A major line of evidence pointed by Beck, and by contemporaries like Daniel Drake,30 in refuting the contagiousness of cholera, was the low attack rates among cholera patients’ care providers. As Beck writes, ‘[i]n Quebec I believe only two physicians died of the disease; in Montreal one; in New-York five or six; in Albany not one’. Chilling numbers by current standards, but mortality due to contagious disease constituted an important occupational hazard among contemporary physicians and nurses.
Beck also noted geographical discontinuities in cholera spread. Arguing against contagion, the disease spared some villages and towns despite close commercial ties to centers where cholera raged.22 Were Beck and his contemporaries led astray by the variability in the clinical presentation of cholera, and by the likelihood that it would have been under-reported or unrecognized in some jurisdictions? Perhaps, given its stigmatizing nature, intentionally so.
The heterogeneity in severity of cholera cases was a source of confusion as late as 1892, when Max von Pettenkofer, the preeminent German hygienist, and several of his colleagues, drank flasks of V. cholerae to disprove Robert Koch's contention that V. cholerae was a specific etiologic agent of cholera.31 Von Petterkofer developed diarrhea, and two of his colleagues developed cholera, but the heterogeneity in presentation was sufficient for von Pettenkofer to claim vindication.
Beck's report preceded John Snow's classic work on the transmissibility of cholera by over two decades. Yet basic elements of Snow's theory, based on spatial and temporal patterns of cholera deaths, were present in Beck's report. Snow saw that cholera deaths, which clustered in space and time, were not distributed in a manner that one would have expected if the disease occurred as a result of miasma. Snow's studies of gasses (derived from his career as a pioneer anesthetist) gave him a profound understanding of the expected behavior of a ‘miasma’, against which he was able to compare empirical data on cholera deaths in London.32 That Beck began his discussion by emphasizing that cholera is not contagious, despite appearances, underlines the striking degree to which the patterns he recorded suggested that it was.
Beck's contemporaries, including Drake and Amariah Brigham, emphasized the movement of cholera epidemics along shipping routes as evidence contradicting the miasmatic nature of cholera, with Brigham suggesting that such patterns supported contagion.21, 30 Drake, ingeniously, posited that invisible microbes could be responsible for the spread of cholera. While he argued against contagion, he thought transmission could occur by ‘poisonous, invisible, aerial insects, of the same or similar habits with the gnat’, and drew an explicit analogy to ‘intermittent fever’ (malaria).30
Why was Beck unable to make the intellectual leap that would have allowed him to intuit the mechanism responsible for cholera's movement across the state? He had no knowledge of microbes, but the same could be said of Drake, and indeed, of Snow, who posited the existence of microbial pathogens based on the patterns of the epidemics they observed.
Ackerknecht examined the intersection of disease etiology theories and political ideology, proposing that an individual physician's stance – contagionist or anti-contagionist – related to his socio-economic position and attitude toward state regulation.24 Anti-contagionists tended to be more liberal, suspicious of state interventions, and against quarantines and other measures that disrupted trade.24, 33 Beck and his political masters may have been aware of the violent unrest created by the attempts of (contagionist) Russian regions to (unsuccessfully) contain cholera's spread using military cordons.25
Beck was a political appointee. Could he be relied on not to disrupt the status quo? Beck's admonitions seem directed at maintaining order and social cohesion in a jittery population. He stresses the impact of fear on susceptibility to cholera: ‘those who remain firmly at their posts, in most instances are safe, while those who ignobly desert them, are sometimes among the first victims’. Beck's writing suggests something familiar: the physician who is able to avoid drawing inconvenient inferences that are at variance with the currently accepted medical model.
David Wootton has written extensively on the subject of non-innovation in medicine. He notes that medical training, acquired via substantial personal effort and cost, may result in a reluctance to embrace novel ideas that render these skills and knowledge obsolete.34 Wootton also notes that the Hippocratic element in medicine was still vital to medical thinking. It regards every case of disease as resulting from a unique interaction between causal influences in the environment and the constitution and ‘exciting factors’ in an individual. The groundbreaking work of Pierre Louis on phlebotomy for pneumonia, which effectively created clinical epidemiology by ‘grouping’ patients with similar afflictions, was not published until 1835.35
Clusters of cholera cases among the poor and laborers implied that predisposing factors were concentrated in these populations. Moral deficiencies, held to be characteristic of the ‘unworthy’ poor – those impoverished due to defective morality – fit this model well. Beck noted the large numbers of affected immigrants from Ireland and Wales: ‘being often times in the most filthy state, and by their habits and exposures very liable to attacks of the disease’. Cholera struck ‘filthy part[s] of the village [and] persons of irregular habits’ in Plattsburgh; a ‘very intemperate’ individual on a Lake Champlain steamer; ‘the intemperate’ in Albany; a laborer who ‘was very intemperate in his habits’ in Buffalo, and so on. Gluttony was also an important risk factor: Beck ‘witnessed a case at Whitehall … undoubtedly brought on by the eating of a large quantity of green peas’. An outbreak in the ‘Dutchess county alms-house occurred after the inmates had eaten immoderately of cucumbers and other vegetables’.
The moralistic underpinnings of medical explanations of cholera were in keeping with the spirit of the times. The 1832 cholera epidemic occurred during the Second Great Awakening, a time of fervent Christian belief that gave rise to many new evangelical denominations.36 Human perfectibility was a hallmark of the return to fundamental Christian ideas in the 1832 milieu.37 Disease was a consequence of moral debility and the violation of natural laws, and was independent of broader social and economic conditions; accordingly, the benefits of abstinence from excesses of food, drink, and sex, accrued to both the physical and spiritual self.37 Benjamin Rush's Inquiry into the Effects of Spirituous Liquors on the Human Body and the Mind, with its ‘Moral Thermometer’ and other late eighteenth-century tracts illustrate graphically the tendency to equate moral consequences with physical health.38 In this framework, cholera's progress could be conceptualized as the earthly manifestation of God's justice.20 Consequently the epidemic should not be a cause for alarm to those upstanding and prosperous citizens who lacked predisposition for the disease (Figure 2).
Under such circumstances, cholera in locales where a homogeneous, upright population might be expected to dwell would be problematic. Beck describes cholera in New Jersey is as follows: ‘July 11th – Among laborers on the canal between Millstone and Griggstown, New-Jersey’. What is important here is what Beck does not say. Along existing waterways, the midpoint between Millstone and Griggstown lies at Princeton. Princeton was the seat of a Presbyterian university, as well as the affiliated Princeton Theological Seminary. The occurrence of cholera in a locale populated largely by current and future clerical leaders was problematic.
A Princeton minister (James W. Alexander) appears to have been extremely concerned at the implications of a cholera-susceptible population in a town full of divines. In a letter to a colleague on 4 August, he wrote: ‘By this time perhaps you have seen in the New York papers, that Cholera rages in Princeton. Through Divine Mercy this is not true. There have indeed been three deaths of Irishmen in the town, and nearly twenty on the neighbouring canal. Great uproar has been occasioned by some cit[izens] who are rusticated here, and who condemned the little Health-Board for having a hospital within the borough’. Again, if cholera is not contagious, why the fuss? ‘The disease is at Scudder's mills, 3 miles; and Kingston, 3 miles; all cases Irish Catholics’.39