Knowledge in the Time of Cholera

by Owen Whooley

  Like the sanitary reformers generally, plumbers justified sanitary reforms on apolitical grounds: “In order that it [the board of health] may be of benefit to the people and extend its usefulness to its full capacity, its complexion should not be characterized by any sort of partisanship. It should be composed of sanitarians, if the objects of the health board are to be attained” (Halley 1887, 241). Plumbers could better serve the people’s trust because they had the requisite expertise and were immune to political corruption. And because sewers, cesspools, and inadequate internal plumbing contributed to disease, plumbers possessed valuable insights into the transmission of disease and the creation of cholera nests. As the “water supply of cities and dwellings, the sewerage of cities and house drainage, are some of the most important features of sanitary science” (Halley 1887, 243), plumbers’ knowledge was needed to unearth the mystery of disease. And unlike the doctor, the plumber had both the skill and motivation to search out disease in its element:

  No doubt he [the doctor] often speculates as to what may have produced the trouble he is striving to remedy, but when it comes to a careful, minute, scientific investigation to determine this cause, he usually has neither sufficient motive, time nor knowledge to make it. Is it a matter connected with defective sewage in relation to—suppose we say diphtheria? This involves questions of sanitary engineering, the work of the plumber, the composition of sewer gases, and tests for them. (Billings 1879, 125)

  Possessing this requisite expertise, plumbers demanded their due recognition within public health, to argue that “we are not arbitrary” (Halley 1887, 245) when it came to sanitary science. William Halley (1887, 245), a master plumber from Ohio, drew on the link between disease and place to demand inclusion on the boards:

  No one profession or calling is able to hold sanitary science in the hollow of its hand. It has been the impression among legislators that physicians alone are competent to serve as members of State boards of health. Not all physicians are sanitarians, and the best medical ability on earth is unable to compass the whole range of practical sanitation. It is granted that medical knowledge is indispensable to a health board, but it requires the learning and skill of other callings to complete the full complement of a thorough, practical, efficient sanitary organization. Sanitary science to be of value must be practical; and the varied aspects of sanitation cannot be reached by medical wisdom alone, but by the technical knowledge and skill of mechanical art.

  As paragons of “practical sanitation,” plumbers demanded not only inclusion but also the authority to carry out their work autonomously, unquestioned by other, nonplumbing sanitarians.

  While sanitary-minded physicians attested to plumbers’ relevant sanitary knowledge, the bulk of allopaths ridiculed their aspirations. For regulars, cholera was a medical problem, and when dealing with disease, it seemed absurd that plumbers would dictate anything to physicians. T. Clarke Miller (1887, 109), regular physician and president of the Ohio State Board of Health, mocked the plumbers’ attempt to assert themselves on the boards:

  The plumbers have been making very commendable progress in the past few years; there are many of them who can be trusted to do safe work in their line; but some of them, by reason of having learned their trade well, have come to consider themselves commanders in the sanitary army, and to assume that the whole burden of practical sanitation rests upon their shoulders, and to felicitate themselves that doctors and architects have heartily joined with them, who have always done, and are still doing, everything that is necessary to do about the relations of plumbing to health. Physicians who kept themselves abreast with the advance of knowledge of the etiology of disease, and have been foremost in the detection of bad plumbing by a knowledge of its results, are not only unnecessary but meddlesome—they know how to cure disease—nothing about how to prevent it. . . . Indeed, we are in danger of having an army of trades seeking to place themselves in the sanitary priesthood. . . . The butcher who knows wholesome meat and furnishes it to his customers is likely to become the “sanitary butcher.”

  Sarcasm aside, Miller was serious in his foreboding. The medical profession could not afford to ignore “the growing army of sanitarians in special lines” (Miller 1887, 108). Regulars might lose their uniqueness and distinction within the sanitary movement if every group professionalized in the name of public health.

  The boards created an arena accessible enough, epistemologically speaking, to allow for challenges to allopathy that extended beyond alternative medical sects; plumbers and other “sanitary professions” entered the fray. The added competition complicated regulars’ attempts to use the boards to promote their professional ends. This was not just frustrating; it was nearly incomprehensible. Regulars believed that medical knowledge should trump other forms of knowledge, for “it will be seen that one may be a good practicing physician without being a sanitarian, but no one can be a good sanitarian without being a good physician; the requisites for one underlie those for the other, as a foundation” (Griscom 1857, 110). Insofar as nonmedical knowledge was relevant, allopathy sought to relegate such knowledge to a secondary status and to assert its control over it. Either physicians should dictate how the complementary, but inferior, knowledge should be deployed or physicians should acquaint themselves with this knowledge and deploy it themselves. Thus, although allopathic physicians begrudgingly acknowledged the relevance of other knowledge, they sought to subordinate it and, in some cases, even to steal it. Allopathic physicians envisioned a system of public health to be managed by doctors and doctors only.

  To the extent that plumbers were never able to gain equal standing to physicians on the boards, allopathic physicians were successful. In most matters, medical knowledge remained valued over knowledge of plumbing. Unsurprisingly, plumbers bristled under this situation: “Last and worse of all, in spite of these severe labors, the plumber is subject to general obloquy. No one appreciates his labors. His bills are usually disputed, and even when he has done his best he feels that it is a thankless task and that no one appreciates his efforts” (Plumber and Sanitary Engineer 1879, 94). Still, plumbers were granted a place at the public health table as active members of boards of health. They were successful in their campaigns against irrelevancy and were able to prevent doctors from fully capturing their knowledge, retaining some autonomy from sanitary physicians. These efforts—along with similar efforts on the part of civic engineers, architects, and other sanitarians—ended up tainting the original promise of sanitary science for allopathy, as regulars were finding it more and more difficult to assert themselves among the cacophony of competing voices.

  Homeopathic Incursions

  Arguments for allopathic control over the boards faltered in the face of the recognition of the diverse components relevant to public health. But even more troubling for regulars was their failure to maintain control over medical knowledge. The establishment boards not only encouraged other sanitarians to challenge allopathy; it emboldened the homeopathic challenge, as homeopaths increasingly demanded equal status to regulars. Furthermore, the manner in which the boards were justified epistemologically—as producing apolitical knowledge—constrained regulars’ attempts to exclude other medical sects from participation. In this favorable context, homeopaths jockeyed for, and typically won, inclusion on the boards. More than anything else, the inclusion of homeopathy aggravated rank-and-file regulars.

  Take the experience of the New York Board of Health. Initially, when the Metropolitan Health Bill was being debated in the legislature, homeopaths petitioned for inclusion. Anticipating an allopathic effort to exclude them, the Homeopathic Medical Society of the State of New York (1866b, 131–132) warned the legislature that a “great injustice would be done if a provision is not made for the appointment of at least one of the medical men composing the board from the ranks of the homeopathic school; and also, if at least, one fourth part of all the public hospitals and dispensaries in the city of New York, should not be placed in the care of homeop
athic physicians.” The legislature was in a bind. Politically, it agreed with homeopaths, but it could not risk alienating allopaths. Rather than addressing such a contentious issue, the legislature punted, remaining silent and declining to make any specifications as to which sect should be represented in the appointments. Once the bill passed, however, the governor appointed four regular physicians who had been active in the sanitary movement. Although this group was less explicitly engaged in the professionalization project of the AMA and NYAM, regulars celebrated the exclusion of homeopaths from the board.

  The enthusiasm was short-lived. As the board made preparations for cholera, homeopathic physicians lobbied for control of at least one cholera hospital. Many homeopaths wanted to use the cholera epidemic as an opportunity “to show the superiority” of their system (Homeopathic Medical Society of the State of New York 1866a, 247). Homeopaths believed that the existence of a homeopathic cholera hospital would create a real-life experiment, whereby the treatment outcomes of the homeopathic hospital could be compared to those under allopathic control. Appealing to past statistical evidence, homeopaths were confident that their system would prove to be more effective—“In no disease has the value of our treatment been more satisfactorily shown, than in epidemic cholera, the statistics of which have been frequently published” (Homeopathic Medical Society of the State of New York 1866c, 322)—and sought to make use of the epidemic to put to rest allopathy’s arguments that homeopathy was quackery and need not be taken seriously.

  Rather than merely requesting recognition, homeopaths demanded it “as a right, that so large a portion of our tax-payers should be fairly represented in our medical institutions” (Homeopathic Medical Society of the State of New York 1866c, 322). E. A. Munger (1865, 22), president of the Homeopathic Medical Society of the State of New York, argued that homeopaths were “entitled to all rights and privileges enjoyed by allopathy.” This position was grounded not only in homeopathy’s equal legal standing, won in the repeals of medical licensing laws, but also in the very rationale of the board. Homeopaths adopted the same trope used by sanitarians generally: adequate sanitary knowledge had to be, by necessity, apolitical and disinterested. Base political motives, professional or otherwise, corrupted knowledge and hampered sanitation. Thus, homeopaths denounced all allopathic arguments as political; exclusion from public health was equated with political “oppression” (Cornell 1868, 4). By painting allopathic physicians with the same political brush that sanitarians painted corrupt politicians, homeopaths offered a rationale for their inclusion that mirrored the rationale of the boards more generally. Underlying this was the familiar homeopathic appeal to democracy that had been successful in the past. Dialogue, transparency, and participation would lead to better knowledge, and, in turn, better sanitation. In demanding inclusion, homeopaths were only asking to “let the public judge of the candor, intelligence, and honesty, with which the claims of homeopathy are treated by men from whom we have a right to demand justice” (Bowers 1868, 406–407).

  Allopaths also rehashed old arguments. As in the debates over licensing, regulars balked at the suggestion that homeopaths should receive official government recognition. They adamantly opposed homeopaths treating any cholera patients, much less an entire hospital’s worth. Many rank-and-file regulars derisively mocked homeopaths’ interest in public health, facetiously wondering how their commitment to infinitesimal dosages would translate into public health interventions: “We have never known such remedies applied there for cleaning the streets, the removal of nuisances, the repair of defective sewage, except in the most diluted infinitesimal doses. What is needed are not little homeopathic wheelbarrows, but big, ‘allopathic’ four-horse teams, to remove the dirt and filth from New York City” (Medical and Surgical Reporter 1866b, 95–96). Having defined homeopathic knowledge prima facie as quackery, regulars felt no compunction to engage in “wanton experimenting” (Blatchford 1852, 136) with homeopaths. The Medical and Surgical Reporter (1866a, 477) warned that if homeopaths had the “right to ask that the public charities shall be made to afford to them an opportunity to experiment with the poor,” then “the Metropolitan Board of Health would soon become the laughing stock of the profession throughout the world, were it to open the door promiscuously to all these parasitic outgrowths of the healing art.” Allopathic physicians went so far as to submit a false report to the board from supposedly well-recognized homeopaths that testified to the inadequacy of homeopathy. The report not only failed to sway the non-physicians on the board; it also alienated them. Judge Joseph S. Bosworth, member of the board, dismissed it as a political attack, and board president Jackson Schultz regarded it as “a mere bundle of opinions” (quoted in Bowers, 1868, 411). When this failed, regulars drew on the AMA’s no consultation clause to argue that inclusion of homeopaths would place those allopathic physicians on the board in violation of professional ethics. Beholden to the clause, allopathic participants would have to sever themselves from the profession or resign from the board. The board was, therefore, risking the loss of all allopathic cooperation.

  Unfortunately for allopathy, homeopaths had considerable support on the board and in the local press. George W. Bradford, a regular physician on the board, lamented in his report to the Medical Society of the State of New York (1867b, 41–42):

  It was so found that a strong element in favor of Homeopathy existed in the Board from the start. The President of the Health Board, the President of the Metropolitan Police Commission, were strong adherents of Homeopathy; and another member of the latter body employed as a family attendant one regarded as a leading exponent of its doctrines and precepts. We successfully opposed this element in its attempt to gain for its friends a foothold in the Board by the appointment of homeopathic inspectors, despite the leanings of some of the newspapers to the heresy, and the zeal of three homeopathic reporters, ever ready to catch at any remark detrimental to the claims of the causes which they had espoused.

  While Bradford overstated the extent of the association of the “homeopathic reporters” with the actual sect, it was true that local reporting on the controversy favored homeopaths, depicting the actions of allopathy as a crass power grab—precisely the type of political maneuvering and patronage that the board was established to combat. The New York Times’ (February 20, 1867, 4) call for homeopathic inclusion employed a rationale that mirrored, almost word for word, the rationale given by state legislatures in the repeal of licensing laws:

  It seems to us—without pretending for a moment to judge of the merits of different schools—that simple justice argues in favor of this petition. It is not part of the case to discuss now the relative merits of any system of medical practice that appeals to the faith of the community. All may be good in their way; none are infallible; each can show a record most convincing in terms; each endeavors now and again to show the others to be foolish and weak. All that needs be said can be summed up in few words. A very large number of the wealthy and intelligent people of New-York and Brooklyn prefer the practice of Homeopathy, the system has passed through the ordeal of much sharp criticism, and in spite of ridicule and opposition has become established on a firm foundation. It has its schools, colleges, dispensaries and clients; it makes converts, and its successful treatment of cholera, of the disease more especially of women and children, has gained for it the confidence of large number so families.

  Those on the board sympathetic to homeopathic inclusion, like President Schultz, were in a difficult position. On one hand, homeopaths made a compelling argument for inclusion that drew on the very arguments that justified the independent board’s existence. On the other hand, the board could not risk alienating allopathic physicians to such a degree that they refused to cooperate. In the end, they compromised. Homeopaths would not be granted control of an entire cholera hospital but would be granted positions within the hospitals and assigned certain wards in which treatments were under their control. This compromise, unsurprisingly, left both protagonists u
nhappy. Homeopaths decried the fact that they would have to practice under the control of allopathy, and while they continued to petition the board for autonomous working conditions, they ultimately cooperated.

  The board’s recognition of homeopaths was more complicated for allopathic physicians, pitting rank-and-file regulars against the elite, sanitary-minded physicians. The no consultation clause, adopted by New York city and state medical societies under the guidance of the AMA, prohibited regulars from working with homeopaths and, in turn, raised questions about the fidelity of sanitary-minded physicians. NYAM went so far as to debate whether to withdraw its resolution of cooperation with the board. This debate centered on what to do about the allopathic members of the board who tacitly recognized the legitimacy of homeopathy by allowing this compromise. These members justified their acquiescence to the urgency surrounding the epidemic: “The sanitary committee, placed as they were in the position of soldier upon the eve of an important battle—to refuse to participate in the fray because another, whose principles they did not admire, insisted upon fighting at their side—would have been cowardice. The committee could not resign, because they were charged with a very grave responsibility as conservators of the public health” (Medical Society of the State of New York 1867b, 43). The rank and file pushed back, noting that “the interests of the public and the profession are too sacred to allow us to overlook for this reason an error of judgment which might have led to such disastrous results, and the tendency of which was to degrade the profession” (Hutchinson 1867, 68–69). Their argument reflected the AMA’s general disdain of homeopathy—its system was absurd and therefore should not be indulged in any way, shape, or form. In the end, as in the case of the University of Michigan, the medical society avoided a major rift by narrowly defining the no consultation clause to only involve issues related to private practice. Board members, participating in government service, were not beholden to the no consultation clause. Rather than withdrawing its cooperation, the academy instead passed a resolution criticizing the board’s position on homeopathy (Duffy 1968, 64).