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The thyroid gland in relation to “toxic goiter.”
302
Amaican JournaI of Surgery
Progress
cIinica1 history and physica examination. It is to be noted that where a mass of gIands diagnosed as tubercuIous suddenIy and aImost compIeteIy disappears within a week or ten days after the first radium appIication the case is probabIy not tubercuIous but proves Iater on to be Iymphadenoma. The technique of treatment is simpIe. The gIands to be treated are marked out on the overlying skin, and these areas are covered with pIates having 2.5 mg. radium eIement per square centimeter of surface, covered by a sheet of R/lone1 meta 0.3 mm. thick and screened with siIver I mm. thick. In 50 consecutive cases treated by this method 37 have been cured, 9 improved, 3 not improved and one dead. The “cures” are patients enjoying perfect heaIth in every way and showing no paIpabIe glands or at most mereIy smaI1 shot-Iike bodies consisting of fibroid tissue”onIy. GRAHAM, ALLEN. The thyroid gIand in reIation to “toxic goiter.” Radiology, May, I 926, vi, 377-379. The prevaihng tendency seems to be to recognize two presumably distinct and independent types of toxic goiter, exophthatmic goiter and toxic adenoma. Except for such differences as may be due to variation in intensity and duration of disease, the author is unabIe to see a fundamenta1 distinction between these two supposedly definite anc1 in some respects diametrically opposite cIinica1 entities. These distinctions are, however, useful to some extent in designating the cIinica1 state of the patient but not the condition of the thyroid gland. The clinical condition caIIet1 toxic goiter does not originate as a disorder of the thyroid gIand primarily. Surgeons are confronted with the question as to how much gIand to remove. The remova of too IittIe tissue yieIds Iess favorabIe cIinica1 resuIts. The remova of too much tissue may resuIt’ in- myxedema. The remova of threefourths to seven-eighths of the gIand from patients treated with iodine may increase the postoperative incidence of cases with basa1 metaboIic rates beIow normaI, with or without cIinica1 manifestations of myxedema, as has been noted in the author’s experience. There is a definite use for iodine after operation to prevent regeneration hyperpIasia in those gIands that have not been compIeteIy invoIuted before operation. The present state of knowIedge concerning the effect upon the thyroid of roentgen and radium radiations is too unsatisfactory to warrant definite conclusions. The variabIe factors invoIved in a study of this probIem are
in Surgery
MARCH. 192,
such as to require reduction to some common denominator before reIiabIe interpretations can be made. In a genera1 way, there is cIinica1 and experimenta evidence to indicate that irradiation produces adhesions between the thyroid and surrounding structures; that fibrosis of varying degrees occurs; that vascuIarity decreases; and that the volume of the thyroid diminishes. It is doubtful whether the above changes can be distinguishect anatomicaIIy from changes of a simiIar nature and of equal degree in thyroids that have not been irradiated. Very Iittle information is avaiIabIe as to the effects of irradiation upon the function of thyroid apart from the anatomica changes that may resuIt. The impIantation of radium produces IocaIized areas of necrosis folIowed by fibrosis. These changes are quite simiIar to those produced by the injection of boiIing water, aIcoho1, quinine and urea, iodine, etc. Iodine is being extensively used as a therapeutic agent without proper consideration for what it may be reasonabIy expected to accompIish. The indications and contraindications are derived from the state of the thyroid itself. HAMILTON, BURTON E. Observations on the diagnosis of thyroid toxicity and cIinica1 use of the basa1 metaboIism test: the thyroid heart. Radiology, May, 1926, vi, 372-376. DeaIing with thyrotoxic patients requires: Iong experience in differentia1 diagnosis, particuIarIy specia1 experience in differentiating neurocirculatory asthenia from thyroid toxicity; (2) a carefully conducted hasa metabolism laboratory; (3) familiarity with the danger signs of severe thyroid toxicity and knowIedge of their statement; (4) special simultaneous recognition and treatment of the usua1 complicating diseases but particuIarIy recognition and care of the 35 per cent of cases with complicating serious heart disorders; (5) safe treatment must afford not onIy a Iow immediate death rate but prompt resuIts. (I)
H. W. The treatment of uterine fibromyomata. J. Mich. M. Sot., January, 1926, XXV, 13-17.
HEWITT,
Symptom-producing fibroids are surgical probIems and should be treated by the surgeon or under his supervision. Roentgen rays or radium may be used in uncompIicated tumors where the onljr symptom is hemorrhage. They should also be used where surgery is contraindicated as in cases of severe anemia, puImonary tubercuIosis, diabetes, or severe cardiorenal disease. Surgery is the treatment of choice in a11 tumors occurring during the reproductive period, a11 tumors associated with adnexal
Amaican JournaI of Surgery
Progress
cIinica1 history and physica examination. It is to be noted that where a mass of gIands diagnosed as tubercuIous suddenIy and aImost compIeteIy disappears within a week or ten days after the first radium appIication the case is probabIy not tubercuIous but proves Iater on to be Iymphadenoma. The technique of treatment is simpIe. The gIands to be treated are marked out on the overlying skin, and these areas are covered with pIates having 2.5 mg. radium eIement per square centimeter of surface, covered by a sheet of R/lone1 meta 0.3 mm. thick and screened with siIver I mm. thick. In 50 consecutive cases treated by this method 37 have been cured, 9 improved, 3 not improved and one dead. The “cures” are patients enjoying perfect heaIth in every way and showing no paIpabIe glands or at most mereIy smaI1 shot-Iike bodies consisting of fibroid tissue”onIy. GRAHAM, ALLEN. The thyroid gIand in reIation to “toxic goiter.” Radiology, May, I 926, vi, 377-379. The prevaihng tendency seems to be to recognize two presumably distinct and independent types of toxic goiter, exophthatmic goiter and toxic adenoma. Except for such differences as may be due to variation in intensity and duration of disease, the author is unabIe to see a fundamenta1 distinction between these two supposedly definite anc1 in some respects diametrically opposite cIinica1 entities. These distinctions are, however, useful to some extent in designating the cIinica1 state of the patient but not the condition of the thyroid gland. The clinical condition caIIet1 toxic goiter does not originate as a disorder of the thyroid gIand primarily. Surgeons are confronted with the question as to how much gIand to remove. The remova of too IittIe tissue yieIds Iess favorabIe cIinica1 resuIts. The remova of too much tissue may resuIt’ in- myxedema. The remova of threefourths to seven-eighths of the gIand from patients treated with iodine may increase the postoperative incidence of cases with basa1 metaboIic rates beIow normaI, with or without cIinica1 manifestations of myxedema, as has been noted in the author’s experience. There is a definite use for iodine after operation to prevent regeneration hyperpIasia in those gIands that have not been compIeteIy invoIuted before operation. The present state of knowIedge concerning the effect upon the thyroid of roentgen and radium radiations is too unsatisfactory to warrant definite conclusions. The variabIe factors invoIved in a study of this probIem are
in Surgery
MARCH. 192,
such as to require reduction to some common denominator before reIiabIe interpretations can be made. In a genera1 way, there is cIinica1 and experimenta evidence to indicate that irradiation produces adhesions between the thyroid and surrounding structures; that fibrosis of varying degrees occurs; that vascuIarity decreases; and that the volume of the thyroid diminishes. It is doubtful whether the above changes can be distinguishect anatomicaIIy from changes of a simiIar nature and of equal degree in thyroids that have not been irradiated. Very Iittle information is avaiIabIe as to the effects of irradiation upon the function of thyroid apart from the anatomica changes that may resuIt. The impIantation of radium produces IocaIized areas of necrosis folIowed by fibrosis. These changes are quite simiIar to those produced by the injection of boiIing water, aIcoho1, quinine and urea, iodine, etc. Iodine is being extensively used as a therapeutic agent without proper consideration for what it may be reasonabIy expected to accompIish. The indications and contraindications are derived from the state of the thyroid itself. HAMILTON, BURTON E. Observations on the diagnosis of thyroid toxicity and cIinica1 use of the basa1 metaboIism test: the thyroid heart. Radiology, May, 1926, vi, 372-376. DeaIing with thyrotoxic patients requires: Iong experience in differentia1 diagnosis, particuIarIy specia1 experience in differentiating neurocirculatory asthenia from thyroid toxicity; (2) a carefully conducted hasa metabolism laboratory; (3) familiarity with the danger signs of severe thyroid toxicity and knowIedge of their statement; (4) special simultaneous recognition and treatment of the usua1 complicating diseases but particuIarIy recognition and care of the 35 per cent of cases with complicating serious heart disorders; (5) safe treatment must afford not onIy a Iow immediate death rate but prompt resuIts. (I)
H. W. The treatment of uterine fibromyomata. J. Mich. M. Sot., January, 1926, XXV, 13-17.
HEWITT,
Symptom-producing fibroids are surgical probIems and should be treated by the surgeon or under his supervision. Roentgen rays or radium may be used in uncompIicated tumors where the onljr symptom is hemorrhage. They should also be used where surgery is contraindicated as in cases of severe anemia, puImonary tubercuIosis, diabetes, or severe cardiorenal disease. Surgery is the treatment of choice in a11 tumors occurring during the reproductive period, a11 tumors associated with adnexal