Knowledge in the Time of Cholera (18 page)

Regulars were losing the epistemic contest. Bewildered, they puzzled over their dwindling prestige: “It may, to say the least, be considered strange, that in almost every other department of knowledge besides that pertaining to the healing art, man seeks and follows with a degree of religious deference, the counsel and advice of those who are supposed to be the best informed and the most skillful in that particular branch which is his immediate concern; but in medicine it seems to be just the reverse” (Blatchford 1852, 70). To allopathic physicians, the widespread adoption of homeopathy represented a new low, a new nadir, in public common sense. “Men, in all ages, have been prone to trust to the absurd pretensions of empiricism in the treatment of disease, but never have intelligent men been so much disposed as at this day, to put confidence in the various sects of practitioners who do not profess to found their art on the science of which we are so proud, or even to be at all conversant with it” (Hun 1863, 6).

It was becoming clear to allopathic reformers that they needed a new strategy. Their intellectual arguments were not cutting it. Operating against a democratic headwind, they changed tack. Rather than attempt to win the intellectual/cultural debate with homeopathy, regulars adopted an organizational solution to their epistemological woes. They believed that the interests of allopathic medicine could be protected only through the formation of a national professional organization whose unity would filter down into local societies (Coulter 1973, 179). Through the establishment of a national medical society, allopathic physicians sought to reconstitute allopathy as a more coherent body, while simultaneously drawing firm boundaries between legitimate medical knowledge and quackery, to organizationally provide the very standards of adjudication absent in their radical empiricism.

In
1846, a small group of allopathic physicians met in New York to form such an organization. The idea of the national professional society was not in itself innovative; homeopaths founded the American Institute of Homeopathy (AIH) in 1844. But whereas the AIH was primarily a scientific society aimed at providing a forum for communication, the AMA was an exclusive society aimed at promoting allopathy at the expense of alternative medical sects. It was a conscious, unabashed tool for the promotion of regulars' professional interests. And the founders saw it as the beginning of a new era for allopathy. In the first address of the society, President Nathaniel Chapman (1848, 8) heralded the event as one that signaled that the profession had awoken “from the slumbers too long indulged,” ready “to vindicate its rights, and redress its wrongs.”

The driving issue for the founding of the AMA was the declining state of the profession (Rothstein 1992). Reformers identified three sources of this decline—an ignorant public, a weak educational system, and homeopathy—and decided to focus its energies on educating the public, reforming medical education, and combating quackery (Coulter 1973). As noted above, the programs of public education and educational reform took a backseat to the efforts to combat homeopathy (Coulter 1969). Because allopathic physicians understood appeals to the public as the sine qua non of quackery, they were reluctant to engage the public in any meaningful way, evidenced by the AMA's closed-door meetings and its lack of a public journal until 1883. Educational reforms were also stymied, often discussed but rarely acted upon, as reformers became mired in a stalemate with the proprietary medical schools, which resisted any attempts to increase educational standards (Ludmerer 1985; Marks and Beatty 1973; Rothstein 1992).

It was to the third task—combating quackery—to which the AMA turned its immediate attention (Fishbein 1947). By establishing the AMA, allopathic physicians sought to create organizational standards to adjudicate competing claims between legitimate medical knowledge and quackery, to draw a “strongly marked line of distinction between the educated and the uneducated, the liberal and the restrictive” (Brinsmade 1859, 22). The AMA's founders (Knight 1846, 750) argued, “In this state of things, the only resource which remains is, for medical men to establish and enforce among themselves such regulations as shall purify and elevate their own body, and thus more fully command the respect and confidence of their fellow men.” The AMA sought to identify and eliminate irregular physicians through the
“
exercise of a moral power” (Hutchinson 1867, 59). If the state legislatures refused to officially recognize the difference between medicine and quackery, regulars would have to do it themselves.

Through the AMA, allopathic physicians sought to exclude homeopaths from the universe of legitimate knowers, turning inward to create their own system of regulation (Starr 1982). The main vehicle by which this was to be achieved was the codification and the enforcement of the 1847 Code of Ethics, specifically the no consultation clause (Rothstein 1992). The AMA restricted its membership to allopathic physicians who had allopathic medical training and rejected “unorthodox” teachings. Not only were homeopaths and other “irregular physicians” prohibited from joining allopathic medical societies, but allopathic physicians themselves were prohibited from seeking or giving consultations to alternative physicians:

Although it is not in the power of physicians to prevent, or always to arrest, these delusions in their progress, yet it is incumbent on them, from their superior knowledge and better opportunities, as well as from their elevated vocation, steadily to refuse to extend to them the slightest countenance, still less support. (AMA 1851, 86)

The AMA was explicit about the rationale behind the no consultation clause; regulars needed to keep their “skirts clear of everything pertaining to irregular medical practices of whatever kind of description. We should not only avoid all complicity with them, but even the suspicion of a quasi recognition of them” (Hutchinson 1867, 62). Consultation was deemed as “giving ‘aid and comfort to the enemy,' quackery, and as such is treason against the honorable profession of medicine” (Butler, Levis, and Butler 1861, 496). In presenting the code to the entire body, Dr. John Bell urged all members to “bear emphatic testimony against quackery in all its forms” (quoted in Fishbein 1947, 37). The intensity of this rhetoric underscored the commitment to defeating homeopathy, as did the severe punishment—expulsion—of those who indulged it. These exclusionary organizational practices represented a marked departure from the long tradition of interaction between the two groups and the recognition of professional equality in previous ethical codes of local medical societies. It raised the stakes of the epistemic contest for the average regular by officially drawing distinctions and prohibiting cooperation through various mechanisms of punishment and censure.

The Code of Ethics was strengthened in the years following the forma
tion
of the AMA. Before a local society could be admitted to the association, it was required to purge all homeopaths (Coulter 1973). In 1851, the no consultation clause was revised to explicitly grant the power to local societies to expel suspected homeopaths: “Each County meeting shall have the power to examine the case and immediately expel any member notoriously in the practice of Homeopathy, Hydropathy, any other form of quackery, without any formal trial, the same to be ratified by the succeeding Convention, any By-Law to the contrary notwithstanding” (quoted in Coulter 1973, 202). In 1854, the AMA, worried that local societies were not effectively policing their boundaries, set up a committee to inspect whether local members were still involved with irregulars. And in 1856, the AMA codified the illegitimacy of homeopathic knowledge by resolving that homeopathic works could no longer be discussed or reviewed in allopathic periodicals, effectively erasing any trace of homeopathic thought from allopathic discourse. The AMA showed great resolve in carrying out these threats, demonstrated best in 1884 when it responded to the New York State Medical Society's repudiation of the Code of Ethics by canceling the membership of most of its members (Burrow 1963, 20).

With these exclusionary practices, the AMA was able to police its members and to foster some cohesion by expelling those physicians who strayed too far afield. Such efforts were mirrored at the local level, with the instigation of the AMA. The example of the New York Academy of Medicine (NYAM) was indicative of this trend toward exclusion. Initially, the reaction of many New York regulars to homeopathy was one of curiosity and engagement, evidenced by the fact that the allopathic Medical Society of the County of New York awarded an honorary membership to Samuel Hahnemann in 1832 (Kaufman 1988). Rather than reforming this corrupted medical society, allopathic leaders in New York State, particularly New York City, decided to found NYAM. The old society was simply too catholic to meet the current challenges. In outlining their reasons for the establishment of NYAM, its founders listed the separation of regular practitioners from irregulars first (Van Ingen 1949). To accomplish this goal, the academy had to define what constituted an irregular physician. This was not a straightforward exercise in definition, for in New York, the boundary between homeopaths and regulars was fluid as they regularly consulted with each other. After much discussion NYAM adopted a broad rule that excluded “all homeopathic, hydropathic, chronothermal and botanic physicians, and also all mesmeric and clairvoyant pretenders to the healing art, and all others
who
at any time or on any pretext claimed peculiar merits for their mixed practices not founded on the best system of physiology and pathology, as taught in the best schools in Europe and America, and shall be deemed to exclude also all such persons as associate with them in consultation” (quoted in Van Ingen 1949, 13). The broad definition was adopted without a dissenting vote. Furthermore, to safeguard the society from homeopath infiltration, NYAM established a Committee of Admissions “to guard the portal of the Academy and to see that no irregular or unqualified practitioner gained entrance” (Van Ingen 1949, 8). As a result, the first fifty years of NYAM witnessed numerous accusations and purgings of homeopaths from its ranks. More energy was expended on these exclusionary actions than on any other activities.

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.
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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.
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