Knowledge in the Time of Cholera

by Owen Whooley

  For all these reasons, many American physicians adopted a wait-and-see policy toward the germ theory. An article on sanitation in Harper’s Magazine explained their caution: “It is, indeed, claimed by some that the causation of certain diseases by specific organisms of microscopical minuteness has been demonstrated; by the majority of medical thinkers, however, the demonstrative evidence is not considered as complete” (quoted in Richmond 1954, 430). Preferring a middle course between complete adoption and outright rejection, most doctors suspended “judgment until more light had been thrown upon the subject by further investigation” (Fitz 1885a, 169). For these skeptics, no evidence, in and of itself, would suffice, as accepting the findings from the bacteriological laboratory involved a redefinition of what constituted evidence in medical knowledge. It demanded a leap of faith, and many physicians resisted jumping.

  However, while doctors reluctantly debated the merits of Koch’s research, the germ theory began to gain a measure of popular support before physicians even agreed that it was valid (Duffy 1993; McClary 1980; Tomes 1998). The media played an important role in building public support for bacteriology (Hansen 1999; McClary 1980; Ziporyn 1988). Media reports found fertile ground for the support of the germ theory among the public who had long balked at the noncontagious arguments of doctors; for them, cholera had always seemed contagious (Rosenberg 1987b). Koch had merely located the source of this contagion. As the germ theory gained public recognition in the mid-1880s, social reformers of many stripes began to promote a code of behavior based on the germ theory, and through their efforts, avoiding germs would eventually become a credo of modern living (Tomes 1998).

  These assessments, both popular and professional, unfolded in the context of an epistemic contest over medicine that had reached a stalemate. Some reformers within both allopathy and homeopathy began to see the germ theory as a potential resource in this contest given its growing public support, even despite all of the intellectual difficulties it presented. While it is difficult to reconstruct the motivations of physicians who embraced bacteriology, it is clear that much of bacteriology’s allure lay in its promise to bring an end to the stalemate. Decades of ugly fighting between sects had taken their toll, manifested in doctors’ profound despondency about the state of their therapeutics, and to some, laboratory analysis offered an escape from this era of therapeutic nihilism (Warner 1991). As is often the case, there was a generational dimension to the adoption of the new ideas. Younger physicians hoped that by associating themselves with the latest science, they would advance their career prospects—carving out a niche in the competitive economic environment of nineteenth-century medicine—while also improving the public image of their sect.

  When Koch announced his finding, bacteriology was neither homeopathic nor allopathic. It was something new altogether, its status unclear. If a sect could capture a popular idea, it might be able to ride it into wider acceptance. However, to transform the research into a discovery that promoted a particular professional agenda, homeopathic and allopathic reformers faced two tasks. They had to wrest ownership of the idea from their competitors and then transform the uncertain research into a paradigmatic discovery that heralded a new future in medicine. To achieve these ends, to make Koch’s research speak to the past and the future, they created distinct narratives of discovery.

  Homeopathy’s Narrative of Prediscovery—In retrospect it may be difficult to understand the homeopathic claim to Koch’s cholera finding, especially since bacteriology would later be folded into allopathy’s professional program to defeat homeopathy. However, both homeopaths and regulars reacted with a mixture of curiosity and skepticism to Koch’s claims (Rothstein 1992, 275). This similarity betrays a fact unacknowledged in most historical accounts of the emergence of the germ theory that situate it within the confines of allopathy—the new findings both resonated with and challenged the intellectual framework of both homeopathy and allopathy. Homeopathic reformers, like their allopathic opponents, saw the potential of Koch’s research to tilt the epistemic contest in their favor.

  Soon after Koch’s announcement, homeopathic reformers staked a claim to Koch’s work. This claim was rooted partially in an appeal to nationalism. Koch was German as was homeopathy’s founder, Samuel Hahnemann. With this “genealogical tactic” (Zerubavel 2011, 82), homeopaths claimed Koch as a codescendant through his shared German ancestry with Hahnemann. The shared national heritage reflected a deeper, more subtle intellectual heritage underlying Hahnemann and Koch. Produced by the same context, their ideas were related. This argument was resonant in the context of nineteenth-century medicine, as nationalism was implicated in the acceptance and rejection of medical theories (Brock 1988; Ogawa 2000; Vernon 1990). Where ideas came from mattered a great deal, and the fact that homeopathy shared a national origin with Koch was no small matter.

  This genealogical argument provided the backdrop for the centerpiece of the homeopathic claim to Koch—its prediscovery narrative. This narrative reframed Koch and his findings as confirmation of Hahnemann’s initial genius (Rothstein 1992, 278). In this case, Koch was simply restating (maybe in a more sophisticated, systematic way) what Hahnemann purported long ago. The narrative proceeded as follows: in the early 1800s, Hahnemann dared to challenge conventional wisdom on cholera specifically and disease generally, but was persecuted for his beliefs. For decades, homeopaths stubbornly maintained Hahnemann’s tradition only to suffer a similar persecution at the hands of allopathic physicians. Finally, Koch rediscovered Hahnemann’s ideas and thus vindicated the entire tradition. The logic of this narrative was one of prediscovery (Merton 1968). Hahnemann’s was the initial “prediscovery,” which had somehow failed to convince; Koch’s research was a rediscovery of Hahnemannian insight under a slightly different guise. The intent was to use Koch’s public popularity to vindicate Hahnemann’s genius and the homeopathic medical system.

  Specifically regarding cholera, Koch’s findings were portrayed as further confirmation of Hahnemann’s original conception of the disease: “The germ theory of disease was anticipated by Hahnemann. As early as 1831 he alleged ‘that cholera was propagated by organisms which were conveyed by the air,’ and he advised the administration of camphor in material doses ‘in order to destroy these pestiferous microbes’ ” (Wood 1899, 109). This view of cholera espoused by Hahnemann sat awkwardly with his understanding of the vital force, an awkwardness that was never fully resolved. Still, this early presage of the germ theory was useful to homeopathic bacteriological supporters, as it allowed them to situate Koch within the homeopathic tradition. Koch’s relevance lay less in the novelty of his claims, but in the support these claims conferred upon old Hahnemannian ideas. The homeopathic narrative linked Hahnemann to Koch and other bacteriologists who should “be elected to membership of the American Institute of Homeopathy for the patient but brilliant, unconscious confirmation of the truth which Hahnemann promulgated” (Maddux 1892, 9).

  With one eye to the past, the prediscovery narrative also looked to the future, linking therapeutic implications of the germ theory to homeopathy’s law of similars. Recall that homeopaths viewed all disease as an imbalance of the vital force. The goal of homeopathic therapeutics was to bring the vital force into equilibrium, by prescribing mild, infinitesimal drug treatments that complemented the ameliorative capacities of the vital force (Coulter 1973). Taken to their logical therapeutic conclusions, both the germ theory and the law of similars arrived at a similar destination—vaccination.6 Vaccination involved giving minute doses of the disease itself. The dilution of the disease for vaccination squared with the homeopathic commitment to infinitesimal dosages. Likewise, the rationale behind vaccination—preventing disease by building up a patient’s resistance to it—squared with the homeopathic emphasis on the vital force. Vaccination was “homeopathy pure and simple” (McClelland 1908, 5). In this narrative, then, Hahnemann provided the foundational thought—the law of similars—upon which the future of bacteriology rested. Linking
Koch to this founding moment, homeopaths situated the germ theory within the homeopathic tradition.

  Despite the prediscovery narrative, Koch’s cholera research was resisted by many homeopaths. The narrative attempts to incorporate Koch into homeopathic tradition were frustrated by an internal division within homeopathy that revolved around tension between the reforming “lows” and the older, more conservative “highs.” Ostensibly a debate over the dilution of medicine, the fundamental issue at stake was the degree of fidelity homeopaths should display toward Hahnemann’s original ideas. Younger, liberal homeopaths—“lows”—embraced ideas from outside homeopathy and argued for more individual freedom in determining doses (Coulter 1973). Without memory of the past battles with allopaths, they wanted more latitude in choosing their intellectual influences and were even open to cooperating with allopathy. The new science of bacteriology was part of lows’ attempt to open homeopathy to new influences, and as such, they were responsible for the homeopathic prediscovery narrative. The “highs,” on the other hand, rejected accommodation to new ideas, worrying that it would blunt homeopath’s critical edge and distinct identity. Assuming a fundamentalist stance toward Hahnemann’s texts, the highs rejected any attempt to incorporate new bacteriological ideas as illegitimate cavorting with allopathy. Veterans of past legal skirmishes with allopathy, they were unwilling to suspend their distrust. But they also pointed to the real intellectual problems in reconciling the germ theory with homeopathy. Because homeopathy considered that the ultimate cause of disease would always remain unknown, highs thought the new focus on etiology was misplaced. In 1886, the Homeopathic Physician proclaimed that “those who seek material causes of disease aided by the microscope will seek in vain” (quoted in Coulter 1973, 354). The idea that all disease could be reduced to a germ was anathema to this emphasis on the vital force. Therefore, while lows tried to convert some highs by linking Koch to Hahnemann, their success was limited. These internal divisions plagued homeopathy for the remainder of the nineteenth century, especially as many highs left the American Institute of Homeopathy to set up the more orthodox International Hahnemannian Association (IHA), which quickly denounced the germ theory. Consequently, the status of the germ theory remained ambiguous within homeopathy.

  Part of this failure can be attributed to the nature of the prediscovery narrative itself, as it imbued Koch’s research with uncertain status vis-à-vis future implications. If Koch’s research was simply a rediscovery of Hahnemann, why should it even matter for homeopaths who had long been committed to these ideas? In what way was the future program it promised different, relevant, or even exciting? Couldn’t the same promise be obtained by simply continuing the homeopathic tradition? Aside from capturing some of the public popularity associated with Koch, the prediscovery narrative suggested to many homeopaths a call to maintain the status quo. This minimized the singularity of Koch’s research and diluted the urgency surrounding the new “discovery.” As such, the prediscovery narrative failed to resolve the status of Koch’s research within homeopathy and prevented its full transformation into a singular homeopathic discovery.

  Allopathy’s Narrative of Emergent Discovery—Prior to the bacteriological revolution, allopathy embraced a radical bedside empiricism, selectively translated from the Paris School. In their repudiation of the rationalist systems of the early nineteenth century, allopathy sought to purge medicine of all speculative hypotheses and theories by making individual sensory observation the foundation for medical knowledge. This legacy of suspicion toward theory presented a problem for allopathic bacteriological reformers. The germ theory proved to be a tough sell. This was especially true as it demanded privileging laboratory facts over clinical bedside observation. Allopathy had staked its epistemological claim in sensory observation, what they could see, touch, and hear, what they witnessed regarding disease in situ. Laboratory analysis removed disease from its natural environment and employed new technologies to expose disease in controlled environments. Adoption of the germ theory would require an epistemological shift that many regulars were resistant to take.

  Advocates of the germ theory initially attempted to fold Koch’s findings into allopathy’s radical commitment to empiricism by appealing to sensory observation. They brought the cholera microbe to skeptics so that they could see it for themselves. In 1884, Dr. E. C. Wendt presented a sample of cholera bacilli prepared by Koch to the New York Academy of Medicine, inviting members of the society to observe with their own eyes what Koch saw (Boston Medical and Surgical Journal January 15, 1885). In 1885, F. S. Bil lings, surgeon general of the U.S. Army, offered a similar opportunity to those interested. But it was difficult for allopathic skeptics to actually see the microbe (Billings 1885, 476). They weren’t trained to do so. For those steeped in the tradition of sensory observation, the way in which these new tools altered sensory experience was confusing. Spots in a culture were foreign, as the overwhelming majority of U.S. doctors lacked access to labs and microscopes (Duffy 1993; Richmond 1954; Tomes 1997, 1998). One bacteriological advocate lamented that the new techniques were “of so elaborate and difficult a character that the number of competent witnesses must necessarily be very small” (Hamilton 1884, 492). Translating them into useful knowledge was not only beyond the skill set of many regulars; it was beyond their imagination. These technical and conceptual difficulties were expressed somewhat comically when Albert L. Loomis, a well-regarded New York physician and future president of NYAM (who later converted to bacteriology), complained when he initially came into contact with the germ theory, “People say there are bacteria in the air, but I cannot see them” (quoted in Fleming 1987, 72).

  To overcome these difficulties, allopathic bacteriological advocates had to reconcile Koch’s research with the still-dominant radical empiricism. To do so, they constructed a narrative of discovery that de-emphasized the theoretical component of Koch’s research. Koch’s research was portrayed as an emergent discovery, driven not by a commitment to the germ theory but by fortuitous empirical findings. What he saw determined the theory, not the other way around. In this “narrative of emergent discovery,” spontaneity was the key theme. Koch went abroad with only his microscope and an abiding motivation to uncover the truth of cholera. Once there, his careful work unearthed the microbial origins of the disease. Excluded from this narrative was any acknowledgment of Koch’s theoretical commitments: “Never before has there been so little theorizing with so much work, and the facts which have finally been accepted are such as have come to light only after a long series of carefully made and oft-repeated experiments” (Loomis 1888b, 56). Koch, who set out to Egypt and India expressly to confirm his germ theory (Coleman 1987), was transformed into an empirical observer who, through patient observation, became the spokesperson for an illuminated factual truth. Koch himself encouraged this myth, publicly framing his “discovery” along a similar empiricist line by downplaying the influence of theory on his research (Gradmann 2009).

  Therefore, in an attempt to make Koch acceptable to the bulk of their allopathic peers, bacteriological advocates transformed his research into an ideal exercise in empirical observation through this narrative of emergent discovery. To consolidate this interpretation, reformers tied the discovery to existing allopathic knowledge, knowledge that had been achieved by empirical means. Advocates argued that the new laboratory facts were complementary to bedside observation: “Recent microscopical and experimental researches in Egypt and Calcutta, made at the expense of the German government, by Dr. Robert Koch, one of the most successful detectives of disease-causing germs, seem to demonstrate, what general observation of the disease has already indicated” (Sanitarian 1884, 108–109, emphasis added). In accordance with the dictates of empiricism, the defense of Koch’s discovery was waged through appeals to the “logic of potent facts” (Medical and Surgical Reporter 1892, 459). By 1894, William Welch (1920a, 27) was stating,

  The evidence now, however, for many infectious diseases is no longer a
prioristic, but is based upon incontrovertible observations and experiments relating to the causative microorganisms. We owe to Pasteur as the pioneer and then to Koch and to their followers, the great mass of positive evidence, which has introduced a new era in the history of medicine.

  In the hands of its bacteriological advocates, the germ theory had morphed into a mass of potent facts and observations that spoke for themselves.

  This narrative did not go unchallenged within allopathy. Much of the internal debate hinged on whether Koch’s research was an exercise in theorizing or whether it was driven by empirical observation. For older physicians especially, Koch’s findings represented just another problematic theory in a long history of reductionist theories. Veterans of past epistemic battles remained skeptical, arguing, “This theory is a very seductive one, and although investigations in order to establish it have been very extensively made, and the statements of some observers are strongly in its favor, yet the facts do not warrant us in accepting it” (Loomis 1888a, 119). Like their homeopathic competitors, allopathic bacteriological reformers faced stiff internal resistance, reflecting the real conceptual mismatch between the prevailing intellectual foundation of their sect and the new laboratory science. To avoid a similar fate of fragmentation, they needed to do more work to link the future of American allopathy to the famous German scientist.