Thyroid disease in the smaller hospital

Abstract

Although the major problems of thyroid disease as encountered in the smaller hospital are relatively the same as those met in the larger institution, minor differences in the management of thyroid cases may result in major consequences. Critical judgment of the merit of any therapeutic measure predicates an intelligent evaluation of the ultimate benefit to the patient; and an appraisal of the results of a method of procedure is best derived from adequate and systematic follow-up studies. A thorough review of case records furnishes a complement of experience that can be attained in no other way. Such review combined with meticulous examination of surviving patients literally brings the thyroid surgeon to judgment. Provision for follow-up studies is lacking almost universally in smaller hospitals. Professional apathy notwithstanding, there are many obstacles which tend to preclude the issue of reviews from hospitals with fewer than 100 beds. Because of these faulty circumstances, much valuable knowledge is not forthcoming, morbidity and mortality data are inaccurate and there are many surgeons with an unwitting concept of their work and its results. The 205 cases reviewed in this study accumulated over a period of thirty years; and although most records were complete a number could not be utilized because much of the necessary information was not recorded. From the details available it was learned that: The diffuse forms of goiter in both the toxic and non-toxic groups have an earlier age incidence than the nodular forms. The diffuse toxic goiter appears predominently a decade later than the diffuse non-toxic variety. There is not an appreciable difference in the age incidence of the nodular non-toxic and the nodular toxic goiters. Malignancy of the thyroid gland is most common after the fourth decade of life and it usually follows a preexisting nodular goiter. As generally understood, and corroborated in these studies, females are more frequently affected by thyroid disease than males. The sexes are affected equally with cancer of the thyroid gland. Except for the examples of acute thyrotoxicosis, symptoms are of comparatively long duration, averaging approximately five years. Swelling is the most constant complaint. Pressure is complained of more commonly by toxic patients. Nervousness, palpitation and weight loss are not confined to toxic cases. Exophthalmos is approximately twice as frequent as gastrointestinal complaints in thyrotoxicosis. Evidence is inconclusive as to any deleterious effects resulting from the various anesthetic agents used in this series. Preliminary ligation of the thyroid arteries is not an absolutely safe procedure and is increasingly giving way to operative attacks on the gland in one or more stages. Subtotal thyroidectomy is the operation of choice, although single adenomatous nodules may be removed locally. Postoperative complications are usually of serious consequence and require immediate, often heroic, treatment. Complications markedly increase the period of hospitalization. The proper use of iodine pre- and postoperatively in toxic cases greatly reduces the incidence of complications and likewise shortens the period of hospitalization. The mortality rate in goiter surgery is higher in smaller hospitals. It is presumed that the mortality rate, 5.8 per cent, in this series closely approaches the average for thyroid cases in the smaller institution, a major consequence. The immediate surgical mortality rate in cancer of the thyroid gland is much higher than that of other surgical conditions of the gland. Surgery offers the greatest probability of cure in both non-toxic and toxic goiter; and should be supplemented with radiation therapy in the treatment of thyroid cancer.