It was not long, however, before Laennec's many labors in Paris began to tell on his health once more. His practice after his return to health and his attachment to the court became large and lucrative. It is characteristic of the man and his ways that he frequently refused, owing to lack of time, to go to see wealthy patients, from whom he would have received large fees, but it is said that he never refused to go to see a poor patient. His hospital patients always received the most solicitous attention, and his time was almost entirely at their disposal. It was not long before Laennec himself, who had taught modern physicians so much about the diagnosis of pulmonary diseases, began evidently to suffer from pulmonary disease himself. There seems no doubt now that almost constant association with tuberculous patients in an overworked subject inclined naturally to be of underweight, and therefore especially susceptible, led to the contraction of the disease.

After about four years in Paris, a dry, hard cough developed insidiously, gradually increased in annoyance, and finally grew so serious as to demand a return once more to his native Bretagne. He lost flesh, became subject to intermittent attacks of fever and suffered from some pleuritic and pulmonic pains. For some time after his return to his native air he improved. He was treated by the usual method employed at the time whenever fever accompanied any ailment. Venesection was the main part of what was then called the antiphlogistic treatment. It is needless to say he did not improve. He was suffering from exhausting disease and the treatment became really an accessory to further exhaustion.

At last there could be no longer any doubt that the end was approaching. The old curé of the village came often to visit him, and brought him all the consolations of religion. {159} With his sincere Christian faith and firm conviction, it was not hard for Laennec to find the moral force and the calm necessary to secure an easy death. Finally one day, on August 13th, his wife saw him take off his fingers one after another the rings he wore, and place them softly upon the table. When she asked him why he did so, he replied, "It will not be long now before someone else would have to do this service for me, and I do not wish that they should have the trouble." Even in death he was thinking of others rather than of himself, and he was calmly facing the inevitable, thoroughly prepared for it. Two hours afterward, at five o'clock in the afternoon, without there having been at any time the slightest loss of consciousness, Laennec passed away.

How faithfully his family had watched over him, and how simple was the feeling of Christian confidence in all of them, may very well be gathered from the letter of his cousin Ambrose to Laennec's brother Meriadec in Paris.

"My dear Meriadec:--Poor Renè is no more. His life was passed in the midst of labor and of benevolence. While he had all the virtues of the true Christian, and a wisdom far beyond what was usually granted to men, they have not sufficed to obtain for him the grace of a longer life. Somehow it was ordained that this glory and ornament of our family was not to remain with us. What a sad reflection it is on our restless eagerness in this life, and on the vanity of our hopes, that a genius like this must perish just when it was about to receive the fruit of its labors! He leaves to us a name, a name difficult to sustain and the example of virtues that it will not be easy to imitate. Let us hope that he will watch over us in the future as he has done in the past, and that he will still continue to aid us after his death. Although I have been prepared for this sad event, I could not suspect how much grief I was to experience in losing my {160} second master, my friend from earliest infancy, and him whom I had become accustomed to consider as my eldest brother. I must confess that for some years now we have all had to pay dear for the short intervals of happiness that it has pleased heaven to accord to us."

Laennec's burial took place in the cemetery of Ploare. The attendance at the funeral was very large. Practically the entire population of the countryside came to mourn for the benefactor that they loved so much. He had made friends even among the simplest of the country people and knew most of them by name. After his return to the country, he had improved somewhat in appearance, and the neighbors had been very glad to express their feelings of gratitude for his apparent improvement in health. Undoubtedly not a little of this state of better spirits was due to the fact that he liked Brittany and the peasants of the neighborhood so well, and always felt so much at home among them.

He was mild and agreeable in his manners, and of a quiet and even temper. His conversation was lively and full of quiet humor, and his friends often said that they never came away from a conversation with him without having learned something. Toward the end of his life, when his great reputation caused him to be honored by medical men from all over the world, and when his reputation made him the lion of the hour, he lost none of his natural affability and kindness of heart. He was remarkable, especially, for his great kindness and courtesy to foreigners, and he is said to have taken special care to make himself understood by English-speaking medical visitors.

It must be confessed that he was somewhat less popular with his contemporaries who did not belong to his immediate circle of friends and students. One of the reasons for this was his genius, which no generation seems ready to {161} acknowledge in any of its members. Another reason was his continued misunderstanding with Broussais. Broussais was the medical theorist of the hour, and medical theories have always been popular, while medical observation has had to wait for due recognition. There were undoubtedly good points in Broussais' theories that Laennec failed to appreciate. This is the only blot on a perfect career, taking it all in all, whether as man or as physician. It can easily be understood with what impatience Laennec, entirely devoted himself to observation, would take up the study of what he considered mere theory, and it is easy to forgive him his lack of appreciation.

Benjamin Ward Richardson says: "It was a common saying regarding Laennec by his compeers that, while he was without a rival in diagnosis, he was not a good practitioner; which means that he was not a good practitioner, according to their ideas of practice, heroic and fearful. To us, Laennec would now be a practitioner very heroic; so much so, that I doubt if any medical man living would, for the life of him, take some of his prescriptions. But in his own time, when so little was known of the great system of natural cure, he would be easily out of court. It was amply sufficient against him that he had a glimmering of the truth as to the existence of a considerable run of cases of organic disease, for which the so-called practice of remedial cure by drugs, bloodlettings and other heroic plans, could do no good but was likely to do grievous harm." We are reminded of Morgagni's refusal to permit bloodletting in his own case, though he practised it himself on others. Like Laennec, Morgagni seems to have doubted the efficacy of bloodletting at a time when unfortunately all medical men were agreed that it was the sovereign remedy.

If Laennec was not popular with his immediate {162} contemporaries, succeeding generations have more than made up for the seeming neglect. Less than twenty-five years after his death, Austin Flint, here in America, hailed him as one of the five or six greatest medical men of all times. Forty years after his death, Professor Chauffard, himself one of the distinguished medical men of the nineteenth century, said:

"Without exaggeration we can call the glory which has come to French medicine because of the great discovery of auscultation a national honor. It must be conceded that for a long time before Laennec, the great man of medicine, those to whom medical science owed its ground-breaking work did not belong to France. Harvey, Haller and Morgagni had made the investigations on which are founded the circulation of the blood, experimental physiology, and pathological anatomy, in other lands than ours. It almost seemed that we were lacking in the fecund possibilities of daring and successful initiative. Auscultation, however, as it came to us perfect from the hands of Laennec, has given us a striking revenge for any objections foreigners might make to our apathy. This discovery has rendered the scientific medicine of the world our tributary for all time. It was an immortal creation, and its effects will never fail to be felt. More than this, it will never be merely an historical reminiscence, because of the fact that it guided men aright, but it will in its actuality remain as an aid and diagnostic auxiliary. Auscultation will not disappear but with medical science itself, and with this stage of our civilization which guides, directs and enlightens it."

Laennec was known for his simple Bretagne faith, for his humble piety, and for uniformly consistent devotion to the Catholic Church, of which he was so faithful a member. His charity was well known, and while his purse was very ready to assist the needy, he did not hesitate to give to the {163} poor what was so much more precious to him, and it may be said to the world also, than money--his time. After his death, and only then, the extent of his charity became known.

Dr. Austin Flint said of him: "Laennec's life affords an instance among many others disproving the vulgar error that the pursuits of science are unfavorable to religious faith. He lived and died a firm believer in the truths of Christianity. He was a truly moral and a sincerely religious man."

Of his death, his contemporary, Bayle, who is one of his biographers, and who had been his friend from early youth, said:

"His death was that of a true Christian, supported by the hope of a better life, prepared by the constant practice of virtue; he saw his end approach with composure and resignation. His religious principles, imbibed with his earliest knowledge, were strengthened by the conviction of his maturer reason. He took no pains to conceal his religious sentiments when they were disadvantageous to his worldly interests, and he made no display of them when their avowal might have contributed to favor and advancement." Surely in these few lines is sketched a picture of ideal Christian manhood. There are those who think it wonderful to find it in a man of genius as great as Laennec. It should not be surprising, however, for surely genius can bow in acknowledgment to its Creator.

Shortly after the death of Pasteur it was well said that two of the greatest medical scientists of the nineteenth century have given to the physicians of France a magnificent, encouraging and comforting example. It is almost needless to say these two were Laennec and Pasteur, and their example is not for France alone, but for the whole medical world. They were living nineteenth century answers to the advocates of free thought, who would say that religious belief and {164} especially Catholic faith make men sterile in the realm of scientific thought.

No better ending to this sketch of Laennec's life seems possible than the conclusion of Dr. Flint's address to his students in New Orleans, already so often quoted from. It has about it the ring of the true metal of sincere Christian manhood and unselfish devotion to a humanitarian profession:

"The career of the distinguished man whose biography has been our theme on this occasion is preeminently worthy of admiration. In his character were beautifully blended the finest intellectual and moral qualities of our nature. With mental powers of the highest order were combined simplicity, modesty, purity and disinterestedness in such measure that we feel he was a man to be loved not less than admired. His zeal and industry in scientific pursuits were based on the love of truth for its own sake and a desire to be useful to his fellow-men. To these motives to exertion much of his success is to be attributed. Mere intellectual ability and acquirements do not qualify either to make or to appreciate important scientific discoveries. The mind must rise above the obstructions of self-love, jealousy and selfish aims. Hence it is that most of those who have attained to true eminence in the various paths of scientific research have been distinguished for excellencies of the heart as well as of the head. The example of Laennec is worthy of our imitation. His superior natural gifts we can only admire, but we can imitate the industry without which his genius would have been fruitless. Let us show our reverence to the memory of Laennec by endeavoring to follow humbly in his footsteps." Quod faustum vertat!

THE IRISH SCHOOL OF MEDICINE

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.

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, 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 {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."

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."

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.