Knowledge in the Time of Cholera Read online

  Chapter 2 describes the allopathic response to the democratic challenges of alternative medical sects, particularly homeopathy. After the 1848 epidemic, allopathic reformers redefined the identity of regulars, embracing a radical empiricism inspired by the Paris School of medicine. While this shift ostensibly allowed allopaths to claim some democratic bona fides, the selective manner in which they adopted the Paris School led to intellectual fragmentation. Eschewing the search for general laws in medicine (Warner 1998), allopathic reformers lacked standards to adjudicate competing knowledge claims. To solve this “problem of adjudication” they adopted an organizational strategy, establishing the AMA and substituting the criterion of membership for epistemological standards in order to deem homeopathy as quackery. Still, the exclusionary politics of the AMA failed to sway legislatures, which remained committed to the idea that open debate would lead to the best medical knowledge. This chapter reveals that epistemic contests are not waged by cultural/epistemological means only; organizational strategies can be usefully analyzed as epistemic practices as well.

  Chapter 3 discusses a key event in the history of cholera—the establishment of the Metropolitan Board of Health of New York City and the rise of public health more generally prior to the 1866 epidemic. United around a common understanding of cholera as a miasma, an eclectic group of actors, which included sanitary-minded allopathic physicians, homeopaths, social reformers, and sanitarians, came together to prevent cholera by cleaning up the environment. This was accomplished to great result, and the board of health was widely credited with having prevented another cholera epidemic in New York City. As public health grew in popularity, allopathic physicians sought to transform sanitary success into justification for their professional recognition. Once again, the legislatures refused to recognize these claims, as sanitarians framed them as contrary to the apolitical nature of the public health enterprise. Public health remained an eclectic movement rather than an allopathic-dominated one. This chapter explores the multiple ways in which claims to epistemic authority can be made, noting that how actors choose to make these claims has ramifications for their professional goals.

  The final two empirical chapters explore the consolidation of allopathic professional authority through epistemic closure. Chapter 4 describes the ways in which American physicians interpreted the “discovery” of the comma bacillus of Robert Koch in 1884. Drawing on an “attributional model” of discoveries, this chapter explores the role of “discoveries” in epistemic contests, showing how the project to configure Koch’s research into a discovery involved both cultural and organizational dimensions. Both homeopaths and allopathic physicians initially staked a claim to Koch’s research, attempting to frame this research into a discovery that justified their respective systems of medicine through different discovery narratives. I show how allopaths offered a more effective discovery narrative, which facilitated the construction of a network linked to German science and allowed them to claim Koch as their own to the detriment of homeopathy.

  The final empirical chapter discusses the consolidation of allopathic professional authority and elimination of sectarian threats. Allopathic reformers sought epistemic closure through an epistemology of the laboratory, based on the germ theory of disease22 and the laboratory sciences imported from Germany (Bonner 1963). This approach redefined cholera as a microorganism, identified in the lab through the microscope, and treatable through vaccines, antitoxins, and inoculations. Despite this reframing, laboratory analysis was routinely ignored during the 1892 cholera scare. Cognizant of government skepticism and the limitations of achieving professional recognition through public health, the AMA adopted a conscious program to circumvent government institutions by aligning itself with private philanthropies. Reformers found allies among industrial philanthropists who were beginning to integrate the laboratory into their businesses and eventually convinced them to fund their program of scientific medicine. Using these philanthropic resources, allopathic reformers were able to make the laboratory the “obligatory passage point” (Latour 1987, 132) for all medical knowledge, to create an organizational infrastructure around the lab under their control and purified of homeopathic influence, and achieve the standardization of medical education along bacteriological lines. Epistemic closure was achieved by allopaths without having to debate the merits of their system in the democratic public institutions where they had been continuously defeated.

  While it is difficult to reconstruct the motivations of actors long dead, especially since the issue of motivation is best approached on an individual case-by-case basis, I’d be remiss not to say something about how I conceive of the actors in this book. These physicians should not be reduced to cynical political operatives. Nor should they be romanticized as disinterested seekers of truth. Between these two extremes lies a more balanced depiction of actors with multiple (often conflicting) motivations. The shifting commitments to particular epistemological systems by nineteenth-century physicians were driven both by a desire to solve intellectual problems and a desire to gain a strategic advantage in the epistemic contest. Physicians, whatever their sectarian allegiance, strove to make sense of cholera while also gaining recognition and power. It is this messy combination of noble truth-seeking and base politicking that makes epistemic contests so compelling.

  The particularities, and peculiarities, of the professionalization of U.S. medicine facilitated the rise of an exceptional medical system, unusual in the developed world. Although a comparative analysis of the organization of medicine in different countries is beyond the scope of this project, suffice it to say that the U.S. medical system is widely viewed as an odd duck. The twin pillars of this exceptionalism—its embrace of private interests and its wholesale adoption of a scientific vision of medicine—originated from the particular trajectory of the epistemic contest that resulted in a profession highly suspicious of government involvement and democratic oversight. In the end, the key emergent theme in the history of U.S. medical politics is the tension between professionalization and democracy, which I discuss in the conclusion. The former stresses the recognition of a protected, privileged group of experts, in which the production of knowledge is mystified and insulated from public oversight. The latter stresses transparency and participation. The animating issue underlying the epistemic contest over medicine was the question of the place of expert knowledge in a democratic society. Indeed, without doing too much injustice to the nuance of the analysis, the entire epistemic contest could be read as an account of the persistent tensions between democratized epistemologies and the exclusive epistemological system proffered by allopathy. Skirting the public institutions of the state, allopathic physicians overcame democratic debate by avoiding it, persuading a small group of elite philanthropists to bankroll their professional project. The success of this “strategy of nondialogue” (Biagioli 1994, 216) was not lost on the AMA; it became its default strategy in subsequent debates over health care and public health in the first half of the twentieth century, and an ingrained part of its professional culture.

  Focusing on the epistemic contest over medicine as determinative in the professionalization of U.S. medicine opens an analytical space for understanding the nature of the ascendancy of the bacteriological model and the triumph of allopathic medicine over other alternative medical sects. The history of this epistemic contest yields a surprising, and disconcerting, finding, namely that the genesis of the U.S. medical system involved a repudiation of democratic principles. It also serves as an example of what the sociology of epistemologies (Abend 2006, 3) can achieve, what an empirical focus on epistemology can tell us about the power/knowledge nexus (Foucault 1980). By taking a quixotic journey into the history of American cholera, we gain insight not only into the strange world of professionalization of U.S. medicine but also into the general politics of knowledge and the everyday practices of epistemology in democratic cultures.

  1

  CHOLERIC CONFUSION

  When cholera
first attacked Europe in 1831, physicians were caught so unprepared that they struggled to even name the new malady, much less prevent its spread.1 Among the names suggested were “cholera asphyxia,” “spasmodic cholera,” “malignant cholera,” “bilious cholera,” “convulsive nerve cholera,” “hyperanthraxis,” and the particularly poetic “blue vomit” (Longmate 1966, 66). Eventually, the disease was anointed “cholera,” a curiously misleading choice, given the amount of baggage the term bore. Under the centuries-old Hippocratic system, cholera referred to an excess of yellow bile (Hamlin 2009, 19). Over time this humoral definition morphed into a more generic stand-in for milder diarrheal diseases. Now, in the panicked days of the first pandemic, cholera underwent another definitional transformation—from “a transitory state of one’s constitution” to “a relentless and deadly invader” (Hamlin 2009, 20). This hasty christening caused much confusion among physicians and officials. The victimized poor, on the other hand, suffered no such appellative confusion; to them the new disease was known simply as “the pestilence.”

  Whatever its name, the new disease killed in a dramatic fashion. Doctors marveled at the speed at which cholera claimed those in their prime (Rosenberg 1987b). According to Dr. M. Magendie (1832, 6), of Sunderland, cholera “cadaverizes in an instant the person whom it attacks.” Victims purged an abundant amount of “rice water” diarrhea. A “loose and relaxed state of the bowels” was attended “by frequent loose or watery discharges” (Atkins 1832, 65) with up to 10 percent of a person’s weight lost within hours. But cholera’s most macabre symptoms were the “cholera voice” and the surreal color of its victims. Patients took on an eerie bluish pallor just before dying, a ghastly visage of impending death. And the blue victims emitted strange sounds. One haunted doctor reported in the Boston Medical and Surgical Journal (BMSJ), “In the most deadly form of cholera there is a tone of voice, a wail, which once heard, can never be mistaken; by him, upon whose ear it has fallen in the accents of anguish, it can never be forgotten” (“Cholera Voice,” 1832, 148). More than the number dead, it was the nature of cholera that caused it to loom large in the popular imagination (Humphreys 2002).

  Cholera plunged Europe into turmoil. Hungary and France each lost over one hundred thousand people to the disease. Cholera claimed another fifty-five thousand in England. These raw mortality counts only hinted at the horrors on the ground. Europe’s inadequate infrastructure of charitable organizations and government institutions was overwhelmed. Churches were converted into makeshift hospitals, while their cemeteries swelled. A report from Paris described the deteriorating scene: “The deaths are so numerous every day that hearses have become altogether inadequate to the purposes for which they are ordinarily used, and the dead are carried to their burial places in large wagons” (BMSJ 1832b, 254). Cholera killed its victims quicker than communities could bury them (Grob 2002, 108). Wherever it touched, cholera produced a type of “epidemic psychology” (Strong 1990) of suspicion, fear, and stigmatization. The feeble actions adopted by European governments heightened tensions, often resulting in riots fueled by rumors of physician-led conspiracies against the poor (Briggs 1961; Burrell and Gill 2005; Durey 1979; Morris 1976). Faced with the breakdown of the social fabric, many looked to the heavens, conjuring up supernatural explanations for cholera. Seizing this opportunity, shrewd religious leaders used the scourge to admonish their flocks for their moral laxity.

  Anticipating cholera jumping the Atlantic, American physicians scoured reports from Europe for any useful information on the disease. The editors at the Boston Medical and Surgical Journal (1831a, 5) instructed every American physician “to watch with eagle eye the progress of this dreadful malady, and to treasure up in his mind every incident in its history which may aid in forming philosophical views with regard to its treatment.” But the profuse reporting offered scant medical intelligence (Hamlin 2009, 110). Measured analyses were difficult given the circumstances. Helpless in the face of “King Cholera,” European doctors could not agree on the most basic details of the disease. Was it a new disease or a more virulent form of an old one? What was its cause? Did it prey on the weak and immoral or kill indiscriminately? Which treatments were most effective? As doctors impotently mulled these questions, deaths accumulated. Hope dwindled. Having tried “every means sanctioned by recorded experience,” a London physician voiced the futility felt by many European doctors: “To our patient, laboring under a violent and advanced attack of Spasmodic Cholera, no solid expectation of recovery could be extended” (BMSJ 1831a, 8). Eventually, American physicians gave up on gaining any insight from abroad. An anonymous letter to the BMSJ (1832a, 189–190) summed up the situation:

  We have nothing, therefore, to learn from the practice of the most distinguished physicians in Europe, except to notice their errors, and to avoid the rocks and shoals upon which they have made shipwreck. Let us turn these scenes of horror to the writers of our own country. . . . Seeing the utter failure of the European physicians, in their treatment of the present epidemic, it behooves our practitioners to make themselves masters of all principal writers of their own country, who have been familiar with cold, sinking febrile disease.

  While few doctors clung to the hope that cholera would not reach the United States or that the country’s salubrious environment would limit its spread, most resigned themselves to the fact that they would get the chance to see the disease for themselves, as the Atlantic Ocean was no longer an insurmountable barrier for Europe’s problems given advances in sea travel.

  On June 26, 1832, the inevitable occurred. Cholera arrived in New York City, by way of Canada. An Irish immigrant named Fitzgerald came down with a strange intestinal illness. Dr. Cameron, a New York physician,

  found him [Fitzgerald] violently affected with vomiting, purging, and most convulsive spasms; the features sunken and the eyes staring; the pulse insensible at the wrist, and the surface cold, and covered with clammy sweat; the countenance black and terrific; tongue of a dark purple during spasms, becoming opalescent as the spasmodic action abated; the fluid rejected was watery, consisting probably of the liquids he was permitted to drink; his dejection resembled rice water, of the consistence of cream. (BMSJ 1832d, 354)

  Undoubtedly a case of cholera. Fitzgerald recovered, but his wife and children contracted the disease and died. Cholera quickly spread through the poorest districts of the city, with the infamous Five Points neighborhood—a place that Charles Dickens (2000,101) described as encompassing “all that is loathsome, drooping, and decayed”—suffering the brunt of the attack (Grob 2002, 105). Initially, city officials debated whether or not to announce cholera’s arrival. The stakes in such a decision were high. Officials, worried about the economic, political, and social ramifications of such an announcement, dawdled (Duffy 1968). In response, the city’s medical society accused the board of health of being unconscionably slow in alerting the public, resulting in unpreparedness and unnecessary death. This spat fueled panic among the public, as it appeared that officials could not agree on even the most basic of issues—whether or not cholera had reached the city. No one seemed to know what they were talking about. Dr. David Meredith Reese (1833, 3) recalled,

  The great ignorance of the unprofessional portion of our population on the subject [cholera] was obviously the prolific source of much imprudence, and threw the timid into a consternation and terror which prevented the adoption of any uniform and rational mode of prevention; while, at the time, the vague as well as contradictory opinions which have found their way into the public press, upon the subject of the causes, prevention, and cure of Cholera, have been very far from inspiring confidence in the members of our profession; and in such perilous times, this confidence is more than ever necessary and important.

  Cooler heads were failing to prevail.

  While officials argued, many abandoned the city to cholera’s chaos. John Pintard, a successful merchant, respected philanthropist and former secretary of the New York Chamber of Commerce, documented t
he deteriorating scene in letters to his daughter. Early in the epidemic, on July 3, Pintard expressed skepticism toward the “unnecessarily alarmed” doctors, opining that “at best we are likely to have a sickly season but we are not timid & shall stand our ground” (Pintard 1832, 66). Steeled by his military pedigree and strong Huguenot faith, Pintard refused to flee the city, unlike many of his fellow New Yorkers. Independence Day celebrations were canceled. Only churches remained open for mourners to pray for their victims, thus transforming the celebratory holiday into a somber occasion of fasting and prayer. By July 8, Pintard (1832, 69) observed, “The city is much deserted & the panic prevails.” Still Pintard stood fast, comforted in the belief that cholera only attacked “intemperate dissolute & filthy people” (Pintard 1832, 72). By the end of the month, however, even this false hope was dashed, as he reported the deaths of a friendly neighbor, a “hard-working” mechanic, and three physicians. Faced with the magnitude of the epidemic, Pintard, like many, turned to religion. Although President Andrew Jackson refused to proclaim a national day of prayer and fasting, state governments did, and Pintard abided by New Jersey’s July 26 day of fasting.