Part 14

In 1843, when the Medical Charities Bill was brought forward, Stokes and Cusack united in the effort to procure for these devoted men an amelioration of the conditions under which they labored. They repaired to London to give evidence on the subject before the House of Commons. Both these friends had had to deplore the loss of many of their dearest and most promising pupils, who, after a short experience of country practice, had fallen victims to fever contracted in the discharge of their duties. They pleaded that in all justice the remuneration for attendance on fever hospitals and dispensaries should be fixed at a liberal scale, and that some provision ought to be made for the widows and children of gentlemen who had lost their lives in the public service. They collected statistics which proved that during a period of twenty-five years the mortality of the medical practitioners of Ireland was twenty-four per cent., while in most instances the cause of death was typhus fever. They {191} showed that, on the authority of Inspector-General Marshall, the comparative mortality of combatant officers in the army was less than half that, amounting to only ten and a quarter per cent. It was little to be wondered at that William Stokes should say, in answer to the chairman's question regarding the existence of any special risk to the medical officer in Ireland: "Such a number of my pupils have been cut off by typhus fever as to make me feel very uneasy when any of them take a dispensary office in Ireland. I look upon it almost as going into battle." Again he observes: "The medical practitioners in Ireland are placed in a position very different from and far more serious than that of their brethren in Great Britain. . . . . The Irish physician is often exposed to contagion in its most concentrated force when himself under the influence of cold, wet, fatigue, and hunger, as he labors among the poor, passing from hovel to hovel in wild and thinly-populated but extensive districts. He has often to ride for many hours in the worst weather, and at night, enduring great fatigue, while himself a prey to mental as well as physical suffering; for if we add to such labor the injurious influence which the knowledge of danger must have on the system of a man feeling that he is struck down by the disease under which he has seen so many sink, and tortured by the thought of leaving a young family unprovided for, we can understand how it happens that the country is so often deprived by death of so many of its best educated and most devoted servants."

Perhaps the most interesting phases of Stokes' purely medical work during the first part of his career is his treatment of the subject of consumption. When not quite thirty-three he wrote a treatise on the diagnosis and treatment of diseases of the chest. His familiarity with the work of Graves and of Auenbrugger gave him command of all the {192} modern methods of physical diagnosis, so that he was able to study tuberculosis to the best possible advantage and with the least possible chance of too favorable judgment with regard to its cure. Notwithstanding the accuracy of his knowledge, however, he insisted that the disease was curable, and that the important point with regard to it was the recognition of it as early as possible, in order that the patient might be given the best chance for life.

At that time most physicians considered tuberculosis to be an hereditary disease, without any idea of its being possibly contagious. Acceptance of heredity seemed to set the stamp of inevitable fatality on the heads of victims of the disease. To announce the curability of tuberculosis then was to run counter to all the medical traditions of the time, and Stokes in doing so must have had in support of his teaching many observations of patients who had been cured notwithstanding the fact that they were assured sufferers from this supposedly fatal disease. We know that Stokes was surely correct in his judgment in this matter, and realize too that his method of treatment, which included abundant feeding and long hours each day in the outdoor air, comprised the best elements of the modern treatment of tuberculosis.

Perhaps one of the most striking anticipations of what is apt to be considered quite modern in medicine is Dr. Stokes' descriptions of the methods by which he considers certain forms of heart weakness, especially that incident to incipient fatty disease, should be treated. His directions are almost exactly those which have made the names of the Schott Brothers known throughout the world during the last twenty-five years. To have anticipated our modern views with regard to tuberculosis, its curability, and the best methods of treatment shows how thoroughly Stokes had studied his cases of consumption. That the same man {193} should also have been able to work out the details of treatment for heart weakness is a triumph that indicates better than anything else perhaps the genius of the physician not only in the observation of disease, but above all in that more important part of medicine--the proper application of therapeutic principles.

Stokes observes, "In the present state of our knowledge the adoption of the following principles in the management of a case of incipient fatty disease seems justifiable:

"We must train the patient gradually but steadily to the giving up of all luxurious habits. He must adopt early hours, and pursue a system of graduated muscular exercises; and it will often happen that, after perseverance in this system, the patient will be enabled to take an amount of exercise with pleasure and advantage which at first was totally impossible owing to the difficulty of breathing which followed exertion. The treatment by muscular exercise is obviously more proper in younger persons than in those advanced in life. The symptoms of debility of the heart are often removable by a regulated course of gymnastics or by pedestrian exercise, even in mountainous countries, such as Switzerland, or the Highlands of Scotland or of Ireland. We may often observe in such persons the occurrence of what is commonly known as 'getting the second wind;' that is to say, during the first period of the day the patient suffers from dyspnoea and palpitation to an extreme degree, but by persevering, without overexertion, or after a short rest, he can finish his day's work and even ascend high mountains with facility. In those advanced in life, however, as has been remarked, the frequent complications with atheromatous disease of the aorta and affections of the liver and lungs must make us more cautious in recommending the course now specified."

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If any proof of Stokes' ability as an observer and a teacher were needed it would be readily found in his original description of the form of respiratory disturbance since known as Cheyne-Stokes respiration. The passage is besides a model of succinct completeness of description that would well deserve to be in the commonplace book of physicians who write, for so many of them need to imitate his conciseness and clarity. It is to be found in his book _Diseases of the Heart and the Aorta_, p 336.

"A form of respiratory distress, peculiar to this affection (fatty degeneration of the heart), consisting of a period of apparently perfect apnoea, succeeded by feeble and short inspirations, which gradually increase in strength and depth until the respiratory act is carried to the highest pitch of which it seems capable, when the respirations, pursuing a descendant scale, regularly diminished until the commencement of another apnoeal period. During the height of the paroxysm the vesicular murmur becomes intensely puerile."

It is curiously interesting to find that a favorite subject of discussion in the Irish medical societies of nearly fifty years ago was a topic which is still frequently on the tapis in medical society meetings. In one of his public addresses Dr. Stokes bewailed the fact that medicine did not have its proper place in the estimation of the people and was not able to assert its dignity as a profession in its proper sphere. He discussed also the remedies for this state of affairs, and as he was a man of eminently broad views, of very large experience, and of sane, conservative judgment, they are worth while pondering at the beginning of the twentieth century, for the practical problems of professional life which he sets forth are still with us. It is for this reason that it has seemed worth while to give a rather lengthy quotation that would adequately represent his conclusions in the matter.

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"Is it by public agitation and remonstrances addressed to deaf or unwilling ears that these medical abuses are to be corrected? Is it by the demand for class legislation? or is it, by the efforts of one and all, to place medicine in the hierarchy of the sciences--in the vanguard of human progress; eliminating every influence that can lower it, every day more and more developing the professional principle, while we foster all things that relate to its moral, literary, and scientific character? When this becomes our rule of action, then begins the real reform of all those things at which we fret and chafe. Then will medicine have its due weight in the councils of the country. There is no royal road to this consummation. On the one hand, the liberal education of the public must advance, and the introduction of the physical sciences in the arts courses of the universities must give the death-blow to empiricism; and, on the other, education of ourselves must extend its foundations, and we should trust far less to the special than to the general training of the mind. When medicine is in a position to command respect, be sure that its reward will be proportionally increased and its status elevated. In the history of the human race, three objects of man's solicitude may be indicated: first, his future state; next, his worldly interests; and lastly, his health. And so the professions which deal with these considerations have been relatively placed: first, that of divinity; next, that of law or government; and, as man loves gold more than life, the last is medicine. But, with the progress of society, a juster balance will obtain, conditionally that we work in the right direction, and make ourselves worthy to take a share in its government, not by coercive curricula of education; not by overloaded examinations in special knowledge, which are, in comparison to a large mental training, almost valueless; but by seeing to the moral and religious {196} cultivation, and the general intellectual advancement of the student."

From this, it is to be feared that Dr. Stokes would have very little sympathy with the specializing trend of modern medical education. Certain it is that not thus were the medical giants of the old days developed; but the times have changed; perhaps we should change with them, only the danger of the change must be ever kept in mind so as to avert, if possible, its most serious consequences at the first warning.

While Stokes felt deeply for the Irish people, and the sad conditions under which they were laboring, unfortunately, like many another educated Irishman, he had very little active sympathy in any of the movements for their relief. He was a man in early middle life when O'Connell's agitation began, but he had no part in the movement. Later on, when his personal friend, Isaac Butt, was engaged in his great political work for Ireland, Stokes tried to dissuade him from it, feeling that the arousing of the people to a realization of their rights only led to a tighter riveting of their chains. Better judgment has prevailed and now practically all classes are united in the Gaelic movement, making it harder to understand Stokes' position, yet his is a case for sympathy rather than blame. His heart was touched, but his head could not see a happy issue for his countrymen, and so he preferred to have them endure in patience rather than suffer further ills through coercive measures.

Dr. Stokes realized, however, all the iniquity of the union of the Irish and English parliaments, and a favorite story of his was told with regard to one of the members of the Irish Parliament who sold themselves to England. This member, finding that he was unnoticed in the distribution of rewards after the passage of the Union, though eighteen of his {197} fellow-members were raised to the peerage, waited on the Secretary of State and in an injured tone complained of having been neglected. The Secretary answered in the blandest manner: "The government, sir, is most anxious to do all it can to assist those who supported it. What is the object of your ambition?"

"Make me aqual to the rest of the blackguards," was the prompt reply of this conscientious legislator.

Stokes used to add: "History does not tell if his quite reasonable request was granted."

In the midst of Stokes' sympathy for his compatriots there was always a counter-current of reactionary feeling, as if he feared the Celtic enthusiasm for reform would overstep the mark and bring evils in its train, even worse than the good it might entail. The following letter to a friend, as representing one phase of this feeling on the part of a true-hearted Irishman, seems worth reproducing, because it suggests thoughts with regard to the present movement which warn of possible dangers from the commercial spirit that must be avoided at all hazards, if Irishmen are to retain the influence their idealism has ever given them in whatever part of the world they might be:

"October 27, 1836.--You will be sorry to hear that I have been for two days down to Connemara, to see poor Macnamara. He is dying. Oh, what a tragedy it will be! We expect him up to town this week. I never saw the glorious Lough Corrib look so beautiful. I was entertained by Miss Blake; she is a perfect specimen of the old Irish aristocracy. Tall, distinguished, elegantly formed, with dark hair and exquisitely fair complexion; she looked, as she stood in her tapestried hall, a lady of romance; her youth, her mourning dress, her classic head, and the symbols of her loved religion all combined to form a picture not easily to be forgotten. {198} The castle, grey and worn, stands on a green platform over the clear and rapid river through which the whole waters of Lough Mask and Lough Corrib rush to the sea. It reverses Byron's simile, 'All green and wildly fresh without,' etc., etc. You will say I am raving; but in truth a little time will level these ancient castles, and their highborn and honorable inhabitants and the feelings which their communion creates, and then 'utility' will have its reign, and 'common sense,' laughing at the past and the beautiful, will build factories with the remains of history, make money, and die."

Dr. Stokes' interest in Irish historical matters can be best judged from the fact that toward the close of his life, when he was extremely busy with his practice and medical work of all kinds, he took the time to write a life of his friend, George Petrie, the distinguished Irish antiquary. It will be recalled by those who are interested in Irish antiquities that Petrie's work eminently deserved this tribute, and that Stokes' life is worthy of Petrie's merit. Dr. Stokes' daughter Margaret, as the result of association with Petrie and her father's interest in Irish antiquities, became a deep student of the same subject and wrote a little volume, _Early Christian Art in Ireland_, which has come to be the standard handbook on this subject for those who want sure and definite information, yet are not specializing in antiquities.

On March 17, 1874, as a recognition of his interest in Irish antiquities, Stokes was nominated to the presidency of the Royal Irish Academy. "It was a new departure for the members of that society," says Stokes' biographer, "which is mainly representative of literature and abstract science, to choose a physician as their head, but it was felt that the time had now come when medicine had obtained, owing to the labors of Stokes and others, such a position in {199} the estimation of literary and scientific men that the election of the Regius Professor of that art in Trinity College (to the presidency of the Royal Irish Academy) would be welcomed by the majority." Certainly no member of the medical profession could have been found more deserving of the tribute because of all that he had done for Irish medicine, and besides his broad, sympathetic, liberal interest in Irish antiquities eminently fitted him for this honorable position.

When Stokes' death was announced at the beginning of January, 1878, the medical world thought that it had lost one of its most representative men. For some years before his death many honors had come, all unsought, to this worthy protagonist of Irish medicine. He had been made a member of the Prussian order of Merit, and an honorary Fellow of many scientific societies on the Continent. He had received the rare distinction of the degree of LL.D. from Cambridge, and had been similarly honored by many other universities. Perhaps the honor that Stokes himself would have appreciated most came after his death, when the country people who had learned to know and love him asked to be allowed to carry his remains from Carrig Breac to the church of St. Fintan--the "grassy churchyard grave," where he was to be laid beside his beloved wife and children. They laid him in the same grave and beneath the same stone with her who was the beloved companion of his life, and on whose tomb he had engraved these words:

"When the ear heard her, then it blessed her; When the eye saw her it rejoiced; When the poor and suffering came unto her They were comforted."

Surely a union like theirs was not destined to be but passing.

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Stokes' beautiful domestic affection was but another index of one of the most beautifully rounded types of man that ever lived. The affective side of his being, profoundly tender, deeply sympathetic, thoughtful always of others first, and humanely devoted to the poor and the helpless above all others, was typical of the best side of the Irish character. For this even more than for all he did for practical medicine (yet the absence of his work would make a large lacuna in nineteenth century medical progress) the race may well be proud of him. His example still lives to animate his professional brethren, one of whom (Sir John Moore) said of him: "Those who have seen Dr. Stokes at the bedside of the sick know how gentle, how refined, how kindly was his bearing toward the patient. Amid all the ardor of clinical observation and research he never for one moment forgot the sufferer before him--no thoughtless word from his lips, no rough or unkind action ever ruffled the calm confidence reposed in him by those who sought his skill and care. In many eloquent lectures delivered in the Meath Hospital he inculcated those Christian lessons of charity and thoughtfulness; and so by precept and example he strove to teach the duties of a true and God-fearing physician."

Dominic Corrigan.

The third of the great trio of the founders of the Irish School of Medicine is Sir Dominic John Corrigan, whose name will be forever associated with the form of pulse which occurs in aortic heart disease. It was his supreme merit to have been the first to describe in all its details this type of heart disease, and the distinguished French clinician, Trousseau, declared that aortic regurgitation should be called Corrigan's Disease. At this time Trousseau was deservedly {201} looked up to as the leading spirit among the clinicians of Europe. He was never tired of commending to his students Corrigan's acute clinical observations, and insisted that it was work of this kind which assured real progress in medicine. Trousseau's suggestion as to nomenclature was not adopted in its entirety, but Corrigan's pulse is well-known all over the medical world, and there is no doubt now that it will continue for many generations to confer deserved honor on the man who first appreciated its full significance though he was not the first to recognize it--and indeed it could scarcely escape notice--but who showed just what diagnostic conclusions might be reached from it.

Corrigan's career should prove a stimulating example to the young physician just taking up that real post-graduate work in medicine which comes after he has received his degree, finished, perhaps, his hospital work, and is beginning his practice. Corrigan was only twenty-seven when he began the series of observations on which was founded his paper on aortic heart disease, which was published when he was about thirty. In this matter of youthful accomplishment, Corrigan is not alone among his distinguished Irish contemporaries. Stokes, it will be remembered, wrote his little book on the stethoscope when he was only twenty-one and had made some very important observations on disease of the chest before he had reached the age of thirty. Graves had showed very clearly the sound metal of his intelligence before he was twenty-five, and had described the cases of the nervous disease which have since come to be called after his name, Graves' disease, before his fourth decade had run more than a year or two. In fact these young men accomplished so much by their careful observation and dependence on their own resources that the medical writer of the modern times is tempted to wonder if perhaps that most precious {202} quality of the human mind in the young adult, its originality, is not obscured by the amount of information that it is expected to absorb before it is tempted to do any thinking for itself.

There is another remarkable feature of Corrigan's achievement, in the recognition and description of this form of heart disease. At the time he was the physician to a hospital which had only room for six medical patients. This appointment to the little Jervis Street Hospital in Dublin had been secured only after competition, and Corrigan had to pay for the privilege of being the attending physician. This he could ill afford to do at the time, and so he resolved, as he told a friend, to make all his opportunities for the study of patients count to the greatest possible extent. He did not visit his hospital merely to see patients, but to study the cases carefully. His success is only another example of the necessity for seeing much, and not many things, if there is to be any real progress. In our day, physicians scarcely consider that they have any hospital experience unless they are the attending physicians to several hospitals, seeing at least one hundred patients a week. The result is that patients do not receive the skilled care they should, and that advance in medicine suffers because of the wasted opportunities for clinical observations while a busy attending physician rushes through a ward and the resident physician has only time for the routine work that enables him to keep just sufficiently in touch with the progress of his cases to satisfy the hurrying chief.