The Remedy

by Thomas Goetz

  On January 7, 1891, Virchow addressed the society, offering a pathological assessment of Koch’s lymph. Inspecting tubercular tissue after a dosage of tuberculin, Virchow detected the dying flesh, or necrosis, that was by now the familiar result of the treatment. But he also clearly detected fresh tubercles, newly sprouted on the edge of the dead tissue. The tuberculin, Virchow suggested, might have some effect on diseased tissue, but it seemed to do nothing whatsoever to abate the actual progress of the disease. Indeed, Virchow argued that the treatment was not only ineffective but also dangerous, and that it likely provoked the spread of the disease.

  Virchow’s negative assessment proved a turning point. In barely two months, the remedy had gone from a great triumph to occasionally ineffectual to possibly detrimental. Students of Virchow’s began referring to the “tuberculin swindle,” and Koch was feeling the pressure. On January 15 he at last published a description of tuberculin in general terms: It was, he explained, an extract of dead tuberculosis bacteria mixed in water with an equal part of glycerin. As Koch himself demurred, “My new remedy against tuberculosis is therefore nothing more nor less than a glycerine extract of a pure culture of tubercle bacilli.” It seems likely that Koch himself didn’t understand how his substance produced a reaction. Still, that reaction was something, Koch continued to believe.

  By this time, the German government had put the funding for his new institute on hold. The Medical Society’s debates continued, casting more doubts on tuberculin and on Koch’s entire approach: his premature announcement of a remedy, his poorly designed and supervised experiments, his maneuvering for financial gain, his secrecy. In just two months, the career he’d spent the past fifteen years carefully building seemed to be suspect, his character and his science under assault.

  By January 25 the controversy had become overwhelming for Koch. With scarcely any notice, he packed up and left for Egypt on a holiday. The tuberculin experiments were left under the supervision of Eduard Pfuhl, his assistant and son-in-law. He refused to return, he wrote Pfuhl, until funding for a new institute was officially approved. In the meantime, he played the tourist, visiting the ruins of Luxor, exploring the delta north of Cairo, and even getting a suntan. He wrote forlorn letters to Hedwig, his now-eighteen-year-old mistress, calling her by her nickname, Hedchen. “You must know that my discovery has brought out the vultures,” he said. “Above all I believe that my work will be successful, but it’s going to take a bit of time to prove it. . . . Tell me what you are doing and if you are thinking of me. . . . Dearest Hedchen, if you love me, then I can put up with anything, even failure. Don’t leave me now, your love is my comfort and the beacon that guides my path.”

  He was supposed to be gone for a few weeks. But he wouldn’t return to Berlin for three full months.

  • • •

  WE KNOW TODAY THAT KOCH WAS BLINDED BY HIS OWN AMBITION. He so wanted tuberculin to be the cure he sought that he failed to follow his own scientific protocols. In this, he had tripped over one of Sherlock Holmes’s maxims: “It is a capital mistake to theorise before one has data. Insensibly one begins to twist facts to suit theories, instead of theories to suit facts.”

  So why did he overreach? The answer is surely a combination of factors that drove him to put too much faith in too little evidence. There was the pressure from his government, pushing him in August 1890 to make a bold announcement, and then, once he had delivered on its request, pushing him again to turn his preliminary observations into fact. There was Koch’s great hunger for his own institute, one designed around his expertise in bacteriology. To that end, tuberculin became his greatest bargaining chip, one that he surely overplayed when he asked to retain monopoly control of the cure and the proceeds from it.

  There was also the great competition with Pasteur and legion other scientists. Fifteen years before, the entire field of bacteriology seemed Koch’s exclusive domain. But in the years since, it had become the most vibrant area in science, with many ambitious upstarts—most of whom had trained either in his lab or with Pasteur. For all Koch’s success in discovery, Pasteur had always bested him when it came to developing therapies, and tuberculin seemed to Koch his best opportunity not only to match his Parisian nemesis, but to outdo him altogether.

  And finally, there was young Hedwig. While she worshipped him, she hadn’t been around when he was doing his best work. Had tuberculin worked, she would have stood beside him as his reputation, and wealth, soared.

  As 1891 wore on, more physicians looked at the numbers and regretted ever having put stock in Koch’s remedy. In March, assessing his own experiments with the vaccine, the director of the New York Bacteriological Institute lamented that “we are . . . assisting at the spectacle of one of the greatest medical and scientific delusions that has ever existed.” At a meeting for internal medicine in Wiesbaden that April, many physicians described their disappointment with Koch’s tuberculin in language that sounded like it came from the confession booth. At first, as one doctor described, “the present speaker allowed Koch’s discovery to affect him with the full enthusiasm that he was bound to feel. . . . But with the passing of time his self-awareness as a physician increasingly came into conflict with that enthusiasm . . . so that today he no longer dares to use the remedy.”

  In May, Nicholas Senn, a prominent surgeon in Milwaukee, Wisconsin (and later a president of the American Medical Association), wrote a scathing essay entitled “Away with Koch’s Lymph!”

  When, six months ago, the telegraph operator at Berlin touched the key of his instrument and flashed to all parts of the civilized world the joyful tidings that a cure for tuberculosis had at last been discovered, the people and the profession felt that the millennium in medicine had come. . . . No other event in the world’s history ever attracted so much attention, and no discovery in medicine or surgery ever found such ready introduction and universal acceptation. . . .

  Enough time has now elapsed to judge of the merits of the treatment of tuberculosis by Koch’s lymph, or, as it is now called, tuberculin. . . . Koch’s lymph has been a deceptive bubble which for a short time commanded the attention and admiration of the whole world, but which has been ruthlessly pricked by the critical scalpel.

  Dr. Senn’s was among the more thorough debunkings of Koch’s remedy, and his repugnance was widely shared. Physicians felt they had been duped into dispensing a secret medicine, despite their training that such was anathema to real science. A Berlin physician who had conducted many early tuberculin trials acknowledged that the dubious experiments with the remedy “did not meet the standards of modern science, and its introduction into the sick human body was irresponsible.” A German magazine went so far as to suggest that for Koch’s next experiment, he should pursue a cure for the “fraud bacillus.”

  Whispers began circulating: Worse than merely being wrong, Koch had tried to profit from the poor souls with TB. Perhaps, it was rumored, he felt compelled to make money to indulge his young and beautiful girlfriend.

  For Koch, the criticism must have been infuriating, particularly considering the praise Pasteur had received after trotting out his vaccines, one after another. Koch, after all, was characteristically the more prudent scientist; he was the more diligent researcher.

  That’s where Koch caught himself in his own trap—because he himself had used the word Heilmittel, “remedy.” He had chosen that term, with all its associations, its mystique of health, and its history of false promises. He had offered the ultimate covenant of medicine: that it could undo what nature had done. He had played on his reputation, and the world had taken him at his word. As Harold Ernst, an American physician who visited Berlin, told the Harvard Medical School in January of 1891, before the backlash had turned to outright disgrace, “He is the one man in scientific medicine who thus far has never made a mistake. . . . He is practically the one man by whom the possibility of research in bacteriology has been laid open to us by the development of [his] me
thods.”

  Koch had violated the principles that he himself had laid down, his own postulates. Koch had gotten ahead of his evidence. He had made a leap and been caught without a place to land.

  • • •

  AMONG THE MANY IRONIES OF KOCH’S REMEDY WAS THAT IT INSPIRED A NEW WAVE OF FALSE CURES. ALMOST IMMEDIATELY AFTER the November announcement, when demand for the remedy was so great around the world, there were those who peddled concoctions they claimed to be Koch’s tuberculin. Then there were the sound-alike medicines: tuberculocidin and tuberculinum and tuberculozyne, tuberclecide and tuberculoids. Taking a page from Koch, these cures claimed to be “scientific,” emerging out of “research laboratories,” and “German treatments.”

  The difference between these quack cures and their sheen of science and Koch’s true science was getting lost. The sad coda to the tuberculin fiasco is that over his career, Koch had established a citadel of evidence that proved, as no one had before, that germs are the agent of disease. He had turned that far-fetched idea into a new truth, one that normalized the radicals and marginalized the traditionalists. In the germ theory itself, he had introduced a remedy that was already reducing tuberculosis’s deadly hold on the world. And in his discovery of the tuberculosis bacterium, he had shifted the disease from something mysterious and impenetrable into something that could be understood and defended against. That idea, more than any single vaccine or specific treatment, was the real remedy, one that would save millions of lives.

  To be sure, the idea of hygiene predated Koch by several decades. In the mid-nineteenth century, hygiene captured the passion of social reformers, who recognized that disease went hand in hand with filth. Edwin Chadwick first captured this spirit in his 1842 report on sanitary conditions in Britain, observing that epidemic and endemic disease “is always found in connexion with the physical circumstances . . . and where the removal of the noxious agencies appears to be complete, such disease almost entirely disappears.”

  In 1858, Florence Nightingale built upon Chadwick’s observations with a statistical analysis of mortality in hospitals. “A vast deal of the suffering, and some at least of the mortality, in these establishments is avoidable. . . . Deficient ventilation and over-crowding accompanying such defects, is to be attributed a large proportion of the evil.” Her conclusions compelled new standards for hospital design and construction. In the 1860s, German science joined the cause, with Virchow in Berlin and Max von Pettenkofer in Munich advocating massive new public sanitation projects.

  But though their purpose was just and their analysis correct, the scientific thesis of these hygienists was largely wrong. They fixated on water and “tainted air” as the agents of disease, rejecting outright any notion of germs. Nightingale offered a typical argument in 1862: “What does ‘contagion’ mean? It implies the communication of disease from person to person by contact. It pre-supposes the existence of certain germs like the sporules of fungi. . . . There is no end to the absurdities connected with this doctrine.”

  What Koch provided through his postulates and his discoveries was proof, real scientific evidence that germs caused disease. So the rationale for hygiene was established: Disease-causing germs must be avoided, rooted out, and eliminated at every opportunity. Moreover, Koch’s evidence was convincing enough to change not just science or policy, but society itself. He wasn’t trading in vague fears about bad air; he was providing specific causal information about microbes—with photographs, no less.

  This specificity provided the leverage for the next wave of reformers to establish social solutions to disease on a vast scale. Where Pasteur focused on treating individuals, Koch’s science led to interventions on a much broader scale, with the potential to affect and improve the lives of many more people. Koch’s science gave the germ theory scale; it gave it a reach far beyond the laboratory or even the doctor’s office. It moved it into the social realm, where true revolutions happen.

  It’s hard to overstate the impact of this idea; it transformed the social landscape of everyday experience. In the 1880s and ’90s, the water pumps seen throughout most European and American cities became suspect, not only because of the source of the water, but because of the metal cup that was typically chained nearby so that anybody could take a drink from it. Once people realized that germs could spread via the cup, these soon were clipped off (to be replaced, a few years later, with the invention of the disposable paper Dixie cup). People became suspicious of public washrooms. Library books became questionable, since borrowed volumes “may bring the dreaded germs of diphtheria or typhoid fever into homes.” Germ theory took such a hold that the New York Public Library assured patrons it would disinfect books periodically, so that “not a live germ can be found.” Not even money escaped scrutiny, with “clean money” campaigns catching on worldwide in the 1890s. The New York City Board of Health subsequently analyzed paper currency and coins for bacteria, finding little on coins but thousands of spores on dirty bills. Though the Board of Health found no evidence of “the actual transfer of disease through money,” it nonetheless recommended that the US Mint remove old currency from circulation more frequently.

  Disinfectants—which had been controversial in hospital operating rooms in the 1860s, when Lister first proposed them—began to be used in ordinary households. The first, appropriately, was called Listerine. Invented in 1879 by a St. Louis doctor as a surgery disinfectant, it was later sold as a floor cleaner and treatment for venereal diseases (and later still, for halitosis). Ivory soap, one of Procter and Gamble’s first products, went on the market in 1879 and was soon followed by other soaps and disinfectants. In 1882, New York’s Casper Cohn started selling Germicide, an apparatus for delivering a proprietary blend of a bacteria-killing formula; his first brochure noted that “although the reception of the germ theory of disease has been gradual, it may now be said to be clearly established in the public mind.”

  Robert Koch can also be thanked for helping to curb the habit of spitting. Before his discoveries, spitting was thought to be merely uncouth. But after he established that contagious germs could be passed via saliva, the habit was seen as downright dangerous. An 1882 essay in Modern Medicine and Bacteriological World made it seem yet more malevolent:

  The man who hawks on the street and constantly clears his throat in company, or expectorates indiscriminately, whether walking or sitting is surely an object of dread to all refined natures, if not an actual menace to public health in general. I have known one pachydermatous individual, who was suffering with lung trouble, and yet thoughtless enough to foist his undesirable presence on a group of men, quickly clear a room or office of his erst-while sympathizers by coughing, hawking, and spitting in a handy spittoon.

  Soon this disdain began to coalesce into a campaign. Citing “the correctness of Koch’s theory” in 1885, Dr. J. M. Emmert, the president of the Iowa State Board of Health, urged that a broad new antispitting social policy be enacted. “How necessary it is,” he argued, “to prevent the spitting by tuberculous persons upon the streets, in stores, hotels, depots, railway cars, in fact anywhere and everywhere.”

  In cities and nations, there were growing campaigns against spitting, turning tolerance into revulsion. In France, this was girded in the tenor of war. “Le crachat, voilà l’ennemi!” (“Spitting, that is the enemy!”) one French periodical told its readers. “Each crachat is, alas! a veritable army of billions of vigorous microbes, that [one] sends to attack the health of [one’s] wife, children, friends, and neighbors.”

  In American cities, antispitting associations began to form, calling on politicians to outlaw public expectoration and posting signs chastising spitters—“Spitting is DANGEROUS and ILLEGAL!”—in rail stations and other public spaces. In 1896, New York City passed an antispitting statute (the predecessor to today’s bans on cigarettes and Big Gulps), and the next year, ordinances were passed in Rochester, New York, and Columbus, Ohio. Soon most major cities in the Unit
ed States had outlawed public expectoration.

  • • •

  IN 1892 THE FIRST ORGANIZATION DEDICATED TO THE ERADICATION of tuberculosis was formed in Pennsylvania; within twenty years, nearly every major city and every European nation had a similar group, dedicated to destroying the disease through not the application of a specific drug or treatment, but the dissemination of information. In fact, the campaign against TB would be the first mass health education campaign directed at one disease. Not just a campaign of doctors and scientists, it would soon recruit the whole of society, from US presidents to housewives. Koch’s germ theory was changing behavior at every level of society. He’d convinced science and society that germs could be lethal and that if we avoided the bad ones, we could avoid disease.

  In August 1892, Koch finally had a chance to demonstrate this himself, when the city of Hamburg, in northern Germany, experienced a violent cholera outbreak. In the space of a few weeks, more than seventeen thousand cases and eight thousand deaths were reported, causing a national panic. Koch arrived and soon began looking in the water for the telltale bacterium, the same one he’d identified years before in India. He soon found it festering in the city’s aboveground water supply. The next question was how to keep the disease from returning. Koch showed that a belowground supply would provide a natural sand filter that screened out the microbe. Based on this work, the German government required all municipalities to examine the sources of their water supply and apply filters where necessary.

  To see disease in order to stop it: This principle had perhaps its greatest champion in Hermann Biggs. While a student at New York City’s Bellevue Medical College, Biggs was taught by William Henry Welch, who had the good fortune of working in Koch’s Berlin laboratory in 1885. (Welch would go on to be one of the most famous physicians in the United States.) In 1882, when Koch discovered the Mycobacterium tuberculosis, Welch impressed upon his students, including Biggs, the significance of the discovery. A decade later, in 1892, Biggs opened a new bacteriological laboratory for the New York City Department of Health, modeled on Koch’s own laboratory principles. Just weeks after opening the lab, Biggs began racking up triumphs, including detecting cholera on a newly arrived ship of immigrants (their quarantine prevented an outbreak spreading in the city) and, in 1893, locking down a Russian ship contaminated with typhus.