The Remedy

by Thomas Goetz

  Why would the invariably discreet scientist take such a risk? To some extent, he was doing his part as a good German. The Lancet hinted at such. The German government, keenly aware that the world would be attending the Belin congress, apparently wanted some show of prowess from its scientists. The politicians had pushed on the host committee, and the committee had turned to Koch, imploring him to reveal some great progress from his laboratory. The journal later reported:

  Koch, like all scientific men, has his own methods of working, and his own system of declaring his results. He had never yet rushed into print with a discovery until he has been sure of his facts, and all who are in any way acquainted with the circumstances under which Koch was practically compelled by his Government superiors and by his colleagues to make the premature statement at the International Medical Congress in Berlin will sympathise most deeply with him that he was compelled to break through his usual reticence.

  Regardless, now that the word was out about his work, Koch spent the next weeks in a fervor. He delegated his administrative and teaching duties at the Institute of Hygiene and turned to the experiments full-time. First on his agenda was to test tuberculin on human subjects—not just to test the safety of the substance on healthy subjects, as he had on himself and his young friend, but to administer actual therapeutic doses to consumptives. By September, those experiments were under way at Berlin’s Charité hospital, with several patients receiving regular injections of tuberculin, under the supervision of Dr. Ernst von Bergmann, an esteemed surgeon at the University of Berlin.

  In October, word of these human experiments began to spread. In a brief update on November 1, The Lancet advised that doctors and the public itself heed Koch’s trademark caution. “Indeed, apart from the fact that we may be on the verge of a revolution in therapeutics, it may be said that bacteriology itself is on its trial in this momentous investigation.”

  By mid-November, Koch was ready to reveal something more. On November 13, in Berlin’s Deutsche Medizinische Wochenschrift, he published “A Further Communication on a Remedy for Tuberculosis.” (This report was quickly translated and published across the world; Conan Doyle read it in the BMJ two days later.) Up front, Koch acknowledged that his research was not yet complete.

  It was originally my intention to complete the research . . . before publishing anything on the subject. But, in spite of all precautions, too many accounts have reached the public, and those in an exaggerated and distorted form, so that it seems imperative, in order to prevent all false impressions, to give at once a review of the position of the subject at the present stage of inquiry.

  The caveats, though, soon gave way to the explicit suggestion that he’d made a stunning discovery. His substance appeared to have a dramatic effect on tubercular tissue, he explained, a reaction that was both pronounced and almost certainly therapeutic. Repeatedly he used one word to describe this new substance: Heilmittel, he called it. “The remedy.”

  • • •

  HOW MUCH WOULD “KOCH’S LYMPH,” AS TUBERCULIN BEGAN TO BE called, cost? How much was available?

  Koch was coy on all counts. He described his remedy only as “a brownish transparent liquid” and failed to elaborate. “As regards the origin and the preparation of the remedy I am unable to make any statement, as my research is not yet concluded; I reserve this for a future communication.” As to where and when his remedy might be available, his paper did offer a suggestion:

  Doctors wishing to make investigations with the remedy at present, can obtain it from Dr. A. Libbertz, Luneburger Strasse, 28, Berlin, N. W., who has undertaken the preparation of the remedy, with my own and Dr. Pfuhl’s cooperation. But I must remark that the quantity prepared at present is but small, and that larger quantities will not be obtainable for some weeks.

  That supply, though, was soon exhausted, and tuberculin would quickly become perhaps the most sought-after substance in the world.

  As Koch described it, tuberculin worked by provoking an intense reaction in the tissue and metabolism of consumptive patients. The response typically began with a strong fever, shaking, and general malaise. Infected tissue swelled up quickly, with noticeable reddening on scrofular wounds in the skin. Gradually, the infected flesh began to die. Koch noted that “the way which this process works is not yet fully understood because histological analyses are still not available. But one issue is already clear: the material does not kill the bacilli in the tissue directly, but instead, the tissue containing tubercle bacilli is affected by this treatment.”

  Curiously, Koch provided little in the way of actual statistical evidence to substantiate his claims. He justified this omission as one of professional courtesy:

  I have purposely omitted statistical accounts and descriptions of individual cases, because the medical men who furnished us with patients for our investigation have themselves decided to publish the description of their cases, and I wished my account to be as objective as possible, leaving to them all that is purely personal.

  Data or no data, Koch’s news was immediately hailed worldwide as the long-awaited cure for tuberculosis. “He has given the world a safe means with which to combat the angel of death named Consumption,” wrote the Vossische Zeitung, one of Germany’s leading newspapers, “for if that dreadful illness is recognized in time and treated properly, it is curable.” In America, a special cable dispatch of The Medical News described it as “the seed of a discovery the extent of whose fruit cannot be grasped by the human mind, and which bids fair to surpass the triumph of Jenner in his warfare against smallpox.” On November 16 the front page of The New York Times declared the news with the headline “KOCH’S GREAT TRIUMPH,” hailing the discovery “as one greater than Jenner’s.” Some desperate souls bought rail tickets to Berlin in the hope of convincing Koch to add them to his experiments.

  There was an immediate demand for additional information and for a demonstration of the therapy. This was hastily arranged for November 17, in Berlin. Von Bergmann would present evidence on his trials; Koch himself would be in attendance. With barely a few hours’ notice, physicians and scientists from throughout Europe hastily rearranged their schedules in order to be in Berlin. Soon, Berlin’s hotels and lodgings were filled with more than a thousand physicians—among them Arthur Conan Doyle.

  • • •

  CONAN DOYLE ARRIVED IN BERLIN ON SUNDAY, NOVEMBER 16. He was exhausted from his travels but invigorated. On the train, he’d met Malcolm Morris, a successful London dermatologist also en route to the demonstration. Morris was accompanied by a patient with lupus, and he had some hope of getting his patient enrolled in Koch’s remedy. They fell to talking, and Morris, who was twelve years older, saw something of himself in the younger doctor. Both were from Catholic families, and both had begun as general practitioners in the provinces. But Morris had aimed higher and broken out, and he urged Conan Doyle to do the same. “He assured me that I was wasting my life in the provinces and had too small a field for my activities. He insisted that I should leave general practice and go to London,” Conan Doyle said later. Morris suggested that he choose some specialty—the eye, Conan Doyle answered. Just right, Morris thought, suggesting, “thus, you will have a nice clean life with plenty of leisure for your literature.”

  This, of course, was the path that Conan Doyle had proposed for himself the previous year, when he allowed himself to dream that Micah Clarke might be a bestseller. But having that plan endorsed by Morris was something different.

  Conan Doyle had been an admirer of the germ theory since his medical school days; as he demonstrated in his “Life and Death in the Blood” essay, he recognized the power of both Koch’s and Pasteur’s work. But of the two, it was Koch with whom he was more philosophically aligned. Pasteur was an impetuous scientist, quick with a hypothesis even when he lacked evidence to support it. Sometimes, as in the case of silkworms, this could set him back years and cost dearly those who believed his conclusions. Moreover,
Pasteur was a chemist by training, not a physician like Conan Doyle.

  Koch, on the other hand, was a physician, and he had risen from obscurity, just as Conan Doyle yearned to. Koch had made his name by assembling evidence first; he built his case slowly and deliberately, just as Dr. Joseph Bell had taught Conan Doyle to do. In Berlin, Conan Doyle would finally have the opportunity to witness this process firsthand.

  When his train arrived in Berlin, Conan Doyle headed straight to the British embassy, where he hoped to get the ambassador’s help in securing one last seat for the next day’s demonstration. Alas, he went away empty-handed; tickets were “simply not to be had and neither money nor interest could procure them.” Not to be dissuaded, Conan Doyle found Robert Koch’s home. If he couldn’t get in by official sanction, perhaps he could impress the great scientist himself that he was worthy of a seat. Conan Doyle knocked on the door and waited.

  A butler answered, and Conan Doyle, who had learned German during his year in Austria, explained why he was there. The butler invited Conan Doyle to step inside and wait while he went upstairs to tell Herr Koch who was at the door.

  Scarcely twenty-four hours before, Conan Doyle had been at home in Southsea, and now here he was in Berlin, in Koch’s own house. Not only might he find his way into the demonstration, but he was about to meet the man whose work he had followed so closely for the past decade. Perhaps his exhausting trip would all be worth it.

  As he waited for the butler to return, the postman arrived to deliver the day’s mail. He carried a large sack and emptied its contents upon a desk in the foyer. A cascade of letters tumbled out, spilling over the tabletop and onto the floor. Conan Doyle sneaked a look at the pile and saw postmarks from all over the world. He realized that these envelopes were likely pleas from a thousand consumptives. These letters, Conan Doyle said later, were pieces of “all the sad broken lives and wearied hearts which were turning in hope to Berlin.”

  The butler returned and gave him the disappointing news: Herr Koch was unavailable. He would not see the unknown English visitor. Crushed, Conan Doyle thanked the butler and walked out. As Conan Doyle noted soon after, “to the Englishman in Berlin, and indeed to the German also, it is at present very much easier to see the bacillus of Koch than to catch even the most fleeting glimpse of its discoverer.”

  Conan Doyle found lodging for the night and, the next morning, headed straight to the lecture hall at the university. He passed a few deutsche marks to a porter guarding a door and slipped inside the outer hall. At an inner door, to the hall itself, he again offered a porter a few marks to let him through, but this one took offense, and Conan Doyle was rudely dismissed. People with tickets began to crowd through the door, bustling past Conan Doyle. He halfheartedly tried to blend in among them and slip through in the throng, but the porter called him out and pushed him back with a scold. Conan Doyle could do nothing but stand there.

  At last, the lecture hall was full, and Dr. von Bergmann came to the door with a few assistants, ready to begin the demonstration. Conan Doyle had one last chance. Begging von Bergmann’s pardon, he stopped him and asked for a seat. “I have come a thousand miles,” he implored. “May I not come in?” In ninety-nine cases out of a hundred, Conan Doyle figured, the request would have worked.

  But von Bergmann was the hundredth man. “There’s no place,” the German answered. “Perhaps you would like to take my place? That is the only place left. Yes, yes, take my place, by all means. My classes are filled with Englishmen already.” Von Bergmann’s coterie laughed at his mean joke, and Conan Doyle backed away.

  Conan Doyle turned toward the door in defeat, but just then another man stopped him. “See here,” he said to Conan Doyle. “That was bad behavior.” It was Henry Hartz, an American doctor from Detroit. He was headed into the hall and had heard von Bergmann’s snide insult. Quickly, Conan Doyle explained his predicament. Hartz couldn’t give up his ticket, but he offered to meet Conan Doyle that afternoon and share his notes from the lecture. Conan Doyle readily agreed. His trip might be saved after all.

  That afternoon, he met Hartz and read the notes closely, making his own copy. The two physicians got on well enough that Hartz invited Conan Doyle to join him the next morning on a visit to von Bergmann’s ward, to see firsthand the patients being treated with tuberculin.

  That next morning, the seventeenth of November, Conan Doyle and Hartz visited von Bergmann’s clinic. Conan Doyle was taken aback by what he saw. “A long and grim array they were of twisted joints, rotting bones, and foul ulcers of the skin, all more or less under the benign influence of the inoculation,” Conan Doyle described. “Here and there I saw a patient, bright-eyed, flushed, and breathing heavily, who was in the stage of reaction after the administration of the injection; for it cannot be too clearly understood that the first effect of the virus [the remedy] is to intensify the symptoms, to raise the temperature to an almost dangerous degree, and in every way to make the patient worse instead of better.” He then visited two other clinics where tuberculin was being tested on human subjects, and at last found his way inside Koch’s own laboratory on Klosterstrasse.

  There he was again denied an audience with Koch, but he did get a glimpse of what was one of the world’s greatest medical laboratories. “It is a large square chamber,” Conan Doyle described it, “well lit and lofty, with rows of microscopes bristling along the deal tables which line it upon every side. Bunsen burners, reservoirs of distilled water, freezing machines for the cutting of microscopic sections, and every other conceivable aid to the bacteriological student, lie ready to his hand.” He noted the array of samples laid out neatly on the tables, potatoes smudged with colonies of red or blue or black molds and fungi. And he got a chance to look under a microscope, one that Koch himself perhaps looked under, to see the spores and dots of Mycobacterium tuberculosis, Vibrio cholerae, and Bacillus anthracis. They looked so insignificant to him, barely more than grains of pepper, yet thanks to Koch, there was no doubt of their great and terrifying power. Conan Doyle noted the paradox:

  It is a strange thing to look upon these utterly insignificant creatures, and to realize that in one year they would claim more victims from the human race than all the tigers who have ever trod a jungle. A satire, indeed, it is upon the majesty of man when we look at these infinitesimal and contemptible creatures which have it in their power to overthrow the strongest intellect and to shatter the most robust frame.

  • • •

  THAT AFTERNOON, CONAN DOYLE RETURNED TO HIS HOTEL ROOM and began writing his first dispatch, a letter to The Daily Telegraph. Though the editors titled the letter “The Consumption Cure,” Conan Doyle’s frank assessment was that it almost certainly was nothing of the sort. “Great as is Koch’s discovery, there can be no question that our knowledge of it is still very incomplete, and that it leaves large issues open to question,” he wrote. “The sooner that this is recognised the less chance will there be of serious disappointment among those who are looking to Berlin for a panacea for their own or their friends’ ill-health.”

  He described the rounds he’d taken in the Berlin clinics, noting that Koch himself couldn’t claim that his substance actually killed bacteria. Conan Doyle suggested a sobering analogy: “It is as if a man whose house was infested with rats were to remove the marks of the creatures every morning and expect in that way to get rid of them.” This was clearly no cure, at least in Dr. Conan Doyle’s assessment.

  With that, Conan Doyle headed back to Southsea, where he had a few days to craft his essay for The Review of Reviews. The essay was a much more deeply considered exploration of Koch and his work than the Telegraph letter, four thousand words in all. It described the man down to his “small, grey, and searching” eyes and “slightly retroussé nose.” Conan Doyle covered Koch’s years in Göttingen working with Jacob Henle and captured his years of obscurity in Wöllstein: “Poor, humble, unknown, isolated from sympathy and from the scientific applian
ces which are the necessary tools of the investigator.” It’s a vivid portrait, and remarkably spot-on, as if Conan Doyle had been somehow observing Koch during those years. In a way, perhaps, he was, since the words could equally describe Conan Doyle: “He was a man of too strong a character to allow himself to be warped by the position in which he found himself, or to be diverted from the line of work which was most congenial to his nature.”

  Conan Doyle succinctly summarized Koch’s work on anthrax and cholera, crediting his research on wound infections as vindicating Lister’s efforts. He praised Koch as the “great master mind” and the “noblest German of them all.” But ultimately, Conan Doyle came to the same, cold assessment that he had in The Daily Telegraph: Koch’s lymph almost certainly had no effect in actually treating the disease. “Unfortunately, it is evident that the system soon establishes a tolerance to the injected fluid, so that the time must apparently come when the continually renewed tubercle tissue will refuse to respond to the remedy. In the case of true phthisis of the lungs . . . the evidence is so slight that we can only regard it as an indication and a hope, rather than a proof.”

  The remedy might not be altogether useless, though. Conan Doyle suggested that it likely had great value as a diagnostic for tuberculosis, in a smaller dose (which, as it happened, would turn out to be exactly its true utility). He concludes by noting Koch’s own candor and thoroughness; he fully expected Koch to emerge from his isolation and volunteer “the weak points and flaws in his own system.”

  Back in Berlin, though, Koch was busy contending with the frenzy that he’d set off: the experiments, the ravenous appetite for tuberculin, the requests from press and politicians and the public. We can’t say whether he was aware of Conan Doyle’s critical assessment; even had he been, he would likely have dismissed it as ill-informed speculation, more noise from the cynical mob. Nonetheless, amid the hysteria breaking out throughout Europe over Koch’s remedy, Conan Doyle’s was almost certainly the first thorough appraisal of tuberculin, based on an examination of patients under treatment. It was a rigorous debunking, using Koch’s own model of logic and analysis to reveal his remedy’s weaknesses.