Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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290 Surgery and Healing in the Developing World
compensatory goiter may develop in response to pituitary recognition of this subnormal
metabolic state and appropriate increase of thyroid stimulating hormone
(TSH). In the infant, the greater human tragedy of cretinism may ensue, which is
failure of development in neurologic, stature, cardiovascular and sensory faculties
with retardation of all growth milestones and permanent developmental arrest. 2
In terms of the individual, particularly at the stages of fetus, infant, and childhood,
“development” refers to physical and functional growth and differentiation,
so that stature, senses, strength and learned psychosocial capabilities are able to proceed
in the growth pattern characterized by growth “milestones” (e.g., age norms for
height, weight, when first beginning to sit up, walk, talk, weaning). Hypothyroidism
is a condition that retards these development processes and in severe cases permanently
stops them. In terms of a society, “development” refers to the socioeconomic
complexity and productivity characterized by appearance and differentiation of specialized
social institutions, literacy, gross domestic product, and consumption and
processing of resources. Hypothyroidism has its highest global incidence in populations
described as “lesser developed” in these socioeconomic uses of the term development.
The consequences of hypothyroidism make it understandably classified as
a disease with quite apparent implications for retarded development of both individuals
and the culture of the society affected.
Hypothyroidism can be studied by measuring hormones in the blood (thyroid
hormones would be low, thyroid stimulating hormone would be elevated), presence
and degree of goiter and cretinism, and metabolic rate estimation through calorie
consumption. As goiter and cretinism are terms describing hypothyroidism in the
adult and child, these terms are defined below, since each may be assessed in the
field without reliance on laboratory analyses of hormone assays, the results of which
are often determined and reported much later.
Goiter is defined as an enlarged thyroid gland, a swelling in the anterior inferior
part of the neck which may be palpable (typically when the size exceeds twice the
adult median thyroid gland size of 18 grams), visible (typically when the size exceeds
four times the adult median thyroid gland size, or around 75 to 100 grams), and
sometimes massive, occasionally grossly distorting the anatomic configuration of
the head, neck and chest (in some instances exceeding a kilogram and approximating
the size of the patient’s head). Goiter may cause problems for the individual that
bears it ranging from disfigurement, discomfort, cough, difficulty swallowing to the
life-threatening complication of obstruction of breathing.
Cretinism is defined as congenital hypothyroidism and has even more significant
consequences than goiter in human development. As described below, cretinism
represents the arrested or retarded intrauterine development of an infant born
with significant impairment ranging from retarded growth and developmental milestones
to stillbirth from insufficient energy utilization and suppressed metabolic
development.
What Causes Hypothyroidism?
The majority of the causes of hypothyroidism are known and most are readily
correctable. The most prominent cause in Africa and many other areas is iodine
deficiency. Iodine is a dietary trace element that could be made available, is cheap
and should be capable of repletion in the intake of those who are deprived of it by
geographical remoteness from sources of this trace element. 3 Lesser common causes
of hypothyroidism in some societies are substances known as goitrogens. These factors
are substances that prevent organification of iodine into thyroxin. The effect of