Primary vs Secondary Hyperparathyroidism:  Time for Reappraisal

In 1925, the first parathyroidectomy was performed in Vienna by Felix Mandl on Albert, the tramcar conductor. Prior to that successful therapeutic intervention and Albert's transient recovery, parathyroidectomy for hyperparathyroidism had not been advocated. Indeed, adenomas and hyperplasia of the parathyroid glands were thought to represent a pathophysiologic response secondary to some underlying cause, and enlargement of one or more parathyroid glands, discovered at autopsy, was not recognized as a primary metabolic derangement. Thereafter, however, as clinical experience with hyperparathyroidism grew, the distinction between primary and secondary hyperparathyroidism developed. Secondary hyperparathyroidism was thought to be due to the chronic hypocalcemic state associated with renal insufficiency and all other forms of hyperparathyroidism were considered primary. Primary hyperparathyroidism was associated with the presence of a single adenoma and secondary hyperparathyroidism with diffuse hyperplasia of all four glands. Textbook descriptions and dogmatic teachings held to these neat views well into the 1950s. Since