by Owen Whooley
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 bacteriology. 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 tuberculosis 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 themse
lves 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.
In the end, the ownership of Koch was not inherent in his ideas. Koch’s “discovery” was not created in India but rather downstream in the way in which American advocates struggled to claim it, to transform it into a discovery, and to link the discovery via networks to a more general system of intellectual reform. Allopathic reformers still had work to do to realize the future promise that they claimed the laboratory held. This future would be expensive, and reformers still had to figure out how to raise the requisite funds for their reforms. But once completed, after the laboratory was institutionalized and regulars had achieved epistemic closure through bacteriology, Koch’s research would finally become what it is now remembered as—a textbook discovery.
5
CAPTURING CHOLERA, AND EPISTEMIC AUTHORITY, IN THE LABORATORY
By the final U.S. cholera epidemic in 1892, bacteriological reformers had gained an important foothold in municipal and state boards of health. The allure of the boards for allopaths, previously spoiled by their intellectual ecumenism, was reinvigorated by Koch’s discovery. Many bacteriological reformers viewed municipal laboratories as the way in which regulars would finally capture control of the boards, defeat cholera, secure the exclusive right to define it, and ultimately wrest epistemic authority from homeopaths and sanitarians. Even though the boards had long been under the control of a diverse group of sanitarians, allopathic physicians had maintained a healthy presence on them and were able to divert some resources to establish municipal laboratories. Thus, the stakes for the 1892 epidemic were high, as it would test these municipal laboratories, which, if successful, would validate bacteriology and, in turn, allopathy.
The early efforts to integrate laboratory analysis into public health were part of a new strategy to combat cholera, and other infectious diseases—a strategy that boasted some government support. In the wake of Koch’s discovery, the U.S. government wanted to clarify the “conflict of opinion” (Shakespeare 1890, 2) over the germ theory between Koch and the British government, which had vocally denounced his findings. By executive order President Grover Cleveland sent Edward O. Shakespeare to evaluate bacteriology in action during a European outbreak of cholera. In the autumn of 1885, Shakespeare, a bacteriologist himself, assembled a “traveling laboratory” and arrived in Europe. He met with Koch, along with other European bacteriological luminaries, and traveled to Spain to evaluate Dr. Jaime Fer-ran’s anticholera inoculations. In 1890, he published his thousand-page Report on Cholera in Europe and India, a tome that served as a clarion call for a bacteriological approach to cholera in the United States. Arguing that “nearly every studious physician of experience” (Shakespeare 1890, 447) believed that cholera was a microbe, Shakespeare laid out a blueprint for a bacteriological attack on the disease that included a national system of maritime quarantine and interventions based on laboratory science. Public health needed to move beyond broad sanitation efforts to a focused program that targeted specific germs, for it was “folly” (Shakespeare 1890, 854) to continue to approach diseases as if they were noninfectious.
Shakespeare’s blueprint focused on three potential benefits of the laboratory. First, the bedrock of the new program was the promise the germ theory held for diagnosis. Diagnosing contagious diseases in an era before laboratory culture methods was fraught with difficulty, as physicians had to “rely on empiric observations and broad experience” (Markel 1997, 41). It was an exercise in intuitive clinical judgment, and predictably, conflicts often arose that stalled interventions. While laboratory methods were not foolproof and only a few physicians were skilled enough to perform them, Shakespeare believed that they promised immediate and accurate knowledge of the disease’s arrival. This perception of their certainty allowed reformers to claim that “the only absolutely positive means of diagnosis of Asiatic cholera” (Welch 1893, 4) was to “see” the microbe. Second, Shakespeare lauded the prophylactic potential of laboratory analysis, albeit with reserve (even though Ferran’s data on his inoculations showed inconsistencies, Shakespeare remained bullish about its prospects). Finally, municipal laboratories could perform an invaluable educational service. If a lab were established “in every city of any size,” all physicians would be exposed to the new sciences and become “acquainted with the results of modern laboratory investigation” (Chapin 1934a, 90–91).
The 1892 cholera epidemic presented an opportunity to put Shakespeare’s vision to work. Once again New York was at the center of the drama, as its bustling port was the place most threatened by the disease. The infrastructure was more or less in place, as the city had experienced a cholera scare in 1887. When cholera failed to materialize that year, Hermann Biggs, the resident bacteriologist of the New York Department of Health, claimed it as a victory for bacteriology (Fee and Hammonds 1995) and parlayed it into ten thousand dollars’ worth of municipal funding to create the world’s first municipal diagnostic bacteriological laboratory. This laboratory became the center of New York City’s public health efforts and the place through which all actions pertaining to cholera had to pass.
As cholera approached in 1892, the focus was on establishing an effective quarantine system based on laboratory science. The preferred preventive measure in the early 1800s, quarantine had fallen into disfavor during the nineteenth century, as cholera continuously evaded its grasp and public health officials, operating under the idea that cholera was filth, concentrated on basic sanitation. Bacteriology redirected attention back toward quarantine. According to Shakespeare’s vision, bacteriological methods would prevent the cholera microbe from gaining entry into the city. A ship believed to be infected would be held up in the port. The lab would then test passengers to see if the comma bacillus was present. If the ship received a clean bill of health, it could dock. If not, the passengers would be removed to quarantine stations where they would be detained until the incubation period of the microbe was over and cholera could no longer be detected. Under this system, bacteriologists were poised to determine quarantine policies, as they were the only ones who could definitively identify cholera aboard ships and understood the life cycle of the bacteria that determined the length of the quarantine. Such was the logic of the new bacteriological regime.
Thus, the board of health, armed with its new laboratory, sought to contain cholera in quarantine and, in turn
, tame the disease once and for all. However, instead of a crowning success, the 1892 epidemic became an unmitigated public relations disaster for city officials, the New York Department of Health, and by association, bacteriologists. Once again, bacteriologists came up against the very problem allopaths had faced in public institutions throughout the course of the epistemic contest—outside interference. During the epidemic, bacteriological recommendations regarding the quarantine were routinely ignored and rejected (Markel 1997). Rather than serving as a rational application of bacteriological principles to sanitary science, by which “the exact replaced the conjectural in this branch of medicine” (Osler in Thayer 1969, 128), quarantine policies were ineffectively jerry-rigged out of xenophobia and political squabbling between local, state, and national authorities (Markel 1997). The results were embarrassing, and quite publicly so. In the end, despite the promise of bacteriology, what reformers got was a political farce that forced them to rethink their professionalization strategy, to look for a way to avoid the state altogether in order to achieve epistemic authority.
On August 30, 1892, cholera arrived in port aboard the SS Moravia, a passenger ship from Hamburg. The Moravia had lost twenty-two passengers to the disease, whose presence was confirmed by laboratory analyses. Unconcerned, bacteriologists expressed confidence that the disease would not jump the quarantine (e.g., “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” [Medical and Surgical Reporter 1893, 421]), provided that protocol was heeded. It wasn’t. Rather than identifying and separating infected passengers according to bacteriological principles, Port Officer William T. Jenkins chose to keep all passengers aboard the ship for two weeks, unnecessarily exposing healthy passengers to cholera. Unsatisfied with Jenkins’s handling of the quarantine, President William Harrison jumped into the fray, declaring a twenty-day quarantine of all ships arriving in American ports. The length of the federal quarantine was determined by an economic, not bacteriological, rationale, as twenty days was a period long enough to make transport too expensive for shipping companies to bear, effectively putting a halt to all trade (Markel 1997, 98). Despite the fact that the economic logic behind the quarantine length contradicted bacteriological science, it was fortunately wrong in the right direction, as it was actually longer than bacteriologists recommended based on the incubation period of cholera.
