learn. His insecurities never fully left him. He talked of “sleepless nights and days of acute fear…a maddening nervousness which prevented me from having a quiet moment.”

Yet others recognized in him extraordinary possibilities. Welch arranged a fellowship for him in Germany, and four years later he became professor of pathology at the Hopkins. Often he went into the field: to a mining town to study meningitis, to the Philippines to study dysentery, to Hong Kong to study plague. Nobel laureate Peyton Rous later called Flexner’s scientific papers “a museum in print, only they stir with life; for he experimented as well as described.”

He never lost his street toughness but his sharp hard edges did become rounded. He married a woman who was herself extraordinary enough to captivate Bertrand Russell (sixty letters from him were in her papers) and whose sister was a founder of Bryn Mawr. The famed jurist Learned Hand became a close friend. And he left his mark on the Rockefeller Institute.

Emerson said that an institution is the lengthened shadow of one man, and the institute did reflect Simon Flexner. Raymond Fosdick, later president of the Rockefeller Foundation, talked of the “steely precision of his reason. His mind was like a searchlight that could be turned at will on any question that came before him.” A Rockefeller researcher said he had “a logic far beyond that of most men, final as a knife.”

But in place of the comfort and monastic purpose and intimacy that Welch gave the Hopkins, Flexner made Rockefeller sharp, edgy, cold. Once, when the usefulness ended of horses that had been immunized against a disease, then bled over and over to produce antiserum, he never considered turning them out to pasture; he considered only either selling them for slaughter “to manufacturers or they can be bled further, with the idea of sacrificing them”—bleeding them to death for a final harvest of serum. He could dismiss a person as easily, ridding the institute of what he termed “unoriginal” men as soon as he made that determination. The room most feared in the institute was Flexner’s office. He could be brutal there, and several prominent scientists were afraid of him. Even at Flexner’s memorial service, a Nobel laureate said, “Individuals were as nothing to Dr. Flexner compared with the welfare of the institute.”

He sought attention for the institute from the press and credit from the scientific community. His own work created controversy. Shortly after the Rockefeller Institute was established, a meningitis epidemic struck the eastern United States. Desperate measures were used to fight the infection. Diphtheria antitoxin was tried, and some physicians even tried the ancient practice of bleeding patients. At the Hopkins, Cushing tried draining pus-filled fluid from the spinal canal.

At the Rockefeller Institute, the meningitis epidemic seemed a particular challenge. Rockefeller and Gates wanted results. Flexner wanted to produce them.

Ten years earlier William Park, who had perfected diphtheria antitoxin, had developed a serum against meningococci. In every laboratory test his serum had worked. But it had had no effect on people. Now two Germans developed a similar serum, but they injected it directly into the spinal column instead of into veins or muscle. Normally the mortality rate from the disease was 80 percent. In 102 patients they cut the mortality to 67 percent, suggestive but not a statistically significant improvement.

Still, Flexner’s instincts told him it meant something. He repeated the German experiments. His patients died at a 75 percent rate. Instead of discarding the approach, however, he persisted; he began a long series of experiments, both in the laboratory, to improve the serum’s potency, and physiologically, searching for the best way to administer it to monkeys. After three years of work, he settled upon the method: first, to insert a needle intrathecally—under a thin membrane lining the spinal cord—and withdraw 50 ccs of spinal fluid, and then to inject 30 ccs of serum. (Unless fluid was withdrawn first, the injection could increase pressure and cause paralysis.) It worked. In 712 people the mortality rate fell to 31.4 percent.

Physicians from Boston, San Francisco, Nashville—all confirmed the work, with one noting, “Remarkable results were obtained in the use of this serum by the country practitioners.”

Not all accepted Flexner’s role. Later, in a bacteriology textbook, Park implied that Flexner had contributed little to the development of the serum. Flexner responded with an angry visit to Park’s lab; a shouting matching ensued. There would be further disputes between the two, public enough that newspapers reported on one.

Ultimately Flexner cut the death rate for patients infected by the meningococcus, the most common cause of bacterial meningitis, to 18 percent. According to a recent New England Journal of Medicine study, today with antibiotics patients at Massachusetts General Hospital, one of the best hospitals in the world, suffering from bacterial meningitis have a mortality rate of 25 percent.

He and the institute received massive amounts of publicity. He liked it and wanted more. So did Gates and Rockefeller. In the first decade of the institute especially, whenever someone there seemed on the edge of something exciting, Flexner hovered about. His constant attention seemed to demand results, and he routinely urged investigators to publish, writing, for example, “In view of the rapidity with which publications are appearing from Belgium and France, I advise the publication of your present results. Please see me about this promptly.”

The pressure did not all come from Flexner. It simply flowed down through him. At a 1914 dinner Gates declared, “Who has not felt the throbbing desire to be useful to the whole wide world? The discoveries of this institute have already reached the depths of Africa with their healing ministrations…. You announce a discovery here. Before night your discovery will be flashed around the world. In 30 days it will be in every medical college on earth.”

The result was a publicity machine. Highly respected investigators mocked the institute for, said one who himself spent time there, “frequent ballyhoo of unimportant stuff as the work of genius” because of “administrators and directors impelled by the desire for institutional advertising.”

Yet Flexner also had a large vision. In his own work, he had what Welch lacked: the ability to ask a large question and frame it in ways that made answering it achievable. And when he judged an investigator original, an asset to the institute, he gave his full support. He did so with Nobel laureates Alexis Carrel and Karl Landsteiner, both of whose work was recognized early, but he also gave freedom and support to young investigators who had not yet made their mark. Peyton Rous, whose undergraduate and medical degrees both came from the Hopkins, would win the Nobel Prize for his discovery that a virus could cause cancer. He made that finding in 1911. The prize did not come until 1966. Initially the scientific community mocked him; it took that long for his work first to be confirmed, then appreciated. Yet Flexner always stood by him. Thomas Rivers, a Hopkins-trained scientist at Rockefeller who defined the difference between viruses and bacteria, recalled, “I am not saying Flexner wasn’t tough or couldn’t be mean—he could, believe me—but he also was tender with people.”

Even in a formal report to the board of scientific directors, thinking of Rous perhaps, or perhaps Paul Lewis, an extraordinarily promising young scientist working directly with Flexner, Flexner said, “The ablest men are often the most diffident and self-deprecatory. They require in many cases to be reassured and made to believe in themselves.” When another scientist Flexner had faith in wanted to switch fields, Flexner told him, “It will take two years for you to find your way. I won’t expect anything from you until after that.”

And finally Flexner believed in openness. He welcomed disagreement, expected friction and interaction, wanted the institute to become a living thing. The lunchroom was as important to Flexner as the laboratory. There colleagues working in different areas exchanged ideas. “Rous was a brilliant conversationalist, Jacques Loeb, Carrel,” recalled Michael Heidelberger, then a junior investigator. Although Rous and Carrel won the Nobel Prize, Loeb may have been the most provocative. “These were really remarkable sessions sometimes. They were a great inspiration.”

Each Friday especially mattered; investigators routinely presented their most recent work in a casual setting, and colleagues made comments, suggested experiments, added different contexts. It was a place of excitement, of near holiness, even though some men—Karl Landsteiner, for instance, another Nobel laureate—almost never made presentations. Flexner actively sought out individualists who did not fit in elsewhere, whether they be loners or prima donnas. The mix was what mattered. Flexner, Rous said, made the institute “an organism, not an establishment.”

And Flexner’s impact, like Welch’s, was extending far beyond anything he did personally in the laboratory, or for that matter, in the Rockefeller Institute itself.

Even before the institute had exerted wide influence, American medical science was attaining world class. In 1908 the International Congress on Tuberculosis was held in Washington. Robert Koch came from Germany, great and imperious, prepared to pass judgment and issue decrees.

At a meeting of the section on pathology and bacteriology, which Welch headed, Park read a paper stating that “it is now absolutely established that quite a number of children have contracted fatal generalized tuberculosis from bacilli” in cow’s milk. Koch insisted Park was wrong, that no evidence supported the idea that cattle gave tuberculosis to man. Theobald Smith then rose and supported Park. Arguments broke out all over the room. But the congress as a whole was convinced; a few days later, it passed a resolution calling for preventive measures against the spread of tuberculosis from cattle to man. Koch snapped, “Gentlemen, you may pass your resolutions, but posterity will decide!”

One delegate noted, “Dr. Koch isolated the tubercle bacillus; today, science isolated Dr. Koch.”

Science is not democratic. Votes do not matter. Yet this vote marked the coming of age of American medicine. It was by no means due solely to the Hopkins. Neither Park nor Smith had trained or taught there. But the Hopkins and the Rockefeller Institute were about to fit two more pieces into place that would give American medicine a true claim to scientific leadership.