Knowledge in the Time of Cholera (9 page)

Regulars could identify the relevant questions regarding cholera, but not
how
to answer them.

This confusion had deep origins in the undecided epistemology of allopathy. In pre-cholera times, the avoidance of epistemic questions was not much of an issue for regulars. This is not to suggest that allopathy lacked an epistemology in the early 1800s, just that it operated on an unspoken and unreflective plane. Typically, unarticulated epistemological commitments are not a problem, as these commitments are a tacit part of the taken-for-granted conventions surrounding knowledge and hierarchies in knowing. However, once the conventional ways are questioned and an epistemological challenge is mounted, the formerly tacit must be made explicit, and unquestioned assumptions must be justified. Cholera brought a sense of urgency to these internal epistemological debates and opportunities for the articulation of alternative epistemological visions by competing medical sects. People were dying; the public was losing confidence; and the long-held intellectual traditions of allopathy weren't helping. In the post-cholera world, regulars needed to articulate their vision for medical knowledge.

In the early decades of the nineteenth century, most allopaths retained a vague commitment to rational systems in making knowledge claims. Under rationalism, the diversity of diseases was reduced to a single (or at most a few) underlying cause, as physicians constructed elaborate speculative systems to make sense of disease (Warner 1997, 40). Ostensibly validated by experience, the “most striking feature” of these systems “was the rationalism that underlay their erection and operation” (Warner 1997, 41). These logical edifices of explanation made the practice of producing medical knowledge more akin to analytical philosophy than empirical science. Armed with these were “rigorously logical” (Shorter 1985, 30) abstract systems, allopaths attained knowledge of a particular case deductively by interpreting it
through
the lens of these systems. The most widespread rational system was developed by Benjamin Rush, who posited all local disease to be the result of vascular tension to be treated by depletive therapies (Duffy 1993). Other competing systems existed, most notably various humoral systems. Regardless of their specific differences, all rationalist systems shared the same orientation toward medical knowledge. Particular diseases were to
be
understood by inserting them into preexisting speculative systems. This is not to suggest that regulars who were committed to rationalism ignored empirical observation or experience altogether; rather their orientation toward observations was to interpret them through the lens of their particular rational system. Inconvenient facts, or those that could not be shoehorned into a given system, were treated as problematic anomalies, either ignored or set aside. Rationalism, thus, fostered a particular posture toward medical knowledge. Medicine was more an exercise in rational argumentation and logical deduction. Rationalistic accounts of cholera focused not on its particular manifestations, but rather on deducing how a given philosophical system could explain the disease. Did cholera represent an excess of bile? Was it an imbalance in the humors? A new manifestation of fever? Victory was won through philosophical speculation, not empirical searching or the presentation of data, as accounts were judged according to the logical argumentation displayed, with analogical reasoning comprising the bulwark of regular claims.

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
unifi
ed 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.