Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (10 page)

In 1877, Billings visited Ernst Wagner’s laboratories in Leipzig, where the fledgling pathologist William Welch was studying. That evening the two Americans met to drink beer and talk medicine at Auerbach’s Keller. Sitting in the very room where Faust was supposed to have struck his deal with Mephistopheles, the discussion ranged widely over a very long evening. Billings left with the impression that the young man might well fit into the future of Johns Hopkins, and Welch left believing that Johns Hopkins would be the future of medicine. Faust was said to have left flying on a wine barrel powered by the devil.

Seven years later, Billings initiated the series of events that resulted in identifying Welch as the philosophical and scientific heart and soul of The Johns Hopkins Hospital and School of Medicine.

William H. Welch was the son and grandson of physicians from Norfolk, Connecticut. Born in 1850, he was two years older than Halsted. Their years at Yale and the College of Physicians and Surgeons overlapped and they were acquainted, but not yet friends. Like Halsted, Welch won the Bellevue internship competition in 1875. There, he studied with Francis Delafield, one of the noted “dead house” men and a pathologist to the hospital. Delafield was renowned for entries in his little book, in which he correlated patients’ clinical diagnoses with his findings at autopsy. He was among the first to remove tissue specimen at autopsy, prepare slides, and stain them with hematoxalin dye to study the abnormal pathology under the microscope. Pathology itself, the study of disease with the naked eye or under the microscope, was a new science, and dedicated pathology laboratories did not exist. More an avocation than a recognized specialty, the study was restricted to a few interested physicians who earned extra income performing autopsies in the dead house for other doctors. The more academically driven internists performed their own autopsies as the final examination in the quest to understand the natural progression of disease. Some, like Welch, under the spell of Delafield, became fascinated with the subject. With no facilities or professors to expand their scientific education in America, interested young men traveled to Austria, Germany, and France, where pathology and histology (the microscopic study of normal tissue) laboratories were flourishing.

Welch spent the summer of 1876 in Strassburg, initially studying histology under Wilhelm Waldeyer. He became adept at using the microscope, which he had been unable to master in New York. His primary impetus for visiting Strassburg was to study pathological anatomy under F. D. von Recklinghausen. Von Recklinghausen was the first to identify the leukocyte, the infection-fighting white blood cell, and he described a condition called neurofibromatosis, which bears his name. He was a man of wide interests and towering intelligence, and was overly confident of his knowledge and judgment. Von
Recklinghausen was an early master of microscopic pathology, but he vehemently resisted all evidence for the bacterial basis of disease. He was particularly vocal about Koch’s identification of the tubercle bacillus as the cause of tuberculosis, claiming it was no more reasonable to come to this conclusion than to ascribe the piles of horse manure on the Viennese streets to sparrows. Still, despite this major lapse, his contributions were significant, and he had much to teach. But von Recklinghausen accepted only students with strong microscope skills, and initially Welch did not qualify.

In September, Welch moved from Strassburg to Leipzig, where he studied with the physiologist Carl Ludwig and the pathologist Ernst Wagner, and where his first encounter with Billings took place. Welch was acutely aware of the plans afoot at Johns Hopkins and eager to learn all he could. Though he had not met Billings before, this was not his first brush with the new institution. The previous summer his closest friend, Frederic Dennis, had encountered Johns Hopkins University president Daniel Coit Gilman during an Atlantic crossing. Dennis openly promoted Welch to Gilman, but was met with enough courteous disinterest for Welch to later say it was “folly for me to aspire to attaining such a position when there are so many distinguished men in the country who have already acquired great reputations as pathologists.”

In April he traveled to Breslau, where Julius Cohnheim was conducting important work in experimental pathology and bacteriology. One of Cohnheim’s many contributions was explaining the nature of the reaction that created pus. The thick, yellow-green substance was obviously associated with infection, but little more than that was known. Cohnheim found it was composed of white blood cells, leukocytes, and cellular debris. The process, he found, was set in motion by infection, to which the body responded by depositing leukocytes in the area and creating pus, thus clearing up a mystery that had confounded physicians for centuries. Noting the predictable presence of
white blood cells in inflammation, he categorically stated, “no blood vessels, no inflammation.”

Welch learned a great deal from Cohnheim, particularly the elements of bacteriology, a science unheard of at home. It was in Cohnheim’s laboratory that Welch first met Robert Koch. Welch also worked closely with Cohnheim in experimental pathology. In the most celebrated of these adventures he was assigned to study the collection of fluid in the lungs, known as pulmonary edema, which was due to more blood being pumped into the lungs than was being pumped out, leaving the fluid behind as pulmonary edema, the essence of heart failure. Blood is delivered to the lungs from the right side of the heart, via the pulmonary artery, aerated in the lungs, and returned to the left side of the heart by the pulmonary vein, and then pumped into circulation by the left ventricle. Welch opened the chests of rabbits and dogs, and immobilized the left ventricle by squeezing that portion of the beating heart between his fingers. The left ventricle stopped pumping, blood backed up, and pulmonary edema resulted. This simple exercise illustrated the nature of pulmonary edema and was a major career milestone for Welch.

When he returned to von Recklinghausen’s laboratory it was as a seasoned scientist adept at the use of the microscope. Much of his time was spent confirming Cohnheim’s theory of inflammation against the intuition of his supervising professor.

RETURNING TO NEW YORK
full of enthusiasm for his new profession, Welch convinced the authorities at Bellevue of the importance of instituting an independent department of pathology. With three small rooms, a $25 furniture allowance, and a few microscopes, he opened the first pathology laboratory in the United States.

In addition to pathological anatomy and general pathology, Welch taught the first laboratory course in the country. His course was enormously popular with the students at Bellevue Hospital Medical
College, and soon medical students from all three medical schools in the city attended his sessions.
¹

The College of Physicians and Surgeons, where Welch had been rebuffed when he presented the idea for a pathology laboratory, soon realized their blunder and tried to win their star alumnus back to the fold. Welch resisted their offers, helped in their search for a substitute, and continued on with his work at Bellevue. To earn a living, he performed autopsies, continued to see private patients, and served as a lecturer at Halsted’s quiz, where he welcomed interested students to his laboratory. He was much revered for his “hands on” method of teaching, relying increasingly on laboratory demonstration and discussion.

Billings had followed Welch’s progress. He often traveled to New York City and sat in on Welch’s classes whenever possible. He attended a session on March 1, 1884, that Welch remembered clearly, not merely for Billings’s presence but because much of the day’s discussions centered around syphilitic lesions of the testicles. In the Victorian manner of the day, even physicians were uneasy with frank discussion of sex-related topics.

AFTER THE SESSION
, Billings quizzed Welch on his goals and how his methods could fit into a new university setting. Both men saw an opportunity, and the discussions advanced further when Billings returned to New York a week later. The next day, Welch traveled to Baltimore to meet with President Gilman and was offered the professorship in pathology.

Returning to New York, he discussed the offer with his medical friends, including Halsted, McBride, and particularly his friend and housemate Frederic Dennis. All counseled him against moving.
Dennis, who seemed to take the defection personally, set in motion a counter-offer from Bellevue. The Bellevue proposal was built around a $50,000 pledge from Andrew Carnegie to build a new laboratory for Welch on a site for which the trustees hurriedly appropriated another $45,000.
²
The general feeling was that exchanging an unlimited future in New York for a position based on the German laboratory model at a new, unknown university, and in Baltimore at that, was pure folly. But Welch believed in the vision of Gilman and Billings, and three weeks later he accepted the offer. At a going-away party in New York his friends, by now resigned to losing him, offered the following thought: “You may become a connoisseur of terrapin and Madeira, but as a pathologist, good-bye.”

The search committee at Bellevue believed they had secured an adequate replacement for Welch in a distinguished German pathologist with a long, black beard named Otto Lubarsch. At one of numerous farewell dinners for Welch, Halsted was seated opposite Lubarsch and they were eating corn on the cob. The German remarked to Halsted, “I wish I had a picture of you eating corn on the cob.”

Halsted’s retort was intentionally spoken quickly and wasn’t translated into German: “I wish I had a picture of you, Dr. Lubarsch, combing your beard with your fork.”

A good deal of laughter followed, and Lubarsch never learned what Halsted had said.

Despite all temptation to stay in New York, it was the right position at the right time, and Welch would become the prime mover in the American medical revolution—the first professor named to The Johns Hopkins medical school, its first dean, and later, the founder of the first school of public health in America. He was instrumental in choosing
the core medical faculty of the fledgling institution, free to pursue his research as he wished, and with an annual salary of $4,000, he would no longer need to practice general medicine to supplement his income.

With the encouragement of the trustees, Welch returned to Europe to keep abreast of recent medical progress. Much had transpired in the laboratory sciences in the eight years since his last visit, and virtually all of it in Western Europe. Bacteriology had taken giant leaps forward in Koch’s labs with the startling cultivation of the tubercle bacillus and the isolation of the cholera bacillus. The focus of investigation of disease abruptly shifted from the pathology laboratory to the bacteriology laboratory. Those who did not run for the speeding train would be left behind.

In 1882, the noted physician and skeptic Alfred L. Loomis said, “People say there are bacteria in the air, but I cannot see them.” When the comment was passed on to Welch, he replied, “That’s too bad. Loomis is such a nice man.”

Such was the dynamic state of affairs. In a mere 20 years, the height of disease awareness and control had passed from fresh air and isolation to the study of bacteriology and the promise of control of bacterial disease.

Welch spent a year working in the laboratories of several of Koch’s distinguished students and a month with the master himself. Before returning to America and his new position, Welch visited Louis Pasteur in Paris. Though he did not have the opportunity to actually study with Pasteur, it was a significant moment for him. Later, Welch proclaimed, “I shall never forget the circumstances of my visit when he put aside his test-tubes and showed me around his laboratory.”
³
This
was early 1885, and Pasteur was already an international celebrity. He had already formulated his germ theory of disease; pasteurization; a vaccine against anthrax, the great killer of sheep; and another against cholera in chickens; and had been working on the rabies vaccine for dogs. Pasteur and Koch had been anointed as the great microbiologists and leaders of the new world of laboratory science, and Welch had become part of the inner circle. And so the stage was set for the new professor to install himself in a new institution with the lofty mission of transforming and elevating American medicine. The reality was nothing so impressive as the promise.

1 There were three medical schools in Manhattan at the time: Physicians and Surgeons, associated with Columbia University; Bellevue; and New York University. The latter two would combine in 1898.

2 According to Donald Fleming, in
William Welch and the Rise of Modern Medicine
, the Bellevue offer required Welch to continue outside work to meet his personal financial needs. When the offer was declined he became estranged from the irate Dennis.

3 Fleming states that Welch was passing through Paris in May of 1885, and did not stop to see Pasteur, saying, “There is nothing special of a scientific nature to lead me there.” This is at odds with the quote above, from a stenographer’s report of a speech given by Welch at the New York Academy of Medicine in 1930, on the occasion of his 80th birthday.