Knowledge in the Time of Cholera Page 14

  The creation of an exclusionary association with rigid membership standards had two strategic benefits for the epistemic contest: it created an organizational and cultural space that denied the epistemic legitimacy of homeopathic claims and, in doing so, brought a measure of unity to allopathy. First, through the Code of Ethics, the AMA drew strict boundaries between homeopathy and allopathy, singling “out the sheep from the goats” (Sayre 1870, 55–56). In excluding homeopaths from consultations, allopathic physicians hoped to destroy public confidence in them, deprive them of clientele, and increase the gulf between homeopaths and allopathic physicians (Rothstein 1992, 171). In absence of firm epistemological standards upon which allopathic physicians could justify their rejection of homeopathic knowledge, regulars substituted membership restrictions, providing organizational standards for adjudication. Second, in defining the other, the AMA established an identity for allopathy despite its intellectual fragmentation. The defining feature of allopathy became opposition to homeopathic quackery. This new identity, rooted in an organization, mitigated some of the centrifugal force that accompanied allopathy’s commitment to radical empiricism.5

  Therefore, the AMA’s epistemological accomplishment was not in facilitating a positive program of cohesive allopathic knowledge; it was in the formalization and institutionalization of the standing of homeopaths as quacks. While factions within allopathy had long been critical of homeopaths and homeopathic knowledge, boundaries between medical sects were not rigidly defined prior to the AMA. Homeopathic and allopathic physicians shared educational experiences. Many homeopathic converts maintained relationships with their regular colleagues after their defection, since, prior to the Code of Ethics, the stigma attached to such conversions was negligible. As competition between the sects intensified after the first two cholera epidemics, maintaining such openness and curiosity toward homeopathy became more difficult, but it nevertheless endured. The AMA changed this; it made it impossible to maintain one’s status as a legitimate physician within the allopathic community while flirting (or giving the impression of flirting with) homeopaths or homeopathic ideas. To do so was to be painted with the debasing brush of quackery.

  As homeopathy became institutionally deemed quackery, allopathy was not compelled to indulge it, even in order to refute it. It could be summarily dismissed as implausible, self-evidently false, and unworthy of attention. The surface ludicrousness of homeopathy did not mask some deep insight. The AMA had evaluated it and declared it foolishness. Prominent allopathic physician Worthington Hooker (1852, v), a self-appointed gadfly, articulated the AMA’s position toward homeopathy:

  Absurd as Homeopathy appears on the face of it to the man of science or of plain common sense, the extent of its absurdity is revealed only by a thorough examination of its pretended facts and its plausible reasonings. . . . A wordy and finespun theory, built upon the loosest analogies, especially if accompanied, as is usual with all forms of delusion and quackery, with reports of wonderful cures, is sufficient to satisfy them, at least till some other system presents itself, with similar appliances for fascinating the ear of popular credulity.

  As quackery, homeopathy failed to meet the most basic requirements of “common sense,” succumbing to bald “delusion.” Homeopathy was “a stupendous monument of human folly” and “a confused mass of rubbish” (Hooker 1849, 136). Another doctor wondered, “Is this not an incomprehensible science, indeed? Where is the mortal mind of capacity sufficient to grasp such a thought?” (Blatchford 1852, 88). Homeopathy, “a wordy finespun theory, built upon the loosest analogies,” was the embodiment of outdated rationalism that allopathy had rightfully discarded.6

  Allopaths claimed that the only explanation as to why anyone would adopt such manifest absurdities was “for the sake of money” (Hun 1863, 36). In the allopathic mind, homeopaths sought not to cure disease but to dupe the urban elite into paying exorbitant sums for their false therapeutics. It consisted of nothing more than “trickery, fraud, and chicanery, together with puffs of extraordinary cures, high pretensions to some peculiar power, some superior knowledge, and long catalogues of great and influential names of patients” (Hutchinson 1867,141) As such, homeopaths were lumped together with other confidence men of the time: “These ignorant tricking practitioners in medicine, constitute a race which may be classed with bogus jewelry pedlars, fraudulent lottery speculators, and all such like ‘sharpers,’ who take advantage of the simple-minded” (Medical and Surgical Reporter 1865, 214). Given its self-evident absurdity and the ignoble motives, allopathic physicians refused to engage with homeopathy in debates. They rejected any challenges from homeopaths to test their system and refused to take their claims regarding cholera seriously. Deemed quackery, homeopathy fell outside the realm of serious, legitimate knowledge. There was no need to indulge it, as it was just the latest in a long tradition of quackery, and when it fell out of favor, “something else equally absurd, (I cannot think of anything more so) will no doubt at once take its place” (Hutchinson 1867, 72–73).

  It is important to point out that the allopathic rejection of homeopathy and its expulsion from the AMA were not determined by the content or nature of homeopathic evidence, but rather by homeopaths’ exclusion from the regular professional community. Under these organizational standards, legitimate knowledge was to be judged according to who proclaimed it. If the doctor was a member of the AMA, his opinions could be considered. If not, they were dismissed outright as quackery. In other words, the distinction between quackery and legitimate knowledge was not based on particular epistemological or intellectual rationales. It was a distinction between legitimate and illegitimate knowers operationalized as membership in allopathic certified professional societies. Membership thus served as a solution to the problem of adjudication introduced by radical empiricism. The AMA established itself as a cohesive organizational community for allopathy, not by reconciling the mess of competing allopathic knowledge, but rather by defining a common other. Allopathic physicians were allopathic insofar as they were not homeopaths. The problems associated with allopathy’s fragmented knowledge base were muted, relegated to internal communications, by the display of public unity of the profession through its professional associations. From this united front, allopathy waged its fight against homeopathy.

  Because knowledge production is a collective endeavor (Longino 2002), the social organization of knowledge affects the knowledge produced (Shapin 2008; Shapin and Schaffer 1985). As an epistemic practice, the formation of the AMA, and the enforcement of its Code of Ethics, affected the content of allopathic knowledge on cholera in two ways. First, the restrictive membership practices limited the pool of perspectives regulars could bring to bear on cholera. As noted above, prior to the AMA, the boundary between allopathic and homeopathic physicians was blurry, especially since many homeopaths were allopathic converts who shared similar educational and professional experiences (Coulter 1973). Regulars often explored and even adopted homeopathic ideas. The AMA erected a rigid separation between the two sects. By expelling homeopaths from allopathic practice, barring consultations with them, and prohibiting discussion of homeopathy in allopathic journals, the AMA effectively eliminated all homeopathic knowledge from consideration. Homeopathic knowledge now fell outside of the “scheme of plausibility” (Shapin 1994, 22). Consequently, extended critiques of homeopathy like the famous one conducted by Oliver Wendell Holmes (1842)—critiques that required significant engagement with homeopathic ideas—were unfeasible after 1847. Allopathic physicians were prohibited from even acknowledging homeopathic ideas to refute them. The outright dismissal of homeopathy prohibited allopathy from making use of possible homeopathic insight into issues like cholera, or from strengthening its own arguments by debating homeopathic claims.

  Second, the AMA’s rigid demarcation encouraged the rejection of entire methodologies (e.g., provings and statistics) due to their association with homeopathy. For cholera, this was most evident in the allopathic rejection of s
tatistical data, a rejection that represented a departure from the Paris School, which embraced quantitative data as a supplement to clinical observation (Ludmerer 1985; Warner 1998). As noted above, the rejection of statistics was driven as much by professional politics as it was by an epistemological rationale. In adopting a radical variation of empiricism, American reformers not only eschewed statistical data because, epistemologically, it abstracted knowledge from the local context of sensory observation and, in turn, ran the risk of devolving into the unwarranted speculative generalizations. They also rejected statistics because they were seen as homeopathic. This out-of-hand rejection of statistics precluded the use of statistical methodology to make sense of disease. Equating statistics with quackery, allopathic physicians rarely deployed them to study cholera, as evidenced by the dearth of statistical data in their discussions on the disease in their professional journals.

  The AMA institutionalized the mistrust of homeopathy and fostered a general skepticism toward all knowledge that originated outside of the allopathic community. Despite the embrace of empiricism, the organizational restrictions on knowledge insisted upon by the AMA reinforced allopathy’s long-held suspicion of appeals to the public and outside meddling. This was well illustrated by the fact that the AMA and NYAM held closed-door meetings, refusing to admit the press “since the public was not considered capable of understanding medical matters” (Van Ingen1949, v). By fomenting mistrust of outsiders, the AMA circumscribed the debates over cholera. Insofar as dialogic interaction is important for the growth of knowledge, this circumscription resulted in lost opportunities for allopathy to gain insight from outside sources, both methodologically in the rejection of certain ways of knowing and therapeutically in the dismissal of homeopathic cures for cholera, which might be more effective (or at least less harmful) in treating the disease (Coulter 1973; Kaufman 1988; Warner 1997). Once again, regulars, through the newly formed AMA, were left promoting an elitist epistemology shielded from potential outside revelations about cholera. Outsiders were not engaged; dialogues did not happen. Rather than partake in debates, allopathic physicians evaded them. They proffered an exclusionary space and dictated who was included as legitimate knowers. As such, any political benefit allopathy accrued from radical empiricism’s ostensibly democratic character was undermined by its organizational policies.

  The AMA’s Coordinated Effort at Exclusion: Two Cases

  Regulars tried to transform this organizational cohesion into a program aimed at preventing homeopaths from gaining government support or, failing that, preventing government recognition from being converted into tangible resources. No matter that doctors within the AMA held widely disparate views; this disparate group was unified primarily to combat a common other. Imparting a sense of cohesion and collective identity, the AMA attempted to use its organizational leverage to dictate to other institutions, especially state institutions, the universe of legitimate doctors as they defined it, so as to minimize homeopathic gains. The AMA punished allopathic physicians who worked alongside homeopaths and, in turn, regular practitioners, either willingly or unwillingly, avoided any association with homeopaths at all costs (Kaufman 1988). Any effort that included homeopaths was suspect in the eyes of the AMA, and in turn, dangerous for allopaths who participated. Conflicts therefore erupted around the government’s various proposals to recognize and include homeopaths in state institutions. And while the government rarely recognized the exclusive claims of allopathy, the AMA was able to limit (or at least frustrate) all efforts of homeopaths to achieve equal standing within such institutions.

  Two examples illustrate this strategy, one at the level of the state legislature, the other at the national level. The first example involved a proposal to include a homeopathic chair in the medical school of the University of Michigan (UM), a case that points to the ability of the AMA to assert itself through local societies to frustrate and delay homeopathic inclusion even in the face of legislative mandates. The 1849 epidemic created an opportunity for homeopaths in Michigan to advocate for inclusion in the medical school, which they seized. In 1855, in response to petitions from the state’s homeopaths, the Michigan state legislature directed the university to establish, teach, and maintain the specific philosophies of both regular and homeopathic schools (Peckham 1994). The Michigan State Medical Society, with the support of the AMA, fought the provision. Citing the no consultation clause, it threatened the university’s board of regents with decertification and the exclusion of any future graduates from membership in allopathic medical societies. Thus pressured, the board of regents refused to abide by the rule. This set off a decade-long debate over who ultimately controlled the University of Michigan, the state legislature (which supported homeopathic inclusion) or the board of regents (which supported the AMA position). In 1867, the legislature tied the establishment of a homeopathic chair to a new funding bill, funding sorely needed by the medical school. Once again, pressured by the AMA, the board of regents balked, offering a compromise solution by which a separate homeopathic school of medicine would be established in Detroit. Like many separate-but-equal compromises, this one stressed the former over the latter. Underfunded, the Detroit school split the homeopathic community, with some homeopaths supporting it and others viewing it as capitulation and continuing to advocate for inclusion at UM.

  Finally, in 1875, the medical school, needing funding for a new hospital, agreed to establish two chairs of homeopathy, provided that homeopathic students received separate diplomas not signed by allopathic professors (Coulter 1969). The Michigan State Medical Society immediately adopted a resolution announcing a state of crisis between the society and the college, citing the potential retribution by the AMA on the college and its graduates (Haller 2005, 162). The AMA weighed in, stating that it would place the university under a ban, cease to recognize graduates from the college, and expel the college’s professors from the AMA for violating the no consultation clause by teaching in the same college with homeopaths. After an intense three-year debate, the AMA decided against censure. In reviewing the consultation clause, the AMA ruled that it only applied to medical consultation, not membership on the same faculty. Still, the AMA turned its focus toward marginalizing the homeopathic professors within the college.

  Although the AMA was only able to delay the inclusion of homeopaths in UM for two decades, it was more successful in preventing homeopaths from serving in the Union Army during the Civil War. With over three hundred thousand Union soldiers dying from injuries or disease, the Civil War “was a medical as well as human tragedy” (Ludmerer 1985, 9) that reverberated throughout American society (Faust 2009). This medical tragedy resulted in part from the woeful understaffing of the Union Army’s medical department (Adams 1996). Yet despite the shortage, homeopaths willing to volunteer were excluded from service by the Army Medical Board, which was under the control of allopathy. In 1862, the Homeopathic Medical Society of Massachusetts petitioned Congress for the inclusion of homeopathy in every military hospital, citing cholera statistics from the 1832 and 1849 epidemics as part of their justification. Senator James Wilson Grimes of Iowa introduced Senate Bill 188, which would allow homeopathic physicians to serve in the army and would place some military hospitals under homeopathic control. For homeopaths the rationale was simple:

  Large numbers of Homeopathic physicians who are perfectly competent to care for the sick and wounded, practitioners who have been duly examined and recommended by Allopathic medical boards, and whose record in civil practice stands high and compares favorably, not to say enviably, with that of the Allopathic school, have been, and are, rejected on account of their medical faith. What seems stranger still, is the fact that thousands of those who are suffering wish the benefits of this practice. These sufferers are the very men who assisted in placing these public servants in office. They are fighting for a common cause, one in which they have as much interest as any other class. They fight, bleed, and die, not for monarchy, but for democracy. (Stow 1864
, 257–258)

  The bill passed, and was signed into law by Lincoln. The federal government gave the go-ahead to begin admitting homeopaths into the army.

  Immediately, the AMA organized against the legislation. “The medical profession throughout the land, believing that such a measure would be detrimental to the life of the sick soldier, and that it would degrade and destroy the efficiency of the medical staff of the army, indignantly protest through their medical societies, medical journals and individually, against the enactment of such a law” (Medical Society of the State of New York 1867a, 65). Inclusion of homeopaths “would dissatisfy and dishearten the medical staff of the army, who understand the true character of homeopathy, and who have entered the service of their country with confidence that the government would strive to elevate the standard and promote the efficiency of the medical staff, results surely to be defeated by the appointment of Homeopaths” (NYAM 1862, 435). Controlling the Army Medical Board, allopathic physicians continued to refuse to admit homeopaths, even those who passed the army exam. Homeopaths admitted under false pretense, “would, if admitted, meet with a summary dismissal” (American Medical Times 1863, 59). The organized defiance succeeded, as the federal government was too preoccupied to enforce the Senate bill.7 Homeopaths never served in the army during the Civil War.