INTRODUCTION Medicine at the Crossroads Riffling through a box of family photos and letters, I found a small cardboard tube enclosing a tightly rolled sheet of paper with lightly stained edges. I carefully pulled it from the tube and began to gently unroll the paper. Swirls began to appear along the border as well as an official-looking seal, a certificate of some sort. "The Kellberg Institute for Hygiene, Massage, and Medical Gymnastics" it read across the top. Medical gymnastics? An image of a woman in a blue hospital gown vaulting over a hospital bed, her gown flapping open immodestly in the back, popped into my head. Who did gymnastics for medical reasons? Below the school name it read Corinne Newmann, the date, May 12, 1916, and her apparent specialty: water therapeutics. It seems my great-grandmother did. I soon learned that medical gymnastics is still around--we just call it exercising today. Swedish immigrants in Chicago founded the Kellberg Institute and offered instruction in the Swedish gymnastics system developed in the early nineteenth century by Swede Per Henrik Ling to promote health and healing. Ling developed a method of medical calisthenics after noticing how his own daily exercises had healed the joint injuries sustained from his strenuous fencing hobby. His regimen also incorporated massage; Ling is the Swede behind Swedish massage. The mainstream medical community did not exactly welcome Ling's system with open arms--outright disdain for his presumption of medical knowledge might be more accurate--yet his system found widespread approval among the general public and a vast group of independent healers with their own divergent ideas of disease, health, and wellness. And yet we now take it for granted that exercise is fundamental to good health. How did that happen? What other now widely accepted ideas began on the margins of medicine? These questions led me deep into the history of what we would now call alternative medicine but what was often known in the nineteenth century as unorthodox or irregular medicine, and at less kind times, quackery. But the more I read, the more difficult it became to determine what was quackery and what was simply a bold innovation. Take hydropathy, or the water cure, which advocated the importance of water to health. Patients did all kinds of odd things like taking cold baths outdoors and wrapping themselves in cold wet bandages as a means of washing away disease. But hydropaths also advised drinking eight or more glasses of water a day. I tried to remember the last time I didn't fill my own water bottle several times a day with the vague notion that I did it to keep healthy. This idea, too, came from a quack? Wading still deeper, I found nineteenth-century irregulars advocating cleanliness and diets of fruits, vegetables, and whole grains, prescribing medications with few side effects and made of natural ingredients, and hypothesizing on the connection of both the mind and body to one's overall well-being--nothing that would seem out of place in modern discussions of health and wellness. At the same time, the more I read about mainstream, or regular, medicine--as it was known at the time--the less regular it seemed. Many of the therapies practiced by these doctors seemed at best odd, and at worst more quackish than the quacks. Bleeding, induced vomiting, blistering, and sweating, often to painful and sometimes deadly degrees, were the primary tools in the doctor's bag. The reasons for prescribing bleeding over vomiting for any given patient seemed to depend more on the doctor's inclination, training, or mood than anything we would recognize as sound evidence today. At the same time, regular doctors lampooned hydropathy's concern for daily baths and regular water consumption, just as they had disdained Ling's exercise regimen. And then there was Missouri physician John Sappington, who manufactured and sold his own brand of pills for fever in the 1830s. "Doctor John Sappington's Anti-Fever & Ague Pills" bore all the marks of the classic patent medicine, and Sappington of the snake oil salesman: he kept the ingredients secret, he advertised in newspapers and magazines, and he made a fortune off of its sale. But Sappington's pills also proved quite effective, particularly against malaria, as one of its secret ingredients was quinine, the first effective treatment for the disease. His regular colleagues denounced him as a quack, but Sappington's pills made him one of the first people in the United States to use quinine to successfully treat malarial fever. How could he be a quack? Or was he a regular doctor who also sold patent medicines, making him what--an irregular regular? The more I read, the more confused about these distinctions I became. These weren't the stories I was used to hearing. Most accounts of early American medicine focus tightly on embattled doctors valiantly protecting the public from harmful--and even deadly--medical charlatans and quacks. The nineteenth century was not called the "golden age of the quack remedy" for nothing, right? But here were quacks advising patients to drink water and prescribing patent remedies with active ingredients that really worked. Calling one group regular and everyone else irregular seemed far too simplistic and even misleading. The contest between regular and irregular medicine brought me into nineteenth-century America, where I found a medical landscape both contentious and wildly hopeful. It was a time when healers of all kinds--regular, irregular, quacks, and everything in between--vied for public favor as the criteria for practicing medicine seemed to be no criteria at all. Phrenologists read character on the topography of human skulls, mesmerists transferred animal magnetism through a hypnotic stare, and Thomsonians found all the drugs they needed growing just outside their doors. These healers fought to win the right to heal the bodies and minds of a people in a new country with their own ideas of who to trust. In an era when reformers banded together to try to remake religion, abolish slavery, outlaw liquor, open free schools, and grant women rights, it seemed only natural to me that some would focus on improving the quality of health care. So why hadn't I heard these stories before? Many of the nineteenth century's healing claims seemed just as ridiculous and unbelievable as I'd always supposed. Why would people think that the shape of their heads revealed anything about their character? Or that sickness resulted from a lack of internal heat? But millions of Americans, educated and not, rich and poor, did believe, or at least hoped these cures would work. And as the contradictions stacked up before me, I wondered where some of these irregular medical systems had even come from in the first place. Which caught on and why? What made them believable? And how did modern medicine, which appears to be a conglomeration of regular and irregular therapies, emerge from this nineteenth-century maelstrom of competing claims? My own feelings of incredulity fit the tenor of the times. Hardeyed skepticism and zealous belief ran hand in hand throughout much of the nineteenth century. The era fairly throbbed with new ideas, technologies, and sciences, each seemingly more novel, unbelievable, and glimmering with possibility than the last. Few could resist giving at least some of these novelties a try. On a fall afternoon in 1873, writer and humorist Mark Twain arrived at the London offices of a fellow American. In town for a series of lectures, Twain had seen an advertisement for Lorenzo Niles Fowler, "practical phrenologist" and decided to investigate. Phrenology wasn't new to Twain. He remembered the itinerant phrenologists from his childhood in Hannibal, Missouri, giving demonstrations and offering advice. These travelers were "popular and always welcome," satisfying the townspeople with "translations of their characters," he recalled. Nearly everyone received positive readings. "I still remember that no phrenologist ever came across a skull in our town that fell much short of the [George] Washington standard," wrote Twain. Phrenology wasn't new either, but by the 1870s, its massive wave of popularity had long since crested in the United States. Devoted phrenologists could still be found, though, courting true believers and those who perhaps just ardently wished to believe that character could be scientifically "read" on the skull and possibly even improved. Entering Fowler's Ludgate Circus office, Twain "found Fowler on duty, amidst the impressive symbols of his trade ... all about the room stood marble-white busts, hairless, every inch of the skull occupied by a shallow bump, and every bump labeled with its imposing name, in black letters." Twain paid Fowler for a reading. It's not clear whether he attempted to disguise his physical appearance. Well known by this time for his short stories, lectures, and best-selling travelogue The Innocents Abroad, or The New Pilgrims' Progress , Twain cut a fairly recognizable figure. Either way, Fowler gave no indication that he recognized Twain. In fact, Twain complained that Fowler "fingered my head in an uninterested way and named and estimated my qualities in a bored and monotonous voice." The reading was fairly typical, a balanced mix of neutral and positive traits, save for one spot particularly galling to the famed humorist. "He found a cavity, in one place; a cavity where a bump would have been in anyone else's skull," recalled Twain. "He startled me by saying that that cavity represented the total absence of the sense of humor!" Twain's colorful report of his analysis in his Autobiography is the only remaining record of his visit; the original chart does not seem to have survived. Although he clearly twisted the results for a good joke, Twain, whose interests ranged "from protoplasm to infinity" according to one biographer, remained both dubious about and fascinated with phrenology, among other irregular healing methods, throughout his life, submitting to at least two other evaluations and writing phrenology into many of his stories and essays. Twain wasn't alone. In a world where an invisible electric substance could transmit messages over telegraph wires, and where mechanical looms operated by a single person could do the weaving of forty women in a single day, who could really say that phrenology wasn't at least plausible? In this fast-changing world, Americans wrestled with hope and doubt in their daily lives, but perhaps nowhere more than in matters of health. Nineteenth-century lives billowed with peculiarly named aches, epidemics, and invalidism: Quinsy. Catarrh. Bilious fever. Ague. King's evil. Flux. Neurasthenia. Nearly everyone, it seemed, suffered. Abraham Lincoln shepherded the country through its great civil cataclysm while battling his own severe depression. Louisa May Alcott wrote Little Women and Little Men while suffering from what she believed to be the terrible effects of the mercury prescribed to treat the typhoid fever she contracted during the Civil War. Harriet Beecher Stowe experienced attacks of hysteria so severe that she remained bedridden for weeks at a time in the years before she wrote Uncle Tom's Cabin . Charles Darwin wrote On the Origin of Species while confined to his home, a vigorous young man done in, according to his doctor, by "intellectual labour and moral anxiety" that turned him into a reclusive invalid by age thirty-three. Sickness, both physical and mental, was a major part of being alive. Large segments of the population suffered poor health most of their lives. Filth pervaded daily life. Water was often polluted. Food preparation and storage were unhygienic. Garbage littered streets and yards along with animal droppings and the bodies of animals that had simply dropped dead. Privies and cesspools overflowed. All created breeding grounds for mosquitoes, flies, and other disease-carrying pests. Malnutrition and poor housing, particularly in rapidly growing urban areas, only magnified health problems and spawned epidemics. Infants died of diarrhea and dysentery from contaminated food. Deaths from tuberculosis, scarlet fever, diphtheria, smallpox, and cholera occurred so regularly that they were considered a matter of course. Not every disease killed, though. Others simply made life exceedingly unpleasant and painful. But even when a sick American visited a regular doctor, he rarely received an effective treatment. Scientifically valid medical knowledge was limited, and modern methods to sort out effective from ineffective and even dangerous treatments did not yet exist. Doctors did not understand the role of viruses and bacteria in causing disease, how most organs functioned, or the significance of personal contact and insects in the spread of infectious disease. Most people, including doctors, rarely washed their hands and did not think twice about sharing forks and cups. Medical advances of the period tended to occur in areas of theory, classification, and diagnosis, but not cures. For the average patient, these advances offered little immediate benefit beyond fancier and sometimes more specific names for their malady. Doctors made diagnoses by asking questions, observing the patient's appearance, taking the pulse, and examining, and sometimes even tasting, urine; few performed physical exams. Lacking both the understanding and the correct therapeutic measures, doctors could only respond to symptoms and speculate about the cause of disease. Regular doctors practiced a form of medicine known as "heroic," a name that came not from the efficacy of the treatment or the prowess of the administrator but from the magnitude of the intervention. Doctors bled, blistered, and purged to draw disease from the patient. The most extreme form of bloodletting was venesection, in which a doctor would slit open a vein and catch the pint or two of blood in a bowl. Doctors also applied blood-sucking leeches and employed a spring-loaded device called a scarificator that delivered a series of moderately deep cuts to the skin from rows of sharp steel blades at the flick of a release lever; it was developed in the eighteenth century as a more merciful bleeding tool. Blistering involved placing hot plasters or irritating chemicals onto the skin to raise sores that were then drained. Doctors purged patients with large doses of medicines containing mercury, antimony, and arsenic. The effect was always drastic and noticeable. And it was just what patients wanted. Sick people in every time and place want to feel better and will seek out the treatment or healer that makes that desire a reality. Everyone could agree that heroic treatments did something. Emetics purged, diaphoretics sweated, bleeding bled and changed the pulse. These treatments instilled confidence in the doctor's skills, and confidence could bleeding "worked" because it nearly always produced some change in the condition of the sufferer that could be interpreted as progress, though it might also have been a strong placebo effect or simply a different symptom brought on by difficult-to-control treatments that were prone to infection. Bleeding and purging could cause a patient's blood pressure to drop by decreasing blood volume and oxygen delivery to tissues. Too much, though, could cause organ failure and eventually death. Blistering opened wounds on the skin that could become infected, particularly in these unsanitary times, and spread to the bloodstream, which could also cause organ shutdown and death. Leeches, on the other hand, are still used in medicine to remove excess blood, helping doctors do everything from preventing clotting to reattaching severed fingers. Heroic approaches to healing reflected contemporary thinking on how disease worked but also an ancient cosmology. Medical theory of the time held that external symptoms revealed the disease, so anything that changed symptoms was viewed as potentially useful. These ideas went back thousands of years to the Greek physician Hippocrates and the Roman physician Galen, who proposed that the body consisted of four humors (black bile, yellow bile, blood, and phlegm) that needed to be kept in balance to be healthy. Every person had his or her own temperament or mixture of humors that could be thrown off balance by a variety of factors, including diet, lifestyle, or environment. The symptoms that people complained of and associated with sickness were not the actual disease but a sign of an internal imbalance that needed adjustment. Fever, for instance, was believed to result from too much blood, so anything that could reduce or eliminate it, usually bloodletting, was viewed favorably. Most of the medicines in active use were also known for their harsh effects. Some we would now think of primarily as poisons, such as the derivations of mercury used to purge and sweat patients. Leading emetics to produce vomiting included ipecac, tartar emetic, and sulfate of zinc. Powerful laxatives to clear the bowels included calomel and the root of the jalap plant. Of these, calomel, or mercurous chloride, was among the most dreaded of drugs. Doctors believed that this powerful cathartic flushed disease from the body and stimulated the cleansing power of the liver. But as a compound of mercury, calomel was also toxic. Patients given doses over a period of several weeks developed swollen mouths, ulcerated gums, and uncontrolled drooling. A 1720 prescription for a patient suffering from swollen joints called for two doses of calomel, followed by bleeding twelve to fourteen ounces of blood. After a day of rest, the patient received two more shots of calomel, more than enough to cause acute mercury poisoning. Doctors considered the visible oral damage and extreme salivation proof that the calomel had worked by producing a physical response that differed from that of the disease. Horrible side effects were considered necessary evils on the path to health. With these treatments, the real wonder is that most people survived. But many people did improve, enduring both their sickness and its treatment. Doctors viewed recovery as confirmation of the effectiveness of their therapies and as proof that their underlying theories were valid. In truth, many illnesses, particularly most infections, simply went away on their own. Thousands of years earlier, Hippocrates identified the body's innate ability to respond to illness and even restore itself to health in some cases. This capacity was given the Latin name vis medicatrix naturae , "the healing power of nature." Mainstream doctors from antiquity onward held nature in high regard but by the late eighteenth century, that esteem had become little more than lip service. Most doctors enthusiastically pursued heroic interventions when they could. They did not necessarily deny nature's power, but few believed that she alone could cure. To claim otherwise, though, would have been career suicide for doctors, an admission that medicine was redundant or worse, helpless in the face of nature's supremacy. Well-known colonial American physician Benjamin Rush advised medical students at the University of Pennsylvania to "always treat nature in a sick room as you would a noisy dog or cat" by "driv[ing] her out at the door and lock[ing] it upon her." Nature often had no answer for chronic illnesses, however. Even after surviving a disease, many people lived with compromised health for the remainder of their lives, as did Louisa May Alcott after surviving typhoid fever and its brutal, if well-intended, medical treatment. Disease became a part of life, and many people treated themselves for the aches and pains of everyday living. Do-it-yourself medical books, medical almanacs, and family recipe books abounded with recipes for healing salves, prophylactics, and popular herbal remedies. Many American colonists had brought their favorite manuals along with them, like Nicholas Culpepper's The Complete Herbal or E. Smith's The Compleat Housewife; Or, Accomplish'd Gentlewoman's Companion . Treating yourself was more convenient and cost less than a visit with a doctor, if one could even be found within a day's journey from home. For some, home care was a powerful way to democratize medicine and spread knowledge. John Wesley, better known as the founder of Methodism, was among domestic medicine's biggest proponents. In 1747 he published Primitive Physick: Or, An Easy and Natural Method of Curing Most Diseases , his own low-cost and nontechnical medical manual that instructed users on how to turn kitchen staples into medicine. Onions, honey, and licorice could treat coughs; apple water, asthma; whey and raisins, nosebleeds. He also recommended the unusual application of toasted cheese as a bandage to staunch bleeding. For millions of Americans, these domestic guides functioned as primary care doctors. Armed with these guides, women served as "Dr. Mom" long before marketers invented the term. Since the earliest colonial days, women acted as their family's doctor, nurse, and pharmacist, providing most home medical care and nearly all birthing assistance. Many women had an impressive knowledge of herbal remedies, traditional rituals, and preventative measures passed down through families, found in books, and gained through firsthand experience. The technical simplicity of contemporary medicine made it possible for women, and others who were at the time denied any formal education, to offer many of the same services as a doctor. Although these alternate healers, and alternate forms of health care, had long existed alongside doctors, many more Americans began to turn away from regular medicine in the nineteenth century. It was not so much that medicine had changed as that American culture had changed after independence from Britain. Early Americans demonstrated a stubborn attachment to the idea that every person possessed the common sense to take care of him- or herself. The conditions of life on a new continent had forced colonists to improvise and make their own way in a rough and challenging new environment. As a result, Americans became proudly self-directed, self-reliant, and confident in their own judgment. This did not mean that no one ever sought the advice or counsel of others but it did foster an environment that prized individual good sense. Breaking away from British control only bolstered American confidence in the power of personal freedom and a concomitant distrust of authority, elitism, and control. The rise of Andrew Jackson, a poorly educated man from the backwoods of the Carolinas, to the presidency in 1828, seemed, to many Americans, to herald the triumph of the common man, equality, and democracy in the new country. The Jacksonians denounced the moneyed aristocracy and espoused a democratic ideology predicated on equality, although this equality remained restricted to white males. Under Jackson, free white men finally earned the right to vote as rules requiring property ownership fell. Celebrations of democracy and the right of the people to have a say in all aspects of life shot through popular culture even as the Jacksonian policies simultaneously supported sexual, racial, and ethnic subordination and exclusion. Slogans such as "knowledge is power" and "knowledge, like money, depends on circulation" became the catchphrases of the day. New technology made print cheaper, so books and newspapers proliferated. Public libraries, political parties, and associations devoted to literature, science, and philosophy encouraged the spread of ideas. This democracy of knowledge covered a wide range of topics, including health and science. These events and institutions spurred an egalitarian ethos among many Americans that clashed with the exclusivity of medical knowledge and skill claimed by regular medicine. The growing feeling that people could decide for themselves was not limited to medicine. Democratization significantly reshaped religious attitudes as well, as nineteenth-century evangelicals like Charles Grandison Finney, Lyman Beecher, and Francis Asbury focused on sin as a human choice rather than an inherent part of human nature. With salvation no longer left in God's hands alone, an individual could save her soul by turning away from sin to embrace moral action and God's grace. This emphasis on personal choice opened the door to new religious groups like the Latter-day Saints, Millerites, and Seventh-day Adventists who questioned religious orthodoxy and offered more contemporary and personally empowering alternatives as they competed with older denominations for adherents. Other people and institutions seized on the democratic impulse to propose social innovations that they hoped would usher in a better world. All of the transformations remaking the nation promised so much hope but came laden with challenges. Poverty, lawlessness, and overcrowding gripped city and town alike. Inequality persisted. To solve these problems, reform organizations dedicated to sanitation, abolition, dress reform, vegetarianism, and countless other issues formed around the country. Utopian communities like the Transcendentalist Brook Farm in West Roxbury, Massachusetts, and those of Robert Dale Owen at New Harmony, Indiana, and John Humphrey Noyes at Oneida, New York, attempted to remake society. Most of these communal experiments disintegrated quickly, but these reform efforts nonetheless raised expectations about the possibility of perfecting both human nature and its institutions. All of these disparate reform efforts shared one overriding goal: to match American reality with American ideals. Early Americans evinced a remarkable faith in the boundlessness and perfectability of the nation. The path to perfection naturally began with the individual. Ralph Waldo Emerson counseled, "Nothing can bring you peace but yourself. Nothing can bring you peace but the triumph of principles." Reformers of all kinds encouraged Americans to work toward the perfection of their individual lives, believing that this would have a cascading effect that uplifted all of humanity. In this dynamic environment, it's hardly surprising that irregular medicine flourished. When these systems first arose, the country's medical marketplace was already among the most varied in the world. Medical practice in the eighteenth century had been loosely organized and lightly regulated, an activity in which just about anyone could--and did--participate. All tastes and budgets could find a medical system to match. People relied on doctors as well as midwives, lay healers, herbalists, and Indian doctors skilled in the use of native plants. Ministers, often the best-educated people in a community, received frequent calls to heal the body as well as the spirit. Trained doctors were in short supply. The problem was particularly severe in the South and the West as people moved farther and farther into the frontier. Before the telephone, a doctor had to be summoned in person. A farmer traveling eight miles to town for help could lose a whole day of precious work. Even then, there was no guarantee that the doctor would be home. As a result, responsibility for medical care often fell on the sick themselves. While Americans had frequented a variety of healers since colonial days, in the nineteenth century, medicine became a war zone as health came face-to-face with a growing commercial society. The capitalist marketplace spawned a business sector of medicine that vended medical services and remedies on a large scale. The pace of change in other health fields only accentuated the lack of progress by regular doctors. For the first time, healers who had generally practiced alone began to band together. Thomsonians, mesmerists, homeopaths, and hydropaths led the first offensive, while osteopaths, chiropractors, and Christian Scientists launched a second advance later in the nineteenth century. Each had different therapies, theories, and techniques, but they all wanted to overturn and supplant regular medical practice--or at least, that's what regular doctors tended to believe. "These systems, however widely they differ in character, all agree in one thing--they are all at war with what they term the 'regular' profession," reported Worthington Hooker to the Connecticut Medical Society in 1852. "And this war, which is one of extermination, they have prosecuted from the beginning." Irregulars identified regular medicine with overly aggressive therapies based on old and speculative ideas. They derisively nicknamed regulars "drug doctors" and "knights of calomel and the lancet." Bloodletting and heroic dosing--and in many cases, drugs altogether-- were virtually banished from most irregular practices. Irregulars claimed that common sense and their experience with an alternate form of healing--often gained through some kind of conversion experience-- had completely discredited regular medicine's damaging and depletive therapies. Most relied on natural remedies and proclaimed nature the source of both the strongest treatments and the most effective preventative medicines. They presented their case to Americans in simple and direct language that reinforced the era's widespread belief in intuition, practical sense, and accessible knowledge, while exploiting regular medicine's weaknesses. Irregular doctors were no more equipped to cure than regulars, but their treatments tended to be milder, cost less, and cause fewer side effects. The proliferation of medical systems and alternative routes to wellness spoke to the lack of scientific advancement and to American hunger for new and potentially more effective treatments. Irregulars speculated on the cause of disease and devised coherent and unified theories that made sense of many confusing and often vague symptoms. They promised a clear path to health and wellness. In many ways, irregulars could make greater claims to scientific authority than regular medicine. Most based their theories on their own observations and experimentation, a method generally considered the most modern form of scientific induction of the time. Irregulars observed the effects of certain drugs or procedures and then made claims based on what they saw. They even got a few things right. Even before the irregular assault gained force, regular medicine as a profession had started to lose status. "Medicine has ever been and is now, the most despised of all the professions which liberally educated men are expected to enter," lamented the Medical Record in 1869. Most doctors commanded little respect. Some could barely scrape together a comfortable living and took on second jobs, usually farming, to get by. One dissatisfied doctor even took to robbing stagecoaches on the side, but he was eventually captured and imprisoned. Jokes about doctors filled newspapers and magazines. When a nation abounds in doctors, one wit said, it grows thin of people. English journalist William Cobbett remarked that American physician Benjamin Rush's penchant for extreme bleeding and purging regimens was "one of those great discoveries which are made from time to time for the depopulation of the earth." Even Thomas Jefferson got in on the critique, attesting that doctors tended to be ignorant, uneducated, and extreme in their therapies, especially considering how little they actually knew about health and disease. Looking to the future, Jefferson hoped "that it is from this side of the Atlantic, that Europe, which has taught us so many other things, will at length be led into sound principles in this branch of science, the most important of all, being that to which we commit the care of health & life." Stories of medical men grave robbing for anatomical material and dissection also did little to win public favor to the medical profession. One of the most notorious incidents occurred in New York City in April of 1788 when medical student John Hicks allegedly waved a cadaver's arm at some children peering through the window of a hospital dissecting room. Hicks then called out, "This is your mother's arm! I just dug it up!," likely unaware that one of the children had recently lost his mother. The boy ran home and told his father, who exhumed his wife's coffin and found it empty. As the story got out, an angry mob gathered around the hospital. Hicks and his fellow students and teachers ran as the crowd broke into the hospital. One doctor and five students remained inside, determined to protect a valuable specimen collection. James Thacher, a physician who witnessed the riot, reported that the mob found several human bodies "in various states of mutilation. Enraged at this discovery, they seized upon the fragments, as heads, legs and arms, and exposed them from the windows and doors to public view, with horrid imprecations." Bands of rioters moved across the city reporting what they had seen inside the hospital as they searched for Hicks. To protect the medical students from the crowd, Mayor James Duane had several escorted to jail. The unrest continued overnight and into the following day until eventually more than five thousand people gathered outside the jailhouse throwing rocks and demanding retribution. Finally, the governor sent the cavalry charging up Broadway to break up the jeering crowd. In the end, at least three and as many as twenty people died in the riot or from wounds sustained in the melee. The New York Doctors' Riot, as it came to be known, was not the first or the last medical riot-- others broke out in Philadelphia and Baltimore--and public anger at doctors lingered long after the disturbances ended. Standard medical practice was partly to blame. Medicine in 1820 was little better than it had been in 1700. Heroic interventions remained the doctor's primary tools, just as they had for centuries. Most of the methods to truly understand disease had yet to be discovered. Medical science was not completely stagnant, of course. Physicians and scientists continued to discover more about the body's structure and function, but they had little in the way of new treatments. Many regular doctors sought to draw a line between themselves and those they saw as quacks by proclaiming their devotion to science, but in truth, the boundary between regular and irregular medicine was hazy at best. British physician Matthew Baillie remarked, "I know better perhaps than another man, from my knowledge of anatomy, how to discover disease; but when I have done so, I don't know better how to cure it." Doctors watched helplessly, and not without a bit of jealousy, as scientific discovery and progress rapidly remade nearly every other aspect of nineteenth-century life. The complete ignorance of the cause of disease prevented effective methods of healing or even lessening symptoms, creating a dilemma for doctors trying to heal those who hungered to be well. Public dissatisfaction with doctors was likely not helped by the poor training most received. Medical schools often had minimal entrance requirements, and degrees could be granted in as few as six months. Most doctors, though, had attended no medical school at all. Medical schools of any kind were slow to develop in the United States. The first medical school, at the College of Philadelphia, opened in 1765, more than a century after the founding of Harvard in 1636. Before 1840, only a third of practicing doctors in New England had attended medical school or completed an apprenticeship. The number was far lower in the West and South. Poor training persisted throughout the nineteenth century. It was so bad that one physician bemoaned in the Medical Record that "after a man has failed in scholarship, failed in writing, failed in speaking, failed in every purpose for which he entered college ... there is one unfailing city of refuge--the profession of medicine." Medical licensing systems, weak as they were, were mostly repealed in the 1820s and 1830s. This encouraged the rise of irregular movements by eliminating the legal boundaries between regular and irregular medicine. Many colonies had chartered medical societies in the eighteenth century with the power to administer licenses that placed a nominal penalty on practicing without a license. But even when in force, these licensing systems did not require doctors to demonstrate any of the principles or practices of medicine. Under pressure from proponents and practitioners of irregular medicine, nearly every state legislature removed restrictions on medical practice in the nineteenth century. These irregular healers seized on the democratic spirit of the time to protest restrictions that they said limited choice and fostered elitism. Unlike Europe, where medical practice received some state and institutional support, the United States adopted a laissez-faire approach to medicine. Irregular healers claimed that their common sense and personal experience with alternate forms of healing completely discredited heroic medicine and its terrible side effects. "The practice of physic requires a knowledge that cannot be got by reading books; it must be obtained by actual observation and experience," proclaimed botanic healer Samuel Thomson. Irregulars reminded regular doctors that the first rule of Hippocrates had been to do no harm: only pain and suffering resulted from bleeding, blistering, and purging. Refusing to submit to the pretenses of regular medicine, irregular healers believed in their own right to practice and in the public's right to choose how and by whom they were treated. Regular doctors viewed these irregular systems with derision. They considered irregular medicine a random mix of inert and sometimes dangerous therapies passed off as legitimate on a gullible and unknowing public. "This subterfuge cannot avail," lamented physician Caleb Ticknor. "Call himself by what name he will, a quack is still a quack--and even if the prince of darkness should assume the garb of heavenly innocence, the cloven hoof would still betray the real personage." But who qualified as a quack was a matter of perspective. Irregulars were "quacks" in the eyes of regulars. In these prescientific times, a quack was always that other guy whose methods seemed improper, unscientific, or deceitful to someone else. That someone else often happened to be losing business to these so-called quacks. Regular doctors were not ignorant of the shortcomings of their therapies. Harvard professor and regular physician Oliver Wendell Holmes, one of the century's most outspoken, shrewd, and witty critics of irregular medicine, demonstrated a surprising evenhandedness in his assessments of his own brand of medicine. He despaired of the lack of progress and innovation in medical science. In 1843, Holmes ignited fierce controversy among regulars for his contention, contrary to popular belief, that physicians often transmitted the contagion of puerperal fever, a deadly infection now known as postpartum endometritis and contracted by women during or shortly after childbirth, to their patients. He also decried the overuse and abuse of drugs by regulars. He placed some of the blame, though, on patients who pressured their doctors to do something with big effects as well as the particularly grandiose American character found in doctors and patients alike. "How could a people which has a revolution once in four years, which has contributed the Bowie-knife and the revolver, which has chewed the juice out of all the superlatives of language in Fourth of July orations, and so used up its epithets in the rhetoric of abuse that it takes two great quarto dictionaries to supply the demand; which insists in sending out yachts and horses and boys to out-sail, out-run, out-fight, and checkmate all the rest of creation," asked Holmes, "how could such a people be content with any but 'heroic' practice? What wonder that the Stars and Stripes wave over doses of ninety grains of sulphate of quinine, and that the American eagle screams with delight to see three drachms of calomel given at a single mouthful?" The American Journal of the Medical Sciences acknowledged that "the majority of physicians over-medicate" despite "all that has been written on this subject," and more than a few regulars denounced their field's neglect of nature's healing power. Nature, according to physician Worthington Hooker, was a "good, kind angel, hovering over the bed of sickness, without fee, and often without even any acknowledgement of her services" as she "saves the life of many a poor patient, who is near being drugged to death by some ignorant quack, or some over-dosing doctor." Until the second half of the nineteenth century, though, most regular doctors did not seriously question the efficacy of their remedies and even fewer experimented with anything other than increasing the dose or expanding the range of ills a remedy could treat. Regulars maintained their commitment to heroic therapies for many reasons. Primarily concerned with asserting and consolidating its power as a profession, regular medicine as a whole tended to be less open to new ideas, particularly those that might diminish confidence in its power in the eyes of patients. Heroic treatments caused big effects that emphasized a doctor's authority and control over the situation. Heroic therapies also made regular medicine distinct, a point that became more important as irregular healers grew more numerous and medicine more competitive. As irregular medicine grew in strength and size, it was only natural for regular doctors to rally around their depletive therapies as a mark of cohesiveness and group identity. From the perspective of the average American and despite protests to the contrary from regular doctors, regular and irregular medicine were often indistinguishable. The professional and educational qualifications for both were minimal and the scientific proof for any treatment virtually nonexistent, so people made choices based on their common sense, convenience, finances, and personal experience. They cared only who made them feel better. For most patients, the decision to seek care rested on a multitude of factors, such as cost, expediency, and their personal relationship with the healer. The sick paid close attention to their own illnesses and actively chose among the burgeoning marketplace of healers, regular and irregular. People often tried one and then another and another. An implicit trust in doctors and medicine was not common before the mid-twentieth century. Whether a doctor earned a degree or completed an apprenticeship mattered less to most people than his ability to instill hope and practice confidently. Americans wanted results, and when regular medicine failed to deliver cures as quickly, easily, or cheaply as they sought, they were not afraid to turn elsewhere. Regular and irregular doctors differed most dramatically on one issue: women. Since colonial days, women had performed nearly all of the tasks that professionally trained doctors, nurses, and pharmacists later assumed. But as regular medicine became more organized in the nineteenth century, many regular doctors dismissed traditional female healing practices as ineffective, irrational, and even dangerous. Prevailing ideas about women's health and anatomy also worked to exclude women from practicing medicine. The common theory of female anatomy and physiology placed responsibility for all female physical and mental symptoms on a woman's reproductive organs. Ruled by reproduction, women were deemed too irrational, emotional, and intellectually inferior to pursue professional careers. Some regulars may also have feared that female doctors would steal their business. Even more, the very image of a professional person seemed to challenge women's acceptance in medicine. In the early nineteenth century, a professional was by definition a man and medicine a profession of gentlemen; a professional female physician thus represented a contradiction in terms. As a result, nearly all regular medical schools and medical societies barred women from entry until the late nineteenth century and many into the twentieth century. Those women who did pursue a career in regular medicine faced discrimination and outright hostility. One of the most egregious incidents occurred in 1869 when students from the Woman's Medical College of Pennsylvania received permission to attend the Saturday morning surgical clinics at the all-male Pennsylvania Hospital in Philadelphia. When the women arrived, the male students greeted them with angry jeers, whistles, and groans. Some men even threw stones. "Ranging themselves in line, these gallant gentlemen assailed the young ladies, as they passed out, with insolent and offensive language, and then followed them into the street, where the whole gang, with the fluency of long practice, joined in insulting them," reported Philadelphia's Evening Bulletin . "During the last hour missiles of paper, tinfoil, tobacco-quid, etc., were thrown upon the ladies, while some of these men defiled the dresses of the ladies near them with tobacco juice." Though opposition to female doctors rarely became violent, women, nevertheless, faced a discouraging path in their chosen field. Irregular healers tended to take a different view. Many welcomed women practitioners and established coeducational medical schools. For some, welcoming women served the practical purpose of building market share. Others championed a woman-positive message that celebrated women's unique skills and intelligence. Healing highlighted the "feminine virtues" of nurture, altruism, and morality that made women good wives and mothers. Most women physicians shared that view, believing they were better positioned to protect and improve the health of women and children. They saw themselves as a link between the practice of medicine and women's everyday lives. Like their male counterparts, female doctors treated patients, presented case reports, debated therapeutic methods and innovations, and read medical journals. Allowing women to participate in medicine also solved a very real health problem. Modesty and propriety kept many women from seeking medical care from male doctors. Even when they did, some doctors declined to perform physical examinations, particularly for gynecological issues, out of respect for the delicate sensibilities of their patients. Women could easily find themselves suffering from a dangerous or inappropriate treatment--or no treatment at all--without the benefit of a thorough analysis. But with female doctors, women could get the medical attention they needed. Next to teaching, medicine attracted more women than any other profession in the nineteenth century, the majority in irregular health systems. Prejudice kept many African Americans out of organized medicine, both regular and irregular alike. While folk and herbal healers as well as midwives and other local healers were common in black communities, many medical schools and medical societies refused to admit black physicians, and many white doctors refused to treat black patients. Even so, David Jones Peck and Rebecca Lee Crumpler became the first African Americans in the United States to earn MD degrees, in 1847 and 1864 respectively, and eight black doctors served in the Army Medical Corps during the Civil War. But more common was the experience of Daniel Laing Jr., Martin Delany, and Isaac H. Snowden, who were expelled from Harvard Medical School in 1851 by Oliver Wendell Holmes in the face of intense pressure and opposition to their presence from white students. Even among otherwise liberal healers, discrimination was common. In 1870, homeopaths in Washington, DC, opposed admitting black candidates to the Washington Homeopathic Medical Society. Black medical schools and medical societies did form, but most were short-lived and underfunded. During the Civil War, the Freedman's Bureau began providing medical care to freed slaves and promoting education, but most African Americans faced intense racism and struggled to find and receive adequate medical care throughout the nineteenth century. By the 1830s, irregular systems had grown so numerous and successful that regular doctors increasingly found themselves facing a precarious and uncertain future. "Why are we sick? Why cannot the doctors cure us," asked health reformer Mary Gove Nichols. "We are tired of professions and promises." Nichols was not the only one. Many Americans began asking themselves, and their doctors, the very same question. The list of those who used and advocated for irregular health treatments, and likely contributed to their popularity, includes many of the nineteenth century's boldface names: Thomas Edison, Margaret Fuller, James Fenimore Cooper, Nathaniel Hawthorne, John D. Rockefeller, Mark Twain, Henry David Thoreau, Harriet Beecher Stowe, Edgar Allan Poe, P. T. Barnum, Abraham Lincoln, Susan B. Anthony, and Ralph Waldo Emerson. Some became outspoken supporters of one system, while others dabbled among the marvels on offer in the medical marketplace. Intrigued and hopeful, Americans, the famous and anonymous alike, came to irregular medicine seeking to make themselves happier, healthier, and more successful. This is their story. Excerpted from Marketplace of the Marvelous: The Strange Origins of Modern Medicine by Erika Janik All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.
