The Medical Detectives
http://www.100md.com
《新英格兰医药杂志》
On a hot and steamy summer day in Berlin — August 4, 1890, to be precise — the 10th International Medical Congress opened with a flair and fanfare that few conference-weary doctors of the 21st century would recognize. At the invitation of Kaiser Wilhelm II, almost 6000 physicians from around the globe flocked to the city that represented the modernity and optimism of medical progress. Perhaps even more enticing was the jam-packed program of lectures delivered by a veritable who's who of medical greats, including Joseph Lister, Rudolf Virchow, and James Paget.
Topping the bill two days later, on the afternoon of August 6, was none other than Dr. Robert Koch, perhaps the greatest medical detective who ever lived. During the preceding 14 years, the distinguished professor of hygiene and bacteriology at the University of Berlin had become a household name as he successively discovered the microbial causes of anthrax (in 1876), tuberculosis (in 1882), and cholera (in 1883). Although Koch was never a commanding speaker (he reputedly had a thin, reedy voice and tended to infuse his sentences with a distracting number of "ums" and "ers"), his colleagues had long since learned to pay closer attention to his words than to his style of presentation, knowing that still another demonstration of something spectacular was likely to transpire.
The eager physicians filling the seats of the stifling-hot auditorium were not disappointed. Within moments after beginning his speech, Koch announced that he had discovered a "remedy for tuberculosis." As expected in a world connected by telegraphs and multiple editions of newspapers and magazines — and one in which tuberculosis was a leading cause of death and illness — Koch's discovery made news around the world. Hours after the lecture, physicians began to clamor for supplies of what was then called "Koch's lymph" to treat their desperate patients. The excitement only intensified when the lecture was formally published in the November 13, 1890, issue of Deutsche Medizinische Wochenschrift and reprinted, in English translation, in the November 15, 1890, issue of the British Medical Journal.1 The following day, the front page of the New York Times heralded the remedy as "Koch's Great Triumph. The Discovery Called a Greater One Than Jenner's."
Koch was careful never to state explicitly that he had discovered a "cure." Instead, he reported that his "remedy" destroyed the tissue in which the tuberculosis germs had settled, so that the entire diseased area would simply be sloughed off and then expelled through coughing. Moreover, Koch was careful to state that the remedy worked best in cases that were "not too far advanced," although he theorized that it might be of some benefit in patients with large pulmonary cavities.
One of the millions of people reading about this incredible discovery was a young general practitioner who was struggling to build a practice in Southsea, Great Britain. During the long stretches of time between appointments with his patients, the doctor took up his fountain pen and wrote beautiful essays, stories, and even novels. In 1887, only a few years before Koch's announcement, the young doctor had published a novel entitled A Study in Scarlet in Beeton's Christmas Annual. It was a compelling tale that introduced the world to a character destined to become the most famous detective ever to grace the written page. The sleuth's name was Sherlock Holmes, and he employed a method he called "deductive reasoning," which was actually based on the diagnostic approach of a doctor. The physician author, of course, was Arthur Conan Doyle.
In his 1924 autobiography, Conan Doyle described the Koch announcement and the events that followed as "life transforming." Only a few hours after reading the translation of Koch's paper in the British Medical Journal, which was accompanied by the notice of a demonstration of the tuberculosis remedy that was to take place in Berlin later that week, Conan Doyle dashed out of his house and boarded a train for London with the intention of getting to Germany as soon as possible. He later recollected, "I could give no clear reason for doing this, but it was an irresistible impulse and I at once determined to go. Had I been a well-known doctor or a specialist in consumption it would have been more intelligible, but I had, as a matter of fact, no great interest in the more recent developments of my own profession."2
Once he reached London, the doctor's pragmatic side intervened, and Conan Doyle stopped by the offices of W.T. Snead, the editor of the magazine Review of Reviews. Securing letters of introduction from Snead to prominent Berliners and, even more important, a green light to write about the event, Conan Doyle then hopped a boat across the Channel. Once in France, he secured a seat on the Continental Express to Berlin and arrived on November 16. Almost as soon as he stepped off the train in Berlin, Conan Doyle set out for the university building where Koch's colleague, Dr. Ernst von Bergmann, was scheduled to demonstrate the miraculous tuberculosis remedy the following morning. Alas, Conan Doyle's trip appeared to be for naught when he learned that tickets to von Bergmann's clinical demonstration were "simply not to be had and neither money nor interest could procure them."2
At this point, the intrepid Conan Doyle decided to seek out Koch at his home, but he was told by a butler that the professor was unavailable. As Conan Doyle later recounted, "To the Englishman in Berlin, and indeed to the German also, it is at present very much easier to see the bacillus of Koch than to catch even the most fleeting glimpse of its discoverer."3 Indeed, the closest Conan Doyle got to Koch was witnessing the upended sacks of mail emptied on the professor's doorstep and the thousands of letters from around the world containing desperate pleas regarding "the sad broken lives and wearied hearts which were turning in hope to Berlin."2
Bright and early on the morning of November 17, Conan Doyle went back to the medical auditorium at the University of Berlin. But neither bribes nor his clumsy attempts at slipping by the ticket taker secured him entry. Realizing that his magazine story was evaporating into thin air, Conan Doyle patiently waited for von Bergmann and literally threw himself in the path of the formidable physician, causing a pileup of the younger doctors who made up the professor's faithful retinue and academic rear guard.
"I have come a thousand miles. May I not come in?" begged the British medical journalist. The query prompted the senior physician to stop, glare through his pince-nez spectacles, and haughtily reply: "Perhaps you would like to take my place? That is the only one vacant!" Humiliated by the laughs and jeers of those who did possess the necessary coupons for entry, Conan Doyle began to turn around and leave the hospital. Fortunately, a tuberculosis specialist from Detroit named Henry J. Hartz was appalled by von Bergmann's display of bad behavior and lack of professional collegiality. Hartz promised to meet with Conan Doyle later that afternoon and share his notes on the demonstration. Even better, the following morning, Hartz quietly escorted Conan Doyle into von Bergmann's clinical wards to examine the patients who had received Koch's lymph.
Within a day after analyzing the mass of clinical data, however, Conan Doyle came to a startling conclusion: "The whole thing was experimental and premature." What is more, he had the temerity to make this statement publicly, first in a letter to the editor, published in the London Daily Telegraph on November 20, 1890,4 and then, more definitively, in his article in the Review of Reviews, which ran in December of that year. While the rest of the world rejoiced over the reported conquest of tuberculosis, Conan Doyle argued that "Koch's lymph" might remove traces of the enemy, but it left deadly germs "deep in the invaded country." Its real value, Conan Doyle asserted, was as "an admirable aid to diagnosis," in that a "single injection" would help doctors decide definitively whether a patient was "in any way tubercular."
Conan Doyle was right. Koch's lymph, or what we now refer to as tuberculin, was essentially a glycerin extract of a pure culture of tuberculosis germs. In the decades before the development of the much safer purified-protein-derivative test for tuberculosis, it became an essential diagnostic tool. A few months later, in early 1891, after several highly publicized treatment failures, many exacerbated cases of tuberculosis, and not a few deaths closely associated with the administration of the so-called curative medication, Koch publicly retracted his even-tempered announcement of a remedy for tuberculosis and announced that although Koch's lymph was an excellent means of diagnosing tuberculosis, the actual cure was nowhere in sight.5
One cannot help but be impressed by the way in which the young Conan Doyle, the creator of the greatest detective in English literature, figured out what took Koch, one of the most illustrious medical detectives in history, and his accomplished colleagues many more months to realize. Sadly, the paper trail ends before we can definitively ascertain how Conan Doyle cracked "The Case of Koch's Lymph."
Source Information
Dr. Markel is director of the Center for the History of Medicine and a professor of pediatrics and communicable diseases and the history of medicine at the University of Michigan Medical School, Ann Arbor.
References
Koch R. A further communication on a remedy for tuberculosis. BMJ 1890;4:1193-1201.
Conan Doyle A. Memories and adventures. London: Hodder and Stroughton, 1924: 82-93.
Dr. Koch and his cure. Rev Revs 1890;2:552-6.
The consumption cure. London Daily Telegraph. November 20, 1890:3.
Koch R. Professor Koch's remedy for tuberculosis. BMJ 1891;1:125-127.(Howard Markel, M.D., Ph.D)
Topping the bill two days later, on the afternoon of August 6, was none other than Dr. Robert Koch, perhaps the greatest medical detective who ever lived. During the preceding 14 years, the distinguished professor of hygiene and bacteriology at the University of Berlin had become a household name as he successively discovered the microbial causes of anthrax (in 1876), tuberculosis (in 1882), and cholera (in 1883). Although Koch was never a commanding speaker (he reputedly had a thin, reedy voice and tended to infuse his sentences with a distracting number of "ums" and "ers"), his colleagues had long since learned to pay closer attention to his words than to his style of presentation, knowing that still another demonstration of something spectacular was likely to transpire.
The eager physicians filling the seats of the stifling-hot auditorium were not disappointed. Within moments after beginning his speech, Koch announced that he had discovered a "remedy for tuberculosis." As expected in a world connected by telegraphs and multiple editions of newspapers and magazines — and one in which tuberculosis was a leading cause of death and illness — Koch's discovery made news around the world. Hours after the lecture, physicians began to clamor for supplies of what was then called "Koch's lymph" to treat their desperate patients. The excitement only intensified when the lecture was formally published in the November 13, 1890, issue of Deutsche Medizinische Wochenschrift and reprinted, in English translation, in the November 15, 1890, issue of the British Medical Journal.1 The following day, the front page of the New York Times heralded the remedy as "Koch's Great Triumph. The Discovery Called a Greater One Than Jenner's."
Koch was careful never to state explicitly that he had discovered a "cure." Instead, he reported that his "remedy" destroyed the tissue in which the tuberculosis germs had settled, so that the entire diseased area would simply be sloughed off and then expelled through coughing. Moreover, Koch was careful to state that the remedy worked best in cases that were "not too far advanced," although he theorized that it might be of some benefit in patients with large pulmonary cavities.
One of the millions of people reading about this incredible discovery was a young general practitioner who was struggling to build a practice in Southsea, Great Britain. During the long stretches of time between appointments with his patients, the doctor took up his fountain pen and wrote beautiful essays, stories, and even novels. In 1887, only a few years before Koch's announcement, the young doctor had published a novel entitled A Study in Scarlet in Beeton's Christmas Annual. It was a compelling tale that introduced the world to a character destined to become the most famous detective ever to grace the written page. The sleuth's name was Sherlock Holmes, and he employed a method he called "deductive reasoning," which was actually based on the diagnostic approach of a doctor. The physician author, of course, was Arthur Conan Doyle.
In his 1924 autobiography, Conan Doyle described the Koch announcement and the events that followed as "life transforming." Only a few hours after reading the translation of Koch's paper in the British Medical Journal, which was accompanied by the notice of a demonstration of the tuberculosis remedy that was to take place in Berlin later that week, Conan Doyle dashed out of his house and boarded a train for London with the intention of getting to Germany as soon as possible. He later recollected, "I could give no clear reason for doing this, but it was an irresistible impulse and I at once determined to go. Had I been a well-known doctor or a specialist in consumption it would have been more intelligible, but I had, as a matter of fact, no great interest in the more recent developments of my own profession."2
Once he reached London, the doctor's pragmatic side intervened, and Conan Doyle stopped by the offices of W.T. Snead, the editor of the magazine Review of Reviews. Securing letters of introduction from Snead to prominent Berliners and, even more important, a green light to write about the event, Conan Doyle then hopped a boat across the Channel. Once in France, he secured a seat on the Continental Express to Berlin and arrived on November 16. Almost as soon as he stepped off the train in Berlin, Conan Doyle set out for the university building where Koch's colleague, Dr. Ernst von Bergmann, was scheduled to demonstrate the miraculous tuberculosis remedy the following morning. Alas, Conan Doyle's trip appeared to be for naught when he learned that tickets to von Bergmann's clinical demonstration were "simply not to be had and neither money nor interest could procure them."2
At this point, the intrepid Conan Doyle decided to seek out Koch at his home, but he was told by a butler that the professor was unavailable. As Conan Doyle later recounted, "To the Englishman in Berlin, and indeed to the German also, it is at present very much easier to see the bacillus of Koch than to catch even the most fleeting glimpse of its discoverer."3 Indeed, the closest Conan Doyle got to Koch was witnessing the upended sacks of mail emptied on the professor's doorstep and the thousands of letters from around the world containing desperate pleas regarding "the sad broken lives and wearied hearts which were turning in hope to Berlin."2
Bright and early on the morning of November 17, Conan Doyle went back to the medical auditorium at the University of Berlin. But neither bribes nor his clumsy attempts at slipping by the ticket taker secured him entry. Realizing that his magazine story was evaporating into thin air, Conan Doyle patiently waited for von Bergmann and literally threw himself in the path of the formidable physician, causing a pileup of the younger doctors who made up the professor's faithful retinue and academic rear guard.
"I have come a thousand miles. May I not come in?" begged the British medical journalist. The query prompted the senior physician to stop, glare through his pince-nez spectacles, and haughtily reply: "Perhaps you would like to take my place? That is the only one vacant!" Humiliated by the laughs and jeers of those who did possess the necessary coupons for entry, Conan Doyle began to turn around and leave the hospital. Fortunately, a tuberculosis specialist from Detroit named Henry J. Hartz was appalled by von Bergmann's display of bad behavior and lack of professional collegiality. Hartz promised to meet with Conan Doyle later that afternoon and share his notes on the demonstration. Even better, the following morning, Hartz quietly escorted Conan Doyle into von Bergmann's clinical wards to examine the patients who had received Koch's lymph.
Within a day after analyzing the mass of clinical data, however, Conan Doyle came to a startling conclusion: "The whole thing was experimental and premature." What is more, he had the temerity to make this statement publicly, first in a letter to the editor, published in the London Daily Telegraph on November 20, 1890,4 and then, more definitively, in his article in the Review of Reviews, which ran in December of that year. While the rest of the world rejoiced over the reported conquest of tuberculosis, Conan Doyle argued that "Koch's lymph" might remove traces of the enemy, but it left deadly germs "deep in the invaded country." Its real value, Conan Doyle asserted, was as "an admirable aid to diagnosis," in that a "single injection" would help doctors decide definitively whether a patient was "in any way tubercular."
Conan Doyle was right. Koch's lymph, or what we now refer to as tuberculin, was essentially a glycerin extract of a pure culture of tuberculosis germs. In the decades before the development of the much safer purified-protein-derivative test for tuberculosis, it became an essential diagnostic tool. A few months later, in early 1891, after several highly publicized treatment failures, many exacerbated cases of tuberculosis, and not a few deaths closely associated with the administration of the so-called curative medication, Koch publicly retracted his even-tempered announcement of a remedy for tuberculosis and announced that although Koch's lymph was an excellent means of diagnosing tuberculosis, the actual cure was nowhere in sight.5
One cannot help but be impressed by the way in which the young Conan Doyle, the creator of the greatest detective in English literature, figured out what took Koch, one of the most illustrious medical detectives in history, and his accomplished colleagues many more months to realize. Sadly, the paper trail ends before we can definitively ascertain how Conan Doyle cracked "The Case of Koch's Lymph."
Source Information
Dr. Markel is director of the Center for the History of Medicine and a professor of pediatrics and communicable diseases and the history of medicine at the University of Michigan Medical School, Ann Arbor.
References
Koch R. A further communication on a remedy for tuberculosis. BMJ 1890;4:1193-1201.
Conan Doyle A. Memories and adventures. London: Hodder and Stroughton, 1924: 82-93.
Dr. Koch and his cure. Rev Revs 1890;2:552-6.
The consumption cure. London Daily Telegraph. November 20, 1890:3.
Koch R. Professor Koch's remedy for tuberculosis. BMJ 1891;1:125-127.(Howard Markel, M.D., Ph.D)