Anaesthesia, Cholera and the Medical Reading Society of Bristol

The Medical Reading Society of Bristol was founded by 11 Bristol doctors in March 1807, "for the purpose of promoting medical knowledge and a friendly intercourse among its members, and for purchasing medical books". This was some 24 years before there was a medical library in the city. It soon elected a 12th member and has never had more than 12 members at any one time. With a few exceptions it has met monthly since its foundation. This month it is celebrating its 200th anniversary. 1807 was also the year that the slave trade abolition act was passed; Bristol of course had made much of its wealth from the slave trade. My interest in this topic of Anaesthesia, Cholera and the Medical Reading Society of Bristol was aroused in November 2005 when I was looking at the minutes from 50 years, 100 years and 150 years ago, which are read out at our meetings, and came across this:

The monthly meeting was held to Dr Swayne's house on November 7, 1855. Absent at 8 o'clock. Mr Morgan, Mr Coe, Mr Smerdon and Mr Cross. Absent at 8¹/₂ o’clock ditto-

Mr Hore proposed Snow on the inhalation of Chloroform in Disease, etc.

Mr Sawer and Dr Budd being proposed as new members to supply the vacancy occasioned by Mr Waldo's resignation, it was decided by the votes of the Society that Dr Budd should be balloted for. He was accordingly balloted for and elected.

I was quite excited by this because, although John Snow had long been a hero of mine, I did not recognize the pamphlet mentioned here. So I sent an email to the secretary of the John Snow Society in London and also one to one of the authors of the definitive biography of John Snow. I did not realise quite what a reaction I would get. In the next five days I received 11 e-mails from various parts of the United Kingdom and America, including one that described the minutes of the Society as a historical treasure. I discovered that professors of history in Michigan knew far more about Bristol physicians of the 19th century than I did. They also told me that between 1848 and 1851 John Snow had written 19 articles On Narcotism by the inhalation of Vapours for the London Medical Gazette and these were later published as three separate pamphlets. The second contained parts 8 to 16. Part 8 was specifically about the actions of chloroform in disease states. This was the pamphlet that Mr Hore, who was the newest member of the Society, had proposed, but which was not actually purchased by the Society. I wonder why not. We know the Society took the London Medical Gazette for 10 years from 1927, but it was not currently taking it in 1855. However, by this time there were other medical libraries in the city, and it may well be that members had already read these articles.

The host Joseph Griffith Swayne was physician obstetrician at the Bristol General Hospital. When he was appointed in 1853 it was on the understanding that he would not undertake any surgery, though this restriction soon lapsed. He had a great interest in analgesia/anaesthesia in labour and he was also involved in the cholera story.

Another member present was Dr Fairbrother. In 1846 he was a physician to the Bristol General Hospital, and it was he who instigated and helped at the first anaesthetic given in Bristol, probably on the 31st of December 1946, possibly the 1st of January 1947, some 11 weeks after Morton's original demonstration in Boston in October. The surgeon was James Goodall Landsdown. The patient was a young man who underwent left above knee amputation. William Herepath, a professor of chemistry at the University provided the ether, and administered it at first, and then Alexander Fairbrother administered it a second time. Lansdown reported the Lancet in December 1847 that by then he had used ether 111 times including 30 during labour, one intermittent etherisation lasting 11 hours. However he went over to using chloroform enthusiastically soon after Simpson had published details of its use.

In 1853 Fairbrother resigned suddenly from the Bristol General Hospital and later became a physician at the Royal Infirmary.

We do know that no anaesthetics were given at the Bristol Royal Infirmary until August 1850, when chloroform was used. The six surgeons on the staff all signed the Surgical Consultation Book to say they had agreed jointly that chloroform should be given. Even then there was a nine-month gap before the second anaesthetic. As we shall see later at least one of the surgeons at the Infirmary was well informed about anaesthesia, and yet there is no explanation as to why they did not try it out.

Joseph Swayne Alexander Fairbrother

1819 - 1895 1809 - ?

Mr William Francis Morgan was one of the six surgeons at the Infirmary, as was Mr Augustin Prichard who was there that evening, but as he had not been appointed until 1850, he cannot be blamed for the delay in introducing anaesthesia there, though certainly he was suspicious of anaesthesia throughout his career.

. .

William Morgan Augustin Prichard

1809 - ? 1818 – 1898

Nathaniel Smith, Henry Clark, Thomas Green and John Harrison, who were the other surgeons who signed the agreement to use chloroform at the Infirmary in 1850. All but Clark were members of the Reading Society at one time or another. Smith was one of the founder members.

Now we come to John Snow and William Budd. Born within two years of each other they were men of very different background, personality and lifespan, though both were acutely aware of how little treatment had to offer for the various fevers that ravaged the country in the 19th century and how vital it was to unravel the mode of transmission of these diseases to prevent them occurring.

William Budd has been described by his biographer, Michael Dunnill, as Bristol's most famous physician. He was born in 1811 into a large Devon medical family; his father and five of his brothers were also physicians. During his training in medicine William spent three separate years in Paris, interrupted by his catching typhoid fever. He qualified at Edinburgh as a doctor of medicine and won a gold medal for his thesis. In 1841 he moved to Bristol and became a consulting physician to the Bristol Royal Infirmary in 1847. He was a genial, vivacious, ebullient man, fond of good food, good wine and female company. An enthusiast in his work he could sometimes be seen running from his home in Park Street to the Infirmary so that he could see more quickly how his patients were getting along. His interest in epidemiology led him to play an active role in the development of the Bristol Water Company. Apart from his pioneering work on cholera, 1849, he described the contagious nature and prevention of Diphtheria, 1861; Anthrax, 1862; Tuberculosis, 1867, Scarlet Fever, 1869, and he also studied cattle plague and sheep smallpox. He is perhaps most renowned for his work on the waterborne transmission of Typhoid 1873. He died when he was 69 having suffered a stroke six years earlier, which had left him hemiplegic.

William Budd John Snow

1811- 1869 1813 - 1858

In contrast John Snow was the son the eldest son of a Yorkshire coal yard labourer. At the age of 14 he was apprenticed to Dr Hardcastle in Newcastle upon Tyne. He first met cholera in 1831 when at the age of 18 he was caring for miners at Killingworth colliery, before moving to York. From the age of 17 he was obsessed with the notion of pure water and at 23 gave a public address in which he suggested the numerous stills scattered around the country would be better put to producing distilled water than spirits. In 1836 he moved to London visiting Liverpool en route, and he walked from Liverpool to London via North and South Wales. In London he lived a frugal life as a bachelor, and was teetotal and a vegetarian. In addition to his pioneering work in on the transmission of cholera, after the discovery of anaesthesia in 1846 he rapidly became the foremost anaesthetist in the British Isles if not further afield. He was certainly the first anaesthetist to approach the subject in a scientific manner. He suffered from nephritis and at one time consulted Richard Bright. He died of a stroke at the age of 45, curiously enough attended in his final illness by William Budd's elder brother George.

Table 1. Members of Medical Reading Society October 1846, when the successful public demonstration of anaesthesia took place in Boston, Massachusetts.

Years of membership

Mr William Mortimer 1807 - 1850

Mr John Estlin 1807 - 1855

Mr John Swayne 1807 - 1847

Mr William Goodeve 1820 - 1858

Mr Isaac Leonard 1823 - 1859

Mr William Morgan 1825 - 1873

Mr Charles Smerdon 1835 - 1870

Mr George Hetling 1838 - 1848

Dr Alexander Fairbrother 1839 - 1876

Mr John Colthurst 1844 - 1856

Mr Augustin Prichard 1844 - 1876

Dr Joseph Swayne 1845 - 1858

Boston 1846. Painting by Robert Hinckley

Notice that there were still three of the Founder Members still there in 1846 and that despite the predominance of surgeons it was Dr Fairbrother who instigated the first anaesthetic in Bristol.

Table 2. Pamphlets on anaesthesia bought by the Medical Reading Society 1847 - 1866

Purchased	Title	Proposer
1847 Oct	Snow J. On the Inhalation of the Vapour of Ether in Surgical Operations. London: Churchill, 1847.	Mr Morgan
1848 Mar	Curling TB The Advantages of Ether and Chloroform in Operative Surgery, London: Highley, 1848	Mr Morgan
Oct	Simpson JY. Answer to religious objections to the use of chloroform in midwifery. Edinburgh: Sutherland & Knox, 1847.	Dr Swayne
Oct	Protheroe Smith Scriptural authority for the mitigation of the pains of labour, by chloroform and other anaesthetic agents. London: Highley, 1848	Dr Swayne
Oct	Merriman S. Arguments against the indiscriminate use of Chloroform in Midwifery. London: Churchill, 1848.	Dr Swayne
1855	Murphy EW. Chloroform: its properties and safety in childbirth. London: Wilson and Maberley, 1855.	Dr Swayne
1858	Snow J. On Chloroform and other Anaesthetics, ed. Richardson BW. London: Churchill, 1858.	Dr Budd
1866	Ellis R. On the safe abolition of pain in labour and surgical operations by anæsthesia with mixed vapours. London: Hardwicke, 1866.	Mr Leonard

Snow’s 1947 paper was bought by the Society just one year after Morton’s successful demonstration in Boston. This was a 20,000 word, 77 page pamphlet published at Snow's own expense, in which he describes the stages of anaesthesia much as we know them today and the means of giving ether in a controlled manner. It is one of the classic papers and anaesthetic literature.

Snow's 1847 temperature controlled vaporiser and facemask

Thomas Blizard Curling was Lecturer on Surgery at Hospital. His pamphlet was based on a lecture he had given to the Hunterian Society in February 1848. In it he reflected on pain and how different people responded, including a few remarkable people who allowed surgery to take place without any complaint. I guess that this was the effect of adrenaline rather like people don't feel pain when they are mauled by a tiger. Overall Curling was very enthusiastic and optimistic about the place of anaesthesia, noting in particular the usefulness of the relaxation produced particularly when reducing dislocations and also that the death rate following amputation was lower in those patients who had been anaesthetised than in those who had not. However he did caution that ‘the administration of anaesthetic agents should be entrusted to a person, who by practice, has acquired a nice perception of their action and the full knowledge of their powers and varying effects, so as to be able to produce and maintain their influence to a proper degree’.

Thomas Blizard Curling James Young Simpson

1811 - 1888 1811 - 1870

In 1848 James Young Simpson's Answer to religious objections to the use of chloroform in midwifery was written because he was very irritated by what he saw was opposition to the relief of pain in labour by the Church. Subsequently the church denied this saying it was only one or two ministers who opposed him. Simpson emphasised that God became an anaesthetist before he became a surgeon, but a Dr Ashwell countered by pointing out that it was still in the age of innocence when there was no pain.

16th century woodcut Agnes Anaesthesia Carstares Simpson’s chloroform bottle

In this woodcut Adam appears to be supporting his own chin. God is working here as an operator anaesthetist, which would be severely frowned on today. I thought you'd like to see Simpson's chloroform bottle and this young lady who 17 years earlier had been the baby born of the first mother to whom Simpson had given chloroform. She was christened Agnes Anaesthesia.

Protheroe Smith was an eminent London obstetrician. He strongly supported Simpson. He actually gave himself some chloroform rectally and found himself sometime later unconscious on the floor. Unfortunately rectal irritation and severe diarrhoea meant this was not a convenient form of administration.

Samuel Merriman in his Arguments against the indiscriminate use of Chloroform in Midwifery takes the line that nature can cope with labour better than people who intervene. He points out how the mortality of women in childbirth has declined and now is only one in 113. He says interventions such as forceps and ergot and anaesthesia are used too early and that pain, even severe pain, never actually killed anyone, and before using chloroform they should be sure that the risks were not greater than those of leaving the pain untreated. He refers to his esteemed friend Doctor Snow and says Snow’s papers on the use of anaesthetic vapours should be studied by all who propose to employ them medicinally

In Chloroform its properties and safety in childbirth Murphy discusses the properties of chloroform and the opposition to its use. He reports that deaths from chloroform had all occurred in surgical cases, 30 deaths in 9000 cases, and none had occurred in labour. There had been one death in an obstetric patient occurring one and a half hours after delivery when there had been sudden dyspnoea and death from an unknown cause. This was the mother's fourth labour and it had been long and tedious due to a narrowing at the diameter of the pelvic cavity. Long forceps delivery had been necessary. Recovery from anaesthesia had been speedy and perfect. I wonder if this actually was a case of Mendelssohn's syndrome, which is exudative pulmonary oedema due to aspiration of gastric juice. If it was then it was not so much a chloroform death as an obstetric anaesthetic death. He also describes a mouthpiece and box for the administration of chloroform, and sets out 10 rules for its safe use.

On the mechanism of action of chloroform and other anaesthetics was John Snow's final paper on anaesthesia and was not actually published until after his death from stroke at the age of 44 years. It summarises both theoretical and practical considerations. Again it is one of the classics of anaesthetic literature. At post-mortem Snow's kidneys were shown to be small and contracted. He had earlier consulted Richard Bright and curiously enough was attended in his final illness by William Budd's elder brother George. Incidentally around this time the society bought two books by George, one on diseases of the stomach and another on diseases of the liver.

Ellis’s On the safe abolition of pain in labour and surgical operations by anæsthesia with mixed vapours describes anaesthesia using different mixtures of alcohol, chloroform and ether at various times during the anaesthetic to improve the quality and safety anaesthesia. A.C.E as it was called remained intermittently in use until 1920s.

In 1958 there was a death in Bristol due to chloroform and Augustin Prichard reported it in the British Medical Journal. John Snow commented and incidentally reminding Prichard that a death had occurred in Bristol in 1854. He also said that if chloroform was a problem why not go back to using ether? In his final letter Augustin Prichard wrote:

I venture to prophesy that anaesthetics will more and more fall into disuse and will ultimately be had recourse to only for the most severe or protracted operations

Snow disagreed strongly and pointed out that Guy's and St Thomas's hospitals which were very slow to take up anaesthesia were the very places where deaths had occurred before those hospitals that were using it more regularly. Prichard would no doubt be interested to hear that there were over 3.5 million anaesthetic given in United Kingdom last year. You can read more about this exchange of letters in a paper by Robin Weller.

Table 3. Pamphlets on cholera bought by the Medical Reading Society 1832-1856

Purchased	Title	Proposer
1832	Lawrie, James. Essay on Cholera founded on observations of the disease in various parts of India and in Sunderland, Newcastle and Gateshead. Glasgow: Smith and son, 1832	Dr Swayne
1833	Hancock, John. Observations on the origin and treatment of Cholera and other pestilential diseases, and on the Gaseous Oxide of Nitrogen as a remedy in such diseases, etc.. London, 1831.	Mr Estlin
1833	Kennedy, James. History of the Contagious Cholera; with remarks on its character and treatment in England 3rd ed.. 1832, Moxon, all of London,	Mr Estlin
1833	L’Académie de Médicine. Rapport sur le Cholera Morbus Paris 1831	Mr Prichard
1848	Parkes, Edmund. Researches into the pathology and treatment of the Asiatic or Algide cholera. London: Churchill, 1847	Mr Prichard
1849	Scot, William. Report on the Epidemic Cholera as it appeared in the territories subject to the Presidency of Fort St George, abridged from the original report printed at Madras in 1824 with introductory remarks by the author. Edinburgh: Blackwood; London: Murray,1847