The histories of venereal disease that discuss technological advances and laboratory discoveries often leave aside how and when these advances changed the practices of medical caregivers who saw patients suffering from such infection. We might recognize, for instance, the development of the Wassermann reaction for diagnosing infection or the reported success of Salvarsan in syphilis treatment, but we know less about how women and men caring for patients understood or utilized such technologies. The latter is a more difficult, less straightforward question, but Anne R. Hanley seeks to answer it in Medicine, Knowledge and Venereal Diseases in England, 1886–1916. Concentrating on the period between the repeal of the Contagious Diseases Acts and the conclusion of the Royal Commission on Venereal Disease, she explores the development and circulation of knowledge claims and clinical practices among different groups of English medical professionals. The testimonies and reports of the Royal Commission on Venereal Disease provide the backbone of her archive, but she also draws on evidence from a wide variety of sources—including case notes, nursing manuals and lecture notes, medical school syllabi and examinations, and medical periodicals—to craft a meticulously researched monograph. Hanley concludes that the circulation of venerealogical knowledge in England was haphazard and opportunistic. The implementation of changes to clinical practice involved very little systematization.
Much of what we learn about the circulation of medical knowledge from this work is not peculiar to venereal diseases; rather, Hanley self-consciously uses venereal disease as a lens through which to examine the history of English medical education and health care at the end of the nineteenth century and the beginning of the twentieth. Debates over the institutionalization of specialisms reveal the limitations and challenges of the categorization of medicine, especially with illnesses like venereal infections that affect so many different parts of the body. Students faced an overcrowded curriculum and very brief rotations in wards. Socioeconomic status dictated access to health care and influenced the circulation of knowledge in important ways. The volume of patients at Poor Law institutions meant that health care providers there saw many cases of venereal infection but rarely had the resources to provide individualized long-term care. Clubs and societies could refuse coverage for people with preexisting venereal conditions. Moreover, they could categorize an illness as something caused by one's own misconduct and refuse to pay for care, thereby accentuating difficulties and disparities in accessibility of treatment.
Within this framework of English medical education, Hanley's ambitious project does tell us much about technologies specific to venereal infections and to what extent these translated into changed expectations in bedside medicine. She explains in intricate detail the multiple obstacles that prevented technologies—such as opsonic indexing, the newly developed Salvarsan, and the Wassermann reaction—from becoming tools of medicine in everyday practice in England. Not only did the cost of the Wassermann test make it out of reach for many, but most doctors lacked the specialist skills necessary for performing the reaction. Physicians might well have read about it in medical periodicals, but the technologies and associated bacteriological understandings only very slowly came to influence patient care.
Gendered divisions in knowledge acquisition and clinical practice posed another category of obstacles. Hanley's chapters on nurses and midwives contribute much to the study of venereal diseases, revealing the experiences of often overlooked historical actors. She blames sexism and doctors’ fears over loss of professional territory for attempts to deny nurses access to certain bodies of knowledge. Midwives, for instance, received training in basic mechanical procedures such as washing infants’ faces and administering silver nitrate as treatment, but they were denied material that would give them the theoretical knowledge of ophthalmia neonatorum or the specifics of the chemical compounds in use. Neither nurses nor midwives could make diagnoses or take any steps that might suggest themselves as alternative experts in medical care. Hanley also extends her work to findings about the gender of the patients, noting that doctors cared more about limiting the knowledge and practice of nurses who cared for working-class men with venereal infections than they did about restricting midwives who tended to see women and infants.
For the most part, Hanley concentrates on the knowledge and experience of medical caregivers. She tells us what doctors learned in undergraduate and postgraduate curricula, what nurses were told in manuals, what skills doctors had or lacked in relation to various technologies, and what procedures nurses could or could not perform. Yet, implicitly and through her well-placed anecdotes, she reveals questions about the related matter of the circulation of knowledge among patients. For instance, a patient with venereal infection inquired of a doctor whether and when he could be married. In another example, one of the testimonies given before the Royal Commission on Venereal Disease recounted a woman whose doctor withheld the details of her diagnosis, frustrating both the patient and the nurse. The nurse's testimony, which expressed her firm belief that women had a right to know if they were suffering from a venereal disease, explained how she had taken the patient to another doctor whom she knew would give her answers. Hanley opens the door here for other scholars to investigate just what various sufferers of venereal diseases knew about their conditions or associated treatment options and how they came to know it.
Similarly, Hanley's significant contribution to our understanding of the development of knowledge of and treatment practice for venereal disease in England lays the groundwork for further studies of medical education, knowledge circulation, and implementation of technologies relative to other diseases in other contexts. Indeed, work building on Hanley's framework will not only help us understand the histories of other diseases or health care systems in other places or periods but also shed light back on venereology itself. With such work we might learn just how haphazard and opportunistic was the circulation of knowledge and use of technologies for venereal disease relative to the knowledge and skills associated with, for instance, cholera or typhoid. Likewise, we could learn just how peculiar to venereal diseases or to England were the gendered restrictions on theoretical knowledge and diagnostic skills.
