August 2012 Newsletter: James Berry and His Thyroid Clinic

HISTORICAL NOTE  

JAMES BERRY AND HIS THYROID CLINIC

Berry’s Ligament is certainly the most well known eponymous anatomical structure of relevance to thyroid surgery, tethering the thyroid gland to the trachea and lying, as it does, at the crucial point where the recurrent laryngeal nerve is most likely to be injured. James Berry was a formidable surgeon who established a Thyroid Surgical Clinic at the Royal Free Hospital in London, one which became recognised as one of the most active clinics in the country both from an educational and technical point of view.

James Berry, a Canadian who undertook his training in London, established one of the first ever dedicated Thyroid Surgical Clinics at the Royal Free Hospital at the beginning of the twentieth century. His clinic was described as having managed "to preserve all that is the best of the essentially British methods in the teaching of surgery to which has been added the cream of Continental and American methods...". What is most impressive is that, over 100 years ago, Berry had established the principles of multidisciplinary care of patients with thyroid disease who required surgery. Consultations were held at 1.30 pm on Wednesdays at The Royal Free Hospital. Cases were all presented to members of the Honorary Staff, both medical and surgical, and examined by all staff present, with medical students encouraged to examine and handle all the cases themselves. The patients were then removed and the case discussed by the staff in order of seniority, with a decision then made as to the best form of management. Operations were done on Mondays commencing 2.00 pm sharp, with Fridays as a second day should it prove necessary. Also impressive was the concept of team-based management in the operating theatres, a concept well ahead of its time. The team comprised the surgeon and surgical assistants, a number of trained surgical dressers each with a sepcific role such as holding retractors, as well as a specialist anaesthetic team, something almost unheard of at the time. Most operating days, the list of operations was formidable, running into a dozen or more. There were two theatres, each with an anaesthetic room, which communicated through the intermediation of a sterilizing room, and when an operation was finished in one theatre, the surgeon and his assistants walked through this to the adjoining theatre where all was in readiness for the next operation. One of the most important factors in the success of this team was that Berry had been fortunate in having an anaesthetist who was accustomed to his methods, and who had worked with him for many years. A second anaesthetist was also available, and helped very much in avoiding the irritating delays between operations which seem inevitable with a single anaesthetist. On Fridays, Berry gave a most valuable clinical lecture utilizing the specimens removed at surgery, as well as museum specimens and the epidiascope, giving the students a complete picture of the thyroid disease with which the Clinic dealt.

(from: Brit J Surgery Vol VIII, No 31; 361-365)

July 2011 Newsletter: Rundle and His Curve

Rundle’s curve is a well known phenomenon, found in many ophthalmology and endocrinology textbooks. It describes the natural history of the orbital changes in Graves’ ophthalmopathy. Whilst all the primary research underlying this observation was undertaken in the London, Rundle was in fact an Australian, and later returned to Sydney to make a significant contribution to the surgical management of thyroid disease.

Francis Felix Rundle was born in Newcastle, NSW, on April 13th 1910. He grew up in that industrial city before studying medicine at the University of Sydney, where he graduated MBBS with 1st class honours in 1932. After graduation he moved to London to further his surgical career. He was subsequently appointed as Assistant Director of the Surgical Unit at St Bartholemew’s Hospital, and Research Associate at the London County Council Thyroid Clinic. His major interest was in Graves’ ophthalmopathy and he produced a series of research papers over the next decade describing the natural history of the orbital changes in Graves’ disease. His graph showing the initial worsening and then partial resolution of those changes became known as “Rundle’s Curve” and remains a fundamental part of endocrinology and ophthalmology teaching to this day.

He was awarded the Jacksonian Prize of the Royal College of Surgeons for his essay on Graves’ ophthalmopathy, and was subsequently appointed Hunterian Professor. His academic career took a backseat to service with the British Army. Rundle then spent a year in the United States at Harvard, Johns Hopkins, and Stanford as the Rockefeller Travelling Fellow. He was so impressed with the role of clinical research that he sought to replicate this environment at future appointments. In 1950 Rundle moved to Sydney and established the Unit of Clinical Investigation at Royal North Shore Hospital. He enlisted to the Unit Dr Hal Oddie, a physicist from Oak Ridge Nuclear Facility USA, to study iodine dynamics and 131I use. With Oddie’s help he was able to set up the first group in Australia to direct management of dosage of 131I in thyrotoxicosis and non-toxic diffuse goitre. He also helped establish a facility at Royal North Shore for the management of thyroid cancer with 131I . His other major contribution to the management of thyroid disease whilst at Royal North Shore was the production, as editor, of the 2nd edition of Cecil Joll’s Textbook of Thyroid Surgery. In its time this book was the definitive reference text on thyroid disease and thyroid surgery. Notable in the 2nd edition was the change in the operative diagram, with a return to anatomical dissection, emphasising formal identification of the recurrent laryngeal nerve, an approach which had formerly been rejected by Cecil Joll. His other major contribution was to appoint to the Unit of Clinical Investigation in 1957, a young Thomas Reeve, recently returned from the USA. Rundle went on to take up a post as the founding Dean of the Faculty of Medicine at the University of NSW and subsequently Director of the Centre for Medical Education Research and Development.

Adapted from: Bartley G. Arch Ophthalmol. 2011;129:356

December 2010 Newsletter: Theodore Kocher and His Nobel Prize

Theodore Kocher is known as the “father of thyroid surgery”. He was also the first surgeon to receive the Nobel Prize, which many have assumed was awarded for his having introduced the modern era of safe and effective thyroid surgery. This however was almost certainly not the case. 

Theodor Kocher (1841-1917) was appointed to the Chair of Surgery in Berne, Switzerland in 1872. He was a skilled and innovative surgeon. He developed artery forceps to ligate major vessels and described the technique of “capsular dissection”, reducing the risk of haemorrhage, recurrent laryngeal nerve injury and hypoparathyroidism. This was in contrast to his contemporary, Theodor Billroth, Professor of Surgery in Vienna, who was considered a somewhat “rough” thyroid surgeon and who had a reportedly high incidence of permanent complications following thyroidectomy. When Kocher retired in 1917 he was able to report his entire series of 5,000 thyroidectomies with only 0.5% mortality, a truly remarkable achievement for the times. Kocher was also the first surgeon to receive a Nobel Prize (in Physiology or Medicine) in 1909. Many assume that the Nobel Prize was awarded in recognition of this significant contribution to safe surgical technique, however that is almost certainly not the reason for the award. The Nobel citation, read by Professor the Count KAH Morner in Stockholm in 1909, states: “Professor Kocher has given us a comprehensive exposition fundamental to our knowledge of this gland ......... through which it became quite clear that complete extirpation of the thyroid gland is reprehensible. A portion of the gland which is capable of functioning, must always be left behind at operation”. In other words, the Nobel Prize was specifically awarded for Kocher’s conclusion that a partial thyroidectomy, not total thyroidectomy, should be performed for benign goitre. Kocher did not arrive at that conclusion because of his concern about the risk of surgical complications – he was a superb technical surgeon. Rather the Nobel Prize was awarded in recognition of Kocher’s meticulous follow-up, representing one of the first ever surgical outcomes studies. Kocher recalled all his patients who had undergone thyroidectomy and was dismayed to find that almost all (89%) who had undergone a total thyroidectomy appeared small, ugly and cretinoid. At the time he attributed this to tracheal asphyxia due to loss of support of the trachea, and applied the term “cachexia strumipriva” . He was so saddened he determined never again to do a total thyroidectomy, and championed lobectomy for benign disease, adding contralateral arterial ligation for toxic goitre. This approach was adopted by thyroid surgeons  worldwide  many of whom visited Kocher in Switzerland. Despite the subsequent demonstration that the observed symptoms were due to thyroxine deficiency, and could be prevented by replacement therapy, subtotal thyroidectomy remained standard of care for benign for the next 100 years.

Wellbourn R. History of Endocrine Surgery. 1990. Praeger, NY

March 2010 Newsletter: Cecil Joll and His Instruments

Joll's thyroid retractor

Thyroid surgeons from last century were at the forefront of developing surgical instruments to facilitate safe and effective thyroid surgery. Such instruments remain in widespread use in all forms of surgery today.

In this current era of sutureless thyroidectomy, where almost the entire procedure can be performed with a small, hand-held, disposable vessel sealing device, it is interesting to reflect on the role of thyroidectomy in the development of surgical instrumentation. Thyroidectomy has historically been considered the hallmark surgical procedure of general surgery. The ability to offer thyroid surgery with an acceptable mortality was the cornerstone upon which many of the major US surgical centres, such as the Mayo Clinic and the Lahey Clinic established their reputations. In order to achieve such high standards, many practitioners of thyroid surgery from last century developed  a range of novel instruments specifically designed to safely facilitate this particular procedure. For example Kocher, Crile, Lahey and Dunhill all developed artery forceps which remain in common use today for a whole range of surgical procedures, not just thyroidectomy. Cecil Joll was an English thyroid surgeon known for his meticulous attention to detail in the design of surgical instruments. He is best known for the Joll’s thyroid retractor. In his book he notes that “a self-retaining goitre retractor is highly important. The most generally useful type which I have developed is shown in the figure. It produces a satisfactory exposure for all classes of goitre and does not exhibit the irritating tendency to slip possessed by many retractors”.  Joll also designed artery forceps specifically for thyroid surgery. Joll’s comments on the importance of artery forceps, and the extraordinary number of these instruments he had available on the table, provide an interesting insight into the challenges, and volume of bleeding routinely faced by thyroid surgeons of that era. Joll states “it is worth while emphasizing the necessity for providing a very large number of efficient artery-forceps of good design. It is my custom to have six dozen pairs of these artery-forceps available for every goitre operation. They should be not less than 5½ inches in length and should have specially large finger loops in order to facilitate the rapid handling required. One extra assistant is deputed solely to hand to the surgeon and his chief assistant, without delay, these forceps as required.”

in: Joll C. Diseases of the Thyroid Gand. William Heinemann, London, 1932

November 2009 Newsletter: IAES - The International Association of Endocrine Surgeons

The IAES owes its origins to Peter Heimann, Professor of Surgery, Bergen, Norway. He was a general surgeon with a particular interest in the thyroid gland, and it was his ambition to polarize the activities of those general surgeons interested in the endocrine system into a special group within the Société Internationale de Chirurgie (SIC).

In 1978, Peter Heimann wrote to some of his friends that he was dying of gastric carcinoma, and stating his fervent wish that a group of endocrine surgeons should be formed. Scientific papers were invited and a single day program set up during the next meeting of the SIC together with the provision for all those interested to meet and discuss plans for the future.

At 9:00 a.m., Thursday, September 4, 1979, a group met in a room of the SIC congress in San Francisco and elected a president, Selwyn Taylor, a president-elect, Richard Egdahl, a secretary-treasurer, Orlo Clark, and a small international committee.

All those who had indicated that they would be present became the founding members and, since then, the membership has been strictly monitored by surgeons from the applicant's own country, as well as by the committee. The IAES currently counts more than 500 members from around the globe.

The meeting's first scientific session opened at 11.00 a.m. and so keen were other members of the congress to attend, that a larger hall had to be found to house the afternoon session. The standard of presentation and the subsequent discussion was of the highest order and it has remained so ever since. At the conclusion of the next meeting, which was held in Montreux, Switzerland, in 1981, the founding president, Selwyn Taylor, handed over to his successor a badge of office, placing it around his neck, and this ceremony has been carried on ever since at each meeting, the latest being in Adelaide in September this year where Leigh Delbridge received the badge of office. The subsequent list of IAES Presidents includes: Richard Egdahl (USA), Per-Ola Granberg (Sweden), Tom Reeve (Australia), Yoshide Fujimoto (Japan), Norman Thompson (USA), Hans Roher (Germany), Ivan Johnston (UK), Orlo Clark (USA), Charles Proye (France), Jon van Heerden (USA), Shiro Noguchi (Japan), Malcolm Wheeler (UK), Henning Dralle (Germany), and Goran Akerstrom (Sweden). It is heartening that the members' enthusiasm is maintained and even increased. The IAES owes much of the success of its early days to the beneficent sponsorship of the parent organization, the SIC.

The original aims of the IAES were to provide "a forum for the exchange of views of those who are involved in expanding the frontiers of endocrine surgery whether by clinical experience, laboratory investigation or in any other way, not for the general surgeon who occasionally operates on a thyroid or adrenal gland."

The IAES, indeed, fulfils these aims, and is proud of its place in the SIC. The recent IAES meeting in Adelaide demonstrated the valuable contribution by endocrine surgeons around the world. the next biennial meeting of the IAES will be held in Yokohama, Japan, in August 2010. Finally, the World Journal of Surgery regularly devotes a complete issue to the contributions of the IAES.

The IAES always presents a plenary session at the SIC congress, the Peter Heimann lecture, as a prestigious reminder of his contribution.

Adapted from: www.iaes-endocrine-surgeons.com/about/history.shtml accessed 3rd Nov 2009