Knowledge in the Time of Cholera (46 page)

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NOTES

INTRODUCTION

1
. I refer to the dominant sect of nineteenth-century America as “regulars,” “allopathic physicians,” or “regular physicians.” In adopting this nomenclature, I intentionally avoid referring to them as “orthodox physicians,” a common practice among many historians. The use of “orthodoxy” tacitly privileges the dominant sect as “real” or “normal” medicine and conveys a degree of cohesion in thought that is historically problematic. This is not to suggest that my nomenclature is neutral. There are problems in using “regulars” and “allopathy” as well, namely the politically charged nature of the labels. Still, my choice of these two terms reflects an attempt at a more neutral nomenclature. The dominant sect referred to themselves as “regulars,” while homeopaths and alternative medical sects (somewhat derisively) called them “allopaths.” Using the two terms interchangeably I hope to, in effect, cancel out their ideological baggage. But there is no escaping the normatively laden nature of name-calling in nineteenth-century medicine. Recognizing this, I use “regulars” and “allopaths” heuristically to maintain the crucial incumbent/challenger distinction by identifying those in the dominant position in opposition to the challengers of alternative medical movements.

2
. The miasmatic theory of disease, popular during the mid 1800s, held that diseases were caused by miasma (pollution), or noxious “bad air” in the atmosphere. Such air contained poisonous vapors and decaying material, that when inhaled, caused disease.

3
. For example, Berlant (1975) examines how advocates of medical science came to monopolize medical work in the United States through the “organizational conduct” of AMA, which captured important organizations (i.e., hospitals) to achieve its goals (Berlant 1975, 48). Similarly, Freidson (1970) highlights the relation of medicine to the state to account for the great autonomy of the U.S. medical profession. Other studies focus on the importance of particular institutions for the consolidation of medical authority, such as hospitals (Rosen and Rosenberg 1983) and the educational system (Ben-David 1960; Ludmerer 1985; Markowitz and Rosner 1973).

4
. This oversight could be avoided if Starr instead conceived of culture
as practice
—that is, culture as a sphere of practical activity shot through by willful action, power relations, struggle, contradiction, and change (Sewell 2005). By con
ceiving
culture as separate from, and indeed hovering above, human action, Starr fails to interrogate the ways in which cultural forms are produced and reproduced through the practical activities of social actors. Starr therefore tries to understand the transformation of medicine within the broader changes in culture and society, not the role that physicians played in
creating
these broader cultural changes.

5
. Incidentally, Starr's temporality is a bit off, as the professionalization of medicine occurred
before
bacteriology's true successes. Furthermore, a valuation of scientific expertise under Progressivism, a key factor for Starr, did not dictate
which
scientific program was to be adopted. Most alternative medical sects saw their own programs as the epitome of science. The Progressive Era's general embrace of science cannot explain why the particular science of bacteriology was adopted.

6
. This research resonates with the program of “social epistemology” as laid out by Steve Fuller (2002), which recognizes that knowledge is intrinsically social and that forms of knowledge contain an implied social order. However, Fuller situates his program of social epistemology squarely within philosophy; his intent is to achieve a normative assessment of the social organization of knowing. The analysis in this book resides more squarely within sociology; I seek to explain rather than prescribe. For this reason, I refer to what I'm doing as a “sociology of epistemologies” (Abend 2006, 3), not social epistemology. In adopting the plural “epistemologies” I intend to convey that epistemology is not
one
empirical object, the way philosophers conceive of it, but many different empirical objects.

7
. Because of the ubiquity of the concept of paradigms in analysis of intellectual change, a word on the relationship between my analysis and Kuhn's is in order. Clearly, there are similarities between Kuhn's paradigm shifts and my exploration of epistemological change. They both challenge the progressive view of knowledge by showing how standards of good research change from era to era. The difference is one of emphasis. Kuhn focuses on scientific paradigms and models of good science that share more or less similar epistemological commitments (i.e., hypothesis testing, empiricism, etc.). I am interested in cases where these assumptions are contentious, arguing that the dynamics of epistemic contest vary in important respects from paradigm shifts.

8
. In terms of knowledge debates, Abbott focuses primarily on the issue of abstraction and the various cognitive strategies professionals used to achieve “optimum abstraction” (Abbott 1988, 105). The case discussed in this book reveals a great diversity in types of strategies—cultural and organizational—deployed in epistemic contests.

9
. Because of their ubiquity and authority, it is easy to forget that professions are a relatively new way to organize knowledge in society. It was not until the early twentieth century that they were institutionalized and became uncontroversial. Prior to this, the history of claims to professional standing were highly suspect. This history of professions is often obscured by sociologists, who tend to take professions for granted and, in the process, unintentionally naturalize them. The case under discussion in this book shows how, in the democratic fervor of the nineteenth-century United States, the legitimacy of professions was widely challenged.

10
. Much of the explicit discussion of epistemology within SSK is relegated to reflexive moments, when SSK contrasts its research agenda with the dominant positivistic accounts of science or when defending itself against accusations of relativism (Kurzman 1994).

11
. The great exceptions to this rule are feminist critiques of science that offer a more conscious exploration of epistemology. Donna Haraway's
Primate Visions
(2006) is an exemplar of this research, as she reveals how gendered thinking insinuates itself in the thinking and practices of primatologists.

12
. While critical philosophical approaches (e.g., American pragmatism and naturalized epistemology) have tried to steer philosophy toward empirical analyses, it remains largely a speculative exercise, focused on elucidating logical arguments rather than studying
how
people negotiate these problems in real-life encounters.

13
. The basic conceit of this book is that concept formation and elaboration are essential exercises in sociological research as good concepts “capture essences, identify dominant forces, determine our focus, and suggest future direction” (Light and Levine 1988,11).

14
. Here I should acknowledge the limitations of a single case study. The strength of a single case study is that it allows for fine-grain process-tracing that can accommodate complex causality and a more detailed examination of context (George and Bennett 2005). My attention to historical detail allows for theory-building regarding epistemic contests by identifying important strategies, processes, and factors at play. But in adopting a single case study method, I trade depth for breadth. When extending the concept of epistemic contests to other cases, there is a limit to what I can say generally. I can say that
if
an epistemic contest is at play, then there are certain qualities it will assume, but whether or not these conditions hold, is, at the end of the day, an empirical question. What I offer future researchers is not a general theory of epistemic contests, but an elaboration of the various strategies, factors, and processes involved in epistemic contests.

15
. This is not to suggest that Gieryn's work ignores epistemological issues altogether. To the contrary, he is concerned with “epistemic authority,” which he defines as “the legitimate power to define, describe, and explain bounded domains of reality” (Gieryn 1999, 1), and some of his case studies—most notably, his analysis of John Tyndall's promotional work for science through London's Royal Institute—involved fundamental debates over the nature of knowledge. Nevertheless, these epistemological dimensions are not explicitly theorized by Gieryn. He is focused on investigating “science-in-culture,” specifically how the adjudication of competing truths is accomplished through settlements of the boundaries of science. He wants to explore how and why science becomes so widely trusted. My analysis orbits around the more fundamental epistemological question of what constitutes legitimate knowledge, of which the answer “science” is only one of many possible answers.

16
. While credibility contests originate in conditions in which science possesses an exalted status, historically the epistemological valuation of science fluctuates
over
time. During the Jacksonian era, science was looked upon with great suspicion (Hofstadter 1963), and this suspicion fueled the epistemic contest over medicine.

17
. The model of historical change animating my analysis is taken from Sewell (1992), who, while acknowledging the influence of structural factors on human action, retains a principal commitment to the role of the agency—the choices and understandings of historical actors—in bringing about transformations.

18
. The counting of cholera epidemics is not as straightforward as one would think. For most of the epidemics discussed here, cholera stayed in the United States for a discrete period of time. This was not the case for the epidemic beginning in 1848. The intensity of the epidemic waned after 1849, but pockets of cholera remained throughout a six-year period, with an uptick in 1854, after which cholera disappeared for over a decade. Following the precedent set by Charles Rosenberg (1987b), I treat 1848, and its subsequent milder incarnations up to 1854, as a single epidemic.

19
. In many ways, for the American South, yellow fever loomed larger than cholera as a medical issue (Crosby 2007; Ellis 1990; Humphreys 1999).

20
. While I draw extensively on Rosenberg's research, my goals are different. Whereas Rosenberg describes how cholera became a secular
social
problem, I am interested in how it eventually became a
medical
problem to be understood through bacteriological science. This is reflected in the scope of my project. I examine all five cholera epidemics through 1892, while Rosenberg's analysis terminates in 1866.

21
. While the best-fit cases were used as exemplars by proponents of the bacteriological theory, the assumption that one is compelled to adopt a single model of disease for all diseases is historically problematic. Indeed, long before the bacteriological revolution, the case of smallpox seemed to point toward the germ theory. Yet it was regarded by many to be a unique case. Similarly, John Snow's waterborne germ theory of cholera was presented not to offer a universal challenge to the miasma theory of disease, but rather to reveal cholera as an anomalous case that did not fit this model (Koch 2005). Part of the accomplishment of proponents of the germ theory of disease was convincing others that a single, universal paradigm explained all diseases. Reasoning by analogy undoubtedly was part of the rhetoric of proponents of the germ theory of disease, but there is no justification in arguing that a single case of success could have sealed the fate of alternative models.

22
. It is a bit misleading to refer to the germ theory as a singular entity during the nineteenth century. As Worboys (2000) shows, there were many variations of the “germ theory,” each with its own nuances. Nevertheless, for the purposes of this book, I refer to the germ theory to denote the belief in some sort of microbial etiology of disease. The different shadings of the germ theories are less important for my analysis.

CHAPTER ONE

1
. Cholera had long circulated throughout India, but it was basically unknown to Europe prior to the 1800s.

2
. This does not mean arenas deterministically predict outcomes. Social structures do not exist independently of human action. Per Giddens's (1984) structuration theory, James Jasper notes, “Behind every ‘structure' is usually another player hard at work” (Jasper 2006, 167).

3
. The use of the term “specificity” in nineteenth-century medical discourse is confusing and often contradictory, as historian John Harley Warner notes (1997, 58–63). During the early nineteenth century, regulars understood specificity as an individualized treatment for specific patients, and knowledge derived from observation of particular cases. This was in opposition to universalistic approaches to medicine. At the same time, they derided alternative medical movements and patent medicine sellers for championing specific remedies, as understood as specific to a particular disease, “as a manifest stigma of charlantry” (Warner 1997, 60). This confusing use of the term often results in a mischaracterization of nineteenth-century medical debates. For the purpose of this chapter, I employ the term in the former sense to signal a particularistic and local foundation for medical knowledge.