Knowledge in the Time of Cholera

by Owen Whooley

  19. In many ways, for the American South, yellow fever loomed larger than cholera as a medical issue (Crosby 2007; Ellis 1990; Humphreys 1999).

  20. While I draw extensively on Rosenberg’s research, my goals are different. Whereas Rosenberg describes how cholera became a secular social problem, I am interested in how it eventually became a medical problem to be understood through bacteriological science. This is reflected in the scope of my project. I examine all five cholera epidemics through 1892, while Rosenberg’s analysis terminates in 1866.

  21. While the best-fit cases were used as exemplars by proponents of the bacteriological theory, the assumption that one is compelled to adopt a single model of disease for all diseases is historically problematic. Indeed, long before the bacteriological revolution, the case of smallpox seemed to point toward the germ theory. Yet it was regarded by many to be a unique case. Similarly, John Snow’s waterborne germ theory of cholera was presented not to offer a universal challenge to the miasma theory of disease, but rather to reveal cholera as an anomalous case that did not fit this model (Koch 2005). Part of the accomplishment of proponents of the germ theory of disease was convincing others that a single, universal paradigm explained all diseases. Reasoning by analogy undoubtedly was part of the rhetoric of proponents of the germ theory of disease, but there is no justification in arguing that a single case of success could have sealed the fate of alternative models.

  22. It is a bit misleading to refer to the germ theory as a singular entity during the nineteenth century. As Worboys (2000) shows, there were many variations of the “germ theory,” each with its own nuances. Nevertheless, for the purposes of this book, I refer to the germ theory to denote the belief in some sort of microbial etiology of disease. The different shadings of the germ theories are less important for my analysis.

  CHAPTER ONE

  1. Cholera had long circulated throughout India, but it was basically unknown to Europe prior to the 1800s.

  2. This does not mean arenas deterministically predict outcomes. Social structures do not exist independently of human action. Per Giddens’s (1984) structuration theory, James Jasper notes, “Behind every ‘structure’ is usually another player hard at work” (Jasper 2006, 167).

  3. The use of the term “specificity” in nineteenth-century medical discourse is confusing and often contradictory, as historian John Harley Warner notes (1997, 58–63). During the early nineteenth century, regulars understood specificity as an individualized treatment for specific patients, and knowledge derived from observation of particular cases. This was in opposition to universalistic approaches to medicine. At the same time, they derided alternative medical movements and patent medicine sellers for championing specific remedies, as understood as specific to a particular disease, “as a manifest stigma of charlantry” (Warner 1997, 60). This confusing use of the term often results in a mischaracterization of nineteenth-century medical debates. For the purpose of this chapter, I employ the term in the former sense to signal a particularistic and local foundation for medical knowledge.

  4. Lewins was onto something. Cholera essentially kills by extreme dehydration. Contemporary treatments involve oral rehydration therapy (ORT) or intravenous hydration, which both involve the prompt replacement of water and electrolytes. Unfortunately, amidst the myriad treatments for cholera during the nineteenth century, all of which promised wondrous results, the potentially effective treatment of saline injections failed to stand out.

  5. My use of the feminine pronoun here is not done out of conformity to current intellectual standards. Given women’s traditional role as nurturers in the household, Thomsonians targeted females as converts. Progressive in its gender politics, Thomsonism placed great emphasis in recruiting female members.

  6. Hahnemann is also credited with inventing the label of “allopathic” medicine, which later became a term of derision that alternative medical sects hurled at regulars.

  7. Contemporary scientific norms, such as those underlying the double-blind experimental design, may bias the modern reader against viewing self-experimentation as worthy of the status of science. However, there is a long, rich history of self-experimentation in medicine (Altman 1998).

  8. New Jersey repealed its licensing laws much later in 1862.

  9. Established in 1816, the Second Bank of the United States was chartered to enable the federal government to better manage its finances, particularly in the wake of spiraling inflation after the War of 1812. In the early 1830s, Andrew Jackson condemned the Bank as a bastion of fraud and vowed to “kill it.” Jackson viewed the Bank as an abrogation of individual liberties and a gross overreach by the Federal Government that granted undue favor to bankers. The Bank loomed large as a controversy in American politics until 1836, when its charter expired.

  10. The concept of elective affinity is used to illustrate the nondeterminative resonance between the practices of the state legislature and the democratized medical epistemologies of Thomsonians and homeopaths. This relationship is not determinative in that it took work and effort—mainly through their rhetorical strategies—on the part of the alternative medical sects to draw these crucial connections. In other words, homologies do not automatically match up; links are achieved through the agency of actors.

  11. For an extended discussion see Haller 2000, 131–138.

  CHAPTER TWO

  1. This particular story seemed to have great resonance, as it was repeated in so many different local contexts that it achieved almost mythical status.

  2. Fortunately, some researchers have begun to address this oversight, bringing organizations back into the study of knowledge struggles. Recent research establishes the integral role that organizations can play in boundary work (Guston 1999; Kleinman and Kinchy 2003; Moore 1996). Organizations serve as important bridges between scientists and political actors, providing neutral spaces for the formation of networks across boundaries, all while maintaining the integrity of the separation between science and politics (Guston 1999; Moore 1996). This chapter identifies another, more basic role for organizations by identifying the ways in which organizations can be marshaled to promote particular epistemological agendas.

  3. My use of the term “radical empiricism” is not meant to imply a relationship between mid-1800 regular medical epistemology and William James’s (1976 [1912]) turn-of-the-century pragmatist philosophy, which also deploys the term. It is only intended to underscore the extreme degree to which regular reformers embraced empiricism and rejected all theory as illegitimate.

  4. Given the intensity of the symptoms, this was not an impressive feat.

  5. The AMA’s success in achieving unity was limited by the geographical dispersion of allopathic physicians. Indeed, the society took on a regional character with most of the membership in its first few decades coming from five states: Massachusetts, Pennsylvania, New York, New Jersey, and Connecticut (Burrow 1963, 17).

  6. Homeopaths were continuously frustrated by regulars’ framing of their system as rationalism. “Their [allopaths’] mode of investigating Homeopathia is wrong. They assume that it is a mere theory, and because it is not, they of course cannot but misrepresent it. Now, if they would admit what is really true, that it is made up of facts arranged systematically for practical purposes, then the inquiry would be, are its proposed facts real facts, or otherwise? If Homeopathia is false, as allopaths declare, let them, in the legitimate way, answer that question. The answer, however, can be obtained only in one way, which is, to repeat Hahnemann’s experiments” (Joslin 1852, 19–20).

  7. The federal government was not too preoccupied to leave army physicians completely to their own devices. Union Surgeon General William Alexander Hammond, much to the chagrin of allopathic physicians, banned the use of the common allopathic treatments, calomel and tartar emetic. While homeopaths may claim some credit for this victory, it was the rotting jaws of soldiers suffering from mercury poisoning that led Hammond to act. Nevertheless, his decision was viewed by allopa
ths as an attack upon their autonomy and as an explicit critique of their system.

  CHAPTER THREE

  1. Lumping these disparate actors under a single heading is a bit misleading as they shared little more than a commitment to urban sanitary reform. I use the label as a convenient shorthand, with the acknowledgment that the “sanitarians” were by no means a monolithic group with the cohesive identity of, say, the homeopaths.

  2. In his classic work On Airs, Waters and Places, Hippocrates called for the close observation of local characteristics, based on the premise that disease is a product of specific locales.

  3. Snow’s map is often depicted as the crucial evidence in establishing the connection between the cholera contagion and contaminated water (Johnson 2006). Actually, the Snow map seems to have had minimal impact in the United States as it was rarely mentioned in the myriad discussions of cholera until after 1900 (after the germ theory became dominant). Snow is far better known now than he was in his lifetime (Hamlin 2009, 180). The idea that his map represented a singular discovery in the United States is a by-product of reading history backward.

  4. Because dot maps fixed disease clusters in space, these maps contained little insight into temporality. Some of the more contagionist persuasion added dates to their dot maps to introduce a temporal dimension.

  CHAPTER FOUR

  1. Historians today acknowledge that an Italian doctor, Filippo Pacini, identified the bacillus forty years prior to Koch, so the attribution of discovery to Koch is not based on getting there first. According to historian William Coleman (1987, 330), this raises the issue of what it was that Koch accomplished: “What then, is in a ‘discovery’? Obviously, the act of seeing the cholera vibrio was no novelty in 1884. And the association of this microbe with Asiatic cholera had also been made long before, and perhaps repeatedly.”

  2. Throughout this chapter, I refer to Koch’s identification of the comma bacillus as a “finding,” “idea,” or “research.” This reflects my claim that research becomes a discovery only after a long process of justifying it as such.

  3. Latour has a tendency to depict these interests as fixed and preexisting; he never addresses their formation. For example, the hygienists, so crucial to Pasteur’s success, are presented as an undifferentiated mass with obvious and enduring interests. Perhaps they were, but as this following case shows, collective actors are not necessarily homogenous and consistent in their interests. Given the heterogeneity of actors and motives, sense-making activities are essential to the success of a network.

  4. Recent historical scholarship suggests Koch himself did not codify these postulates. Rather it was his colleague, Friedrich Löffler, who formally defined and popularized the postulates (Gradmann 2008). Nevertheless, Koch’s own research subscribed to them, albeit in a less systematic fashion than that in which they were subsequently laid out.

  5. Koch later abandoned the healthy organism stipulation of the first postulate when he discovered asymptomatic carriers of cholera.

  6. The logic behind vaccination was not new, as in the United States it dated back to the Puritan’s use of inoculation for smallpox in the 1700s.

  7. Given cholera’s waterborne nature, it was probably not the best idea to dump it into a river.

  CHAPTER FIVE

  1. In the past, cholera had been associated with certain immigrants groups, most notably the Irish in 1832 (Kraut 1995).

  2. A similar dynamic played out during an outbreak of the plague in San Francisco in first decade of the twentieth century, when anti-immigrant sentiment toward the Chinese shaped the city’s response to the epidemic (Chase 2004). Nativism also arose during the 1892 typhus epidemic in New York with Russian Jews once again the scapegoats (Markel 1997).

  3. A curious Rockefeller would later send specimens of her herbal remedies to the scientific laboratories he funded to see if they did indeed possess medicinal properties (Chernow 1998, 6).

  4. Rockefeller was already sixty-two when the RIMR was founded.

  5. In contrast to the minimal standards of proprietary schools, Hopkins expected much more of its students, prior to their arrival, during their stay, and after their graduation. Its other innovations included the requirement of a bachelor of arts for admission, acceptance of female students, a four-year graded curriculum, and a grading system for interns and residents.

  6. While the Flexner Report looms large in the historical imagination as a cause of medical educational reforms, recent histories offer a more measured analysis, viewing it as part of the broader movement of educational and scientific reforms (e.g., Banta 1971; Ludmerer 1985).

  7. These costs were hard to bear even for hospitals, as the expense of laboratories strained already tight budgets (Rosenberg 1987a). Still, by pooling resources and consolidating practices, hospitals adjusted.

  8. Homeopathy was defeated but not dead. It experienced a rebirth in the 1960s and 1970s, as scientific medicine became criticized for its dehumanization of the patient. However, the new incarnation differed drastically from its nineteenth-century counterpart, as it embraced its more mystical side in an attempt to offer a holistic alternative to mainstream medicine.

  CONCLUSION

  1. De Kruif would later publish his own history of the early decades of the germ theory, entitled Microbe Hunters (1926), a romantic, best-selling hagiography that would form the foundation of the conventional truth-wins-out narrative of the emergence of laboratory medicine.

  2. Not all literature celebrated these developments in medical science. The counterpoint to Arrowsmith, the villain to this laboratory hero, was Georg Letham, the main character in Ernst Weiss’s (2009) novel Georg Letham: Physician and Murderer. Weiss, a doctor himself writing in the epicenter of bacteriology—Austria and Germany—was suspicious of the new laboratory sciences and the model of medicine it promoted. His novel recounts the dark story of Dr. Georg Letham, who murders his patients, via bacteriological infection, in order to advance his scientific research on yellow fever. The novel presages (albeit in an extreme way) later critiques that laboratory sciences dehumanized medicine. And written in Austria in 1931, it is an eerie premonition of the horrific experiments that would be conducted by Nazi scientists a decade later.

  3. Gottlieb was modeled after Frederick D. Novy, a bacteriologist, and Jacques Loeb, an American physiologist and experimental biologist at the Rockefeller Institute. Both were heroes and mentors to de Kruif (Rosenberg 1963).

  4. Fourcade (2009) describes a similar process in twentieth-century economics, demonstrating how the particular political, cultural, and institutional contexts in different countries gave rise to distinct professional and disciplinary configurations.

  5. In his history of early attempts on the part of reformers to achieve government-led health insurance, historian Ronald Numbers (1978) argues that the AMA initially entertained the idea and were “almost persuaded” to accept such reforms. Eventually, according to Numbers, the red-scare politics of World War I coupled with resistance by local medical societies led to the defeat of such efforts. Numbers’s provocative title, Almost Persuaded, obscures what is a much more ambiguous history. As even his own evidence shows, the AMA was always thoroughly ambivalent toward such plans. The sum total of its engagement with the reform efforts—aside from a few individuals—was to establish a committee to investigate the issue, and it did this only when such reforms appeared to be inevitable (especially in the wake of the establishment of government health care insurance in Germany and Britain). It is telling that the only official declaration the AMA made during this period came in 1921, when it publicly rejected such plans. Rather than “almost persuaded,” the AMA’s initial forays into investigating government-led health insurance represented an attempt to hedge its bets. Once the perceived inevitability of such reforms gave way, the AMA showed its true colors by actively working to defeat them—a position consistent with the strategic orientation it embraced in the aftermath of the epistemic contest.

  6. Jamie Fer
ran’s vaccine (discussed in chapter 5) was beset with problems and the international medical community was reluctant to embrace his conclusions (Bornside 1982). In 1892, Waldemar Haffkine developed an anticholera vaccine that was looked upon quite favorably by the international medical community. However, after a number of missteps and controversies, enthusiasm waned and the vaccine never caught on (Löwy 1992).

  7. Vaccination actually preceded laboratory science as the smallpox vaccine was developed by Edward Jenner in 1796. Even earlier, during the colonial period in the United States, Cotton Mather suggested that inhabitants of the Massachusetts Bay Colony could get inoculated against small pox (Silverman 1984).

  8. Although Joseph Lister published his famous paper “On the Antiseptic Principle of the Practice of Surgery” in 1867, the mechanisms behind these techniques were later made explicit by Louis Pasteur. As the germ theory gained widespread acceptance, such techniques were refined, leading to the rise of sterile surgery.

  9. The tension between democracy and science identified here diverges from Robert Merton’s (1973) understanding of the complementary and reinforcing relationship between democracy and science. Merton’s claims emerge from a comparison between Western democracies and the restrictive practices of authoritarian regimes. This comparative lens leads Merton to stress the ways in which democratic social orders promote the scientific norms of value neutrality (or disinterestedness) and unrestricted rational and open discussions (or universalism). The key assumption underlying his claim is that science is open to all. While this may be formally true, I am stressing the barriers that are erected to prevent widespread participation, which retard democratic participation not just in the production of scientific knowledge but also in policy issues in which science is involved. As always Merton’s actual analysis is more nuanced than the caricature of it, and he was cautious in not overstating the positive relationship between science and democratic social orders (Sica 2010). Still, we must recognize the ways in which science clashes with democratic values.