Thursday, 1 May 2014

The foundations of a career

William  Stokes – His Life and Work. By his son  Sir William Stokes, 1898.   

This review was written on June 4th 2004

I read the biography of Dr. William Stokes by his son, Sir William Stokes, in May 2002. It was published by T. Fisher Unwin of London in 1898 in the Masters of Medicine series of biographies.  I had read this short biography many years ago and had been much influenced by the life of William Stokes and by the contribution he made to the advancement of medicine and to the standards of the medical profession.  It was one of the books, mostly biographies, which had a profound influence on my own career and which was important in enhancing my appreciation of my role as a doctor. 

William Stokes
Stokes was born in Dublin in 1804 and died in 1878. He was descended from a distinguished family  which had lived in Ireland for five generations and which first arrived from Gloucestershire in 1680 when his predecessor, Gabriel Stokes, an engineer, took up the position of Deputy Surveyor in Ireland.  After qualifying in Edinburgh, Stokes returned to Dublin where he was soon appointed to the Meath Hospital. It was here that he established his reputation as a teacher and physician.

Sir William Stokes, his son and biographer, qualified as a doctor in Dublin and, unlike his father, trained as a surgeon and was also attached to the Meath Hospital as well as the Royal College of Surgeons.

William Stokes worked closely with a senior colleague in the Meath, Robert Graves. Both these physicians played an outstanding part in enhancing the reputation of the Irish School of Medicine.  Indeed, while they were the leading pair to advance the mid-nineteenth century reputation of the Irish school, they were only two of a very distinguished group of progressive physicians and surgeons who brought great honour and fame to Dublin medicine.
Long before I had read Stokes’ biography, I was aware of his reputation, particularly in the field of cardiology.  He had published two important monographs, the first, which brought him early international notice, was Diseases of the Chest published in 1837.  My interest, however, was mainly in his second major publication, Diseases of the Heart and Aorta, which was published in 1850.  This brought him added fame and, like his previous book, it was translated into the principle European languages.
I had read Diseases of the Heart and Aorta in the early 1950s after my return to Ireland following my postgraduate training in clinical cardiology, and I delivered an address to the Royal Irish Academy of Medicine in 1955, entitled Diseases of the Heart and Aorta – a Modern Clinical Review. This address was published in the Irish Journal of Medical Science that year. It was subsequently reproduced many years later as an addendum when a facsimile copy of Stokes’s work was published by the Classics of Cardiology Library in the United States in 1985.

At this time I had become interested in the Irish contributions to cardiology during the nineteenth century. I later published a paper O’Bryan Bellingham - a Centenary Tribute. Bellingham was a physician appointed to St. Vincent’s Hospital about 1840 and had written this book mainly about aneurysm but it included much about the heart. I published a few papers about the articles on heart disease which made Sir Dominic Corrigan famous. Finally, before my commitment to research and the management of coronary disease in early 1960 occupied an increasing amount of my time, I published The Views of the 19th Century Irish Cardiologists on Coronary Artery Disease, a paper I had read in Boston at the invitation of Dr. Paul White. 

So ended my brief interest in probing medical history. I had been warned by my senior colleague and mentor, Dr. Patsy O’Farrell, that writing medical history was one of the most compelling addictions known to Man, but my escape from such a fate was inevitable as the coronary epidemic gathered pace at the end of the 1950s and as I found myself responsible for all coronary and other heart problems admitted to St. Vincent’s Hospital.

The Meath hospital in 1822
Stokes and Graves were responsible for the dramatic change from the obscurantism and the empiricism of medicine which existed in the early part of the 1800s to the hands-on clinical approach to disease. This new clinical approach was the bedrock of good medical practice and was based on careful history taking and physical examination. Such practice depended on a detailed knowledge of anatomy, pathology and physiology, correlated with the patient’s symptoms and physical signs. They also led a change in medical practice from the irrational cupping, bleeding, purging and starvation of their predecessors to less harmful interventions.

Stokes made an outstanding contribution to medicine when he inaugurated the Pathological Society in Dublin in 1838. The meetings were held weekly and were a forerunner of our current grand rounds and death conferences. It was an immediate and popular innovation and was widely attended by medical people at the time, including teaching hospital staff, outside practitioners and students.  Numerous pathological specimens were presented with the clinical details of each case and such were the many contributions to the society that discussion was not permitted because of time restrictions. 

It was largely through his intervention that Trinity College set up the first Department of Hygiene or Preventive Medicine and Public Health in these Islands, and that the University was the first in these islands to provide a diploma in this subject.  Perhaps one factor which quickened my own involvement in preventive medicine was Stokes’s vision in this particular area. He had a passionate interest in what we now call health promotion and clearly considered it as an integral part of the doctor’s function. Later, as President of the British Medical Association, on the occasion of its annual general meeting in Ireland in 1867, he addressed the audience and was optimistic about the participation of physicians in prevention, but sadly, as I can confirm, the subject received little interest from the organised profession at least until a few years ago. The importance of including prevention and health promotion as in integral part of medical practice was raised by me at a few meetings of the Irish Medical Association at the time of my Presidency. It was received by all my colleagues with the classical glazed look of the indifferent. 

Stokes had an intense interest in the reputation and the welfare of the medical profession but he was also passionately interested in his patients and in the standards and ethos of his hospital.  He was nationalist in the sense that he had a singular patriotism for his country and an intense interest in its culture, its history and its welfare.  He combined his patriotism with a firm belief that the welfare of the country was best assured by its continued representation in Westminster. He was totally opposed to the Repeal movements which were so active in Ireland during the years following the Union. Yet he had a great sympathy and a great affection for many of our great repealers and separatists of the time, such as Wolfe Tone, Robert Emmet, Thomas Davis and, later, Isaac Butt.

Stokes had a profound sympathy for the poor and particularly for their sufferings during the many famines that occurred during the earlier part of the nineteenth century. He believed that the reputation and the welfare of the profession would be assured by our doing everything possible to improve the lot of society and to provide a compassionate service for our patients.  I was a member of the General and Executive Councils of the Irish Medical Association for about twelve years. Before and during that time the Association had a clear commitment to the public welfare and a better health service. In 1974 we published a working party report advocating a compulsory insurance service for the entire population of the country but this proposal, while warmly supported by the members of the Association and still widely advocated, has not yet been established thirty years later. There was a sense of responsibility about the role of the profession in society among doctors at the time. It certainly enhanced the reputation of the profession with the public and appeared to do no harm to our own financial circumstances. While things may have changed now as we live in more materialistic and secular times, it was evident that the Association’s more altruistic motives were an expression of the traditions established one hundred years earlier by Stokes and his colleagues.

Stokes travelled much during his lifetime, both on the continent and throughout the island of Ireland.  He was closely associated with Lord Dunraven, George Petrie and the many other historians, archaeologists, architects and amateurs, including some doctors, who were doing so much at this time of enlightenment to create an interest in Irish history, culture and the artifacts of the past.  Stokes became an intimate friend of George Petrie who contributed so much to the recording of Irish antiquities and ecclesiastical architecture, both pre-Christian and post-Christian, and whose seminal work, Round Towers of Ireland is in my father’s library. Petrie was only one of many, mainly Protestant, professional and middle class, who provided the thrust of the rapidly expanding movement of enquiry into the history, antiquities, culture and language of the old Irish and Celtic tradition. Many of these pioneers, like Stokes and William Wilde, were doctors. The interest of these new patriots was to lead to the Celtic Twilight, advanced by Yeats, Standish O’Grady, Padric Colum, James Stephens and many others, whose books have an honoured place in my father’s library. And there were a myriad of others who, free from the narrow prejudices of religion and politics, contributed in different ways to the great revival of interest in Ireland’s past, and who could all claim the distinction of being true patriots.

Musing about his interest in the Irish countryside and its archaeology and antiquities, William Stokes prophesied (page 60 of his biography) truth, a little time will level these ancient castles and their high borne and their honourable inhabitants and the feelings which their communion creates, and  then “utility” will have it’s reign, and “common sense”, laughing at the past and the beautiful, will build factories with the remains of history, make money, and die.

My latter days as a cardiologist were almost entirely devoted to the treatment of coronary disease, and to research into its natural history, causes and prevention. I also had bedside teaching responsibilities. The coronary epidemic peaked in the early sixties and affected all adults and both sexes at this time. It was to prove the greatest epidemic of the latter half of the twentieth century in the Western world. 

The ECG; the early years.
There was much confusion in the mid-nineteenth century about the exact nature of coronary disease. Indeed the confusion about the pathological basis and the clinical manifestations of coronary disease still existed up to the time I qualified in 1945.  It was only with the rapid advances in clinical cardiology immediately after the last Great War and the widespread application of electrocardiography then, that the precise pathological nature and diagnosis of myocardial infarction and chronic angina of effort was appreciated by contemporary cardiologists. We were to wait a few more years before other acute coronary syndromes, such as unstable angina and non-Q wave infarction, were recognised, and it required many more years still, and the arrival of the coronary care unit in the mid and late 1960s, before the precise diagnosis of coronary heart disease extended to the entire profession. 

Stokes was familiar with the diagnosis of angina but had no insight into its pathological basis, the narrowing of the coronary arteries by atherosclerosis, nor did the symptoms of the disease have the same diagnostic specificity it has to-day. He was not familiar with the pathological concept of myocardial infarction nor was there any great significance attached to disease of the coronary arteries. He used the term ‘fatty heart’, probably referring to examples of infarction. Another term in use at the time by pathologists was haemorrhagic myocarditis, almost certainly referring to acute heart attacks.

Practice what ye preach...
There was no rational treatment available for the treatment of heart disease in Stokes’s time nor indeed had physicians much to offer in terms of treatment for any serious medical condition until after the last Great War. However, he did recommend exercise in the treatment of heart cases, thus preceding by nearly one hundred and fifty years the acceptance by the profession of the use of graduated aerobic exercise in the prevention and management of coronary heart disease.  His exercise prescription is mentioned in his book “Diseases of the Heart and Aorta” and is quoted on page 139 of his son’s biography.  He advocates walks in the highlands of Ireland, Scotland and Switzerland for his heart patients.

Reading Stokes’s life made a profound impression on me and greatly enhanced my pride in the medical profession and my interest in clinical medicine. It must also have enhanced my commitment to the wider aspects of prevention.  However, I had read the life of William Osler (by his colleague in Johns Hopkins, the neurosurgeon Harvey Cushing) about the time I qualified and this too had a great influence on my appreciation of the role of doctors in society and of the huge satisfaction to be derived by those who were lucky enough to have or to acquire a vocation which conferred a commitment to the welfare of patients, society and to the ancient ethos of the profession. This commitment can only be acquired by sharing a visceral insight into the patient’s plight as if it were one’s own personal problem.

Osler was perhaps the greatest physician of his time and certainly earned the greatest reputation internationally.  Born and bred in Canada where he qualified as a doctor in McGill University, he moved and established his reputation in Philadelphia and subsequently in the John’s Hopkins Hospital in Baltimore.  His essays, principally aimed at medical students and his own colleagues, have been published frequently and are a clear expression of his great humanity, his culture and his appreciation of how the medical profession can contribute so much to the welfare of society.  His best known essay, Aequanimitas, certainly had a profound effect on my own life and attitudes, and encouraged a maturity to face the slings and arrows of outrageous fortune in a philosophical way.  Like Stokes, he was totally committed to clinical medicine as manifested by careful history taking and by thorough physical examination. 

I like to think that, when I was trained in London in internal medicine and cardiology, I developed the same appreciation of the importance of clinical medicine. I slowly acquired an insight into clinical practice by the mental co-ordination of anatomy, physiology, pathology as the basis of symptoms and physical signs leading to an integrated appreciation of disease.  Like Osler and Stokes and many other predecessors, I was fortunate that I had little access to special investigations and I had no personal or financial interest in any matters outside my consultation work and my clinical practice. 

Another source of inspiration to me was Paul White’s “Heart Disease” which was first published in 1935. I read the 1944 second edition when I was a final year medical student.  Paul White was popularly known as General Eisenhower’s physician but this title endowed on him by the media overshadowed his great clinical reputation as one of the early and most progressive cardiologists in the United States.  His book is remarkable in that he lays as much importance on the prevention of heart disease, both primary and secondary, as he does on the limited treatment which was available at that time.  He had many of the qualities of Stokes and Osler and his book had an immediate effect on me in that I was determined to specialise in cardiology after qualification. I was to resist offers by my own teaching hospital to specialise in anaesthesia or to take up a surgical career. Instead, I spent four months unemployed after I qualified and completed my one-year residence at St Vincent’s Hospital. I eventually found a locum job in London where I later attended the National Heart Hospital as a post-graduate student. 

Paul White was a man of wide vision with an intense interest in the role the profession could play in encouraging the public health. He played a major role in the American Heart Association and subsequently he was to encourage the world-wide spread of the Heart Foundation concept.  I met Paul White on several occasions during my subsequent visits to the United States, including his invitation to me to speak to the Massachusetts Medical Society about the nineteenth century cardiologists in Dublin. He was always interested in his junior colleagues and students, and he was, of course, the doyen of the medical faculty at the Massachusetts General Hospital.  It was his custom to invite all visitors to his home where, among the other aspects of his hospitality, one was expected to mow the lawn in front of his house.  This was all part of his philosophy that exercise was not only important from the physiological and health points of view, but particularly from the point of view of the management of coronary disease.  He was an early pioneer in advocating graduated exercise for coronary disease but he was preceded by one hundred years by William Stokes who advocated graduated exercise for the “fatty heart”. 

Stokes, Osler and White had much in common as physicians. Reading their works was certainly a great inspiration to me and the source of the great satisfaction I enjoyed during my years as a clinical cardiologist.  I could claim with confidence that I never knew a moment of ennui or depression while I was working in the wards of the hospital, in the outpatients department or in my private consulting room.  I was fortunate that, indifferent as I was to the prospect of entering the medical profession and bored as I was by my first three academic years on the university campus, I had the good fortune to find myself in a profession which amply suited my temperament and my social background.  Stoke’s commitment to his patients inspired him more than any other consideration. It is surely the most important ingredient of the Hippocratic spirit.

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