Thomas Wakley, the founder and first editor of the Lancet, did for medicine what Florence Nightingale did for nursing, turning it from a corrupt dishonourable trade into a caring scientific profession. Yet Florence Nightingale has appeared on British banknotes and is known across the world, whereas Wakley is little known outside medicine and not even all that well known within it.
One reason for the discrepancy must be that there is no decent biography of Wakley. Instead, there are three poor and dreary ones. His fascinating, important, and influential life cries out for a good one. But what we do now have is an excellent and enjoyable novel on Wakley’s progression from prize-fighter to being the creator and first editor of the Lancet by Nick Black, physician, health services researcher and professor at the London School of Hygiene and Tropical Medicine and regular contributor to the Lancet and the BMJ. Black advances his argument of the equivalence of Nightingale and Wakley not in the text of Bare-knuckle Surgeon but in his notes at the end.
The novel begins in 1811 with the 16-year old Wakley about to be beaten in a prize fight, but he picks himself up and fells his gold-toothed opponent. This is a man who will overcome multiple setbacks to achieve his dream, which initially was to be a surgeon but transmuted into a need to reform medicine. He is fighting in order to raise money to free himself from his conservative father, a farmer who through the Enclosure Acts is swallowing up the land of his poor neighbours in Devon. Wakley had already shown his courage and need for independence by going to see when he was 11.
The prize fight has been organised by the apothecary to whom Wakley has been apprenticed. The apothecary is a swindler, but Wakley exploits his misconduct to get him to sign the form he needs to enter medical school. After working for two general practitioners and wondering how they manage to stay up-to-date, he becomes a medical student at Guy’s Hospital and is quickly horrified by what he sees. He watches incompetent surgeons kill patients while other surgeons stand by. Medical students must scramble to get any education, and hardly anybody seems interested in science. There is no accountability: “It’s as if our profession believes medicine has to be closely guarded. The hospitals, societies, colleges seem to fear scrutiny. No-one is interested in finding out if their patients get better. Meanwhile, the public are to be grateful for anything they do, even if it kills them.”
Despite all these concerns, Wakley still wants to be a surgeon, but he soon discovers that surgical jobs are reserved for the family members of surgeons. Nepotism and corruption are rife. He tries repeatedly to find work as a surgeon but eventually his passion for reform trumps his urge to be surgeon: “‘As I was coming home today, I suddenly realised why I haven’t been able to resolve how I can be a surgeon and yet devote myself to reform.’ He stood up. ‘The answer was obvious all along. Doing both was impossible.’”
But how to go about reform? He’d already taken to writing short pieces, and in 1817 he wrote to The Times questioning whether what was being reported as a typhus epidemic was really was typhus. “Two days later, when he opened the paper and saw it, he could barely contain his excitement. He’d never seen his name in print.” We’d learnt already in the novel that for Wakley “To be the centre of attention, even if it was only for a few minutes, was glorious.”
Inspired by the Political Register, the campaigning publication of the radical William Cobbett, Wakley hit on the idea of the Lancet. He still had to raise the money, and in addition to the financial risk there was great personal risk. A supporter warns him: “The medical establishment won’t hesitate to punish you if you take them on….how far are you prepared to go, knowing you’ll be subjected to unfounded assaults not just on your professional position but your personal life as well?”
As he seeks to raise the money, he’s asked about his vision for the Lancet: “Well, it has to be weekly. Monthly or quarterly is useless for generating debate. Trouble is, doctors have never subscribed to a weekly.” He paused. “It has to be like a young stallion, not like an old carthorse….It’s got to rouse and excite. Show doctors they no longer have to accept the way hospitals and colleges and societies are run. Challenge corruption and nepotism, poor education and incompetence. Doctors have got to be held to account for what they do.” It also had to be “entertaining” and include a variety of material, including theatre reviews and poetry.
Wakley recognised that he had something in common with reformers in other areas, not just politics but Constable and Turner in painting and Shelley, Byron, and Keats (a contemporary as a medical students at Guy’s) in poetry. The novel does a good job of evoking the feel, smells, and issues of the age.
After Wakley raises the money from a funder who wants to be anonymous, he sets about assembling the first issue. He has to write most of it himself, while his wife writes theatre reviews. The novel builds to a convincing climax as the day of publication of the first issue (5 October 1823) draws near. The novel ends with Wakley’s eyes filling with tears as he handles the first issue “still warm from the printer.”
It’s a hard thing to write a novel, and a lifetime of writing for journals, as Black has done, is no preparation, something much more is needed. The creative life is hard, joy one day, despair the next. ( I know this from my wife a painter and other friends who are what are now called “creatives.) It takes imagination, research, dedication, and courage to write a novel. You expose yourself in a way that you do not with contributions to scientific journals.
Somerset Maugham, whose many novels are still widely read, acknowledged in his Ten Novels And Their Authors that, although there are many great novels, there are no perfect ones. In an introductory essay “The Art of Fiction” he outlines what he expects from a successful novel: a widely interesting theme; a coherent and persuasive story with an end that is the natural consequence of the beginning; episodes that grow out of the story; characters observed with individuality whose actions and words fit with their character; and easily-read writing fits the matter “as a well-cut shoe.” For Maugham the story must move briskly along, and above all the novel must be entertaining, “the essential quality, without which no other quality avails.” For me Black does well on these criteria.
In this novel he doesn’t make the case that Wakley is as important in reforming medicine as Nightingale was in reforming nursing. Wakley has identified the problem and just launched a means that he will hope lead to reform, but dangerous, unscientific, corrupt, and nepotistic medicine is still the norm in 1823. We must await the next volume for Black to make his final case, and I hope that he’s busy with it now.
Richard Smith’s non-medical blogs
https://richardswsmith.wordpress.com/