In the use of the so-called antithyroid substances, most noted propylthiouracil, the production of thyroid hormone is decreased. These compounds cause an enlargement and marked hyperplasia of the thyroid gland, with corresponding depression of metabolism and a decrease in the formation of thyroid hormones. The iodine content of the thyroid decreases, although the ability of the gland to trap iodine is not destroyed.
In considering the various diseases of the thyroid, for sake of brevity, we will deal with:
1. Congenital Anomalies: These are of the aberrant type of thyroid and thyroglossal duct cysts, sinuses and fistulae.
a. Acute form – suppurative and non-suppurative.
b. Chronic – which comprises Simple; Reidels Struma; Hashimotos Disease; Specific infections (actinomycosis, syphilis and tuberculosis).
3. Iodine Deficiency Goiter: Subiodic goiter; Simple goiter; colloid goiter – pubertal, Adolescent Gestational; Menopausal; Endemic; Sporadic.
4. Hypothyroidism” Adult myxedema; Cretinism; Juvenile myxedema.
5. Non-Toxic Nodular Goiter, arising from pre – existing subiodic goiter, from pre – existing Graves disease, and fetal adenoma.
a. Graves Disease.
b. Plumbers Disease (toxic adenoma)
(1) Under the congenital anomalies or aberrant type of thyroids, we remember from the embryonic development of the thyroid, the path of its descent into its final location in the neck. Any variations which may occur during its descent will give rise to these aberrant thyroid itself. These are subject to the same cell changes which occur in the thyroid gland per se.
The thyroglossal duct cysts, it must be recalled, will be differentiated by the fact that they are in the midline. They may be ruptured and form a fistula which in turn may drain from time to time. They may a drain into the mouth if the duct cyst is above the hyoid bone.
In my experience there have been times when we have had a normal thyroid gland and have had a hyperactive aberrant gland located in some position in the neck which will give rise to thyroid – toxic symptoms. In these case we remove the aberrant gland.
The thyroglossal duct cysts usually are noted in the early years of life and do not harm unless their size produces a poor cosmetic effect and are removed for this reason; or due to some infection of the tract they will rupture and form a fistulous tract, which must be excised.
(2) A Thyroiditis – The acute form of thyroiditis will occur following some other form of infection through the body, such as pneumonia, bronchitis, diseased tonsils, or any other form of infection. As a rule, these cases will subside under treatment with the antibiotics or sulphonamids within 10 days to 3 weeks. Occasionally when there is suppuration, we will find pressure symptoms, high temperature; and of course radical incision and drainage of the affected site is surgically indicated.
B. In Chronic Thyroiditis, we must consider such conditions as Reidels Struma, Hashimotos Disease and the specific infections such as actinomycosis, syphilis and tuberculosis.
The Reidels Struma is known also as the Woody type of thyroiditis or the Ligneous type of goiter. In these cases, there is a dense struma throughout the gland which on section cuts almost like cartilage. Reidels struma does not occur too frequently (approximately 2 percent of all thyroidectomies have been performed upon Reidels struma). It is more common in women than in men. The clinical symptoms and signs of Reidels struma depend upon the presence of the goiter, the alterations of thyroid function, and the disturbance due to pressure.
The gland is usually smooth except in about 30 percent of patients in whom a nodular goiter had previously existed. In about one – half of the cases bilateral involvement occurs. Malignancy must be differentiated in cases which had a pre – existing nodular goiter. There is one differential point in determining the diagnosis between Reidels struma and malignancy. In Reidels struma, the structures adjacent to the gland become adherent to the gland but are never fixed to the skin. When there is compression of the trachea or deviation of its structure, we may have unilateral laryngeal paralysis that is associated with hoarseness.
Early in this disease, signs of hyperthyroidism are present Later, as normal functioning tissue of the gland is encroached upon, there may be myxedema. The most striking symptoms are due to pressure. Dyspnoea is present in about 50 percent of the cases.
In Hashimotos Disease, we find that one per cent of all thyroidectomies were due to this type of pathological process. It course almost entirely in females. In this type of case, usually, the onset has been slow. The goiter has been present from three to five years. The patients nutrition usually is good. We will find pressure symptoms such as hoarseness, dysphagia, aphonia, tightness in the throat, a feeling of pressure over the neck, stridor, coughing and hoarseness. The gland is uniformly enlarged and is usually fixed to some neighboring structure, especially to the trachea.
This type of chronic thyroiditis is amenable to X- ray therapy. However, since diagnosis is difficult in differentiation from carcinoma, these cases usually come to surgery. In the operative treatment of both these types of cases, due to the woody texture of the gland and its attachment to neigh – boring structures, particularly the trachea, we experience our greatest difficulty in thyroidectomy, because of danger of injury to the re – current laryngeal nerve.
In most of these cases there already has been nerve involvement caused by the encroachment on the surrounding structures and it is here that we run into recurrent nerve paralysis. There is practically no tendency for this disease to recur after thyroidectomy. However, following operation, myxedema is very apt to occur and of occur the patient must then be kept on thyroid hormone.
In operating these types of patients, where the gland has developed and grown about the trachea or even posterior to the trachea, we must consider the danger of hemorrhage due to the numerous venous, spaces which are lateral and posterior to the trachea, and it is in these cases that we will experience our post – operative bleeding most frequency.
(3) Iodine Deficiency Goiter or Simple Goiter (Subiodic goiter) We find that these cases occur endemically in certain well defined geographic areas throughout the world. From its terminology, we can observe that it is due to a decrease in iodine storage capacity by the thyroid. A concentration of at least 1 percent of iodine must be maintained in the thyroid gland to prevent goiter. In regions throughout the world where there is a decrease in the amount of available iodine, especially over a long period of time throughout succeeding generation, we find the incidence of this type of goiter to be tremendous.
We will find that males and females are equally affected. Many of these cases are affected from the time of birth. These cases vary in the gamut from frank cretinism, present at birth, to asymptomatic enlargement of the thyroid gland occurring at puberty. In the female, we find that pregnancy and menopause usually will cause a vast increase in the size of the gland. The gland enlarges because there is glandular hyperplasia and hypertrophy which are trying to produce a sufficient amount of thyroid hormone despite the relatively low iodine intake. After a goiter has been present a number of years, it is subject to degenerative processes which may result in hemorrhage into the gland.
In the treatment of these cases, early use of iodine, especially in the goiterous belts throughout the world, will give a prophylaxis against this type of disease. A small daily in take of iodine will be sufficient to cover the need and this may be supplied in the form of iodized salt. In its lieu, we may use one drop of Lugols solution per week. This will produce 8500 micrograms of iodine. Avoidance of an excess of goitrogenic substances in the diet, such as cabbage, is advised. If hypo thyroidism exists, dessicated thyroid substance in dosages from one – half to three grains daily is indicated.
It has been our practice for many years in this type of case to use many of the homoeopathic remedies. It must be remembered that the ancients treated their cases of goiter by administering sea – sponges which had been burnt. This will correspond to our present Spongia tosta. The small amount of iodine in this drug is responsible for its marked therapeutic effect. Other drugs which are commonly used are Iodine in potentized form and especially Red iodide of Mercury in our 3x triturate tablets.
This is especially indicated in case where there is associated hoarseness and metallic type of cough. In our practice we have found that many of the psychosomatic symptoms, such as nervousness, apprehension, so forth, are well cared for by the use of Actea racemosa and Pulsatilla.
(4) It would be wise at this time to mention Myxedema. These are the cases which have a reduction in the necessary thyroid hormones. The classical case of myxedema is known to all of us. Cretinism in the young is very easily distinguished. However, there are borderline cases of myxedema which often are overlooked. We should look for a generalized deposit of fat about the shoulders and upper trunk.
Mentally, the patient is retarded and slow, there is lack of interest, a disinclination to work, sleepiness and a slow monotonous type of speech and there is usually a gain in weight. The hair is dry, coarse and brittle. However, these patients, if they are aware of these deficiencies in their psyche, may then develop nervousness, fretfulness or peevishness. We find in these cases that there is a decreased muscle tone in the heart, with feebleness of cardiac action. There will be a low pulse pressure, with increased capillary permeability.
Pathologically, the changes which occur in the thyroid gland are pressure, destruction of the cellular elements which the gland depends upon for the production of this hormone and eventually the small thyroid gland which is left, represents no more than is left in a totally thyroidectomized patient, so far as its functional ability; goes.
(5) Non – toxic Nodular Goiter – Colloid changes with nodule formation and degeneration are common in apparently normal people over 45 years of age. Their presence indicates a gradually diminishing activity of the thyroid gland.
Nodular goiters arise from simple or subiodic goiters, from chronic Thyroiditis, and in congenitally aberrant thyroid tissue. They may appear as a result of diffuse hyperplastic goiter with hyper – thyroidism. There is a tendency for the follicular cells to pile up on one another to form metaplastic masses which later, through growth and coalescence, give rise to readily palpable masses.
The overgrowth of these cells is thought to be due to an increased stimulation by the thyrotropic hormone of the pituitary. These nodular goiters are commonest in the endemic areas of the world. Adenomas arising in such cases are functionally less active than the surrounding normal tissue. They take up less radio active iodine and produce encapsulated lesions, or diffuse, multiple enlargements merging almost imperceptibly into the normal elements of the gland. They are rarely neoplastic, but rather a metaplasia of the normal glandular elements.
The importance of these, aside from their unsightliness, must be stressed because of the complications which may arise, namely, malignancy, pressure syndromes and thyrotoxicosis. Cases which have this criteria must be operated upon. There is a school of thought which believes that all nodular goiters should be operated upon due to the possibility of some nodules being malignant. It is my belief that these nodules should be removed. Due to the tendency for recurrence in cases where nodules have been removed, it is good surgical practice to perform subtotal thyroidectomies in such cases.
(6) Hyperthyroidism or Toxic Goiter – These cases comprise Graves Disease (exophthalmic goiter) or Parrys Disease (primary hyperplastic goiter) with or without ophthalmos; Plummers Disease (toxic anenoma or toxic nodular goiter).
It may be noted here that the onset to toxic symptoms in Plummers syndrome usually occurs a number of years after the nodular goiter has been noticed. On the other is more acute in Graves Disease the thyrotoxic symptoms precede any noticeable enlargement of the gland. The onset is more acute in Gravers Disease. The goiter in toxic adenoma is nodular, usually asymmetrical and larger than we see in Graves Disease. GRavers Disease is seen in younger people, while Plummers Disease in those who are over 40.
It is believed that a neurohormonal mechanism is involved in the pathogenesis of toxic goiter. Nervous impulses stimulate the anterior pituitary to produce an increased output of thyrotropic or thyroid – stimulating hormone, followed in turn by increased activity of the thyroid cells, with over – production and release of thyroid hormone. There is a tendency for spontaneous remission and intermission, each of which will leave in its wake residual pathology. It is these cases which produce our mixed types of thyrotoxicosis in which hyperplastic and adenomatous changes may co – exist.
In a later stage, if hypertrophy and hyperplasia continue for a sufficient time, a stage of exhaustion from over – work will occur. The acini of the cells become smaller and atrophic. Aside from this, there is fibrous tissue replacement of the parenchyma of the gland. These are the cases which give rise to the so called “burnt out” type of goiter.
In a thyrotoxicosis most frequently there has been psychic trauma. This is noted in 90 percent of the cases of Gravers Disease and 40 percent Plummers Disease. However, there previously must have been a susceptible constitution.
In the symptoms, initially, we find fatigue and weakness and palpitation eventually running into fibrillation; and, if not treated, irritability and intolerance of heat, prominence of the eyeballs and increased sweating. In the female, there may be disturbances of the menstrual function, usually amenorrhoea; diarrhoea may be a frequent symptom in these cases.
In the fulminant cases of Graves Disease you will find that it is the vital organs such as the heart and liver which break down, rather than the thyroid itself. The thyroid crises which were common after thyroid surgery were due most often to disturbance in liver metabolism. The thought that cases of Graves Disease must have poor nutrition is not actually true. In fact, 4 percent of the cases are overweight. However, as time goes on, the patient will lose appetite and then there is ensuing rapid loss of weight. In a number of cases, there is marked irritability, the patient is restless and ill at ease. There is body hyper – activity and emotional instability. The mental picture may go on to a stage of manic – depressive disturbances and it is difficult at times to distinguish these cases from true psychoses.
Tremor may be so fine that it may only be detected by placing the tips of your fingers upon the outstretched hand of the subject. Your thyroid patient has a scared look with an anxious expression. There may be marked flushing of the face. The ocular changes, classically Stellwags sign, von Grafes sign and Moebius sign are well known to all of us. Commonly these signs are bilateral, but they are often more striking in one eye than in the other or occasionally confined to one side.
The goiter, on palpation, is usually smooth, uniformly enlarged and presents a thrill on palpation and a bruit during auscultation. In the laboratory tests for diagnosis, the basal metabolic rate is much more important than all the other laboratory methods. Evaluation of the basal metabolic rate must be made. There are cases in which a basal rate of plus 15 may be very significant, if it is known that previously this patient had a lower rate, for instance from minus 10 to a minus 20. It is found that the serum cholesterol is lowered in the thyrotoxic patient. Under treatment it is found that with reduction of the basal metabolic rate, there is an increase in the serum cholesterol value.
The blood iodine determination is a valuable test in determining the border line case. The protein – bound fractions in hyperthyroidism will vary from 8 to 22 gammas per 100 cc.; in hypothyroidism, the range will be from .0 to 4.0.