Source: The Lancet 367,1647-8,
May 20, 2006.
BOOK REVIEWS
Operations without
Pain: The Practice and Science of Anaesthesia in Victorian Britain
Stephaine J. Snow, Palgrave Macmillan, 2006,
ISBN1-403-93445-2
The Medical Detective:
John Snow and the Mystery of Cholera
Sandra Hempel,
Granta Books, London. 2006, ISBN1: 862-07842-4
Also issued in the United States
as:
The Strange Case of the
Broad Street Pump: John Snow and the Mystery of Cholera.
Sandra Hempel,
University of California Press, January 15, 2007, ISBN: 0520250494
To read these two books, as
I did, in the aftermath of the Hwang Woo-suk scandal was a strange and
ultimately revealing experience. Could two worlds be further apart than that of
the Victorian epidemiologist and anaesthetist John Snow and South Korean
stem-cell scientist Hwang Woo-suk? And could the respective pristine and sordid
images of science and scientists be more different?
The Hwang affair makes
public how fiercely competitive and global the biotech industry now is, and also
the extent to which nationalistic fervour rides on the promise of scientific
glory. Above all, Hwang's so-called cloning breakthroughs were to demonstrate to
his countrymen, as much as to the rest of the world, how a nation newly shorn of
state planning and patronage could successfully compete in the "free"
international market. That science is politics (whatever else it might be) and
that all we ever hear is rhetoric may be the most important conclusions to draw
from the affair. But there is at least one other as worthy of note, especially
when it comes to thinking of John Snow—namely, that the producers of scientific
innovation never stand alone. They are always embedded in domestic and
international cultures and are identities-in-the-making: individual,
professional, and institutional. If this is often overlooked in the face of more
singular and celebratory accounts, it is partly because of the ease with which
we forget that the heroic way of styling scientists and their achievements is
itself the product of a specific context—the high-noon of late-19th-century
nationalism and imperialism, when the positivist notion that scientific "facts"
are wholly separable from social values, religion, and ideology had taken hold.
It is largely upon such
foundations that Snow's iconic status has been fashioned. Whether as
epidemiologist tracking the water-borne source of cholera at the famous Broad
Street pump, or pioneer technologist of anaesthesiology ministering to Queen
Victoria, he appears out of the ordinary. Through single-minded dedication to
scientific truth and progress he is seen bringing infinite benefit to
mankind—albeit as unsung prophet in his own time. A humble practitioner—teetotaller,
virgin, and vegetarian to boot—Snow inheres all the purity of his name, a
saviour in secular dress.
But why should we have to
revert to the language of divinity to make sense of his accomplishments? As we
are unlikely to invoke the Antichrist to account for the rise and fall of Hwang,
so for Snow, it makes better sense to try and match the man to his context.
Doing so requires an understanding that prestigious careers in early-Victorian
medicine were not established by wielding modern scientific knowledge about the
human body. Rather, they were made by attending to the perceived-to-be unique
individual characteristics of patients, especially those of the piper-paying
rich.
It was Snow's misfortune to
have neither the background nor the patronage to allow him to break into the
physician elite that privately ministered to these precious bodies. A farm-labourer's
son, he could not acquire the necessary Fellowship in the Royal College of
Physicians, which was restricted to those with degrees from Oxford or Cambridge.
After obtaining his Licentiate from the Society of Apothecaries, in 1838, and,
the same year, membership in the Royal College of Surgeons, he hung out his
shingle in Soho. Meanwhile, waiting for patients, he involved himself in the
reputation-enhancing Westminster Medical Society—a haven for ambitious doctors
with interests in science and the politics of reform. It was here that Snow
cultivated an interest in respiration and the kind of analytical techniques that
he would eventually apply in determining the transmission of cholera.
Snow's career as an
anaesthetist also hinged on his finding a means to earn an income. Almost from
the moment ether anaesthetic was introduced into Britain late in 1846, Snow
dabbled with perfecting a method of regulating its administration. It was a
problem that had put off some surgeons from using what was otherwise generally
heralded as a major boon for dentistry and surgery. Snow, soon after gaining a
foot in the door of St George's Hospital to demonstrate his techniques, produced
On the Inhalation of the Vapour Ether in Surgical Operation (1847). Textbook
publications of this sort were the way to advertise one's wares and build a
reputation. And it worked: Snow's meal ticket was made, and he never looked
back.
To suggest that market
wisdom impelled him, rather than genius or the disinterested imperatives of
science, is not to underestimate Snow's achievement. On the contrary, it's the
only way fully to comprehend it, for it was not his face-mask technology in and
of itself that was revolutionary, but rather what it signified symbolically and
literally: the transformation of traditional doctor-patient relations as
modelled on deferential interactions with the social elite. Snow's face-mask
literally allowed the doctor to regulate and control the patient. Personhood was
surrendered in the process.
Medicine too—in terms of
doctor-patient relations—never looked back, although the transformation from the
"biographical" to the "scientific" approach to patients did not take place
overnight. Revealingly, in Scotland, the handkerchief, a far less de-personalised
means of administrating chloroform, continued in use for the wealthy, and was
vigorously defended "‘in the face" of Snow's innovation.
In laying out much of this
story, Stephanie Snow's Operations With Pain is a good example of modern
scholarship in the history of innovation and specialisation in medicine. Given
that so little is known of how science was actually brought to the bedside in
British medicine, it is a welcome addition to the literature. It is perhaps all
the more remarkable in coming from a distant relative of John Snow,
consideration of which may excuse the book's suggestively celebratory
dust-jacket portrait of the great man.
Far less forgivable is
Sandra Hempel's popular account of Snow's "demystification" of cholera.
Predictably, The Medical Detective, full of hindsight evaluations, tells
a Smilesean story of self-making, with the enlightened hero everywhere battling
against the forces of darkness. Hempel pumps her Snow pure, necessarily treading
lightly around such uncomfortable truths as that during his lifetime the only
backing Snow obtained for his theory was from self-interested local gut
spinners, bone boilers, and the like. Readily did they perceive that his theory
trumped the costly and interfering disinfectant legislation pushed by the
reigning miamaticists (Chadwick, Nightingale, and the like). If cholera was
water borne, what worry from unsavoury disease-indicating smells? According to
the rules of hagiography, however, there can be no place for historical
infelicities of this sort, let alone their careful unpicking.
Romantic schoolgirl stuff
though it is, Hempel's narrative is hardly innocuous. It is precisely the kind
of representation of the great and good in science and medicine that fatefully
ricochets back on the present. By failing to inquire seriously into the contexts
for, and meanings of, discovery and innovation, it supports a wholly
individualist impression of how modern biomedicine was installed and operates.
Ultimately, the Hempels of this world are responsible for why the Hwangs of it
are made to swing alone, cast all-too-easily into ethical mires supposedly of
their own making. Thus functions the politics of the pristine.
Roger Cooter
Professorial Fellow WTCHM, University College London
r.cooter@ucl.ac.uk
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