Source: The Lancet 367,1647-8, May 20, 2006.


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

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