Cheyne-Stokes respirations are a harbinger of impending death. These famous last gasps are described as a regularly oscillating respiratory pattern with recurring apneic and hyperpneic periods. Cheyne-Stokes respirations are associated with a variety of clinical conditions including cerebrovascular accident, head injury, subarachnoid hemorrhage, cerebral tumor, meningitis, encephalitis, cardiac disease producing congestive heart failure, central nervous system respiratory depression due to morphine intoxication or sedation, narcolepsy, carbon dioxide narcosis due to pulmonary hypoventilation or the obesity cardiorespiratory syndrome (Pickwickian), high altitude, and prematurity.
In 1818 John Cheyne (1777–1836) reported the case history of a patient who suffered from a stroke and heart failure. He wrote, “A.B., sixty years, of a sanguine temperament, circular chest, and full habit of body, for years had lived a very sedentary life, while he indulged habitually in the luxuries of the table…In the latter end of January 1816, he consulted me…but he neglected my directions with regard to diet; nay, his appetite being remarkably keen, he ate more than usual, and took at least a pint of port wine or Madeira daily, as was his habit. The patient suddenly developed palpitations and displayed signs of severe congestive heart failure. The only particularity in the last period of his illness, which lasted eight or nine days, was in the state of 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.”
In 1854 William Stokes (1804–1878) described this breathing pattern again in his textbook, The Diseases of the Heart and Aorta. Stokes considered periodic respiration to be an ominous indicator of prognosis, and wrote, “This symptom, as occurring in its highest degree, I have only seen during a few weeks previous to the death of the patient.” Both Cheyne and Stokes were teaching in Dublin, Ireland, at the time of their writings on this subject.
John Cheyne was born on February 3, 1777, in Leith, Scotland. His father was a surgeon and when John was 13 years old he used to help his father dress and bleed patients. He entered Edinburgh University at age 15 and graduated at age 18. Having taken a diploma at Surgeons’ Hall he obtained a medical degree in June of 1795. He then secured an appointment as assistant surgeon to the Royal Regiment of Artillery and was posted to Ireland to suppress the rebellion of 1798. He served 4 years in the army before returning to Leith to practice with his father and work at Ordnance Hospital.
While in Scotland Cheyne studied pathology and dissection with Charles Bell and wrote his first book, Essays on the Diseases of Children, in 1801. He wrote one of the important early monographs on laryngology, Pathology of the membrane of the larynx and bronchia, in 1809.
In 1809 he went to Dublin, where, after an initial struggle to gain practice, Cheyne was appointed physician to the Meath Hospital and professor of medicine at the Royal College of Surgeons (1813–1819). He moved to the House of Industry Hospitals in 1815 and reached the summit of his ambition when appointed Physician-General to the army in Ireland in 1820.
He was cofounder and editor of the Dublin Hospital Reports, in which his celebrated account of a patient with irregular breathing was described. His detailed accounts of a variety of diseases and his writings on education gained him a worldwide reputation as a great teacher and practitioner. He wrote two essays on acute hydrocephalus (1808 and 1819), a book on apoplexy (1812), and a monograph on typhus fever.
Cheyne was affected by endogenous depression in 1825. He went to England for a temporary rest, but whatever benefit he obtained was lost when on his return he found a close friend mortally ill. As a therapeutic exercise Cheyne wrote the posthumously published Essays on Partial Derangement of the Mind (1843). Cheyne retired to Sherrington in Buckinghamshire, England, where his son lived, and died there on January 31, 1836.
William Stokes (1804–1878) was born in Dublin, Ireland. His grandfather was a Professor of Mathematics and his father, Whitley Stokes, was a respected physician and a senior Fellow of Trinity College who left the established church to follow the teachings of the Reverand John Walker and join the so-called “Walkerite” sect. As a result, Stokes’ father resigned from his fellowship of Trinity College and would not expose his son to a society that he believed did not follow the scriptures accurately.
Although born in Dublin, William spent much of his early life at his father’s country house in Ballinteer in the Dublin hills where he learned by heart the ballads of Sir Walter Scott, who remained one of his favorite authors. As he grew older he helped his father in the laboratory, saw patients with him, and rambled with him through the Irish countryside on archaeologic and scientific excursions.
Stokes’ father had initiated teaching in the natural sciences at Trinity College and lectured on these subjects there from 1806 onward. His father’s Dublin household was visited by numerous intellectuals such as George Petrie, an artist, archaeologist, and musician, whose biography Stokes was to write, Henry Grattan, James Martineau, the Unitarian Pastor and scholar, and James Arthur O’Connor (1792–1841), the Irish landscape painter. The Reverand John Walker acted as a private tutor and taught William the classics and mathematics.
In 1822 Stokes enrolled in a course of anatomy in the College of Surgeons School in Ireland, where his father had succeeded John Cheyne as Professor of Medicine. Initially he was interested in chemistry, and went to Glasgow University to study this under Thomas Thompson, who was Professor of Chemistry there. After 2 years, however, Stokes decided to switch to medicine and he went to Edinburgh, where he graduated M.D. in 1825. While there he heard of Laennec’s 1819 book of teachings on auscultation and, at the age of 21, Stokes wrote An Introduction to the Use of the Stethoscope, a book which was the first on this topic in English.
Stokes’ father resigned from Meath Hospital in Dublin in 1826 and William was elected in his place. He introduced the stethoscope to the medical school and this innovation caused much comment, often sarcastic rather then laudatory.
In 1837, at the age of 33, he wrote a monograph entitled Treatise on the Diagnosis and Treatment of Diseases of the Chest. Although he was by this time a well-established and well-liked physician, the College of Physicians could not make him a Fellow because he had not graduated in Arts and his medical degree had been obtained in Edinburgh and not Dublin. These problems were finally circumvented by Trinity College when they awarded Stokes an honorary M.D.; Stokes was then admitted to Fellowship.
Stokes was President of the College of Physicians from 1849 to 1850. In 1854 his monograph Diseases of the Heart and Aorta contained a description of the Stokes-Adams Syndrome (syncope or epileptic convulsions occurring in complete heart block). This syndrome had first been described by Robert Adams (1791–1875), a surgeon at the Richmond Hospital, in a Dublin Hospital Report in 1827.
Stokes was one of the few physicians who ever received the Prussian Order Pour le Mérite. During the Dublin epidemic of typhus in 1826 he worked among the poor and developed the disease himself in 1827. He also recorded the first case of cholera in the Dublin epidemic of 1832. He became Regius Professor of Medicine in Dublin, succeeding his father, in 1845. Stokes is said to have commented, “my father left me but one legacy, the blessed gift of rising early.” William Stokes was a cofounder of the Dublin zoo.
A stroke of apoplexy in November 1877 left him hemiplegic. He died January 7, 1878.