Every one of the "Big Four," as they are known at Hopkins, was a character, a larger-than-life personality: pathologist William Henry Welch, a stout bachelor whose favorite pastime was a week of swimming, carnival rides and five-dessert dinners in Atlantic City; surgeon William Stewart Halsted, whose severity with students masked an almost debilitating shyness; internist William Osler, king of pranks; and gynecologist Howard Kelly, snake collector and evangelical saver of souls.
As Hopkins' most famous medical school professors, they sat in John Singer Sargent's London studio in 1905 for a portrait that now hangs in the Welch Medical Library. (Lore has it that much of Halsted's figure was painted in disappearing pigment, so disgusted was Sargent with Halsted's strident objection to having blue shadows painted under his eyes. Halsted does, in fact, appear a bit fuzzier than his colleagues, but curators and art experts insist that is only because Sargent painted him farther in the background, and used a thinner wash, for perspective.) Each of the doctors, in his own way, had a profound and lasting influence on American medical education and research.
Welch (1850-1934) joined the faculty first. He came by a necessarily tortuous route, because the last thing he had wanted as a youth was to follow in his country-doctor father's footsteps and take up medicine. The sight of blood, he said, had always made his knees weak. From age 13 he yearned to teach classics, preferably at Yale, where he eventually went to college. No job awaited him after graduation, however, and, at a loss for what else to do, he enrolled at the College of Physicians and Surgeons in New York, to the delight of his father, who expected they might practice together when Welch graduated. The New York college was then considered one of the best medical schools in the country, even though its only entrance requirement was that an applicant be able to read and write. Welch, always a diligent student but a lifelong procrastinator, found the program so amazingly simple that he didn't have to study for the final, most critical test.
"To tell the truth," he admitted to his sister Emma, "it was the easiest examination I ever entered since leaving boarding school."
Such was the sorry, undemanding state of American medical education in the mid-19th century that Welch would overturn.
Upon graduation, Welch put off unwelcome talk of joining his father in Connecticut by sailing for Germany to train in pathology and bacteriology. Then came a dreary teaching job at Bellevue College in New York, where extravagant promises of a hefty research budget and a lab turned out to mean $25 and three small rooms furnished with kitchen tables. A popular intellectual who enjoyed New York's nightlife with his many friends, Welch made the best of it, combing upstate marshes for frogs for his students to use as pathology specimens. With a boxful of croaking creatures in tow, he would ride the train back to New York City and, not wanting to be found out, make a showy pretense of being distracted by all the noise from reading his newspaper.
"I appeared to be as ignorant and much astonished as the other occupants of the sleeping car," Welch wrote.
Welch had high hopes that organizers of the proposed Hopkins medical school might want to recruit him. A friend had earlier praised him to the president of the University, Daniel Coit Gilman, and a chance meeting with John Shaw Billings in Leipzig, Germany, when Welch was still in training, seemed to him to have boosted his chances. Billings, the administrator of the Surgeon General's Library, and an authority on hospitals, had been asked to design and organize the proposed hospital and medical school and was busy studying various German laboratories and methods in 1876 when he came upon the 26-year-old Welch hard at work in a German laboratory. The two met that night for beers, and Welch sensed that Billings was delighted by his attitude toward science and his mastery of German technique. In fact, as soon as he got back to his hotel, Billings told Francis King, the hospital trustee who had come with him on the fact-finding trip:
"The young man should be, in my opinion, one of the first men to be secured when the time comes to begin the medical school."
So when the call from Hopkins finally came, complete with assurances of an all-expenses-paid, German-style laboratory, as many research assistants as he needed and freedom from seeing patients unless he cared to see them, Welch couldn't resist. (Unlike his garrulous father, whose life revolved around midnight house calls and trading gossip with his patients' families, Welch preferred the pure science of work with cadavers to treating patients.)
Knowing well Welch's weakness for fine food, his cosmopolitan friends teased him relentlessly, begging him not to move to a wasteland like Baltimore.
"Well, goodbye," he remembered one saying, finally, at his farewell dinner. "You may become a connoisseur of terrapin and madeira, but as a pathologist, goodbye."
Welch didn't take long to prove the man wrong. He arrived in 1884, five years before the Hospital and nine years before the medical school officially opened, and headed back to Europe for more grounding in scientific method. By 1886, he had opened his laboratory and was training 16 graduate students - committed research scientists who already had medical degrees and were attracted by Welch's reputation for serious scientific study. His was the first graduate training program for doctors in the country.
Bringing Welch to Hopkins set the precedent of importing top-flight faculty from other parts of the nation at the risk of antagonizing the Baltimore community. But Welch's immediate popularity prevented such resistance.
His students found him a bit eccentric: An inveterate night owl, he had trouble waking up in the morning and sometimes missed his own lectures. According to one of his proteges, Simon Flexner, he completely ignored his students at first, leaving them to their own devices in the laboratory, until on their own each came up with a bit of research that excited him. He always maintained an affable distance that prompted the nickname "Popsy," which they rarely dared to use in his presence. As far as they knew, he had no romantic attachments, but he was such a private man they couldn't be sure, and they devised a little ditty they sang behind his back:
"No one knows where Popsy eats,
No one knows where Popsy sleeps,
No one knows whom Popsy keeps,
Welch awed his students with his seeming grasp of any subject. Said Flexner, reflecting on Welch's rather one-sided conversations on those rare evenings when he dined with some of his most promising students:
"He often became so absorbed that the ash from his perpetual cigar dropped unnoticed onto his swelling waistcoat to join the thick grey powder that was already there. A spell fell over the room as the quiet voice talked on, and the young men, some of them already a little round-shouldered from too much peering into the microscope...resolved to go to art galleries, to hear music, to read the masterpieces of literature about which Welch discoursed so excitingly."
Welch's students needn't have felt quite so overwhelmed, however. Like many intellectual conversationalists, Welch had a gift for steering the subject to one with which he was deeply acquainted - or at least seemed to be. At holiday dinners, he amazed his relatives with long, involved discussions of the most esoteric topics -- until someone finally realized his words of wisdom came straight from the Encyclopedia Britannica, which he read right before he came to the table.
Osler may have been the supreme prankster, but Welch liked to play a good joke himself. Once, by studying aerodynamics, he convinced a few of his friends, and even some of his closest relatives, that he had a pilot's license and that, in fact, one of the Wright brothers had taught him how to fly in Atlantic City. He was delighted that they bought his story even though they knew that all his life he had never even learned how to drive a car.
On another occasion, he primed Halsted for a wicked joke by complaining for days about a vague discomfort in his chest. Finally, one day when the two were climbing the steps of the Maryland Club, Welch stopped as if stunned, and told Halsted the pain was now very sharp. Wasting no time, Halsted pressed his ear against Welch's chest and felt the most inhuman, resounding thumps. Under his shirt, Welch had hidden a rubber bulb connected to another in his pocket, which he rhythmically squeezed for a monstrous pseudoheartbeat.
While Welch made some notable research contributions - he discovered the gas bacillus - probably his greatest legacy lies in having trained some of the most eminent scientists of the time. Among them were Walter Reed, James Carroll and Jesse Lazear, who showed that yellow fever is transmitted by mosquitoes. Their finding, considered one of the greatest achievements of modem medical science, led to the virtual eradication of the disease. Medical schools and institutes across the country vied for Welch's former students and graduate scientists to fill top posts, and Welch served as a sort of national placement officer for academic physicians. It is somewhat ironic that the medical institution committed itself to supplying highly trained researchers to "rival" schools, because it never had room for all its trainees. Trainees understood that few could stay on as faculty members. But the result was the rapid expansion of the revolution in quality of American medical education and research that Hopkins wrought. Wherever these Hopkins doctors went, they took with them higher standards and expectations.
Welch also played a key role, with University President Gilman and medical institutions planner Billings, in pulling together the original medical school faculty, including Halsted and Osler. In 1916, Welch also founded the nation's first school of public health at Hopkins, and 10 years later he headed Hopkins' Institute of the History of Medicine, now lodged in the medical library that bears his name. He also was instrumental in the founding of the Rockefeller Institute for Medical Research, and served as the first chairman of its board, and of the Journal of Experimental Medicine.
Halsted (1852-1922) came to Hopkins next. An almost excruciatingly slow, meticulous surgeon known for his gentle handling of tissue at a time when bloody slashing, and no thought of germs, were more common, the aristocratic Halsted fought a lifelong battle against drug addiction - including cocaine - after a bout of self-experimentation with its newfound anesthetic properties. In practice in New York, Halsted had discovered that an injection into a major nerve trunk could numb a whole limb, or block the spinal cord. While his experiments led to modern dental anesthesia, he personally landed in a hospital for mental disorders. Welch approached him in New York after the surgeon's release from the hospital in 1886 and offered him a research position while he recovered.
Welch's unswerving support helped Halsted start his career, but though he was appointed to the job of chief surgeon, his formerly dazzling personality and surgical approach were permanently altered. Gone were the daring, inimitable speed, the willingness to take risks he'd been known for in New York. Instead, Halsted became shy and reticent even with his students, and in surgery he stressed a whole new method to control of bleeding, absolute cleanliness and careful reconstruction of tissue. His insistence on perfection took on mildly eccentric proportions in his home life; he insisted on personally selecting the leather from which his European shoes were cut, and shipped dozens of his dress shirts to Paris or London every year for laundering. He also sent his wife out regularly to scout Baltimore's lumberyards for the only wood he cared to bum in their fireplaces - white oak and hickory.
Halsted's knowledge of surgical anatomy and dissection, which he passed on to his students by operating before them on an old wood army hospital table left over from the Franco-Prussian War, was unparalleled, his technique precise. Today, most laymen are familiar with the eponymous "Halsted radical," the initial life-saving surgical treatment for breast cancer, which he first described in 1891. In his day, however, a "Halsted" meant something quite different. His colleagues used the term to mean any drawn-out procedure that seemed to take longer than absolutely necessary. So involved and slow would Halsted become during surgery that a single instance seemed to sum it up: During a particularly tedious procedure, with his colleagues getting restless and irritated, he asked the man working next to him if he'd mind scooting over.
"You've been standing on my foot for the last half hour," Halsted informed his fellow surgeon.
Halsted revolutionized surgery by insisting on skill and technique rather than brute strength. Using an experimental approach, he developed new operations for intestinal and stomach surgery, gallstone removal, hernia repair and disorders of the thyroid gland.
Thanks largely to Halsted, surgeons worldwide began wearing gloves during operations. That shift came about after one of his nurses - Caroline Hampton, whom he later married - complained that the mercuric chloride she was supposed to wash with gave her a rash. He asked the Goodyear Rubber Co. to try to make two pairs of thin rubber gloves to protect her hands. His surgical assistants were quick converts and began to wear them during operations, swearing that the gloves made them more dextrous. The idea that the gloves also might help in germ control actually didn't occur to any of them for years, which Halsted remarked on, somewhat bemused, long after.
"Operating in gloves was an evolution rather than an inspiration or happy thought," Halsted said, "and it is remarkable that during the four or five years when as operator I wore them only occasionally, we could have been so blind as not to have perceived the necessity for wearing them invariably at the operating table."
Halsted had been at Hopkins seven years before he convinced the trustees that he had kicked his drug habit. They made him full professor of surgery in 1892. Until then, he had been given the title of "acting professor." But about six months after Halsted was promoted, he confided in Osler, who had been surprised to find Halsted one day shivering unnaturally, that he was still taking morphine.
"Although he had never been able to reduce the amount to less than three grains daily," Osler wrote, "on this he could do his work comfortably and maintain his excellent physical vigor (for he was a very muscular fellow). I do not think that anyone suspected him - not even Welch."
He remained addicted the rest of his life.
Osler (1849-1919) had arrived in 1888 as physician in chief. A British Canadian, Osler was already considered America's premier doctor and was known as a superb clinical teacher. He was famous for using alliteration to help his students remember what they needed to know. Four F's, for instance, lead to typhoid fever, he told them: fingers, food, flies and filth. His 1892 text, Principles and Practice of Medicine, became the landmark text of internal medicine and has been continually updated.
A short, wiry man with a handlebar mustache, Osler had an uncontrollable urge to pull practical jokes that constantly got him into trouble. Two years before he arrived at Hopkins, he had bamboozled a respected medical journal into printing the outlandish medical findings of Egerton Yorrick Davis, an imaginary retired Army surgeon who supposedly had set up practice in Canada; after that, its editor refused ever to publish any of Osler's legitimate work - or even believe it. While Osler's jokes didn't always backfire, plenty of people failed to find them funny, including some naive, first-time female patients. Osler delighted in "consoling" these unsuspecting women as they waited nervously for their appointments with the newly arrived Dr. Kelly. You are in the most capable hands, Osler would assure each of them; and don't worry, old Kelly's senile tremor disappears as soon as it's time to operate. Doubt, then puzzlement would cross their faces when in walked the rather baby-faced Kelly, the youngest of the "Big Four." Osler remains the Will Rogers of the medical world, "Osleriana" appearing regularly in the Journal of the American Medical Association. He was the first to say, "A physician who treats himself has a fool for a patient."
Perhaps Osler's greatest contribution to medicine was the establishment of the medical residency program, an idea that spread across the country and remains in place today in most training hospitals. Through this system, doctors in training make up much of the Hospital's medical staff. The success of his residency system depended, in large part, on its pyramidal structure with interns, fewer assistant residents and a single chief resident, who originally occupied that position for years.
Osler also instituted another first by getting his medical students to the bedside early in their training; by their third year they were taking patient histories, performing physicals and doing lab tests examining secretions, blood and excreta instead of sitting in a lecture hall, dutifully taking notes. He diminished the role of didactic lectures and once said he hoped his tombstone would say only, "He brought medical students into the wards for bedside teaching."
He himself liked to say, "He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all."
Osler was a staunch advocate of good nursing, hygiene and prevention, and his stature as the outstanding American internist of the time made him instrumental in getting U.S. doctors to prescribe only those drugs that were proved effective. He also fought against low-standard profit-making medical schools before he left for Oxford in 1905.
Billings, the Hospital's planner, generally is credited with having recruited Osler, but according to Simon Flexner, Welch's biographer, Osler was actually a second choice. When Welch pleaded Osler's case, Billings agreed with reluctance, believing Osler to be far too interested in pathology, a field Welch had well-covered. Hopkins chronicler Augusta Tucker relates this account of Osler's job interview in 1888, when Osler was still at the University of Pennsylvania:
"Dr. Billings, stopping off between trains in Philadelphia, went to Dr. William Osler's rooms on Walnut Street and without sitting down, said, 'Will you take charge of the Medical Department at the Johns Hopkins Hospital?' Dr. Osler, without a moment's hesitation, answered, 'Yes.' Dr. Billings replied, 'See Welch about the details; we are to open very soon. I am very busy today, good morning.' He left, having been in the room approximately two minutes; and while there he altered the course of medical education in the United States forever."
(Osler had not been caught off guard, having been sounded out already by Welch.)
Osler brought Kelly (1858-1943), a skillful gynecological surgeon, into the fold in 1889 from the University of Pennsylvania Medical School. Kelly was a reptile collector and a Bible-thumping fundamentalist Christian who read the good book in the original Greek and Hebrew and called a prayer meeting before every operation.
Kelly was only 31 when Hopkins hired him, and he gave his house staff, the gynecology residents, great responsibilities, much as Osler did. Kelly is credited with establishing gynecology as a true specialty; he concentrated mainly on new surgical approaches to women's diseases and to understanding underlying pathology. He invented numerous medical devices, including a urinary cystoscope. When radium was discovered, Kelly was among the first to try it for cancer treatment (he is said to have gotten a sample straight from Marie Curie), and he founded the privately owned Kelly Clinic in Baltimore, once one of the country's leading centers for radiation therapy. He introduced the use of absorbable sutures to Hopkins, and was partly responsible for bringing the German artist Max Broedel, the father of medical illustration, to Baltimore. Broedel later headed the nation's first Department of Art as Applied to Medicine, at Hopkins.
Kelly's home crawled with children - he and his wife had nine - and exotic varieties of snakes, and he was recognized as an expert among amateur herpetologists. Social reform attracted his attention as well; Kelly battled energetically for election reforms, often standing guard at the polls to keep people from voting two and three times. He fought organized prostitution and worked diligently to help rehabilitate "ladies of the evening." He was an avid Bible quoter who frequently locked horns with the irreverent Baltimore columnist H.L. Mencken, who had this to say about his energetic "old sparring partner" in 1921, when Kelly was 63:
"Before cock-crow in the morning he has got out of bed, held a song and praise service, read two or three chapters in his Greek Old Testament, sung a couple of hymns, cut off six or eight legs, pulled out a pint of tonsils and eyeballs, relieved a dozen patients of their appendices, filled the gallstone keg in the corner, pronounced the benediction, washed up, filled his pockets with tracts, got into a high-speed automobile with the Rev. Dr. W.W. Davis and started off at 50 miles an hour to raid a gambling house and close the red-light district at Emory Grove, Maryland."
But, Mencken admitted (writing under a pseudonym), "put a knife in his hand, and he is at once master of the situation, and if surgery can help the patient, the patient will be helped."