Knowledge in the Time of Cholera (38 page)

Hunting Germs

Public health had long frustrated allopathic dreams, offering enticing resources but maintaining an ecumenism that prevented allopathic takeover. After bringing medical education and hospitals under the control of the laboratory, bacteriologists turned their attention to public health. The germ theory sought to reorient public health away from cleaning up filth toward hunting germs. But like clinicians, public health officials were reluctant to give up their traditional practices, especially since the multiple cosmetic sanitary reforms had won them public esteem. Many public health officials balked at embracing bacteriology, so much so that as late as 1915, the uncompromising bacteriologist and health officer of Providence, Rhode Island, Charles V. Chapin (1934b [1915], 37) complained, “There is probably not a single large municipal health department in the country which is operated along strictly logical lines.” Reiterating “the timeworn phrase about dirt and disease” (Chapin, 1934c [1902], 23), the boards of health had failed to adopt the targeted “rational” approaches suggested by bacteriology. Chapin complained that “the age of bacteriology has produced an immense amount
of
scattered information. But no one as yet had attempted to draw it all together into a coherent patterns of logical public health principles and measures” (Chapin quoted in Cassedy 1962, 110), and he vowed to bring public health in line with the laboratory.

While upsetting to bacteriologists, this resistance was not overly disconcerting to most reformers, public health officials like Chapin aside. Having consolidated authority in a number of different organizations, regulars were now less dependent on public health for their prestige. As these other organizations gained strength through the laboratory, bacteriological reformers became less concerned about public health and boards of health. As a result, allopathy's long-felt ambivalence toward public health was allowed full flowering in the twentieth century. Regulars were content to leave sanitation to public officials, as long as these officials were willing to defer to the laboratory in their educational and sanitary programs. The GEB provided funds to establish schools of public health attached to, and controlled by, medical schools, but their graduates were not to be doctors. Organizing public health education in this way, sanitary science became a residual category for allopaths, a mere appendage to the laboratory where the true breakthroughs were happening. Public health was demoted in allopaths' imagination, no longer placed at the forefront of controlling disease, but reduced to the practical application of laboratory findings. This new understanding of public health was reinforced in the Rockefeller Foundation's forays into the field, both domestically and abroad, as it only funded programs in which public health interventions were based on the laboratory sciences.

Rather than fight to make public officials doctors, bacteriologists allowed public health to remain in lay hands, provided that boards of health did not encroach on medical practice. The AMA's strategy toward the boards of health shifted from one aimed at control to one aimed at mitigating their influence and protecting the autonomy of individual physicians. As long as physicians maintained ultimate authority, public health programs would be supported. However, if they started to interfere with the autonomy of the individual practitioner, allopaths ensured their demise. For example, the AMA effectively killed a campaign to develop public health dispensaries, which they viewed as competition (Starr 1982). Thus, while regulars tolerated a degree of ecumenism on the actual boards, they effectively circumscribed their activities.

Homeopathy's
Enfeebled Resistance and the Mirage of Cooperation

The consolidation of multiple organizations under bacteriological control did not bode well for homeopathy, which saw its tenuous grasp of medical practice evaporate in the early twentieth century. Having ceded its claims to the germ theory, every gain by the lab was a gain for allopathy at the expense of homeopathy. Some historians have argued that rather than suffer defeat, homeopaths chose to join allopathy and cooperate with the medical reforms (Rothstein 1992; Starr 1982). But this is history from the viewpoint of the winner. While it is true that some homeopaths did convert, most resisted the laboratory and its vision of medicine. This enfeebled resistance, however, could not withstand the multifaceted reform program backed by Rockefeller resources.

Bacteriological reformers offered a more ambiguous target for homeopaths than past allopathic reformers, as they tempered their exclusionary rhetoric. For decades, homeopaths had made great political hay by exposing the exclusionary practices of the AMA, condemning such efforts as elitist and antidemocratic. Whenever regulars sought to gain some special recognition, homeopaths cried foul to state legislatures, arguing that regulars were trying to illegitimately monopolize medical practice and stifle debate. These arguments resonated with the legislatures, resulting in the universal repeal of state licensing laws and homeopathic inclusion in government bodies. Homeopaths were able to maintain this equal legal standing even during the bacteriological revolution. Between 1870 and 1890, regulars sought to reestablish licensing laws at the state level that targeted newer “quacks,” like osteopaths and chiropractors (Baker 1984). Resigned to the enduring presence of homeopaths and eclectics, regulars hoped to include them in licensing in a manner that would facilitate ultimate allopathic control, proposing legislation for a single board of medical examiners in which regulars were the majority. Alternative sects countered with legislation proposing either separate boards for each sect or a single board with equal representation. As before, state legislatures sided with alternative medical movements, refusing to grant allopathy control over the boards, adopting one of the two alternative proposals.

These de jure, formal legal protections did not preclude homeopaths from being effectively shut out of medical practice de facto. As allopathic physicians seized control of the organizational infrastructure of medicine
through
the lab, they used their organizational leverage to ensure that homeopaths remained secondary medical citizens, despite their legal equality. The posture they adopted, however, differed from the vitriolic rhetoric of regulars past. Bacteriological reformers framed their interventions as moving beyond
both
homeopathy and allopathy, transcending the bitter sectarian debates for a medical system committed not to dogma, but to science. Flexner (1910, 156) argued, “Modern medicine has therefore as little sympathy for allopathy as homeopathy. It simply denies outright the relevancy or value of either doctrine.” Whereas the “sectarian begins with his mind made up,” science “believes slowly; in the absence of crucial demonstration its mien is humble, its hold is light,” and in the process, it “brushes aside all historic dogma” (Flexner 1910, 157). Once again, drawing on the forgetfulness of the laboratory, the reformers disavowed theoretical commitments. The future would not be shaped by sectarian theories, but by the “methods of thought and observation and in developing the scientific spirit” (Welch 1920a, 5). Gates justified the actions of the Rockefeller Foundation in similar terms: “The day of dogma and philosophic formulae in science has passed away. . . . Medicine is becoming no longer a creed but a science” (Gates 1911b, 3). Framed as atheoretical and nondogmatic, medical science would lead to the “ebbing vitality of homeopathic schools” in a “striking demonstration of the incompatibility of science and dogma” (Flexner 1910, 161). This more measured tone proved tough for homeopaths to combat, for whoever defended one system over another, whether it was homeopathy, eclecticism, or allopathy, was portrayed by bacteriological reformers as out of touch and retrograde.

This commitment to the atheoretical science of the future was not just a strategic or cynical ploy on the part of the reformers. It resulted in tangible reforms to the way allopaths ran their profession. For decades, the AMA had focused on delineating the boundaries between allopathy and “quackery,” by internally policing its members through the Code of Ethics and no consultation clause. In 1903, bacteriological reformers successfully lobbied for a revision of the Code of Ethics. Arguing that the era of sectarianism was over, they stressed the importance of freedom of inquiry and consultation for the development of the new science. The old Code of Ethics was replaced with a new Statement of Principles. Ostensibly, homeopaths were now welcome to join allopathic professional societies, provided they give up their commitment to sectarian dogmas. They would be allowed to practice their
therapeutics
but not to publicly advocate for, or identify with, the homeopathic system.

Homeopaths struggled to respond to allopathy's new positioning. The AMA's public display of welcome reduced the rhetorical punch of homeopathy's traditional arguments that juxtaposed their openness, transparency, inclusiveness, and commitment to debate with the exclusionary practice of allopathy. Now, at least superficially, regulars were abandoning the very practices that homeopaths had long transformed into legislative achievements and public sympathy. Internally, homeopaths debated what this all meant. How genuine was the AMA's invitation? Could homeopathy have a place in bacteriology? Once again, these debates pitted older homeopaths and veterans of numerous sectarian battles (the “highs”) against the younger homeopaths (the “lows”), for whom the battles of the past had less experiential relevance. DeWitt G. Wilcox (1904, 6) voiced the seduction that the new medical science held for the lows: “We are, to my mind, entering an era of new medicine, not the product of any one school, but the logical outgrowth of scientific research along all lines of life and health. . . . Gentlemen, we have got to get into the bandwagon of progress, or walk; and unless we do get in we have no right to complain because the old school holds the reins and pounds the brass drum.” Lows believed that homeopaths “need not approach the study of bacteriology with the slightest fear that it will destroy the well-grounded temple into which they have built their hopes and allied their dreams” (Maddux 1892, 1). For their part, highs acknowledged that “the spirit of the times is encouraging amalgamation and co-operation,” but they expressed concern that “the dominant school of medicine is not yet ready to accept these conditions” (Wood 1902, 39). Recalling past battles, highs smelled an allopathic trap.

While these internal debates weakened the cohesion of homeopathy, in many ways they were beside the point. By the first decades of the twentieth century, allopathic physicians had positioned themselves organizationally to kill off homeopathy. Having established the laboratory as an obligatory passage point around which all medical organization pivoted, allopathic physicians had gained such a stranglehold on the practice of medicine that they were able to effectively prevent homeopaths from participating in the new organizational infrastructure. The AMA could change its tone because the locus of its power was now centered in the new medical infrastructure it had built using Rockefeller funds.

Th
e marshaling of philanthropic resources to attack homeopaths was most evident in medical education. Flexner “excoriated almost all the existing homeopathic, eclectic, and osteopathic schools for poor standards, and made no allowance for the survival of any of them in his reconstruction plans for medical education” (Gevitz 1992, 84). It followed that his criteria for assessing medical schools was hostile to homeopathic schools. As these assessments determined access to funding, it was no accident that in the twenty-five years following the report, homeopathic schools decreased from fourteen to two, largely due to financial inadequacy. Furthermore, as states adopted and consolidated licensing boards, the boards adopted the AMA's ranking of medical schools, granting licenses only to those educated in institutions that achieved an adequate score. In this way the boards conformed to the ecumenical letter of the law, while institutionalizing standards that penalized homeopathy. The boards standardized basic scientific training for all aspiring doctors, regardless of sect; the only differences in evaluation between sects were restricted to therapeutics. These basic standards promoted laboratory sciences, while demoting the status of pharmacology and symptomology, the central disciplines of homeopathy (Coulter 1973).

Leveraging their new position of organizational authority, the AMA sought legislation in other areas of medicine as well, which mitigated the formal ecumenism of the licensing laws. These included hospital and prescribing/drug regulations and later eligibility for insurance reimbursement (Starr 1982, 333). For example, the Pure Food and Drug Act, endorsed by the AMA, instituted tighter regulations on the production of drugs and thereby prohibited homeopaths from creating their own medications—a central component of their distinct identity (Coulter 1973). Additionally, since allopathic physicians controlled hospitals, homeopaths were forced to conform to their standards in order to practice in the new epicenters of medicine. Unable to lay a claim to the new medical science of bacteriology and compelled to join allopathy lest it be shut out from medical practice, homeopathy was increasingly marginalized as a therapeutic orientation. Contrary to its expansive goals of the nineteenth century in which it sought to become
the
medical system, by 1910, homeopathy offered a much narrower alternative to allopathy; a homeopath was no longer a medical revolutionary, but “
one who adds to his knowledge of medicine a special knowledge of homeopathic therapeutics and observes the law of similia
” (Homeopathic Medical Society of the State of New York 1910, 215). This drastic reduction in homeopathic ambi
tions
was evidence of a stark new reality: homeopaths had lost the epistemic contest and were now exiled to the fringes of medicine.
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