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Response to Review no. 573

I am delighted that Dr Zuck appreciates the ‘good heavy covers’ of Operations Without Pain: The Practice and Science of Anaesthesia in Victorian Britain, for it is clear that little else about the book, not even its title nor its place in the Palgrave series of Science, Technology and Medicine in Modern History, pleases him. What is curious though, is that when the criticisms are pared down to their essence Dr Zuck seems to be in accord with many of the central arguments of the book, although he never acknowledges this.

In the main Dr Zuck addresses two questions that I used to structure part of my first chapter. First, how can we reconcile Humphry Davy’s experiments with nitrous oxide in the 1790s with the later work of Henry Hill Hickman, Crawford Long, Horace Wells, and, of course, William Morton? Secondly, why did inhalational anaesthesia emerge in the 1840s? Let us begin with Davy. The first point Dr Zuck addresses is my discussion of Humphry Davy’s experiments on nitrous oxide in the 1790s, in particular Davy’s suggestion that the gas, ‘may probably be used with advantage during surgical operations in which no great effusion of blood takes place’. Dr Zuck says that Davy’s treatise on nitrous oxide does not get a ‘careful reading’ very often—he overlooks the fact that my arguments are based on exactly that. He provides an example of a trial of nitrous oxide at the Askesian Society in March 1800 which produced such alarming effects that onlookers believed William Allen, who breathed the gas, was having a stroke. ‘Does one need more explanation of why Davy’s suggestion was not taken up?’ says Dr Zuck. It seems to me that we do. We need to understand why such experiments in the 1800s seemed so dangerous to onlookers whereas when nitrous oxide was introduced as an anaesthetic in the 1860s, although it often produced exactly the effects described above, most doctors understood it to be a useful, though short-acting, anaesthetic. The powers of nitrous oxide did not change during this sixty-year period: what did change were understandings of the human body. When doctors saw patients inhaling nitrous oxide in the 1860s the effects were the same as in the 1800s but the construction placed upon them—the meaning that was attributed to these effects—had changed radically since the 1800s. Thus my intention was to compare the different medical models of the body in play at different times to see if this provided some method of deepening our understanding of the early history of anaesthesia. Put very simply, my argument goes as follows. Davy and his associates, just like those at the Askesian Society, did not pursue nitrous oxide beyond its benefits as a stimulant on two counts: first, their construction of the human body led them to believe that it was impossible to separate sensibility from the key functions of respiration and circulation; and, secondly, because they believed pain was integral to healing. Henry Hill Hickman’s experiments on suspended animation took place some twenty-four years later and show several key differences. First, Hickman believed it was possible to separate the functions of mind and body, and, secondly, and probably most importantly, he took the view that pain served no function—it was not a necessary accompaniment to a surgical operation. It was because of this different way of understanding the body and its functions that Hickman believed it viable to propose creating a temporary state of asphyxia to suspend the life of the mind thereby removing the sensations of pain. As we know, Hickman’s work received little attention. Now Dr Zuck states: ‘the truth is that … before Henry Hickman no one was looking; it never appears to have entered anyone’s mind that it could be done’. Exactly my point, I think. At the time Davy performed his experiments with nitrous oxide, his model of the body did not permit the possibility of suspending sensibility without risking life. Hickman, however, did believe this was possible because, as a consequence of new research, the model of the body had changed. Following Hickman, the work on the nervous system during the 1830s by Marshall Hall and others established that it was theoretically possible to separate the functions of respiration and circulation from those of sensation and volition so that by 1846, ‘not only had a social receptivity to the control of sensibility at all levels been established through the increasing use of opiates, but the new anatomical and physiological constructions of the body showed how it was perfectly possible for life to be sustained in a body devoid of sensibility’(p. 35). This, then, is the model of the body that Snow based his development of anaesthetic principles and practice upon. But, as we know, inhalational anaesthesia did not emerge from this body of knowledge because for most well-trained doctors breathing ether and nitrous oxide was regarded as dangerous beyond the initial stimulating phase. I quote:

Although elite practitioners, like Snow, were able to interpret the effects of ether on the body by drawing on the physiological work of Flourens, Hall and others, which recognised that separation of sensibility and life was possible, most doctors perceived it as similar to poisoning or asphyxia. … Had medicine been reliant solely on the bodies of science for the development of new medical techniques, then anaesthesia, as we know it, may well not have emerged’ (p. 184).

Inhalational anaesthesia emerged in the United States of America from the use of nitrous oxide and ether as recreational agents. It was serendipitous that Crawford Long gave the youths in his home town ether to inhale because he did not have the means to prepare the nitrous oxide they had requested. As a consequence he was prompted to experiment with ether after noting the way in which it removed sensibility to pain in both himself and others. It is also clear that the local reception to his experiments was not favourable enough for him to pursue them or to attempt to get them taken up on any grand scale. In part this was because he had no framework in which to place the effects of ether; but it was also because pain continued to be regarded as functional during surgical operations. For Horace Wells too, the idea of experimenting with nitrous oxide came from watching a public exhibition of its effects. When his experiment failed before the audience at the Massachusetts General Hospital he had no theoretical framework of knowledge that could explain the failure. William Morton had learnt from Charles Jackson of ether’s power to remove pain when used locally on teeth. His experiments during the summer of 1846 were largely experiential, and were certainly driven in large part by his anticipation of the financial benefits that would accrue to his dental practice if he could find an effective way of alleviating pain. Serendipity also played a part in his work with ether in that his demonstration at the Massachusetts General Hospital was successful enough to convince the audience. Dr Zuck taxes me with excluding, ‘the crooked timbers of humanity’ from my analysis. Yet my summary was: ‘Morton proved the bridge between self-experimentation, dental arts, commercial aspirations and the international medical elite’. This, I trust, conveys the complex and varied factors that governed the establishment of ether.

Now, Dr Zuck chooses to interpret the shift in the understanding of the body that occurred between Davy and Morton as a Kuhnian paradigm shift. This is certainly one way. But my choice was to interpret it in a manner which made meaningful the reaction of doctors and patients to the introduction of ether and chloroform in the 1840s. Hence my use of medical types—biographical and scientific—which draws on the raft of work by the historians Ackerknecht, Jewson, and Pickstone. As I explain in my introduction, one of my key interests is the relationship between the science and practice of anaesthesia and the dynamics of patient-doctor encounters. The framework of biographical and scientific medicine that encapsulates the different knowledge-structures and social relations of each type aids my analysis. It reveals, for example, how patients in hospitals and private practice had different experiences of anaesthesia. As I show, even Snow was influenced by the social relations governing the relationship between patient and doctor in private medicine. Dr Zuck believes my discussion of these changes in understanding that stemmed from scientific medicine’s model of the body is, ‘moving in the right direction’. Again, this is a quibble about language rather than essence of argument. There are many different ways of ‘doing history’: at times, some are more pertinent than others.

Dr Zuck makes several points about my analysis of the patterns by which anaesthesia became established. First, he contests my argument that ether was so problematic that many doctors had marginalized it by the time Simpson introduced chloroform in November 1847. But the evidence speaks for itself—Snow, in his first book on ether, which he completed in September 1847, noted that some surgeons had abandoned ether. Other references can be found on p. 62. If Dr Zuck cares to read some of the manuals on anaesthesia listed in the Bibliography, he will find that most writers agree that although most hospitals trialled ether it entered regular use in only a few. In regard to the argument that anaesthesia was established in two phases, the first lasting from 1846 to the 1860s—described as a, ‘time during which a question mark hovered over its viability—were its risks greater than its benefits?’—and the period from the 1860s onwards when anaesthesia was established but remained subject to public scrutiny on account of fatalities, Dr Zuck says: ‘Dr Snow … feels that the doubts persisted for up to twenty years’. My analysis is based on the evidence gleaned from Snow’s casebooks, the archives of several London hospitals, nineteenth-century medical journals, and a wide selection of published literature. Historians may interpret evidence differently, of course, but few of us depend on our ‘feelings’ alone to reconstruct medical and social practices.

It is surprising that Dr Zuck downplays Snow’s approach to ether: ‘after all’, he says, ‘the chap just prepared a table of concentrations at different temperatures, designed an appropriate apparatus, and experimentally determined the percentages necessary to produce the required depths of anaesthesia’. But most doctors ‘just’ obtained ether and tried it out on themselves or patients. If no recognition is given to the way in which Snow’s mindset differed radically to that of others who encountered ether, and certainly to the American dentists, then it is impossible to appreciate the contribution Snow made to anaesthesia. Snow’s early papers and his first book on ether lay out very clearly the way in which he believed anaesthetic practice should be rooted in scientific principles—the laws of physiology and chemistry. Here, it seems, Dr Zuck is at odds with himself. Whereas he is keen to recognize the introduction of anaesthesia as a Kuhnian paradigm shift, he is equally keen to portray Snow’s approach to ether as nothing out of the ordinary. Snow’s approach surely defines the ‘magnitude’ of the ‘conceptual change’ Zuck talks about in Kuhnian terminology.

Given that Dr Zuck raises niggles at every turn of his review, there is neither the time nor the space in which to address these comprehensively. Instead I will focus on those parts of the review where my argument appears to be either mis-represented or passed over.

I will begin with my use of Snow and his casebooks. Dr Zuck says I use Snow as, ‘an exemplar of anaesthetists practising during the 1850s’ and that it would be, ‘misleading to generalize from his experience’. In my introduction I explain that, building on previous work which established that Snow’s practice was determined by science, ‘I want to extend these arguments by exploring the relationship between analysis, experimentation and the practice of anaesthesia. Snow is used throughout this work as a key exemplar’ (p. 5). Thus I am taking Snow as an exemplar in terms of his use of science. In Chapter 5, which contains my analysis of Snow’s practice, I explain that, given Snow’s standing as a specialist practitioner, it is reasonable to assume that his practice, ‘illustrates the breadth and scope of anaesthetic use in surgery and dentistry in London during the 1850s’. In other words, Snow’s anaesthetic practice was the most highly developed of any practitioner at the time. Chapter 5, incidentally, is titled ‘Anaesthesia in London, 1846–60’, which, for most readers, should convey the focus of my analysis.

Another point that needs correction is with regard to my arguments about the development of anaesthesia as a specialty. In Chapter 6 I map out how, ‘technology became the means through which specialists extended their control over the anaesthetic process’. I continue: ‘although technology grew to characterize specialism, anaesthetists did not found their claims for status and authority upon this aspect of their practice. Instead, they focussed on the way in which successful anaesthesia was highly dependent upon the administrator’s skill in managing patients’ apprehension of, and response to gas inhalation’(p. 168). Dr Zuck counters that he, ‘would have thought that the ability to give an effective anaesthetic smoothly and safely was the primary consideration of most surgeons’. But the point is that the more calm and relaxed a patient was at the commencement of the inhalation, the smoother the anaesthetic would be. It is exemplified by the case of Frederic Hewitt, anaesthetist at the London Hospital, who described going to great lengths to hide all vestiges of apparatus from the patient (p. 169) and was re-iterated in many of the anaesthetic manuals of the last decades of the nineteenth century. If budding specialists had claimed status on the basis of their technological skills they would not have succeeded so well. Clinical skills and experience were: ‘the “most important criterion” of medical practice at this point in history’ (p. 180).

At times, parts of my argument seem to be ignored. For example, in relation to Chapter 4 on the risks of anaesthesia, Dr Zuck notes that I say that by the early 1850s the patient’s dread of surgery had metamorphosed into a particular fear of the anaesthetic. He continues: ‘it is not generally recognized that patient reluctance dates back to the very earliest days of general anaesthesia’ and elaborates at some length on the matter. However, I explain earlier in the same chapter that when ether was introduced, ‘expressions of anxiety on the part of the patient were frequently linked to the practical novelties of the process’. I give examples of administrators who allowed their patients to try ether out in advance, in order to diminish their fear, and my conclusion is: ‘these problems diminished with chloroform which was a far easier gas to breathe. But patient anxiety remained’ (p. 102). Thus my points about the rapidity with which patient fear emerged are clearly made.

At several points Dr Zuck queries, ‘the high level of intellectualization’ of the book. He is particularly tetchy about my discussion of the differences between mesmerism and inhalational anaesthesia. He notes that I do not mention, ‘the down-to-earth fact that ether is a substance that can be seen, felt, smelled, and measured, while hypnotism is not’. My own words on the subject were: ‘The characterization of ether inhalation as a “scientific” technique gave it an undisputable legitimacy and from a patient’s perspective, the chemical, the flask and the breathing tube were all visible artefacts of its chemical nature’(p. 47)—earlier I had spoken of the way in which the pungent smell of ether lingered on the breath and clothes of patients. Dr Zuck’s quibbles, it seems, are again with my chosen vocabulary rather than the essence of my argument.

It is a shame that Dr Zuck’s review does not engage with some of the intriguing questions and paradoxes which the history of anaesthesia brings to light. For instance, although chloroform was so easy and effective to use, occurrence of fatalities quickly established it as a ‘high risk’ anaesthetic. Some medical communities in North America and some in Europe chose to abandon chloroform and return to ether. Britain, however, together with southern American states and much of Europe continued to use chloroform. This suggests that, certainly in Britain, surgeons were prepared to take the risks of chloroform in exchange for its efficacy. Equally, British patients were prepared to tolerate the risks of chloroform, whereas patients in Boston were likely to sue the surgeon for using a ‘high risk’ anaesthetic when there was a safer alternative. But despite the ‘mass of more recent work’ contained in the Proceedings of the History of Anaesthesia Society such questions remain unasked. I am in complete agreement with Dr Zuck’s assessment of Duncum’s history of inhalation anaesthesia, first published in 1947, as, ‘the bible of the historian of anaesthesia’. It will be clear throughout my references that I have drawn on it widely. But, like the bulk of recent work, Duncum’s focus is upon the development of anaesthetics, apparatus, and techniques. If the history of anaesthesia is to contribute to the wider social history of medicine, then the focus of work has to be extended to take account of complexities such as those raised by the story of chloroform and risk. As my concluding pages show, the history of anaesthesia resonates in current practice. Risk remains a central concern of practitioners, as does patient anxiety about ‘going under’. History also explains international differences in the trajectory of the specialty and the development of the different types of anaesthetic specialist. Knowledge of such matters could serve to influence its future development. Thus history would have served anaesthesia well.