by Peter Watson
But he was never just a medical man. In 1848 a typhus epidemic swept through the Prussian province of Upper Silesia, and Virchow was one of the team of physicians sent by the government to visit the afflicted region and survey the damage. While there, Virchow came face-to-face with the destitute Polish minority, struggling in appalling circumstances. And so, instead of returning to Prussia with a set of strictly medical guidelines, Virchow’s report recommended political change, plus sweeping educational and economic reforms. It was hardly what the government had bargained for.
His political beliefs led him to take part in the uprisings of 1848 in Berlin, where he fought on the barricades, afterward becoming a member of the Berlin Democratic Congress and editor of a weekly entitled Die medizinische Reform. This was heady, but in 1849 he was suspended from his academic positions. He quit Berlin and took up the recently created chair in pathological anatomy at the University of Würzburg, the first of its kind in Germany. While there he was for a time distanced from political activity, and it was then that he achieved his greatest scientific contributions, establishing in particular his concept of “cellular pathology.” In 1856 Virchow returned to Berlin as professor of pathological anatomy and director of the newly created Pathological Institute.
THE FOUNDATION OF BIOETHICS
Now that he was back in Berlin, however, Virchow’s old political instincts began to revive. He became a member of the Berlin City Council, where he concerned himself with public health and was instrumental in improving both the sewage system and the water supply of the city. Emboldened by these successes, he was in 1861 elected a member of the Prussian lower house, representing the liberal German Progressive Party, which he helped to found. Most notably, the Progressives opposed Bismarck’s policy of rearmament and forced unification, a resistance that provoked Bismarck so much that he challenged Virchow to a duel. Virchow had the sense not to rise to the bait, and in the Franco-Prussian War of 1870–71 proved himself no mean nationalist, helping to organize hospital facilities and hospital trains for the wounded.
Virchow had a very modern view of epidemiology, believing that some diseases are “artificial,” stressing their sociological side, arguing that political and socioeconomic factors were significant etiological elements. He even argued that epidemics could arise in response to social upheaval and could only be eliminated or alleviated through social change. No less controversial (then) was his argument that it is “the constitutional right of every citizen to be healthy.” Society, he insisted, had the responsibility “to provide the necessary sanitary conditions for the unhampered development of its members.”3 This, a kind of medical Bildung, is now regarded as the foundation of bioethics.
He made some mistakes. He was skeptical about bacteriology. Germs, he was convinced, could not be the sole etiological agent in an infectious illness, environmental and sociological factors being clearly responsible in his view for the typhus and cholera epidemics of 1847–49.
Toward the end of his life, from about 1870 on, he turned to another science: anthropology. Co-founder of the German Anthropology Society (in 1869) he made several studies of skull shapes and carried out a nationwide racial survey of schoolchildren. From this, he concluded that there was no “pure” German race, a highly controversial result.
Anthropology led to archaeology and in 1870 he began his own excavations in Pomerania. In 1879 he traveled with Heinrich Schliemann to Hissarlik, where Troy was being excavated (see Chapter 21), and he subsequently helped to attract antiquities to Berlin, for which the city became known. 4
His eightieth birthday in 1901 was celebrated as far afield as St. Petersburg and Tokyo. In Berlin there was a torchlight parade. His taste for public argument, and his dogmatism, had some unfortunate side effects, most notably his opposition to Ignaz Semmelweiss’s insight that hand-washing by doctors between patients would prevent puerperal fever. But Germany had progressed in less than half a century from speculative and philosophical healing to become the world center of modern scientific medicine, and Virchow was probably the most important figure in that transformation.
NEW KNOWLEDGE ABOUT INFECTION
As important as Virchow, and perhaps more so, was Robert Koch (1843–1910), the man who devised so many of the basic principles and techniques of modern bacteriology.5 It was Koch who isolated the causes of anthrax, tuberculosis, and cholera, and in his many travels he also influenced authorities in several countries to introduce public health legislation based on new knowledge about the microbial origin of infection.6
Robert was one of thirteen children (two of whom died in infancy). He grew up with an intimate knowledge of animal and plant life and the new art of photography. By the time he was ready for the local primary school, he had taught himself to read and write. At Göttingen he first thought of studying philology (as he also considered immigrating to America) but enrolled in natural sciences, soon transferring to medicine.
No bacteriology was yet taught at Göttingen but Jacob Henle, the anatomist, did consider the possibility that contagious agents could include living organisms.7 After graduation in 1866 Koch attended Rudolf Virchow’s course on pathology at the Charité Hospital in Berlin, and his career in some ways mirrored Virchow’s. He volunteered for service as a field hospital physician in the Franco-Prussian War and became interested in archaeology and anthropology. But his successes surely owed a great deal—more so even than in Virchow’s case—to the scale of his microscopic investigations. He installed a laboratory in his own home, where he had an excellent microscope by Edmund Hartnack of Potsdam, plus a number of microphotographic devices, and a darkroom. He began by studying anthrax.
It had been known for some time that anthrax was caused by rod-like microorganisms observed in the blood of infected sheep.8 Koch’s first contribution was to invent techniques for culturing them in samples of cattle blood, which enabled him to study the microorganisms under his microscope. He traced their life cycle, identified spore formation and germination. More important, he found that although the bacilli were relatively short-lived, the spores remained infective for years. He proved that anthrax developed in mice only when the inoculum contained viable rods or spores of Bacillus anthracis, publishing his results in 1877, together with a technical paper that detailed his method of fixing thin films of bacterial culture on glass slides, enabling them to be stained with aniline dyes. This made possible the study of their structure by microphotography. Medicine was thus the direct beneficiary of the recent developments in three separate areas—dyestuffs, microscope technology, and photography.
Koch’s next move was to equip his microscope with Ernst Abbe’s new condenser and oil-immersion system (manufactured by Carl Zeiss), which enabled him to detect organisms significantly smaller than B. anthracis.9 As a result (using mice and rabbits), he identified six transmissible infections that were pathologically and bacteriologically distinctive. He deduced that human diseases would derive from similarly pathogenic bacteria.
On the strength of this, in 1880 Koch was made government adviser (Regierungsrat) in the Kaiserliches Reichsgesundheitsamt (Imperial Department of Health) in Berlin. He shared a small laboratory with his assistants, Friedrich Loeffler and Georg Gaffky, both army doctors. They were charged with developing methods to isolate and cultivate pathogenic bacteria and to establish scientific principles that would improve hygiene and public health. (Johanna Bleker has shown that it wasn’t until the 1850s and 1860s that German doctors thought of hospitals as places of effective science.)
Koch played a part in the development of the use of strictly sterile techniques, isolating new disinfectant substances, comparing their destructive action on different bacterial species.10 He found that carbolic acid was inferior to mercuric chloride, bringing about the “dethronement” of Lister’s “carbolic spray,” and he found that live steam was much better than hot air in sterilization. This revolutionized operating room practices.11
In 1881 he turned his attention to tuberculosis. Inside
six months, “working alone and without a hint to colleagues,” he confirmed that the disease was transmissible (which not everyone accepted) and isolated from a number of tuberculous specimens of human and animal origin a bacillus with specific staining properties. He then induced TB by inoculating several species of animals with pure cultures of this bacterium. His lecture, to the Physiological Society in Berlin on March 24, 1882, was described by Paul Ehrlich as the “greatest scientific event.”12 The demonstration of the tubercle bacillus in the sputum was soon accepted as of crucial diagnostic significance.
In the same year, there was an outbreak of cholera in the Nile Delta. The French government, alerted by Louis Pasteur to the possibility that the epidemic could reach Europe, and told that the cause of cholera “was probably microbial,” sent a four-man scientific mission to Alexandria. Koch arrived just over a week later, leading an official German commission. Within days he had observed colonies of tiny rods in walls of the small intestine in ten bodies that had died of cholera. He found the same again in about twenty cholera patients. Though promising, this organism failed to induce cholera when fed to or injected into monkeys and other animals. However, Koch’s observations in Egypt were confirmed in Bengal, where his commission traveled next, and where cholera was endemic. In the spring of 1884 he identified village ponds, used for drinking water and all other domestic purposes, as the sources of why cholera was endemic in Bengal. He had, he said, observed cholera bacilli in one such pond.13
Although Koch and his work caught the eye (and continue to do so), the bacilli of swine erysipelas, glanders (an infectious disease of horses), and diphtheria were isolated by Loeffler, and the typhoid bacillus by Gaffky.14 Advances were being made at such a rate that additional institutes of public health were established in Prussia, and in 1885 Koch was appointed to the new chair of hygiene at the University of Berlin. There was a hiccup when Koch announced he had developed a substance which prevented the growth of the tubercle bacilli, a substance which, it was subsequently found, didn’t always work and sometimes had toxic side effects.15 It emerged in this way that dosage was all-important. This hiccup strained relations between Virchow and Koch but, over Virchow’s objections, an Institute for Infectious Diseases went ahead as planned in Berlin. The circle around Koch was by now more impressive than that around Virchow and included Paul Ehrlich and August von Wasserman.16 As a result of Koch’s work, a communicable diseases control law was passed in 1900, the year in which his institute moved to larger quarters, adjoining the Rudolf Virchow Hospital, making it the most famous medical complex in the world.
Koch achieved a level of fame for a doctor that has probably never been equaled, not even now. Toward the end of his life, he was in demand all over the world—South Africa, where he investigated rinderpest, Bombay (plague; he identified rats as the source but overlooked fleas as the vector), St. Petersburg (typhus), and Dar-es-Salaam (malaria and blackwater fever). He eventually isolated four types of malaria.17
In 1905 he received the ultimate accolade, the Nobel Prize for Physiology or Medicine. He died of angina on April 9, 1910. “Addicted” to chess and a great admirer of Goethe, Robert Koch probably benefited mankind—and the poor as well as the better off—more than anyone else to that point, and maybe since.
THE DISCOVERY OF ANTIBIOTICS AND THE HUMAN IMMUNE RESPONSE
Despite the stirring achievements of Virchow and Koch, which would take time to work through their effects, at the beginning of the twentieth century people’s health was still dominated by a “savage trinity” of diseases that disfigured the developed world: tuberculosis, alcoholism, and syphilis. TB lent itself to drama and fiction. It afflicted the young as well as the old, the well-off as well as the poor, and it was for the most part a slow, lingering death: as consumption it features in La Bohème, La Traviata, Der Tod in Venedig (Death in Venice), and Der Zauberberg (The Magic Mountain). Anton Chekhov, Katherine Mansfield, and Franz Kafka all died of the disease.18
The fear and moral disapproval surrounding syphilis a century ago mingled so much that despite the extent of the problem it was scarcely talked about. Despite this, in Brussels in 1899, Dr. Alfred Fournier established the medical speciality of syphilology, using epidemiological and statistical techniques to underline the fact that the disease affected not just the “demi-monde” but all levels of society, that women caught it earlier than men, and that it was “overwhelming” among girls whose poor back-ground forced them into prostitution. This paved the way for clinical research, and in March 1905 Fritz Schaudinn, a zoologist from Roseningen in East Prussia, noticed under the microscope “a very small spirochaete, mobile and very difficult to study” in a blood sample taken from a syphilitic.19 A week later Schaudinn and Eric Achille Hoffmann, a bacteriologist originally from Pomerania, and a professor at Halle and Bonn, observed the same spirochaete in samples taken from different parts of the body of a patient who only later developed roseolae, the purple patches that disfigure the skin of syphilitics. Difficult as it was to study, because it was so small, the spirochaete was clearly the syphilis microbe, and it was labeled Treponema (it resembled a twisted thread) pallidum (a reference to its pale color). The discoveries owed much to the invention of the ultramicroscope in 1906 by the German chemist Richard Zsigmondy at the Schott Glass Manufacturing Company, which provided specialized glass for Zeiss (see Chapter 18). These advances meant the spirochaete was now easier to experiment on than Schaudinn had predicted, and before the year was out a diagnostic test had been identified by August Wasserman. It followed that syphilis could now be identified early, which helped prevent its spread. A cure was still needed.
The man who found it was Paul Ehrlich (1854–1915). Born in Strehlen, Upper Silesia, he had an intimate experience of infectious diseases: while studying tuberculosis as a young doctor, he had contracted the disease and been forced to convalesce in Egypt. His crucial observation was that, as one bacillus after another was discovered, associated with different diseases, the cells that had been infected also varied in their response to staining techniques. Clearly, the biochemistry of these cells was affected according to the bacillus that had been introduced. This deduction gave Ehrlich the idea of the antitoxin—what he called the “magic bullet”—a special substance secreted by the body to counteract invasions.
By 1907 Ehrlich had produced no fewer than 606 different substances or “magic bullets” designed to counteract a variety of diseases. Most of them worked no magic at all, but “Preparation 606” was found to be effective by a Japanese assistant, Dr. Sachahiro Hata, from Tokyo. Ehrlich called this magic bullet Salvarsan, which had the chemical name of asphenamine. He had in effect discovered the principle of both antibiotics and the human immune response. He went on to identify what antitoxins he could, to manufacture them, and to employ them in patients via the principle of inoculation. Besides syphilis he continued to work on tuberculosis and diphtheria, and in 1908 he was awarded the Nobel Prize for his work on immunity.20
THREE FOOTNOTES: THE DISCOVERY AND REDISCOVERY OF THE GENE
Even after all this time, the coincidence in the rediscovery of the work of the botanist-monk Gregor Mendel makes for moving reading. Between October 1899 and March 1900, three other botanists—two Germans (Carl Correns and Erich Tschermak) and the Dutchman Hugo de Vries—published papers about plant biology, each of which (in a footnote) referred to Mendel’s priority in discovering the principles of what we now call genetics. Thanks to this coincidence, and their scrupulousness in acknowledging his achievement, Mendel—once forgotten—is now a household name.21
Johann Mendel was born in 1822 in Heinzendorf in what was then Austria and is now Hync
freed him economically and gave him peace of mind to pursue his studies. The abbot of the monastery was much concerned with the improvement of agriculture and had established an experimental monastery garden, where the director, Matthew Klácel, was interested in variation, heredity, and evolution in plants. He favored the Hegelian philosophy of gradual development, an approach that contradicted Christian orthodoxy and led to his dismissal and immigration to America, after which Mendel took over.22
Mendel was too sensitive for pastoral work (he was frequently disturbed by the suffering he saw among the poor). Instead, he was dispatched to the University of Vienna to expand his intellectual horizons.23 In Vienna he was taught experimental physics by Christian Doppler (identifier of the “Doppler effect”) and by Andreas von Ettingshausen, the statistician. This proved important for Mendel’s ideas about plant breeding. He also studied with Franz Unger, known for his views on evolution and lectures stressing sexual generation as the basis of the great variety in cultured plants. Unger argued that new plant forms evolved by the combination of certain elements within the cell, though he was unclear as to what exactly these were.24
Back in Brno, Mendel was elected abbot in 1868, and he too used his time to promote farming. In 1877 he helped introduce weather forecasts for farmers in Moravia, the first in central Europe.25
