Knowledge in the Time of Cholera

by Owen Whooley

  The real problems arose when Jenkins refused to comply with the federal mandate. Despite seeking the advice of “four of the most eminent bacteriologists in the nation” (Biggs, Welch, T. Mitchell Prudden, and George Sternberg), Jenkins ignored their advice to coordinate his activities with the federal government, balking at what he perceived as undue federal meddling. Jenkins’s rejection of federal oversight took a darkly comedic turn with the unfortunate handling of another cholera ship, the SS City of Berlin. Unlike the Moravia, this ship from Antwerp was determined to be free of cholera. Defying President Harrison’s twenty-day quarantine, Jenkins gave the ship permission to dock. The U.S. Collector of the Port of New York, however, refused to grant entry to the City of Berlin. What followed was a “dramatic illustration of the confrontation between state and federal rights culminating in an almost comic sending of the unfortunate steamship up and down the bay between the quarantine station and the port collector, as each official refused to recognize the authority of the other” (Markel 1997, 99). Passengers were needlessly confined to the ship, as it yo-yoed up and down the port. Ignored during this entire squabble were the negative laboratory findings. Federal and local officials not only refused to recognize each other’s authority; they failed to recognize the authority of the lab.

  The problematic handling of the SS Moravia and the SS City of Berlin was only a prelude to the farce involving another cholera-infected ship, the Normannia, on September 3, 1892. Because the ship’s passenger manifest contained a number of luminaries, including the famous British entertainer Lottie Collins, U.S. senator John McPherson of New Jersey, and newspaper editor E. L. Godkin, the press took a special interest in it, scrutinizing the intensifying conflict between Jenkins and federal officials. This created a circus-like media atmosphere. Reporters, not allowed to board the infected ship, commandeered small boats and conducted interviews with passengers by screaming across the water (Markel 1997). Godkin himself wrote a number of widely circulated letters that documented and condemned conditions on the ship.

  Jenkins decided to keep the Normannia passengers aboard until a quarantine hospital could be procured. Once again healthy passengers were unnecessarily exposed to cholera. Furthermore, ignoring bacteriological advice, the port failed to provide clean water to the passengers, enabling the spread of the disease. Describing the scene on the ship, Harper’s Weekly reported,

  In the mean time the Normannia’s 600 passengers were penned up in the ship with death lurking on every side of them; no water, save that from the polluted Elbe, until the second or third day of their detention; and almost every hour bringing from the steerage its story of a “new case.” And those steerage passengers, unclean cholera-trafficking wretches that they are—heavens! what must have been the torture of the uninfected—huddled together in quarters reeking in filth, where sleep was impossible and the moments agonizing in expectation of the plague? (Whitney 1892, 920)

  The magazine damned the quarantine as “utterly unnecessary and barbarous to a degree bordering on the fiendish” (Whitney 1892, 919). The New York Times (September 9, 1892, 1) described the sentiments of the passengers: “It is a game of life and death to them, and they cannot understand why the authorities should be so tardy in removing them from what they regard as an imminent source of danger—enforced existence where they now are.” When the city finally designated a hotel on Fire Island as a site for a cholera hospital, the decision immediately set off explosive local resistance by the island’s inhabitants. Local fishermen formed a mob, dubbed the “Clam Diggers” by the press, and threatened to burn down the hotel/cholera hospital. The Clam Diggers refused to let the ship dock, threatening riots and violence should cholera be brought ashore. Governor Roswell Flower had to call in the National Guard and the Naval Reserve to force the mob to back down. Even after officials secured their cholera hospital, they failed to heed the advice of bacteriologists. The hospital might have done more harm than good, as sanitary conditions in the hotel were filthy, especially the water supply. Once again, healthy passengers were exposed to an environment that only cholera could love—an environment not so different from that aboard the Normannia.

  Throughout the 1892 cholera scare, bacteriological knowledge was continuously ignored, resulting in ineffective policies that were universally repudiated by the local and national press. Officials inconsistently applied quarantine and sanitary measures to different groups throughout the ordeal. Cabin-class passengers were given preferential treatment in deference to their class status; steerage passengers were not afforded the same level of concern (Markel 1997). Moreover, the debates over cholera took on an increasingly racial tone.1 The link between race and disease was joined with nativist fears to produce a lethal public backlash against the Russian Jewish immigrants who were blamed for bringing cholera to the States (Markel 1997). Despite repeated proclamations from bacteriologists that the disease was not in any way related to race or nationality, sanitary efforts targeted Russian Jewish immigrants, deemed the “scum of invalided Europe” (Whitney 1892, 920). Once tied to place, cholera now was written over with ethnicity (Markel 1997).2 In fact, the primary effects of the 1892 epidemic were felt, not in public health, but in immigration reforms; fear of disease provided justification for the restrictive anti-immigration policies of the early twentieth century (Markel and Stern 2002).

  Although only 130 people died during the 1892 epidemic, the press universally denounced the official handling of it. There was to be none of the celebratory praise like that which the board received in 1866. What promised to be a crowning moment for the laboratory became an embarrassment, complete with bumbling officials, petty politicians, and victimized celebrities.

  Bacteriological reformers drew two lessons from the ordeal. First, as was the case in 1866, the municipal boards of health were too susceptible to political manipulation—too open to outside meddling—to offer unambiguous professional benefits for allopaths. Second, if bacteriologists wanted to win the epistemic contest, they were going to have to search for a way to achieve it outside of state institutions, to create organizational spaces insulated from the vagaries of politics.

  CIRCUMVENTING THE STATE

  The inability to translate the 1892 epidemic into a victory for bacteriology, and thereby usher in a new era of medical science, highlighted the persistent professional obstacles facing allopathic reformers in public institutions throughout the epistemic contest. Public institutions like state legislatures and boards of health had long recognized input from a plurality of voices when it came to cholera. They refused to grant sole, or even final, authority to allopaths on the matter. The state’s celebration of openness undermined allopathic legislative efforts for privileged recognition, resulting in a dismal record that amounted to “little other than a long panorama of heroic endeavor and humiliating defeat” (Markham 1888, 5). As early as 1870, the AMA was questioning whether its legislative actions were not entirely misguided: “Legislative enactments in the various States of this Union clearly show that no reliance can be placed on either the uniformity or permanency of any laws now relating to the practice of medicine” (quoted in Medical Society of the State of New York 1870, 39). The political corruption of bacteriological interventions during the 1892 cholera epidemic intensified calls for a new strategy and revealed that bacteriological reformers had much work to do if they were going to achieve a system of medicine under the control of the laboratory.

  The external obstacles to their program were compounded by the reluctance of many rank-and-file regulars to embrace bacteriology. Between 1884 and 1892, a widespread consensus around the idea that cholera was a germ had taken hold within allopathy. The preeminent textbook of the period defined cholera as a “specific, infectious disease, caused by the comma bacillus of Koch, and characterized clinically by violent purging and rapid collapse” (Osler 1895, 132). But as the last chapter showed, the manner in which reformers had to alter Koch to make him palatable for most allopathic physicians downplayed the revolut
ionary demands of the germ theory. In smuggling Koch into the predominant radical empiricism as such, questions remained as to the significance and reach of bacteriology. Beyond diagnostic testing, what relevance did it have for medical practice? Furthermore, it was a long intellectual distance between the recognition of cholera as a germ to the view that medical knowledge should be radically reformed along the lines of the laboratory. While the new laboratory sciences had a home in allopathy within a particular network, they were by no means considered the definitive source of medical knowledge by most allopaths, many of whom remained committed to bedside empiricism. Bacteriological reformers still had to persuade reluctant regulars to elevate the status of laboratory knowledge.

  Fortunately for bacteriological reformers, the intellectual environment in the United States had become more amenable to assertions of expert knowledge. The Civil War fundamentally upended the intellectual current of the country, especially in the North (Menand 2001). Post–Civil War intellectuals attributed the violent sundering of the Union to the overwrought moralism, inflexible ideologies, and political excesses of the antebellum period. According to thinkers who subscribed to the loose school of pragmatism, ideas had been taken too seriously and proved too explosive. Pragmatists, wanting to avoid rigid ideology, focused their attention on procedures, stressing the importance of expertise, disinterested inquiry, and detached professionalism as the means for a functioning democracy (Menand 2001). Of course, these ideas did not emerge from scratch. Indeed, the early sanitary reformers rallied for disinterested inquiry as superior to urban politics. What pragmatists supplied was a philosophical justification for the role of expertise in democracy, thus tempering the democratic condemnations of hierarchies in knowing, prevalent during the Jacksonian period, and paving the way for the Progressive Era. Emotionally wrought appeals to mass constituencies were being replaced by a buttoned-up model of the scientific expert, and the context of the epistemic contest was altered in the process.

  This chapter describes how bacteriological reformers, embedded in this context of larger intellectual change, embraced a new strategy that effectively circumvented the state to achieve professional authority under the epistemology of the laboratory. By enlisting the support of private philanthropies, especially the Rockefeller Foundation, they repositioned the laboratory, moving it to the center of medical knowledge, to promote a new vision of medical science outside the auspices of public institutions. The significant economic resources supplied by Rockefeller allowed a handful of bacteriologists to carry out a multipronged, coordinated reform of America medicine, creating an entirely new medical system that orbited around the laboratory. In other words, with Rockefeller money, reformers transformed the laboratory into an “obligatory passage point” (Latour 1987, 132) through which all medical knowledge on cholera (or any other disease) would have to pass, much as Shakespeare envisioned.

  Winning important philanthropic allies, bacteriological reformers remade the epistemological foundation for medicine, created a new identity as scientists for physicians, and dramatically altered the organizational infrastructure of medicine. As gatekeepers of the lab, bacteriologists controlled medical practice. The laboratory became so pivotal that contesting it meant challenging an entire institutional infrastructure of medicine—a task that proved too daunting for any challengers to accomplish. This feat of reorganization was even more impressive given that it was accomplished outside the bounds of the state, as none of the reforms were legally mandated until well after they were in place. By the time the dust of the epistemic contest had settled, allopaths had achieved “one of the more striking instances of collective mobility in recent history” (Starr 1982, 79). Successfully circumventing the type of democratic debate that had long stymied their efforts to professionalize, they overcame the state’s traditional commitment to democratized knowing, replacing it with an insulated system of medical expertise in which their epistemic authority went unchallenged. In turn, they created a medical profession unique to the developed world.

  THE EPISTEMOLOGY OF THE LAB

  Reorganizing medicine around the laboratory required a radical reformulation of the epistemological foundation of allopathic medicine. Bacteriological reformers, recognizing that this would be a difficult sell to many of their peers, attempted to downplay the radicalism of their vision. As discussed in chapter 4, they initially framed the new epistemology of the lab as a continuation of, and improvement upon, radical empiricism, as a rational approach to empiricism. Thus, while the laboratory may have been a subversion of radical empiricism (Warner 1991), it was not readily identifiable as such. According to its advocates, bacteriology was simply taking up the radical empiricist mantle of eliminating speculation; advances in bacteriology promised “an epoch in the attitude of medical thought, as well as in medical science, by tending to do away with isms, schools, and theories, and all medical philosophy not founded on demonstrable facts” (Roe 1899, 57). As did radical empiricism, the laboratory rejected speculative theory, championing the role of facts in the production of medical knowledge. But it would bring order to radical empiricism. In a somewhat dialectical fashion, it sought to mold empiricism with a rational underpinning in order to achieve a cohesive program of medical research and avoid the unwieldy, proliferating observations that plagued radical empiricism. What the new epistemology promised was organized and disciplined observation. Framed merely as a technical reform for observation, the laboratory’s revolutionary epistemic implications were downplayed. But they remained nonetheless.

  Despite the best attempts to de-emphasize the epistemological shift the laboratory demanded, bacteriologists’ understanding of empirical observation diverged widely from radical empiricism. Whereas bedside empiricism, as practiced in the United States, was a passive epistemology based on the observations of sensory experience, the laboratory subscribed to an interventionist epistemology. This represented a dramatic departure in the understanding of how medical knowledge could be achieved. Previously, medical facts could be “read” from nature. They were visible and apparent to the careful observer. Now, they needed to be wrested from nature, as they were hidden and obscured. Diseases could not just be perceived; they had to be acted upon to be made visible. In other words, laboratory science stresses intervention in natural processes (Hacking 1983). Its “epistemically advantageous” character derives from its ability to enculturate an object, to extract it from nature and then alter it in such a way as to wring scientific knowledge from it (Knorr-Cetina 1999, 27). “Objects are not fixed entities that have to be taken ‘as they are’ or left by themselves,” Knorr-Cetina (1999, 26–27) elaborates. “In fact, one rarely works in laboratories with objects as they occur in nature.” Laboratories allow for the control of the complexity of nature by creating an enhanced environment that improves upon nature (Knorr-Cetina 1999) and allows for the emergence of “pure, isolated, phenomena” (Hacking 1983, 226). This is precisely what Koch’s culture method for growing bacteria offered. By removing cholera from its natural habitat and placing it in the laboratory, Koch extracted the comma bacillus from its complex natural habitat, where it was essentially invisible and brought it into the lab, where it became visible in its pure form through the microscope, reproducible on cultures, and generally manipulable. By enhancing perception and, in turn, constituting new perceptual objects (Shapin and Schaffer 1985, 36), the lab subjected cholera to spatial and temporal discipline, reducing the “noise” of the disease and rearticulating it as an isolated bacillus. The whole notion of cholera as a germ was dependent upon this special space in which it could be seen as such. Under the epistemology of the laboratory, the researcher did not have to bow to nature’s whims to find knowledge; nature could be bent to the will of the researcher. It was this new ideology of scientific expertise based on intervention that was the truly revolutionary aspect of the lab (Maulitz 1979, 92).

  In part, bacteriologists’ attempt to obscure the epistemological implications of the laboratory was facilit
ated by the laboratory itself. Sociologists of science have carried out numerous studies of the scientific laboratory for over two decades (e.g., Knorr-Cetina 1999; Latour and Woolgar 1986; Pickering 1984). And while the modern laboratory, operating under “Big Science,” with its extensive scope, collective team-based organizational structure, and complex technological apparatus, is much different from the modest bacteriological laboratories of the nineteenth century, the underlying epistemology of the lab remains consistent, if dramatically extended. We can draw on this contemporary research to understand how the laboratory was able to mask the radical demands that its epistemology was placing on rank-and-file allopaths. Sociologists of science have noted the penchant of the laboratory for inducing a particular form of forgetting. Once the lab produces a fact, the intermediary steps are forgotten, purged from the final inscription (Latour and Woolgar 1986). In this process of forgetting, the theoretical rationale (e.g., the bacteriological theory of disease) for performing the experiment in the first place is consumed by the fact (e.g., cholera as a microbe) as are the complex contingencies involved in scientific research. Facts therefore seem to emerge from the lab, rather than being produced by them. Washing away their history, laboratories give facts an empirical veneer that naturalizes them. The laboratory’s forgetfulness helped bacteriologists reconcile their new epistemological system with radical empiricism, allowing them to downplay the theoretical commitment to germ theory. Stressing the facts the lab had discovered, they framed laboratory science as atheoretical: “Almost from the beginning the student of today is taught methods, where a hundred years ago he was taught theories” (Osler in Thayer 1969, 131). This obscured the revolutionary aspect of the laboratory and allowed for a certain resonance with radical empiricism. The lab was framed not as the embrace of a new epistemology, with its concomitant celebration of certain facts over others (laboratory data over bedside observation), but as a new powerful form of empiricism. Facts were remembered and celebrated; the theoretical and epistemological commitments underwriting these facts were forgotten.