Knowledge in the Time of Cholera (5 page)

However epistemic authority is framed, the concept of the epistemic contest directs attention toward conflicts among competing epistemological systems. Such conflicts, though not commonplace, are particularly disruptive. Epistemological assumptions form the core of the taken-for-granted world. These ever-present criteria for assessing beliefs inform and determine the manner in which individuals make sense of reality. In most cases, they remain unarticulated. Individuals do not need to be able to articulate justificatory arguments in order to employ them in the pursuit of knowledge (BonJour 1978). Such standards are institutionalized in the social practices of knowing however internalized and unconscious they may become. They are rarely questioned, much less discarded. For this reason, knowledge
disputes
typically do not operate on the level of epistemology. But when they do, the urgency of the debates is intense.

To overcome the inertia of commonsense thinking, epistemic contests require certain conditions. Crises and major disruptions are often necessary in establishing opportunities for epistemic contests, but they are not sufficient. In the case of American medicine, cholera led to an epistemological crisis; the great influenza did not. Still, even with such exogenous crises, it takes significant
work
to destabilize epistemological assumptions—work performed by actors competing for recognition as legitimate knowers. The stress on the agency of actors in waging epistemic contests is paramount. Context matters, but it is what actors
do
that affects the trajectory of epistemic contests. It is true that the epistemic contest over medicine was enabled by certain long-term structural changes in the United States during the nineteenth century. And it is true that the arrival of cholera created a sense of panic and urgency that exposed some fundamental fissures within allopathic medicine. But neither was decisive in creating an epistemic contest. Rather, as I show, alternative medical movements seized the opportunity cholera provided to demand that allopathic physicians give an epistemological account of their authority as knowers. They forced the specific medical debates that cholera elicited onto the level of medical epistemology, thus shaking the foundation of allopathic medicine and giving birth to a nearly century-long struggle over what medical knowledge consists of. Cholera offered alternative medical movements an opportunity to assert themselves vis-à-vis allopathy. They transformed it into an epistemic contest.

Though constrained by structural factors, epistemic contests unfold according to their own internal logic, rendered contingent by the strategic back and forth between competing actors.
¹⁷
Actors engage in what I have called elsewhere “knowledge advocacy” (Whooley 2008), championing certain versions of knowledge in a struggle to achieve epistemic authority and gain recognition. These visions clash, for the knowledge advocates argue
against
alternative visions of knowledge as much as they argue
for
their own. Interactive struggle then is central to explaining the trajectory of epistemic contests and its resultant effects on knowledge production. The epistemic contest over medicine evolved according to the dynamic, give-and-take between allopathic physicians, alternative medical movements, and medical reformers, as it traversed different organizational settings and involved a wide array of actors. Medical sects did not present fully formed articulations of their epistemologies and stick to them over the course of the con
test.
Rather, their epistemological positions arose in relation to each other and were modified over time according to their interaction.

The stakes of epistemic contests are great. When one epistemic system is elbowed out by another, epistemic closure—the ascension and dominance of one epistemic system over others—is achieved. What is forfeited in closure is an entire way of understanding the multitudinous experiences of reality, and in turn, any future insights that alternative styles of reasoning might offer. The possible forms that knowledge can assume are restricted. While productive and necessary, epistemological systems all have their blind spots, allowing for certain types of questions and answers to arise while forbidding others. Thus, epistemic closure does not just result in the selection of certain ideas over others; it involves the selection of an entire approach to knowledge at the expense of others.

The legacy of epistemic contests is evident in the power disparities—cultural and organizational—they leave in their wake. Solutions to the problem of knowledge are solutions to the problem of order (Shapin and Schaffer 1985). In the resolution of epistemic contests, certain actors are granted trust by society, while others are denied as legitimate knowers. With victory comes enticing spoils—cultural capital, formal legitimacy, organizational resources, and institutional support. These spoils become institutionalized, as the taken-for-granted practices of these organizations—“how institutions think” (Douglas 1986)—come to embody the winning epistemology, and subsequently disseminate it through processes like isomorphism (DiMaggio and Powell 1983). As such, the power disparities in terms of who is and is not recognized as a knower become imbued with an inertial quality as the patterned thinking is transformed into common sense.

Because professional privilege is one of these spoils, epistemic contests can be implicated in professional politics. Ultimately, both professional struggles and epistemic contests are about the power to define the real, and as such commonly overlap. Insofar as professions represent a privileged economic position granted on the basis of specialized knowledge, defining the standards and nature of knowledge is crucial for professionals. This is not to say that professional struggles
necessarily
involve epistemic contests; professional debates need not involve fundamental questions over the nature of knowledge. They can revolve around a whole host of other issues (e.g., organizational control). Nor do epistemic contests necessarily spur professional struggle; they can—and do—occur outside of the system of professions. However, when professional struggles take on the form of epistemic
contests,
as was the case in nineteenth-century medicine, epistemology becomes decisive.

In the end, the analytical payoff of the concept of the epistemic contest comes from its emphasis on embedded struggle over time in accounting for epistemological shifts. Rather than offering teleological accounts of the development of knowledge, I offer a conflict model of knowledge production that is shaped by the strategic give-and-take between actors, strategies shaped in part by the organizational contexts in which they unfold. Unlike most histories of this medical period, which take the point of view of particular medical sects, I elevate the
interaction between actors
—what William Sewell (2005, 6) refers to as “unfolding of human action through time”—to the center of the analysis. To understand the eventual consolidation of medical authority around the bacteriological model of disease, we must understand how and why medical sects made certain choices, and adopted certain strategies, in response to the actions of their challengers. At its core the dispute over medical knowledge and epistemic authority in the nineteenth century was
relational
, emerging out of the dynamic dealings between the actors involved. This is not a history of allopathy
or
homeopathy
or
any of the other actors described herein, but rather of their contentious relationship. In elevating the role of struggle—in stressing politics
and
knowledge—I show that the eventual content of medical knowledge had its birth, not fully in an external reality, but in the legacy of intellectual debates and extra-scientific polemics in which it was embroiled. The development of medical knowledge did not involve a simple reading of an external world or the discovery of certain facts; it involved a struggle to control and define the very standards by which knowledge was to be judged. And out of such epistemological struggle was born a unique and exceptional institution—the modern U.S. medical profession.

WHY CHOLERA?

This book recounts how regular physicians won the epistemic contest over medicine and, in turn, were able to consolidate professional authority, lost after the 1832 cholera epidemic, under the bacteriological paradigm in the early twentieth century. First, it explores the origins and development of the epistemic contest. How did alternative medical movements create an epistemic contest that translated into successful legislative campaigns between 1830 and 1890? Second, it describes the process by which regulars,
through
the AMA, were able to defeat all epistemic challengers to create an exceptionally powerful profession. How did allopathic physicians consolidate their professional authority around the bacteriological paradigm so as to legitimate the development of an institutional structure that excluded other medical sects? How did such epistemic closure shape the modern medical profession?

To consider the establishment of an epistemology in general, to follow it through its various arenas, to note the number of actors involved in debunking or championing it, and to trace its trajectory over eighty years would be too large a task to furnish the type of close analysis necessary to understand the struggle for epistemic and professional legitimacy in all its subtlety and complexity. Fortunately, such a herculean task is unnecessary. Epistemic contests become manifest in specific debates. And not all medical debates are created equal. I have re-created the history of the epistemic contest through the case study of cholera during the period between 1832 and 1912—a period that witnessed four cholera epidemics in the United States.
¹⁸
The data for this book has been culled from a wide array of primary source documents (e.g., medical journals, speeches, pamphlets, private papers, sociology meeting minutes, etc.). Using this extensive body of archival data, I painstakingly reconstruct the epistemic contest through a content analysis of both the specific claims of cholera being made as well as the epistemological assumptions underlying these claims. In doing so, I recount the muddled history of the epistemic contest over medicine in general, beginning with the successful challenge of alternative medical movements in the mid-1800s and ending with the allopathic achievement of epistemic closure under the epistemology of the laboratory at the turn of the century. Put differently, I provide a historical/sociological analysis of the politics of nineteenth-century medicine with cholera as its focus.

The choice of cholera results from its tremendous historical importance—it was
the
medical issue of its day—as well as from some pragmatic methodological concerns. Historically, cholera was a major cause of the epistemic contest; analytically it offers a mirror to the more general problems animating nineteenth-century medicine in the United States. And while cholera was not the only issue involved in the epistemic contest,
¹⁹
as “the classic epidemic disease of the nineteenth century” (Rosenberg 1987b, 1), it was arguably the most important in both the reach of its influence and the persistence of its threat. As an exogenous shock to the medical profession, cholera disrupted the traditional workings of U.S. medicine and pre
sented
a host of problems, epistemological and otherwise, for the medical profession.

Thus, while the epistemic contest became manifest over a number of different issues (e.g., the therapeutic value of bloodletting) and disease definitions (e.g., tuberculosis, yellow fever), cholera as a case has a number of benefits over other possible issues. First, epidemics are useful “sampling devices” as they bring to the fore many social, economic, political, and intellectual issues that are less visible during more tranquil periods (Rosenberg 1966). There exists a rich tradition of using cholera as a sampling device to study larger social phenomena. For example, Charles Rosenberg's seminal study
The Cholera Years
(1987b) explores the secularization of American society by showing how the understanding of cholera evolved from the scourge of the sinful to a consequence of remedial faults in sanitation.
²⁰
Additionally, researchers have used cholera as a lens to examine a number of issues, including the sociopolitical history of nineteenth-century Hamburg (Evans 2005); the evolution of the bourgeoisie in postrevolutionary France (Kudlick 1996); political conflict in Lower Canada (Bilson 1980); the vagaries of British class politics (Durey 1979); the cultural norms of Victorian England (Gilbert 2008); resistance to tsarist policies in Russia (Friedan 1977); and the role of medicine in reinforcing American nativist policies and politics (Markel 1997). I use cholera as a sampling device to explore the intellectual crises within medicine in the early nineteenth century, taking advantage of the fact that cholera remained a pertinent issue over the entire period of professionalization that I seek to understand. While certainly cholera loomed larger during the initial period under study (1832 to 1866), it remained a persistent puzzle for medicine into the twentieth century. And it forced allopathic physicians to reassess their epistemology by offering opportunities for the elaboration of alternative visions for medical epistemology. When it came to cholera, the intellectual and professional stakes were high.

While most of the historical research on cholera focuses on other national contexts, historians have long recognized cholera's significance on American medicine. For nineteenth-century physicians, there was no medical problem more vexing and more significant than cholera. Cholera's importance is alluded to (if not expounded upon) in the historical scholarship on the disease. The professional status of allopathic physicians depended greatly on achieving an understanding of cholera (Rosenberg 1987b). Likewise, the consensus among historians of alternative medical movements is that the failure of regular physicians to stem the tide of the 1832 epidemic
was
used by alternative movements to challenge allopathy (Berman and Flannery 2001; Coulter 1973; Haller 2000; Kaufman 1988; Whorton 1982). And many of the doctors who would eventually lead the charge in reforming American medicine cut their teeth on the study and treatment of cholera, especially in Paris in 1832 (Warner 1998).