Knowledge in the Time of Cholera

by Owen Whooley

  When the academy bowed out, the reform mantle was assumed by a diverse group of sanitarians. Whereas the regulars proposed reforms focused on medical control, the subsequent push for reform offered a more ecumenical vision of sanitary science. Elite, sanitary-minded physicians, like John Griscom, Elisha Harris, Joseph Smith, and Stephen Smith, collaborated with community leaders, like wealthy industrialist/philanthropist Peter Cooper. This eclectic group of elites was united by a commitment to responsible citizenry, not by any notion of professional expertise, for while physicians were central to the burgeoning sanitary movement, the bulk of the movement consisted of lay community members. As such, calls for sanitary reform took on a less explicitly medical character. First through the New York Sanitary Association and later the Citizens’ Association of New York, sanitarians worked to portray the existing boards as woefully and irredeemably corrupt. They produced reports and pamphlets that connected disease to filth and filth to political corruption. Their justification for special recognition rested on the purported apolitical disinterestedness of their sanitary science. “Politicians make poor sanitarians,” because it was against their political interests to produce accurate sanitary knowledge requisite for effective intervention (Halley 1887, 241). From 1859 to 1866 reformers continuously introduced sanitary bills to the legislature, only to be defeated by the Democratic Party machine and “paltry officials who hang like leeches to the municipal body,” as the New York Times described opponents of the bill (Duffy 1968, 546). Defeating such entrenched interests was proving to be a heavy lift.

  In 1863, the Citizens’ Association established the Council of Hygiene and Public Health, charged with conducting a thorough sanitary survey of the entire city. The new survey was carried out in order to rebut a city inspector’s report, which denied the existence of any sanitary problems. The comprehensive Report of the Council of Hygiene and Public Health of the Citizens’ Association of New York upon the Sanitary Condition of the City was an impressive feat of investigation. The council divided the city into thirty-one specified districts, assigned an inspector to each district, and supplied them with a standardized form to record the sanitary conditions of their district. Inspectors were instructed to gather information on a wide variety of conditions, from “the nature of the ground” to the “location and character of water closets” in tenement houses (Smith 1911, 54–55). Stephen Smith (1911, 54–55), author of the final report, outlined the exhaustive list of relevant factors that investigators were asked to note:

  Commencing at a given corner of the district, he [the investigator] was first to go around the square and note: 1. Nature of the ground. 2. Drainage and sewerage. 3. Number of houses in the square. 4. Vacant lots and their sanitary condition. 5. Courts and alleys. 6. Rear buildings. 7. Number of tenement houses. 11. [sic] Drinking shops, brothels, gambling saloons, etc. 12. Stores and markets. 13. Factories, schools, crowded buildings.14. Slaughter-houses (describe particularly). 15. Bone and offal nuisances.16. Stables, etc. 17. Church and school edifices.

  Returning to the point of starting, he was to commence a detailed inspection of each building, noting: a. Condition and material of buildings. b. Number of stories and their height. c. number of families intended to be accommodated, and space allotted to each. d. Water supply and house drainage. e. Location and character of water closets. f. Disposal of garbage and house slops. g Ventilation, external and internal. h. Cellars and basements, and their population. i. Conditions of halls and passages. j. Frontage on street, court, alley—N.E.S. or W.18. Prevailing character of the population. 19. Prevailing sickness and mortality. 20. Sources of preventable disease and mortality. 21. Condition of streets and pavements. 22. Miscellaneous information.

  The identification of so many different conditions demonstrates the breadth of sanitary knowledge. When aggregated into a single report, the findings were both surprising and disturbing, as the report revealed the presence of cholera nests and unearthed an invisible smallpox epidemic to boot. The sheer scale and detail of the Report impressed the media and the public, who joined in denouncing the sanitary situation of the city. By making disease in the city legible, sanitarians had produced a comprehensive condemnation of politicized sanitation (or lack thereof).

  In addition to the Report’s revelations about the failure of city officials to perform their trusted duties, additional investigations found outright fraud. In conjunction with the survey, the Citizens’ Association issued a pamphlet chronicling the abuses of the City Inspector’s Department and showed that despite a generous allocation of funds for sanitation, little of the money actually went to cleaning up the city: “Under the present rule of ignorant and corrupt politicians, this city expends directly and indirectly nearly half a million of dollars for health purposes, not one dollar of which is intelligently applied to improve its sanitary state. Small-pox, scarlet fever, cholera infantum, and allied diseases, rage among the poor like consuming epidemics without one effort put forth by our one hundred and eighty-three health officials” (American Medical Times 1862, 99). Politicians were not just inept; they were corrupt. They had abused their power and betrayed the public’s trust.

  With the reports attracting widespread attention, reformers reintroduced a bill in 1865, hoping to capitalize on the renewed outrage. This time reformers received a much-needed boost from an unlikely ally—cholera. The arrival of cholera in port aboard the Atalanta in November brought a new sense of urgency to the proposed reforms. Although cholera remained contained to the port until spring, the looming specter of another epidemic lent credence to the reformers’ calls. The disease was poised to attack the filthy city again. Faced with a looming epidemic, the press ratcheted up their critiques of the City Inspector’s Department and their editorial support for the reforms. While Harper’s mocked the board’s apathy in a cartoon, the Nation (“Street Commissioners to the Cholera” November 9, 1865, 583) did so in verse:

  Cholera, cholera, cholera, come!

  Come to the city we dock for thy home! Come to Manhattan!

  New York never gave

  Prince, hero, charlatan, exile, or knave,

  Cholera, such a reception as we,

  Queen of men’s terror! Have plotted for thee!

  By not attending to the egregious filth, the city was rolling out a welcome mat for cholera, so went the criticisms.

  Pressured by sanitarians, the media, and the looming threat of cholera, the legislature passed “An Act to Create a Metropolitan Sanitary District and Board of Health Therein.” It became law on February 26, 1866. The sanitarians’ dream of an independent board of health was finally realized. The decade-long reform effort came to an end just as cholera arrived.

  The composition of the first permanent board of health and its wide-reaching activities indicated both a particular understanding of cholera—cholera rooted in place as filth—and a broad view of relevant knowledge. Sanitation was framed as thoroughly social, not narrowly medical. While physicians were recognized as an integral part of the Metropolitan Board of Health of New York City, the legislation expressly ensured that they would remain in the minority, as reformers did not want the board to be dominated by doctors (Duffy 1968, 2). The board consisted of four police commissioners, the health officer, and four other commissioners appointed by the governor, three of whom had to be physicians. Valued as having pertinent insight, physicians had a total of four seats on the board, but lay community members maintained the majority with five, and leadership positions went to nonmedical members. Thus, the board was decidedly not the medical organization under the control of allopathic physicians envisioned by NYAM in 1857. Rather, it was constructed as a coalition of lay community members and relevant professionals committed to sanitary science as a cooperative endeavor patterned on “mutually supporting roles” (Rosenkrantz 1974, 58). This reflected the intellectual ecumenism of sanitary science and the cooperative, but not dominant, place of medical knowledge within it. The broad understanding of the relationship between disease
and the environment precluded defining sanitary science in terms of medical knowledge only.

  Cartoon showing political board appointees asleep on the job from Harper’s Weekly, August 5, 1865, p. 496. Courtesy of the National Library of Medicine.

  The actions of the board reflected the numerous forms of knowledge it brought to bear on cholera. When Governor Fenton issued a “Proclamation of Peril” on April 24, giving the board wide authority to carry out the reforms necessary to combat cholera, it immediately set to work (Duffy 1974). Two thousand police officers fanned out across the city, reporting every instance of sanitary neglect over the fifty telegraph lines that the board had established throughout the city (Chambers 1938, 274). Upon notice, the board removed the offending nuisances, as it took control of the street-cleaning contracts and garbage removal. In dealing with cases of cholera, doctors were instructed to report all cases to the board, which would confirm each case and quickly remove those with cholera to quarantine hospitals. Cholera nests were destroyed, their inhabitants relocated, while salvageable buildings were disinfected. Furthermore, the board closed the most egregious of the city’s polluters (e.g., fat- and bone-boiling establishments), sent engineers to investigate new buildings for adequate ventilation, and organized a corps of physicians to staff cholera hospitals. As they went well beyond medical interventions, these diverse actions required the input and coordination of a wide array of experts.

  The board’s proactive approach seemed to pay off. Cholera threatened the city throughout the summer of 1866 but never really gained a foothold. Whether legitimate or not, the board received credit for the epidemic’s mildness (Duffy 1968, 18). In its review of the epidemic on its one-year anniversary, the New York Times (March 31, 1867, 3) applauded the board:

  The community was watching with considerable anxiety for the advent of cholera, and speculations were freely indulged as to the effect which its presence would exert upon the health and business of the City. A newly-formed Board of Health had entered upon its duties; people were hoping that it might in some way be instrumental in averting or diminishing the ravages of what had been in previous years a terrible scourge. Although it may be said that no inference can be drawn from the fact that mortality from cholera last year in New-York was less than during the previous visitation, we are unwilling to admit the validity of the assertion. In other cities on the continent where the disease obtained a foothold the loss of life was fearful, and certainly the conditions which favored its spread existed in full force in New-York. Hence we believe that the methods adopted by the Board of Health were instrumental in saving many lives and even in limiting the epidemic.

  Accepting the Times’ evaluation, other cities followed suit and established their own municipal boards of health, as the Metropolitan Board of Health became the model for sanitary reformers throughout the country (Duffy 1990; Rosenberg 1987b). In these cities, the sanitary reforms followed a similar trajectory; spurred by the threat of cholera, a coalition of politicians, physicians, and social reformers agitated for and won reform. State boards of health were also formed, beginning with Massachusetts in 1869. Even a short-lived National Board of Health was created in 1879 (Smillie 1943). As reforms spread, the sanitary movement, formerly a hodgepodge of reforming physicians and concerned citizens, became organized. A collective identity crystallized among sanitarians and was formalized with the founding of the American Public Health Association (APHA) in 1872. Unlike the AMA, the APHA was not a professional association but “a body of informed persons of good will to facilitate the enlightenment of the public and promote the appointment of more competent health authorities” (Smith quoted in Rosenkrantz 1974, 58). It became the central node for a wide array of diverse actors in the growing national movement, facilitating exchanges between diverse local reformers. No longer isolated in particular communities, to be a sanitarian now meant belonging to a national community of reformers, a diverse community, but a community nonetheless. By the early 1870s, the public health movement was nationally popular and institutionalized.

  A COOPERATIVE SUCCESS, A PROFESSIONAL PROBLEM

  With their popularity and resources, boards of health became a key prize in the epistemic contest. One might surmise that given the initial support regulars displayed toward sanitary reform and the participation of elite, sanitary-minded physicians on the board that the regulars would view the boards as a positive occurrence, an opportunity to advance their professional and epistemic goals. This was not the case. To the chagrin of regulars, the public health movement was inclusive and ecumenical in nature. This framing, which had allowed sanitarians to overcome entrenched politicians, created unintended problems for allopathic physicians in their epistemic contest over disease with homeopaths and other sanitarians that hindered the professional agenda of the AMA and local allopathic societies.

  Despite the widespread celebration of public health after the 1866 epidemic, the bulk of allopathic physicians developed ambivalence toward the boards and sanitary science in general. On one hand, the boards of health seemed to offer an opportunity to improve the public image of allopathy (Rosenkrantz 1974). In 1873, President C. R. Agnew of the Medical Society of the State of New York urged his colleagues to embrace public health in order to gain “a new and enduring title to the respect and the gratitude of the public” (Agnew 1874, 4). Sanitary-minded physicians appealed to nobler sentiments, pointing out that “the vocation of the medical man is not bounded by the narrow confines of curing the sick, but embraces a far nobler work—a work of illimitable extent—the prevention of disease, and the prolongation of life; a field of science ‘where the harvest is truly plenteous, but the laborers are few’ ” (American Medical Times 1860, 47). The American Medical Times (1860, 46) argued that to “defend and relieve our fellow men from the preventible [sic] causes of disease, is manifestly the highest mission and best service of medical science and skill.” According to sanitary-minded physicians, this “highest mission” of the profession required doctors to put aside professional concerns and work cooperatively to end disease and, in turn, put themselves out of business.

  Not all allopathic physicians agreed with this noble sentiment. Cholera as filth demanded wide-scale reforms, ranging from the disinfection of tenement cellars to new ventilation systems, from water sanitation to street cleaning. Reformers lacked any means by which to weight the impact or relevance of one factor vis-à-vis any other. The embrace of public health, therefore, required the embrace of a nonhierarchical, cooperative spirit, precisely at the time during which regulars sought to distinguish themselves as possessing epistemic authority. Because “cholera should not be treated as a disease, but as a pestilence” (Smith 1869, 59), sanitarians embraced an ethos of intellectual ecumenism anathema to the professional agenda of the AMA, embodied in the no consultation clause. Regulars not directly involved in the sanitary movement balked at this ecumenism, for it inhibited the profession’s claim of a privileged standing within sanitary science and precluded their attempts to control the definition of cholera. Medical knowledge was placed on par with other forms of knowledge.

  This was all the more troubling given the demands the boards of health asked of physicians—they wanted physicians to forfeit some of their autonomy by reporting their own cases to the boards and turning over their cholera patients to board-controlled hospitals. Most rank-and-file regulars did not welcome nonmedical board members inserting themselves between them and their patients. Their dismay was manifest in their widespread hesitation, and often blatant uncooperativeness, in reporting cases of disease to the board (Hammonds 1999; Maulitz 1979). They feared that their patients would be taken away from them, removed to one of the cholera hospitals to be treated by another doctor or, even worse, a homeopath. In this way, the boards’ demands were contradictory to the economic logic of allopathic medical practice, abhorrent to their self-interest. There was a class dimension to allopathic ambivalence toward public health. Most of the sanitary-minded physicians were wealthy elites from
families with a historical commitment to moral reform and civil service. While their medical knowledge was valued in the sanitary movement, their participation was rooted in their standing as important members of the community, “less in scientific acumen than in responsible citizenship” (Rosenkrantz 1974, 58). Rank-and-file regulars felt that they could ill afford the luxury of participation, given their precarious professional and economic situation. Indeed, the AMA’s professionalization strategy was to deny the legitimacy of control over medicine by anyone other than allopathic physicians themselves. The entire premise of their professional project was to gain control over disease, not to share it with others. And this is precisely what the sanitary movement was asking them to do. Therefore, while the elite, sanitary-minded physicians preached cooperation, the majority of rank-and-file regulars felt that the professional benefits of sanitary science could only be accrued if and when allopathy controlled the boards of health.

  Professionalizing Plumbers?

  In addition to their troublesome economic implications, the boards of health encouraged even more challenges to allopathic authority, as a variety of new actors began to assert their right to participate in the management of disease. By rooting disease in place, the idea of cholera as filth extended the contours of the epistemic contest beyond the bounds of medicine. Other “experts” had something relevant to say. This expansion was exemplified by the attempt of plumbers to improve their own standing through their association with public health. Prior to 1866, it would have been unthinkable for allopathic physicians to envision a challenge to their authority from plumbers. After 1866, it was the reality of the epistemic contest.