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Hyperthyroidism in elderly patients
HYPERTHYROIDISM JAMES W.
IN ELDERLY PATIENTS* HENDRICK, M.D.
AMARILLO,
H
YPERTHYROIDISM in eIderIy individuaIs is not an infrequent finding in a Iarge group of patients with cardiac symptoms. The diagnosis is frequentIy missed because, first, the teaching has been that toxic goiter is a disease of the young and middIe age, and second, symptoms of hyperthyroidism in the aged are often different from those found in the young. The majority of patients over sixty years of age with hyperthyroidism have adenomatous goiters. PIummer has shown that adenomatous goiter is present from fifteen to seventeen years before toxicity deveIops unIess provoked by the ‘indiscriminate use of iodine. In a study of eighty patients over sixty years of age with hyperthyroidism, the cardinal feature was that they were not stimuIated to the degree that a Iike group of younger patients wouId be. This feature accounts for their Iess dramatic symptoms. It may be that the oIder patients have been overstimuIated so Iong by the overactive thyroid that they have become Iess responsive. The constant finding in the entire group was weight loss. It varied from a few pounds to practicalIy haIf the norma weight. As a ruIe the weight Ioss extended over a period of one to four years. A normaI or excessive appetite was noted in the activated group, whereas, in the nonactivated cases the appetite was often poor. Cardiac compIaints with paIpitation and weakness on exertion were the next in order of frequency. Angina1 symptoms were frequentIy noted. Most of the group had been treated for varying periods of time for heart troubIe with practicaIly no response to the treatment. AuricuIar fibriIIation was a frequent finding. The heart sounds were * Read before the American Association
TEXAS
Ioud and sharp and often there was a mitra1 systoIic murmur present. The systoIic bIood pressure varied from 150 to 260 mm. of mercury. The diastoIic pressure was not raised in proportion to the systoIic pressure. The puIse pressure was markedIy eIevated in a11 cases. The puIse rate varied from 88 to 130. Most of the patients had taken digitaIis over a Iong period of time with IittIe response, particuIarIy to auricuIar fibriIIation when it was present. Some of the cases had cardiac decompensation and eight were not improved suffIcientIy by medica measures to attempt surgical reIief. In the cases in which auricuIar fibriIIation was not present, the use of digitaIis did not prove to be of any assistance. The patients in the activated group were sensitive to heat; their skin was warm and moist, and seIdom was pigmentation noted; whereas, in the nonactivated group the skin was without tine, was dry and coId. Pigmentation was frequentIy noted in this Iatter group. Among the patients with marked weight Ioss, gastrointestina1 symptoms were observed with crises of vomiting and diarrhea. Many of the Iatter had been studied for gastrointestina1 maIignancy. Eye findings were not constant. A few cases had exophthaImus (Fig. I), but they were patients that gave a history of having deveIoped exophthaImic goiter earIier in Iife and were what HertzIerl termed “burned out individuaIs.” Stare was occasionaIIy seen in the activated but not in the nonactivated group. A psychosis is more frequentIy seen in the oIder group of cases and is often ascribed to seniIe dementia. The entire group compIained of muscIe weakness and were easiIy fatigued. This
for the Study of Goiter,
466
Rochester,
Minnesota,
ApriI 13-17,
1940.
NEW SERIES VOL. L.11, No.
3
Hendrick-Hyperthyroidism
was out of proportion to their age and frequently led to the diagnosis of heart trouble. Digital tremor was seen but was not a constant finding.
lntrathorncic cxtensicms a malignancy. were noted in a few cases. Frequently cases are encountered that have progressed to such an extent and the
FIG. 2. Large cervical goiter, also Iarge intr:lthoracic goiter. PuIse rate IZO. Auricular fIbriIIation present. BasaI metaboIic rate, +22.
FIG. I. Apathetic hyperthyroidism. Low basal metabolic rate and auricuIar fibriIlation present. Pulse 144, auricuIar fibrilkion. BasaI metaboIic rate, + I 4. Many years’ duration.
The basal metabolic rate as a rule was elevated but not to the degree found in younger individuals. Two years ago I reported a group of toxic cases2 with basal metabolic rates within normaI Iimits. Several of the cases incIuded in that group are reported here. In the nonactivated or apathetic group as designated by Lahey,3 the basa1 metabolic rates were around plus twenty. There was a very definite goiter present in every patient. Some had rather large adenomatous goiters. In the cases that had taken iodine over a Iong period of time, the gland was hard and firm, often simulating
cardiac damage is so marked, that they can not be corrected surgically. Eight cases in this series were of this type. They did not respond suflicientIy to medical measures to attempt pole ligation and all expired within a period of a few months. The oIder group requires very meticulous preoperative care. Frequently they have other complications, such as old rheumatic hearts, generalized arteriosclerosis, impaired renal function and prostatic hypertrophy with retention, any of which add an additional burden to the hyperthyroidism. Most of the cases that had a diagnosis of hyperthyroidism made previously had taken iodine from a few months to several years. Such cases are iodine fast. If the iodine had not been administered, they could have been prepared much easier and with a Iarger margin of safety. It is often surprising how much can be done for those individuaIs with evidence of severe heart
468
American
JournaI
of Surgery
Hendrick-Hyperthyroidism
disease when they are carefuIIy prepared and are operated upon in stages. A high carbohydrate diet, Lugol’s solution, digitalis if auricuIar fibriIIation is present and diuretics in the presence of edema are given. When the patient is first seen a preIiminary evaIuation of the risk shouId be made, because at no other time can this be done so advantageousIy. After the patient has been at rest with sedation and LugoI’s, it is aImost impossibIe to judge the proper time for operative interference without knowIedge of the origina status of the patient. In determining the status of a patient we have in addition to a compIete physica examination with routine Iaboratory work, a stereo of the chest (Fig. 2), an eIectrocardiogram and bIood chemistry determinations if there is any indication of renaI impairment. In particuIar we consider the pulse rate after bed rest of six to eight days, the Iength of time the disease has been present, whether iodine has been previousIy administered, and Iast, but not Ieast, the weight Ioss and the rapidity of the same. PreoperativeIy we foIIow the preparation of the patient by the change of these factors and not by the Iowering in the basa1 metaboIic rate. It is in oIder peopIe that stage operations can be used most advantageousIy. If there is any doubt about the risk, one Iobe is removed, the patient is permitted to recuperate at home six to eight weeks and then the other Iobe is removed. LocaI anesthesia, with Iight anaIgesia of gas, heIium and oxygen, was used. These patients toIerate deep anesthesia very poorIy. Furthermore, they do not toIerate Iarge doses of barbiturates as such drugs produce too much depression. Codeine and smaI1 doses of morphia are used to reIieve pain and restIessness. PostoperativeIy the patient, if a poor risk, is pIaced in an ice cooIed oxygen tent for two or three days. Five or IO per cent gIucose in norma saIine soIution is given sIowly up to 2000 to 3000 cc. daiIy. This provides nourishment, stimuIates renaI
JUNE,
1941
function, takes care of the water balance and prevents acidosis. These measures assist in preventing postoperative thyroid reactions. DiIigent postoperative care must be exercised to prevent pulmonary compIications which often end fataIIy. If too much sedation is administered, the patient is depressed, mucus forms in the trachea, the patient is unabIe to cough it up and bronchopneumonia deveIops. Often the patient can readiIy expeI1 the mucus by having him bend over the edge of the bed or by eIevating the foot of the bed. A study of seventy-two patients who were operated upon was made. These cases were divided roughIy into the activated and nonactivated groups. NONACTIVED
OR
Number
APATHETIC
of Cases
Length of Time w~$t;~s_ at,
Average 67 Oldest
77
Youngest 60
PE2”:‘,,
GROUP
22
B.M.R., Per Cent
Weight LOSS
Average plus 28 Highest plus 42 Lowest minus II
Average
Years
Average 22 Longest
Average
42 Shortest
240/170 Lowest I 48/86
4
170/9Q Highest
Postoperative Mortality. Per Cent
2 or 9.9
34 pounds
ACTIVATED
1 Lennth
of Cases 50
1
T B.M.R., Per Cent
Age
Average 66
GROUP
Number
Average 18 Longest 28 Shortest
13
Average I So/92 Highest 230/13a
I
Average pIus 32 Highest plus 32 Lowest minus 8
Weight LOSS
Average 26 pounds
Postoperative Mortality, Per Cent
2 or 4
The operative mortaIity in the group of patients over sixty years of age was 5.5 per cent. In a Iarge group of cases under sixty years of age the operative mortaIity was I.2 per cent. The foIIowing case reports iIIustrate our management for goiter patients of this age group :
NEW SERVESVOL. LII, No. 3
CASE
Hendrick-Hyperthyroidism REPORTS
CASE I. Mrs. E. W. H., years, housewife, (Fig. 3),
age sixty-eight compIained of
Jo~~rnal of Surgery
469
caloric diet and bed rest. After two weeks her pulse rate was 96 and regular, the basal metaboIic rate was pIus thirty-six, and there had
FIG. 3. Goiter present thirty-five auricdar fibriIIation present;
weight Ioss, paIpitation, weakness, choking attacks and nervousness of three years’ duration. She stated that a goiter had been present for thirty-five years. She first noticed gradual loss of weight and had attacks of indigestion accompanied by vomiting and diarrhea. She had been treated for coIitis, heart troubIe and high bIood pressure. Examination reveaIed a markedly emaciated woman, weight one hundred three pounds (norma weight one hundred and sixty-eight), skin moist and warm, puIse rate 138; the heart was GbriIIating; bIood pressure 240/130 mm. of mercury. There was digita tremor and eye stare present. Her basa1 metaboIic rate was pIus fifty-two. Both Iobes of the thyroid were noduIar and firm. There were no puIsations or bruits. She was hospitaIized, put on Lugor’s soIution, digitaIis, high
American
years. P&e rate 138; basal metabolic rate,
been a gain of six pounds. A biIatera1 thyroidectomy was done. The patient went into a coma after a few hours and remained stuperous for four days, during which time she was given 3,000 cc. of 5 per cent gIucose saIine intravenousIy daily and two transfusions of 400 cc. of whoIe blood. The puIse rate did not exceed 130. She graduaIIy improved and was dismissed from the hospita1 on the sixteenth day. One year Iater the basa1 metabohc rate was pIus six, puIse rate 78, and bIood pressure Igo/rzo. She expired in 1938 from apoplexy at the age of seventy-seven, nine years after the operation. This patient wouId have done better with a two-stage operation. CASE II. Mrs. T. E. E., age sixty-six, housewife, was referred by Dr. E. E. Davis, of AIbuquerque, New Mexico. The patient stated
470
American Journnl of Surgery
Hendrick-Hyperthyroidism
she was referred to Dr. Davis from Indiana for tubercular treatment. She complained of coughing, choking, loss of weight and strength. She was very nervous but had an exceIIent appetite. Examination: poorIy nourished white woman, weight ninety-six pounds (normal weight one hundred and forty pounds), skin moist and warm, digita tremor, Iid Iag and stare. The right lobe of thyroid was markedIy enIarged, nodular and firm. The Ieft Iobe was substerna1, producing trachea1 deviation. The pulse rate was I IO, and the heart was fibriIIating. Her basa1 metaboIic rate was pIus thirtyfour. The patient was hospitaIized, given a high carbohydrate diet, LugoI’s soIution and digitalis. After tweIve days her puIse rate was 102 and her basa1 metaboIic rate pIus thirty-two. A right Iobectomy was done. ConvaIescence was uneventfu1 and she was sent home. After eight weeks she returned. She had improved considerabIy and had gained six pounds in weight, but stiI1 compIained of choking. Her pulse rate was IOO. The auricuIar fibriIIation had disappeared. The intrathoracic Ieft Iobe was removed. No follow-up report was obtainabIe. CASE III. Mrs. J. E. F., age sixty-nine, housewife, was referred by Dr. W. P. Martin, of CIovis, New Mexico. The patient stated she had smothering attacks, marked Ioss of strength and weight, poor appetite and attacks of diarrhea and vomiting. Examination reveaIed an eIderIy woman with evidence of marked weight loss. Her skin was coo1 and dry. No digita tremor or ocuIar signs were present. The thyroid was three or four times the norma size and both Iobes were very firm. The puIse rate was g6 and reguIar. BIood pressure was 160 systoIic and 80 diastoIic. Moist raIes were found over the bases of both Iungs, and there was one pIus edema of the ankIes. The urine showed a two pIus albumen, and there were coarse and fine granuIar casts. Her basa1 metaboIic rate was plus six. The patient was hospitaIized, given LugoI’s soIution, a high carbohydrate diet, and two weeks Iater a right hemithyroidectomy was done. She was given an immediate bIood transfusion, put under an ice cooled oxygen tent, and given 3,000 cc. of 5 per cent gIucose saIine soIution daiIy by sIow drip. She graduaIIy became unconscious. Her pulse rate remained under IOO and was reguIar. At the end of four days she began to improve and was dismissed on the sixteenth postopera-
JUNE,X~JI
tive day and permittec1 to go to her home. After two months she returned feeIing much better and a Ieft hemithyroidectomy was done. She was pIaced immediateIy under the ice cooled oxygen tent and given 400 cc. of titrated bIood. Her convaIescence was without incident. When seen five years Iater she had regained her former weight and was abIe to do her own house work. She had Iost her apathetic appearance and was again interested in outside activities. CASE IV. A maIe, age sixty-two, was referred by Dr. H. A. IngaIIs, of RosweII, New Mexico. He compIained of pain on exertion, shortness of breath, and Ioss of thirty pounds in weight. He had been treated for angina for the preceding three years. Exertion produced a substerna pain which radiated to the left shouIder and Ieft arm. At first nitrogIycerin wouId give relief. Examination revealed a we11 nourished man, weight one hundred sixty-two pounds (former weight one hundred ninetyfour pounds), skin moist and warm, sIight stare and Iid Iag. Both Iobes of the thyroid were markedIy enIarged and firm. His puIse rate was I 18 and irreguIar. BIood pressure 180 systoIic and IOO diastoIic. His basa1 metabolic rate was pIus forty-one. After two weeks rest in bed, a high carbohydrate diet, LugoI’s solution and digitaIis, his puIse rate was g8 and reguIar. A right hemithyroidectomy was done. He made an uneventfu1 convaIescence and was discharged on the tenth postoperative day. He was requested to return after six weeks for the second Iobectomy, but he was not seen again for two and one-half years. When he returned he stated he had feIt so we11 after the first procedure that he did not think any further treatment was necessary. However, IateIy his former symptoms have returned. Examination reveaIed his puIse rate to be 106 and reguIar. His basa1 metaboIic rate was plus twenty-four. He was given preoperative treatment as before, except for digitaIis. A Ieft hemithyroidectomy was done. He had marked angina1 pain for ten days, then it disappeared. He was discharged on the fourteenth postoperative day and has since resumed his former position. For the past three years he has had no angina1 attacks. CONCLUSION
The diagnosis and management of hyperthyroidism in the younger individua1 is often difficult. In the aged ones diagnostic
NEW SERILS
VOL. 1.11, No.
1
Hendrick--Hyperthyroidism
acumen is even more taxed, and only by attention to many details can the elderly patient be carried safeIy through operation. However, the end results are highIy satisfactory and years of life are added. The medical profession, particularly the genera1 practitioner, must be made more aware of the fact that hyperthyroidism can exist in elderly patients and be taught to recognize it as such, for he is the person who usuahy sees these cases in the beginning. The medical profession in genera1 must become more acquainted with the excehent operative
resuIts
A~nerican Journal
that
can be obtained
of Surgery
471
in a Iarge
percentage of these patients. REFERENCES I. HERTZLER,
P. 69. St. Company.
A. E. Diseases of the Thyroid GIand. Louis, Missouri, Igzg, C. V. Mosby
J. 14.. Hyperthyroidism with norma hasa metaboIic rate. Tr. Am. Goiter Ass., pp. 5 r8-
2. HENDRICK,
523, 1938. F. H.
3. LAHEY,
Slug.,
93:
Apathetic
1026,
hyperthyroidism.
Ann.
1931.
J. W. Diagnosis and management of noduIar or adenomatous goiter. Texas State J. LW., 3o, no. I I, March, 1933.
4. HEXDRICK,
IN eady tubercle formation, . . . the appearance of the gray center of the tubercIe is simuItaneous with the appearance of aIlergy. There may be more than alIergy, how-ever, because other allergic reactions may not caseate at al1. From-“Age MorphoIogy of Primary Tubercles “-by Henry C. Sweany (Charles C. Thomas).
IN ELDERLY PATIENTS* HENDRICK, M.D.
AMARILLO,
H
YPERTHYROIDISM in eIderIy individuaIs is not an infrequent finding in a Iarge group of patients with cardiac symptoms. The diagnosis is frequentIy missed because, first, the teaching has been that toxic goiter is a disease of the young and middIe age, and second, symptoms of hyperthyroidism in the aged are often different from those found in the young. The majority of patients over sixty years of age with hyperthyroidism have adenomatous goiters. PIummer has shown that adenomatous goiter is present from fifteen to seventeen years before toxicity deveIops unIess provoked by the ‘indiscriminate use of iodine. In a study of eighty patients over sixty years of age with hyperthyroidism, the cardinal feature was that they were not stimuIated to the degree that a Iike group of younger patients wouId be. This feature accounts for their Iess dramatic symptoms. It may be that the oIder patients have been overstimuIated so Iong by the overactive thyroid that they have become Iess responsive. The constant finding in the entire group was weight loss. It varied from a few pounds to practicalIy haIf the norma weight. As a ruIe the weight Ioss extended over a period of one to four years. A normaI or excessive appetite was noted in the activated group, whereas, in the nonactivated cases the appetite was often poor. Cardiac compIaints with paIpitation and weakness on exertion were the next in order of frequency. Angina1 symptoms were frequentIy noted. Most of the group had been treated for varying periods of time for heart troubIe with practicaIly no response to the treatment. AuricuIar fibriIIation was a frequent finding. The heart sounds were * Read before the American Association
TEXAS
Ioud and sharp and often there was a mitra1 systoIic murmur present. The systoIic bIood pressure varied from 150 to 260 mm. of mercury. The diastoIic pressure was not raised in proportion to the systoIic pressure. The puIse pressure was markedIy eIevated in a11 cases. The puIse rate varied from 88 to 130. Most of the patients had taken digitaIis over a Iong period of time with IittIe response, particuIarIy to auricuIar fibriIIation when it was present. Some of the cases had cardiac decompensation and eight were not improved suffIcientIy by medica measures to attempt surgical reIief. In the cases in which auricuIar fibriIIation was not present, the use of digitaIis did not prove to be of any assistance. The patients in the activated group were sensitive to heat; their skin was warm and moist, and seIdom was pigmentation noted; whereas, in the nonactivated group the skin was without tine, was dry and coId. Pigmentation was frequentIy noted in this Iatter group. Among the patients with marked weight Ioss, gastrointestina1 symptoms were observed with crises of vomiting and diarrhea. Many of the Iatter had been studied for gastrointestina1 maIignancy. Eye findings were not constant. A few cases had exophthaImus (Fig. I), but they were patients that gave a history of having deveIoped exophthaImic goiter earIier in Iife and were what HertzIerl termed “burned out individuaIs.” Stare was occasionaIIy seen in the activated but not in the nonactivated group. A psychosis is more frequentIy seen in the oIder group of cases and is often ascribed to seniIe dementia. The entire group compIained of muscIe weakness and were easiIy fatigued. This
for the Study of Goiter,
466
Rochester,
Minnesota,
ApriI 13-17,
1940.
NEW SERIES VOL. L.11, No.
3
Hendrick-Hyperthyroidism
was out of proportion to their age and frequently led to the diagnosis of heart trouble. Digital tremor was seen but was not a constant finding.
lntrathorncic cxtensicms a malignancy. were noted in a few cases. Frequently cases are encountered that have progressed to such an extent and the
FIG. 2. Large cervical goiter, also Iarge intr:lthoracic goiter. PuIse rate IZO. Auricular fIbriIIation present. BasaI metaboIic rate, +22.
FIG. I. Apathetic hyperthyroidism. Low basal metabolic rate and auricuIar fibriIlation present. Pulse 144, auricuIar fibrilkion. BasaI metaboIic rate, + I 4. Many years’ duration.
The basal metabolic rate as a rule was elevated but not to the degree found in younger individuals. Two years ago I reported a group of toxic cases2 with basal metabolic rates within normaI Iimits. Several of the cases incIuded in that group are reported here. In the nonactivated or apathetic group as designated by Lahey,3 the basa1 metabolic rates were around plus twenty. There was a very definite goiter present in every patient. Some had rather large adenomatous goiters. In the cases that had taken iodine over a Iong period of time, the gland was hard and firm, often simulating
cardiac damage is so marked, that they can not be corrected surgically. Eight cases in this series were of this type. They did not respond suflicientIy to medical measures to attempt pole ligation and all expired within a period of a few months. The oIder group requires very meticulous preoperative care. Frequently they have other complications, such as old rheumatic hearts, generalized arteriosclerosis, impaired renal function and prostatic hypertrophy with retention, any of which add an additional burden to the hyperthyroidism. Most of the cases that had a diagnosis of hyperthyroidism made previously had taken iodine from a few months to several years. Such cases are iodine fast. If the iodine had not been administered, they could have been prepared much easier and with a Iarger margin of safety. It is often surprising how much can be done for those individuaIs with evidence of severe heart
468
American
JournaI
of Surgery
Hendrick-Hyperthyroidism
disease when they are carefuIIy prepared and are operated upon in stages. A high carbohydrate diet, Lugol’s solution, digitalis if auricuIar fibriIIation is present and diuretics in the presence of edema are given. When the patient is first seen a preIiminary evaIuation of the risk shouId be made, because at no other time can this be done so advantageousIy. After the patient has been at rest with sedation and LugoI’s, it is aImost impossibIe to judge the proper time for operative interference without knowIedge of the origina status of the patient. In determining the status of a patient we have in addition to a compIete physica examination with routine Iaboratory work, a stereo of the chest (Fig. 2), an eIectrocardiogram and bIood chemistry determinations if there is any indication of renaI impairment. In particuIar we consider the pulse rate after bed rest of six to eight days, the Iength of time the disease has been present, whether iodine has been previousIy administered, and Iast, but not Ieast, the weight Ioss and the rapidity of the same. PreoperativeIy we foIIow the preparation of the patient by the change of these factors and not by the Iowering in the basa1 metaboIic rate. It is in oIder peopIe that stage operations can be used most advantageousIy. If there is any doubt about the risk, one Iobe is removed, the patient is permitted to recuperate at home six to eight weeks and then the other Iobe is removed. LocaI anesthesia, with Iight anaIgesia of gas, heIium and oxygen, was used. These patients toIerate deep anesthesia very poorIy. Furthermore, they do not toIerate Iarge doses of barbiturates as such drugs produce too much depression. Codeine and smaI1 doses of morphia are used to reIieve pain and restIessness. PostoperativeIy the patient, if a poor risk, is pIaced in an ice cooIed oxygen tent for two or three days. Five or IO per cent gIucose in norma saIine soIution is given sIowly up to 2000 to 3000 cc. daiIy. This provides nourishment, stimuIates renaI
JUNE,
1941
function, takes care of the water balance and prevents acidosis. These measures assist in preventing postoperative thyroid reactions. DiIigent postoperative care must be exercised to prevent pulmonary compIications which often end fataIIy. If too much sedation is administered, the patient is depressed, mucus forms in the trachea, the patient is unabIe to cough it up and bronchopneumonia deveIops. Often the patient can readiIy expeI1 the mucus by having him bend over the edge of the bed or by eIevating the foot of the bed. A study of seventy-two patients who were operated upon was made. These cases were divided roughIy into the activated and nonactivated groups. NONACTIVED
OR
Number
APATHETIC
of Cases
Length of Time w~$t;~s_ at,
Average 67 Oldest
77
Youngest 60
PE2”:‘,,
GROUP
22
B.M.R., Per Cent
Weight LOSS
Average plus 28 Highest plus 42 Lowest minus II
Average
Years
Average 22 Longest
Average
42 Shortest
240/170 Lowest I 48/86
4
170/9Q Highest
Postoperative Mortality. Per Cent
2 or 9.9
34 pounds
ACTIVATED
1 Lennth
of Cases 50
1
T B.M.R., Per Cent
Age
Average 66
GROUP
Number
Average 18 Longest 28 Shortest
13
Average I So/92 Highest 230/13a
I
Average pIus 32 Highest plus 32 Lowest minus 8
Weight LOSS
Average 26 pounds
Postoperative Mortality, Per Cent
2 or 4
The operative mortaIity in the group of patients over sixty years of age was 5.5 per cent. In a Iarge group of cases under sixty years of age the operative mortaIity was I.2 per cent. The foIIowing case reports iIIustrate our management for goiter patients of this age group :
NEW SERVESVOL. LII, No. 3
CASE
Hendrick-Hyperthyroidism REPORTS
CASE I. Mrs. E. W. H., years, housewife, (Fig. 3),
age sixty-eight compIained of
Jo~~rnal of Surgery
469
caloric diet and bed rest. After two weeks her pulse rate was 96 and regular, the basal metaboIic rate was pIus thirty-six, and there had
FIG. 3. Goiter present thirty-five auricdar fibriIIation present;
weight Ioss, paIpitation, weakness, choking attacks and nervousness of three years’ duration. She stated that a goiter had been present for thirty-five years. She first noticed gradual loss of weight and had attacks of indigestion accompanied by vomiting and diarrhea. She had been treated for coIitis, heart troubIe and high bIood pressure. Examination reveaIed a markedly emaciated woman, weight one hundred three pounds (norma weight one hundred and sixty-eight), skin moist and warm, puIse rate 138; the heart was GbriIIating; bIood pressure 240/130 mm. of mercury. There was digita tremor and eye stare present. Her basa1 metaboIic rate was pIus fifty-two. Both Iobes of the thyroid were noduIar and firm. There were no puIsations or bruits. She was hospitaIized, put on Lugor’s soIution, digitaIis, high
American
years. P&e rate 138; basal metabolic rate,
been a gain of six pounds. A biIatera1 thyroidectomy was done. The patient went into a coma after a few hours and remained stuperous for four days, during which time she was given 3,000 cc. of 5 per cent gIucose saIine intravenousIy daily and two transfusions of 400 cc. of whoIe blood. The puIse rate did not exceed 130. She graduaIIy improved and was dismissed from the hospita1 on the sixteenth day. One year Iater the basa1 metabohc rate was pIus six, puIse rate 78, and bIood pressure Igo/rzo. She expired in 1938 from apoplexy at the age of seventy-seven, nine years after the operation. This patient wouId have done better with a two-stage operation. CASE II. Mrs. T. E. E., age sixty-six, housewife, was referred by Dr. E. E. Davis, of AIbuquerque, New Mexico. The patient stated
470
American Journnl of Surgery
Hendrick-Hyperthyroidism
she was referred to Dr. Davis from Indiana for tubercular treatment. She complained of coughing, choking, loss of weight and strength. She was very nervous but had an exceIIent appetite. Examination: poorIy nourished white woman, weight ninety-six pounds (normal weight one hundred and forty pounds), skin moist and warm, digita tremor, Iid Iag and stare. The right lobe of thyroid was markedIy enIarged, nodular and firm. The Ieft Iobe was substerna1, producing trachea1 deviation. The pulse rate was I IO, and the heart was fibriIIating. Her basa1 metaboIic rate was pIus thirtyfour. The patient was hospitaIized, given a high carbohydrate diet, LugoI’s soIution and digitalis. After tweIve days her puIse rate was 102 and her basa1 metaboIic rate pIus thirty-two. A right Iobectomy was done. ConvaIescence was uneventfu1 and she was sent home. After eight weeks she returned. She had improved considerabIy and had gained six pounds in weight, but stiI1 compIained of choking. Her pulse rate was IOO. The auricuIar fibriIIation had disappeared. The intrathoracic Ieft Iobe was removed. No follow-up report was obtainabIe. CASE III. Mrs. J. E. F., age sixty-nine, housewife, was referred by Dr. W. P. Martin, of CIovis, New Mexico. The patient stated she had smothering attacks, marked Ioss of strength and weight, poor appetite and attacks of diarrhea and vomiting. Examination reveaIed an eIderIy woman with evidence of marked weight loss. Her skin was coo1 and dry. No digita tremor or ocuIar signs were present. The thyroid was three or four times the norma size and both Iobes were very firm. The puIse rate was g6 and reguIar. BIood pressure was 160 systoIic and 80 diastoIic. Moist raIes were found over the bases of both Iungs, and there was one pIus edema of the ankIes. The urine showed a two pIus albumen, and there were coarse and fine granuIar casts. Her basa1 metaboIic rate was plus six. The patient was hospitaIized, given LugoI’s soIution, a high carbohydrate diet, and two weeks Iater a right hemithyroidectomy was done. She was given an immediate bIood transfusion, put under an ice cooled oxygen tent, and given 3,000 cc. of 5 per cent gIucose saIine soIution daiIy by sIow drip. She graduaIIy became unconscious. Her pulse rate remained under IOO and was reguIar. At the end of four days she began to improve and was dismissed on the sixteenth postopera-
JUNE,X~JI
tive day and permittec1 to go to her home. After two months she returned feeIing much better and a Ieft hemithyroidectomy was done. She was pIaced immediateIy under the ice cooled oxygen tent and given 400 cc. of titrated bIood. Her convaIescence was without incident. When seen five years Iater she had regained her former weight and was abIe to do her own house work. She had Iost her apathetic appearance and was again interested in outside activities. CASE IV. A maIe, age sixty-two, was referred by Dr. H. A. IngaIIs, of RosweII, New Mexico. He compIained of pain on exertion, shortness of breath, and Ioss of thirty pounds in weight. He had been treated for angina for the preceding three years. Exertion produced a substerna pain which radiated to the left shouIder and Ieft arm. At first nitrogIycerin wouId give relief. Examination revealed a we11 nourished man, weight one hundred sixty-two pounds (former weight one hundred ninetyfour pounds), skin moist and warm, sIight stare and Iid Iag. Both Iobes of the thyroid were markedIy enIarged and firm. His puIse rate was I 18 and irreguIar. BIood pressure 180 systoIic and IOO diastoIic. His basa1 metabolic rate was pIus forty-one. After two weeks rest in bed, a high carbohydrate diet, LugoI’s solution and digitaIis, his puIse rate was g8 and reguIar. A right hemithyroidectomy was done. He made an uneventfu1 convaIescence and was discharged on the tenth postoperative day. He was requested to return after six weeks for the second Iobectomy, but he was not seen again for two and one-half years. When he returned he stated he had feIt so we11 after the first procedure that he did not think any further treatment was necessary. However, IateIy his former symptoms have returned. Examination reveaIed his puIse rate to be 106 and reguIar. His basa1 metaboIic rate was plus twenty-four. He was given preoperative treatment as before, except for digitaIis. A Ieft hemithyroidectomy was done. He had marked angina1 pain for ten days, then it disappeared. He was discharged on the fourteenth postoperative day and has since resumed his former position. For the past three years he has had no angina1 attacks. CONCLUSION
The diagnosis and management of hyperthyroidism in the younger individua1 is often difficult. In the aged ones diagnostic
NEW SERILS
VOL. 1.11, No.
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Hendrick--Hyperthyroidism
acumen is even more taxed, and only by attention to many details can the elderly patient be carried safeIy through operation. However, the end results are highIy satisfactory and years of life are added. The medical profession, particularly the genera1 practitioner, must be made more aware of the fact that hyperthyroidism can exist in elderly patients and be taught to recognize it as such, for he is the person who usuahy sees these cases in the beginning. The medical profession in genera1 must become more acquainted with the excehent operative
resuIts
A~nerican Journal
that
can be obtained
of Surgery
471
in a Iarge
percentage of these patients. REFERENCES I. HERTZLER,
P. 69. St. Company.
A. E. Diseases of the Thyroid GIand. Louis, Missouri, Igzg, C. V. Mosby
J. 14.. Hyperthyroidism with norma hasa metaboIic rate. Tr. Am. Goiter Ass., pp. 5 r8-
2. HENDRICK,
523, 1938. F. H.
3. LAHEY,
Slug.,
93:
Apathetic
1026,
hyperthyroidism.
Ann.
1931.
J. W. Diagnosis and management of noduIar or adenomatous goiter. Texas State J. LW., 3o, no. I I, March, 1933.
4. HEXDRICK,
IN eady tubercle formation, . . . the appearance of the gray center of the tubercIe is simuItaneous with the appearance of aIlergy. There may be more than alIergy, how-ever, because other allergic reactions may not caseate at al1. From-“Age MorphoIogy of Primary Tubercles “-by Henry C. Sweany (Charles C. Thomas).