Abstract
Cheyne-Stokes respiration – an abnormal pattern of breathing, oscillating between hyperventilation and apnoea – was first described in the 19th century by Dr John Cheyne and Dr William Stokes. Although primarily known for this condition, both men contributed a lot more to the understanding and practice of medicine than this eponym.
Keywords: Cheyne-Stokes, John Cheyne, William Stokes
Cheyne-Stokes respiration – an abnormal pattern of breathing, oscillating between hyperventilation and apnoea – was first described in the 19th century by Dr John Cheyne and William Stokes. Stokes also pops up in eponymous medicine for his work on syncope (the Stokes-Adams syncopal attack). In truth, what we now call Cheyne-Stokes respiration had been already been described by Hippocrates over two millennia earlier ‘respiration throughout like that of a man recollecting himself, and rare, and large’.
Cheyne, a Scottish physician and surgeon, documented this form of terminal respiration in his snappily named monograph ‘A case of Apoplexy in which the fleshy part of the heart is converted into fat’. In this original paper, Cheyne made the following observation:
The only peculiarity in the last days if his illness which lasted nine days, was in the state of the respiration: For several days his breathing was irregular; it would entirely cease for a quarter of a minute, then it would become perceptible, though very low, then by degrees it became heaving and quick, and then it would gradually cease again: this revolution in the state of his breathing occupied about a minute, during which there were about thirty acts of respiration.
Stokes observed this pattern in an obese man’s final days of life. The man exhibited many of the signs and symptoms of heart failure (coupled with likely decompensated alcohol-induced cirrhotic liver disease and hemiplegia).
It consists in the occurrence of a series of inspirations, increasing to a maximum, and then declining in force and length, until a state of apparent apnea is established. In this condition the patient may remain for such a length of time as to [appear] dead, when a low inspiration … marks the commencement of a new ascending and then descending series of inspirations … The decline in the length and force of respirations is as regular and remarkable as their progressive increase.
Many of the underlying pathophysiological misconceptions that its two name-sakes hypothesised were corrected by the subsequent research on the Cheyne-Stokes phenomenon by Camille Biot (of Biot Respiration eponymous fame).
John Cheyne (1777–1836)
Cheyne was born and educated in Scotland. He spent much of his early years assisting his doctor father by helping to look after some of his less affluent patients; performing checks ups, delivering medication, and changing dressings. His Leith Grammar School experience was not a happy one – despite being taught by a headmaster who was ‘the most learned, wise and virtuous man of his age’. This mocking description he attributes to the fact that the master ‘would flog the whole form till he became pale and breathless and unable to proceed’.
In contrast to Stokes, in his youth Cheyne was an extremely high-achieving and motivated student. He started medical school at the age of 15 (below the minimum age requirements but avoided suspicion due to his physique): he graduated with a full medical degree by 18 and then spent his early years of military service as a surgeon in the Artillery Corps in Woolwich – ‘in complete dissipation of time’.
He became restless and eventually he moved to Ireland via Scotland where he was appointed as Professor at Meath Hospital. It was here that he may have crossed paths with Stokes. He was primarily interested in childhood diseases, publishing papers on paediatric respiratory infections. Later in life, he resigned his professorship (so that his ‘private practice might not suffer’) and became the Physician General to the Army in Ireland.
As his health deteriorated due to a ‘nervous fever’, and lamenting his inability to yield an additional £1500 to his £5000 salary, he retired to rural England where he developed a keen interest in religion.
Despite his failing health, he ran a local clinic for sick villagers and still found time to write medical papers. His last book ‘Essays on Partial Derangement of the Mind – In supposed Connexion with Religion’ was published in 1843, seven years after his death.
William Stokes (1804–1878)
Stokes was the son of the Regus Professor of Medicine at Trinity College Dublin. As a youth, he was regarded as lazy, incompetent and only completed a day in formal schooling after throwing a slate at his teacher’s head. He was described as ‘indolent and apathetic’ towards physical pursuits; he would instead often be found reading poetry in a thick hedge, his ‘nest’.
Stokes first enrolled to study anatomy at the Irish College of Surgeons, where his father had succeeded Cheyne as Professor of Medicine. After studying chemistry in Glasgow, he turned to medicine, and soon after his graduation he went on to become a visionary in his field.
In 1828, whilst working as a physician in Meath under Robert Graves’ (of Graves’ disease eponymy) tutelage, he published a short book entitled ‘Clinical reports of the medical cases in the Meath Hospital’ which he dedicated to Cheyne. Over the ensuing years, he became friends with René Laennec, who is accredited with the invention of the mono-aural stethoscope (the use of which was regarded as a passing fad). Stokes published the first English language book on the use of the stethoscope and dedicated most of his working life to exploring thoracic disease, publishing two major works, Disease of the Chest (1837) and Diseases of the Heart and Aorta (1854).
He was instrumental in developing medical education: he believed medical students should be encouraged to have interests outside of medicine and to follow a more apprenticeship-based course. He believed that surgeons and medics should get the same basic training and he felt that medicine was not a single science but ‘an art, depending on all sciences’.
Stokes certainly practised what he preached and maintained a healthy extra-medical lifestyle. He published in architecture and archeology and was particularly fond of folk music – on one occasion ‘he got so charmed that, beginning with moving his hands he ended by holding Mr Otway, a barrister, no chicken in years, and skipping around the room’.
The Stokes family home (5 Merrion Square) was considered the beating heart of Dublin society. It attracted many leading luminaries and up-and-comers such as a young Oscar Wilde with its parties, ‘stimulating conversation’, plays and music nights which often continued until the small hours.
In 1849, Stokes won the Presidency of the College of Physicians in a landslide vote against his former mentor, friend and colleague, and ex-College President, Robert Graves. What made his appointment all the more remarkable was that only 10 years earlier, the College of Physicians had refused to make him a fellow because he had not graduated in arts, and his medical degree had been obtained in Edinburgh and not from Oxford, Cambridge or Dublin (a situation circumvented by the old ‘Honorary MD’ trick). He held many illustrious positions in his twilight years; appointed physician to the Queen in Ireland in 1862, BMA President 1867, and President of the Irish Academy in 1874.
In 1877, a year after receiving the Prussian Order of Merit, he suffered a stroke and died two months later.