THE IRISH SCHOOL OF MEDICINE. [Footnote 6]

Robert Graves, M.D.

[Footnote 6: For much of the material embodied in this series I am

indebted to Sir Charles Cameron, the Historian of the Royal College

of Surgeons in Ireland, whose courtesy to me while on a visit to

Dublin in 1904 is one of the precious memories I shall always

cherish. At the same time Sir Christopher Nixon and Sir John Moore,

for letters of introduction to whom I was indebted to Prof. Osier,

not only gave me valuable suggestions, but demonstrated how kind is

the Celtic nature at its best.]

It has been always generally recognized that a very important portion

of what is called English literature is really due to the native

genius of the English-speaking writers of Irish birth and parentage,

whose Celtic qualities of mind and heart have proved the sources of

some of the most significant developments in the language of their

adoption. What a large lacuna would be created in English literature

by the removal from it of the work of such men as Dean Swift,

Goldsmith, Burke, Sheridan, and Moore! It is not so generally known,

however, that if the work of the distinguished Irish physicians and

surgeons of the last century were to be blotted out of English medical

literature there would be left quite as striking and as wide a gap. It

is, indeed, to what is known as the Dublin School of Medicine, for

medical schools have very properly been named usually after the cities

rather than the countries in which they were situated, that we owe not

a little of our modern progress in practical medicine, and especially

the advance in the clinical teaching of the medical sciences. Now that

the Gaelic movement is calling attention more than ever before to

things Irish, it {168} Seems only proper that this feature of the

national life should be given its due prominence and that the great

members of the Irish School of Medicine should not be without honor in

their own and other English-speaking countries.

There are three great names in the history of Irish medicine

recognized by all the world as well deserving of enduring fame. These

three names are Robert James Graves, William Stokes, and Dominic

Corrigan. Graves' name is indelibly attached to the disease known as

exophthalmic goitre, which he described and separated from other

affections before anyone else had realized its individuality. William

Stokes was, perhaps, the best authority on diseases of the heart and

lungs in his time. His name will be preserved in the designation of

the peculiar form of breathing which occurs in certain comatose

conditions and has received the name Cheyne-Stokes respiration, in

honor of the men who first called attention to it. Corrigan was in his

time one of the greatest authorities on the heart, and especially on

the pulse. His name is preserved in the term Corrigan pulse, which is

applied to a peculiar condition that occurs very characteristically in

disease of the aortic valves of the heart.

The lives of these men deserve to be better known, for they can

scarcely fail to be an inspiration to others to do work of a high

order in medicine--work that will represent not alone present success

and emolument but will stand for medical progress for all time.

Dr. Robert Graves was the youngest son of the Rev. Richard Graves,

D.D., Senior Fellow of Trinity College and Regius Professor of

Divinity in the University of Dublin, and of Elizabeth, daughter of

James Drought, also a fellow of Trinity College, whose family had been

long settled in King's County. His father, as a tribute to his

distinguished learning, was later promoted to the deanery of Armagh.

There {169} were two other sons in the family, Richard and Hercules.

All three of the boys passed through Trinity College with high honors

and, in fact, established a record there that has since been

unequalled, for at the degree examinations of three successive years

the gold medal in classics and in science, then the highest

distinctions attainable by students of Trinity, was conferred upon one

of the brothers.

Dr. Graves received his degree of Bachelor of Medicine at the

University of Dublin in 1818. After this he studied for some time in

London, and then spent three years on the continent, at Berlin,

Goettingen, Vienna and Copenhagen, as well as in Paris and certain

Italian schools, finally studying also for some months in Edinburgh

before his return to Dublin. As Dr. Stokes very well says: "In this

large and truly liberal education, which embraced the training of the

school, the university and the world, we can discover in part the

foundations of his subsequent eminence. He did not content himself, as

is so commonly the case, with commending--to use his own words--'the

life of a practitioner without practice,' but he made himself intimate

with the recent discoveries and modes of thinking in every great

school of medicine, whether abroad or at home, and formed friendships

with the leading physiologists and physicians of Europe, with many of

whom he kept up a correspondence during his life."

An interesting incident in his travels serves to illustrate very well

his facility for the acquisition of languages. Once while on a

pedestrian journey in Austria he neglected to carry his passport, and

was arrested as a spy. He was thrown into prison and for a time his

condition seemed serious enough. He insisted that he was a British

subject, but his assertions in this matter were immediately repudiated

by the Austrian authorities in the little town, who insisted that no

{170} Englishman could possibly speak German as well as he did. He was

kept in prison for some ten days until authentic information could be

obtained with regard to him, and, during this time, such was the state

of the prison that he suffered many privations. Later in life this

gave him a sympathy with the prisoners of Ireland and led to his

making suggestions for the amelioration of their condition.

Like practically all the great medical men who have proved to be

original workers, Graves' interest was not confined alone to medicine.

During his sojourn in Italy he became acquainted with Turner, the

celebrated English landscape painter, and was his companion in many

journeys. Graves himself was possessed of no mean artistic powers, as

his friend Stokes tells us, and his sketches are characterized by

natural vigor and truth. His thorough appreciation of his companion,

however, and the breadth of his sympathy and admiration for the great

painter of nature can perhaps best be understood from some candid

expressions of his with regard to their work in common: "I used to

work away," he said, "for an hour or more and put down as well as I

could every object in the scene before me, copying form and color as

faithfully as was possible in the time. When our work was done and we

compared drawings the difference was strange. I assure you there was

not a single stroke in Turner's drawing that I could see like nature,

not a line nor an object, and yet my work was worthless in comparison

with his. The whole glory of the scene was there."

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.

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.

{200}

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.

Before publishing his classic paper on the _Permanent Patency of the

Aortic Valves_, on which his reputation as a wonderful clinical

observer in medicine rests, Corrigan had called attention to some

mistakes in the classification of heart murmurs as made by Laennec in

Paris. At this time Laennec was considered to be the best authority in

Europe {203} on diseases within the thorax. As regards diseases of the

lungs, he well deserved the reputation. To him the medical world owes

all that it knows about diseases of the chest, as far as these can be

detected by means of the ear. His young contemporary in Ireland,

however, was able to show that in diseases of the heart some of the

ideas acquired in long years of study of the lungs were leading

Laennec into false conclusions as regards the significance of murmurs

of the heart. Even genius does not succeed in doing more than one

thing well, and especially in the matter of taking a second step into

the unknown. While the distinguished Frenchman might have been thought

just the one to complete the work he began so well on the heart, and

while his experience with the lungs might have been expected to help

him in the recognition of the significance of heart murmur, this did

not prove to be the case. The privilege of solving the mystery of

heart diseases was to be left for his Irish contemporaries, one of the

most successful of whom in this matter was Corrigan.

Anyone who wishes to see how little subsequent study has added to our

knowledge of aortic disease should read Corrigan's original paper on

this subject. He describes all the varying forms of affections of the

aortic valve, with their various clinical manifestations. His paper is

illustrated by a set of plates that would still be valuable for

demonstrative purposes, and which serve to show how painstaking were

his pathological studies. He illustrated experimentally his ideas of

how the murmurs and thrills occur by means of an apparatus consisting

of rubber tubes through which water might be allowed to flow under

pressure, and varying calibre. Some of his conclusions, derived from

experimental observations, will not stand the test of our modern

knowledge, but they are very suggestive. Perhaps the best idea of the

clinical {204} value of Corrigan's observations can be given by a

quotation from his original paper, in which he discusses the

interesting and difficult question of the relationship between

aneurism of the aorta and inadequacy of the aortic valve. He said:

"The two diseases, aneurism of the aorta and inadequacy of the

valves, may, however, be combined. Aneurism of the ascending aorta

may, by extending to the mouth of this vessel, dilate it so that the

valves are unable to meet, and there is then a combination of the

two diseases; there is aneurism and there is permanent patency of

the aortic opening. The first cases that came under my observations

presenting the signs of inadequacy of the aortic valves were cases

in which the valves were rendered useless in this way, namely, by

the mouth of the aorta sharing in the aneurismal dilatation. These

cases led me into an error; for, meeting the signs of permanent

patency of the aortic orifice in conjunction with aneurism, I

erroneously attributed to the aneurism the signs which arose from

the permanent patency. Aneurism of the aorta of itself does not

produce the signs arising from permanent patency of the mouth of the

aorta. It can only produce them in the way already described, by

involving in the dilatation the mouth of the aorta; and hence, when

in conjunction with an aneurismal tumor of the arteria innominata or

aorta, there are found visible pulsation, _bruit de soufflet_, and

_fremissement_ in the ascending aorta, and the trunks arising from

it, we may be certain that, in addition to the aneurism, there is a

defect in the aortic valves, or that the aneurism has extended

downward, involving the mouth of the aorta. On the other hand, if

these signs be absent, the valves are sound and the mouth of the

aorta is not included in the disease. The propriety of performing

Mr. Wardrop's or indeed the common operation for aneurism about the

neck might depend on the information {205} thus obtained of the

state of the aortic valves. To perform either in a case where the

aneurismal dilatation was so extensive as to involve the mouth of

the aorta, or where the aortic valves were diseased, would only

bring the surgical treatment of the disease into unmerited

discredit."

Another very distinct contribution of Corrigan to the medicine of his

time was his insistence on the distinction that exists between typhoid

and typhus fever. This is one of the most interesting features of his

little book on the _Nature and Treatment of Fever_. With our present

knowledge, it seems hard to understand that these two fevers should

have been so long confounded, but as a matter of fact it was not until

the middle of the nineteenth century that the distinction between them

was recognized even by the most acute observers. In this matter the

French and Americans anticipated most of the rest of the world, though

Corrigan's teaching in the matter had been correct for many years

before others in the British Isles came to the true position.

It was his work among the poor particularly that enabled Corrigan to

recognize the differences between these two diseases. He came to have

one of the largest practices that any practitioner in Dublin, or for

that matter in any city of the world, has ever enjoyed, if enjoyment

it can be called. His office used to be crowded with patients who

would occupy all his time if he allowed them to do so. In order to

secure opportunities for his other work, for his lectures, for his

hospital visitation, and for his pathological investigation, he had a

back entrance to his house through which he could steal out--even

though there were many patients waiting for him--when he felt that it

was time for him to fill another engagement.

Late in life, after his return from Parliament when he took up his

practice again, it was only a very short time {206} before the same

state of affairs developed once more. It almost seemed as though every

sick Irishman and Irish woman wanted to have the opinion of Dr.

Corrigan. He had also a large consultant practice, though he was known

for being a very different man from the ordinary type of the medical

consultant. As one of his younger colleagues said, "he never wore the

supreme air of a consultant." He was always simple and easy in his

manner, was always congenial and ready to listen to what had developed

and had been found in the case before consultation with him, and had

none of that superciliousness that was supposed to characterize the

true high-grade consultant physician in the British Isles a half a

century ago.

Within a few years after his essay on aortic heart disease, Corrigan

published a paper on chronic pneumonia or, as he called it, cirrhosis

of the lungs. Corrigan's successful achievements in medicine depended

mainly on the fact that he studied the pathological anatomy of fatal

cases with the greatest care. He had detected that in certain cases of

chronic pneumonia the process seemed to be quite different from

tuberculosis. Observations made postmortem showed that his clinical

observations were justified by the differences observed in the organ.

As a result he formulated his opinions on the subject. He called

particular attention to the fact that what he found corresponded very

closely with the pathological process which had been observed by

Laennec in the liver, and to which the French medical pathologist had

given the name of cirrhosis. It would seem as though the pathology of

the time was so crude that Corrigan must surely fall into serious

errors in his account of what he saw. Twenty years later, Virchow was

to revolutionize pathology by the publication of his "Cellular

Pathology." Notwithstanding the progress made since his time, {207}

however, Corrigan's description of the condition of the lungs that he

noted and of the pathological process observed is so true that even to

the present day this paper remains of distinct value in medicine and

represents the beginning of correct ideas on the subject.

After Corrigan's death in 1881 the London _Lancet_ said: "In the light

of recent pathology Corrigan's speculations on cirrhosis of the lungs

are more meritorious than ever and continue to be regarded as in the

main sound. They anticipated by forty years much of the present

pathology." Needless to say it is only a genius of a very high order

that is thus capable of rising above the limitations of environment,

and in spite of the defective knowledge of his times observing

correctly and drawing proper conclusions, though all the usual

accepted principles would seem to be sure to lead him from the truth.

The principal lesions of chronic pneumonia, after having been the

subject of much disputation, with conclusions now one way and now

another in the intervening years, are at the present time recognized

as being essentially due to the pathological processes Corrigan

originally pointed out.

The man who thus made a permanent place for himself in the history of

medicine was the son of a poor shopkeeper in one of the outlying

districts of Dublin. His early education was obtained at Maynooth

College, which had at that time a department for the training of youth

for secular vocations, though it has since become an exclusively

clerical institution. It is needless to say he acquired an excellent

knowledge of the classics, of which he made abundant use later in

life, and of which he was always very proud. The physician in

attendance at Maynooth in his time took quite a liking to him, and it

was the result of his suggestion that Corrigan took up medicine as his

profession. For a time {208} he was under the tutelage of this Doctor

O'Kelley, who seems to have been a very intelligent man, and a rather

painstaking clinical observer. Most of his medical studies were made

in Dublin and he attended the practice at Sir Patrick Dun's Hospital.

It was the fashion at this time, however, for Irish students of

medicine to finish their medical education at Edinburgh, whenever

possible, and Corrigan spent several years there, receiving his degree

of Doctor in Medicine in 1825.

He had attracted considerable attention in Edinburgh for his acute

powers of observation, and received an appointment to the Meath Street

Dispensary shortly after his return. From the service here he was

appointed to the Jervis Street Hospital. He had to pay, however, for

the privilege of being attending physician here, and this, as he said,

made him more careful in endeavoring to secure all the advantages

possible from his service.

After his publication of the article on "The Permanent Patency of the

Mouth of the Aorta," or "Inadequacy of the Aortic Valves," he at once

became recognized as one of the best clinicians in the city. This

article appeared, in April, 1832, in the _Edinburgh Medical and

Surgical Journal_, at a time when, as has been said, its author was

not yet thirty years of age. As soon as he began his work at the

Jervis Street Hospital, he gave a course of lectures, and as he was an

excellent talker and a good demonstrator, he at once attracted a large

class. In 1834 he joined Hargrave's School, in Digges Street, Dublin,

as lecturer on the practice of medicine, and continued to hold the

position for more than ten years. His success as a lecturer attracted

many students from the other medical schools. Corrigan's class was

often three times as large as that of other medical lecturers in the

city. It not infrequently happened that as a result of his {209}

popularity the medical class was two or even three times as large as

the surgical and anatomical classes at the same institution. This was

very unusual, for Dublin was famous for its anatomical instruction,

and there were often five times as many pupils enrolled in the anatomy

classes as in the medical classes.

It was not long before honors began to be showered upon Corrigan. When

he was about forty the diploma of the London College of Surgeons was

conferred upon him, and, as according to the by-laws of the

institution the diploma can only be conferred after examination,

Corrigan's examination was made to consist of the reading of the

thesis, "Inadequacy of the Aortic Valves," before the faculty and the

other members of the college. In 1849 the University of Dublin

conferred upon him the degree of M.D., _honoris causa_.

There was only one setback in Corrigan's medical career in Dublin.

When first proposed for honorary fellowship in the Irish College of

Physicians, he was rejected. The reason was entirely apart from

medical matters. Corrigan was the most active member of the Irish

Board of Health, which had charge of the famine cases in Ireland,

during the awful years between 1845 and 1850. This Board proposed to

allow about five shillings per day to physicians who would be sent to

the country to attend famine fever cases. It is easy to understand

that this remuneration was considered inadequate and the Board's

decision in the matter raised a storm of protest. Graves wrote very

bitterly with regard to it, and blamed Corrigan for any part he might

have had in it. The result was that for some time Dr. Corrigan was the

most popularly hated physician in the medical profession of Dublin.

Corrigan made, up for any lack of tact he might have had {210} in this

matter, however, before long, and in 1855 he obtained the license of

the college. Two years later he was elected a Fellow. Before another

two years had passed he was elected President of the College, and had

the unprecedented honor of being re-elected four years in succession.

The college further made up for its offense by having a statue of Dr.

Corrigan, by the famous Irish sculptor Foley, made for its hall while

he was still alive.

His own self-sacrificing work during the famine fever years was well

known. After he had achieved nearly every distinction that his brother

physicians could confer upon him, he was created a baronet. It was

understood that this distinction was mainly meant as a reward for his

services during the famine, though also for the time which he had so

unstintedly given to the improvement of national education in Ireland,

in the capacity of a Commissioner of Education.

Not long after his creation as a baronet, Sir Dominic stood, in

Dublin, for a seat in Parliament in the Liberal interests. At first he

was unsuccessful. In 1869, however, he was returned as one of the

members of the government and sat in Parliament for five years. As he

was a very eloquent speaker, it was thought that he would produce a

very distinct impression in Parliament. His type of eloquence,

however, did not prove to have any special influence in the cold

British House of Commons, though Sir Dominic was always looked upon as

one of the men to be counted on whenever there was under consideration

legislation that affected Irish interests.

He was defeated for re-election in 1874, but it is rather to his

credit than otherwise, since he had been approached by the vintners of

Dublin, who were at that time all-powerful in municipal politics, and

offered the membership, provided he would agree not to actively

support the Sunday Closing {211} Bill, which was to come up at the

next session of Parliament. Such an agreement Sir Dominic absolutely

refused to consider as consistent with his legislative honor, and the

result was the close of his Parliamentary career.

His years in Parliament, however, did not separate him from his

interests either in medicine or in general science. He continued to be

especially interested in zoology and made liberal contributions to the

Dublin Zoological Garden. His residence at Dalkey, the grounds of

which ran down to a rocky coast line, enabled him to obtain many

specimens for his aquarium, and these were often transferred to the

Dublin Zoological Gardens, for which he was one of the most active

collectors. It was his custom during his Parliamentary career, though

he was more than seventy, to leave London on Friday night and reach

Dublin about eight o'clock on Saturday morning. From the station he

went directly to the Zoological Gardens and took part in the pleasant

breakfast which the Council of Officers of the Zoological Society,

with some invited guests, had there every Saturday morning. He was

noted for his humor, and his presence at these breakfasts was always

appreciated, because in spite of his advancing years he was sure to

add to the pleasure of the occasion.

His friends feared that his Parliamentary career might prove a serious

drawback to his health at his time of life, and their fears were not

without foundation. He suffered severely from gout, which left its

marks upon his feet and made it very difficult for him to walk for a

time, and maimed him for all his after-life. Though a man who had

worked very hard all his life and who, at the age of seventy,

practically took up another career, that of politics, Sir Dominic

lived to be nearly eighty years of age; thus illustrating the old

aphorism that "it is not work but worry that kills," and {212}

furnishing another example of the fact that great men are great also

in their superabundant vitality, and are able to spend their lives in

the hardest kind of work, yet, barring accident, live on to an age

beyond even that which is considered the average term of human

existence.

Few men have had happier lives than Corrigan, if the high esteem of

contemporaries can ever confer happiness. There was no honor in the

gift of his Dublin professional brethren or of scientific bodies in

which he was interested which was not conferred upon him. He was the

president of the Royal Zoological Society, the president of the Dublin

Pathological Society, of which he was one of the founders, and the

first president of the Dublin Pharmaceutical Society. When not yet

fifty years of age he was made physician in ordinary to the Queen in

Ireland, and had the unapproached record of five elections to the

presidency of the King and Queen's College of Physicians in

Dublin--more than enough to make up for the one serious setback in his

medical career, his black-balling by the college only a few years

before. Foreign medical societies invited him to honorary membership

and foreign universities conferred many degrees on him.

It is easy to understand then that his death was followed by tributes

of the loftiest character to his professional work, to his standing as

an influential member of the community and as a man of the highest

intelligence and thoroughly conservative patriotism. The London

_Lancet_ said in its obituary: "By the death of Sir Dominic Corrigan,

the medical profession loses one of its most conspicuous members, the

University at Edinburgh one of its most illustrious graduates, and the

Irish race one of its finest specimens. Though a perfect Irishman, Sir

Dominic was as much at home in London, and though a sincere Catholic

in religion, he had {213} too much humor and too much humanity in his

constitution to be a bigot. It were well for Ireland if all her public

men displayed so much moderation, sense, and good humor as Sir Dominic

habitually displayed in dealing with difficult and delicate

questions."

About the same time the _British Medical Journal_ said, after calling

attention to the distinguished contemporaries with whom Corrigan had

been associated, that he was "_haud minimus inter magnos_--not the

least among the great ones." "Indeed," his biographer added, "in

originality of conception which, confirmed by later and independent

observation, is the true test of genius, in a correct appreciation of

the operation of natural laws, in producing and modifying the

phenomena of disease, in a rare aptitude for testing his hypotheses by

actual experience, and in a forcible exposition of them, he probably

had no equal among his contemporaries."

In the midst of all his honors and political influence, including

association with the highest English officials in Ireland, Sir Dominic

Corrigan had remained a consistent and faithful Catholic. Educated at

Maynooth as a boy, he was proud to remain the physician to the college

during many of the busiest years of his life when he must have often

found it very difficult to spare the time to fulfil the duties

attached to the position. He was the consultant physician till the end

of his life. He is not even yet, after a quarter of a century,

forgotten by the poor of Dublin, who recall his kindly help in

affliction and his generous aid often given in ways that would be

arranged with studied care so as not to hurt delicate Irish

susceptibilities.

The Irish School of Medicine has in Graves and Stokes and Corrigan a

greater group of contemporaries than has been given to any other

nation at one time. If we were to eliminate from nineteenth century

medicine all the {214} inspiration derived from their work there would

be much of value lacking from the history of medical progress. These

men were deeply imbued with the professional side of their work as

physicians, and were not, in any sense of the word, money-makers.

Another very interesting phase in all their careers is that no one of

them occupied himself exclusively with medical studies. All of them

had hobbies followed faithfully and successfully together with

medicine, and all of them were deeply interested in the uplifting of

the medical profession, especially in securing the rights of its

members and saving poor sick people from exploitation by quacks and

charlatans. All of them gave of their time, their most precious

possession, for the political and social interests of their

fellow-men, and felt in so doing that they were only accomplishing

their duty in helping their generation to solve the problem that lay

immediately before it.

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