Robert James Graves MD FRS

JMS Pearce
Hull, England, United Kingdom

 

He fed fevers
Robert Graves

Title page of Clinical Lectures on the Practice of Medicine by Robert J. Graves, M.D., F.R.S.
Fig 1. Clinical Lectures on the Practice of Medicine

 

In Paris in 1828 there was a remarkable epidemic of acute sensori-motor polyneuropathy known as épidémie de Paris. Described by Auguste-Francois Chomel, the cause was a mystery.1 As a neurologist, my interest in Robert Graves (1796–1853) was aroused by his observing patients during this epidemic and first predicating disease of the peripheral nerves as a cause of the paralysis: “What I wish to impress upon your attention is, that pain, numbness, spasm, and loss of power from an affection of the circumferential parts of the nerves may commence in these extremities, and be propagated towards the centre, so as to be finally confounded with diseases originating in the central parts themselves.”2 His account, delayed until 1843, is found in his Clinical Lectures (Fig 1).

The idea that paralysis and impaired sensation of the limbs might result from diseases remote from the brain, cord and spinal roots had not yet been recognized. The symptoms had been observed in “alcoholic paraplegia” and probably in lead and arsenic poisoning, but wasting was then attributed to disorders of the muscles, and sensory loss to defects of the skin. Trousseau remarked: “Graves had created a class of peripheral or reflex paralyses…”3

Although Graves is best remembered for his description of hyperthyroidism and its associated ophthalmopathy, he also radically reformed medical teaching and made several other major contributions. For example, in his lectures on gout in 1843 he provided an early description of “fugitive inflammation,” now named angioneurotic edema or Quincke’s disease. In his Clinical Lectures (1835) he gave new accounts of the pinhole pupil in pontine hemorrhage, timing the pulse by watch, and abandoning the practice of bleeding patients with fevers.4

 

Graves’ disease

Before Graves, Caleb Hillier Parry (1755–1822) in 1786 had reported six cases of exophthalmic goiter, palpitations, and anxiety (not published until 1825).5,6 In 1835 Graves published a detailed description of exophthalmic goiter7 so that the disease still carries his name. Karl Adolph von Basedow (1799–1854) independently reported the same symptoms in 1840.

Graves’ account appeared in the London Medical and Surgical Journal for 23 May 1835 and was part of his clinical lectures at Meath Hospital in 1834–35. He described three young women with tachycardia and thyroid enlargement. His eminent colleague William Stokes had referred a fourth patient with severe exophthalmos. He observed goiter with prominent eyes, a nervous state, rapid pulse, weight loss, weakness, and pallor:

Beginning of "Affections of the Thyroid Gland" in Robert Graves's Clinical Lectures
Fig 2. Clinical Lectures: “Affections of the Thyroid Gland”

I have lately seen three cases of violent and long continued palpitations in females, in each of which the same peculiarity presented itself, viz enlargement of the thyroid gland; the size of this gland, at all times considerably greater than natural, was subject to remarkable variations in every one of these patients …The palpitations have in all lasted considerably more than a year and with such violence as to be at times exceedingly distressing, and yet there seems no certain grounds for concluding that organic disease of the heart exists … She next complained of weakness on exertion, and began to look pale and thin …It was now observed that the eyes assumed a singular appearance, for the eyeballs were apparently enlarged, so that when she slept or tried to shut her eyes, the lids were incapable of closing. When the eyes were open, the white sclerotic could be seen, to a breadth of several lines, all around the cornea.6,7

The mechanism of hyperthyroidism was uncertain but improvement in symptoms after thyroidectomy caused Rehn later to conclude that the clinical features were due to an overactive thyroid gland. Mobius and William Osler (1909) supported this idea: “due to disturbed function of the thyroid gland, probably a hypersecretion of certain materials which induce a sort of chronic toxaemia.” Trousseau introduced the eponym in 1862: Du Goître Exophthalmique, ou Maladie de Graves.

 

Robert Graves MD FRS

Graves was one of an extraordinary group of physicians and surgeons who contributed to the Irish School of Medicine, and brought medicine in Dublin to international fame. In 1838 he co-founded the Pathological Society of Dublin with collaborators Robert William Smith, professor of surgery; the surgeon Abraham Colles; the physician Sir Dominic Corrigan, president of the Royal College of Physicians of Ireland; and William Stokes, who in 1846 re-described Cheyne-Stokes respiration (after John Cheyne in 1818). Stokes is also associated with Stokes-Adams syndrome, which he described in 1846. This was a remarkable constellation of talented physicians, each of them distinguished by eponyms.

Ink drawing of Robert James Graves
Fig 3. Robert James Graves. From An introduction to the history of medicine, with medical chronology, bibliographic data and test questions by Fielding H. Garrison (1913). Wellcome Collection. CC BY 4.0.

Descended from a colonel in Cromwell’s army, Graves’ father Richard Graves was himself an outstanding scholar and Regius Professor of Divinity at Trinity College Dublin. Robert Graves studied the classics and graduated BA with a Gold Medal. He entered medical school at Trinity College and graduated in 1818. He studied with Sir William Blizard, founder of the London Hospital Medical College, then successively in Berlin, Gottingen, Copenhagen, Paris, and Edinburgh, before returning to Dublin in 1821 to set up the Park Street School of Medicine. He was highly critical of the poor clinical teaching and promptly set out to reform it with help from Stokes.

Aged just twenty-five, he served as a physician at Meath Hospital, established in 1753 as a charitable institution to serve the poor. Eulogies abounded. He was described as “a striking figure, tall, dark haired, with flashing eyes and a very animated way of expressing himself. To these rich gifts must be added that of eloquence, to which the Irish brogue adds a certain golden timbre.”8 His daily lectures at Sir Patrick Dun’s Hospital were highly praised. He was a renowned clinician and teacher. Of his textbook Clinical Lectures on the Practice of Medicine, Sir William Hale-White commented that the lectures were unlike a modern textbook in that they could be read with enjoyment in front of the fire. The famous French physician Armand Trousseau regarded Graves’s book as a masterpiece and recommended the perusal of his work to his pupils, to consider it as their breviary.

Gifted with the common touch, he was involved in every detail of prescribing and nursing and coping with relatives. Armand Trousseau wrote: “Graves is, in my acceptation of the term, a perfect clinical teacher. An attentive observer, a profound philosopher, an ingenious artist, and an able therapeutist: he commends to our admiration the art whose domain he enlarges, and the practice of which he renders more useful and more fertile.”

In 1843, Graves became president of the Royal College of Physicians of Ireland and resigned from Meath Hospital where his statue stands, a site of pilgrimage for visiting physicians. After this, he became less active and possibly depressed. A founder of the Dublin Journal of Medical Science, he served as its editor until his death.

He was forthright in criticizing contemporary government health policies and this may have prevented his being awarded a knighthood. He was, however, elected a Fellow of the Royal Society and an honorary member of many European medical societies. He married three times. Two of his wives predeceased him, as did two daughters. He fell ill in the autumn of 1852 and died in his fifty-seventh year of liver cancer on March 20, 1853. Because of his unconventional practice of prescribing food and liquids to patients with fevers, he suggested that his epitaph should read, “He fed fevers.”

 

References

  1. Chomel A-F. De l’épidémie actuellement régnante à Paris. J Hebomadaire de Medecin 1828;1:333 et seq.
  2. Graves RJ. Pathology of Nervous Diseases. In: Clinical lectures on the practice of medicine (2nd edn). 1848; II: 504–505. Reprinted by New Sydenham Society, pp. 574, 579–80. London 1884.
  3. Pearce JMS. Robert Graves and multiple neuritis. J Neurol Neurosurg Psychiatry. 1990 Feb; 53(2): 113.
  4. Graves RJ. Gout. In: Clinical lectures on the practice of medicine (2e). 1848; I: 462–463. [angioneurotic edema]
  5. Parry Caleb Hillier. Collections from the Unpublished Medical Writings. London, Underwood 1825, Vol II. pp. 111–120. https://archive.org/details/b2130578x_0002/page/112/mode/2up
  6. Major RH. Classic descriptions of disease. Springfield, Illinois, Charles C Thomas. 3rd ed., sixth printing 1965. Pp. 275–9.
  7. Graves, R. J. “Palpitation of the heart with enlargement of the thyroid gland.” Lond Med Sur J 1835;7:516–517.
  8. Taylor S. Graves of Graves’ Disease, 1796-1853. J.Roy Coll Phys London 1986;20(4):298–300.

 


 

JMS PEARCE is a retired neurologist and author with a particular interest in the history of science and medicine.

 

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