The Remedy
Page 2
On the other hand, public health—which focuses on the populace’s well-being (in contrast to clinical medicine’s concern with individual cases)—had made more headway by 1870, with ideas such as hygiene and sanitation finding allies in municipal governments. After decades of increasingly virulent cholera outbreaks, the largest cities in Europe (London, Paris, Berlin, and Naples) began massive sewer projects in the 1850s and ’60s. These were constructed under the as- sumption that disease came from the smell emanating from the waste, not the germs the waste contained, but the result was the same: cleaner cities and improved health. Even so, these ideas were just emerging, and the most basic measures of public health—starting with the idea of just counting who died of what—were controversial, seen by medical doctors as challenging their authority and their duties to individual patients.
Then, like so much else in these waning years of the 1800s, things began to change.
• • •
THE LAST DECADES OF THE NINETEENTH CENTURY WERE REPLETE with new discoveries. A list of inventions from 1875 to 1900 serves as nothing less than an inventory of the toolbox for modern life: the telephone, the lightbulb, the phonograph, the fountain pen, the cash register, the dishwasher, the escalator, the vacuum cleaner, the modern bicycle, the internal combustion engine, the Kodak camera, the flashbulb, the X-ray machine, the radio, the tape recorder, the paper clip, the zipper, subways, electric power plants, and drinking straws. All these modern tools were invented in a burst of innovation unprecedented in human history.
Significantly, these were improvements at the human scale. Each of these inventions (even drinking straws) came with the promise of making life’s daily toils a little less complicated and a little more comfortable. They offered an irresistible step into the future, when things wouldn’t be quite so much work. “If once tried,” promised an advertisement for one of the most marvelous of all the era’s discoveries, “this will always afterwards be used.” The great invention in this case was perforated toilet paper, but the description could apply equally to most of the tools and products that transformed the lives of everyday people.
Though it was hardly apparent (or even relevant) to the average consumer, all these discoveries were the consequence of the scientific and engineering breakthroughs from earlier in the century. The X-ray machine was the result of Wilhelm Roentgen’s work on electromagnetic radiation; the gasoline-powered engine required a new understanding of chemistry; the electrical inventions were the fruit of Michael Faraday’s work on electromagnetism and electrochemistry in the 1820s and ’30s; even the classic Gem paper clip would have been impossible before discoveries in both chemistry and electricity allowed steel to be galvanized. All these inventions were born of science that had happened just a few years earlier.
Medical science, though, lagged behind. The breakthroughs that would inform modern medicine had yet to appear by 1870. But over the next quarter century, those insights would come, and medicine would begin to scratch at the big mysteries of life and death and illness. Vaccines and antitoxins and medications began to suggest a way not just to understand these mysteries, but also perhaps to solve them, to remedy them.
• • •
AND SO HERE IS OUR STORY: IN AUGUST 1891 TWO MEN OF SCIENCE crossed paths in Berlin in what would be an episode of historic magnitude. Their encounter would change the trajectory of each of their lives and begin to transform the course of science itself.
The first is Robert Koch, a medical doctor turned bacteriologist. Though today Koch’s name is little known outside his native Germany or university microbiology departments, he was, in his day, the most celebrated scientist on earth. With a single-mindedness bordering on righteousness, he pursued the idea that many diseases are caused by germs and that those germs can be isolated and identified. Koch’s great nemesis would be tuberculosis; it was the province of his greatest discovery and his most tragic disgrace.
Through a quirk of history, Koch’s undoing was put in motion by another physician: Arthur Conan Doyle. Conan Doyle is famous to us today as the creator of Sherlock Holmes, but his brush with Koch took place while he was still a practicing doctor in England; literature was then only a diversion. Like Koch, Conan Doyle saw the world through a scientific lens, one that informed his medical career and also, quite profoundly, his stories. It’s not too much to say that, without Robert Koch, and without this encounter, there may never have been a Sherlock Holmes as we know him.
For years, Koch and Conan Doyle’s story has merited at most a curious footnote, a coincidental intersection of two dissimilar biographies. But in truth, theirs was a historic if unwitting collaboration. Koch and Conan Doyle shared more than a passing coincidence; they shared a trajectory from the nineteenth century of leeches and cod-liver oil to the twentieth century of microscopes and antibiotics. Though circumstances placed these men at odds, history might now consider them comrades, joined in a battle for science over superstition, for process over haste, for scrutiny over supposition, for data over dogma. What Koch accomplished in the laboratory, Conan Doyle appropriated in his literature. What Koch proved to science, Conan Doyle proved to society. And, ultimately, both their lives would be undone by tuberculosis.
This book also tells a larger tale about how medicine became modern and where cures come from. And it helps us answer some larger questions: How does a scorned idea grow to acceptance and then revolution? And what does it mean to cure a disease, to ward off death so that many millions of people can live?
If there’s one caution to this tale, it’s this: Avoid the temptation to read the story, and the science within it, as the inevitable march of progress, a predetermined direction for human history. Especially where scientific investigations are concerned, it’s a fallacy to treat history as an unstoppable trajectory away from ignorance and toward insight. Though we can, retrospectively, catalog science along a tidy arc from one discovery to another, the actual course of research is marked more by darkness than by light, more by failure than by triumph.
There is no inevitable path for science; every fact won is hard fought and is self-evident only in retrospect. On the cold frontiers of science, there are no inevitabilities, no simple answers. And there are no easy remedies.
Part I
CHAPTER 1
1871 • The Doctor in Wöllstein
Photo of Robert Koch, circa 1882
On January 16, 1871, in the French city of Orléans, Robert Koch was exactly where he’d hoped to be: in a field hospital, up to his elbows in the blood and pus and piss of war. The hospital, such as it was, was a converted train station in the center of town. In the distance, from more than a hundred kilometers away, came the boom of cannons, the German artillery shelling French troops in the Siege of Paris.
When the young doctor first applied to join the German effort against the French, the previous July, he was rejected on account of his nearsightedness. But a few months later, Koch tenaciously applied a second time. By now, the growing scope of the war had lowered the bar to entry, and he was accepted. Koch was assigned to the medical unit, given some rudimentary instructions on trauma surgery and care, and dispatched to a field hospital a mile or two behind the front lines. After a couple of movements, he was now in Orléans, with a battle raging a few kilometers outside of town. Litters of soldiers, their bodies torn to pieces, were being carried to the makeshift medi- cal facility.
“The situation of the wounded or ill soldiers is mostly different from what the public thinks about it,” he wrote to his parents. “I was sadly eyewitness to scenes that prove that a human life is worth nothing, even though they might be saved with a little effort. Every romanticism that people project into the war who know the war from books is nothing against the uncountable bad experiences that you encounter as participant in a war.” At twenty-seven years old, Robert Koch was finally getting the dose of adventure he had craved—and it was more brutal than he could ever have imagined.
But while it lasted, the war gave Koch a purpose. In the field hospital he worked on a dozen men at once; he would rush from one desperate case to another with scarcely time to wipe the muck off his hands. Some soldiers, their limbs barely attached, needed an immediate amputation. Others required some bandages and a few hours’ rest on a cot before being sent back into the battle. And some could only be covered with blankets stiff with the blood of their comrades so that they might die with at least a modicum of comfort.
The son of an engineer, Koch was born in December 1843 in Clausthal, a small mining town in the Harz Mountains, in central Germany. One of thirteen children, eight of them sons, Koch grew up yearning for some sort of adventure in life, to break out of the middle. He began his studies hoping to be a naturalist, at the time the most glamorous of the sciences. The nineteenth century had begun with the explorations of Alexander von Humboldt, the Prussian naturalist who won worldwide fame studying the climate and geology of Latin America. In the 1830s, Charles Darwin embarked on his voyages on the HMS Beagle, publishing his observations on botany and biology to great renown. In 1859 he published his On the Origin of Species, making science seem at once revolutionary and relevant. These scientists lived lives of romance and adventure, and they inspired young Koch. The natural sciences promised opportunity. Every expedition seemed to yield great progress, tremendous leaps forward in human knowledge.
But dreams were one thing, and the realities of the Koch family were another: Robert watched with envy as two older brothers emigrated to the United States. Then he enrolled at Göttingen University, where he would study that most prosaic and tenuous of sciences—medicine. Göttingen was surely chosen out of convenience: It was just fifty kilometers down the road from Clausthal. But it was more than just a provincial school. Unlike France, where Paris was the absolute center of science and academic research, Germany was a decentralized nation. The German state was not officially unified until 1871, when Otto von Bismarck consolidated the German peoples into one nation. Germany had thus developed a network of intellectual centers, in Berlin and Munich, but likewise in Heidelberg, Wittenberg, Halle, Göttingen, and other cities. In the 1860s, when Koch attended university, science was flourishing throughout the country, from Breslau in the east to Heidelberg in the west and Munich in the south. Göttingen University was a thriving center of physical sciences, a hub of new ideas in biology and medicine. There, Koch had the opportunity to study with Georg Meissner, a master scientist and an innovator in devising animal experiments, and Friedrich Henle, a pioneer in microscopy.
In the late 1840s and early 1850s, Henle had published his Handbook of Rational Pathology, which made an early case that living agents—he called them contagions—could cause human disease. “The contagion is not itself the disease, but the inducer of the disease,” Henle wrote. “If it could be possible to prove that a contagion can be cultured outside the body . . . then such a contagion could only be a plant or an animal.” If it could be possible to prove—Henle wanted to pinpoint microbes as the cause of disease, but he could only gesture at the proof; he could not provide it.
Henle was a good match for Koch, as both were chronically shy, more inclined to heads-down research than to socializing. From Henle, Koch learned the techniques of a master microscopist: a great attention to detail, thoroughness, and care of process. As it happened, Koch was at Göttingen while Henle was hard at work on his magnum opus, a three-volume assessment of human anatomy titled the Handbook of Systematic Human Anatomy. (The first volume was published in 1866, the year Koch graduated.) This was the first great work of anatomical description since Vesalius’s historic On the Structure of the Human Body three centuries earlier. Where Vesalius’s breakthrough was to make an unflinching assessment of human anatomy, teasing out the networks of organs and nerves and vessels in human flesh, Henle’s innovation was to turn the microscope to the next order of magnitude, noting the structures within organs, the sheaths of cells around nerve fibers and ligaments, parsing the rods and cones within the human eye.
At twenty-two, in 1866, Koch passed the state medical examination and was tempted by his brothers’ calls to join them in America. He briefly considered becoming a ship’s doctor and seeing the world. Instead, he impetuously returned to Clausthal and married his home- town sweetheart, Emma Fraatz. Emma was the youngest daughter of an official of the local evangelical church, and Koch had kept company with her before leaving for Göttingen. She was a serious and practical young woman, and she quickly made clear that she would not be leaving Germany for some foreign adventure. Koch was in Germany to stay.
Koch first found a position at a local facility for disabled children in Langenhagen, a small village near Hanover. On the side, he set up a practice attending to the needs of the local villagers. He and Emma lived in a few rooms in the house of a local farmer. Soon enough his practice was flourishing, and he had enough money to buy a small carriage (a useful status symbol for the young doctor) and enough time to ramble through local marshes collecting various plants and water samples, which he’d bring home and examine under a cheap microscope. One evening, when he returned home from the clinic, Emma told him she was pregnant. Life for Robert Koch seemed to be settling in comfortably, if modestly.
But the calm was soon over. His institution had financial problems, and his position, he was informed, was being eliminated. Koch would have to make his way somewhere else. First he tried Braetz, but three months later he’d moved again to Niemegk, a village near Potsdam. The townspeople there seemed to prefer faith healers to physicians, though, and Koch struggled to find patients. Emma, now caring for their daughter, Gertrud, began to grow frustrated with Robert’s efforts. “It’s going awful here,” she wrote to her father from Niemegk in 1869. “We have to skimp and save every penny and I’m still not sure we’ll make it. I keep telling Robert we have to leave here, that he MUST find a better position, but Robert has given up all hope and now has the idea again to go overseas. He can’t make up his mind about anything.”
At last they moved again, to Rackwitz, a town then in eastern Prussia, now in Poland. The family took an apartment over the post office, and Koch got a few patients. Emma seemed more hopeful than she’d been in months. Things improved considerably after a local gentleman, the Baron von Unruhe-Bomst, shot himself with a revolver. Koch successfully treated him for the wound, and soon more patients were coming his way. He began to turn his little yard into a naturalist’s laboratory, with pigeons, chickens, and a beehive. He even began going to the local beer hall with the town mayor. Once again, things seemed to be back on track for young Dr. Koch.
• • •
THEN, IN JULY 1870, THE WAR BEGAN. KOCH WATCHED THREE OF HIS seven brothers join the French War, as the Franco-Prussian War was called in Germany. For Koch, it was the chance to do something, to turn his safe but anonymous life toward something greater. Out there, in France, heroes were dying on battlefields; men were making their mark; history was being written. If he couldn’t take his wife and new daughter to America, Koch decided to choose the path open to him. After scarcely consulting with Emma, he went to war.
He was first posted to a field hospital near Metz, the capital of the Lorraine region of France, where he slept in a hayloft. “The smell of dead bodies, many dead horses and thousands of bags, guns and helmets were near the rural road, at least this was what we could see in the darkness,” he wrote to his father. “We drink a cup of black coffee, of course, without sugar or milk and eat a piece of dry bread. At noon there is boiled beef and bread again or maybe even a thin soup. . . . One has no appetite for a second plate,” he wrote, though he did admit that the local wine was worth drinking.
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nbsp; At Metz, the Prussian army had tied up 180,000 French troops and 70,000 citizens in a months-long siege. With food running short and dysentery and cholera spreading, the French tried repeatedly to battle their way out of the city. Each time, they were pushed back by the Germans, with enough casualties among the Prussian troops to keep Koch and his fellows in the medical corps busy. For a fledgling doctor such as Koch, used to treating injured farmers and their pregnant wives, the tumult of the siege was a dizzying mix of duty, disgust, and opportunity. It gave him his first glimpse of the true mechanism of death: not the wound, but the infection that came later. Eventually the French began to starve, and they surrendered the city on October 27.
Koch was then transferred 120 kilometers to the south, to Neufchâteau, a French town already occupied by the Prussians. There he was stationed at a hospital for soldiers suffering from typhoid fever. Today we understand typhoid to be an infectious disease caused by the Salmonella bacterium and typically spread through exposure to feces or similar unsanitary conditions. But in 1870 it was little understood, perhaps contagious, perhaps spread through tainted water. Generally, it was simply considered one of the risks of war. At the hospital, Koch had his hands full; the Germans suffered more than 73,000 cases of typhoid during the war, with nearly 9,000 fatalities.
Koch’s experience with typhoid was eye-opening. After the initial fever, the infection settles in the intestines, inflaming the organs and distending the abdomen. As it spreads to other organs—the pancreas, the liver—internal bleeding becomes likely, resulting in bloody stool. Delirium is common, especially if the infection makes its way to the brain. The death rate in Koch’s day was about 20 percent. Koch, who’d gotten a sense of the microbial world from Henle, must have suspected there was some agent at work, some unseen contagion spread-ing from soldier to soldier. But with no diagnostic tools or effective medicines, he could only watch, offering the comfort of a damp cloth or a blanket, as the sickness set in. It was depressing and hopeless work, and Koch despaired. He pined for simple things: a newspaper, a lamp, home-cooked food, his family. He must have been relieved when he was transferred once again, this time to the field hospital in Orléans.