No, I don’t have in mind the famous, or infamous, brothers that bought, and now own our political system. But before we find out about this Koch, here is a short quiz: Who is the scientist most responsible for the advent of “the germ theory” (the theory that infections are caused by germs)?
1. Louis Pasteur
2. Joseph Lister
3. Robert Koch
4. Arthur Conan Doyle
If you made the connection with milk pasteurization and voted for Pasteur – you’d be partially correct. But if you are halfway good at test-taking, you’d vote for Robert Koch.
Thomas Goetz’s book, The Remedy: Robert Koch, Arthur Conan Doyle, and the Quest to Cure Tuberculosis, tells the fascinating story of the titanic battle of personalities involved in putting medicine on its modern footing. Believe it or not, well into the second half of the19th-centuryy scientists and physicians still believed in Hippocrates’s four humors: black humor, yellow humor, phlegm and blood. In the human body, the interaction of the four humors explained differences of age, gender, emotions, and disposition.
Malaria, a common disease throughout the world, was considered the result of foul-smelling air. The very name of malaria originates from “bad air” (mal =bad, aeria=air). The influence of the humors changed with the seasons and times of day and with the human life span.
Just imagine: 23 centuries of accepted dogma, and nobody raising questions. Today, we rigorously design our experiments so as to distinguish between the ‘treatment’ group and the ‘control’ group. We employ sophisticated statistical methods to measure the veracity and significance of the results. But it has not always been thus.
For thousands of years, anthrax decimated herds of cows, tuberculosis killed millions of people, influenza killed 50 million people worldwide in the 1918-1919 winter- one-third of Europe’s population, 188,000 in the waves of polio epidemics that paralyzed and killed, tens of thousands of children in the U.S.
Today, we see rats and recoil in disgust; until the end of the 19th century, they were a taken-for-granted part of daily life. And yet, the best science and medicine could offer in those days was bloodletting with leeches, a variety of useless tinctures, massage and iron lungs for the polio-stricken children.
What comes next is a tale of incredible human ingenuity under adverse circumstances, clash of big egos vying for scientific supremacy, sex, intrigue, and greed.
Robert Koch and his postulates
Robert Koch was a small town doctor in Germany of the 19th century. He served in the Imperial German Army invasion of France. There, he witnessed the horrors of war at first hand. In his field hospital, he treated soldiers with infected wounds, whose only options were amputation or sepsis and death.
Incredibly, Koch was the only one to look at the wounds under the microscope. He observed tiny, barely visible “things” that gave him the idea that they must be somehow connected to the cause of those putrefying wounds. But how do you prove it beyond a shadow of a doubt?
Speculations about the existence of germs existed for many years, but they were dismissed and ridiculed by the medical establishment of Europe. The evidence was always observational, correlational, leavened with rank speculation.
Koch returns to his practice in Germany, but at night he dissected in his kitchen the carcasses of dead cows killed by anthrax, hunting for the cause of the disease. He observed, under his primitive microscope, what became known later as Bacillus anthracis. Out of this amazing achievement, considering the primitive conditions, he formulates the four postulates, that are the basis of modern medical microbiology.
1. The organism must always be present, in every case of the disease.
2. The organism must be isolated from a host containing the disease and grown in pure culture.
3. Samples of the organism taken from pure culture must cause the same disease when inoculated into a healthy, susceptible animal in the laboratory.
4. The organism must be isolated from the inoculated animal and must be identified as the same original organism first isolated from the originally diseased host.
Sounds boring? Too nitpicking? These postulates became the gold standard in demonstrating the cause and effect of infection. They firmly established the “germ theory” of disease and drove a stake in the heart spontaneous generation, which had been the undisputed theory since the 4th century BC.
However mundane this looks to us, it was revolutionary. Adhering to these operational principles, within a few years, he discovered the cause of tuberculosis, again demonstrating decisively its bacterial cause: Mycobacterium tuberculosis. This time it wasn’t a cow disease, but a disease that afflicted humanity for millennia, killing untold millions. In 1905, he received the Nobel Prize for his discovery.
Louis Pasteur, chemist and showman
At the same time, that Koch was laboring in his kitchen on the cause of anthrax. Louis Pasteur, a chemist, did not concern himself with disease; he investigated the cause of spoilage of milk and wine. This led to the discovery of the causative microorganisms, and to the process of “pasteurization”, heat-treating the milk to sterilize it.
Pasteur was French, flamboyant, not given to the Germanic obsession with rules and order. He leapfrogged Koch and developed a vaccine for anthrax. His vaccination experiments, an exercise in PR and self-promotion, were carried out and reported with a typical French flourish. Nonetheless, he too received credit for the establishment of the germ theory as the basis for infectious disease.
There was no room for two giants, or so they thought. There was also the historical animosity between the French and the Germans. And so, what ensued was a highly personal, poisonous competition for scientific primacy.
Koch became the hero of the German Empire and the object of adulation throughout Europe. But as this frequently happens – it all went to his head. Not to be scooped again by Pasteur, he closed himself in his lab and secretly developed a “plasma” which he called tuberculin, and claimed that it cured TB. He demanded fat royalties from the German government for his invention. He dumped his wife and took up with a young art student.
And then came the tragic fall: the secret potion turned out to be less than useful. In many cases, it was toxic, even lethal. Koch’s name was sullied for a long time thereafter, and his rival Pasteur harvested all the adulation of an adoring public. Never mind that later examination of his lab notes raised the possibility of scientific fraud.
The Greek tragedians or Shakespeare couldn’t have written a better story.
The other characters
I listed four names in the quiz. Why Joseph Lister? He was a British surgeon and a pioneer of antiseptic surgery. By applying Pasteur’s advances in microbiology, he promoted the idea of sterile surgery while working at the Glasgow Royal infirmary. Lister successfully introduced carbolic acid (now known as phenol) to sterilize surgical instruments and to clean wounds, which led to a reduction in post-operative infections and made surgery safer for patients. Interestingly, American surgeons refused to believe in sterile technique. It took many years for them to acknowledge what by then became obvious to their European colleagues: they were killing their patients with post-operative infections. This is how President Garfield died in 1881; it wasn’t the assassin’s bullet that did him in, it was the surgeon who infected him by repeatedly exploring his wound with his fingers and unsterilized instruments.
But what does Conan Doyle have to do with all this? In case you didn’t know (I didn’t), he was a young small town physician in England and was an admirer of Koch’s scientific work. He traveled to Berlin to witness the manufacture of tuberculin in Koch’s lab but was not granted admittance. Not easily discouraged, he visited patients who received the mysterious treatment. He discovered that Koch violated his own principles when he worked in secret and refused to disclose his methods, so that others could not confirm them. On his return to England, he published a scathing report on Koch’s cure, essentially calling it a cruel hoax.
Here is the surprise ending: Arthur Conan Doyle admired Koch’s meticulous methods, attention to detail, focused observations, and scientific deduction. So when he later created the Sherlock Holmes character, argues Goetz, Koch’s methods were his template for the private detective. Maybe. But regardless of this literary detour, I highly recommend “The Remedy” as a fascinating account of a critical junction in medical history, and great storytelling.