Knowledge in the Time of Cholera (32 page)

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.”

CONCLUSION: POLARIZATION AND THE LAB

Contrary to the heroic narratives, the 1884 “discovery” of the comma bacillus was not
the
defining moment in resolving medical debates over the disease and deciding the allocation of epistemic authority in medicine. American germ theory advocates still had much work to do in consolidating the authority of the lab and convincing others of the veracity of bacteri
ology.
However, by 1894, a decade after Koch's announcement, reformers had produced an account of Koch's research that configured it as a discovery and located it solidly within the allopathic tradition. Furthermore, they had created a network infrastructure in which the status of this discovery was taken for granted. For at least one important subset of allopathy, Koch was king and cholera was a microbe. In this network, infectious diseases had been transformed into entities that could only be identified in a laboratory through the determination of the presence or absence of a specific microorganism (Cunningham 2002).

Full medical reform along the lines of the germ theory and the laboratory would require further time, investment, and resources. Given allopathy's checkered history with government institutions, the procurement of such resources remained a question. Nevertheless, while widespread consensus around bacteriology would not be achieved until the 1910s, the groundwork for this revolution had been laid. Allopathy defined and established the terrain for future medical and professional debates, having wrested Koch's findings from homeopaths. By establishing networks to Koch's laboratory and promoting bacteriology, reformers began the transformation of Koch's research on cholera into a paradigmatic discovery for allopaths. If the germ theory of cholera was to gain recognition, it would be regulars who benefited.

To apply the attribution of a discovery to an idea is to eliminate its uncertainty by naturalizing it as a self-evident truth. Indeed, this chapter reveals practices by which bacteriological advocates attempted to eliminate uncertainty and ambiguity surrounding Koch's research. In many ways, they succeeded in rendering evaluations of it more definite. So what happened to the uncertainty of Koch's findings so evident in the 1880s? The conventional narrative would have us believe that it was eliminated by additional research. This claim fails on three accounts. First, much of the uncertainty surrounding Koch's findings centered on his inability to meet the third postulate—reproducing the disease in animal hosts. Subsequent attempts to achieve this result faltered and were met with skepticism. Second, advocates had to contend with the problem of healthy carriers; not all individuals infected with the comma bacillus succumbed to the disease. Opponents of the germ theory, like Pettenkofer, went so far as to purposefully consume the bacillus to deny its causal connection to cholera. Lacking an understanding of the immune system, researchers would not solve the problem of the
healthy
carrier until the twentieth century, when immunology developed. Finally, the heroic narrative fails to acknowledge the magnitude of the epistemological shift the germ theory required. Any account that depends on “evidence” as a causal explanation is limited, because it fails to acknowledge that what counted as evidence was contentious. Bacteriological advocates could not simply present their findings for evaluation; they needed to convince their peers that the epistemological assumptions underlying these findings were themselves legitimate.

The flaws in the conventional accounts demand we look elsewhere to explain the resolution of the uncertainty in Koch's findings, namely, to the interpretive practices that advocates deployed to downplay or obscure this uncertainty. The narrative and network constructed by allopathic bacteriologists created an invisible college, in which the germ theory of disease went unquestioned. From this intellectual and organizational foundation, a small group of influential, committed elites embarked on a program to convince others of the “discovery-ness” of Koch's research. Though not yet dominant, there was now a space within allopathy where Koch's findings were part of the taken-for-granted common sense. This was not just an abstract intellectual space; it was rooted in an organizational infrastructure of a handful of elite medical schools and boards of health. As advocates structured (or restructured) these organizations along the lines of the laboratory, the germ theory became integrated into the operating assumptions of these institutions. In the process, the theory's uncertainty was replaced by a certain unquestioning acceptance.

Uncertainty and ambiguity were also absorbed through a process of polarization that followed the establishment of the allopathic network. Regular reformers transformed Koch's research into an
allopathic
discovery. They folded Koch's particular finding into their professional project of medical reform. Koch became an allopath, and his findings became entangled in the epistemic contest between regulars and homeopaths in the United States. This newly acquired association resulted in the extreme polarization between regulars and homeopaths in their interpretation of Koch's findings. As the new owners of the idea, allopathic physicians tempered their criticism of Koch's claims. Newly contextualized within the larger body of bacteriological work, Koch's cholera research was not to be judged in isolation but rather as part of a system of bacteriological findings. Cholera was connected to other bacteriological “discoveries” (e.g., Koch's discovery of the tubercu
losis
bacillus, Pasteur's research on anthrax, the discovery of the diphtheria bacillus antitoxin in 1883). While each of these findings had its own problems, individual uncertainties were diluted in a larger collective of claims, as “discoveries” drew strength through mutual reinforcement and analogical reasoning. Advocates dealt with the deficiencies in the research on any one disease by arguing that limitations had been overcome in research on another disease. Uncertainty was reframed as a temporary situation. Moreover, as bacteriology became linked to an allopathic future that promised professional recognition, the stakes for critics within allopathy who questioned it increased dramatically. They could reject the germ theory, but now that the germ theory was solidified as an
allopathic
theory, they ran the risk of being associated with homeopaths or other quacks. The more professional goals were tethered to bacteriology, the less intellectual space remained within allopathy from which to criticize it.

For homeopaths, the ambiguity surrounding Koch's research was resolved in the opposite direction. Philosopher Hilary Putnam describes a phenomenon of intellectual competition called recoil. When an idea gets attributed to one party, the opposing party, “dominated by the feeling that one must put as much distance between oneself and a particular philosophical stance as possible” (Putnam 1999, 4), “recoils” from it completely, denying that the idea possesses any insight whatsoever. In essence, this is what happened for homeopaths and bacteriology. Now that Koch was associated with allopathy, there could be no more entertainment of his ideas. Koch was unambiguously wrong. The initial similarity in reactions of homeopathic and allopathic reformers gave way to a highly polarized situation in which the sects opposed each other. What was once seen compatible with homeopathy (and even synonymous with it) was now viewed as “diametrically opposed” to the teachings of Hahnemann (Tooker 1885, 6).

As the associational hue of the newly minted discovery rendered it unacceptable to homeopaths, many came to repudiate the legitimacy of the germ theory entirely, denying that Koch had discovered anything. But as public support for the germ theory grew, this position of denial became increasingly untenable and detrimental to homeopath's professional project. Shifting from a strategy of denial to containment, homeopaths sought to downplay the relevance of Koch's work, deeming it immaterial to therapeutic practice. They justifiably pointed to the germ theory's lack of therapeutic breakthroughs, which, at the end of the day, were the measure by which
medical
theories were judged. When it came to actually treating people, the germ theory was next to useless, nothing but “a delusion and a snare” (Tooker 1885, 20). In adopting this tack, homeopaths altered their own claims to medical expertise. In order to carve a niche for homeopathy in an environment increasingly distracted by the promises of the germ theory, they repositioned themselves in a more restrictive sense as experts in medical therapeutics.

Regardless of the strategy adopted, as bacteriology gained popular support and as allopathic reformers increasingly reorganized medical institutions along the lines of the lab, homeopaths found themselves in a precarious situation, having lost out to regulars in the battle over ownership of Koch. They had ceded the germ theory and its discoveries to allopathy and therefore excluded themselves from any claim to its future accomplishments. As disparate bacteriological findings coalesced into a new medical paradigm rooted in the laboratory, homeopaths lost prestige. Locked out of the lab, homeopaths became more and more marginalized from mainstream medicine. Having opted out of this process, they were relegated to the sidelines for much of the remainder of the epistemic contest over medical knowledge in the nineteenth century, passive spectators to the main events.

Once regulars had captured the discovery, assessments of it no longer centered on the content of the idea, but rather on who was associated with the discovery. To argue that this was a predetermined, natural outcome of regulars' preexisting intellectual commitments, as many conventional accounts do, is to engage in an impoverished exercise of reading history backward. The fact is that bacteriology, if it was to be adopted, was going to require some fundamental revisions of both sects' understanding of disease and a reformulation of the epistemological foundation underlying their disease models. The germ theory contradicted homeopathy no more than it contradicted the dominant understandings of disease among allopaths. The epistemological leap from radical bedside empirical observation to the interventionist laboratory was no greater (and probably less) than the leap homeopaths would have had to make.