Issue: August 2007
August 01, 2007
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Robert James Graves: 1796-1853

A superb general physician, Graves' contributions to medicine extend into the fields of cardiology, endocrinology, neurology, infectious disease and more.

Issue: August 2007
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The golden age of Irish medicine is associated with many great names — Stokes, Cheyne, Corrigan — but among these greats many consider Robert James Graves to be the most outstanding and extraordinary of his time.

Robert James Graves
Robert James Graves

Source: Royal College of Physicians of Ireland

Graves is widely known in endocrinology for his paper, Newly observed affection of the thyroid gland in females, published in 1835. In it, he details the clinical features known today as Graves’ disease. However, his contributions to medicine extended far beyond the then unknown field of endocrinology. Most notable among them was his devotion to the use of bedside teaching.

“Graves’ major contribution to medicine was the initiation of teaching-ward rounds in these islands,” T. J. McKenna, MD, professor in the department of endocrinology and diabetes mellitus, St. Vincent’s University Hospital, Dublin, told Endocrine Today. “He provided an example of an academic physician whose guiding principles might, with advantage, be embraced by those in pursuit of an academic medical career.”

In a description by Armand Trousseau, a prominent French physician of the same time, Graves is described as “a perfect clinical teacher. … An attentive observer, a profound philosopher, an ingenious artist, 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.”

Early influence

Graves was born in Dublin, Ireland, in 1796 to Richard Graves, a senior fellow at Trinity College.

Graves was educated at Trinity College where he maintained first in his class and was the recipient of the gold medal for scholastic excellence, the highest distinction awarded to a student by the university. He graduated with a medical degree in 1818.

After graduation, Graves spent the next several years traveling around Europe and studying at the important medical centers in England, Germany, Austria and France.

Upon his return in 1821, Graves was appointed as a staff physician at Meath Hospital, the principal public hospital in Dublin. There he introduced the system of clinical and bedside teaching that he observed and admired while in Europe.

Graves was described as tall, dark and dynamic. His daily teaching clinic, which was taught in English instead of the traditional Latin, was said to be attended by more than 100 students.

Breaking from the traditional methods of teaching medicine, which required students to have extensive book knowledge but little practical experience, Graves had his students examine patients, present histories and review physical findings and treatments with their professor at the bedside of the patient. His methods also required students to attend autopsies to correlate the findings with symptoms and signs observed before a patient’s death.

Although his interests were diverse, Graves was frequently involved in the treatment of infectious diseases and fevers, specifically typhus, which was at epidemic proportions during this period of Ireland’s history.

“While being a relatively wealthy man, he had a real concern for the underprivileged and disadvantaged for whom he was an effective champion,” McKenna said. “In his youth, with little thought for his own health, he led a small group of physicians across Ireland from Dublin to Galway where typhus was raging.”

At the time, low diet was recommended as “an indispensable condition in the treatment of fevers.” However, Graves completely reversed medical practice on this point and instead recommended exposure to fresh air and the increased consumption of food and liquids.

“He requested that his epitaph should read, ‘He fed fevers,’ which clearly, in his own estimation, was his most significant contribution to medical science,” McKenna said.

In 1824, Graves cofounded the Park Street School of Medicine. Shortly after, he was appointed professor at the Institute of Medicine at Trinity College, a post which he held until 1841.

Graves’ disease

During this time he made many original contributions to medicine. In 1834, Graves delivered a series of lectures detailing three cases of violent palpitations in women with enlarged thyroids and apparent enlargement of the eyeballs.

“Graves gave one of the first descriptions of the association of goiter, generalized increase in metabolism and ocular abnormalities, which have come to be known as thyroid ophthalmopathy,” McKenna said. “Graves described florid thyrotoxicosis in a woman who, in retrospect, had autoimmune mediated thyrotoxicosis.”

The disease would later be identified as the most common form of hyperthyroidism. Trousseau suggested the eponym Graves’ disease. In Europe, the condition is now frequently referred to as von Basedow’s disease after Karl Adolph von Basedow. The eponym Graves’ disease is more commonly used in the United States.

Clinical lectures

After leaving Trinity College and Meath Hospital, Graves was appointed president of the Royal College of Physicians of Ireland in 1843. The same year he published a major textbook, A system of clinical medicine, based on lectures delivered in Sir Patrick Duns Hospital.

A second edition was published in 1848 and translated into French, German and Italian. The second edition included a criticism by Trousseau who described Graves’ work as “the most remarkable and important lectures. … There is not one of them, in fact, which does not abound in practical deductions.”

First among them is a lecture about clinical instruction, in which Graves admires the German method of clinical teaching and instructs that “from the very commencement, the student ought to witness the progress and effects of sickness, and ought to persevere in the daily observation of disease during the whole period of his studies.

“Remember, therefore, that however else you may be occupied — whatever studies may claim the remainder of your time, a certain portion of each day should be devoted to attendance at a hospital, where the pupil has the advantage of receiving instruction from some experienced practitioner,” he wrote.

Graves even encouraged his students to learn the cost of prescriptions so that when they entered private practice they could consider a patient’s financial situation when they prescribed the appropriate medicines.

The 70 lectures included in the textbook cover a wide range of topics: inflammation, scarlatina, cholera, influenza, gout, rheumatism, nervous diseases, paralysis, pneumonia, asthma, gangrene, pericarditis, headaches, tape worm, venereal disease, sleeplessness, extensive lectures on fever and diseases of the digestive organs, kidney, skin, respiratory organs, heart and more. Among the many novel concepts included in the textbook was the pinhole pupil after pontine hemorrhage, timing the pulse by watch and abandoning the practice of bleeding patients with pyrexia.

When Graves’ term as president of the Royal College of Physicians ended, he became a much less prominent figure in medicine and little is known about his last few years of life. He died of an abdominal tumor on March 20, 1853.

In the closing of his criticism, Trousseau aptly summarizes Graves’ contribution to medicine, “there is not a day that I do not in my practice employ some of the modes of treatment which Graves excels in describing with the minuteness of the true practitioner.” – by Leah Lawrence

For more information:
  • Graves RJ. Clinical lectures on the practice of medicine. Dublin: Fannin and Co.; 1864.
  • Jay V. Dr. Robert James Graves. Arch Pathol Lab Med. 1999;123:284.
  • McKenna TJ. Graves’ disease. Lancet. 2001;357:1793-1396.
  • Whitehead RW. Historical annotation: Robert James Graves, physician, educator, scientist. Circulation. 1969;39:719-721.