Although
we in the thyroid world commemorate Graves for the first description
of the disease which bears his name, his position in the overall
scheme of medical history will forever be linked to that extraordinary
group of physicians and surgeons who contributed to what has become
known as the Irish School of Medicine which brought medicine in
Dublin an international fame in the nineteenth century. Members
of the group included physicians and surgeons (Stokes, Corrigan,
Adams, Wilde) many of whom earned eponymous distinction. A truly
remarkable group by any criteria. Graves’ great gift was
as a clinical teacher. He prepared himself meticulously for this
career by studying first in London then in Berlin, Copenhagen
and Edinburgh. His proficiency in German lead to his arrest in
Austria as a spy because no “Englishman” could speak
German as well as he did. Apart from his clinical and linguistic
skills, Graves was also a talented artist. On one of his trips
to Italy Graves encountered and compared his work with a fellow
traveller who turned out to be the acclaimed landscape painter
Joseph Turner. His time abroad in particular his period in Berlin,
where he studied infectious diseases under Hufeland stood him
in good stead when he returned to Ireland where he found himself
in the middle of a typhoid epidemic. This experience was put to
great use in an attempt to stem the appalling death rate, about
one million mainly fever related accompanying the Irish Potato
famine of 1845-1847. Graves’ work at this time and in early
epidemics led to his wish, conveyed to his friend Stokes that
his epitaph might be “He fed Fevers”.
Despite his unselfish commitment to practicing
medicine in Ireland, Graves’ family background would not
necessarily endear him to the majority of the native Irish population;
his ancestors were awarded land captured during Cromwell’s
campaigns in Ireland. However as recounted by Drury (1985) citing
Irish medical historian William Doolin, Graves “more than
repaid us for the uninvited presence of his family among us “.
Graves’ father Richard Graves was himself an outstanding
scholar rising to be Regius Professor of Divinity in Trinity College,
Dublin. Graves followed in his father’s footsteps, graduating
with a BA degree and in the process being the Gold Medal Winner,
at that time the highest student award. It was in the College
Historical Society, founded by Edmund Burke, acclaimed as one
of the greatest orators in the English language, that Graves honed
the oratorical skills inherited from his preacher father. Graves
entered medical school in Trinity College Dublin from which he
graduated in 1818 and subsequently gained a licentiate from the
Royal College of Physicians of Ireland, a college whose Presidency
he eventually attained and where his lifesize statue stands to
this day and is a frequent site of pilgrimage for visiting thyroidologists.
As previously stated Graves’ greatest
professional attributes were his skill as a clinical teacher and
his lectures in Sir Patrick Dun’s hospital were as recounted
by Selwyn Taylor (1989) “ the talk of the town”. His
contribution to the identification of hyperthyroidism, although
accidental, was a product of this clinical skill. Graves account
of three patients with three cases of tachycardia and thyroid
enlargement in young women and added a fourth with severe exophthalmos
who had been referred by a colleague, William Stokes. This work
was published as part of the London Medical Society Clinical Lectures
(1835). The author was of the opinion that the syndrome he described
was of cardiac origin.
Carl A. von Basedow practiced medicine
in Merseburg in Germany and described the coincidence of palpitation
of the heart, exophthalmos and struma (goitre), the so called
Merseburg Triad. To explain the changes in the tissues behind
the eyeball, he evoked a cause mediated by some “dyscrasia
of the blood” (Basedow 1840).
Although Basedow described many of the
main features of what we now know as hyperthyroidism his publication
was 5 years later than Graves despite having followed his patients
for several years. Notwithstanding this later publication the
disease is referred to as Basedow’s Disease in many non
- English speaking countries. The other contender for being first
to describe hyperthyroidism was Caleb Hillier Parry who practicing
in Bath in England and who observed exophthalmic goitre in 1786
but his findings were only published by his son in 1825, three
years after his death (Parry 1825). There is little doubt then
that Parry was the first to describe the disorder which is now,
at least in the Anglophone world, termed Graves’ disease.
If this is so, why is it so called ? The explanation given by
a number of biographers of Graves (Drury 1985, Taylor 1989, Coakley
1996, Sawin 1998) was that Graves had the unbidden services of
an excellent French publicist to advance the Irishman’s
case against that of the Englishman or the German. Armand Trousseau
was Chair of Medicine in the Hotel-Dieu in Paris. He was a fervent
admirer of both Graves and Stokes as clinical teachers and cited
their work in his clinical lectures and publications (Trousseau
1868). When Graves’ textbook was translated into French,
Trousseau wrote the foreword in which he commended to readers
the work of Graves and indeed first used the term Graves’
Disease but Trousseau’s fellow countrymen in France did
not follow his lead. There is little doubt that the predominance
in publishing of the English language also contributed to Graves’
eponym. Thus hyperthyroidism of autoimmune origin gained and to
this day retains in the anglophone world the title of Graves’
Disease. For years his image formed the masthead for the longest
established thyroid association, the American Thyroid Association
(ATA) Unfortunately the ATA chose to dispose of his image in favour
of a “more modern” cartoon of a thyroid gland.
There has always been a lot of perhaps
rather pointless, but invariably good humoured controversy tinged
with nationalistic tones as to who deserved the appellation as
the discoverer of “exophthalmic goitre”. Perhaps with
modern knowledge “immunogenic hyperthyroidism” might
be a less controversial title. It appears that Graves was unaware
of Parry’s work or that Basedow was unaware of Graves’
contribution but Basedow did however quote Parry’s work.
An excellent commentary on these questions is contained in work
by the late Clark Sawin (Sawin, 1998).
Although Robert Graves received in his
lifetime all the honours that his local medical community could
bestow, his outspokenness in terms of criticising contemporary
government health policies probably prevented his being awarded
a knighthood. He was however honoured by being elected a Fellow
of the Royal Society and an honorary member of many European medical
societies. His personal life was not so fulfilled. He was married
three times. Two of his wives predeceased him as did two daughters.
Graves
fell ill in the autumn of 1852 and died in his 57th
year of an abdominal tumour on March 20, 1853.
A statue of Graves was unveiled in the Royal College of Physicians
of Ireland in Dublin and in 1996 the 200th Anniversary of
his birth was commemorated in the same college by a Graves’
200 Celebrated Thyroid Meeting. The genesis of this was a
conversation between the author and the late Wieland Meng
who had organised a similar meeting in Halle in 1990 to commemorate
“150 years of Morbus Basedow”. It seemed fitting
that within the same decade the two pioneers of our discipline
should be honoured in their respective homelands.
Peter PA Smyth
University College Dublin, Ireland. |
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The statue of Graves in the Royal
College of Physicians of Ireland, Dublin |
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Acknowledgement:
The excellent biographies of Graves by S. Taylor and D. Coakley
were a source of much of the material in this essay. Photographs
of Graves are reproduced by kind permission of the Royal College
of Physicians of Ireland.
References
