Knowledge in the Time of Cholera Page 15

  In both of these cases, the AMA was able to undermine the inclusionary policies of government institutions albeit with different levels of success. The AMA, brandishing its no consultation clause, was able to rebuke or significantly delay government-mandated recognition of homeopathy, whether such government recognition was done in the name of equality, democracy, or even mere expediency. Drawing firm distinctions between the two sects, regulars appealed to the epistemic illegitimacy of homeopathy, its quackery, to justify their refusal to cooperate with such mandates. The varying degrees of success of these efforts were determined by the degree to which the AMA could exert its control over public institutions. In the case of the University of Michigan, this control extended only so far, as the legislature took an active role in the controversy to promote the equal treatment of homeopaths as codified in the state’s statutes. In the Union Army, allopathic control of the Army Medical Board, coupled with the lack of government oversight of the board, allowed the AMA to successfully prevent homeopaths from achieving equal status. By pressuring its members, the AMA ensured that the formal, legal recognition of homeopathic claims of equality did not translate into tangible resources.

  CONCLUSION: ORGANIZING FOR EPISTEMOLOGY

  The founding of the AMA, and the particular policies it adopted, were shaped by the epistemic contest. Needing to adjudicate between good allopathic knowledge and impoverished homeopathic quackery, and lacking the epistemological standards to do so, regulars adopted an organizational solution. This chapter illustrates that epistemic contests are waged by a variety of means, involving both cultural and organizational strategies. Indeed, precisely because epistemic contests lack basic cultural agreement on the ideals of knowledge, organizational strategies assume great importance. To myopically focus on cultural strategies as the means to resolve such intellectual disputes obscures the rich repertoires actors deploy in advocating for their visions of knowledge. And unduly restricting one’s analysis to either organizational or cultural factors is to buy into a false choice driven more by theoretical biases than historical and empirical imperatives. Epistemic contests can be (and often are) adjudicated, not through specific debates over the merits of some form of knowledge over others, but through organizations, which set the parameters of the debate and determine who can and can’t engage in it, or even whether the debate can occur at all. Advocates of epistemological positions negotiate this organizational terrain, attempting to harness organizations in the service of their epistemological ends.

  Hampered by a lack of well-defined epistemological standards and in-effectual intellectual arguments, allopathic physicians adopted an organizational strategy to solve the problem of adjudication and carry out a program of exclusion. How successful was this strategy? Beyond the specific outcomes of the University of Michigan and the Union Army, it had mixed effects on the professional project of allopathy. On one hand, the AMA imposed some intellectual order on a situation lacking firm epistemological standards. Through membership restrictions and the no consultation clause, the AMA introduced organizational criteria by which to adjudicate competing knowledge claims, something not possible within the confines of radical empiricism. Defining homeopathy as quackery, it successfully prohibited homeopathic thought from gaining a foothold within allopathic circles. It established a firm boundary between allopathy and homeopathy, registering important distinctions, an invaluable contribution in the messy context of nineteenth-century medical practice. And while the exclusionary membership policies did not solve internal fragmentation, they did bring a measure of organizational cohesion to allopathy. In essence, it enabled the development of a “thought collective” (Fleck 1979) with only a modicum of shared thought, allowing allopathic physicians to wage the epistemic contest with homeopathy in spite of its own intellectual fragmentation. Allopathic physicians avoided cultural/intellectual debates with homeopaths by deeming them as falling outside of the realm of legitimate knowers, unworthy of engagement. Instead, they shifted the epistemic contest to an organizational terrain where they had more leverage.

  On the other hand, the early AMA’s exclusionary practices circumscribed allopathic approaches to knowing in a way that ensured a continued degree of internal intellectual fragmentation. By artificially restricting the parameters of the debate, the AMA encouraged the summary dismissal of methodological and intellectual insights associated with nonallopathic sources (e.g., statistical methods) that may have helped resolve some of these internal debates. And as much as the AMA tried to contain these debates within the confines of the organization, they led to incoherent public appeals on pressing issues like cholera, especially in opposition to the neat statistical rhetoric of homeopaths.

  Perhaps more important, the strategy of exclusion was discordant with the democratic spirit of the time, as it sought to restrict, rather than promote, dialogue and openness. In adopting this strategy, allopaths forfeited any claim to a democracy that was part of the original allure of radical empiricism. Homeopaths picked up on this, adopting antimonopolistic rhetoric reminiscent of Thomsonism. They argued that the AMA, in its efforts to exclude homeopaths, was trying to ensure that the practice of medicine was determined “by creed, not fitness” (Homeopathic Medical Society of the State of New York 1874, 27). According to homeopaths, allopathic physicians were content to “call names, make faces and throw stones at opponents whom they dare not face in a fair field” (Cornell 1868, 4). Avowing that “the medical profession is not an aristocracy created for the benefit of a caste” (Bowers 1871, 112), homeopaths portrayed themselves as champions of openness and democracy to great effect. Taking New York as one example, we see that the legislature continuously legislated in homeopaths’ favor throughout the nineteenth century (see table 2.1). The AMA, and its local satellites like the New York Academy of Medicine, repeatedly failed to make a convincing case for the exclusion of homeopaths to the legislature. This failure resulted in part from the lack of intellectual coherence that plagued radical empiricism. But it also stemmed from the antidemocratic critiques to which allopathy was especially vulnerable. The AMA’s campaign of exclusion did little to assuage allopaths’ antidemocratic reputation.

  Table 2.1. Continual allopathic defeat in the New York State Legislature

  In the end, the early actions of the AMA failed to radically change the general trajectory of the epistemic contest over medicine. But this is not to say that it was a complete failure or that its early activities should be dismissed as ineffectual and thus irrelevant. While the formation of the AMA did not translate into an immediate professional victory for allopathy, it was an important event in the process of professional consolidation and epistemic closure, as it established the organizational terrain of the epistemic contest for the rest of the century, shaping the terms of the epistemological debate and the subsequent knowledge produced in the context of this epistemic contest. From 1848 on, the sorting out of cholera, and the painful struggle that followed from it, would have to go through the AMA.

  3

  THE INTELLECTUAL POLITICS OF FILTH

  In 1866, the United States braced itself for another cholera epidemic. The disease had threatened invasion for a number of years—an ominous prospect for a country wrought by civil war. The war’s dramatic pageant of death claimed over 620,000 soldiers plus an undetermined number of civilians (Faust 2009). The country, mired in turmoil, was also deep in mourning. The sheer scope of the war’s mortality—it claimed nearly 2 percent of the U.S. population—altered the country’s relationship to death, creating what Frederick Law Olmstead called “a republic of suffering” (quoted in Faust 2009, xiii). Such a republic was in no position to deal with another cholera outbreak. Fortunately, cholera waited almost exactly a year to the day from Lee’s surrender at Appomattox before reappearing on U.S. shores. The battered country did not have to contend with cholera during combat. A small solace, but a solace nonetheless.

  In 1866, cholera still induced fear. Thirty years after the first epidemic, doc
tors and patients alike vividly recalled the bluish pallor, the aching muscle cramps, and the speed at which the disease claimed its victims. However, unlike the previous two U.S. epidemics, this fear was tempered by familiarity. Living memory blunted the more exaggerated terrors. Cholera had lost some of its foreign mystique, and the previous epidemics, though serious, never reached the dire levels predicted by the panic-stricken press.

  Familiarity may have bred some comfort, but much of the cautious optimism had another source. Due to promising developments in sanitary science prior to 1866, there was hope that this time officials might be able to prevent an epidemic, or at least contain its effects. A diverse group of public health reformers argued something unthinkable during 1832 and 1849—that cholera was, in fact, an easily manageable disease. They contended that if localities instituted a few key preventive sanitary measures, they could sit by and watch as the disease harmlessly passed by their communities. The premise underlying the optimism of the sanitary movement was that disease was filth. The Sanitarian (1873, 222–223), a major organ for the new sanitary movement, proclaimed unequivocally, “No truth is better established than that dirt and impurity are potent instrumentalities for the propagation of cholera. . . . Want of pure air, want of pure water, want of drains, want of sewers, and in cities want of salubrious exercise grounds, combine to produce dampness, stagnation, uncleanliness, misery, disease and death.” The lesson to be drawn from the localization of disease was simple, yet revolutionary in its effects: clean up filth, eliminate cholera.

  This is not to suggest that the arrival of cholera was taken lightly. The optimism was very cautious, uncertainty still abundant. Indeed, in 1866, Dr. W. C. Roberts of the New York Academy of Medicine warned against excessive confidence, reminding his audience that cholera was still “the one great epidemic. None of the diseases which have at different times ravaged the earth have equaled it in extent, rapidity, and simultaneousness of progress, nor [sic] in mortality” (NYAM 1871, 37). President of the Albany Medical Society James M’Naughton (1852, 126) endorsed this caution: “Familiarity [with cholera] has not divested this formidable scourge of its interest, or of its terrors. It is deservedly regarded as one of the most destructive diseases, by which the destroying angel has ever executed its commission.” Hoping for the best, but expecting the worst, the public still understood cholera to be a grave threat.

  As in past cholera epidemics, attention turned to New York City, cholera’s favorite port of entry. In January 1866, the Nation (1866, 40) reported that it “was generally expected by men of science, as well as by the public at large, not only that we shall have a visit from the cholera during the coming spring, but that it will first show itself in New York, and commit here its worst ravages, and from this spread itself over the country, along every line of railroad.” Aware of cholera’s typical course, New York City officials took proactive measures. On February 26, 1866, after a decade of stunted reform efforts, reformers had secured the passage of the Metropolitan Health Bill, establishing the country’s first permanent and politically independent municipal board of health. It was hoped that the newly formed board, insulated from city politics and the pernicious influence of patronage, would finally clean up the city and prevent the spread of cholera. Without delay, the board went to work readying the city. Between March 2 and March 7, the board issued a dizzying amount of decrees in a coordinated effort to clean up the city (Duffy 1974, 3). Police were instructed to submit weekly reports of all instances of filth on streets, wharves, and piers; physicians were directed to report all cases of contagious infections to the board; and warnings were sent to all owners and landlords that all establishments risked demolition if not cleaned. Taking on entrenched political interests and city graft, the board also ordered a review of all of the city’s sanitary contracts and threatened to void the contracts of those who were not honoring them (Duffy 1974).

  Still, anxieties would not be mollified until the board proved its mettle during an actual epidemic. Cholera would be the board’s first test. Reeling from overcrowding, draft riots, and general urban unrest, the situation in the city remained precarious, and New Yorkers waited with bated breath to see if the new Metropolitan Board of Health could overcome the impending epidemic. The delay of the state legislature in passing the Metropolitan Health Bill compounded the general angst as many questioned the board’s preparedness; while the board struggled “with vigor” to quickly carry out its reforms, “it was late in the season for much of their work, and Summer will be upon us probably before the most important part has been completed” (New York Times April 9, 1866, 4).

  As cholera neared, the board intensified its efforts. It hired thirty temporary assistants to carry out a comprehensive sanitary audit of the city, ordering them to locate and then remove the most egregious offenses. A citywide cleaning effort got under way, a welcomed departure from the previous sanitary regime, politically connected and hygienically neglectful. By April 9, the New York Times was predicting that even if the board could not prevent cholera, it should at least curb its excesses (Duffy 1974). The paper also encouraged the board to maintain its nerve in the face of the “powerful and selfish interests which are trying to perpetuate the nuisances and causes of disease in our City” (New York Times, April 9, 1866, 4).

  On April 13, cholera arrived. The board immediately lobbied the governor’s office to proclaim a state of emergency and extend its already substantial power. Granted this unprecedented authority by Governor Reuben Fenton’s poetically named “Proclamation of Peril,” the board, with the full assistance of the Metropolitan Police, carried out an ambitious emergency program. It eliminated so-called cholera nests, isolated affected individuals and establishments, strengthened and maintained a quarantine system, and cleaned up the city’s sewers, tenements, and other nuisances. Medical care was organized around house-to-house visits. Once indentified, the sick were transported to one of the board’s six dispensaries or cholera hospitals established specifically for the epidemic (Duffy 1974). Never had the city coordinated such an extensive medical campaign.

  Cholera arrived and departed with little more than a whimper as it was largely contained to the port. Only six hundred New Yorkers died out of a population of over eight hundred thousand. The board had passed its first test with aplomb. This is not to suggest it was easy or without controversy. The board faced stiff local resistance in every neighborhood in which it sought to establish a cholera hospital. Still, despite these moments of public outrage during the epidemic, assessments of the board were almost universally complimentary after it. The final verdict came a year later, when the New York Times (March 31, 1867, 3) concluded, “It ought to be permanently remembered to the credit of the Board, that having to deal thus early with the epidemic, they succeeded in checking its progress.” Regardless of whether it was actually the sanitary reforms that led to the decreased mortality or simply a milder form of the disease, the Metropolitan Board of Health of New York City received the credit. It had tamed cholera, and, in doing so, offered other cities and communities a blueprint, which many began to implement shortly thereafter. With their proliferation throughout the country, boards of health became the new front in the epistemic contest over medicine, as multiple actors salivated over their extensive resources and power.

  FRAMING EPISTEMIC AUTHORITY

  The establishment of the Metropolitan Board of Health was a watershed moment, both in the U.S. experience with cholera and in the history of American medicine. Not only did the board usher in a period of interventionist sanitary reforms that would eventually conquer cholera; it also embodied a shift to a new secular conceptualization of disease, marking the date when cholera became a “social” rather than “spiritual” problem (Rosenberg 1987b). Cholera as a scourge from God could not be combated by mere human measures; cholera as filth could. The arsenal against the disease now included more than just prayer.

  Yet the understanding of cholera as a social problem did little to mute the medical deba
tes surrounding the disease. An important event, the establishment of the boards of health did little to resolve the epistemic contest. In fact, it stoked the epistemic contest by introducing a new type of organization with resources and power to fight over. As the boards of health became the main organization body that responded to cholera, they became an alluring prize to be won for allopathic physicians desiring to promote their professional goals. And the public esteem granted to the boards in the wake of the 1866 epidemic sweetened their allure.

  The boards also introduced some complicating factors into the epistemic contest for allopaths. Prior to the boards’ establishment, regulars focused mainly on ensuring homeopaths’ marginalization. The boards, and the sanitary reform movement that underwrote their establishment, brought new players into the epistemic contest, all of whom sought the recognition to speak authoritatively on cholera and disease in general. A motley group of reformers, the “sanitarians” included influential community members, civil engineers, plumbers, progressive politicians, and physicians from all sects (Rosenkrantz 1974).1 The new actors each staked a claim to defining cholera in order to achieve different ends. Politicians sought patronage and potential kickbacks that accompanied a new institution with significant resources. Political reformers sought to use the boards as a model for their program to introduce rationality and integrity into municipal government. Homeopaths and other professionals (e.g., plumbers) sought inclusion on the boards and recognition for their essential contributions to the elimination of filth. And regulars tried to harness the boards to achieve professional and epistemic authority by taking credit for their sanitary successes. With all these competing actors and interests converging in the boards of health, the boards became not only the primary organizations to deal with cholera; they also became important sites for the epistemic contest over medical knowledge, ownership over the understanding and definition of disease, and the means by which society was to intervene. The boards became contentious arenas in which diverse actors asserted their status as privileged knowers and claimed epistemic authority.