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Surgical indications in thyroid disorders
SURGICAL INDICATIONS
IN THYROID DISORDERS*
B. A. GOODMAN, Assistant
M.D.,
P.A.C.S.
Professor of CIinicaI Surgery, New York Post-Graduate NEW
YORK
T
HE indications for surgery in disorders of the thyroid gIand are based essentiaIIy upon the underIying pathoIogic anatomy of the gIand or upon the cIinica1 manifestations of disordered thyroid function. Intimate correIation of structura1 aIteration in the gIand with cIinica1 symptoms is not aIways demonstrabIe. It is quite possibIe to have a change in the size or consistency of the gIand without any cIinica1 symptoms, and the reverse is aIso true. In some instances the entire thyroid syndrome may be interpreted as being mereIy an expression of sympathetic or vegetative nervous system aberration, and not due to disease of the thyroid gIand per se. MorphoIogicaIIy, important differences exist, and it is possibIe to differentiate between the diffuse and the noduIar or socaIIed adenomatous types of goiter. Either type may be toxic or non-toxic, depending upon the character of the secretion and whether it is increased or diminished. The functiona capacity of the thyroid gIand is inff uenced not onIy by its secretory production but aIso by the abiIity of the acini to retain or discharge thyroxin; variations in the clinica manifestations are dependent upon tissue reaction to the avaiIabIe thyroid secretion. l CLASSIFICATION Two points of view prevai1 about the cIassification of thyroid disease. According to one, the various types of goiter are regarded as phases of one continuous process within the gIand; the other theory is that each type represents a distinct pathoIogic entity. In the interest of cIarity, however, it is necessary to adhere to one classification, and the foIIowing cIinica1 * From the Thyroid
Medical SchooI, CoIumbia University
CITY
cIassification of thyroid disorder’ which has been found exceedingIy practica1 is taken herein as a basis for surgica1 indication: A. Goiters with hypothyroidism or norma1 secretion : I. SimpIe endemic, or coIIoid goiter. 2. Non-toxic adenoma or noduIar goiter. B. Goiters with hyperthyroidism, i.e., hypersecretion or aItered secretion : I. AdoIescent goiter or puberty hyperpIasiaphysioIogic gIand with overfunction (non-surgica1 group). 2. Primary hyperthyroidism : Graves’ or Basedow’s disease (exophthaImic goiter). 3. Secondary hyperthyroidism :Toxic adenoma or toxic noduIar goiter. C. InfIammatory, degenerative, and neopIastic goiter. In terms of diffuse and noduIar goiter, there are the diffuse toxic and the diffuse non-toxic types. SimpIe endemic or coIIoid goiter without hyperthyroidism beIongs to the diffuse non-toxic form, and Graves’ disease, to the hyperpIastic or diffuse toxic. NoduIar goiter incIudes the bosseIated and adenomatous types, and may Iikewise be either toxic or non-toxic; without hyperthyroidism nodular goiter is generaIIy referred to as simple or benign adenoma. Certain types of thyroid disorderparticuIarIy primary hyperthyroidismmay be controIIed medicaIIy, but by and Iarge, surgery is the method of choice, and especiaIIy so when the economic status of the patient does not permit Iong-continued, and perhaps costIy, medica care. Benign enIargements of the thyroid gIand requiring surgery incIude both the diffuse and noduIar varieties. Apart from
Clinic of the New York Post-Graduate
387
HospitaI, Columbia
University.
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the cosmetic consideration, there are surgical indications for reIieving the effects of pressure on the respiratory passages and blood vesseIs, aIthough in endemic goiter, where enlargement is chieff y outward, signs of compression are Iess frequentIy encountered. NoduIar or adenomatous goiters, however, aIthough usuaIIy smaIIer than the diffuse, generally grow inward or downward, and more frequently produce pressure effects. SPECIFIC SURGICAL INDICATIONS The specific (and perhaps more frequent) indications for surgery resoIve themseIves essentiaIIy into the foIIowing conditions : A. Hyperthyroidism I. Hyperthyroidism in chiIdren (juveniIe Graves’ disease). 2. Primary hyperthyroidism, diffuse parenchymatous goiter, exophthaImic goiter (Graves’ or Basedow’s disease). 3. Acute hyperthyroidism. 4. Persistent hyperthyroidism; recurrent hyperthyroidism. 5. Hyperthyroidism due to aberrant or ectopic thyroid tissue. 6. Hyperthyroidism in diabetes. 7. Hyperthyroidism in pregnancy. 8. ReIative hyperthyroidism. g. Chronic hyperthyroidism. IO. Secondary hyperthyroidism: (a) NoduIar toxic goiter or toxic adenoma. (b) Substerna and intrathoracic goiter (toxic). (c) Iodine hyperthyroidism. B. Nodular goiter: I. Non-toxic adenoma. 2. Pseudo-adenoma. 3. Fetal adenoma. 4. Substerna and intrathoracic goiter (non-toxic). C. Degenerations: cystic; maIignant. D. InAammations of the thyroid: I. Acute thyroiditis (acute strumitis). 2. Chronic thyroiditis (chronic strumitis).
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E. TubercuIosis. A. HYPERTHYROIDISM. Hyperthyroidism may be primary or secondary. Whether considered as a thyrotoxicosis (i.e., an intoxication) or as a disease of hypercombustion, it demands surgica1 intervention, with remova of a sufficient amount of thyroid tissue to aboIish hyperfunction and restore the normaI function of the gIand. There are, however, certain contraindications to be taken into consideration, nameIy, the extremeIy Iong duration of the disease, proIonged period of iodine therapy, continued high puIse rate despite preoperative treatment, and the age of the patient. Hypertbyroidism in Children (Juvenile Graves’ Disease). Hyperthyroidism in children invariabIy reffects a primary change in the thyroid gIand, whereas in aduIts hyperthyroidism may aIso occur, with or without exophthaImos, as a secondary manifestation of adenomatous or coIIoid goiter.3 TypicaI exophthaImic goiter in chiIdren as young as three years of age is not unusua1, according to Lahey;4 on the other hand, the CriIes5 regard the occurrence of hyperthyroidism in subjects under five years as a medica curiosity. Varied opinions have been expressed in connection with the management of the condition. BeiIby and McCIintock3 consider it more hazardous to administer medica treatment to chiIdren than to aduIts. They point out that these young subjects possess a factor of development not present in oIder persons, and-due to the markedIy increased metaboIismskeIeta1 growth takes pIace too rapidIy, whiIe the body is coincidentIy deprived of its avaiIabIe energy. It is aIso Lahey’s preference to treat chiIdren surgicaIIy. He at first tried iodine and x-ray therapy in a number of cases, but resuIts proved unsatisfactory. In intenseIy toxic cases he empIoys the two-stage subtota1 thyroidectomy. This is contrary to the opinion of the CriIes who regard chiIdren as exceIIent operative risks, if adequateIy prepared, and believe the one-stage thyroidectomy can usuaIIy be undertaken without danger.
NEW SER~CS Var. XLII,
No.
2
Goodman-Thyroid
Surgery
American
Journal
of Surgery
389
Opinions aIso differ as to the amount of Conservative treatment of exophthaImic thyroid tissue that shouId be removed from goiter has a reIativeIy high mortaIity (from children at operation. Beiiby and McCIin30 to 35 per cent) ;I surgica1 intervention is tack agree with AIberts6 that, owing to the therefore the treatment of choice in these inherent tendency of the thyroid gIand in cases. chiIdren to hypertrophy, one can hardIy be Acute Hypertbyroidism. Acute hypertoo radica1 in these cases. They advocate thyroidism must be distinguished from the remova of as much if not more tissue hyperthyroidism in generaI. In the acute in these young patients than is ordinarily stage, frequentIy termed thyroid c&is, one removed in the aduIt. This is not in agreerecognizes a rapidly increasing, fuiminating ment with the generaIIy accepted viewtype of the disease, characterized by an point, that a Iarger remnant of thyroid acceIerated pulse rate, emotiona instatissue shouId be Ieft in chiIdren than in Activated Apathetic others, not only to guard against myxHyperthyr~idism Hyperthyroidism edema, but to provide adequate secretion for the maintenance of metaboIism and for Usually in the younger Generally occurs in Age .......... age group. older age group. norma growth and deveIopment. Kocher Duration. ...... Usually has existed More recent in onset: many years ago (1882-1883) cautioned acute. over considerable period of time in against a too extensive remova of thyroid chronic state. Obvious; seldom misNon-obvious; fretissue in children which, in his opinion, taken. Activated, agiquently overlooked. tated, apprehensive, Calm, slow; apathy produced “cachexia strumipriva.” emotionally unstable. is outstanding feaPrimary Hyperthyroidism, Difuse Partul-2. Apprehensive; typical Calm;no eye signs. Eyes. encbymatous Goiter, Exophthalmic Goiter eye signs. Large, firm. hyperSmall. firm. pebbly. Gland. . . Disease). When (Graves’ or Basedow’s hypervascuplastic, fuIIy deveIoped with goiter, tachycardia, I*r. Hot, soft, flushed, CooI, wrinkled, pigSkin. . tremor, eye signs, flushed and cIammy skin, moist, clammy. mented. Pigmentation disappears with emotiona instability, etc., the cIinica1 relief of hyperthypicture of this condition is so typica that roid&m. Pounding apex beat, No striking apex beat. Heart. its diagnosis is seldom, if ever, mistaken for pI?Zdiffused over cordium. any other. It usualIy occurs in young Toxic, rapid. Not tonic; persistently but moderately individuaIs, and in most instances is we11 eievated. established within a year or Iess from its Higher than in apaModerately elevated. R.M.R., _. _. thetic type; often exonset. Lahey has designated this typicai tremely high. Initial loss. followed Outstanding Feature: Weight loss. hyperthyroid condition as activated hyperby gain: due to in50-60-100 pounds thyroidism, to distinguish it from another creased appetite and over B period of time. food tntnke in restate of hyperthyroidism which he terms spanse to metabolic demand. apathetic ~ypert~yro~d~sm. WhiIe they do Uncountabie pulse Terminal phase. Reasonable pulse rate not vary essentiaIIy in origin, these condisweating, de(rzo), good quafity, rate, non-toxic in chnraclirium and thrashing tions present certain striking differences, as sround in bed. ter. Drowsiness, apathy, coma. indicated in the tabIe on the, opposite coIumn.* deIirium, vomiting, Apathetic hyperthyroidism should be biIity, sleeplessness, suspected in patients with a history of diarrhea, anorexia, and an extremely severe In many cases these crises are progressive weakness, persisting over a intoxication. by diagnostic procedures or Iong period of time. There is usuaIIy a precipitated by emergency surgery empIoyed to eraditendency to overestimate the patient’s cate diseased organs other than the thyroid abiIity to withstand surgery. For this gIand.7 While there is a definite indication reason a two-stage thyroidectomy is espefor surgery in cases of thyroid crisis to ciaIIy indicated. * Based on Lahey’s differentiations. interrupt the course of the disease, it _’
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shouId be withheId unti1 the “storm” has been overcome. Surgery shouId then be done in two stages of subtota1 hemithyroidectomy, with an interva1 of from six to eight weeks between the first and second procedure. Persistent Hyperthyroidism; Recurrent Hyperthyroidism. FoIIowing inadequate or insuffIcient surgery for hyperthyroidism, definite indication for a second operation is occasionaIIy found. It is interesting to note that surprisingIy smaI1 amounts of thyroid tissue wiI1 produce or maintain a cIinica1 hyperthyroid state. This prevaiIs in persistent as we11 as in recurrent hyperthyroidism. In the former, preoperative symptoms fai1 to abate after operation, whereas in recurrent hyperthyroidism, a free interva1 of approximateIy six months or more intervenes, during which time the hyperthyroid symptoms disappear. The recurrence is thought to be due to a compensatory hyperpIasia or growth of the thyroid remnant. It is necessary therefore to accompIish IittIe short of tota abIation in order to prevent a second recurrence. The most satisfactory resuIts are achieved in instances where a permanent hypothyroid state is obtained, and the desired metaboIic IeveI maintained by substitution therapy. Hyperthyroidism Due to Aberrant or Ectopic Thyroid Tissue. Indications for surgery are Iikewise present in instances of hyperthyroidism due to aberrant or ectopic thyroid tissue. The foIIowing possibiIities exist when there is definite cIinica1 hyperthyroidism without thyroid enIargement at the norma site in the neck: I. LateraI aberrant thyroid-singIe or multipIe, papiIIiferous cIusters aIong the anterior border of the sternomastoid muscIe and beside the juguIar vein. They are potentiaIIy maIignant and shouId therefore be removed as soon as the diagnosis has been estabIished. Inasmuch as the tissue is radiosensitive, x-ray therapy shouId foIIow radica1 resection. 2. Lingua1 thyroid-associated with dysphagia, dysphonia, or dyspnea, or a
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combination of these symptoms, and, less frequentIy, hemorrhage. The condition is comparativeIy rare. Montgomery,s who recentIy pubIished a comprehensive and thorough review of the Iiterature, accepts onIy 144 cases as true IinguaI thyroid out of .the 23 I cases reported; I 18 of the 144 occurred in femaIes. The norma thyroid is absent in two-thirds to three-fourths of the cases. Aberrant thyroid tissue has aIso been found in the skuI1, the Iarynx, and in the vicinity of the ribs, the cIavicIe, and the spine.9 In isoIated instances it has been seen in ovarian cysts, and as metastasis in the breast. AIthough ectopic thyroid tissue is generaIIy an unsuspected finding, its presence, when definiteIy determined, invites surgica1 remova if it is accessibIe. Hyperthyroidism in Diabetes. Hyperthyroidism occurring in an individua1 who has diabetes presents an unpromising outIook. It interferes with the management of the case, diminishes carbohydrate toIerante, and increases the severity of gIycosuria. EIimination of the hyperthyroidism does not cure the diabetes, aIthough the carbohydrate toIerance is definiteIy increased. FoIIowing thyroidectomy Iess inand the diabetes is suIin is required, more readiIy controIIed. A two-stage operation is preferabIe in this group to minimize the higher mortaIity which prevaiIs when hyperthyroidism and diabetes occur coincidentaIIy. Hyperthyroidism in Pregnancy. In pregnancy compIicated by hyperthyroidism subtota1 thyroidectomy is indicated at the earIiest possibIe stage of the pregnancy (which need not be interrupted). EIimination of the hyperthyroidism by surgery aims to prevent diffIcuIties which might otherwise occur at term due to intensification of the hyperthyroidism, or with surgica1 intervention (cesarean section), instrumenta deIivery, etc. Relative Hyperthyroidism. ReIative hyperthyroidism is the term which the present writer has appIied to certain phases of an apparentIy non-toxic goiter. The condition
NEW SERIFS VOL. XLII,
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is found in a middle-aged group of patients who give a history of noduIar enIargement of the thyroid over an indefinite period. CIinicaI manifestations of thyrotoxicosis may or may not be estabIished; hyperthyroidism in the generaIIy accepted sense of the word is not present. The basa1 metabolic rate aIthough beIow the average norma represents nevertheIess an increase in the rate, as comparison with previous readings of periodicaIIy taken basa1 metaboIic rates wiI1 show. A reIative hyperthyroidism therefore exists. The effects of the thyroid secretion of this cryptic stage are definiteIy deIeterious, especiaIIy in its seIective cardiac action. The surgica1 indication therefore is for thyroidectomy. Chronic Hyperthyroidism. AIthough not generaIIy so employed, the term “chronic” is used by Davison lo to designate a condition that has existed over a Iong period of time (usuaIIy for severa years) with unmistakabIe toxic signs and symptoms, despite a persistentIy Iow basa1 metaboIic rate. With the exception of the metaboIic rate, which may be norma or subnorma1, these cases resembIe the earIy toxic stage of secondary hyperthyroidism (toxic adenoma or noduIar toxic goiter). The symptoms of nervousness, tachycardia, choking sensation, and occasionaIIy Ioss of weight deveIop insidiousIy. In the presence of a norma or subnorma metaboIic rate with evidence of cIinica1 hyperthyroidism, the cIinician may be misIed if too much emphasis is pIaced upon the basa1 metaboIic rate. These cases invite earIy thyroidectomy as a means of preventing myocardia1 invoIvement from toxic secretions. Secondary Hyperthyroidism. (a) NoduIar Toxic Goiter or Toxic Adenoma. This condition is most frequentIy observed in patients of middIe age and beyond; and there is a pronounced tendency to cardiac invoIvement. UnIess the thyrotoxicosis is recognized earIy, the heart may become permanentIy damaged, before surgery is instituted. The basa1 metaboIic rate, whether norma or subnorma1, shouId be
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disregarded in the presence of unmistakabIe evidence of hyperthyroidism. The mortaIity from toxic adenoma is higher than from primary hyperthyroidism, due to the more advanced age of these patients and the damaged heart muscIe. The chief changes in noduIar goiter, outside of the thyroid gIand, occur in the heart, and it shouId be kept in mind that, even during the apparentIy quiescent are produced stage, harmfu1 substances by the abnorma1 thyroid tissue. “ Innocent” noduIar or adenomatous goiters are thought to be uItimateIy more devastating than Graves’ disease. Treatment therefore shouId be designed not onIy to reIieve the patient of immediate diffIcuIty, but aIso to protect future heaIth; this is best accomplished by the surgica1 eradication of all diseased parts of the thyroid gland. Nodular or adenomatous goiter may extend SubsternaIIy, since continuous growth is an inherent property of thyroid adenomata. Its retrosterna1 descent, according to Heyd,” is on a definiteIy mechanica basis. (b) Substerna and Intrathoracic Goiter (Toxic). With the exception of the factor of toxicity there is essentiaIIy IittIe difference between the toxic and nontoxic types of substerna and intrathoracic goiter; both therefore wiI1 be considered under this heading. Substerna goiter is usuaIIy due to enIargement and extension of a normaIIy pIaced gIand-not to mispIaced or aberrant thyroid tissue. RetrosternaI goiters invariabIy arise from adenomatous thyroid they are never encountered in tissue; Graves’ disease. Substerna goiter differs from intrathoracic goiter in the extent to which it invades the thoracic cage. ArbitrariIy, the IeveI of the aortic arch is taken as the dividing Iine; if situated above this IeveI it is designated as substernal, and if beIow, as intrathoracic goiter. or absence of thyroid The presence enIargement beIow the superior thoracic aperture may be ascertained by practiced paIpation for a mass which rises to strike
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the examining fingers in the suprasterna1 notch when the patient swaIIows. X-ray of the chest is of diagnostic vaIue in determining the presence of a suspected retrosterna1 thyroid enIargement, either by mass density shadow, trachea1 deviation, or by narrowing of the trachea at the point of the greatest diameter of the thyroid mass. The chief associated symptoms are those due to pressure effects, nameIy dyspnea, hoarseness, and paroxysma coughing or choking speIIs which usuaIIy occur at night. Hyperthyroidism and cardiac disabiIity may intervene. SurgicaI remova is indicated in these cases, and even in the absence of symptoms, noduIar goiters extending beIow the sternum shouId be expIored. (c) Iodine Hyperthyroidism. Not infrequentIy it is possibIe to observe cases of previousIy non-toxic goiter, particuIarIy of the adenomatous type, that deveIop into a definite thyrotoxicosis foIIowing the injudicious administration of iodine; for this reason iodine hyperthyroidism is herewith incIuded among the surgica1 indications. In connection with its frequent occurrence, Poate12 caIIs attention to the great increase in the number of oId goiters which become toxic, pointing to its coincidenta occurrence with the increased avaiIabiIity of iodine preparations to the genera1 pubIic. Among the virtues attributed to these preparations is that of curing goiter, so that sufferers from thyroid conditions frequentIy dose themseIves before consuIting a physician. The administration of iodine in hyperthyroidism, except as a may in fact be preoperative routine, regarded as one of the greatest errors in the treatment of the condition. The spIendid resuIts obtained within the first few weeks are apt to be misIeading, as IittIe benefit is usuaIIy derived after this period. Patients who have had no iodine medication respond best to a preoperative iodine preparation and show a better postoperative course. Iodine shouId therefore be
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withheId unti1 the indication for surgery has been estabIished. B. NODULAR GOITER. Asymmetry of thyroid enIargement and noduIar outIine cIinicaIIy distinguish noduIar goiter from the biIateraIIy symmetrica coIIoid and diffuse hyperpIastic types of gIands. There may be onIy a singIe discrete noduIe anywhere in the thyroid tissue, or muItipIe adenomata of varying sizes may be present, giving a noduIar or “ bosseIated ” surface to the gIand. CIinicaIIy, it is not aIways possibIe to know whether the thyroid noduIe is a pseudo-adenoma or a true adenoma; histoIogicaIIy, differentiation is made between these and the feta1 adenoma. It is obvious that the principa1 distinction between the non-toxic and the toxic noduIar types-previousIy referred to under the headings “Relative, Chronic, Secondary Hyperthyroidism, etc.“-is a functiona one, and in terms of the degree of toxicity. The surgica1 indication is the same in both groups, but usuaIIy deemed more imperative in the obviousIy toxic type, especiaIIy so since adenomata of the thyroid are not amenabIe to irradiation therapy.ll Sudden or dramatic appearance of a goiter usuaIIy impIies one of two possibiIities : either intracapsuIar hemorrhage into a previousIy unnoticed adenoma or cyst adenoma, or disIodgment into view of a retrosterna1 goiter. NoduIar goiters require surgery, not onIy because of their increasing size, but aIso because of the presence or probabiIity of maIignancy. AIIen Graham’3 goes so far as to state that 90 per cent of maIignant neopIasms of the thyroid start in adenomata, especiaIIy feta1 adenomata. While this percentage may represent an overestimation, it is indicative of the possibiIities, particuIarIy in the hard, discrete variety. C. DEGENERATION: CYSTIC OR MALIGNANT. Cystic degeneration giving rise to cyst-adenoma is not an infrequent occurrence in adenoma of the thyroid. In hemorrhagic cyst-adenoma or papiIIary
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cyst-adenoma there is mereIy the added factor of hemorrhage or of papiIIary projections into the cyst. There is also the possibiIity of calcification, in which case the firm consistency of the tumor when encountered cIinicaIIy necessitates its differentiation from maIignancy. Thyroid maIignancy, according to CIute and Warren,14 may be suspected in the presence of a firm, hard, discrete type of tumor in the gIand, and when there has been recent growth, either sIow or rapid. WhiIe thyroid maIignancy is more apt to occur in persons in middIe Iife or Iater, it may aIso be present in the younger age group. This fact was borne out recentIy aIso by Potter and by these writers, Morris,‘” both of whom report eight and five cases respectiveIy in patients under 20 years of age, incIuding two fata cases in children of 9 and 13 years. The occurrence of enIarged Iymph nodes near the goiter shouId arouse suspicion, as shouId aIso secondary evidences of pressure, such as hoarseness, diffIcuIty in swaIIowing and breathing. Apart from the IaryngeaI and trachea1 compression, there is often pressure upon, or direct invoIvement of, the recurrent IaryngeaI nerves, and even biIateraI abductor paraIysis. In rare cases bone metastases, from an apparentIy benign adenoma, may be the first indication of maIignancy. Examination of biopsy specimens is advisabIe to ruIe out a caIcified benign adenoma or chronic fibrosing thyroiditis. ApproximateIy onIy 50 per cent of the cases are diagnosed preoperativeIy. MaIignancy is sometimes not suspected or detected unti1 surgery has been done. In cases in which it is possibIe to make a cIinica1 diagnosis of carcinoma, a high rate of recurrence may be expected. OnIy rareIy is there recurrence of any cIinica1 significance after remova of nonmaIignant or simpIe goiter. A recurrence which foIIows soon after operation, therefore shouId arouse a suspicion of maIignancy. The pathoIogist in such cases wiI1 usuaIIy review the origina materia1, to be
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sure no areas of maIignancy were overIooked at the origina examination. Metastasis may occur earIy or very late, and may take pIace even without invasion of the capsuIe, by spread into the bIood stream, especiaIIy to the Iungs. Metastasis to bones (peIvis, vertebrae, sternum, cIavicIe, femur, skuI1, and ribs-in the order of descending frequency) is not unusua1. Metastatic invasion may occur before there is any evidence of marked local enIargement. I6 It is therefore easiIy understood why in genera1 the prognosis is Iess favorabIe for maIignant adenoma than for adenocarcinoma (often papiIIary) where the diagnosis is usuaIIy made by the pathoIogist. D. INFLAMMATIONS OF THE THYROID. Inflammation of the thyroid may be associated with or be independent of the goitrous process. It may be of the suppurative or the non-suppurative type; in the Iatter case it is either intra- or extracapsuIar. Acute Thyroiditis (Acute Strumitis). Acute thyroiditis may occur spontaneously, foIIowing trauma, or as a compIication of acute disease-inff uenza, typhoid, etc. It is simiIar to other inflammatory conditions and is associated with chiIIs, high temperature, and pain in the thyroid region. The thyroid gIand may be swoIIen and exquisiteIy tender, and the entire area boggy and intenseIy inflamed. The condition shouId be treated by incision and drainage when suppuration is but suppuration may be overpresent; Iooked unti1 spontaneous rupture into the skin, esophagus or trachea has occurred. Chronic Thyroiditis (Chronic Strumitis). The onset of chronic thyroiditis is insidious, indications of gIanduIar disturbance being absent. The cIinica1 manifestations may incIude hoarseness, dyspnea and, in some instances, a sense of fuIness in the throat; they are chieffy due to trachea1 pressure by the dense, fibrosed gIand. The condition is apt to be mistaken for maIignancy. The simiIarity of RiedeI’s struma (known aIso as benign granuIoma of the thyroid) and Hashimoto’s strumitis Iymphomatosa has
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Ied many writers, in&ding Ewing,l’ to consider RiedeI’s struma as a Iater stage of the same pathoIogic process. Hashimoto, however, beIieved his disease to be a distinct entity. Three different stages of the condition have been observed in our clinic, as reported by Heyd’*-an earIy stage presenting onIy a moderate Iymphoid increase with compressed epitheIia1 eIements, an intermediary stage characterized by marked increase in Iymphatic tissue with destruction of the epithelial eIements, and a Iate stage in which aImost compIete fibrosis of the gIand is present. Meeker-l9 reported a case of RiedeI’s struma in a man of 50 years presenting remnants of the uItimobranchia1 body (the first case of its kind in an aduIt; the patient showed other anomaIies-branchiogenic cyst, etc.). It is suggested that thyroids containing such rudiments may be of Iow vitaIity, and consequentIy susceptibIe to the extreme form of atrophy and fibrous repIacement seen in RiedeI’s struma. CompIete thyroidectomy is indicated in chronic thyroiditis, especiaIIy when both lobes are invoIved. Myxedema, however, has been observed in about 40 per cent of the reported cases after radica1 resection.20 In seIected cases the isthmus may simpIy be divided and a segment of tissue overIying the trachea removed to reIieve pressure. E. TUBERCULOSIS. TubercuIosis of the thyroid gIand is rare, and of IittIe importance cIinicaIIy. If operated upon when not suspected, the prognosis after Iobectomy is good. It shouId not be forgotten, however, that the tubercuIous thyroid is but part of a generaIized tubercuIosis, or secondary to a focus eIsewhere. TOTAL IN
ABLATION
OF
SELECTED
CARDIAC
THE
THYROID
GLAND
CONDITIONS
TotaI abIation of the thyroid gIand in cardiac conditions unreIated to thyroid disease had its origin in the work of BIumgart, BerIin and their associates, the first report of which was pubIished in 1927. This procedure is based on a study of the
NOVEMBER, 19x8
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norma reIationship existing between the metaboIic rate and bIood veIocity, an advanced or Iowered metaboIic rate having a paraIIe1 inffuence in increasing or decreasing the bIood ffow. Inasmuch as the bIood ffow is reduced in congestive faiIure, aIthough the basa1 metaboIic rate is normaI, it appeared that a reduction in metaboIic demands might resuIt in definite cIinica1 improvement in chronic cardiac conditions. SubtotaI thyroidectomy was tried at first, but onIy temporary improvement resuIted, a reIapse to the preoperative state occurring with a return to a norma metaboIic rate. TotaI thyroidectomy is beIieved to be indicated onIy in cases of sIowIy progressive heart Iesion, in which a11 avaiIabIe medica procedures have proved ineffective. The operation is contraindicated in patients whose metaboIic rate is Iower than minus 20, as we11 as in the presence of acute puImonary or active rheumatic infection or severe impairment of renaI function. Marked or moderate improvement is reported21 in approximateIy 70 per cent of cases of angina pectoris and congestive faiIure observed two and one-haIf years after operation. WhiIe the empIoyment of so drastic a measure as remova of the thyroid gIand for the improvement of cardiac disease has graduaIIy gained adherents, acceptance of this means has not been universa1. HertzIer,22 for exampIe, questions the correctness of the diagnosis in the cases thus benefited, hoIding that pronounced cardiac improvement wouId appear to be presumptive evidence of the toxicity of the thyroid gIand. ResuIts from tota abIation on the whoIe seem to be more satisfactory in cases of angina than in congestive faiIure where no cardiac reserve is avaiIabIe. In cardiac decompensation resuIting from hyperthyroidism, however, subtota1 thyroidectomy gives better resuIts.23 SUMMARY With the exception of the so-caIIed borderhne types of thyroid disease, reference has been made to most of the con-
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ditions requiring surgery, in&ding certain disorders not ordinarily designated in this category. In most instances the various phases of the subject have been fuIIy discussed. The cIassification empIoyed herein is based upon clinica manifestations of the disordered gIand, and is presented aIong with the physical findings as a practical diagnostic guide for surgica1 indication. REFERENCES I. KASPAR, FRITZ. Ueber die konservative und chirurgische Kropfbehandlung. Wien. med. Wcbnscbr., 86: 1377; 1404; 1429 (Dec.) 1936. z. HEYD, CHARLES GORDON. Goiter surgery. J. M. Sot. New Jersey, 33: 345-35 I (June) 1936. 3. BEILBY, GEORGE E., and MCCLINTOCK, JOHN C. Hyperthyroidism in chiIdren. New York J. Med., 37: 563-568 (March 15) 1937. 4. LAHEY, FRANK H. Surgical treatment of hyperthyroidism. Bull. N. Y. Acad. Med., IO: 65-81 (Feb.) 1934. 5. CRILE, GEORGE, and CRILE, GEORGE, JR. Hyperthyroidism in chiIdren under five years of age: report of four cases. Am. J. Surg., 37: 389-395 (Sept.) 1937. 6. ALBERTS, MAX W. Hyperthyroidism in chiIdren. Minnesota Med., 13: 175-177 (March) 1930. 7. BAYLEY, ROBERT H. Thyroid crisis. Surg., Gynec. @ Obsl., 59: 41-47 (JuIy) ‘934. 8. MONTGOMERY, M. L. Lingua1 thyroid: a comprehensive review. West. J. Surg., Obst. @ Gynec., 44: 54; $5; 127 (Jan.-Feb.) 1936. 9. MEEKER, L. H. (Department of PathoIogy, New York Post-Graduate Hospital CoIumbia University). Persona1 communication.
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IO. DAVISON, T. C. Chronic hyperthyroidism. Am. J. Surg., 35: 50~5 I I (March) 1937. I I. HEYD, CHARLES GORDON. Intra-thoracic goiter. Proc. Interstate Post-Grad. M. A. Nortb America, PP. 192-195, 1937. 12. POATE, HC.GH R. G. Some surgica1 aspects of the goiter probIem. M. J. Australia, 23: 842-847 (June 20) 1936. 13. GRAHAM, ALLEN. The mahgnant thyroid. Proc. Interstate Post-Grad. M. A. North America, pp. 264-269, 1928. 14. CLUTE, H. M., and WARREN, S. The prognosis of thyroid cancer. Surg., Gynec. & Obst., 60: 861-874 (April) 1935. 15. POTTER, E. B., and MORRIS, W. R. Carcinoma of the thyroid gIand: a report of five cases in young individuaIs. Am. J. Surg., 27: 546550 (March) ‘935.
16. DINSMORE, R.
S., and CRILE, G., JR. Thyroid problems and end-resuIts of operations on the thyroid gIand. Surg. Clin. Nortb America, 15:
859-884 (Aug.) 1935. 17. EWING, JAMES. Neoplastic Diseases. 3rd Edition, Phila., 1928. Saunders, page 961. 18. HEYD, CHARLES GORDON. Riedel’s struma: benign granuIoma of the thyroid. Surg. Clin. North America, 9: 493-513 (June) 1929. 19. MEEKER, L. I-I. RiedeI’s struma with remnants of the post-branchia1 body. Am. J. Patb., I : 57-67 (Jan.) 1925. 20. JAFF~, R. H. Chronic thyroiditis. J. A. M. A., 108: 105-110 (Jan. 9) 1937. 21. BERLIN, DAVID D. TotaI thyroidectomy for intractabIe heart disease. Summary of two and one-half years surgical experience. J. A. M. A., 105: 1104-I 107 @Ct. 5) 1935. 22. HERTZLER, ARTHUR E. Evaluating the results of tota thyroidectomies in cardiac disturbances. Am. J. Surg., 29: 342 (Sept.) 1935. 23. LAHEY, FRANK H. The diagnosis and management of thyroid conditions. West. J. Surg., Obst. e* Cynec., 43: 361-370 (JuIy) 1935.
IN THYROID DISORDERS*
B. A. GOODMAN, Assistant
M.D.,
P.A.C.S.
Professor of CIinicaI Surgery, New York Post-Graduate NEW
YORK
T
HE indications for surgery in disorders of the thyroid gIand are based essentiaIIy upon the underIying pathoIogic anatomy of the gIand or upon the cIinica1 manifestations of disordered thyroid function. Intimate correIation of structura1 aIteration in the gIand with cIinica1 symptoms is not aIways demonstrabIe. It is quite possibIe to have a change in the size or consistency of the gIand without any cIinica1 symptoms, and the reverse is aIso true. In some instances the entire thyroid syndrome may be interpreted as being mereIy an expression of sympathetic or vegetative nervous system aberration, and not due to disease of the thyroid gIand per se. MorphoIogicaIIy, important differences exist, and it is possibIe to differentiate between the diffuse and the noduIar or socaIIed adenomatous types of goiter. Either type may be toxic or non-toxic, depending upon the character of the secretion and whether it is increased or diminished. The functiona capacity of the thyroid gIand is inff uenced not onIy by its secretory production but aIso by the abiIity of the acini to retain or discharge thyroxin; variations in the clinica manifestations are dependent upon tissue reaction to the avaiIabIe thyroid secretion. l CLASSIFICATION Two points of view prevai1 about the cIassification of thyroid disease. According to one, the various types of goiter are regarded as phases of one continuous process within the gIand; the other theory is that each type represents a distinct pathoIogic entity. In the interest of cIarity, however, it is necessary to adhere to one classification, and the foIIowing cIinica1 * From the Thyroid
Medical SchooI, CoIumbia University
CITY
cIassification of thyroid disorder’ which has been found exceedingIy practica1 is taken herein as a basis for surgica1 indication: A. Goiters with hypothyroidism or norma1 secretion : I. SimpIe endemic, or coIIoid goiter. 2. Non-toxic adenoma or noduIar goiter. B. Goiters with hyperthyroidism, i.e., hypersecretion or aItered secretion : I. AdoIescent goiter or puberty hyperpIasiaphysioIogic gIand with overfunction (non-surgica1 group). 2. Primary hyperthyroidism : Graves’ or Basedow’s disease (exophthaImic goiter). 3. Secondary hyperthyroidism :Toxic adenoma or toxic noduIar goiter. C. InfIammatory, degenerative, and neopIastic goiter. In terms of diffuse and noduIar goiter, there are the diffuse toxic and the diffuse non-toxic types. SimpIe endemic or coIIoid goiter without hyperthyroidism beIongs to the diffuse non-toxic form, and Graves’ disease, to the hyperpIastic or diffuse toxic. NoduIar goiter incIudes the bosseIated and adenomatous types, and may Iikewise be either toxic or non-toxic; without hyperthyroidism nodular goiter is generaIIy referred to as simple or benign adenoma. Certain types of thyroid disorderparticuIarIy primary hyperthyroidismmay be controIIed medicaIIy, but by and Iarge, surgery is the method of choice, and especiaIIy so when the economic status of the patient does not permit Iong-continued, and perhaps costIy, medica care. Benign enIargements of the thyroid gIand requiring surgery incIude both the diffuse and noduIar varieties. Apart from
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the cosmetic consideration, there are surgical indications for reIieving the effects of pressure on the respiratory passages and blood vesseIs, aIthough in endemic goiter, where enlargement is chieff y outward, signs of compression are Iess frequentIy encountered. NoduIar or adenomatous goiters, however, aIthough usuaIIy smaIIer than the diffuse, generally grow inward or downward, and more frequently produce pressure effects. SPECIFIC SURGICAL INDICATIONS The specific (and perhaps more frequent) indications for surgery resoIve themseIves essentiaIIy into the foIIowing conditions : A. Hyperthyroidism I. Hyperthyroidism in chiIdren (juveniIe Graves’ disease). 2. Primary hyperthyroidism, diffuse parenchymatous goiter, exophthaImic goiter (Graves’ or Basedow’s disease). 3. Acute hyperthyroidism. 4. Persistent hyperthyroidism; recurrent hyperthyroidism. 5. Hyperthyroidism due to aberrant or ectopic thyroid tissue. 6. Hyperthyroidism in diabetes. 7. Hyperthyroidism in pregnancy. 8. ReIative hyperthyroidism. g. Chronic hyperthyroidism. IO. Secondary hyperthyroidism: (a) NoduIar toxic goiter or toxic adenoma. (b) Substerna and intrathoracic goiter (toxic). (c) Iodine hyperthyroidism. B. Nodular goiter: I. Non-toxic adenoma. 2. Pseudo-adenoma. 3. Fetal adenoma. 4. Substerna and intrathoracic goiter (non-toxic). C. Degenerations: cystic; maIignant. D. InAammations of the thyroid: I. Acute thyroiditis (acute strumitis). 2. Chronic thyroiditis (chronic strumitis).
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E. TubercuIosis. A. HYPERTHYROIDISM. Hyperthyroidism may be primary or secondary. Whether considered as a thyrotoxicosis (i.e., an intoxication) or as a disease of hypercombustion, it demands surgica1 intervention, with remova of a sufficient amount of thyroid tissue to aboIish hyperfunction and restore the normaI function of the gIand. There are, however, certain contraindications to be taken into consideration, nameIy, the extremeIy Iong duration of the disease, proIonged period of iodine therapy, continued high puIse rate despite preoperative treatment, and the age of the patient. Hypertbyroidism in Children (Juvenile Graves’ Disease). Hyperthyroidism in children invariabIy reffects a primary change in the thyroid gIand, whereas in aduIts hyperthyroidism may aIso occur, with or without exophthaImos, as a secondary manifestation of adenomatous or coIIoid goiter.3 TypicaI exophthaImic goiter in chiIdren as young as three years of age is not unusua1, according to Lahey;4 on the other hand, the CriIes5 regard the occurrence of hyperthyroidism in subjects under five years as a medica curiosity. Varied opinions have been expressed in connection with the management of the condition. BeiIby and McCIintock3 consider it more hazardous to administer medica treatment to chiIdren than to aduIts. They point out that these young subjects possess a factor of development not present in oIder persons, and-due to the markedIy increased metaboIismskeIeta1 growth takes pIace too rapidIy, whiIe the body is coincidentIy deprived of its avaiIabIe energy. It is aIso Lahey’s preference to treat chiIdren surgicaIIy. He at first tried iodine and x-ray therapy in a number of cases, but resuIts proved unsatisfactory. In intenseIy toxic cases he empIoys the two-stage subtota1 thyroidectomy. This is contrary to the opinion of the CriIes who regard chiIdren as exceIIent operative risks, if adequateIy prepared, and believe the one-stage thyroidectomy can usuaIIy be undertaken without danger.
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Opinions aIso differ as to the amount of Conservative treatment of exophthaImic thyroid tissue that shouId be removed from goiter has a reIativeIy high mortaIity (from children at operation. Beiiby and McCIin30 to 35 per cent) ;I surgica1 intervention is tack agree with AIberts6 that, owing to the therefore the treatment of choice in these inherent tendency of the thyroid gIand in cases. chiIdren to hypertrophy, one can hardIy be Acute Hypertbyroidism. Acute hypertoo radica1 in these cases. They advocate thyroidism must be distinguished from the remova of as much if not more tissue hyperthyroidism in generaI. In the acute in these young patients than is ordinarily stage, frequentIy termed thyroid c&is, one removed in the aduIt. This is not in agreerecognizes a rapidly increasing, fuiminating ment with the generaIIy accepted viewtype of the disease, characterized by an point, that a Iarger remnant of thyroid acceIerated pulse rate, emotiona instatissue shouId be Ieft in chiIdren than in Activated Apathetic others, not only to guard against myxHyperthyr~idism Hyperthyroidism edema, but to provide adequate secretion for the maintenance of metaboIism and for Usually in the younger Generally occurs in Age .......... age group. older age group. norma growth and deveIopment. Kocher Duration. ...... Usually has existed More recent in onset: many years ago (1882-1883) cautioned acute. over considerable period of time in against a too extensive remova of thyroid chronic state. Obvious; seldom misNon-obvious; fretissue in children which, in his opinion, taken. Activated, agiquently overlooked. tated, apprehensive, Calm, slow; apathy produced “cachexia strumipriva.” emotionally unstable. is outstanding feaPrimary Hyperthyroidism, Difuse Partul-2. Apprehensive; typical Calm;no eye signs. Eyes. encbymatous Goiter, Exophthalmic Goiter eye signs. Large, firm. hyperSmall. firm. pebbly. Gland. . . Disease). When (Graves’ or Basedow’s hypervascuplastic, fuIIy deveIoped with goiter, tachycardia, I*r. Hot, soft, flushed, CooI, wrinkled, pigSkin. . tremor, eye signs, flushed and cIammy skin, moist, clammy. mented. Pigmentation disappears with emotiona instability, etc., the cIinica1 relief of hyperthypicture of this condition is so typica that roid&m. Pounding apex beat, No striking apex beat. Heart. its diagnosis is seldom, if ever, mistaken for pI?Zdiffused over cordium. any other. It usualIy occurs in young Toxic, rapid. Not tonic; persistently but moderately individuaIs, and in most instances is we11 eievated. established within a year or Iess from its Higher than in apaModerately elevated. R.M.R., _. _. thetic type; often exonset. Lahey has designated this typicai tremely high. Initial loss. followed Outstanding Feature: Weight loss. hyperthyroid condition as activated hyperby gain: due to in50-60-100 pounds thyroidism, to distinguish it from another creased appetite and over B period of time. food tntnke in restate of hyperthyroidism which he terms spanse to metabolic demand. apathetic ~ypert~yro~d~sm. WhiIe they do Uncountabie pulse Terminal phase. Reasonable pulse rate not vary essentiaIIy in origin, these condisweating, de(rzo), good quafity, rate, non-toxic in chnraclirium and thrashing tions present certain striking differences, as sround in bed. ter. Drowsiness, apathy, coma. indicated in the tabIe on the, opposite coIumn.* deIirium, vomiting, Apathetic hyperthyroidism should be biIity, sleeplessness, suspected in patients with a history of diarrhea, anorexia, and an extremely severe In many cases these crises are progressive weakness, persisting over a intoxication. by diagnostic procedures or Iong period of time. There is usuaIIy a precipitated by emergency surgery empIoyed to eraditendency to overestimate the patient’s cate diseased organs other than the thyroid abiIity to withstand surgery. For this gIand.7 While there is a definite indication reason a two-stage thyroidectomy is espefor surgery in cases of thyroid crisis to ciaIIy indicated. * Based on Lahey’s differentiations. interrupt the course of the disease, it _’
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shouId be withheId unti1 the “storm” has been overcome. Surgery shouId then be done in two stages of subtota1 hemithyroidectomy, with an interva1 of from six to eight weeks between the first and second procedure. Persistent Hyperthyroidism; Recurrent Hyperthyroidism. FoIIowing inadequate or insuffIcient surgery for hyperthyroidism, definite indication for a second operation is occasionaIIy found. It is interesting to note that surprisingIy smaI1 amounts of thyroid tissue wiI1 produce or maintain a cIinica1 hyperthyroid state. This prevaiIs in persistent as we11 as in recurrent hyperthyroidism. In the former, preoperative symptoms fai1 to abate after operation, whereas in recurrent hyperthyroidism, a free interva1 of approximateIy six months or more intervenes, during which time the hyperthyroid symptoms disappear. The recurrence is thought to be due to a compensatory hyperpIasia or growth of the thyroid remnant. It is necessary therefore to accompIish IittIe short of tota abIation in order to prevent a second recurrence. The most satisfactory resuIts are achieved in instances where a permanent hypothyroid state is obtained, and the desired metaboIic IeveI maintained by substitution therapy. Hyperthyroidism Due to Aberrant or Ectopic Thyroid Tissue. Indications for surgery are Iikewise present in instances of hyperthyroidism due to aberrant or ectopic thyroid tissue. The foIIowing possibiIities exist when there is definite cIinica1 hyperthyroidism without thyroid enIargement at the norma site in the neck: I. LateraI aberrant thyroid-singIe or multipIe, papiIIiferous cIusters aIong the anterior border of the sternomastoid muscIe and beside the juguIar vein. They are potentiaIIy maIignant and shouId therefore be removed as soon as the diagnosis has been estabIished. Inasmuch as the tissue is radiosensitive, x-ray therapy shouId foIIow radica1 resection. 2. Lingua1 thyroid-associated with dysphagia, dysphonia, or dyspnea, or a
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combination of these symptoms, and, less frequentIy, hemorrhage. The condition is comparativeIy rare. Montgomery,s who recentIy pubIished a comprehensive and thorough review of the Iiterature, accepts onIy 144 cases as true IinguaI thyroid out of .the 23 I cases reported; I 18 of the 144 occurred in femaIes. The norma thyroid is absent in two-thirds to three-fourths of the cases. Aberrant thyroid tissue has aIso been found in the skuI1, the Iarynx, and in the vicinity of the ribs, the cIavicIe, and the spine.9 In isoIated instances it has been seen in ovarian cysts, and as metastasis in the breast. AIthough ectopic thyroid tissue is generaIIy an unsuspected finding, its presence, when definiteIy determined, invites surgica1 remova if it is accessibIe. Hyperthyroidism in Diabetes. Hyperthyroidism occurring in an individua1 who has diabetes presents an unpromising outIook. It interferes with the management of the case, diminishes carbohydrate toIerante, and increases the severity of gIycosuria. EIimination of the hyperthyroidism does not cure the diabetes, aIthough the carbohydrate toIerance is definiteIy increased. FoIIowing thyroidectomy Iess inand the diabetes is suIin is required, more readiIy controIIed. A two-stage operation is preferabIe in this group to minimize the higher mortaIity which prevaiIs when hyperthyroidism and diabetes occur coincidentaIIy. Hyperthyroidism in Pregnancy. In pregnancy compIicated by hyperthyroidism subtota1 thyroidectomy is indicated at the earIiest possibIe stage of the pregnancy (which need not be interrupted). EIimination of the hyperthyroidism by surgery aims to prevent diffIcuIties which might otherwise occur at term due to intensification of the hyperthyroidism, or with surgica1 intervention (cesarean section), instrumenta deIivery, etc. Relative Hyperthyroidism. ReIative hyperthyroidism is the term which the present writer has appIied to certain phases of an apparentIy non-toxic goiter. The condition
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is found in a middle-aged group of patients who give a history of noduIar enIargement of the thyroid over an indefinite period. CIinicaI manifestations of thyrotoxicosis may or may not be estabIished; hyperthyroidism in the generaIIy accepted sense of the word is not present. The basa1 metabolic rate aIthough beIow the average norma represents nevertheIess an increase in the rate, as comparison with previous readings of periodicaIIy taken basa1 metaboIic rates wiI1 show. A reIative hyperthyroidism therefore exists. The effects of the thyroid secretion of this cryptic stage are definiteIy deIeterious, especiaIIy in its seIective cardiac action. The surgica1 indication therefore is for thyroidectomy. Chronic Hyperthyroidism. AIthough not generaIIy so employed, the term “chronic” is used by Davison lo to designate a condition that has existed over a Iong period of time (usuaIIy for severa years) with unmistakabIe toxic signs and symptoms, despite a persistentIy Iow basa1 metaboIic rate. With the exception of the metaboIic rate, which may be norma or subnorma1, these cases resembIe the earIy toxic stage of secondary hyperthyroidism (toxic adenoma or noduIar toxic goiter). The symptoms of nervousness, tachycardia, choking sensation, and occasionaIIy Ioss of weight deveIop insidiousIy. In the presence of a norma or subnorma metaboIic rate with evidence of cIinica1 hyperthyroidism, the cIinician may be misIed if too much emphasis is pIaced upon the basa1 metaboIic rate. These cases invite earIy thyroidectomy as a means of preventing myocardia1 invoIvement from toxic secretions. Secondary Hyperthyroidism. (a) NoduIar Toxic Goiter or Toxic Adenoma. This condition is most frequentIy observed in patients of middIe age and beyond; and there is a pronounced tendency to cardiac invoIvement. UnIess the thyrotoxicosis is recognized earIy, the heart may become permanentIy damaged, before surgery is instituted. The basa1 metaboIic rate, whether norma or subnorma1, shouId be
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disregarded in the presence of unmistakabIe evidence of hyperthyroidism. The mortaIity from toxic adenoma is higher than from primary hyperthyroidism, due to the more advanced age of these patients and the damaged heart muscIe. The chief changes in noduIar goiter, outside of the thyroid gIand, occur in the heart, and it shouId be kept in mind that, even during the apparentIy quiescent are produced stage, harmfu1 substances by the abnorma1 thyroid tissue. “ Innocent” noduIar or adenomatous goiters are thought to be uItimateIy more devastating than Graves’ disease. Treatment therefore shouId be designed not onIy to reIieve the patient of immediate diffIcuIty, but aIso to protect future heaIth; this is best accomplished by the surgica1 eradication of all diseased parts of the thyroid gland. Nodular or adenomatous goiter may extend SubsternaIIy, since continuous growth is an inherent property of thyroid adenomata. Its retrosterna1 descent, according to Heyd,” is on a definiteIy mechanica basis. (b) Substerna and Intrathoracic Goiter (Toxic). With the exception of the factor of toxicity there is essentiaIIy IittIe difference between the toxic and nontoxic types of substerna and intrathoracic goiter; both therefore wiI1 be considered under this heading. Substerna goiter is usuaIIy due to enIargement and extension of a normaIIy pIaced gIand-not to mispIaced or aberrant thyroid tissue. RetrosternaI goiters invariabIy arise from adenomatous thyroid they are never encountered in tissue; Graves’ disease. Substerna goiter differs from intrathoracic goiter in the extent to which it invades the thoracic cage. ArbitrariIy, the IeveI of the aortic arch is taken as the dividing Iine; if situated above this IeveI it is designated as substernal, and if beIow, as intrathoracic goiter. or absence of thyroid The presence enIargement beIow the superior thoracic aperture may be ascertained by practiced paIpation for a mass which rises to strike
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the examining fingers in the suprasterna1 notch when the patient swaIIows. X-ray of the chest is of diagnostic vaIue in determining the presence of a suspected retrosterna1 thyroid enIargement, either by mass density shadow, trachea1 deviation, or by narrowing of the trachea at the point of the greatest diameter of the thyroid mass. The chief associated symptoms are those due to pressure effects, nameIy dyspnea, hoarseness, and paroxysma coughing or choking speIIs which usuaIIy occur at night. Hyperthyroidism and cardiac disabiIity may intervene. SurgicaI remova is indicated in these cases, and even in the absence of symptoms, noduIar goiters extending beIow the sternum shouId be expIored. (c) Iodine Hyperthyroidism. Not infrequentIy it is possibIe to observe cases of previousIy non-toxic goiter, particuIarIy of the adenomatous type, that deveIop into a definite thyrotoxicosis foIIowing the injudicious administration of iodine; for this reason iodine hyperthyroidism is herewith incIuded among the surgica1 indications. In connection with its frequent occurrence, Poate12 caIIs attention to the great increase in the number of oId goiters which become toxic, pointing to its coincidenta occurrence with the increased avaiIabiIity of iodine preparations to the genera1 pubIic. Among the virtues attributed to these preparations is that of curing goiter, so that sufferers from thyroid conditions frequentIy dose themseIves before consuIting a physician. The administration of iodine in hyperthyroidism, except as a may in fact be preoperative routine, regarded as one of the greatest errors in the treatment of the condition. The spIendid resuIts obtained within the first few weeks are apt to be misIeading, as IittIe benefit is usuaIIy derived after this period. Patients who have had no iodine medication respond best to a preoperative iodine preparation and show a better postoperative course. Iodine shouId therefore be
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withheId unti1 the indication for surgery has been estabIished. B. NODULAR GOITER. Asymmetry of thyroid enIargement and noduIar outIine cIinicaIIy distinguish noduIar goiter from the biIateraIIy symmetrica coIIoid and diffuse hyperpIastic types of gIands. There may be onIy a singIe discrete noduIe anywhere in the thyroid tissue, or muItipIe adenomata of varying sizes may be present, giving a noduIar or “ bosseIated ” surface to the gIand. CIinicaIIy, it is not aIways possibIe to know whether the thyroid noduIe is a pseudo-adenoma or a true adenoma; histoIogicaIIy, differentiation is made between these and the feta1 adenoma. It is obvious that the principa1 distinction between the non-toxic and the toxic noduIar types-previousIy referred to under the headings “Relative, Chronic, Secondary Hyperthyroidism, etc.“-is a functiona one, and in terms of the degree of toxicity. The surgica1 indication is the same in both groups, but usuaIIy deemed more imperative in the obviousIy toxic type, especiaIIy so since adenomata of the thyroid are not amenabIe to irradiation therapy.ll Sudden or dramatic appearance of a goiter usuaIIy impIies one of two possibiIities : either intracapsuIar hemorrhage into a previousIy unnoticed adenoma or cyst adenoma, or disIodgment into view of a retrosterna1 goiter. NoduIar goiters require surgery, not onIy because of their increasing size, but aIso because of the presence or probabiIity of maIignancy. AIIen Graham’3 goes so far as to state that 90 per cent of maIignant neopIasms of the thyroid start in adenomata, especiaIIy feta1 adenomata. While this percentage may represent an overestimation, it is indicative of the possibiIities, particuIarIy in the hard, discrete variety. C. DEGENERATION: CYSTIC OR MALIGNANT. Cystic degeneration giving rise to cyst-adenoma is not an infrequent occurrence in adenoma of the thyroid. In hemorrhagic cyst-adenoma or papiIIary
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cyst-adenoma there is mereIy the added factor of hemorrhage or of papiIIary projections into the cyst. There is also the possibiIity of calcification, in which case the firm consistency of the tumor when encountered cIinicaIIy necessitates its differentiation from maIignancy. Thyroid maIignancy, according to CIute and Warren,14 may be suspected in the presence of a firm, hard, discrete type of tumor in the gIand, and when there has been recent growth, either sIow or rapid. WhiIe thyroid maIignancy is more apt to occur in persons in middIe Iife or Iater, it may aIso be present in the younger age group. This fact was borne out recentIy aIso by Potter and by these writers, Morris,‘” both of whom report eight and five cases respectiveIy in patients under 20 years of age, incIuding two fata cases in children of 9 and 13 years. The occurrence of enIarged Iymph nodes near the goiter shouId arouse suspicion, as shouId aIso secondary evidences of pressure, such as hoarseness, diffIcuIty in swaIIowing and breathing. Apart from the IaryngeaI and trachea1 compression, there is often pressure upon, or direct invoIvement of, the recurrent IaryngeaI nerves, and even biIateraI abductor paraIysis. In rare cases bone metastases, from an apparentIy benign adenoma, may be the first indication of maIignancy. Examination of biopsy specimens is advisabIe to ruIe out a caIcified benign adenoma or chronic fibrosing thyroiditis. ApproximateIy onIy 50 per cent of the cases are diagnosed preoperativeIy. MaIignancy is sometimes not suspected or detected unti1 surgery has been done. In cases in which it is possibIe to make a cIinica1 diagnosis of carcinoma, a high rate of recurrence may be expected. OnIy rareIy is there recurrence of any cIinica1 significance after remova of nonmaIignant or simpIe goiter. A recurrence which foIIows soon after operation, therefore shouId arouse a suspicion of maIignancy. The pathoIogist in such cases wiI1 usuaIIy review the origina materia1, to be
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sure no areas of maIignancy were overIooked at the origina examination. Metastasis may occur earIy or very late, and may take pIace even without invasion of the capsuIe, by spread into the bIood stream, especiaIIy to the Iungs. Metastasis to bones (peIvis, vertebrae, sternum, cIavicIe, femur, skuI1, and ribs-in the order of descending frequency) is not unusua1. Metastatic invasion may occur before there is any evidence of marked local enIargement. I6 It is therefore easiIy understood why in genera1 the prognosis is Iess favorabIe for maIignant adenoma than for adenocarcinoma (often papiIIary) where the diagnosis is usuaIIy made by the pathoIogist. D. INFLAMMATIONS OF THE THYROID. Inflammation of the thyroid may be associated with or be independent of the goitrous process. It may be of the suppurative or the non-suppurative type; in the Iatter case it is either intra- or extracapsuIar. Acute Thyroiditis (Acute Strumitis). Acute thyroiditis may occur spontaneously, foIIowing trauma, or as a compIication of acute disease-inff uenza, typhoid, etc. It is simiIar to other inflammatory conditions and is associated with chiIIs, high temperature, and pain in the thyroid region. The thyroid gIand may be swoIIen and exquisiteIy tender, and the entire area boggy and intenseIy inflamed. The condition shouId be treated by incision and drainage when suppuration is but suppuration may be overpresent; Iooked unti1 spontaneous rupture into the skin, esophagus or trachea has occurred. Chronic Thyroiditis (Chronic Strumitis). The onset of chronic thyroiditis is insidious, indications of gIanduIar disturbance being absent. The cIinica1 manifestations may incIude hoarseness, dyspnea and, in some instances, a sense of fuIness in the throat; they are chieffy due to trachea1 pressure by the dense, fibrosed gIand. The condition is apt to be mistaken for maIignancy. The simiIarity of RiedeI’s struma (known aIso as benign granuIoma of the thyroid) and Hashimoto’s strumitis Iymphomatosa has
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Ied many writers, in&ding Ewing,l’ to consider RiedeI’s struma as a Iater stage of the same pathoIogic process. Hashimoto, however, beIieved his disease to be a distinct entity. Three different stages of the condition have been observed in our clinic, as reported by Heyd’*-an earIy stage presenting onIy a moderate Iymphoid increase with compressed epitheIia1 eIements, an intermediary stage characterized by marked increase in Iymphatic tissue with destruction of the epithelial eIements, and a Iate stage in which aImost compIete fibrosis of the gIand is present. Meeker-l9 reported a case of RiedeI’s struma in a man of 50 years presenting remnants of the uItimobranchia1 body (the first case of its kind in an aduIt; the patient showed other anomaIies-branchiogenic cyst, etc.). It is suggested that thyroids containing such rudiments may be of Iow vitaIity, and consequentIy susceptibIe to the extreme form of atrophy and fibrous repIacement seen in RiedeI’s struma. CompIete thyroidectomy is indicated in chronic thyroiditis, especiaIIy when both lobes are invoIved. Myxedema, however, has been observed in about 40 per cent of the reported cases after radica1 resection.20 In seIected cases the isthmus may simpIy be divided and a segment of tissue overIying the trachea removed to reIieve pressure. E. TUBERCULOSIS. TubercuIosis of the thyroid gIand is rare, and of IittIe importance cIinicaIIy. If operated upon when not suspected, the prognosis after Iobectomy is good. It shouId not be forgotten, however, that the tubercuIous thyroid is but part of a generaIized tubercuIosis, or secondary to a focus eIsewhere. TOTAL IN
ABLATION
OF
SELECTED
CARDIAC
THE
THYROID
GLAND
CONDITIONS
TotaI abIation of the thyroid gIand in cardiac conditions unreIated to thyroid disease had its origin in the work of BIumgart, BerIin and their associates, the first report of which was pubIished in 1927. This procedure is based on a study of the
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norma reIationship existing between the metaboIic rate and bIood veIocity, an advanced or Iowered metaboIic rate having a paraIIe1 inffuence in increasing or decreasing the bIood ffow. Inasmuch as the bIood ffow is reduced in congestive faiIure, aIthough the basa1 metaboIic rate is normaI, it appeared that a reduction in metaboIic demands might resuIt in definite cIinica1 improvement in chronic cardiac conditions. SubtotaI thyroidectomy was tried at first, but onIy temporary improvement resuIted, a reIapse to the preoperative state occurring with a return to a norma metaboIic rate. TotaI thyroidectomy is beIieved to be indicated onIy in cases of sIowIy progressive heart Iesion, in which a11 avaiIabIe medica procedures have proved ineffective. The operation is contraindicated in patients whose metaboIic rate is Iower than minus 20, as we11 as in the presence of acute puImonary or active rheumatic infection or severe impairment of renaI function. Marked or moderate improvement is reported21 in approximateIy 70 per cent of cases of angina pectoris and congestive faiIure observed two and one-haIf years after operation. WhiIe the empIoyment of so drastic a measure as remova of the thyroid gIand for the improvement of cardiac disease has graduaIIy gained adherents, acceptance of this means has not been universa1. HertzIer,22 for exampIe, questions the correctness of the diagnosis in the cases thus benefited, hoIding that pronounced cardiac improvement wouId appear to be presumptive evidence of the toxicity of the thyroid gIand. ResuIts from tota abIation on the whoIe seem to be more satisfactory in cases of angina than in congestive faiIure where no cardiac reserve is avaiIabIe. In cardiac decompensation resuIting from hyperthyroidism, however, subtota1 thyroidectomy gives better resuIts.23 SUMMARY With the exception of the so-caIIed borderhne types of thyroid disease, reference has been made to most of the con-
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ditions requiring surgery, in&ding certain disorders not ordinarily designated in this category. In most instances the various phases of the subject have been fuIIy discussed. The cIassification empIoyed herein is based upon clinica manifestations of the disordered gIand, and is presented aIong with the physical findings as a practical diagnostic guide for surgica1 indication. REFERENCES I. KASPAR, FRITZ. Ueber die konservative und chirurgische Kropfbehandlung. Wien. med. Wcbnscbr., 86: 1377; 1404; 1429 (Dec.) 1936. z. HEYD, CHARLES GORDON. Goiter surgery. J. M. Sot. New Jersey, 33: 345-35 I (June) 1936. 3. BEILBY, GEORGE E., and MCCLINTOCK, JOHN C. Hyperthyroidism in chiIdren. New York J. Med., 37: 563-568 (March 15) 1937. 4. LAHEY, FRANK H. Surgical treatment of hyperthyroidism. Bull. N. Y. Acad. Med., IO: 65-81 (Feb.) 1934. 5. CRILE, GEORGE, and CRILE, GEORGE, JR. Hyperthyroidism in chiIdren under five years of age: report of four cases. Am. J. Surg., 37: 389-395 (Sept.) 1937. 6. ALBERTS, MAX W. Hyperthyroidism in chiIdren. Minnesota Med., 13: 175-177 (March) 1930. 7. BAYLEY, ROBERT H. Thyroid crisis. Surg., Gynec. @ Obsl., 59: 41-47 (JuIy) ‘934. 8. MONTGOMERY, M. L. Lingua1 thyroid: a comprehensive review. West. J. Surg., Obst. @ Gynec., 44: 54; $5; 127 (Jan.-Feb.) 1936. 9. MEEKER, L. H. (Department of PathoIogy, New York Post-Graduate Hospital CoIumbia University). Persona1 communication.
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IO. DAVISON, T. C. Chronic hyperthyroidism. Am. J. Surg., 35: 50~5 I I (March) 1937. I I. HEYD, CHARLES GORDON. Intra-thoracic goiter. Proc. Interstate Post-Grad. M. A. Nortb America, PP. 192-195, 1937. 12. POATE, HC.GH R. G. Some surgica1 aspects of the goiter probIem. M. J. Australia, 23: 842-847 (June 20) 1936. 13. GRAHAM, ALLEN. The mahgnant thyroid. Proc. Interstate Post-Grad. M. A. North America, pp. 264-269, 1928. 14. CLUTE, H. M., and WARREN, S. The prognosis of thyroid cancer. Surg., Gynec. & Obst., 60: 861-874 (April) 1935. 15. POTTER, E. B., and MORRIS, W. R. Carcinoma of the thyroid gIand: a report of five cases in young individuaIs. Am. J. Surg., 27: 546550 (March) ‘935.
16. DINSMORE, R.
S., and CRILE, G., JR. Thyroid problems and end-resuIts of operations on the thyroid gIand. Surg. Clin. Nortb America, 15:
859-884 (Aug.) 1935. 17. EWING, JAMES. Neoplastic Diseases. 3rd Edition, Phila., 1928. Saunders, page 961. 18. HEYD, CHARLES GORDON. Riedel’s struma: benign granuIoma of the thyroid. Surg. Clin. North America, 9: 493-513 (June) 1929. 19. MEEKER, L. I-I. RiedeI’s struma with remnants of the post-branchia1 body. Am. J. Patb., I : 57-67 (Jan.) 1925. 20. JAFF~, R. H. Chronic thyroiditis. J. A. M. A., 108: 105-110 (Jan. 9) 1937. 21. BERLIN, DAVID D. TotaI thyroidectomy for intractabIe heart disease. Summary of two and one-half years surgical experience. J. A. M. A., 105: 1104-I 107 @Ct. 5) 1935. 22. HERTZLER, ARTHUR E. Evaluating the results of tota thyroidectomies in cardiac disturbances. Am. J. Surg., 29: 342 (Sept.) 1935. 23. LAHEY, FRANK H. The diagnosis and management of thyroid conditions. West. J. Surg., Obst. e* Cynec., 43: 361-370 (JuIy) 1935.