The early days of thyroidectomy.
|Abstract:||Although the normal thyroid gland is invisible and impalpable, its enlargement gives such an obvious swelling in the front of the neck that this pathology has been observed from ancient times. Old names for the swollen gland included 'bronchocele', which means a cystic mass in the neck, 'struma', (Latin for a swollen gland) and 'goitre', which comes from the Latin word 'gutta', the throat, and which is a term which is still used today. The term 'thyroid' was introduced by the 17th century anatomist Thomas Wharton, of London, and is derived from the Greek word thyreos, a shield, based on its shield-like appearance wrapped over the front of the trachea. He believed that its function was to give women a beautifully rounded neck!|
Thyroid gland (Physiological aspects)
Thyroid hormones (Physiological aspects)
Thyroid diseases (Care and treatment)
Thyroid diseases (History)
|Publication:||Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Association for Perioperative Practice ISSN: 1750-4589|
|Issue:||Date: June, 2011 Source Volume: 21 Source Issue: 6|
|Product:||Product Code: 2834135 Thyroid & Antithyroid Prep NAICS Code: 325412 Pharmaceutical Preparation Manufacturing SIC Code: 2834 Pharmaceutical preparations|
Although the normal thyroid gland is invisible and impalpable, its
enlargement gives such an obvious swelling in the front of the neck that
this pathology has been observed from ancient times. Old names for the
swollen gland included 'bronchocele', which means a cystic
mass in the neck, 'struma', (Latin for a swollen gland) and
'goitre', which comes from the Latin word 'gutta',
the throat, and which is a term which is still used today. The term
'thyroid' was introduced by the 17th century anatomist Thomas
Wharton, of London, and is derived from the Greek word thyreos, a
shield, based on its shield -like appearance wrapped over the front of
the trachea. He believed that its function was to give women a
beautifully rounded neck!
An important component of thyroxine, the hormone secreted by the thyroid gland, is iodine. A common cause of thyroid enlargement is iodine deficiency. Iodine is found in sea water, and thus iodine deficiency is likely to be found in mountainous areas far removed from the sea. Thyroid enlargement in mountainous areas of central China was apparently well known nearly 5000 years ago and Chinese physicians were using sea weed for this condition in the 4th century AD; of course, seaweed is a rich source of iodine! In this country, if you look at the map, Derbyshire is about as far away from the sea as you can get; thyroid enlargement was common, and the local name for this was 'Derbyshire neck'. Even in the 1950's, when I was a young surgeon in Sheffield, we were operating on old ladies with this condition--a situation now solved in developed countries by the introduction of iodination of table salt.
Other inland areas, where iodine deficient thyroid enlargement was common, included Switzerland and the Mid-West of the USA. Much of the early work on thyroid disease, as we shall see, took place in Swiss medical centres, and at the Mayo Clinic, in Rochester, Minnesota with the Mayo brothers, and the Cleveland Clinic, in Ohio, with George Crile.
Not surprisingly, removal of the enlarged thyroid before the days of anaesthesia and antiseptic surgery was regarded as a hazardous or indeed hopeless exercise. Like the Chinese pioneers, physicians would recommend seaweed; either dried or burnt, and no doubt had some success. Amazingly enough, Pierre-Joseph Desault, an influential surgeon at the Hotel Dieu in Paris, carried out an excision of a large thyroid mass in a female patient, in 1791, by careful dissection and first tying the superior and inferior thyroid arteries. The vertical neck wound suppurated, but the patient recovered. Even with the advantages of anaesthesia and antisepsis in the latter part of the 19th century, the results of operations on the thyroid were so bad as result of haemorrhage and damage to related structures that most authorities regarded the operation as too hazardous to be attempted. Even that master surgeon Theodor Billroth, who had performed the first successful gastrectomy, practically abandoned thyroidectomy unless the patient was threatened with asphyxia from the enlarged mass.
Modern thyroid surgery owes a great deal to one man, Theodor Kocher, who was born, bred and spent his whole professional life in Bern, Switzerland; an area, of course, where thyroid disease was endemic. By meticulous surgery, he reduced his operative mortality to under O.5%. A series of 600 thyroidectomies which he published in 1898 included a single fatality, and that was due to an over-dose of chloroform.
In 1882, another distinguished Swiss thyroid surgeon, Jaques-Louis Reverdin, of Lausanne, reported hitherto unrecorded complications of thyroidectomy, which, in those days, comprised almost total removal of the gland. Patients became depressed, weak, sluggish, obese, anaemic and with puffy faces, all of which resembled the features of cretinism in children and myxoedema in adult subjects. Of course, they were indeed suffering from thyroid deficiency. Kocher reviewed his own cases and confirmed this phenomenon. It was soon obvious that preservation of some active thyroid tissue was necessary, the operation of partial thyroidectomy. Another complication that was encountered was tetany. At that time the parathyroid glands were unknown, and indeed were only discovered by Yvar Sandstrom in Uppsala, Sweden in 1880. It took almost 20 years for the function of these glands in controlling the level of calcium in the blood to be sorted out and for surgeons to learn the importance of preserving the parathyroids at thyroidectomy. Theodor Kocher received the Nobel Prize for Medicine in 1909 for his work on thyroid disease, the first of a handful of surgeons to be so honoured. There remained the problem of dealing with the overactive thyroid gland--hyperthyroidism. These patients in advanced disease, with tachycardia, perhaps even in heart failure, represented a terrible operative risk. George Crile, at the Cleveland Clinic, introduced the operation of 'stealing the thyroid' in 1907. The patient was heavily sedated for several days, not informed of the time or even day of the operation and was anaesthetised in the ward before being transferred to the theatre, or, indeed, even operated upon in the ward on the bed! Combined with expert and rapid surgery, there was a gratifying improvement in results.
Meantime, at the Mayo Clinic, the physician Henry Plummer showed that administration of potassium iodide rapidly, although only temporarily, brought the symptoms of hyperthyroidism under control, allowing a window in which to perform thyroidectomy safely. Since the 1940's, more effective and long-lasting antithyroid drugs have been introduced, together with radioactive iodine therapy, so that many cases of hyperthyroidism nowadays can be treated medically.
No competing interests declared
Provenance and Peer review: Commissioned by the editor; Peer reviewed; Accepted for publication December 2011.
Correspondence address: Department of Anatomy, University of London, Guy's Campus, London, SE11UL.
About the author
Professor Harold Ellis CBE, FRCS
Emeritus Professor of Surgery, University of London, Department of Anatomy, Guy's Hospital, London
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