Knowledge in the Time of Cholera

by Owen Whooley

  Still the damage was done. The controversy over homeopathy solidified the rank and file’s suspicion of public health. Immediately after the epidemic, allopathic physicians clamored to claim that the board of health had “originated in the Academy of Medicine and that the Health Bill should be regarded as the legitimate offspring of the Academy” (NYAM April 28, 1866, 7). But as the epidemic receded in memory and as the ecumenical colors of public health were revealed, allopaths distanced themselves from the board. It was no longer considered an allopathic offspring but rather a misguided endeavor susceptible to the pernicious influence of homeopaths. Even in New York, where reform efforts were initiated by a preeminent allopathic medical society, sentiments toward the board cooled.

  CONCLUSION: A PLAN ABANDONED

  In the end, the struggle between homeopathy and allopathy on the board followed a similar script to the debates over licensing, albeit with additional actors included in the fray. Regulars, initially viewing the boards as an opportunity to suppress homeopathy and promote their professional goals, saw these hopes dashed by a public institution unwilling to grant them a privileged epistemic recognition. Both the state legislatures and the boards of health supported a measure of transparency and inclusivity that clashed with the exclusionary program of the AMA. Just as democratic legislatures were suspicious of allopathy’s claim that its knowledge should be granted a privileged position, so too were the boards. As subsequent chapters will show, the boards of health, which were held in high public esteem and possessed many resources, remained a key arena for the epistemic contest over cholera. However, the boards’ understanding of disease as filth, their ecumenical organizational form, and their apolitical justification of epistemic authority prohibited regulars from harnessing them to advance their own professional agenda. They were too susceptible to democratic influences to provide allopathy’s desired outcomes.

  This episode in the epistemic contest makes clear that claims to epistemic authority can be framed along a variety of dimensions, and how they are framed restricts the possible professional claims that can be legitimately made in their name. Because the professions have become the way in which modern societies have organized expert knowledge (Abbott 1988), the relationship between epistemic authority and professionalization has been naturalized, so it is assumed to be not only unproblematic but also nearly synonymous. Justify one’s knowledge, gain professional recognition. By showing how the manner in which epistemic authority was framed hindered, rather than advanced, the professional goals of allopathy, this case encourages researchers to decouple epistemic authority and professional strivings, recognizing them as distinct and separate (although often intertwined).

  The fight over the boards of health (and, in turn, the definition of cholera as espoused by the boards) was waged on multiple fronts. Initially, it focused on entrenched urban politicians versus sanitarians. At this point, regular involvement was unofficial and restricted to elite sanitary-minded physicians. Sanitarians’ claim to a privileged epistemic position rested on a disinterested, apolitical ethos toward knowledge. They successfully convinced state legislatures that public health should be removed from political calculus and placed under the control of those who could soberly assess the sanitary situation of the city and honestly carry out the requisite reforms. They won the authority to control cholera not on the content of their knowledge, nor on their particular epistemological stances toward medical knowledge, but on the basis of their orientation toward knowledge. Insofar as the new boards were seen as successful, allopaths benefited from their association with them. However, on two other fronts—allopathic physicians versus nonmedical actors and allopathic physicians versus homeopaths—the apolitical, disinterested justification stymied regulars’ professional goals. Regulars were willing to adopt the rhetoric of disinterestedness when taking on political patronage, but less willing to extend this ethos in their interactions on the boards themselves. This made them vulnerable to attacks on the part of other sanitarians that their efforts to control the boards were political in themselves, contrary both to the intellectual ecumenism of public health and the ideals of democracy. The allopathic attempt to harness the boards for professional ends was framed by opponents as a bald political power grab, precisely the type of politics the boards were to be insulated from. This argument proved effective. While the legislatures agreed that the boards needed to be protected from political corruption, they did not want them to be insulated entirely from debate and democratic oversight. Instead, what the legislatures sought to do with the boards was to demarcate a politically untainted space in which debate could happen in a productive fashion. As such, regulars’ exclusionary epistemology, and their attempts to impose this epistemology on others, fell on deaf ears.

  Linking practices of exclusion to bad knowledge, homeopaths and plumbers effectively thwarted their powerful allopathic opponents. This chapter, therefore, demonstrates how intellectual disinterestedness as an ideal can be a resource for less powerful actors—a “weapon of the weak” (Scott 1985)—when advocating for inclusion within the context of democratic cultures. By drawing the analogy between democratic participation and intellectual ecumenism, plumbers and homeopaths effectively placed the onus on allopaths to justify their exclusion of others and their own privilege. The commitment to disinterestedness provided a platform for resistance by reframing issues of knowledge as issues of democracy, by situating them within a discursive space that politicized claims to intellectual privilege. In turn, the ethos of apolitical knowledge became, ironically, an effective political tool.

  In the end, while the new boards of health offered enticing resources for allopathic professional goals, regulars were unable to harness them, leading many regulars to become skeptical toward public health. Undermined once again by the persistent tension between the exclusionary epistemology upon which allopathy asserted its professional claims and the democratic epistemology of government institutions, regulars had to ambivalently swallow their status as one voice among many.

  4

  CHOLERA BECOMES A MICROBE

  The conventional narrative of the “discovery” of the cholera microbe reads as part medical mystery, part international brain race, and part microbial military campaign. In 1883, a smoldering cholera epidemic in Egypt raised the specter of yet another deadly pandemic. Barring some intervention, Europeans worried that the summer of 1883 would bring another season of cholera to their continent. This time, however, rather than await cholera’s arrival, European governments decided to go after it. Armed with new tools of observation and a new germ theory of disease, they dispatched their best scientists, in the hope that cholera, perpetually elusive to quarantines, could be arrested by scientific acumen alone.

  The Egyptian outbreak not only offered an opportunity to test new scientific ideas; it also held the potential for glory for burgeoning national scientific programs. European officials assembled elite scientific teams and sent them to Egypt to uncover the mysteries of cholera and win prestige for their country. France acted first, allocating fifty thousand francs for a cholera expedition. Dubbed Mission Pasteur, after the famous French bacteriologist Louis Pasteur, the French team included two of Pasteur’s most promising assistants, Emile Roux and Louis Thuillier. The intrepid bacteriologists arrived in Egypt on August 15 and promptly occupied the best hospitals in Alexandria, where they carried out microscopic examinations of stool and blood specimens (Brock 1988). Their initial examinations led to sightings of a microbe that the expedition hoped might be the elusive cause of cholera. But the early leads went nowhere, and before anything could be confirmed, the cholera moved on from Egypt, having claimed somewhere between sixty thousand to ten thousand victims. One of these victims was the twenty-eight-year-old Thuillier. Reeling from the tragic blow of losing one of the brightest bacteriological minds in the world, the French expedition returned to Europe empty-handed.

  Not to be outdone, Germany sent its own expedition on August 24, fast on the heels of t
he French team. Robert Koch, who had identified the tuberculosis bacillus the year before, was named the leader of the German Commission. Given great leeway to dictate the research program, Koch used the generous resources allotted by the German government to amass an impressive expeditionary force. Whereas the French team was outfitted only for microscopic and animal inoculation studies, the German team assembled “a complete travelling bacteriological laboratory” that included culture vessels, inoculation equipment, sterilization apparatuses, and other tools requisite for bacteriological examination (Brock 1988, 141–142). Koch was unambiguous about his goal; he wanted to validate bacteriology by isolating the organism that caused cholera. The extensive equipment amassed was necessary if the research was to fulfill Koch’s stringent postulates for identifying the microbial origin of diseases.

  Unlike its French counterparts, the German team succeeded. After the Egyptian epidemic abated, Koch followed cholera to India, departing on November 13. Within days of his arrival, Koch first observed the comma bacillus. After a few months of additional bacteriological and epidemiological research, Koch announced his discovery on February 4, 1884. Unable to reproduce the disease in animals, and thus failing to fulfill his own postulates, Koch knew that ironclad evidence of causation eluded him (Coleman 1987, 316). Nevertheless, he unabashedly reported, “It can now be taken as conclusive that the bacillus found in the intestine of cholera patients is indeed the cholera pathogen” (quoted in Brock 1988, 160). He went on to describe the bacillus as “not a straight rod, but rather . . . a little bent, resembling a comma. The bending can be so great that the little rods almost resemble half-circles. In pure culture these bent rods may even be S-shaped” (quoted in Brock 1988, 160). The innocuous appearance of this S-shaped microbe belied its deadly character, and it took a significant stretch of the nineteenth-century medical imagination to link the tiny organism to the destruction cholera wrought.

  On May 2, 1884, Koch returned to Germany to a royal welcome. He met the kaiser and received a medal during an audience with Imperial Chancellor Otto von Bismarck. Koch had left for Egypt as a promising scientist; he returned a national hero. The bacillus, however, did not make the trip as Koch feared unintentionally introducing cholera to the Continent.

  Was this the breakthrough discovery in medicine’s tortured history with cholera? Did cholera become a microbe in 1884? Conventional histories answer both of these questions with a resounding yes (e.g., Chambers 1938; de Kruif 1996). According to these accounts, Koch’s discovery was recognized immediately, and physicians worldwide mobilized in the name of the germ theory. News of it “spread to all of the laboratories of Europe and had crossed the ocean and inflamed the doctors of America. The vast exciting Battle of the Germ Theory was on!” (de Kruif 1996, 119).

  In reality, the situation was far more complex. It would take time to sort out the meaning of Koch’s research, time to configure it into the paradigmatic discovery of which future medical textbooks would write. At a basic level, it was hard for others to see what Koch saw, as his laboratory techniques had yet to be standardized. Only a handful of scientists in the world possessed the requisite technical skill to reproduce Koch’s findings (Coleman 1987). Furthermore, bacteriology required a radical reorientation in the way most physicians thought about disease.

  Whether cholera was a microbe thus depended on who was asked. Koch’s research unleashed a firestorm of commentary. The British, sensitive to European criticism of their colonial empires and long averse to quarantines that inhibited free trade (Vernon 1990), scoffed at Koch’s conclusion immediately and vehemently. The British Medical Journal dismissed the “bogey-germ” (quoted in Brock 1988, 150), while the English government published an official refutation (Ogawa 2000). Britain’s beloved, pioneering nurse, Florence Nightingale, rejected the germ theory, as it seemed to undermine her efforts to improve sanitary conditions of hospitals (Rosenberg 1987a, 134). In France, Pasteur, perhaps out of competitiveness or wounded pride, raised questions as to the validity of Koch’s claims. Even within Germany, Max von Pettenkofer, one of the world’s most famous scientists, expressed skepticism.

  The United States reacted to the news of Koch’s research in conflicting and inconsistent ways. The New York Times (October 28, 1883, 8) seemed convinced, reporting, “The cable announced recently that Robert Koch, who went from Germany to study the Egyptian cholera epidemic, has found what many medical men of several nations have long looked for in vain—the cause of the disease.” However, burying the article on page 8, the paper’s editors hardly gave their vote of confidence to the newsworthiness of the event. In fact, Koch was only mentioned twice in the New York Times during the key years of 1883 and 1884. Coverage in other American papers displayed a similar pattern. Though reported, Koch’s cholera research failed to provoke sustained headlines or to win a prominent place above the fold (Hansen 1999).

  Still, the American press was more responsive than U.S. physicians, whose reviews were decidedly mixed. In the early 1880s, few members of the American medical profession were receptive toward “bacterian” ideas (Maulitz 1982).While Germany and France were well into a transition toward a university system based on specialization and modeled on scientific expertise, the U.S. educational system was still based on a more traditional theological model (Rudolph and Thelin 1991). Scientific research in the United States remained an amateur and community-based affair (Bender 1976), primarily carried out, not in universities, but in local learned societies (Oleson and Voss 1979). Far removed from European laboratory science, U.S. physicians were consumers rather than producers of medical research (Richmond 1954). Given this intellectual environment, American doctors were ill-equipped to interpret Koch’s research and, in turn, its status as a discovery was by no means taken for granted. Bacteriological research produced in the laboratory demanded a shift in epistemic assumptions, and many American physicians were unwilling to make this leap yet. Instead, Koch’s research got folded into the existing epistemic contest over medicine, where it was challenged and reinterpreted, in order to serve a variety of masters and ends.

  THE MAKING OF A DISCOVERY

  Contrary to the interpretations of triumphalist histories, Koch’s discovery was neither self-evident nor unprecedented,1 nor did it spread unimpeded throughout the developed world. Its status was more ambiguous, its dissemination complicated by fits and starts. In the United States, both homeopathic and allopathic physicians reacted to Koch’s announcement in complex, often contradictory, ways. As with so many issues related to cholera, confusion reigned. Just because Koch spotted an S-shaped organism in his microscope did not mean American physicians would accept cholera as a germ. Much work still needed to be done to Koch’s research by bacteriological reformers in order to make it palatable to Americans. Not only did U.S. doctors have to make sense of the strange new finding; they had to figure out what such research meant to the larger struggle over medical epistemology. The hero’s welcome Koch would eventually receive in the United States in 1908 was a long way off.

  The conventional histories of Koch’s discovery offer little insight into the complex process by which the idea of cholera as a germ gained traction in the United States. In subscribing to a simple diffusion model, they treat Koch’s research2 as self-evident and self-interpreting. Koch’s idea spoke for itself; the germ theory is portrayed as “an all purpose deus ex machina” that drove its own acceptance (Tomes and Warner 1997, 8). As discussed in the introduction, the diffusion model assumes a simplistic notion of scientific realism, whereby scientists uncover an objective reality, revealing the evident truth to the world. It misattributes agency to the “discovered” ideas, whitewashing away the ambiguity, uncertainty, and controversy often surrounding new ideas.

  Even critical histories succumb to the dubious causality of the diffusion model. In his study of the social transformation of U.S. medicine, Starr (1982, 135) writes,

  The key scientific breakthroughs in bacteriology came in the 1860s and 1870s in the work
of Pasteur and Koch. The 1880s saw the extension and diffusion of these discoveries, and by 1890 their impact began to be felt. The isolation of the organisms responsible for the major infectious diseases led public health officials to shift from the older, relatively inefficient measures against disease in general to more focused measures against specific diseases.

  Here Starr falls prey to the crude causal explanations of the diffusion model. Uncritically accepting the bacteriological findings as “scientific breakthroughs,” Starr describes their diffusion using the passive voice (e.g., the 1880s “saw the extension and diffusion of these discoveries”). The “isolation of organisms”—an idea—is given its own agency, as it “led” public health officials to certain measures. Letting ideas speak for themselves, these analyses offer limited insight into how these ideas came to be seen as paradigmatic discoveries. For even if we take for granted that a discovery is true (in whatever sense of the word), we still need to account for its acceptance. To avoid the tendency of ascribing to an idea “an ontological life of its own” outside of its historical emergence (Tomes and Warner 1997, 9), we need to historicize knowledge claims, embedding them in the context of their reception to unearth the processes by which actors advocate for ideas so as to get them institutionalized as discoveries.

  Discoveries are not born. They are not unearthed in single moments of time but materialize over a long period following that moment. The sociology of scientific knowledge (SSK) has long criticized the folk understanding of a discovery “as a unitary event, one, which, like seeing something, happens to an individual at a specifiable time and place” (Kuhn 1962, 760). In practice, discovery is a social process involving two components—the production of a fact and the subsequent conferral of the status of discovery upon that fact. In relation to the first phase—the production of a fact—SSK, through laboratory studies, has produced a comprehensive body of research that illuminates the way in which scientists produce or construct scientific knowledge in practice (e.g., Knorr-Cetina 1999; Latour and Wool-gar 1986; Pickering 1984;). It is the second phase—how the special status of “discovery” is conferred upon an idea—that remains underexamined. Discoveries do not spring up fully formed in the research process. Rather, they are defined as such through public struggles over the meaning of a given idea between actors with various agendas. In other words, discoveries are produced via work performed on an idea subsequent to its creation. The transformation of an idea into a discovery is a process that occurs literally after the fact.