The Remedy

by Thomas Goetz

  At this point, Koch had been at war for nearly five months. The adventure was far messier than he’d anticipated. There were the sights—the severed limbs and distended bellies; the almost dead and the dead. But even more horrifying was the stench, the foul and constant odor of soldiers mangled by war.

  Compared to the world wars that followed it, the Franco-Prussian War seems insignificant now, of interest only to archivists of nineteenth-century maps showing long-obsolete borders. Yet in fact it was a seminal conflict. Though it lasted less than a year, it was the prototype for the wars of the twentieth century in terms of the issues behind the conflict (the taut borders of Europe and the influence of overseas dominions and resources), the scale of its battles (these could involve hundreds of thousands of troops at once), and the conditions faced by soldiers on the front lines (for the first time, rifles and cannons were accurate and massively deadly). And like few wars before but all wars since, it served as a laboratory for medicine, creating a rich opportunity for physician-scientists to study the grotesque impact of new weaponry on the human body and the effectiveness, or lack thereof, of efforts to treat those injured so horribly.

  In their way, the weapons deployed for this conflict were beautifully designed specimens of breakthrough technology. The Germans deployed the newly patented Krupp cannon, which could be loaded from the breech rather than the front. The Krupp made it possible to fire six-pound shells far more quickly than France’s muzzle-loading cannon, meaning more missiles exploding in the air, raining a heavier barrage of zinc shrapnel down upon French troops. (The Germans also made history by deploying the first antiaircraft guns, firing at French balloons.) For their part, the French army debuted the mitrailleuse, an early mounted machine gun that could fire a hundred rounds per minute—a barrage the German troops called the “battle squirt.” As an 1873 report on the war described it, “The growling of this ‘wild beast of battle’ resembles nothing so much as the running of an anchor cable through a ship’s cathead, or the closing of heavy iron shutters.”

  But though the mitrailleuse made a terrifying noise, it inflicted fairly few of the casualties showing up at Koch’s hospital. The real agent of destruction was the French rifle, the chassepot, a rapid-fire, high-velocity rifle that could be accurate from a stunning 1,200 meters away (nearly three-quarters of a mile). It was, as one German officer described it, “a gorgeously worked murder weapon.” (The Germans were equipped with their patented needle gun, an older, less impressive piece of technology that could fire from only 700 meters, creating what was called the chassepot gap, where French troops could hit the Germans, but not vice versa.)

  Unlike in previous wars, where the rifles created the soundtrack but the bayonet did most of the damage, in this war there were remarkably few wounds from knifepoint. Rather, the wounded soldiers that Koch and his colleagues tended to bore the unique scars of long-range rifle shots: diffuse, open wounds with splintered bone fragments and bits of clothing mixed in with the damaged flesh. Most of the soldiers who came in to the hospital bore limb wounds, as those with wounds to the abdomen usually died on the battlefield. Amputation was the routine treatment, and a miserable death from gangrene the routine result.

  Ether, thankfully, was now available to surgeons, having been invented twenty-five years before, but still, the typical procedure was brutal and fast. The surgeon would fix on the wound, pick the opportune place to separate the limb, and then hack through it with a saw. An amputation was over in less than a minute; a skilled hand could finish in twenty-five seconds. If the soldier was lucky, the surgeon took care to leave enough skin intact to fix a flap over the stump.

  Charles Alexander Gordon, an English doctor observing hospital conditions during the war, described a German facility this way:

  It was not an unfrequent sight to see the blood and discharges from wounds soaking into the bedding, where they speedily underwent decomposition, and thus became sources of various evils, producing at the same time a most offensive and sickening odour.

  Patients were left for many hours in the clothes in which they had been wounded, and such was the pressure of the times, that clothing, after being taken off patients, has been left lying in the wards for 36 and even 48 hours afterwards, giving out offensiveness.

  Still, despite such appalling conditions, the Germans were in far better shape than the French. For one thing, Germany had made better preparations at the outset. They recruited 5,548 physicians for the war effort, 3,000 nurses, and nearly 500 apothecaries. The French, on the other hand, had barely 1,000 available surgeons when the war began, and fewer nurses and other staff in turn. Germany, too, had taken some essential preventive measures, mandating smallpox vaccines for all new troops. The French had no such requirement, with devastating consequences. While fewer than 300 German soldiers died of smallpox, the inevitable outbreak on the French side eventually claimed the lives of 25,000 troops. (In a demonstration of the ancillary costs of war, the epidemic subsequently spread to civilian populations on both sides of the new border in France and Germany. This time Germany paid the higher price, with 177,000 civilian fatalities to France’s 90,000.)

  The Prussian advantage went beyond preparations. In treatment and recovery, too, German troops fared better—chiefly because their commanders had subscribed to the methods of the Scottish surgeon Joseph Lister, who a few years earlier had developed the principle of “antiseptic surgery” against the threat of germs. In the civilian world, the germ theory—the idea that some disease was caused by microscopic agents, or germs, that would release toxins and attack the body—was a radical notion. It contradicted the conventional wisdom that disease was a product of bad air, or miasma. But on the battlefield, such disputes were academic. Lister had demonstrated that his approach saved lives, so the Germans, keenly aware that disease had historically always been more deadly to military forces than actual battle, made Lister’s antiseptic procedure compulsory at all medical facilities.

  By today’s standards, Lister’s treatment was coarse, even brutal. It looked nothing like today’s sterile surgical environment, with its stainless-steel basins and bright lights, everyone swathed head to toe in pristine blue scrubs. Surgeons weren’t even required to wash their equipment or hands. Rather, Lister’s antisepsis took for granted that a doctor’s hands would be filthy with the last patient’s blood and guts and that instruments would be poorly cleaned. His new technique called for a doctor to douse a wound with a dilution of carbolic acid, otherwise known as phenol, an extract of coal tar. In German facilities, this took the form of what was called Lister’s cerate: one part crystallized carbolic acid, six parts linseed oil, nine parts chalk. Bandages, too, would be soaked in the stuff before wounds were dressed. It was a caustic, painful bath. (Today phenol is used in paint stripper, among other things.) Many surgeons disliked Lister’s cerate because its use made procedures take longer; an amputation was harder to dispatch in thirty seconds when there was so much dousing and swabbing to be done. But the results were real and demonstrable. Antisepsis did the job, killing many of the bacteria in and around the wound. As Dr. Gordon observed, “this preparation, spread upon tinfoil . . . proved to be both convenient and effective.” Though the German hospitals were far from clean, the measures the Germans did take would prove revolutionary. In fact, for the first time in any war, the Germans would be the first to lose more men directly to battle wounds than to subsequent infection.

  The French, meanwhile, followed the principles of François Broussais, a renowned French physician from earlier in the century. Alas, Broussais’s work was woefully out of date—he was a firm believer in bleeding by leeches—and had disastrous consequences for the French side. Whereas Lister’s cerate eliminated bacteria, Broussais’s technique was to apply salves to open wounds in the hope of soothing inflammation. In the French hospitals, open jars of greasy ointment lined the shelves behind an operating table, ready for the surgeon to scoop out a dollop with his unwashed hands,
wiping the stuff into the patient’s wound. With the next patient, he’d go back to the same tub with the same dirty hand. One couldn’t have designed a better procedure for disseminating infectious disease, and the results bore this out: of 13,173 amputations performed in French military hospitals, 10,006 ended in death, a fatality rate of nearly 70 percent. (One wonders if the survival rate would have been better if they’d just left the mangled limbs attached.)

  Hospital disease was the catch-all term for any infection that befell patients outside battle, and it was common in both German and French facilities. Some cases were classified as pyemia (a severe fever known today as sepsis, where the blood is poisoned by Staphylococcus infection), others were gangrene (where an infection starts to kill large amounts of tissue), and still others were typhoid or typhus (a fever that appeared symptomatically, like typhoid, though it was spread by lice harboring Rickettsia bacterium). Whatever the classification, when a merely wounded soldier developed a hospital disease, he was considered effectively lost. In German field hospitals such as Koch’s, these patients were moved into their own wards, since the illness did seem to spread from the sick to the not-yet-sick. Whether this quarantine was motivated by a belief in germs or simply in bad air, it was the reality of the battlefield. As Dr. Gordon observed, “In this war, as in all others, it has been shown that, wherever large accumulations of wounded took place, there pyaemia, in one form or other, appeared, and proved as fatal as it had ever done.”

  Though the infections meant misery and near-certain death for soldiers, they offered a morbid opportunity for enterprising physicians, none more than Edwin Klebs, a Prussian physician a decade older than Koch. Klebs was stationed in Karlsruhe, a German border city near Strasbourg, and, like Koch, attended to cases in the town’s railroad depot, which had been converted to a hospital. In addition to the requisite surgeries and amputations, Klebs also performed autopsies on fallen soldiers.

  One afternoon, out of curiosity, he slipped some tissue from a fatal gunshot wound under a microscope. What he saw through the lens amazed him. “I found rod-shaped bodies, so-called bacteria,” Klebs wrote in a subsequent report, noting that these organisms increased in number when present with pus and fever. Significantly, he observed that they weren’t all identical, but rather comprised some smaller sporelike shapes in clumps, some rods, and others somewhere in between. So far, Klebs’s observation was simply an association—he’d noticed that these bodies appeared along with infection; others before him had made similar observations. But then Klebs took a bold leap from association to causation, proposing an actual relationship between the bacteria and the infection: He asserted that the one created the other. “These parasitical organisms are the cause of severe manifestations,” he declared. His methodology here was sound if not airtight: First he noted that the bacteria appeared in every instance of open, inflamed wounds. Second, he also tried to reproduce the bacteria in cultures. This was only somewhat successful, since his samples were generally contaminated.

  Klebs was on the right path: The bacteria were the cause of the pus, the fever, and the infection at root. But his proposal was not convincing. He lacked a definitive chain of evidence that might convince his colleagues and overturn the orthodoxy that inflammation was caused by internal mechanisms of the cells, a theory advanced, most notably, by Rudolf Virchow, the leading pathologist of Europe (and former mentor to Klebs). Klebs might have made the jump from association to causation, but his profession would not follow—at least not yet. As a surgeon reviewing Klebs’s report remarked, “Does disease follow bacteria, or do bacteria follow disease? We still don’t know the answer.”

  • • •

  AMONG THE PRUSSIAN MEDICAL STAFF, KLEBS WAS AN EXCEPTION, not only because he had the wherewithal to pull out his microscope, but also because, in his station hospital, with its stone walls, granite floors, and solid roof, he had the relative luxury to do so. Back in the field hospitals, physicians such as Koch were sunk too deep in the slop of war to think about science. But Koch wasn’t intimidated by the horrors he witnessed. In his few months, he enthusiastically wrote to his father, he had learned more than in all his prior surgical training. Finally his life had a purpose, a focus, an outcome. “I will never regret the decision to participate in this war. Apart from the scientific experiences that I had gained—worth more than 6 months in a clinic—I have gained much experience in life. This will serve me well in coming years.”

  Still, by mid-January, Koch had grown concerned that his practice in Rackwitz was in jeopardy, and he made an official request to be sent back. It was quickly granted. A few months later, the entire Franco-Prussian War was over, not a year after it had begun. That was long enough, still, to claim some 170,000 lives: 30,000 German and 140,000 French.

  Robert Koch returned to Emma and daughter, Gertrud, in Rackwitz and resumed his medical practice. It was as if the war had never happened. At twenty-seven, he again began to suspect that his life was settling into stasis. Then he received an invitation from the Baron von Unruhe-Bomst—whom he had treated for that gunshot wound a couple of years before—to take up a government position as the local health officer in Wöllstein, a town to the north. By April 1872, Koch and family were on the move again.

  Wöllstein, an agricultural town of three thousand in eastern Germany tucked between two lakes, had a history dating to 1458. (Today the town sits in western Poland and is known as Wolsztyn.) For centuries it had been a center for sheep farming and wool production. In the 1870s, wool was the world’s leading textile, and Germany the largest producer, with Wöllstein, which means “wool stones,” as a hub.

  Koch settled his family into 12 Strasse am weissen Berge (“Road to the White Mountain”), a large Gothic building almost dead center in the town that had previously functioned as a hospital for the poor. Upstairs were the living quarters: four rooms and a kitchen, with a large bay window over the street. Koch’s examination room was downstairs. Out back was a garden, filled with trees and flowers, where his daughter could run around.

  Koch thrived in Wöllstein. His neighbors trusted him and kept him busy with smallpox vaccinations, injuries and illnesses, and aches and pains. The days were long but full. Emma was happier, too, and proved to be a diligent doctor’s wife, handling patients and minding the family budget. After a few months, she proudly told her husband that she’d saved enough to buy something for the practice. She suggested either a carriage, which would make his visits to patients much easier, scattered as they were throughout the countryside, or a new microscope. He chose the scope.

  • • •

  THE MICROSCOPE WAS FIRST DEVELOPED IN THE SEVENTEENTH century by fixing a single lens onto a stand, with an assist from a nearby candle. The instrument’s first great demonstration was Robert Hooke’s Micrographia. Published in 1665 by the Royal Society in London, Hooke’s book is said to be the first scientific bestseller. The diarist Samuel Pepys, who bought a copy he saw in the window of his local bookshop, wrote that he stayed up until two in the morning reading it, calling it “the most ingenious book I read in my life.” Hooke was the first to use the word cells to describe the pores in wood; he thought they looked like a monk’s room, or cell. The thirty-eight plates in his book, many of them massive drawings that the reader had to unfold to see in full, showed meticulous hand drawings of fleas, gnats, and lice in exquisite detail. The precision is remarkable even now, as is Hooke’s written description:

  By the means of Telescopes, there is nothing so far distant but may be represented to our view; and by the help of Microscopes, there is nothing so small, as to escape our inquiry; hence there is a new visible World discovered to the understanding. By this means the Heavens are open’d, and a vast number of new Stars, and new Motions, and new Productions appear in them, to which all the ancient Astronomers were utterly Strangers. By this the Earth it self, which lyes so neer us, under our feet, shews quite a new thing to us, and in every little particle of its matter, we now b
ehold almost as great a variety of creatures as we were able before to reckon up on the whole Universe it self.

  Hooke was soon on to experiments with telescopes and gravity (his research preceded Newton’s by a decade, the grounds of a long-standing grudge between the two men). But his microscopic discoveries were soon elaborated by Antonie van Leeuwenhoek, a Dutchman who was too much a tinkerer to be satisfied with pondering insect anatomy. Van Leeuwenhoek improved upon Hooke’s microscope by adding a small glass bead as a lens, thus amplifying the tool’s resolution. His lens-grinding technique could achieve a magnifying power of 266 times, allowing him to discern features just .00135 millimeters apart. Soon, van Leeuwenhoek was peering beyond the anatomical to the cellular, sketching out the parts of blood, human spermatozoa, and various animalcules.

  It would be more than a century and a half before microscopes were significantly improved. In the 1820s, Joseph Jackson Lister, the father of the antiseptic surgeon, began experimenting with how a second lens could bend an image back upon itself and increase the microscope’s power accordingly. Twenty years later the German lens makers Carl Zeiss perfected the industrial manufacture of the tool, allowing economies of scale to kick in. Leeuwenhoek had made it powerful, Lister made it reliable, and Carl Zeiss made it affordable: Those three components allowed the technology to flourish.