• Cheyne-Stokes respiration
• apnoea

Neurologists who care for emergencies often encounter Cheyne-Stokes respiration. Abnormal breathing, in which periods of apnoea alternate with a series of gradually increasing depth and frequency, followed by a similar decrease is said to have been described by Hippocrates, although his description is not wholly convincing.¹ It is often observed in grave cerebral illnesses. Dr J B Lyons^2,3 has written informative details of the works of both Cheyne and Stokes.

In 1818, John Cheyne described⁴ a 60 year old man, who suffered from gout who he said was:

“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.”

He complained of palpitations and pain in the chest. He had fallen from a chair, but could not remember doing so. Cheyne found an “extremely irregular and unequal pulse” on examination, and the patient was confused and had a headache. After blood letting and the use of leeches, he improved.

“On the 10th of April he was found in bed, speechless, and hemiplegiac. . . . The only peculiarity in the last period of his illness, which lasted eight or nine days, was in the state of the respiration. For several days, his breathing was irregular; it would 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”

Cheyne diagnosed apoplexy “that must have depended upon increased action of the vessels of the head”. At post mortem examination was found a left cerebral infarct:

“ . . .some fluid between it [the arachnoid] and the pia mater, and the vascularity of the latter increased, more particularly over the middle and posterior lobes of the cerebrum of the left side, where, in a large patch, it was thickened and of a deep red colour”

The heart was three times larger than normal, the left ventricle greatly enlarged, the right ventricle converted into a soft fatty substance—aorta steatomatous.

John Cheyne (1777–1836) studied medicine at Edinburgh,² where Alexander Monro (1733–1817), who described the interventricular foramen, was one of his tutors. In 1809 he moved to Dublin where he was appointed physician to the Meath Hospital and professor of medicine at the College of Surgeons. He subsequently became Physician General in the Irish army in 1820, the highest medical ranking in Ireland.¹ He was a founder of the Dublin Hospital reports, in which he described the foundation of Cheyne-Stokes respiration. He wrote books on croup, Essays on diseases of children, and An essay on hydrocephalus acutus, or dropsy in the brain. In his Cases of apoplexy and lethargy, he distinguished subarachnoid from intracerebral haemorrhage, probably the first physician to provide an illustration of subarachnoid haemorrhage.

Thirty six years later, in one of several distinguished texts,⁵ William Stokes described a disorder of the pattern of respiration, not caused by a lung condition, but by an enfeebled heart, due to fatty degeneration of this organ or other causes¹:

“The symptom in question was observed by Dr Cheyne, although he did not connect it with the special lesion of the heart. 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 apnoea is established. In this condition the patient may remain for such a length of time as to make his attendants believe that he is dead, when a low inspiration, followed by one more decided, marks the commencement of a new ascending and then descending series of inspirations. This symptom . . .I have only seen during a few weeks previous to the death of the patient. . . .”

He noted that a coexistence with disease of the aortic valve was common.

William Stokes (1804–1878)³ was born in 1804, the son of a physician, Whitley Stokes, MD (1763–1845), a distinguished and religious polymath, who became Regius Professor of Physic at Dublin University in 1830. Many of his family achieved prominence in academic society. He was taught privately by Rev John Walker in classics and mathematics, his father eschewing formal education. Stokes succeeded his father as Regius Professor of Medicine in Dublin in 1842. He received many honours, including those of the Universities of Oxford, Cambridge, and Edinburgh. By commendation of the English ambassador, he was decorated by the Emperor Wilhelm I with the Prussian order Pour le Mérite for contributions to medicine.

William Stokes, an original and outstanding physician, is also well known for his account of the Stokes-Adams syndrome.⁶