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Robert graves: graves' disease of the thyroid.

Robert Graves was born in Dublin in 1796; his father was Professor of Divinity. Robert entered Trinity College, Dublin at the precocious age of 15 and took his degree in arts in 1815 and in medicine in 1818. He then proceeded to postgraduate medical studies in London, Edinburgh and then widely on the continent of Europe. On returning to Dublin, this erudite young man was appointed visiting physician to the Meath Hospital in 1821, where he introduced that new-fangled French invention, the stethoscope. He also replaced teaching of medicine by rote in the lecture theatre with bedside teaching, the students taking histories and examining the patients at the bedside, as he had observed in the German clinics. He died in 1853, probably of cancer.

In 1835, Graves published a two-page article in the London Medical and Surgical Journal - I have a copy of this paper in front of me as I write. In it, he describes three women suffering from palpitations of the heart accompanied by enlargement of the thyroid gland. In the third patient, a lady of 20 that he did not see himself but whose symptoms were 'detailed to me by a friend', 'the eyeballs were apparently enlarged so that the lids were incapable of closing'. He attributed the thyroid enlargement to the violent action of the heart. Hardly a brilliant classical description!

Four years later, in 1840, Carl von Basedow published two detailed papers, occupying 17 pages, in a Berlin medical journal. I have its English translation. He gives an excellent account, in three female patients, of the triad of enlargement of the thyroid, palpitations of the heart and exophthalmos. This was accompanied by night sweats, increasing appetite and yet emaciation. He recommended the use of Iodine in treatment - good advice!

Hardly surprisingly, on the continent of Europe, and especially in German-speaking countries, this illness is given the eponym 'Basedow's Disease'. Carl von Basedow was born in 1799. He studied medicine at the University of Halle in Germany and, after qualification, spent another two years in Paris, where he concentrated on surgery. Returning to Germany, he practised in the town of Merseburg in surgery and general practice.

In 1848, von Basedow added to our knowledge of this disease by publishing the autopsy findings on one of his patients described in the 1840 paper; probably the first protocol of a post mortem examination in this disease. He died in 1854 as the result of septicaemia, following a scratch received while performing an autopsy on a victim of typhus fever. However, this is not the end of my story.

Caleb Parry (1755 - 1822) was born in Gloucestershire, studied medicine in Edinburgh and qualified in 1777. He was at school with Edward Jenner, with whom he maintained a lifelong friendship; indeed, Jenner's classical publication on vaccination in smallpox was dedicated to 'My Dear Friend'. Parry settled in Bath, built up a large practice and became the most celebrated physician in that fashionable health resort. He amassed a comfortable fortune from his many wealthy and famous patients. Parry was a cultivated man with wide interests. He studied the nature of the arterial pulse in experiments on sheep and rabbits. He came to the sensible conclusion that the pulse wave was due to the impact of the left ventricle during systole. It was during one of his experiments that he sustained a stroke, in 1816, the cause of his ultimate death, six years later.

Parry was a shrewd clinical observer. In 1788 he read a paper at a meeting of the local medical society in which he attributed the features of angina pectoris to disease of the coronary arteries. This was published in 1799 and Parry was thus one of the first to make this association.

In 1786, he noted a case of goitre 'of enormous size' associated with exophthalmos - 'the eyes protruded from their sockets'. This was in a married lady aged 37. She had a tachycardia of 156, with an irregular beat, and was in heart failure, with oedema of the legs and a swollen abdomen, presumably due to ascites.

During the rest of his lifetime, Parry observed five further examples, all in female patients, in which thyroid enlargement was associated with cardiac palpitations but not with eye changes. One of his patients, a lady of about 50, suffering from palpitations, with a pulse racing at 136 and with an extremely enlarged thyroid gland, went into heart failure, with ankle oedema and ascites, and died. Permission for autopsy was refused.

In 1825, three years after Parry's death, his account of these patients was published posthumously in his 'Collected Works'. This can easily be referred to in Ralph Major's 'Classic Descriptions of Disease' (1945).

It was Sir William Osler (1849-1919), that great physician and Regius Professor of Medicine at Oxford, who suggested that the syndrome should be relabelled 'Parry's Disease', and I agree!

About the author

Professor Harold Ellis CBE, FRCS

Emeritus Professor of Surgery, University of London; Department of Anatomy, Guy's Hospital, London

No competing interests declared

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KEYWORDS Robert Graves / Graves' disease / Thyroid / Parry's disease

Provenance and Peer review: Commissioned by the Editor; Peer reviewed; Accepted for publication January 2012.

by Professor Harold Ellis

Correspondence address: Department of Anatomy, University of London, Guy's Campus, London, SE1 1UL.
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Author:Ellis, Harold
Publication:Journal of Perioperative Practice
Date:Apr 1, 2012
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