Makers of Modern Medicine

THE IRISH SCHOOL OF MEDICINE6

There are men and classes of men that stand above the common herd: the soldier, the sailor, and the shepherd not infrequently; the artist rarely; rarelier still, the clergyman; the physician almost as a rule. He is the flower (such as it is) of our civilization; and when that stage of man is done with, and only to be marvelled at in history, he will be thought to have shared as little as any in the defects of the period, and most notably exhibited the virtues of the race.

--Robert Louis Stevenson, Preface to Underwoods.

The physician who is not also a scholar may be a more or less successful practitioner, but his influence will be confined, his methods mechanical and his interests narrow. The doctor, the lawyer and the minister of religion can do but inferior work, unless to a knowledge of their several sciences they bring the insight, the wide outlook, and the confidence which nothing but intimate acquaintance with the best that has been thought and said can confer. The more accomplished the specialist, the greater the need of the control which philosophic culture gives.

--Bishop Spalding.Robert Graves, M.D

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 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 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, Göttingen, 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 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 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 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 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, 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 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 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."

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 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; 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 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."