Knowledge in the Time of Cholera (6 page)

Second, the physical reality of cholera caused it to dominate the public imagination far beyond its actual mortality rates. Few diseases can match cholera in the speed and intensity with which it kills. Symptoms and biology play a role in the panic elicited by an epidemic as they offer an underlying reality to historical experience (Humphreys 2002). The physical event of cholera was (and is) dramatic and terrifying; it was (and is) a shocking disease. According to the current understanding of cholera, the cholera toxin paralyzes the intestines, causing the intestinal cells to rapidly secrete water and electrolytes. The body purges copious amounts of rice water stool—up to 10 percent of a person's body weight within hours. Severe dehydration sets in quickly, causing intense muscle cramps, sunken eyes, and a bluish tint to the tongue, lips, and other extremities. If left untreated, 70 percent of its victims die. An individual in his or her prime can be dead within ten hours. Therefore, while the mortality of cholera may not have been as severe as some other endemic and epidemic diseases, its biological nature caused it to loom large in the nineteenth-century medical imagination.

Finally, as suggested above, the way in which cholera became redefined as a medical problem confounds the conventional narrative of the rise of the bacteriological model of disease. The eventual consolidation of medical authority around the bacteriological model of cholera does not fit the straightforward truth-wins-out narrative for a number of reasons:

• First, Koch's famous discovery of cholera was beset with inconsistencies. It did not even satisfy his own postulates. While certainly other disease entities that were widely accepted also fell short of Koch's postulates, the failure of cholera to meet these standards shows that it was not a natural fit for the bacteriological model.

• Nor is it clear that the bacteriological definition was more effective in treating cholera. Unlike other diseases such as diphtheria and rabies, in which a bacteriological model led to effective vaccines, a cholera vaccine was never popular. Treatment of cholera is fairly simple—a patient is given a large amount of saline injections to rehydrate. This therapy targets the
symptoms
of cholera—copious diarrhea and dehydration—and does not depend on an understanding of its etiology.

• In terms of prevention, the miasmatic theory of cholera—the notion that disease is caused by miasma (pollution), or noxious “bad air” in the atmosphere—was more effective in eradicating cholera as it led to many of the sanitary reforms responsible for the disease's demise in the United States (Duffy 1990; Rosenberg 1987b; Tesh 1988). Even the self-proclaimed champion of the “new germ theory of disease,” Paul Ewald (2002, 77), acknowledges that the water treatments, adopted under the miasmatic theory, were (and are) the most useful approach to cholera. Recent calls to reintroduce environmental factors into the study of cholera represent a shift away from the reductionism of the germ theory toward the “biocomplexity” of the miasmatic theory (Colwell 2002; Colwell and Huq 2001).

• Finally, recent evidence shows that the bacteriological understanding of cholera is not as clear as once depicted (Hamlin 2009), questioning the argument that the bacteriological model is the objectively “right” one. In analyzing cholera's killer instinct, Waldor et al. (2003) identified two components of cholera's attack that facilitate its rapid spread—(1) the TCP pilus in cholera vibrio that allows it to replicate rapidly and (2) the cholera toxin that triggers rapid dehydration. The gene for the cholera toxin is actually supplied by an outside source—a virus called CTX phage. Without this gene, cholera does not know how to be a pathogen (Johnson 2006). This classic case of coevolutionary development of two different organisms raises the question, is cholera caused primarily by the bacterial microorganism cholera vibrio, or by the virus called CTX phage? As researchers discard the germ-in-the-laboratory model of cholera for a more environmental approach (Hamlin 2009), does this simple etiological question even make sense?

While certainly not enough to dismiss the truth of the bacteriological model of cholera, these issues introduce more uncertainty and messiness than is common and, in turn, undermine the straightforward model of dissemination and acceptance of past research. To understand the emergence and acceptance of the bacteriological definition of cholera, we cannot fall back on an argument of therapeutic or preventative efficacy. Nor can we account for this model by pointing only to bacteriological success in explaining other diseases. Like any paradigm, the bacteriological model fits better for some
cases
than others; to understand why it became the universal model for
all
diseases requires that we investigate those diseases, like cholera, for which it was problematic.
²¹

EXPERT KNOWLEDGE IN DEMOCRATIC CULTURES

The epistemic contest over cholera witnessed four cholera epidemics, the emergence of a number of alternative medical movements, rancorous legal debates, government resistance to professional claims on democratic grounds, untold etiological theories of cholera, and sadly, rampant death at the hands of enthusiastic, but unknowledgeable physicians. By tracing the intellectual debates over cholera through various institutions (e.g., state legislatures, boards of health, professional societies, etc.) and among a diverse set of actors (e.g., allopathic physicians, homeopaths, public health reformers, etc.), I demonstrate how regular physicians, through the AMA, were able to overcome all of these challenges to create a powerful profession unfettered to the whims of the state and the vagaries of democratic decision-making.

Each chapter is organized around a pivotal moment in the history of cholera, exploring issues pertaining to epistemological politics so as to develop the concept of the epistemic contest. The first two chapters describe the initial confusion surrounding cholera, the decline in authority for allopathic medicine that resulted, and the limited allopathic response to this professional/epistemic crisis.
Chapter 1
focuses on the effective campaigns of alternative medical sects to transform the perceived allopathic failure during the first cholera epidemic into an epistemic contest that eventually led to the wholesale repeal of licensing laws. Thomsonism, an egalitarian, anti-intellectual grassroots medical movement, and homeopathy, an elite urbane sect that sought to claim the mantle of science, offered more democratic epistemological visions for medicine that contrasted with the elitist, obfuscating epistemology of rationalism. They compelled regulars to provide an epistemological justification for their professional privileges in state legislatures. Drawing on theories of rhetoric, I show how the democratized epistemologies of alternative medical sects resonated, rhetorically and epistemologically, with the state legislatures influenced by Jacksonian ideals. Licensing laws were universally repealed in the 1840s; the medical market was deregulated; and an epistemic contest was born.

Chapter
2
describes the allopathic response to the democratic challenges of alternative medical sects, particularly homeopathy. After the 1848 epidemic, allopathic reformers redefined the identity of regulars, embracing a radical empiricism inspired by the Paris School of medicine. While this shift ostensibly allowed allopaths to claim some democratic bona fides, the selective manner in which they adopted the Paris School led to intellectual fragmentation. Eschewing the search for general laws in medicine (Warner 1998), allopathic reformers lacked standards to adjudicate competing knowledge claims. To solve this “problem of adjudication” they adopted an organizational strategy, establishing the AMA and substituting the criterion of membership for epistemological standards in order to deem homeopathy as quackery. Still, the exclusionary politics of the AMA failed to sway legislatures, which remained committed to the idea that open debate would lead to the best medical knowledge. This chapter reveals that epistemic contests are not waged by cultural/epistemological means only; organizational strategies can be usefully analyzed as epistemic practices as well.

Chapter 3
discusses a key event in the history of cholera—the establishment of the Metropolitan Board of Health of New York City and the rise of public health more generally prior to the 1866 epidemic. United around a common understanding of cholera as a miasma, an eclectic group of actors, which included sanitary-minded allopathic physicians, homeopaths, social reformers, and sanitarians, came together to prevent cholera by cleaning up the environment. This was accomplished to great result, and the board of health was widely credited with having prevented another cholera epidemic in New York City. As public health grew in popularity, allopathic physicians sought to transform sanitary success into justification for their professional recognition. Once again, the legislatures refused to recognize these claims, as sanitarians framed them as contrary to the apolitical nature of the public health enterprise. Public health remained an eclectic movement rather than an allopathic-dominated one. This chapter explores the multiple ways in which claims to epistemic authority can be made, noting that
how
actors choose to make these claims has ramifications for their professional goals.

The final two empirical chapters explore the consolidation of allopathic professional authority through epistemic closure.
Chapter 4
describes the ways in which American physicians interpreted the “discovery” of the comma bacillus of Robert Koch in 1884. Drawing on an “attributional model” of discoveries, this chapter explores the role of “discoveries” in epistemic contests,
showing
how the project to configure Koch's research into a discovery involved both cultural and organizational dimensions. Both homeopaths and allopathic physicians initially staked a claim to Koch's research, attempting to frame this research into a discovery that justified their respective systems of medicine through different discovery narratives. I show how allopaths offered a more effective discovery narrative, which facilitated the construction of a network linked to German science and allowed them to claim Koch as their own to the detriment of homeopathy.

The final empirical chapter discusses the consolidation of allopathic professional authority and elimination of sectarian threats. Allopathic reformers sought epistemic closure through an epistemology of the laboratory, based on the germ theory of disease
²²
and the laboratory sciences imported from Germany (Bonner 1963). This approach redefined cholera as a microorganism, identified in the lab through the microscope, and treatable through vaccines, antitoxins, and inoculations. Despite this reframing, laboratory analysis was routinely ignored during the 1892 cholera scare. Cognizant of government skepticism and the limitations of achieving professional recognition through public health, the AMA adopted a conscious program to circumvent government institutions by aligning itself with private philanthropies. Reformers found allies among industrial philanthropists who were beginning to integrate the laboratory into their businesses and eventually convinced them to fund their program of scientific medicine. Using these philanthropic resources, allopathic reformers were able to make the laboratory the “obligatory passage point” (Latour 1987, 132) for all medical knowledge, to create an organizational infrastructure around the lab under their control and purified of homeopathic influence, and achieve the standardization of medical education along bacteriological lines. Epistemic closure was achieved by allopaths without having to debate the merits of their system in the democratic public institutions where they had been continuously defeated.

While it is difficult to reconstruct the motivations of actors long dead, especially since the issue of motivation is best approached on an individual case-by-case basis, I'd be remiss not to say something about how I conceive of the actors in this book. These physicians should not be reduced to cynical political operatives. Nor should they be romanticized as disinterested seekers of truth. Between these two extremes lies a more balanced depiction of actors with multiple (often conflicting) motivations. The shifting commitments to particular epistemological systems by nineteenth-century physi
cians
were driven both by a desire to solve intellectual problems and a desire to gain a strategic advantage in the epistemic contest. Physicians, whatever their sectarian allegiance, strove to make sense of cholera while also gaining recognition and power. It is this messy combination of noble truth-seeking and base politicking that makes epistemic contests so compelling.

The particularities, and peculiarities, of the professionalization of U.S. medicine facilitated the rise of an exceptional medical system, unusual in the developed world. Although a comparative analysis of the organization of medicine in different countries is beyond the scope of this project, suffice it to say that the U.S. medical system is widely viewed as an odd duck. The twin pillars of this exceptionalism—its embrace of private interests and its wholesale adoption of a scientific vision of medicine—originated from the particular trajectory of the epistemic contest that resulted in a profession highly suspicious of government involvement and democratic oversight. In the end, the key emergent theme in the history of U.S. medical politics is the tension between professionalization and democracy, which I discuss in the conclusion. The former stresses the recognition of a protected, privileged group of experts, in which the production of knowledge is mystified and insulated from public oversight. The latter stresses transparency and participation. The animating issue underlying the epistemic contest over medicine was the question of the place of expert knowledge in a democratic society. Indeed, without doing too much injustice to the nuance of the analysis, the entire epistemic contest could be read as an account of the persistent tensions between democratized epistemologies and the exclusive epistemological system proffered by allopathy. Skirting the public institutions of the state, allopathic physicians overcame democratic debate by avoiding it, persuading a small group of elite philanthropists to bankroll their professional project. The success of this “strategy of nondialogue” (Biagioli 1994, 216) was not lost on the AMA; it became its default strategy in subsequent debates over health care and public health in the first half of the twentieth century, and an ingrained part of its professional culture.