Knowledge in the Time of Cholera (12 page)

LICENSING REPEAL AND PROFESSIONAL COLLAPSE

The visions of medicine proposed by Thomsonians and homeopaths differed in the degree to which they sought to flatten hierarchies in medical knowledge (see
table 1.1
). Nevertheless, both offered a more democratic epistemology than allopathy. And in articulating competing epistemological visions and demanding an account of regular medical knowledge, Thomsonians and homeopaths shifted medical debates over particular issues, like cholera, onto the level of epistemology. By provoking comparisons between sects, these alternative medical sects suggested the possibility of choice in medicine. Seizing the opening afforded by the epidemic, they transformed cholera into an epistemic contest.

As argued above, epistemic contests play themselves out in institutional arenas, whose natures affect their trajectory. After the first cholera epidemic, no arena was more significant than state legislatures, where medical sects vied for authority through licensing laws. Prior to 1832, regulars looked optimistically to their professional future, having gained a measure of professional recognition with the passage of licensing laws in thirteen states (Numbers 1988). Laws varied across states but generally they either prohibited the practice of medicine by nonlicensed physicians (punishable
by
fine or imprisonment) and/or prohibited nonlicensed practitioners from suing for fees, an economic prohibition that could cripple a practice. Licenses were granted by medical schools, societies, or board of examiners, all bodies under allopathic control. While these laws were mainly symbolic, as it was difficult to enforce them (De Ville 1990; Kett 1968; Shryock 1967; Haller 2000), they had important symbolic value, for despite their limitations, they endorsed allopathy's claim to a privileged professional position. Allopathic optimism dissipated after the 1832 cholera epidemic, as the Thomsonians and homeopaths used regulars' cholera failure to advocate for the repeal of such laws. Rapidly, the regulations were repealed. Beginning with Alabama and Ohio in 1833 through the final elimination of all regular legal privileges in New York in 1844, states deregulated medical practice, the exceptions being New Jersey and the District of Columbia.
⁸
The repeals both humbled the profession and ushered in a period of intense competition between medical sects (Numbers 1988). By 1848, the arrival of the second cholera epidemic in
the
United States, government regulation of medicine had reached its “nadir” (Kett 1968, 27).

Table
1.1. Contrasting styles of reasoning among nineteenth-century medical sects

Map of repeal of state licensing laws. Mark Treskon.

How did alternative medical movements achieve such success in their campaigns against licensing? By examining the legislative debates over licensing laws in the New York State legislature—the state with the longest and most protracted struggle—we can gain a general sense of how these competing rhetorics and epistemic visions played out in the state legislatures. In the New York State legislature, alternative medical movements' vision of knowledge found an audience generally receptive to their democratic ethos and hostile to regulars' appeals to authority. Thomsonism's elevation of common sense and homeopathy's recognition of the public as legitimate judges shared affinities with the culture and organizational practices of the legislature, which, despite its failings and contradictions, had been influenced by Jacksonian democratic ideals. In the end, Thomsonians and homeopaths offered something more substantial to the legislatures than better efficacy in addressing cholera. They offered a new vision of medicine that democratized knowledge.

Deregulation in New York

During the Jacksonian era, American political institutions underwent a democratic transition (Pessen 1969), as political reforms expanded suffrage and sought to make government more responsive to the people (Kass 1965). In the new era of mass political parties (Schudson 1998), politicians had to placate a growing electorate, if not in substance, at least in rhetoric. Certainly within the political realm, the rhetoric of democracy and the common man became common currency among all political parties and actors. Historians have long debated the extent to which the egalitarianism as espoused by politicians during this period was genuine (see, for example, Feller 1990; Kohl 1989). Even if the appeal to the common man was cynical, it provided an important cultural trope used by both political parties, Whigs and Democrats (Kohl 1989; Wilson 1974). The use of such rhetoric—the instrumental and, yes often, cynical appeals to democracy by politicians—reflected a substantive shift in political calculus toward a participatory role for the public, and politicians adapted accordingly, clamoring to present themselves as attentive to public input.

By 1832, democratic reform had already reached the New York State legislature. In the 1820s, New York expanded the franchise by repealing property
qualifi
cations for voting. Throughout the 1830s and 1840s, Jacksonian Democrats, organized under Martin Van Buren's Albany Regency, controlled the legislature, but the Whigs maintained a significant minority status. Regardless of who was in control, however, the similarities between the parties outweighed their differences (Benson 1961; Kass 1965). An emerging consensus among historians is that Whigs and Democrats shared a commitment to key unquestioned values—the permanence and immutability of the Constitution, the defense of liberty and republicanism as the prime goal of political activity, and the liberal economic precepts of private property and free enterprise (Feller 1990). More important, both political parties sought to gain mass appeal, differing only in their conceptions of and means to individual freedom, not in the significance of freedom as an ideal (Wilson 1974). Both learned to act and talk within a democratic universe, where “everyone loved the people, bowed gladly to their sovereignty, celebrated their virtue and their judgment” (Meyers 1957, 257).

While the actions of politicians rarely lived up to their professed democratic ideals, they did shape how the legislature viewed knowledge. The appeals to the common man by both New York Whigs and Democrats implied a view of knowledge production that advocated common sense and a mistrust of authoritative accounts. De Tocqueville (2000, 512) was struck by Americans' self-reliance on intellectual matters, their suspicion of authorities, and their continued appeals to common sense, noting “each American appeals to the individual exercise of his own understanding alone.” The Jacksonian era represented the first flowering of anti-intellectualism in America, as citizens adopted “the widespread belief in the superiority of inborn, intuitive, folkish wisdom over the cultivated, over-sophisticated, and self-interested knowledge of the literati and the well-to-do” (Hofstadter 1963: 154). Legislators were not immune to such anti-intellectualism. As historian Jean H. Baker (1983) shows, they were also socialized into these anti-intellectual values through shared educational experiences that promoted challenges to authority and organized dissent, values that were later reinforced by political parties.

This anti-intellectual, democratic view of knowledge informed the institutional practices of the legislature. While the legislature was by no means a bastion of measured deliberation, its structure of decision-making processes stressed debate and encouraged the exchange of competing viewpoints. Pressing issues were sent to committees for investigation. Committees gathered information (often statistical data) and submitted reports, along with
their
recommendations, to the entire chamber. Committees were required not only to give their recommendations but also to
demonstrate
their reasons for their conclusions. Thus, even if political machinations operated behind the scenes, in its formal procedures, the legislatures championed ideals of open debate. Arguments needed to be justified in front of the whole chamber as well as to the public through the media. The operating ideal implicit in these institutional practices bowed toward a democratic epistemology in which competing arguments were presented, debated, and then collectively decided upon. The epistemologies of Thomsonians and homeopaths, which sported flatter hierarchies in knowing, mirrored the changing conception of the public evident in the New York State legislature. Alternative medical movements did not succeed in the legislature simply because they rode a favorable cultural wave. Nor was it because they spoke the legislature's language or because they successfully framed cholera. Rather, the epistemologies tacit in their rhetoric aligned with the legislature's own understanding of knowledge.

Take for example the ideological resonance between legislators and Thomsonians—their shared commitment to common sense, anti-intellectualism, and self-sufficiency in matters of knowledge. Both viewed knowledge production through the lens of democracy and the egalitarian ideals of the Jacksonian era. The
Boston Thomsonian Manual'
s (1841, 98) complaint that “the art of healing, as it is called, has been long confided to a few interested individuals, who by degrees obtained sufficient power and influence to sway the public mind and chain posterity to whatever they might indicate for the health and lives of the people” could have easily been written by Jacksonian political reformers. Just as the people should choose and challenge their politicians, so should patients choose and challenge their doctors. In many ways, Thomsonians applied Jacksonian political logic to medicine, for their appeal to the common man, laissez-faire economic arguments, and condemnation of monopolies mimicked that of Andrew Jackson and the Democratic Party. Thomsonian rhetoric against monopolies was familiar to legislators, who often employed similar arguments in political matters, like the controversy over the Second Bank of the United States.
⁹

Similarly, the sympathetic hearing given to the homeopaths by the New York State legislature stemmed from the resonance of their statistical rhetoric, and the fundamental epistemic assumptions underlying this rhetoric, with the legislature's epistemology. This elective affinity (Weber 2002 [1909])
¹⁰
between homeopaths and the legislature operated on a number of
levels.
First, there was a technical affinity. Both homeopaths and the legislature were engaged in gathering and producing statistical data. In a period of negative liberalism, when the government remained hesitant in acting, “one thing a government that saw itself as doing very little did do was gather statistics” (Kelman 1987, 275). Legislatures were familiar with statistical and numerical data, as they were prevalent in policy debates. Second, the homeopathic approach to knowledge production shared certain homologies with the legislature's own understanding of debate and deliberation as expressed through its institutional practices. The decision-making processes of the legislature stressed demonstration and encouraged the exchange of competing viewpoints. Contrasted with the authoritative testimony of allopathy, which attempted to convey medical knowledge through a monologue, homeopathic rhetoric embraced transparency and dialogue. Finally, the rise of statistical thinking and numeracy was tied up in the very changes in the conception of the public during this period as embodied in the legislature, which mandated that claims had to be demonstrated to the public and endorsed by it in order to be legitimate. No longer passive bystanders, the public was encouraged to participate both in the politics of the day and, for alternative medical sects, in shaping medical knowledge.

This epistemological resonance explains the success of alternative medical sects in convincing the New York State legislature to repeal the licensing laws, despite strong allopathic resistance. Thomsonians took the lead in the fight for repeal. In 1834, they gathered over thirty thousand petitions in a successful effort for the repeal of a law prohibiting unlicensed practitioners from using botanicals when treating patients (Haller 2000). Homeopaths also petitioned against licensing, and while they accumulated fewer petitions, they had the support of their more influential patients. After a decade of fierce advocacy and near misses, the legislature voted to repeal all restrictions on medical practice in 1844, placing the alternative sects on equal legal footing with allopathy.