Anaesthesia, 2002, 57, pages 667–675 ..................................................................................................................................................................................................................... SPECIAL ARTICLE John Snow, Thomas Wakley, and The Lancet* Sir Peter Froggatt** * Based on the John Snow Lecture delivered at the Annual Scientific Meeting of the Association of Anaesthetists of Great Britain and Ireland in Belfast, 14 September 2001. ** Formerly Vice-Chancellor and President, The Queen’s University Belfast. Accepted: 1 March 2002 periodicals it appeared on news-stands before its stated Prologue date of issue. Those who read Saturday’s Lancet or BMJ on Few doctors gain fame as pioneers in one field; fewer Friday, Tuesday’s Hello Magazine the previous week-end, still in two. Our contemporary, Sir James Black, is one or February’s Playboy in January will be familiar with this of the latter: a Nobel Laureate, he developed two marketing ploy. So it was that the Review for January 1847 families of drugs – beta-adrenergic blocking agents, and was circulating at Christmas 1846. One reader was H2 inhibitors. John Snow is another: a pioneer of Edward Hutton a surgeon at the Richmond Hospital in inhalation anaesthesia, he also proposed [1] then clarified Dublin. Hutton was drawn to two letters from Boston, a [2] a role for faecally polluted matter in the spread of long one from Dr John Ware and a short one from the cholera. This latter discovery is stamped on the medical surgeon, John Collins Warren, who had excised a neck memory by the alleged termination of a cholera tumour under ether anaesthesia on 16 October. There outbreak in an area just east of Regent Street when followed a long extract from an article by Dr Henry Jacob on 7 and 8 September 1854 Snow persuaded the St Bigelow Jr., published in The Boston Medical and Surgical James’s parish vestreymen to remove the handle from Journal (forerunner of The New England Journal of Medicine) the water-pump in Broad (now Broadwick) Street. (In in November which reported several major operations fact the outbreak was nearly over before the pump using ether anaesthesia and giving unambiguous preced- handle was removed! [3].) ence to the Boston dentist, William Thomas Greene Nevertheless, the ÔBroad Street pump-handle affairÕ Morton, who had in fact anaesthetised Warren’s patient serves as a dramatic coup de the´aˆtre and is seared into [5]. The editor of the Review, Dr (later Sir) John Forbes, medical folk-lore while his definitive work on the included as a postscript his own eye-witness account of Lambeth, and Southwark and Vauxhall, companies’ water Robert Liston’s two pioneering operations under ether supplies lies largely unknown outside the ranks of the anaesthesia at University College Hospital London on 21 epidemiological cognoscenti (and often within their ranks as December, the first such in Europe [6]. well!) and was largely ignored selling only 56 of the 300 Meanwhile, back at the Richmond Hospital a mid-arm copies printed leaving poor Snow to lament: ÔI spent more amputation was listed for 31 December The patient was than £200 in hard cash and realised in return scarcely as Mary Kane, an 18-year-old from County Meath with many shillingsÕ [4, p. xxii]. The way of the prophet is hard suppurative arthritis of the elbow-joint following the indeed. This article will consider Snow’s anaesthesia work prick of a thorn from a hawthorne branch. She was not most particularly as seen through the eyes of The Lancet, a patient of Hutton but of his colleague, Dr John then owned and edited by Thomas Wakley and the MacDonnell (Fig. 1). MacDonnell was from Belfast, premier journal-cum-medical newsletter in the English younger son of Dr James MacDonnell who was the language. Since this meeting of the Association of principal mover and shaker in founding in the 1790s the Anaesthetists of Great Britain and Ireland is in Belfast I Belfast General Dispensary and Fever Hospital (ancestors will start with a short description of the first operation of today’s Royal Victoria Hospital) and much more under ether anaesthesia in Ireland on New Year’s Day besides [7, 8]. Hutton showed the Review to MacDonnell 1847. who postponed the operation for 24 h and used the time to construct a crude ether dispenser which he tested on himself Ôrendering myself insensible for some seconds, five The first ether anaesthesia in Ireland or six timesÕ. On Friday, 1 January 1847, he proceeded The British and Foreign Medical Review is long defunct with the amputation under ether anaesthesia assisted by but it was a leading journal in its day. Like many his hospital colleagues and in front of Ôseveral eminent Ó 2002 Blackwell Science Ltd 667 Sir Peter Froggatt John Snow, Thomas Wakley, and The Lancet Anaesthesia, 2002, 57, pages 667–675 ................................................................................................................................Æ ...................................................................................... physicians and surgeons of DublinÕ and an opportunistic (23 Ely Place) nearly two miles away across the Liffey. class of students who happened to be on site. The patient The article concluded with the prophetic if somewhat felt nothing until she came around in time to see florid words: MacDonnell Ôput a thread in my armÕ [9]. Eight days later ÔI regard this discovery as one of the most important of he could tell the Surgical Society of Ireland that ÔI now the century. It will rank with vaccination and other of looked on the patient as perfectly safe … I have never the greatest benefits that medical science has bestowed seen any case turn out so completely favourableÕ [10]. on man … it offers … an occasion beyond measure Such was the first case under ether anaesthesia in Ireland: more worthy for Te Deums in Christian cathedrals and it was 11 days after its first use in London, 10 days after for thanksgiving to the Author and Giver of all good, Paris, but 3 weeks before Berne, 4 before Vienna, and 6 than all the victories that fire and sword have ever before The Hague. No longer would a surgeon, in the achievedÕ [9]. familiar words of Celsus, Ôneed to be void of all tolerance and pity and entirely deaf to the shrieks and outcries of his The literature (such as it was) had been read, a suffering patientsÕ. workable if crude apparatus extemporised, constructed, On the very evening of the operation, New Year’s Day and tested on a human volunteer, the operation per- 1847, nowadays a public holiday, MacDonnell, in his formed successfully, and the case report prepared, posted, residence (4 Gardiner’s Row), wrote-up the case in some proofed, printed and published in a national journal on 6 2000 words and sent, or perhaps even personally delivered January, all in just 4 working days without the aid of fax, it, to the editor of The Dublin Medical Press at his residence e-mail, internet, electronic typesetting, word processing or even telephone. Only Ôinformed consentÕ, not yet invented, was missing. The energy and urgency of the Victorians rarely ceases to amaze. John Snow and Thomas Wakley The editor and co-founder (with Henry Maunsell) of The Dublin Medical Press was Arthur Jacob who shone even at this zenith of Dublin medicine crowded as it was with such luminaries as Robert Graves, William Stokes, Dominic Corrigan, John Cheyne, Robert Adams, Abraham Colles and William Wilde, an impressive coterie of eponymous fame who in fact formed only the tip of a larger iceberg. Jacob had impressive credentials. He was the first to describe the layer of retinal rods and cones (Jacob’s membrane) and rodent ulcer (Jacob’s ulcer) and he held the chair of anatomy at the Royal College of Surgeons in Ireland for 40 years. He was also an inspired commentator and formidable controversialist second only to Thomas Wakley as a medico-political polemicist and he modelled The Dublin Medical Press mainly on Wakley’s Lancet. Wakley had founded The Lancet in 1823 and used it as a vehicle for his polemical and often abusive writings which were of a pungency and incisiveness never before or since displayed in medical literature and rarely outside it; only in the vicious but inspired satirical cartoons of Gillray, Cruikshank and Rowlandson does one find an equal. It is now time to bring Wakley on-stage. Thomas Wakley (1795–1862) Figure 1 John MacDonnell (1796–1892) in later life. From a sepia print in a family album. (Supplied to me by Professor Eoin Wakley was born in 1795, the youngest of eight sons of an O’Brien, Dublin, and reproduced by permission of Mrs Louise affluent farmer in Devon [11–15]. He early showed his Shorter, Kilsharvan, County Meath.) pugnacious independence by sailing in his early teens as a 668 Ó 2002 Blackwell Science Ltd Anaesthesia, 2002, 57, pages 667–675 Sir Peter Froggatt John Snow, Thomas Wakley, and The Lancet ......................................................................................................................................................................................................................Æ cabin-boy with an East Indiaman to Calcutta which ÔI disapprove of Wakley, no man more; he is an ill- exposed him to some of life’s brutalities and corruptions intentioned fellow … There are men who donÕt mind and awoke in him a passion for their relief which never left being kicked blue if they can only get talked about. him. In 1815, he entered the medical school of the United But Wakley is sometimes right’, Dr Sprague added Hospitals of Guys and St Thomas’s which at that time judicially, ÔI could mention one or two points on faced each other across St Thomas Street before St which Wakley is in the rightÕ. Thomas’s buildings were demolished to make way for London Bridge Station in 1862. Qualifying MRCS in We may not know today where the profession is going, 1817, he was even then an impressive figure – tall, strong, but those who want to know where it is coming from handsome and vigorous, a good athlete and boxer, could do worse than read Wakley’s Lancet leaders over hospitable and gregarious but generally abstemious and a nearly 40 years.