Reprinted from the Journal of Nervous and Mental Disease, December, 1893. 
The Treatment of Graves' 
Disease by Thyroidectomy. 
BY 
JAMES J. PUTNAM, M.D.- 
Boston, Mass. Reprinted from the Journal of Nervous and Mental Disease, December, 1893. 
THE TREATMENT OF GRAVES' DISEASE BY 
THYROIDECTOMY.1 
JAMES J. PUTNAM, M.D., 
Boston, Mass. 
EVERY neurologist must have noticed with interest, 
within the past few years, the growth of a sen 
timent among the German surgeons in favor 
of partial removal of the thyroid in the treatment of 
Graves' disease, a measure which in most neurological 
text-books, even the most recent, is not spoken of with 
favor. The number of typical cases in which the opera- 
tion has been done, is, to be sure, rather small, and the 
number of surgeons who have done them is smaller still, 
but the proportion of successful results is very large. 
Thus, Moebius, who was the first to bring strongly into 
prominence the idea that Graves' disease is a species of 
thyroid cachexia {Zsch. f. Nkr., 1890), refers to a few 
cases in most of which a substantial cure was obtained 
through operation. Wette, in his admirable analysis of 
Riedel's operations on goitre in general (Arch. f. Klin. 
Chir. vol. xliv.), gives three new cases of partial thyroid- 
ectomy in Graves' disease, and a summary of thirty 
others. Only one of these ended fatally, while in all but 
one of the rest cure or great improvement was noted. To 
this collection a dozen typical cases and sevoral analogous 
cases can now be added. In fact, the history of thyroidec- 
1 Read at the annual meeting of the American Neurological Asso- 
Association, July, 1893. 2 
JAMES J. PUTNAM. 
tomy in general is largely in point, since the symptoms 
which have made this operation at once desirable and dan- 
greous have been similar, in the majority of cases, to the 
symptoms of Graves' disease. The literature of the sub- 
ject is thoroughly summarized by Moebius in Schmidt's 
Jalvrb., for the past few years. 
Woelfler, to be sure, in his exhaustive treatise on the 
surgical treatment of goitre, expresses some doubt as to 
whether thyroidectomy is really so very useful in true 
Graves' disease. He thinks that exophthalmus was not 
present in many of the cases cited in favor of the opera- 
tion, and that cardiac and nervous symptoms are so com- 
mon in cases of ordinary goitre that they ought not to 
count for much in support of the diagnosis. 
In view of the cases which have accumulated within 
the past two years this criticism falls to the ground. Ex- 
ophthalmus certainly has been cured by operation ; and 
the nervous symptoms attending ordinary goitre cannot 
be separated by any sharp line from those of true Graves 
disease.2 
It is curious and interesting to note in this connection 
that Winckler (Wiener. Med. Wochenschr., 1892, vol. xlii., 
p. 1521) in discussing the efficacy of nasal operations in 
Graves' disease, asserts that exophthalmus may be cured 
in this way, but that exophthalmus does not necessarily 
mean Graves' disease. The truth is that typical Graves' 
disease shades off in various directions into partial forms 
often of special origins. 
In spite of the attractive picture given by the sum- 
maries that I have quoted, there are still many questions 
for which we must find an answer before we can confi- 
dently recommend the operation to our patients as a 
matter of routine. We need to know how complete a 
cure is to be looked for; whether the severity of the 
operation is fairly measured by the death-rate ; whether 
the probability of a favorable result is influenced by the 
manner in which the disease began, that is, whether the 
thyroid enlargement was the first, and apparently the 
2 This opinion is also endorsed by F. Muller in an excellent paper 
in the Deutsches Arch, fur Klin. Med., Vol. LI., 1893. THYROIDECTOMY IN GRACES' DISEASE. 
3 
causal element; whether the character of the growth and 
its size make a difference as to the result; whether there 
is danger that tetany, myxoedema or other ills will make 
their appearance, and the like. 
Before attempting an answer to these questions, I wish 
to report one additional case of operation for Graves' dis- 
ease, done by Dr. J. C. Warren, partly at my suggestion, 
on a patient previously under treatment in the neurologi- 
cal department of the Massachusetts General Hospital. 
The patient was an unmarried woman, twenty-nine 
years old. She had never been robust, and had had a 
number of attacks of protracted vomiting at different 
times in her life. This is noteworthy, because her pres- 
ent illness was ushered in by such an attack. She had 
the influenza three times within the four years of our 
visitation with the epidemic, and with each attack this 
tendency to protracted vomiting showed itself. The 
last attack of influenza occurred in April, 1892, and the 
subsequent vomiting continued more or less for several 
days, confining her to the house and causing great pros- 
tration. Immediately after this, the "lump in the 
neck " was noticed for the first time. It is possible that 
these attacks of vomiting either caused some irritability 
of the vagus centres or indicated that it was present. 
The prominence of the eyes and the palpitation were 
noticed a few months after the enlargement of the neck. 
The patient first presented herself in the Out-Patient 
Department of the Massachusetts General Hospital in the 
autumn of 1892. She had already been under treatment 
at the private hospital of the Good Samaritan, but in 
spite of complete rest and good care she had failed to 
improve. While there her larynx was examined by Dr. 
Algernon Coolidge, and a lack of tension was found but 
no unilateral paralysis. All the symptoms of a moder- 
ately severe form of Graves' disease were present,tachy- 
cardia, exophthalmus, tremor, nervous agitation, dysp- 
noea-and beside these there was an unusual amount of 
muscular twitching, of choreiform character. There was 
a systolic murmur in the mitral area, transmitted toward. 4 
JAMES J. PUTNAM. 
the axilla; and the pulmonic second sound was accentu- 
ated. In the neck was a soft, non-pulsating tumor, de- 
scending slightly on swallowing, and this extended from 
the sternum to the thyroid cartilage, and laterally to the 
middle of the sterno-mastoid muscle. A loud vascular 
murmur was heard over the tumor when the stethoscope 
was applied. 
After a fair trial of electricity and internal medication, 
thyroidectomy was proposed to her by both Dr. Coolidge 
and myself, and she entered the wards of the hospital. 
The operation was done by Dr. J. C. Warren, on February 
2, 1893. There was a large amount of bleeding, but 
no more than is often met with in such cases. After 
a large plexus of superficial veins had been clamped and 
tied, the right lobe of the thyroid was shelled out with the 
fingers, the isthmus clamped, and the right lobe cut off 
with the scissors. A silk ligature was passed around the 
isthmus near the median line and tied. Then the isth- 
mus was cut off close to the ligature. The arteries were 
tied with catgut and the wound washed with corrosive 
(1-5,000), and sewed with interrupted silk sutures, two 
drains being left hanging from the most dependent por- 
tion in front. The pulse and respiration were bad during 
the operation, and subcutaneous injections of brandy and 
strychnia were given. Wette's careful paper points out 
that this sort of occurrence is not uncommon, and that in 
all probability it is usually due to injury of the recurrent 
nerve, which sometimes happens even when the utmost 
pains are being taken to prevent it. During the opera- 
tion the pulse ran up to between 180 and 200, and the 
prostration was extreme, though there was nothing in the 
operation itself to cause it. When the patient came out 
of the ether, much mucus was found to have collected in 
the throat and had to be swabbed out. This occurrence 
is worth mentioning, because Wolff speaks of it as prob- 
ably an occasional cause of death. On the afternoon after 
the operation the pulse was 185, the temperature 104° F., 
and there was great difficulty in breathing. For the next 
four days she remained in what seemed to be a critical THYROIDECTOMY IN GRAVES' DISEASE. 
5 
condition. The voice was reduced to a faint whisper. 
There was great prostration, some vomiting and no de- 
sire for food. On the second day after the operation 
there was considerable cough, pain and dyspnoea, and 
some delirium. She once tried to tear off the dressing 
and to get out of bed. The sharp fever indicated by the 
chart was not to be explained by any septic condition of 
the wound. A low friction rub was heard below the 
seventh rib on the right side, in the axillary line, and 
above this, rales and tubular breathing and bubbling 
sounds transmitted from the large bronchi. It was diffi- 
cult to examine thoroughly because she could not easily 
be moved, but Dr. F. C. Shattuck feared that pneumonia 
was threatening. These signs were less marked the next 
day and rapidly disappeared. The course of the case 
after this was steadily favorable. She remained in the 
hospital for two weeks, and after leaving it she came 
again under my care and I have seen her from time to 
time up to the present date. Up to a month ago she had 
improved slowly but steadily, and eventually felt better 
than at any time since first taken sick. The nervous 
twitching had disappeared. Her pulse had dropped to 
about a hundred and she felt stronger. Since then, per- 
haps on account of the hot weather, she has not felt so 
well, though still decidedly better than before the opera- 
tion. The remaining portion of the tumor has at times 
been swelled, evidently from vascular engorgement, but 
of late it has been steadily diminishing in size. On the 
whole her prospects for eventual recovery seem to me to 
have been improved by the operation. 
An examination of the larynx, made soon after the 
operation by Dr. Coolidge, showed a paralysis of the 
muscles supplied by the right recurrent nerve. Both ab- 
duction and adduction of the right cord are deficient, and 
during phonation the left cord crosses the median line. 
This paralysis still persists, and the voice is feeble, but 
clear and articulate.3 
3 Three months have passed since this statement was written. A 
present, the patient is much better than before the operation, but by 6 
JAMES J. PUTNAM. 
I examined the tumor immediately after it was re- 
moved, and found it to be of a firm consistency and homo- 
geneous, somewhat granular in appearance. There were 
a few little cysts about the size of the head of a large pin 
or a little larger. A number of pieces were immediately 
placed in Muller's fluid, and were afterwards examined 
by Prof. Councilman. He reported the structure to be 
adenomatous in character and not at all like that of the 
normal thyroid. The arborescent, follicular-looking 
tufts were covered with a high, cubical epithelium, quite 
different from the characteristic flat epithelium of the 
normal gland. There was no colloid to be seen. In two 
of Muller's cases [1. c.] a similar condition was found. 
This observation is important in several respects. In 
the first place, it was noticed during the first two or three 
days after the operation that a gelatinous sort of sub- 
stance oozed out from the wound, which was supposed 
to come from the cut surface of the gland. It occurred 
to me at the time that the prostration and other nervous 
symptoms might have been due in part to the absorption 
of this material, though I finally abandoned the idea as 
improbable, for various reasons. I supposed at the time 
that this matter was colloid, and it is now an interesting 
subject for speculation what it may have been, and 
whether it did possess toxic properties. Certainly, 
where the large cut surface of a thyroid is exposed in 
this way in an open wound the best opportunity would 
seem to be furnished for poisoning from excess 'of thy- 
roid secretion, if such a thing is possible. With a view 
to test this point, I made a quantity of glycerine extract 
from the extirpated tumor and injected a large dose 
under the skin of a cat. This was followed by vomiting 
and perhaps some prostration, but nothing more serious 
occurred, and I was unable to pursue the investigation 
further. 
The change in histological structure is also interesting 
no means well. The paralysis has almost disappeared, and the thyroid 
stump is smaller. The pulse has remained high until recently, but is 
now 108. The patient is very anaemic, but is gaining slowly. THYROIDECTOMY IN GRA YES' DISEASE. 
7 
because it would seem that it is characteristic of the in- 
jured thyroid. The only observations that I know of in 
regard to this point are two in number. The first are 
those of Halsted and Welch, which were originally com- 
municated in a paper (not yet published) which was read 
at a meeting of the Association of American Physicians 
three years ago, and again referred to by Dr. Welch at 
the last meeting of the same society. These observers 
found that, with dogs, any injury of the thyroid, even a 
comparatively slight one, led to the transformation of 
the normal tissue into one of the same general kind with 
that which 1 have described. 
The other set of experiments are by Canizzero of 
Catania (Deutsche Med. Wochenschr., 1892, p. 184). He also 
found that when the thyroid was injured by being de- 
tached from its bed and sewed to the muscles in front, 
the tissue took on what he calls an embryonic character, 
and the colloid disappeared. 
The disappearance of the colloid is of some in- 
trinsic interest in connection with the pathology of 
Graves' disease, and is also of importance as giving us 
some information, though of a negative character, with 
regard to the chemical nature of the efficient thyroid 
secretion. 
Colloid has been hitherto considered to be a necessary 
element of the thyroid juice, but apparently this is not 
the case, for a gland altered in the way I have described, 
or even a small portion of it, is evidently abundantly 
able to ward off myxoedema. 
It is worth noting in this connection that Vassale and 
Sacchi found that the removal of the hypophysis caused 
an increase in the colloid contents of the thyroid, and 
vice versa, but they concluded, on various grounds, that 
this did not betoken an increased functional activity. 
IMMEDIATE EFFECTS OF OPERATION, AND THE SORTS OF 
CASES IN WHICH UNFAVORABLE RESULTS OCCUR. 
There is some liability to sudden death after operation 
for Graves' disease as well as for other forms of goitre 8 
JAMES J. PUTNAM. 
(Striimpell, Wolff, Frank), and this danger is the more 
alarming because we do not fully understand the cause 
of the fatal result nor how to avoid it. Besides this, 
symptoms of the following kinds are not unlikely to 
occur : excessive prostration, dysnoea, tachycardia of high 
degree, vomiting, sleeplessness, pain (especially in the 
shoulder), pneumonia, pleurisy, laryngeal paresis. 
The first few days after operation for goitre of any 
kind are liable to be a distressing period to the patient 
and an anxious one for the physician. Of the cases 
of Graves' disease of which I have notes, unpleasant 
symptoms occurred immediately after the operation in 
four--or about one out of eight-but it is to be remembered 
as regards many of the others, that no mention is made 
of this early period, and that perhaps the reporters of 
the cases have sometimes passed it over as immaterial 
when the final result was favorable. 
The case which I have related above gives a good pic- 
ture of several of these mischances. Fortunately, the 
patient's condition is often less serious than it seems, for 
the outbreaks of tachycardia and dyspnoea are probably 
only an exaggeration of those which occur in unoperated 
cases from time to time, and any one who has witnessed 
bad forms of these knows how alarming the patient's con- 
dition may become and yet eventually clear up entirely. 
Of course, the essential thing is not the immediate 
but final result of the operation ; but nevertheless the 
patient's friends, if not the patient himself, should be 
warned of what may occur during the earlier periods. 
Can we judge beforehand, in any case, whether the 
operation will be well borne or not ? It is probable, but 
not certain, that to a limited extent we can do so. The 
nervous centres of a patient with goitre are in a condition 
of very unstable equilibrium, and it is probably those 
that show the greatest instability which are most likely 
to suffer. Nevertheless this is not an invariable rule, 
since some very bad cases are reported to have done ex- 
ceedingly well. The dangers present during and after 
operation are probably due, to a great extent, to the same influences that make the condition of a goitrous patient 
at all times distressing and alarming, namely, a weakened 
or diseased heart and cardiac nerves; a similar condition 
of the respiratory apparatus ; and irritation of the thy- 
roid nerves or of the trunk of the recurrent. To these,, 
the effect of etherization, mucus in a paralyzed larynx, 
change of shape and softening of the trachea are some- 
times superadded. (Compare Wette and Wolff.) 
In considering the liability to a fatal result, we ought 
not to confine ourselves to the cases of Graves' disease 
alone. Jankowski, in 1885, made a careful study of the pub- 
lished cases of all goitre operations as regards the ill ef- 
fects of the operation, and found, as one might expect,, 
that with improvedsurgical technique the mortality rate 
has been steadily falling. He considered it, however, to be 
still about 11.6 per cent. Wette's statistics of Riedel's oper- 
ations in Jena, make, however, a much more favorable 
showing. Between 1882 and 1891 ninety-two operations 
were done,with but one death that could fairly be referred 
to the operation itself. One other patient died, however,, 
apparently from the injury to the recurrent laryngeal 
nerve, from washing out the wound with a solution of car- 
bolic acid. Nearly 90 per cent, of the remaining patients 
were nearly or quite relieved of the symptoms for which 
the operations were done, and it is noteworthy that these 
were, to a great extent, similar to those from which pa- 
tients with Graves' disease suffer, namely, disorders of 
respiration and tachycardia. 
Among these cases of goitre there were many which 
were more serious than those with which we, as neurolo- 
gists, ordinarily have to deal. 
Paresis or paralysis of some of the laryngeal muscles 
after thyroidectomy is very common. My patient pre- 
sented them, and Jankowski observed them in 14.03 per 
cent, of 614 cases. Fortunately, this paralysis almost al- 
ways passes away in time, though sometimes not for 
weeks or months. Jankowski calls attention to the im- 
portance of making a thorough examination of the larynx 
before operating, because what often happens is that the 
THYROIDECTOMY IN GRAVES' DISEASE. 
9 10 
JAMES J. PUTNAM. 
operation only intensifies a pre-existing condition. It is 
also important to examine the heart carefully before 
operating, but we should be careful in interpreting the 
significance of what we find. 
The investigations of Schranz have shown that the 
patients with ordinary goitre, even of the mildest type, 
are far more likely to show weakness and irritability of 
the heart, and eventually the structural changes to which 
this weakness leads, than non-goitrous persons ; and this 
is but one of the many indications that the difference be- 
tween simple goitre and Graves' disease is mainly one of 
degree. Schranz says that such patients are liable to 
bear etherization badly, but this is not invariably true. 
A patient with Graves' disease, for many years under my 
care, was recently obliged to undergo an operation for 
ovariotomy, and it was noteworthy that her pulse became 
slower and steadier under the ether. Again, attention 
has recently been called to the fact that chloroform is 
often of great use in tachycardia of acute " heat-stroke," 
just because it diminishes the irritability of the cardiac 
centres. 
THE DEGREE AND PERSISTENCE OF IMPROVEMENT, AND 
PERIOD AT WHICH IT APPEARS AFTER OPERATION. 
In some of the cases reported, the symptoms began to 
improve almost from the moment of the operation. This 
is especially true of the palpitation, less so of the exoph- 
thalmus, though this also occasionally improved early.1 
In other cases, again, the improvement began later and 
was very gradual, occupying many months. Recurrence 
of goitre or of nervous symptoms seems to have been 
very rare, although some of the cases were under obser- 
vation for a number of years. A certain degree of nerv- 
ousness and a liability to palpitation on exertion, not 
enough, however, to prevent even manual labor, remained 
in a good many instances. An interesting andimportant 
1 It is probable that when the exophthalmos is of acute or recent on- 
set it is due to congestion, and may therefore quickly disappear. This 
sometimes occurs spontaneously, as in the cases observed by Gowers and 
by Coggeshall. THYROIDECTOMY IN GRACES' DISEASE. 
11 
point concerns the liability of the goitre, orthat part 
of it left behind by the operation, to grow larger again. 
This liability is recognized by the surgeons, though 
■generally overrated. Rose is often quoted as sayiing that 
so long as a bit of the gland remained behind the goitre 
is liable to return and plague you. On the other hand, 
Wolff, in a recent and careful review of the facts, insists 
that the shrinkage of the remaining portion is the almost 
invariable rule, and Wette reports but one case of second 
ary enlargement. 
DOES THE RESULT VARY ACCORDING TO THE CHARACTER 
OF THE TUMOR ? 
If it is true that the goitre is a principal cause of the 
symptoms in some cases but not in others, as suggested 
by Wette and other observers, we might fairly expect to 
find that thyroidectomy would be more effective for good 
in some classes of cases than in others, and more effective 
where the goitre appeared first, than where it seemed to 
be secondary, in time of appearance and in prominence, 
as a symptom. As a matter of fact we do not find this 
to be the case. The same success seems to have attended 
the extirpation of vascular, parenchymatous, and cystic 
growths, and to have been seen in those cases which 
originated in fright (Lemke), or where the goitre was 
not the first sign of the disease, as in those of a different 
order. This fact suggests that we ought not to make too 
much of the favorable action of thyroidectomy as an 
argument for the thyroidal origin of Graves' disease. It 
would seem that however the disease is first initiated, 
we have to deal eventually with a vicious circle of mor- 
bid conditions, of which the enlargement of the thyroid 
is an important link. The enlarged thyroid evidently 
becomes, if it is not at first, a centre for the irritation 
perhaps the chemical irritation-of important nerves, 
and it is by getting rid of these irritations that the cure 
is probably brought about.4 In short, we have to deal 
4 This seems to me, at least, the best explanation now possible. 
Moebius, Muller and others believe in the " Thyroidal Cachexia " 
theory, but it is by no means proved, or even made probable by the 
. facts now at our command. 12 
JAMES J. PUTNAM. 
with a patient whose nervous system is, in certain re- 
spects, in a highly irritable state. Yet there is all the 
time a certain capacity for improvement, and if even par- 
tial rest can be secured for the nervous centres they have 
a chance to recover their tone, and of this chance they 
are able to avail themselves. It is only in this way that 
we can explain the remarkable effects occasionally pro- 
duced by the treatment of diseases of the nasal cavity, 
(Hack, Musehold, Hopmann, Fraenkel, Stoker, Semon, 
Winckler, and others) or by oophorectomy (Jeuttner). 
We see something similar to this in the effect of opera- 
tions for facial neuralgia, where great temporary relief is 
often gained if even a portion of the irritating impulses 
which fall upon the diseased nervous centre can be re- 
moved by the resection of a single one of several diseased 
nerves. 
Not only is it true that among the successful cases of 
thyroidectomy for Graves' disease we have to deal with 
a variety of kinds of tumor, but we also find that even 
the enucleation of a cyst or the removal of a sarcoma may 
be effective in the same way (Tillaux, Rehn, Ollier). The 
probability is that the vascular goitres are not character- 
istic of all stages of Graves' disease, but only of the first 
stage, and not necessarily met with even in that. As 1 
have already indicated, the tendency is for the gland to 
assume eventually some such structure as that which I 
have described, or else to undergo some form of degener- 
ation. 
In most of the cases where operation has been done 
hitherto, the goitre has been large and the symptoms 
urgent. We still need very much to know whether a 
good result may be expected where the goitre is small 
and indolent and the symptoms mild. I should, myself, 
be inclined to advise operation even in such cases as this, 
provided other means within the power of the patient 
had been fairly tried. It is possible that even a relatively 
slight operation would sometimes be sufficient to make 
the rest of the gland shrink. Even a division of the isth- 
mus has been known to do this occasionally. It is prob- THYROIDECTOMY IN GRAVES' DISEASE. 
13 
■able that the tendency to shrinkage is greater with some 
sorts of goitres than with others, and that it varies with 
the condition of the patient. (Horsley). The experiments 
of Beresowski upon dogs show that when a portion of the 
healthy thyroid is removed, short of the amount which 
would invite the occurrence of myxoedetna, there is al- 
ways a certain degree of regeneration, but that this ceases 
long before the original size of the gland has been 
reached. Halsted and Welch also found regeneration 
to occur, but, as I have said, with changes in histological 
structure. 
CHARACTER OF THE OPERATION. 
With regard to this point I am not prepared to give 
an expert opinion, and there are many points in regard 
to which we are still in the dark. It is not clear, for ex- 
ample, why the patient should improve after tne removal 
of one-half or two-thirds of the gland, while the rest re. 
mains, for the part which is left is usually much larger 
than the whole of a normal gland. Wette believes that 
the benefit is mainly derived from getting rid of a part of 
the sum of irritations which the diseased nervous centres 
have had to sustain. Others have supposed that the good 
was done by diminishing the quantity of secretion. 
Wette's opinion seems to me the more probable of the 
two, though Rehn has reported a case where the opening 
and cleansing of a fistula containing detrital matter 
brought relief. Perhaps the irritation of the nerves is of 
chemical origin, or due to the local action of diseased 
secretion. 
Mikulicz has advised an operation which is claimed to 
avoid the danger of injuring the recurrent laryngeal 
nerve, besides giving other advantages. This consists in 
transfixing the gland and resecting all but that which 
remains attached to the deep structures of the neck. 
The operation of tying the four nutrient arteries has 
also been repeatedly done' (Rudygier, Kocher, Drees- 
mann) with a view to making the gland shrink. The re- 
sults, however, do not seem to be quite as brilliant as 
those obtained by thyroidectomy and the improvement 
comes on more slowly. Moreover, it is doubtful if the  JAMES J. PUTNAM. 
14 
operation itself is any easier (Lemke). One caution has- 
been suggested by several surgeons (Lemke), namely,, 
that iodine should never be injected if there is any prob- 
ability that thyroidectomy may be performed later. It 
is attended with some risk, the results are rarely so effect- 
ual as those obtained with the knife, and it renders a 
subsequent operation more difficult. 
More light is needed on the question of how much of 
the goitre should be removed. Now that we have an as- 
sured means of curing or preventing myxoedema, we can 
afford to be a little more bold than would formerly have 
been justifiable. 
Finally, what shall we say as to the nature of Graves' 
disease and the relation of the goitre to the other symp- 
toms ?. This is a question to which a satisfactory answer 
cannot be given, and fortunately the interests of the 
therapeutic's inquiry do not seem to make it necessary.. 
The following points are, however, certainly significant, 
i. Some of the characteristic symptoms of Graves' disease 
at least can be excited by irritations of the nerve-fila- 
ments in the nose, or by disturbances of the circulation 
there. It is a mooted topic whether the exophthalmus 
tachycardia,and thyroid enlargement occasionally induced 
in this way, and sometimes relieved by treatment of the 
nasal cavity, are fully equivalent to real Graves' disease 
or whether something must be superadded, and this ques- 
tion I will not attempt to discuss here. 2. Simple 
thyroid enlargement is apt to be associated with similar 
symptoms, and especially with disturbance of the heart's 
action. This is seen even in the case of animals, as for 
example, an interesting instance noticed, where 
a horse was obliged to run for a long distance. This 
fact naturally leads to the further question whether the 
relation between swelling of the thyroid and change in 
the heart's action may not rest on a physiological as veil 
as a pathological basis. 
The thyroid is, it seems to me, to be regarded as a 
body having a double function. In the universal amaze- 
ment at the wonderful discoveries with regard to its im- THYROIDECTOMY IN GRAVES' DISEASE. 
15 
portance for nutrition, there has been a tendency to slight 
the arguments for its importance as an erectile organ, and 
as regulating the blood supply of the brain, and even to 
scoff at them as trivial. 
One series of observations have been published, how- 
ever, with regard to this point, which deserve more atten- 
tion than they have received. They were made a few 
years ago by Stahel, a German physiologist, who has since 
died, and were reported and endorsed by Waldeyer at a 
meeting of the Berliner Med. Ges. in 1887. Stahel found 
that there is an inverse relation, as regards size, between 
the internal carotid artery and the superior thyroid ar- 
tery. The internal carotid artery cannot expand in the 
bony canal of the skull, through which it passes, and the 
pressure of blood behind it, when excessive, leads to the 
formation of the carotid bulb, and also finds relief in the 
expansile circulation of the thyroid. A similar relation 
exists between the inferior thyroid artery and the verte- 
bral. It is well known that the thyroid is capable of 
swelling rapidly and containing a very large amount of 
blood. It is also well known, and the fact is brought into 
special prominence by the investigations of Schranz, that 
goitre and functional-eventually organic-diseases of 
the heart are very apt to go hand and hand. Usually 
the pulse is more rapid in goitrous patients, and this, as 
Wette thinks, is either because the accelerator cardiac 
fibres are stimulated, or because the inhibitory fibres, al- 
ways the first to suffer, are paralyzed. 
Occasionally the influence of goitre seems to be to slow 
the pulse (Wette), and possibly in health this action is 
exerted oftener than in disease. Broadly speaking, it is 
probable that Graves' disease generally occurs only when 
the regulatory apparatus of the circulation is disturbed, 
and very frequently this disturbance is associated with 
emotional excitement. It can hardly be doubted that 
we shall eventually discover some physiological arrange- 
ment of which the symptom-complex of Graves' disease 
is a caricature. 
If the appearance of a person be noted whose atten- 
tion is suddenly fixed, it will generally be seen that the. 16 
JAMES J. PUTNAM. 
•eyelids open wide, the eyes get a staring look, the pulse 
beats perhaps more slowly at first, then faster. If the 
attention passes into fear, these phenomena may be inten- 
sified, and, in addition, the hand may be seen to tremble. 
If, instead of fear, shame or anger is present, the face 
may become suffused, and if I am not mistaken, the neck 
swells. Add to this the fact that emotions often cause a 
watery secretion in the bowels, and we have a tolerable 
picture of Graves' disease. 
I do not care to insist too much upon the pertinacity 
-of this simile, and certainly not to claim originality for 
it, but I think it does give us a hint why it is that the 
vascular apparatus of the orbit ant the thyroid are liable 
to suffer more than other parts of the vasco-motor system. 
It is especially to be remembered that emotional excite- 
ment may give rise to the symptoms of Graves' disease 
in an acute form, which then pass away under the influ- 
ence of rest. Gowers records a case of this sort, and my 
colleague, Dr. F. Coggeshall, has observed the case of a 
young girl who had acute Graves' disease in consequence 
■of a whipping, but recovered in a few weeks. It seems 
-evident that the anatomical changes-in the form in 
which we see them-are not the real cause of the symp- 
toms. Neither does the thyroidal cachexia theory fully 
stand criticism. It is therefore safest to study the dis- 
ease, provisionally, as a neurosis and to seek for its phy- 
siological analogies. 
In conclusion, it seems to me clear enough that we are 
not obliged to assume that the goitre is the cause of the 
other symptoms in order to explain the favorable results 
of thyroidectomy. The thing which is needed for a cure 
in every case, and in every stage of the disease, is an ade- 
quate physiological rest for the disturbed nervous centres, 
and any influence may secure this which removes a 
good number of peripheral stimulations, or any influence 
which increases the stability of the central nervous sys- 
tem. That the diseased and engorged thyroid may be a 
centre for these abnormal stimuli cannot be doubted. THYROIDECTOMY IN GRAVES' DISEASE. 
AUTHOR AND REFER- 
ENCE. 
AGE. 
SEX. 
CHARACTER AND DURA- 
TION OF SYMPTOMS. 
OPERATION AND IMMEDI- 
ATE EFFECTS 
FINAL RESULT. 
Andry. 
Bull. Med., June 5, 1889. 
43 
F. 
Eleven years' duration. Dy- 
spnoea marked. Otherwise 
typical. 
Excision. Immediate relief 
of dyspnoea. Death. 
Death from operation. 
Barker. 
Lancet, 1883, No. 24. 
21 
F. 
Seven years' duration. Tu- 
mor small and movable, 
consisting of enlarged 
right lobe. 
Removal of right lobe. 
Cure, including relief from 
neuralgia and amenor- 
rhoea. 
Cai rd. 
Edinburgh Med. Chir. 
Soc., 1891, Vol. vi., 
p. 17. 
Excision of right lobe. 
Great improvement, diminu- 
tion in size of remaining 
lobe. 
Determeyer. 
Deutsche Med. Wbchen- 
schrift, 1893, No. 11. 
37 
F. 
Typical case. 
Partial excision. Conve- 
lescence satisfactory. 
Great improvement. Last 
seen five months after 
operation. 
Dreesmann. 
Deutsche Med. Wochen- 
schr., 1892, Vol. xviii., 
P- 5- 
47 
F. 
Typical case. 
Ligature of the thyroid 
arteries. Convalescence 
satisfactory. Gradual im- 
provement. 
Substantially complete cure. 
' Only slight exophthalmus 
remaining. Patient last 
seen two years after opera- 
tion. 
Ibid. 
23 
F. 
Typical case. 
Ligature of thyroid arteries 
in two operations. Mod- 
erate improvement after 
each. 
Great improvement. Slight 
exophthalmus remains. 
Very slight remnant of 
goitre to be felt. 
Ibid. 
20 
F. 
Typical case. 
Ligature of thyroid arteries. 
No change of symptoms 
at first. Finally gradual 
improvement. 
Great improvement. Slight 
exophthalmus remains. 
Tremor and sweating no 
longer present. Pulse 80. 
Only a small remnant of 
goitre to be felt. Patient 
last seen six months after 
the operation. 18 
JAMES J. PUTNAM. 
AUTHOR AND REFER- 
AGE- 
SEX. 
CHARACTER AND DURA- 
OPERATION AND IMMEDI 
FINAL RESULT. 
ENCE. 
TION OF SYMPTOMS. 
ATE EFFECTS. 
Dubrueil. 
22 
M. 
Typical case. Cystic goitre 
Enucleation of cyst. Con- 
Substantially complete cure. 
Gaz. Med., 1887, No. 34, 
with calcareous degenera- 
valescence satisfactory. 
P- 397- 
tion of the walls. 
Frank. 
Berlin KI. Wochenschr., 
. . . 
Details not given. 
Details not given. 
Death from operation. 
1888. 
Ibid. 
(< < < 
Complete cure. 
Ibid. 
U ( ( 
No improvement. 
Ibid. 
(i I < 
Result not stated. 
Kummell. 
24 
F. 
Nutrition poor. Tumor 01 
Removal of right lobe, and 
Great improvement at time 
Deutsche Med. Wochen- 
moderate size. 
part of left. Convalesence 
of writing. Six weeks 
schr., 1890, p. 438. 
satisfactory. Improvement 
began early. 
after the operation all the 
symptoms had greatly 
abated Pulse was 70 to 80. 
Substantially complete cure. 
Lemke. 
17 
M. 
Symptoms of two years' 
Removal of left lobe of 
Deutsche Med. Wochen- 
standing. 
giotre. Convalescence sat- 
Diminution in size of re- 
schr., 1891, No. 2. 
isfactory. Improvement 
maining lobe, restora- 
rapid. 
tion of normal nutrition. 
Patient last seen at end of 
Lemke. 
Excessive tachycardia, ema- 
a year. 
47 
M. 
Removal of largest hah 
Substantially complete cure. 
Deutsche Med. Wochen- 
ciation. 
of goitre. Convalescence 
Only slight nervousness 
schr., 1892, No. 11. 
satisfactory. 
remaining. Patient last 
seen after a year. 
Lemke. 
39 
F. 
Symptoms apparently due 
Removal of greater part of 
Great improvement. The 
Unpublished case com- 
to fright, mental symp- 
goitre. 
only symptom present at 
municated by letter. 
toms. 
time of writing is palpita- 
tion on exertion. THYROIDECTOMY IN GRAVES' DISEASE. 
19 
Lemke. 
46 
F. 
Uniform enlargement of the Tracheotomy ; three weeks The patient died from acute 
Deutsche Med. Wochen- 
schr., 1892, No. 11. 
F. 
thyroid of moderately large 
amount. Excessive dysp- 
noea. 
later, extirpation of the 
right half of the gland. 
Convalescence s a t i s f a c- 
tory. 
influenza two months lat- 
er. Before her illness the 
exophthalmus had disap- 
peared. The pulse was still 
irregular. 
Ibid. 
20 
Large goitre. 
Extirpation of right half of 
goitre. Only moderate 
bleeding Convalescence 
satisfactory,and rapid im- 
provement in all the 
symptoms. 
Great improvement, permit- 
ingregular work; diminu- 
tion in size of the rem- 
nant of goitre. Patient 
under treatment at the 
Polyclinic at the end of 
nine months. 
Lister. Cited by Fraser. 
Edinburgh Med. Jour., 
1887, Vol. xxxiii., p. 
347- 
young 
girl 
Typical case. 
Removal .with knife and 
curette. Convalescence sat- 
isfactory. Improvement 
began early. 
" Resection " of tumor. Con- 
valescence satisfactory. 
Great improvement. 
Mikulicz. 
Centralb. f. Chir., 1885, 
No. 51. 
Berlin KI. Wochenschr., 
1886, 4. 
35 
F. 
Typical case. Cardiac en- 
largement. 
Improvement in all the 
symptoms but not com- 
plete cure. Patient last 
seen at the end of a few 
months. 
Ollier. Cited by Benard. 
ZfoTZ. 
21 
F. 
Typical case. Growth con- 
tains a large cyst. 
Repeated injections of io- 
dine. Temporary pain and 
prostration. 
Great improvement. No en- 
largement of the thyroid 
to be felt. 
Rehn. 
Berlin KI. Wochenschr., 
1884. 
22 
F. 
Soft vascular goitre of size 
of fist, of several years' 
duration. Severe nervous 
symptoms. 
Extirpation of whole thy- 
roid. Considerable bleed- 
ing. Paresis of recurrent 
nerve lasting four months 
Recovery. Patient last seen 
one and a quarter years 
after operation. 
Ibid. 
36 
F. 
Hard tumor of right lobe, 
size of fist, eight years' 
standing; severe nervous 
symptoms of a year's 
standing. 
Removal of diseased lobe. 
Temporary increase of 
tachycardia and dyspnoea. 
At end of week pulse 
normal. 
Recovery. At end of a year 
doing hard work. Last 
seen after one year. 20 
JAMES J. PUTNAM. 
AUTHOR AND REFER- 
ENCE. 
AGE. 
SEX. 
CHARACTER AND DURA- 
ATION OF SYMPTOMS. 
OPERATION AND IMMEDI- 
ATE EFFECTS. 
FINAL RESULT. 
fold. Cited by Wette. 
Arch. f. Klin. Chir., 
1892, Vol. xliv., p. 792' 
M. 
Severe case. Poor nutrition 
Removal, except of left lobe. 
Substantial recovery, per- 
and bad hygienic influ 
Slow but steady improve- 
mitting hard work. Pati- 
ences. 
ment. 
ent last seen four and one- 
half months after opera- 
Riedel. Cited by Wette 
Arch. f. Klin. Chir., 
20 
F. 
Goitre of many years' stand- 
Removal of largest half of 
tion. 
Substantially complete cure. 
ing. Nervous and mental 
goitre. No bad symp- 
Patient able to exert her- 
1892, Vol. xliv., p. 796. 
symptoms of high degree ; 
toms noted. 
self freely as in dancing. 
nutrition greatly impaired; 
Exophthalmus gone. In- 
excessive exophthalmus ; 
crease in weight from 80 
growth parenchymm- 
to 135 Patient last seen 
Ibid. 
M. 
atous ; very vascular. 
Removal of goitre. No bad 
three years after operation. 
23 
Goitre of right lobe of 
Substantially complete cure. 
thyroid of ten years'stand- 
ing, of about the size of 
fist, containing a large 
colloid cyst ; symptoms 
symptoms noted. 
Patient last seen one year 
after operation. 
Ibid. 
F. 
moderately severe. 
49 
Large bilateral go'tre of 
Enucleation of multiple nod- 
Gradual but steady improve- 
twenty-four years' stand- 
ules, some of very large 
ment, and at the end of a 
ing. Symptoms severe. 
size. " Resection " of sub- 
year again of forty pounds 
Tumor contains paren- 
clavicular portion. Mod- 
in weight and only slight 
chymatous nodules with 
erate fall of pulse ; bron- 
nervousness remaining. 
fibres and calcareous de- 
chitis and pleurisy; great 
generation ; very vascular. 
prostration for weeks. 
Very gradual improve- 
Rupprecht. 
Jour.' Ber. der Ges. f. 
ment. 
35 
M. 
Goitre not noticed until 
three years after tachy-l 
Enucleation of goitre. No 
bad symptoms noted. Rap-1 
Substantially complete cure. 
Nat. und Heilkunde, 
Dresden, 1890, p. 63. 
cardia and palpitation. 
id improvement. THYROIDECTOMY IN GRAVES' DISEASE. 
21 
Sprengel. 
Schmidt's J. B., Vol. 
ccxxix., p. 138. 
Steltzner. Cited by Gan- 
ser. 
bstrac t in Schmidt's J. 
B., Vol. ccxxix., p.138. 
Ibid. 
Stierlein. 
28 
F. 
Symptoms said to be char- 
acteristic. 
Slight goitre since child- 
Removal of whole goitre. 
Partial removal of goitre. 
Removal of goitre (right 
Cure complete, except ex- 
ophthalmus unchanged. 
Tetany and mental enfeeble- 
inent. 
Tetany Symptoms said not 
to have improved 
Substantially complete cure 
Beitr. z. Kt. Chir. 
hood and tremor for sev- 
eral years ; all conditions 
worse since the influenza 
in 1890. Growth "par- 
enchymatous ; " very vas- 
cular. 
lobe). No bad symptoms. 
Patient last seen one and 
a half year after operation. 
Striimpell. 
Lehrbuch Vol. ii. 
. . . 
Details not given. 
Removal of one-half of 
goitre. 
Sudden death immediately 
after operation. 
Tillaux. 
Butt, de I' Acad, de Med., 
April 27, 1880. 
Bit ll. de Soc. de Chir., 
August 3, 1881. 
29 
F. 
Goitre hereditary in family. 
Cardiac enlargement, men- 
tal depression, growth 
contains large hemor- 
rhagic cysts. 
Intra-capsula removal of 
goitre. Pain in right arm 
and shoulder ; vomiting ; 
secondary hemorrhage; 
suppuration. After twelve 
days gradual improve- 
ment. 
Substantially complete cure. 
Patient last seen three 
years after operation. 
Trzebichy. 
Arch. f. KI. Chir., 1888, 
Vol. xxxvii., p. 498. 
Substantially complete cure. 
Watson. 
Edinburgh Med. four., 
Sept. 1873, p. 252. 
young 
F. 
Typical case ? Duration 
many years. 
Removal of the gland. Ex- 
cessive hemorrhage. 
Good result. 22 
JAMES J. PUTNAM. 
AUTHOR AND REFER- 
ENCE!. 
AGE. 
SEX. 
CHARACTER AND DURA- 
TION OF SYMPTOMS. 
OPERATION AND IMMEDI- 
ATE EFFECTS. 
FINAL RESULT. 
Watson. 
F. 
Duration twenty three years 
Good result. 
Ibid. 
Cystic goitre 
Watson. 
Ibid. 
F. 
Multilocular cystic goitre. 
Good result. 
Wolff. 
Berlin KI. Wochenschr., 
30 
F. 
Symptoms due to fright. 
Exophthalmus and nerv- 
Removal of right lobe. Rap- 
id improvement. 
Substantially complete cure, 
permitting hard work. 
1887, No. 28. 
Wolff. 
ous symptoms first, then 
goitre; voice husky. 
30 
F. 
One year's standing Goitre 
Removal of one lobe, both 
Still under observation. 
Ibid. 
came first, and was vascular 
diseased. Convalescence 
Wolff. 
M. 
in character. 
satisfactory. 
21 
Typical case. 
Right lobe and isthmus re- 
Death. Examination of 
Deutsche Med. Wochen- 
schr., 1893. 
moved Immediately after 
operation irregular breath- 
wound showed nothing to 
account for it, and it is 
McNaughton Jones re- 
ing and cyanosis, trache- 
ascribed either to disturb- 
ports a case of recovery 
after treatment of the 
otomy, death. 
ance of heart action or to 
the accumulation of mu- 
goitre by a seton. Brit- 
ish Med. Journal, Dec. 
cus in the throat. 
1874. 
Lemke. 
Deutsche Med. Wochen- 
16 
M. 
Large goitre. Severe palpi- 
Extirpation of the right 
Substantially complete cure. 
schr., 1892, No. 11. 
tation ; no exophthalmus. 
half. No bleeding of con- 
sequence. Convalescence 
entirely satisfactory. THYROIDECTOMY IN GRAVES' DISEASE. 
23 
Rehn. 
F. 
Goitre since childhood, now 
Removal of right middle 
Great improvement. 
Still 
Ibid. 
of firm consistency. Mod- 
lobe. Large hemorrhage 
palpitation at time. 
Last 
erate symptoms of three 
from rupture of brittle 
seen three years 
after 
years' standing. No ex- 
artery. Gradual improve- 
operation. 
Stierlein. 
ophthalmus 
ment. 
25 
Goitre of right lobe 01 
Removal of right lobe. Sup- 
Great improvement; palpi- 
Beitr. Kl.Chir.z . 
thyroid. Palpitation ; in- 
crease of cardiac dullness 
puration ; then rapid im- 
tation only on violent ex- 
provement. 
ertion Patient last 
seen 
to the right; no exoph- 
one and a half years 
after 
Tillaux. Cited by Benard. 
thalmus. 
operation. 
33 
M. 
Nervous symptoms but no 
Enucleation of diseased por- 
Great improvement. 
Contnb. a I'elude de 
exophthalmus Goitrou 
lion. 
Goitre. Exopthal, 1882. 
tendency hereditary Sar- 
comatous degeneration of 
the growth. 
- 
- 
- 
- - zz 
- -. . 
ZZZZZZ 
There was no exophthalmus in the four last cases given. This list might be made very much larger by adding 
reports for ordinary goitre with nervous sj mptoms. 
Roux [Remarques sur 115 operations du goitre. Weisbaden, Bergmann, 1891.] has reported five favorable cases 
which came to my notice too late to be incorporated in this list. 
In all, the summary includes 51 cases. There were four deaths attibutable to the operation, but in almost all the 
rest, greater or less improvement, and often substantial cure, seems to have taken place. Of course these results are not to be 
placed entirely to the credit of the operation, since prolonged rest is almost always beneficial, and the influence of time is 
often of itself useful, and even curative. [See Muller, 1. c ] THE ALLIANCE PRESS, 
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