Knowledge in the Time of Cholera

The Struggle over American Medicine in the Nineteenth Century

Owen Whooley

• Publisher: University of Chicago Press
• Year: 2013
• ISBN:
  9780226017778
• Topic: Biological Sciences
• Subtopic: Science General
• Index: Biological Sciences

Vomiting. Diarrhea. Dehydration. Death. Confusion. In 1832, the arrival of cholera in the United States created widespread panic throughout the country. For the rest of the century, epidemics swept through American cities and towns like wildfire, killing thousands. Physicians of all stripes offered conflicting answers to the cholera puzzle, ineffectively responding with opiates, bleeding, quarantines, and all manner of remedies, before the identity of the dreaded infection was consolidated under the germ theory of disease some sixty years later.
These cholera outbreaks raised fundamental questions about medical knowledge and its legitimacy, giving fuel to alternative medical sects that used the confusion of the epidemic to challenge both medical orthodoxy and the authority of the still-new American Medical Association. In Knowledge in the Time of Cholera, Owen Whooley tells us the story of those dark days, centering his narrative on rivalries between medical and homeopathic practitioners and bringing to life the battle to control public understanding of disease, professional power, and democratic governance in nineteenth-century America.

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 the 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.

Faces of cholera, from Horatio Bartley, Illustrations of Cholera Asphyxia in Its Different Stages, Selected from Cases Treated at the Cholera Hospital, Rivington Street (New York: S. H. Jackson, 1832). Collection of the New York Historical Society.

While Pintard captured the panic among the living, an apothecary named Horatio Bartley (1832) memorialized the dead, sketching haunting images of cholera victims from the Rivington Street Hospital. His sketches show blue-hued, skeletal faces, writhing in pain. The victims’ sunken eyes betray no awareness, revealing another of cholera’s more unnerving symptoms—“the entire loss of all consent, sympathy, or catenation . . . between the brain and the nervous system, and the heart and the sanguiferous system” (BMSJ 1833a, 271). Victims were literally severed from their corporeality, assuming a ghostly countenance.

As summer went on, the blue visages of cholera became a common sight throughout the United States. By the end of the epidemic in New York City, where cholera deaths reached their peak on July 19, 3,515 people had died out of a population of 250,000. With riverboats its chief mode of transportation (Chambers 1938), cholera spread south, first toward Philadelphia and reaching the South in late August. By late September cholera had “extended as far south as Edenton, North Carolina, and westward to St. Louis” (BMSJ 1832e, 253), with New Orleans suffering the brunt of the outbreak. It also traveled westward via the Erie Canal and the Cumberland Road (Grob 2002, 105). Local attempts to pull together ad hoc medical committees to mount a defense were unsuccessful. Towns employed a variety of measures to prevent the epidemic to no avail, constructing roadblocks, imposing quarantines, even shooting cannons into the air in an effort to alter the poisonous atmosphere. Wheeling, West Virginia, undertook one of the more unusual plans:

To test the virtue of coal smoke and heat in staying the epidemic, cart loads of coal were deposited at intervals of fifty yards along each side of the principal streets and fired; the volumes of dense black smoke enshrouding the town—deserted streets, except by the frequent funeral train—sorrow and alarm depicted on every face, formed a scene more easily imagined than described; its impressions are still very vivid in my mind. (Hildreth 1868, 228)

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 little, 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, formerly 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 ...

Table of contents

• Cover
• Copyright
• Title Page
• Dedication
• Epigraph
• Contents
• Acknowledgments
• Introduction: Of Cholera, Quacks, and Competing Medical Visions
• 1. Choleric Confusion
• 2. The Formation of the AMA, The Creation of Quacks
• 3. The Intellectual Politics of Filth
• 4. Cholera Becomes a Microbe
• 5. Capturing Cholera, and Epistemic Authority, In the Laboratory
• Conclusion: Medicine after the Time of Cholera
• Appendix: A Comment on Sources
• Notes
• Reference List
• Index