Cholera Chloroform and The Science of Medicine A L... - (CHAPTER 3 London Medical and Surgical Training 1836-1838)

Chapter 3
London Medical and

Surgical Training,
1836–1838
N AUGUST 1836 Snow left behind his family and his temperance ac-
I tivities in York to continue his medical training in London. He took a cir-
cuitous route, however, traveling first to Liverpool, perhaps to visit teetotal acquaintances.
Copyright © 2003. Oxford University Press, Incorporated. All rights reserved.
Thereafter, according to Richardson, he “trudg[ed] it afoot from Liverpool through the

whole of North and South Wales, turned London-ward, calling at Bath on the way, on
a visit to his uncle, Mr. Empson.” Like his uncle, who had hiked from New York to Mon-
treal and back a few years earlier, Snow enjoyed walking. This tour from Liverpool to
London covered almost 400 miles and probably took four or five weeks (Fig. 3.1).1
It is likely that Snow’s visit with Uncle Charles had a purpose beyond familial duty
and personal friendship. Snow intended to be a full-time student, and it is improb-
able that he could have saved enough during his three years as an apothecary assis-
tant to cover fees, books, and room and board for as much as two years of medical
training. He probably received financial help from Uncle Charles and perhaps from
his parents as well.2
Requirements for Certification

Dual qualification necessitated that candidates complete the requirements of both
the Royal College of Surgeons in London and the Worshipful Society of Apothe-
56
Paneth, Nigel, et al. <i>Cholera, Chloroform, and the Science of Medicine : A Life of John Snow</i>, Oxford University
Press, Incorporated, 2003. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indonesiau-ebooks/detail.action?docID=3052046.
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London Medical and Surgical Training, 1836–1838 57
Figure 3.1. Place-names, towns, and cities of significance to Snow.
caries. The Lancet, a London medical journal published every Saturday, listed cur-
rent requirements in an issue each fall before the beginning of the academic year.
There were two sessions for lectures—a winter session from 1 October to mid-April,
with a two-week break around Christmas, and a session from 1 May to the end of July.
Hospital attendance was available the entire year. The examiners in Apothecaries’
Hall specified the lectures they expected students to take in each session and when
to begin and end medical practice. The Royal College of Surgeons, however, listed
only the numbers of courses and length of surgical practice expected of students
who wanted to take the qualifying examination. Some lecture courses and hospital
rotations satisfied both college and hall (the monikers for these two medical corpo-
rations). Table 3.1 suggests how medical students might have planned their semes-
Table 3.1. Schedule of lecture courses and hospital attendance for dual qualification for students in London beginning in October 1835
1st Winter Session 1st Summer Session 2nd Winter Session 2nd Summer Session 3rd Winter Session
(Oct. ‘36–Apr ‘37) (May ‘37–July ‘37) (Oct. ‘37–Apr ‘38) (May ‘38–July ‘38) (Oct. ‘38–Apr ‘39)
Chemistry Botany Anatomy and Physiology Forensic Medicine Dissections
Anatomy and Physiology Electives Anatomical Demonstrations Midwifery and Diseases of Midwifery with
Women and Children attendance on cases
Anatomical Demonstrations Dissections
Dissections Midwifery (lectures) Medicine (physic)
Materia Medica and Medicine (physic, lectures)
Therapeuticsa
Surgery (lectures)
Surgery (lectures) Hospital attendance Hospital attendanceb Hospital attendance c
(through September)
Key: Italics—Required by Apothecaries Hall (AH) only.

Bold—Required by College of Surgeons (CoS) only.
Normal—Required by both college and hall.
a Pharmacology, including identification and compounding, preservation, and administration of mineral and vegetable drugs. The CoS required only a three month ses-
sion.
bCoS required twelve months of surgical attendance at an approved hospital in London, Dublin, Edinburgh, Glasgow, or Aberdeen; or six months in one such hospital
plus twelve months in an approved provincial hospital (such as the Newcastle Infirmary).
cAH required a total of eighteen months of medical practice, which could overlap with surgical practice, at a recognized hospital or dispensary.
Source: Lancet 1 (1836–37): 6–7.
ters if they hoped to qualify in the shortest time: twenty-two months to become a
Member of the Royal College of Surgeons (MRCS) in London, thirty-one months
for a prospective Licentiate of the Society of Apothecaries (LSA).3
Snow took his surgical examination in May 1838 after eighteen months of train-
ing in London and the apothecary examination the following October. Therefore,
both college and hall must have accepted some of his certificates of attendance from
lecture courses at the uncertified medical school in Newcastle.4 In addition, the Royal
College of Surgeons in London credited him with the full twelve months he had
spent at the Newcastle Infirmary; to fulfill the remainder of its hospital requirement
he needed only six months at a London hospital, but the examiners at Apothecaries’
Hall would only accept half of Snow’s clinical training at the Newcastle Infirmary.
They insisted he spend a full year in hospital practice before qualifying.5
The London Medical Schools

When Snow arrived in metropolitan London twenty-one schools of varying size and
curricular range competed for students of medicine and surgery, who had to amass
the required certificates of attendance at lectures, anatomical demonstrations, and
dissecting (Fig. 3.2). Some of these schools were attached to hospitals where a stu-
dent could also satisfy clinical requirements. Most were proprietary schools that of-
fered a full complement of lecture courses, although a few advertised only a limited
number of subjects. Two institutions of higher learning—King’s College and the new
London University—had affiliated medical schools that offered all the required lec-
ture courses, demonstrations, and dissecting opportunities.

London proprietary schools of anatomy, medicine, and surgery traced their ori-
gins to the mid-eighteenth century and emerging doubts about the value of indi-
vidual apprenticeships. It was more efficient for a few surgeons and apothecaries to
offer formal instruction to a large assemblage of apprentices than for each master to
teach his own. A number of committed and enterprising practitioners had renovated
and extended buildings in the metropolis to provide amphitheaters for lectures,
rooms for anatomical demonstrations and dissecting, surgical museums, and occa-
sionally herb gardens and garrets for the study of botany and materia medica. When
the London Corporation of Surgeons was reconstituted as the Royal College of Sur-
geons, the availability of institutional training was so extensive that the new medical
corporation eliminated the apprenticeship as a requirement for membership. That
meant a loss of income for hospital surgeons in the metropolis, but some soon of-
fered lecture courses, students paid for tickets to attend, and hospital-based medical
schools were in competition with the proprietary schools.6 There were advantages
in attending an institution where lecture halls and wards were in close proximity, es-
pecially because after the first winter session theoretical and clinical instruction be-
came more integrated.
Figure 3.2. Hospitals and medical schools of London, 1836–1837 (adapted from Lancet, 24 September 1836).
When Snow reached London in 1836, medical education was still part of a bour-
geoning market economy. Every school distributed a prospectus of the courses it in-
tended to mount in the coming session, the names of the lecturers it had retained,
the facilities it provided, and the perquisites that students received if they purchased
“perpetual” tickets of admission, that is, took all courses at one school for a reduced
fee compared to purchasing tickets for individual courses at several.7 Newspaper ad-
vertisements trumpeted the star quality of a school’s faculty and the success rate of
its students in qualifying examinations. However, the editorial staff at the Lancet was
generally unimpressed with what the schools actually delivered:
The puffs and pretensions are innumerable, whereas the claims of the differ-
ent teachers and establishments to distinction, where, indeed, any exist, are
easily enumerated. The whole system . . . is the prolific source of extortion
and fraud. . . . [It requires] from the students the outlay of such enormous
sums of money in the purchase of “tickets” [of admission] and “certificates”
[of having attended the expected number], under the colour of enforcing at-
tendance on lectures not one-fourth of which, from their multiplicity, can ever
be heard. . . .8
Nevertheless, if one hoped to practice general medicine in England and Wales, there
was really no alternative to accumulating all the certificates expected by the exam-
iners at college and hall.
Snow, like hundreds of other incoming medical students in London in October
1836, had to decide where to take courses in the forthcoming session. Lectures dur-
ing the first ten days were open to the public free of charge, with the expectation
that students would shop for bargains (Table 3.2).9 Snow became a perpetual stu-
dent at the Hunterian School of Medicine at 16 Great Windmill Street, near Hay-
market in Westminster (an incorporated city in West London). The Hunterian, a
continuation of the first school of anatomy in London, was renowned for having
dedicated instructors. Among them in the fall of 1836 was John Epps—physician,
phrenologist, medical radical, and temperance reformer.10 With so many schools to
choose from, it is possible that Snow gravitated to a school that had at least one fac-
ulty member who shared his antispirit views, but the Hunterian also offered students
excellent facilities, including an extensive pathological museum and a large dissect-
ing room. The perpetual fee at the school was £34, which included access to the read-
ing room and library, and it was the lowest priced among schools that offered a full
complement of courses for dual qualification. Although not attached to a hospital,
it was located near several of them.11
Snow found affordable lodgings near Soho Square, a short walk from the Hunter-
ian School of Medicine. He rented a room at 11 Bateman’s Buildings, a terrace of
row houses along an alley that connected Soho Square to Queen Street (now Bate-
man Street). Each house in this eighteenth-century speculative development had
Table 3.2. London medical schools, amenities, and “perpetual” fees as of October 1836
Private schools and colleges with a full
complement of lecture courses and dissecting Private schools with limited offerings Hospital-based schools with various offerings
Aldersgate School of Medicine Mr. Dermott’s Theatre of Anatomy Charing Cross Hospital Medical School
(library & medical society; £36 15s) (anatomy, including demonstrations and (only medicine, midwifery, anatomy, and
dissecting, physiology, surgery; £10 10s.) surgery; £19 19s.)
Blenheim Street School of Medicine
(£36 15s.) Dr. Robert’s Lecture Room Free Hospital Medical School
(Theory and practice of medicine; £5 5s.) (no chemistry or botany; no fees listed)
Hunterian School of Medicine
(library, reading room, museum; £34) Mr. Smith’s Theatre of Anatomy Guy’s Hospital Medical School
(anatomy, including demonstrations and (full complement; £69 6s.)
Mr. Grainger’s School, Webb Street
dissecting, physiology, surgery; £10 10s.
(museum; medical society; practice London Hospital Medical School
Midwifery, including hospital practice; £5 5s.)
privileges at Surrey Dispensary and (full complement; £61 19s.)
the London Fever Hospital; £48 6s.) Dr. Waller’s Lectures on Midwifery
Middlesex Hospital Medical School
(cases from the London Midwifery
King’s College Medical School (full complement; £45)
Institution; £5 5s.)
(£63)
St. Bartholomew’s Hospital Medical School
St. George’s Hospital Theatre of Anatomy
London University College Medical School (full complement; £66 4s., plus £1 10s.
(anatomy, physiology, demonstrations,
(£70 10s.) for use of library)
dissecting; £16 16s.)
St. George’s Hospital School of Anatomy and St. George’s Hospital Medical School
Medicine (£39 18s., no anatomy)
(£46 4s; including anatomy
St. Thomas’s Hospital Medical School
and demonstrations, £16 16s.)
(full complement; £55 13s.)
Westminster School of Medicine
(£45)
Source: Lancet 1 (1836–37): 7–15.
three storeys above ground, as well as rooms in the cellar. Number 11 was one of the
smaller houses, containing approximately 250 square feet of living space per floor,12
but it would have been sufficient as a place to read and sleep. Most of a first-year
medical student’s time was spent at school, either in a lecture hall or in the dissect-
ing room.
Snow the Medical Student

Whether to enhance his qualifications or to establish close relationships with senior
London doctors, Snow decided to repeat several courses he had already taken in New-
castle. During the winter session of 1836–1837 at the Hunterian School of Medicine,
he attended Mr. P. Bennett-Lucas’s lecture course on anatomy and physiology, the
associated anatomical demonstrations, plus dissecting on his own; chemistry with
Dr. Hunter Lane; and the principles and practice of medicine, still termed physic by
the Royal College of Surgeons, with Dr. Michael Ryan, an Irish physician with par-
ticular interests in obstetrics and a medical radical.13 Snow decided to attend Dr.
Jewell’s lectures on midwifery and diseases of women and children at the Hunterian
Theatre of Anatomy, perhaps because the course fee included attendance on cases at
the Royal Lying-in Hospital on Queen Street, near both the Hunterian School and
Theatre. This facility was listed as a Hospital for Clinical Midwifery in the Hunter-
ian Theatre’s schedule of courses, indicating that students who walked its wards with
Dr. Jewell would be taught obstetrics, an emerging specialty within general practice
also pursued by Hardcastle and, a few years hence, by Snow himself14 (Table 3.3).
Apothecaries’ Hall expected students to take botany and electives during their first
three-month summer session in London. John Epps lectured in botany at the Hunter-
ian School of Medicine, and Snow completed that course with him, probably dur-
ing the 1837 summer session. When he was not in the lecture hall or the physic gar-
den, he was probably dissecting in the “dead room.” In all, Snow would take four
courses from Epps—two in materia medica, one in forensic medicine, as well as
botany.15
During his first year in London, Snow developed a close friendship with a class-
mate, Joshua Parsons. “It happened,” recalled Parsons, “that we usually overstayed
our fellows [in the dissecting room], and often worked far on into the evening. The
acquaintance thus grew into intimacy, which ended by our lodging and reading to-
gether.”16 Each day was built around the lecture courses. The instructors arrived at
the appointed hour, expounded information and opinion (sometimes reading ver-
batim material previously published in a medical journal), and then rushed off to
resume private practice or do their hospital rounds, but outside the prescribed lec-
tures medical education was largely self-directed. It was left to the students to sup-
plement lecture notes with textbooks, to observe symptoms on the wards, to note
the appearance of diseases in the glass jars on display in the anatomical museum, to
64 Cholera, Chloroform, and the Science of Medicine
Table 3.3. Snow’s likely schedule of lecture courses during the winter
session of 1836–1837
Monday Tuesday Wednesday Thursday Friday Saturday
9:00 |← Chemistry →|
10:00
11:00 |← Practical anatomy and demonstrations →|
Noon
1:00
2:00
3:00 |← Anatomy and physiology →|
4:00 |← Principles and practice of →|
medicine (physic)
5:00
6:00
7:00 Surgery a Midwifery b Surgery Midwifery Surgery Midwifery
aWe assume he attended these lectures; surgery was not a required course for apothecary candidates and
therefore not listed by Snow’s examiner.
bTaken at the Hunterian Theatre of Anatomy, not the Hunterian School of Medicine.
Source: Lancet 1 (1836–37): 12; Society of Apothecaries, “Court of examiners entrance books,” MS 8241/10,
61 (“John Snow”).
correlate structures they could dissect with the demonstrator’s cadaver (or, if avail-
able, a wax model), to conduct experiments in the chemistry laboratory, and to study
medicinal plants in the physic garden.17 The goal was to amass sufficient informa-
tion to pass one comprehensive certifying examination at the very end of formal
training.
Snow left no diary of his experiences as a medical student, but those who did may
be instructive. For example, James Paget entered the medical school attached to St.
Bartholomew’s Hospital two years before Snow began at the Hunterian. “For the
great majority of students, and for myself at first,” wrote Paget in his memoirs, “work
at that time had to be self-determined and nearly all self-guided: it was very little
helped by either the teachers or the means of study.” For most students “there was
very little, or no, personal guidance; the demonstrators had some private pupils,
whom they ‘ground’ for the College [of Surgeons] examinations, but these were only
a small portion of the school.” The situation was somewhat better, he thought, at the
nearby “Aldersgate Street school, where were . . . some active demonstrators, and
where more ‘grinding’ was done.”18 It appears that Snow and Parsons had neither
the need nor the resources to hire a grinder. Both were older and more experienced
than the typical medical student: Snow was twenty-three with almost nine years of
medical experience, while Parsons, although a year younger, had served a five-year
apprenticeship and had already completed twelve months at the North London Hos-
pital. The two friends probably drilled each other until Parsons became dually qual-
ified in October and left London to set up a general practice in Somerset.19
Snow, on the other hand, had to take another series of lectures and fulfill the re-
quirements for hospital attendance. During the winter session of 1837–1838 he took
second courses in materia medica, chemistry, and midwifery with the same instruc-
tors as the year before, but in the new academic year Dr. Robert Venables offered
physic, Mr. G. Jones delivered the lectures in anatomy and physiology, and Mr. Sav-
age gave the anatomical demonstrations (Table 3.4).20 In addition, Snow attended
medical and surgical practices at the Westminster Hospital. It lay relatively far from
his lodgings, nearly a mile to the south, beyond St. James Park on Broad Sanctuary
by Westminster Abbey and the Houses of Parliament. Although a mile meant little
to an enthusiastic walker like Snow, it seems odd that he avoided University College
Hospital on Gower Street, St. Pancras, only a third of a mile from his lodgings. Uni-
versity College Hospital offered case-study clinical instruction by, among others, the
respected surgeons Astley Cooper and Robert Liston. Parsons had attended this in-
stitution when it was called the North London Hospital; perhaps he was dissatisfied
with his training there and had urged his roommate to go elsewhere, or Snow may
have been dissuaded by a change in the University College fee schedule that penal-
ized students who attended practices at the hospital but were not enrolled for
lectures.21
For the next twelve months Snow was expected to be at the Westminster Hospi-
tal shortly after noon six days a week. Most of the time, apparently, he shadowed the
Table 3.4. Snow’s likely schedule of lecture courses during the winter session of
1837–1838
Monday Tuesday Wednesday Thursday Friday Saturday
9:00 |← Materia medica and therapeutics →|
10:00 |← Practical anatomy and demonstrations →|
11:00 |← Chemistry →|
Noon
1:00
2:00
3:00 |← Anatomy and physiology →|
4:00 |← Principles and practice of →|
medicine (physic)
5:00
6:00
7:00 Midwifery Midwifery Midwifery
Source: Lancet 1 (1837–38): 14–15; Society of Apothecaries, “Court of examiners entrance books,” MS
8241/10, 61 (“John Snow”).
resident medical officers. One physician staffed the out-patient clinic each day. For
example, Dr. John Bright came on Tuesdays and Fridays; Drs. George Roe and John
Burne covered the other weekdays.22 In clinics physicians diagnosed and prescribed
for patients, most of whom were accident victims, members of the laboring classes
who paid subscriptions to friendly societies and provident funds to cover hospital
care. After seeing the resident physician the patients waited at the dispensary for the
hospital apothecary to compound and distribute medicines. If their complaints were
unrelieved, patients could return the following day and repeat the procedure with a
different physician. Only nonchronic cases were considered for admission to the hos-
pital. Many of those cases required the attention of the house surgeons, of which
there were four when Snow “walked the wards” at the Westminster: Sir Anthony
Carlisle, Anthony White, George Gurthrie, and B. Lyon.23
These physicians and surgeons were proponents of what came to be called hos-
pital medicine. This approach sought to develop the same habits of mind charac-
teristic of accomplished practitioners at the bedside, but to do so in metropolitan
clinical settings where students had two advantages not available to most appren-
tices. First, one could observe many more patients and a broader array of diseases
in urban hospitals than in individual practices. Second, hospitals with morgues in
which demonstrators could teach dissecting (or even a simple “dead room” in which
students were left to their own, often notorious, devices) offered the opportunity
to compare one’s clinical observations and diagnoses with anatomical structures
and pathological lesions post mortem. Hospital medicine was touted as the pre-
ferred venue for the clinical–pathological method. Next to anatomy, the Lancet con-
sidered “Clinical Medicine—the study of disease, by the bedside of the patient, in
the wards of an hospital, and of manual surgery, in the operation theatres of those
institutions—” the most important subject for the aspiring surgeon.24 Snow may
already have been introduced to this relatively recent medical perspective while at-
tending practices at the Newcastle Infirmary, but he most assuredly experienced it
at the Westminster Hospital.
The Lancet was typical of advanced British medical thinking in its advocacy of
hospital medicine, although not everyone agreed that experiential empiricism was
its proper foundation. According to this journal, “medicine is, above all other sci-
ences, a science of observation,—to be successfully studied only by careful and long-
continued watching of the symptoms of disorder, the phenomena of health, and the
results of employing remedial agents for the cure of disease.”25 Methodical observa-
tion was often difficult to carry out in the out-patient clinic because there was such
a high turnover of patients. Students could follow the medical staff on the wards for
“fever patients” who could not be treated in their own homes, but such admissions
depended on seasonal fluctuations in infectious diseases. The surgical wards, how-
ever, offered numerous learning opportunities during the academic sessions when
house surgeons could be assured that the operating theaters were filled with gawk-
ing medical students and a few senior students were available (often paying a hefty
fee for the privilege) to assist as dressers and clinical clerks. However, for the ma-
jority of students, attending a hospital practice was their best chance to observe a
greater variety of diseases than they could possibly have confronted as an appren-
tice to a solo practitioner. The Lancet recommended a system for making the most
of this opportunity: “The moment . . . a student enters an hospital he should com-
mence making an accurate record of a certain number of cases in the wards. . . .
He should . . . make a selection of the most common diseases, or accidents, and
this limitation of his labour will enable him to follow a certain number of cases to
their termination. . . ,” whether to cure or death of the patient. One advantage of
attending hospital practices was that in the event a “case terminate[d] unfavourably,
the post-mortem appearances of the subject” should be examined in the dead room.26
The object was to develop a personal collection of case notes that could be consulted
for years thereafter. Snow’s extant casebooks and his remarkable facility at recalling
specific cases during medical society meetings indicate that he mastered this objec-
tive, probably a result of a combination of his own initiative, Hardcastle’s tutelage,
and training in London.27
Whether a particular student’s experience corresponded to the ideal posed by the
Lancet depended largely on the views of the hospital staff where one received prac-
tical training unless, like Snow, the student had learned to keep case notes at the bed-
side during an apprenticeship. Again, James Paget’s recollections of his student years
at Bart’s are instructive, whether or not they are representative. “In the second win-
ter” session of 1835–1836, he wrote in his memoirs, “I gave myself to Hospital prac-
tice more than in the first. . . . In the first year, I had not neglected Hospital prac-
tice; but I had done little more than go round the surgical wards, . . . seeing what
was rare, talking about cases, sometimes hearing a very few words of teaching. Be-
sides, I had often sat . . . in the outpatients’ room.” Like Snow at the Westminster
Hospital, Paget was not a surgeon’s assistant responsible for dressing wounds, “partly
because the dresserships were expensive (10 guineas at least), partly because they
seemed to offer scarcely more opportunities of studying surgery than I had had in
my apprenticeship.”28 He found the instruction in the medical wards more congen-
ial and spent most of his time there, serving several months as a clinical clerk for
one of the house physicians. He thought the “teaching was admirable . . . and their
expectation of what might be learned by continued research” set a standard for the
remainder of his career.29 One physician stood out because “he would make those
who went round with him examine for themselves, and would tell and show them
how to learn, and have his case-books well kept. . . . This precision, and the early
hours, were too much for the great majority of students,” but the baker’s dozen who
attended the morning rounds “imitate[d] him in his mode of study. . . .”30 Ac-
cording to Paget, “I worked steadily all through the winter, still dissecting as much
as I could, and helping in the post-mortem examinations whenever I had a chance.”31
That is, he took full advantage of the learning opportunities the new hospital med-
icine had to offer, even at an institution he considered in decline compared to the
teaching available at University College Hospital—and, perhaps, at another relative

newcomer in medical education, the Westminster Hospital.
Several events punctuated the weekly routines during Snow’s twelve-month rota-
tion at the Westminster Hospital. At the end of April 1838, he completed the six
months on the wards of a London hospital required by the Royal College of Sur-
geons. He took the qualifying examination on 2 May. It is likely that his experience
was similar to Paget’s two years earlier:
The examination was very simple. The ten examiners sat at the outer side of
a long curved table. Each in turn, I think, took a candidate; and, when he had
finished, others could ask questions. My examiner-in-chief was Mr. Anthony
White, of the Westminster Hospital [one of Snow’s teachers]: his questions
were not difficult, and I believed that I brought them to a close by giving an
account of the otic ganglion and its nerve-communications, in reply to some
enquiry about branches of the fifth nerve. That ganglion was then known to
few; and he who knew about it seemed to be thought sure to know all com-
mon things. After Mr. White, Sir Astley Cooper asked me some questions, and
seemed satisfied. . . ; and then I was courteously dismissed.32
Groups of candidates—those who had completed all required lecture courses and
months of hospital attendance—entered a room at the Royal College of Surgeons in
Lincoln’s Inn Fields and were examined orally, one after the other. The examiners
were particularly interested in the candidates’ knowledge of anatomy. Snow must
have satisfactorily answered whatever questions they put to him. Subsequently, the
London Medical Gazette published a notification: “College of Surgeons. List of Gen-

tlemen who have received diplomas. May 1838.” Of 114 successful candidates,
“J. Snow, York” ranked seventh. He had become a Member of the Royal College of
Surgeons in London.33
Shortly before Snow earned his first medical title, the apothecary at the West-
minster Hospital had resigned his post, and Snow began the process of submitting
a full application, including eight references, as his replacement. The work of a hos-
pital apothecary was wide-ranging, and, according to the Lancet, the Westminster’s
had been extraordinarily effective: “(owing to the exertions of the apothecary and
the matron) the diets are as wholesome and plentiful, the clothing is of as good a
quality, and is as clean, and, in short, the whole working machinery is as efficient,
as in any hospital in London.”34 Snow was aware that the hospital charter would en-
gage only a Licentiate of the Society of Apothecaries, but he assumed that the ex-
aminers would permit him, as they occasionally had allowed others, to take the qual-
ifying examination several months early, but they refused his request to be examined
at the end of the summer session in July. When he appealed, they reminded him that
his practice obligation would not be met until the end of September and again re-
fused to grant him an exception. He was forced to withdraw his application.35 At the
time it was a setback. Instead of building a practice from a base at a major teaching
hospital with an annual salary to tide him over, Snow would have to scratch out a
living in an open market glutted with general practitioners. One might wonder
whether he did not later come to consider the legalistic intransigence of Apothe-
caries’ Hall a bit of good fortune, for in the same editorial in which the Lancet ap-
plauded the Westminster Hospital for the conditions it had established for ward pa-
tients, it castigated the house committee for its “mal-treatment of the apothecary by
the imposition on him of unprofessional duties, in addition to those of his own de-
partment . . .” such as filling out forms, which was the proper job of a secretary.
“What wonder, then, is it that no man of competent ability can be found long to fill
this degraded medical office?”36 Over the years taking the apothecary post at the
Westminster Hospital would have resulted in a considerable loss of time and energy
for activities that Snow valued more than financial security—research and medical
society meetings.
Snow the Public Health Investigator

In November 1836, during Snow’s second month at the Hunterian School, Dr. Lane
lectured on arsenic and its chemical properties. Snow took a special interest in the
subject, so he lingered a bit after the lecture. Dr. Lane called his attention to an ar-
ticle in a foreign medical journal that described a new method of preparing cadav-
ers for dissecting: injecting a saturated solution of arsenite of potash (potassium car-
bonate) into the blood vessels to eliminate most of the dried blood, followed by red
ink into the arteries to highlight them. At Lane’s suggestion Snow replicated this pro-
cedure in the cadaver he was dissecting and later in several others at the request of
some classmates.
However, Snow had inadvertently introduced a public health problem at the med-
ical school. While dissecting one of the prepared cadavers, a student became ill with
severe abdominal cramps, vomiting, and diarrhea. Snow does not appear to have
considered arsenic poisoning the cause until “the summer of 1837, [when] I injected
another body, and dissected it, with five of my fellow students, during the very hot
weather of, I think, August. Decomposition was retarded considerably [by the ar-
senic solution], but there was only one of us who did not suffer more or less indis-
position, principally bowel complaints: and the subject gave out a peculiar odour,
which I suspected arose from the arsenic rising in combination with the volatile
products of decomposition.”37 He did not have time to test his suspicion until the
Christmas recess, when he cut out a few portions of the cadaver for examination.
He found no evidence of arsenic in the tissue, which supported his notion that the
solution had turned gaseous and disappeared from the tissue. Again his studies took
precedence, and it was not until “some time afterwards” that he devised “an experi-
mentum crucis” to determine if the indispositions he and his fellows had experienced
was due to inhaling arsenic vapors or individual constitutional factors (since not
everyone was identically affected). The phrase that Snow employed in his first known
publication, a letter to the editor of the Lancet, was defined in a popular contem-
porary text, A Preliminary Discourse on the Study of Natural Philosophy: “If more than
one cause should appear, we must then endeavour to find, or, if we cannot find, to
produce, new facts. . . . Here we find the use of what Bacon terms ‘crucial instances,’
which are phenomena brought forward to decide between two causes, each having
the same analogies in its favour. And here, too, we perceive the utility of experiment
as distinguished from mere passive observation.”38 Snow’s notion of a crucial ex-
periment in this instance involved placing “some animal substances, in a state of de-
composition, on a dish, along with solution of arsenite of potash, and also powdered
arsenious acid. . . .” He covered the dish with “a bell-glass receiver to collect the
gases given off, and, at the end of two or three weeks, . . . added the air contained
in the glass to a sufficient quantity of pure hydrogen to make an inflammable mix-
ture, and burnt this as it proceeded from a small jet. . . .” The result was “a small
quantity of metallic arsenic”—in short, the arsenic was in the vapor. He informed
the school authorities, who accepted his recommendation to discontinue the “mode
of injection” he had introduced at the Hunterian.39
Snow’s investigations of poisonous cadavers coincided with his participation in a
study of poisonous candles undertaken by the Westminster Medical Society. The so-
ciety was founded in 1809 by Mansfield Clarke and Benjamin Brodie, the latter a
lecturer in surgery at the Hunterian School of Medicine in Great Windmill Street,
which is why meetings were initially held in the school’s museum. “For some years
the Society seemed almost to be an appendage of the school, every student who at-
tended the lectures becoming also a member. . . .”40 However, the rules were
changed the year before Snow reached London to include a formal proposal and ap-
proval process. Weekly meetings were held every Saturday evening from October
through April, with a pause for the summer months. Snow did not attend a meet-
ing until 8 April 1837, when he was a guest of Dr. John Epps, who was scheduled to
comment on the therapeutic administration of strychnine, bismuth, and arsenic.41
When the 1837–1838 session of meetings resumed in October, Snow was proposed
as an ordinary member and approved.42
The society had taken a distinctly radical turn a few years earlier, when five months
of debate about medical reform “culminat[ed] in motions calling for the merger of
the three estates into one democratic faculty. These motions were passed by massive
majorities, despite stonewalling tactics by the diehards.”43 Eventually, members who
sought a compromise prevailed, although at the expense of defections by extremists
at both ends of the political spectrum.
The Westminster Medical Society had a reputation for debating matters relating
to public health such as the cholera epidemic of 1832, and the members decided to
investigate “arsenical candles” during Snow’s first year as a member.44 On 28 Octo-
ber 1837 Dr. James Scott reminded the membership of potential risks from inhaling
the fumes of stearin candles infused with white arsenic, which were considerably
cheaper and burned brighter than candles manufactured from pure wax or sper-
maceti. Earlier in the year a Mr. Everitt had demonstrated at a meeting of the Medico-
Botanical Society in London that such candles produced vapors containing arsenic;
he had boiled candles in water and reduced the precipitate with sulfurized hydrogen
gas to several grains of arsenic per candle. Whereas some medical men did not be-
lieve a moderate amount of arsenic was harmful, Dr. Scott had recently received re-
liable information that at least two manufacturers had dramatically increased the
proportion of arsenic to stearin in response to public demand. “Now, as these can-
dles were not only much in use in private families, but had lately been introduced
into some of the churches, and were likely to find their way into the theatres,” Dr.
Scott “thought it would come within the province of the objects of the Society, to
state its opinion respecting the safety of such a quantity of a poisonous mineral
burnt, and its vapour inhaled.”45 In the ensuing week Mr. Richard Phillips and “Mr.
Snow had succeeded in detecting arsenious acid in these lights,” thereby confirming
Everitt’s findings. Everitt, in attendance as a guest at the meeting on 4 November, of-
fered to give a public demonstration for the society later in the month. A commit-
tee was formed “to communicate with Mr. Everitt and Mr. Phillips,” who had agreed
“to carry on the investigation.”46
Poisonous candles reappeared episodically on the society’s agenda in the ensuing
weeks, but a select committee carried out investigations behind the scenes through-
out. As promised, Mr. Everitt repeated several chemical analyses on arsenic–stearin
candles before the membership in mid-November. Mr. Golding Bird, a recent grad-
uate of Guy’s Hospital Medical School, extended the chemical investigation by burn-
ing candles in conditions with varying amounts of oxygen present; he detected var-
ious arsenic compounds under all conditions.47 The second set of experiments were
physiological in nature. “A lofty and spacious apartment of Dr. Scott’s house in the
Strand” was converted into a laboratory in which members of the select committee
constructed four boxes with ventilation holes and glass fronts for viewing the
responses of linnets, green finches, guinea pigs, and rabbits. They burned
arsenic–stearin candles in two boxes and spermaceti candles in the other two over a
seventy-two-hour period (in six twelve-hour blocks). Hourly observations were
recorded in a register. Although the guinea pigs and rabbits were unaffected, most
of the birds in boxes exposed to the vapors of arsenic candles died, whereas those
“in the boxes with pure lights were as gay at the end of the experiments as before
they commenced.” The select committee detailed these investigations at a meeting
on 9 December and concluded “that the vapour given off . . . during combustion
is likely to be prejudicial. In closing their Report, the Committee express their wish
to be of service to the public in a matter of so much importance, in the absence of
all medical police in this kingdom, the only country in Europe where the public
health is so little regarded by the governing powers.” Before the society could vote
on whether to accept the committee’s report, however, the bylaws required it to
be printed, distributed to the full membership, and, if approved, made available to

the public. After considerable discussion the society deferred a decision on whe-
ther to pay the printing costs and refund the expenses incurred in conducting the
investigations.48
During the week of 10–16 December 1837, three members of the society under-
took additional but ex-officio investigations. Mr. Golding Bird made post-mortem
examinations of five birds exposed to arsenic vapors by the select committee. He de-
tected minute amounts of arsenic in the body of one bird but nothing on any feath-
ers. The drinking water was heavily contaminated, and “he thought it probable they
had been poisoned in this manner,” perhaps because the deleterious effects of in-
gested arsenic was common knowledge. After he reported his findings at the 16 De-
cember meeting, Joshua Toynbee and Snow reported that they had “conducted a se-
ries of experiments on these candles, to ascertain the effects of their combustion on
animal life.” First, they had experimented on guinea pigs, but Snow and Toynbee’s
animals, like their counterparts in Dr. Scott’s experiments, presented no symptoms
of illness, regardless of the length of exposure or the level of arsenic in the candles.
Similar experiments on some birds, however, were inconclusive because the appara-
tus ignited during the investigation. The report of the meeting does not mention any
discussion of the select committee’s report.49
Then the medical media became involved. The Lancet’s leading editorial on 23 De-
cember reminded its readers of the coverage it had already given to the Westminster
Medical Society’s investigation of “Arsenical Candles.” The editorial gave additional
information on the subject, including a history of their discovery by a French chemist
in the 1820s, but thanks to “the vigilance of the French Government,” the candles
were tested, found to be deleterious to health, and their manufacture banned in that
country. “‘Cheap wax lights,’“ as they came to be called, made a commercial jump
over the channel, and their investors made a hefty profit “at the expense of the well-
being of the English community,” claimed the Lancet.50 The editorial then summa-
rized the “variety of experiments” conducted by the select committee from the West-
minster society and used the results to condemn the secretary of state for the Home
Department of England for permitting the sale of candles that expose “the animal
economy . . . to the action of five times a greater quantity of arsenic than any pru-
dent physician would venture to administer internally. . . .”51 Whereas the Lancet
referred to summations of society meetings by one of its reporters, the London Med-
ical Gazette printed actual extracts from the committee’s report, accompanied by an
editorial early in January 1838. At a special meeting early in February, a majority of
the Westminster Medical Society soundly condemned this caper by a disgruntled
member and decided to spend no more time or money on the topic. The society had
not repudiated its own committee’s findings, it had acted on procedural grounds be-
cause premature publication of significant passages from the report interrupted the
deliberative process called for in its bylaws. 52
A New Scientific–Medical Perspective

While the poison candle caper prevented the Westminster Medical Society from tak-
ing an unambiguous position on a public health matter, Snow’s involvement in the
investigative process is suggestive of the training he was receiving in London. In his
first year as a member of the Westminster Medical Society, he aligned himself with
those who considered medicine a science rather than just an art practiced at the bed-
side. Like his concurrent investigation of arsenic vapors in the cadavers prepared at
the Hunterian School of Medicine, his chemical analyses and physiological experi-
ments conducted for the society were pragmatic investigations designed to address
potential health hazards, not pure science. The only remarkable aspect of Snow’s in-
vestigative method in both instances was its typicality for his cohort. He considered
chemistry one of the collateral sciences of medicine, a common view in the 1830s.
For example, the subtitle of the London Medical Gazette at the time was “A Weekly
Journal of Medicine and the Collateral Sciences.” He was part of a cadre of young
medical practitioners whose training included an emerging laboratory complement
to clinicopathological dimensions of hospital medicine.53
The arsenic candles investigations show Snow as a collateral scientist in keeping
with the new scientific approaches to medicine that were part and parcel of his train-
ing. His approach to these investigations also reveals a model that would recur in his
anesthesia and cholera research. At an early stage in his career he demonstrated an
ability to set up a series of experiments that traced an agent as it circulated in a med-
ical school dissection room, in rooms where arsenic candles were burned, and in the
bodies of everyone who entered them. That is, he was already concerned with chem-
ical analysis, employing animal experimentation, and asking questions about what
he would later term modes of communication—the pathways by which a specific
poison was introduced into a community and where and how it lodged in the body.
Must arsenic be ingested to be poisonous (the common assumption at the time), or
could it also be poisonous if inhaled (an unusual assumption)? A decade later he
would articulate the principles of how ether and chloroform circulate in the body
and cause their specific effects; shortly thereafter he would hypothesize how cholera
could circulate through the water supplies of a neighborhood, a town, and a me-
tropolis. This facility in imagining systems circulation and transmission in terms of
patterns and pathways was the unifying conceptual orientation in Snow’s work.
The hospital medicine to which Snow was exposed was an English variant of
developments in western Europe associated with the Enlightenment. In mid-
eighteenth-century London several surgeons believed that students should base their
knowledge of medicine on anatomy rather than observations accumulated at the
bedside as apprentices learning a craft. William Hunter established a private anat-
omy school in Covent Garden in 1746. His brother, John Hunter, joined him two
years later, and the school prospered for more than a decade. In 1766 William Hunter
on his own purchased and renovated a house at 16 Great Windmill Street as a com-
bined residence and school, the forerunner of the Hunterian School of Medicine. Al-
though its successful run was nearly over when Snow arrived, anatomy schools such
as the Hunterian that emphasized morbid anatomy had set the stage for the incor-
poration by English hospital-based medical schools of the more expansive curricu-
lum pioneered in France.54
In Paris between 1790 and 1830, a group of medical reformers, the Idéologues,
augmented the provision of care and surgery in Parisian hospitals by the introduc-
tion of teaching and research. They believed that conventional Hippocratic–Galenic
notions of humoral imbalance needed to be replaced by a scientific form of medi-
cine within an Enlightenment worldview: modeled on the natural sciences, founded
on the principles of Lockean empiricism, and pragmatic in the sense of under-
standing the “human economy”—how individual and social systems functioned.55
Their covering law, the medical equivalent to Newton’s theory of gravity, was that
specific diseases were connected to particular organs or tissues in the body. They be-
lieved enlightened medical thinking should correlate empirical observation of indi-
vidual patients at the bedside, statistical manipulation of multiple observations in
clinical settings, and pathological findings from postmortem dissecting. Supporters
of the Idéologue orientation gained control of several hospitals in Paris, where they
reconfigured medical education to include training in sciences collateral to their vi-
sion of enlightened medicine, especially anatomy, physiology, mathematics, and
chemistry.56 A leading figure was Pierre Louis (1787–1872), who devised the “nu-
merical method,” involving statistical analysis of many cases in the Paris clinics to
show that venesection was only minimally effective in the treatment of pneumonia.57
Statisticians like Louis were among the adherents of the new scientific–medical
perspective in England during the middle third of the nineteenth century, but the
general tendency was to think of hospital medicine as a branch of natural philos-
ophy. Natural philosophy was the inquiry into the principles and laws underlying
phenomena in nature, and in 1830 John Herschel had published a primer for ac-
tualizing it that was still popular reading during Snow’s training period.58 Accord-
ing to Herschel, natural philosophers should limit their searches to verifiable prox-
imal causes; they should seek to trace, in whatever discipline they investigated, “the
operation of general causes, and the exemplification of general laws. . . . Every
object which falls in his way elucidates some principle, affords some instruction,
and . . . [gives] a sense of harmony and order.”59 Experience acquired by obser-
vation and experiment (what Bacon termed active observation) was the founda-
tion of natural philosophy. Herschel’s “perfect observer” was acquainted “not only
with the particular science to which his observations relate, but with every branch
of knowledge which may enable him to appreciate and neutralize the effect of ex-
traneous disturbing causes.” We should observe until we are in a position to de-
duce general conclusions that encompass more than our experience, then test the
validity our deductions by experimentation and further observation. That is, “the
successful process of scientific enquiry demands continually the alternate use of
both the inductive and deductive method”—or, in our term, hypothetico-deductive
reasoning.60
The view that corollary sciences and analogical reasoning were central to the study
of medicine lay at the core of natural philosophy. According to Herschel, “there is
scarcely any natural phenomenon which can be fully and completely explained in
all its circumstances, without a union of several, perhaps of all, the sciences. . . .
Hence, it is hardly possible to arrive at the knowledge of a law of any degree of gen-
erality in any branch of science, but it immediately furnishes us with a means of ex-
tending our knowledge of innumerable others. . . .”61 For example, Herschel’s jus-
tification for analogical reasoning and horizontal moves among collateral sciences
parallels Snow’s decision to use chemistry when investigating two medical problems
associated with potential arsenic poisoning. Only in his mid-twenties, Snow was al-
ready the “perfect observer” and keen experimenter that Herschel considered central
to scientific progress.
* * *
Snow qualified as an apothecary in October 1838.62 He had already decided to re-

main in London, having moved the month before to lodgings in Frith Street, only a
few blocks from Bateman’s Buildings. Here, in the heart of Soho, he set up a surgery
in his apartment and hoped to establish himself as a general practitioner and ac-
coucheur. Starting his own practice in central London “seems crazy.”63 There was a
surfeit of surgeon–apothecaries in the metropolis as a whole, a half-dozen within a
few blocks of where Snow hung his shingle. None of the conventional routes must
have been available or seemed sufficiently attractive. Most medical students from the
provinces returned to their home districts after qualifying, often relying on medical
relatives to help them become established or joining an existing practice as a junior
partner.64 Snow had burned his bridges to Yorkshire and Northumberland several
years before. He does not appear to have had substantial medical connections in
York, a city also suffused with medical men. If he had chosen not to continue as
Hardcastle’s assistant (or never been asked) in 1833, there seems little reason to think
he would return five years later to the city where his former master still maintained
an active practice. In addition, Warburton’s oldest son was already a partner and due
to inherit his father’s practice, which ruled out any temptation Snow may have had
to renew his temperance activities from a base in Pateley Bridge.
Opening a practice in London had certain advantages that must have outweighed
the risks. The Westminster Medical Society offered a scientific community and the
kind of comradeship that might equal the friendships he had made in the Yorkshire
temperance movement. He lacked the connections, the affluence, and the patronage
usually required to secure a hospital appointment in the metropolis, but he could
hope to become a lecturer in one of the medical schools. What is more, London now
had a university that would grant a doctor of medicine to someone who had not at-
tended Oxford or Cambridge, which meant that Snow could aspire to become a
physician and, perhaps, shatter the glass ceiling of social advancement that kept med-
ical men of his background from attending patients in the upper classes.
Notes
1. Richardson, L, v. Galbraith suggested the motive for the stopover in Liverpool; personal
communication, 4 October 2000. For the probable daily pace of a long-distance walker in the
1830s, see Galbraith, JS-EY, 49.
2. He may have spent as much as £170 on his London training, of which it seems unlikely
that he could have saved more than half as an assistant apothecary from 1833 to 1836; S. Snow,
JS-EMP, 147–48. By 1836 William Snow was an established farmer, perhaps with an annual
income around £120; Ibid., 46.
3. “Regulations of Apothecaries’ Hall and College of Surgeons,” Lancet 1 (1836–37): 6–7.
Apothecaries’ Hall required a five-year apprenticeship in addition to lectures and hospital
rounds and set the minimum age for qualification at twenty-one. The Royal College of Sur-
geons expected at least five years devoted to acquiring professional knowledge, which could
include a short apprenticeship; candidates for qualification had to be at least twenty-two years
of age.
4. In chemistry, medicine, materia medica, therapeutics, surgery, anatomy, and physiology;
G. G. Turner and Arnison, Newcastle upon Tyne School, 17–20. See also Richardson, L, vii–viii.
5. Society of Apothecaries, “Court of examiners entrance books,” MS 8241/10, 61 (“John
Snow”).
6. Bailey, “The medical institutions of London,” British Medical Journal 1 (1895): 1289;
Clark-Kennedy, “London Hospitals,” 111–12; Peterson, Medical Profession, 15, 71.
7. It was not until the 1850s that “private education in the anatomy schools was co-opted
or destroyed by the hospital medical schools”; Peterson, Medical Profession, 64–65, 72. See also
Desmond, Politics of Evolution, 12–13.
8. “Advertisement,” Lancet 1 (1836–37): 5. See also Peterson, Medical Profession, 66. For the
editorial policy of the Lancet and the medical radicalism of its founding editor, Thomas Wak-
ley, see Desmond, Politics of Evolution, 14–15, and passim.
9. Peterson termed it a “supermarket approach to medical education” (66).
10. John Epps, MD, was from Edinburgh and in 1826 a member of the Phrenological So-
ciety there. He was editor for the London Medical and Surgical Journal, author of a book on
homeopathy and dropsy, and contributor to the Lancet and M-CR; Medical Directory, 1845.
See also Desmond, Politics of Evolution, 166, 421.
11. Richardson, L, v–vi. See also Snow, “Arsenic as a preservative of dead bodies” (1838),
264, where he mentioned taking chemistry and performing dissections “at the school in Great
Windmill-street.” Mr. Smith, who examined Snow for the LSA, noted the number of lecture
courses completed between October 1836 and October 1838 and the names of the instruc-
tors; Society of Apothecaries, “Court of Examiners entrance books,” MS 8241/10, 61 (“John
Snow”). All but one of the instructors were on the faculty of the Hunterian School of Medi-
cine; “Hunterian School of Medicine,” Lancet 1 (1836–37): 12. In the previously cited letter to
the Lancet, Snow described dissecting in August 1837—between sessions, when only perpet-
ual students had access to the school’s facilities. See also Cope,“Private medical schools,” 91–92,
and Peterson, Medical Profession, 72.
12. Monmouth House and various ancillary buildings occupied an entire city block south
of Soho Square until demolished in 1773. Two large houses facing the square were subse-
quently erected and leased by Lord Bateman, along with a collection of houses created for the
artisans involved in the construction. Part of their pay included grants of subleases to the
houses in which they lived, which came to be called Bateman’s Buildings; see Sheppard, Parish
of St. Anne Soho, 113–14. Stephanie Snow estimates rent for a room was 13–18 shillings per
week; JS-EMP, 147–48. In 1841 (three years after Snow moved out) a census enumerator listed
17 persons at 11 Bateman’s Buildings, among the most crowded of the sixteen houses in the
terrace; UK, Home Office, 1841 Census, H.O. 107/730/2A, 1–8.
13. P. Bennet Lucas became a member of the Royal College of Surgeons of Edinburgh in
1833. In London, besides his appointment at the Hunterian School of Medicine, he was a sur-
geon at the Metropolitan Free Hospital. Among his writings is a text entitled Anatomy and
Surgery of the Arteries and an article on asphyxia in the Cyclopaedia of Practical Surgery. He
was a contributor to the Lancet and the Provincial Medical and Surgical Journal. John Hunter
Lane was from Surrey but qualified as a surgeon (1829) and received the MD (1830) from
Edinburgh. He lectured on chemistry and forensic medicine in the Liverpool School of Med-
icine before coming to the Hunterian. He was a regular contributor to the London medical
journals; Medical Directory, 1845. Michael Ryan read medicine in Ireland, received the MD
from Edinburgh, and focused his practice on obstetrics. He was for a time editor of the Lon-
don Medical and Surgical Journal; see Desmond, Politics of Evolution, 171, 427. According to
the Apothecaries’ Act of 1815, Scottish graduates could not practice in England unless they
received an English qualification, whether the LSA, the MRCS of London, or an MD from
Oxford, Cambridge, or (eventually) University College London. Apparently, few bothered to
add English credentials and practiced without them.
14. We have not found biographical information on Jewell. The weekly schedule we con-
structed from the course descriptions in Lancet 1 (1836–37): 12 is the most likely scenario for
fulfilling the courses noted in Society of Apothecaries, “Court of Examiners entrance books,”
MS 8241/10, 61 (“John Snow”). It is possible that he attended lectures in surgery offered by
James Wardrop (1782–1869), MRCS of Edinburgh, and highly recommended in Lancet 1
(1836–37): 20. The Society of Apothecaries did not require comparative anatomy, which was
taught at the Hunterian during the 1836–1837 session by Robert Grant, a surgeon and physi-
cian educated in Edinburgh, Lamarckian evolutionist, lecturer in comparative anatomy at Uni-
versity College London, and fiery agitator for radical medical reforms; Medical Directory, 1845;
see also Desmond, Politics of Evolution, 422. We do not know if Snow attended Grant’s lec-
tures in 1836–1837.
15. Society of Apothecaries, “Court of examiners entrance books,” MS 8241/10, 61 (“John
Snow”).
16. Quoted in Richardson, L, v.
17. Although the Anatomy Act of 1832 made it easier for medical schools to obtain ca-
davers legally, wax models were still used for demonstration purposes; see LMG 19 (1836–37):
32. A collection of wax models from the early nineteenth century is on display at the Gordon
Pathological Museum of Guy’s Hospital, London.
18. S. Paget, Memoirs of Sir James Paget, 40–41.
19. Galbraith, “Joshua Parsons,” 108.
20. Lancet 1 (1837–38): 14–15; Society of Apothecaries, “Court of examiners entrance
books,” MS 8241/10, 61 (“John Snow”). Robert Venables, MA and MB (1823) from Oxford,
published his “Lectures on clinical history, pathology, and treatment of urinary disease” in
LMG (1837–38); Medical Directory, 1845.
21. “Advice to students,” Lancet 1 (1837–38): 20; see also 11, 15. The North London Hos-
pital in Gower Street was opened in 1834, replacing the University Dispensary in Euston Square
that had provided practical training for medical students of the newly founded University of
London between 1828 and 1833. In 1838 the name was changed to University College Hos-
pital; Newman, Medical Education, 113–14.
22. Snow was not trained by Richard Bright, a physician at Guy’s Hospital, a respected clin-
ical researcher on kidney diseases, and the developer of a chemical test for the kidney disease
later named for him.
23. Lancet 1 (1837–38): 15. Westminster Hospital had been a dispensary in James Street
until 1834, when it moved to a new location and added a medical school; Newman, Medical
Education, 113. For the reputation of the medical officers and the method of teaching at West-
minster Hospital, see S. Snow, JS-EMP, 135–37.
24. “Advice to students,” Lancet 1 (1837–38): 20. For the significance of the shift from the
“history taking” in conventional bedside medicine to the study of physical signs in hospital
settings, see Peterson, Medical Profession, 14–15, and her citations of studies by Figlio and
Waddington.
25. “Advice to students,” Lancet 1 (1837–38): 20.
26. Ibid., 21.
27. There are parallels between the Lancet’s ideal case report and Snow’s format set forth
in the extant casebooks (CB) from the last decade of his life, although the latter contains idio-
syncrasies evolved over many years by a skilled experienced practitioner. Moreover, a number
of his publications include statements such as the following: “The following case from my
note-book”; in “Case of malignant hæmorrhagic small-pox” (1845), 585–86.
28. S. Paget, Memoirs and Letters, 59–60.
29. Ibid., 60.
30. Ibid., 61.
31. Ibid., 63.
32. Ibid., 64–65; Newman, Medical Education, 20, appears to be based on Paget’s account.
33. According to the Charter of 1822, examiners had to be selected from the twenty-one
members of the council, and examinations were held in the college building; see Bailey, “Med-
ical institutions of London,” British Medical Journal 2 (1895): 1291. “College of Surgeons,”
LMG 22 (21 July 1838): 688.

34. “Editorial—1 April 1837,” Lancet 2 (1836–37): 60. The hospital apothecary, Mr. Thur-
man, also retired as secretary of the Westminster Medical Society in October 1837; Lancet 1
(1836–37): 177.
35. Richardson, L, vi–viii; S. Snow, JS-EMP, 140–43.
36. Lancet 2 (1836–37): 59–60.
37. Snow, “Arsenic as a preservative of dead bodies” (1838), 264.
38. Ibid.; Herschel, Preliminary Discourse, 150–51. John Herschel (1792–1871), a mathe-
matician, chemist, researcher in optics, astronomer, and translator of various literary works,
was the son of William Herschel (1738–1822), also an astronomer.
39. Snow, “Arsenic as a preservative.”
40. Bailey,“Medical Institutions of London,” British Medical Journal 2 (1895): 26, and British
Medical Journal 1 (1895): 1389. See also Hunt, Medical Society of London, 16–17; S. Snow,
JS-EMP, 170.
41. S. Snow, JS-EMP, 172; see also “Westminster Medical Society,” Lancet 2 (1836–37): 123,
where Epps is recorded as warning that even “small doses of liquor arsenicals . . . in deli-
cate females, soon brought on uterine hæmorrhage, though he had never witnessed a case in
which it had gone to an alarming extent.” Official minutes or reporters’ abstracts of meetings
were regularly published in the London medical journals.
42. Galbraith, JS-EY, 54. “Westminster Medical Society. To the Editor. . . ,” Lancet 1
(1836–37): 232. According to the new bylaws, three members had to propose a candidate for
membership, and a majority of the society had to approve. Successful candidates had to pay
an introductory fee of one guinea, which also covered annual dues for three years.
43. Desmond, Politics of Evolution, 105.
44. “Westminster Medical Society,” Lancet 2 (1831–32): 21–24, 51–54, 85–88, 146–50; dis-
cussions of cholera occurred on 31 March , 7 April, 14 April, and 28 April 1832.
45. “Westminster Medical Society,” Lancet 1 (1837–38): 212. It is possible that Everitt was
a misspelling of David Everett, LSA (1839).
46. Ibid., 243. There were several medical men named Phillips, of which the most likely in
this instance was Richard Phillips, LSA (1836), MRCS (1837).
47. Ibid., 425. While still apprenticed, Golding Bird became a student at Guy’s, where he
soon developed a reputation as an accomplished chemist. He received the LSA in 1836 and
earned an MD from St. Andrews in 1838; see Coley, “The collateral sciences in the work of
Golding Bird.”
48. “Westminster Medical Society,” Lancet 1 (1837–38): 425–27.
49. Ibid., 463.
50. Editorial, Lancet 1 (1837–38): 457.
51. Ibid., 458.
52. “Poisonous Candles,” LMG 21 (1837–38): 577–80; “Westminster Medical Society,” LMG
21 (1837–38): 585–88; “Westminster Medical Society,” Lancet 1 (1837–38): 722.
53. However, the institutional approach to laboratory medicine did not develop as early in
England as it did in France and the German states. See also Seale and Pattison, Medical Knowl-
edge, 33–35.
54. See Cope, “Private medical schools,” 90–93; the Hunterian School of Medicine was
sometimes called The Great Windmill Street School. See also Hays, “The London lecturing
empire”; S. Lawrence, “Entrepreneurs and private enterprise”; Long, History of Pathology, 95;
and Newman, Medical Education, 82–111.
55. Holloway, “Medical education,” 303–04. The Idéologues sought to emulate Giovanni
Morgagni (1682–1771), whose essay De sedibus (1761; The Seat and Causes of Disease, 1769)
argued for the correlation of clinical symptoms with pathological manifestations discovered
during autopsies—which made morbid anatomy central in a medical student’s education.

Leading figures among the Idéologues included Pierre Cabanis (1757–1808),
physician–philosophe, and Marie F. X. Bichat (1771–1802), who substituted tissues for hu-
mors as basic units of health and disease; see Porter, Greatest Benefit, 306–07.
56. Teaching was integrated with research as hospital clinicians devised nosological systems
for classifying diseases as distinct entities, either by “distinguishing separate diseases that had
previously been believed to be the same, or . . . unifying as a single disease category a dis-
parate collection of manifestations previously thought to be separate diseases” as in the re-
search showing that different types of consumption were one disease, tuberculosis; Seale and
Pattison, Medical Knowledge, 33.
57. See Porter, Greatest Benefit, 316–18, on the influence of the Paris “school” of hospital
medicine in London. The Paris school of medicine included, besides Louis, René T. H. Laen-
nec (1781–1826), a physician at two large Paris infirmaries, the Salpêtrière and Hôpital Necker,
and developer of the stethoscope; Jean N. Corvisart (1755–1821), physician to Emperor
Napoleon, proponent of morbid anatomy and the clinicopathological approach to under-
standing internal diseases; and Gaspard L. Bayle (1774–1816), physician at the Charité hos-
pital and researcher on phthisis (tuberculosis) and cancer pathology. See Porter, Greatest Ben-
efit, 312–13.
Contemporary validation that the ideas from the Paris school were debated during Snow’s
medical training is found in Edwin Lankester’s “Essay on the uncertainty of medical science,
and the numerical method of M. Louis,” London Medical and Surgical Journal 10 (1836–37):
468–76, read at a meeting of the Medical Society of London in November 1836. Lankester
(with whom Snow would later work very closely) argues that Louis’s method is not just a me-
chanical collection of facts. Instead, a judicious use of the method would assist those who
wished to move medicine from an art to a science. Some critics “will feel disposed to say, that,
from the very nature of medicine, it is impossible to reduce it to the rank of a true science.
To this I would answer,” wrote Lankester, “that it is as possible for the mind of man to have
the relation of cause and effect in one series of actions as in another. . . . If the astronomer
has thus succeeded, surely it is not too much to suppose that the medical philosopher may
equally give laws to the relations of bodies infinitely more accessible to the apprehension of
the sense” (476). However, the manner in which Lankester presented the numerical method
indicates that its use in England was not the norm.
58. In an 1831 letter to W. D. Fox, Charles Darwin wrote, “If you have not read Herschel
in Lardners Cyclo—read it directly”; Darwin, Correspondence, 1: 118. Herschel’s Preliminary
Discourse (1830) was republished in Dionysius Lardner’s Cabinet cyclopædia in 1831.
59. Herschel, Preliminary Discourse, 87; quotation from 15.
60. Ibid., 132; 174–75.
61. Ibid., 174.
62. “Apothecaries’ Hall. List of gentlemen who have received certificates. Thursday, Octo-
ber 4,” LMG 23 (1838–39): 144; “John Snow, York,” was eighth on a list of ten.
63. Christopher Hamlin’s phrase, taken from his review of an early draft of the manuscript.
64. In the sample used by Digby, seventy-eight per cent of GPs in the north of England
had their “main place of practice in [the] area of birth”; British General Practice, 74.

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Chapter 3

London Medical and

Thereafter, according to Richardson, he “trudg[ed] it afoot from Liverpool through the

Requirements for Certification

Figure 3.1. Place-names, towns, and cities of significance to Snow.

Key: Italics—Required by Apothecaries Hall (AH) only.

The London Medical Schools

ture courses, demonstrations, and dissecting opportunities.

Snow the Medical Student

teaching available at University College Hospital—and, perhaps, at another relative

London Medical Gazette published a notification: “College of Surgeons. List of Gen-

Snow the Public Health Investigator

be printed, distributed to the full membership, and, if approved, made available to

A New Scientific–Medical Perspective

Snow qualified as an apothecary in October 1838.62 He had already decided to re-

LMG 22 (21 July 1838): 688.

during autopsies—which made morbid anatomy central in a medical student’s education.

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