Knowledge in the Time of Cholera Read online

  Therefore, while allopaths had shed speculative systems that they believed undermined their professional claims, radical empiricism unintentionally produced similar fragmentation and unintelligibility toward cholera, as it prevented medical knowledge from traversing local contexts and the idiosyncrasies of the individual. It did little to improve regulars’ understanding of the disease, providing only a confused mass of disjointed observations. In 1849, as in 1832, there were a number of contradictory accounts of cholera without any standards to assess and compare them. In 1832, the problem of adjudication grew out of the incommensurability of competing rationalist systems and the underdeveloped epistemological account of allopathic knowledge; in 1849, it was created by the reluctance of those committed to radical empiricism to engage in any sort of generalization. Allopathic knowledge of cholera in 1849 had changed only marginally since 1832. Allopathic physicians could recognize cholera at the bedside and were able to diagnose it consistently,4 but they still lacked any effective therapies or any effective sanitary techniques to limit its spread. Suggestions were simply rehashed from the 1832 epidemic and included everything from wearing wool to fleeing to the country. In fact, the resistance to theorization and the fragmentation that ensued led some to adopt a posture of extreme skepticism toward all therapeutic interventions, a position of “therapeutic nihilism” (Starr 1976). And while all agreed that cholera preyed on certain predispositions, both at the local and individual levels, with no way to compare the relative influence of these different predispositions, which ranged from fear of cholera to dampness in cellars, the list of predispositions multiplied into a hodgepodge of empirical observations and basic common sense, hardly a scientific achievement.

  But more than its therapeutic and preventative failures, it was allopathy’s inability to provide an adequate account of cholera that proved most damaging during the epidemic. While there was now near-universal acceptance that cholera represented a specific disease with its own identity (Rosenberg 1987b, 149), its etiology continued to be a most vexing question. By 1849, only the rare doctor still subscribed to a theological or supernatural causal argument (Rosenberg 1987b). But the materialist explanations remained as numerous as in 1832, with additional theories emanating from the voguish sciences of chemistry, microscopy, and pathological anatomy (Richmond 1947). Cholera was described variously as contagious, noncontagious, or contingently contagious, caused by miasmic gases, consumption of alcohol, atmospheric changes, “a motivating agent,” or corrupted vegetables. Juxtaposed to the tidy statistical ratio of cholera offered by homeopathy, this internal confusion did not compare favorably.

  Although the terms of the debates were unstable and ill-defined (Richmond 1947), in general allopathic physicians fell into two broad camps—contagionists versus noncontagionists—with a number of theories competing for prominence within each. Contagionists were the minority. They believed that cholera spread via infectious people and drew on the disease’s movement—and its tendency to cluster—as evidence. This account was somewhat undermined by the experiential observation that medical professionals attending to cholera patients rarely succumbed to the disease. Still, contagionists “assumed cholera to be the result of some specific poison” even though “nothing demonstrable is known concerning the nature of the cholera poison. All that has hitherto been advanced in this direction is pure hypothesis” (Metcalf 1869, 2). This mysterious poison was described variously as “animalculae” (New York Journal of Medicine 1849b), a “morbific agent” (Macneven 1849, 195), a “vegetable fungus” (Dickson 1849, 13), and “cryptogamic” (Seymour 1857, 188).

  Most regulars remained skeptical of these early germ, or animacular, theories. The bulk of physicians subscribed to some sort of noncontagious account of cholera, where there was more intellectual energy. Noncontagionists focused on miasmas (poisonous emanations from the soil or filth), atmospheric causes (e.g., humidity, static electricity in the air, etc.), zymotic causes, or newer theories of fermentation inspired by chemistry. Atmospheric theories saw cholera as a form of “meteratorious” epidemic, in which the atmosphere created a poisonous condition. Fermentation theories argued that cholera originated in a specific poison which only gained lethality when “fermented” by favorable conditions. Many fermentationists offered some sort of “zymotic” causal account by which decaying organic matter released toxins into the atmosphere (Eyler 1973). However, these theories, like the contagionist theories, were plagued by ambiguities and inconsistencies. As such, noncontagiousness theories were not immune to critique. For example, atmospheric theories had trouble explaining the obvious fact that cholera traveled. Pouncing on this inconvenient fact, a doctor of the contagionist persuasion derided the atmospheric theory as merely a scapegoat used to mask doctors’ ignorance (Rosenberg 1987b, 147).

  Given these basic disagreements as to the nature of cholera, a coherent picture of the disease failed to develop from the copious studies allopaths undertook. The New York Academy of Medicine (NYAM) established a special committee to conduct an extensive analysis on the contagion question. Their conclusion? It was “premature and inexpedient for this Academy to pronounce at the present time any positive opinion in regard to the contagious or non-contagious nature of Cholera” (quoted in Van Ingen 1949, 39). Compounding things was the fact that there was “a want of uniformity in the mode of making reports, which obscures, or even renders inaccessible the truth” (AMA 1850, 107). The problem of adjudication, which underwrote every debate on cholera, led to the inconsistent presentation of observations. Furthermore, neither animacular nor atmospheric theories even satisfied the criteria of sensory observation (i.e., they were not readily observable through the senses) and thus remained problematic for a profession committed to radical empiricism. Etiological candidates and studies proliferated, but there was no way to weed out the good versus the bad, the true from the false.

  Regulars’ mood soured into despair. One allopathic physician lamented, “That which for the present, has a great though transient interest, seems to absorb the whole medical mind of the country; and, docti indoctique scribimus, of cholera! cholera!! cholera!!!—upon which no one sheds new light” (AMA 1850, 107). Another offered this sober prediction: “Of cholera, it is probable, it [the specific cause] will never be known” (Seymour 1857, 188).

  ALLOPATHY GETS AN ORGANIZATION

  By midcentury, regulars faced an increasingly precarious professional position. While they had disassociated themselves from the excesses of rationalism, they suffered from an ascendant homeopathy and an inability to offer a coherent framing of cholera. Both of these problems could be traced, in part, to the embrace of radical empiricism. Eschewing theorizing and privileging local observation, regulars lacked standards by which to adjudicate competing claims. Intellectual fragmentation compromised their social standing. It also made them vulnerable fodder for homeopathic critique. Appealing to their own systematic empirical observations and the universal law of similars, homeopaths attacked regulars as unsystematic in their empiricism. Because regulars’ growing suspicion of medical systems and rational theories precluded them from establishing general principles, “the old school is without a system of practice, or practice without a principle, and it is even a boast of its advocates, that there is no rule or law as a guiding principle in the application of remedies in disease” (Grabill 1857, 1). Or as another homeopath put it: “The physician remaining in the old school is bewildered with opposing theories and oppressed with an accumulation of heterogeneous and unarranged materials” (Sharp 1856, 98). These arguments gained traction. The public took a harsh view of allopathic accounts and treatments of cholera and sought out homeopathy as an alternative (Coulter 1973; Kaufman 1988). Particularly disconcerting for regulars was the support of homeopathy among the urban upper class (Coulter 1973). Emboldened by the repeal of licensing laws, homeopaths began to advocate for more inclusion in government institutions. One allopathic physician observed, “The Homeopaths are urging their claims to recognitio
n on State and municipal boards whenever they can get an opportunity” (Medical and Surgical Reporter 1867, 16). Legislatures seemed open to homeopathic arguments, and by the end of the 1840s, many allopathic physicians were resigned to the reality of unwelcoming legislatures:

  The public, on the subject of medicine, intend well, but on everything connected with it they are lamentably ignorant. . . . Can we be surprised, then, that our legislators should be deluded into the endorsement of fantastic systems and modes of treatment, by the plausible assertions of cunning imposters, by partial and deceptive statements, the truth of which they have not the requisite knowledge to determine, and are compelled to take on trust? (Hutchinson 1867, 58)

  Public “delusion” combined with the egalitarian ethos of the Jacksonian period (“Equality is the procrustean bed in which everything must be shaped” [Clark 1853, 272]) to make legislatures resistant to granting privileges to one sect over any others. “The history of the legislation touching the practice of physic and surgery” afforded a “melancholy illustration of the truth” of this reluctance (Hutchinson 1867, 56).

  Regulars were losing the epistemic contest. Bewildered, they puzzled over their dwindling prestige: “It may, to say the least, be considered strange, that in almost every other department of knowledge besides that pertaining to the healing art, man seeks and follows with a degree of religious deference, the counsel and advice of those who are supposed to be the best informed and the most skillful in that particular branch which is his immediate concern; but in medicine it seems to be just the reverse” (Blatchford 1852, 70). To allopathic physicians, the widespread adoption of homeopathy represented a new low, a new nadir, in public common sense. “Men, in all ages, have been prone to trust to the absurd pretensions of empiricism in the treatment of disease, but never have intelligent men been so much disposed as at this day, to put confidence in the various sects of practitioners who do not profess to found their art on the science of which we are so proud, or even to be at all conversant with it” (Hun 1863, 6).

  It was becoming clear to allopathic reformers that they needed a new strategy. Their intellectual arguments were not cutting it. Operating against a democratic headwind, they changed tack. Rather than attempt to win the intellectual/cultural debate with homeopathy, regulars adopted an organizational solution to their epistemological woes. They believed that the interests of allopathic medicine could be protected only through the formation of a national professional organization whose unity would filter down into local societies (Coulter 1973, 179). Through the establishment of a national medical society, allopathic physicians sought to reconstitute allopathy as a more coherent body, while simultaneously drawing firm boundaries between legitimate medical knowledge and quackery, to organizationally provide the very standards of adjudication absent in their radical empiricism.

  In 1846, a small group of allopathic physicians met in New York to form such an organization. The idea of the national professional society was not in itself innovative; homeopaths founded the American Institute of Homeopathy (AIH) in 1844. But whereas the AIH was primarily a scientific society aimed at providing a forum for communication, the AMA was an exclusive society aimed at promoting allopathy at the expense of alternative medical sects. It was a conscious, unabashed tool for the promotion of regulars’ professional interests. And the founders saw it as the beginning of a new era for allopathy. In the first address of the society, President Nathaniel Chapman (1848, 8) heralded the event as one that signaled that the profession had awoken “from the slumbers too long indulged,” ready “to vindicate its rights, and redress its wrongs.”

  The driving issue for the founding of the AMA was the declining state of the profession (Rothstein 1992). Reformers identified three sources of this decline—an ignorant public, a weak educational system, and homeopathy—and decided to focus its energies on educating the public, reforming medical education, and combating quackery (Coulter 1973). As noted above, the programs of public education and educational reform took a backseat to the efforts to combat homeopathy (Coulter 1969). Because allopathic physicians understood appeals to the public as the sine qua non of quackery, they were reluctant to engage the public in any meaningful way, evidenced by the AMA’s closed-door meetings and its lack of a public journal until 1883. Educational reforms were also stymied, often discussed but rarely acted upon, as reformers became mired in a stalemate with the proprietary medical schools, which resisted any attempts to increase educational standards (Ludmerer 1985; Marks and Beatty 1973; Rothstein 1992).

  It was to the third task—combating quackery—to which the AMA turned its immediate attention (Fishbein 1947). By establishing the AMA, allopathic physicians sought to create organizational standards to adjudicate competing claims between legitimate medical knowledge and quackery, to draw a “strongly marked line of distinction between the educated and the uneducated, the liberal and the restrictive” (Brinsmade 1859, 22). The AMA’s founders (Knight 1846, 750) argued, “In this state of things, the only resource which remains is, for medical men to establish and enforce among themselves such regulations as shall purify and elevate their own body, and thus more fully command the respect and confidence of their fellow men.” The AMA sought to identify and eliminate irregular physicians through the “exercise of a moral power” (Hutchinson 1867, 59). If the state legislatures refused to officially recognize the difference between medicine and quackery, regulars would have to do it themselves.

  Through the AMA, allopathic physicians sought to exclude homeopaths from the universe of legitimate knowers, turning inward to create their own system of regulation (Starr 1982). The main vehicle by which this was to be achieved was the codification and the enforcement of the 1847 Code of Ethics, specifically the no consultation clause (Rothstein 1992). The AMA restricted its membership to allopathic physicians who had allopathic medical training and rejected “unorthodox” teachings. Not only were homeopaths and other “irregular physicians” prohibited from joining allopathic medical societies, but allopathic physicians themselves were prohibited from seeking or giving consultations to alternative physicians:

  Although it is not in the power of physicians to prevent, or always to arrest, these delusions in their progress, yet it is incumbent on them, from their superior knowledge and better opportunities, as well as from their elevated vocation, steadily to refuse to extend to them the slightest countenance, still less support. (AMA 1851, 86)

  The AMA was explicit about the rationale behind the no consultation clause; regulars needed to keep their “skirts clear of everything pertaining to irregular medical practices of whatever kind of description. We should not only avoid all complicity with them, but even the suspicion of a quasi recognition of them” (Hutchinson 1867, 62). Consultation was deemed as “giving ‘aid and comfort to the enemy,’ quackery, and as such is treason against the honorable profession of medicine” (Butler, Levis, and Butler 1861, 496). In presenting the code to the entire body, Dr. John Bell urged all members to “bear emphatic testimony against quackery in all its forms” (quoted in Fishbein 1947, 37). The intensity of this rhetoric underscored the commitment to defeating homeopathy, as did the severe punishment—expulsion—of those who indulged it. These exclusionary organizational practices represented a marked departure from the long tradition of interaction between the two groups and the recognition of professional equality in previous ethical codes of local medical societies. It raised the stakes of the epistemic contest for the average regular by officially drawing distinctions and prohibiting cooperation through various mechanisms of punishment and censure.

  The Code of Ethics was strengthened in the years following the formation of the AMA. Before a local society could be admitted to the association, it was required to purge all homeopaths (Coulter 1973). In 1851, the no consultation clause was revised to explicitly grant the power to local societies to expel suspected homeopaths: “Each County meeting shall have the power to examine the case and immediately expel any member notoriously in t
he practice of Homeopathy, Hydropathy, any other form of quackery, without any formal trial, the same to be ratified by the succeeding Convention, any By-Law to the contrary notwithstanding” (quoted in Coulter 1973, 202). In 1854, the AMA, worried that local societies were not effectively policing their boundaries, set up a committee to inspect whether local members were still involved with irregulars. And in 1856, the AMA codified the illegitimacy of homeopathic knowledge by resolving that homeopathic works could no longer be discussed or reviewed in allopathic periodicals, effectively erasing any trace of homeopathic thought from allopathic discourse. The AMA showed great resolve in carrying out these threats, demonstrated best in 1884 when it responded to the New York State Medical Society’s repudiation of the Code of Ethics by canceling the membership of most of its members (Burrow 1963, 20).

  With these exclusionary practices, the AMA was able to police its members and to foster some cohesion by expelling those physicians who strayed too far afield. Such efforts were mirrored at the local level, with the instigation of the AMA. The example of the New York Academy of Medicine (NYAM) was indicative of this trend toward exclusion. Initially, the reaction of many New York regulars to homeopathy was one of curiosity and engagement, evidenced by the fact that the allopathic Medical Society of the County of New York awarded an honorary membership to Samuel Hahnemann in 1832 (Kaufman 1988). Rather than reforming this corrupted medical society, allopathic leaders in New York State, particularly New York City, decided to found NYAM. The old society was simply too catholic to meet the current challenges. In outlining their reasons for the establishment of NYAM, its founders listed the separation of regular practitioners from irregulars first (Van Ingen 1949). To accomplish this goal, the academy had to define what constituted an irregular physician. This was not a straightforward exercise in definition, for in New York, the boundary between homeopaths and regulars was fluid as they regularly consulted with each other. After much discussion NYAM adopted a broad rule that excluded “all homeopathic, hydropathic, chronothermal and botanic physicians, and also all mesmeric and clairvoyant pretenders to the healing art, and all others who at any time or on any pretext claimed peculiar merits for their mixed practices not founded on the best system of physiology and pathology, as taught in the best schools in Europe and America, and shall be deemed to exclude also all such persons as associate with them in consultation” (quoted in Van Ingen 1949, 13). The broad definition was adopted without a dissenting vote. Furthermore, to safeguard the society from homeopath infiltration, NYAM established a Committee of Admissions “to guard the portal of the Academy and to see that no irregular or unqualified practitioner gained entrance” (Van Ingen 1949, 8). As a result, the first fifty years of NYAM witnessed numerous accusations and purgings of homeopaths from its ranks. More energy was expended on these exclusionary actions than on any other activities.