by Thomas Goetz
At long last he had returned to tuberculosis. But this time, he wasn’t merely investigating questions of causality. This time he wanted glory. This time he wanted a cure.
• • •
THERE HAD, OF COURSE, BEEN MANY CURES FOR TUBERCULOSIS OVER the past decade, the past century, the past millennium. The trouble was none of them seemed to work.
In the seventeenth century the English philosopher John Locke endorsed horse riding as a genuine cure. He had seen it work firsthand, after a doctor ordered a friend to ride six or seven miles a day, until he reached 150 miles. “When he had travelled half the way,” Locke reported, “his Diarrhoea stopped, and at last he came to ye end of his journey and was pretty well (at least somewhat better). . . . And in four days he came up to London perfectly cured.”
In the mid-eighteenth century, before he became one of the most extreme voices of the French Revolution, Jean-Paul Marat practiced medicine in Paris, where he peddled an “antipulmonic water” for consumption. It appears to have been limewater, or calcium hydroxide, and altogether worthless, but Marat made a fortune on it. Folk cures were equally absurd. Milk from donkeys was believed to be curative, as was mutton fat. The proverbial leeches were widely used for tuberculosis, on a scale that’s staggering to consider today. In France, the epicenter of bleeding in Europe, leech usage soared early in the nineteenth century, rising from 3 million leeches used in 1824–25 to a staggering 41.5 million in 1843 (a shortage in domestic leeches meant that most of these leeches were imported); a great number of these were used for tuberculars.
Some argued that playing musical instruments exposed one to the disease, while others—including Adolphe Sax, inventor of the saxophone—argued that wind instruments strengthened the lungs and were a worthy treatment. Opium was widely used and considered effective. Even a professed skeptic, the French physician Pierre Louis, did some tests and came away hopeful that it helped. “It frequently produces so material an improvement in chronic phthisis, that the patients fancy themselves cured, or almost cured, after having taken a few doses,” Louis noted. Alas, though those few doses of the narcotic surely made the patient feel better, they did nothing to abate the progress of the disease.
There was also a blood remedy, in particular the blood of freshly slaughtered animals. A visitor to the Union Stock Yards in Chicago around 1890 reported that every day outside the gates there were “many regular visitors who daily drink blood, while warm from the animal, as a cure for consumption.” Others believed that the blood of a species immune to tuberculosis would be a cure. In the 1880s, doctors at the Sorbonne in Paris experimented with transfusing dogs’ blood into humans. (They also tried the blood of goats.) The results were promising, an American medical journal reported: “There has been neither pain, fever, reaction nor ultimate blood poisoning. . . . Appetite and sleep returned, weight increased and depression gave way to cheerfulness.” What became of such research one can only speculate.
Perhaps the most popular cure was cod-liver oil. A by-product of Europe’s thriving trade in codfish, cod-liver oil was seen as a cure-all for much of the nineteenth century. Its value for tuberculosis was first tested by Dr. C. J. B. Williams of the Brompton Hospital for Consumption in London. Williams swore by the stuff for more than thirty years, during which period many tons were dispensed out of his hospital. He wrote several articles attesting to its efficacy, claiming it was “more beneficial in the treatment of Pulmonary Consumption than any agent, dietetic, or regimental, that has yet been employed.” This enthusiasm, inevitably, sparked a trade in rip-off oils, with many cheaper fats and greases bleached and sold as oil from cod; lard, whale blubber, and “tanner’s oil” (the runoff from slaughterhouses) were common substitutes. Though cod-liver oil is now recognized as having valuable nutritional benefits, largely due to the presence of omega-3 fatty acids that may reduce risk of heart disease, as a treatment for tuberculosis, it has negligible benefits.
Ironically, the germ theory itself gave birth to the most brazen of all quack cures, the Microbe Killer, a tonic sold by the legendary American huckster William Radam. A gardener in Austin, Texas, Radam read about the growing authority of Europe’s microbe hunters and was inspired to use the sheen of science to make a killing. In 1887 he began selling a potion that, he claimed, had been specifically engineered to vanquish microbes. (He was clever enough first to patent and trademark his discovery.) “It is pure water,” Radam explained, “permeated with gases which are essential to the nourishment of the system, and in which micro-organisms cannot live and propagate, or fermentation exist.” Boosted by an innovative nationwide advertising campaign in the United States, the Microbe Killer made Radam rich, allowing him to move from Texas to a luxury apartment overlooking New York’s Central Park. He died in 1902, but his heirs continued to sell the cure until 1912, by which time the Food and Drug Act finally empowered the government to forbid the sale of false cures. Federal agents heard news that a freight train was en route from New York to Minneapolis carrying a massive shipment of the Microbe Killer. They intercepted the train, seized the haul, and destroyed the bottles, burying the debris in a pit in St. Paul. Radam’s company was soon out of business.
Some desperate souls turned to surgical treatments, and several highly experimental and potentially deadly procedures were tested in the late nineteenth century. In a thoracoplasty, a surgeon would remove several ribs from the patient, deforming the chest wall with the intention of collapsing the lungs, hoping to give the patient some relief and, perhaps, allowing the infected lung to heal. In an artificial pneumothorax, a hole was punched in the chest wall and gas (air or oxygen) injected into the lungs; the gas was intended either to kill the germs or to soothe the infected lung. In a phrenic crush, the phrenic nerve, which controls the diaphragm, would be cut, collapsing the lung, thus closing the injury. And there was the thoracotomy, the removal of a lung or a lobe of the lung. These procedures were as grisly as they sound, with high fatality rates and low rates of success. But such was the desperation of those with TB, and such was the prolonged course of the disease, that many underwent these treatments hoping for a more comfortable life on the other side of recovery.
Finally, there were the climate cures. The first sanitariums for consumptives opened in the last years of the eighteenth century, but it wasn’t until 1840, when George Bodington opened a facility devoted to the treatment of consumption in Birmingham, England, that these institutions began to spread widely across Europe and the United States. Part of the argument for sanitariums was that “purer air” would invigorate weak lungs. But beyond that, the theories were contradictory. Some believed that high mountain air was most beneficial, while others advocated seaside locations, where the ocean breezes would bathe the lungs in warm air. Still others advocated dry desert conditions. Sanitariums sprang up in locations as diverse as Sante Fe, New Mexico, and Davos, Switzerland.
Inside these facilities, the treatments were as varied as the locations. While some institutions advocated vigorous exercise, the better to strengthen the lungs, others rendered their patients completely immobile. This meant more than mere bed rest. Patients were required to lie prone in their beds twenty-four hours a day, with orders not to stir. Nurses would spoon food into patients’ mouths and bring them bedpans for relief. This could go on for many months or as long as a year. Needless to say, such conditions were miserable and debilitating for patients—psyches were scarred, careers abandoned, marriages ruined, families lost. It makes one wonder how accurate was the inscription on the largest hotel in Davos, Hilares mox sani, “The merry are soon cured.”
This steady parade of overhyped cures speaks to the desperation of the sufferers. With each new treatment, hope was refueled and then disappointed. So on to the next. The market was always ready to offer something new.
If it was torment for patients, it was bleak for physicians as well. As a doctor from Mansfield, Ohio, lamented in 1890:
We have tried in vain
for centuries to “cure” consumption. People by the thousand and hundreds of thousands have flocked from one health resort to another, vainly seeking to free themselves from the lion grip of pulmonary consumption; they have, figuratively speaking, soaked themselves in cod liver oil, and clad themselves, inside and out, with iron; they have loaded their poor stomachs with the hypophosphites, and been pumped with the pneumatic cabinet, and injected with carbonic acid gas; but the end was all the same—it was only a question of time until the funeral knell sounded the requiem of their departed spirits.
Harvard anatomist and author Oliver Wendell Holmes in 1860 wrote off altogether the effort of curing the disease. “I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes.”
From today’s vantage point, some of these cures look ridiculous or barbaric. Medical and surgical treatments are available now for a broad range of diseases—diabetes, heart disease, HIV/AIDS, glaucoma, certain cancers, tetanus, strep and staph infections, and pneumonia—so we assume that scientists, somewhere, are going down a checklist, ticking off diseases one by one.
This was the premise, after all, of America’s first “war on cancer,” declared by President Richard Nixon in 1971. The expectation then was that science, having been called to war, would take five years to find the cure. But in the more than four decades since then, many of today’s cancer patients have scarcely a better chance of survival than they would have faced forty years ago. Yet the conversation around cancer continues to invoke the word cure, and the term is nearly as common when discussing other chronic or life-threatening ailments. We are too easily beguiled into thinking that a great remedy is around the next bend, that every disease can be cured. The danger lies where, in our desperation, we fail to distinguish between the true breakthrough and the sham cure.
• • •
BY THE SUMMER OF 1890, KOCH BELIEVED HE WAS ONTO SOMETHING. He was searching for some internal antiseptic, a chemical that might be ingested or injected and rid the body of the tuberculosis bacterium from within. Using those hordes of guinea pigs, he worked his way through a long list of possible agents: acids, alkalis, toxins, and dyes. None of them panned out. Then he tried a new substance, a lymph, which seemed to have some sort of reaction in animals. In Koch’s experiments, guinea pigs that had been infected with tuberculosis tended to live between six and eight weeks. But those inoculated with this new substance—he would call it tuberculin—lived longer. Most curiously, treated tissue had necrotized, or died—it “rather melts or wastes away,” as Koch wrote in his notebook. This wasn’t the expected result: Rather than treating the infection, as an antiseptic would, the substance seemed to kill off the flesh that the microbes fed upon. Though unexpected, it seemed a promising effect. Indeed, it tracked with Koch’s success elsewhere.
The effect is known as amplification, an increase from one state to another. Amplification had been the essential tool in Koch’s cabinet, the phenomenon common to so much of his work. Microscopy is amplification: boosting the perceived size of an object from the invisible to the visible. And cultures work by amplification, deliberately growing a small number of bacteria into a much larger quantity. In these cases, amplification was a pragmatic tool; it made microbes visible. (Amplification is still an essential principle of laboratory science today. The traditional technique for sequencing DNA involves amplifying one piece of DNA into billions, making it easier to read the sequence of nucleotides and thus diagnose disease or genetic conditions.)
So when Koch saw something like amplification after treatment with tuberculin, he was encouraged. By killing off the underlying flesh, tuberculin seemed to undermine the parasitic strategy of the bacteria, giving them no place to roost. Today we understand this sort of thinking as confirmation bias. Koch wanted to believe his treatment was working, so he looked for evidence that it was. And the necrotized flesh gave Koch an explanation for how tuberculin worked. Unfortunately, he failed to apply his own microscopic techniques and wait to see if the bacteria had been truly vanquished.
By June, Koch decided that he was satisfied with his animal experiments. It was time to test the substance on healthy human subjects—starting with himself and his teenage mistress. He took a syringe, filled it with two or three milliliters of the fluid, and injected it into his arm. Later he repeated the procedure on Hedwig. Two assistants were next, and in each case the reaction was similar: “3 to 4 hours after the injection: aching limbs, fatigue, tendency to cough, rapidly increasing breathing difficulties,” he wrote in his notebook; “in the 5th hour unusually violent shivering set in, lasting for about an hour. At the same time there was nausea and vomiting as the body temperature rose to 39.6 centigrade; after about 12 hours all these complaints receded.”
Today we recognize this as an immune reaction, a concept that was then only just emerging (advanced by scientists working in Koch’s own laboratory). The spike in temperature—normal human temperature is thirty-seven degrees centigrade—was especially exciting to Koch, as it seemed to be another manifestation of amplification, evoking a “fever cure,” the ancient notion that a fever burns disease out of the body. (At the time, fever cure was still a popular idea. It faded with the development of aspirin and other pain relievers at the turn of the twentieth century, but it is finding new traction today; recent research has shown little to no benefit to reducing a fever through aspirin or other anti-inflammatories, while there may be potential benefits to letting a fever run its course.) But to the extent that it echoed folk wisdom rather than evidence-based science, the appearance of fever should have provoked caution in Koch. In fact, it contradicted one of his favorite dictums, that “the least reliable results were obtained from experiences gathered at the sickbed.” But Koch was impatient for success. He had let his biases get the better of him.
• • •
ON AUGUST 3, 1890, THE TENTH INTERNATIONAL MEDICAL CONGRESS opened in Berlin. Some six thousand physicians and scientists had come to Berlin, filling the Circus Renz, a massive circular building in central Berlin. The space was turned out splendidly, with a triumphal arch of evergreen festooned with flowers and flags from all nations. This Tenth Congress was the successor to the London congress where, nine years earlier, Pasteur had reported on his anthrax vaccine and where Koch had demonstrated his meticulous laboratory techniques. This time the audience hoped for even more miracles.
It was an oppressively hot day. Outside, the air was muggy and thick; inside, it was downright suffocating, with the thousands of attendees pressed together and hundreds of gas and electric lights radiating heat. On the main platform, a colossal statue of Asclepius, the Greek god of medicine and healing, stood guard over the proceedings, holding a snake and a staff.
With a dozen German dignitaries and ministers at his side, Rudolf Virchow, the congress president, rose to call the meeting to order. He was greeted by cheers and applause. “In this imperfect world all practical progress is made only step by step,” Virchow said, making sure to note the accomplishments of German science, in particular Berlin’s new sanitation system, which he had championed personally. Next, Joseph Lister offered an update on his antiseptic techniques. (He was done with carbolic acid, he explained, and now preferred a salt of cyanide of mercury and zinc, or a dilution of mercuric chloride.)
Then came Koch, who began by offering broad observations on the state of bacteriological research. The size of the hall and the lack of amplification made for horrible acoustics, and the audience struggled to make sense of what Koch was saying. He continued for several minutes, until he turned to the one question that, he said, was often asked of him: “What has been achieved by all the arduous labor that has been invested in the examination of bacteria?” He recognized the validity of the question and wanted to highlight the practical benefits. “There must be a remedy for tuberculosis,” he said, explaining how he’d been testing all so
rts of substances for their curative properties on the disease: ethereal oils, naphthylamine, paratoluidin, xylidine, tar dyes, mercury, and silver and gold compounds. “All of these substances,” he reported, “remained absolutely without effect if tried on tuberculous animals.”
Then Koch hinted at something new. “I have at last hit upon a substance which has the power of preventing the growth of tubercle bacilli, not only in a test tube, but in the body of an animal.” Noting that his experiments were ongoing and not yet definitive, he could only hint at their implications.
All I can say at present is that if guinea pigs are treated they cannot be inoculated with tuberculosis, and guinea pigs which already are in the late stages of the disease are completely cured, although the body suffers no ill effects from the treatment. From these experiments, I will draw no other conclusion at present than that it is possible to render pathogenic bacteria within the body harmless without ill effect on the body itself.
Koch teased, but volunteered no specifics, no details on what his substance might be. Indeed, he was so restrained that, in the days after the congress, the reports of his remarks were generally tepid. “Dr. Koch was shrewd enough not to name his ‘cure,’ so we did not learn much from the distinguished director,” an American physician reported. The Lancet was even more dubious. “Dr. Koch’s address treated chiefly of what is already known. The new points were . . . some observations on tuberculosis . . . and on the possible curative treatment of phthisis.” Nonetheless, the idea was now out there—there should be a real cure, and he might have it.