The Surgery of the Thyroid Gland.

SURGERY IN SIMPLE GOITRE The Solitary Nodule The apparently solitary swelling, clinically and colloquially referred to as a ' simple adenoma,' may histologically be a hyperplastic nodule (due to compensatory hyperplasia) or a neoplastic nodule (innocent or malignant). The management of the solitary nodule is influenced in some hands by the availability or not of 131I facilities for investigation. 131I Facilities Not Available It is impossible to distinguish with certainty, by clinical methods alone, the hyperplastic nodule from the neoplastic. It is for this reason thatgiven these circumstances-the removal of any solitary symptomless swelling in the thyroid is advised. It is generally agreed that the solitary nodule should not be treated by simple enucleation but by resection of the affected lobe. There is less general agreement about the management of the contralateral lobe. It is known that a large hyperplastic nodule is rarely, if ever, truly solitary, but that there are numerous minute areas of focal hyperplasia scattered throughout both lobes.'0 Removal of the affected lobe only is followed in a proportion-a small proportion-by the appearance of a nodule on the opposite side. It is agreed that the incidence of this occurrence can be reduced by performing a subtotal thyroidectomy in all cases of apparently unilateral simple goitre. A contrary point of view, which I believe to be the more reasonable practice, is to perform lobectomy on the side of the swelling, to palpate the opposite side to exclude a palpable nodule or nodules and to do no more surgically if the contralateral lobe feels normal. If it is true that a low level of circulating thyroid hormone is responsible for triggering off the mechanism of anterior pituitary stimulation, increased TSH production, thyroid focal hyperplasia-then it is illogical further to reduce thyroxin production by removing a substantial part of the remaining lobe. Strong additional support is given to this restricted surgical attack in the case of the solitary nodule (i) by the low rate of subsequent nodular involvement of the contralateral lobe, (2) by the greater morbidity of the bilateral as compared with the unilateral operation, and (3) by the experience that postoperatively the continued growth of any remaining impalpable thyroid nodules may be discouraged by the administration of thyroid extract (I20 mg. daily) or of 1-thyroxine sodium (0.3 mg. daily).