Michael Bliss, historian from the University of Toronto, delivered an address at the recent AAES meeting in New York describing the interaction between Harvey Cushing, a surgeon, and the Endocrine Society which had just elected him one of its first presidents. Cushing was scathing about the budding specialty of endocrinology, regarding many of its members as charlatans who practiced “endo-criminology:” In 1920 Cushing was elected president of the Society for the Study of Internal Secretions (later to become the Endocrine Society) without his knowledge at a meeting he did not attend of a society dedicated to a discipline that he believed was mostly “poppycock” and for which he coined the term “endo-criminology”. He was well aware that much of what passed for “glandular therapy” was the old scam of peddling replacements for vital fluids. He only agreed to serve because of his ongoing pituitary interest, out of a sense of duty and to help suppress quacks. His 1921 Presidential address at the society’s Boston meeting room began with a beautiful image of the state of the field: “We find ourselves embarked on the fog-bound and poorly charted sea of endocrinology”. The bulk of his talk, an update on the pituitary, was devoted to outlining how little was known, how little clinical progress had been made, the uselessness of giving patients pituitary extract – “The Lewis Carroll of today would have Alice nibble from a pituitary mushroom in her left hand and a lutein one in her right and presto! She is any height desired”- and how wrong it was for a credulous profession to tolerate “polypharmaceutical charlatanism”. He further stated that “This society must discountenance the exploitation of the few discoveries which have already been made by those who recklessly under full sail plow through a fog bank of therapeutics, their horns tooting” The audience knew he was attacking the Endocrine Society’s founder, first secretary, and greatest enthusiast, a Californian half-quack named Henry Harrower who had a major mail-order business selling every kind of glandular extract.

Extract from “Harvey Cushing – A Life in Surgery”. Bliss M. Oxford University Press, Oxford, 2005.

Routine laryngoscopy is part of the pre-operative assessment for patients undergoing thyroid or parathyroid surgery and is, as such, an integral component of endocrine surgical practice. Indirect laryngoscopy however was actually invented by an opera singer. The laryngoscope was invented by the Spanish singer Manuel Garcia in order to allow him to inspect his own vocal cords during singing practice. He recalled “I have often thought of using a mirror to observe the larynx from within while singing but had always considered it impossible. In September 1854, on a visit to Paris, I decided to see whether it could be done. I went to the famous instrument-maker Charriere, and asked if he had a thin mirror with a long shaft that could be used to inspect the throat. He had a small tooth mirror, sent to the London Exhibition in 1851 which nobody wanted. I bought it and took it to my sister’s, with another little pocket mirror, impatient to begin my experiment. I warmed the mirror in hot water, dried it carefully, and placed it against the tongue. When I cast in light with the pocket mirror against it, I saw the larynx wide open before me.” Manuel Garcia the younger (1805-1906) was in fact the son of his more famous father, Manuel de Populo Vicente Garcia (1775-1832), who premiered the role of Count Almaviva in the Barber of Seville. Manuel Garcia the younger was a famous voice teacher who trained Jenny Lind and Johanna Wagner as well as Mathilde Marchesi. He spent much of his time analysing the singing voice, and published a distinguished treatise on singing, Nouveau Traitz sur l'Art du Chant, in 1856. His two sisters were celebrated singers of their day: Maria Malibran (1808-1836) and Pauline Viardot (1821-1910).

Extract from History of Surgery, Knut Haeger. Harold Starke, London 1988: 216

At the IAES Meeting in Durban in August, Jon van Heerden presented the story of Mother Joachim, the first successfully removed phaeochromocytoma in the US. Whilst a number of such tumours had been previously removed in Europe, the accurate recording and astute observations make a fascinating story.

Mother Joachim was a 30 yr old nun from Ontario, Canada, and was referred to the Mayo Clinic with a letter from Dr Duncan stating “I feel much as Festus felt in sending Paul to Rome – not having any definite accusation … she complains of weakness … and vomiting associated with severe headaches”. She was admitted to Saint Mary’s Hospital in June 1926. A description of her attacks was accurately recorded: “sudden onset pain in the back … and right side of neck associated with nausea and vomiting. Rapid heartbeat … Blood pressure 300/160 mm Hg. … Hands cool and sweaty”.

It was believed that her hypertension was mediated through the sympathetics and sympathectomy was considered. Because of the persistent lumbar pain, surgical exploration was performed by Dr Mayo on October 11, 1926. The operation lasted 64 minutes and it was noted that “exploration of the left adrenal showed it to be twice normal size … a rounded tumour apparently the size of a lemon was situated beneath the tail of the pancreas and enucleated intact. Considerable venous hemorrhage was controlled by pack”. The day after the operation Dr Mayo rep-orted that “her blood pressure immediately dropped and she feels much better this morning than she has for a long time” All this was done without any intravenous lines or therapy and without alpha blockade!

That she survived at all is attributed to practice of administering twice daily coffee enemas to post-surgical patients. Apart from some basal atelectasis her post-operative course was uneventful and she was discharged home on December 13, 1926. The procedure was reported in JAMA 1927;89:1047-50 with the accompanying operative diagram. In a letter to Dr Mayo dated February 28, 1927 Mother Joachim wrote “I am feeling wonderfully well and gaining weight each day. I have never had that terrible pain in my head again”. Mother Joachim eventually died in May 1944, 18 years after her operation. Notice of her death was received in a letter which reported “Mary Joachim’s operation was entirely successful … however she seems to have had a heart condition. Coronary thrombosis took her while she slept. She had taught her music pupils the previous day and was cheery and bright as usual”.

Extracts from Dr Jon van Heerden’s lecture and from a previous published report: van Heerden J. First Encounters with Pheochromocytoma. Am J Surg 1982;144:277

Cecil Joll devoted an entire chapter of his historic book to non resectional surgical treatment of thyrotoxicosis. The following are selected extracts.

Thymectomy: Markham (1858) was the first to note the co-existence of enlargement of the thymus and thyroid in exophthalmic goitre. Zesas (1910) advocated removal of the thymus to the exclusion of thyroidectomy. Von Harberer treated 35 cases in this way, with three deaths, two of which he attributed to incomplete removal of the thymus. However a powerful argument against thymectomy is that, in young patients, thymic enlargment is so great extending downwards over the pericardium that any attempt to remove it from above is certain to fail, and if thoracotomy were adopted the mortality would be appalling.

Cervical sympathectomy: It is argued that cutting off the sympathetic influence reduces the activity of the thyroid gland to such a degree that normal function is restored. It must also be valuable in curing exophthalmos if this is due to overaction of Muller’s and Landstrom’s muscles. Jaboulay was the first to operate for exophthalmic goitre by performing sympathectomy in 1896. Of 31 cases, 18 were re-examined four to fourteen years later and only three of these were classified as “cured”. T Kocher (1902) operated three times on the cervical sympathetic for thyrotoxicosis with one death, one success and one failure.

Intraglandular injections: Attempts have been made to destroy the thyroid by injection of boiling water, alcohol, quinine and carbolic acid. I adopted this in one case injecting boiling water directly into the gland. The patient wrote to me a year later to say she was completely cured. It must be admitted that injections into the thyroid gland are by no means free from risk: at least two sudden deaths have occurred with Porter’s method and the eventual results are certainly not so satisfactory as with other surgical procedures.

Ligation of Arteries: Blizard carried out the first ligation of the superior thyroid artery not later than 1811 but his patient died. As late as 1921, only 30 percent of the cases of exophthalmic goitre at the Mayo Clinic were submitted to primary thyroidectomy, most of the remaining 70 percent being treated, often in stages, by ligation of the arteries. Considerable difference of opinion exists as to the degree of improvement which follows ligation. There is, however, enough direct evidence of histological changes in the gland to justify retention of this method in the armamentarium of the surgeon who has to treat thyrotoxicosis.

From Joll CA. Diseases of the Thyroid Gland. 1932. William Heineman, London

“Exopthalmic goitre” widely known as Graves’ Disease in the English-speaking world was actually first noted by Caleb Hiller Parry in 1786. It was not until 1825 however that his account of eight patients with “enlargement of the thyroid gland in connexion with palpitation of the heart” was published posthumously. In 1835 Robert Graves described three patients with “a newly observed affectation of the thyroid gland in females”, noting palpitations, thyroid enlargement and exophthalmos. Subsequently Basedow, in 1840, described three patients with“exophthalmos due to hypertrophy of cellular tissue in the orbit, goitre and palpitations” and the disorder bears his name in Europe. Graves ascribed the observed thyroid enlargement as being due to overaction of the heart. However a primary role for the thyroid itself was strongly suggested by the effects of surgical operations. In the nineteenth century patients were treated with setons, thyroid artery ligation, or partial thyroidectomy primarily to relieve local pressure effects, however the toxic features were sometimes also noted to be relieved. The significance of this was first appreciated by Ludwig Rehn, of Frankfurt-am-Main in 1884. He reported three cases of Basedow’s disease whose toxic symptoms were cured incidentally when their goitres were removed for relief of dyspnoea. It was he who proposed thyroid overactivity as the primary mechanism of the symptoms manifest in this disorder. Toxic symptoms also subsided after thyroid resection in one of Mikulicz’s patients. Paul Mobius of Leipzig made the same suggestion as Rehn two years later and in 1893 William Greenfield of Edinburgh described primary thyroid hyperplasia in patients with exophthalmic goitre. Berry, the famous English thyroid surgeon, suggested in 1901 that the thyroid secretion in toxic goitre was altered in quantity, although he also proposed that it might be altered in quality and attributed the disease to a specific “thyroid toxin”. It was up to Plummer, a physician from the Mayp Clinic, to demonstrate that excess thyroxine in itself caused all the features of hyperthyroidism excepting exphthalmos.

From: Welbourn RB. The history of endocrine surgery. 1990. Praeger, New York