History of Thyroid Surgery
Early Descriptions
Goitre (enlarged thyroid gland) has been recognised as a discrete disease since ancient times, with the first references in China in 2700BC. The ancient writers however did not know of the thyroid gland itself or its relationship to the formation of a goitre. The term of goitre is derived from the Latin word ‘guttur’, the throat. Celsus originally described goitre as a bronchocoele (a herniation of the bronchus) in 15 AD, and Roman medical authorities also used this term (Fig. 1). Indeed Julius Caesar noted that a big neck was to be frequently found in the Gauls, thereby inadvertently noting the prevalence of endemic goitre in those from mountainous areas.
Fig. 1: Woman with bronchocoele
Thyroid comes from the Greek ‘thureos’ meaning shield-shaped. Leonardo da Vinci was the first to identify and draw the thyroid gland in 1511 during the Italian Renaissance. He thought the gland was there to fill up empty spaces in the neck. Vesalius also described the thyroid, naming it the laryngeal gland. Bartholomaeus Eustachius noted that the thyroid had two lobes connected by the isthmus. Others speculated on the function of the thyroid, with Galen suggesting that its role was to lubricate the larynx and Parry that it was there to act as a blood buffer to protect the brain from sudden increases in blood flow from the heart.
It was Thomas Wharton (also famous for his description of the submandibular duct) who named it in his book ‘Adenographia’ the ‘glandulae thyroideae’ or thyroid in 1656, not because of the shape of the gland but because of the proximity to the shield-shaped thyroid cartilage. The bronchocoele terminology was still used into the 19th century however, despite these earlier descriptions.
Early Treatment of Goitre
In 1600 BC the Chinese were using burnt sponge and seaweed for the treatment of goitres. Pliny the Elder specifically noted epidemics of goitre in the Alps (much later discovered to be due to iodine deficiency) and also mentioned the use of burnt seaweed in their treatment. The Arthorva Veda (2000BC) is an ancient Hindu collection of incantations which contains exorcisms for goitre. In 150 AD Galen, an instrumental figure in the transition from ancient to modern medicine, referred to 'spongia usta' (burnt sponge) for the treatment of goitre. Other early attempts at the treatment of goitre included toad’s blood applied to the neck or stroking the goitre with a cadaverous hand.
One of the earliest references to a successful surgical attempt for the treatment of goitre can be found in the medical writings (‘Al Tasrif’) of the Moorish physician Ali Ibn Abbas. In 952 A.D., he recorded his experience with the removal of a large goitre under opium sedation using simple ligatures and hot cautery irons as the patient sat with a bag around his neck to catch the blood. Early developments in thyroid surgery occurred in Salerno, Italy in the 12th century, involving hot irons and the insertion of setons through the gland.
The first successful typical partial thyroidectomy was performed by the French Surgeon, Pierre Joseph Desault, in 1791 during the French Revolution. Dupuytren followed in 1808 with the first total thyroidectomy, but the patient died 36 hours after the operation. Hedenus, a German surgeon from Dresden reported in 1821 the successful removal of six large goitres, a feat not equalled for 40 years.
Despite these limited descriptions of early successes, the surgical approach to goitre remained shrouded in misunderstanding and superstition. Thyroid surgery in the 19th century carried a mortality of around 40% even in the most skilled surgical hands, mainly due to haemorrhage and infection. The French Academy of Medicine actually banned thyroid surgery in 1850 and German authorities called for restrictions on such ‘foolhardy performances’. Leading surgeons avoided thyroid surgery if at all possible, and would only intervene in cases of respiratory obstruction. Samuel Gross wrote in 1848:
"Can the thyroid gland when in the state of enlargement be removed…?
If a surgeon should be so foolhardy as to undertake it. . . . .every step he takes will be environed with difficulty, every stroke of his knife will be followed by a torrent of blood and lucky it would be for him if his victim lives long enough to enable him to finish his horrid butchery.
No honest and sensible surgeon would ever engage in it."
Advancements could only take place in the field of thyroid surgery with the introduction of improved anaesthesia, antiseptic techniques, and improved ways of controlling haemorrhage during surgery. The first thyroidectomy under ether anaesthesia took place in St Petersburg in 1849; the second half of the 19th century saw the introduction of Lister’s antiseptic techniques through Europe, and the development of haemostatic forceps by such figures as Spencer Wells in London led to much better haemostasis than could be achieved by crude ligatures and cautery.
Fig.2: Billroth teaching in ViennaTheodore Billroth (Fig. 2), surrounded by endemic goitres from the Alps and thus able to perfect his technique, performed 20 thyroidectomies in Zurich in the 1860s, but his mortality rate from haemorrhage and sepsis was 40%. He abandoned thyroid surgery for nearly a decade until he arrived in Vienna, which coincided with the three advances mentioned earlier. He was able to reduce the mortality of thyroid surgery from 36% to less than 10%, and became the foremost thyroid surgeon of his time.
Perhaps the best known thyroid surgeon however, was Theodor Kocher (Fig. 3), appointed to the chair in surgery at Bern in 1872. Up to 90% of schoolchildren there were afflicted with goitre, and he was quickly able to acquire immense experience in thyroid surgery. He markedly reduced thyroid surgical mortality to less than 1% by 1898 and in the same year described the transverse collar incision which still bears his name today.
Jacques Louis Reverdin of Geneva reported on ten patients who had developed symptoms of hypothyroidism following total thyroidectomy, calling it ‘myxoed me operatoire’. This prompted Kocher to review his own patients, reporting in 1883 that removal of the thyroid produced hypothyroidism or ‘cachexia strumi priva’, thus acknowledging that the thyroid did indeed have a function. William Ord would not coin the term ‘myxoedema’ until 1878. Kocher refrained from total thyroidectomy after his experiences with surgical myxoedema, except in the treatment of cancer, for the remainder of his career.
Fig.3: Theodor Kocher
The medical community would ultimately provide adequate treatment for those suffering from myxoedema. George Murray would in 1891 ultimately demonstrate that injected thyroid extract would provide treatment for the disorder. Fox would later demonstrate that the extract could be effectively taken by mouth.
Kocher was a versatile and meticulous surgeon with achievements in a variety of surgical fields. To this day the surgical manoeuvre to mobilise the duodenum, the right subcostal incision for gallbladder surgery, a method for reducing a dislocated shoulder, and a variety of surgical instruments all bear his name. He was awarded the Nobel Prize for Medicine in 1909 in recognition of his life’s work in thyroid surgery and research, and remains the only surgeon to obtain this prize for clinical work.
William Halsted pioneered thyroid surgery in the USA after studying under both Billroth and Kocher, and came to the conclusion that:
‘‘The extirpation of the thyroid gland for goitre typifies perhaps better than any other operation the supreme triumph of the surgeon’s art.’’
Thyroid hormones
The idea that the thyroid produced an iodine containing substance was investigated in the last century, and it was Edward Calvin Kendall, who in 1914 isolated thyroxine, the active principle hormone of the thyroid gland. Kendall initially assigned the wrong indole nucleus structure to L-thyroxine, but his crystalline extract was in fact the correct stucture and biological activity. This discovery by Kendall, and additionally his work on the adrenal gland hormones was rewarded with the Nobel Prize for medicine in 1950.
In the 1920's Kendall's thyroxine became available to clinicians, but it was very expensive as three tons of animal thyroid was required to extract only 33 grams of thyroxine. This problem was overcome by Harrington in 1926, working at the University Medical School in London, who determined the correct stucture of four iodine atoms per molecule of thyroxine (T4), allowing thyroxine to be synthesised and thus be readily available to physicians.
Harrington's synthetic product was also costly so even in the 1960's thyroid replacement therapy was mainly desiccated animal thyroid. The synthesis of sodium L-thyroxine and its ability to be absorbed orally revolutionised thyroid replacement however, making it safe and cheap. Today thyroxine is available world wide.
Early workers had wondered if there were other thyroid hormones, beside thyroxine. In 1952 Rosalind Pitt-Rivers and her post doctoral fellow, Gross, discovered and synthesised tri-iodothyronine (T3) showing it was biologically more active than thyroxine.
Treatment of thyrotoxicosis
The posthumously published medical writings of Caleb Hillier Parry in 1825 contain a detailed description of exophthalmic goitre which he had noted as far back as 1786. However, Jurjani's 'Treasure of Medicine' published 700 years earlier in 1110 had associated exophthalmus, the protrusion of the eyes we now associate with Graves' disease, with goitre. Robert Graves in Dublin in 1835 and Carl Von Basedow in Merseburg, Germany in 1840 further described the association of goitre with palpitations, exophthalmos, emaciation, and extreme nervousness, and both their names are today still associated with this form of thyrotoxicosis.
Surgeons were especially reluctant to operate on thyrotoxic patients for fear of fatal haemorrhage, failure to cure the disease, and the condition of ‘thyroid storm’. Rehn of Frankfurt-am-Main reported on three thyroidectomies on toxic patients in 1884, stating that the surgery had cured their symptoms. Charles Mayo (who first used the term ‘hyperthyroidism’), George Crile and Frank Lahey in the USA all made major contributions to the successful surgical treatment of thyrotoxic patients.
Fig.4: Thomas Peel DunhillHowever, Thomas Peel Dunhill (Fig. 4), of St Vincent’s Hospital in Melbourne, would prove the most aggressive early advocate of thryoidectomy in the profoundly thyrotoxic patient, recognising that cure of the disease required removal of sufficient thyroid tissue. By 1908, he had performed 47 thyroid lobectomies in such patients, with 10 of them undergoing a second lobectomy after failure to respond to their initial procedure.
Dunhill was aggressive in the removal of all of 1 lobe, the isthmus, and a portion of the second at the initial procedure if he felt it was indicated, unlike his American colleagues. In 1911 Dunhill visited the USA and England and communicated his results to the thyroid surgeons in both countries (230 cases of exophthalmic goitre operated on with only four deaths). At this time the mortality of surgery at St Thomas’s Hospital, London was 33%. Dunhill left Australia to join the staff of St Batholomew’s Hospital in London in 1920 where he served with great distinction, including acting as surgeon to the Royal household. His technique did change over the years, and by the 1920s he had adopted the Mikulicz subtotal thyroidectomy in his operations.
Although it had been known for some time that seaweed kelp reduced goitre size, it was not until 1811 that Bernard Courtois discovered iodine in burnt seaweed, which fostered the idea that this was the active ingredient in the treatments that were successfully prescribed for goitre. Ten years later Coindet was the first to recommend iodine in the preoperative treatment of goitre to decrease vascularity and so lessen the operative risk. During the 1930s iodine became the standard preoperative preparation worldwide, further improving results.
During the 1940s two more developments changed the situation again. Radioiodine was used therapeutically in Boston in 1942, and antithyroid drugs (thiouracil) were used in Boston the following year. Beta blockers were developed twenty years later in 1965, and together this group of treatments: drugs, radioiodine and surgery, still form the basis of the treatment of thyrotoxicosis today.