Knowledge in the Time of Cholera

by Owen Whooley

  In justifying repeal, the legislature promoted debate, recognizing no one way to knowledge as inherently superior to others, for to do so was to “march to error.” Unlike under the politics of assent, learned men should not automatically command deference. Instead, the legislature championed the importance of debate in cultivating knowledge. Rather than discuss the merits of Thomsonism or homeopathy, the legislature took the occasion of licensing disputes to discuss the approach to medical knowledge generally. In this, the New York Assembly Select Committee on Petitions (1843, 7) shared a vision of knowledge similar to the Thomsonian and homeopathic view:

  And it is also clear that in the minds of your committee that such enactments operate to restrain rather than incite research and investigation into the hidden truths of science, by placing it in the power of one school of the profession, encircled as they now are by the strong arm of the law, to apply the epithets of quack and empiric with great force and effect to those (perhaps equally scientific as themselves) who in their investigations venture to overstep the prescribed limits of the legalized profession, and discover what to their minds is the evidence of error in the old system, and reason sufficient to induce them to propose a new and different one.

  Medicine would benefit from a free market of ideas.

  The importance of this epistemological resonance is underscored by the fact that the legislature supported repeal even though it remained skeptical about the validity of the Thomsonian and homeopathic systems of medicine. Indeed, many legislators were vocal in expressing their contempt toward Thomsonian and homeopathic ideas. In considering the incorporation of a homeopathic college in 1846, the Select Committee on Medical Colleges and Societies of the New York Senate (1846, 4) portrayed homeopathic thought in a decidedly negative light:

  Your committee feels that whatever may be their present convictions regarding the importance of homeopathy, as a new era in the treatment of disease, it is impossible to deny great industry to its advocates, and a furious zeal in the propagation of its doctrines. . . . And it certainly does require zeal of no common character to uphold principles so adverse to common sense (emphasis added).

  Such negative assessments are rife in the legislative reports. Committees produced either scathing or ambivalent critiques of the alternative medical systems but supported repeal anyway. The New York State legislature may not have believed in the merits of the alternative medical systems, but it did recognize their right to take place in the debate as legitimate knowers. Without formally recognizing the legitimacy of Thomsonian or homeopathic thought, the legislature endorsed their vision of an open market of ideas, much to the chagrin of regulars: “And they [the committee] also most confidently entertain the belief, that a discerning and enlightened people will ever be found to award to it [a given medical sect] a generous confidence and due appreciation commensurate with its merits” (New York Assembly Select Committee on Petition 1843, 6, emphasis added). The logic of the repeals, therefore, was based on a vision of how medical knowledge should be produced (i.e., by open debate), not on the merits of the particular medical systems.

  Regulars tried to deny the legitimacy of the alternative medical movements’ claims by defining them as invalid. They denounced Thomsonians as quacks, likening them to religious fanatics and primitives who sought a return to the medicine of the Dark Ages. As the editors of the Boston Medical and Surgical Journal (1842, 217) argued, “Neither has the quack a right to meddle with what, to him, is as incomprehensible as a steam engine to a Hottentot.” Dismissing homeopaths similarly, regulars condemned all efforts to air medical debates in public. The crux of their position was to deny the public’s (and by extension, the legislatures’) capability to judge medical knowledge. Their hierarchal view of knowledge held that medical knowledge could emanate legitimately only from within the ranks of regular physicians. According to regulars, “the prejudices of the public are always on the side of feeling, and never on the side of reason” (Hull 1840, 60). Medical matters were simply too complicated for the public to understand. Worthington Hooker, future president of the AMA and author of a scathing critique of homeopathy, claimed, “The science of medicine is so much a mystery to the common observer, that he cannot, as you have already seen, apply his tests to a direct examination of the physician’s knowledge. He is not competent to make the estimate in this way; and if he is not aware of this, he will certainly be deceived” (Hooker 1849, 227). The denigration of the public as knowers was manifest in allopaths’ use of Latin, their resorting to authoritative testimony, and their refusal to comparatively test their system against homeopaths or Thomsonians, instead dismissing them as quacks, unworthy of serious engagement. Fundamentally, regulars condemned outsiders for meddling in medicine as it contradicted their hierarchal epistemology. They rejected the legislature’s ruling on medical matters, refused to endorse open debate as a valid way to attain better knowledge, and decried the pernicious effects that the repeals would have. Joseph Bates (1849, 26) expressed regulars’ concerns:

  What effect has this? It has this democratic effect: It not only allows, but even holds out faltering inducements for every person to tamper with disease, and trifle with human life!! It cripples the energies of medical science, and degrades and paralyzes the influence of the profession. It throws open wide the fountains of wretchedness and crime, from which emanate those foul exhalations, that supply the polluted torrent whose invidious billows break, and dash against the time honored temples of medical science, infecting and poisoning the social horizon with their spray, far more malignant than the miasmata from the Pontine marsh.

  Allopaths believed that this “democratic effect” would spell disaster for medicine.

  Their arguments, however, fell on deaf ears, as allopathic appeals to paternalistic authority and their restricted notion of the community of legitimate knowers clashed with the democratic culture of the legislatures. This disconnect was not lost on regulars; the New York Journal of Medicine (1844a, 283) lamented that “a large portion of the public think that education and science are not necessary to qualify men for medical practice.” Regular physician Dan King (1849, 371) wondered how it was possible that “the wild man of the forest, or the wilder quack in society, is deemed amply qualified” to practice medicine. For allopaths, the repeal of medical licensing laws represented nothing less than “a triumph of quackery over the Medical profession” (New York Journal of Medicine 1844a, 283).

  CONCLUSION: KNOWING IN DEMOCRATIC SPACES

  Disputes over licensing laws followed a similar pattern in other states, producing time and again the same outcome of repeal (see table 1.2).11 Alabama and Ohio repealed their laws in 1833, hardly waiting for cholera to even clear out. From there, repeal spread throughout the thirteen states that had licensing laws on the books. In Georgia, alternative medical sects argued that licensing laws were monopolistic and ultimately detrimental to medicine (“Have not some of the most important discoveries in science been made by those in the humblest walks of life?” [Powell quoted in Haller 2000, 132]). They won repeal in 1837, with the legislature eliminating all former restrictions so that they “shall cease to operate on, or have any relation to any free white person now practising, or who may hereafter, practice medicine in this State” (“An Act” March 4, 1837, 1). In Maryland, where Thomsonians refused to be “slaves to medical aristocrats” (Rose 1838), no licenses were required after 1839.

  Table 1.2. Repeals of state medical licensing laws, post-1832

  State after state, alternative medical sects effectively transformed cholera into licensing repeals, validating their democratized medical epistemologies in the process. Thomsonians and homeopaths racked up victories, not because the legislatures necessarily agreed with their knowledge claims (and specifically those regarding cholera), but rather because they supported the way in which they envisioned medical knowledge. However cholera might be defined, the state legislatures recognized openness as an ideal in knowing and established an unregulated medical
system that ensured the perpetuation of the debate. In 1843, the New York Assembly Select Committee on Petitions (1843, 5–6) articulated what would be the legislatures’ approach to medical knowledge for the remainder of the century:

  Is it natural or reasonable to suppose, that if left free to act upon their judgments and the unbiased dictates of reason, exempt from the influences of sympathy, the people would be any more willing to entrust their health and lives in the hands of known, ignorant and unskillful pretenders to the healing art, than they would their money or property in the hands of a pretender to mechanical knowledge, without evidence of skill in or acquaintance with the pursuit in which he proposes to render service? . . . Your committee cannot conceive that such would be found to be the fact or result; nor do they see any good reason to believe that those who should be disposed to enter upon the practice of the honourable and responsible profession of physic and surgery, would suppose themselves absolved from any of the obligations or necessities of acquiring a full and perfect knowledge of the science, when placed before the public, to rise or fall entirely upon their own resources and merits. But on the contrary, that it would open a broader field of competition, operating, as in all other pursuits, to produce greater and more efficient exertion to qualify themselves to meet and successfully combat their competitors for eminence and fame.

  Better medical knowledge would be obtained through competition, not control. State legislatures refused to recognize one sect over another as the legitimate source of medical knowledge; instead a “broader field of competition” won out.

  The outcomes of these licensing disputes reflected a basic tension in claims to professionalization and expertise in democratic contexts—a tension that persisted throughout the epistemic contest over medical knowledge. The democratic understanding of how knowledge is best achieved (i.e., openness, transparency, and debate) clashed with the hierarchical vision of knowledge (i.e., restriction, autonomy, and noninterference) proffered by allopaths in justifying their professional privileges. The formal knowledge upon which professionals claim autonomy can be a threat to democratic decision-making (Freidson 1986). Alternative medical movements played off the tension between democracy and expertise to advance their own agendas. Without a compelling argument to grant this control over knowledge, institutions such as state legislatures were hesitant to impart it. Indeed, throughout the history of the epistemic contest, allopathy faced repeated resistance when trying to justify its claims to authority and autonomy in public institutions of the state—problems that would ultimately lead it to adopt a professionalization strategy that sought to evade state institutions.

  In focusing on the rhetorical strategies of medical sects within state legislatures, this chapter offers a more nuanced way to think about the changing fortunes of allopathic medicine in the wake of the 1832 cholera epidemic. In the past, historians have often resorted to macro-cultural explanations to explain the licensing repeals, viewing the deprofessionalization of allopaths as caused by the changing cultural winds, with the spirit of Jacksonian democracy serving as the catalyst for revolts against professionalization (e.g., Marks and Beatty 1973; Rothstein 1992; Starr 1982). Such macro-cultural accounts misleadingly marshal Jacksonianism as a causal explanation for its very components. But macro-cultural shifts do not exist in some amorphous ether, hovering above social life; they are aggregations of local-level practices spanning a variety of contexts. Homeopaths and Thomsonians did not ride the wave of Jacksonian values. Rather, they actively seized the opportunities afforded by this context to transform the 1832 cholera epidemic into a successful legislative campaign and an epistemic contest. Through framing, rhetoric, and political activism, they took advantage of the Jacksonian cultural shift to achieve a particular end; in doing so, they reinforced and contributed to this shift. Without the intervention of Thomsonians and homeopaths, the legislatures would not have been compelled to act, and the licensing laws may have endured. In the end, it is actors, real breathing people, who bring about cultural change. Epistemic contests don’t just happen; they are made.

  Moreover, they are made in particular contexts or arenas. This chapter also calls attention to the manner in which local conditions shape the nature and outcomes of epistemic contests. Localizing the epistemic contest as such helps narrow and specify what it means when sociologists say that such and such a frame has “resonance” (Benford and Snow 2000). Macro-cultural accounts define a larger cultural context and then ex post facto deem a particular strategy as “fitting” this context. By embedding practices within institutional contexts, we can better see just how resonance occurs in practice. In this case, it was the democratizing intent of the alternative sects’ epistemologies, expressed through their frames, that resonated with the burgeoning cultural and organizational commitments to democracy in the state legislatures.

  The 1832 epidemic may have led to the birth of the epistemic contest over medical knowledge, but by no means did it settle it. What it did was fundamentally alter the medical market by making it more accessible to outside challengers and alternative medical movements—a situation that would endure throughout the nineteenth century. In this expanded and flattened terrain, allopathy could not simply appeal to authority; it had to either convince the public that its claims to authority were justified or find other ways to capture authority. As would be typical of regulars throughout the nineteenth century, they chose the latter option.

  2

  THE FORMATION OF THE AMA, THE CREATION OF QUACKS

  The official ineptitude toward cholera, so redolent in 1832, repeated itself in 1849. If the 1832 epidemic was a tragedy, the 1849 epidemic would have seemed a farce, were it not for the increase in corpses.

  The nearly two decades that separated the two epidemics bore vigorous medical debate and an intensifying epistemic contest, but little insight. Answers to the most basic questions regarding cholera remained as elusive as ever. The bewilderment induced by the disease is well illustrated in a muddled description of cholera in an 1849 issue of the Boston Medical and Surgical Journal (1849, 123):

  Here, now, are singular facts, plainly showing the mysterious and capricious character of this dreadful disease. It appears, here, there, elsewhere, suddenly, and often giving no warning, without reference to lines of travel, regardless of natural water courses, wholly independent of the direction of the prevailing winds, and uncontrolled by the topographical character or geological formation of the districts within its general course. Spending itself where it lights first, either gently or ferociously, it disappears, and while neighboring points are standing in awe of its proximity, and daily expecting its desolating presence, it suddenly appears in altogether another region, a hundred or two miles away. And again, two or three weeks, or two or three months afterwards, while those who seemed to have escaped are still warm in the congratulations of each other, and are beginning to talk and write about the superior healthfulness of their towns, the destroyer retraces its steps, strikes their best and their worst, the strong and their feeble, alike, and carries mourning to every household.

  This frustrated description of cholera could have been easily written in 1832. Cholera remained a baffling foe, its capricious nature making it impossible to pin down. Given the lack of progress in medical knowledge on cholera, it is not surprising that the 1849 epidemic followed a similar script of medical ineffectiveness, useless interventions, widespread panic, and death. Not learning from the past, the United States was doomed to repeat it.

  The disease followed much the same route as it had in 1832. Once again, the Atlantic Ocean failed as a barrier. On December 1, 1848, cholera returned to New York City on a ship carrying passengers prostrate with the disease from Le Havre, France. With no quarantine station or cholera hospital established, city officials refused to let the ship dock, sentencing its passengers to a horrific stay anchored just beyond the shore. Thirty of the three hundred passengers on board died. Fortunately, the onset of frigid weather prohibited cholera from spre
ading beyond the harbor (Duffy 1968), despite the fact that many passengers had escaped the infected ship, reaching mainland via small boats (Rosenberg 1987b, 104).

  Cholera reasserted itself in the summer, once again stirring complacent physicians and city officials into action. In May, the city established a special Medical Council of three prominent allopathic physicians, charged with containing the epidemic. They promptly declared cholera to be noncontagious (Duffy 1968). Aimed at assuaging growing panic, this announcement led to a series of misguided policies and interventions. If city officials and allopathic physicians had learned any lessons from 1832, they did not show it. The program was largely the same—clumsy sanitary and quarantine measures, polarizing debates over the nature of cholera that delayed every proposed action, and the continued use of heroic treatments to the detriment of patients. In a testament to such stagnation, the council reprinted the same 1832 broadside of recommendations to the public with only a few “verbal changes” (Rosenberg 1987b, 109). Seventeen years after the original outbreak of cholera, officials had little more to offer than “Be Temperate in Eating and Drinking!”

  As the epidemic intensified, hostility toward health officials grew. The Medical Council’s policies were met with widespread skepticism and, occasionally, outright revolt. When the council took over and transformed four city schools into temporary cholera hospitals, it incited ire from the press and local communities in the process. People avoided the new hospitals at all costs; to be sent to them was seen as a death sentence. One of the council’s rare innovations was a massive effort to remove pigs and other livestock from the streets. As of 1842, there were a recorded ten thousand hogs roaming the city. Because the council believed that there was some connection between cholera and filth, it decided to remove the pigs as part of its effort to clean up the city. Undoubtedly an eyesore—Charles Dickens described them as “having, for the most part, scanty, brown backs, like the lids of old horse-hair trunks; spotted with unwholesome black botches . . . long, gaunt legs, too, and such peaked snouts, that if one of them could be persuaded to sit for his profile, nobody would recognize it for a pig’s likeness” (Dickens 2000, 97)—the pigs performed an essential service for the city. By removing the pigs, officials removed one of the most important scavengers from the streets at the precise time they needed them, increasing the city’s filth and facilitating cholera’s spread (Duffy 1968; Rosenberg 1987b). Moreover, these removal efforts were met with riots, as the hogs were essential to the livelihood of the poor.