PATIENT NO. AGE SEX 21 12 F HOSPITAL DATE U. S. Naval Hospital, Guam August, 1964 This 12 year old female, native of Rongelap Atoll, was accidentally subjected to radioactive fallout from a nuclear explosion in 1954. She subsequently suffered hematopoietic depression and "beta burns of the skin that healed in several months." Thereafter, she was subjectively and objectively in good health until March, .1964, when examination revealed a grossly irregular (nodular) thyroid gland. Protein bound iodine was reported as normal, and the child was referred to this hospital on August 17, 1964, for surgical management of the pathologic gland. Admission studies revealed a normal physical examination except for four to five hard nodules in the thyroid, with no palpable lymph nodes. Laboratory studies were negative except for an unexplained leukocytosis of 15,700 (with a normal smear) and a sedative rate of 38. PBI was not repeated. The increased likelihood of malignant degeneration in thyroid glands exposed to radiation (whether x-irradiation or atomic blasts as in Japan}, together with the infrequency of nodular goiter during adolescence among these Island people, made us fairly certain that we were dealing with a malignant tumor of the thyroid. At operation on August 18, 1964, the gross picture was one of malignancy, with the thyroid having a cobble-stone appearance and "feel," the nodules being for the most part extremely indurated and unlike the findings in a nodular goiter. [It was decided to remove the entire thyroid gland, with dissection of the anterior compart- ment of the neck, en bloc. The extreme irregularity of the thyroid gland, with nodules being of different color and consistency, made identification of parathyroid tissue extremely difficult. One parathyroid gland was identified after its pedicle was divided (it was attached to the undersurface of the right lobe of the thyroid gland), and this was implanted in the belly of the right sternomastoid gland. No other parathyroids were seen, and none were subsequently found in the specimen by the pathologist. Postoperatively, the patient had attacks of frank tetany on the second and fourth postoperative days, each time responding to intravenous calcium glucoheptonate. Since that time she has been maintained on a high calciume-low phosphorous diet, calcium lactate tablets, Deltalin (vitamin Dz), and amphogel, in varying amounts. At first an attempt was made to wean her of all medications (as her serum calcium and phosphorus suggested return of parathyroid function). However, it was found that she could not tolerate complete withdrawal, so attempts were redirected toward establishing a program that would regulate her calcium/phosphorus balance with a minimum of medication, As of now this program includes the following: Deltalin 100,000 units daily, calcium lactate two tablets (grains XX) t.i.d., amphogel 30 cc t.i.d., a high calcium/low phosphorus diet, and thyroid extract grains I t.i.d. The child seems to be doing quite well on this program, has no suggestion of neuromuscular hyperirritability, and participates freely in available activities. Her serum calcium is 9.4, with a serum phosphorus of 5,7, and an alkaline phosphatase of 6 B.U. ea ae ree ee =T eas weer ae ey - eee - ~