by Thomas Goetz
GOTHAM
Published by the Penguin Group
Penguin Group (USA) LLC
375 Hudson Street
New York, New York 10014
USA | Canada | UK | Ireland | Australia | New Zealand | India | South Africa | China
penguin.com
A Penguin Random House Company
Copyright © 2014 by Thomas Goetz
Penguin supports copyright. Copyright fuels creativity, encourages diverse voices, promotes free speech, and creates a vibrant culture. Thank you for buying an authorized edition of this book and for complying with copyright laws by not reproducing, scanning, or distributing any part of it in any form without permission. You are supporting writers and allowing Penguin to continue to publish books for every reader.
Gotham Books and the skyscraper logo are trademarks of Penguin Group (USA) LLC.
LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA
Goetz, Thomas, 1968 November 14–author.
The remedy : Robert Koch, Arthur Conan Doyle, and the quest to curetuberculosis / Thomas Goetz.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-592-40751-4
ISBN 978-0-698-14857-4 (eBook)
I. Title.
[DNLM: 1. Doyle, Arthur Conan, 1859–1930. 2. Koch, Robert, 1843–1910.3. Tuberculosis—history—Europe. 4. Tuberculosis—history—United States.5. Germ Theory of Disease—history—Europe. 6. Germ Theory of Disease—history—United States. 7. History, 18th Century—Europe. 8. History, 18th Century—United States. 9. History, 19th Century—Europe. 10. History, 19th Century—United States. WF 11 GA1]
RA644.T7
614.5'42—dc23 2013039611
Illustration on page ix from Review of Reviews, 1890. Photograph on page 3 courtesy of Humboldt University of Berlin, University Archives. Photographs on pages 25 and 85 courtesy of Robert Koch Institute. Photograph on page 53 by Felix Nadar. Photographs on pages 111 and 139 courtesy of University of Minnesota Libraries. Photograph on page 161 by the author. Photograph on page 189 by Bain News Service, image courtesy of Library of Congress. Illustration on page 211 by Sidney Paget. Image on page 227 courtesy of the National Library of Medicine. Image on page 245 courtesy of National Museum of American History (photographer unknown).
While the author has made every effort to provide accurate telephone numbers, Internet addresses, and other contact information at the time of publication, neither the publisher nor the author assumes any responsibility for errors or for changes that occur after publication. Further, the publisher does not have any control over and does not assume any responsibility for author or third-party websites or their content.
Version_1
In memory of Frederick C. Goetz and Cecilia M. Goetz
CONTENTS
TITLE PAGE
COPYRIGHT
DEDICATION
INTRODUCTIONThe Disease
Part I
CHAPTER 11871 • The Doctor in Wöllstein
CHAPTER 21875 • The Germ Theory
CHAPTER 31878 • The Rivalry
CHAPTER 41882 • The Breakthrough
Part II
CHAPTER 51882 • The Doctor in Southsea
CHAPTER 61887 • The Detective
CHAPTER 71890 • The Remedy
Part III
CHAPTER 81891 • The Fall of Dr. Koch
CHAPTER 91892 • The Rise of A. C. Doyle
CHAPTER 101900 • The New Century
EPILOGUEThe Cure
ACKNOWLEDGMENTS
NOTES
INDEX
INTRODUCTION
The Disease
Robert Koch, as depicted at the height of his fame, 1890
In train after train, consumptives filled the passenger cars, their hacks and coughs competing with steam whistles and screaming brakes as the engines came to a halt in Potsdamer Platz. They came to Berlin without any sense of where to go or what to do once they arrived. And they kept coming, for days, weeks, and months. It must have struck Berliners as a sort of zombie pilgrimage: Here were the walking dead of Europe, all suddenly flocking to their city in search of something—some fantastic substance that did not yet officially exist.
They began arriving in August 1890, when rumors first began to circulate that a treatment, a remedy, for consumption, or tuberculosis, had been discovered by Europe’s greatest scientist, Robert Koch. Koch made no promises; he had only hinted at a substance that seemed to arrest the disease. But a hint was all it took. This was the deadliest disease in the world, and these were the most desperate souls. If there was hope to be had in Berlin, they would seek it out.
Tuberculosis was a cunning disease, coming on slowly, almost casually. At first it seemed innocuous, beginning with a cough; a cold, perhaps, or a touch of bad air. But then that cough turned malevolent, becoming stronger and more painful and extracting blood with each spasm. Then the appetite would go, replaced by fatigue, a deep dullness that would pull the sufferers into lethargy. Eventually, bodies would begin to wither and dissipate from within. For most consumptives, this played out over months and years. Even when the end seemed imminent, it was as if the consumptives could not muster the energy to die—until, finally, they did, by the thousands and hundreds of thousands and millions. In the last half of the nineteenth century, at least one-quarter of all deaths were due to tuberculosis, a steady pall that loomed over every country in Europe, over the United States, and indeed worldwide.
So the consumptives came to Berlin, and inevitably, death came with them. They died in the passenger cars on the way to the city, they died in the hotels, and they died in the clinics and hospitals where they waited for a dose of this extraordinary remedy. The city didn’t know what to do with them all. Hotels and hospitals filled up. Coffeehouses were converted into sanitariums.
With concern rising that Berlin’s own population was at an increased risk of infection, the Berlin police department began instituting emergency measures to control the onslaught. Joseph Lister himself, one of the most famous physicians in Europe and a pioneer of the germ theory of disease, suggested that the horde created a “serious danger to the public health of this city likely to arise from the sudden invasion of patients suffering from every form of tuberculosis and coming from all the corners of the earth.”
The tide grew still larger after November 13, when Koch finally offered some specifics for his remedy. A public demonstration of the substance was scheduled for November 17 in Berlin, and now scientists crowded among the consumptives on the trains. The finest medical men in Europe were all eager to see firsthand how Koch’s substance could destroy the worst disease humanity had ever known.
On one of those trains was a young English physician, making the pilgrimage not for the cure, but to scrutinize the evidence behind it. This man, an unknown provincial doctor who yearned to become something greater, was en route to play detective and to assess what Dr. Koch had created. He idolized Koch, but his years in practice had hardened him to the promise of quick cures and easy fixes. He was headed to Berlin to discern whether this remedy might really work. And this trip would change his life: He would arrive as an observer of history but leave as a figure in it. He would arrive as a physician but leave as a writer.
This doctor’s name was Arthur Conan Doyle.
• • •
DEADLY AS IT WAS, HORRIBLE AS IT WAS, TUBERCULOSIS WAS ALSO entirely ordinary in the last decades of the nineteenth century. For that entire century, the numbers are staggering. In England, as many as a quarter of all deaths were due to cons
umption. In the United States, the disease was the leading cause of death; in German towns, tuberculosis was the second-largest killer, after gastrointestinal diseases—but when one includes deaths attributed to generic “lung” conditions, most of which are likely to have been TB, it accounts for a plurality of deaths by far.
These figures are fuzzy and, if anything, probably underestimated the scope of the disease. Record keeping was poor at the time, and tuberculosis often traveled under aliases. Manifest in the lungs, it was known as consumption or phthisis; on the skin, it was called scrofula or lupus; it could also appear in other organs and be mistaken for cancer. It wreaked most of its toll in its pulmonary form, and it couldn’t have chosen a better hiding place. Deep inside the lungs, tuberculosis could take so long to make its creep that, for many, death seemed to come from some other cause—influenza or pneumonia or some fever—leaving the true underlying disease invisible, a shadow in the background.
Not that anybody—even public officials, even family—was all that concerned about the precise cause of death in general in the mid- to late nineteenth century. After all, these were the hours just before the dawn of modern medicine, when neither diagnosis (such as it was) nor treatment (such as it was) could be of much use. When death could come from any direction for any reason at any time, questions about cause didn’t seem so important. Fathers, mothers, husbands, wives, children, siblings—whatever took them, they were gone, like so many others.
Indeed, it is difficult to imagine, from the security of our twenty-first-century perspective, how familiar death was in the late nineteenth century. Suffering, injury, and disease were altogether routine, part of the ordinary experience of everyday life. People tend to use average life span to illustrate historic differences in health, but those figures—in 1870 the average life span in Europe and the United States was about thirty-six years, compared to about eighty years today—don’t nearly make the point strongly enough. Rather, to get a true sense of the pervasiveness of death, one must look at the annual death rate: how many of the living ended up dead every year.
In England circa 1870, twenty-two people out of a thousand died every year. This means that more than 2 percent of the population was dying off every year, a constant deduction in humanity and accretion of misery. Today, the death rate is about five per one thousand, which is to say, four times as many people were dying then than are now.
Today, we just can’t conceive of so much death, all the time, all around us. Death is so unfamiliar today that almost any expiration seems exceptional. We lament the passing of the generations as if each loss were a tragedy rather than biology. But in 1870, death was a constant presence, lurking around every corner, something that visited families and friends regularly (if not routinely). The dead came from all stages of life: the old, of course, but also those in the prime of life. Back then, every year, nearly 2 percent of those between ages thirty-five and forty-four died, and those between forty-five and fifty-four died at twice that rate. And then there were the very young. Infant mortality in England and the United States hovered around a stunning 20 percent of all live births—and in some areas, a rate of 30 to 40 percent wasn’t uncommon. (Today, the infant mortality rate is about four per one thousand live births, twenty times less than it was in 1870.) And though wealth offered some protection, this carnage largely knew no class boundaries, afflicting the rich and the poor alike.
The causes were inadequately tabulated and even less understood, but the categories were as common to the nineteenth century as they are obscure to us today. There were the deadly fevers (scarlet fever, spotted fever, puerperal fever, typhoid fever) that made every spike in temperature fearful. Once or twice a year, pneumonia and influenza would sweep through a community, culling the weak, the old, the young. There were outbreaks of cholera; not the stomach flu of today, this was a horrid bout of diarrhea and vomiting that would slaughter whole families in a fortnight and then move on to take the neighbors as well. And if disease wasn’t bad enough, there were the many accidents and their consequences, the trauma of a broken bone or a deep cut often leading to infection, gangrene, and death. (Twice as many people died from accidents in 1870 as they do today.)
And most of all, there was consumption. In nineteenth-century Europe and the United States, this was the most common of all ways to die. It was a languid, almost casual disease, the first chronic disease, in many respects. As a result, few doctors believed that there could be anything contagious about it whatsoever. Rather, it seemed largely hereditary, passed along in families with “weak constitutions.”
As for treatments, there was no end of them: tonics and salves and cod-liver oil. These were hardly cures; at best, they seemed restorative. But, as one pamphlet warned, “To the drowning man, a stick, a straw, or any old piece of wood looks like a help to save himself from death. So, to the consumptive, any kind of flimsy statement or any brand of manufactured ‘patent’ medicine appears to offer a hope of cure and a chance for life.”
In truth, there was no true remedy for tuberculosis, no drug that would dispatch the disease and restore the individual. Some doctors despaired that there would ever be a cure for it and felt that any offer of treatment was deceitful and unethical. They chose to treat it not as a disease but, rather, as a fact of life, counseling patients to learn to live with the condition as long as they might. Instead of scrounging for a cure, they should reconcile themselves to the fact that their fate had been determined. Whether brought on by God or family, consumption was their lot.
In fact, tuberculosis is caused by a microbe particularly suited to humans (and, curiously, to cows). This bacteria, Mycobacterium tuberculosis, seems almost engineered to exploit the human tendency to mask fear with denial: It is perfectly content to spend years in the human body, making itself inconspicuous as the infection slowly spreads, until it at last reveals itself to its human host. But in 1870 it was not only invisible; it was inconceivable. There was no way to fathom that a disease such as consumption could be the work of a contagion, a germ. The very notion of germs was radical, an idea outside the bounds of traditional medicine. Perhaps diseases such as smallpox or measles—which came on quickly, appeared to spread from person to person, and produced symptoms visible to the naked eye—had some contagion behind them. But consumption bore none of those characteristics.
Still, some scientists had started to investigate the idea that tiny “animalcules,” as they were described, invisible to the human eye, might be agents of disease. In France, Louis Pasteur had done the most to advance such notions, and since at least 1850 this idea, referred to as “the germ theory,” had been much discussed in Europe. Using microscopes (which, like the stethoscope, had only recently been widely adopted by medical science), some had begun to identify tiny particles in the blood, chains of cells that seemed to move and grow and even reproduce. To those who believed in the germ theory, the vision of these microbes opened the door to a new era of science and a new utility to medicine. Dr. John Tyndall, one of England’s most prominent scientists and essayists, was among these believers; in a lecture entitled “On Haze and Dust,” delivered before the Royal Institution of Great Britain in January 1870, he thrilled to the idea. “When he clearly eyes his quarry, the eagle’s strength is doubled, and his swoop is rendered sure,” he told his colleagues. “If the germ theory be proved true it will give a definiteness to our efforts to stamp out disease which they could not previously possess.”
Tyndall’s argument was dynamic, enthusiastic—and tentative. As his hedging made clear, with its “if the germ theory be proved true” caveat, the theory was still largely conjecture. There was no certainty to it, no evidence that these curious organisms under the microscope had any real relation to disease. For a matter of science, this was a mortal deficiency. Lacking proof, the germ theory would drift outside the harbors of science, an alluring idea, but one unmoored to the day-to-day reality of medicine.
• • •
PICTURE, IF YOU WILL, THE PROVERBIAL DOCTOR’S BAG, A LEATHER satchel filled with the tools of the modern general practitioner: antibiotics; aspirin; a stethoscope, otoscope, and various other scopes; a blood pressure monitor; a prescription pad. Now open the bag and turn it upside down, shaking loose all those implements that didn’t exist in 1870. Though one or two tools might remain—the stethoscope or the speculum—the bag would be mostly empty. In fact, most of the resources that constitute modern medicine had not arrived by 1870, and those ideas and instruments that did exist were novel, regarded by many as avant-garde gadgets that threatened a doctor’s autonomy.
This isn’t to say that the last quarter of the nineteenth century was the Dark Ages of medicine; rather, it was when the light started to break. After two millennia of misapprehension, medicine was finally shaking off its attachment to the “four humors” (blood, phlegm, and black and yellow bile) and turning to the more empirical disciplines of pathology and microscopy. In 1858 the first edition of Gray’s Anatomy appeared, giving clear, accurate illustrations of the human body. In the 1850s and ’60s, medical laboratories began to appear in Europe and the United States, separate from hospitals and doctors’ offices, designed as distinct quarters for scientific inquiry and discovery. Surgery was just emerging as a respectable trade, recently delivered from the era of hacksaws and slugs of whiskey by the discovery of reliable anesthetics. “Gentlemen, this is no humbug,” remarked one witness to a demonstration of ether at the Massachusetts General Hospital in 1846. Within a decade, surgery was a booming trade and, increasingly, a respectable one as well.
But for those physicians tasked with caring for patients, their bags remained discouragingly bare. Practically speaking, not much really worked. For prevention, there was a smallpox vaccine (developed in 1796 by Edward Jenner but made compulsory in Britain only in the 1850s and ’60s), but little else. For treatment, there were salves and ointments and tonics, but almost nothing that we would today consider a real, functional medication. For every opiate or digitalis (an extract of the foxglove plant that was used to treat dropsy, or heart failure), there were cabinets of cod-liver oil and other elixirs, the best of which were harmless, the worst of which were outright poisons. In short, medicine had very little to offer in the way of effective treatments that would truly heal or cure.
