Copyright © 2004 by the Johns Hopkins Bloomberg School of Public Health
BOOK REVIEWS |
Cholera, Chloroform, and the Science of Medicine: A Life of John Snow
National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892-6603
By Peter Vinten-Johansen, Howard Brody, Nigel Paneth, Stephen Rachman, and Michael Rip
ISBN 0-19-513544-X, Oxford University Press, New York, New York (Telephone: 800-451-7556, Fax: 919-677-1303, Website: http://www.us.oup.com/us/), 2003, 437 pp., $49.95 (hardcover)
The absence of a comprehensive history of epidemiology must in part reflect epidemiology’s initial appearance as a public health problem-solving tool that was seemingly (as Thomas Huxley once said of science in general) "nothing but trained and organized common sense" (Huxley’s emphasis (1)). Thus, in searching for missing forefathers, modern epidemiologists keep looking for historical heroes who once did what we would like to think we would do now. John Snow (1813–1858) is a worthy forefather, not just because he (mostly) got it right about cholera but also because his two 1854 investigations (of Thames River water and the "Broad Street pump" (2)) seem to have been ahead of their time. How did he do it? Missing from the hundreds of works on Snow—including an often-republished 1858 remembrance of Sir Benjamin Ward Richardson (3), David Shephard’s 1995 biography (4), and a 1995 doctoral dissertation by Stephanie Snow (5)—is any comprehensive examination of the bases, evolution, and context of Snow’s thinking. This new biography (6) by Peter Vinten-Johansen and his Michigan State University colleagues (the self-described "Snowflakes") seeks to repair this deficiency.
Six of the book’s 16 roughly chronologic chapters deal in whole or in part with cholera and epidemiology, the rest emphasizing Snow’s pioneering career as an anaesthetist. The tone is not only scholarly but remarkably homogeneous, given the book’s five authors, and the conclusions are supported by 994 footnotes and a bibliography of approximately 469 entries (occupying 80 and 17 of its 437 pages, respectively). On the whole, it is a rich and rewarding effort that takes us into an era in which, some might argue, epidemiology was born.
Although there is little new here for historians, much of this material will probably be new to epidemiologists, especially the information on Snow’s early years and his remarkably self-disciplined upward mobility. The authors also examine links between Snow’s epidemiologic approaches and his work in respiratory physiology, pathology, and experimental science—a laudable attempt to understand his thinking processes. Still, there are disappointments, such as the distancing of Snow as a person and a "Snow-centric" emphasis on what he alone thought and did, omitting much of the context within which his ideas evolved.
For example, obvious paradoxes are not addressed. Constantly reminded of Snow’s generosity and genius (his mistakes are nowhere given equal weight), we wonder why a friend described him as "not particularly quick of apprehension, or ready in invention" (3), why he left no disciples, why he was privately funny but publicly thin-skinned, why he was a stiff and ineloquent speaker, and why the respect of his contemporaries was sometimes punctuated by sharp criticism. Even his testy exchanges with cholera co-theorist William Budd (once considered the "father of epidemiology") are omitted. Nor do we learn why Snow was famously described by Richardson, the closest thing to a protégé, as "very reserved and peculiar... not easy to be understood and very peculiar" (3).
Missing too is discussion of (and even citations of) published minutes of meetings in which Snow played a role, including those summarizing papers he presented that were not published elsewhere. This prevents the reader from evaluating many scientific exchanges between Snow and his colleagues, leaves us in the dark about what ideas he was being exposed to, and misses a chance to provide scholars with a more complete bibliography.
Other omissions are of context and background. The 1832 cholera pandemic, which profoundly influenced Snow’s generation much as the 1918 influenza pandemic influenced physicians in the next century, is not addressed in depth, nor do we learn much about subsequent ideas on cholera that influenced Snow, like those of S. W. J. Merriman. Nor is there discussion of contemporary successes in "germ theory" (e.g., the 1837 establishment of Trichomonas vaginalis vaginitis, the 1850 discovery of the bacterial cause of anthrax, or the experimental disease transmission work of the physiologists around Magendie and the Alfort school), an important backdrop for Snow’s ardent contagionism. We do not even learn about (Friedrich Gustav) Jacob Henle, whose contagionist views so closely paralleled those of Snow. Unaware of the full scientific background within which Snow worked and thought, readers might imagine that Snow invented epidemiology, contagionism, and the germ theory all at once.
The problem of missing context is most visible in an otherwise minor chapter on cholera spot-mapping that lionizes Snow for his deductive reasoning (though Snow probably did not fully appreciate the power of his 1854 Broad Street maps). A table noting 20 other selected contemporary cholera maps, most of which come off badly in comparison because of their illustrative rather than problem-solving intent, makes Snow look smart. However, a better understanding of Snow’s thinking might have come from discussion of the pre-1854 role of maps in problem-solving—including, for example, Pascalis-Ouvière’s successive case-numbered map or Jewells’ map of lines connecting successive cases (both arguing against yellow fever contagion), or cholera maps making etiologic points (e.g., Mendenhall’s successive case-numbered map showing importation of cholera index cases and secondary case clustering), or cholera maps Snow is certain to have examined himself (e.g., Lea’s 1849 map implicating spring water). Even Henry Whitehead’s alleged drawing of an initial case map in the Broad Street pump investigation goes unmentioned. The reader is well placed inside Snow’s head but sees little of the world outside it.
Vinten-Johansen et al. present a forceful argument that Snow was ahead of his time—a logical thinker, a "systems-network" reasoner, a finder of truths invisible to others. However, alternative interpretations remain unexplored—for example, that Snow was less ahead of his time than of it, less an innovator than a synthesizer, and more an adaptor and (like Henle) an organizer of facts into logical frameworks. That Snow was proven posthumously to be mostly right about cholera and uncommonly (but far from universally) wrong about most everything else could be an argument in favor of his genius, but alternatively it might reflect scientific caution—falsifying what was accepted rather than discovering what was unknown, applying and perfecting rather than innovating, being happily behind the cutting edge (sharpening it but rarely leading it), carefully choosing his battles, and taking care to be often right but never wrong.
Such issues may be clarified by future research. Interpreting, refining, validating, or rejecting the ideas of others, Snow might or might not have been the visionary Vinten-Johansen et al. describe, but their scholarly evidence does show how well his approach anticipated the puzzle-fitting and fact-organizing epidemiology of today. This biography is the most comprehensive and best-referenced work about John Snow published to date. One can disagree with its conclusions, but it is likely to remain an essential resource for decades to come.
Acknowledgments
The reviewer discloses the following relationship with the authors of this book. During its writing, he had discussions with two of the coauthors, supplied research materials to them, and reviewed drafts of and provided critique and comment on eight of the 16 chapters.
REFERENCES
- Huxley TH. On the educational value of the natural history sciences (1854). In: Huxley TH. Collected essays. Vol 3. Science and education. New York, NY: D Appleton & Company, 1894:38–65.
- Snow J. On the mode of communication of cholera. Second edition, much enlarged. London, United Kingdom: John Churchill, 1855.
- Richardson BW. The life of John Snow, M.D. In: Snow J. On chloroform and other anaesthetics: their action and administration. London, United Kingdom: John Churchill, 1858:i–xliv.
- Shepard DA. John Snow: anaesthetist to a queen and epidemiologist to a nation. A biography. Cornwall, Prince Edward Island, Canada: York Point Publishing, 1995.
- Snow SJ. John Snow[,] 1813–1858: the emergence of the medical profession. (Doctoral dissertation). Keele, United Kingdom: Keele University, 1995.
- Vinten-Johansen P, Brody H, Paneth N, et al. Cholera, chloroform, and the science of medicine: a life of John Snow. New York, NY: Oxford University Press, 2003.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||