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Diagnosis and Surgical Treatment of Goiter
Medical Clinics of North America November, 1942. Philadelphia Number
DIAGNOSIS AND SURGICAL TREATMENT OF GOITER'* DAMON B. PFEIFFER, M.D., F.A.C.S.t
and ALBERT G. MARTIN, M.D.t
WE propose to limit our present discussion to the common types of thyroid disorders, colloid goiter, diffuse toxic goiter, nodular goiter (adenomas) with and without, toxic change, and inflammatory goiter. DIFFUSE TOXIC GOITER
Case I. Exophthalmic Goiteri Pre-existing Colloid Goiter Activated by Iodine Overdosage Our first case for presentation is that of a young white woman. We first saw her in 1936 when she was twenty-eight years old. At that time she complained of dyspnea, palpitation, emotional instability, and loss of weight. The symptoms were all severe and of four or five months' duration. A goiter, which had been present since the age of sixteen, had become increasingly prominent in the past five months. The symptoms mentioned had all been present in a less acute form for approximately twelve years. When they first appeared a doctor told her she had a goiter and gave her iodine for a few months. Symptoms of acute hyperthyroidism followed. Examination showed a thyroid gland which was diffusely enlarged. Exophthalmos was present. The pulse rate was 132 and the blood pressure in millimeters of mercury was 136 systolic and 68 diastolic. The heart action was forceful. A capillary pulse could be demonstrated in the nail beds. The patient was exceedingly nervous, very self-conscious, and her voice had a tremulous quality. She weighed 112 pounds. The basal metabolic rate was +65 per cent. After a period of preparation, bilateral subtotal thyroidectomy was performed on October 1, 1936. Sixty grams of hyperplastic thyroid gland were removed. Recovery was uncomplicated. The basal metabolic rate after 10 per cent. operation was Six years have passed since the operation. The patient has carried on a
+
• From the Damon B. Pfei1fer Surgical Clinic, Abington Memorial Hospital. t Associate Professor of Surgery, Graduate School of Medicine, University of Pennsylvania; Surgical Consultant and Honorary Chief, Surgical Service A, Lankenau Hospital; Chief of Surgical Service, Abington Memorial Hospital, Abington, Pa. t Assistant Instructor in Surgery, Graduate School of Medicine, University of Pennsylvania; Assistant Surgeon, Lankenau Hospital. 1739
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DAMON B. PFEIFFER, ALBERT G. MARTIN
normal, active life in her community. Although she had been married for five years before operation, she had not become pregnant. Approximately one year after operation she became pregnant and was uneventfully delivered of a normal child. She weighs 132 pounds, her pulse rate is 82, and her blood pressure in millimeters of mercury is 118 systolic and 76 diastolic.
The diagnosis of exophthalmic goiter in this case was clear. Among other characteristic features was the increase in pulse pressure with its attendant capillary pulsation. An increase in pulse pressure usually accompanies severe toxicity. After operation a return to normal should occur. In this case there was a blood pressure change in millimeters of mercury from 136 systolic and 68 diastolic to 118 and 76, respectively, accompanied by a fall in pulse rate from 132 to 82. The patient is representative of many individuals all over the country who have hyperthyroidism, whose family physicians have made a proper diagnosis, and who return to their communities as useful citizens after thyroidectomy. The early use of iodine in this case calls for special comment. When the patient was a girl of sixteen, a doctor told her she had a goiter and gave her iodine for a few months. Symptoms of hyperthyroidism followed. In all probability the lesion present at that time was a simple colloid goiter which was activated by iodine overdosage. Simple colloid goiter usually develops at or about the time of adolescence. As is well known, it is found most frequently in the goiter zones. Prophylaxis consists of administering a 10-mg. iodine tablet once a week or instructing the patient to use· iodized salt. The average individual using iodized salt ingests 8 mg. of iodine a week. Prophylaxis has been used with marked success in the Great Lakes region and other areas where goiter is endemic. Once established, a. colloid goiter should never be treated by large doses of iodine, for fear of activation similar to that in the instance just discussed. We believe that colloid goiters should be operated upon. Judgment must of course be exercised; for the slight enlargement often seen at the time of puberty is usually only temporary. Large goiters are not only undesirable for cosmetic reasons but constitute a source of potential danger from toxic or degenerative changes.
DIAGNOSIS AND SURGICAL TREATMENT OF GOITER
1741
Preoperative Preparation in Hyperthyroidism
The preoperative preparation of patients with hyperthyroidism is important. Essentially, it consists of a high caloric, high vitamin diet, iodine administration, and rest. We like to see our patients ingest 5000 calories a day, if possible. Fruit juices are given liberally, and furnish an excellent source of vitamin C in addition to their calories. One or two vitamin B complex capsules are given with each meal. These tablets contain 333 units of vitamin B1 , 500 micrograms of riboflavin, 10 mg. of nicotinic acid, 130 micrograms of vitamin B6 , and 170 micrograms of pantothenic acid. Iodine is given in the form of Lugol's solution, 10 to 15 minims three times daily. Patients are usually kept in bed, although this is not a hard and fast rule. Elderly patients do better if they sit out of bed in a chair for a few hours each day, and an occasional emotional, severely toxic patient will be quieter and happier if he is allowed to get up for a short period each day. Frequently patients require sedation and for this purpose we prefer the bromide elixirs, in doses of 5 to 10 cc. three times daily. When bromides are given we like to give the first dose just before noon, the second in the mid afternoon, and the third an hour or two after the evening meal. Seven to twelve days of preparation is the average time. Just as the initial basal metabolic rate is only one. index of toxicity, a fall in the rate is only one of the manifestations of response to treatment. A patient is ready for operation when the pulse rate falls and levels off at a relatively lower level, when he shows a gain in weight, and when examination of the gland indicates involution. Postoperative Care in Hyperthyroidism
Postoperatively, we commonly give 5 cc. of Lugol's solution by rectum when the patient returns to the floor. As soon as the patient is conscious he is placed in a sitting position in bed. Morphine sulfate, grain Yo, is given every three hours unless the respiratory rate falls to 16, and this dosage is maintained for twenty-four to forty-eight hours. In the first twenty-four hours 3500 cc. of parenteral fluid, of which 1500 cc. are normal salt solution, is given intravenously.
1742.
DAMON B. PFEIFFER, ALBERT G. MARTIN
Glucose in quantities of 200 to 350 gm. is given intravenously. Ice caps are applied to the head and precordium. The oxygen tent is used frequently. The tent is usually preferred to the B.L.B. mask because of its general cooling effect. Tincture of benzoin inhalations are given frequently during the first three days. On the day after operation, Lugol's solution by mouth is resumed and continued during the patient's stay in the hospital. Thereafter no more iodine is given. Fluids by mouth are begun as soon as the patient can drink and the diet is rapidly built up to the preoperative level. Most patients leave the hospital seven to ten days after the operation. They are instructed to lead a quiet, well regulated life for at least three months, when they return for a follow-up visit. Case n. Diffuse Toxic Goiter, Illustrating Dangers of Acute Infections Arising during Hyperthyroidism and the Importance of Stage Operations The next patient is a fifty-four-year-old woman whom we saw four years ago. At that time she complained of nervousness, palpitation, intolerance of heat and a swelling in the neck for two years. For several months amenorrhea, ankle edema and hoarseness were also present. During the two years of active symptoms she had lost 60 pounds in weight. She was exceedingly nervous and apprehensive. Exophthalmos was present. The thyroid gland was enlarged bilaterally, the nght side being somewhat more prominent than the left. Breit was present. The pulse rate was 124 and the blood pressure in millimeters of mercury was 168 systolic and 78 diastolic. The basal metabolic rate was +81 per cent. She weighed 157 pounds. A diagnosis of diffuse toxic goiter was made and the patient was prepared for operation. This was an instance of late diagnosis, but fortunately no iodine had been given. Nine days after admission to the hospital, the pulse had fallen to 84 and the basal metabolic rate to +39 per cent. On the tenth day the patient developed a severe tonsillitis and, after a chill, her temperature rose to 104° F. A throat culture showed hemolytic streptococci; a blood culture showed no growth. Full doses of iodine were continued, a 5000 calorie diet was maintained, and sulfanilamide treatment was begun. On the fifteenth hospital day a peritonsillar abscess was incised, with release of a large amount of pus. Five days thereafter the tonsillitis had subsided. The patient had lost 12 pounds and her pulse rate had risen from 84 to 100. By the twenty-eIghth hospital day the pulse had become stable at 80, the patient had regained 2 pounds, and the basal metabolic rate was +28 per cent. Right subtotal hemithyroidectomy was performed. Sixty grams of hyperplastic tissue were removed, comprising seven-eighths of the right lobe, the isthmus and the pyramidal lobe. Recovery was uncomplicated, and the patient was dischar~ed on the eleventh postoperative day. Lu~ol's solution, 10 minims three tImes a day, a high caloric diet and vitamm B complex were continued.
DIAGNOSIS AND SURGICAL TREATMENT OF GOITER
1743
Eight weeks after operation the patient was readmitted for the second stage. The time interval is somewhat longer than usual. On readmission the pulse was 96, the basal metabolic rate +27 per cent, and she had gained 13 pounds. Left subtotal hemithyroidectomy was done, 50 gm. of hyperplastic gland being removed. Although the throat was negative before operation, recovery was complicated by acute follicular tonsillitis. The patient was discharged ten days after operation. A month later, tonsillectomy was performed and recovery was uneventful. The basal metabolic rate at that time was +1 per cent.
This case illustrates two principles of treatment. First, the danger of acute infection arising during hyperthyroidism is shown by the severe reaction to the initial attack of tonsillitis. Thyroid crisis was imminent. Fortunately, iodine and other preparation had been carried out for nine days and the patient had not received any iodine before coming to the hospital. Fortunately, too, sulfanilamide was available. Drainage of the peritonsillar abscess was indicated. Similarly, operations for acute appendicitis and other emergencies are indicated during thyrotoxicosis. However, when thyrotoxicosis co-exists with other, nonemergency illnesses, the treatment of the thyroid disorder receives precedence. It is not unknown for postoperative hernia or gallbladder patients to go into thyroid crises on the second or third postoperative day. Such occurrences can be prevented by being on the alert to recognize symptoms of hyperthyroidism and to make the proper investigations before doing ~lective surgery. The second principle illustrated is the importance of doing stage operations where toxic goiter is complicated by an infectious process. The presence of infection greatly heightens toxicity. Other instances in which stage operations should be considered are in patients over sixty years of age, in patients who have had toxic symptoms over a year, in patients who have lost considerable weight, and in patients who have become iodine fast. In addition to the factor of infection, the patient just discussed had lost 60 pounds in weight during two years of active symptoms. TOXIC AND NONTOXIC NODULAR GOITER (ADENOMAS)
Adenomas of the thyroid can be divided into three classes: fetal adenoma, colloid adenoma, and papilliferous cystad-
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DAMON B. PFEIFFER, ALBERT G. MARTIN
enoma. The classification is a pathological differentiation; for it is rare that one can make the exact diagnosis clinically. Adenomas per se may be regarded as discrete autonomous tumors, which usually are nontoxic. The diffuse nodular goiter, on the other hand, represents focal hypertrophy at numerous points within the gland, often on the basis of a pre-existing colloid goiter. The clinical findings in nodular goiter are well known. If single, a discrete rounded tumor is found in either lobe or, more rarely, in the isthmus. The remainder of the gland is not enlarged. Multiple nodules produce greater distortion of the gland, depending upon their size and number. Nodular goiter usually is found in an older group of patients than those exhibiting diffuse toxic goiter. When toxic nodular goiter is present, exophthalmos is rarely found and the response to iodine treatment is less satisfactory than in diffuse toxic go iter. The operative mortality rates for patients with toxic nodular goiter are higher than for patients with exophthalmic goiter. As has been mentioned, adenomas occur in older patients, many of whom have already developed degenerative diseases of the cardiovascular, hepaticorenal and pulmonary systems. The progress of the disease is more insidious, and the toxic changes may be present for several years before the patient is brought to surgery. Toxicity is usually manifested by the general effects of nervousness, loss of weight and intolerance to heat. In addition, the cardiovascular system often shows severe effects such as rapid pulse, elevated blood pressure, and fibrillation. Fibrillation may be intermittent, the heart resuming normal rhythm without medication. When the heart fibrillates in this way a toxic nodular goiter or, more rarely, a diffuse toxic goiter, should be suspected. After surgery about 60 to 70 per cent of patients with fibrillation show a return to normal rhythm. Iodine administration is particularly fraught with danger; for in many nontoxic nodular goiters severe toxic changes have been induced by well meant but none-theless meddlesome courses of iodine preparations. These patients should never receive iodine unless they are being prepared for surgery.
DIAGNOSIS AND SURGICAL TREATMENT OF GOITER
1745
Fetal adenomas are characterized by small cells resembling those found in fetal life. The capsule is usually definite and there is compression of the surrounding tissue. Colloid adenomas show large alveoli distended with colloid. When toxic, the cells are characteristically smaller and contain less colloid. Any single colloid adenoma may contain cells of all types. A papilliferous cystadenoma may represent nonmalignant degeneration of a colloid adenoma, but may show its characteristic structure from the start. Ade~omas may be regarded as benign tumors of the thyroid gland and as such they are subject to growth, to necrosis, to hemorrhage and sometimes to malignant degeneration. The nodular goiter contains numerous hypertrophied areas. In general, these nodules show pathological changes similar to colloid adenomas. Their surrounding stroma is dense and the thyroid tissue between them is compressed to an extreme degree. These are the tumors which account for large pendulous goitersand substernal goiters. We feel that nodular goiter, if nontoxic, should be operated upon to prevent the complications of growth, pressure symptoms, toxicity, necrosis and occasional malignant change. The operation is one of election but, even so, procrastination on the part of the patient must be overcome. Patients with toxic nodular goiter should be prepared for operation at once and should be operated upon when they are in fit condition. The preparation follows the same general plan as in diffuse toxic goiter, but often takes a few more days. Mention should be made of menopausal symptoms which often accompany hyperthyroidism. We do not mean amenorrhea alone which is a common symptom, but rather hot flushes with amenorrhea occurring in women of menopausal age. The nervous symptoms of the menopause so closely resemble those of hyperthyroidism that the two states may occasionally be confused. In this situation the basal metabolic rate and occasionally a diagnostic course of Lugol's solution are of value in differentiating the two conditions. In a certain number of cases, however, thyrotoxicosis, usually in the form of toxic nodular goiter, and the menopause will co-exist. When they do, we feel both conditions should be treated. In
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DAMON B. PFEIFFER, ALBERT G. MARTIN
addition to preparing the patient for operation, progynon-B or theelin in rather large doses are given. The dose varies with the individual and no set rule of therapy can be postulated. It should be remembered that patients with hyperthyroidism often require two to four times as much hormone before operation as they will need after operation. As yet we have had little experience with stilbestrol. Case Ill. Nontoxic Thyroid Adenoma, with Easy Postoperative Course The next patient is a forty-four-year-old white woman who was admitted to the Lankenau Hospital last year. For eight years she knew she had a goiter. No symptoms of hyperthyroidism had ever been present. Nine months before admission she developed difficulty in swallowing which gradually became worse. Closer questioning revealed hoarseness and some difficulty in breathing of a few weeks' duration. There were no other complaints. She had not taken iodine. Examination showed a large, elastic tumor which filled the right lobe of the thyroid and extended medially across the midline of the neck. The tumor was roughly spherical and measured approximately 5 cm. in diameter. The patient's general condition was excellent. The pulse was 84, the blood pressure in millimeters of mercury was 130 systolic and 68 diastolic and the basal metabolic rate +3 per cent. She weighed 150 pounds. Examination of the vocal cords showed only congestion. There was no x-ray evidence of substernal thyroid enlargement. A diagnosis of nontoxic thyroid adenoma was made, and the patient was operated upon the day after admission to the hospital. When the gland was exposed a large adenoma was found which occupied the entire right lobe. The isthmus and left lobe were normal. Right subtotal lobectomy was done, with removal of 60 gm. of thyroid gland. Recovery was entirely uneventful and she was discharged nine days after operation. This patient received no iodine during her hospital stay. Postoperative vocal cord examination showed normal motion of both cords. The pathological report was fetal adenoma. At the present time the patient is in excellent health. The scar is inconspicuous, the remaining thyroid tissue shows no abnormalities, her pulse is 88, her blood pressure 128 systolic and 70 diastolic, and her weight 149 pounds.
This case illustrates a number of points, the most significant of which is the smooth, easy postoperative course which can be expected in nontoxic adenoma. The patient came to us to be relieved of pressure symptoms. There was no evidence of toxicity. Such a situation must, of course, be relieved surgically, but it should be emphasized that an operation for uncomplicated adenoma is as different from an operation for
DIAGNOSIS AND SURGICAL TREATMENT OF GOITER
1747
toxic nodular goiter as day from night. A safe operation, a short hospital stay, and an excellent prognosis can be offered these patients. We insist that every patient for whom a thyroid operation is contemplated should have the vocal cords examined before and after operation. One or more basal metabolic determinations are usually required. An x-ray examination for substernal goiter should also be made, especially in patients with nodular goiter and in patients who exhibit pressure symptoms. In operating for adenoma or nodular goiter, one has three procedures from which to chQose: enucleation, lobectomy and subtotal thyroidectomy. We believe no hard and fast rules can be made. The entire gland should always be carefully explored. A discrete, single adenoma is ideally suited for enucleation. In cases similar to the one just mentioned where the adenoma fills an entire lobe, subtotal lobectomy is often a safer and technically simpler operation than enucleation. When several nodules are found in one lobe of the thyroid, a careful search will usually reveal one or more nodules in the other lobe. For such cases, subtotal thyroidectomy is recommended .. Case IV. Toxic Nodular' Goiter, Illustrating Advantages of Stage Operation in Selected Cases The next patient is a woman of sixty-two years who looks ten years older than her actual age. She came to us four months ago complaining of a lump in the left side of the neck. She gave an indefinite history of weight loss and nervousness of twelve to fourteen months'. duration. Dyspnea on slight exertion and evening ankle edema had been noted for about three months. The patient was tense. The folds of her skin hung loosely, indicating recent weight loss. The thyroid gland was generally and irregularly enlarged, and a hard, well circumscribed mass about 4 cm. in diameter was present in the left lobe. She had no exophthalmos. A fine tremor of the fingers was very evident. The heart was moderately enlarged. Cardiac rhythm 'was normal. A short systolic aortic murmur was heard. The blood pressure in millimeters of mercury was 140 systolic and 86 diastolic. The basal metabolic rate was +36 per cent, the vocal cords moved normally, and x-ray examination showed a calcified nodule in the left lobe of the thyroid. A diagnosis of toxic nodular goiter was made and tb,e patient was prepared for operation. It was thought that a two-stage operation would be necessary. . Eight days after entering the hospital the patient had gained 4 pounds, her pulse had slowed from 88 to 72, and the basal metabolic rate had fallen to +22 per cent. On the ninth hospital day, left lobectomy was performed.
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DAMON B. PFEIFFER, ALBERT G. MARTIN
The patient's blood pressure before operation was, in millimeters of mercury, 130 systolic and 70 diastolic. Ten minutes after the operation was begun the pressure rose to 240 systolic and 120 diastolic. Fifteen minutes later, at the end of the operation, the pressure was 210 systolic and 110 diastolic. A rise in pressure of this magnitude confinued the preoperative opinion that stage procedures were indicated. The pulse pressure, it will be noted, rose from 50 to 120. We feel that when blood pressure and pulse pressure show dramatic and sudden rises in the course of a thyroid operation, the operation should be terminated as expeditiously as possible. Usually lobectomy will be the procedure chosen; for, as in this case, one lobe will have been partially amputated when the change in circulation occurs. In the case of this patient a smooth recovery followed the first stage. Pathological examination showed a large calcified adenoma and numerous smaller colloid adenomata with areas of involution and other areas of hyperplasia. Four weeks later right lobectomy was performed. The blood pressure this time varied between 140 systolic and 80 diastolic at the start and 160 systolic and 100 diastolic at the end of the operation. No significant pulse pressure changes occurred. The postoperative course was uneventful' and the patient left the hospital ten days after the second operation. Pathological examination showed multiple colloid adenomata with areas of involution and other areas of hyperplasia. The patient has gained 4 pounds; her nervousness and tremor are gone, and the basal metabolic rate is +12 per cent. Laryngeal examination shows nonual motion of both vocal cords.
The point of greatest interest brought out by this case is the smooth blood pressure and pulse pressure curve during the second operation. We are not advocates of frequent stage operations. However, stage operations have occupied a prominent place in recent surgical literature and their value has been properly stressed. It is gerterally accepted that in elderly patients who are in poor general condition, in patients who have had severe hyperthyroidism for over a year, in patients who have lost considerable weight (over 60 pounds), in patients with heart disease, the so-called thyrocardiacs, and in patients with irtfectious processes, stage procedures should be considered. As Lahey has often pointed out, the decision for or against stage procedures should be made when the patient is first seen, and not after preoperative preparation is well under way. There will be patients in whom a subtotal thyroidectomy is contemplated who show the circulatory disturbances manifested by this patient in her first operation. When this occurs, the operation must be terminated promptly if a fatality is to be avoided.
DIAGNOSIS AND SURGICAL TREATMENT OF GOITER INFL.AMMATORY GOITER
1749
(THYROIDITIS)
Case V. Ligneous Thyroiditis Complicated by Dietary Deficiencies The next patient, a woman of thirty-four, came to us for appendectomy and myomectomy in June, 1939. Her hospital stay was uneventful and at that time she had no thyroid symptoms and no enlargement of the thyroid. In January, 1941, we saw her again. She complained of nervousness, precordial pains and palpitation. The symptoms were unrelated to exertion. There had been no weight loss. Her family doctor had given her an iodine preparation for seven weeks before we saw her. Examination showed a diffuse general enlargement of the thyroid with no thrill or bruit and no substernal extension. The blood pressure in millimeters of mercury was 140 systolic and 95 diastolic, and the pulse rate 72. No exophthalmos was present and there was no tremor of the fingers or tongue. The basal metabolic rate was +2 per cent and when it was repeated four days later it was +4 per cent. A careful history revealed nervousness, dietary deficiencies, especially in fruits and vegetables which she seldom or never ate. Since the diagnosis of the thyroid state was not clear-cut and since the dietary deficiency was marked, we decided to keep the patient under observation on an adequate high vitamin diet. No iodine was given. On this program she showed marked improvement, losing her nervousness, precordial pain and palpitation. She gained 12 pounds in weight. The thyroid gland remained enlarged at first but gradually became smaller and as it decresed in size it also became firmer than the average gland. In August, 1941, the patient began to notice a feeling of oppression in the throat and chest. As this sensation became more marked, it could be reproduced by deep palpation of the thyroid gland. The basal metabolic rate was -8 per cent, the blood pressure in millimeters of mercury was 130 systolic and 80 diastolic, and the pulse rate 84. The vocal cords moved normally. X-ray showed no substernal extension. A diagnosis of thyroiditis was made and on October 28, 1941, a subtotal thyroidectomy was done, with removal of 112 gm. of thyroid tissue. The gland tissue was firmer than normal. The pathological report was ligneous thyroiditis. Recovery was uneventful and the patient was discharged eight days after operation. The basal metabolic rate at that time was -13 per cent. The vocal cords moved normally. At the present time, the patient has no complaints. The pressure symptoms have gone, and the nervousness and precordial distress noted early in 1941 have not returned. The basal metabolic rate is -9 per cent.
The case is cited to illustrate the importance of searching for nutritional disturbances in patients who may have toxic goiter and to stress the point that when a diagnosis of thyroid disease is uncertain, one should not operate before the clinical picture is clear. 'there is more to the surgical treatment of thyroid disease than the various operative procedures. The menopausal factor has been mentioned. Undernourished persons may show
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DAMON B. PFEIFFER, ALBERT G. MARTIN
symptoms which resemble those of hyperthyroidism and, conversely, in hyperthyroidism nutritional deficiencies are common. Looking back on the case of the patient just cited, it is obvious that thyroiditis was present from the start. At that time, however, the exact nature of the thyroid disease was not definite. There was no evidence of hyperthyroidism. We feel that nothing is lost and a great deal may be gained in such patients by keeping them under close clinical observation until the picture becomes clarified. If one operates hastily, a certain number of unnecessary operations will be performed. If hyperthyroidism develops while the patient is under observation, then of course the picture is clarified and operation should be done as soon as possible. Occasionally, as in this case, a diagnosis of thyroiditis will be made and operation will follow. The exception to the policy of observation is found in patients who are suspected of harboring a carcinoma of the thyroid. In such instances, operation should never be delayed. SUMMARY
Cases have been presented to illustrate certain major points in the diagnosis and surgical management of thyroid disorders. The possible harmful effect of iodine administration has been stressed. The general methods of diagnosis, preparation, and postoperative care for colloid goiter, diffuse toxic goiter, nodular goiter, both toxic and nontoxic, and thyroiditis have been discussed. No attempt has been made to give the technical details of operative procedures. At the present time, definitive treatment of the great majority of thyroid disorders means surgical treatment. However, as has been said, there is more to the treatment of thyroid disease than operation alone. Cardiac, nutritional and endocrine factors call for close cooperation between internist and surgeon throughout the treatment of thyroid disease.
DIAGNOSIS AND SURGICAL TREATMENT OF GOITER'* DAMON B. PFEIFFER, M.D., F.A.C.S.t
and ALBERT G. MARTIN, M.D.t
WE propose to limit our present discussion to the common types of thyroid disorders, colloid goiter, diffuse toxic goiter, nodular goiter (adenomas) with and without, toxic change, and inflammatory goiter. DIFFUSE TOXIC GOITER
Case I. Exophthalmic Goiteri Pre-existing Colloid Goiter Activated by Iodine Overdosage Our first case for presentation is that of a young white woman. We first saw her in 1936 when she was twenty-eight years old. At that time she complained of dyspnea, palpitation, emotional instability, and loss of weight. The symptoms were all severe and of four or five months' duration. A goiter, which had been present since the age of sixteen, had become increasingly prominent in the past five months. The symptoms mentioned had all been present in a less acute form for approximately twelve years. When they first appeared a doctor told her she had a goiter and gave her iodine for a few months. Symptoms of acute hyperthyroidism followed. Examination showed a thyroid gland which was diffusely enlarged. Exophthalmos was present. The pulse rate was 132 and the blood pressure in millimeters of mercury was 136 systolic and 68 diastolic. The heart action was forceful. A capillary pulse could be demonstrated in the nail beds. The patient was exceedingly nervous, very self-conscious, and her voice had a tremulous quality. She weighed 112 pounds. The basal metabolic rate was +65 per cent. After a period of preparation, bilateral subtotal thyroidectomy was performed on October 1, 1936. Sixty grams of hyperplastic thyroid gland were removed. Recovery was uncomplicated. The basal metabolic rate after 10 per cent. operation was Six years have passed since the operation. The patient has carried on a
+
• From the Damon B. Pfei1fer Surgical Clinic, Abington Memorial Hospital. t Associate Professor of Surgery, Graduate School of Medicine, University of Pennsylvania; Surgical Consultant and Honorary Chief, Surgical Service A, Lankenau Hospital; Chief of Surgical Service, Abington Memorial Hospital, Abington, Pa. t Assistant Instructor in Surgery, Graduate School of Medicine, University of Pennsylvania; Assistant Surgeon, Lankenau Hospital. 1739
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DAMON B. PFEIFFER, ALBERT G. MARTIN
normal, active life in her community. Although she had been married for five years before operation, she had not become pregnant. Approximately one year after operation she became pregnant and was uneventfully delivered of a normal child. She weighs 132 pounds, her pulse rate is 82, and her blood pressure in millimeters of mercury is 118 systolic and 76 diastolic.
The diagnosis of exophthalmic goiter in this case was clear. Among other characteristic features was the increase in pulse pressure with its attendant capillary pulsation. An increase in pulse pressure usually accompanies severe toxicity. After operation a return to normal should occur. In this case there was a blood pressure change in millimeters of mercury from 136 systolic and 68 diastolic to 118 and 76, respectively, accompanied by a fall in pulse rate from 132 to 82. The patient is representative of many individuals all over the country who have hyperthyroidism, whose family physicians have made a proper diagnosis, and who return to their communities as useful citizens after thyroidectomy. The early use of iodine in this case calls for special comment. When the patient was a girl of sixteen, a doctor told her she had a goiter and gave her iodine for a few months. Symptoms of hyperthyroidism followed. In all probability the lesion present at that time was a simple colloid goiter which was activated by iodine overdosage. Simple colloid goiter usually develops at or about the time of adolescence. As is well known, it is found most frequently in the goiter zones. Prophylaxis consists of administering a 10-mg. iodine tablet once a week or instructing the patient to use· iodized salt. The average individual using iodized salt ingests 8 mg. of iodine a week. Prophylaxis has been used with marked success in the Great Lakes region and other areas where goiter is endemic. Once established, a. colloid goiter should never be treated by large doses of iodine, for fear of activation similar to that in the instance just discussed. We believe that colloid goiters should be operated upon. Judgment must of course be exercised; for the slight enlargement often seen at the time of puberty is usually only temporary. Large goiters are not only undesirable for cosmetic reasons but constitute a source of potential danger from toxic or degenerative changes.
DIAGNOSIS AND SURGICAL TREATMENT OF GOITER
1741
Preoperative Preparation in Hyperthyroidism
The preoperative preparation of patients with hyperthyroidism is important. Essentially, it consists of a high caloric, high vitamin diet, iodine administration, and rest. We like to see our patients ingest 5000 calories a day, if possible. Fruit juices are given liberally, and furnish an excellent source of vitamin C in addition to their calories. One or two vitamin B complex capsules are given with each meal. These tablets contain 333 units of vitamin B1 , 500 micrograms of riboflavin, 10 mg. of nicotinic acid, 130 micrograms of vitamin B6 , and 170 micrograms of pantothenic acid. Iodine is given in the form of Lugol's solution, 10 to 15 minims three times daily. Patients are usually kept in bed, although this is not a hard and fast rule. Elderly patients do better if they sit out of bed in a chair for a few hours each day, and an occasional emotional, severely toxic patient will be quieter and happier if he is allowed to get up for a short period each day. Frequently patients require sedation and for this purpose we prefer the bromide elixirs, in doses of 5 to 10 cc. three times daily. When bromides are given we like to give the first dose just before noon, the second in the mid afternoon, and the third an hour or two after the evening meal. Seven to twelve days of preparation is the average time. Just as the initial basal metabolic rate is only one. index of toxicity, a fall in the rate is only one of the manifestations of response to treatment. A patient is ready for operation when the pulse rate falls and levels off at a relatively lower level, when he shows a gain in weight, and when examination of the gland indicates involution. Postoperative Care in Hyperthyroidism
Postoperatively, we commonly give 5 cc. of Lugol's solution by rectum when the patient returns to the floor. As soon as the patient is conscious he is placed in a sitting position in bed. Morphine sulfate, grain Yo, is given every three hours unless the respiratory rate falls to 16, and this dosage is maintained for twenty-four to forty-eight hours. In the first twenty-four hours 3500 cc. of parenteral fluid, of which 1500 cc. are normal salt solution, is given intravenously.
1742.
DAMON B. PFEIFFER, ALBERT G. MARTIN
Glucose in quantities of 200 to 350 gm. is given intravenously. Ice caps are applied to the head and precordium. The oxygen tent is used frequently. The tent is usually preferred to the B.L.B. mask because of its general cooling effect. Tincture of benzoin inhalations are given frequently during the first three days. On the day after operation, Lugol's solution by mouth is resumed and continued during the patient's stay in the hospital. Thereafter no more iodine is given. Fluids by mouth are begun as soon as the patient can drink and the diet is rapidly built up to the preoperative level. Most patients leave the hospital seven to ten days after the operation. They are instructed to lead a quiet, well regulated life for at least three months, when they return for a follow-up visit. Case n. Diffuse Toxic Goiter, Illustrating Dangers of Acute Infections Arising during Hyperthyroidism and the Importance of Stage Operations The next patient is a fifty-four-year-old woman whom we saw four years ago. At that time she complained of nervousness, palpitation, intolerance of heat and a swelling in the neck for two years. For several months amenorrhea, ankle edema and hoarseness were also present. During the two years of active symptoms she had lost 60 pounds in weight. She was exceedingly nervous and apprehensive. Exophthalmos was present. The thyroid gland was enlarged bilaterally, the nght side being somewhat more prominent than the left. Breit was present. The pulse rate was 124 and the blood pressure in millimeters of mercury was 168 systolic and 78 diastolic. The basal metabolic rate was +81 per cent. She weighed 157 pounds. A diagnosis of diffuse toxic goiter was made and the patient was prepared for operation. This was an instance of late diagnosis, but fortunately no iodine had been given. Nine days after admission to the hospital, the pulse had fallen to 84 and the basal metabolic rate to +39 per cent. On the tenth day the patient developed a severe tonsillitis and, after a chill, her temperature rose to 104° F. A throat culture showed hemolytic streptococci; a blood culture showed no growth. Full doses of iodine were continued, a 5000 calorie diet was maintained, and sulfanilamide treatment was begun. On the fifteenth hospital day a peritonsillar abscess was incised, with release of a large amount of pus. Five days thereafter the tonsillitis had subsided. The patient had lost 12 pounds and her pulse rate had risen from 84 to 100. By the twenty-eIghth hospital day the pulse had become stable at 80, the patient had regained 2 pounds, and the basal metabolic rate was +28 per cent. Right subtotal hemithyroidectomy was performed. Sixty grams of hyperplastic tissue were removed, comprising seven-eighths of the right lobe, the isthmus and the pyramidal lobe. Recovery was uncomplicated, and the patient was dischar~ed on the eleventh postoperative day. Lu~ol's solution, 10 minims three tImes a day, a high caloric diet and vitamm B complex were continued.
DIAGNOSIS AND SURGICAL TREATMENT OF GOITER
1743
Eight weeks after operation the patient was readmitted for the second stage. The time interval is somewhat longer than usual. On readmission the pulse was 96, the basal metabolic rate +27 per cent, and she had gained 13 pounds. Left subtotal hemithyroidectomy was done, 50 gm. of hyperplastic gland being removed. Although the throat was negative before operation, recovery was complicated by acute follicular tonsillitis. The patient was discharged ten days after operation. A month later, tonsillectomy was performed and recovery was uneventful. The basal metabolic rate at that time was +1 per cent.
This case illustrates two principles of treatment. First, the danger of acute infection arising during hyperthyroidism is shown by the severe reaction to the initial attack of tonsillitis. Thyroid crisis was imminent. Fortunately, iodine and other preparation had been carried out for nine days and the patient had not received any iodine before coming to the hospital. Fortunately, too, sulfanilamide was available. Drainage of the peritonsillar abscess was indicated. Similarly, operations for acute appendicitis and other emergencies are indicated during thyrotoxicosis. However, when thyrotoxicosis co-exists with other, nonemergency illnesses, the treatment of the thyroid disorder receives precedence. It is not unknown for postoperative hernia or gallbladder patients to go into thyroid crises on the second or third postoperative day. Such occurrences can be prevented by being on the alert to recognize symptoms of hyperthyroidism and to make the proper investigations before doing ~lective surgery. The second principle illustrated is the importance of doing stage operations where toxic goiter is complicated by an infectious process. The presence of infection greatly heightens toxicity. Other instances in which stage operations should be considered are in patients over sixty years of age, in patients who have had toxic symptoms over a year, in patients who have lost considerable weight, and in patients who have become iodine fast. In addition to the factor of infection, the patient just discussed had lost 60 pounds in weight during two years of active symptoms. TOXIC AND NONTOXIC NODULAR GOITER (ADENOMAS)
Adenomas of the thyroid can be divided into three classes: fetal adenoma, colloid adenoma, and papilliferous cystad-
1744
DAMON B. PFEIFFER, ALBERT G. MARTIN
enoma. The classification is a pathological differentiation; for it is rare that one can make the exact diagnosis clinically. Adenomas per se may be regarded as discrete autonomous tumors, which usually are nontoxic. The diffuse nodular goiter, on the other hand, represents focal hypertrophy at numerous points within the gland, often on the basis of a pre-existing colloid goiter. The clinical findings in nodular goiter are well known. If single, a discrete rounded tumor is found in either lobe or, more rarely, in the isthmus. The remainder of the gland is not enlarged. Multiple nodules produce greater distortion of the gland, depending upon their size and number. Nodular goiter usually is found in an older group of patients than those exhibiting diffuse toxic goiter. When toxic nodular goiter is present, exophthalmos is rarely found and the response to iodine treatment is less satisfactory than in diffuse toxic go iter. The operative mortality rates for patients with toxic nodular goiter are higher than for patients with exophthalmic goiter. As has been mentioned, adenomas occur in older patients, many of whom have already developed degenerative diseases of the cardiovascular, hepaticorenal and pulmonary systems. The progress of the disease is more insidious, and the toxic changes may be present for several years before the patient is brought to surgery. Toxicity is usually manifested by the general effects of nervousness, loss of weight and intolerance to heat. In addition, the cardiovascular system often shows severe effects such as rapid pulse, elevated blood pressure, and fibrillation. Fibrillation may be intermittent, the heart resuming normal rhythm without medication. When the heart fibrillates in this way a toxic nodular goiter or, more rarely, a diffuse toxic goiter, should be suspected. After surgery about 60 to 70 per cent of patients with fibrillation show a return to normal rhythm. Iodine administration is particularly fraught with danger; for in many nontoxic nodular goiters severe toxic changes have been induced by well meant but none-theless meddlesome courses of iodine preparations. These patients should never receive iodine unless they are being prepared for surgery.
DIAGNOSIS AND SURGICAL TREATMENT OF GOITER
1745
Fetal adenomas are characterized by small cells resembling those found in fetal life. The capsule is usually definite and there is compression of the surrounding tissue. Colloid adenomas show large alveoli distended with colloid. When toxic, the cells are characteristically smaller and contain less colloid. Any single colloid adenoma may contain cells of all types. A papilliferous cystadenoma may represent nonmalignant degeneration of a colloid adenoma, but may show its characteristic structure from the start. Ade~omas may be regarded as benign tumors of the thyroid gland and as such they are subject to growth, to necrosis, to hemorrhage and sometimes to malignant degeneration. The nodular goiter contains numerous hypertrophied areas. In general, these nodules show pathological changes similar to colloid adenomas. Their surrounding stroma is dense and the thyroid tissue between them is compressed to an extreme degree. These are the tumors which account for large pendulous goitersand substernal goiters. We feel that nodular goiter, if nontoxic, should be operated upon to prevent the complications of growth, pressure symptoms, toxicity, necrosis and occasional malignant change. The operation is one of election but, even so, procrastination on the part of the patient must be overcome. Patients with toxic nodular goiter should be prepared for operation at once and should be operated upon when they are in fit condition. The preparation follows the same general plan as in diffuse toxic goiter, but often takes a few more days. Mention should be made of menopausal symptoms which often accompany hyperthyroidism. We do not mean amenorrhea alone which is a common symptom, but rather hot flushes with amenorrhea occurring in women of menopausal age. The nervous symptoms of the menopause so closely resemble those of hyperthyroidism that the two states may occasionally be confused. In this situation the basal metabolic rate and occasionally a diagnostic course of Lugol's solution are of value in differentiating the two conditions. In a certain number of cases, however, thyrotoxicosis, usually in the form of toxic nodular goiter, and the menopause will co-exist. When they do, we feel both conditions should be treated. In
1746
DAMON B. PFEIFFER, ALBERT G. MARTIN
addition to preparing the patient for operation, progynon-B or theelin in rather large doses are given. The dose varies with the individual and no set rule of therapy can be postulated. It should be remembered that patients with hyperthyroidism often require two to four times as much hormone before operation as they will need after operation. As yet we have had little experience with stilbestrol. Case Ill. Nontoxic Thyroid Adenoma, with Easy Postoperative Course The next patient is a forty-four-year-old white woman who was admitted to the Lankenau Hospital last year. For eight years she knew she had a goiter. No symptoms of hyperthyroidism had ever been present. Nine months before admission she developed difficulty in swallowing which gradually became worse. Closer questioning revealed hoarseness and some difficulty in breathing of a few weeks' duration. There were no other complaints. She had not taken iodine. Examination showed a large, elastic tumor which filled the right lobe of the thyroid and extended medially across the midline of the neck. The tumor was roughly spherical and measured approximately 5 cm. in diameter. The patient's general condition was excellent. The pulse was 84, the blood pressure in millimeters of mercury was 130 systolic and 68 diastolic and the basal metabolic rate +3 per cent. She weighed 150 pounds. Examination of the vocal cords showed only congestion. There was no x-ray evidence of substernal thyroid enlargement. A diagnosis of nontoxic thyroid adenoma was made, and the patient was operated upon the day after admission to the hospital. When the gland was exposed a large adenoma was found which occupied the entire right lobe. The isthmus and left lobe were normal. Right subtotal lobectomy was done, with removal of 60 gm. of thyroid gland. Recovery was entirely uneventful and she was discharged nine days after operation. This patient received no iodine during her hospital stay. Postoperative vocal cord examination showed normal motion of both cords. The pathological report was fetal adenoma. At the present time the patient is in excellent health. The scar is inconspicuous, the remaining thyroid tissue shows no abnormalities, her pulse is 88, her blood pressure 128 systolic and 70 diastolic, and her weight 149 pounds.
This case illustrates a number of points, the most significant of which is the smooth, easy postoperative course which can be expected in nontoxic adenoma. The patient came to us to be relieved of pressure symptoms. There was no evidence of toxicity. Such a situation must, of course, be relieved surgically, but it should be emphasized that an operation for uncomplicated adenoma is as different from an operation for
DIAGNOSIS AND SURGICAL TREATMENT OF GOITER
1747
toxic nodular goiter as day from night. A safe operation, a short hospital stay, and an excellent prognosis can be offered these patients. We insist that every patient for whom a thyroid operation is contemplated should have the vocal cords examined before and after operation. One or more basal metabolic determinations are usually required. An x-ray examination for substernal goiter should also be made, especially in patients with nodular goiter and in patients who exhibit pressure symptoms. In operating for adenoma or nodular goiter, one has three procedures from which to chQose: enucleation, lobectomy and subtotal thyroidectomy. We believe no hard and fast rules can be made. The entire gland should always be carefully explored. A discrete, single adenoma is ideally suited for enucleation. In cases similar to the one just mentioned where the adenoma fills an entire lobe, subtotal lobectomy is often a safer and technically simpler operation than enucleation. When several nodules are found in one lobe of the thyroid, a careful search will usually reveal one or more nodules in the other lobe. For such cases, subtotal thyroidectomy is recommended .. Case IV. Toxic Nodular' Goiter, Illustrating Advantages of Stage Operation in Selected Cases The next patient is a woman of sixty-two years who looks ten years older than her actual age. She came to us four months ago complaining of a lump in the left side of the neck. She gave an indefinite history of weight loss and nervousness of twelve to fourteen months'. duration. Dyspnea on slight exertion and evening ankle edema had been noted for about three months. The patient was tense. The folds of her skin hung loosely, indicating recent weight loss. The thyroid gland was generally and irregularly enlarged, and a hard, well circumscribed mass about 4 cm. in diameter was present in the left lobe. She had no exophthalmos. A fine tremor of the fingers was very evident. The heart was moderately enlarged. Cardiac rhythm 'was normal. A short systolic aortic murmur was heard. The blood pressure in millimeters of mercury was 140 systolic and 86 diastolic. The basal metabolic rate was +36 per cent, the vocal cords moved normally, and x-ray examination showed a calcified nodule in the left lobe of the thyroid. A diagnosis of toxic nodular goiter was made and tb,e patient was prepared for operation. It was thought that a two-stage operation would be necessary. . Eight days after entering the hospital the patient had gained 4 pounds, her pulse had slowed from 88 to 72, and the basal metabolic rate had fallen to +22 per cent. On the ninth hospital day, left lobectomy was performed.
1748
DAMON B. PFEIFFER, ALBERT G. MARTIN
The patient's blood pressure before operation was, in millimeters of mercury, 130 systolic and 70 diastolic. Ten minutes after the operation was begun the pressure rose to 240 systolic and 120 diastolic. Fifteen minutes later, at the end of the operation, the pressure was 210 systolic and 110 diastolic. A rise in pressure of this magnitude confinued the preoperative opinion that stage procedures were indicated. The pulse pressure, it will be noted, rose from 50 to 120. We feel that when blood pressure and pulse pressure show dramatic and sudden rises in the course of a thyroid operation, the operation should be terminated as expeditiously as possible. Usually lobectomy will be the procedure chosen; for, as in this case, one lobe will have been partially amputated when the change in circulation occurs. In the case of this patient a smooth recovery followed the first stage. Pathological examination showed a large calcified adenoma and numerous smaller colloid adenomata with areas of involution and other areas of hyperplasia. Four weeks later right lobectomy was performed. The blood pressure this time varied between 140 systolic and 80 diastolic at the start and 160 systolic and 100 diastolic at the end of the operation. No significant pulse pressure changes occurred. The postoperative course was uneventful' and the patient left the hospital ten days after the second operation. Pathological examination showed multiple colloid adenomata with areas of involution and other areas of hyperplasia. The patient has gained 4 pounds; her nervousness and tremor are gone, and the basal metabolic rate is +12 per cent. Laryngeal examination shows nonual motion of both vocal cords.
The point of greatest interest brought out by this case is the smooth blood pressure and pulse pressure curve during the second operation. We are not advocates of frequent stage operations. However, stage operations have occupied a prominent place in recent surgical literature and their value has been properly stressed. It is gerterally accepted that in elderly patients who are in poor general condition, in patients who have had severe hyperthyroidism for over a year, in patients who have lost considerable weight (over 60 pounds), in patients with heart disease, the so-called thyrocardiacs, and in patients with irtfectious processes, stage procedures should be considered. As Lahey has often pointed out, the decision for or against stage procedures should be made when the patient is first seen, and not after preoperative preparation is well under way. There will be patients in whom a subtotal thyroidectomy is contemplated who show the circulatory disturbances manifested by this patient in her first operation. When this occurs, the operation must be terminated promptly if a fatality is to be avoided.
DIAGNOSIS AND SURGICAL TREATMENT OF GOITER INFL.AMMATORY GOITER
1749
(THYROIDITIS)
Case V. Ligneous Thyroiditis Complicated by Dietary Deficiencies The next patient, a woman of thirty-four, came to us for appendectomy and myomectomy in June, 1939. Her hospital stay was uneventful and at that time she had no thyroid symptoms and no enlargement of the thyroid. In January, 1941, we saw her again. She complained of nervousness, precordial pains and palpitation. The symptoms were unrelated to exertion. There had been no weight loss. Her family doctor had given her an iodine preparation for seven weeks before we saw her. Examination showed a diffuse general enlargement of the thyroid with no thrill or bruit and no substernal extension. The blood pressure in millimeters of mercury was 140 systolic and 95 diastolic, and the pulse rate 72. No exophthalmos was present and there was no tremor of the fingers or tongue. The basal metabolic rate was +2 per cent and when it was repeated four days later it was +4 per cent. A careful history revealed nervousness, dietary deficiencies, especially in fruits and vegetables which she seldom or never ate. Since the diagnosis of the thyroid state was not clear-cut and since the dietary deficiency was marked, we decided to keep the patient under observation on an adequate high vitamin diet. No iodine was given. On this program she showed marked improvement, losing her nervousness, precordial pain and palpitation. She gained 12 pounds in weight. The thyroid gland remained enlarged at first but gradually became smaller and as it decresed in size it also became firmer than the average gland. In August, 1941, the patient began to notice a feeling of oppression in the throat and chest. As this sensation became more marked, it could be reproduced by deep palpation of the thyroid gland. The basal metabolic rate was -8 per cent, the blood pressure in millimeters of mercury was 130 systolic and 80 diastolic, and the pulse rate 84. The vocal cords moved normally. X-ray showed no substernal extension. A diagnosis of thyroiditis was made and on October 28, 1941, a subtotal thyroidectomy was done, with removal of 112 gm. of thyroid tissue. The gland tissue was firmer than normal. The pathological report was ligneous thyroiditis. Recovery was uneventful and the patient was discharged eight days after operation. The basal metabolic rate at that time was -13 per cent. The vocal cords moved normally. At the present time, the patient has no complaints. The pressure symptoms have gone, and the nervousness and precordial distress noted early in 1941 have not returned. The basal metabolic rate is -9 per cent.
The case is cited to illustrate the importance of searching for nutritional disturbances in patients who may have toxic goiter and to stress the point that when a diagnosis of thyroid disease is uncertain, one should not operate before the clinical picture is clear. 'there is more to the surgical treatment of thyroid disease than the various operative procedures. The menopausal factor has been mentioned. Undernourished persons may show
1750
DAMON B. PFEIFFER, ALBERT G. MARTIN
symptoms which resemble those of hyperthyroidism and, conversely, in hyperthyroidism nutritional deficiencies are common. Looking back on the case of the patient just cited, it is obvious that thyroiditis was present from the start. At that time, however, the exact nature of the thyroid disease was not definite. There was no evidence of hyperthyroidism. We feel that nothing is lost and a great deal may be gained in such patients by keeping them under close clinical observation until the picture becomes clarified. If one operates hastily, a certain number of unnecessary operations will be performed. If hyperthyroidism develops while the patient is under observation, then of course the picture is clarified and operation should be done as soon as possible. Occasionally, as in this case, a diagnosis of thyroiditis will be made and operation will follow. The exception to the policy of observation is found in patients who are suspected of harboring a carcinoma of the thyroid. In such instances, operation should never be delayed. SUMMARY
Cases have been presented to illustrate certain major points in the diagnosis and surgical management of thyroid disorders. The possible harmful effect of iodine administration has been stressed. The general methods of diagnosis, preparation, and postoperative care for colloid goiter, diffuse toxic goiter, nodular goiter, both toxic and nontoxic, and thyroiditis have been discussed. No attempt has been made to give the technical details of operative procedures. At the present time, definitive treatment of the great majority of thyroid disorders means surgical treatment. However, as has been said, there is more to the treatment of thyroid disease than operation alone. Cardiac, nutritional and endocrine factors call for close cooperation between internist and surgeon throughout the treatment of thyroid disease.