Whooley, O. Knowledge in the Time of Cholera: The Struggle over American Medicine in the Nineteenth Century. Chicago: University of Chicago Press. 2013. xiii + 307pp. £19.50 (pbk) ISBN 978–0‐226–01763–1

Abstract

After centuries of confinement to the Indian subcontinent, the bacterium Vibrio cholerae began its deadly global spread in the early 19th century. Since that time, cholera epidemics have occurred on every continent, killing by the thousands and causing major disruptions to social institutions and belief systems. When cholera first burst onto the world scene its symptoms were unfamiliar and particularly frightening. The illness killed with a suddenness and brutality that were terrifying. Rapid dehydration could lead to death within hours of the onset of symptoms. Most unsettling of all was that no one understood what caused it, how to control it or even if it was a new disease. Even the threat of a cholera epidemic could evoke mass panic. Many societies that experienced their first cholera epidemics in this era were already in the throes of major demographic, social, economic and political change. The dreaded disease was a toxic new ingredient in that simmering stew. Public officials and medical experts struggled mightily to deal with the problem. Scholars from many nations and academic disciplines have focused their analytical lenses on cholera. Medical historians have studied it extensively, focusing primarily on the evolution of efforts to understand its causes and on the relationship between medical experts, their patients and the state. The disease has also been used as a lens for examining topics as diverse as the evolution of political ideas, institutional effectiveness, social tensions, imperialism, epidemiological science, the public health movement and racial profiling. While most of this literature focuses on Europe and the US, there is a growing body of scholarship on responses to cholera in the developing world. Cholera may, indeed, be one of the most extensively studied illnesses. Given this vast body of literature, Whooley's book is especially noteworthy. Not only has he identified an important missing chapter in the scholarly literature, he has offered it to readers in a thoughtful and engaging monograph. First and foremost, his is a study of the relationship between epistemology and medical professionalisation in the US. Whooley asks: ‘How did this disease come to be seen as a microbe and how did this understanding get folded into the professional project of allopathic medicine?' (p. 7) Sociological analyses of medical professionalisation tended to focus far more on organisational and ideological strategies than upon epistemology; yet professional knowledge is not only important, it is the very foundation upon which most claims to professional status are based. When cholera first reached the US there was widespread disagreement about the nature of the disease. By the early 20th century almost everyone agreed that cholera was a microbe best understood and managed in the laboratory. It was allopathic physicians who aligned themselves with that perspective yet, as Whooley explains, to regard this as merely the inevitable march of scientific progress is to oversimplify or even misread events. What transpired instead was a prolonged and multifaceted epistemic contest. It involved the creation of an exclusive professional organisation (the American Medical Association). It pitted allopathic physicians not only against practitioners from other medical sects (especially homeopathy), but also against state legislators and public health officials, most of whom were more predisposed to support enlightened common sense than the physicians' claims of having exclusive expert knowledge. [R]egulars achieved epistemic closure, and in the process, created the US medical professional, unique to Western developed nations in its authority, suspicion of government intervention, and extreme embrace of a scientific-technological approach to medicine. (p. 226) The US medical profession is distinctive in the ways that Whooley notes, and his analysis adds a new dimension to our understanding of how it came to be so. Nevertheless, in reading his analysis one cannot help but be struck by both continuities and changes in medical knowledge and practice. While the US profession clearly is characterised by that ‘extreme embrace of a scientific-technological approach,’ medical socialisation and practice continue to perpetuate a 19th century (pre-laboratory) perspective that privileges knowledge derived from an individual practitioner's personal clinical experience. Legitimate knowledge, in other words, comes not only from the laboratory but also from the bedside. Claims that medical authority is based on laboratory science are useful in interactions with the outside world but, among peers and students, knowledge acquired from treating patients remains extremely important. This is a valuable and interesting book that will be of interest to scholars from many fields. It makes a contribution to cholera studies but, more importantly, it adds new dimensions to the sociological literature on medical professionalisation. Furthermore, Whooley's conceptualisation of the epistemic contest, elaborated in his concluding chapter, should prove useful in analysing many intellectual debates. I expect we will see it utilised repeatedly by future scholars.