Various operations have been devised and carried out according to the local conditions present; the entire gland should never be removed except in malignant cases.
(1) Ligature of the superior and inferior thyroid arteries on one side may be undertaken as a preliminary to removal of half the gland, but it often so relieves symptoms that the patient is satisfied and refuses further operation.
(2) Section of the has been performed for the relief of urgent dyspnma, a free incision or a resection of a portion of the isthmus on each side of the middle line permitting the relief of the lateral compres sion of the trachea. Sometimes the entire isthmus requires removal.
(3) Thyroidectomy usually means removal of one lateral half of the gland with or without the isthmus as instituted by Kocher. There is some danger in giving chloroform or ether in these cases, and many surgeons recommend that the operation be carried out under local anxsthesia, but this is sometimes impracticable, but the amxsthesia must be light. A transverse curved incision is made over the most prominent part of the tumour and prolonged over the sterno-mastoid. The muscles depressing the hyoid bone are cut across or retracted, and the capsule of the gland exposed and divided without injuring the underlying large veins; the lobe is next carefully enucleated by the finger and the internal jugular vein guarded. The superior and inferior thyroid arteries are ligatured, and the recurrent laryngeal nerve avoided by leaving behind a piece of the lower end of the lobe under which the nerve runs close to the trachea, and finally the isthmus is divided; the capsule is eventually sutured and the wound treated in the ordinary way, a small drain being left in; this latter precaution is to prevent acute thyroidism, which is liable to supervene from the absorption of the internal secretipn of the gland squeezed out during the enucleation process. The parathvroids which lie behind the
lateral lobes close to the trachea with the inferior thyroid artery and recurrent nerve should be avoided, otherwise a fatal tetanv may supervene soon after the operation. Where the tumour forming a goitre is en capsuled (this constitutes the majority of them) the capsule consists of a thinned-out layer of the gland substance, which should be divided and the enucleation effected from the inside of this. The parenchymatous or adeno-parenchymatous forms are not encapsuled, and Berry insists that these should be treated by the knife being boldly carried through the entire gland structure, leaving behind only the portion of the lobes where the recurrent nerves lie. Thyroidectomy has a mortality of less than r per cent. if performed before serious dyspncea has supervened, and with some operators it has fallen to almost nil.
The treatment of cystic goitre by tapping, injecting irritants, &c., ha s given way to enucleation, which may be easily effected even in large cyst by freely incising the gland tissue down to the cyst wall, which is then divided so as to permit all its contents to escape, after which the cyst wall can he peeled off the surrounding gland substance; small cysts can usually be easily enucleated entire. Sometimes a free incision into the cyst wall where this could not be removed has proved successful when the margins of the wound have been sutured to the skin incision and the cavity plugged with antiseptic gauze. Should the entire gland require removal, as in malignant cases, myxcedema is certain to follow; this must be treated by thyroid feeding. Tetany has been successfully met by the injection of parathyroid emulsion.