Knowledge in the Time of Cholera (2 page)

Contrast this reaction with a later foreign epidemic. In 1918, the “Spanish” influenza hit the United States for the first time. The “great influenza” epidemic was the worst in the country's history (Barry 2005), and by all objective measures, an even more stunning failure for the medical profession. The influenza claimed between 500,000 and 670,000 Americans and upward
of
five million worldwide, 3 percent of the world's population. By contrast, the 1832 cholera epidemic killed only about 10,000 Americans. Yet, unlike in 1832, no one questioned the authority of the allopathic medical profession. Fortified within institutions like hospitals, laboratories, and research universities, regulars, through the AMA, had achieved such a high level of professional authority that they remained unchallenged by even the most deadly of epidemics. Operating under the banner of science and the bacteriological paradigm, allopathic physicians had wrested control of medicine from competing sects, winning recognition as
the
experts in treating, controlling, and understanding disease. The medical profession emerged from the influenza epidemic as influential as ever.

Two epidemics, two conspicuous failures, and yet two widely divergent professional outcomes. What happened to the profession in the intervening years, between these two epidemic bookends, that these failures could yield such different results? Cholera destabilized allopathic authority and led to a retraction of professional privileges that gave birth to a period of rancorous medical competition; the Spanish influenza reinforced physicians' clout as local, state, and federal agencies turned to them—and only them—to combat the flu (Barry 2005). These contrasting outcomes reflected a dramatic shift in the allocation of professional authority between the two epidemics—a shift whose origin clearly was not driven by the profession's effectiveness in combating infectious diseases. The medical profession failed in both cases, and by all standards, much more spectacularly in 1918. And yet the ramifications of these failures differed greatly. Why was the public unwilling to extend the benefit of the doubt to allopathic doctors during the deadly cholera, but willing to during the deadlier influenza epidemic?

Over the same period, medicine underwent a major change in epistemology, in how medical knowledge was produced and understood. During the 1832 cholera epidemic, Dr. Henry Bronson, a professor at Yale Medical School, offered this account of the disease:

If I am asked the essential, non-contagious cause of cholera, I answer frankly—
I do not know
. Every agent in nature, real or imaginary, has been accused. Electricity, magnetism, earth, air, water, sun, moon, planets, comets, have each been arraigned in vain. There is a mystery which hangs over the origin and spread of epidemics, which will probably never be re
moved.
The philosophers of the present day are no wiser on this subject than those who lived three thousand years ago. (1832, 86)

Typical of the writings on cholera during the first two cholera epidemics, Bronson's muddled assessment reveals an unstable definition of the disease. Many possible causes, from comets to magnetism, are interrogated; all are found wanting. Bronson betrays the great confusion of allopathy, not only toward the cause of cholera, but also where to even look for such a cause. There was no paradigmatic account of disease. It is not that Bronson cannot make sense of the evidence; he has little vision of what the evidence should even look like. Absent this, he throws out some ideas and, finally dejected, expresses skepticism that cholera's mystery will ever be solved. This is the lament of a doctor, who not only lacks a coherent road map to make sense of the disease, but doubts that such a road map even exists. His despondency is palpable. This inchoate account, however, does gesture toward the dominant perception of medical epistemology during the 1832 cholera epidemic. Lamenting that the “
philosophers of the present day
are no wiser on this subject than those who lived three thousand years ago,” Bronson identifies medicine as a practice of philosophy. This reflects the prevailing view of medicine during the period. Medicine was an exercise in philosophizing rather than scientific researching. Deploying rationalist, speculative systems to understand disease, doctors were less focused on interpreting facts; they were in the business of crafting elaborate philosophical systems.

Sixty years later, William Osler offered a very different account of cholera. In
The Principles and Practices of Medicine
, the preeminent medical textbook of the period, Osler (1895, 132) concisely defines cholera as “specific, infectious disease, caused by the comma bacillus of Koch, and characterized clinically by violent purging and rapid collapse.” Here we have a much neater definition of cholera. Gone are the uncertainty, the hesitating prose, and the horde of causal candidates. Cholera is now a specific disease caused by a specific microorganism. The authority appealed to is Robert Koch, a German laboratory scientist. In offering a scientific fact, plainly and succinctly stated, Osler displays confidence in the epistemological foundation of his profession. No longer armchair philosophers, Osler's doctors derive hard truths from the laboratory. Medicine is a science.

Bronson and Osler would hardly recognize the cholera of which the other speaks. The idea of cholera being caused by a microscopic organism would
have
seemed just as absurd to Bronson, as searching for cholera's etiology in comets would have for Osler. This incommensurability speaks to a radical shift in medical epistemology. Typically, epistemological change is viewed as the straightforward product of scientific advancement, the progressive illumination of truth. Such accounts, however, invert temporality; epistemological systems must be accepted prior to recognizing something as truth, as these systems set the standards by which truth is judged. Bronson to Osler was not just a shift from ignorance to insight, from darkness to light. It involved a reformulation of what medical knowledge
is
and how it is to be obtained. To accept cholera as a germ meant accepting the laboratory as the loci of medical insight and the disease cultures growing in these labs as legitimate medical facts. For Bronson and his peers, this would have been unthinkable. But by 1895, they were well on their way to becoming medical common sense. In sixty years, medical knowledge had made the dramatic leap from an exercise in philosophical inquiry to a science rooted in the experimental methods of the laboratory.

These two changes—a dramatic shift in professional authority on one hand and an epistemological change on the other—coalesced to produce a medical profession unusual in the developed world. These changes were not just concurrent but intimately related, each contributing to the development of a medical profession widely recognized as exceptional among developed countries, in its steadfast—and successful—opposition to government incursions into medical practice (most evident in the AMA's various campaigns against government-run health insurance), and its fixation on scientific and technological solutions. While physicians of many different countries eventually embraced the laboratory sciences, none did so with as much fervor as the U.S. medical profession.

In this book, I explain how debates over medical professionalization in the nineteenth century—conflicts over issues like licensing, board of health composition, government recognition of alternative medical sects—
became
epistemological, in the sense that underlying these specific issues was the animating question of what constituted legitimate medical knowledge. Professional struggle was inextricably tied to fundamental intellectual debates waged on the level of epistemology, in which the very identity of what constituted a medical fact was at stake. Or more accurately, these professional debates were
made
epistemological through a confluence of broad social changes, which enabled epidemics like cholera, and alternative medical
movements,
which seized the opportunities afforded by cholera to force allopathic medicine to justify its expertise in epistemological terms. Cholera and quacks joined to foment epistemological angst for allopathic medicine. And the eventual character of the profession would be inscribed with their indelible marks, as the allopaths would have to solve their riddles to achieve professional authority.

By emphasizing epistemological struggle and change, I provide a framework to better understand the professionalization of U.S. medicine and, in doing so, offer a more nuanced account of a key (if not
the
key) cause of the exceptionalism of the U.S. medical system. When professionalization is no longer viewed as flowing directly from medical discoveries, and instead is seen as evolving according to the vicissitudes of epistemic politics, a very different story of the professionalization of American medicine emerges. It is a story of missed opportunities, of intellectual roads not taken, and of significant contributions by alternative medical movements that have all but disappeared from our historical consciousness. It is a story of the recurrent failures of allopathic physicians to reconcile their professional aspirations with the democratic ideals of American culture, and the repeated acceptance and recognition of alternative movements by government institutions. It is a story of the consolidation of professional authority by allopathic physicians through a strategy that circumvented the state—and public oversight—by securing the financial support of private philanthropies. But foremost, it is a story about the long-standing tension between the logic of professionalization and the ideals of democracy out of which an exceptional U.S. medical profession was born—one that raises difficult questions about the role of professions in democratic cultures.

HEROIC DISCOVERIES, MISLEADING STORIES

Conventional accounts of U.S. medical professionalization link professional authority to improvements in medical knowledge without paying attention to the epistemological changes that underlie these “improvements.” In these narratives, the allocation of authority follows on the heels of scientific discoveries, properly meted out according to the merit of the knowledge attained. We can call these accounts, somewhat crudely, “truth-wins-out narratives.” The logic of these narratives, often referred to as the “diffusion model” (Latour 1987), holds that ideas, by their self-evident truth, force people to assent to them. Advocates of these discoveries are subsequently
accorded
requisite acclaim and authority, often in the form of professional privileges.

In the case of the professionalization of U.S. medicine, the truth-wins-out narrative has two variations. In its most basic form, professional authority was awarded to those who subscribed to true ideas, who made the key “discoveries” in the new science of bacteriology. “True” ideas won out over lesser, partial truths. Professionalization followed the imperatives of scientific progress, with the consolidation of professional power achieved through the gradual, rational incorporation of scientific principles into medical practice (see, for example, Bulloch 1979; de Kruif 1996; Duffy 1993; Rutkow 2010). The second variation of the truth-wins-out narrative shares the logic of scientific progress but adds the element of efficacy. Here professional authority is achieved, not only through the power of ideas, but in the results they obtain, as developments in medical knowledge led to more effective therapeutic or sanitary interventions, which legitimated professional authority of physicians. The germ theory rapidly led to new cures that justified its assumptions and solidified the authority of doctors.

The seductive common sense of the truth-wins-out narrative muddies how we understand the history of the U.S. medical profession, the progress in medicine generally, and the origins of the tremendous authority afforded doctors in the United States. It ignores the heterogeneity of nineteenth-century medical thought, reducing professionalization to a single linear process. Rather than exploring the ascendancy of one
way
of thinking about medicine, it tells of a single march toward progress in medical knowledge. It obscures significant ideas once entertained but ultimately discarded and dismisses alternative medical movements as aberrations or mere repositories of ignorance, that is, if they are even considered at all. Intellectual developments are decontextualized, depoliticized, and presented as evolving according to the dictates of disinterested research rather than as part of a specific professional project. And the dissemination of bacteriological ideas is given no explanation other than a vague appeal to the propulsion of their self-evident truth: “By this time [1880] the news of Koch's discoveries had
spread
to all of the laboratories of Europe and
had crossed the ocean
and inflamed the doctors of America” (de Kruif 1996 [1926], 119). Exercising what E. P. Thompson (1968, 12) terms the “condescension of posterity,” the truth-wins-out narrative naturalizes professional authority, transforming the flux of the nineteenth century into something of a predetermined outcome.

While
the truth-wins-out narrative is rarely laid out as explicitly as this, its underlying logic persists in our understandings of professionalization, as it squares with commonsense notions of the development of science, notions which the sociology of science has spent decades combating. But the history of knowledge does not conform to the strictures of common sense, and the truth-wins-out narrative cannot bear the weight of historical scrutiny. Take the two key discoveries in the history of cholera lauded in the truth-wins-out narrative—John Snow's discovery of the waterborne nature of the disease in 1855 and Robert Koch's identification of the cholera microbe in 1884. These true ideas, rapidly accepted, gave birth to bacteriology and scientific medicine, which led to the disease's demise. A tidy story, yes, but it's wrong. Snow's famous cholera map can only be considered a tipping point in the debate over the etiology of cholera by reading history backward. The map, almost an afterthought in Snow's work, had little effect in convincing skeptics of the validity of the contagion theory (Koch 2005; Vinten-Johansen et al. 2003). There is almost no mention of it in American allopathic journals prior to the twentieth century. Likewise, Koch's widely reported discovery of
Vibrio cholerae
did not provide the decisive “win” for the bacteriological model of cholera (Rosenkrantz 1985; Warner 1991), as it was beset with inconsistencies that fostered widespread skepticism (Rothstein 1992, 267). And in terms of combating cholera, the bacteriological model did not produce much in the way of improvements in therapeutics (unlike diphtheria or rabies, no widely used cholera vaccine was ever embraced) or prevention (effective sanitary improvements were done in the name of the now discredited miasmic theory of disease)
²
(Dubos 1987; Duffy 1990; McKeown 1976, 1979). These issues—the ambiguity surrounding the theory initially and the lag between the promise of the germ theory and its results—are not just evident in the history of cholera; generally, the biomedical model only yielded significant therapeutic advantages in the 1930s, long after it was accepted by allopaths as legitimate (Spink 1978). Thus, in 1892, the year of the final U.S. cholera epidemic and the dawn of allopathic professional control, the efficacy of the bacteriological model existed largely in its promise. This messy, ambiguous historical record of cholera thus begs the questions, how did this disease come to be seen as a microbe and how did this understanding get folded into the professional project of allopathic medicine?