Relationship of thyrotoxicosis to the present war effort

RELATIONSHIP OF THYROTOXICOSIS TO THE PRESENT WAR EFFORT ITS MODERN

TREATMENT

ABRAHAM 0. WILENSKY, M.D. NEW YORK, NEW YORK

T

HE medical aspects of the present military emergency have been distinguished to a Iarge extent by the number of nervous and psychiatric problems which the drafted men are presenting. UndoubtedIy, a certain proportion of these wiII find their bases in a congenital imbaIance of the nervous mechanism ordinarily intensified and brought to the fore by the probIems of civi1 Iife and now considerabIy muItipIied in its intensity by the strange environment of military Iife and of the fears which it brings forward. Some of these symptomatoIogies, at Ieast, wiI1 acquire the characteristics of true thyrotoxicosis : exophthalmic goiter, Graves disease, Basedow’s disease, primary hyperthyroidism. It is important that these cases be recognized by the draft boards before induction into the army, or, at least, very soon thereafter so that intensification of the disease by military environment can be forestaIIed. Proper cure of the disease wiI1 resuIt in an individua1 who, while not fit in any way for combatant service, can and wiI1 stiI1 be abIe to fuIfiI1 many of the necessary noncombatant duties. The statistics of Love and Davenport compiled from the conscription records of the War Department for the first WorId War, give the approximate frequency of endemic goiter among young men of draft age in this country. A regiona intensity is shown in that there is a greater incidence and a Iarger number of severe cases in the middIe northwest than on the eastern coast of the United States. According to Plummer, there was an increase in the intensity of the disease in the middIe west from about 1924 to 1930 with a definite

decrease since then in intensity and in the number of cases in which crises have occurred. The foIIowing table contains a summary of this information : -

I ‘roportior for AI1 1rypes IncIuding Exophthalmic Goiter

state

Idaho. ......... Oregon ......... Washington. .... Montana. ...... Utah ........... Wyoming. ...... Alaska. ........ ...... W’rsconsm. Michigan, ...... North Dakota. Minnesota. ..... Iowa. .......... Illinois. ........ Indiana. ....... Ohio, .......... West Virginia. .. Nevada. .......

3” 33 33 24

CoIorado.......

9 12

20

18 21 22 18

-

1

I ‘roportior for Endemic Goiter, per 1,000

for Exophthalmic Goiter

I

27 26 23 21

16

I

15 ‘3 14 II

I3 I0 II I2

8

North Dakota. South Dakota. .. Nebraska. ...... Kansas ......... California. ..... Missouri. ..... Virginia ...... Pennsylvania. Rest of U. S ...

7

3 4

7 3 3 3 5 4 5 4

z

IO

3 7 IO

ii 8

12 II

I‘roportion

1

7 8 6 6 8 6

2

‘j 0 4

4 3 3

2 I

6 9

7 9

4 4 3 4

2

-

I

-

According to Pepper, there were 6,219 cases of exophthaImic goiter (2.78 per 1,000) in the armed forces of the United States during the first WorId War and I, 176 cases of simple goiter. He very rightIy remarks that there is little reason 221

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to beIieve that this disease wiII fail to occur just as frequentIy now. With the increased emotiona aspects of this war I an incIined to beIieve that the number wiI1 be Iarger. This tendency seems to be shown in the statistics of McKinIey who found that in a total of 209 rejections by the MedicaI Advisory Board for Hennequin, Sherburne, Scott, Wright and Carver counties, comprising both rura1 and urban communities, 7.6 per cent were rejected for hyperthyroidism. This is rather a Iarge number. The statistics on exophthaImic goiter compiIed by Love and Davenport probabIy indicate a too high incidence of the disease. More IikeIy the Iarge majority had diffuse coIIoid or adenomatous goiters. True exwas frequentIy not ophthaImic goiter distinguished from the condition Iater classified in the army either as irritabIe heart of soIdiers, disordered action of the heart, effort syndrome, or neurocircuIatory asthenia, the incidence of which under the conditions then prevaiIing was high. This was emphasized by Peabody, Wearn and Tompkins for the American Army and by Lewis and his co-workers for the British Army, and was first noted by Da Costa in the American Civil War. NevertheIess, sufficient numbers of cases of thyrotoxicosis have, and are sure to occur again to make this an important probIem in the medica care of enIisted men. CLASSIFICATION

OF

CASES

For cIinica1 purposes cases of thyrotoxicosis (exophthaImic goiter, Graves disease, Basedow’s disease, primary hyperthyroidism) had best be divided into the foIIowing groups : I. CIassicaI cases of exophthaImic goiter showing a11 the cardina1 symptoms of thyrotoxicosis, exophthaImos, rapid puIse, irritabiIity and nervousness, sweIIing of the thyroid and Ioss of weight. AIthough the severity of the iIIness may be of a11 grades, the great majority are more commonIy of the severer type. The

May.1943

cIinica1 manifestations are we11 marked; the basa1 metaboIic rate is reIativeIy high; diarrhea and loss of weight are frequentIy present; and the patients sometimes run high temperatures. Adequate preparation of the patient for subtotal thyroidectomy is commonIy diffIcuIt. Operation carries with it, usuaIIy, a great degree of risk, and many of the fataIities faI1 into this group. Recurrences are very apt to foIIow. 2. Cases of thyrotoxicosis in which the cardina1 symptoms are present with the exception of exophthaImos : AIthough here aIso a11 grades of severity can be found, usuaIIy the cIinica1 disturbance is reIativeIy miId. With the exception of exophthalmos the symptoms are distinct. The basa1 metaboIic rate is commonIy not very high. The preparation of the patient for operation is reIativeIy easy; operation is not attended with any excessive degree of danger frequentIy present in the exophthalmic group; patients make a good recovery and the recovery is usuaIIy permanent. 3. Cases faIIing into any of the preceding two groups, but in which psychotic symptoms of one kind or another-usuaIIy of the excitatory type-form the chief subjective symptom for which the patient seeks reIief. The cardinal symptoms of thyrotoxicosis are present and eIicitabIe, but they seem to be without their usua1 emphasis. They are reIativeIy miId in most of the instances. In some of the cases, the symptomatoIogy is of such a nature that the underIying condition is not recognized as a form of thyrotoxicosis unti1 an increase in the basa1 metaboIic rate is discovered. The Iatter is usuaIIy reIativeIy Iow, very rareIy over 40 or 50. It wiI1 faI1 appreciabIy with ordinary therapeutic measures without the exhibition of iodine. Preparation for operation is somewhat disturbed by the menta1 disposition of the patient; but, nevertheIess, it is reIativeIy easy to accompIish. Operation is not accompanied by any untoward risk. ResiduaI symptoms, as wil1 be further eIaborated, subsequentIy aIways incIude those reIated to the mental state.

NEW SERIES VOL.LX, No. 1

Wilensky-Thyrotoxicosis

4. Cases of IocaIized adenoma of the thyroid with symptoms of miId hyperthyroidism: The patients are not very 21; the symptoms are not very marked; the basa1 metabohc rate is onIy midIy eIevated; preparation for operation is very easiIy accompIished; operation carries a minimum of risk; good recoveries are made and the latter are permanent. SubsequentIy, these patients do not carry any potentiaIity for recurrences of symptoms unIess new adenomas deveIop. GENERAL

THERAPEUTIC INTOLERANCE

CONSIDERATIONSFOR

HEAT

Because of their increased metaboIism, toIerance for heat is decreased in patients with thyrotoxicosis. The body surface is warm, moist and frequentIy erythematous. Sweating is a common symptom. The patients require Iess bedcIothes to be comfortabIe, Iighter garments and Iower room temperatures. It is notorious how severe postoperative febriIe reactions are, and how badIy these patients behave generaIIy, when operation is done in the hot periods of our summer months; and some patients are Iost under such circumstances from hyperthermia every year. This is a very important item in the make-up of these patients. For this reason, and ,because in army Iife it is reIativeIy easy to accompIish, a11 patients with any form of thyrotoxicosis, and especiaIIy those with exophthaImic goiter should be segregated to hospita1 centers on our northern, eastern and western seaboards where the heat never becomes excessive. The patients shouId never be sent to hospitaIs in our southern, middIe and middle eastern areas where, during the summer, the temperatures and humidity are high. This is a most important point. Because of the Iarge number of medica officers drawn from civiIian Iife, the care of these patients should be entrusted to specialists who have hade adequate training and experience in the handIing of this disease.

American

COMPLICATING

Journal

of Surgery

223

FACTORS

There are two important complicating factors: (I) vaIvuIar or myocardia1 heart disease, and (2) diabetes. Thyrotoxic patients with heart disease (thyrocardiacs) shouId be we11 prepared for the ordea1 of subtota1 thyroidectomy by the usua1 we11 tried physica and medicina1 means. The preparation for operation shouId proceed aIong the preIiminary rkgime outIined elsewhere in this communication unti1 the heart condition is put in as favorabIe a condition as is possibIe. There should be no hurry about this. The fina preparation for operation shouId be begun when this is accompIished. Diabetes is a rather infrequent complication. With our modern means of combatting this disorder, it shouId give no great cause for alarm. TREATMENT

Preoperative Preparation for Subtotal Thyroidectomy. No matter in which group the cases faI1, the proper preoperative preparation is of paramount importance if success is to foIIow. Good resuIts after operation and the degree of cure correspond compIeteIy and accurateIy to the thoroughness with which this is carried out, and with the degree of co-operation shown by the patient and by his famiIy. The Iatter item is very much more important in this disease than is customariIy understood because the very nature of the iIIness contributes an obstinacy of spirit and action which is not often seen in other diseases. The object of a11 of this preparation is to reduce the toxicity of the disease to a state in which operation wiI1 not be attended with any excessive amount of risk, because it is found that when the toxicity of the manifestations are marked, operation is unduIy dangerous and is foIIowed by an excessive mortaIity. The prevaiIing guides upon which this judgment is made is based on the nervous symptoms exhibited, the puIse rate, the basa1 metabolic rate and the gain in weight. When the preparation has been adequate, the ner-

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vousness of the patient is very much diminished, the p&e rate faIIs to Iess than IOO per minute, the patient stops losing weight and begins to gain and the basa1 metaboIic rate faIIs to a Iow IeveI, usuaIIy under 23. PracticaIIy speaking, one puts the patient through a course of medica treatment and tries to obtain as much of a medica cure as is possibIe. The foIIowing rCgime for the preoperative preparation has been found to yieId superior resuIts : I. Rest in bed under hospital conditions. It is not possibIe in the greatest number of the cases to prepare a patient properIy at home. In the hospita1 the patient is under his physician’s absoIute contro1 and a11 kinds of disturbances can be eliminated. These incIude absence from business and from business worries, no visitors and no other patients in the same room. UsuaIIy this is a compIete test of the patient’s and his famiIy’s wiIIingness to co-operate. 2. A high caloric diet, never less than 3,500 calories per day. The patient may rebe1 against this after a few days, so that it is necessary to make sure that he takes the fuI1 amount of diet ordered. The patient shouId be weighed frequentIy-at Ieast twice each week-to guard against any Ioss of weight. 3. Plenty of sedation is required given (a) in the form of medication and (b) by physical means. PhenobarbitaI given in such dosage as to make the patient sIeepy a good part of the twenty-four hours is preferred. Hydrotherapy in the form of the Priesnitz pack, given two or three times daiIy, is an exceIIent adjuvant sedative measure. The patient is wrapped in an oId sheet, wrung out of water at a temperature of ~o’F., and then covered with a second bIanket. If one of the doses of the phenobarbita1 is given about fifteen or twenty minutes before the pack, the patient very commonIy faIIs asIeep in the pack and that is a very desirabIe feature. OccasionaIIy the pack must be omitted because the patient is refractory toward it.

MAY, 1943

4. The basal metabolic rate should be determined once each week as, besides the clinica aspects, this gives a very reIiabIe index of the improvement which has taken pIace. 5. In the usual run of case, iodine had best not be administered unti1 the effect of the preIiminary treatment has become apparent. Maximum preIiminary benefit is obtained in from two to three weeks and is recognizabIe both by an ameIioration in the genera1 cIinica1 picture and in an appreciabIe faI1 in the basa1 metaboIic rate. At this stage and onIy at this stage, iodine in the form of. LugoI’s soIution shouId be administered. The dosage shouId be adequate, not Iess than ten minims three times each day and sometimes somewhat more. When the patient responds adequateIy, a further betterment of the subjective symptomatoIogy and a further faI1 in the basal metaboIic rate occurs. CommonIy the patient at this stage feeIs, acts and Iooks very weI1. Therapeutic E$ect of the Preliminary Preparation. The effect of a11 of this preIiminary treatment wiI1 be one of three: (I) The cases which respond readiIy and quickIy. These are the miIder type of case, commonIy in the group without exophthaImos and Iess frequentIy in the group with exophthaImos. The basa1 metabolic rate faIIs to a Iew IeveI, 25 or Iess, the patient stands operation we11 and no untoward incidents occur. (2) The cases in which a moderate amount of difhcuIty is present, chiefly in that the basa1 metaboIic rate faIIs very sIowIy or not to the Iow IeveI to which we shouId Iike it to faI1. These cases shouId be watched more carefuIIy, the rhgime shouId be carried out more sIowIy and for a Ionger period. UsuaIIy our object is accompIished. (3) The cases in which marked diffIcuIty in preparation is present. The dif%cuIty is cIinicaIIy apparent in that the patient’s symptomatoIogy does not improve, there is a persistent Ioss of weight, and the basa1 metaboIic rate remains at a high IeveI and does not faI1.

NEW SERIES VOL. LX, No.

2

WiIensky-Thyrotoxicosis

Under such conditions the prehminary treatment without LugoI’s soIution shouId be persisted in for a much Ionger time. OnIy then, when a11 the possibiIities of this are exhausted, shouId LugoI’s soIution be given. RareIy a dramatic response occurs; the symptoms improve and the basa1 metaboIic rate quickIy faIIs to the desired low IeveI; or no improvement foIIows. The latter form the group of most difficuIt cases to manage and the difficuIty sometimes is insuperabIe. If LugoI’s soIution produces no effect within tweIve or fourteen days, the chances are that no further good wiI1 be accompIished by it as the patients have the tendency to become iodine fast. This tendency is a very important and common item in the make-up of hyperthyroidism. It is important to remember that as far as possibIe iodine shouId not be administered until one is of the opinion, first, that a11 the possible good has been accompIished by the preceding preliminary treatment, and, second, that the patient is about ready for the fina preparation for operation. Then the iodine shouId be given in adequate dosage for a period not exceeding tweIve days and the patient shouId be operated upon immediateIy. If operation is not done at this most opportune moment, it commonIy happens that the good effect of the iodine as a preparatory measure for operation is lost (i.e., the patient becomes “iodine fast “) and operation done subsequentIy is done at an increased risk. Operative Treatment. Operation is the fina stage of the active treatment. Satisfactory results are obtained onIy by remova1 of an adequate amount of thyroid (biIatera1) thytissue, i.e., by subtota1 roidectomy. Other operative procedures such as poIe Iigation or any uniIatera1 operations can be considered onIy as preIiminary procedures for the former. These are commonIy referred to as stage operations. It is my firm opinion that when a patient is so sick that stage operations must be

American

Journal

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considered, he is not ready for any operation, either because of the severity of the iIIness or because he has been badIy or insu&cientIy prepared. When a patient with thyrotoxicosis has been we11 prepared, a compIete operation can be done in one sitting with no more risk than with a partia1 or stage operation. As a matter of fact, when the stage operation must be considered, it is my experience that the Iatter, even a uniIatera1 poIe Iigation, carries infiniteIy more risk than a complete subtota1 thyroidectomy on a patient we11 and adequateIy prepared. It is aIways my hope that patients wiI1 come at an earIy stage of their iIIness and before iodine has been given. Then with any kind of cooperation on the part of the patient and the patient’s famiIy, preparation can aIways be done properIy and adequateIy. Then, too, I am aIways abIe to do the entire operation at one sitting with as IittIe risk as possibIe. An important point to remember is that neither the patient nor the famiIy know when the operation is to be done so that no undue nervous tension is provoked. The patient is put through a sham immediate preparation for operation so that when the time comes, the true fIna preparation can be carried out without awakening any suspicion that operation is about to be done. This is very important. For this reason, aIso, avertin given by rectum is the anesthetic and anesthesia of choice. The nurse gives this to the patient as she customariIy does an ordinary enema and the patient faIIs asIeep caImIy without any rise of p&e rate. This is done in the patient’s room, and the anesthetist and the operating room environment is not visibIe to the patient. The steps of the operation are we11 known and need no repetition here. Suffice it to say that onIy a smalI strip of thyroid tissue at the posterior border of the gIand on either side is Ieft with a smaI1 segment of the upper pole. The raw area of thyroid tissue is cIosed by suture. Proper precautions are of course necessary that neither

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WiIensky-Thyrotoxicosis

the recurrent nerves nor the parathyroid glands are injured or removed accidentaIIy. I usualIy drain either side of the neck with a smalI tube for twenty-four or forty-eight hours. This does not interfere with heaIing and the wounds are usuaIIy entireIy heaIed by the end of the week. LugoI’s soIution is continued in the immediate postoperative period and in decreasing doses Iater and for severa months. Hyperpyrexia sometimes occurs within the first few days after operation and is treated by coId packs and aspirin to reduce the temperature, and by intravenous gIucose and Lugol’s soIution to decrease any toxicity. TypicaI thyroid crises are seen very rareIy when the patient has been we11 prepared. The convaIescence shouId not be hurried. It usuaIIy takes severa months before the fuI1 benefit of subtotaI thyroidectomy is obtained. And the patient shouId be kept under foIIow-up observation for a Iong time. APPRAISAL

OF

RESULTS

In the great majority of the cases, the ritgime outIined in this paper wiI1 be foIIowed by a more or Iess compIete subjective cure. NevertheIess, in the great majority of instances, most of the demonstrable preceding objective symptoms, such as exophthaImos and tremor, can be demonstrated postoperativeIy to some degree. There aIso continues some of the underIying potentiaIity for nervous disturbances which shouId be taken as a warning that, even if the patient is apparentIy subjectiveIy cured, any undue and extraordinary stimuIus can cause a recurrence of symptoms. For this reason a searching inquiry into the possibIe causative factors which produced the iIIness originaIIy should be made with the object of eIiminating this from the patient’s Iife. In this regard, the home and business influence and atmosphere is of paramount importance. In observing the patient after operation, the determination of the basa1 metaboIic rate shou1d not be made for at Ieast one

MAY, 1943

month after discharge of the patient from the hospita1. It is preferabIe that this shouId fall to sIightIy beIow normaI. Recurrences of symptoms occur in a smaI1 proportion of the cases-probably IO to 15 per cent. These recurrences are based upon physical changes associated (I) with an insuffIcient remova of thyroid and/or (2) with a gIand substances, hyperpIasia and/or hypertrophy of the part of the gIand Ieft; or they are based upon undemonstrabIe bioIogica1 chemica1 changes, either in the part of the gIand Ieft or in other gIands of the endocrine system, notabIy the pituitary. Not aIways is there any increase in the basa1 metabolic rate; aIthough there are cases, especiaIIy when there is enIargement of the stump of the gIand, in which the metaboIic rate can rise to a height comparabIe to that preceding operation. When a fuI1 bIown recurrence of symptoms occurs, the patient shouId be put through a course exactly simiIar to that preceding the first operation and shouId then be re-operated upon and any excess of thyroid gIand tissue should be removed. Sometimes the amount of residuaI thyroid tissue after subtota1 thyroidectomy is smaI1, but it has happened in my experience that the remova of even such smaII amounts has given good secondary resuIts. In other cases we are left with the therapeutic use of Lugol’s soIution with or without the use of radiotherapy. These are most diffIcuIt cases to handIe and not always does success foIIow our efforts. The most diffIcuIt group are those in whom, preceding the primary operation, the symptomatoIogy had incIuded outstanding psychotic symptoms. In al1 of my experience I have never seen one case in which these psychotic symptoms have disappeared compIeteIy. It sometimes happens that they are sIightIy Iessened for a very short period but then they aIways have recurred. Good psychiatric treatment is indicated but the outIook for the disappearance of the psychotic symptoms is very poor.