John Snow

“ I have reason to conclude that the increased secretion of saliva is caused, not so much by the action of the chloroform on the mucous membrane of the mouth, and the extremities of the gland ducts, as by its action on the capillary circulation of the glands themselves; for on inhaling the vapour carefully by the nostrils, so that none enters the mouth, I still find that there is an increased secretion of saliva. ”

“ I need hardly say that if cases of disease were propagated in this way, it would be quite impossible to trace them.
If the cholera had no other means of communication than those which we have been considering, it would be constrained to confine itself chiefly to the crowded dwellings of the poor, and would be continually liable to die out accidentally in a place, for want of the opportunity to reach fresh victims; but there is often a way open for it to extend itself more widely, and to reach the well-to-do classes of the community ”

“ Fear is an affection of the mind, and can no longer exist when the patient is unconscious; but the action of that amount of chloroform which is consistent even with disordered consciousness is stimulating, and increases the force and frequency of the pulse, in the same way as alcohol. I believe that no one would assert that a person would die the sooner of fright for having taken a few glasses of wine, or a small amount of distilled spirits, whatever might be the state of his health. ”

“ British people would not desert their friends or relatives in illness, though they should incur danger by attending to them; but the truth is, that to look on cholera as a “catching” disease, which one may avoid by a few simple precautions, is a much less discouraging doctrine than that which supposes it to depend on some mysterious state of the atmosphere in which we are all of us immersed and obliged to breathe. ”

“ I infer that they have been more talked about than read, for few people seem to be aware of the enlarged and positive physiological arguments which they contain. Chloroform and ether are not alone discussed, but all narcotics. Narcotics are not alone considered, but various of the great functions of life. The records of a vast number and variety of experiments are here related, and an amount of information, original in kind, collected, which will always remain as a memorable record in the history of medical literature. ”

“ But from all that I have been able to learn of cholera, both from my own observations and the descriptions of others, I conclude that cholera invariably commences with the affection of the alimentary canal. The disease often proceeds with so little feeling of general illness, that the patient does not consider himself in danger, or even apply for advice, till the malady is far advanced. ”

“ But, in the face of all the struggles incidental to the existence, so to have managed as to have stolen out of time hours which other men knew not in their calendar—so to have defied the inexorable taskmaster as to perform more than is included in his demands; so to have willed and acted as to live on when death has done his worst; to assist all coming wayfarers in their conflict wherever they may meet it; to prove that there is something more in life than labour lost, and nothing more in death than an idea—Hoc opus hic labor est—in this there is achieved the grand attainment ”

“ Baker, of Staines, who attended two hundred and sixty cases of cholera and diarrhœa in 1849, chiefly among the poor, informed me, in a letter with which he favoured me in December of that year, that “when the patients passed their stools involuntarily the disease evidently spread.” It is amongst the poor, where a whole family live, sleep, cook, eat, and wash in a single room, that cholera has been found to spread when once introduced, and still more in those places termed common lodging-houses, in which several families were crowded into a single room. ”

“ When symptoms like those of pain are present during an operation, one may generally know whether they are the consequences of it, by observing whether or not they are connected with each cut of the knife. But even when a flinch or a groan follows each manipulation of the surgeon, it does not necessarily follow, provided the patient does not speak, that he is suffering pain. Some amount of consciousness is essential to the presence of pain, but many of the lower animals execute movements like those caused by pain, after the head is cut off, and when, of course, there can be no consciousness. ”

“ As there is no difference whatever, either in the houses or the people receiving the supply of the two Water Companies, or in any of the physical conditions with which they are surrounded, it is obvious that no experiment could have been devised which would more thoroughly test the effect of water supply on the progress of cholera than this, which circumstances placed ready made before the observer. ”

“ It is not improbable that, amongst the multitudes of new bodies which chemistry makes known every year, some agent may be found superior to those hitherto used; and besides the great practical advantages which are directly derived from the discovery of inhalation for the prevention of pain, the method of breathing medicinal substances in the gaseous state offers great facilities for the investigation of their effects, and cannot fail to hasten the time when the mode of action of medicines will be a branch of exact knowledge. ”

“ For the morbid matter of cholera having the property of reproducing its own kind, must necessarily have some sort of structure, most likely that of a cell. It is no objection to this view that the structure of the cholera poison cannot be recognised by the microscope, for the matter of small-pox and of chancre can only be recognised by their effects, and not by their physical properties.
The period which intervenes between the time when a morbid poison enters the system, and the commencement of the illness which follows, is called the period of incubation. ”

“ There arose hereupon much discussion amongst the learned, much sneering and jeering even; for the pump-handle removal was a fact too great for the abstruse science men who wanted to discover the cause of a great natural phenomenon in some overwhelming scientific problem. But it matters little. Men with great thoughts in their heads, think of little things which little men cover with their wide-spread feet. ”

“ No fewer than three hundred thousand people of both sexes, of every age and occupation, and of every rank and station, from gentlefolks down to the very poor, were divided into two groups without their choice, and, in most cases, without their knowledge; one group being supplied with water containing the sewage of London, and, amongst it, whatever might have come from the cholera patients, the other group having water quite free from such impurity. ”

“ Knowing that weakness of human nature which leads a man, in the presence of all evidence, never to admit intoxication as possible in his own proper person, Dr. Snow felt that, in any case where an intoxicated person had been robbed, such person might allege that he had been made insensible by narcotic vapour. The two cases specially noticed in his letter admitted readily of such interpretation, and were clearly not cases in which chloroform had been administered. ”

“ He says:—“But they who object to delirium tremens appear to see no harm in delirium ferox: whereas it is just as incorrect to say delirium is fierce, as to say that it trembles: it is the patient who is furious, even as it is the patient who trembles.” Now, in speaking of a patient, we may speak either of his mind or his body: we may say that a person is learned, or that he is fat. ”

“ The mining population of Great Britain has suffered more from cholera than persons in any other occupation,—a circumstance which I believe can only be explained by the mode of communication of the malady above pointed out. Pitmen are differently situated from every other class of workmen in many important particulars. There are no privies in the coal-pits, or, as I believe, in other mines. The workmen stay so long in the mines that they are obliged to take a supply of food with them, which they eat invariably with unwashed hands, and without knife and fork. ”

“ The reply to this is, that people travel both against the stream and with it, and thus convey the malady from village to village and from town to town on the banks, whilst the water serves as a medium to propagate the disease amongst those living at each spot, and thus prevents it from dying out through not reaching fresh victims.
The principles I have laid down afford a satisfactory explanation of the circumstances, that absence of drainage promotes the prevalence of cholera, and that it flourishes better on a clay soil than on primitive rocks, sandstone, or gravel. ”

“ Usually the more feeble the patient is, whether from illness, or any other cause, the more quietly does he become insensible; whilst if he is strong and robust, there is very likely to be mental excitement in the second degree, and rigidity of the muscles, and probably struggling in the third degree of narcotism. Patients in a state of debility resemble children, not only in coming quietly and easily under the influence of chloroform, but also in the circumstance, that the common sensibility is suspended with less narcotism of the nervous centres than is generally required in robust persons. ”

“ There are certain circumstances, however, connected with the progress of cholera, which may be stated in a general way. It travels along the great tracks of human intercourse, never going faster than people travel, and generally much more slowly. In extending to a fresh island or continent, it always appears first at a sea-port. It never attacks the crews of ships going from a country free from cholera, to one where the disease is prevailing, till they have entered a port, or had intercourse with the shore. ”

“ Fatalists in letters, men of this class, if it be pleasure to call them so; but great fatalists too—honest reviewers of their own works, who fear their own criticisms, and none other; who offer immense labours, and die to them as they offer. ”

“ Mr. Erichsen’s attention was at once excited by these symptoms, and, desisting from the use of the catheter, he immediately commenced dashing the patient’s face and chest with water. The chloroform had, of course, been removed. In the course of about a minute, the noise with the breathing gradually lessened, and it became apparent that the respiration was ceasing altogether. Mr. Erichsen now put his finger into the patient’s pharynx, and dragged forwards the root of the tongue; at the same time attempting artificial inflation of the lungs, by applying his own mouth to that of the man. ”

“ If the mortality in the workhouse had been equal to that in the streets immediately surrounding it on three sides, upwards of one hundred persons would have died.
There is a Brewery in Broad Street, near to the pump, and on perceiving that no brewer’s men were registered as having died of cholera, I called on Mr. Huggins, the proprietor. He informed me that there were above seventy workmen employed in the brewery, and that none of them had suffered from cholera,—at least in a severe form,—only two having been indisposed, and that not seriously, at the time the disease prevailed. ”

“ I always request the patients who are operated on at the dentist’s, to drive home, as it is not advisable to walk, or use any exertion for an hour or two after the action of chloroform. Indeed, the patient is usually disinclined for any exertion for twenty minutes or half an hour after the influence of this agent, and sometimes for much longer; although I have seen a patient mount the box of a sort of dog-cart, and drive himself away, within five minutes after having several teeth extracted whilst he was in a state of complete insensibility from chloroform. ”

“ I use the term degree in preference to stage, as, in administering chloroform, the slighter degrees of narcotism occur in the later stages of the process, during the recovery of the patient, as well as in the beginning. The division into degrees is made according to symptoms, which, I believe, depend entirely on the state of the nervous centres, and not according to the amount of anæsthesia, which there is good reason to conclude, depends, in a great measure, on the local action of the chloroform on the nerves. The different degrees of narcotism glide insensibly into each other. ”

“ It is probable that there must have been some little circulation going on through the brain whilst the respiration lasted, and in fact, the slight fluttering pulse and feeble sounds of the heart, once or twice perceived, indicate that the circulation was not absolutely arrested. Under these circumstances, we may inquire why the action of the heart does not recover. If the circulation were going on in the coronary arteries, it might be expected that the blood from the lungs, which has been aerated by respiration, and freed from the narcotic vapour, would restore the action of the heart. ”