VOL. XXXIII, No. 5 September.
1941 215
Indications for Operation in Goiter *
ULYSSES GRANT DAILEY, M.D., Chicago, Ill.
FROM the standpoint of the surgeon, the follow-
ing broad types of thyroid disease exist:
1. The simple or nontoxic goiter with its dif-
ferent subvarieties.
2. Goiter with hyperthyroidism, specific and
nonspecific.
3. Thyroiditis.
I. Acute.
Acute nonsuppurative thyroiditis (not
surgical).
Acute suppurative thyroiditis.
II. Chronic.
a. Ligneous, or woody thyroiditis.
(Reidel)
b. Lymphogenous thyroiditis.
(Hashimoto)
c. Tuberculous thyroiditis.
d. Syphilis (not surgical).
4. Neoplasm.
I. Benign adenoma.
II. Cancer. Types:
a. Diffuse carcinoma.
b. Adenocarcinoma.
Papillary, nonpapillary.
c. Squamous cell carcinoma
d Carcinoma in lateral thyroid
masses.
e. Sarcomas.
I. INDICATIONS FOR OPERATION
IN NONTOXIC GOITER
A simple symmetrical goiter which is causing
no pressure, which is not as yet large enough to
be unsightly may be dismissed by leaving it up
to the patient after careful explanation of its
significance. Many persons have carried such
glands for years without trouble. Even though
thyroidectomy has been thoroughly standardized
* Read before the National Medical Association, 47th
Annual Meeting, Chicago, August 21, 1941.
and the hazard reduced to a low level, it does not
seem correct for the surgeon to urge operation in
these cases. If, for cosmetic reasons and the avoid-
ance of the small chance of future trouble, the
patient desires strumectomy, his request in the
absence of contraindications otherwise, may be ac-
ceded to .
The nodular goiter, large or small, or the large
symmetrical goiter, offers a different problem. It is
probable that all such are destined for surgery, al-
though the reasons and the urgency will vary in
different cases. Granted that good thyroid surgery
is available, operation may be suggested for cos-
metic reasons; operation may urgently be required
when pressure symptoms (dysphonia, cough, dys-
phagia) become manifest. The question of surgery
may arise because of future possibilities in con-
nection with thyroid pathology:
1. A certain number of nodular goiters tend
to give evidence (after an average of fourteen
years existence-Plummer), of toxicity (adenoma
with hyperthyroidism-nonspecific hyperthyroid-
ism-Dailey.) This consideration deserves some
weight in deciding as to operation here, especially
after the nodules have existed several years. If
operation is done a subtotal thyroidectomy, in the
interest of complete removal of nodules, should
be performed.
2. In the case of a single nodule the question
of the later occurrence of carcinoma may be dis-
cussed. A solitary nodule is likely to be so-called
fetal adenoma. It is variously stated that carcinoma
is apt to develop in these in one to three per cent
of cases. Enucleation of solitary nodules should
therefore be advised.
Operation is often contraindicated in persons
past middle age who carried large goiters over a
long period. Certainly these patients with a limit-
ed life expectancy should not be surgerized for
goiter except under definite indications such as
pressure.
216 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
II. INDICATIONS FOR OPERATION
IN TOXIC GOITER
Since the middle nineteen-twenties following
Plummer's discovery, (announced in 1923) that
by the administration of iodin the symptoms of
hyperthyroidism could be quickly abated and the
safety of thyroid operations vastly increased, a
standardized preoperative regime, almost univer-
sally employed and effective for a large per-
centage of cases, was soon developed. Given the
average case of hyperthyroidism, ten days to two
weeks' treatment consisting of rest, high calory
diet and fifteen drops per day of tincture of iodine
is sufficient to bring the patient into condition for
operation. So true is this that in the minds of
many the indications for operation in this state
have become oversimplified. The truth is that
whereas the points of emphasis have shifted, there
is fully as much room for individualization as in
the pre-iodin days.
For the purpose of considering the indications,
it is convenient to divide the cases into groups.
But before proceeding to this it may be well to
lay down in review certain general criteria of safe
operability for hyperthyroid patients.
1. Thyroidectomy for hyperthyroidism must be
considered as always an elective procedure. The
late Charles H. Mayo laid down this dictum as
long ago as 1911, but it was many years before
surgeons in general heeded this teaching.
2. The same authority also was as far as I
know the first to utter the warning never to oper-
ate when the patient is losing weight, or when
weakness is pronounced, when the morale is poor,
and when in spite of standard preoperative man-
agement, clinical improvement fails to occur.
3. The basal metabolic rate must not be evalu-
ated in arbitrary terms, but having in mind its
limitations, one is rarely justified in operating
upon a patient whose B.M.R. is more than plus
50. It will be very exceptional that the discrepancy
between clinical improvement and fall in the meta-
bolic rate will be great enough to abrogate this
rule.
4. Never operate in the presence of an upper
respiratory infection.
SEPTEMBER, 1941
5. Obviously cardiac decompensation must be
corrected before subjecting the hyperthyroid to
surgery.
INDICATIONS FOR SURGERY IN VARIOUS GROUPS
OF HYPERTHYROID PATIENTS
The inference that surgery in general is the
treatment of choice for hyperthyroidism is correct.
It is our belief and practice that at the present
writing maximal subtotal thyroidectomy offers the
best chance for the cure or the nearest possible ap-
proach to cure for the largest number of patients
with this disease. There are, however, alternate
methods of curative treatment and types of therapy
other than surgery that may be of temporary value,
pending the time when operative treatment may
be employed with relative safety: These are: 1.
Roentgen therapy. 2. Medical treatment.
SPECIAL GROUPS OF HYPERTHYROID PATIENTS
WITH REFERENCE TO OPERATIVE INDICATIONS
1. Juvenile hyperthyroidism.
2. Very mild or very early cases (formes
frustes).
3. Cases that fail to improve under standard
management:
(a) very acute, severe, cases.
(b) chronic cases under hitherto pro-
longed misguided medical treat-
ment that have become iodin
refractory.
4. Cases with pronounced exophthalmos.
5. Cases with cardiac decompensation.
6. Thyrotoxicosis and pregnancy.
7. Cases associated with the female meno-
pause.
8. Cases in the elderly.
9. Cases complicated with other medical dis-
eases.
10. Cases with coincident surgical diseases
needing operation.
11. Indication for reoperation in toxic thy-
roids.
1. Hyperthyroidism in children occurred
twice in a consecutive series of 127 operative
cases. Both were girls, ages eleven and thirteen
respectively. The disease in them is strictly surgic-
VOL. XXXIII, No. 5 Indications for Operation in Goiter
al and is governed by much the same indications
as in the adult. The earlier teaching that relatively
smaller amounts of thyroid tissue should be re-
moved is fallacious. Maximal subtotal thyroidec-
tomies should be performed if satisfactory results
are to be obtained. Removal of infected tonsils,
usually after, rather than before the thyroidectomy,
is an essential feature of the management of these
cases. In spite of removal of large amounts of
tissue, hyperthyroidism is apt to be persistent. It
is particularly desirable that these young people
have prolonged follow-up observation.
2. Cases of mild hyperthyroidism: In the past
ten or fifteen years medical practitioners have been
more and more thyroid conscious, with the result
that an increased number of cases with milder
symptoms are seen. There are those, for example,
with only one or two presenting symptoms; slight
increase of objective nervousness, moderate tachy-
cardia, little or no weight loss. Surgery is best for
most of these, but I believe that a trial of medical
treatment at the hands of a physician versed in
thyroid disease is justified. A number of them will
apparently recover. I have known at least one
proved case of hyperthyroidism to get well and
remain so for as much as twenty years without
any treatment. I am not including cases in which
the cardiac feature so dominated the clinical pic-
ture that the thyroid factor was temporarily over-
looked. Such cases are of toxic thyroids and surgery
is the sovereign remedy. They are operated upon
under the same limitations as outlined for toxic
goiters in general.
3. Cases that fail to improve clinically under
standard management: (a) Very acute, severe
cases: There are reports in the literature of severe
cases with death in a few days. The tendency is to
believe that these cases were those with latency,
provoked into crisis by some emotional shock, the
latter being practically always a feature of the
history in such cases. The condition is one of pre-
operative thyroid crisis and differs in no essential
way from postoperative crisis. Obviously surgery
is not to be considered until the crisis is overcome.
Death occurs at times in spite of liberal iodin,
oxygen, sedatives and ice. If and when the patient
comes around under appropriate management, sur-
217
gery should be undertaken with great circumspec-
tion. We believe, following Richter, (1931) that
a maximal operation should be the choice. Antici-
patory precautions in the postoperative course,
collaboration of the thyroid internist, oxygen, io-
din, ample parenteral fluidization, (including car-
bohydrate and blood for transfusion) should be
arranged for.
(b) Patients who have suffered long with toxic
goiter, whose liver, heart and vital organs have
borne for years the effects of uncontrolled thyro-
toxicosis and have undergone numerous "courses'
of iodin, are problems. In spite of the authoritative
opinion of Means and his coworkers, I find it dif-
ficult not to disregard a few clinical experiences
which seem to indicate that a period of rest from
iodin in these patients is beneficial. Such a rest,
together with the usual physical buildup (includ-
ing vitamins B and C) followed by a return to
iodin usually suffices to bring the patient into fair
condition. Individualization must be the watch-
word, and it is here that stage operation may be
good judgment. Obviously fibrillation and conges-
tive heart failure require digitalis; and one may
postulate hepatic damage and give large quantities
of carbohydrate intravenously.
4. Cases with pronounced exophthalmos.
Means believes that cases in which exophthalmos
is severe and out of proportion to the tyhrotoxico-
.Sis form a subspecies in which thyroidectomy is
contraindicated. The treatment is medical, with
iodin and thyroid administered in combination.
(Illinois Medical Society, Chicago, May 22, 1941).
5. Cases with cardiac decompensation, must of
course be digitalized.
6. Thyrotoxicosis and pregnancy. As stated by
Means, "women with toxic goiter may become
pregnant, or pregnant women may become thyro-
toxic. In either event it is the thyrotoxicosis. not
the pregnancy, which should be interrupted. If the
thyrotoxicosis is not interrupted, it often causes
the interruption of the pregnancy."
7. In my experience, women at the menopause
with hyperthyroidism offer special problems of
medical management. It is my belief that at least
in some of these women, operation should be de-
ferred until the factor of the menopausal disturb-
218 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
ance is fully evaluated and cared for by appropriate
estrogenic therapy. The emotional factor thus
abated, the thyroid picture becomes more clearcut,
and surgical therapy following standard prepara-
tion may be more intelligently applied.
8. Elderly patients with hyperthyroidism are
nearly all poor risks. They are prepared with spe-
cial care, pneumonia and vascular accidents being
especial cause for concern. It is our routine in this
particular class to employ prophylactically sulfathi-
azole and/or sulfapyradine. Acute respiratory in-
fection, no matter what the degree is a rigorous
contraindication to surgery. Local anesthesia, em-
ployed almost entirely in our thyroid work, is used
exclusively in the elderly. The oxygen tent is em-
ployed routinely in the first forty-eight hours
postoperatively. Regardless of these precautions, a
certain percentage of cardiovascular accidents will
occur in these patients. All that can be done is to
keep the patients as well sedated as possible. Tend-
ency to delirium in the elderly before operation
should suggest postponement. Postoperatively, it
is of bad omen and the patient will sometimes
pass out without signs even at postmortem exam-
ination, that denote cause.
9. Obviously a patient with hyperthyroidism
may be subject to other disease. One of my pa-
tients with proved hyperthyroidism, was found to
have incipient pulmonary tuberculosis. She died
of the latter disease two years after a successful
bilateral lobectomy. In general it is true that al-
most always the thyrotoxicosis is the dominant
feature of coincident disease, and demands first
attention. Exceptions will be referred to in later
paragraphs. Patients with psychosis had best not
be operated upon until a competent psychiatric
opinion is had. Generally, especially if taking the
form of delirium it denotes a severe grade of tox-
icity; if so, it is appropriate to bring this element
under control before surgerizing; this is especially
the case in the elderly, as previously remarked.
'When, however, it is a matter of previous person-
ality background superimposed upon by the thy-
roid state, adequate thyroidectomy may be fol-
lowed by a brilliant result. This happened in one
of our earlier cases in which we hesitated to op-
erate. The patient went elsewhere and after psy-
SEPTEMBER, 1941
chiatric consultation was promptly thyroidecto-
mized with complete abolition of mental symp-
toms.
The relationship of diabetes to hyperthyroidism
is important as well as interesting. It is well known
that sugar is not infrequently found in urine of
hyperthyroid patients. This glycosuria is transient
and ordinarily disappears after thyroidectomy. True
diabetes mellitus, however, as a coincident disease
is met with (3 in 127 operated cases) and has the
following relations:
1. It complicates the preoperative preparation
for thyroidism.
2. The diabetic patient must be prepared for
a thyroidectomy as for any other major operation.
Thyrotoxicosis aggravates diabetes mellitus.
Thyroidectomy not only relieves hyperthyroid-
ism, but is followed by marked improvement in
the diabetes. The latter is therefore additional in-
dication in thyrotoxicosis for operation. Obviously
we find here especial need for medico-surgical co-
operation. (Note that Wilder, Foster and Pem-
berton, Endocrinology 18, 455, 1934; - Rudy,
Blumgart and Berlin, American Journal of Medi-
cal Sciences, 190, 51, 1935, did complete thyroid-
ectomies for diabetes mellitus. The results, how-
ever, did not justify a continuance of the practice.
Thyroidectomy for heart disease, and for diabetes
insipidus may be said to be of historic and experi-
mental interest only).
It has already been emphasized that operation
should be postponed in the presence of acute res-
piratory infections. This is particularly true of
acute tonsillar infections which should be treated
until entirely well. The sulphonamides are of great
value in shortening the period of delay on this
account.
10. Cases with coincident surgical disease re-
quiring operation: In 1915 I saw a case operated
upon for fibroid. The operation was easy, but the
patient died on the third day in what was un-
doubtedly a thyroid crisis. The fact that the patient
had hyperthyroidism was unrecognized at the time
of the operation. In fact it was only incidentally
discovered by a casual consultant just before death.
Recovery of the thyroid gland post mortem proved
the cause and nature of death. This experience did
VOL. XXXIII, No. 5 Indications for Operation in Goiter
more than anything else to make me thyroid con-
scious, and since then I have always fully under-
stood the necessity of taking note of the thyroid
first when another disease is present requiring
elective surgery. This is true even for chronically
infected tonsils which are believed to have an
aggravative effect upon thyrotoxicosis. In acute
surgical emergencies such as acute appendi-
citis, ruptured gastrointestinal ulcer or ectopic
pregnancy, the necessitous operation is indicated
and may be done with reasonable safety by quick-
ly preparing the patient with intravenous iodin
continuing throughout and after the operation. It
is, however, especially unfortunate to be forced to
operate under this circumstance.
11. Indications for reoperation in toxic thy-
roids:
1-In the immediate postoperative course, for
secondary hemorrhage, when the hematoma causes
pressure, or otherwise endangers the patient.
2-To remove additional thyroid tissue purpose-
fully (single lobectomy) or unintentionally left,
if causing persistent manifestations of hyperthy-
roidism. Surgery should not be advised before the
effects of prolonged iodinization and radio therapy
have been tried. Pregnant women with residual
hyperthyroidism should be watched with especial
care.
3-To correct the result of recurrent nerve in-
jury (Brian Kings' operation).
4-I have operated for the cure of a sinus due
to leaving a small gauze sponge in the operative
field.
5-For the removal of keloid or otherwise un-
sightly cicatrix.
The following is a list of measures in standard
preoperative management:
1. Diet: High calory (4000-5000 daily).
Foods high in vitamins C and B are emphasized.
In some instances the vitamins themselves are
administered.
2. Iodinization: Lugol's solution. Five drops
three times a day in water.
3. Rest: Up to the past year, this has been
a rather rigid confinement to bed for ten davs
immediately preceding the expected time of opera-
tion. Lately we have individualized in this particu-
219
lar, the average person being required to rest only
a part of the day, two to four hours, with ten
hours bed rest at night; the other time spent in
the chair and freedom to walk about in the hos-
pital. Obviously very sick patients need varying
periods of complete rest, but all patients should
have a week or two of partial exercise immediate-
ly prior to surgery.
Digitalis is not used except under definite in-
dication for cardiac pathology.
X-ray studies of the neck and upper chest are
routinely done to:
1. Record preoperatively the state of the
trachea as to deviation and collapse.
2. Presence or absence of intrathoracic exten-
sion.
3. Classification or not in the thyroid.
4. Possible pulmonary complications.
Electrocardiograms are made only on the recom-
mendation of the internist or in very severe or
complicated thyroids.
Basal metabolism estimations are made where
possible before iodinization is instituted, and at
four or five day intervals before operation.
Sodium amytal or nembutal is judiciously used
for sleep. We have observed no ill effects from
these agents.
The general run of hyperthyroid patients in
our experience are cooperative. A few need the
assurance of an experienced physician who has
complete confidence in himself. Merely his occa-
sional presence at the bedside is often all that is
necessary. Only the exceptional patient needs
special measures in connection with morale and
emotion.
III. INDICATIONS FOR OPERATION
IN THYROIDITIS
1. Acute:
(a) Acute nonsuppurative thyroiditis
such as is seen in connection with influenza and
other acute infectious diseases is not surgical.
(b) Acute suppurative thyroiditis is
occasionally seen. Prompt incision and drainage is
indicated. Too long delay in surgical intervention
may result in rupture into fascial planes or trachea.
There have been two cases in my experience due
220 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
to traumatism with lodgment of foreign body and
infection.
II. Chronic:
1. Ligneous Thyroiditis (Reidel).
Partial thyroidectomy is indicated for re-
moval of infected tissue and to relieve tendency
to pressure.
2. Lymphogenous Thyroiditis (Hashi-
moto).
With this disease we had no experience.
The treatment is thyroidectomy. Means advises
(J. H. Means, Diseases of Thyroid, p. 503) a
trial of x-ray before surgery. Resulting improve-
ment helps to differentiate between Hashimoto
and Reidel's struma, since x-ray is ineffective
against the latter.
3. Tuberculous thyroiditis.
One case has occurred in the Provident Hospi-
tal outpatient ward which was diagnosed as tuber-
culosis of the thyroid. Surgery should be avoided.
X-ray with supportive treatment is indicated.
4. Syphilis of the thyroid is a rarity and
is not surgical. No cases have occurred in our ex-
perience.
IV. INDICATIONS FOR OPERATION IN
NEOPLASMS OF THE THYROID
Benign: The discussion of this group was in-
cluded under the Nodular Goiters. Other benign
Infantile Paralysis (Acute Anterior Poliomyelitis)
JOHN W. CHENAULT, M.D.
Chief Orthopedic Surgeon, Infantile Paralysis Center, Tuskegee Institute, Alabama
T 0 understand and discuss the condition which
we call Infantile Paralysis, a brief reference
to its history must be of value. Infantile Paralysis
is a misnomer applied to this disease which has
persisted and we have, by general usage, almost
universally adopted the name. The more scientific
name of acute anterior poliomyelitis, coined by
Kursmald, is more accurate, meaning an inflam-
matory reaction of grey nerve matter of the central
nervous system.
Where or .when this disease first appeared, no
SEPTEMBER, 1941
goiters are of academic interest, being excessively
rare.
Malignant: In general, there are three types of
primary epithelial cancers in the thyroid,-( 1)
the diffuse carcinoma, (2) the adenocarcinoma
and ( 3 ) the squamous cell carcinoma. The first and
third types are highly malignant and are apt to
reach the surgeon in a stage in which they are
either inoperable or are susceptible only of pallia-
tive surgery.
Sarcomas are exceedingly rare.
Secondary tumors are rare.
The adenocarcinoma is the type of interest to
the surgeon. There are two distinct types: The
papillary-a relatively benign growth highly fav-
orable for operation. Thyroidectomy and radiation
are followed by a large percentage of cures. Me-
tastasis is uncommon.
The nonpapillary type is much more malignant,
is very invasive and a highly radical operation is
required for its treatment. The tributary cervical
lymph nodes, the sternomastoid muscle and invari-
ably, the internal jugular vein on the homolateral
side are extirpated, en bloc, if possible. Sometimes
the contralateral side, as well, should be removed.
Carcinoma of lateral aberrant thyroid masses is
usually of the papillary type. Radical resections
should be done. Postoperative irradiation improves
the chances.
one knows. According to Harmon "recognizable
references to this disease are to be found in the
Bible, since a son of Jonathan (II Samuel IV:5)
was lame from a paralytic disorder which the great
Osler considered to be poliomyelitis." Hippocrates,
the venerable father of medicine, recorded the oc-
currence of a winter epidemic of paralysis on the
Isle of Thasos. There have been several references
in the Eighteenth, and early nineteenth century
medical writing from northern Europe. Shaw, in
1823, described a wasting paralysis of the limbs