Knowledge in the Time of Cholera Read online

  IN PARIS WE TRUST

  After 1849, the epistemological fragmentation within allopathy came to a head. The repeal of the licensing laws meant that allopathic physicians could no longer hide behind legal statutes when challenged by outsiders. They had been decertified. And in the open medical market, with competing medical sects offering alternative epistemologies, inchoate epistemological commitments no longer sufficed. Finding the status quo of internal divisions over the old rationalism and crude proto-empiricism untenable in such an environment, elite reformers within allopathy searched for a new epistemic foundation for their medical knowledge. They found it in Paris.

  To regain their status, allopaths needed a coherent epistemological account of what it was they were doing, and in the 1840s, a group of reformers embraced a vision adapted from the Paris School. Reformers’ motivations were multiple (Warner 1998, 12). Many came to reforms rather unintentionally. As young doctors trying to gain a leg up in the overcrowded antebellum medical market, some traveled to Paris, the world’s center of medical innovation, for additional education, only to become socialized into a new vision of medicine (Warner 1998). Some were dissatisfied with the heroic practices and intellectual stagnation of the previous generation. For these doctors, the very term “system” had become an epithet of derision (Warner 1997, 50), and they gravitated to the next new thing. And others, concerned about the waning status of allopathy, consciously sought collective uplift through a reformulation of medicine along “scientific” lines. Whatever their original motivation, the driving question for all reformers became, how could allopathy move beyond rationalism and capture public acclaim in the context of Jacksonian democracy?

  Between 1820 and 1861, nearly seven hundred doctors traveled to Paris to supplement their education, forging such a strong “living link between the Parisian medical world” and U.S. allopathy (Jones 1970, 144) that this period is often called the “French period” of American medicine (Ackerknecht 1967). Initially it was not the French ideas that drew Americans to Paris; it was the institutional infrastructure of French medicine, which afforded students and doctors with access to a large cache of patients, an opportunity unavailable in the United States (Warner 1998). State-run hospitals and clinics provided access not only to a large patient population but to cadavers for autopsy as well. Additionally, the laxer sexual mores allowed physicians to gain experience working with female patients. For the elite of the U.S. medical profession, precisely the men who would become the leaders in medical societies, schools, and journals, studying in Paris became a rite of passage that shaped their professional identities through the mid-1800s. At least a third of this number would end up teaching at American medical schools (Jones 1970). Given the influence of this group, the Paris School as an ideal became the “most powerful source of change in antebellum American medicine” (Warner 1998, 4).

  Drawn to Paris’s practical educational opportunities, these doctors came to embrace its medical epistemology: “Paris is confessedly the seat of medical knowledge, and undoubtedly comprehends within its precincts the greatest body of men learned and eminent in every department of science, and especially in that of the healing art” (Yates 1832, 1–2). At its most basic, the Paris School embraced empiricism as the foundation for medical thought, as it sought to erect a body of knowledge built from careful empirical observations. It stressed systematic physical examinations of patients, “an anatomo-clinical paradigm rooted in the systematic correlation of signs and symptoms observed at the bedside with lesions found in the organs at autopsy” (Warner 1998, 4). Employing new techniques like auscultation, the Paris School championed an empirical approach to medicine in which patients were examined thoroughly both externally through assisted sensory observation and internally through autopsy. By extending the “medical gaze,” the Paris School sought to penetrate superficial symptoms to get at the root cause of disease (Foucault 1994). This empiricism was embodied in the stethoscope (Warner 1998, 137), the autopsy, and the central role of the clinic in medical training (Foucault 1994). The new tools from Paris would refine observation to such a point that the need for speculative systems would be eliminated: “Percussion and auscultation; the various forms of specula, such as the ophthalmoscope, the microscope, the endoscope, and more lately the laryngoscope, have all furnished the most useful results, and added very materially to our knowledge of diseases by dissipating those false notions of physiology and pathology, which were founded upon mere theory and speculation” (Quackenbush 1869, 4–5).

  The Americans who studied in Paris returned to the United States with a firm commitment to the Paris School, viewing empiricism as the way to address the professional crisis facing them at home. Through their letters, translations of French works, and their advocacy of educational reforms, these doctors transmitted the Paris School to the United States (Jones 1970). But the Paris School that these Americans championed assumed a different identity in the U.S. context. Transmission is a selective process, not one of passive diffusion. Allopathic reformers saw the new epistemology as the antidote to the rationalism that precipitated their dwindling prestige. But they did not merely transplant the Paris School to the United States; they selectively embraced particular aspects of it, adapting it to fit their professional needs (Warner 1998). In other words, they transformed the ideals of the Paris School to address the epistemic contest with homeopaths.

  In essence, for Americans, the Paris School came to represent an effort to excise all philosophical speculation from medicine so as to transform it into a science built on observations and facts. In setting the Paris School in opposition to rationalism, American reformers transformed the school’s systematic empiricism, rooted in an extensive organizational infrastructure and buttressed by numerical methods, into a radical empiricism based on observations gleaned only through sensory input—a sensual empiricism that sought facts through sight, touch, and sound.3 This epistemology was more radical than that of the Paris School as it rejected the validity of abstracting general theories from local observation. As such, the Paris School was reformulated in negative terms as an antisystem that sought to shear medicine of all theoretical scaffolding and deal “only with positive tangible facts” (Bissell 1864,18). Less a formal methodology, the Paris School became equated with a general orientation toward medical knowledge characterized by an “allegiance to empirical fact, to knowledge gained and verified by direct observation and analysis of nature, coupled with the opposition to rationalism, hypothesis and speculative systems of pathology and therapeutics” (Warner 1998, 8). This commitment to facts, it was hoped, would save the profession plagued by theoretical speculation divorced from reality (e.g., Bissell 1864; Quackenbush 1869).

  Radical empiricism was explicitly set against Enlightenment rationalism and displayed an animus against all speculation. It attempted to purge the knower of all theoretical speculation so as to obtain more objective, fact-based knowledge. Medicine needed to become an empirical pursuit of truth based on facts, uncovered through the experienced, intelligent use of the senses. The model knower was the individual physician who diligently and thoroughly observed the particular patient. The locus of the production of knowledge was at the bedside, where the doctor interacted with and observed the illness. And medical knowledge would progress through the incremental accrual of discrete facts, grounded in tangible (visible, audible, olfactory) observations rather than flighty bouts of speculation. The metaphor driving this empirical vision was one of accumulation: “The science of medicine has been aptly likened to an ant-hill, in its slow but steady growth, no one individual adding but a mite to the mass of facts which compose this hill of science” (Jones 1861, 10). As such, reformers policed all medical knowledge for theoretical musings, deriding—and dismissing—that which appealed to generalization and speculation as illegitimate. What was not an observable fact was not allowed. While such atheoretical observation is impossible, set within the context of the epistemic contest over medical knowledge, its appeal to regu
lar reformers was that it seemed a remedy to the disastrous professional consequences they believed followed from rationalism. In addition, it was attractive because it built upon the nascent empiricism already existing within allopathy. And because empiricism was rooted in sensory observation, making knowledge ostensibly available to everyone, it appeared more democratic, allowing allopaths to claim some democratic bona fides.

  But the animus toward generalization and theorizing was often taken to extremes. In 1844, Elisha Bartlett, an influential reformer and committed advocate of radical empiricism, gave the fullest account of the new epistemology in An Essay on the Philosophy of Medical Science (Warner 1998, 175). Bartlett denied the legitimacy of any hypothesis or theoretical speculation that might bias observation; medical knowledge “is in the facts and their relationships, classified and arranged, and in nothing else” (Bartlett 1844, 7 emphasis in the original). Hypotheses and theories “shut up, or obscured, or perverted” the senses (Bartlett 1844, 218). Speculation corrupted observation, for “one of the first and most inevitable effects of a belief in any a priori system of medicine is an utter disqualification of the mind for correct and trustworthy observation” (Bartlett 1844, 206 emphasis in the original). A nomadic professor who taught at a number of medical schools in different states, Bart lett did his best to socialize the next generation of doctors into this empirical ethos. For this generation of students, medical knowledge would no longer be achieved by armchair physicians who constructed elaborate rational systems; it would be gained by staying close to sensory observations at the bedside and the uncovering of simple facts.

  Strategically, radical empiricism had three benefits for allopaths in regards to the epistemic contest. First, it represented a return to the Hippocratic tradition of empirical, bedside observation upon which medicine should be built—a tradition that was lost during the age of rationalism and speculative systems. The flip side of this positive embrace of empiricism was a rejection of rational systems, allowing allopathy to shed the most obvious target of its critics (Warner 1998).

  Second, radical empiricism allowed regulars to turn the rationalism epithets back at their opponents. In this way, they attempted to one-up homeopaths in their commitment to empiricism. Like homeopaths, allopathic physicians sought to claim the mantle of scientific medicine via empiricism, albeit through a different understanding of what empiricism meant. Allopathic radical empiricism differed significantly from homeopathic empiricism; homeopaths were not as averse to generalizing and theorizing across contexts as allopaths were. This difference stemmed from the origins of the two systems. Because homeopathic empiricism did not arise in opposition to theorization, homeopaths expected facts to accrete into a coherent body of medical knowledge with the aid of theory; facts were a means to the end of universal laws, like the law of similars. Allopathy’s aversion to anything that reeked of rationalism, on the other hand, precluded the search for underlying rules to make sense of discrete observations. Facts were the end. This radical positioning allowed allopaths to portray homeopaths as rationalist because they did not go far enough in their rejection of theorization. They framed homeopaths as backward, focusing on the law of similars and the notion of the vital force as signs of their theoretical excess, rather than their empirical strivings through provings and statistics.

  Finally, the commitment to observable facts implied some transparency in knowledge that resonated with the democratic ethos of the time. The success of Thomsonism and homeopathy in adopting democratic rhetoric to serve their ends was not lost on allopathic reformers. They sought to exploit it for themselves, albeit in a more conservative way; their empiricism would be accessible to outside observers but still require expertise to be done correctly. This was not to be naïve empiricism, but one undertaken only by elite observers. Still, the fact that it posited an understanding that medical insight was more accessible made it an improvement, democratically speaking, over the blatant elitism of rationalism.

  Ultimately, reformers hoped that radical empiricism would yield accurate medical knowledge on diseases like cholera by stemming the impetus toward inaccurate speculation (Warner 1998). They championed a new identity for the American physician: “The fact-hunter, as he has been sneeringly called, provided he be also a fact-finder, and a fact-analyzer, is the only true contributor to the advancement and improvement of medical science,” announced Bartlett (1844, 220). This new identity required nothing short of the adoption of an entirely new epistemology.

  Proliferating Accounts of Cholera and the Problem of Adjudication

  Despite the great hope reformers placed in radical empiricism, it was accompanied by its own set of problems. In Paris, empiricism was buttressed by a strong institutional infrastructure, a profession with firm support from the state, an organized community of medical elites, and a coherent program of medical education that made new medical tools widely available. The situation in the United States was much different. Allopathic physicians did not have government support and were left to their own devices to carry out their reforms. Moreover, American medicine lacked any sort of infrastructure that could bring coherence to a new epistemology reticent to theorizing across contexts. Hospitals remained on the periphery of medical practice (Rosner 1982). Medical education, lacking access to large patient populations, remained didactic, and standards remained very low (Ludmerer 1985; Markowitz and Rosner 1973; Starr 1982). Education was so limited that new doctors received little training in the science of observation. As such, the adoption of the microscope, stethoscope, and other tools of the Paris School was hindered. For example, use of the stethoscope was confined to only the most elite doctors after the Civil War (Rosenberg 1987a, 91). The senses were not being channeled into devices that could be standardized across contexts.

  Without these important institutional means to organize the production of knowledge, the embrace of radical empiricism presented a problem: allopathic physicians remained committed to the centrality of sensory observation in developing a truly scientific medicine but lacked the institutions to provide coherence to this endeavor, to aggregate local observations into a generalizable knowledge. Radical empiricism, therefore, devolved into proliferating claims made by individual doctors according to their own observations. A “fact” would be observed and reported, but what if other individual doctors did not make the same observation? There was no adequate method by which to weigh one individual observation against another. There was no way to know if doctors were on the same page, or even seeing the same things. In other words, radical empiricism suffered from a problem of adjudication. How were allopathic doctors to decide when observations disagreed? The rejection of anything that reeked of rationalism precluded allopathic physicians from developing underlying rules and laws to bear on discrete observations. The animus against speculation and generalization bound medical knowledge to its local context and hindered efforts to develop a general body of medical knowledge.

  Quantification could have offered a solution to the problem of adjudication. By eliminating extraneous information, numbers simplify and standardize data, making it liquid, comparable, and mobile (Carruthers and Espeland 1991; Porter 1994). As such, quantification might have offered regulars a natural escape from the local and the particular. After all, the Paris School, under the influence of Pierre Charles Alexandre Louis, promoted statistical reasoning and the “numerical method” (Ackerknecht 1967; Matthews 1995). Louis collected numerical data on patients in hospitals so as to compare treatments and differentiate diagnoses. The numerical method never caught on in the United States, despite some influential supporters like Bartlett and the prolific author and Harvard-educated physician Austin Flint. In part, this resistance reflected the institutional reality of U.S. medicine; without large, state-run hospitals it was technically difficult to collect and aggregate numerical data. In part, it reflected the transformation of the Paris School into radical empiricism in the American context. Radical empiricism stressed local observation; data that was ab
stracted from local-level sensory observation, or was not focused on the particular case, was foreign (or at least problematic) to its analytical orientation. Numbers could not be seen, heard, or touched. And like many nineteenth-century medical thinkers (Hacking 1990), allopathic physicians questioned whether information on collectives had relevance for the treatment of individual patients. For example, the New York Journal of Medicine (1844b, 327), while admitting the importance of statistics in other fields of inquiry, stated, “[statistical] laws present nothing individual, their application to individuals is only within certain limits.” In doing so, they raised the common criticism that aggregate information bore little relevance to treating individual patients—a critique that Louis himself faced in France (Matthews 1995). Allopathic physicians rejected statistics for the same reason that universal laws were difficult to come by under radical empiricism. Both dealt in abstract aggregation, whereas the new epistemology was oriented toward the particular and individual.

  But most important, the rejection of statistics reflected an ideological opposition. Regulars had come to associate statistics and quantification with homeopaths and, in turn, rejected it out of hand. They dismissed homeopathic statistics as rhetoric, presented in “the advertising style of quackery” (Hooker 1852, 109) so as to dupe the public. They questioned the trustworthiness of the data that underlay homeopathic statistical claims: “The value of statistics, and especially when they relate to therapeutics, depends upon the principles on which they are collected, and the mental and moral character of him who collects them. It is often said that ‘figures cannot lie;’ but the annals both of quackery and of medicine show, that false statements can be made as easily in figures as they can be in words” (Hooker 1852, 107–108). Because of this outright rejection of statistical reasoning, allopaths lagged far behind their European peers in the collection and analysis of vital statistics (Duffy 1990; Haller 1981; Meckel 1998).