Friday, 30 May 2014

A political Education - Coming of age in Paris and New York

A political Education – Coming of Age in Paris and New York. André Schiffrin. Melville House Publishing, Hoboken, New Jersey. 2007, pp 271

This review was written in 2007

I picked up this book rather casually from Ulick O’Connor and I read it rather quickly over about ten days. Schiffrin was a Jew who was born in Russia and who lived subsequently with his family in France up to the last war. He escaped as a child to Vichy France when the Germans arrived on the scene and eventually escaped to America after many tribulations. Many of his Jewish friends and their families were involved in the Holocaust.

Schiffrin arrived in New York at the age of seven. He later became involved in socialist activities and joined socialist groups. He was ever conscious of the dangers to himself during these years leading up to and involving McCarthy and the atmosphere of fear and victimisation which existed then in the bitterly anti-communist and anti-socialist America. The book gives a good idea of the tensions which existed in the 1950s and 1960s. These years included the Korean War and the slow build-up of industrial capitalism, the power of the few and the wealthy, as American dominance advanced in world politics.

His visit to Cambridge was of particular interest because of the stark differences in Oxbridge university tradition compared to the American university, Yale, which he attended as an undergraduate student. Cambridge and the discovery of England provided perhaps an over-idealised tribute to the informality, the lack of emphasis on work as a means of achieving wealth and power, and the intellectual freedom as part of an inherent discipline which were features of English society. He attributes much of the student rebellion which occurred in England and elsewhere in the 1960s to the rigid division between faculty and students.

His description of America during the 1950s and 1960s gives a good insight into the students’ riots in Berkeley and elsewhere. Schiffrin is not without a strong sense of vanity and to some extent he expressed the attitude of Jews and their sensitivities to a widespread prejudice among the gentile population. One notes his many assumptions about Oxbridge and its exceptional role in maintaining an academic ambience removed from the worst evidence of capitalism, Cambridge had given him the freedom which he felt that he never had in America in the difficult political years of the 1950s and 1960s. However, he maintains that the more desirable culture of England was later transformed for the worst by Margaret Thatcher and Tony Blair.

He was not without a tendency to name dropping having met many of the elitist writers and historians during his time in Cambridge. His views were summed up by his line

So I found myself in the Empyrean heights of English culture, a much headier place than the relatively provincial scene at Yale.

Schiffrin, in chapter 6, refers to the failure of the Socialists in the 1950s and the 1960s because of the frenetic atmosphere created by McCarthy. He also notes the failure of the socialists to get any working class support. He goes on to say ‘’The left shrivels, impotent; representing no more than an intellectual expertise, looking for customers.’’

Schifrin used the blood donations policies of America and England as a metaphor for the difference in the political philosophies of the two countries. In America one paid for blood donations, in Britain (and in Ireland) blood donations were provided by volunteers.

His book is a devastating commentary on the activities of the CIA, both at a national and international level, and at every level of politics, social life, education and propaganda in the United States. Reading Schiffrin’s book inevitably gives rise to questions about the nature and reality of democracy as we think we understand it.  Certainly the huge influence of money with its connotations of corruption seems to be incompatible with the political philosophy of Plato and what we understand to be democracy or government by the people for the people.

Like America, we have in Ireland serious doubts about the nature of our current democracy although superficially our problems are somewhat different from those in America. Nevertheless, the power of money and the philosophy of money as represented by such public representatives as Charlie Haughey, Bertie Aherne and Mary Harney are serious impediments to the true nature of democracy.  In Ireland, too, our political structures are such that parliament is no longer the institution which governs the day-to–day life of the people. The rigid whip system in parliament has virtually emasculated the independence and the views of the individual deputies. The governments of the Fianna Fáil Party, particularly during the Bertie Ahern regime, allowed too much personal power to the Taoiseach and his advisors in the cabinet and elsewhere. An extreme form of patronage was inconsistent with the principles adopted by the Cumann na nGaedheal government of the 1920s where the leading politicians eschewed any influence in the making of public appointments and where a civil service had the highest standards of ethical behaviour and public service. Why should a constituency in Ireland elect a member of parliament whose personal views and those of his constituency about the country’s administration are throttled as soon as he or she enters the legislative chamber? Clearly a system of whip control is necessary for some financial bills and a few requiring government to function  but that they should be throttled in relation to moral, social and political issues which should be by agreement of all parties is unacceptable in a proper democracy. Also we have a civil service which nowadays must cause concern about its accountability and integrity, unlike the civil servants which served us so well in our early years as an independent nation. At least we can rely on the integrity of our National Army since it foundation in 1918 and hopefully on our police force which has served the Nation well.

P.S. I reviewed this book in 2007. I am now less certain about the integrity of out police force following  information I have read in the recent press. RM

Friday, 23 May 2014

Reason or Faith

The Military History of the Irish Civil War. The Fall of Dublin. 28th of June to the 5th of July 1922. Liz Gillis. Mercier Press, Cork. pp 157.

This review was written on April 5th 2014

The Civil War started on 28th of June 1922 with the attack on the anti-Treaty IRA in the Four Courts by the National Army. This book describes this initial event of the War in Dublin and with the early defeat of the anti-Treaty forces there. The uneasy peace between the anti-Treaty military leaders and the representatives of the Provisional Government had dragged continuously on from January to the end of June in efforts to avoid a conflict on the issue of the Treaty but the final breakdown was inevitable because of the failure by Rory O’Connor and Liam Mellows and their immediate supporters to reach a compromise with the Government and the leaders of the National Army.

Liam Mellows
Rory O’Connor and Liam Mellows were the most intractable opponents of the Treaty settlement within the IRA. They had been two of the four members of GHQ during the War of Independence who opposed the Treaty. The other nine members of GHQ supported the Treaty. I believe that, if O’Connor and Mellows had joined their colleagues who were anxious to reach a settlement with Mulcahy and Collins and the other military and political leaders supporting the Treaty, the Civil War havoc might have been avoided or might have been confined to modest limits in Cork and the more intractable members of the active IRA members there.

Rory O'Connor
Apart form their unwillingness to compromise, O’Connor and Mellows and the anti-Treaty colleagues close to them had occupied the Four Courts from April, more than two months before the War. Later several other important commercial buildings and hotels in central Dublin were occupied by their comrades.  Well before June 1922 some of the leaders of the Government pressed for an attack on the anti-treaty forces but there was reluctance on the part of the National Army leaders to face the more numerous and well armed anti-treaty forces until they were confident that they could match their strength.

The Four Courts were occupied by more than one hundred supporters of O’Connor and Mellows since April and its leadership was of course a significant threat to the welfare and the prestige of the Provisional Government. The attack by the National Army was finally precipitated by a number of circumstances: the political pressure of Griffith and the British Government, the assassination of General Wilson in London and particularly by the kidnapping of Ginger O’Connell, a prominent and popular officer within the National Army. The general disorder created by the IRA members in Dublin included the theft of equipment and motors and the occupation of some important commercial buildings and hotels in O’Connell Street, Parnell Squire and their environment as well as the Four Courts.

By the end of June the National Army had established its headquarters in Beggars Bush barracks and by this time had gathered a disciplined cohort of officers and men to proceed against the irregulars. Some of its members had been ex-army soldiers in the Great War and it was, of course, obvious that they were assisted by equipment supplied by a helpful if somewhat reluctant departing British Army. The irregulars were handicapped by their immobility, being confined to their buildings, and by poor communication between their different centres within the city. There was a clear lack of a central command.  They must have also been psychologically handicapped by the lack of public support.

The Four Courts was attacked by shells delivered from a battery provided by the British and was manned by an ex-British army member of the National Army.  It took 3 days for the occupants to surrender. In the meantime the building was reduced to a shell by an assertive and determined army. The occupants of the Four Courts surrendered or escaped, and the destruction of the building included the loss of a huge collection of historical records stored there which went up in flames.

Explosion at the Four Courts
Among those who left the Four Courts before it was attacked was Liam Lynch. He was greatly admired by my father as a leader of the IRA in Cork during the War of Independence. He was opposed to the Treaty, was outspoken in his views but during the immediate post-Treaty period he appeared to be a moderate during the attempts at a settlement between the two sides of the IRA until the start of the Civil War. My father released him from detention before the Four Courts event, thinking that he might have a moderating influence on the more intractable irregulars but on this issue my father was sadly mistaken. Lynch escaped the Dublin events and returned to the South where he was appointed chief of staff of the irregulars. He was to prove totally opposed to surrender long after the anti-Treaty cause was obviously lost.  His recalcitrance was to prolong the war unnecessarily and he was to die a lonely figure in the Knockmealdowms in the hands of the National Army, still convinced that the Treaty would be rejected by the Irish       people through the influence of his military intervention.

The next few days after the fall of the Four Courts saw a vigorous attack on all the other occupied buildings in the O’Connell Street area which were finally cleared of all irregulars. The action in Dublin was over after eight days fighting.

Three of the Four Courts garrison were killed while ‘’at least’’ seven Free State soldiers died, mainly by mines left in the Four Courts after the surrender. Eight irregulars were injured while 70 Free State soldiers were injured. Surprisingly, there were about 60 deaths among the citizens and many injured.

Cathal Bruagh lying in state
Among those killed among the irregulars in O’Connell Street was Cathal Brugha, Minister for Defence in the pre-Treaty cabinet, a heroic survivor of the 1916 rebellion but a dedicated opponent of the Treaty settlement. He joined the irregulars on O’Connell Street when the Four Courts was attacked.  For the second time in six years the centre of Dublin was in shambles. It is fortunate that, despite the destruction of the GPO, The Custom House and the Four Courts during the six years of the revolution these buildings were subsequently restored as were many other commercial buildings in the capital.

Press release from Rory O'Connor at the Four Courts
Before the outbreak of the Civil War the numerous British barracks outside Dublin were occupied partly by the anti-Treaty IRA, particularly in the South, and otherwise by National Army personnel. However, by September all irregulars had been dislodged and the viable barracks and all small and large towns and cities were in the hands of the Provisional government. For the following eight months the Civil War had degenerated into a scattered country-wide campaign dominated by widespread destruction of private and public property, destruction of the railways, arson, bank robberies, criminality and a total lack of central republican control. And some of the counties which my father as chief of staff had found wanting during the War of Independence, to wit Wexford and Kerry, were far from inactive during the Civil War.

The lack of a police force was a major factor as regards local disturbances. Public control was entirely in the hands of the National Army. My review The Army and the Railway, published formerly in my blog will remind the reader of some of the major problems facing the army at this time.

Final letter from Liam Mellows to his mother.
Clearly the Civil War should have finished by September or October with the control of all towns and cities in the hands of the Government. The following seven or eight months of civil disturbance was to lead to an increase in mutual bitterness and  disillusionment among the population and to a serious and lasting blow to the economic and commercial standards of the 26 counties.

Liam Mellows
The actions of the irregulars literally petered out in April or May 1923 with little formal ending and the dumping of arms ‘’perhaps for a renewal of arms at a later day!’’. The failure to finish the war earlier can be attributed to Lynch’s implacable resistance to surrender but can be at least partly attributed to poor political leadership on both sides. De Valera in particular and some of his closest colleagues such as Seán T O’Kelly, Jim Ryan  and Frank Aiken, should have intervened when all was obviously lost while the Provisional Government leaders were at fault by making a strict rule to make no contact with the political leaders on the other side. My father, as head of the Army, and with the approval of Eóin McNeill, met De Valera in September, despite the cabinet’s decision not to contact the opposing leaders, but the meeting was futile because Dev refused to intervene. He said according to my father

Some men are led by faith and some men are led by reason. Personally, I would tend to be led by reason, but as long as there are men of faith like Rory O’Connor taking the stand that he is taking, I am a humble soldier taking after them.

When he reported his meeting with Dev to the cabinet he was criticised, at least by O’Higgins and probably Cosgrave.

The Mercier Press has published several other local accounts of the Civil War which can be recommended to students of the Civil War, this ‘’compound disaster’’ as it was described by my father.

Friday, 16 May 2014

King George V

King George V  His life and ReignHarold Nicolson.

This review was written on July 12th 2004

I am spending a few days in my son Richards dower house in Clones with Louise.  She has gone golfing to St Helens while I am alone here reading Harold Nicolsons “King George and his Reign”, and paying a few casual visits to the outside, pulling the odd weed in his extensive young garden, surveying the quiet sea and listening to its incessant voice, and enjoying the sandy surroundings on a beautifully mild, sunny day.  I walked earlier on the strand at the waters edge in my bare feet to the headland south of Clones, exactly thirty minutes each way  a perfect ambience and opportunity for lifes contemplation.  Contemplating life means again facing the challenge of writing my medical memoirs, a task I should undertake but I continue to shirk.  Despite the occasional urging of others and my own awareness of my unusual professional career, I find it impossible to undertake this task. (Memoirs of a Medical Maverick was eventually published by Liberties Press in 2010 - RM)

King George - his Life and Reign by Harold Nicolson was published in 1952 by Constable and Co.  It is in my fathers library.  It is underlined with notes and his shorthand comments.  The book is well written if somewhat florid in the style of fifty years ago.  It is heavy going but, notwithstanding this, it is educational and clearly important for anyone interested in recent European history.  It is laudatory in its account of George V but it clearly emerges from Nicolsons record that George V was an exceptionally dedicated monarch, and that his influence played a crucial part in the welfare and survival of his country and its dominions during the tumultuous years from 1910 to the time of his death in 1936.  He was a modest and highly conscientious man who felt a deep love and concern about all his subjects, whatever their standing in society. His concern extended to the countries in the British dominions and colonies, and indeed to humanity in general.  Under the constitution (or lack of), he had no executive or political power, but he had an important advisory and conciliatory role which was independent of the political system which prevailed in Britain.

King George V and Queen Mary visit Maynooth in 1911
His biography underlines the crucial part King George played in advising and guiding politicians during the many crises that occurred before, during and after the Great War.  His concern for the people of Ireland alone was an example of his fairness and dedication, although his monarchy tended to be spurned by the anti-Treaty members of the Dail and gradually by many of the Free State population after 1922.  It was probably King Georges speech at the opening of the Stormont parliament which induced Lloyd George to arrange a truce with Sinn Fein and the IRA, and recent papers released by the British confirm that King George made a special plea to the British government to release McSwiney when his hunger strike was receiving international attention, a request which was refused on the grounds that it might be bad for themorale of the British troops in Ireland. Democracy may be the best political system to order the affairs of human society but it does have its defects arising from the whims of powerful individuals, cliques, and political parties and, more recently, from the power of large industrial and commercial groups. It also allows a degree of independence and self interest to the individual which may not be balanced by an equal degree of social responsibility.  Certainly, the party system has its critics, including Lloyd George (Tempestuous Journey - Lloyd George: His Life and Times) and Winston Churchill (Thoughts and Adventures) although neither put forward any realistic alternative,
Nicolsons biography would suggest that, in the case of George V, the closest to an ideal political system may be the British democratic one where the head of state has an important advisory function only and is responsible directly to the people for upholding the constitution and for the integrity of the parliamentary system.  It would have been difficult to promulgate any real political injustice in Britain while King George was head of state.

Royal cousins Tsar Nicholas II, King George V and Kaiser Wilhelm II
Whether a hereditary monarchic system is best or a president who is chosen by the people is a moot point. The monarchic system provides a continuity of confidence among the people even when the monarch may lack good judgment and a sense of the responsibility of his office. Unfortunately, under the hereditary monarchic system, one cannot ensure that the wisdom, dedication and good judgment of King George will be shared by every monarch.  It is also difficult to ensure that an elected non-executive president will have the necessary intellectual, independent and dedicated faculties, free from the taint of political ambition and possessing an effective advisory role. 

Our experience in Ireland, where we have had a non-executive president since 1937, is worth reviewing.  Our first President had no political background but was appointed by agreement between all political parties because of his distinguished academic and cultural background. Apart from the routine of approving legislation passed by Parliament, he had no obvious advisory role.  His successors, OKelly, De Valera, Childers and Paddy Hillery were members of the Fianna Fail party and were elected by popular vote because of the influence of their political colleagues and the political machine.  ODallaigh, appointed before Hillery, was a judge and was not a member of a political party. He was elected by agreement and at short notice because of Childerss unexpected death in office but he resigned soon after his appointment because of a perceived insult by the then Minister for Justice, a member of the Fine Gael Party.

Our presidents lack the long monarchic tradition of the British and up to 20 years ago have, with the exception of the first president, Dr. Douglas Hyde, been successfully nominated and elected by the dominant Fianna Fail Party. Their nominees havbeen mostly senior members of the party who had come to the end of their effective political careers. From the point of view of their playing a real role in national or international affairs, their tenure of the presidency was hardly inspiring, perhaps with the exception of Erskine Childers. However, we have been fortunate in our last two presidents who have represented the country internationally with great dignity and who have been active on public issues without trespassing too closely into the political arena. Mary Robinson was elected against the nominee of the government party. She was nominated by the Labour Party and received considerable Fine Gael support, although Fine Gael had put forward its own candidate. Both these parties were in opposition at the time. 

Mary McAleese was supported by Fianna Fail but she had not been a member of the Party and appeared to have sprung herself on them in the absence of a convenient party nominee. Both Robinson and McAleese proved to be excellent choices. They were free from the stigma of party politics and they owed their election to the apolitical influence of the electorate. I suspect that our political system incorporating a non-executive president is as good as we are likely to devise as long as the choice of president is made by a public uninfluenced by narrow political pressures. Surely the presidency, if it is to play an effective role in Ireland, deserves better than being represented by a candidate whose only recommendation is his or her retirement from the dominant political party.

Chapter 21 of King Georges biography, The Irish Treaty, deals with the Irish situation in 1921.  Nicolson confirms the complacency and lack of realism of the British in dealing with Ireland and the Irish question.  Sir Hamar Greenwood was Chief Secretary for Ireland at the time. His poor judgment, his lack of integrity and his Tory attitude to the Irish must have been significant factors in creating the persistent difficulties between London and the local administration. His predecessor, Augustine Birrell, would have been clearly a better catalyst. 

It is clear that Sir Neville Macready, the head of the army in Ireland, was by far the most realistic about Anglo-Irish relations and had the greatest understanding of the situation (see later review of the Macready biography, the Annals of an Active Life). The King himself, according to Nicolson, believed all the British forces, including the police, should have been under Macready. My father, as head of the IRA during the War of Independence, believed that the comprehensive intervention of the British Army during the War would have lead quickly to the end of hostilities. With the army in charge, it would have eliminated the tensions, divisions, and squabbles which existed between the administration, the police and the British army in Irelandand contributed to the gross incompetence of the British authorities and the atrocities which were inevitable on both sides. Full army control was not allowed by the British because of the administrations reluctance to admit that the Irish affair constituted a war and was entirely an internal matter to be dealt by the police.

Why did the Dail, on 16 August 1921, reject unanimously the generous British offer of dominion status?  Were the members completely divorced from the political realities of the situation by the rhetoric of the Republic? Were they dominated and rubber stamped by de Valera? Was the latter influenced by ChildersBrugha or StackWere they the victims of Devs remoteness and his refusal to communicate or to seek advice? The Dail was certainly not representing the views of the people nor had it been elected by the majority of the electorate. Never did a man look into his own heart and do so so disastrously as when Dev failed to compromise on the Treaty. Dev was very difficult to deal with during the long drawn negotiations from early July to October in an attempt to arrange a treaty with the representatives of the British GovernmentHis vacillation was an almost insuperable challenge to a person of the volatile and mercurial temperament of Lloyd George.  There is no doubt that King George V played a vital part in maintaining Lloyd Georges patience during the three months he was subjected to Devs haggling on so many academic and trivial points.

Nicolsons summary is inaccurate in some respects, sometimes by omission rather than commission. He finishes the chapter on Ireland by maintaining that the Civil War was in no sense the responsibility of His Majestys Government.  This is probably not true when one recalls Lloyd Georges failure to act at the time of the Clune truce initiative in November 1920 when he insisted on the condition of decommissioning and he disastrously thought that he had murder by the throat. A truce in 1920 would have avoided the bitterness of the last six months of the War of Independence and it would have diminished the later commitment of the extreme IRA to the rhetoric of the Republic, and the certainty of the subsequent Civil War. There was no mention of decommissioning when the truce was arranged in July 1921.

He states, page 356, that …a formal truce was signed in Dublin between Sir Neville Macready and Mr Richard Mulcahy, Chief of Staff of the IRAThis is not correct. The truce was signed by Macready on the British side and by Cathal Brugha, Minister for Defence of Sinn Fein, on the Irish side. Of course, for reasons of protocol, Mulcahy should have signed on behalf of the Irish, an anomaly which reflects his unwillingness to question Brugha and to face up to Brughas antipathy to the army leaders. When I questioned my father about this lack of protocol and of courtesy on Brughas part he replied I would do nothing to threaten the fragile nature of the Truce

King and conquerors.

Friday, 9 May 2014

The Perfect Heresy

The Perfect Heresy. The Cathars of Languedoc in the 13th Century. Stephen O’Shea. Second edition published in 2001. Read on Kindle in January 2013.

This review was written on February 12th 2013

In the 11th, 12th and earlier 13th Centuries the Cathars, otherwise known as the Albigensian, had become a significant minority of the population of Languedoc in the South of France and in Northern Spain in Aragon and Catalonia. Languedoc was at that time independent of the Kings of France. It was annexed to the Kingdom of France shortly after the campaign against the Cathars had culminated when the King of France and the French armies had an important if later and less brutal role in eliminating the heresy.

I first visited Languedoc in the late summer of 1976 when I was staying with my friend Jacqueline at her sister Michelle’s house close to Manosque by the Durance tributary of the Rhone. After a few weeks with Michelle, where I was to write my book Beat Heart Disease, Jacqueline and I toured the Languedoc region starting from Avignon and going by Montpellier, Carcassonne and the many other towns of the region extending almost as far as Toulouse It was a beautiful and evocative part of France and its peaceful ambience was far removed from that part of the world where such cruelties, massacres and pogroms took place in the earlier years of the 13th century.

The Cathars are described by the author as the members of the most notorious and subservient creed of all times. The book deals with the policies of the Church and Rome, and the Catholic clergy and laity, to extirpate the large and increasing numbers of Cathars who were heretics threatening the tenets of Rome. The brief, violent and largely successful campaign of about 16 years resolutely sought the extirpation of the Cathars and of other heresies in the South of France and in Spain. At times the killings were indiscriminate; the citizens of whole towns and villages were massacred, a policy evocative  of the earlier massacres which occurred on behalf of Christianity during the first Crusade. The massacre of the Cathars occurred during the times of Innocent III and Gregory IX and with their connivance and that of their successors. The Inquisition was established in the South of France and in Spain shortly after the Cathar campaign and was to extend and torment Catholics of Europe and Latin America for centuries to come. And it was the Dominican Order which led the clergy in its campaign to destroy the Cathars and which was responsible for the initiation and the continuation of the subsequent Inquisition.  

The Cathar symbol of the dove
The Cathars deplored the cupidity and worldliness of Rome and its clergy. Their communion was apparently directly with Jesus and God and they denied the role of the sacraments and the outer secular and political manifestations of the Church. They could only reach perfection or completeness by living lives of poverty, simplicity and self-denial. It was up to the individual man or woman to decide whether he or she was willing to renounce the material world and to adopt a life of tolerance and self-denial.

They did not care if you treated others, including Jews and Muslims, as a friend or got into bed before marriage, giving rise to the comment among their critics that ‘’They could not commit sin below the waist’’. If they failed to reach perfection in this life, they were destined to be reborn to the human form to await the perfection of total self-denial. The God deserving of Cathar worship was a God of light who ruled the invisible, the ethereal, the spiritual domain

The philosophy of the Cathars is best described in the first chapter of the book. Just as some of the tenets of the Catholic Church seem unreal and without logic to me to-day, it seems that the tenets of the Cathars must have seemed unreal to the fervent believers of Rome eight centuries ago.

Montségur - the last stonghold of the Cathars.
Despite a distance of eight centuries, there is quite an extensive literature about the Cathars and their Perfect Heresy The title owes its description to their philosophy aimed at achieving perfection in this life and only thus could they reach Godliness in the next world. This book provides a good review of this so-called Perfect Heresy and I am left most vividly with the paradox that great masses of people can be moved by such irrational but apparently harmless beliefs and that others can be equally irrational in callously destroying them for equally irrational and not very different beliefs. The Roman Catholic Church had in the past a lot to learn about Christianity. Perhaps to-day’s announcement of the Pope retiring may be symptomatic of a greater humility and tolerance among its clergy. Certainly Innocent lll and Gregory lX of the 13th century showed little humility towards their brethren in Languedoc.

I read this book on Kindle. The text of the book extended to two thirds of its length. The last third is largely made up of the references of which there are 260. For the reader to access these references requires more of a problem on Kindle than on a book in the hand. Most of these references are quite extensive, up to ten lines or more, and are important to the reader in understanding the main text. I would advise the reader to check the excerpt of The Perfect Heresy on Kindle before buying the book. It gives a very clear summary of what the book is about.

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.