History of Medicine

Theodor Kocher and the Birth of Endocrinology 

     At one time almost everyone in the valleys of Switzerland was afflicted with goiter. Mark Twain remarked that the two principle sights in Switzerland were Mont Blanc and goiter. Large goiters were burdensome and could impinge on the trachea, impairing

goiter patient, from and side (from Wellcome Library)

breathing. But the medical world was ignorant of the thyroid's function. Claude Bernard declared in 1879, well after surgeons started removing the gland, that nothing was known of its importance. Iodine was perceived as helpful for goiter by some, but little used. Not surprisingly it was in Switzerland where progress was made.

     Theodor Kocher, a Swiss, played a leading role in revealing the impact of the thyroid on human physiology. His surgical skills and wide knowledge were legendary and attracted students from around the globe.

     He was born in Bern in 1841. After medical school he decided

Theodor Kocher (from NIH via Wikipedia)

on a surgical career. He rose quickly to be Professor of Surgery at Bern University (at age 31) and remained there for the rest of his career. His influence was enormous. Only a partial list of achievements would include: rapid adoption of Listerism, inventing the “Kocher maneuver” for reducing shoulder dislocations, using physiological saline to combat shock  (later taken up by George Crile), and introduction of “Kocher clamps” for hemostasis. His neurosurgical researches greatly influenced Harvey Cushing and his deliberate, careful surgical technique helped cement a friendship with William Halstead. He published the first complete chart of human dermatomes (1896). Between 1909 and 1914 an average of 40 Americans visited his clinic every year. His textbook of surgery went through five editions and was translated into six languages. His discoveries concerning the thyroid gland earned him a Nobel Prize, though not without heartache and strife.

     Removal of goiter by surgery had been risky. The famous Theodor Billroth had removed numerous ones, but with frequent

Goiter removal, from Kocher's Surgical Text, 2nd edition
(Hathi Trust)

 complications and significant mortality. But with careful study of anatomy and adherence to asepsis Kocher managed to render thyroid removal a safe procedure, using a horizontal incision whose scar was barely visible. He performed the operation frequently.

     In the fall of 1882, at a Congress in Geneva, Kocher met Jaques-Louis Reverdin, a Geneva-based surgeon, who had noted that two of his own thyroidectomized patients had developed features of cretinism. He asked Kocher if he had observed the same. Kocher abruptly realized that he had - once. A local practitioner had informed him eight years earlier that an eleven-year-old girl had become sullen and zombie-like after losing her goiter. Kocher tracked her down and was stunned to find the “ugly appearance of a half-idiot” before him. He halted further

Jacques-Louis Revedin 9from Wikipedia)

thyroidectomies, contacted former patients, and turned up many with hypothyroid features - but only those with total loss of thyroid tissue.  Though the record is unclear he must have been shaken by the damage he had inflicted. He reported the findings in a long paper in 1883.

     Reverdin referred to the clinical picture of his patients as “myxoedéme opératoire”, after the term “myxoedema” coined a few years before (1877) by William Ord in England for patients

William Ord (from Wellcome Library)

with adult onset of cretinism and atrophied thyroid glands. Reverdin also acknowledged William Gull’s earlier description of the same syndrome. Kocher invented the name “cachexia strumipriva” and initially thought the syndrome due to oxygen insufficiency related to removal of the thyroid and adjacent vasculature.

     Kocher attempted transplanting thyroid tissue to improve his sluggish patients, noted initial improvement, but was discouraged that it was transient. He tried isolating an active substance from thyroid tissue, in vain. In England George Murray gave injections of thyroid extract, with positive results, then switched to oral administration of thyroid extract, also effective. Trial and error led to a reasonably accurate dosage. Kocher and others adopted similar replacement therapy, starting with thyroid tissue spread on bread much as caviar would be, and moving on to extract.

     Kocher was awarded the Nobel Prize in 1909, the first surgeon to receive one, for contributions to the physiology, pathology, and surgery of the thyroid. In his acceptance speech he ungenerously neglected the work of Ord and Gull that had clearly described myxoedema (he had actually corresponded with Ord on the subject) and failed to admit Revedin’s priority (Revedin is remembered also for performing the first skin allotransplant).

     But Kocher’s achievements should not be diminished. He went on to perform over 4000 thyroidectomies (partial), with excellent results. In addition to the accomplishments noted above he pioneered new techniques in gallbladder and stomach surgery, neurosurgery, and head and neck surgery. He taught a whole generation of surgeons and left a great imprint on American surgery. And his thyroid work ushered in a new medical specialty – endocrinology.

Sources used:

World J Surgery 2000, 24:2-9. (Biography)

J Roy Soc Med 2014, 107: 376-7 (Biography)

J Roy Soc Med 2011, 104: 129-32 ( thyroid work)

BMJ Sept 29, 1923, pp 560-1 (transplants)

Nobel Lecture, available at: http://www.nobelprize.org/nobel_prizes/medicine/laureates/1909/kocher-lecture.html

 Wellbourn, R B: The History of Endocrine Surgery. 1990

Tröler, U. Der Nobelpreisträger Theodor Kocher, 1841-1917. 1984

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