Chapter VII: Preface (6)

After wandering for some three years in Europe, Graves returned to Dublin and at once took a leading position in his profession as well as in society. He came back at a very fortunate period for him. In 1807, Dr. Cheyne, who had been educated in Edinburgh, made the first step toward the foundation of a new school of medical observation, by the {171} publication of the first volume of the Dublin Hospital Reports. Dr. Stokes says that the best proof of the value of these reports is that they appear to have given the tone to the subsequent labors of the Irish school which inherited their practical nature and truthfulness. Within a year after Graves' return he appeared as one of the founders of the new school of medicine in Park Street, and was also elected physician to the Meath Hospital, where he commenced to put into effect that system of clinical observation and instruction which has done so much to establish the lasting reputation of the Dublin School of Medicine.

For the next thirty years Graves' life is full of the teaching and the practice of medicine. He was noted for his tenderness toward the poor, but the rich soon came to appreciate his skill. Nothing ever made him neglect his poor patients. Meantime he left his mark on every subject that he handled in medicine. Fevers, nervous diseases of many kinds besides that named after him, tuberculosis, and other forms of pulmonary disease, were all illuminated by his practical genius in a way that has made them clear for succeeding generations in medicine.

With regard to fevers especially Graves' work will count for all time, because he set their treatment on so practical a basis. The trained nurse is quite a modern acquisition, yet seventy-five years ago Dr. Graves insisted that the services of a properly qualified nurse in severe, continued fever are inestimable. He emphasized the necessity for moral management in fever, and friends and relatives are seldom capable of discharging this office. "If they chance to discover from the physician's remarks or questions the weak points of the patient's case they generally contrive to let him know them in some way or another. If the patient is restless, for instance, the ill-judged anxiety of his friends {172} will most certainly keep him from sleeping. If he happens to take an opiate and they are aware of the nature of his medicine they will surely inform him of it in some way or another, though it may be only by a hint and his anxiety for sleep conjoined with their disturbing inquiries prevents its due operation."

We are apt to think that the modern aphorism, nursing (meaning trained care) is more important than medicine in the treatment of fever, is the result of observations in our own day. Dr. Graves, however, felt very deeply that the most important element in the treatment is the conservation of the patient's strength with the preservation of his morale, and this can be best accomplished when the patient is constantly under the care of an experienced nurse, noting every symptom and averting every possible source of worry and every form of exhaustion of energy.

With regard to fever treatment, however, Graves' name is immortal in medicine because of his insistence on the doctrine that fever patients must be fed. A century ago the presence of fever was supposed definitely to indicate that the patient should have no food. Any contribution to his nutrition was supposed to feed the fever rather than the patient. Graves pointed out, however, that at the end of a long-continued fever the most serious condition is the emaciation and weakness of the patient. He insisted that, appetite or no appetite, fever patients should be fed regularly. The result was at once noteworthy. Only the very hardy individuals had recovered before this; now even weaker patients had a good chance for life. The mortality from fever fell very strikingly, and in his time Dublin was overrun with typhoid and typhus fever and the saving of life produced by the new method of treatment was very considerable. Graves himself, when he saw how much he had accomplished by his {173} new doctrine, said that he wanted no better epitaph on his tombstone than the words, "He fed fevers."

Some of Dr. Graves' very particular hints with regard to treatment of fever show how careful he was in clinical observation. He deprecates the allowance of very much fluid for patients, since their thirst cannot be assuaged in that way, and the amount of liquid taken may be harmful by causing depression. He suggests, therefore, the use of acidulated water made by means of a little currant jelly or raspberry vinegar, given in small portions and at regular intervals. Much better than plain water he considers water to which some light bitter has been added, such as cascarilla. Small quantities of this will appease the morbid thirst of fever more effectually and for a much longer period than large draughts of water.

Even more interesting in these modern times, however, than Graves' attitude toward the treatment of fever is the position he took with regard to the habits of life that were best for the consumptive. At that time tuberculosis of the lungs was considered to be an inflammatory disease requiring the patient to be in the house most of the time, carefully protected from cold, and during any rise of temperature to be kept in warm rooms, without any special encouragement to take food. Graves and Stokes changed all that, and for the time completely revolutionized the principles of treatment for this serious ailment. Alas! their work, notwithstanding the good results shown in a certain number of cases, failed to attract widespread attention, and not until our own time did the principles that they laid down as the rational basis of successful therapeutics for tuberculosis come to be generally adopted.

Graves insisted that his patients when suffering from beginning tuberculosis should not be confined to the house, {174} but on the contrary should be out of doors most of the time. He emphasized what he called the taking of exercise, but in such a way that he agrees much more than might be thought with modern ideas on this subject. Now, it is insisted that tuberculous patients must not overtire themselves by taking exercise, though they must be in the open air a large part of the time. Graves explains the exercise that he would like to have them take by saying that they should spend four or five hours every day riding in a carriage, or, as he seems to prefer, in an open jaunting-car. And that they should spend at least as much time sitting outside in quiet.

Besides this the most important element in treatment he considers to be the encouragement of the appetite--as might be expected from the man who first fed fevers. His directions in this matter are very explicit, and he suggests various methods by which patients can be tempted to eat more and more food, and emphasizes the use of cereals and of milk and eggs as likely to be of most service in helping these patients to gain in weight and strength so as to be able to resist the further advance of the disease. This, it may be said in passing, is just the ideal treatment for the consumptive at the present time.

Others of Graves' opinions in regard to tuberculosis are in general surprisingly modern. He insists, for instance, that the main causes of the disease are overcrowding in towns, the long hours of hard work in factories, and abuse of alcohol. He thought that the population of country places, though fed no better as a rule than in the city, do not develop the disease so frequently because of their opportunity for fresh air. He placed very little confidence in the opinion that cold has anything to do with tuberculosis, though he disputed Laennec's dictum that bronchitis was never the beginning of tuberculosis. Graves advises his students not to try to {175} protect their throats by means of mufflers, for this will only render them more liable to cold. His advice is rather to harden themselves against cold. For this he suggests the use of water plentifully on the chest and throat, to be employed not too cold during the winter time, unless one is used to it. He also suggests the use of vinegar and alcohol as hardening fluids. They should be applied freely, and in his experience were effective.

Another interesting anticipation of modern methods was with regard to child feeding in summer diarrhoea. It is often thought that only in recent years, with the development of the science of bacteriology, the danger of continuing milk feeding when infants are already ill in the summer has come to be recognized. Milk is now known to be an excellent culture medium for various forms of bacteria, that is, it is a substance on which microbes grow plentifully, and it is often used in the laboratory to raise microbes. Dr. Graves, however, without any knowledge of modern bacteriology, but from clinical observation alone, pointed out that the only way to avoid summer diarrhoea is to stop all milk feeding.

"Let the infant," he says, "abstain from milk in any shape for twenty-four hours, sometimes for the space of two or even three days. It is incredible how small a portion of milk, even in the most diluted state, will keep up this disease, acting like a species of poison on the intestinal mucous surface."

Here, of course, was scientific intuition running far beyond medical knowledge, and pointing out a serious danger and the best means of avoiding it. There is scarcely a subject touched upon in Dr. Graves' clinical lectures, however, which is not illuminated in this way by precious sidelights, many of which unfortunately were obscured by medical {176} theories, and conclusions founded on them without due experience.

We have already said that his careful clinical observations led him to separate the type of disease which has since come to be known as Graves' disease from a number of other forms of nervous disturbances of the heart rhythm. There is at least one other class of disease usually considered to be much more modern, the type of affection known as Raynaud's disease, or a tendency to spontaneous stoppage of the circulation in the extremities, and also the other type now known as Weir Mitchell's disease, or erythromelalgia, in which there is suffused redness and pain in the extremities, examples of which Graves picked out from his hospital service and described in such a way that it is easy to recognize them even at this distance of time. His two volumes of clinical lectures on the practice of medicine are much more than an index of the medical teaching of his time. They contain anticipations of many a supposed after-discovery, besides an immense amount of very practical observations made at the bedside, and valuable hints for treatment, the result of his personal experience.

One of the best proofs of the greatness of the work accomplished by Graves is to be found in the tribute to his character, and what he achieved, by Professor Trousseau, who was at the time the acknowledged leader of the clinicians of Europe. He said:

"For many years I have spoken of Graves in my clinical lectures; I
recommend the perusal of his work; I entreat those of my pupils who
understand English to consider it as their breviary; I say and
repeat that, of all the practical works published in our time, I am
acquainted with none more useful, more intellectual; and I have
always regretted that the clinical lectures of the great Dublin
practitioner have not been translated into our language."

{177}

A little later in the same lecture he said:

"And nevertheless, when he inculcated the necessity of giving
nourishment in long-continued fevers, the Dublin physician,
single-handed, assailed an opinion which appeared to be justified by
the practice of all ages; for low diet was then regarded as an
indispensable condition in the treatment of fevers. Had he rendered
no other services than that of completely reversing the medical
practice upon this point, Graves would, by that act alone, have
acquired an indefeasible claim to our gratitude."

His tribute closes with the following very striking passage:

"I freely confess that I had some difficulty in accepting,
notwithstanding the imposing authority of Graves, what he states of
the influence of certain remedies, such as mercurials, essence of
turpentine, spirituous preparations, nitrate of silver, etc.; but
the Dublin professor speaks with so much conviction that I ventured
to follow his precepts, and I must say that my early trials very
soon encouraged me to adopt unreservedly what I at first accepted
only with misgivings. There is not a day that I do not in my
practice employ some of the modes of treatment which Graves excels
in describing with the minuteness of the true practitioner, and not
a day that I do not, from the bottom of my heart, thank the Dublin
physician for the information he has given me.

"Graves is, in my acceptation of the term, a perfect clinical
teacher. An attentive observer, a profound philosopher, an ingenious
artist, an able therapeutist, he commends to our admiration the art
whose domain he enlarges, and the practice which he renders more
useful and more fertile."

After this tribute from one who was himself one of the greatest medical teachers of his generation, it will be very interesting to find how much Graves anticipated nearly three-quarters of a century ago the principles of the bedside {178} teaching of medicine which have come to be acknowledged as the only sure basis of a genuine, practical medical education. For him the only possible way to learn medicine practically was to study it at the bedside, and he insisted over and over again that while the theoretical sciences allied to medicine were eminently fascinating, they were of little actual value in teaching the student how to solve the all-important problem of treating patients. In his address before the Dublin Medico-Chirurgical Society, an association of students in connection with the Dublin hospitals, he said in 1836:

"Many causes contribute to prevent students from attaining what
after all should be the great object of their wishes--practical
knowledge. The different sciences to which you are required to turn
your attention successively possess so many fascinations that you
may attach to some an undue degree of importance; but be assured of
this, that however accurate be your knowledge of anatomy, healthy
and morbid, however skilful you may be in the chemical theories and
manipulations, however extensively you may have mastered the
necessary properties of botany, however well you are acquainted with
the nature and properties of drugs--be assured, I say, that you have
acquired all this knowledge in vain unless you have diligently
studied symptoms at the bedside of the patient and have observed the
consequences and causes of disease in the dead room. In fact, in
whatever other pursuits you may employ your afternoon hours, the
morning should always be dedicated with earnestness to the hospital;
from its wards all appearance of levity and inattention must be
banished, for your neglect of the opportunities there presented for
observation loads you with a serious amount of responsibility, I had
almost said of guilt. It is no light thing to have life entrusted
into your hands; we are all liable to err, we all commit mistakes;
{179} the rules of our art are not invariably precise and certain;
but they only are guilty who have not used every opportunity of
acquiring practical knowledge; he is doubly guilty who, conscious of
his neglect, embarks in practice and commences with the decision and
boldness true experience alone can confer."

At a comparatively early age Graves realized more than most men that medicine is an art and not a science, and that each individual case presents problems that have to be studied out for themselves and for which no general principles of diagnosis, prognosis or therapeutics serve. He appreciated that there was no royal road to medical wisdom, in the sense of a scientific shortcut by means of which manifestations of disease and their indications for treatment might be grouped together and easily learned. Nor, may we add, has any such road been found since. Each physician must train himself by patient, repeated observation, and without this discipline and training there can be no real success. Accordingly he said to his students in Dublin:

"The chief object of medical science is to relieve suffering and to
save life: you must, therefore, anxiously watch the action of
remedies and, by constantly noting down the effects of treatment,
learn to appreciate its merits and apply it when required. Nor is
this an easy task; some indeed have vainly imagined that the method
of treating or curing disease could be compressed within the limits
of a few short directions made easily deducible from some general
principles and easily applicable in any particular case; but it is
not so. Gentlemen, we have as yet discovered no such general
principles to serve as guides. This discovery presupposes a
knowledge of the laws and relations of the vital powers far beyond
what we now possess: no, we must toil onward by a much more {180}
laborious and circuitous route and must commence by making ourselves
thoroughly masters of a vast number of individual cases, assisted by
the observations and the writings of practical men; we may afterward
proceed to arrange our knowledge, to classify it so as to render it
more available; analogy and induction are here our only or at least
our most valuable guides, and they will seldom fail to instruct us
how to act when properly consulted."

While recognizing all the difficulties of medical practice and the essential individualization of all its problems, Dr. Graves had little or no patience with the skeptic who thought that medicine could accomplish but little for the cure of many ailments. He said once before the Medico-Chirurgical Society:

"Many, indeed, aiming at acquiring the character of medical
skeptics, think they exhibit proofs of superior discrimination when
they, with apparent candor, make the confession that the more they
see the less confidence they have in the resources of medicine. This
confession should be interpreted not as a reproof of our art, but as
a testimony of the want of skill of the would-be philosophical
asserter of so false a proposition. No, God be praised, our
predecessors have not toiled in vain; the anxious experience of ages
has not been recorded to no purpose; our art is in truth boundless
in resources and, when applied with ability, most successful. There
are, indeed, some acute and many chronic diseases which baffle our
powers of diagnosis, and defy our modes of treatment; such appear to
be, however, not numerous when compared with the great mass of cases
capable of cure or alleviation. The medical skeptic, however acute
his powers of reasoning may be, and however he may labor to render
plain subjects obscure and direct facts ambiguous, can never rob the
good practitioner of the {181} pure, the inward joy he feels when
conscious that he has snatched a patient from the jaws of death."

Knowing that such were his ideas with regard to the practice of medicine, it is all the more interesting to review the system of teaching that Graves considered most likely to produce genuine practitioners of medicine. Those who have been mainly concerned with the reform of medical education here in America in recent years can scarcely fail to be struck with the appropriateness of Graves' ideas on this subject nearly a century ago. When a very young man he did not hesitate to express his deprecation of the conventional and artificial methods of medical instruction in his own time, and he anticipated what is best in the methods that have gradually come into vogue at the end of the nineteenth and the beginning of the twentieth centuries. His views will always remain a suggestive storehouse of thought for those who have the higher medical education at heart.

In his introductory lecture at the opening of the Medical course at the Meath Hospital in Dublin in 1821, he declared very definitely what he considered to be the principal aim of the medical student:

"Students should aim not at seeing many diseases every day; no,
their object should be constantly to study a few cases with
diligence and attention; they should anxiously cultivate the habit
of making accurate observations. This cannot be done at once; this
habit can be only gradually acquired. It is never the result of
ability alone; it never fails to reward the labors of patient
industry. You should also endeavor to render your observations not
only accurate but complete. You should follow when it is possible
every case from its commencement to its termination; for the latter
often affords the best explanation of previous symptoms and the best
commentary on the treatment."

{182}

Graves was inculcating in principle what Corrigan and himself and Stokes were to exemplify so thoroughly in practice in the next few years. Before the end of the decade in which this address was delivered at the Meath Hospital, Corrigan at the little Jervis Street Hospital, where there were only beds for six medical patients altogether, was to make his great discoveries with regard to aortic disease, and to lay the sound basis of the diagnosis of affections of the heart for all time. There are many passages in this address of Graves that might well serve for warnings to the present day and generation as regards methods of medical education which do not include sufficient practical teaching. He said, for instance:

"The chief objection to our present mode of teaching is that,
however well inclined the student may be, he is never obliged to
exercise his own judgment in distinguishing diseases and has no
opportunity of trying his skill in their cure, and consequently at
the end of his studies he is perhaps well grounded in the accessory
sciences--is a perfect medical logician--able to arrange the names
of diseases in their classes, orders and different subdivisions; he
may be master of the most difficult theories of modern
physiologists; he may have heard, seen and, if a member of the
medical society, he may also have talked a great deal; but at the
end of all this preparation what is he when he becomes a full
doctor?--a practitioner who has never practised!"

These words have quite as suggestive applications to most phases of our modern education as they had to that of Graves' time. There are other passages that bear so significant a meaning in this regard that one can scarcely refrain from quoting:

"Our present method of instruction is indeed very useful and nothing
better can be devised for a beginner; but for {183} the more
advanced student it is by no means sufficient, nor is it calculated
to give him practical experience, without which all other
acquirements are of no avail. I say it does not give him experience,
because he has at no time been charged with the responsibility of
investigating a case for himself, and by himself; because at no time
has he been called on to make a diagnosis, unassisted by others; and
above all because he has never been obliged to act upon that diagnosis
and prescribe the method of treatment. If those who had been thus
educated, and who had been made doctors upon so slender a
foundation, were to confess the truth, we should be presented with a
picture calculated to excite dismay if not a stronger feeling. How
many doubts and distracting anxieties attend such a man at his first
patient's bedside. If the disease be acute and life in imminent
danger, and if he shrink under this sudden and unusual load of
responsibility, he gains little credit for professional ability. If,
on the contrary, inexperienced as he is, he assumes that decision of
judgment, that energy of practice which experience alone can confer,
is it not probable that the result will be still more disastrous?"

Graves' last days and the circumstances of his death and burial are given by Professor Stokes, his great personal friend, and himself one of the most distinguished physicians of his time. We quote the concluding paragraph of Professor Stokes' biographical notice:

"It was in the autumn of 1852, he being then in his fifty-seventh
year, that the symptoms of the malady which was to prove fatal first
showed themselves. In the following February he began to succumb to
the disease. Although at times his sufferings were great, yet he had
many intervals of freedom from pain. And he then showed all his old
cheerfulness and energy. To the very last he continued to {184} take
pleasure in hearing of any advance of knowledge that tended to
ameliorate the condition of man, or to throw light on his relations
to a future state. In this latter point of view, the discoveries of
Layard greatly interested him, as illustrative of the Sacred
History; and thus he was permitted to fill up the intervals of his
sufferings, even to the last; for his mental faculties never failed
or flagged,--a mercy for which he often expressed a fervent
gratitude; and so he was providentially enabled to review the past,
and to form a calm and deliberate judgment on the religious
convictions of his earlier years. And once the truthfulness of these
were ascertained, he adhered to them with that earnestness which
characterized all his decisions.

"It was after the attainment of this state of patient expectation
that one who was dear to him expressed a prayerful wish for his
recovery. 'Do not ask for that,' he replied; 'it might prove a fatal
trial.'

"His mind having become thus satisfied he made few remarks on these
subjects, except in reply to the inquiries of others. Thus, when
referred to the prophetic illustration of purifying and redeeming
love, 'A fountain shall be opened for sin and for uncleanness,'
'No,' he said, 'not a fountain, but an ocean.'

"On the day before his death he desired (a second time) to partake
of the Holy Communion, with his family. When some explanations were
commenced, he answered, 'I know all that; I do not regard this as a
charm, but I wish to die under the banner of Christ.' Feeling
himself sinking, he asked for prayer, and a petition was offered
suitable to his condition; but he seemed to long for something more
and, when questioned, replied, 'I want some prayer that I know, some
of the prayers of my youth, some of my father's prayers.' The Litany
was commenced, he immediately took up the {185} well-known words,
and when the speaker's voice faltered he continued them alone, and
distinctly, to the end of the strain, 'Whom thou hast redeemed with
thy most precious blood.'

"On the twentieth day of March, 1853, and without renewed suffering,
he ceased to breathe.

"His tomb is in the cemetery of Mount Jerome. It bears the following
inscription dictated by himself:

"ROBERT JAMES GRAVES,
Son of Richard Graves, Prof. of Divinity,
Who,
After a Protracted and Painful Disease,
Died in the Love of God, and
In the
Faith of Jesus Christ."

William Stokes.

Very closely associated with the name of Robert Graves in all that made the Irish School of Medicine influential for good, about the beginning of the second quarter of the nineteenth century, is that of William Stokes. Stokes' work on Diseases of the Chest and, later in life, his treatise on Diseases of the Heart and Aorta stamp him as one of the great physicians of all time. His name is assured of immortality in medicine, because with that of the well-known Scotch physician, Cheyne, who came to Dublin late in the second decade of the nineteenth century, it is associated in the term most commonly used for a form of breathing, having special diagnostic and prognostic significance in certain serious diseases, and which is known as Cheyne-Stokes respiration. Even more interesting, however, than Stokes the physician, is, as we shall see, Stokes the man, and all that he stood for in his generation in Dublin, during a long life.

{186}

William Stokes was of a family that had long been distinguished in Dublin for scholarship. While his ancestors came originally from England, five generations occupied more or less prominent positions in the public life of Ireland, and they had lived in Dublin for more than one hundred and fifty years before Stokes began to be prominent in Irish medicine. His father, Whitley Stokes, had been a scholar and Senior Fellow of Trinity College, and was prominent in the scientific, political, and literary circles of the Irish capital at the end of the eighteenth and the beginning of the nineteenth century. He had been a member of the United Irishmen, but fearing that the revolutionary principles that were being propagated would only bring about an ineffectual rebellion, he separated himself from them, though years after when the United Irishmen came under the ban of the English government his previous connection with them cost him suspension from the fellowship. Later on, however, Whitley Stokes became the Regius Professor of the Practice of Medicine at Trinity College, a chair which he held until succeeded in the early forties of the nineteenth century by his son, William, the subject of this sketch. Something of the character of the man can be judged from the fact that though he was a distinguished physician and interested in every branch of science, taking an active part in the foundation of Trinity College Botanical Gardens, and being one of the founders of the Zoological Garden in Phoenix Park, he was also the author of a prize essay in reply to Tom Paine's Age of Reason, which was then attracting so much attention.

Our William Stokes was the second son of Whitley Stokes, and was born in Dublin in 1804. Like many another distinguished investigator in science, he was not looked upon as a bright student as a boy, and indeed could be prevailed upon to interest himself only very slightly in what is usually {187} considered to be the absolutely necessary fundamental work in education. He had a great love for poetry and romance, which indeed he carried with him all his life. The Scottish Border Ballads were his favorite reading, and he spent days in committing them to memory. Almost needless to say his apparent indolence and disinclination to any steady, methodical system of study were, as his son, the late Sir William Stokes, records in his biography of his father, sources of real concern to his parents, and caused his mother specially much anxious thought. One day while reading his favorite author, Sir Walter Scott, he fell asleep--to be awakened shortly after by some warm drops falling on his face. He started up to find his mother bending over him. It was her tears that had awakened him. Stung with remorse at having been the cause of so much sorrow to the mother whom he loved very dearly, his nature underwent an immediate and salutary change, and the dreamy, indolent boy became thereafter the ardent and enthusiastic student.

Stokes amply made up for any neglect of study there might have been in his boyhood days as soon as he entered upon the medical course to which he felt called. Here he came to be looked upon as one of the most ardent and painstaking of students.

His preliminary medical studies were begun in Dublin at the Meath Hospital. Chemistry he learned in the laboratory of Trinity College and anatomy in the Royal College of Surgeons. After spending several years thus he went to Glasgow, where for two years more he was occupied mainly at chemistry in the laboratory of Professor Thompson. Like most of the young Irishmen of his time, he next proceeded to Edinburgh in order to complete his education in clinical medicine and, if possible, obtain his medical degree from that famous institution. It was at Edinburgh, under the magnetic {188} influence of that great teacher, Allison, that Stokes began to develop the rare powers of original observation which at an early age placed him in the front rank of the best medical men of the time.

It is interesting to note that before he left Edinburgh he published his first medical work, a treatise on the use of the stethoscope, which was undoubtedly the means of bringing that instrument--and with it Laennec's fruitful system of physical diagnosis by means of auscultation--to the general notice of the English-speaking medical profession. Even after all that has been written on the subject, it remains a very valuable little book. It was dedicated to the famous Cullen, who had already published a series of cases which had been illustrated by the use of the stethoscope, and to whom Stokes probably owed the idea of the need for a formal little treatise on the subject. It is typical of the slow adoption of medical novelties even when they are of great importance that more than ten years afterward, old-time, though distinguished, physicians not infrequently made fun of Stokes for spending so much time in the study of cases with the stethoscope, since in their opinion it was little more than a toy. This was done in no bitter, carping spirit, but with the most friendly complacency and condescension. Stokes, however, intensely practical in his way, realized the value of the instrument, and as the result of his teaching it soon began to be more generally used; thus introducing into English-speaking medical circles that exact knowledge of diseases of the chest which can only be obtained by means of this little instrument and the methods of auscultation which are associated with it.

Immediately after graduation, Stokes settled down in his native city to practise. In 1826, when Stokes was only twenty-two, Dublin was visited by one of those epidemics of typhus fever which were so common in the first half of the {189} nineteenth century, and which consisted evidently, at least to a great degree, of what we now call typhoid fever, but intermixed with many cases of the real, dread typhus. The mortality in such epidemics, as we have reason to know from statistics here in New York, was always over twenty-five per cent, and often reached far above fifty per cent. The manner of contagion was unknown, only it was very well understood that those much in contact with the patients were likely to contract the disease. Among the poorer classes in Dublin the fever raged with virulence, but young Stokes devoted himself to the care of patients to an extent that severely taxed his physical powers of endurance. He devoted himself especially to the poorer classes. He did not contract the fever during the height of the epidemic in 1826, but he did in 1827, when it recurred, but fortunately he suffered in the mild form.

An epidemic of another disease, Asiatic cholera, the danger from which has been almost entirely removed by the progress of scientific medicine in modern times, followed not long after. It showed itself in Dublin, when Stokes was about twenty-five. He it was who recognized the first case of the disease, and sounded the note of warning that probably saved many lives by calling attention to the danger that was just beginning. Once more he devoted himself to the care of the patients, and, as with regard to typhus fever, wrote an account of his experiences, which is in itself a valuable medical document that shows the powers of observation of the young medical man.

Stokes spent himself in labor for the poor, and his deep interest in their welfare led him to sacrifice much time in order to organize medical charities for his unfortunate countrymen during the sad years of that awful fifth decade of the nineteenth century. His interest in this matter of {190} organization led him also to realize how much might be accomplished by public hygiene and efficient government sanitation. He recognized too how much would be accomplished along these lines if men were given proper training to make them specialists in these subjects. To Stokes then, almost more than to any other man, is due the development of public sanitation as a special science, and its organization for the proper safeguarding of public hygiene.

His efforts, especially with regard to the physicians of Ireland, who so nobly sacrificed, not unfrequently at the expense of other practice, their time, health, and often even their lives, in order to aid their stricken countrymen, form one of the best monuments to his tender sympathy and his goodness of heart as a man. His testimony before the Parliamentary Committee was at this time of the utmost value in securing due recognition of their services.

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."

{194}

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.

{195}

"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.