Thyroid Historic perspective

Dr T Balasubramanian

Goitre & mountains

Goitre was first seen in inhabitants of Alps

Initially they did not know that goitre is enlargement of thyroid gland

It was documented that consuming sea weeds caused remarkable cure in these patients

It goes without saying that sea weeds contain large amounts of iodine

Goitre

Greeks used the term Bronchocele to explain the goitrous swelling

Thyroid gland was discovered 200 years before Greeks used this term

Davinci and thyroid

Davinci discovered thryoid gland as early as 1500

He drew sketches of the gland in great detail

He used the term laryngeal glands to describe the thyroid

He also discussed in great detail the vasculature of the thyroid gland

Fabricious

In 1619 it was Fabricious who described thyroid enlargement caused swelling in the midline of neck

He also clearly described that this swelling moved up and down when the patient attempts to swallow

The name Thyroid

Thomas Wharton in 1656 used to term Thyroid first

Thyroid is a Greek word to indicate shield shape

It was coined with the thyroid cartilage in mind as it is shaped like a shield.

Cretinism & thyroid gland

Alpine travellers were the first to associate cretinism with goitre in mother

Paracelsus in 1527 was the first to link goitre and cretinism

Platter in 1562 came out with convincing proof that cretinism was seen in children born of goitrous mothers

History of thyroid physiology

Initially goiter was thought to be caused by excess of phlegm

Chinese merchants were the ones who taught the Europeans that consuming sea weed could cure goitre

Courtois in 1812 discovered that sea weeds contained large quantities of iodine

Coindet in 1820 popularized iodine treatment for goitre in Sweden

Mortiz Schiff's contribution

Mortiz Schiff a physiologist from Geneva showed in 1856 removal of thyroid glands in dogs caused death due to some deprivation

This work never got the recognition it deserved

Mortiz Schiff (contd)

It was Mortiz Schiff who first proved that thyroid hormone can be substituted

He used thyroid extracts to save dogs in whom he performed total thyroid removal

Role of iodine in preventing goitre

In 1850 Chatain a pharmacist suggested that goitre could be prevented by consuming iodine

It was only after Akron study which was carried out in school children that goitre preventive role of iodine came to be recognised

Thyrotoxicosis

Parry was the first person to describe thyrotoxicosis

His work was not published till much later

Coindet described the symptoms of thyrotoxicosis without realizing its significance

Graves in his talk described few of his patients with goitre and palpitation. He initially considered it to be a cardiac malady

Basedow discussed in detail the symptoms of thyrotoxicosis

Thyrotoxicosis (contd)

In 1890 it was observed consumption of too much thyroid extract caused tremors and palpitation

It was approximately during this time surgeons were successful in partially removing this hyperfunctioning thyroid glands

Myxoedema

Was discovered much later than thyrotoxicosis

It was first described in London. The term myxoedema was used because of oedematous skin due to accumulation of myxoid tissue

Initially it was considered to be a neurologic / skin disease

Felix Semon

Felix Semon Prussian otolaryngologist described that patients who underwent total thyroidectomy for goitre treatment developed puffy faces similar to that of myxodematous patients seen in London

He was not beleived at first

A committee was constituted which concluded 5 years later that his observation was true

Exogenous thyroxine

Brown sequard documented the regenuating effects of consuming testicular extract of dogs

This provoked scientists to try out other organ extracts too

In 1891 Murray injected sheep thyroid extract which cured a patient with myxoedema

Search for thyroxine

Kendell used iodine as a marker to identify T3. He used the term thyroxine

Baumann identified iodine in the thyroid gland extract

It was the english man Harrington who indentified the exact molecular structure of thyroxine

Harrington suspected there could be another hormone in addition to thyroxine

Thyroid hormone synthesis

Harington added an e to thyroxin

He successfully synthesized thyroxine

Since it was a free acid absorption was poor

Hence until 1960's dessicated thyroid was used in the management of goitre

Goitre & exophthalmos

Fredrich Muller in 1893 identified that patients with goitre and exophthalmos had increased metabolic rate

He was the first person to associate goitre with exophthalmos

Thyroid surgery (History)

Roger Frugadi in 1170 used shoe laces to transfix large goitres which he allowed to slough

First thyroid surgery was performed by Albucais in spain. This surgery was performed to treat a patient with goitre. He used a cruciate incision for this purpose.

Setaceum

This technique in thryoid surgery was practised by Roland and Roger

This was practised when the goitre was adherent

Shoe lace ligature is encircled around the mass and firmly kept tied for 3 hours

The goitre which had become avascular was sectioned away.

Thyroid tunneling

Guy de Chauliac tunneled thyroid tumors with cautery. He passed a seton through the tunnel and removed the mass in toto. He was able to produce reasonable results following this procedure.

Cure by King's touch

Was practised for more than 500 years from 1100 to 1600.

Heinrichs the IV started this procedure

He was credited with nearly 1000 cures by simply touching the neck of the patient. (Such was the devotion they had towards their king thosedays).

Benjamin Gooch's advice

According to Benjamin Gooch thryoid surgery is not for those with weak heart (he meant the surgeon's)

He described his futile attempts to stop bleeding from the neck following surgery by using digital pressure by his assistants for two days who worked as a relay team

Thyroid incisions

Albucasis cruciate incision

Adolf Vogel circular incision

Benjamin Gooch Vertical incision

Desault Median longitudinal incision

Desault's technique

Considered to be father of thyroid sugery

He was the first to emphasise ligation of superior / middle / inferior thyroid pedicles before removing thyroid

His feat was considered unbeleivable

Dupuytren's technique

He staged thyroidectomy procedure

This allowed for better wound healing during procedures

He was the first to observe tracheal flattening / distortion

Ischemic atrophy

Luiga porta ligated thyroid arteries to induce ischemic destruction of thyroid gland

He first ligated both superior arteries of thyroid gland and this was ineffective

He ligated both superior and inferior arteries of one side. This provided temporary relief for about 6 months

He proved that arteries supplying the opposite lobe was not capable of maintaining integrity of opposite lobe

Patrick Heron Watson's technique

In 1894 in completed 5 cases of thyroidectomy in Edinburg

He used long median incision to expose neck

Separated strap muscles / fascia mobilized superior pole using fingers

Used aneurysm needle to thread around superior pole and ligated it. Repeated same maneuver in the other portions of gland and excised it in full

Excellence of Hedenus

He stimulated the interest of thyroid surgery in Germany

Used midline vertical incision to expose the gland

Ligated superior and inferior thyroid arteries

Transfixed and double ligated the isthumus

Removed the mass completely

Incisions

Paul Sick's contribution

Credited with the first total extirpation of thyroid gland in 1867

He was the first to report symptoms of thyroid deprivation

Theodor Kocher and his 100 thyroid surgeries

Kocher was credited with more than 100 thyroid surgeries

He advised against total thyroidectomy

He believed total thyroidectomy somehow disturbed blood supply to the brain

Recurrent laryngeal nerve

Anton Wolfer was the first to draw attention to the recurrent laryngeal nerve

He also beleived ligation of inferior thyroid artery somehow damaged the nerve

Billroth's approach

He used lateral incisions placed over the inner border of sternomastoid muscle

He divided sternohyoid, omohyoid and sternothyroid muscles transversely

Artery forceps was freely used by Billroth. This facilitated better haemostasis

Near total thyroidectomy

First performed by Mikulicz

He left a sleeve of thyroid gland along the tracheo oesophageal groove in order to protect the recurrent laryngeal nerve from injury

He insisted that this technique is useful even in treating malignant lesions of thyroid gland

Study of thyroid vasculature

Kocher studied vasculature of thyriod gland by injecting colored fluid in the cadaver large vessels

He attempted to explain the tracheal oedema that followed thyroid surgery by suggesting vascular congestion to be the cause.

Berne's classification of thyroid surgeries

Total extirpation

Partial thyroidectomy

Enucleation

Mayo's contribution

Mayo could boast of the most experience in thyroid surgery than anyone else in this world

He was instrumental in disseminating vital knowledge pertaining to thyroid surgery to other surgeons

His clinic played a vital role in this purpose and still continues to do so

Thank you

Muokkaa otsikon tekstimuotoa napsauttamalla

Muokkaa jsennyksen tekstimuotoa napsauttamallaToinen jsennystasoKolmas jsennystasoNeljs jsennystasoViides jsennystasoKuudes jsennystasoSeitsems jsennystasoKahdeksas jsennystasoYhdekss jsennystaso