Knowledge in the Time of Cholera

by Owen Whooley

  The Production of Promise

  The germ theory’s inconsistencies with each sect’s tradition perhaps could be overlooked if advocates were able to construct an enticing enough future. As Karl Popper (1992, 16) notes, “Scientific discovery is impossible without faith in the ideas which are of a purely speculative kind.” To construct such faith, however, bacteriological advocates had to deal with the present uncertainty and ambiguity of Koch’s research. Turning their gaze to an imagined future, they engaged in promissory practices to overcome the present limitations of the research itself. In other words, proponents of the germ theory in the United States sought to explain away the uncertainty surrounding Koch’s research via an appeal to an imagined future in which the germ theory would eradicate all infectious disease. In this way, Koch’s discovery became folded into a larger program of bacteriological reform, a type of “promissory science” that justified current investment through ambitious promises of returns (Fortun 2008).

  Advocates adopted two rhetorical moves to create a sense of promise around Koch’s research. First, they assured skeptics that any current uncertainty in Koch’s research would be eliminated by future research. For example, F. S. Billings (1885, 476), a bacteriological expert on the swine plague, argued, “Although the remaining proof, cultivation of the disease by means of the bacilli, has not yet been made, still in the present early state of our knowledge of the subject, we have no reason for declining to accept the bacillus as the cause of cholera.” Billings points to future certainty to be achieved via the promise of further bacteriological research so as to downplay the present deficiencies. An extreme variation of this practice was an appeal to the present uncertainty as the very justification for investing in bacteriology: “The contributions of bacteriology to the medical art are all the more remarkable, because its methods and processes are still enveloped in much mystery—mystery which teaches us to expect much from the further developments of the new science as it gradually disperses the fogs which now envelop it” (Eliot 1896, 92).

  Second, advocates promised a wide array of practical payoffs in the near future. In 1887, before the New York Academy of Medicine, Dr. E. O. Shakespeare (1887, 478) claimed:

  In the discovery of a reliable and an easily applicable distinctive means of diagnosis of Asiatic cholera at the very first moment of invasion of a locality or a country, I consider that Koch has conferred upon the human race an inestimable benefit for, with the proper application of this means of diagnosis, health authorities and Governments will now more than ever before have it in their power to prevent an invasion of cholera and cut short the spread of an epidemic. The value of this discovery, as I have said before, I consider incalculable.

  The diagnostic promise was particularly robust in that it required no commitment to Koch’s shakier causal claims; if cholera was correlated with Koch’s bacillus, then the laboratory identification of the microbe could be an effective diagnostic tool regardless of issues of causality. Cholera, a disease with such violent symptoms that it was rarely misdiagnosed anyway, became a disease whose presence or absence could be determined with greater certainty by laboratory analysis. This would eliminate the debates over the presence of the disease that seemed to plague each epidemic: “The possibility of recognizing the first case of cholera in any given community, no matter how slight or how abnormal its symptoms, is capable of proving of immense value in permitting appropriate measures to be taken to prevent the spread of disease” (Fitz 1885b, 197). Of course, fulfilling this diagnostic promise would require the investment of public health laboratories, which de facto meant an investment in the bacteriological paradigm itself.

  Additionally, advocates envisioned a new future for sanitation, a rational program focused on locating and destroying germs. The identification of microbes would be the means by which sanitary science would become truly scientific. While admitting its limited effect on therapeutics, T. Mitchell Prudden (1889, 94–95), future director of the Rockefeller Institute for Medical Research, optimistically argued that “knowing definitely, as we do now, what causes the disease, how and under what conditions it spreads, and what will destroy the germs, we are to-day in a condition, wherever sanitary and proper quarantine regulations are efficiently carried out, to largely prevent the access of the disease to our country, to stay the progress of an epidemic at its very outset, and to promptly allay the panic which the advent of a mysterious and deadly scourge is so prone to incite.” In 1893, the editorial board of the Medical and Surgical Reporter (March 18, 1893, 421) claimed, “With our present knowledge of the comma bacillus, and how to destroy it, we can act with intelligence and effect in our efforts to ward off the coming pestilence.” In actuality, the acceptance of bacteriology in public health had few early practical effects (Marcus 1979), and medical historians generally agree that the most effective sanitary reforms of the nineteenth century came under the older miasmatic theory of disease discussed in the previous chapter (Dubos 1987; McKeown 1976, 1979).

  Beyond these diagnostic and preventative claims lay more tenuous predictions of prophylactic and therapeutic breakthroughs. Because Koch had identified the enemy, therapeutics could now be targeted toward combating the specific bacteriological culprit. Here was the dream of specificity, whereby specific treatments would attack specific microbes, the “magic bullets” later popularized by Paul Ehrlich, the German scientist who developed Salvarsan, a cure for syphilis. Advocates claimed that while it “cannot be claimed that it [Koch’s discovery] has as yet aided the therapeutics of cholera,” there are reports that “indicate that the problem of protective vaccination against cholera is nearly solved” (AMA 1892a, 529). These reports were only eluded to, not cited nor addressed directly. In 1892, the Journal of the American Medical Association (AMA 1892d, 757) predicted, “To-day bacteriology is about to revolutionize medicine by elaborating a specific treatment of the infectious diseases.” Koch evoked visions in which a specific treatment would be developed for each specific germ. In the most expansive terms, Koch’s discovery would result in nothing less than the eradication of the threat of cholera: “If, then, the germ theory of cholera be true, and it be a contagious and portable disease, then, as a matter of course, it must be ad-mitted that it is a preventable disease” (Dixon 1885, 417). The discovery was reframed as so conclusive that “it will hereafter become actually a criminal act for any civilized government to permit of a spread of this highly infectious disease [cholera]” (AMA 1892c, 442).

  Both homeopathic and allopathic advocates offered these promises in an attempt to obscure the ambiguity in Koch’s findings and to foster a sense of anticipation. Both of their narratives attempted to construct a future for their sects based upon Koch. The initial appeal of the germ theory to its advocates “could be described in large part as almost an expression of faith; that is, the appeal was not based entirely on tangible evidence: to believe in the germ theory was to be optimistic” (Romano 1997, 54). In terms of efficacy, however, the logic of the allopathic narrative of emergent discovery reconciled epistemological tensions within the sect better and painted a more convincing future for reluctant physicians. While the logic of prediscovery could be read as a call to maintain the status quo for homeopathic skeptics, the allopathic narrative reframed Koch’s research as unimpeachable empiricism. The basic premise of empiricism is that good discoveries should be pursued. Even if orthodox skeptics might reject Koch’s specific findings, his approach and method were unassailable and thus worthy of further investigation. By tying a theoretically sanitized version of Koch’s research to a brighter future, allopathic bacteriological advocates provided an interpretive schema that aligned Koch with allopathic interests in the epistemic contest. As such, the skeptics were willing to withhold final judgment and entertain the possibility that future facts would emerge to confirm Koch. It was through this faith in a future pregnant with scientific possibilities that regular advocates of the germ theory transformed Koch’s research into a watershed discovery that open
ed a promising new horizon, one free of homeopathic challengers.

  A NETWORK TO THE LABORATORY

  Allopathic reformers solidified their narrative claim to Koch by forging an organizational network to German science. The establishment of such a network was built on the interpretive practices discussed above, as the allopathic narrative served as the justification for the network. In other words, creating a network only made sense if there was sufficient justification for seeing bacteriology as related to allopathic practice; the narrative supplied this rationale. Even if this justification was contested, it was a justification nonetheless.

  Still, to consolidate control over Koch’s research and its status as a discovery, young elite reformers within allopathy began a conscious program of building networks with German laboratory science. As the previous generation had traveled to Paris for advancement, a new cadre of elite doctors traveled to Germany to learn under Koch, creating an “invisible college” (Crane 1972) of bacteriological advocates who returned from Germany bent on reorganizing U.S. medicine along the lines of the laboratory sciences. Building on their narrative of emergent discovery, allopathic reformers constructed a network linked to Koch that would eventually transform the microbial account of cholera into a discovery owned by regulars.

  The German-American network that would emerge at the turn of the century was not built from scratch in 1884. American doctors already had some links in place. Prior to the rise of bacteriology, some American doctors, consisting mainly of German-American physicians—sons of German immigrants making use of immigrant networks—traveled to Germany to take advantage of educational opportunities unavailable in the United States. However, while the emigration of American doctors to Germany began as early as the 1850s, it was not until the emergence of bacteriological findings that Germany came to be seen as an alternative to Paris (Bonner 1963). The second wave of American doctors traveling to Germany was driven by a reforming impulse. In search of postgraduate training in German labs, approximately fifteen thousand elite doctors, mainly from the eastern United States, traveled to Germany to study medicine between 1870 and 1914 (Bonner 1963, 23). This group of doctors would transform the meaning of the German experience for U.S. doctors from one centered on educational opportunities into a radical program of reform for U.S. medical science through the laboratory. More than its sheer size, it was the composition of this latter group that would facilitate the rise of bacteriology in the United States. These were the future leaders of the profession. For example, virtually all Harvard medical school faculty members of the late nineteenth and early twentieth centuries spent time in German universities (Bonner 1963, 63). These German-trained doctors would eventually use their positions of influence to disseminate bacteriological thinking and to link their organizations to the German lab.

  An analysis of the backgrounds of the most important American allopathic bacteriological reformers uncovers a persistent pattern of German connections, and more specifically, connections to Koch (Bonner 1963). William Welch, the stout bacteriologist and indefatigable medical reformer, is the exemplar. No individual played a more important role in reorganizing American medicine (Fleming 1987). An early supporter of laboratory analysis, Welch received training in Germany, though not in bacteriology. Upon returning to the United States, he ran a laboratory at Bellevue Hospital in New York. Although poorly funded (it lacked even a microscope), Welch’s Bellevue lab was one of the few medical labs in the country at the time. In 1885, just a year after Koch’s announcement of his discovery, Welch was offered the opportunity to establish a medical school at Johns Hopkins University. That summer, Welch left his lab in New York and traveled to Germany specifically to study bacteriology under Koch. He returned a committed bacteriologist and sought to mold the Johns Hopkins medical school along the lines of the German university. In doing so, Welch (1920b, 43) carved an institutional space within American medical education for laboratory research: “I believe it would do much to advance medical education and to encourage original research in medicine in this country, if the way were more freely open for academic careers in the sense in which it is in the German universities.” Central to Welch’s vision was the laboratory, as “well-equipped laboratories are essential to medical education” (Welch 1920b, 45). Johns Hopkins would become a key node in the network of U.S. bacteriologists, and Welch a leading figure in the bacteriological revolution in U. S. medicine.

  Welch was a consummate institution builder. He was involved with not only Johns Hopkins but also the Rockefeller and Carnegie Foundations and several public health ventures. As such, he was indispensable in connecting U.S. medicine to the German program and in disseminating its vision of medicine through the training and placement of his students. Through Hopkins, he would socialize a generation of elite physicians into the bacteriological method and the laboratory ethos. His colleagues and students, the “Welch Rabbits,” would dominate medicine at the turn of the century, occupying leadership positions in a number of important organizations, which they reformed along bacteriological lines (see table 4.1).

  Some Welch rabbits, from the Wellcome Library, London.

  Table 4.1. Welch’s network*

  *This list is not intended to be exhaustive but rather illustrative of the extent of Welch’s influence. His network was vast, and I have identified only those individuals who rose to positions of prominence. Additionally, not all positions each individual held are listed here.

  Welch was linked closely to another major U.S. reformer and a future director of the Rockefeller Institute, T. Mitchell Prudden. A possibly apocryphal story holds that when studying with Koch, both Welch and Prudden were warned by Koch not to bring cholera cultures back to the United States for fear of unleashing an epidemic. Unable to contain their excitement, the young doctors each stole a cholera culture from Koch’s lab. However, Welch and Prudden separately reconsidered the ramifications of transporting the bacillus to the United States, unintentionally running into each other on a Berlin bridge the night before their departure to dump their samples in a river (Fleming 1987, 76).7 True or not, this single tale involves four of the major players—Koch, Welch, Prudden, and cholera—in the bacteriological reform of American medicine.

  The network first introduced the laboratory into public health. In an effort to turn back the ambivalence many regulars had developed toward the intellectual ecumenism of public health, allopathic bacteriological reformers hoped to use the prestige of laboratory science (Rosenkrantz 1974). Those leading this effort were rooted firmly in the U.S./German laboratory network. Hermann Biggs, a student of Welch’s at Bellevue who would later go on to head the Division of Pathology, Bacteriology and Disinfection of the New York City Health Department, studied bacteriology in Germany, picking up additional bacteriological bona fides by studying with Pasteur in France. Biggs and Prudden would become the first public health officials to put Koch’s research to practical use, isolating the comma bacillus aboard a vessel in the port of New York in 1887. Through his actions in the health department, especially in combating diphtheria, Biggs became one of the most vocal advocates for bacteriological reform (Hammonds 1999). He remade the department along bacteriological lines, in an attempt to transform the laboratory into the obligatory passage point for all subsequent sanitary knowledge and interventions in New York. Other cities adopted this model (Jardine 1992).

  Institutionalizing the laboratory in the United States would take great time and effort, but with this growing network, reformers had laid a foundation, culturally and organizationally, for a reformulation of allopathic medical epistemology. For these reformers, the new network meant more than a mere association with particular research or specific scientific figures; it highlighted their commitment to a new vision of medical knowledge centered on the laboratory. Under this new epistemology, the laboratory was not just another source of medical knowledge; it was to become the preeminent and privileged space for the development of that knowledge. Medical science would radiate outward
from it. As such, the German program became synonymous with laboratory science, and laboratory science became synonymous with the future of medical science that the United States needed to embrace. As Welch (1920b, 74) argued:

  The supremacy of Germany in science is due above all else to its laboratories, and no more fruitful record of scientific discoveries within the same space of time can be found than that afforded by this laboratory during Koch’s connection with it from 1880 to 1885. Thence issued in rapid succession the description of those technical procedures which constitute the foundation of practical bacteriology and have been the chief instruments of all subsequent discoveries in this field, the determination of correct principles and methods of disinfection, and the announcement of such epochal discoveries as the causative germs of tuberculosis—doubtless the greatest discovery in this domain—of typhoid fever, diphtheria, cholera, with careful study of their properties.

  Although not perfect—“they have had the misfortune to produce a Hahnemann” (Squibb 1877, 6)—the Germans were unsurpassed in medical research. Allopaths thus traded Paris for Berlin. By linking themselves to Germany, U.S. reformers sought to put Germany’s growing prestige in the service of the epistemic contest over U.S. medicine. The laboratory promised a brighter future for American medicine, for “it would be to the present epoch that posterity would look back as the time when those signal discoveries were made which led to the final adoption of the parasitic theory of the origin of all infectious diseases” (Flint 1884, 422). Through its narrative of discovery and the grounding of such narrative in an international network, reformers had transformed Koch’s cholera research into one of these “signal discoveries.”