The Great Influenza

In September 1876 the most important medical event in American history happened with the foundation of Johns Hopkins University in Baltimore. The speech dedicating the school made clear its goal to make a scientific institution that would rival those of Germany and the rest of Europe. The speech did not mention God, though science is similar to religion in that science is largely about asking two questions: “What can I know?” and “How can I know it?” (14).

The history of medicine up to that point was one of error and a lack of finessed procedure. Hippocrates created the theory of the four humors, and Galen would go on to systematize them, but both theorists were wrong. Their theories were based on observations of nature and not explorations of it (14). The Renaissance saw some new discoveries and scientists, but the most important discovery before the 1800s was Edward Jenner’s discovery of the smallpox vaccine in the late 1700s. More important, though, Jenner developed a “rigorous methodology” that future scientists would replicate (20).

Prior to Jenner’s methodology, scientists tended to focus on observable facts and reason. There are several difficulties in developing medical knowledge when one only uses reason, though. First, the treatments of Galen and others seemed to work, as, for example, bleeding a patient (a common treatment for many ailments) did actually relieve some symptoms. Thus, there was no reason to look for another treatment. Second, biology does not lend itself to reason and logic. Physics is based on math, but biology is “chaos” (24). Cells exist in duplicate or sometimes have been proven useless by evolution. A good scientist could not make sense of these purely through logic. The scientific method, however, would go a long way toward fixing this incongruity of biology and the lack of logic.

In the 1800s, scientists in Paris came up with the theory of tissues and noted that diseases invaded the body rather than being the results of imbalances. Numbers systems began to be used to catalog disease and measure temperature, blood pressure, etc. This was an important development for standardizing medical treatments and research. While the 1800s saw medical advances, it also saw things stagnate, as doctors learned new theoretical things but not how to better treat patients, as little of the theoretical knowledge gained about cholera and typhoid, for example, “translated into curing or preventing disease” (28).

Medicine as a whole became less formalized, especially in the United States, where a belief in Thomsonism took hold. Thomsonism was based on the belief that medicine was so simple that literally anyone could act as a physician (29). In addition to the problem of untrained physicians, no American institutions were funding medical research, not even for those Americans who went to Germany to learn from the great experts, creating a dearth of medical knowledge and advancement. Johns Hopkins University sought to reverse that. It was successful, and by the time of World War I, American medical knowledge had surpassed that of Europe.

This chapter is mostly a biography of William Henry Welch. Welch was “no great pioneer even in his own field of medical research” (37) but was “arguably the single most influential scientist in the world” (36). He was an impresario whose true legacy was inspiring others to be great researchers and scientists.

He was born in Norfolk, Connecticut, in 1850 and witnessed many revolutionary changes in his lifetime. He learned to embrace evolution, for instance, even though it went against the religious faith of his childhood. He went to Yale, where he hoped to teach Greek. Instead, he decided to apprentice for his physician father before attending the College of Physicians and Surgeons in New York. There, he caught the attention of Francis Delafield, a professor who encouraged him to study in Europe. Welch went to Germany and met with other scientists.

Germany at the time was the center of science and medicine. Many Americans went but few were interested in studying laboratory research. Welch came away from the trip believing that German medical schools were far superior to those of the United States because they required thorough preparation from their students, had independent financing, and were supported by research from the German government and other universities (44).

The chapter ends with the creation of the medical school at John Hopkins University. In 1877 Daniel Gilman, the first president of Hopkins, sent Dr. John Shaw Billings (the creator of the world’s first medical library) to Europe to assemble the best possible medical faculty. There, Billings met with Welch in a beer hall in Leipzig and was impressed with him. He told Hopkins to hire Welch.

However, that would be put on hold. The B&O Railroad stock collapsed as part of the Panic of 1877, which made it impossible for Hopkins to find funding. Welch wanted to teach a laboratory course, but no medical school in the United States had a laboratory for teaching. He ended up at Bellevue in New York, where he worked as a pathology lecturer for scant pay but where he could teach a laboratory class (though one without equipment) (47). Welch would go on to train the team that fought the influenza virus of 1918.

Welch’s course became popular, but he did not do well financially, nor was he actually able to do much research. In Europe, though, scientists were making many medical advancements, one of the most important of which was developing the germ theory of disease. Prior to the germ theory, people believed that disease was caused by a chemical process, filth in the environment (such as the smell of feces), or a miasma (some other weather condition or wind that brought disease with it). The germ theory, which is closer to the truth, states that specific tiny organisms invade a person’s body, multiply, and cause a specific disease. This was a novel theory, as germs themselves had just been isolated, but no one really knew what they did. The German Robert Koch, however, isolated the anthrax bacteria and proved how it worked. Welch replicated Koch’s experiments and showed it to his students, many of whom were inspired by the way lab research solved a medical problem, just as Welch had been.

In 1884 Welch was offered a position at Hopkins, but his prep school roommate Frederick Dennis begged him to stay in New York. Dennis even raised money to build a lab at Bellevue, but Welch insisted on going to Baltimore. This ended their friendship, and Welch would never have a close friend (or wife or family) again, even though he remained in Baltimore for nearly 50 years.

Hopkins gave Welch enormous power. He returned to Europe to learn from Koch’s proteges and other great researchers. Then, he developed a nice laboratory at Hopkins that even other scientists used before the hospital opened in 1889 and the medical school officially opened in 1893. Welch himself became a reason students and researchers wanted to work there. Still, Welch did not do much actual research. While Welch had spent years in New York bemoaning his need to pay his bills rather than being able to do research, truth be told, he was not good at research, for “he lived upon the surface and did not root” (60). That is, he could not truly penetrate the unknowns of the scientific world, but he could ask the right questions and appreciate the answers others found. However, he had two areas of genius: “He had not only knowledge but judgment” (61), and he “inspired” all who met him (62). His students were intrigued by his mysteriousness as well as his ability to talk at length about nearly any scientific topic. Inspired by him, Welch’s medical students eventually led a “revolution” in the sciences (64).

Hopkins sought to make medical schools more rigorous. Instead of having student fees pay instructors, Hopkins itself paid faculty salaries. And, unlike existing American medical schools, the school required students to have a college degree, to be fluent in German or French, and to have a background in basic science courses. Welch worried that students would not come to the school, but they “came flocking” (64). While the school increased in prominence, most of the prominence was gained through Welch himself. Barry argues Welch had great power and applied it in three great areas: He had the power to place people in positions of influence, the power to reform medical education, and the power to direct “tens of millions of dollars into laboratory research” (68).

Private funding for lab research was the norm in Europe, and in the late 1880s it was starting to pay off. Koch and the French scientist Louis Pasteur had figured out how to immunize people from cholera and typhus. And, in December 1890, Koch’s proteges Emil Behring and Shibasaburo Kitasoto proved that serum from an animal immune to tetanus (pigeons) could cure a human patient. This was revolutionary: “Scientists had discovered a way not simply to prevent a disease. They had found a way to cure a disease. It was the first cure” (70). Welch noted the discovery, orating that it was a huge breakthrough in part because it was “entirely the result of laboratory work” (71).

Building on that work, the Americans William Park and Anna Williams (working at the New York City Board of Health) perfected a way to make a much more potent toxin than the Europeans could make; they also figured out how to mass produce a diphtheria antitoxin. Their methods are still used to mass produce medicines today.

In 1901 the second great medical program in the United States was created with the founding of the Rockefeller Institute for Medical Research in New York. Welch was offered the position to head it but declined, though he did participate in the launch as the chair of the institute and its board of scientists. Welch instead offered the head of the school to Simon Flexner, a Hopkins alum and professor. Flexner and Welch, though close colleagues, were opposites. Where Welch made Hopkins warm and intimate, Flexner made Rockefeller “sharp, edgy, cold” (75). Flexner put Rockefeller on the map by experimenting with a meningitis serum that proved quite effective. He became famous and, unlike Welch, sought more fame. Also unlike Welch, Flexner was able to ask big questions and figure out ways of answering them. Additionally, Flexner was more open to disagreement and sought conversations and even friendships with his staff.

The chapter ends with Barry noting that Hopkins and the Rockefeller Institute gave American medical science world-class status.

The Rockefeller Institute opened a hospital, the Rockefeller Institute Hospital, in 1910. While Flexner believed the hospital should be a place for scientists to test what they theorized in the lab, Rufus Cole, the hospital’s first director, thought medical doctors ought to combine research with treatment so researchers could learn from both the patient (and with the patient’s help) and the lab. The hospital, thus, created “the model of clinical research” that is still used today (82).

By the early 20th century, America was known for having advanced scientific minds, but those minds were arranged at the tops of institutions. Medical schools were slow to make changes that would allow American doctors to fill out the ranks below the heads of Hopkins and the Rockefeller Institute. But changes were starting. In 1904 the American Medical Association began to reform medical schools. Flexner himself did a report on the status and quality of the schools and concluded that 120 of more than 150 medical schools ought to be closed. His report caused a stir, especially given the changing times. In the Progressive Era Americans started to trust experts more, and they also were drawn to muckraking news stories like those written about the failing medical schools. As a result, medical schools began to change, adapting Flexner’s model—a model based on the program created at Hopkins. The result was that more doctors would become better educated and eventually help fill the ranks of medical workers in the United States, which at that point had “outstanding generals” but “no army to lead” (82). Changing the medical schools in the United States would help them create that army.

Additionally, Flexner’s report drew the attention of philanthropists who began to pour money into medical schools. The largest single donor remained the Rockefeller Foundation, which had established Flexner’s own institute, but millions of dollars went to other schools across the country. Welch also sought to create another type of school, one that focused on public health. In 1918 funds were made available to Welch to open the Johns Hopkins School of Hygiene and Public Health, but Welch was sick with influenza by the time it opened.