James C. Eisenach, M.D., Editor.

Edited by Ellis RH. London, Wellcome Institute for the History of Medicine, 1994. Pages: 633. Price:$38.00.

John Snow (1818–1858) was an astute laboratory investigator of basic problems related to situations encountered in the early days of anesthetic practice. Above all, he was a shrewd physician and the foremost clinical anesthetist of his day. He probably accomplished more to aim newly introduced anesthesia toward today's pattern of clinical practice and research than any other early practitioner of the art.

Snow recorded many observations and conclusions from most of the patients he attended during the period 1848–1853 in the capacity of both anesthetist and general practitioner. The case books containing this material ultimately came into the possession of the Royal College of Physicians, London, where they have since resided very much underutilized as a primary source of historical material. These case books have been made readily available to the anesthesia community through a most scholarly and comprehensive compilation, editing, and annotation by the late Dr. Richard Ellis. He found these volumes in deteriorating condition, and his motives for preparing the current work included prevention of further wear and tear on these fragile 19th century documents and to ensure that the material remains accessible to future interested parties.

The introduction to the actual case books written by Ellis contains the most detailed and comprehensive biography of Snow since that published in 1858 (included in Snow's posthumously published volume on chloroform) by Dr. Benjamin Ward Richardson, one of Snow's close professional colleagues. Snow's early life, medical training, and career as a practitioner are described. Ellis proposed that the professional status finally attained by John Snow, as well as that of some of his siblings, was exceptional in view of the meager educational opportunities available in the early 19th century for the children of poor working class families. Snow came to London in 1836 for further medical education and then practiced his profession for the remainder of his life in that locality.

Ellis describes in detail the history, format, characteristics, and peculiarities of the case books as well as some of the problems encountered in their analysis and transcription. The volumes constitute a fascinating portrait of anesthesia practice in its early years. Probably few will want to read the text in its entirety, because the accounts tend to become repetitious, and Snow's motivation for keeping such a chronicle over the period of 15 yr is not apparent. However, anyone interested in anesthesia will profit by thumbing through the book randomly choosing selections from the large amount of material presented. A brief section on Snow's prescription records with tables summarizing medicines popular in Victorian times, their actions, and directions for their use will assist modern physicians to follow Snow's nonanesthetic practice. Another most helpful feature of the volume is provision of five separate indexes to categories of information presented in the text: dentists, surgeons and other medical men, patients and others, medical conditions, and places mentioned. In the comments on the brief case histories presented, one can discern the origins of many of the observations and conclusions recapitulated in Snow's book on the inhalation of chloroform.

Many questions and conclusions will strike the mind of the contemplative anesthetist on perusing these pages. When compared with medical writings from the era of Dr. Thomas Beddoes and his contemporaries less than two generations previously, advances in medical knowledge and accuracy of diagnosis in the interval become apparent. Snow's terminology is modern, and there is seldom any doubt as to the nature of the medical conditions with which he was dealing. An engaging profile of mid-19th century surgical practice emerges. The most common conditions encountered appear to be genitourinary or rectal problems, but a wide variety of complaints were treated. Opening of body cavities was avoided whenever possible, and strangulated hernia was almost always a lethal situation. Cupping and leeches were used by Snow in his practice, and he occasionally administered anesthetic vapors therapeutically for treatment of various disease states. Chloroform was the agent most commonly used, but he occasionally used ether, amylene, and the Dutch Liquid.

Snow often described the anesthetic course of his obstetric deliveries in far greater detail than many of his other cases, which may indicate his particular fondness for and interest in this branch of medical practice. His patients, sometimes from notable families, are identified in detail. He often included their address, family relationship, ethnic origin, and other personal facts. One can easily locate the accounts of his administrations of chloroform to Queen Victoria for labor and delivery. (On one of these occasions, Prince Albert administered chloroform to the Queen before Snow's arrival.)

Snow did not write much about upper airway obstruction occurring with anesthesia despite the presence in some of his patients of anatomic features that predispose to this problem, such as extreme obesity. Perhaps he was so highly skillful in managing this situation that it was not a concern to him. Also, a very high percentage of his patients vomited meals that they had taken immediately before anesthesia. Snow did not recognize the danger of this situation. One would have thought that, perhaps for no other reason than aesthetics, he would at some time in his career begin insisting on preanesthetic fasting.

"The Case Books of Dr. John Snow" deserves an honored place in the literature relating to anesthesia's past. The volume will be a valued addition to every collection dealing with the history of anesthesia.

Norman A. Bergman, M.D., Clinical Professor of Anesthesiology, Oregon Health Sciences University, 3181 SW Sam Jackson Park Road, Portland, Oregon 97201.