Knowledge in the Time of Cholera (8 page)

Of the largest U.S. cities, only Boston and Charleston were spared.

Yet, as quickly as it came, cholera went. On August 15, the board of health in New York started closing down its cholera hospitals and two weeks later, it disbanded the Medical Council that had been established to combat cholera. By October, the disease had all but disappeared, and while sporadic cases were reported in 1833 and 1834, it would be fifteen years until the next epidemic. For those who lived through the epidemic the experience would linger. Pintard (1832, 92) admitted, “I shall never forget the solemn impressions of the late dreadful month of July, when the face of heaven appeared to be obscured with a somber shroud of pestilence and death.” Still, life returned to normalcy. However, for physicians, the cholera epidemic would have ramifications far beyond painful memories, as it ushered in a long period of crisis for American medicine. Public confidence in regular medicine waned (Berman and Flannery 2001; Whorton 1982), as doctors were blamed for their inability to combat cholera and accused of fleeing in cowardice during their patients' time of greatest need. American doctors' opportunity to observe the workings of cholera in their own country did little to demystify the disease or assuage panic. To the contrary, it raised fundamental questions about the adequacy of medical knowledge. An anonymous letter to the
BMSJ
(1833b, 314) voiced the dismay of many physicians:

Numerous are the pamphlets and compilations already before the public, detailing the extensive ravages of this destroyer of mankind; and yet how
li
ttle, in view of all that has been written, worthy of retention! What has hitherto been laid down in regard to the proper mode of treating epidemic cholera? To what source shall we direct the inquiring student for the gratification of his laudable curiosity, and the establishment of his views upon the best method of combating this disease? Upon this branch of the subject, previous accounts are irregular and contradictory. The little that is valuable lies buried in confusion, and covered with an almost impenetrable mass of worthless matter.

The 1832 cholera epidemic forever altered the medical landscape, creating problems for the medical profession that would be transformed by enterprising alternative medical sects into a professional crisis of epistemological proportions.

THE MAKING OF AN EPISTEMIC CONTEST

This chapter recounts how an epistemic contest developed out of the 1832 cholera epidemic. The epidemic disrupted the normal functioning of regular medicine. But in itself it did not cause allopathic medicine to reevaluate its intellectual foundations or question its professional future. Rather, alternative medical movements transformed the opportunities afforded by the epidemic into a crisis that forced allopaths to give an epistemological account of their knowledge. In the politics of knowledge that ensued, regulars' budding professional program was derailed, as state licensing laws, passed prior to the epidemic, were universally repealed. The intensification of competition in the newly unregulated medical market was joined with fierce debates over the nature of knowledge to produce an epistemic contest that would take nearly a century to resolve. Cholera may have entered the United States through a poor, unfortunate Irish immigrant, but alternative medical movements ensured that its humble origins belied its eventual impact.

When cholera arrived, the intellectual foundation of allopathic medicine was already in a fragile state. Rationalism—the intellectual foundation of allopathy—was coming under increasing scrutiny by some within allopathy who advocated for a more empirical approach to medical knowledge. Cholera exacerbated these internal tensions. Unable to provide a coherent picture of the disease, regular practitioners attempted to justify their professional authority, not on intellectual grounds, but on their standing as learned men. With deaths mounting, however, these epistemological debates, for
merly
latent and circumscribed within the profession, became public issues with life or death ramifications. Alternative medical practitioners, particularly Thomsonians and homeopaths, drew on the uncertainty introduced by cholera to force public medical debates onto the terrain of epistemology. What they offered were more democratic medical epistemologies. Epistemologies imply a social order (Shapin and Schaffer 1985). At the most basic level, they discriminate between those who are legitimate knowers and those who are not. From this basic distinction follows cultural (i.e., whose testimony is to be trusted) and organizational effects (i.e., who controls the institutional production of knowledge). Epistemic contests open possibilities for the reformulation of hierarchies in knowing. As this chapter shows, Thomsonians and homeopaths sought to undermine the traditional social order of knowing in medicine, by proffering more democratic visions for medical epistemology, which posited a role for the public in the production of medical knowledge.

To explain alternative medical sects' success in transforming cholera into an effective epistemological challenge, I embed these epistemological debates within the institutional contexts in which they unfolded, rather than conceiving them as unfolding in an abstract entity like the “public sphere.” Epistemic contests do not occur in vacuums; they traverse the written page and enter into institutional and organizational contexts that shape their trajectories. Involved in sense-making (Weick 1979), organizations have internal cultures that shape the way information is understood, disseminated, and ultimately assessed (Vaughan 1996). In this way, organizations can be viewed as “epistemic settings” (Vaughan 1999) that delineate acceptable practices and procedures for the production and evaluation of knowledge. They are rhetorical spaces [that] “structure and limit the kinds of utterances that can be voiced within them with a reasonable expectation of uptake and choral support” (Code 1995, ix–x). I draw on the metaphor of an arena to make sense of the influence of organizations on epistemic contests. Arenas are defined by rules, more or less formalized, that shape strategic action—and influence outcomes—within them (Jasper 2006). Different capacities are needed to compete successfully in certain arenas, and therefore strategies must be designed to fit the context in which they are operating.
²
For intellectual disputes, actors must necessarily either forgo rhetorical arguments that are incongruous with that arena or lose.

The post-cholera medical debates turned on the issue of licensing and, as such, were situated in state legislatures. By the 1830s, regular physicians
had
begun to gain professional authority, successfully lobbying thirteen state legislatures to pass licensing laws (Numbers 1988). Yet, only a decade after the 1832 epidemic, these laws were universally repealed. Drawing on the insights of “new rhetoric,” which links the success or failure of rhetorical arguments to the particular audiences and contexts that they address (Perelman and Olbrechts-Tyteca 1969), I examine the case of the New York State legislature in detail, to reveal the ways in which alternative medical movements' arguments—and the manner in which they were rhetorically presented—resonated with antebellum state legislatures. While regulars' hierarchal notions of medical knowledge clashed with the culture of the state legislature that was increasingly influenced by the ideals of Jacksonian democracy, alternative medical movements, seizing the democratic moment, promoted more egalitarian visions for medicine, which convinced the state legislatures to repeal the licensing laws and deregulate American medicine. In recounting this history, this chapter identifies the genesis of allopaths' problematic relationship with the state that would frustrate their professional goals and perpetuate the epistemic contest over medicine for nearly a century.

THE DECAY OF RATIONALISM AND THE CRUTCH OF AUTHORITATIVE TESTIMONY

In his 1833 presidential address to the Medical Society of the State of New York, Thomas Spencer summed up the regular profession's anxiety in the wake of cholera. Taking inventory of the ignorance surrounding the disease, Spencer (1833, 217) declared,

Epidemics have in every age excited the dismay of mankind, and swept from the stage of human action a vast proportion of the inhabitants of the globe. The apprehension they produce is greatly enhanced by the rapidity of their movements, and the mysterious character in which these insidious enemies are enshrouded. It therefore becomes peculiarly important that the nature of every disease prevailing under this form, should be carefully investigated, and that the symptoms and mode of treatment found most successful, should be faithfully recorded.

This reasonable call for more research on cholera was sullied by the fact that, symptomatic of his peers, Spencer offered no clue as to
how
to answer these
questions
or what a “careful investigation” would actually entail. Instead, he goes on to dismiss cholera, not as something new, but as “a disease long known by the name of diarrhea serosa” (Spencer 1833, 218). In one quick stroke, Spencer explained away cholera's mysteriousness, claiming it was merely a variation of a familiar disease. A simple name change divested it “of mysticism” (Spencer 1833, 220).

Spencer's startling conclusion contradicted allopathic common sense. Upon what did he justify his unusual claim? On the one hand, Spencer suggests that it is built upon empirical observations, the “detail of the symptoms and the practical results to which my observations and investigations have conducted me” (Spencer 1833, 218). Yet such observations are never presented, nor is the nature of his investigations. This appears to be little more than a rote appeal to experience. On the other hand, he seems to situate cholera within a traditional rational system of disease (e.g., “Is it
rational
to believe, that diarrhea has its essential character changed, by becoming epidemic, and is thus rapidly disseminated by contagion?” [Spencer 1833, 288 emphasis added]). As to the components of this rational system, Spencer likewise remains silent. Without evidence to assess or a rational system through which to make sense of his claims, Spencer's declaration ultimately stands or falls on his own authority.

As founder of the Medical College of Geneva (New York), Spencer was considered one of “the most eminent physician of central New York,” (“Death of Doctor Thomas Spencer” 1857, 6) and an important figure in allopathy. And while his conclusion may have been atypical, the fact that such a preeminent doctor succumbed to such muddled reasoning when encountering cholera underscores the epistemological problems facing regular medicine. When cholera arrived in the United States, the epistemological foundation of allopathy was languishing in ambiguity—torn between understated commitments to rationalism and jejune calls for empiricism. By 1832, the traditional foundation for allopathic knowledge—rationalism, or an approach to medicine by which particular cases were interpreted through universal, speculative systems of disease—was coming under criticism by regular reformers calling for knowledge rooted in bedside observation. Cholera intensified these calls, and the tensions between rationalism and empiricism, evident in Spencer's attempt to walk a fine line between the two, grew.

Given the uncertain foundation of medical knowledge, it is not surprising that during this period cholera was a truly heterogeneous thing, lacking
a
fixed identity and prone to multiple, often contradictory, interpretations. Regulars could not reach consensus on the most basic questions of the epidemic. Debate focused on three major issues, none of which would be resolved until decades later. These questions included:

•
Was cholera a new disease?
Despite its unusual symptoms and morbidity, many U.S. doctors doubted that cholera was something altogether new. The debate over cholera's identity focused on “whether this be a
new
species of
morbid action
, one
peculiar to itself
, or whether it be
similar
to the medical actions that obtain in other cases, in the same structures, and
differing
from them
only in degree
” (Hott 1832, 60). Complicating matters was the fact that the very
idea
of specific disease entities—that diseases had discrete causes and characteristic courses—was contested (Rosenberg 1987b, 72).

•
How was cholera transmitted?
Allopathic physicians “copiously argued in many a bulky library” (
BMSJ
1835, 13) whether cholera was contagious or not. Sides were chosen depending on which contradictory evidence was stressed. Some noted cholera's movement along lines of travel, deeming it contagious (e.g.,
BMSJ
1832e, 254). Other reports, focusing on the isolation of cases and the lack of illness among medical professionals, declared it “to be wholly independent of contagion” (Comstock 1832, 353). Candidates for noncontagious causes proliferated: atmospheric influences (Clarke 1846), foul air (Comstock 1832), sudden changes in temperature (Williams 1844), and cosmic events like the alignment of the planets or an approaching comet (Allen 1832). Confusing the situation further, some doctors questioned whether the “distinction drawn between epidemic and contagious diseases was altogether fanciful. The fact is, that contagious diseases may become epidemic; and epidemic diseases, originally dependent upon atmospheric causes, may become contagious” (
BMSJ
1831a, 14). As the distinction between contagious and noncontagious broke down, its contours became difficult to even outline.

•
How should cholera be treated?
Doctors threw their entire therapeutic kitchen sink at cholera. Among the suggested treatments were: traditional, heroic treatments like bloodletting, calomel, chloroform, opium, and emetics (
New York Journal of Medicine
1849a); “sedative anti-spasmodics” (
BMSJ
1831a, 13); saline (Sterling 1849); brandy and laudanum (
BMSJ
1831a); hot milk and brandy (
New York Journal of Medicine
1849b); wearing wool; and
fl
eeing to the country (
New York Journal of Medicine
1849a). Treatments would receive glowing reports in medical journals, only to be dismissed in the next issue.