Knowledge in the Time of Cholera (17 page)

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 observa
tions.
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 abstracted 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).

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 recognition 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).