The Remedy

by Thomas Goetz

  In 1900, Koch finally returned to Berlin to accept the appointment as director of a new Institute for Infectious Diseases. (The previous institute, established after the frenzy over tuberculin, had become too small for the demands of modern microbiology.) This would be his final official affiliation in Berlin. The designation was largely honorary; he appeared to have no official administrative or scientific duties. But at this new institute, as before, he would have a personal lab to carry out his own work. There, perhaps, he could rebuild his reputation and return to the serious study of microorganisms and disease.

  Then tuberculosis, Koch’s great nemesis and accomplice at once, again demanded his attention. In July 1901 he was invited to London to attend the British Congress of Tuberculosis, conceived as an international assessment of the battle against TB as the new century dawned. Though there had been much research since Koch’s great discovery of the bacilli twenty years earlier, true progress toward cures or treatments had been disappointing. But there was hope in hygiene, especially in new ideas about preventive measures between animals and humans, where it was suspected many cases of the disease began.

  As far as the congress organizers were concerned, Koch’s presence was largely ceremonial, a nod to his original discovery of the bacilli. But Koch had other ideas. On the first day, he received a medal for his contributions to science and then was invited to the podium to deliver some remarks. His topic was the relationship between human and bovine tuberculosis. Since his 1882 discovery, it was widely known that cows, as well as humans, suffered from something like tuberculosis. Building on the germ theory, most scientists believed that cows could be a vector for the human disease, the bacteria passing through the milk of an infected animal. This theory seemed in keeping with Koch’s work, since it traced a specific trajectory from animals to humans. It was bolstered by the discovery of a mycobacterium in cows in 1898.

  As Koch began his remarks, though, the audience seemed baffled by his flow of thought. Instead of endorsing a link between the human and bovine diseases, Koch’s language went the other way, until it dawned on the crowd that Koch, remarkably, was outright denying any connection between the two diseases. He had inspected the bovine bacterium, he said, and found it altogether unlike the human bacterium he had isolated twenty years earlier. Therefore, he said, there could be no connection. As for any preventive measures aimed at intercepting the spread of tuberculosis from cows to people, he considered them altogether useless. “I should estimate the extent of infection by the milk and flesh of tubercular cattle and the butter made of their milk as hardly greater than that of hereditary transmission,” he said, knowing full well that the disease’s bacteriological nature made hereditary transmission impossible. “I therefore do not deem it advisable to take any measures against it.”

  His remarks couldn’t have been more disruptive than if he’d renounced the germ theory altogether. Here was Koch, the great visionary, denying a link that dozens of other scientists—building on Koch’s own work—had validated. The claim drew immediate retorts, with von Behring the most vocal. They were undoubtedly the same disease, von Behring stated, insisting that most cases of pulmonary tuberculosis in childhood came from infected milk.

  But Koch’s opinion couldn’t be dismissed. After all, his argument rested on his undisputed expertise with the microscope: Two different bacteria, he held, were responsible for the disease in the two host organisms. Almost immediately, governments in Britain, Germany, and the United States organized commissions to assess the evidence and reinvestigate whether there was, in fact, a link between the diseases.

  The issue was more than merely academic. In recent years, public health officials in Europe and the United States had been recommending that all milk be purged of infectious microbes by a quick boil prior to sale. The process is known, of course, as pasteurization, after its inventor, and Koch’s great rival, Louis Pasteur. Pasteur had created the method in the 1860s as a treatment for preserving wine, in order to rid it of uninvited yeasts. With a likely link between tuberculosis in humans and cows, it seemed natural to extend that process to milk.

  Pasteur himself had died in 1895. It was somehow fitting that he would be coming back from the grave to confront Koch one last time. Even with one of them dead and buried, the two scientists were again on opposite sides of a debate.

  Within a few months, the various commissions began to deliver their verdicts. Alas, it seemed clear that Koch was absolutely and outrageously wrong. The microbe, the American and British groups reported, was the same in both humans and cows; it was just that the tubercle bacilli, so wily all along, took a slightly different form in the bovine. (The German commission, misguidedly, sided with its national hero.) As von Behring had insisted, infected milk was a significant source of tuberculosis infection in humans. The statistics were unequivocal: In New York and Britain, as many as two-thirds of childhood cases were attributable to infected milk. Among adults, cases of crossover infection were less common, but they did, undoubtedly, happen often enough to be of great concern. The research convinced many cities, especially in the United States, to mandate the pasteurization of milk. Those cities that did so soon saw the number of TB cases drop significantly. Alas, in Europe, particularly in the United Kingdom, farmers resisted such measures, unnecessarily dooming many citizens to a fatal disease.

  For Koch, it was a horrible blunder. He had once more stepped willfully into a controversy over tuberculosis. Once more he found himself squarely on the wrong side of the evidence. And once more he would refuse to concede his error. Though he had made his name on careful observation and meticulous research, he had now twice shot off an opinion, cloaking it in his authority rather than heeding his own methods of investigation and reinvestigation. And now he had twice been proven wrong.

  The embarrassment grew later that year, in the fall of 1901, when von Behring, not Koch, was selected to receive the first Nobel Prize in physiology or medicine. The Nobel Prizes had been generating excitement in science circles for several years, ever since they had been spelled out in the last testament of Swedish industrialist Alfred Nobel. This was to be the year for the first prizes, with the announcement scheduled for December 10, the fifth anniversary of Nobel’s death.

  The choice of von Behring, in recognition of his work on the diphtheria antitoxin, offended Koch, and not just because von Behring had worked under Koch in Berlin. Koch felt slighted also because von Behring’s work would have been impossible without Koch’s. The very notion of immunology and antitoxins relied on the bacteriology that Koch had standardized. It was Koch who had laid the groundwork for modern medicine—Pasteur as well, to be sure, but he was dead, and the prize could go only to the living. And who among the living had done more for medical science than Robert Koch?

  The determination that von Behring’s one antitoxin therapy was more prizeworthy than Koch’s years of microbial discoveries once again put Koch on the less celebrated side of bacteriology. Just as Pasteur’s treatments for anthrax and rabies sometimes outshone Koch’s detective work, here von Behring was receiving the laurels (nothing less than the highest medical honor ever created!) because he had cooked up a treatment, rather than the process that enabled it. And Koch no doubt heard that, when von Behring arrived in Stockholm to accept the prize, he took the stage and promised to use the prize money to prove that human and bovine TB were the same disease. Even worse, von Behring said he hoped to develop a vaccination for tuberculosis in cows and perhaps in humans, too.

  Koch’s offense would only grow when, in 1902, the second Nobel Prize for physiology or medicine went to Ronald Ross, for identifying the mosquito as the vector for malaria, and then again in 1903, when the Nobel was given to Niels Ryberg Finsen, for treatment of skin diseases. Then, in November 1904, the news appeared in Science and elsewhere that Koch would at last be recognized by the Nobel commission and had been chosen to receive that year’s prize. But it was a cruel rumor; the reports were
in error. Instead, the Russian physiologist Ivan Petrovich Pavlov was invited to Stockholm that December, in recognition for his work on reflexes.

  Koch’s work, it seemed, would go unrecognized. Had his failed remedy so tarnished all his previous contributions? Had that one failure—and what was science without failure?—undone his many triumphs: the work on anthrax, cholera, the postulates, the wound theory, and the discovery of tuberculosis bacteria, perpetrator of such misery, the greatest disease of the age?

  A year later, in October 1905, at last Koch received a telegram from Stockholm informing him that he would indeed receive the Nobel Prize in medicine. This time it was official: The award was being given, the telegram said, for his work in 1882 identifying the bacteriological agent of the worst disease that humanity had ever known, tuberculosis. In his Nobel lecture on December 12, 1905, Koch reflected on the current state of tuberculosis research, noting the dramatic decrease in fatalities from the disease since the mid-1800s. He attributed this drop-off to several factors, including better housing and health among the lower classes and “improved knowledge of the risk of infection,” which is to say, acceptance of the germ theory. He also praised the efforts at removing contagious tubercular patients from the general population and sending them to sanitariums, which both improved the health of tuberculars and reduced the spread of the disease. He allowed, however, that hospitalizing all these people would be “out of the question,” given their sheer numbers.

  “If we look back on what has happened in recent years in the fight against tuberculosis as wide-spread infectious disease, then we cannot help but gain the impression that quite an important beginning has been made,” he concluded. “If the work goes on in this powerful way, then the victory must be won.”

  In Koch’s last years, more committees and honors would come his way. The Institute for Infectious Diseases was officially renamed the Robert Koch Institute. He took more trips to foreign lands, accompanied always by Hedwig. Still, he would never shirk controversy. At the 1908 International Congress on Tuberculosis, in Washington, DC, he doubled down on his insistence that there was no connection between bovine and human tuberculosis. But this time, the reaction was rather cool. Where in previous years his opinion had forced international investigations and would have swayed his colleagues and steered the agenda, this time he was the outlier. In its final resolutions, the congress repeatedly contradicted Koch’s conclusions, choosing instead to recognize bovine tuberculosis as contagious. As one delegate remarked, “Dr. Koch isolated the tubercle bacteria; today, science has isolated Dr. Koch.”

  Even in his moments of greatest glory, Koch was always the outsider. Science for him had begun as the pure pursuit of knowledge, and it was that focus, that purity of purpose, that allowed him to make his breakthroughs. His deep flaw was that, like so many men, he hungered not just for discovery, but also for the glory and recognition and stature that came with it. He overreached, and then he castigated those who would hold him to his own standards. He claimed a cure before he had the evidence, and then spent the rest of his life trying to prove his point.

  In 1904, when he could plainly see the field of tuberculosis research drifting away from him, he wrote to a friend from his Breslau days, who knew him when he was an unknown country physician and who was there when bacteriologists seemed to have the gods at their backs. “Your letter most vividly takes me back to the old days,” Koch wrote,

  when we could freely and without interference pursue our studies. Over time, this has greatly changed, alas. Whatever I tackle and undertake nowadays, a crowd of jealous and resentful individuals always turns up and jumps onto the same subject in order to start a controversy. . . . Today every little yapping dog will inoculate a single calf, write half a dozen articles about it afterward and carry on as if this case of his has solved the whole question, and of course in his favor. . . . Yes indeed, research would be a fine thing if everyone could think logically, but unfortunately this is the case for a small fraction only. Besides I believe that in my work my lot was particularly hard and I encountered more criticism, unjustified criticism, than anyone else.

  Even in his last years, Koch couldn’t quite admit that more than any enemy or adversary, he was the agent of his own disappointments.

  • • •

  IN MARCH 1910, KOCH WAS BACK IN HIS LABORATORY IN BERLIN, once again working on tuberculin, when he felt a sharp pain in his chest. It was almost certainly a heart attack. After another episode in April, he arranged to move to the clinic of Dr. Franz Dengler, outside Baden-Baden. As it happened, Koch was now just across the Rhine River from Alsace, the territory that Germany had seized forty years before, after the Franco-Prussian War. The clinic had opened as a sanitarium in 1890, built, in classic protocol, next to a hot springs in the Black Forest. In his first days there Koch reported feeling better. Perhaps he would be able to return to Berlin soon. Perhaps he might even return to the laboratory. Then, on the evening of May 27, he stepped out onto his balcony, taking in the fresh air and the sun setting over a nearby park. Just before dinner, a friend stopped by to check in on him. He found Koch on the balcony, slumped in a chair, dead of a heart attack. He was sixty-seven years old.

  • • •

  IN 1901, ARTHUR CONAN DOYLE DID WHAT HE HAD VOWED NEVER to do: He brought Sherlock Holmes back to life.

  In March of that year, Conan Doyle had gone on holiday with his friend Bertram Fletcher Robinson in Norfolk, in the East of England. As they toured the area, Robinson told Conan Doyle about his youth in Devon and of the legend of Richard Cabell, a seventeenth-century local man who was rumored to have sold his soul to the devil and who led a pack of hellhounds across the moor for years after his death. Conan Doyle was inspired by the tale and began sketching out a mystery, “a real Creeper,” as he imagined it. Since every mystery needs a detective, he revived his own, in Sherlock Holmes. And in August 1901, the first installment of this new Holmes novel appeared in The Strand. This was The Hound of the Baskervilles.

  Conan Doyle made clear that, technically, the story didn’t mean that Holmes had returned from the dead. He set the story in 1889, before the standoff with Moriarty at Reichenbach Falls. But chronology notwithstanding, Holmes was back, and the public was overjoyed. In that first installment, The Strand sold thirty thousand more copies than usual, and the story was celebrated as Holmes’s—and Conan Doyle’s—return to form.

  The final installment of Baskervilles appeared in April 1902. Within eighteen months The Strand would have another Holmes story for its readers, and this time Holmes was back for real. In “The Adventure of the Empty House,” Holmes turns up one day at 221b Baker Street to surprise Dr. Watson. He survived the fall at Reichenbach Falls, he tells his friend, and spent the past three years (it was a ten-year absence in real time) traveling in Florence, Tibet, the Middle East, and, finally, France. “I owe you many apologies, my dear Watson,” Holmes explains, “but it was all-important that it should be thought I was dead, and it is quite certain that you would not have written so convincing an account of my unhappy end had you not yourself thought that it was true.” This wasn’t just Holmes speaking to Watson; this was Conan Doyle speaking to the entire world.

  What made Conan Doyle change his mind and bring Sherlock Holmes back from the dead? First, in 1900 Conan Doyle had spent several months serving with the British army in South Africa, where the Boer War was under way. He reported for duty as a surgeon in the Royal Army Medical Corps, and just as Koch had during the Franco-Prussian War three decades earlier, he soon discovered how odious war could be. “You can find your way from Modder to Bloemfontein by the smell of dead horses,” he wrote in his diary. The human toll affected him deeply, particularly after an epidemic of typhoid fever that broke out among British troops. Though he’d written about infectious disease in his Koch essays a decade before, the face-to-face ravages appalled Conan Doyle. “The outbreak was a terrible one,” he noted. “We lived in the midst of death—a
nd death in its vilest, filthiest form.”

  Then, in September 1901, the American actor William Gillette brought his play Sherlock Holmes from Broadway to London. The play, a mash-up of various Holmes plots, had run to a packed house for eight months in New York. Audiences loved Gillette’s embodiment of the Holmes character, down to the bent briar pipe, the cape, the magnifying glass, and the deerstalker hat. The magnifying glass had of course appeared in Conan Doyle’s stories; Gillette found the prop particularly well suited to the theater and brandished it with a flourish. The cape and hat were not Conan Doyle’s invention, but rather had appeared in Paget’s drawings. But the pipe was all Gillette’s inspiration, as was the phrase he added to the script: “Elementary, my dear Watson.” (The line never appears in a Conan Doyle story.)

  On September 9, Conan Doyle attended the play’s opening night at the Lyceum Theatre. Though he knew of the play’s success in New York, it was quite another thing to watch the crowd thrill to Gillette’s performance with his own eyes. After the final curtain, Conan Doyle stepped out of the audience to join Gillette onstage. The applause went on for many minutes, and Conan Doyle, standing next to the physical embodiment of his detective, took bow after bow. It was a thrilling moment, giving him a visceral, firsthand encounter with how deeply people adored Sherlock Holmes. “Sherlock is going to be a record,” he wrote his brother about the play, “and beat Charley’s Aunt”—Charley’s Aunt being the most successful play ever staged in London theater at the time, running for a record 1,466 performances in the 1890s. Though Sherlock didn’t quite beat that mark, it was indeed a smash for several years.

  There was also the matter of Conan Doyle’s wife, Touie, and her health. Consumption still racked her. It had been nearly a decade now since her diagnosis, and she’d likely been suffering from the disease for years longer. After the Conan Doyles returned from Davos in 1897, they had immediately started construction on Undershaw, a new estate in Surrey. Conan Doyle had heard the area described as an “English Switzerland,” with good air ideal for Touie’s health. He spared no expense in creating a large, airy house situated to capture plenty of sunshine. But the disease held fast. Like so many millions before, Touie never shook it. She and Conan Doyle took other palliative trips, including several months in Egypt and a spell back to Switzerland, but full recovery was elusive, and by 1900 she was considered, in the language of the day, an invalid.