Knowledge in the Time of Cholera (34 page)

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 revolutionary 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 facilitated 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.

In promoting the epistemology of the lab as a “new era in the history of medicine” (Welch 1920a, 27), bacteriologists sought to elevate technical ex
pertise
over clinical experience. Whereas previously a physician's epistemic authority was rooted in his ability to
observe
well, it would now be rooted in his ability to
intervene
well by applying certain technical methods (Warner 1991). Doctors should be granted epistemic authority not because they possessed some art or intuitive skill of observation, but because they possessed the superior technical, scientific knowledge that allowed them to intervene via laboratory analyses. The revolutionary aspect of this shift cannot be understated. Bacteriological reformers were asking their peers to discard decades' worth of medical common sense and to change their thinking about many basic facets of medical practice: