Knowledge in the Time of Cholera (29 page)

In constructing these narratives, allopaths and homeopaths had to walk a precariously fine line between embedding Koch within their respective traditions and arguing that the singularity of his idea demanded a departure from these very traditions. They had to balance a tension between continuity and discontinuity, framing the discovery as simultaneously
emanating from
the preexisting knowledge of their sect but
moving toward
a new knowledge base. To reconcile Koch with the past
and
anticipate a brighter future, the narratives deployed the logic of cognitive awakening (DeGloma 2010), in which the event of the “discovery” provided a flash of insight that demanded
reformulation
of the past and plotted a new course for the future. Through the construction of a new future, bacteriological advocates engaged in a type of
promissory practice
through which they glossed over the uncertainties and ambiguities in Koch's actual research to make bold claims (i.e., further discoveries, revolutions in medical therapies, and even the elimination of disease altogether) for its future implications. Ultimately, the allopathic discovery narrative proved more effective in resolving the continuity/discontinuity dilemma to successfully supply the rationale for an allopathic network linked to the German laboratory. Through the concatenation of the interpretive, narrative work of its advocates
and
the building of alliances with German science—this effective combination of cultural and organizational strategies—allopathic bacteriologists transformed Koch's cholera research into a discovery that promoted allopathy's interests in the epistemic contest.

NARRATING KOCH IN AMERICA

Early medical writings on the germ theory, Koch's research included, were plagued by inconsistencies in terminology, overzealous “discoveries” that later proved to be false, and technical difficulties in replicating findings (Hamlin 2009; Richmond 1954; Tomes 1997; Tomes and Warner 1997). In many ways, bacteriology raised more questions than it answered (Rothstein 1992, 267), as early bacteriological research contained a high degree of ambiguity. Ideas, and especially muddled ideas, cannot speak for themselves. Koch's identification of the cholera microbe was no exception to this rule of uncertainty, as it failed to meet his own rigorous standards. Koch established four postulates a microbe must meet in order to prove a causal link to disease:
⁴

1. The microorganism must be found in abundance in all organisms suffering from the disease, but not in healthy organisms.

2. The microorganism must be isolated from a diseased organism and grown in a pure culture.

3. The cultured microorganism should cause disease when introduced into a healthy (animal) host.

4. The microorganism must be isolated again from the diseased experimental host and identified as being identical to the original specific causative agent.

Koch's
cholera research did not meet the third postulate as he could not reproduce cholera in a healthy organism (Gradmann 2009). This failure was fodder for critics who argued that Koch's causal claims were exaggerated and overstepped the bounds of his evidence. Subsequent attempts to inoculate animals were plagued by technical issues and were viewed with wide skepticism (Coleman 1987; Ogawa 2000; Rothstein 1992).

To overcome this, Koch supported his microscopic research with epidemiological evidence, while drawing analogies to other diseases (e.g., leprosy and typhoid fever) widely believed to have a microbial cause that also failed to meet the third postulate (Porter 1998). Cobbling this evidence together, he radically simplified cholera, equating “all questions of cholera's cause with the doings of the bacillus” (Hamlin 2009, 215). His causal argument rested on a presence/absence reasoning, which argued that the bacillus was a necessary cause because in its absence, there was an absence of cholera, other things being equal (Coleman 1987). However, even this presence/absence argument was undermined by the presence of cholera bacilli in “healthy carriers,” violating the first postulate.
⁵
The healthy-carrier problem would not be solved until the early 1900s with developments in immunology.

Koch's critics picked up on these problems. These critics were not marginal figures in the world of nineteenth-century medical science. Pettenkofer, perhaps the world's most famous German scientist (Richmond 1954), accepted Koch's bacillus as one important factor in the development of cholera, but he believed that the germ itself was harmless unless it underwent a process of fermentation caused by environmental factors in a type of poisonous metamorphosis. In 1892, to prove his fermentation theory, Pettenkofer publicly swallowed the comma bacillus to demonstrate its harmlessness, taking his failure to develop cholera as conclusive evidence of the microbe's inherent innocuousness. His fermentation theory gained widespread support in the United States (Richmond 1954). Louis Pasteur himself, a major proponent of the germ theory, remained skeptical of Koch's research (Brock 1988). And most British physicians, from whom American doctors had taken their cues for decades, opposed Koch's findings out of nationalistic pride and commercial concerns about trade.

There were good intellectual reasons to question the germ theory beyond the specifics of Koch's research, as it flew in the face of much medical common sense. For one, it was inconsistent with medicine's focus on predisposition; since medicine lacked any notion of the immune system, it seemed arbitrary to attribute the cause of disease to a small microorganism
irrespective
of the traits of the individual (Rosenberg 1987a, 138). It seemed to contradict a basic, widely accepted empirical observation—cholera affected some types of people (e.g., the poor, the malnourished, etc.) more than others. The germ theory seemed to also deny the relevance of the atmosphere and filth, the focus of public health for decades and the organizing principles behind most sanitary measures. And finally, skeptics had difficulty accepting the seeming randomness and meaninglessness of attributing the cause to a small microorganism (Rosenberg 1987a, 138). The skepticism toward the germ theory “was neither irrational nor reactionary; it was a reasonable position, taken by many leaders of the profession” (Rothstein 1992, 267).

In the United States, most of the opposition to Koch arose from a hesitancy to confer privileged epistemic status to laboratory analysis. During this period, Americans lagged far behind Europe in the medical sciences (Richmond 1954). The microscope and the laboratory were foreign to the overwhelming majority of American physicians, as most schools did not teach microscopy until the 1890s (Rothstein 1992). In fact, before 1884, there was no English-language medical text that discussed bacteriology in a comprehensive way (Bonner 1963). Given their unfamiliarity with the laboratory, American doctors were reluctant to grant primacy to it over other forms of evidence (Tomes and Warner 1997). Why, critics asked, should the bacteriological cause of cholera trump other known causes (e.g., poor sanitary conditions) gleaned from different types of data (e.g., sanitary surveys)? Drawing on clinical experience—in which doctors treated cholera patients at close proximity without succumbing to the disease—and epidemiological data—which pointed to environmental factors as causes of the disease— these critics argued that, while the bacillus might be correlated with cholera, there was no evidence to warrant Koch's causal claims: “There is no doubt, then, some relation between these bacilli and the cholera process. Nevertheless, the coincidence of the process with the bacilli does not prove the bacilli are the cause of cholera. The inverse may be true” (Kinsman 1886, 528). The comma bacilli might be thought of as “a concomitant effect rather than as the cause of cholera” (Blake 1894, 881). This “innocent bystander” argument, formerly used to reject bacteriological accounts of tuberculosis (Maulitz 1979), was common among Koch's critics.

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.