Abstract
What do the eminent nineteenth-century German physician Robert Koch, the cholera pandemics of that same century, the American Medical Association, and the Alabama State Legislature all have in common? Another question: Is Owen Whooley’s treatment of how all of these played important roles in the rise of allopathic medicine in the United States a work of medical sociology, sociology of the professions, medical history, or, in his words, the “sociology of epistemology” (p. 30)? If you are hoping for “all of the above,” you will find this treatment at once fascinating and strangely familiar, as if you’ve heard the bits and pieces before but find them put together here anew in an ambitious and stimulating narrative.
At its core, Knowledge in the Time of Cholera argues that the ascendency and professionalization of organized medicine in nineteenth-century North America was not a foregone conclusion. Rather, its success was the result of a number of contingent clinical and epidemiological, political, and, ultimately, epistemological struggles over how to explain and control cholera in the United States. These pandemics, starting in about 1832 in the United States and recurring periodically throughout the world even today, are themselves the subject of many publications in the history of medicine (e.g., Charles Rosenberg, The Cholera Years [1962]), and this work might be taken to indicate that cholera is one of the most important and studied of disease models. A walk through my university library’s stacks will reveal over thirty linear feet of bookshelf devoted solely to cholera and its causative bacterium, Vibrio cholerae. Whooley relies on these familiar works in broad outline, but he goes further by exploring and attributing contingent import to events found in some less well-known corridors of medical history. For example, he recounts in detail how various U.S. state legislatures passed, then repealed, then passed anew, protectionist licensing laws designed to shield allopathic medicine from other aspirants to the throne of cultural legitimacy and professional dominance.
The symptoms and course of cholera command attention by the rapidity of onset and the severity of the clinical presentation, marked by profuse diarrhea and acute vomiting and leading to lethal levels of dehydration and metabolic imbalances. Death often comes within hours or days. There was no cure, nor a known etiology, both of which helped make the recurring waves of the disease terrifying. And if the public was afraid of death’s random knock, various types of healers at the time (regular or allopathic physicians, homeopaths, Thomsonians) were equally anxious that they could not adequately explain or treat the disease.
Allopathic physicians, putatively grounded in rational explanations and a proto-empiricism, had no clear understanding of cholera or how to treat it. The anti-elitist Thomsonians, favoring a more democratic epistemology, were grounded in common sense, folk wisdom, a decentralized view of social order, and a system of cure not dissimilar to the Greek humoral system of opposites (hot/cold, wet/dry). Homeopaths were not as wedded to a strong democratic ethos, but like the Thomsonians they believed that patients could essentially be their own doctors. Compared to the heroic and often injurious treatments of the so-called expert allopaths (e.g., bloodletting), cholera treatments given by these alternative practitioners were far more benign and were pointed to as evidence of the callousness of the regulars.
A race was on between these contending medical sects to not only explain and treat cholera, but to win the larger “epistemic contest” (p. 21) over the very bases and types of evidence upon which such explanations should legitimately rest. The contest was as much “What is a medical fact?” as “What is cholera?” And when the allopathic regulars did no better with cholera than the homeopaths or Thomsonians, those protective licensing laws slowly got repealed, helped along in no small way by partisans from the alternative medicine communities. By 1864, medical licensing was back where it began some fifty years earlier.
Not surprisingly, the sanitation movement’s focus on cleanliness and pollution remediation helped slow the spread of cholera. In 1854, a cholera outbreak in London led physician John Snow to track the geographic spread of disease using neighborhood dot maps; the cases all centered around the Broad Street public water supply pump, which, when disabled, helped reduce cholera mortality. Although the movement still had no root-cause theory of disease (Snow was challenged to show that the disease was not simply in the neighborhood’s air), in 1866, on the eve of another wave of cholera in New York City, the nation’s first board of health was established; and it moved quickly to contain the disease at the ports. But sanitation’s successes were not enough to overcome its weak theories of disease etiology, which were similar to miasma theory. Miasma, or “bad air,” theories and those of the homeopaths and the Thomsonians eventually weakened when germ theory and Robert Koch’s 1884 microbiological identification of Vibrio cholerae gained greater acceptance in the last quarter of the century. These developments helped provide allopathic medicine with a laboratory-based explanation of cholera’s cause; more importantly, they helped legitimate an explanatory framework that could be exploited in the cultural and political battle for state-sanctioned legitimacy as a profession.
The “tidy story” (p. 7) of a self-evident and logical progression to professionalization for the allopaths is wrong, in Whooley’s view. It was politics that drove the science, not science that drove the politics. Or one could also say that the politics and the science were inseparable. Whooley calls on Andrew Abbott’s (1988) ecological model of the professions for reinforcement here, where “knowledge is the ‘currency of competition’ among professions” (p. 13). Chapters on the role of the American Medical Association, the rise of municipal boards of health, and the history of laboratory-based work to discover the cholera microbe ably serve to complicate the tidy story and help advance Whooley’s theory of epistemic warfare. A closing chapter on Medicine after the Time of Cholera (another allusion perhaps to Gabriel García Márquez’s 1985 Love in the Time of Cholera) summarizes the argument and speculates about some lasting impacts of the struggle.
That this book is being reviewed by historians, sociologists, and humanists alike speaks to the success of Whooley’s interest in bridging disciplines and explanatory schemata. His writing is fluid, well-documented, and enlivened by many personal and historical details and notes. The multi-layered story of the contested rise of allopathic medicine (i.e., culturally situated, historically dependent, politically driven) makes Knowledge in the Time of Cholera sound more like science studies than history (cf. Steven Shapin, Never Pure [2010]), but that may be an artificial distinction. Still, there are points in the book where I would like to have seen more explicit causal arguments about how each event in his narratives helped propel events in the other narratives, but that may be quibbling about a highly engaging and informed project.