The Medical Treatment of Hyperthyroidism

THE CONCEPTION that treatment of Graves' disease (i) is primarily surgical, is widespread despite the fact that American as well as European literature contains numerous reports of satisfactory results with non'surgical treatment in selected cases. It is undoubtedly true that since Plummer and Boothby (2, 3, 4) inaugurated routine preoperative iodine preparation, the prognosis of surgical pro' cedures in Graves' disease has been markedly improved. It is also true that a high percentage of cures is obtained by subtotal thyroidectomy, but the results are by no means universal. Because of these operative failures, and because of those cases not amenable to surgery, it is the immediate concern of the internist, from a practical point of view, to continue his search for a satisfactory medical treatment. The mode of action of different types of therapy is still far too speculative to be discussed in this purely clinical paper, but one must admit that it is extremely dif' ficult for patho'physiologists to comprehend how a large number of hyperthyroids are cured or helped by simply cutting out a piece of an overactive gland. It appears likely that the enlargement of the thyroid is by no means the cause of the hyperthy roidism, but rather a sequel. The relationship between the siz£ of this gland and the degree of hyperthyroidism has never been determined. Even the exact histological study of Sunder-Plassmann (5), in which he was able to show much damage to the local sympathetic fibers as a result of subtotal thyroidectomy, by no means covers the entire subject, as was first pointed out by Bauer (6, 7), and his conclusions were too far reaching. This lack of information as to the theoretical considerations relating to the mechanism of action confronts the research worker in the field with an impor' tant problem directly related to treatment. In the face of present day literature, it is impossible for us to agree with Richter (8), when he claims that the treatment of Graves' disease is entirely surgical. On the other hand, we cannot concur with Jenkinsons' view (9) that every case should be treated primarily medically and only failures then subjected to surgery. We hold with the majority of workers that a certain group of cases are surgical, the remainder medical, to be treated surgically only after non'operative failure. Most workers agree, that as soon as it becomes apparent that the results of medical therapy are not good, surgery should be immediately resorted to with the least possible delay so that the optimal time for operation is not missed. On the other hand, too early surgical intevention, especially in early acute Graves' disease, is also not advisable because postoperative crises are most common in these cases, even with preoperative iodinisation, and incomplete results as well as recurrences are relatively frequent. To this group belong the cases with diffuse hyperplasia, as pointed out by Barr (10). In contrast, patients whose hyperthyroidism is partly burned out by medical treat' ment, respond later to surgery with much better results.