Wednesday 3 August 2016

THE HISTORY OF THYROID SURGERY

I am once again back with an outstanding account of history of medicine from the pen of my senior colleague Dr. H.S. Adenwalla. Besides being one of the most respected senior Plastic Surgeons of our tme Dr. Adenwalla is Head of the Charles Pinto Centre for Cleft Lip, Palate and Craniofacial Anomalies in Jubilee Mission Medical College and Research Institute in Trichur, Kerala.

Physicians hundreds of years ago had learned by observation that eating roasted sponges sometimes reduced goitrous swellings. In 1820 the Swiss scientist Jean Francois Coindet had discovered that iodine was the effective component of sponges and ever since then iodine became the sheet anchor of all therapy for goiters. It was rubbed into the gland, taken by mouth and even injected into the gland. The treatment had some effect and is still used in iodine deficient areas to prevent goiters. But it did nothing for the large goiters that either killed their victims with asphyxiation or, in cases of toxic goiters, with ultimate heart failure. A tracheostomy was performed as a last resort for asphyxiation. No one really knew as to what was the function of the thyroid gland, which unlike other glands had no duct to carry away its secretions. Scientists made the most fantastic speculations about its function.

The Roman physician Celsus had written an account of his experience with thyroid surgery. He enucleated the nodules and most of his patients either died of sepsis or severe hemorrhage.  Two hundred years later Galen described an operation on a child. The patient survived the hemorrhage but lost the ability to speak. Galen described a nerve behind the thyroid gland, the slightest disturbance of which would affect speech. This nerve was later called the recurrent laryngeal nerve which controlled the vocal cords.

A thousand years after Galen, Paracelsus issued dramatic warnings against a surgical solution of the thyroid problem. Roland, a noted surgeon, burned holes with hot iron and drew threads of horse hair to tie off chunks of thyroid tissue hoping that those parts would necrose and die. Desault and Dupuytren tried surgery but with no success. Until by 1877 some hundred and fifty operations were performed on the thyroid resulting in death due to haemorrhage or pyaemia and the few that survived lost their speech.

Then came the work of Semmelweis, Pasteur and Lister and the advent of antiseptic surgery, anaesthesia and the creation of the artery forceps, the stage was now set for the epic speech delivered by Edmund Rose, a fourty year old surgeon from Zurich at the annual congress of German surgeon in 1877. Rose said that “total extirpation of the thyroid was the only remedy for this condition and it could be done without undue haemorrhage and without  damaging the vocal nerve if the surgeon took pains to study in detail the anatomy of the thyroid gland.” Rose’s lecture focussed the attention of European surgeons on the thyroid gland. In his talk, he acknowledged the work of Theodore Billroth of Zurich and Theodore Kocher of Berne both of whom had successfully done total thyroidectomies as early as 1872, a good five years before his presentation. Both Billroth and Kocher described a method whereby they systematically tied off the major vessels that supply the thyroid gland, and carefully avoided touching the recurrent laryngeal nerve. However, there came up at the time a few reports of the patients developing spasms, no one knew why and no one knew what to do for them. This neglected “tetany” killed a few patients due to severe spasm of the thoracic muscles. We know today that this was due to the inadvertent removal of the parathyroid glands and all that one has to do is give calcium to control it, but no one knew anything about the parathyroids at that time.

Theodore Kocher was now at the height of his fame. The world was talking about how he had mastered the operation on the thyroid gland, and how he had saved hundreds of young women from a ghastly death and then suddenly his world came tumbling down. It  was Reverdin who first pointed out to Kocher that one of his fourteen cases on whom he had done a total thyroidectomy had become a cretin and he suspected that the cause was the total removal of the thyroid. Kocher made Roux his assistant write to everyone of his patients to come for a checkup, and when they came, it was the saddest day for this great surgeon. He realised that he had created a generation of Cretins. Roux reports that he found the Professor sitting in his room with his head in his hands and when he looked up at me he said, “Roux have you ever known the moment when God suddenly hurls you down from a peak of self-complacency and lets you recognize what small bungling creatures we are?” The history of Medicine has given a full account of what this meant for the new born science of thyroid surgery. They described the nature of the mistake, how it came to be made and what its consequences were and how it was gradually amended. But they did not name the victims and they do not tell you what Theodore Kocher felt when he first recognized the terrible thing he had done by totally removing the thyroid gland. So what did this great surgeon and scientist do? He went before the Congress of German surgeons in Berlin on the 4th of April 1885 and told them what he had done and the result of his mistake. He strongly advocated that the total gland should never be removed otherwise they would have many of their patients end up with what he called “cachexia strumipriva” later on labeled as myxoedema or cretinism.

Kocher was not the type of man to accept defeat. He went back and experimented on animals and ultimately came to the conclusion that if a small portion of the gland was conserved the horrible complication would not occur. Many surgeons without proper training took to doing thyroid surgery. They did not have the dexterity and expertise of men like Kocher, Billroth and Reverdin and so many complications kept occurring until the great Lahey at the Lahey clinic wrote his monumental paper on thyroid surgery and the recurrent laryngeal nerve. The complications of damage to the parathyroid was recognized and surgeons learned the use of calcium to treat tetany. In 1891 George Redmayne Murray in England extracted desiccated thyroid extract from pigs. Edward Calvin Kendall of the Mayo clinic extracted the pure form from hog thyroid glands. The hormone was synthesised by Charles Robert Harrington and George Barger British chemist in 1927. In 1960 Levothyroxine was synthesised and with these advances total thyroidectomy for cancer became a safe operation and both myxoedema and cretinism if detected early could be treated.

Today when we race through a subtotal or total thyroidectomy we little realise what the great surgeons of yore went through to give us simple answers to our problems in this, and other fields of surgical endeavor. 


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