Knowledge in the Time of Cholera

by Owen Whooley

  This method of adjudication through argumentation was not without its problems. Notably, arguments between incommensurable systems tended to end in stalemates. Because each system was built on its own unquestioned premises and assumptions, it was difficult to compare them. The assumptions that held within each specific system rarely held across different systems. What was logical in one was potentially inconceivable in another. This incommensurability was exacerbated by the fact that in journal articles and correspondence regular physicians often failed to explicitly lay out the systems they subscribed to, choosing instead to vaguely proclaim ideas “rational” or “irrational.” Inevitably, this incommensurability made it difficult to compare and assess disputed claims about cholera.

  Even prior to 1832, some regulars had grown ambivalent toward such rational systems. This ambivalence stemmed in part from frustration over the isolated islands of knowledge that the various systems created. Additionally, some worried that the rational systems, while elegant, could not capture the complexity of what they witnessed at the bedside. Patients with all their corresponding idiosyncrasies often did not fit into tidy rationalist systems. Finally, the ambivalence reflected a concern about the heroic therapies promoted by rationalist systems, like mercury and bloodletting, which “worked” in the sense that they induced visible and demonstrable physiological changes (Rosenberg 1987a, 74). Many allopaths became concerned that these extreme therapies were harmful and that rationalism encouraged their rote application to the patients’ detriment and discontent (Warner 1997; Young 1967). These concerns, issued prior to the cholera epidemic, grew in its aftermath.

  The initial turn away from rationalism was “by no means monolithic” (Warner 1997, 46), and calls for empiricism would not achieve coherence until later, when they were consolidated around the Paris School of medicine. Still prior to the epidemic, many were advocating a type of proto-empiricism whose parameters, although vague, were set in opposition to rationalism. Not yet a full-fledged, well-articulated epistemological system, proto-empiricism represented more of a general ethos or guiding principle that stressed the primacy of experience over logical argumentation in making knowledge claims. Its adherents were committed to inductive reasoning, reluctant to pigeonhole hard-won experience into a speculative system. This budding commitment to empiricism had roots in the “medical cosmology” of bedside medicine (Jewson 1974). In practice, bedside medicine stressed the interrelationship between the patient and the doctor built on familiarity gained over time, in which the local doctor had extensive knowledge of his patients. To treat disease, doctors discussed the symptoms of the patient and applied their wisdom to determine treatment (Lachmund 1998). Everything revolved around firsthand experience and observation. Proto-empiricism sought to make this practical technique of bedside observation the foundation for medical knowledge.

  The essential intellectual component of this proto-empiricism was the doctrine of specificity (Warner 1997).3 This principle claimed that a disease could only be understood by taking into account the idiosyncrasies of the (1) patient and (2) the region in which the disease occurred. Disease was seen as polycentric and polymorphous, varying across individuals and contexts (e.g., disease in New York was qualitatively different from disease in Georgia). Given such variation, doctors had to tailor diagnoses and treatment to the specific case. This epistemological stance contrasted greatly with rationalism, as it caused a reluctance to universalize and draw analogies between disparate geographic regions or even between two different patients. Because knowledge was understood as specific and localized, empirical allopaths were not particularly concerned with accumulating particular facts so as to achieve a universal explanation of disease. Medical knowledge was oriented toward the exigencies of treating a particular patient, not toward achieving universal, abstract knowledge. These doctors refused to engage in the type of philosophical speculation rampant under rationalism. In fact, what proto-empiricism offered was less a positive program for the future of medical knowledge, and more a critique of past rationalism, a negative program of “tearing down” the troublesome speculative systems (Warner 1997, 59). As such, while the early commitment to empiricism was still without a cohesive vision, it nonetheless offered a firm position from which to critique rationalism.

  Torn between rationalism and proto-empiricism, allopaths lacked a clearly articulated epistemological foundation, which produced a fragmented knowledge base and internal discord over the most basic assumptions regarding medical knowledge. Under periods of business as usual, such fragmentation was not too damaging. But cholera changed this, as it increased the public stakes of these debates. It forced these debates, formerly circumscribed within allopathy, into the light of day. Such fragmentation led not only to inconsistent accounts of cholera but also to muddled interventions and ultimately death.

  In addressing their disunity, regulars retreated to claims of authority based on their status as learned men in the community. Regular professional identity during the early nineteenth century was not built on a shared, coherent body of knowledge, but on a shared sense of status, derived more from common therapeutic practices than a coherent system of thought (Warner 1997). All regulars, regardless of their epistemological commitments, subscribed to a similar conception of the hierarchy in medical knowledge that situated themselves at the apex of authority on medical matters and denied the legitimacy of knowledge emanating from those outside of the regular community. And both rationalist and empiricist allopaths rooted their knowledge claims in their positions of authority in the community; their status as learned men required that their views be privileged. For rationalists, this authority rested on their access to a tradition of philosophical medical thought. For empiricists, it was grounded in a notion of doctors as superior observers. Regardless of its ultimate foundation, this was a type of “generalized wise man” model (Parsons 1991, 295) of authority, based more on who regulars were than on what or how they knew. Thus, while never very extensive during this period (Shorter 1985), the deference allopaths received from the public was based upon local reputations as learned men and moral citizens. Respect was demanded in a manner akin to the way that local communities confer trust and authority to the ideas of clergy and other learned men. Upon this shared identity as members of the learned elite, regulars attempted to unite despite their disparate epistemological orientations.

  Grounding their authority on their reputations, regular physicians felt little compulsion to justify or explain themselves to the lay public. Instead, they resorted to authoritative testimony in communicating knowledge. Regulars made claims through dogmatic assertions of personal and traditional authority. They refused to offer accounts for their assertions, to present data that supported their claims, or to entertain competing ideas from alternative sects. Rather than lay out their reasoning, regular physicians stated their conclusions, offering only the barest of justifications. “Facts” were not presented but proclaimed. Their status spoke for their competence, their privilege derived from the source of knowledge—who was proclaiming it—not on the content. Regulars’ use of Latin in defining medical terms and composing treatises reflected the underlying assumptions of hierarchy in knowing to which allopathy subscribed. Because of its inaccessibility and opacity, Latin demarcated legitimate knowers from non-knowers. Knowing the language of medicine signified membership in an elite community. If one could not participate in such Latinate discourse, one was not meant to meddle in medicine. Consequently, authoritative testimony as a rhetorical strategy served to mystify knowledge in such a way that masked the epistemological uncertainty permeating the profession. It allowed regulars to tell rather than show. In essence, they covered up their lack of epistemological coherence through strategies of avoidance, by simply refusing to discuss them, and/or by deflection, shifting these concerns onto issues better handled by their rationalist systems.

  Still, the denial of epistemological issues and refusal to engage with these basic issues had corrosive effects and
presented problems for allopaths in their attempts to make sense of cholera. Authoritative testimony prohibited regulars from discriminating between legitimate accounts and spurious ones within their own sect, a persistent epistemological problem that plagued allopathy throughout the nineteenth century. There was no way to reach any consensus on cholera with knowledge that was based primarily on the reputation of the knower. For rationalists, authoritative testimony allowed them to gloss over contradictions in their competing rational systems, thereby prohibiting the type of hard-won consensus the public clamored for. Since they simply stated claims, rather than showing their reasoning, there was little to actually assess. The criteria and logic of any testimony remained invisible. So while masked, the conflicts and contradictions between rationalist systems went unresolved; regulars committed to rationalism presented a unified front, but in actuality confusion reigned. Unsurprisingly, this confusion found its way into the proclamations on cholera.

  For empiricists who had discarded the traditional systems and replaced them with an empiricism that put a premium on experience, authoritative testimony did little to solve the problem of communication beyond the local context. Traditionally, testimonies would be assessed according to the reputation of the testifier, as doctors drew on their familiarity with their peers’ reputations to make determinations of trustworthiness. Proto-empiricists lacked the standard or techniques to assess the validity of experiences as testified to by others in situations where personal familiarity with the knower was lacking. This was especially problematic for a disease like cholera that traversed local contexts. Cholera was a disease born of the structural changes in the first half of the nineteenth century. Revolutions in transportation and communication overthrew the “tyranny of distance” (Howe 2007, 225), as did rapid urbanization. Natural barriers to international interaction like the Atlantic Ocean were now easily traversed by both people and diseases. Inland, the emergence of a national market system, organized around canals and railroads, facilitated the diffusion of cholera throughout the United States. This movement was painstakingly recorded by the press, which grew threefold in the decades between 1820 and 1850 (Reynolds 2008), following the same transportation revolution as cholera itself (Mindich 2000, 96). As people’s horizons grew with increased interactions across local contexts (Haskell 1985) and rapid urbanization (Howe 2007), they became more familiar with what was going on beyond their local communities and began to think in terms of larger, more impersonal collectives. Thus, these very changes, which enabled cholera to spread, also undermined the traditional authority of doctors. Local personalism and trust based primarily on familiarity no longer held in this new environment (Halttunen 1986). The trans-local character of cholera not only compromised allopathic locally rooted authority; it also threw the inadequacies of its epistemological foundation into stark relief. Because allopathy lacked a well-articulated general program for medical knowledge, it struggled to make claims and assessments that traversed the local. Without any universal standard or measure of good knowledge, and with little information beyond individual declaration offered as proof, there was no way to tell a useful testimony from a useless one, no method to communicate effectively across localities in order to develop a clear, comprehensive picture of the disease.

  The end result of this epistemological discord was a lack of coherence in accounting for cholera. In the face of such confusion, regulars dug in their heels, leaning more and more on authoritative testimony. Rather than reaching conclusions on cholera, allopathic journals produced little more than incessant testimony and irresolvable debates. For example, take the endless, circular discussion on treatments for cholera. In an 1832 article in the Boston Medical and Surgical Journal, Dr. Robert Lewins (1832, 273) argued that a cure “may be accomplished by injecting a weak saline solution into the veins of the patient. . . . The most wondrous and satisfactory effect is the immediate consequence of the injection.”4 In the very next edition of the same journal, Dr. P. Bossey (1832, 245), however, offered the opposite claim; saline injections were found “totally inert and injurious.” Yet another doctor was told by an English doctor “that common table salt—a spoonful in a tumbler of water—not only speedily relieved him [the patient] from violent pains, but ultimately restored him to perfect health” (BMSJ 1831b, 170). Every author supported his claims with personal testimony which was inevitably followed by counterclaims. With no way to assess these competing claims, with no evidence beyond individual testimony, regular medical knowledge devolved into an endless proliferation of divergent claims, and the public was left confused as to what it all meant.

  DEMOCRATIZING MEDICAL KNOWLEDGE

  The use of authoritative testimony did not resolve internal epistemological debates within allopathy, but it did mask them via the omission of evidence of these debates in allopathic journals and meetings. However, the attempt to justify knowledge on authority, problematic within the profession, was even more dubious outside of the profession, as alternative medical movements began to demand an epistemological account from allopaths to justify their professional privileges. While regulars sought to avoid epistemological conflicts, alternative medical sects afforded them no such opportunity, leveraging the epidemic to force an epistemic contest over medicine.

  In part, the challenge to medical authority reflected the tenor of the times, in which challenges to authority were becoming rife throughout American culture. During the early nineteenth century, “the politics of assent” of the previous era gave way to the rough and tumble world of political parties (Schudson 1998). Democratization touched all sectors of American society—in religion through the Second Great Awakening, in reform movements like temperance and abolitionism, and in government with the rise of mass political parties and the extension of voting rights. And the growth of a vibrant press literally made knowledge more available to the public (Schudson 1981). Anti-intellectualism accompanied Jacksonian democracy, which “completed the disestablishment of a patrician leadership that had been losing its grip for some time” (Hofstadter 1963, 51). Cholera arrived precisely at the time that these democratic trends were crystallizing into conditions ripe for an epistemic confrontation in medicine. The crutch of regular testimony solved some problems, but it faced an increasingly hostile environment. Authoritative testimony declared rather than showed, leading to problems for regulars when entering public institutions that asked them to engage in debate by showing their reasoning.

  Alternative medical movements seized these trends and married them to critiques of regulars’ handling of cholera to mount a forceful attack on allopathy’s professional program. Cholera provided an opportunity for alternative medical movements that, in different ways, sought to democratize knowledge. The lesson of cholera was clear enough to the public; regulars’ heroic therapies inflated the mortality of the disease (Rosenberg 1987b, 72). Many turned to the milder alternative medical sects, and their ranks swelled. Regulars lamented these conversions, complaining that the public “through sheer ignorance of the steps leading indirectly to the temple of science . . . swallows with avidity the monsters of quackery practice” (BMSJ 1831a, 13). Regular physicians’ concern for their professional status grew, as did their sense of panic. By 1835, Edward Deloney (1835, 111) complained, “At no period of the world, even in the dark ages of superstition, has the profession of medicine been thronged with imposters of the most daring effrontery than at the present time.”

  The failure of regulars to stem cholera, or even provide a coherent account of it, became a crucial symbolic resource for alternative medical sects. Armed with alternative framings of cholera, these sects took aim at regular therapeutics, their use of authoritative testimony, and their privileged professional position. But most important, the cholera epidemic offered an occasion for alternative medical movements to force medical debates onto the level of epistemology. By offering competing medical epistemologies resonant with increasing democratic sentiments, these alternative medical sects made allopathy’s elitis
t orientation seem retrograde.

  Thomsonism: Every Person, His or Her Own Doctor

  The most radical attempt to democratize medical knowledge arose out of rural New Hampshire. Samuel Thomson, a combative, somewhat paranoid, and yet charismatic farmer, suspected regulars of withholding information from the people so as to garner power and wealth. In response, he developed his own herbal system of medicine—Thomsonism—that was simple enough for anyone to use. His vision was nothing less than a system of medicine without doctors.

  When he first published his New Guide to Health in 1822, Thomson saw his system as the defender of true medical knowledge—knowledge that was available to all. Under the Thomsonian system every person was to become his or her own physician (Kett1968).5 The antiauthoritarian and even conspiratorial character of Thomson’s critique fell on fertile soil during the Jacksonian era, and his system spread throughout the country via a network of itinerant “healers.” It caught on, especially in poorer, rural areas (Coulter 1973, 92), growing through the careful exploitation of popular sentiments, egalitarianism, nationalism, and romanticism (Whorton 1982, 24). Although statistics from the era are notoriously imprecise, historians believe that during its height in the 1830s, Thomsonism claimed over a million followers (Berman and Flannery 2001; Haller 2000). In 1833, a Thomsonian magazine published a list showing authorized agents in twenty-two states and territories (Rothstein 1992, 45). By 1840, Thomson had sold one hundred thousand family rights, and approximately half of the citizens in Mississippi and Ohio were curing themselves using Thomsonian methods (Numbers 1988).