Knowledge in the Time of Cholera (14 page)

The outcomes of these licensing disputes reflected a basic tension in claims to professionalization and expertise in democratic contexts—a tension that persisted throughout the epistemic contest over medical knowledge. The democratic understanding of how knowledge is best achieved (i.e., openness, transparency, and debate) clashed with the hierarchical vision of knowledge (i.e., restriction, autonomy, and noninterference) proffered by allopaths in justifying their professional privileges. The formal knowledge upon which professionals claim autonomy can be a threat to democratic decision-making (Freidson 1986). Alternative medical movements played off the tension between democracy and expertise to advance their own agendas. Without a compelling argument to grant this control over knowledge, institutions such as state legislatures were hesitant to impart it. Indeed, throughout the history of the epistemic contest, allopathy faced repeated resistance when trying to justify its claims to authority and autonomy in public institutions of the state—problems that would ultimately lead it to adopt a professionalization strategy that sought to evade state institutions.

In
focusing on the rhetorical strategies of medical sects within state legislatures, this chapter offers a more nuanced way to think about the changing fortunes of allopathic medicine in the wake of the 1832 cholera epidemic. In the past, historians have often resorted to macro-cultural explanations to explain the licensing repeals, viewing the deprofessionalization of allopaths as caused by the changing cultural winds, with the spirit of Jacksonian democracy serving as the catalyst for revolts against professionalization (e.g., Marks and Beatty 1973; Rothstein 1992; Starr 1982). Such macro-cultural accounts misleadingly marshal Jacksonianism as a causal explanation for its very components. But macro-cultural shifts do not exist in some amorphous ether, hovering above social life; they are aggregations of local-level practices spanning a variety of contexts. Homeopaths and Thomsonians did not ride the wave of Jacksonian values. Rather, they actively seized the opportunities afforded by this context to transform the 1832 cholera epidemic into a successful legislative campaign and an epistemic contest. Through framing, rhetoric, and political activism, they took advantage of the Jacksonian cultural shift to achieve a particular end; in doing so, they reinforced and contributed to this shift. Without the intervention of Thomsonians and homeopaths, the legislatures would not have been compelled to act, and the licensing laws may have endured. In the end, it is actors, real breathing people, who bring about cultural change. Epistemic contests don't just happen; they are made.

Moreover, they are made in particular contexts or arenas. This chapter also calls attention to the manner in which local conditions shape the nature and outcomes of epistemic contests. Localizing the epistemic contest as such helps narrow and specify what it means when sociologists say that such and such a frame has “resonance” (Benford and Snow 2000). Macro-cultural accounts define a larger cultural context and then ex post facto deem a particular strategy as “fitting” this context. By embedding practices within institutional contexts, we can better see just
how
resonance occurs
in practice
. In this case, it was the democratizing intent of the alternative sects' epistemologies, expressed through their frames, that resonated with the burgeoning cultural and organizational commitments to democracy in the state legislatures.

The 1832 epidemic may have led to the birth of the epistemic contest over medical knowledge, but by no means did it settle it. What it did was fundamentally alter the medical market by making it more accessible to outside challengers and alternative medical movements—a situation that would
endure
throughout the nineteenth century. In this expanded and flattened terrain, allopathy could not simply appeal to authority; it had to either
convince
the public that its claims to authority were justified or find other ways to capture authority. As would be typical of regulars throughout the nineteenth century, they chose the latter option.

2

THE FORMATION OF THE AMA, THE CREATION OF QUACKS

The official ineptitude toward cholera, so redolent in 1832, repeated itself in 1849. If the 1832 epidemic was a tragedy, the 1849 epidemic would have seemed a farce, were it not for the increase in corpses.

The nearly two decades that separated the two epidemics bore vigorous medical debate and an intensifying epistemic contest, but little insight. Answers to the most basic questions regarding cholera remained as elusive as ever. The bewilderment induced by the disease is well illustrated in a muddled description of cholera in an 1849 issue of the
Boston Medical and Surgical Journal
(1849, 123):

Here, now, are singular facts, plainly showing the mysterious and capricious character of this dreadful disease. It appears, here, there, elsewhere, suddenly, and often giving no warning, without reference to lines of travel, regardless of natural water courses, wholly independent of the direction of the prevailing winds, and uncontrolled by the topographical character or geological formation of the districts within its general course. Spending itself where it lights first, either gently or ferociously, it disappears, and while neighboring points are standing in awe of its proximity, and daily expecting its desolating presence, it suddenly appears in altogether another region, a hundred or two miles away. And again, two or three weeks, or two or three months afterwards, while those who seemed to have escaped are still warm in the congratulations of each other, and are beginning to talk and write about the superior healthfulness of their towns, the destroyer retraces its steps, strikes their best and their worst, the strong and their feeble, alike, and carries mourning to every household.

This frustrated description of cholera could have been easily written in 1832. Cholera remained a baffling foe, its capricious nature making it impossible
to
pin down. Given the lack of progress in medical knowledge on cholera, it is not surprising that the 1849 epidemic followed a similar script of medical ineffectiveness, useless interventions, widespread panic, and death. Not learning from the past, the United States was doomed to repeat it.

The disease followed much the same route as it had in 1832. Once again, the Atlantic Ocean failed as a barrier. On December 1, 1848, cholera returned to New York City on a ship carrying passengers prostrate with the disease from Le Havre, France. With no quarantine station or cholera hospital established, city officials refused to let the ship dock, sentencing its passengers to a horrific stay anchored just beyond the shore. Thirty of the three hundred passengers on board died. Fortunately, the onset of frigid weather prohibited cholera from spreading beyond the harbor (Duffy 1968), despite the fact that many passengers had escaped the infected ship, reaching mainland via small boats (Rosenberg 1987b, 104).

Cholera reasserted itself in the summer, once again stirring complacent physicians and city officials into action. In May, the city established a special Medical Council of three prominent allopathic physicians, charged with containing the epidemic. They promptly declared cholera to be noncontagious (Duffy 1968). Aimed at assuaging growing panic, this announcement led to a series of misguided policies and interventions. If city officials and allopathic physicians had learned any lessons from 1832, they did not show it. The program was largely the same—clumsy sanitary and quarantine measures, polarizing debates over the nature of cholera that delayed every proposed action, and the continued use of heroic treatments to the detriment of patients. In a testament to such stagnation, the council reprinted the same 1832 broadside of recommendations to the public with only a few “verbal changes” (Rosenberg 1987b, 109). Seventeen years after the original outbreak of cholera, officials had little more to offer than “Be Temperate in Eating and Drinking!”

As the epidemic intensified, hostility toward health officials grew. The Medical Council's policies were met with widespread skepticism and, occasionally, outright revolt. When the council took over and transformed four city schools into temporary cholera hospitals, it incited ire from the press and local communities in the process. People avoided the new hospitals at all costs; to be sent to them was seen as a death sentence. One of the council's rare innovations was a massive effort to remove pigs and other livestock from the streets. As of 1842, there were a recorded ten thousand hogs roaming the
city.
Because the council believed that there was some connection between cholera and filth, it decided to remove the pigs as part of its effort to clean up the city. Undoubtedly an eyesore—Charles Dickens described them as “having, for the most part, scanty, brown backs, like the lids of old horse-hair trunks; spotted with unwholesome black botches . . . long, gaunt legs, too, and such peaked snouts, that if one of them could be persuaded to sit for his profile, nobody would recognize it for a pig's likeness” (Dickens 2000, 97)—the pigs performed an essential service for the city. By removing the pigs, officials removed one of the most important scavengers from the streets at
the
precise time they needed them, increasing the city's filth and facilitating cholera's spread (Duffy 1968; Rosenberg 1987b). Moreover, these removal efforts were met with riots, as the hogs were essential to the livelihood of the poor.

1849 cholera broadside, distributed by the New York Medical Council, reprinted almost verbatim from the 1832 broadside. The Granger Collection, New York.

These poorly conceived plans lacked physician support, as doctors and city officials continued their mutual disdain. Physicians, fearing the loss of clientele to the council, were reluctant to report cholera cases or turn over their patients to cholera hospitals. This inaction was met with a sharp rebuke from the council. The bickering and lack of coordination fueled the public's misgivings about authorities' ability to combat cholera. By June, many had fled the city, and by July, the height of the epidemic, business had halted to a standstill.

For all its tribulations, New York City's experience with the 1849 epidemic was comparatively mild by national standards (it had claimed over 5,017 victims, 1 percent of the city's 515,000 inhabitants [Alcabes 2009]). But cholera traveled more widely in 1849 than it had in 1832. After arriving in the port of New Orleans on December 6, cholera rapidly spread inland throughout the South. Terror accompanied the disease wherever it went. Mark Twain, chronicler of steamboat life along the Mississippi River, recalled the hysteria: “The people along the Mississippi were paralyzed with fear. Those who could run away, did it. And many died of fright in the flight. Fright killed three persons where the cholera killed one” (Twain 2010, 352). As for those who couldn't flee, they “kept themselves drenched with cholera preventives” (Twain 2010, 352). Perhaps fortified with the fearlessness of youth—Twain, a teenager at the time, remained calm. Rather than stomach the gruesome cholera preventive his mother prescribed, he poured it down the floorboards, to “good result” as “no cholera occurred down below” (Twain 2010, 352).

Twain's experience with the disease emphasized the link between cholera and economic development. Cholera followed improvements in transportation, most notably the extension of railroad and steamship transportation. The Gold Rush of 1849 brought the disease west with disastrous results. “It was in the infant cities of the West,” according to Charles Rosenberg (1987b, 115), “with no adequate water supply, primitive sanitation, and crowded with a transient population, that the disease was most severe.” Western cities like St. Louis, which lost 10 percent of its inhabitants, were devastated. Even isolated towns did not escape cholera's reach. Based on incomplete statistical data, the AMA later estimated that cholera had claimed over
thirty
thousand victims (Newman 1856), one of which was former president James K. Polk.

Local officials scrambled to do anything to halt cholera's spread. In Pitts-burgh, where “great fear came suddenly upon the people, and the excitement was unbounded,” officials adopted a two-pronged attack; they removed “damaged vegetables” from the market and burned tar throughout the city (“The Cholera at Pittsburgh” 1854, 4166). It was in Cincinnati, however, that cholera reached its absurd apogee. There the city council spent $3,000 to fund a project of burning Youghiogheny coal at street crossings in an effort to alter the poisonous atmosphere. The
Christian Advocate Journal
(“A City in Mourning” 1849, 119) dutifully reported the program's inevitable failure: “The coal was duly fixed and fired, and had mixed with it large quantities of sulphur and tar, but neither the coal nor the tar had any effect in scaring off the disease.” Compounding this inevitable failure, the Cincinnati Board of Health became a lightning rod for medical disputes; as one observer noted, homeopaths, eclectics, and allopaths were “each jockeying for position on the Board of Health, at the city hospital, and for favor with the public” (Chambers 1938, 218). Rendered impotent by these sectarian disputes, the board was summarily dismissed midway through the epidemic.
All
physicians were removed from the board, replaced by a lawyer, an editor, a liquor dealer, a preacher, and a mechanic (Rosenberg 1987b, 118). The city's curious cholera experiences were not restricted to the dubious exploits of the board. In a single day, the Cincinnati press reported on a cholera patient who rose from the grave—an event mildly referred to in the title as a “cholera incident” (“Cholera Incident” 1849, 124)—and an entire family of six who succumbed to the disease—the father, dying not from the disease directly, but from grief after watching his wife and four children succumb (“A Sad Story—Effect of the Will,” 1849, 124).
¹
Stories like these proliferated throughout the country, spawning many cholera myths that intensified anxiety.