6 December 1967 ADULT HYPERTHYROIDISM groups of hyperthyroid patients treated by surgery or antithyroid drugs. I am wondering whether there is any concrete evidence that radioiodine therapy produces cancer or will produce cancer of the thyroid. DR. CONARD: Though we have only one case of cancer of the thyroid in the exposed Marshallese group, one has to consider the possibility that this is related to radiation exposure, particularly since the incidence of such malignancy is ap- parently quite low in the Marshall Islands, something like two cases in 15,000 people in ten years. I think the statistics are in favor of this case being radiation-induced, though there is no certainty of it. One must also consider the apparent increase in thyroid cancer in the exposed Japanese adults. In answer to the question about the normal PBI values we reported, it should oe remembered that these values were obtained early in our studies, and at that time hypothyroidism may have been borderline. Later, when definite signs of hypothyroidism developed, the blood thyroxine levels becameclearly low. DR. WERNER: Perhaps we can now deal more directly with the therapy of our patient, 16 years old and allergic to antithyroid drugs and iodides. Dr. Sterling. @ DR. STERLING: It seems to me, offhand, that there are three possible choices of treatment. One is immediate surgery, another, radioiodine therapy, and the third might be—even though she has a sensitivity to these drugs—propylthiouracil and iodide. One might give her sodium perchlorate, which I have used with success in people sensitive to all the other medicaments. I have seen one patient who was sensitive to perchlorate, as well. I would be tempted to give perchlorate under careful observation in the hope of wapidly preparing her for subtotal thyroidectomy. 1775 DR. WERNER: I had originally planned to suggest surgery on the ground that surgery could be carried out with a minimum risk of hypothyroidism. However, we have discovered in reviewing the ex- perience at our hospital—and I see Dr. Beierwaltes has discovered this at his hospital, also (50)—that the surgeons have been doing almost as good a job in producing hypothyroidism as those of us who use '![. Each year from the 1940’s when our surgical rate of hypothyroidism was around 3 to 6%, there has been a progressive rise in the postoperative incidence of hypothyroidism, so that now the incidence is in the range of 30°. This statistic removes some of the relative value of surgery over '"J, However, the trend is not an irreversible one, whereas so far, at least, the high incidence of hypothyroidism in ''[ therapy seems to be essentially inescapable despite majorefforts. The surgeons, represented by Dr. Feind and Dr. Gould, will want to speak about this. DR. CARL R. FEIND, Department of Surgery, Columbia University College of Physicians and Surgeons, New York: In 1940, the surgeons were treating almost all of the thyrotoxic patients. For the past ten years, the only ones that we have been treating are those that have been referred to us for very specific reasons. These are patients who did not tolerate antithyroid drugs, or who had glands that were not treated with J for other reasons. Most such patients were younger people in their reproductive period. The surgeon, in treating a select group like this, should tend to overshoot at operation, because, if he Jeaves too much gland behind, he has a patient who has persistent or recurrent toxicity andis still in the samesituation as when he was originally referred. Thyroid is given after subtotal thyroidectomy, as is done after treatment with 13]. In fact, most patients who are receiv- ing antithyroid drugs are also given tri-