Knowledge in the Time of Cholera (15 page)

As before, physicians could offer little in the way of a coherent explanation for cholera, let alone effective treatments. Homeopaths argued with allopathic physicians, rationalists with empiricists, contagionists with non-contagionists. Indeed, doctors were still disputing whether cholera was in fact a unique disease in its own right. This prompted one allopathic doctor to beg his fellow physicians “to discard the name of cholera in his treatment of the disease, and when called to the bed-side of the patient come untrammeled by any specious reasoning” (Page 1849, 3). Doctors deployed a variety of exotic and none too effective treatments, which, according to one allo
pathic
physician, were “unwarrantably conjectural, experimentative, and often entirely irrational” (Dick 1849, 3).

Wondering “who shall decide when doctors disagree” (Lynde 1848, 2), many Americans once again sought refuge in religion. On August 3, President Zachary Taylor called for a national day of fasting to purify the country's soul and to stifle the spread of cholera. Clergy and moral reformers drew on the notion of predisposing causes to admonish their flocks to change their ways (Rosenberg 1987b). To them, cholera was a killer of the sinful. “Hecatombs of the licentious have been sacrificed, and multitudes of inebriates have fallen easy prey to the ravager,” noted the
New York Evangelist
. “Intemperance in eating or in drinking—excessive indulgence of any kind—and all illicit indulgences are calculated to invite the disease and increase its violence” (“Best Preparation for the Cholera” 1849, 94). Responding to this outbreak of piety, indulgers and inebriates did not sit idly by as their lifestyle was condemned on medical and moral grounds. Brewers in Baltimore claimed that malt liquor made one immune to cholera (“Malt Liquors and the Cholera” 1849, 125), even mustering statistical data in an effort to convert skeptical teetotalers.

As before, cholera lost much of its vigor once summer ended. Cases were documented intermittently every year between 1849 and 1854, even reaching epidemic proportions in 1854. For five years, the country was on edge, but after 1854, cholera disappeared again.

Still its effects on medicine endured.

ALLOPATHY RESPONDS

The 1849 cholera epidemic unfolded within a different professional terrain, as the epistemic contest had evolved. The program of legislative reforms carried out by homeopaths and Thomsonians after 1832 had been incredibly successful. With licensing protections revoked in state after state, the medical market opened, fueling the epistemic contest and encouraging more vigorous competition between medical sects.

The makeup of the competition had also changed. Subsequent to the successful campaign to get licensing laws repealed, Thomsonism fragmented, succumbing to infighting after the death of Samuel Thomson. In many ways, the repeal of the New York State law, in which the Thomsonians played such a key role, was the final salvo of the movement. The schism revolved around a number of issues, including fights over succession, financial squabbling,
and
competing proprietary claims. While Thomson himself had long served as a lightning rod for these very issues, the strength of his personality as well as his ability to centrally control the movement through the distribution of its patented system kept the problems in check (Berman and Flannery 2001; Haller 2000). After his death, however, the suppressed problems erupted, nearly destroying the movement. The seeds of discontent coalesced around debates over whether Thomsonians should establish a formal education system (Haller 2000). Reformers called New Light Thomsonians sought to establish medical schools and formal training, a plan anathema to Thomson's original intent of making every person his own physician (Haller 2000). Unable to resolve the tensions between the New Light Thomsonians and the more traditional Thomsonians, the movement split. Some members reorganized into a broader, loosely defined sect known as Eclecticism, named such because of its eclectic adoption of ideas from a variety of medical sects. Eclecticism would endure until the twentieth century, but its ecumenical pragmatism blunted the original democratic critique of Thomsonism. The movement never again mustered the same type of epistemological challenge to allopathy but instead was content to follow homeopathy's lead.

Homeopathy stepped into the breach, establishing itself as
the
main challenger to allopathy—a position it would hold into the twentieth century. Homeopaths sought to democratize medicine in a more tempered way than Thomsonians. To regulars' opacity and elitism, homeopaths invited the public to assess competing knowledge claims. They also offered a sophisticated system of medical knowledge and an articulated epistemological program that claimed the scientific mantle through an appeal to empiricism. And regulars' recycled—and ineffective—response to the 1849 epidemic emboldened the homeopathic challenge. Homeopathy's popularity grew, for the second epidemic confirmed for many what was hinted at during the first—in opposition to allopathy's heroic treatments, homeopaths offered milder treatments which may not have done much positive good but certainly did not have the same type of negative effects on patients as allopathic therapeutics (Coulter 1973; Haller 2005; Kaufman 1988; Rothstein 1992; Warner 1997). Adept at using statistical rhetoric to support this claim, homeopathic ranks swelled (Coulter 1973), and many allopathic physicians converted to homeopathy (Haller 2005; Kaufman 1988). On the ascent, homeopaths began to challenge allopathy on a number of different fronts, demanding inclusion in all aspects of medicine.

Cognizant of the changing dynamics of the epistemic contest, allopathic
physicians
turned their focus to the homeopathic challenge. This chapter chronicles regulars' response to the ascendant homeopaths. Even prior to 1849, reformers within allopathy sought to reformulate the epistemological foundation of allopathy and establish an organizational infrastructure to deal with the vitalized “quackery.” As alternative medical movements shifted medical debates onto epistemological grounds, allopathic reformers felt the pressure to respond in kind. Their epistemological response was to discard rationalism in an effort to establish a new, more coherent epistemological foundation for its knowledge. They promoted a program of radical empiricism inspired by the Paris School of medicine, which sought to ground medical knowledge, not in abstract speculative systems, but in sensory, bedside observations. In doing so, reformers hoped to tap into the democratic zeitgeist that alternative medical movements had captured so effectively.

However, in rejecting the universalizing impulse as retrograde rationalism, allopathic physicians were left with a dearth of epistemological standards to adjudicate between competing allopathic claims and, more troublesome, to dispense with competing homeopathic claims. To resolve this “problem of adjudication,” reformers adopted an
organizational
strategy that would have long-lasting effects; in 1847, a group of elite allopathic physicians established the American Medical Association (AMA). The second section of this chapter examines the formation and early practices of the AMA as an organizational response to the epistemological problem of adjudication. The early AMA brought a measure of cohesion to allopathy and established itself as
the
major organizational player for the future of the epistemic contest. In turn, it affected the content of allopathic knowledge produced on cholera by creating a community of knowers insulated from outside influence that rejected methodologies associated with homeopaths. While this strategy had mixed
professional
effects, it would shape the contours of the epistemic contest over cholera for the remainder of the century.

ORGANIZATIONAL PRACTICES AND EPISTEMIC CONTESTS

Historians have longed dismissed the AMA's early activities as ineffective and inconsequential (e.g., Burrow 1963; Duffy 1993; Starr 1982; Stevens 1971). The organization initially outlined three goals—educating the public on medical issues, reforming allopathic medical education, and combating “quackery” in all its guises through legislative efforts. Yet even generous
assessments
of the early activities of the AMA acknowledge that it failed to make much progress along any of these lines (see Fishbein 1947; Porter 1998). Indeed, the early period of the AMA, from roughly 1840 to 1880, witnessed the declining status of the profession (Numbers 1988).

While correct in pointing out the AMA's inability to achieve its specific professional goals during its first fifty years, these accounts overlook an important epistemological function of the early AMA. This oversight is not just a product of damning historical evidence; it stems from the way in which previous research conceptualizes professionalization as an abstract process, one that contains underlying teleological assumptions that blind researchers to the role of historical contingencies in the development of professions (Freidson 1986). Because the early AMA failed to move allopathy closer to the ultimate goal of the monopolization of work, it is dismissed as unsuccessful and even irrelevant.

By embedding the formation of the AMA and its initial practices within the context of the ongoing epistemic contest over medical knowledge, this chapter offers a corrective reinterpretation of the early AMA. Rather than reading this early history through an abstract, ideal-typical conceptualization of professionalization, I situate the founding of the AMA within the context of the specific problems facing allopathy at the time. These were professional problems, but not generically so; they were inextricably intertwined in the epistemic contest over medical knowledge. In a period of epistemological flux and intense competition between competing medical sects, allopathy faced a problem of adjudication. How could true medical knowledge be recognized and legitimated over false belief in an intellectual environment devoid of shared epistemological assumptions? How could regulars distinguish their knowledge from homeopaths in such an environment?

What the early AMA provided was an organizational criterion that served as a proxy for epistemic standards to adjudicate knowledge claims. Organizations play an integral role in shaping the epistemological landscape, defining the “schemas of plausibility” (Shapin 1994, 22) and outlining the nature of epistemic legitimation (Biagioli 1994). Consequently, organizational formation can be an important epistemic practice. As noted in the previous chapter, organizations participate in sense-making (Weick 1979) as epistemic settings (Vaughan 1999) that establish the parameters of acceptable knowledge practice. However, because intellectual and epistemic authority is often viewed primarily as a cultural product, these epistemological functions tend to go unnoticed in much of the research on knowledge
struggles
as researchers tend to appeal solely to cultural factors to account for the allocation of intellectual authority. While organizational practices are shown to be integral in the
production
of science (e.g., laboratory studies show how organizational arrangements shape facts produced in the lab), the interaction between cultural and organizational practices has been under-theorized in the sociology of science “downstream,” which focuses primarily on cultural practices like boundary work (Gieryn 1983, 1999), rhetorical repertoires (Gilbert and Mulkay 1984), public performances (Hilgartner 2000), and framing to account for the resolution of public debates over science and the authority of science.
²
Analyses of cultural strategies must be complemented by analyses of organizational practices, or the ways in which actors draw upon and deploy organizations to construct boundaries and capture credibility.

This is especially pertinent when examining epistemic contests, whose distinctiveness lies precisely in the absence of shared cultural valuations of knowledge. Epistemic contests are not waged by cultural means only. When the very parameters and terms of cultural debates are up for contention, there is an increased tendency for actors to speak past one another from incommensurable epistemological positions. Such incommensurability tends to undermine the efficacy of cultural arguments, spurring actors to adopt a more diverse set of strategies. In turn, organizational strategies play a more crucial role in actors' repertoires in epistemic contests than they do in typical knowledge disputes. Only by examining the
interaction
between cultural and organizational practices can the trajectory of epistemic contests be explained.

In this chapter, I identify and explore the epistemological function of organizational practices, specifically the role of organization formation in waging epistemic contests. Whereas the previous chapter demonstrated the importance of organizational
context
on the trajectory of epistemic contests, in this chapter, organizational
practices
are shown to be intricately involved in epistemic contests, shaping their trajectory. Organizations are no longer banished to the background as mere settings for cultural disputes over knowledge. In this case, organizational formation (i.e., the establishment of the AMA) emerges as an important epistemological strategy in itself. If we think of epistemological commitments in terms of “dwelling in” an intellectual system (Polanyi 1958), then organizations serve as the formal dwellings that shape the epistemological terrain for actors. Organizations are an important resource in epistemic contests as they legitimate particular episte
mological
positions by configuring and institutionalizing communities of knowers and marshaling resources to promote the production of knowledge along certain epistemological lines. Given these functions, actors attempt to harness the power of organizations to promote their epistemological agendas and to alter the epistemological terrain through organizational practices. This is precisely what regulars attempted to do with the AMA.

IN PARIS WE TRUST

After 1849, the epistemological fragmentation within allopathy came to a head. The repeal of the licensing laws meant that allopathic physicians could no longer hide behind legal statutes when challenged by outsiders. They had been decertified. And in the open medical market, with competing medical sects offering alternative epistemologies, inchoate epistemological commitments no longer sufficed. Finding the status quo of internal divisions over the old rationalism and crude proto-empiricism untenable in such an environment, elite reformers within allopathy searched for a new epistemic foundation for their medical knowledge. They found it in Paris.