Goiter With Especial Reference to Treatment with Iodin BY ARNOLD S. JACKSON, Section in Surgery, Madison, Wisconsin T HE problem of goiter has ceased 4,000,000 drafted men examined for to be of purely regional in- goiter, approximately 27 per cent of terest and is now one of every 1000 recruits in the northwest national importance. While goiter is states had simple goiter and 9 per cent endemic in the region of the Great had exophthalmic goiter. Since we Lakes and in the Saint Lawrence know that simple goiter occurs five or valley, a considerable percentage of six times as often in women as in men, the population from the Atlantic to these statistics do not reveal the true the Pacific coasts is afflicted with this situation. Of the recent surveys that condition. It is true that residents of have been made, the most interesting the southern states enjoy a natural and significant is that by the Health protection against goiter and that the Department of the State of Michigan incidence of simple goiter is compara- where approximately 31,000 school tively low. Geographical boundaries, children were examined, 14,914 of however, are everywhere being broken whom had goiter. Fifty-four per cent down by the development of modern of the girls and 40 per cent of the boys transportation and highways. There were affected. In Wisconsin, a recent is a continual shifting and interming- survey of two counties showed that ling of the population, such as no age goiter occurred in about 75 per cent of has ever known before. Moreover, the girls. the occurrence of exophthalmic goiter is not limited by any natural barriers. The extent to which goiter occurs in the United States is seldom appreciated. The work of Marine and Kimball and the reports of the draft boards throughout the country first gave general recognition to the great prevalence of goiter. Statistics from the Mayo Clinic, and from other clinics, long emphasized the importance of surgical diseases of the thyroid, but they did not reveal the alarming extent of simple goiter. An analysis of the statistics published by the War Department shows that of Although the profession and the general public are awakening to the importance of goiter as an economic and social problem I have found no reports showing that goiter is not only more prevalent than has generally been supposed but that it is rapidly increasing. Young women frequently have goiters and the great majority of girls in the middle west have not only a physiologic but a pathologic enlargement of the thyroid. In the belief that the incidence of goiter is rapidly increasing, a series of 500 women patients examined at the Jackson Clinic during the year 1924 was About 20 per cent of the colloid goiters of youth never become complicated by adenomas and consequently are spontaneously cured after the period of full development. Nevertheless, it is at once evident from the figures quoted that a much higher percentage of the younger generation has goiter. For the past two years I have been treating more than 300 children for goiter. Some of these have normal thyroids and are merely taking prophylactic treatment. I have been impressed with the fact that the more children I see the earlier seems the occurrence of thyroid disturbance and especially of adenomas. This discouraging factor emphasizes the need of starting prophylactic treatment in younger children. My observations lead me to the belief that it is especially necessary to administer preventive treatment to expectant mothers. Since an accurate study of my cases was not begun until 1923, it is still too early to draw any except general conclusions. I believe that a larger dose of iodin than that generally advocated can safely be given, and we are administering 20 or 30 mgm. a week to all children over ten. In younger children, or as a prophylactic, 10 mgm. a week is used. Unquestionably, more can be accomplished by pro phylaxis than by treatment. The success of the Marine-Kimball method of treatment is largely due to its continuance; once therapy is commenced it is maintained until the greatest possible benefit has been obtained. Attempts at treatment in the past often resulted in failure because therapy was continued for only one or two years. To be successful treatment should be instituted at the age of ten or younger and continued until the age of twenty-one. Results of treatment vary greatly; in some patients a noticeable reduction in the size of the gland occurs in a few months' time, while in others there is little or no improvement. Another cause of failure in the treatment of colloid goiters is due to lack of recognition of the influence on the thyroid gland of undue physical and mental strain imposed by our modern system of scholastic requirements and social obligations. Whenever these conditions are seen to be a factor in keeping the thyroid gland overworked, activities should be limited and, if necessary, the child should be withdrawn from school for a year's rest. When one looks into the future of a number of generations one has cause to wonder whether the same conditions will exist in this country as now prevail in Switzerland where one-sixth of the recruits for the army are yearly rejected because of goiter, cretinism, deaf-mutism, or some coexistent condition. In tracing goiter through families I have frequently found a marked increase in the size of the goiter with each new generation. As yet, the occurrence of cretinism in this country has been negligible, but the Swiss are a much older nation than ours and in time we may have to face a problem similar to that of the Swiss. The profession and the public are everywhere awakening to the importance of the prophylactic treatment of goiter, and this year every school child in Michigan will receive iodin. Other States will rapidly follow the lead of Michigan. In Wisconsin, we expect to start this treatment in several hundred towns or cities this year, and where it has already been commenced it will be continued. In a consideration of the surgical treatment of goiter we find there has likewise been a widespread interest aroused in recent years. Through the efforts of Mayo, Plummer, Crile and others, there has been a great dissemination of knowledge pertaining to diseases of the thyroid, and the mist that long confused the subject of goiter is now clearing. The beneficial effects of surgery are often so spectacular and fascinating that the larger and more tedious problem of prophylaxis is inadvertently allowed to slip into the background. The one factor that has aroused general interest and confidence in goiter surgery is the remarkable reduction in operative mortality. The patient no longer dreads this operation, neither does the family physician hestitate to advise it. Statistics from different clinics show a mortality rate of from 1 to 5 per cent on various series of cases. Between October 1, 1923, and October 1, 1924, we performed a total of 171 operations on the thyroid, including 141 thyroidectomies with no deaths. Every patient with a surgical disease of the thyroid who has come to the Clinic for examination has been accepted for operation. When one analyzes the excellent results of surgery in a small series such as this and studies the remarkable results obtained in larger clinics, it is obvious that certain factors have been of prime importance in the reduction of mortality. Among the most important of these factors is the early recognition of cases of hyperthyroidism by the family physician. The severely emaciated patients, in whom marked visceral changes have occurred, are no longer commonly encountered. The laity is coming to recognize that prompt surgical intervention in the treatment of toxic cases of goiter is just as important as is prompt recognition and operation for acute appendicitis. Likewise, we find that the surgeon has made great improvement in his art, not in individual brilliancy, but in the perfection of operative teamwork. The well trained, swiftly moving operating teams now being everywhere developed have reduced the time of operation in most instances from hours to minutes. Formerly, the element of time was often the deciding factor between life and death in cases of severe hyperthyroidism. The introduction of improved methods of anesthesia and the perfection of team work in the operating room has eliminated the element of shock or cardiac strain from thyroid surgery. We are able to perform a thyroidectomy in twenty to forty minutes, the patients are wide awake at the completion of the operation, and in four or five days they are able to leave the hospital. This is in marked contrast to former conditions when the period of convalescence often extended over several weeks. In a comparison of the various methods of anesthesia now used in thyroid surgery, one is impressed by the fact that ether has largely been discarded. Some surgeons prefer nitrous oxid, others ethylene, or novocain, and some continue to employ ether. The anesthetic is perhaps a matter of individual choice since the end results seem to be largely the same. With regard to the question of lowered mortality, however, I believe that the three most important complications now encountered in operations for goiter; namely, injury to the recurrent laryngeal nerve, hemorrhage, and pneumonia may be practically eliminated through the use of local anesthesia. So far in my experience I have had no cases of permanent injury to the recurrent laryngeal nerve, only two cases of pneumonia, and two cases of hemor rhage. This I attribute largely to the use of morphin-scopolamin-novocain anesthesia in 95 per cent of cases. At the completion of the operation any injury to the nerve, or any undetected bleeding vessels may be readily discovered and the condition remedied, by having the patient cough and strain. While the incidence of postoperative pneumonia is not eliminated, it is markedly reduced by the use of local anesthesia. Morphin and scopolamin are necessary to insure the success of a local anesthetic. The occasional so-called morphin-scopolamin "jag" is readily controlled by additional morphin or a few inhalations of nitrous oxid. Still another factor that has aided in lowering mortality in operations for goiter has been the use of the basal metabolism unit. The question of diagnosis has been greatly simplified from the standpoint of the internist, and the surgeon has been able to follow more closely the condition of his patient. The errors that once occurred through defective metabolic units, untrained technicians, or inexperience in interpreting results have largely been eliminated. The metabolic unit has not lessened the importance of a careful physical examination and history, nor does it reveal the extent of cardiac or renal involvement. The question of loss in weight and strength is still of prime importance. When properly interpreted, however, the metabolic unit is the thermometer which registers the degree of toxicity in thyroid disease. The metabolic rate alone does not indicate the patient's ability to withstand operation, but it serves as a valuable guide to the improvement following medical and surgical measures, and thereby indicates when one may and when one may not operate. Accompanying the perfection of operative teamwork, the working out of a careful preoperative and postoperative regimen has been an important advance in the development of modern surgery. Perhaps in operations for goiter more than in any other field of surgery, with the possible exception of urologic surgery, has this advancement been responsible for the great reduction in mortality. All patients at the Clinic receive at least three days preparation, including digitalization, a forced fluid and dietary regimen. Patients suffering with hyperthyroidism require at least 4500 calories daily to maintain body weight. Ordinarily all my patients are permitted to be out of bed several hours daily; I am opposed to absolute rest in bed, since such patients lose strength rapidly. The extremely hyperthyroid patient and the patient with severe cardiac decompensation are exceptions. The one factor that has been of most importance in enabling us to complete a year and a half in thyroid surgery with no mortalities has been the use of Lugol's solution of iodin in cases of exophthalmic goiter. The recent advocacy of the use of Lugol's by Plummer has revolutionized the treatment of this disease and has reduced the mortality rate to a negligible figure. By means of Lugol's solution of iodin we are able to abort or prevent the crises that in the past often terminated fatally in exophthalmic goiter. Most striking is the effect on patients seen in gastrointestinal crises. Formerly such patients were often unable to retain any food by mouth or rectum for many days. I have known patients to lose 40 to 50 pounds during one of these crises. The mortality in these cases under medical treatment ran as high as 25 per cent. Especially serious were the cases of hyperthyroidism occurring in children. Now patients seen for the first time in a crisis respond remarkably well to iodin. Within forty-eight hours the extreme restlessness, nervousness, and emotional irritability so typical of these cases begin to disappear. As soon as the thyroid gland is put at rest, the anxious, startled facial expression vanishes, the patients become quiet and composed, and no longer thrash about in bed and chafe their extremities. Even in patients in whom the disease has not progressed so far, there is a surprising clinical improvement. After three days intensive treatment the heart quiets down, insomnia no longer is a factor, and there is a lessening of the tremor and a return of strength. Coincident with the clinical improvement is a decrease in the pulse pressure; the diastolic pressure rises and the systolic pressure falls. There is an average reduction in the basal metabolic rate of 20 per cent. During the past year I have steadily increased the amount of Lugol's solution, and at the same time have reduced the period of preparation. Patients with mild cases of exophthalmic goiter are only required to be at the hospital one or two days before operation. Very toxic patients receive massive doses of Lugol's solution while under observation at the hospital for four or five days. If the general condition then warrents a primary thyroidectomy, operation may be performed; otherwise a test ligation or a multiple stage thyroidectomy is performed. Following operation for exophthalmic goiter patients are again given large doses of iodin in decreasing amounts. The factors of sleep, quiet, and rest for a period of twenty-four hours following the first hypodermic preceding operation are important to success. Just before leaving the operating room a hypodermic of morphin is given, the eyes are not uncovered and as a result patients are drowsy for many hours after operation. The technic of administering Lugol's solution is simple, but there are several qualifying factors. There must be no question of the diagnosis, since a failure to recognize a truly hyperplastic gland may lead to a fatal error. Iodin is not effective in the |