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Dangerous tendencies in iodine therapy
DANGEROUS
TENDENCIES
IN
IODINE THERAPY FREDERICK S. WETHERELL,
M.D.
SYRACUSE, N. Y.
S
INCE iodine as a preventive of goiter has been wideIy advocated by public health authorities and advertised by commercia1 houses, the physician rareIy sees a patient with goiter who has not at some time taken iodine in one form or another. The administration may have been under the supervision of a physician, but more often the patient has treated himseIf on the advice of a friend or as a resuIt of “educationa1” advertising. Now that there seems to be an increase in goiter in the Northeast, we are presented with more and more patients who are in a dangerous condition from the injudicious use of the drug. With every good thing that comes out in medicine we have the concomitant bad feature; charlatans, commercia1 drug firms, and newspapers making stock of the new discovery and eager to make profit from a rea1 boon to mankind. In the denser portions of the Midwestern goiter belt the quack has had a firmer hoId than in the East, but one is Ied to believe that the Iaity in that region is now awakening to the dangers of self-treatment. Jackson reports 50 cases of what he chooses to call “ iodine hyperthyroidism.” As many cases as this in the territory from which he draws his work is proof positive not onIy of the guIIibiIity of the pubIic but of the uncertain knowIedge of the average physician who attempts to treat goiter with iodine. In 28 of his cases iodine toxemia foIIowed treatment by the famiIy physician. A quack remedy that the patient has taken over a fairly Iong period of time, however, accounts for most of the dangerous and uncontroIIabIe cases. My idea in presenting this paper is to sound a warning against the spread of this form of quackery in the eastern portion of the so-caIIed
goiter beIt. AIthough the charIatan is usuaIIy the patent medicine man, he is not the onIy quack. To pIace the makers of iodized food stuffs in the same category does not seem too severe, even though they are there unwittingIy. Big business cmtches at anything that wiI1 increase saIes. Recently I had occasion to advise against the iodizing of a weII-known brand of peanut butter. AIready we are putting iodine in water and salt, and unIess manufacturers are watched we wiII be getting doses in aII sorts of canned and bottIed goods. Thus far, the amount of iodine we receive from other than natura1 sources is probabIy so infinitesima1 that no harm is done; whether or not it is truIy beneficia1 as a prophyIactic wiI1 be determined onIy a good many years hence after carefu1 study of the situation. At present we shouId institute propaganda for the contro1 of this potential danger. So far as seIf-treatment by the Iaity is concerned I believe that welIdirected pubhcity by heaIth authorities wouId soon scotch the evi1. This is especiahy possibIe in the East where health pubIicity is we11 organized and the public is accustomed to newspaper articIes by heaIth authorities. PubIic education in the dangers of iodine therapy is not enough. The treatment of goiter is a much more subtIe and delicate matter than most of us have reaIized, and the physician must give time to a study of diagnosis and methods of treatment. UnfortunateIy, a certain fearIessness of iodine has deveIoped foIIowing PIummer’s report on its use in exophthaImic goiter and the genera1 knowIedge we have of its use as a prophyIactic in SwitzerIand, ItaIy, and our own states where goiter is most prevaIent. We are bombarded with pamphIets from pharmaceutica1 houses, and patients of a11
248
American
Journal
of Surgery
WethereII-Iodine
ages and with a11 types of goiter come to the demanding to be cured with iodine. If the patient has an exophthaImic goiter, he has sometimes received a series of treatments with the usual weII-known recurrence of symptoms. How diffIcuIt this type of case is to dea1 with every surgeon who does any amount of thyroid surgery we11 knows. He aIso knows the briIIiant resuIts obtained when LugoI’s soIution is properIy employed preparatory to operation to reduce the basa1 metaboIic rate or contro1 a crisis, and after operation to combat postoperative hyperthyroidism. AIthough the continued administration of iodine in exophthaImic goiter is futiIe and dangerous, it is the adenomatous type of goiter that is pecuIiarIy susceptibIe to to the misuse of the drug. A certain amount of hyperpIasia in toxic adenoma probabIy accounts for much of the symptom complex of this condition. It is probably because of this hyperpIasia that iodine is so often effective in this condition and produces a temporary but deIuding benefit. AIthough it may appear dogmatic to prohibit the use of iodine in goiters after the age of twenty-one, I am convinced that it is a sound policy for the genera1 practitioner to foIIow. WhiIe there may be possible exceptions to this ruIe, adherence to it wiI1 go a Iong way toward the contro1 of the misuse of iodine. Patients have an uncanny facuIty of finding out what they are taking and broadcasting their IittIe knowledge. If adenomas have not developed before the the size of a coIIoid age of twenty-one, goiter may be controI!ed or reduced by the judicious use of iodine. Yet, as Am has pointed out, this is not aIways true. Some simpIe coIIoid goiters fai1 to respond to treatment. The simpIe administration of iodine alone is often not efficacious because the chiId continues under a nervous or physica strain from overactivity in schoo1 work, too much excitement at home, and other causes. This nervous numerous tension throws an extra burden on an aheady overtaxed gland. The activities of most chiIdren with goiter shouId be restricted so that they wiI1 Iead quiet Iives,
physician
SEPTEMBER, 192,
Therapy
as much of the time as possible devoid of undue stimulation. In many cases adenomas have deveIoped before the age of twenty-one, and in these iodine is very IikeIy to produce toxic symptoms. In these cases a cure with iodine cannot possibIy be expected, but if the patient is carefuIIy watched whiIe under treatment it is possibIe to retard the growth of the adenoma. At the first sign of toxic symptoms the iodine shouId be stopped, and one shouId be careful that the gratification of seeing the gIand reduced in size does not bIind one to the deveIopment of toxemia. Hyperthyroidism seIdom develops in adenomatous goiters in chiIdren except through the misuse of iodine. For this reason particuIarIy, I beIieve that the administration of iodine to chiIdren of schoo1 age should be absoIuteIy under the controI of a physician who understands the probIem. As prophyIaxis means prellention, the prescribing of iodine is no Ionger within the province of the pubIic heaIth physician once a goiter has deveIoped. The administration of iodine is then treatment, and the child shouId be referred to a competent physician chosen by its parents. The administration of iodine in prophyIactic doses to schoo1 chiIdren has in many instances been the cause of parents and oIder members of the famiIy taking some of the drug at home, without supervision. HeaIth offIciaIs, therefore, need to go a step further in their work. By that we mean that they shouId inform the famiIy that what is good for the chiId may be harmfu1 if taken by aduIt members. SUMMARY I. Immediate steps should be taken by heaIth authorities to warn the pubIic of the dangers of seIf-administration of iodine. 2. Before using iodine in goiter, physicians shouId acquaint themselves with the indications as brought out in many contributions by Ieading authorities. 3. HeaIth agencies shouId limit themIeave the seIves to prophyIaxis and treatment of existing goiters to the persona1 supervision of a private physician.
TENDENCIES
IN
IODINE THERAPY FREDERICK S. WETHERELL,
M.D.
SYRACUSE, N. Y.
S
INCE iodine as a preventive of goiter has been wideIy advocated by public health authorities and advertised by commercia1 houses, the physician rareIy sees a patient with goiter who has not at some time taken iodine in one form or another. The administration may have been under the supervision of a physician, but more often the patient has treated himseIf on the advice of a friend or as a resuIt of “educationa1” advertising. Now that there seems to be an increase in goiter in the Northeast, we are presented with more and more patients who are in a dangerous condition from the injudicious use of the drug. With every good thing that comes out in medicine we have the concomitant bad feature; charlatans, commercia1 drug firms, and newspapers making stock of the new discovery and eager to make profit from a rea1 boon to mankind. In the denser portions of the Midwestern goiter belt the quack has had a firmer hoId than in the East, but one is Ied to believe that the Iaity in that region is now awakening to the dangers of self-treatment. Jackson reports 50 cases of what he chooses to call “ iodine hyperthyroidism.” As many cases as this in the territory from which he draws his work is proof positive not onIy of the guIIibiIity of the pubIic but of the uncertain knowIedge of the average physician who attempts to treat goiter with iodine. In 28 of his cases iodine toxemia foIIowed treatment by the famiIy physician. A quack remedy that the patient has taken over a fairly Iong period of time, however, accounts for most of the dangerous and uncontroIIabIe cases. My idea in presenting this paper is to sound a warning against the spread of this form of quackery in the eastern portion of the so-caIIed
goiter beIt. AIthough the charIatan is usuaIIy the patent medicine man, he is not the onIy quack. To pIace the makers of iodized food stuffs in the same category does not seem too severe, even though they are there unwittingIy. Big business cmtches at anything that wiI1 increase saIes. Recently I had occasion to advise against the iodizing of a weII-known brand of peanut butter. AIready we are putting iodine in water and salt, and unIess manufacturers are watched we wiII be getting doses in aII sorts of canned and bottIed goods. Thus far, the amount of iodine we receive from other than natura1 sources is probabIy so infinitesima1 that no harm is done; whether or not it is truIy beneficia1 as a prophyIactic wiI1 be determined onIy a good many years hence after carefu1 study of the situation. At present we shouId institute propaganda for the contro1 of this potential danger. So far as seIf-treatment by the Iaity is concerned I believe that welIdirected pubhcity by heaIth authorities wouId soon scotch the evi1. This is especiahy possibIe in the East where health pubIicity is we11 organized and the public is accustomed to newspaper articIes by heaIth authorities. PubIic education in the dangers of iodine therapy is not enough. The treatment of goiter is a much more subtIe and delicate matter than most of us have reaIized, and the physician must give time to a study of diagnosis and methods of treatment. UnfortunateIy, a certain fearIessness of iodine has deveIoped foIIowing PIummer’s report on its use in exophthaImic goiter and the genera1 knowIedge we have of its use as a prophyIactic in SwitzerIand, ItaIy, and our own states where goiter is most prevaIent. We are bombarded with pamphIets from pharmaceutica1 houses, and patients of a11
248
American
Journal
of Surgery
WethereII-Iodine
ages and with a11 types of goiter come to the demanding to be cured with iodine. If the patient has an exophthaImic goiter, he has sometimes received a series of treatments with the usual weII-known recurrence of symptoms. How diffIcuIt this type of case is to dea1 with every surgeon who does any amount of thyroid surgery we11 knows. He aIso knows the briIIiant resuIts obtained when LugoI’s soIution is properIy employed preparatory to operation to reduce the basa1 metaboIic rate or contro1 a crisis, and after operation to combat postoperative hyperthyroidism. AIthough the continued administration of iodine in exophthaImic goiter is futiIe and dangerous, it is the adenomatous type of goiter that is pecuIiarIy susceptibIe to to the misuse of the drug. A certain amount of hyperpIasia in toxic adenoma probabIy accounts for much of the symptom complex of this condition. It is probably because of this hyperpIasia that iodine is so often effective in this condition and produces a temporary but deIuding benefit. AIthough it may appear dogmatic to prohibit the use of iodine in goiters after the age of twenty-one, I am convinced that it is a sound policy for the genera1 practitioner to foIIow. WhiIe there may be possible exceptions to this ruIe, adherence to it wiI1 go a Iong way toward the contro1 of the misuse of iodine. Patients have an uncanny facuIty of finding out what they are taking and broadcasting their IittIe knowledge. If adenomas have not developed before the the size of a coIIoid age of twenty-one, goiter may be controI!ed or reduced by the judicious use of iodine. Yet, as Am has pointed out, this is not aIways true. Some simpIe coIIoid goiters fai1 to respond to treatment. The simpIe administration of iodine alone is often not efficacious because the chiId continues under a nervous or physica strain from overactivity in schoo1 work, too much excitement at home, and other causes. This nervous numerous tension throws an extra burden on an aheady overtaxed gland. The activities of most chiIdren with goiter shouId be restricted so that they wiI1 Iead quiet Iives,
physician
SEPTEMBER, 192,
Therapy
as much of the time as possible devoid of undue stimulation. In many cases adenomas have deveIoped before the age of twenty-one, and in these iodine is very IikeIy to produce toxic symptoms. In these cases a cure with iodine cannot possibIy be expected, but if the patient is carefuIIy watched whiIe under treatment it is possibIe to retard the growth of the adenoma. At the first sign of toxic symptoms the iodine shouId be stopped, and one shouId be careful that the gratification of seeing the gIand reduced in size does not bIind one to the deveIopment of toxemia. Hyperthyroidism seIdom develops in adenomatous goiters in chiIdren except through the misuse of iodine. For this reason particuIarIy, I beIieve that the administration of iodine to chiIdren of schoo1 age should be absoIuteIy under the controI of a physician who understands the probIem. As prophyIaxis means prellention, the prescribing of iodine is no Ionger within the province of the pubIic heaIth physician once a goiter has deveIoped. The administration of iodine is then treatment, and the child shouId be referred to a competent physician chosen by its parents. The administration of iodine in prophyIactic doses to schoo1 chiIdren has in many instances been the cause of parents and oIder members of the famiIy taking some of the drug at home, without supervision. HeaIth offIciaIs, therefore, need to go a step further in their work. By that we mean that they shouId inform the famiIy that what is good for the chiId may be harmfu1 if taken by aduIt members. SUMMARY I. Immediate steps should be taken by heaIth authorities to warn the pubIic of the dangers of seIf-administration of iodine. 2. Before using iodine in goiter, physicians shouId acquaint themselves with the indications as brought out in many contributions by Ieading authorities. 3. HeaIth agencies shouId limit themIeave the seIves to prophyIaxis and treatment of existing goiters to the persona1 supervision of a private physician.