THOMAS
PEEL
DUNHILL,
THE
FORGOTTEN
MAN
OF
THYROID
SURGERY
by
I.
D.
A.
VELLAR*
THE
MODERN
surgeon
approaches
the
surgery
of
thyrotoxicosis
with
confidence,
the
confidence
derived
from
the
excellence
of
modem
anaesthesia,
the
euthyroid
state
of
the
patient
and
the
knowledge
that
blood
transfusion,
antibiotics
and
the
specific
management
of
the
occasional
crisis
are
always
available
to
extricate
the
patient
from
any
of
these
complications.
Though
full
of
confidence
in
his
own
and
others'
abilities,
he
usually
matches
this
by
a
profound
ignorance
of
the
contribution
of
the
thyroid
pioneers
whose
activities
at
the
turn
of
the
century
helped
to
lay
the
foundation
for
the
safe
management
of
the
thyrotoxic.
One
of
these
pioneers
was
an
Australian,
Thomas
Peel
Dunhill
(fig.
1),
whose
contributions
to
thyroid
surgery
have
been
almost
entirely
forgotten.
To
understand
fully
the
role
of
Dunhill,
it
is
important
to
look
at
the
position
of
thyroid
surgery
and
in
particular,
the
surgery
of
toxic
goitre
at
the
turn
of
the
nineteenth
century
and
in
the
first
two
decades
of
the
twentieth
century.
It
will
then
be
possible
to
appreciate
more
fully
the
achievements
of
these
thyroid
pioneers,
who
enabled
the
mortality
of
the
surgery
of
toxic
goitre
to
be
reduced
from
30-50
per
cent
(it
was
30
per
cent
at
St.
Thomas's
Hospital,
London,
as
recently
as
1910)
to
a
minute
fraction
of
one
per
cent
today.
The
early
history
of
the
surgery
of
the
thyroid
gland
may
be
traced
in
Halsted's
painstaking
compilations
included
in
his
article.
'The
operative
story
of
goitre-
the
author's
operation'
in
the
Johns
Hopkins
Hospital
Reports,
1920.1
However,
the
recognition
of
goitre
goes
back
many
thousands of
years.
The
Arthorva
Veda,
an
ancient
Hindu
collection
of
incantations
dating
from
2000
B.C.,
contains
extensive
forms
of
exorcisms
for
goitre.
In
more
recent
times,
Julius
Caesar
remarked
at
the
frequent
occurrence
of
a
big
neck
as
one
of
the
characteristics
of
the
Gauls.
Juvenal,
the
Roman
poet,
indicated
the
frequency
of
goitre
when
he
wrote:
'Quis
tumidum
guttur
miratur
in
Alpibus?'
('Who
wonders
at
goitre
in
the
Alps?')
'Goitre'
is
derived
from
the
Latin
'guttur',
the
throat,
and
Fabricius
ab
Aquapendente
of
Padua
was
probably
the
first
to
employ
this
term
when
he
described
sufferers
from
goitre
as
'gutturosi'.
In
the
sixteenth
to
eighteenth
centuries,
it
was
also
called
'struma'
and
often
confused
with
enlargement
of
the
cervical
lymph
nodes.
That
goitre
was
definitely
associated
with
enlargement
of
the
thyroid
gland
does
not
appear
to
have
gained
general
recognition
until
the
eighteenth
century.
Against
this
background
Halsted's
researches,
based
partly
on
his
own
work
and
that
of
the
German
medical
historians
Mandt
and
Gunther,
showed
that
some
100
operations
were
performed
on
the
thyroid
gland
between
1596
and
1861.
The
majority
of
these
operations
were
*Department
of
Surgery,
St.
Vincent's
Hospital,
Fitzroy,
Victoria
3065,
Australia.
Medical
History,
1974,
vol.
18.
22
Thomas
Peel
Dunhill,
the
Forgotten
Man
of
Thyroid
Surgery
performed
before
the
introduction
of
ether
to
medicine
in
1846.
Though
the
opera-
tions
claimed
to
have
been
performed
in
the
sixteenth
and
seventeenth
centuries
are
shrouded
in
doubt
and
ambiguity,
it
appears
fairly
certain
that
Pierre
Joseph
Desault
excised
a
large
adenoma
of
the
thyroid
in
1791.
The
patient,
a
young
woman
aged
twenty-eight,
recovered.
Desault's
second
attempt
at
thyroidectomy
ended
disastrously,
the
patient
dying
from
uncontrollable
haemorrhage.
As
in
other
branches
of
surgery
at
that
time,
control
of
haemorrhage
and
the
prevention
of
infection
were
proving
formidable
obstacles
for
the
surgeons.
Tissues
were
grasped
by
hooks,
pincers,
or
with
the
fingers.
Ligatures
were
expected
to
slough
off
as
the
wound
healed
with
the
inevitable
accompaniment
of
laudable
pus
(and
many
a
time
secondary
haemorrhage
as
well).
The
intrepid
Baron
Dupuytren
in
the
early
part
of
the
nineteenth
century
removed
a
large
adenoma
of
the
thyroid.
Though
technically
successful,
the
patient
died
of
respiratory
failure
thirty-five
hours
later.
This
case
was
reported
in
1817.
Probably
the
greatest
achievements
of
the
early
thyroid
surgeons
belong
to
J.
A.
W.
Hedenus
of
Dresden.
He
excised
part
of
the
thyroid
with
success
in
six
patients.
Like
most
of
the
operations
performed
at
that
time,
he
operated
to
relieve
pressure
symp-
toms
resulting
from
the
enlarging
goitre.
Other
isolated
successful
operations
for
non-toxic
goitre
were
reported
from
Britain,
Italy
and
America.
However,
the
general
attitude
towards
operating
on
the
thyroid
at
that
time
was
forcefully
stated
by
Robert
Liston
when
he
wrote:
'You
could
not
cut
the
thyroid
gland
out
of
the
living
body
in
its
sound
condition
without
risking
the
death
of
the
patient
from
haemorrhage.
It
is
a
proceeding
by
no
means
to
be
thought
of'.
Samuel
D.
Gross
was
even
more
forceful
in
his
views.
He
asked:
'In
a
word,
can
the
thyroid
gland
when
in
a
state
of
enlargement,
be
removed
with
a
reasonable
hope
of
saving
the
patient?
Experience
emphatically
answers
no'.3
The
twin
scourges
of
sepsis
and
haemorrhage
actually
forced
the
French
Academy
of
Medicine
in
1850
to
prohibit
operations
on
goitre.
The
advent
of
general
anaesthesia
in
1846,
the
introduction
of
Listerian
principles
of
antisepsis
and
asepsis
in
the
1870-1890
period,
which
were
adopted
at
first
by
the
surgeons
of
the
German
school,
and
the
development
of
satisfactory
haemostats,
all
helped
to
eliminate
the
'smash
and
grab'
school
of
surgery
and
of
course
substantially
reduced
surgical
mortality.
Thyroid
surgery
particularly
bene-
fited
from
these
advances
and
in
the
period
1861-1883
nearly
500
operations
on
the
thyroid
gland
were
reported.
This
was
the
period
dominated
by
Theodor
Billroth
and
his
school
and
marked
the
debut
of
Theodor
Kocher
to
thyroid
surgery.
Switzerland,
having
such
a
large
number
of
patients
with
goitre,
naturally
became
the
centre
of
thyroid
surgery.
This
interest
was
initiated
and
fostered
by
Billroth
when
he
held
the
Chair
of
Surgery
in
Zurich
during
the
period
1860-1867.
Professor
A.
Liucke
carried
on
the
work
at
Berne
and
he
of
course
was
succeeded
by
Kocher
who
held
the
Chair
of
Surgery
at
Berne
from
1872-1911.
During
his
tenure
of
the
Chair
of
Surgery
at
Zurich,
Billroth
performed
twenty
major
operations
on
the
thyroid.
Eight
of
these
patients
died,
a
mortality
of
40
per
cent.
Sepsis
accounted
for
the
majority
of
the
deaths.
By
the
time
Billroth
had
established
himself
in
Vienna,
Lister's
antiseptic
methods
had
been
adopted
by
the
German-Austrian-Swiss
school
of
surgery.
Once
more,
but
now
with
greater
confidence,
Theodor
Billroth
directed
his
talents
towards
the
problems
of
goitre
surgery.
By
1882,
he
had
reduced
his
mortality
to
8
per
cent.
23
I.
D.
A.
Vellar
In
forty-eight
major
operations
on
the
thyroid,
including
twenty-two
total
extirpa-
tions,
Billroth
injured
the
recurrent
laryngeal
nerve
some
thirteen
times.
Eight
of
the
twenty-two
total
extirpations
developed
tetany.
Two
of
these
patients
died.
This
improvement
in
results
was
achieved
with
a
somewhat
crude
technique.
Billroth
did
not
dissect
out
and
isolate
the
superior
and
inferior
thyroid
arteries
and
ligate
them
as
a
definite
step
in
excision
of
the
thyroid.
He
tied
all
vessels
en
masse
as
they
were
encountered.
It
was
this
technique
almost
certainly
that
caused
the
recurrent
laryngeal
nerve
to
be
caught
and
damaged
or
cut
with
the
inferior
thyroid
artery.
The
high
proportion
of
cases
who
had
the
thyroid
totally
removed
and
developed
tetany,
naturally
provoked
intense
interest
and
discussion
amongst
Billroth
and
his
disciples.
Anton
Wlier,
one
of
Billroth's
assistants,
postulated
that
the
tetany
resulted
from
a
disorder
of
the
cerebral
circulation
following
removal
of
the
thyroid
gland.
Billroth
however,
incriminated
division
of
the
numerous
nerves
of
the
thyroid
gland
and
believed
that
tetany
only
occurred
in
individuals
who
were
predisposed
to
nervous
affections!
One
has
to
remember
that
Sandstrom
had
just
described
the
parathyroid
glands
(1880)
and
that
physiological
knowledge
of
thyroid
and
parathyroid
function
was
nil.
It
is
indeed
ironical
that
the
improvements
in
operating
technique
and
haemostasis
allied
with
Listerian
antisepsis
and
asepsis,
enabled
total
extirpation
of
the
thyroid
to
be
carried
out
successfully
and
thus
unveiled
postoperative
myxoedema
and
tetany.
Billroth,
adopting
a
relatively
crude
technique
of
thyroidectomy,
had
trouble
with
tetany
and
recurrent
laryngeal
nerve
damage.
Kocher,
the
meticulous
dissector,
was
plagued
by
postoperative
myxoedema,
but
the
recurrent
laryngeal
nerve
was
safe
in
his
hands.
Historically,
the
honour
of
the
first
successful
total
thyroidectomy
belongs
to
Paul
Sick.
He
achieved
this
in
1867.
The
patient
was
a
ten-year-old
boy
and
Sick
operated
to
relieve
increasingly
severe
dyspnoea.
Sick
noted
in
his
follow-up
examination
that
the
boy
'formerly
joyous
and
lively,
he
is
now
silent,
quiet
and
dull'.4
He
speculated
that
some
alteration
in
the
blood
might
have
impaired
the
nutrition
of
the
brain.
Sick
of
course
was
actually
describing
post-operative
myxoedema.
However,
he
failed
to
correlate
removal
of
the
thyroid
with
the
changes
which
he
described.
Five
years
after
Sick's
successful
operation,
Theodor
Kocher
obtained
the
Chair
of
Surgery
at
Berne
at
the
age
of
thirty-one
years.
Kocher
succeeded
Liicke
who
had
initiated
goitre
surgery
at
Berne
in
1872.
By
1874,
he
had
performed
two
total
excisions
of
the
thyroid
successfully.
One
of
these
was
on
an
eleven-year-old
girl.
Kocher
noted:
'According
to
the
report
of
the
physician
she
enjoyed
unclouded
health
during
the
past
two
weeks
after
her
return
home,
but
latterly
a
remarkable
change
in
the
behaviour
of
the
child
has
taken
place.
She
has
become
peevish
and
dull
and
will
not
work
except
under
compulsion,
whereas
formerly
she
was
a
spirited
and
joyous
creature.
We
shall
learn
from
the
further
progress
of
the
case
whether
there
is
any
relation
between
the
extirpatio
strumae
and
the
altered
mental
condition.'5
These
were
prophetic
words
because
in
1883
Kocher
published
his
famous
paper
detailing
results
of
total
thyroidectomy
and
describing
a
standard
approach
for
thyroid
lobectomy.
By
now,
Kocher
had
per-
formed
thirty-four
total
excisions
of
the
thyroid.
Eighteen
of
these
returned
for
follow-up
examination.
Sixteen
showed
hypothyroidism.
These
are
described
fully.
Kocher
noted
the
similarity
between
cretinism
and
the
postoperative
state
he
now
24
Thomas
Peel
Dunhill,
the
Forgotten
Man
of
Thyroid
Surgery
designated
'cachexia
strumi
priva'.
Without
any
precise
knowledge
of
thyroid
func-
tion,
Kocher
speculated
as
to
the
cause
of
the
cachexia
strumi
priva
and
the
anaemia
which
was
such
a
prominent
feature
of
the
disorder.
Softening
of
the
trachea
was
incriminated
as
well
as
some
disorder
of
the
cerebral
circulation.
Kocher
states:
'We
believe,
therefore,
that
the
symptoms
which
condition
the
picture
of
idiocy
are
probably
determined
by
the
disturbance
of
the
cerebral
circulation,
while
the
cachexia
is
to
be
explained
by
the
influence
upon
breathing,
upon
the
supply
of
oxygen
in
so
far
at
least
as
it
may
not
be
ascribed
to
the
cutting
out
of
that
function
of
the
thyroid
gland
which
serves
in
the
formation
of
the
blood'.
Only
one
of
the
eighteen
cases
which
returned
for
follow-up
examination
showed
tetany
and
this
was
regarded
by
Kocher
as
a
manifestation
of
the
intense
cerebral
disturbance.
Although
these
observations
of
Kocher
contained
in
the
famous
article
entitled
'Ueber
Kropf
Extirpation'
were
eventually
to
lead
him
to
the
Nobel
Prize
for
medicine
in
1909,
he
was
actually
antedated
by
J.
L.
Reverdin
of
Geneva.
In
1882
Reverdin
reported
fourteen
total
excisions
of
the
thyroid
gland.
He
noted
that
some
months
after
the
operation
the
patients
developed
a
feebleness,
pallor
and
heaviness.
The
face
became
swollen
and
resembled
very
closely
cretinoid
facies.
Reverdin
called
the
condition
'myxedeme
operatoire'.
The
threats
of
sepsis,
haemorrhage
and
damage
to
the
recurrent
laryngeal
nerve
had
now
given
way
to
post-operative
tetany
and
cachexia
strumi
priva.
It
was
these
complications
that
caused
Kocher
to
abandon
almost
completely
total
thyroidectomy
(he
reserved
this
for
certain
malignant
goitres)
and
to
concentrate
on
removal
of
one
lobe
only.
This
single
lobectomy
proved
to
be
the
basis
of
all
Kocher's
surgery
for
goitre
after
1883.
Towards
the
end
of
his
surgical
career,
he
still
attacked
only
one
lobe
but
now
left
the
posterior
part
of
the
lobe
behind.
By
1883
the
Swiss
surgeons,
in
particular
Reverdin
and
Kocher,
had
become
acquainted
with
some
of
the
English
literature
pertaining
to
the
thyroid,
in
particular
a
paper
read
by
William
Withey
Gull
in
1873
to
the
Clinical
Society
of
London.
This
paper
was
titled
'On
a
cretinoid
state
supervening
in
adult
life
in
women'.8
Gull
pointed
out
many
similarities
between
this
condition
(now
designated
myxoedema)
and
sporadic
cretinism.
The
actual
term
'myxoedema'
was
first
used
by
William
Ord
in
1877.
Ord
coined
this
term
to
describe
the
'mucous
dropsy'
of
the
skin.
He
was
able
to
perform
a
post-mortem
examination
on
a
patient
suffering
from
severe
thyroid
deficiency,
noting
a
markedly
diminished
thyroid
gland
and
the
appearance
of
a
gelatinous
or
mucinoid
substance
in
the
sub-
cutaneous
tissue,
thereby
giving
the
disease
entity
its
name.
It
was
this
paper
that
suggested
to
Reverdin
the
term
'myxedeme
operatoire'.
In
1883
Sir
Felix
Semon
after
closely
studying
the
contributions
of
Kocher
and
Reverdin
(Semon
spoke
German
fluently),
stated
that
cretinism,
myxoedema
and
cachexia
strumi
priva
were
closely
allied
conditions
having
in
common
either
absence
or
complete
degeneration
of
the
thyroid
gland.
This
hypothesis
was
proved
experimentally
by
Victor
Horsley
when
he
removed
the
thyroid
gland
in
monkeys,
producing
a
state
identical
to
myxoedema
in
the
human.
The
role
played
by
the
lack
of
thyroid
secretion
in
the
production
of
myxoedema
had
to
await
the
isolation
of
thyroxine
by
Kendall
in
1914.9
Having
shown
that
excision
of
the
thyroid
gland
produced
myxoedema
and
having
noted
the
resemblance
of
'myxoedema
operatoire'
to
sporadic
cretinism,
it
appeared
logical
25
I.
D.
A.
Vellar
to
clinicians
to
try
substitution
therapy
in
these
disorders.
Moritz
Schiff
claimed
that
an
animal
could
be
safeguarded
against
some
of
the
effects
of
thyroid
deprivation
by
transplantation
of
the
thyroid
from
another
animal
of
the
same
species.
The
effect
of
this
procedure
was
solely
due
to
the
thyroid
secretion
contained
in
the
thyroid
homograft
and
not
to
the
graft
resuming
function.
This
claim
of
Schiff
impressed
Horsley
who
stated
in
1890:
'It
seems
to
me
that
these
observations
of
Professor
Schiff
and
Dr.
von
Eiselsberg
are
of
especial
value
as
they
suggest
to
my
mind
that
possibly
myxoedema
may
be
treated
with
success
by
transplanting
thyroid
tissue
into
the
patient'.10
The
work
of
George
Redmayne
Murray,
Hector
MacKenzie
and
Fox
made
this
unnecessary.
In
1891,
Murray
treated
myxoedema
successfully
by
injection
of
an
extract
made
from
sheep's
thyroid.'1
One
year
later
MacKenzie
showed
that
feeding
of
fresh
thyroid
glands
was
equally
efficacious'2
and
finally
Fox
in
1892
described
how
the
clinical
features
of
myxoedema
could
be
completely
reversed
by
taking
thyroid
extract
by
mouth.'3
The
serious
side-effects
of
total
thyroidectomy
(cachexia
strumi
priva
and
tetany)
had
a
profound
effect
on
many
surgeons.
Billroth's
assistants
were
able
to
study
these
conditions
closely.
One
of
his
assistants
was
Johann
von
Mikulicz-Radecki.
After
being
an
assistant
to
Billroth
in
Vienna
for
some
years
Mikulicz
became
Professor
of
Surgery
at
Cracow.
In
1886
he
wrote:
'I
refer
to
the
general
and
local
disturbances-tetany,
cachexia
strumi
priva
and
paralysis
of
the
muscles
of
the
larynx-which
follow
strumectomy
and
which
together
demand
either
an
essential
curtailing
of
the
indications
for
operation
or
a
modification
of
the
operative
method'."4
Although
Mikulicz
had
no
accurate
idea
of
the
function
of
the
thyroid
and
probably
had
taken
no
notice
of
the
parathyroids
(he
subscribed
to
Billroth's
theory
that
both
tetany
and
cachexia
strumi
priva
were
somehow
due
to
operative
interference
with
nerves
in
the
vicinity
of
the
thyroid),
he
realized
correctly
that
excision
of
a
lobe
was
never
followed
by
tetany
or
cachexia.
He
also
appreciated
that
if
the
dissection
spared
the
region
of
the
recurrent
laryngeal
nerve,
then
paralysis
of
the
vocal
cord
would
be
eliminated.
He
achieved
this
by
leaving
thyroid
tissue
behind
in
the
vicinity
of
the
inferior
thyroid
artery,
thereby
protecting
the
recurrent
laryngeal
nerve
(and
incidentally
and
unwittingly),
the
parathyroids.
Although
Mikulicz
himself
usually
removed
one
lobe
almost
entirely
and
partially
resected
the
second
lobe,
in
one
case
he
performed
a
bilateral
partial
resection,
leaving
part
of
the
posterior
aspects
of
both
lobes
behind.
This
procedure
forms
the
basis
for
the
modem
partial
thyroidec-
tomy
operation.
It
was
never
adopted
by
Kocher
who
remained
content
to
remove
one
lobe
of
the
thyroid
only,
after
dissecting
and
ligating
the
superior
and
inferior
thyroid
arteries.
The
only
change
in
Kocher's
technique
was
his
adoption
of
the
collar
incision
advocated
by
Boeckel
and
the
employment
of
local
anaesthesia
almost
exclusively
after
1896.
The
employment
of
local
anaesthesia
was
precipitated
by
a
death
under
chloroform
anaesthesia
which
Kocher
experienced
in
1895.
By
1900,
Kocher's
mortality
for
non-toxic
goitre
was
less
than
one
per
cent
and
in
1907
he
had
amassed
3,333
cases
of
non-toxic
goitre
with
a
mortality
of
0.3
per
cent.
All
of
these
cases
had
a
single
lobectomy.
By
the
end
of
the
nineteenth
century
Kocher
had
evolved
a
safe
technique
for
all
non-toxic
goitre
and
thyroid
extract
was
widely
used
to
treat
myxoedema,
post-operative
hypothyroidism
and
cretinism.
Tetany
still
26
Thomas
Peel
Dunhill,
the
Forgotten
Man
of
Thyroid
Surgery
remained
an
enigma.
Sandstrom
in
1880
was
the
first
to
describe
the
parathyroid
glands
as
anatomic
entities,"5
although
both
Remak
in
1851
and
Rudolf
Virchow
in
1864
briefly
mentioned
them.
Sandstrom
thought
that
the
parathyroids
represented
undeveloped
embryonic
thyroid
tissue.
This
view
bedevilled
medical
thinking
for
many
years
for
though
Gley
in
1891
in
a
series
of
communications
before
the
Societe
de
Biologie
in
Paris
presented
his
evidence
that
thyroidectomy
per
se
did
not
produce
fatal
tetany
unless
the
parathyroid
glands
were
also
removed,
he
still
considered
that
the
parathyroids
represented
embryonic
thyroid
tissue.'6
In
goitre
surgery
it
was
well
recognized
that
total
ablation
of
the
thyroid
gland
led
to
tetany
in
a
number
of
cases.
This
led
to
confusion
as
many
investigators
still
blamed
tetany
on
thyroid
deprivation
and
tried
unsuccessfully
to
treat
it
with
thyroid
extract.
It
was
left
to
two
Italian
physiologists,
Vassale
and
Generali,
to
prove
by
a
series
of
convincing
experiments
that
it
was
loss
of
parathyroid
function
that
caused
tetany.17
They
removed
the
parathyroids
but
left
the
thyroid
intact
and
showed
that
the
experimental
animal
developed
tetany.
Conversely,
they
removed
all
thyroid
but
left
one
of
the
parathyroids
in
situ
and
showed
that
tetany
did
not
develop.
They
concluded
that
parathyroids
were
not
thyroid
rests
and
that
they
had
a
special
metabolic
function
separate
from
the
thyroid.
MacCallum
then
showed
in
1911-1913
that
the
hyperexcitability
of
the
nervous
system,
the
hallmark
of
tetany,
resulted
from
calcium
lack
in
the
blood
and
that
the
manifestations
of
tetany
were
reversed
by
giving
calcium.'8
Analytical
methods
at
that
time
were
relatively
crude
and
it
was
sometimes
difficult
to
detect
the
rather
minimal
alterations
in
the
calcium
levels
which
were
able
to
produce
tetany
in
experimental
animals
As
the
nineteenth
century
drew
to
a
close,
the
figure
of
Kocher
stood
like
a
colossus
over
the
field
of
goitre
surgery.
His
experience
with
the
surgery
of
non-toxic
goitre
was
truly
phenomenal
and
his
mortality
and
morbidity
exceedingly
low.
However,
he
confined
himself
mainly
to
a
single
lobectomy
performed
through
a
collar
incision
under
local
anaesthesia,
utilizing
a
mid-line
split
of
the
strap
muscles.
Preliminary
extracapsular
ligature
of
both
superior
and
inferior
thyroid
arteries
preceded
removal
of
the
lobe.
At
this
time,
the
importance
of
the
parathyroid
glands
was
just
beginning
to
be
appreciated
by
surgeons
and
the
physicians
had
a
potent
cure
for
myxoedema.
In
contrast
to
these
advances,
the
management
of
thyrotoxicosis
or
Graves'
Disease,
was
far
from
satisfactory.
Caleb
Hillier
Parry,
a
physician
in
Bath,
first
described
the
condition
of
exophthalmic
goitre
in
1786.
He
briefly
reported
this
condition
in
his
Elements
of
Pathology
and
Therapeutics
in
1815.
A
fuller
account
of
exophthalmic
goitre
is
given
in
an
article
entitled
'Enlargement
of
the
thyroid
gland
in
connection
with
enlargement
or
palpitation
of
the
heart'
published
posthumously
in
1825.1'
Robert
James
Graves,
in
1835,20
and
Carl
Adolf
von
Basedow,
in
1840,21
gave
further
descriptions
associating
goitre,
palpitation,
exophthalmos,
emaciation
and
extreme
nervousness.
Though
the
clinical
description
and
recognition
of
this
disease
became
well
established,
controversy
raged
as
to
the
causation
of
the
exophthalmic
goitre
and
its
management.
Early
observers
such
as
Parry
and
Graves,
thought
that
the
heart
was
the
primary
cause
of
the
disease.
Tillaux,
about
1880,
advanced
the
compression
theory,
that
the
symptoms
of
exophthalmic
goitre
were
due
to
pressure
of
the
enlarged
thyroid
gland
on
related
nerves
and
blood
vessels.
27
I.
D.
A.
Vellar
Jaboulay
and
Jonnesco
incriminated
disordered
sympathetic
activity
and
advocated
removal
of
the
cervical
sympathetic
chain
and
ganglia
as
the
definitive
step
for
the
cure
of
exophthalmic
goitre.22
Others
claimed
that
it
was
in
the
parathyroid
glands
and
the
thymus
that
the
cause
of
the
disease
was
to
be
found.
As
late
as
the
early
twentieth
century,
workers
such
as
McCarrison
still
obstinately
adhered
to
a
psychic,
nutritional
and
infectious
cause
of
Graves'
Disease.-2
The
dominance
of
the
focus
of
infection
as
the
source
of
all
ills,
coupled
with
the
influence
of
Arbuthnot
Lane
in
incriminating
chronic
intestinal
stasis
as
the
aetiology
of
such
diverse
ailments
as
Graves'
Disease,
tuberculosis,
rheumatoid
arthritis
and
tic
doloureux,
often
led
to
somewhat
unorthodox
management
of
these
conditions.
McCarrison,
in
his
book
The
Thyroid
Gland
quotes
the
following
management
of
a
case
of
Graves'
Disease
24
'Roentgen
ray
examination
by
Dr.
Jordan
revealed
the
presence
of
a
greatly
dilated
stomach
with
pyloric
spasm,
an
elongated
duodenum
and
a
state
of
chronic
irritation
of
the
colon
resulting
in
unduly
rapid
emptying
of
its
contents'.
Arbuthnot
Lane
performed
a
gastro-jejunostomy,
appendicectomy
and
freed
the
pelvic
colon
as
the
definitive
management
of
this
patient's
thyrotoxicosis.
Within
ten
months,
it
was
claimed
that
the
patient
lost
most
of
her
toxic
symptoms,
although
from
the
description
given
she
was
fortunate
to
have
survived
a
period
of
severe
thyroid
crisis
as
a
result
of
abdominal
intervention.
Her
amelioration
was
almost
certainly
due
to
a
spon-
taneous
remission.
From
this
one
case,
McCarrison
concluded
that
Graves'
Disease
was
due
to
'alimentary
toxaemia'.
More
enlightened
observers
of
course
incriminated
the
thyroid
gland
itself.
As
most
of
the
cases
of
exophthalmic
goitre
were
associated
with
enlargement
of
the
thyroid,
it
was
natural
that
the
thyroid
gland
itself
should
be
blamed
for
the
con-
dition.
This
theory
was
expounded
even
before
any
precise
knowledge
of
thyroid
function
was
available.
Indeed,
several
surgeons
such
as
Tillaux
(1880),
Rehn
(1880)
and
Mikulicz
(1885)
more
or
less
accidentally
discovered
that
thyrotoxicosis
could
be
cured
by
operating
on
the
thyroid
gland.
It
seems
that
the
indication
for
surgery
in
each
case
was
respiratory
difficulty.
Each
surgeon
was
agreeably
surprised
that
the
symptoms
of
thyrotoxicosis
diminished
greatly
or
even
disappeared
after
the
operation.
These
represent
the
earliest
recorded
surgical
attacks
on
exophthalmic
goitre.
It
is
of
interest
that
Mikulicz
performed
a
double
resection
of
the
thyroid
to
cure
the
thyrotoxicosis,
an
operation
which
had
to
wait
for
some
fifty
years
before
being
accepted
as
the
standard
technique
for
the
cure
of
toxic
goitre.
This
delay
was
certainly
due
to
the
dominant
influence
of
Kocher
and
the
inherent
dangers
of
surgery
in
ill-prepared
patients
who
were
often
in
advanced
stages
of
cardiac
failure
and
emaciation.
Theodor
Kocher,
as
has
been
noted,
concentrated
on
a
single
lobectomy
for
the
management
of
both
toxic
and
non-toxic
goitres.
Between
1884
and
1887
he
had
operated
on
five
cases
of
'Basedow's
Disease',
as
he
called
it,
with
one
death.
By
1907,
although
he
had
operated
on
3,333
cases
of
non-toxic
goitre
with
a
mortality
of
0.3
per
cent,
he
had
performed
only
200
operations
on
toxic
goitre
with
a
mortality
of
4.5
per
cent.
His
definitive
management
at
that
time
was
a
lobectomy
combined
with
ligation
of
the
opposite
superior
thyroid
artery.
If
the
thyrotoxicosis
was
marked,
he
performed
preliminary
ligation
of
one
or
both
superior
thyroid
vessels
before
excising
one
lobe,
and
states
:25
'Even
without
excising
the
gland
28
Thomas
Peel
Dunhill,
the
Forgotten
Man
of
Thyroid
Surgery
we
can
get
very
good
results
in
Basedow's
Disease
by
simple
ligature
of
three
arteries'.
Furthermore,
Kocher
in
his
textbook
of
surgery,
1911,
still
wrote
that:
'Excision
should
not
be
undertaken
when
the
disease
is
advanced,
i.e.
when
the
pulse,
besides
being
rapid
is
also
small
and
irregular,
or
when
the
heart
is
dilated
and
oedema
is
present.
If
there
is
severe
thyro-intoxication,
the
slightest
excitement
causing
acceleration
of
the
heart's
action
(180
beats
or
more
per
minute)
with
an
increase
in
the
dilatation,
it
is
advisable
to
begin
by
ligating
one
or
possibly
two
arteries
and
to
postpone
the
excision
until
the
patient's
condition
shows
distinct
improvement'.26
What
was
the
rationale
for
operating
on
the
thyroid
gland
in
Graves'
Disease?
P.
J.
Moebius
in
1886
postulated
that
disordered
function
of
the
thyroid
was
the
raison
d'Wtre
of
Graves'
Disease
and
W.
S.
Greenfield
in
1893
provided
histological
evidence
to
support
this
contention
when
he
was
one
of
the
first
to
describe
the
typical
hyperplasia
seen
in
the
thyroid
gland
in
thyrotoxicosis.27
Kocher,
very
early
in
his
career,
agreed
with
Moebius
that
the
thyroid
was
primarily
at
fault
in
Graves'
Disease
and
that
the
surgical
attack
should
therefore
be
directed
at
the
thyroid
both
by
lobectomy
and
ligature
of
vessels.
Kocher
of
course
was
under
the
misapprehension
that
ligature
of
the
thyroid
arteries
was
sufficient
to
interfere
with
the
function
of
the
gland
and
consequently
mitigate
the
effects
of
the
thyro-intoxication.
The
im-
portance
of
a
direct
surgical
attack
on
the
thyroid
gland
in
thyrotoxicosis
was
gradually
gaining
acceptance
and
in
1906
Schultze
was
able
to
say:
'Clinically,
it
makes
no
dif-
ference
whether
the
secretion
of
the
gland
is
increased
or
altered
or
is
altered
chemically
as
the
result
of
changes
in
the
blood,
in
the
alimentary
canal
or
in
the
central
nervous
system,
the
fact
remains
that
the
removal
of
the
growing
gland
does
away
with
the
symptoms
and
upon
failure
to
remove
the
diseased
gland
depends
the
failure
to
cure'.28
This
succinctly
summarized
the
situation
as
seen
from
the
rather
practical
point
of
view
of
the
surgeon.
It
had
some
measure
of
scientific
support.
If
one
were
to
completely
remove
the
thyroid,
then
myxoedema
resulted
and
the
picture
presented
by
myxoedema
was
dramatically
opposed
to
that
seen
in
hyper-
thyroidism.
If
one
were
to
feed
thyroid
extract
in
excess,
then
many
of
the
clinical
manifestations
of
Graves'
Disease
were
produced.
Finally,
excision
of
part
of
the
thyroid
gland
caused
amelioration
or
cure
of
the
thyro-intoxication
and
in
some
cases
caused
diminution
in
the
exophthalmos.
This
all
added
up
to
an
attractive
well-
rounded
rationalization
of
the
problem.
Casting
a
shadow
across
this
however,
were
the
results
of
surgical
therapy.
The
mortality
was
often
appalling.
Though
infection
was
now
fairly
well
controlled
as
a
result
of
aseptic
surgery
(ushered
in
by
the
intro-
duction
of
steam
sterilization
by
von
Bergmann
in
1886),
haemorrhage
from
the
vascular
and
friable
thyroid
gland
was
often
frightening.
The
technique
of
shelling
out
the
large
adenomatous
or
colloid
goitres
with
ligature
and
division
of
the
thyroid
arteries
and
clamping
the
relatively
avascular
thyroid
isthmus,
found
limited
applica-
tion
in
the
surgery
of
the
exophthalmic
goitre.
Many
surgeons
likened
this
pro-
cedure
to
operating
on
an
enormous
arteriovenous
fistula
in
the
neck
and
the
blood
loss
was
often
sufficient
to
cause
the
death
of
the
patient.
Deaths
resulting
from
thyroid
crisis
after
operation
were
not
uncommon,
nor
were
fatalities
from
the
use
of
chloroform
anaesthesia.
The
subjects
themselves
hardly
made
for
safe
operating.
Treated
for
many
years
by
physicians
with
an
assortment
of
remedies
that
were
often
29
I.
D.
A.
Vellar
dangerous
as
well
as
being
useless,
they
were
grossly
emaciated
and
waterlogged
from
congestive
cardiac
failure
before
they
were
offered,
almost
as
ritual
sacrifices,
to
the
surgeons.
These
were
truly
the
'last
resort'
cases
which
gave
surgery
of
toxic
goitre
such
an
evil
reputation.
Kocher
undoubtedly
had
the
greatest
influence
in
the
early
development
of
thyroid
surgery
in
America.
Kocher
stated
that
he
could
cure
75
per
cent
of
his
patients
suffer-
ing
from
toxic
goitre
by
removal
of
one
lobe
and
perhaps
a
ligature
of
the
superior
thyroid
vessels
on
the
contralateral
side.
At
Rochester,
Minnesota,
Charles
and
William
Mayo
had
operated
on
some
110
cases
of
exophthalmic
goitre
between
1890
and
1907.29
Ether
anaesthesia
was
routinely
used.
The
mortality
was
nine
per
cent
and
the
standard
operation
was
removal
of
one
lobe.
In
the
severe
cases,
they
followed
Kocher's
advice
by
ligating
the
superior
thyroid
vessels
as
a
preliminary
measure.
By
1909,
Charles
Mayo
was
able
to
report
on
400
cases
of
hyperthyroidism
treated
surgically.
The
mortality
was
now
five
per
cent.
Some
of
these
cases
were
treated
by
a
bilateral
ligation
of
the
superior
thyroid
vessels
as
the
definitive
procedure.
Others
had
a
lobectomy
plus
ligation
of
the
opposite
superior
thyroid
vessels.
This
ligation
was
carried
out
at
a
second
operation
for
continuing
toxicity
after
the
removal
of
a
single
lobe.
The
vast
majority
had
a
single
lobectomy
performed.
Mayo
claimed
a
70
per
cent
cure.
In
1910,
Charles
Mayo
described
his
current
practice
in
managing
hyperthyroidism.'0
Early
cases
were
treated
by
a
ligature
of
the
superior
thyroid
vessels
alone
and
this
was
still
employed
as
a
preliminary
before
excisional
surgery
in
severe
thyrotoxicosis.
The
usual
operation
was
excision
of
one
lobe
and
the
isthmus.
Mayo
wrote:
'Some
few
cases
do
not
recover
their
normal
health
after
operation
because
either
too
little
of
the
gland
was
removed
or
the
remaining
portion
of
the
gland
increased
its
size
and
output
of
secretion.
Such
cases
require
ligation
of
some
of
the
vessels,
and
a
resection
of
the
remaining
lobe
may
even
be
necessary
at
a
later
period'.
His
mortality
following
lobectomy
was
now
3.9
per
cent.
This
paper
of
Mayo's
mentions
for
the
first
time
the
need
for
an
attack
on
the
second
lobe
if
the
patient
were
to
relapse.
Three
years
later
in
1913,
the
standard
operation
by
Charles
Mayo
was
still
excision
of
one
lobe
and
the
isthmus.8'
Relapses
were
treated
by
ligature
of
the
inferior
thyroid
artery
and
removal
of
half
of
the
remaining
lobe.
The
pre-operative
preparation
of
severely
toxic
patients
is
of
interest.
Irradiation
of
the
thyroid
was
sometimes
used
in
an
attempt
to
improve
the
patient.
In
the
more
severe
cases,
Porter's
technique
was
employed.
This
involved
the
injection
of
boiling
water
into
the
thyroid
to
produce
necrosis
of
the
gland
and,
it
was
hoped,
diminution
in
thyroid
activity.82
It
is
incredible
that
the
technique
of
Porter
based
on
the
Wyeth
injection
of
angiomata
with
boiling
water,
did
not
kill
more
patients
by
producing
uncontrollable
crisis.
Charles
Mayo's
mortality
for
surgery
of
thyrotoxicosis
was
now
three
per
cent
and
he
claimed
75
per
cent
cures.
In
1913
he
also
employed
the
cervical
sympathectomy
operation
of
Jonnesco,
not
to
control
the
thyrotoxicosis
as
Jaboulay
claimed,
but
to
improve
the
gross
ex-
ophthalmos.*
This
he
hoped
to
achieve
by
the
ptosis
resulting
from
the
operation
and
by
the
paralysis
of
the
mythical
muscle
of
Muller.
In
summary,
the
operative
manage-
ment
of
the
patient
suffering
from
thyrotoxicosis
at
Rochester
up
to
the
outbreak
of
the
Great
War
was
based
on
the
following
principles.
30
Thomas
Peel
Dunhill,
the
Forgotten
Man
of
Thyroid
Surgery
First,
the
patients
were
never
subjected
to
operation
during
an
exacerbation
of
the
thyrotoxicosis.
Then,
if
bed-rest
did
not
induce
a
remission,
Roentgen
irradiation
and
injections
of
boiling
water
were
employed.
If
the
case
was
very
severe,
preliminary
ligation
of
the
superior
thyroid
vessels
was
performed
and
then
the
patient
was
sub-
jected
to
thyroidectomy.
Balfour
described
thyroidectomy
as
follows:
'In
our
clinic
the
removal
of
a
large
part
of
the
hyperactive
gland
is
practised.
The
entire
right
lobe,
isthmus
and
a
part
of
the
left
lobe,
sometimes
as
much
as
4/5ths
of
the
gland,
should
be
removed
as
a
rule'.
He
continues:
'Practically
never
is
less
gland
retained
than
the
size
of
the
normal
gland',
and
finally
outlines
the
management
of
the
recurrent
toxicity:
'Should
a
recurrence
of
symptoms
take
place
due
to
over-activity
of
the
remaining
portion
of
the
gland,
a
resection
of
a
portion
of
the
remnant
may
be
made'.34
The
cure
rate
was
quoted
as
75
per
cent
and
the
operative
mortality
one
per
cent.
This
is
the
first
time
that
a
bilateral
attack
on
the
thyroid
is
mentioned
at
Rochester.
However,
a
large
remnant
was
obviously
left
behind
(equal
to
the
size
of
a
normal
gland).
Whether
this
was
dictated
by
fear
of
removing
too
much
gland
and
thus
rendering
the
patient
myxoedematous,
or
failure
to
realize
that
in
thyrotoxicosis
a
very
small
amount
of
the
hyperplastic
thyroid
gland
serves
quite
admirably
in
main-
taining
normal
thyroid
function,
is
difficult
to
ascertain.
By
1918,
the
standard
technique
at
the
Mayo
Clinic
for
toxic
goitre
consisted
of
removal
of
the
larger
lobe,
the
isthmus,
and
part
of
the
second
lobe.35
In
the
case
of
simple
goitre,
a
Mikulicz-type
resection,
leaving
behind
the
posterior
portion
of
each
lateral
lobe,
was
carried
out.
By
1920,
the
Mikulicz
technique
was
applied
also
to
toxic
goitre.36
In
the
space
of
thirty
years,
Charles
Mayo
had
moved
from
the
employ-
ment
of
the
Kocher
technique,
namely,
excision
of
a
single
lobe
for
toxic
goitre,
to
the
Mikulicz
technique
leaving
behind
the
posterior
part
of
each
lateral
lobe,
thereby
initiating
the
modem
surgical
attack
for
thyrotoxicosis
in
America.
The
other
two
members
of
the
triumvirate
often
mentioned
by
some
American
authors
as
being
the
responsible
founders
of
thyroid
surgery
in
exophthalmic
goitre
were
Halsted
and
Crile.
William
Stewart
Halsted
with
Frank
Hartley
and
Richard
Hall
introduced
cocaine
to
general
surgery
in
1885-1886.3
Halsted
also
pioneered
nerve-block
anaesthesia.
All
three
became
addicted
to
cocaine.
Halsted,
with
the
help
of
William
Henry
Welch,
the
great
pathologist
at
Johns
Hopkins,
cured
himself
of
the
addiction,
but
Hall
and
Hartley
eventually
died.
Frank
Hartley
was
a
dashing
swashbuckling
surgeon.
He
was
an
early
hero
of
the
Mayo
brothers.
However,
his
erratic
behaviour
caused
both
Charles
and
William
Mayo
to
become
disenchanted
with
Hartley
as
a
surgeon.
As
early
as
1905,
Hartley
had
written
an
interesting
article
entitled
'Thyroidectomy
for
exophthalmic
goitre'.38
Hartley
had
operated
on
twenty-
one
cases
of
exophthalmic
goitre
between
1887
and
1905,
with
one
death.
In
five
of
these
cases,
Hartley
performed
a
simultaneous
attack
on
both
lobes
of
the
thyroid.
He
probably
removed
the
whole
of
one
lobe
and
varying
amounts
of
the
other.
He
claimed
a
90
per
cent
cure
rate
and
was
one
of
the
earliest
surgeons
to
point
out
that
cure
in
Graves'
Disease
depended
on
removal
of
a
sufficient
amount
of
thyroid
gland.
Halsted
went
to
the
Johns
Hopkins
Hospital
in
Baltimore
in
1887.
Up
to
1889
only
seven
goitre
operations
had
been
performed
in
Halsted's
unit,
six
by
Halsted
and
one
by
Harvey
Cushing.
Almost
certainly
these
were
lobectomies
by
the
Kocher
technique.
31
C
I.
D.
A.
Vellar
Halsted
became
interested
in
the
blood
supply
of
the
thyroid
and
the
recently
dis-
covered
parathyroid
glands.
As
a
result
of
injection
studies
carried
out
by
Halsted
and
Evans,
who
was
a
medical
student
at
the
Johns
Hopkins,
the
blood
supply
to
the
parathyroids
was
finally
elucidated.89
Halsted
considered
that
post-operative
tetany
developed
far
more
commonly
as
a
result
of
interference
with
the
blood
supply
of
the
parathyroids,
rather
than
from
their
total
removal.
He
therefore
advocated
'ultra
ligation'
of
the
thyroid
arteries
distal
to
the
points
of
take-off
of
the
parathyroid
arteries
themselves.
He
combined
this
with
leaving
a
slice
of
the
thyroid
lobe
behind
to
protect
the
parathyroids
and
of
course
the
recurrent
laryngeal
nerve
as
well.
Halsted
never
ligated
the
trunk
of
the
inferior
thyroid
artery.
Halsted
stated:
'For
the
removal
of
a
thyroid
lobe
in
a
moderately
difficult
case
of
exophthalmic
goitre,
ten
minutes
is
ample
time
if
the
experienced
skilful
operator
is
well
assisted'-one
may
comment
that
this
seems
to
be
brilliantly
fast
operating
for
a
surgeon
who
was
such
a
notoriously
slow
operator
that
it
was
said
that
the
top
half
of
his
abdominal
incisions
were
invariably
healed
by
the
time
he
had
completed
sewing
together
the
bottom
half!
It
is
possible
to
follow
the
evolution
of
Halsted's
operative
technique
through
his
various
publica-
tions.
In
1907
in
a
paper
entitled
'Surgical
tetany
and
the
parathyroids',
Halsted
advocated
single
lobectomy
for
toxic
goitre,
leaving
the
posterior
part
of
the
gland
behind.40
He
had
performed
ninety
operations
for
toxic
goitre
between
1892
and
1907.
His
mortality
was
just
over
two
per
cent.
Again
in
1912
Halsted
mentioned
the
operation
for
exophthalmic
goitre.'1
On
this
occasion
he
described
the
removal
of
the
second
lobe
if
the
patient
had
not
benefited
from
an
attack
on
one
lobe.
It
is
apparent
that
an
attack
on
the
second
lobe
almost
certainly
performed
at
a
separate
(second)
operation,
was
not
Halsted's
standard
operation
for
exophthalmic
goitre.
This
remained
sub-total
removal
of
one
lobe
and
one
lobe
only.
This
is
well
docu-
mented
in
a
curious
paper
entitled:
'The
excision
of
both
lobes
of
the
thyroid
gland
for
the
cure
of
Graves'
Disease'.'2
Here
it
is
stated
that
between
1902
and
1913
Halsted
had
to
attack
at
two
or
more
operations
the
greater
portion
of
both
lobes
of
the
thyroid
gland
in
thirty-nine
cases
of
Graves'
Disease,
a
minute
experience
as
will
be
seen
when
compared
to
the
operative
experience
of
Dunhill.
Finally,
in
a
paper
entitled
'The
significance
of
the
thymus
in
Graves'
Disease'
in
1914,
Halsted
stated
that
he
had
operated
on
500
cases
of
Graves'
Disease.43
Sixty
per
cent
were
cured
by
a
single
lobectomy,
but
forty-seven
required
excision
of
the
second
lobe
as
the
response
to
a
unilateral
attack
was
unsatisfactory.
Halsted
noted:
'It is
undoubtedly
because
surgeons
have
so
universally
confined
their
operations
to
the
excision
of
one
lobe
plus
perhaps
the
ligation
of
an
artery
of
the
other
that
the
results
have
not
been
better
than
they
are'.
Dunhill,
of
course,
had
realized
this
as
far
back
as
1907.
To
conclude,
Halsted
in
the
magnus
opus
titled
The
Operative
Story
of
Goitre-the
Author's
Operation
written
in
1920,
depicted
his
operation
both
diagrammatically
and
descriptively.
A
sub-total
excision
of
one
lobe
appears
to
be
the
standard
procedure.
The
second
lobe
is
attacked
at
a
second
operation.
Certainly
Halsted
cannot
claim
priority
(for
what
it
is
worth)
of
initiating
a
simultaneous
attack
on
the
second
lobe
in
exophthalmic
goitre.
George
Washington
Crile
was
the
direct
antithesis
of
Halsted.
Crile,
an
extrovert,
32
Thomas
Peel
Dunhill,
the
Forgotten
Man
of
Thyroid
Surgery
revelled
in
operating
before
large
audiences.
Halsted
appeared
to
be
the
mechanical
plodder,
while
Crile
was
the
committed
enthusiast.
Halsted
was
the
surgical
product
of
an
era
when
anatomy
and
pathology
dominated
medicine.
Crile
grappled
with
physico-biochemical
aspects
of
disease
and
even
as
an
operating
surgeon
was
able
to
hold
his
own
with
the
physiologists
and
biochemists
of
his
day.
In
1911,
Crile
wrote
an
article
entitled
'Graves'
Disease-a
new
principle
of
operation
based
on
a
study
of
352
operations'."
He
claimed
that
fear
plus
the
apparent
impulses
derived
from
the
thyroid
gland,
caused
an
overactivity
of
the
sympathetic
supply
to
the
thyroid
gland.
This
overactivity
released
the
thyroid
secretion
and
this
caused
the
hyper-
thyroidism
so
often
seen
after
operations
on
toxic
goitres.
Crile
therefore
developed
his
system
of
stealing
the
gland
under
'anoci
association'
anaesthesia.
The
patient
was
given
pre-operative
inhalations
of
various
sorts.
On
the
day
of
the
operation,
the
innocuous
inhalations
were
substituted
by
ether.
The
patient
was
therefore
anaesthetised
in
bed,
the
ether
then
changed
to
nitrous
oxide,
and
oxygen,
and
the
field
of
operation
infiltrated
with
local
anaesthetic.
One
lobe
only
was
removed.
Crile's
technique
was
the
same
as
Kocher's.
He
then
attempted
to
leave
behind
pieces
of
the
upper
and
lower
poles
of
the
thyroid
to
protect
the
parathyroids
and
recurrent
laryngeal
nerve.
Finally,
in
1922,
Crile
adopted
the
Mikulicz
technique,
leaving
behind
the
posterior
part
of
both
lobes.'5
In
essence,
the
use
of
local
anaesthesia
plus
light
general
anaesthesia
helped
to
avoid
anaesthetic
disasters
and
Crile
practised
a
relatively
bloodless
thyroidectomy
by
using
a
large
number
of
artery
forceps
as
he
clipped
and
cut
his
way
through
the
lobe
of
the
thyroid.
He
had
a
mortality
of
1.8
per
cent
for
toxic
goitre.
Like
Kocher
and
Charles
Mayo,
Crile
believed
in
pre-
liminary
ligation
of
the
superior
thyroid
vessels
if
the
toxicity
was
severe.
Though
the
surgery
of
toxic
goitre
had
shown
a
vast
improvement
in
morbidity
and
mortality
in
America,
and
the
experience
of
surgeons
like
Charles
Mayo
and
George
Crile
ran
into
thousands,
little
progress
had
been
made
in
England.
The
leading
thyroid
surgeon
at
this
time
was
James
Berry.
As
late
as
1913
in
the
Lettsomian
Lectures
on
'The
Surgery
of
the
Thyroid
Gland
with
Special
Reference
to
Exophthalmic
Goitre',
Berry
could
only
muster
sixty
cases
of
thyrotoxicosis
to
the
end
of
1912.46
Twenty-seven
of
these
were
described
as
suffering
from
exophthalmic
goitre.
Two
patients
died.
At
St.
Thomas's
Hospital
between
1908
and
1912,
nineteen
patients
with
toxic
goitre
had
been
subjected
to
operation
with
a
mortality
of
33
per
cent.47
The
reason
behind
this
high
mortality
appeared
to
be
the
relative
inexperience
on
the
part
of
the
English
sur-
geons,
anaesthetic
disasters
and
the
'last
resort'
type
of
case
that
was
continually
handed
over
by
the
attending
physician.
The
English
surgeons
were
the
victims
of
the
miscon-
ception
that
the
majority
of
the
cases
of
exophthalmic
goitre
got
better
without
surgery.
A
vicious
circle
was
set
up.
Patients
were
operated
on
very
late,
the
mortality
was
predictably
high
and
so
the
physicians
refused
to
refer
patients
for
early
operation.
Like
America,
the
early
development
of
thyroid
surgery
in
Australia
was
strongly
influenced
by
the
experiences
of
Theodor
Kocher.
One
of
the
earliest
articles
relating
to
the
thyroid
appeared
in
1882
and
was
simply
titled
'Case
of
myxoedema'
by
James
D.
Dunlop.48
The
first
account
of
successful
removal
of
a
goitre
is
contained
in
an
article
by
T.
N.
Fitzgerald,*
which
appeared
in
1884.'9
This
operation
was
*Sir
Thomas
Naghten
Fitzgerald
(1838-1908).
Irish
surgeon
who
migrated
to
Australia.
Appointed
33
I.
D.
A.
Vellar
carried
out
for
a
non-toxic
goitre
causing
difficulty
in
breathing.
Fitzgerald
followed
Billroth's
technique
closely
and
appears
to
have
removed
at
least
one
lobe
after
twenty
minutes
of
careful
dissection.
There
is
some
evidence
that
this
may
indeed
have
been
a
total
excision
of
the
thyroid.
In
the
discussion
that
followed,
Dr.
Jamieson
of
the
Melbourne
Hospital
mentioned
Kocher's
experience
with
total
thyroidectomy
and
the
cachexia
strumi
priva
following
this
procedure.
He
drew
attention
to
the
close
resemblance
of
the
clinical
picture
following
this
procedure
to
the
myxoedema
recently
described
by
William
Ord
in
England.
Dr.
Edward
Barker,*
surgeon
to
the
Melbourne
Hospital
and
former
pupil
of
the
great
Robert
Liston,
then
stated
that
he
had
removed
the
thyroid
on
two
occasions,
the
first
in
1864
and
the
second
in
1869.
He
stated
that
both
patients
died
within
two
years
of
the
operation
from
'exhaustion'.
It
is
unfortunate
that
Barker
did
not
provide
a
fuller
description
of
the
state
of
these
two
patients
as
he
may
have
been
describing
post-operative
myxoedema
following
total
thyroidectomy,
at
least
ten
years
before
Kocher's
case
of
1874.
Fitzgerald
mentioned
that
he
had
excised
the
thyroid
(?how
much)
on
three
occasions
prior
to
the
case
he
presented.
He
had had
some
trouble
with
haemorrhage
in
one
case
but
all
eventually
recovered
and
all
were
well.
It
would
seem
that
these
operations
were
not
total
removals.
Fitzgerald,
a
brilliant
and
dextrous
operator,
advocated
operation
in
every
case
of
symptomatic
goitre.
As
usual
he
tended
to
play
down
the
technical
difficulties
and
although
he
used
the
Billroth
technique
of
en
masse
ligation
of
the
thyroid
tissue,
he
did
not
operate
on
the
toxic
goitre.
The
first
account
of
exophthalmic
goitre
appearing
in
the
Australian
literature
is
represented
by
an
article
in
the
Australasian
Medical
Gazette
for
1885-1886
by
W.
Simpson
Flett.5°
The
author
devoted
himself
to
the
medical
treatment
current
at
that
time,
stressing
the
need
for
attention
to
diet
and
hygiene
and
Flett
mentions
the
use
of
ammonio-citrate
of
iron
for
the
anaemia,
belladonna
for
palpitations,
potassium
iodide
or
potassium
bromide
to
shrink
the
gland,
and
digitalis
for
swollen
feet.
External
applications
of
tincture
of
iodine
to
the
thyroid
and
the
use
of
electricity
to
the
gland
are
also
described.
The
author
in
common
with
most
of
his
colleagues
regarded
surgery
as
a
last
resort
type
of
therapy,
mentioning
the
cachexia
strumi
priva
described
by
Kocher
and
Reverdin,
which
followed
total
extirpation
of
the
gland.
One
can
sympathize
with
the
physician
unhappily
pursuing
a
course
between
the
Scylla
of
not
operating
on
the
severe
thyrotoxic
and
the
Charybdis
of
patients
dying
during
or
shortly
after
surgery
for
thyrotoxicosis.
In
the
decade
1890-1900
the
attention
and
interests
of
most
physicians
were
concentrated
on
myxoedema
and
cretinism
and
the
application
of
thyroid
substitution
therapy.
Some
of
the
difficulties
encountered
in
thyroid
therapy
are
pointed
out
by
Lendon.51
He
tells
how
a
country
patient
of
his
suffering
from
myxoedema
was
apparently
failing
to
respond
to
the
ingestion
of
fresh
sheep's
thyroid,
until
he
discovered
she
was
ingesting
the
sub-
mandibular
salivary
glands.
When
the
patient
corrected
this
error
in
anatomy,
she
improved
rapidly!
surgeon
to
the
Melbourne
Hospital.
Brilliant
technician
who
was
never
quite
converted
to
the
antiseptic
school
of
surgery.
Reputed
to
have
earned
one
million
pounds
during
his
surgical
lifetime.
Taught
G.
A.
Syme
and
William
Moore.
*Edward
Barker
(1818-1885).
English
surgeon
who
trained
at
University
College
Hospital
before
migrating
to
Victoria
in
1840.
He
became
the
first
lecturer
in
surgery
to
the
University
of
Melbourne.
34
Thomas
Peel
Dunhill,
the
Forgotten
Man
of
Thyroid
Surgery
The
first
account
of
thyroidectomy
for
Graves'
Disease
in
the
Australasian
literature
appears
in
the
Transactions
of
the
Inter-colonial
Medical
Congress
of
1896.
In
a
rather
skimpy
article,
Albert
Martin
described
excision
of
one
lobe
of
the
thyroid.62
He
made
no
attempt
to
dissect
the
vessels
but
used
an
aneurysm
needle
and
en
masse
ligation
to
remove
the
lobe.
In
the
same
issue,
J.
0.
Closs
of
Dunedin
described
four
cases
of
Graves'
Disease
treated
by
excision
of
one
lobe."
There
was
one
death
due
to
post-operative
thyroid
crisis.
He
followed
Kocher's
technique
closely
in
preference
to
the
Mikulicz
resection.
The
first
reported
thyroidectomy
for
Graves'
Disease
in
Australia
emanated
from
Bendigo,
Victoria.
Here
in
1897,
an
intrepid
surgeon
named
W.
J.
Long,*
operated
on
a
case
of
exophthalmic
goitre."
He
removed
one
lobe
of
the
thyroid
and
the
related
recurrent
laryngeal
nerve
as
well.
The
patient,
a
young
woman,
had
a
post-operative
crisis
but
recovered
from
this
and
was
much
improved,
but
was
left
somewhat
hoarse.
Chloroform
was
the
anaesthetic
agent.
It
can
be
readily
seen
that
though
there
were
a
few
cases
of
successful
removal
of
the
thyroid
or
part
of
the
thyroid
for
non-toxic
goitre
causing
pressure
symptoms,
operation
was
rarely
practised
for
exophthalmic
goitre.
Haemorrhage,
post-operative
crises
and
death
on
the
table
from
chloroform
anaesthesia
plagued
the
surgeon
who
dared
to
operate.
Current
medical
thinking
at
that
time
is
reflected
in
a
review
of
James
Berry's
book
Diseases
of
the
Thyroid
Gland
and
Their
Surgical
Management."
The
reviewer
deplores
the
fact
that
Berry
fails
to
quote
the
Australian
experience
with
regard
to
hydatid
disease
of
the
thyroid!
He
agrees
however,
with
Berry's
assertion
that
surgical
treatment
was
worse
than
useless
in
exophthalmic
goitre.
The
reviewer
then
states
that:
'Many
operations
have
been
practised
in
these
cases
and
the
larger
ones
are
very
dangerous
and
whilst
good
results
have
followed
in
some
cases,
these
are
insufficient
to
justify
the
risk.
Also
there
is
a
strong
tendency
towards
recovery'.
This
then
was
the
state
of
affairs
in
Australia
when
Dunhill
commenced
his
medical
studies.
Thomas
Peel
Dunhill
graduated
in
1903
from
the
Clinical
School
of
the
old
Melbourne
Hospital.
Like
Sir
Hugh
Devine,**
whom
he
influenced
so
much,
Dunhill
completed
a
course
in
pharmacy
before
entering
medicine.
Dunhill
obtained
passes
in
theory
and
practice
of
medicine,
surgery,
obstetrics
and
diseases
of
women
and
children
as
well
as
in
forensic
medicine.
At
the
honours
examination
held
in
the
first
term
of
1904
he
obtained
First
Class
Honours
in
medicine,
surgery
and
obstetrics
and
in
diseases
of
women
and
children.
Aged
twenty-seven,
he
was
older
than
the
usual
medical
graduate
and
had
already
published
an
article
as
a
medical
student
on
'Albuminuria
following
severe
exercise
in
healthy
persons'.56
His
surgical
residency
at
the
Melbourne
Hospital
was
spent
with
William
Moore.
It
was
probably
during
this
period
that
the
problems
in
the
management
of
exophthalmic
goitre
first
attracted
him.
He
recalled
many
years
later
how
he
had
seen
his
chief
'of
indomitable
courage'
operate
on
two
cases
of
toxic
goitre
under
chloroform
anaesthesia.
Both
patients
had
*W.
J.
Long.
Graduated
from
the
University
of
Melbourne
in
1892
and
then
practised
as
a
surgeon
in
Bendigo,
a
Victorian
provincial
centre.
Elected
a
Fellow
of
the
Royal
Australasian
College
of
Surgeons
in
1928.
**Sir
Hugh
Berchmans
Devine
(1878-1959).
Surgeon
to
St.
Vincent's
Hospital,
Melbourne.
He
became
the
leading
abdominal
surgeon
in
Australia
and
devised the
Devine
Frame,
a
square
metal
retractor
to
aid
and
facilitate
exposure
in
the
abdomen.
35
I.
D.
A.
Vellar
died.
Having
completed
his
residency
at
the
Melbourne
Hospital,
Dunhill
had
to
decide
where
his
future
in
medicine
lay.
Not
being
wealthy
(he
came
from
'Tragowell',
a
sheep
and
cattle
station
near
Kerang
in
north-east
Victoria)
and
not
having
con-
nexions
of
the
right
kind,
he
left
the
Melbourne
Hospital
and
accepted
the
invitation
of
Mother
Berchmans
Daly
to
join
the
staff
of
St.
Vincent's
Hospital.
Although
he
had
already
decided
to
pursue
a
career
in
surgery,
as
there
were
no
surgical
vacancies
at
St.
Vincent's
at
that
time,
he
was
appointed
in
1905
physician
to
outpatients,
and
anaesthetist.
By
1906,
he
was
listed
as
surgeon
to
outpatients
and
surgical
pathologist.
His
chief
was
now
David
Murray
Morton.
In
the
same
year
he
was
awarded
his
Doctorate
in
Medicine
for
a
thesis
entitled
'An
Investigation
of
Opsonic
Indices
as
a
Guide
to
Therapeutic
Innoculation
by
Vaccines
with
some
Results
of
Innoculation'.
He
was
now
about
to
embark
on
his
life's
work
with
thyrotoxicosis,
which
legiti-
mately
entitles
him
to
be
ranked
with
Kocher,
Mayo,
Crile
and
Halsted.
St.
Vincent's
Hospital,
Melbourne,
was
officially
opened
on
5
November
1893.
The
first
Rectress,
Mother
M.
Berchmans
Daly,
was
appointed
in
1892.
It
would
not
be
exaggerating
to
say
that
the
foundation
of
the
hospital
and
its
continuing
success
was
entirely
due
to
the
efforts
of
this
first
Rectress.
She
proved
to
be
an
extraordinary
organizer,
an
indefatigable
worker
and showed
a
rare
insight
in
the
appointment
of
staff
to
the
new
hospital.
It
was
on
account
of
her
that
Thomas
Dunhill
and
Hugh
Devine
were
able
to
make
their
mark
in
surgery.
Whilst
Dunhill
was
an
outpatient
physician,
he
became
interested,
naturally,
in
the
management
of
exophthalmic
goitre.
The
medical
management
at
that
time
reflected
the
total
lack
of
specific
therapy
and
this
of
course
resulted
from
a
lack
of
understanding
of
thyroid
function.
The
list
of
remedies
which
at
one
time
or
another
were
claimed
as
specific
for
the
patient
with
exophthalmic
goitre,
was
truly
impressive.
Kocher
had
wamed
of
the
danger
of
using
iodides
in
goitre
patients
and
this
probably
delayed
the
exhibition
of
iodides
in
toxic
goitre
for
many
years
until
Henry
Plummer
reintroduced
this
method
of
treatment
in
1923.57
Sodium
phosphate,
sodium
chloride,
ergot,
belladonna,
morphia
and
bro-
mides
were
used
in
conjunction
with
rest
in
bed
and
a
milk
diet.
Ice-bags
placed
on
the
neck
and
over
the
praecordium
were
also
in
vogue.
Aconite,
stropanthus
and
digitalis
were
also
used.
Finally,
faradic
currents
and
tincture
of
iodine
were
applied
locally
to
the
gland.
Almost
certainly
any
amelioration
resulted
from
a
spontaneous
remission
or
from
the
disease
processburning
itself
out.
Whilst
this
uncommon
eventwas
awaited,
the
severe
thyrotoxics,
often
grossly
emaciated
and
perhaps
blind
from
the
corneal
ulceration,
succumbed
to
intercurrent
pulmonary
infection,
cardiac
failure
or
from
the
uncontrollable
vomiting
and
diarrhoea,
coma
and
hyperpyrexia
of
uncontrolled
thyroid
crisis.
Invoking
the
theory
that
the
body
normally
produces
some
factor
that
neutralized
the
thyroid
toxin
responsible
for
the
production
of
the
clinical
signs
of
exophthalmic
goitre,
physicians
introduced
a
host
of
remedies
derived
mainly
from
animals
that
had
had
the
thyroid
gland
removed.
The
first
of
these
remedies
was
the
milk
of
thyroidectomized
goats
marketed
commercially
as
Rodagen.
Another
preparation
was
called
Thyroid-
ectin
and
this
was
prepared
from
the
serum
of
thyroidectomized
animals.
It
was
taken
orally.
At
about
this
time,
1906,
Beebe
from
New
York
advocated
the
use
of
cytolytic
serum.58
This
was
obtained
by
injecting
an
animal
with
thyroid
extract
and
then
36
Thomas
Peel
Dunhill,
the
Forgotten
Man
of
Thyroid
Surgery
injecting
the
serum
of
this
animal
into
a
patient
suffering
from
toxic
goitre.
Though
holding
some
theoretical
attraction,
this
method
too
was
eventually
discarded.
The
same
fate
awaited
the
use
of
adrenaline,
thymus
extracts
and
parathyroid
extracts.
Dunhill,
on
the
advice
of
Dr.
Grant
and
Dr.
Maudsley,
the
in-patient
physicians
at
St.
Vincent's
at
that
time,
had
been
giving
the
milk
of
thyroidectomized
goats
to
a
group
of
patients
suffering
from
exophthalmic
goitre.
Dunhill
used
to
operate
on
the
goats
at
Melbourne
University
and
after
he
had
removed
the
thyroid
and
the
goat
recovered,
he
would
milk
the
goat
himself
and
return
to
St.
Vincent's,
there
to
dis-
tribute
the
milk
to
thyrotoxic
patients.
By
1907,
Dunhill
had
realized
the
inefficiency
of
medical
treatment
available
at
that
time
for
patients
suffering
from
thyrotoxicosis.
He
was
also
impressed
by
Kocher's
results
in
operations
on
the
thyroid
using
local
anaesthesia
and
of
course
he
had
seen
the
disasters
which
had
accompanied
general
anaesthesia
in
the
surgery
of
toxic
goitre.
It
is
readily
understood
now
how
the
com-
bination
of
anoxia,
chloroform
overdosage
and
cardiac
failure
often
proved
lethal.
Dunhill
had
also
read
A.
E.
Barker's
paper
in
the
Practitioner
of
September
1907,
which
described
the
use
of
a
mixture
of
eucaine
and
adrenaline
(j
per
cent
eucaine
and
1
in
250,000
adrenaline)
for
local
anaesthesia
in
thyroid
surgery.59
Dunhill
also
doubted
the
claimed
efficacy
of
other
operative
procedures
on
the
thyroid
gland
such
as
the
exteriorization
of
the
gland
and
unilateral
or
bilateral
cervical
sympathectomy.
These
operations
had
been
popularized
by
Jaboulay
in
his
book
Chirurgie
du
Grand
Sympathetique
et
du
Corps
Thyroide.60
The
operations
on
the
cervical
sympathetic
chain,
whilst
producing
a
certain
questionable
cosmetic
improvement
by
the
ptosis
produced,
nevertheless
failed
to
attack
the
site
of
disordered
function.
Disheartened
by
the
results
of
medical
treatment
of
Graves'
Disease
and
guided
by
Kocher's
ex-
perience
with
local
anaesthesia,
Dunhill
embarked
on
his
career
as
a
thyroid
surgeon.
As
an
outpatient
surgeon
at
St.
Vincent's,
he
had
no
beds.
He
was
allowed
the
use
of
a
bed
by
his
chief,
David
Murray
Morton.*
Into
this
bed,
situated
on
a
balcony
leading
off
from
St.
Clare's
female
ward,
was
admitted
a
thirty-six-year-old
Irish
servant
girl,
Mary
Lynch.
She
had
been
admitted
under
the
care
of
Dr.
Grant
with
exophthalmic
goitre
on
25
March
1907.
Despite
the
usual
rest
in
bed,
sodium
phos-
phate,
sodium
bromide,
Rodagen
and
thyroidectin,
she
continued
to
lose
weight
and
commenced
vomiting.
In
Dunhill's
own
words:
'She
was
emaciated
and
had
all
the
symptoms
in
an
extreme
degree.
She
could
not
work.
She
preferred
any
risk
to
re-
maining
as
she
was'.
On
30
July
1907,
with
the
assistance
of
Murray
Morton,
Dunhill
removed
the
right
lobe
of
the
thyroid
under
eucaine
and
adrenaline
anaesthesia.
He
also
noted
that
after
this
operation
the
patient
was
able
to
get
up
from
the
operating
table
and
walk
back
to
her
own
bed!
The
hospital
record
of
this
event
(fig.
2)
is
the
very
essence
of
brevity.
The
house
surgeon's
signature
belongs
to
Dr.
A.
E.
Harker.
'Exopthalmos'
is
of
course
spelt
incorrectly,
and
R.
D.
signifies
'Relieved
Discharged'.
This
operation
of
Dunhill's
was
the
fourth
thyroidectomy
performed
at
St.
Vincent's
Hospital
since
its
inception
in
1893.
The
first
thyroidectomy
(consisting
of
removal
of
the
left
lobe)
was
carried
out
by
G.
A.
Syme**
on
3
April
1902.
This
was
for
a
non-toxic
*David
Murray
Morton
(1871-1959).
General
practitioner
who
later
became
senior
surgeon
at
St.
Vincent's
Hospital,
Melbourne.
Assisted
Dunhill
during
his
first
thyroidectomy.
Foundation
Fellow
of
the
Royal
Australasian
College
of
Surgeons.
**Sir
George
Adlington
Syme
(1859-1929).
A
pupil
of
Sir
Thomas
Naghten
Fitzgerald,
he
was
37
I.
D.
A.
Vellar
goitre;
chloroform
was
used
and
the
patient
recovered.
The
first
thyroidectomy
for
thyrotoxicosis
was
performed
by
William
Moore,*
Dunhill's
chief
at
the
Melbourne
Hospital,
who
was
also
an
in-patient
surgeon
to
St.
Vincent's
Hospital
at
that
time.
This
was
performed
on
14
June
1904
and
chloroform
anaesthesia
was
used.
The
patient,
a
woman
in
her
thirties,
was
three
months
pregnant.
She
had
moderately
severe
thyrotoxicosis.
One
lobe
was
removed.
There
was
a
mild,
post-operative
crisis
which
she
was
able
to
survive
and
she
was
discharged
relieved.
The
third
thyroidectomy
ended
tragically.
A
seventeen-year-old
girl
with
severe
thyrotoxicosis
was
operated
on
by
William
Moore
under
ether
and
chloroform
anaesthesia.
She
collapsed
and
died
as
the
operation
was
being
completed.
The
fourth
thyroidectomy
was
of
course
Dunhill's
first
operation
on
Miss
Lynch.
It
took
no
small
amount
of
courage
to
attempt
a
thyroidectomy
on
such
a
severely
thyrotoxic
patient.
The
local
statistics
for
the
surgery
of
exophthalmic
goitre
were
hardly
encouraging
and
the
medical
atti-
tude
dictated
that
surgery
was
to
be
regarded
as
the
last
throw
of
the
dice.
The
secret
of
Dunhill's
continuing
success
lay
in
his
technique.
Instead
of
the
scalpel
and
forceps
dissection
of
the
goitre
which
often
produced
disastrous
bleeding
from
the
fragile,
dilated
arteries
and
veins,
he
dislocated
the
gland
by
gentle
finger
dissection,
dissected
cleanly
the
vascular
pedicle
and
early
in
the
operation
ligated
and
cut
both
the
superior
and
inferior
thyroid
arteries.
His
lobectomy
was
thus
gently
executed
and
relatively
bloodless.
Dunhill
published
his
first
article
on
thyroidectomy
in
exophthalmic
goitre
in
the
Inter-colonial
Medical
Journal
of
Australasia,
20
November
1907.61
He
had
by
then
operated
on
seven
cases,
all
under
local
anaesthesia.
These
cases
constituted
a
type
of
surgical
chain
reaction.
When
Dunhill
had
operated
successfully
on
Miss
Lynch,
all
the
other
patients
after
seeing
the
improvement
which
surgery
had
effected,
submitted
themselves,
one
by
one,
to
operation!
All
of
these
cases
had
severe
thyrotoxicosis,
all
had
one
lobe
and
the
isthmus
removed,
all
recovered
and
the
short-term
results
were
good,
there
being
a
gratifying
reduction
in
the
pulse
rate
plus
significant
weight
gain.
In
the
space
of
six
months,
Dunhill
performed
more
successful
operations
on
patients
with
exophthalmic
goitre
than
the
combined
experience
of
the
Melbourne
Hospital,
the
Alfred
Hospital
and
the
Homeopathic
Hospital
since
the
inception
of
those
in-
stitutions.
Most
important,
his
mortality
was
nil.
This
was
sufficient
to
merit
editorial
comment
in
the
same
issue.62
With
a
not
surprising
'middle
of
the
road'
bias
the
follow-
ing
comments
were
made:
'The
difficulty
in
estimating
the
possible
value
of
such
sur-
gical
procedure
as
described
by
T.
P.
Dunhill
lies
in
the
fact
that
there
is
still
room
for
difference
of
opinion
as
to
the
part
played
by
the
thyroid
gland
in
producing
the
symptom
complex
characteristic
of
the
affection.
How
far
the
result
in
Dr.
Dunhill's
cases
will
be
curative
remains
to
be
seen.
It
is
not
to
be
desired
that
a
cacoethes
seccandi
should
immediately
attach
to
the
treatment
of
Graves'
Disease,
but
the
successively
inpatient
surgeon
to
St.
Vincent's
Hospital
and
the
Melbourne
Hospital.
In
1894
he
performed
the
first
successful
excision
of
a
meningioma
in
Australia.
Became
the
first
President
of
the
Royal
Australasian
College
of
Surgeons.
*William
Moore
(1859-1927).
Inpatient
surgeon
to
St.
Vincent's
Hospital
and
the
Melbourne
Hospital.
As
Dunhill's
chief
he
helped
to
stimulate
his
interest
in
the
thyroid
gland.
Was
instrumental
in
eliminating
the
bribery
and
corruption
which
attended
the
election
of
medical
staff
to
the
Melbourne
Hospital.
38
Thomas
Peel
Dunhill,
the
Forgotten
Man
of
Thyroid
Surgery
careful
observations
of
a
series
of
cases
by
any
one
surgeon
would
do
much
to
clear
up
some
uncertainty
as
to
the
probable
benefit
and
possible
danger'.
Dunhill
was
more
than
equal
to
the
challenge.
He
had
realized
that
the
use
of
local
anaesthesia
had
eliminated
the
risk
of
death
from
the
use
of
chloroform,
and
that
one
lobe
and
the
isthmus
could
be
removed
bloodlessly
by
ligation
and
division
of
the
thyroid
arteries
and
veins
and
then
dislocating
the
gland
forwards
and
medially.
He
had
also
not
hesitated
to
operate
on
two
patients
with
auricular
fibrillation,
a
condition
which
practically
contraindicated
operation
in
Kocher's
view.
Both
of
these
patients
sur-
vived.
Dunhill's
next
communication
was
titled
'The
surgical
treatment
of
exophthal-
mic
goitre'
and
this
was
published
in
1908.63
This
is
a
sober,
well-reasoned
article,
opening
with
a
review
of
the
then
recent
literature
showing
the
rationale
of
the
opera-
tive
treatment
of
Graves'
Disease
and
finally
he
discusses
his
own
cases.
In
the
year
since
he
had
operated
on
Miss
Lynch,
he
had
performed
lobectomy
thirty-two
times
in
twenty-five
patients.
He
had
had
one
death,
his
thirteenth
case.
All
the
patients
were
severely
thyrotoxic.
All
had
initially
the
larger
lobe
and
the
isthmus
removed.
However,
in
six
patients,
a
second
operation
was
required
in
which
at
least
half
of
the
remaining
lobe
was
ablated.
Dunhill
had,
by
this
stage,
grasped
the
essence
of
the
problem-enough
gland
had
to
be
removed
to
cure
the
patient.
In
the
six
cases,
the
initial
improvement
was
not
maintained
after
a
single
lobe
had
been
excised.
Dunhill
did
not
hesitate
to
remove
part
of
the
remaining
lobe
to
effect
a
cure.
His
third
case,
a
women
aged
thirty-five,
had
one
lobe
and
the
isthmus
removed
on
10
October
1907.
She
failed
to
maintain
the
initial
improvement
and
so
had
most
of
the
remaining
lobe
removed
under
local
anaesthesia
on
17
December
1907.
The
famous
Miss
Lynch
eventually
returned
to
have
most
of
the
remaining
lobe
removed
in
March
1908.
Again,
unlike
Kocher
and
Charles
Mayo,
who
regarded
cardiac
failure
and
an
irregu-
lar
pulse
as
contraindications
to
surgery,
Dunhill
insisted
that
a
marked
improvement
in
the
cardiac
state
could
follow
if
the
thyrotoxicosis
was
controlled
by
adequate
removal
of
the
gland.
Two
of
his
cases
were
in
extremis
in
gross
cardiac
failure
with
auricular
fibrillation,
yet
both
withstood
removal
of
one
lobe
and
isthmus
under
local
anaesthesia
and
showed
marked
improvement.
The
one
death
ironically
appears
to
be
associated
with
his
first
attempt
to
perform
a
simultaneous
bilateral
attack
on
the
thyroid.
In
a
case
of
severe
thyrotoxicosis
with
bilateral
enlargement
of
the
gland,
Dunhill
removed
one
lobe,
the
isthmus
and
half
the
second
lobe
in
one
operation.
The
patient
subsequently
died
in
thyroid
crisis.
Dunhill
thought
that
this
resulted
from
trying
to
do
too
much
at
one
time
and
reflected
that
a
staged
attack
might
have
produced
happier
results.
Dunhill
insisted
that
the
operation
should
never
be
regarded
as
a
last
resort
and
pleaded
for
early
surgical
intervention.
Of
his
first
twenty-five
patients
operated
on
for
thyrotoxicosis,
only
five
were
referred
by
his
medical
col-
leagues.
All
the
others
were
directly
or
indirectly
referred
by
his
first
six
successful
cases.
These
ideas
were
even
more
forcefully
presented
to
the
Eighth
Australasian
Medical
Congress
held
in
Melbourne
in
October
1908."
At
this
time,
Dunhill
had
performed
forty-seven
thyroidectomies
for
exophthalmic
goitre.
Ten
of
these
opera-
tions
were
second
operations
on
the
remaining
lobe
of
the
thyroid
because
the
patient
had
relapsed
after
a
single
lobectomy.
In
contrast,
Charles
Mayo,
reporting
on
his
experiences
in
1909,
recommended
ligation
of
the
superior
thyroid
vessels
to
the
39
L
D.
A.
Vellar
remaining
lobe
to
control
any
relapse
after
a
single
lobe
had
been
removed.
Dunhill
vehemently
denied
that
simple
ligation
could
control
recurrent
thyrotoxicosis.
At
this
time,
knowledge
of
the
physiology
and
biochemistry
of
the
thyroid
was
rudimentary.
Surgeons
knew
that
if
the
whole
thyroid
was
excised,
then
myxoedema
and
tetany
followed.
Just
how
much
thyroid
one
could
remove
without
causing
these
dreaded
complications
was
not
known.
In
1908
Dunhill
had
attempted
to
rationalize
the
attack
on
the
second
lobe
by
incriminating
the
size
of
the
lobe.65
He
wrote:
'I
had
just
begun
to
recognize
that
in
a
large
bilateral
vascular
goitre,
the
removal
of
one
lobe
was
not
enough
to
cure
the
case.
The
disease
being
a
thyrotoxicosis,
the
large
vascular
lobe
which
remains
is
still
larger
than
a
normal
thyroid
and
pours
out
thyrotoxic
material
sufficient
to
cause
all
the
symptoms
of
exophthalmic
goitre'.
Thyroxine
had
not
yet
been
discovered
and
it
was
widely
thought
that
the
secretion
of
a
toxin
from
the
thyroid
lay
at
the
root
cause
of
exophthalmic
goitre.
Not
only
was
Dunhill
advocating
an
attack
on
the
second
lobe
(unlike
the
American
authorities
such
as
Mayo,
Crile
and
Halsted
who
were
content
to
perform
a
single
lobectomy
and
a
ligation
of
the
superior
or
inferior
thyroid
vessels
for
relapse)
he
strongly
advised
surgery
for
the
thyrocardiac.
Dunhill
indeed
was
the
first
surgeon
to
convincingly
demonstrate
the
efficacy
of
thyroidectomy
in
the
thyrocardiac
patient.
By
1909
Dunhill's
exploits
were
filtering
through
to
the
general
public.
He
was
the
only
person
in
Victoria,
probably
Australia,
who
was
consistently
curing
or
greatly
improving
patients
suffering
from
exophthalmic
goitre
by
safe
operating.
He
made
his
first
contribution
to
the
international
literature
in
1909,
in
a
paper
entitled
'Remarks
on
partial
thyroidectomy,
with
special
reference
to
exophthalmic
goitre
and
observa-
tions
on
113
operations
under
local
anaesthesia'."
He
had
by
then
performed
eighty-
eight
operations
on
patients
suffering
from
exophthalmic
goitre,
by
far
the
largest
experience
of
any
Australasian
surgeon.
Half
of
these
cases
were
physician
referred,
a
major
breakthrough
in
medical
education.
Once
again,
he
reiterates
in
this
article
the
rationale
of
his
operative
therapy
for
exophthalmic
goitre,
the
necessity
for
early
operation
if
the
case
fails
to
respond
to
rest,
the
importance
of
removing
enough
of
the
gland,
and
despite
the
death
of
his
thirteenth
case,
as
a
result
of
the
experience
gained
he
did
not
hesitate
to
complete
the
operation
in
one
stage
in
suitable
cases,
removing
one
lobe,
isthmus
and
at
least
one
half
of
the
other
lobe.
He
wrote:
'Latterly,
with
increasing
rapidity
in
operating,
I
have
been
removing
one
lobe,
the
isthmus
and
half
of
the
second
lobe
at
one
operation,
when
I
have
judged
that
wise.
The
time
taken
and
the
amount
of
handling
necessary
for
this
are
less
than
was
required
for
the
removal
of
one
lobe
in
my
earlier
operations';
and
again
'Of
the
exophthalmic
cases,
52
were
typical
cases
with
classical
symptoms,
15
of
these
52
had
part
of
the
second
lobe
subsequently
removed.
Of
this
class
I
can
say
that
in
every
case
where
the
re-
moval
of
the
larger
lobe
has
not
effected
a
cure,
the
removal
of
part
of
the
second
lobe
has
done
so
(always
excepting
the
one
case
which
died).
In
many
of
the
latter
cases
one
and
a
half
lobes
were
removed
at
one
operation'.
Dunhill
continued
to
operate
on
cases
in
cardiac
failure
and
with
auricular
fibrilla-
tion
and
whereas
authorities
such
as
Kocher,
William
Osler
and
Charles
Mayo
re-
garded
this
as
a
more
or
less
absolute
contraindication
to
surgery,
Dunhill
convin-
cingly
demonstrated
the
curative
effect
of
thyroidectomy
in
the
thyrocardiac.
'Eight
40
Thomas
Peel
Dunhill,
the
Forgotten
Man
of
Thyroid
Surgery
cases
with
irregular
heart
beats
and
pronounced
oedema,
of
these
4
had
part
of
the
second
lobe
subsequently
removed:
one
had
a
third
operation
because
the
upper
lobe
left
after
the
second
operation
was
unsightly.
The
original
goitre
had
been
of
immense
size.
Every
one
of
these
stood
the
operation
well'.
To
summarize,
by
1909
Dunhill
had
grasped
the
necessity
for
early
operation,
was
carrying
out
a
one-stage
bilateral
attack
on
the
thyroid
in
exophthalmic
goitre
in
selected
cases
and
he
did
not
hesitate
to
operate
on
the
thyrocardiac.
Cases
were
now
coming
to
Dunhill
from
all
over
Australia
and
New
Zealand.
By
1910,
Dunhill
had
performed
312
operations
on
the
thyroid,
200
being
on
exophthalmic
goitre.67
He
had
lost
only
three
patients!
One
died
of
pneumonia
post-operatively,
two
were
mori-
bund
when
subjected
to
surgery,
the
typical
last
resort
cases
which
Dunhill
was
trying
to
eliminate
by
earlier
surgery.
The
same
message
is
hammered
home-earlier
surgery
if
the
patient
is
not
responding
to
conservative
management,
the
necessity
for
local
anaesthesia,
the
importance
of
avoiding
surgery
at
the
height
of
a
crisis
or
if
bron-
chitis
was
present
and
the
necessity
to
remove
enough
thyroid.
This
meant
removing
one
lobe
and
at
least
one-half
to
two-thirds
of
the
other
lobe
at
one
operation.
Dunhill
stated:
'The
operation
must
frequently
result
in
failure
if
only
one
lobe
is
removed,
the
other
lobe
at
the
same
time
being
large
and
vascular.
Removal
of
one
lobe
may
not
do
a
patient
any
good
at
all,
and
it
is
because
one
whole
lobe
is
generally
left
that
the
operation
is
frequently
spoken
of
as
not
being
successful.
That
I
should
think
is
the
explanation
of
the
statement
which
occurs
in
the
British
Medical
Journal
of
1st
October,
1910,
where
13
cases
were
operated
upon
at
St.
Thomas's
Hospital,
5
died,
5
improved
and
3
remained
in
statu
quo'.
He
had
not
encountered
myxoedema
or
tetany
in
any
of
his
cases,
certainly
his
methods
of
operating
ensured
the
survival
of
some
thyroid
and
parathyroid
tissue,
the
posterior
aspect
of
the
second
lobe
being
left
behind.
By
the
time
1910
had
drawn
to
a
close,
a
number
of
other
important
achievements
involving
Dunhill
and
St.
Vincent's
Hospital
require
to
be
noted.
Firstly,
Dunhill,
with
the
help
of
Hugh
Devine
and
the
Mother
Rectress
of
the
hospital,
had
succeeded
in
having
St.
Vincent's
Hospital
recognized
as
a
clinical
school.
The
first
clinical
lec-
turers
in
surgery
were
Murray
Morton
and
Douglas
Shields,
and
the
first
surgical
tutors
T.
P.
Dunhill
and
Hugh
Devine.
Dunhill
recalls this
part
of
his
life
in
a
letter
to
Hugh
Devine
written
some
months
before
his
death
in
1957.
He
wrote:
'Those
were
great
days.
I
remember
spending
most
of
my
time
during
the
first
year
or
two
on
a
continuous
triangular
circuit-Professor
Allen
at
the
University,
Mother
Berch-
mans
at
St.
Vincent's
and
the
Chief
Medical
Officer
of
the
City
Council
[Colonel
Norris]
who
finally
gave
what
he
called
his
"permissive
tolerance"
for
the
use
of
the
semi
basement
at
St.
Vincent's
for
a
teaching
hospital'.
1910,
of
course,
was
also
the
year
Dunhill
and
Hugh
Devine
assisted
Douglas
Shields
when
Shields
operated
on
the
Countess
of
Dudley
and
removed
a
stone
from
her
ureter.
Douglas
Shields
was
then
surgeon
to
the
Governor
General
of
Australia,
even
though
he
did
not
hold
a
senior
surgical
degree.8
Shields
had
to
operate
in
the
ballroom
of
Government
House
which
had
been
converted
into
a
makeshift
operating
theatre.
This
operation
proved
to
be
a
success
and
the
relieved
Countess
was
later
instrumental
in
setting
up
a
private
hospital
for
Douglas
Shields
in
Park
Lane
when
Shields
moved
to
England
in
1912.
41
I.
D.
A.
Vellar
During
this
time,
Dunhill
was
steadily
moving
up
the
surgical
pyramid.
In
1906
he
was
surgeon
to
outpatients.
In
1907
he
is
listed
as
junior
surgeon
to
inpatients
and
in
1910
he
is
designated
with
Hugh
Devine
as
assistant
surgeon
to
inpatients.
The
sur-
geons
to
inpatients
for
that
year
consisted
of
David
Murray
Morton
and
Douglas
Shields.
David
Murray
Morton
played
an
important
role
in
encouraging
Dunhill's
interest
and
talents
in
the
surgery
of
the
thyroid.
As
has
already
been
noted,
it
was
he
who
gave
Dunhill
a
bed
so
that
Dunhill
could
operate
on
Miss
Lynch
and
he
actually
assisted
Dunhill
at
this
operation.
Dunhill
decided
to
travel
overseas
in
1911
and
to
visit
some
of
the
thyroid
centres
in
England
and
America.
Whilst
in
England,
he
was
supposed
to
deliver
a
paper
before
the
surgical
section
of
the
Royal
Society
of
Medi-
cine
on
3
February
1912.
However,
Dunhill
was
unable
to
be
in
London
at
this
time
and
so
the
paper
was
delivered
by
James
Berry,
probably
the
most
experienced
thyroid
surgeon
in
England
at
that
time.69
In
those
days
manuscripts
were
accepted
and
printed
with
alacrity,
for
the
same
paper
entitled
'Partial
thyroidectomy
under
local
anaesthesia
with
special
reference
to
exophthalmic
goitre'
appeared
in
the
Lancet
of
17
February
1912.70
It
is
virtually
the
paper
he
published
in
the
Australian
Medical
Journal
of
20
November
1910.
The
Lancet
publication
was
obviously
intended
for
English
and
American
consumption
in
case
the
colonial
literature
had
escaped
them!
The
discussion
that
followed
Dunhill's
paper
at
the
Royal
Society
of
Medicine
is
of
more
than
passing
interest.
Sir
Victor
Horsley
opened
the
discussion.
He
agreed
with
Dunhill
that
the
danger
of
operation
was
nil
(!)
but
apparently
he
refused
to
operate
on
the
really
severe
cases.
Again,
Horsley
only
removed
one
lobe.
Horsley
stated
that
true
exophthalmic
goitre
often
got
well
with
Faradism
and
rest-cure
treatment!
He
had
seen
no
deaths
from
general
anaesthesia.
Horsley's
experience
in
the
surgery
of
exophthalmic
goitre
was
minute
when
compared
with
Dunhill's
and
by
not
operat-
ing
on
the
severe
cases
he
certainly
kept
his
mortality
down.
The
remaining
discussion
appeared
to
be
in
Dunhill's
favour.
The
surgeons
participating,
however,
failed
to
mention
their
own
figures,
probably
because
their
personal
experiences
were
embar-
rassingly
small.
On
27
February
1912,
the
discussion
was
continued
by
Dr.
Hector
MacKenzie."
He
queried
the
truth
of
some
of
Dunhill's
claims
and
the
reason
for
this
is
clear-the
operative
mortality
at
his
own
hospital,
St.
Thomas's,
was
appalling
(six
cases
out
of
nineteen)
and
he
obviously
could
not
believe
that
this
unknown
surgeon
from
the
colonies
could
claim
only
four
deaths
in
230
cases
of
exophthalmic
goitre.
MacKenzie
was
followed
by
Albert
Kocher,
the
son
of
the
great
Swiss
thyroid
pioneer
Theodor
Kocher.
Albert
Kocher
mentioned
the
experience
at
the
Berne
Klinik
with
Graves'
Disease
(800
cases).72
Operative
treatment
consisted
in
the
main
of
removal
of
one
lobe
with
perhaps
ligation
of
the
contralateral
superior
thyroid
artery.
Rarely
was
a
second
operation
performed
on
the
remaining
lobe,
but
he
stressed
the
difficulty
of
performing
this
second
operation.
No
mention
was
made
of
a
bilateral
attack
on
the
gland.
Theodor
Kocher
was
still
dominated
by
the
spectre
of
cachexia
strumi
priva-
which
was
to
haunt
him
till
the
end
of
his
surgical
career.
The
other
English
surgeons,
such
as
Barker
and
Symonds
contented
themselves
with
discussion
of
their
own
min-
uscule
experiences.
Dunhill's
record
of
only
four
deaths
in
230
cases
of
exophthalmic
goitre
was
ignored.
Throughout
the
discussion
ran
a
thick
vein
of
incredulity
at
42
Thomas
Peel
Dunhill,
the
Forgotten
Man
of
Thyroid
Surgery
Dunhill's
results
and
a
thinly
veiled
suspicion
of
the
truthfulness
of
his
claims.
James
Berry
then
summarized
the
paper
and
discussion.73
He
himself
had
operated
on
only
eleven
cases
of
true
exophthalmic
goitre,
and
two
had
died.
He
said:
'It
is
a
little
diffi-
cult
to
reconcile
the
optimistic
view
of
Dr.
Dunhill
with
the
actual
results
that
are
being
obtained
in
this
country
by
most
of
those
who
do
from
time
to
time
operate
for
this
disease.
I
can
but
congratulate
Dr.
Dunhill
on
the
excellent
results
he
has
been
able
to
obtain,
although
at
the
same
time,
with
Dr.
Hector
MacKenzie,
I
wish
that
he
had
indicated
a
little
more
clearly
how
many
of
his
cases
really
come
under
this
cate-
gory
of
genuine
Graves'
Disease'.
James
Berry
crystallized
his
own
philosophy
in
the
management
of
exophthalmic
goitre
by
stating:
'In
the
very
great
majority
of
the
cases
of
true
Graves'
Disease
which
have
come
under
my
notice,
I
have
declined
to
operate,
as
I
have
not
considered
that
the
benefits
to
be
obtained
justified
the
risks
except
in
rare
and
isolated
instances'.
In
reality,
not
one
surgeon
present
at
that
meeting,
with
the
possible
exception
of
Albert
Kocher,
could
remotely
approach
Dunhill's
experi-
ence
or
results.
As
far
as
surgery
of
exophthalmic
goitre
was
concerned,
Dunhill
was
decades
ahead
of
his
English
contemporaries
and
his
mortality
rate
was
one
of
the
lowest
in
the
world.
During
his
stay
in
England
in
1911,
Dunhill
journeyed
to
Leeds
to
see
Moynihan
operate
and
to
Edinburgh
to
see
Stiles,
before
leaving
for
America
on
27
August
1911.
His
English
hosts
entertained
Dunhill
to
dinner,
and
a
number
of
apocryphal
stories
have
arisen
from
the
encounter
between
Dunhill
and
Dr.
Dickinson
Berry,
the
anaes-
thetist
wife
of
James
Berry.
She
is
purported
to
have
remarked:
'Dr.
Dunhill,
you
don't
really
operate
on
those
dreadful
people
with
the
pop
eyes
do
you?'
A
less
kindly
version
has
her
telling
Dunhill:
'Of
course
Graves'
Disease
is
obviously
much
milder
in
Australia
than
it
is
in
England'.74
During
his
stay
in
America,
Dunhill
visited
all
the
leading
surgical
centres.
He
went
to
New
York,
Baltimore,
Chicago
and
Rochester.
He
saw
some
of
the
leading
sur-
geons
there
including
Kelly,
Cushing,
Murphy,
Halsted
and
the
Mayo
brothers.
He
met
Halsted
at
Johns
Hopkins
and
discussed
with
him
the
importance
of
the
bilateral
attack
on
the
thyroid
gland
to
achieve
the
best
results
in
the
treatment
of
exophthalmic
goitre.
He
even
gave
Halsted
reprints
of
his
publications.
When
Dunhill
returned
to
England
and
had
James
Berry
deliver
his
paper
at
the
symposium
on
the
thyroid
gland
arranged
by
the
Royal
Society
of
Medicine,
this
pub-
lication
must
certainly
have
come
to
Halsted's
notice
(and
to
the
notice
of
the
Mayo
brothers
and
George
Crile
as
well).
Halsted,
about
a
year
later,
published
an
article
entitled:
(1)
'The
excision
of
both
lobes
of
the
thyroid
gland
for
the
cure
of
Graves'
Disease'
(II)
'The
preliminary
ligation
of
the
thyroid
arteries
and
of
the
inferior
in
preference
to
the
superior
artery'.75
This
paper
was
read
before
the
American
Surgical
Association
on
7
May
1913.
In
effect,
it
stated
that
in
thirty-nine
cases
of
exophthalmic
goitre
operated
on
by
Halsted,
a
staged
removal
of
part
of
the
second
lobe
became
necessary
to
cure
the
disease.
Dunhill
had
pointed
this
out
six
years
earlier.
Halsted's
technique
left
behind
the
posterior
part
of
each
lobe
to
safeguard
the
para-
thyroid
glands
and
the
recurrent
laryngeal
nerve.
Dunhill
removed
one
lobe
and
the
isthmus
completely
and
one-half
to
two-thirds
of
the
remaining
lobe.
As
far
as
can
be
determined,
Halsted
did
not
attack
both
sides
of
the
gland
at
the
one
operation
and
43
I.
D.
A.
Vellar
certainly
he
did
not
precede
Dunhill
in
pointing
out
the
necessity
for
removing
part
of
the
second
lobe.
Indeed,
1912
appeared
to
be
a
watershed
as
far
as
publications
concerning
the
surgery
of
exophthalmic
goitre
in
America.
Prior
to
this
year,
a
one-
sided
lobectomy
with
contralateral
ligation
appeared
to
be
the
standard
operation
for
toxic
goitre,
not
only
by
Halsted
but
also
by
Charles
Mayo
and
Crile.
Was
it
purely
a
coincidence
that
after
Dunhill's
visit
to
the
American
centres
in
1912
that
increasing
mention
is
found
of
the
need
to
remove
sufficient
thyroid
tissue
to
effect
a
cure
and
in
particular
the
need
to
attack
the
second
lobe?
This
trend
is
reflected
in
an
article
by
Balfour
in
1914
emanating
from
the
Mayo
Clinic.76
For
the
first
time,
a
definite
state-
ment
is
made
concerning
an
attack
on
the
second
lobe
of
the
thyroid
in
exophthalmic
goitre.
'In
our
Clinic,
the
removal
of
a
large
part
of
the
hyperactive
gland
is
practised,
the
entire
right
lobe,
isthmus
and
a
part
of
the
left
lobe,
sometimes
as
much
as
four-
fifths
of
the
gland,
should
be
removed
as
a
rule'.
Dunhill
had
been
doing
this
since
the
end
of
1907
in
favourable
cases.
Balfour
claimed
a
75
per
cent
cure
rate
with
a
mortal-
ity
of
1
per
cent.
On
his
return
to
St.
Vincent's
Hospital,
Dunhill
had
advanced
to
become
surgeon
to
inpatients
to
replace
Douglas
Shields
who
had
left
for
England
in
1912.
Dunhill
was
now
chairman
of
the
medical
staff
at
the
young
age
of
thirty-seven.
His
surgical
career
in
Australia
was
now
interrupted
by
the
outbreak
of
the
first
World
War.
Dunhill
was
appointed
to
the
1st
AIF
in
December
1914,
with
the
rank
of
major.
He
was
posted
as
surgeon
to
the
First
Australian
General
Hospital
in
1915.
At
the
time
of
his
enlistment,
Dunhill
was
firmly
established
as
the
leading
goitre
surgeon
in
Australasia.
Unfortunately,
his
professional
colleagues
were
not
above
the
petty
jealousies
and
resentment
which
his
success
invited.
H.
C.
Hinder,
surgeon
to
the
Royal
Prince
Alfred
Hospital,
Sydney,
wrote
an
article
in
1913
entitled:
'The
removal
of
the
thyroid
gland'."
Hinder
says,
amongst
other
things,
'a
considerable
stir
was
created
in
the
surgical
world
of
Australia
by
the
removal
of
the
thyroid
gland
under
local
anaesthesia.
It
is
very
hard
to
say
why,
because
thyroids
had
been
removed
both
under
local
and
general
anaesthesia
for
years
past,
but
when
a
few
surgeons
persisted
in
using
the
local
method
and
persuaded
themselves
and
the
public
that
this
method
was
attended
by
a
very
much
lower
mortality,
men
began
to
look
into
the
matter'.
Hinder
failed
to
quote
his
experience
in
the
surgery
of
toxic
goitre.
Dunhill's
detractors
failed
to
concede
that
it
was
his
vast
experience,
combined
with
a
superlative
operative
technique,
plus
the
added
safety
of
avoiding
general
anaes-
thesia
that
enabled
him
to
salvage
cases
which
would
have
certainly
died
in
other
surgeons'
hands.
Dunhill
went
to
Egypt
with
the
First
Australian
General
Hospital
and
there
became
ill
(probably
with
nephritis).
He
was
temporarily
invalided
back
to
Australia.
Whilst
in
Egypt
he
had
met
McCarrison,
whose
theories
and
practices
with
regard
to
toxic
goitre
were
directly
opposed
to
his
own.
At
a
scientific
meeting
held
in
Melbourne
on
3
May
1916,
he
contributed
to
the
discussion
on
goitre
and
in
particular
ex-
ophthalmic
goitre.78
He
gently
demolished
the
theory
that
the
septic
focus
in
con-
junction
with
the
intestinal
auto-intoxication
theory
of
Arbuthnot
Lane
was
the
prime
cause
of
exophthalmic
goitre.
Of
course,
he
said,
septic
foci
should
be
looked
for,
causes
of
worry
removed
and
medical
treatment
given
a
reasonable
trial,
but
if
44
Thomas
Peel
Dunhill,
the
Forgotten
Man
of
Thyroid
Surgery
no
improvement
resulted,
operation
had
to
be
resorted
to.
Dunhill
embarked
again
for
France
in
April
1917.
He
rejoined
the
First
Australian
General
Hospital
at
Rouen
and
in
September
1917
was
promoted
to
Lieutenant
Colonel.
Despite
his
army
commitments
he
still
found
time
to
write
and
pursue
his
interest
in
the
thyroid.
'A
discussion
on
the
surgery
of
exophthalmic
goitre'
appeared
in
1917.79
This
is,
as
usual,
a
methodical,
lucid
account
of
the
whole
problem.
Dunhill
discusses
the
various
theories
proposed
in
the
pathogenesis
of
exophthalmic
goitre.
He
recognized
the
difficulty
in
incriminating
the
thyroid
gland
when
the
so-called
'toxin'
from
the
thyroid
had
not
been
isolated.
Kendall,
working
in
Rochester,
had
actually
isolated
thyroxine
in
1914.
However,
the
physiological
action
of
the
hormone
had
not
been
fully
elucidated
in
1917.
Medical
thinking
had
been dominated
by
the
necessarily
rigid
Koch
postulations
linking
specific
bacteria
with
specific
disease
entities,
and
this
had
played
an
important
part
in
the
activities
of
McCarrison
and
Arbuthnot
Lane.
As
Dunhill
had
accumulated
by
now
an
impressive
personal
experience
in
thyroid
surgery
(1,500
operations)
of
which
over
one-half
were
on
patients
suffering
from
toxic
goitre,
he
was
able
to
speak
with
increased
authority
on
the
important
factors
which
enabled
a
cure
to
be
achieved
by
surgery
in
the
thyrotoxic.
Firstly
there
was
the
necessity
for
removing
sufficient
thyroid
tissue.
Dunhill
stated
that
though
some
improvement
may
result
from
a
unilateral
lobectomy
plus
ligature
of
the
arteries
of
the
contralateral
side,
for
cure
to
be
achieved
the
bulk
of
the
second
lobe
had
often
to
be
removed.
Dunhill
then
discussed
typical
problems
encountered
by
the
thyroid
surgeon,
namely,
patients
with
extreme
emaciation,
those
with
extreme
proptosis
which
often
progressed
to
corneal
ulceration
and
the
destruction
of
the
eye,
those
requiring
three
operations
before
sufficient
thyroid
tissue
was
removed
to
make
the
patient
euthyroid,
and
finally
the
cardiac
cripple
resulting
from
uncontrolled
thyro-
toxicosis
and
auricular
fibrillation.
As
far
as the
latter
was
concerned.
Dunhill
stated
that
the
congestive
cardiac
failure
and
anasarca
could
be
completely
controlled
by
thyroidectomy,
the
pulse
itself
often
becoming
perfectly
regular
after
operation.
In
this
article
he
destroys
McCarrison's
argument
that
'There
is
no
definite
proof
that
the
cures
effected
by
surgical
means
(i.e.
by
hemithyroidectomy
alone
or
with
ligation
of
arteries)
are
more
lasting
than
those
effected
by
medical
means'.
Dunhill
continued:
'One
would
like
to
point
out
in
this
report
that
hemi-thyroidectomy
is
not
the
opera-
tion
which
is
performed
for
the
cure
of
Graves'
Disease.
In
1909
I
wrote
in
the
British
Medical
Journal
that
it
was
necessary
to
remove
a
portion
of
the
second
lobe
(always
leaving
behind
sufficient
for
physiological
purposes).
Later
Halsted
wrote
of
the
necessity
for
partial
double
lobectomy
for
the
cure
of
the
disease.
The
Mayos
and
Crile
have
written
similarly.'
One
of
the
cases
mentioned
in
this
article
was
that
of
a
nursing
sister
at
the
Middlesex
Hospital.
Dunhill
was
asked
to
see
this
patient
by
Dr.
Pasteur,
then
the
senior
physician
at
the
Middlesex.
Pasteur
thought
the
patient
too
ill
to
operate
on.
And
his
doubts
were
shared
by
the
surgical
staff
at
the
Middle-
sex.
Dunhill
removed
most
of
the
thyroid
in
two
operations
and
obtained
a
complete
cure,
thereby
presaging
the
enormous
effect
he
would
have
on
thyroid
surgery
when
he
returned
to
England
in
1920.
Dunhill
saw
out
the
rest
of
the
war
as
consulting
surgeon
to
the
Rouen
area.
He
arrived
back
in
Melbourne
on
the
Niagara
on
11
August
1919.
The
remaining
45
I.
D.
A.
Vellar
months
in
Australia
were
somewhat
turbulent
and
worrying
for
him.
As
a
result
of
his
war
service,
Dunhill
had
made
the
acquaintance
of
many
leading
British
surgeons,
in
particular
George
Gask,
surgeon
to
St.
Bartholomew's
Hospital.
Gask
had
been
appointed
Professor
of
Surgery
in
charge
of
the
surgical
unit
at
St.
Bartholomew's.
He
offered
Dunhill
the
position
of
Assistant
Director.
Dunhill
was
forty-four
years
old,
solidly
established
as
a
general
surgeon
in
Melbourne
and
the
leading
thyroid
surgeon
in
Australasia.
The
conditions
of
the
appointment
are
interest-
ing.
He
had
to
obtain
the
English
Fellowship
and
he
had
to
agree
to
stay
for
a
minimum
of
five
years.
The
position
was
half-time
and
the
salary
£900
a
year.
The
prospect
of
reading
for
the
English
Fellowship
at
the
age
of
forty-four
must
have
been
a
little
disturbing.
Dunhill,
of
course,
had
a
Melbourne
M.D.
and
no
senior
surgical
degree.
However,
Gask
finally
waived
this
condition
and
Dunhill
accepted
the
Assistant
Director's
post.
The
idea
of
the
unit
system
appealed
to
Dunhill's
personality.
He
thought
that
this
would
provide
the
ultimate
in
medical
and
surgical
care
for
the
patient.
His
experience
in
the
war
had
converted
him
to
the
concept
of
team-work
in
medicine
and
its
corollary,
increasing
specialization.
Before
leaving
for
London,
Dunhill
was
feted
at
a
number
of
dinners
held
in
his
honour.
His
old
chief,
David
Murray
Morton,
rightly
eulogised
that
Dunhill's
work
on
the
thyroid
was
known
to
the
world
and
had
brought
fame
on
the
city
of
Melbourne,
its
medical
school
and
on
St.
Vincent's
Hospital.
In
reply,
Dunhill
showed
a
combination
of
prescience
and
altruistic
innocence.
He
felt
strongly
that
more
specialization
in
medical
practice
was
needed.
He
thought
that
the
concept
of
team-work
should
be
extended
to
embody
a
type
of
nationalization
of
medicine.
He
warned
that
if
the
medical
profession
did
not
lead
in
this
matter,
they
would
ultimately
be
driven.
Finally,
he
suggested
that
the
Government
pay
the
specialists
the
same
salaries
as
those
of
Supreme
Court
judges!"'
Dunhill
sailed
for
England
on
5
May
1920.
It
may
be
fairly
stated
that
a
prophet
is
least
heeded
amongst
his
own
people,
and
this
perhaps
applies
even
more
to
the
medical
profession.
When
Dunhill
presented
his
work
on
exophthalmic
goitre
in
England
in
1912,
he
was
made
the
subject
of
thinly
veiled
attacks
directed
towards
the
truthfulness
of
his
claims.
Having
laid
down
the
guide
lines
for
the
treatment
of
exophthalmic
goitre
in
numerous
publications,
it
is
not
entirely
surprising
to
read
a
defamatory
article
by
Stewart
McKay*
surgeon
to
the
Lewisham
Hospital,
New
South
Wales,
entitled:
'The
role
played
by
the
phy-
sician
and
surgeon
in
the
treatment
of
Graves'
Disease'.81
In
this
article
McKay
repeats
the
surgical
dicta
of
George
Crile
in
relation
to
the
management
of
ex-
ophthalmic
goitre,
and
then
claims
to
have
discovered
(or
plagiarised)
the
secret
of
success.
This
was
a
sub-total
removal
of
the
thyroid
gland,
leaving
behind
the
posterior
part
of
each
lobe.
He
then
accuses
the
Melbourne
surgeons
(meaning
Dunhill)
of
not
appreciating
this
secret
in
technique.
Whilst
this
modification
of
the
Mikulicz
resection
was
to
form
the
basis
of
the
modern
operation
for
thyroidec-
tomy
and
at
about
this
time
(1920)
was
slowly
being
adopted
by
the
Mayo
Clinic
and
Crile,
the
thyroidectomy
performed
by
Dunhill
(removal
of
one
lobe,
the
isthmus
*Stewart
McKay
(1867-1948).
Gifted
disciple
of
Lawson
Tait,
and
surgeon
to
the
Lewisham
Hospital
in
New
South
Wales
for
thirty
years.
Pugnacious
and
aggressive,
he
wrote
on
a
multitude
of
subjects
from
the
behaviour
of
crayfish
to
the
life
of
Lawson
Tait.
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Thomas
Peel
Dunhill,
the
Forgotten
Man
of
Thyroid
Surgery
and
two-thirds
of
the
other
lobe)
removed
approximately
as
much
tissue
and
the
results
were
comparable.
Dunhill
had
to
work
out
this
technique
for
himself
and
had
had
a
vast
personal
experience
with
it.
His
morbidity
and
mortality
rates
com-
pared
with
the
lowest
in
the
world
and
his
results
were
excellent.
McKay's
experience
hardly
bore
comparison.
This
article
provoked
a
stinging
reply
by
Frank
Davies,*
who
was
Dunhill's
anaesthetist
for
many
years.
Davies
rightly
pointed
out
the
envy
and
petty
jealousies
which
ran
through
McKay's
article.82
The
Dunhill
era
would
be
somewhat
incomplete
without
mention
of
his
classic
contribution
to
the
British
Journal
of
Surgery
entitled:
'Some
considerations
on
the
operation
for
exophthalmic
goitre'.10
Aided
by
a
series
of
magnificent
illustrations
by
A.
K.
Maxwell,
he
vividily
describes
his
technique
of
thyroidectomy
whether
per-
formed
in
stages,
which
he
advocates
for
the
very
severe
case
of
thyrotoxicosis
(one
senses
that
the
article
was
written
for
the
benefit
of
other
surgeons
grappling
with
the
problem
of
exophthalmic
goitre),
or
the
one-stage
bilateral
attack
on
the
thyroid.
As
mentioned
previously,
Dunhill
differed
somewhat
from
the
modem
practice
of
sub-total
thyroidectomy
by
always
doing
a
complete
excision
of
the
lobe
on
one
side
and
excision
of
the
major
part
of
the
lobe
on
the
other
side.
With
the
second
lobe,
he
left
the
superior
pedicle
intact,
but
of
course
cut
the
inferior
thyroid
artery.
Dunhill's
subsequent
surgical
career
at
St.
Bartholomew's
is
well
known.
He
obviously
had
some
trepidation
at
chancing
his
arm
with
the
London
physicians
and
surgeons
and
it
appears
he
sounded
out
the
Mother
Rectress
at
St.
Vincent's
Hospital
(Mother
Berchmans
Daly)
as to
the
possibility
of
returning
to
his
old
post
if
he
failed
in
London!
Subsequent
events
hardly
made
that
necessary.
As
Dunhill's
career
at
St.
Vincent's
came
to
an
end,
two
other
stars
commenced
to
shine
in
the
surgical
firmament,
namely
Hugh
Devine
and
Leo
Doyle.**
Devine
was
a
con-
temporary
and
Doyle
the
heir
apparent
of
the
Dunhill
era.
As
it
is
now
over
sixty
years
since
Dunhill
carried
out
his
first
thyroidectomy
for
thyrotoxicosis,
some
sort
of
objective
assessment
of
his
contributions
to
thyroid
surgery
is
possible.
There
is
no
doubt
that
in
Australasia
he
alone
was
responsible
for
breaking
the
vicious
circle
of
late
patient
referral
producing
high
operative
mortality,
and
thereby
propagating
late
patient
referral.
By
his
own
efforts,
he
per-
suaded
physicians
into
realizing
the
proper
role
of
surgery
in
thyrotoxicosis.
He
was
the
first
to
champion
surgery
in
the
thyrocardiac.
He
influenced
Devine
and
Doyle
in
Australia
and
Joll
in
England.
He
was
the
first
to
advocate
a
bilateral
attack
on
the
gland
in
thyrotoxicosis.
These
achievements
should
ensure
that
the
name
of
Dunhill
will
rightly
take
its
place
with
Billroth,
Kocher,
Mayo,
Crile
and
Halsted
in
the
history
of
the
development
of
thyroid
surgery.
ACKNOWLEDGEMIENTS
I
would
like
to
thank
Professor
K.
F.
Russell
of
the
Department
of
Anatomy
and
Medical
History,
University
of
Melbourne,
for
helpful
advice
and
criticism,
and
Professor
R.
C.
Bennett,
Professor
of
Surgery
at
St.
Vincent's
Hospital,
for
making
available
the
facilities
of
his
department.
Both
*Frank
L.
Davies
(1878-1962).
General
practitioner
anaesthetist
at
St.
Vincent's
Hospital.
He
gave
most
of
Dunhill's
anaesthetics
for
his
abdominal
surgery.
**Leo
Doyle
(1891-1953).
Probably
one
of
the
most
gifted
technical
surgeons
in
Australia
in
his
time.
An
acknowledged
master
in
the
use
of
local
anaesthesia,
he
was
equally
at
home
in
the
thorax
or
cranium
as
in
the
abdomen.
47
D
I.
D.
A.
Vellar
Dr.
Ray
Hennessy,
consultant
ear,
nose
and
throat
surgeon
and
Mr.
Leonard
Murphy,
consultant
urologist
at
St.
Vincent's
Hospital
helped
considerably
with
their
continuing
encouragement.
Mr.
R.
Grace,
Chief
Secretary,
St.
Vincent's
Hospital,
kindly
made
available
the
records
of
the
Hospital
and
Sister
Maureen
Walters,
Rectress,
St.
Vincent's
Hospital,
Melbourne,
assisted
with
the
early
history
of
the
Sisters
of
Charity
in
Australia.
I
am
indebted
to
the
following
librarians
for
their
services:
Miss
E.
Binns,
Medical
Records,
St.
Vincent's
Hospital;
Miss
A.
Bush,
Medical
Librarian,
St.
Vincent's
Hospital;
Miss
V.
Dunn,
Medical
Librarian,
Royal
College
of
Surgeons
of
Australasia,
Melbourne.
Finally,
for
their
patient
collation
and
typing
of
the
manuscript,
I
thank
Mrs.
C.
Bates-
Brownsword,
Mrs.
K.
Broomhall
and
Miss
L.
Sangster,
all
of
the
University
Department
of
Surgery
at
St.
Vincent's
Hospital,
Melbourne.
REFERENCES
1.
HASTED,
W.
S.,
'The
operative
story
of
goitre:
the
author's
operation',
Johns
Hopk.
Hosp.
Rep.,
1920,
19,
71.
2.
LISroN,
R.,
Lectures
on
the
Operations
of
Surgery
and
on
Diseases
and
Accidents
Requiring
Operations.
With
numerous
additions
by
Thomas
D.
MUtter,
Philadelphia,
1846,
p.
318.
3.
GRoss,
S.
D.,
A
System
of
Surgery,
4th
ed.,
Philadelphia,
1866,
p.
394.
4.
SICK,
P.,
'Ueber
die
totale
Exstirpation
einer
Kropfig
Entarten
Schilddriuse
und
uber
die
Riickwirkung
dieser
Operation
auf
die
Circulations
Verhaltnisse
im
Kopfe',
Med.
Corresp-Blatt
Wurttemberg.
Arztl.
Ver.,
Stuttgart,
1867,
37,
199.
5.
KocHER,
T.,
'Zur
Pathologie
u.
Therapie
d.
Kropfes',
Dt.
Z.
Chir.
Leipzig,
1874,
4,
417.
6.
KOCHER,
T.,
'Ueber
Kropf
Extirpation
u.
ihre
Folgen',
Arch.
klin.
Chir.
Berlin,
1883,
29,
254.
7.
REVEDIN,
J.
L.,
'Accidents
consecutifs
a
l'ablation
totale
du
goitre',
Rev.
Med.
Suisse,
Geneve,
1882,
2,
539.
8.
GuLL,
W.
W.,
'On
a
cretinoid
state
supervening
in
adult
life
in
women',
Trans.
clin.
Soc.
Lond.,
1874,
7,
180.
9.
KENDALL,
E.
C.,
'A
method
of
decomposition
of
proteins
of
the
thyroid
with
a
des-
cription
of
certain
constituents',
Collected
Papers
of
the
Mayo
Clinic,
1914,
6,
352.
10.
HORSLEY,
V.,
'Note
on
a
possible
means
of
arresting
the
progress
of
myxoedema,
cachexia
strumi
priva
and
allied
diseases',
Br.
med.
J.,
1890,
i,
287.
11.
MURRAY,
G.
R.,
'Remarks
on
the
treatment
of
myxoedema
with
thyroid
juice,
with
notes
of
four
cases',
Br.
med.
J.,
1892,
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50
