L776 PANEL DISCUSSION ON HYPERTHYROIDISM iodothyronine. As [ said, we are now oper- ating on a select group, and to misjudge and leave too much thyroid behind would be a grave error. DR. ERNEST A. GOULD, Department of Surgery, Washington Hospital Center and George Washington School of Medicine, Washington, D.C.: tf I had my choice here, I would rather be left with a little remnant of thyroid gland that hadn’t been affected by radioactive iodine than have all of my gland and have to wait to see whether myxedema will ensue or not. Dr. Werner, my feeling about this patient is, medical treatment has had its chance; now let us give definitive treatment. This patient can be handled readily -and rapidly, and the treatment will be terminated. Now, J have no argument with those who want to talk about hypothyroidism after surgery in these people. In agreement with Dr. Feind, I would much rather make these people mildly hypothyroid. As a matter of fact, this is the goal, I think, in good surgery of hyperthyroidism today, because the replacement of thyroid hormone is so easily done. Certainly, in a patient who has already been treated for three years, who has questionable rheu- matic heart disease, which may be of con- siderable importance later, I should think removal of the one known stress on the myocardium of this patient is terribly important. Thus, I would certainly have urged that this patient be prepared and promptly operated upon with hypothermia. I know that Dr. Sterling is skillful with perchlorate, but, again, what are we gaining by suboptimal treatment of a patient who, after three years, cannot be brought into a euthyroid state and kept there? DR. KRISS: I am not convinced we have diagnosed this patient. We have diagnosed hyperthyroidism, but the question of all the other symptoms that have been present hereraises doubts in my mind as to whether everything can be ascribed to hyperthy- JUL LE? Volume 277 roidism. If I referred the patient to a sur- } geon, I might ask him to do a muscle ° biopsy, rather than a_ thyroidectomy. DR. WERNER: Well, to give our own reasoning, we chose J as the method of therapy. Surgery without an antithyroid drug or other preoperative medication and only hypothermia as preparation exposes a young patient to the msk of storm and death. Besides, we doubted that she had rheumatic or other connective tissue disease, after her dramatic recovery when medication was stopped, and after the return of symptoms with iodides. We excluded perchlorate to prepare for surgery, or chronically, since perchlorate may produce aplastic anemia, among otherthings. She has become euthyroid since her !"I treatment andis perfectly well today, without myalgia, arthralgia or fever. I just want to make one final comment. 4 According to a recent statistical bulletivWe” 7 of the Metropolitan Life Insurance Company, mortality from toxic goiter decreased almost 90% since 1941, whereas mortality from thyroid cancer showed only minor fluctuations. In the light of our discussion, the factors responsible for these results need to be brought out, since they bear heavily on choice of therapy in hyperthyroidism. Summary A case history was presented of a 16year-old girl with hyperthyroidism. She had been chronically treated with antithyroid drugs for 34 years but throughout this same period of time manifested fever and joint pains. Subsequent discussion presented a review of the evidence concerning the primary action of thyroid hormone within thecell; a survey of the nature of the pathogenesis and etiology of Graves’ disease; and a discussion of radiation effects on the thyroid celj. There then followed a debate as to the proper method of treatment of this patient and of hyperthyroid patients in general. It was pointed out tha the high incidence of hypothyroidism after