Knowledge in the Time of Cholera Read online

  Though constrained by structural factors, epistemic contests unfold according to their own internal logic, rendered contingent by the strategic back and forth between competing actors.17 Actors engage in what I have called elsewhere “knowledge advocacy” (Whooley 2008), championing certain versions of knowledge in a struggle to achieve epistemic authority and gain recognition. These visions clash, for the knowledge advocates argue against alternative visions of knowledge as much as they argue for their own. Interactive struggle then is central to explaining the trajectory of epistemic contests and its resultant effects on knowledge production. The epistemic contest over medicine evolved according to the dynamic, give-and-take between allopathic physicians, alternative medical movements, and medical reformers, as it traversed different organizational settings and involved a wide array of actors. Medical sects did not present fully formed articulations of their epistemologies and stick to them over the course of the contest. Rather, their epistemological positions arose in relation to each other and were modified over time according to their interaction.

  The stakes of epistemic contests are great. When one epistemic system is elbowed out by another, epistemic closure—the ascension and dominance of one epistemic system over others—is achieved. What is forfeited in closure is an entire way of understanding the multitudinous experiences of reality, and in turn, any future insights that alternative styles of reasoning might offer. The possible forms that knowledge can assume are restricted. While productive and necessary, epistemological systems all have their blind spots, allowing for certain types of questions and answers to arise while forbidding others. Thus, epistemic closure does not just result in the selection of certain ideas over others; it involves the selection of an entire approach to knowledge at the expense of others.

  The legacy of epistemic contests is evident in the power disparities—cultural and organizational—they leave in their wake. Solutions to the problem of knowledge are solutions to the problem of order (Shapin and Schaffer 1985). In the resolution of epistemic contests, certain actors are granted trust by society, while others are denied as legitimate knowers. With victory comes enticing spoils—cultural capital, formal legitimacy, organizational resources, and institutional support. These spoils become institutionalized, as the taken-for-granted practices of these organizations—“how institutions think” (Douglas 1986)—come to embody the winning epistemology, and subsequently disseminate it through processes like isomorphism (DiMaggio and Powell 1983). As such, the power disparities in terms of who is and is not recognized as a knower become imbued with an inertial quality as the patterned thinking is transformed into common sense.

  Because professional privilege is one of these spoils, epistemic contests can be implicated in professional politics. Ultimately, both professional struggles and epistemic contests are about the power to define the real, and as such commonly overlap. Insofar as professions represent a privileged economic position granted on the basis of specialized knowledge, defining the standards and nature of knowledge is crucial for professionals. This is not to say that professional struggles necessarily involve epistemic contests; professional debates need not involve fundamental questions over the nature of knowledge. They can revolve around a whole host of other issues (e.g., organizational control). Nor do epistemic contests necessarily spur professional struggle; they can—and do—occur outside of the system of professions. However, when professional struggles take on the form of epistemic contests, as was the case in nineteenth-century medicine, epistemology becomes decisive.

  In the end, the analytical payoff of the concept of the epistemic contest comes from its emphasis on embedded struggle over time in accounting for epistemological shifts. Rather than offering teleological accounts of the development of knowledge, I offer a conflict model of knowledge production that is shaped by the strategic give-and-take between actors, strategies shaped in part by the organizational contexts in which they unfold. Unlike most histories of this medical period, which take the point of view of particular medical sects, I elevate the interaction between actors—what William Sewell (2005, 6) refers to as “unfolding of human action through time”—to the center of the analysis. To understand the eventual consolidation of medical authority around the bacteriological model of disease, we must understand how and why medical sects made certain choices, and adopted certain strategies, in response to the actions of their challengers. At its core the dispute over medical knowledge and epistemic authority in the nineteenth century was relational, emerging out of the dynamic dealings between the actors involved. This is not a history of allopathy or homeopathy or any of the other actors described herein, but rather of their contentious relationship. In elevating the role of struggle—in stressing politics and knowledge—I show that the eventual content of medical knowledge had its birth, not fully in an external reality, but in the legacy of intellectual debates and extra-scientific polemics in which it was embroiled. The development of medical knowledge did not involve a simple reading of an external world or the discovery of certain facts; it involved a struggle to control and define the very standards by which knowledge was to be judged. And out of such epistemological struggle was born a unique and exceptional institution—the modern U.S. medical profession.

  WHY CHOLERA?

  This book recounts how regular physicians won the epistemic contest over medicine and, in turn, were able to consolidate professional authority, lost after the 1832 cholera epidemic, under the bacteriological paradigm in the early twentieth century. First, it explores the origins and development of the epistemic contest. How did alternative medical movements create an epistemic contest that translated into successful legislative campaigns between 1830 and 1890? Second, it describes the process by which regulars, through the AMA, were able to defeat all epistemic challengers to create an exceptionally powerful profession. How did allopathic physicians consolidate their professional authority around the bacteriological paradigm so as to legitimate the development of an institutional structure that excluded other medical sects? How did such epistemic closure shape the modern medical profession?

  To consider the establishment of an epistemology in general, to follow it through its various arenas, to note the number of actors involved in debunking or championing it, and to trace its trajectory over eighty years would be too large a task to furnish the type of close analysis necessary to understand the struggle for epistemic and professional legitimacy in all its subtlety and complexity. Fortunately, such a herculean task is unnecessary. Epistemic contests become manifest in specific debates. And not all medical debates are created equal. I have re-created the history of the epistemic contest through the case study of cholera during the period between 1832 and 1912—a period that witnessed four cholera epidemics in the United States.18 The data for this book has been culled from a wide array of primary source documents (e.g., medical journals, speeches, pamphlets, private papers, sociology meeting minutes, etc.). Using this extensive body of archival data, I painstakingly reconstruct the epistemic contest through a content analysis of both the specific claims of cholera being made as well as the epistemological assumptions underlying these claims. In doing so, I recount the muddled history of the epistemic contest over medicine in general, beginning with the successful challenge of alternative medical movements in the mid-1800s and ending with the allopathic achievement of epistemic closure under the epistemology of the laboratory at the turn of the century. Put differently, I provide a historical/sociological analysis of the politics of nineteenth-century medicine with cholera as its focus.

  The choice of cholera results from its tremendous historical importance—it was the medical issue of its day—as well as from some pragmatic methodological concerns. Historically, cholera was a major cause of the epistemic contest; analytically it offers a mirror to the more general problems animating nineteenth-century medicine in the United States. And while cholera was not the only issue involved in the epistemic contest,19 as “the classic epidemic disease
of the nineteenth century” (Rosenberg 1987b, 1), it was arguably the most important in both the reach of its influence and the persistence of its threat. As an exogenous shock to the medical profession, cholera disrupted the traditional workings of U.S. medicine and presented a host of problems, epistemological and otherwise, for the medical profession.

  Thus, while the epistemic contest became manifest over a number of different issues (e.g., the therapeutic value of bloodletting) and disease definitions (e.g., tuberculosis, yellow fever), cholera as a case has a number of benefits over other possible issues. First, epidemics are useful “sampling devices” as they bring to the fore many social, economic, political, and intellectual issues that are less visible during more tranquil periods (Rosenberg 1966). There exists a rich tradition of using cholera as a sampling device to study larger social phenomena. For example, Charles Rosenberg’s seminal study The Cholera Years (1987b) explores the secularization of American society by showing how the understanding of cholera evolved from the scourge of the sinful to a consequence of remedial faults in sanitation.20 Additionally, researchers have used cholera as a lens to examine a number of issues, including the sociopolitical history of nineteenth-century Hamburg (Evans 2005); the evolution of the bourgeoisie in postrevolutionary France (Kudlick 1996); political conflict in Lower Canada (Bilson 1980); the vagaries of British class politics (Durey 1979); the cultural norms of Victorian England (Gilbert 2008); resistance to tsarist policies in Russia (Friedan 1977); and the role of medicine in reinforcing American nativist policies and politics (Markel 1997). I use cholera as a sampling device to explore the intellectual crises within medicine in the early nineteenth century, taking advantage of the fact that cholera remained a pertinent issue over the entire period of professionalization that I seek to understand. While certainly cholera loomed larger during the initial period under study (1832 to 1866), it remained a persistent puzzle for medicine into the twentieth century. And it forced allopathic physicians to reassess their epistemology by offering opportunities for the elaboration of alternative visions for medical epistemology. When it came to cholera, the intellectual and professional stakes were high.

  While most of the historical research on cholera focuses on other national contexts, historians have long recognized cholera’s significance on American medicine. For nineteenth-century physicians, there was no medical problem more vexing and more significant than cholera. Cholera’s importance is alluded to (if not expounded upon) in the historical scholarship on the disease. The professional status of allopathic physicians depended greatly on achieving an understanding of cholera (Rosenberg 1987b). Likewise, the consensus among historians of alternative medical movements is that the failure of regular physicians to stem the tide of the 1832 epidemic was used by alternative movements to challenge allopathy (Berman and Flannery 2001; Coulter 1973; Haller 2000; Kaufman 1988; Whorton 1982). And many of the doctors who would eventually lead the charge in reforming American medicine cut their teeth on the study and treatment of cholera, especially in Paris in 1832 (Warner 1998).

  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 un
knowledgeable 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.